Search

A new era of precision diagnostics and therapy for patients with neuroendocrine neoplasms began with the approval of somatostatin receptor (SSTR) radiopharmaceuticals for PET imaging followed by peptide receptor radionuclide therapy (PRRT). With the transition from SSTR-based γ-scintigraphy to PET, the higher sensitivity of the latter raised questions regarding the direct application of the planar scintigraphy-based Krenning score for PRRT eligibility. Also, to date, the role of SSTR PET in response assessment and predicting outcome remains under evaluation. In this comprehensive review article, we discuss the current role of SSTR PET in all aspects of neuroendocrine neoplasms, including its relation to conventional imaging, selection of patients for PRRT, and the current understanding of SSTR PET-based response assessment. We also provide a standardized reporting template for SSTR PET with a brief discussion.

Background There has been growing interest in the potential of emerging internet-delivered psychological treatments for supporting the mental health needs of university students. However, no large-scale prospective effectiveness trials examining their real-world potential have been reported. Objective The aim of the current study was to evaluate the acceptability and effectiveness of a brief, 5-week, internet-delivered and therapist-guided intervention for anxiety and depression, when delivered as part of routine care by a university counselling service. Design A large, prospective, single-group Phase-IV clinical trial. Students ( n = 1326) engaging with the university counselling service were provided the opportunity to receive the intervention based on their preferences and identified needs. Students completed standardised measures of anxiety and depression at pre-treatment, each week of the intervention, post-treatment and 3-month follow-up. Results Over a 4 year period, 1081 students (10% of those presenting to the counselling service) participated in the intervention. Large clinical reductions in symptoms of both anxiety (% reduction = 41%; Cohen's d = 0.94) and depression (% reduction = 36%; Cohen's d = 0.81) were observed alongside high levels of acceptability. The intervention required relatively little counsellor time ( M = 36.28 mins; SD = 20.56) per student, and symptom deterioration was observed in less than 5% of students. Conclusion The findings of the current study are supportive of internet-delivered interventions provided as routine care to university students. Further research is needed to carefully explore whether these interventions could be used with a larger proportion of students presenting to counselling services, paying close attention to acceptability, engagement and clinical outcomes.

We present the case of a 36-year-old woman who underwent (18)F-FDG PET/CT with suspicion of a primary breast malignancy. However, PET/CT detected an occult renal cell carcinoma with metastases to the thyroid, breast, lungs and lymph nodes. Thyroid and breast metastases are atypical metastatic sites of renal cell carcinoma. Breast metastases from extra mammary tissue are extremely rare, more so from renal cell carcinoma. Histopathologic confirmation of the breast lesions is imperative to avoid unnecessary mastectomy and imaging can help in raising the suspicion of metastatic involvement versus primary breast malignancy.

Ga-DOTANOC PET/CT is well documented in evaluation of well-differentiated neuroendocrine tumors and in other lesions with somatostatin receptor expression such as pheochromocytoma, paraganglioma, neuroblastoma, meningioma, and mesenchymal tumors causing oncogenic osteomalacia. Causes of interpretative pitfalls include prominent pancreatic uncinate process activity, inflammation, osteoblastic activity (degenerative bone disease/fracture/vertebral hemangioma), splenunculi/splenosis, and others. We present a case of extraskeletal paravertebral lesion detected in a known case of breast cancer with increased Ga-DOTANOC uptake later proved to be hemangioma. This is a novel finding and should be kept as a rare benign differential in evaluation of lesions with somatostatin receptor expression.

