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Objective The clinical significance of decreased physiological lung uptake of 123I-metaiodobenzylguanidine (MIBG) has not been well investigated. This study aimed to elucidate the association between a decrease in lung MIBG uptake with antidepressant intake and the myocardial MIBG uptake in patients who were clinically diagnosed with Lewy body disease (LBD) and patients who were diagnosed as not having LBD. Methods We retrospectively reviewed the heart and lung uptakes on 167 consecutive MIBG scans, antidepressant status, and clinical diagnosis of LBD. The images were visually classified into two groups: decreased lung uptake and preserved lung uptake. A semi-quantitative analysis was performed using the heart-to-mediastinum ratio (H/M), lung-to-mediastinum ratio (L/M), and myocardial washout rate (WR). Results All 17 patients with decreased lung uptake were on treated with antidepressants, while none of the 150 patients with preserved lung uptake were treated with any antidepressants. Of the 17 patients with decreased lung uptake, 6 patients were clinically diagnosed as LBD and other 11 were clinically diagnosed as non-LBD. There was not significant difference in early H/M, delayed H/M, and myocardial WR between the 11 non-LBD patients with decreased lung uptake and 83 non-LBD patients with preserved lung uptake (2.87 ± 0.69 vs. 2.89 ± 0.44, 3.09 ± 0.48 vs. 2.98 ± 0.59, and 21.8 ± 11.3% vs. 21.1 ± 12.5%, respectively). Moreover, in LBD patients, there were no significant differences in those values between six patients with decreased lung uptake and 67 patients with preserved lung uptake (1.68 ± 0.32 vs. 1.73 ± 0.42, 1.34 ± 0.21 vs. 1.54 ± 0.57, 46.2 ± 22.8% vs. 42.8 ± 21.3%, respectively). Conclusions Antidepressants probably blocked MIBG uptake in the lungs, and a decreased lung uptake was not significantly associated with heart uptake. A remarkable decrease in lung uptake can be a signal to check a patient’s medication status.

Purpose To reduce postoperative complications, intraoperative lymph node (LN) diagnosis with 18F-fluoro-2-deoxy-D-glucose (FDG) is expected to optimize the extent of LN dissection, leading to less invasive surgery. However, such a diagnostic device has not yet been realized. We proposed the concept of coincidence detection wherein a pair of scintillation crystals formed the head of the forceps. To estimate the clinical impact of this detector, we determined the cut-off value using FDG as a marker for intraoperative LN diagnosis in patients with esophageal cancer, the specifications needed for the detector, and its feasibility using numerical simulation. Methods We investigated the dataset including pathological diagnosis and radioactivity of 1073 LNs resected from 20 patients who underwent FDG-positron emission tomography followed by surgery for esophageal cancer on the same day. The specifications for the detector were determined assuming that it should measure 100 counts (less than 10% statistical error) or more within the intraoperative measurement time of 30 s. The detector sensitivity was estimated using GEANT4 simulation and the expected diagnostic ability was calculated. Results The cut-off value was 620 Bq for intraoperative LN diagnosis. The simulation study showed that the detector had a radiation detection sensitivity of 0.96%, which was better than the estimated specification needed for the detector. Among the 1035 non-metastatic LNs, 815 were below the cut-off value. Conclusion The forceps-type coincidence detector can provide sufficient sensitivity for intraoperative LN diagnosis. Approximately 80% of the prophylactic LN dissections in esophageal cancer can be avoided using this detector.

The aim of this study was to assess the clinical results after extensor indicis proprius opponensplasty in patients with carpal tunnel syndrome and severe thenar muscle atrophy. Forty patients who underwent this procedure during open carpal tunnel releases. The mean follow-up period was 17 months (range 10 to 36). Kapandji scores significantly improved from 5.5 before surgery to 9.6 at final follow-up. Thumb pronation angle also significantly improved from 111° before surgery to 149°. Side and pulp pinch strength significantly improved postoperatively, as well as DASH scores at final follow-up. In conclusion, the extensor indicis proprius tendon transfer technique represents a reliable opponensplasty procedure to achieve consistent results in patients with severe carpal tunnel syndrome. Level of evidence: IV

