FDG PET Imaging of Extremities in Rheumatoid Arthritis.

BACKGROUND: The primary objective of this study was to evaluate the utility of fluorodeoxyglucose positive emission tomography imaging in assessing the degree of joint inflammation and response to therapy in patients with rheumatoid arthritis using standard PET parameters. METHODS: Five subjects with newly diagnosed RA were enrolled in this IRB-approved prospective study. After standard conventional workup that included clinical and laboratory evaluation and disease activity score (DAS3v) calculation, subjects underwent baseline FDG PET scans of their hands and feet prior to initiation of treatment and after six months of standard treatment. The uptake of FDG in involved joints was assessed qualitatively (visual evaluation) as well as semi quantitatively using standardized uptake value (SUV). Findings from the FDG PET scans were correlated with clinical and laboratory parameters including DAS and ESR. RESULTS: In all five patients, increased FDG uptake was noted in various joints affected by RA. The intensity of uptake varied from mild to intense (SUVmax values from 3.10 to 6.0). Overall, these correlated well with the clinical evaluation of involved joints. FDG PET imaging provided additional information by showing involvement in joints that were difficult to evaluate clinically (e.g. mid foot joints). The PET data also provided a distribution of joint involvement with varying degrees of severity in the same subject. On objective analysis using Spearman rank correlation coefficient for statistical analysis, no significant correlations were observed (p>0.05) between DAS, ESR, and the different PET parameters at baseline (before treatment) despite large calculated positive correlation coefficients. This was due to the small sample size (n=5). At post-treatment, the significant correlations were those between DAS and Maximum metabolic disease burden (MDB max) (RS=0.9, p=0.04) and between ESR and MDB max (RS=0.9, p=0.04). The positive correlations between total metabolic disease burden (Total MDB) and DAS (RS=0.7) and between Total MDB and ESR were also large (RS=0.7) but not significant. The non-significance was due to the small sample size. CONCLUSIONS: FDG PET imaging provides a unique noninvasive quantitative method in assessing disease status and response to therapy and can serve as a useful adjunct to clinical evaluation in management of patients with rheumatoid arthritis.

Acquired constricting and restricting lesions of the descending duodenum.

The descending duodenum is a structure with distinct pathologic processes and anatomic relationships that requires a systematic approach to the differential diagnosis. Because of its tubular shape and fixed position in the retroperitoneum, both intrinsic duodenal and juxtaduodenal diseases are capable of producing luminal narrowing and obstruction. Duodenal lesions may be located in the mucosa or submucosa. Extraduodenal lesions may originate in adjacent structures--such as the pancreas, liver, gallbladder, colon, and lymph nodes--or from other retroperitoneal structures. Causes of duodenal obstruction include intraluminal masses, such as bezoars; duodenal inflammation, such as as peptic ulcers and Crohn disease; hematomas; and benign or malignant mucosal and intramural tumors. Pancreatic inflammation; tumors; and extrinsic compression caused by gallbladder processes, hepatic masses, retroperitoneal fluid collections, and tumors, including lymphoma, may produce duodenal obstruction. Abdominal radiography, barium studies, multidetector computed tomography, magnetic resonance imaging, and positron emission tomography may be used to depict and characterize duodenal strictures. Integration of imaging, clinical, laboratory, and endoscopic findings plays a major role in establishing a diagnosis of obstructive duodenal strictures.

Accuracy of multi-detector computed tomography, fluorodeoxyglucose positron emission tomography-CT, and CA 19-9 levels in detecting recurrent pancreatic adenocarcinoma.