Supplemental digital content is available in the text., Objectives We performed a systematic review and meta-analysis to evaluate the impact of 18F-FDG PET, PET/CT, and PET/MRI on staging and management during the initial staging of breast cancer. Methods We searched the PubMed, Embase, Cochrane Library, and KoreaMed databases until March 2020 to identify studies that reported the proportion of breast cancer patients whose clinical stage or management were changed after PET scans. The proportion of changes was pooled using a random-effects model. Subgroup and metaregression analyses were performed to explore heterogeneity. Results We included 29 studies (4276 patients). The pooled proportions of changes in stage and management were 25% (95% confidence interval [CI], 21%–30%) and 18% (95% CI, 14%–23%), respectively. When stage changes were stratified according to initial stage, the pooled proportions were 11% (95% CI, 3%–22%) in stage I, 20% (95% CI, 16%–24%) in stage II, and 34% (95% CI, 27%–42%) in stage III. The relative proportions of intermodality and intention-to-treat changes were 74% and 70%, respectively. Using metaregression analyses, the mean age and the proportion of initial stage III to IV and histologic grade II to III were significant factors affecting the heterogeneity in changes in stage or management. Conclusions Currently available literature suggests that the use of 18F-FDG PET, PET/CT, or PET/MRI leads to significant modification of staging and treatment in newly diagnosed breast cancer patients. Therefore, there may be a role for routine clinical use of PET imaging for the initial staging of breast cancer.

18F fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT) is a standard imaging tool in staging as well as response evaluation for lymphoma. Here, we present a young male with extensive extranodal lymphoma with cardiac involvement which presented as diffuse myocardial lesion mimicking hypertrophic obstructive cardiomyopathy. 18F-FDG PET/CT helped in the staging by revealing multiple systemic involvements. Interim PET after three cycles of chemotherapy showed a complete metabolic response to therapy in all the extranodal sites including the cardiac involvement, thus retrospectively confirming the lymphomatous involvement. Previous literature also conforms to the superior role of 18F-FDG PET/CT in the clinical management of extensive extranodal lymphoma.

Rationale: To evaluate the detection rate of incidental second primary neoplasms in patients with prostate cancer on 18F-Fluciclovine PET/CT. Methods: Imaging reports and patient demographic data were retrospectively reviewed from 663 clinical 18F- Fluciclovine PET/CT studies, performed in 601 patients for the assessment of their prostate cancer (643 - recurrence evaluation, 20 - initial staging) from August 2016 to April 2021. Maximum standardized uptake value (SUVmax) of the suspected second neoplasms was determined. The results of 18F- Fluciclovine PET/CT were correlated with clinical and radiological studies to determine the nature of the suspected second neoplasms. Results: Fifty-five patients (9.1%) had findings suspicious for a second neoplasm. 39/55 had a known second malignancy diagnosis prior to the PET/CT. An incidental second primary neoplasm was first suspected on 18F- Fluciclovine PET/CT in 16/601 patients (2.7%). Three of the sixteen patients had PET/CT suggestive of a meningioma that was corroborated on magnetic resonance imaging (MRI). Of the remaining 13 patients, 11 had a tissue diagnosis confirming a malignancy. Second malignancies included renal cell carcinoma (RCC; 5/11; 45.5%), urothelial carcinoma (n = 2), multiple myeloma, chondrosarcoma, cutaneous squamous cell carcinoma, squamous cell carcinoma of the esophagus and lung (n = 1, each; except for one patient with both esophageal and lung carcinomas). Among histopathologic confirmed malignancies, clear-cell RCC had the lowest uptake (SUVmax 3.4), and cutaneous squamous cell carcinoma had the highest uptake (SUVmax 13.6). Of the two patients with no histopathologic confirmation, one had ultrasound and MRI findings corroborating the diagnosis of RCC. The other patient had a solitary lung nodule suspicious for primary lung carcinoma and elected to undergo observation. Conclusion: Incidental findings consistent with a second primary neoplasm are not infrequently seen on 18F- Fluciclovine PET/CT performed for assessment of prostate cancer (9.1%). Of the incidentally detected primary cancers, RCC was the most common (45.5%). These findings indicate the need for a careful analysis of 18F-Fluciclovine PET/CT images, due to the broad tumor imaging capabilities of this radiotracer.