Breast positron emission tomography (PET) has had insurance coverage when performed with conventional whole-body PET in Japan since 2013. Together with whole-body PET, accurate examination of breast cancer and diagnosis of metastatic disease are possible, and are expected to contribute significantly to its treatment planning. To facilitate a safer, smoother, and more appropriate examination, the Japanese Society of Nuclear Medicine published the first edition of practice guidelines for high-resolution breast PET in 2013. Subsequently, new types of breast PET have been developed and their clinical usefulness clarified. Therefore, the guidelines for breast PET were revised in 2019. This article updates readers as to what is new in the second edition. This edition supports two different types of breast PET depending on the placement of the detector: the opposite-type (positron emission mammography; PEM) and the ring-shaped type (dedicated breast PET; dbPET), providing an overview of these scanners and appropriate imaging methods, their clinical applications, and future prospects. The name “dedicated breast PET” from the first edition is widely used to refer to ring-shaped type breast PET. In this edition, “breast PET” has been defined as a term that refers to both opposite- and ring-shaped devices. Up-to-date breast PET practice guidelines would help provide useful information for evidence-based breast imaging.

Purpose Esophagectomy with extended lymph node (LN) dissection is a standard treatment for resectable esophageal cancer to prevent recurrence, but severe, potentially life-threatening postoperative complications are still important issues. Accurate diagnosis of LN metastases would enable the decision to dissect or leave the LNs in regions with high risk of complications. Advancements in intraoperative gamma probe and radioactivity detectors have made intraoperative navigation surgery possible using a radiotracer as a marker. F-FDG is one such candidate markers, and the diagnostic power of FDG through counting the radioactivity close to each LN should be elucidated. Materials and methods In 20 patients, 1073 LNs including 38 metastatic LNs were prospectively investigated. Preoperative FDG PET was performed on the same day before esophagectomy and visually surveyed in each LN station to identify abnormal uptake. The FDG radioactivity of each individual dissected LN was measured by a well-type counter, and the pathological diagnosis was compared with LN radioactivity on a one-by-one basis and with the preoperative FDG PET findings for each LN station. Results Lymph node station-based analysis showed a sensitivity and specificity of 28.6% and 96.7%, respectively. One-by-one LN-based analysis using a cutoff value obtained from the receiver operating characteristic curve showed a sensitivity and specificity of 94.7% and 78.7%, respectively, demonstrating higher accuracy compared with the use of LN weight or the shortest diameter. Conclusions The FDG uptake by each LN is a potentially useful marker for navigation surgery in esophageal cancer and has higher accuracy than LN weight or diameter.

The clinical significance of decreased physiological lung uptake ofWe retrospectively reviewed the heart and lung uptakes on 167 consecutive MIBG scans, antidepressant status, and clinical diagnosis of LBD. The images were visually classified into two groups: decreased lung uptake and preserved lung uptake. A semi-quantitative analysis was performed using the heart-to-mediastinum ratio (H/M), lung-to-mediastinum ratio (L/M), and myocardial washout rate (WR).All 17 patients with decreased lung uptake were on treated with antidepressants, while none of the 150 patients with preserved lung uptake were treated with any antidepressants. Of the 17 patients with decreased lung uptake, 6 patients were clinically diagnosed as LBD and other 11 were clinically diagnosed as non-LBD. There was not significant difference in early H/M, delayed H/M, and myocardial WR between the 11 non-LBD patients with decreased lung uptake and 83 non-LBD patients with preserved lung uptake (2.87 ± 0.69 vs. 2.89 ± 0.44, 3.09 ± 0.48 vs. 2.98 ± 0.59, and 21.8 ± 11.3% vs. 21.1 ± 12.5%, respectively). Moreover, in LBD patients, there were no significant differences in those values between six patients with decreased lung uptake and 67 patients with preserved lung uptake (1.68 ± 0.32 vs. 1.73 ± 0.42, 1.34 ± 0.21 vs. 1.54 ± 0.57, 46.2 ± 22.8% vs. 42.8 ± 21.3%, respectively).Antidepressants probably blocked MIBG uptake in the lungs, and a decreased lung uptake was not significantly associated with heart uptake. A remarkable decrease in lung uptake can be a signal to check a patient's medication status.

Cerebral blood flow (CBF) / cerebral blood volume (CBV) ratio derived by [15O] H2O/ CO2 and CO positron emission tomography (PET) examination has been used as an index for cerebral perfusion pressure (CPP). CBF/CBV was demonstrated to be related mean arterial pressure (MAP) in baboons. However, this formula has not been confirmed to be proportionate to CPP. We have developed a new index for CPP using the Poiseuille equation based on a simple model. Our model suggests that CBF/CBV2 is proportionate to CPP and that it is mathematically a more accurate index than CBF/CBV. This new index needs experimental validation in the future.