CONTEXT: We compared the accuracy of fluorodeoxyglucose positron emission tomography-CT (FDG-PET-CT), multi-detector computed tomography (MDCT) and CA 19-9 levels in detecting pancreatic cancer recurrence in patients with resected CA 19-9 positive pancreatic adenocarcinomas. METHODS: We retrospectively evaluated 122 patients with pancreatic adenocarcinomas who underwent surgical resection of the tumor between January 2002 and December 2011. Twenty-five patients had MDCT, FDG-PET-CT and CA 19-9 levels performed no less than six weeks post-operation and within 8 weeks of each other for detection of tumor recurrence. Of these, 20 patients had high pre-operative CA 19-9 levels that dropped to a normal level postoperatively which will be the focus of this study. The sensitivity, specificity, positive and negative predictive value (PPV, NPV), and accuracy of MDCT, FDG-PET-CT, and CA 19-9 in detecting recurrence were compared. RESULTS: Operations performed included pyloric sparing pancreaticoduodenectomy (n=9), pancreaticoduodenectomy (n=7), distal pancreatectomy (n=3) and total pancreatectomy (n=1). Three patients had no recurrence, but local recurrence and distant metastasis were seen in 8 (40%) and 12 (60%) patients, respectively. In our study, sensitivity, specificity, PPV, NPV and diagnostic effectiveness (accuracy) were: 82%, 100%, 100%, 50%, 85% for MDCT; 82%, 100%, 100%, 50%, 85% for FDG-PET-CT and 94%, 100%, 100%, 75%, 95% for CA 19-9. The difference in recurrence detection accuracy of the tests was not statistically significant. A combination of CA 19-9 with MDCT or FDG-PET-CT was 100% accurate in detecting cancer recurrence in our patients. CONCLUSION: Our data suggests that CA 19-9 levels can be used reliably to detect recurrent pancreatic adenocarcinomas in patients with CA 19-9-positive primary tumors. Combination of CA 19-9 with MDCT or FDG-PET-CT is potentially the most accurate approach in detecting pancreatic cancer recurrence.

Chemoradiotherapy for unresectable stage IVB head and neck cancer.

OBJECTIVE: As the occurrence of unresectable stage IVB head and neck cancer is expected to continue, we present our experience over the last 17 years with chemoradiotherapy management of 14 cases to clarify the effectiveness and safety of this treatment scheme. METHOD: Of the 1,267 individuals who were diagnosed with carcinoma of the upper aerodigestive tract between 1992 to 2008, 14 patients were treated by induction chemotherapy followed by concurrent chemoradiation or simultaneous chemoradiotherapy for stage IVB disease. The median follow-up time was 54.5 months. RESULTS: The complete objective response rate was 79%. Six individuals remained disease-free during a followup period ranging from 24 to 149 months. The disease-free survival rate at five years was 68%. Local, regional, and distant failure rates were 21%,14%, and 7% respectively. Most of the patients (79%) experienced transient mucositis during treatment. Significant late complications consisted of dental caries or osteoradionecrosis (14%) and esophageal stricture (7%). CONCLUSION: Definitive chemoradiotherapy administered for unresectable stage IVB head and neck cancer has the potential of achieving long-term disease-free survival in up to two-thirds of the patients with a low risk of complications.

Mickey Mouse Sign on Bone Scan: This Mouseketeer Rebels Against Paget Disease.

ABSTRACT: An 81-year-old man with prostate adenocarcinoma demonstrated interval progression of the osteoblastic metastatic disease on surveillant bone scan with a new lumbar lesion resembling the configuration of Mickey's head (Mickey Mouse sign), a sign considered to be specific for Paget disease, even in the presence of malignancy. However, our case demonstrates that this appearance can be caused by other etiologies. In the era of SPECT/CT and MRI, it is prudent to obtain further cross-sectional correlation at the time of radionuclide bone scintigraphy to clarify the underlying cause for "Mickey Mouse sign" to prevent misinterpretation, allowing for efficient and accurate patientcare.

Pediatric Cardiac PET/CT Imaging.

With the routine availability of PET/CT imaging for oncologic purposes, there has been renewed interest in and acceptance of cardiac and neurologic applications of PET/CT. As our understanding of the pathophysiology underlying various pediatric heart diseases has improved, there has been a parallel advance in imaging modalities. Cardiac MR imaging and cardiac PET continue to improve in the pediatric domain. Molecular imaging holds promise to provide a more robust assessment of the cardiac pathophysiology in a 1-stop setting with less radiation exposure to the patient, an important consideration for the pediatric patient population.