Parathyroid carcinoma (PTC) is a rare endocrine tumor and uncommon cause for primary hyperparathyroidism.18F-fluorocholine (FCH) positron emission tomography and computed tomography (PET/CT) has shown promising results in the detection of parathyroid adenoma, though its role in PTC is undefined due to the paucity of incidence. The authors in this case report discuss the possible complimentary role of FCH PET/CT with 18F-fluorodeoxyglucose PET/CT in the evaluation of the management of suspected recurrence, since this rare entity has high loco-regional and distant recurrence of the disease.

Differentiated thyroid cancer (DTC) with thyroglobulin elevation and negative I scintigraphy (TENIS) syndrome is a diagnostic and therapeutic dilemma. Treatment of differentiated thyroid cancer has an excellent outcome, but treatment options in TENIS are limited with the exception of surgically amenable disease. We present a case of TENIS syndrome with incidental detection of tumor thrombus in right pulmonary vein extending to the left atrium on F-FDG PET/CT and subsequently complicating as an occipital bleed. The timely detection of the thrombus facilitated early initiation of anticoagulant therapy. However, the intracranial bleed precluded the continuation of anticoagulant therapy.

Immunoglobulin G4-related disease is an autoimmune entity with multisystem involvement. F-FDG PET/CT can provide important information about disease extent and severity and also aid in treatment response evaluation. We report a case of a 57-year-old woman presenting with abdominal discomfort, belching, and loss of weight in whom F-FDG PET/CT provided valuable information in diagnosis and monitoring treatment response.

The detection of synchronous or metachronous malignancies is on the rise with the advent of whole-body F-FDG PET/CT. It has shown its utility in detecting second primary carcinoma in patients undergoing imaging for evaluation of primary carcinoma, influencing the management and overall survival. Primary malignant melanoma of the lung is an extremely rare entity, accounting for 0.01% of all lung tumors. It is an even rare occurrence as a synchronous malignancy. We present the case of a 33-year-old woman with primary parotid myoepithelial carcinoma and incidental detection of second primary malignant melanoma of lung during F-FDG PET/CT imaging.

Adenoid cystic carcinoma of the buccal mucosa has an increased propensity for recurrence and distant metastases. Due to the poor prognosis at late detection of distant metastases, it is advisable to keep a close follow-up. In the present case, 18F-fluorodeoxyglucose positron emission tomography/computed tomography proved invaluable in the comprehensive workup of the patient, including detection of local recurrence, distant metastases, and in assessing treatment response.

Extrathyroidal manifestations of autoimmune thyroid disorders include thyroid-associated ophthalmopathy, thyroid dermopathy, and thyroid acropachy. Thyroid acropachy is an extreme manifestation of autoimmune thyroid disorder characterized by clubbing and swelling of fingers and toes, with or without periosteal reaction of the distal bones. We present a 50-year-old woman, posttreatment for carcinoma breast (6 years back) and referred for bone scan for generalized body ache. Bone scan findings resulting in detailed clinical evaluation prompted toward the suspicion of a thyroidal disease with ultimate diagnosis of Graves' disease.

Tumoral calcinosis is a rare entity presenting with periarticular calcium deposits, leading to multiple swellings and biochemical hyperphosphatemia and normocalcemia. Skeletal scintigraphy in these cases is helpful by providing a whole-body survey and delineating the common multifocality of this entity. We present the case of a 16-year-old boy with multiple swellings around the knee and elbow joints, having developed over 4 years and diagnosed as tumor calcinosis.

Peptide receptor radionuclide therapy targets highly expressed somatostatin receptors in well-differentiated neuroendocrine tumors, producing stability or a partial response in most patients with inoperable or metastatic disease. However, neuroendocrine tumors showing increased 18F-FDG uptake have limited treatment options and a poor outcome, and the role of peptide receptor radionuclide therapy is still unclear. Here, we present the case of a young man with mediastinal paraganglioma and extensive metastatic disease showing avidity on both somatostatin receptor imaging and 18F-FDG imaging. The patient experienced a partial response to peptide receptor chemoradionuclide therapy (177Lu-DOTATATE and low-dose capecitabine), as well as a significantly improved quality of life. This case highlights the utility of peptide receptor chemoradionuclide therapy when there is extensive disease avid for both somatostatin receptor and 18F-FDG and a lack of other suitable treatment modalities.