123I-metaiodobenzylguanidine scintigraphy is used to differentiate Lewy body disease from other neurodegenerative disorders. We identified 2 cases with remarkably changed pulmonary uptake between 2 metaiodobenzylguanidine scintigraphies; pulmonary uptake was reduced when patients were taking selective serotonin reuptake inhibitor/serotonin noradrenaline reuptake inhibitor and preserved during the medication-naive or withdrawal state, suggesting that pulmonary uptake involves not only the noradrenaline transporter, but also the serotonin transporter. Pulmonary accumulation may affect the heart-to-mediastinum ratio as the region of interest on the planner image is usually placed on the heart and includes part of the lung. Therefore, we should pay attention to the medication state of patients with decreased pulmonary uptake.

This study aimed to assess efficacy and limitations of regional cerebral blood flow imaging using single-photon emission computed tomography (rCBF-SPECT) in the diagnosis of Alzheimer’s disease (AD) with amyloid-positron emission tomography (amyloid-PET). Thirteen patients, who underwent both rCBF-SPECT and amyloid-PET after clinical diagnosis of AD or mild cognitive impairment, were retrospectively identified. The rCBF-SPECTs were classified into 4 grades, from typical AD pattern to no AD pattern of hypoperfusion; amyloid-beta (Aβ) positivity was assessed by amyloid-PET. Four patients were categorized into a typical AD pattern on rCBF-SPECT, and all were Aβ+. The other 9 patients did not exhibit a typical AD pattern; however, 4 were Aβ+. The Mini-Mental State Examination score and Clinical Dementia Rating scale were not significantly different between Aβ+ and Aβ– patients. A typical AD pattern on rCBF-SPECT can reflect Aβ+; however, if not, rCBF-SPECT has a limitation to predict amyloid pathology.

Purpose of the report This study aimed to determine the most effective metabolic index of FDG-PET and MET-PET to differentiate high- and low-grade gliomas, and then to characterize tumor metabolism according to the 2016 WHO classification. We also developed a new calculation method of potential infiltrative tumor volume to overcome the current limitations of tumor evaluation according to metabolic index, which focuses solely on tumor core area. Materials and methods Patients who underwent both FDG-PET and MET-PET, as well as surgical treatment, were retrospectively identified. All tumors were diagnosed histologically and included 44 high-grade and 19 low-grade gliomas. Metabolic indices of tumor-to-normal (T/N) ratio and maximum value within the tumor itself were compared between high- and low-grade tumors. A calculation method for potential infiltrative tumor volume was developed and compared between these 2 grades. Results T/N, calculated as tumor value divided by normal cortex value, was the most effective (area under the curve, 0.800 for FDG-PET; area under the curve, 0.773 for MET-PET) for differentiating high- and low-grade gliomas. Potential infiltrative volume effectively distinguished between high- and low-grade glioma (43.8 ± 30.2 mL vs 14.0 ± 12.6 mL; P = 0.005 [t test]). A combination of T/N, with a cutoff value of 0.9 or higher on FDG-PET and/or 3.0 or higher on MET-PET, and potential infiltrative volume, with a cutoff value of 20.0 mL or higher, provided a diagnostic accuracy of 89% in distinguishing high- from low-grade gliomas. Conclusions Evaluation of potential infiltrative volume surrounding the tumor core area, in addition to the T/N ratio of the tumor core, may help distinguish between high- and low-grade gliomas.

In internal 131I therapy for thyroid cancer, a decision to continue treatment is made by comparing 131I scintigraphy and [18F]FDG-PET. However, with current SPECT and PET systems, simultaneous imaging of diagnostic PET nuclides and therapeutic 131I nuclides has not been achieved so far. Therefore, we demonstrated that the recently developed Compton PET hybrid camera with Ce:Gd3(Al,Ga)5O12 (GAGG)- Silicon Photomultiplier(SiPM) scintillation detectors can be used to simultaneously image 131I Compton image and 18F PET image.