Metachronous mediastinal and lung metastases from head and neck cancer: A case series, literature review and considerations for treatment.

Metachronous mediastinal and lung metastases (MMLM), important sources of morbidity and mortality, in people with head and neck cancer (HNC) have received little attention. Between 1980 and 2004, 37 patients with treated HNC and MMLM diagnosed on follow-up imaging (with histological confirmation in 14 cases) were identified. The median interval from diagnosis of HNC to the appearance of MMLM was 14.5 months. The overall median survival was 4 months, and the 1-year crude survival rate (CSR) was 16%. A meaningful difference in the 1-year CSRs between the palliative radiation treated and untreated subjects (39% and 4%, respectively, p < 0.01) was observed. Because associated costs of health care utilization are considerable, and yet survival is limited, optimum management of MMLM-HNC with improvement of prognosis remains a challenge.

Immunotherapy and Thyroid Dysfunction: Relevance to Nuclear Medicine.

We report a case of a 66-year-old woman with small cell lung cancer (stage IIB, T2N1M0), who received immunotherapy with nivolumab monthly for 2 months and then presented with thyrotoxic symptoms associated with suppressed thyroid-stimulating hormone levels and elevated free thyroid hormone levels, although previous thyrotropin performed 1 month ago was normal. Thyroid uptake and scan demonstrated diffusely decreased uptake in both thyroid lobes. The 4-hour percentage uptake was 0.7%, and the 24-hour percentage uptake was 0.3%. This was followed by development of hypothyroidism within few weeks. Findings suggested drug-induced thyroiditis secondary to nivolumab therapy.

Horner Syndrome Secondary to Metastatic Squamous Cell Carcinoma in the Neck: A Case Series.

BACKGROUND: Horner syndrome caused by metastatic squamous cell carcinoma of the head and neck is not common, and when diagnosed, may have serious clinical implications. We aim at highlighting the clinical significance of this finding. METHODS: We retrospectively reviewed charts of 6 patients with Horner syndrome secondary to metastatic head and neck squamous cell carcinoma (HNSCC) in the neck. RESULTS: All 6 patients had pathologically confirmed nodal metastatic HNSCC. There was one unknown primary and in the remaining 5 patients the primary tumor was identified in the oropharynx, larynx, and oral cavity. Three patients died within 1 month of diagnosis, before initiation of any treatment. One patient received radiation only while 2 patients received chemoradiation with cisplatin as the tumors were unresectable given carotid sheath involvement. Median survival was 4.5 months. Only 1 out of the 6 patients survived and had complete resolution of Horner syndrome after treatment. CONCLUSION: This is the first case series of neck metastasis from mucosal HNSCC as an unusual cause of Horner syndrome and is usually associated with very poor prognosis.

Potential value of quantitative analysis of cerebral PET in early cognitive decline.

BACKGROUND: In patients diagnosed with Alzheimer's disease, positron emission tomography brain scans can have characteristic hypometabolic patterns that strongly support this diagnosis, but this pattern is often subtle or absent in early stages. A sensitive and objective method for detection of positron emission tomography abnormalities may have value in early detection of Alzheimer's disease. METHODS: A 2-fluoro-2-deoxy-D-glucose positron emission tomography scans from cognitively impaired patients (n = 43) were compared individually to 28 normal controls using statistical parametric mapping, hypometabolic regions visualized, and clinically correlated. The objective SPM results were compared to the official Nuclear Medicine report based upon subjective interpretation criteria. RESULTS: A total of 22/43 had abnormalities per the Nuclear Medicine physician, while 21/43 appeared normal. The objective analysis detected abnormalities in 41/43 participants, including 19 of 21 that appeared normal. In these 19, 8 had findings consistent with early Alzheimer's disease. CONCLUSION: Objective analysis of positron emission tomography brain scans may extend the ability to detect early brain abnormalities in patients with cognitive decline.