Liver radiotracer activity interfering with the inferior myocardial wall in a patient undergoing myocardial perfusion imaging (MPI) with 99mTc-Sestamibi is a known pitfall. We report a patient with pituitary macroadenoma who was subjected to stress-MPI study for pre-anesthetic clearance. The post-stress raw image showed the liver radiotracer activity in close approximation to the anteroseptal wall of the left ventricular myocardium, secondary to right hemi-diaphragmatic eventration.

Groove pancreatitis is a rare form of chronic pancreatitis that affects the groove area adjacent to the second part of the duodenum. Clinical and biochemical features often overlap with other subsets of chronic pancreatitis, while the imaging features resemble that of carcinoma of the head of pancreas. We present a 38-year-old man with abdominal pain, nausea, vomiting, and loss of weight who underwent (18)F-FDG PET/CT to rule out a pancreatic malignancy. PET/CT imaging features of groove pancreatitis are distinct from the other subsets of chronic pancreatitis, such as alcoholic and autoimmune pancreatitis, and helpful in the diagnosis and planning further management of the patient.

Purpose Male breast cancer (MBC) is a rare malignancy, with recurrence being one of the main adverse predictors for prognosis. The aim of the study was to evaluate the diagnostic and predictive value of fluorine-18-fluorodeoxyglucose (18F-FDG) PET/CT in the setting of suspected recurrence of MBC. Patients and methods Retrospective analysis of PET/CT findings was performed in 23 previously treated, histologically proven patients with MBC (mean age: 59.3±10.9 years; range: 36–79 years) with suspected recurrence. Kaplan–Meier disease-specific survival analysis was made with respect to histological, hormonal profile as well as PET/CT findings. Results Of the 23 patients, 19 (82.6%) showed recurrence. Recurrence at primary site with/without regional/distant site recurrence was seen in 12 (52.2%) patients. Only metastatic recurrence without primary site was seen in seven (30.4%) patients. Bone was the most common site of distant metastasis (14/23) followed by lungs (9/23), liver (4/23), brain (2/23), and adrenal (1/23). No recurrence (regional/distant) was noted in 4/23 (17.3%) patients; however, three of them had 18F-FDG-avid soft tissue lesions in esophagus, rectum and tongue, correspondingly, confirmed as second primaries with histopathology. Disease-specific survival analysis yielded nodal (P=0.01) as well as distant metastases (P=0.02) as the main survival predictors on PET/CT. Lung (P=0.001), followed by liver (P=0.009), and skeletal (P=0.01) metastases were the most adverse survival predictive factors. Conclusion 18F-FDG PET/CT showed good diagnostic and prognostic utility in recurrent MBC. It was better than bone scan in evaluation of skeletal metastases. Most importantly, 18F-FDG PET/CT helped in early detection of second malignancy and their clinical management in studied patients.

Primary signet ring cell adenocarcinoma of the breast is a rare neoplasm. Similar to other mucinous neoplasms, it has low FDG avidity and poor prognosis compared with the traditional ductal/lobular carcinomas. We present a case of a 40-year-old woman with signet ring cell adenocarcinoma and skeletal fluorosis showing higher uptake of Ga-prostate-specific membrane antigen in the primary lesion and the metastatic sites compared with F-FDG on PET/CT imaging. Additionally, diffuse increased prostate-specific membrane antigen uptake was noticed in the entire skeleton, likely due to skeletal fluorosis.