Objective We previously reported In-labeled anti-cadherin17 (CDH17) IgG visualized CDH17-positive gastric cancer xenografts. Unfortunately, a long waiting time was required to obtain high-contrast images due to long blood retention (blood half-life: 26 h). To accelerate blood clearance, we have developed anti-CDH17 minibody (D2101 minibody) and evaluated the pharmacokinetics in gastric cancer mouse models. Methods Two different single chain Fvs (scFvs), D2101 mutant and D2111, were developed from each parental IgG. The binding ability to CDH17 and stability in plasma were evaluated. D2101 minibody, constructed based on D2101 mutant scFv, was labeled with Cu (Cu-D2101 minibody), and the in-vitro and in-vivo properties were evaluated by cell ELISA, biodistribution experiments, and PET imaging in mice bearing CDH17-positive AGS and CDH17-negative MKN74 tumors. Results D2101 mutant and D2111 scFvs showed similar affinities to CDH17. D2101 mutant scFv was more stable than D2111 scFv in plasma. No loss of binding affinity of the D2101 minibody by chelate conjugation and radiolabeling procedures was observed. The biodistribution of Cu-D2101 minibody showed high uptake in AGS tumors and low uptake in MKN74. The blood half-life of Cu-D2101 minibody was 6.5 h. Improved blood clearance of Cu-D2101 minibody provided high tumor-to-blood ratios compared with the previous results of parental IgG in AGS xenograft mice. PET studies showed consistent results with biodistribution studies. Conclusions Cu-D2101 minibody exhibited higher tumor-to-blood ratios at earlier time points than those of the radiolabeled parental IgG. Cu-D2101 minibody has potential as an immunoimaging agent for CDH17-positive tumors.

Background Neoadjuvant chemoradiotherapy followed by an optimal surgery is the standard treatment for patients with locally advanced rectal cancer. FDG-PET/CT is commonly used as the modality for assessing the effect of chemoradiotherapy. Objective The purpose of this study was to investigate whether PET/CT-based volumetry could contribute to the prediction of pathological complete response or prognosis after neoadjuvant chemoradiotherapy. Design This was a retrospective cohort study. Settings This study was conducted at a single research center. Patients Ninety-one consecutive patients with locally advanced rectal cancer were enrolled between January 2005 and December 2015. Intervention Patients underwent PET/CT before and after neoadjuvant chemoradiotherapy. Main outcome measures Maximum standardized uptake value and total lesion glycolysis on PET/CT before and after neoadjuvant chemoradiotherapy were calculated using isocontour methods. Correlations between these variables and clinicopathological factors and prognosis were assessed. Results PET/CT-associated variables before chemoradiotherapy were not correlated with either clinicopathological factors or prognosis. Maximum standardized uptake value was associated with pathological complete response, but total lesion glycolysis was not. Maximum standardized uptake value correlated with ypT, whereas total lesion glycolysis correlated with both ypT and ypN. High total lesion glycolysis was associated with a considerably poorer prognosis; the 5-year recurrence rate was 65% and the 5-year mortality rate 42%, whereas in lesions with low total lesion glycolysis, these were 6% and 2%. On multivariate analysis, high total lesion glycolysis was an independent risk factor for recurrence (HR = 4.718; p = 0.04). Limitations The gain in fluoro-2-deoxy-D-glucose uptake may differ between scanners, thus the general applicability of this threshold should be validated. Conclusions In patients with locally advanced rectal cancer, high total lesion glycolysis after neoadjuvant chemoradiotherapy is strongly associated with a worse prognosis. Total lesion glycolysis after chemoradiotherapy may be a promising preoperative predictor of recurrence and death. See Video Abstract at http://links.lww.com/DCR/A464.

In internal 131I therapy for thyroid cancer, a decision to continue treatment is made by comparing 131I scintigraphy and [18F]FDG-PET. However, with current SPECT and PET systems, simultaneous imaging of diagnostic PET nuclides and therapeutic 131I nuclides has not been achieved so far. Therefore, we demonstrated that the recently developed Compton PET hybrid camera with Ce:Gd3(Al,Ga)5O12 (GAGG)- Silicon Photomultiplier(SiPM) scintillation detectors can be used to simultaneously image 131I Compton image and 18F PET image.

We previously reported that radioimmunotherapy (RIT) using 90Y-labeled anti-ROBO1 IgG (90Y-B5209B) achieved significant anti-tumor effects against small-cell lung cancer (SCLC) xenografts. However, subsequent tumor regrowth suggested the necessity for more effective therapy. Here, we evaluated the efficacy of combination 90Y-B5209B and cisplatin therapy in NCI-H69 SCLC xenograft mice. Mice were divided into four therapeutic groups: saline, cisplatin only, RIT only, or combination therapy. Either saline or cisplatin was administered by injection one day prior to the administration of either saline or 90Y-B5209B. Tumor volume, body weight, and blood cell counts were monitored. The pathological analysis was performed on day seven post injection of 90Y-B5209B. The survival duration of the combination therapy group was significantly longer than that of the group treated with RIT alone. No significant survival benefit was observed following the isolated administration of cisplatin (relative to saline). Pathological changes following combination therapy were more significant than those following the isolated administration of RIT. Although combination therapy was associated with an increase of several adverse effects such as weight loss and pancytopenia, these were transient. Thus, cisplatin pre-treatment can potentially enhance the efficacy of 90Y-B5209B, making it a promising therapeutic strategy for SCLC.