Costosternal chondrodynia simulating recurrent breast cancer unveiled by FDG PET.

FDG-PET imaging, which is routinely used to assess recurrent breast cancer, is nonspecific for malignancies and can detect several inflammatory lesions. Costochondritis following breast reconstructive surgery, presenting with excruciating chest pain or "chondrodynia," is a rare variant of Tietze's syndrome thought to occur due to traction exerted by large breast implants. Diagnosis is usually clinical because no abnormalities are identified on conventional imaging. Two cases have been reported in the literature, but none with FDG-PET. We report a patient with treated breast cancer, presenting with chest pain where FDG-PET to assess for recurrence was consistent with costochondritis and peri-implant inflammation.

Bone marrow metastases in salivary duct carcinoma of the parotid gland.

Salivary duct carcinoma (SDC) is a rare and extremely aggressive salivary gland cancer. An 81-year-old woman with SDC underwent a total parotidectomy with facial nerve sacrifice and a neck dissection. Following surgery, she was diagnosed with disseminated bone marrow metastases. She underwent chemotherapy and trastuzumab for palliation. We present a case of SDC of the parotid which was diagnosed with disseminated bone marrow metastasis following surgery for the primary. This case also highlights the importance of having a high index of suspicion while evaluating highly aggressive tumours like SDC for any atypical findings during workup.

ACR-ACNM Practice Parameter for the Performance of Fluorine-18 Fluciclovine-PET/CT for Recurrent Prostate Cancer.

The American College of Radiology (ACR) and American College of Nuclear Medicine (ACNM) collaborated to develop a clinical practice document for the performance of fluciclovine positron-emission tomography (PET) / computed tomography (CT) in the evaluation of patients with suspected prostate cancer recurrence based on the elevation of prostate-specific antigen (PSA) level (biochemical recurrence) after prior therapy. Prostate cancer is the third leading cause of cancer death in the United States. Up to 50% of patients diagnosed with prostate cancer will develop biochemical failure after initial therapy. The differentiation of local from extraprostatic recurrence plays a critical role in patient management. The use of functional imaging targeting features of cancer metabolism has proven highly useful in this regard. Amino acid transport is upregulated in prostate cancer. Fluciclovine (anti-1-amino-3-F-18-fluorocyclobutane-1-carboxylic acid, FACBC, Axumin™) is an artificial amino acid PET tracer which demonstrates utility in the diagnosis of recurrent prostate cancer with significant added value to conventional imaging.

Accurate grading of 3 synchronous liposarcomas assessed by PET-CT in a single patient.

Positron emission tomography (PET) with 2-fluoro-deoxyglucose (FDG) has become an established imaging modality that can accurately and noninvasively differentiate malignant neoplasms from benign masses. It is increasingly being used to grade malignant neoplasms as well and has almost replaced other studies like gallium 67-citrate scans for metabolic imaging. We describe an interesting case of 3 synchronous liposarcomas with different radio-opacifications on computed tomography (CT). The more aggressive lesion with more opacity on CT showed intense FDG activity and was found to be a high-grade liposarcoma on pathology. The well-differentiated lesion with more fat content appearing less radio-opaque on CT showed almost no FDG activity and an intermediate grade lesion with intermediate radio-opacity on CT showed mildly increased FDG activity. Dual modality imaging with integrated PET/CT systems have strengthened the confidence of classifying these lesions even before knowing the pathology as depicted in this case.

A Potential Role for F-18 FDG PET/CT in Evaluation and Management of Fibrosing Mediastinitis.

Fibrosing mediastinitis is an uncommon benign disorder, and its pathogenesis and management remain unclear. Conventional imaging techniques (chest radiographs, CT, MRI) may suggest its diagnosis but are frequently nonspecific, and it frequently mimics a malignant process by presenting as a mediastinal mass without calcifications, encasing, and infiltrating adjacent mediastinal structures, and showing an overall aggressive behavior. The value of FDG PET imaging in this entity remains largely unknown with only a few case reports in the literature, and often, biopsy is necessary for definitive diagnosis. We report a case of biopsy proven fibrosing mediastinitis highlighting the utility of PET in the evaluation and management of the disease.