Immunoglobulin G4-related disease (IgG4-RD) with multisystem involvement is known to mimic various malignancies and can be diagnosed with high clinical suspicion. We hereby report an atypical case of IgG4-RD, who presented as an inflammatory pseudotumor resembling gall bladder malignancy with hepatic, omental, and subcutaneous involvement. The characteristic tracer uptake pattern described on FDG PET/CT may not be always present in IgG4-RD, especially in the setting of postabdominal surgery. FDG PET/CT revealed the disease progression despite glucocorticoids and aided in response evaluation after second-line drug, rituximab.

Ectopic Cushing syndrome constitutes approximately 10% of all patients with Cushing syndrome. The clinical features of hypercortisolism result from elevated levels of adrenocorticotropic hormone produced by a tumor. The present case presented with clinical and biochemical parameters suggestive of Cushing syndrome with normal pituitary and adrenals on imaging. Ga-DOTANOC PET/CT done to localize an ectopic adrenocorticotropic hormone-producing tumor revealed metastatic medullary carcinoma of the thyroid as the culprit lesion.

IgG4-related disease (IgG4-RD) continues to be a diagnostic challenge and a great mimicker of malignancies. We report here a case of young man who presented with subacute intestinal obstruction with initial imaging and clinical features suggestive of carcinoma colon. F-FDG PET/CT showed diffuse peritoneal carcinomatosis pattern typically seen with abdominal malignancies. However, the histopathology and the raised IgG4 levels diagnosed it to be IgG4-RD. Although F-FDG PET/CT has typical patterns corresponding to the multisystemic involvement of IgG4-RD, the index case did not show any such findings.

An 85-year-old man with prostate cancer for metastatic workup underwent Gallium Prostate-Specific Membrane Antigen (Ga-PSMA) PET/CT (Ga-PSMA PET/CT), which revealed unusual tracer uptake in the shaft and glans of penis as well as multiple systemic metastases in liver, skeletal, and lymph nodes. The penile lesion was proved to be metastatic adenocarcinoma from prostate on fine needle aspiration cytology. The patient underwent Lutetium (Lu)-labeled PSMA radioligand therapy, which also revealed diffuse tracer uptake in the penile shaft as well as other metastatic sites.

Skeletal muscle uptake of F-FDG can result from a variety of physiologic and pathologic conditions. It is important for the physician to interpret these uptake patterns in the correct context to avoid a misdiagnosis. We present a case of a 36-year-old man with progressive, repeated episodes of regurgitation who was diagnosed with adenocarcinoma of the stomach. F-FDG PET/CT showed increased tracer uptake in the primary tumor and in the intercostal and sternocleidomastoid muscles. The pattern of tracer uptake along with the clinical history and examination of the patient helped differentiate a physiologic variant from a pathologic cause.

Orbital metastases are known to arise from primary breast carcinoma followed by prostate, malignant melanoma, and lung carcinoma. We report a case of orbital metastasis as the initial presentation of an occult primary gall bladder carcinoma. The FDG PET/CT helped in localizing the occult distant primary site, which previously escaped detection, and also enabled the evaluation of orbital metastasis.

(18)F-Fluorocholine (FCH) PET/CT is evolving as a functional imaging modality for the preoperative imaging of abnormal parathyroid tissue(s) helping to localize eutopic and ectopic parathyroid tissue and limit the extent of surgery. FCH PET/CT may show incidental uptake in various thyroid lesions necessitating further evaluation, whereas the role of (18)F-fluorodeoxyglucose (FDG) PET/CT in the detection of incidental thyroid nodules is well documented. The case of a middle-aged woman with dual pathology of parathyroid adenoma and papillary thyroid cancer detected on FCH and FDG PET/CT is presented.

Hepatic epithelioid hemangioendothelioma (EHE) is an uncommon vascular tumor, primarily seen in 20–40 years of age. We report the case of a 14-year-old boy with EHE and distant metastases identified on 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT), leading to a change in the management plan.18F-FDG PET/CT proved to be useful in identifying the rare sites of metastasis and planning further treatment.