Patients with adult spinal deformity (ASD) are surgically treated for pain relief; however, visualization of the exact origin of the pain with imaging modalities is still challenging. We report the first case of a 60-year-old female patient who presented with painful degenerative kyphoscoliosis and was evaluated with flourine-18-fluoro-2-deoxy-D-glucose positron emission tomography/computed tomography ((18)F-FDG-PET/CT) preoperatively. Because her low back pain was resistant to conservative treatment, she was treated with posterior spinal correction and fusion surgery from Th2 to the ilium. One year after the surgery, her low back pain had disappeared completely. In accordance with her clinical course, (18)F-FDG-PET imaging revealed the uptake of (18)F-FDG in the paravertebral muscles preoperatively and showed the complete absence of uptake at 1 year after surgery. The uptake site coincided with the convex part of each curve of the lumbar spine and was thought to be the result of the increased activity of paravertebral muscles due to their chronic stretched state in the kyphotic posture. This case report suggests the possibility of using (18)F-FDG-PET/CT to visualize increased activity in paravertebral muscles and the ensuing pain in ASD patients.

SummaryObjective Multiple hippocampal transection (MHT) is a surgical procedure developed to avoid postoperative memory decline. Its efficacy has been documented in only a few small series with relatively short observation periods. We prospectively evaluated the long-term seizure and cognitive outcomes of MHT combined with multiple subpial transection or lesionectomy (MHT + MST/L). Moreover, we quantitatively evaluated the structural and metabolic neuroradiologic changes after the procedure to elucidate the anatomofunctional correlates of memory preservation. Methods Twenty-four patients underwent MHT + MST/L for treatment of drug-resistant mesial temporal lobe epilepsy (mTLE) and were followed for more than 5 years. Indications for the procedure were the following: (1) verbally dominant-sided surgery in patients with a radiologically normal hippocampus or normal/near normal memory, and (2) surgery for patients with concomitant epileptic activity on the contralateral side, that is, when the surgery was considered a high risk for severe postoperative memory decline. Seizure outcome was evaluated using Engel's classification 1, 2, and 3 years after surgery, and at the last visit (LV). Three subgroups were evaluated as well: magnetic resonance imaging (MRI) negative (MN), hippocampal sclerosis (HS), and normal hippocampus with extrahippocampal lesion (NHEL). The long-term cognitive outcome was followed through to LV in patients who underwent verbally dominant-sided surgery. Hippocampal volume (HV), diffusion tensor parameters (DTP), and glucose utilization (GU) were determined from MRI and fluorodeoxyglucose–positron emission tomography (FDG-PET) studies performed before and >6 months after surgery. Results Whereas the rate of Engel class I as a whole was 71% at 1 year and 67% at LV, the rates in the MN, HS, and NHEL groups were 60%, 67%, and 100% at 1 year, respectively, and 70%, 56%, and 80% at LV, respectively. Memory indices after verbally dominant-sided surgery transiently declined at 1 month but recovered to and remained at the preoperative level through LV. The HV, DTP of the fornix, and GU of the temporal lobe on the treated side showed pathologic changes even when the transiently declined memory indices had recovered to the preoperative level. Significance The long-term outcome for complex partial seizures after MHT + MST/L was comparable to that seen after anterior temporal lobectomy. The long-term cognitive outcome was favorable, even for patients with a high risk of severe postoperative memory decline. MHT + MST/L may be a treatment option for mTLE in which resective surgery carries a risk of postoperative memory decline, particularly in patients without MRI lesion. A discrepancy between the preserved memory and the pathologic neuroradiologic changes indicates the necessity for further studies including functional MRI.