Spontaneous tumor lysis syndrome in colon cancer: a case report and literature review.

Although tumor lysis syndrome is well described, it is rarely seen or suspected in solid malignancies. Early recognition of this entity is paramount in reducing morbidity and mortality. Treating physicians should be aware of this possibility in solid tumor patients with either bulky disease or extensive liver involvement.

Follicular dendritic sarcoma masquerading as fibrosing mediastinitis.

Fibrosing mediastinitis (FM) is a rare disorder resulting from abnormal immunological-mediated fibro-proliferative reaction in the mediastinum. Here, we describe a case of a 46-year-old female with an incidentally found 11×9 cm posterior mediastinal mass. Multiple biopsies of this unresectable, 18-fluorodeoxyglucose avid mass revealed marked fibrosis without any evidence of malignancy, suggesting idiopathic fibrosing mediastinitis as our initial diagnosis. Multiple interventions including a trial of steroids, fluconazole, and azathioprine to target fibrosing mediastinitis were not successful. Repeat biopsy was consistent with primary mediastinal follicular dendritic cell sarcoma. The manuscript highlights the heightened need for suspecting occult malignancies in cases of FM presenting with an indeterminate cause.

Successful Treatment of Richter Transformation with Ibrutinib in a Patient with Chronic Lymphocytic Leukemia following Allogeneic Hematopoietic Stem Cell Transplant.

Patients with chronic lymphocytic leukemia (CLL) who progress to Richter transformation (RT) have a poor prognosis. Multi-agent chemotherapy regimens do not have good response rates. There are few case reports on the use of ibrutinib in RT. Here, we present a patient who was heavily pretreated for CLL, including allogeneic stem cell transplant, and progressed to RT. She had a mixed response to multi-agent chemotherapy and was started on ibrutinib. She had a complete response for 16 months on single-agent ibrutinib with minimal toxicity.

Incidence of contralateral-bilateral nodes in the human papillomavirus era.

OBJECTIVES/HYPOTHESIS: HPV-positive oropharyngeal squamous cell carcinoma has a more favorable prognosis when compared to HPV-negative disease, regardless of the presence of nodal metastases. However, the importance of contralateral neck treatment based on HPV status has not been well studied. Given the historically poor prognostic implications of cervical nodal metastases, this study sought to elucidate the relationship between HPV status and contralateral/bilateral nodal metastasis in patients with oropharyngeal squamous cell carcinoma. STUDY DESIGN: Retrospective cohort analysis. METHODS: Data were collected on patients with oropharyngeal squamous cell carcinoma from 2001 to 2014. Nodal status was determined by contrast-enhanced computed tomography, positron emission tomography, or surgical pathology when available. Survival rates and associations between HPV status and demographic/tumor characteristics were assessed. RESULTS: Of 178 total patients, 46 (26.0%) had contralateral/bilateral metastases. There was no significant difference in incidence of contralateral/bilateral nodal metastases between HPV-positive and HPV-negative patients (24.6% vs. 29.1%, P = .53). Tonsil primaries had significantly lower incidence of contralateral/bilateral nodal metastases compared to tongue base (20.9% vs. 34.3%, P = .048). On multivariate regression, tumor size was the only factor associated with contralateral/bilateral nodal metastases (T4 vs. T1-3 odds ratio = 5.15, 95% confidence interval: 2.4-11.2). Five-year overall survival among all patients with and without contralateral/bilateral nodal metastases was 45.4% and 65.2%, respectively (P = .007). CONCLUSIONS: Our results did not show a significantly different incidence of contralateral/bilateral nodal metastases between HPV-positive and HPV-negative patients. T4 stage and tongue base location, however, were associated with contralateral disease. These data suggest treatment of bilateral necks might be warranted in these cases, regardless of HPV status. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:1328-1333, 2017.