Extraskeletal osteosarcoma is a rare, high-grade soft tissue malignancy, accounting for approximately 1% of all soft tissue sarcomas. Despite the histologic resemblance to osteogenic osteosarcoma, it is considered as a distinct entity because of the differences in clinical behavior and response to treatment. Hence, imaging plays a vital role in establishing the nonskeletal origin of the tumor, differentiating it from osteogenic osteosarcoma. We present F-FDG PET/CT findings in a case of isolated primary extraskeletal osteosarcoma confirmed on histopathology.

Sclerosing encapsulating peritonitis also called as abdominal cocoon is a less understood condition mostly due to idiopathic causes and sometimes secondary to tuberculosis or peritoneal dialysis. This report describes the typical features of "abdominal cocoon" on F-FDG PET/CT in a young woman, which was later diagnosed to be secondary to tuberculosis. Because the early features of this unusual entity are often nonspecific, high clinical suspicion along with understanding of the typical radiological/PET/CT features of this intriguing entity may guide the physician in ruling out the secondary treatable causes like tuberculosis, as noted in the index case.

Ga-PSMA-HBED-CC PET/CT has proven to be a useful modality in patients with prostate carcinoma, especially in those with suspected recurrence and in detection of locoregional and distant metastases. However, with expanding use of this tracer, several recent reports of in vivo expression of PSMA in nonprostatic benign and malignant entities have been published. We report a patient with PSMA-avid synchronous urinary bladder paraganglioma and metastatic prostate carcinoma.

Insulinomas are the most common functioning pancreatic neuroendocrine tumors and the leading cause of persistent hypoglycemia with hyperinsulinemia in adults. Glucagon-like-peptide-1 (GLP) receptor analogs are the latest agents being used in the detection of insulinomas, with initial reports suggesting high sensitivity due to universal GLP1 receptor expression on these tumors. PET/CT imaging in this patient using Ga DOTA-Exendin, a GLP receptor analog, proved useful for accurate localization of the culprit lesion, aiding in the definitive management of the patient.

Hepatobiliary scintigraphy is a widely used functional imaging modality for diagnosis of a variety of liver diseases, as well as for detecting biliary tract abnormalities. Neonates or infants with persistent jaundice beyond the physiological period are usually evaluated with hepatobiliary scintigraphy. The authors present a 5-month-old girl with neonatal jaundice, ascites, and umbilical and bilateral inguinal hernias in whom spontaneous rupture of the biliary duct resulted in intraperitoneal bile leak with passage of tracer into bilateral inguinal hernial sacs.

Background: Global burden of hospital-associated infection (HAI) is on the rise and contributes significantly to morbidity and mortality of the patients. Mobile phones are indispensible part of communication among doctors and other health care workers (HCWs) in hospitals. Hands of HCWs play an important role in transmission of HAI and mobile phones which are seldom cleaned and often touched during or after the examination of patients without hand washing can act as a reservoir for transmission of potent pathogens. This study aimed to investigate the rate of bacterial contamination of mobile phones among HCWs in our tertiary care hospital and to compare it with personal mobile phones of non-HCWs (control group). Materials and Methods: The mobile phones and dominant hands of 386 participants were sampled from four different groups, hospital doctors and staff (132), college faculty and staff (54), medical students (100) and control group (100). Informed consent and questionnaire was duly signed by all the participants. Samples were processed according to standard guidelines. Results: 316 mobile phones (81.8%) and 309 hand swab samples (80%) showed growth of bacterial pathogens. The most predominant isolates were Coagulase-negative Staphylococcus , Staphylococcus aureus , Acinetobacter species, Escherichia coli , Klebsiella pneumoniae, Pseudomonas species and Enterococcus species. Conclusion: Hundred percent contamination was found in mobile phones and hands of HCWs indicating mobile phones can be the potential source of nosocomial pathogens. Our study results suggest that use of mobile phones in health care setup should be restricted only for emergency calls. Strict adherence to infection control policies such as proper hand hygiene practices should be followed.