The number of patients diagnosed with renal tumor has been increasing with the extensive application of ultrasonography and computed tomography (CT).1 Surgical resection remains necessary for a definitive diagnosis of renal tumor, but it is not always clinically beneficial, especially for elderly patients or those with severe comorbidities. For these patients, avoiding surgery and proceeding to active surveillance has become the mainstay of patient management.2,3 Without surgical intervention, the evaluation of tumor malignancy is helpful for treatment strategy decisions such as the timing of surgery or maintaining active surveillance. F-18 fluorodeoxyglucose (FDG) positron emission tomography (PET) is a widely used effective modality for evaluating tumor activity by estimating glucose metabolism. The usefulness of FDG-PET imaging in oncology is based on a correlation between glucose metabolism and the degree of tumor malignancy, which has been reported for various tumors.4–12 Although we have observed differential FDG uptake in renal tumor, there are few studies concerning FDG-PET for renal cell carcinoma (RCC), most likely because of difficulties in differentiating the radioactivity of FDG accumulated in renal tumors from the radioactivity of FDG excreted via the urinary system during physiological processes. In addition, false-negative cases can lead to a low sensitivity for RCC detection.13–15 The use of FDG-PET for routine evaluation of renal tumors has not been recommended. However, recently dedicated PET-CT have improved image resolution and signal-to-noise ratio. In addition, attached-CT for photon attenuation correction provides anatomical information on FDG-PET images. A comparison of diagnostic CT and attached-CT facilitates the identification of renal tumors on FDG-PET images, which enable us to place region of interest (ROI) on renal tumor more accurately. Calculation semiquantitative values using these ROI help elucidate the characteristics of FDG uptake of a renal tumor. In this study, we hypothesized that glycolytic metabolism would reflect tumor aggressiveness in renal tumors. Pathological findings such as histological subtype, nuclear grade, and TNM stage are the most widely used indicators for renal tumor aggressiveness.16–18 We investigated the correlation of preoperative renal tumor metabolic activity with tumor pathology. This study applied a semiquantitative value of metabolism as defined by the standardized uptake value (SUV) in a greater number of cases than previously investigated.

Introduction Anti-myelin oligodendrocyte glycoprotein (MOG) antibodies have recently been associated with epilepsy with FLAIR hyperintense cortical lesions on MRI. Association between anti-MOG antibodies and epilepsy without detectable structural brain lesion on MRI is unknown. Case report A 48-year-old right-handed man with a four-and-a-half year history of anti-MOG antibody associated demyelinating disease presented with persistent global aphasia. Brain MRI showed no new lesion or cortical lesion in the left hemisphere. Electroencephalogram, magnetoencephalography, and brain perfusion single-photon emission computed tomography suggested epileptic foci in the left temporal and parietal lobes, and the patient's aphasia transiently responded to intravenous diazepam, compatible with aphasic status epilepticus. Cerebrospinal fluid showed mildly elevated cell count and positive oligoclonal bands. The patient only partially responded to antiepileptic drugs but responded to steroid pulse therapy. Six months later, the patient again exhibited global aphasia. Brain MRI showed tumefactive white matter lesion in the left temporo-parietal lobes. Conclusion Autoimmune epilepsy without obvious causative lesion on MRI can be seen in the course of anti-MOG antibody associated demyelinating disease. The subsequent emergence of tumefactive lesion closely located to the epileptic foci may suggest some association between autoimmune epilepsy and demyelinating lesions.

Identification of secondary colonic neoplasia proximal to obstructing colorectal cancer is essential for determining the range of colorectal resection. We examined the accuracy of 18-fluoro deoxy glucose-positron emission tomography (FDG-PET) for detection of colonic neoplasia. We recruited patients with obstructing colorectal cancer from our registry. Preoperative FDG-PET was performed, and the detection rate for colonic neoplasia was estimated. Preoperative colonoscopy or postoperative colonoscopy within a year after operation was employed as the indexed standard. Ninety-three patients were included in this study. Colonic neoplasia proximal to obstruction was confirmed in 83 cases. The sensitivity and positive predictive value of FDG-PET were 25.3% and 77.8%, respectively. The sensitivity was higher in larger lesions (3.2% for 21 mm) and in higher pathological grade lesions (14.6% for low-grade adenoma, 38.5% for high-grade adenoma, 66.7% for carcinoma in situ, and 100% for invasive carcinoma). The round shape in PET images was a predictor for neoplasia, with an area under the curve of 0.75293 at an aspect ratio of 1.70. FDG-PET should be used as a screening modality for invasive colorectal cancer (CRC) proximal to obstructing colorectal cancer.

Background and aim The predictors of severe gastrointestinal (GI) events in GI lymphoma patients are unclear. We aimed to develop a risk scoring system for GI events requiring surgery. Methods In this retrospective study of 192 patients with GI lymphoma, the state of lymphoma, macroscopic findings, examination results, and International Prognostic Index were assessed. We developed a risk score for GI events that required surgery and assessed its accuracy by calculating the area under the receiver operating characteristic curve (AUC). Internal validation was performed using bootstrap resampling. Results Severe GI events occurred in 21 (11%) patients. We developed a 4-point scoring system (the FLASH score) comprising the following three independent predictors (weighted by regression coefficients): (i) focal appearance and large size (≥ 40 mm), 1 point; (ii) aggressive lymphoma of the small bowel, 2 points; and (iii) high (18)F-fluorodeoxyglucose positron emission tomography uptake, 1 point. The score predicted severe GI events with an AUC value of 0.91 (internal validation; AUC, 0.86). Risk was classified into three categories: the GI event rate was 0% in the low-risk group (0 points), 9% in the intermediate-risk group (1-2 points), and 61% in the high-risk group (3-4 points) (AUC, 0.89). Conclusions We developed and internally validated a risk scoring system (the FLASH score) that included macroscopic findings to predict severe GI events in GI lymphoma patients. Patients with high scores are candidates for elective surgery to prevent GI events.

The purpose of this study was to evaluate the performance characteristics and safety of florbetapir (I8F) positron emission tomography (PET) in patients with Alzheimer’s disease (AD) and mild cognitive impairment (MCI) and cognitively normal (CN) control patients from Japan. Florbetapir (I8F) PET was obtained in 48 subjects (15 AD patients, 15 MCI patients, and 18 CNs) within a multicenter phase 2/3 study. Amyloid burden was assessed visually and classified as positive or negative for pathologic levels of amyloid aggregation, blind to diagnostic classification. Cerebral to cerebellar standardized uptake value ratios (SUVRs) were determined from the florbetapir (I8F) PET images. Safety was assessed by monitoring adverse events, vital signs, clinical laboratory assessments, and electrocardiograms. Demographic variables and cognitive scales were summarized by using descriptive statistics for each group. Fisher’s exact test and one-way analysis of variance were used to compare amyloid positivity and mean SUVRs, respectively, between diagnostic groups. Florbetapir (I8F) PET was rated visually amyloid positive in 80.0 % of AD patients, 33.3 % of MCI patients, and 16.7 % of CNs. Mean SUVRs were highest in the AD group and lowest in the CN group for each brain region (P

Cerebellar liponeurocytoma is a rare tumor that usually develops in adult patients, and is categorized as World Health Organization grade II. Because of the small number of reports on its radiological and pathological features, the disease remains poorly characterized. The current case involved a 59-year-old man with tumor in the upper cerebellar vermis. Preoperative positron emission tomography (PET) showed high uptake on (11)C-methionine PET, but low uptake on (18)F-fluorodeoxyglucose PET. These findings resemble those of central neurocytoma and oligodendroglioma, but are incompatible with other brain tumors. Subtotal tumor removal was performed by suboccipital craniotomy. Histopathological examinations showed sheets of small, isomorphic cells with round nuclei and clear cytoplasm, and focal vacuolated cells resembling adipose cells. On immunohistochemistry, tumor cells were positive for synaptophysin and NeuN. Vacuolated cells were immunoreactive for perilipin. Based on these findings, cerebellar liponeurocytoma was diagnosed. Genetic analyses revealed absences of both chromosome 1p/19q loss and isocitrate dehydrogenase 1 mutation, further ruling out oligodendroglioma. These radiological and genetic aspects of cerebellar liponeurocytoma, which are mostly in common with central neurocytoma, should prove helpful in differentiating this rare tumor from other tumors with similar morphology.

Among diffuse gliomas, oligodendrogliomas show relatively better prognosis, respond well to radiotherapy and chemotherapy, and seldom progress to very aggressive tumors. To elucidate the genetic and epigenetic background for such behavior and tumor evolution during tumor relapse, we comparatively analyzed 12 pairs of primary and recurrent oligodendrogliomas with 1p/19q-codeletion. Initial treatment for these patients was mostly chemotherapy alone. Temozolomide was used for 3, and procarbazine, nimustine and vincristine (PAV chemotherapy) were used for 7 patients. World Health Organization histological grade at recurrence was mostly stable; it was increased in 2, the same in 9, and decreased in 1 cases. Whole-exome sequencing demonstrated that the rate of shared mutation between the primary and recurrent tumors was relatively low, ranging from 3.2-57.9% (average, 33.3%), indicating a branched evolutionary pattern. The trunk alterations that existed throughout the course were restricted to IDH1 mutation, 1p/19q-codeletion, and TERT promoter mutation, and mutation of the known candidate tumor suppressor genes CIC and FUBP1 were not consistently observed between primary and recurrent tumors. Multiple sampling from different regions within a tumor showed marked intratumoral heterogeneity. Notably, in general, the number of mutations was not significantly different after recurrence, remaining under 100, and no hypermutator phenotype was observed. FUBP1 mutation, loss of chr. 9p21, and TCF12 mutation were among a few recurrent de novo alterations that were found at recurrence, indicating that these events were clonally selected at recurrence but were not enough to enhance malignancy. Genome-wide methylation status, measured by Illumina 450 K arrays, was stable between recurrence and the primary tumor. In summary, although oligodendroglioma displays marked mutational heterogeneity, histological malignant transformation accompanying events such as considerable increase in mutation number and epigenetic profile change were not observed at recurrence, indicating that noticeable temporal and spatial genetic heterogeneity in oligodendrogliomas does not result in rapid tumor progression. Electronic supplementary material The online version of this article (doi:10.1186/s40478-017-0422-z) contains supplementary material, which is available to authorized users.

Background. Hand20 is an illustrated, self-administered questionnaire comprising 20 short and easy-to-understand questions to assess upper limb disorders. This study aimed to test the reliability, validity, and responsiveness of Hand20. Methods. Eighty-five patients with three upper limb disorders (51 with trigger finger, 29 with ulnar impaction syndrome, and five with carpal tunnel syndrome) completed Hand20, the Japanese Society for Surgery of the Hand version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-JSSH), and the 36-Item Short-Form Health Survey (SF-36). Reliability was assessed by internal consistency. To test the validity, a factor analysis of Hand20 was performed and the correlation coefficients between Hand20 and DASH-JSSH and those between Hand20 and SF-36 were calculated. Responsiveness was evaluated in 47 patients with trigger finger as the standardized response mean and effect size after treatment. Results. A Cronbach's α coefficient of 0.967 confirmed the unidimensionality of Hand20. The correlation coefficient between Hand20 and DASH-JSSH was 0.84. The correlations between Hand20 and the SF-36 subscales ranged from -0.236 to -0.596. Moderate correlations were observed for "Role-physical" (r = -0.596) and "Bodily pain" (r = -0.557). The correlation between the Hand20 and "Physical functioning" was weak (r = -0.313). The standardized response mean and effect size of Hand20 was 1.50 and 1.60, respectively. Conclusions. The Hand20 has evaluation capacities equivalent to those of DASH-JSSH. There was a moderate correlation between Hand20 and SF-36.

The purpose of this study is to investigate the structural changes of the carpal tunnel, median nerve, and flexor tendons in magnetic resonance imaging (MRI) before and after endoscopic carpal tunnel release (ECTR). We studied 36 hands undergoing ECTR. In MRI, the cross-sectional area of the carpal tunnel and the median nerve at the hamate and the pisiform levels were measured. The distance from the volar side of carpal bone to the median nerve or tendons and the volar displacement were measured. In post-operative MRI, the transverse carpal ligament could not be well delineated and the carpal tunnel was significantly enlarged both at the hamate and pisiform levels. The median nerve was enlarged at the hamate level. The median nerve and flexor tendons significantly moved to the volar side. The volar displacement of the median nerve and flexor digitorum superficialis in the long and ring fingers was greater than the other tendons.

Objective The multicenter prospective cohort study (Japan Cooperative SPECT Study on Assessment of Mild Impairment of Cognitive Function: J-COSMIC) aimed to examine the value of 123I-N-isopropyl-4-iodoamphetamine cerebral blood flow (IMP-CBF) SPECT in regards to early diagnosis of Alzheimer’s disease (AD) in patients with mild cognitive impairment (MCI). Methods Three hundred and nineteen patients with amnestic MCI at 41 participating institutions each underwent clinical and neuropsychological examinations and 123I-IMP-CBF SPECT at baseline. Subjects were followed up periodically for 3 years, and progression to dementia was evaluated. SPECT images were classified as AD/DLB (dementia with Lewy bodies) pattern and non-AD/DLB pattern by central image interpretation and automated region of interest (ROI) analysis, respectively. Logistic regression analyses were used to assess whether baseline 123I-IMP-CBF SPECT was predictive of longitudinal clinical outcome. Results Ninety-nine of 216 amnestic MCI patients (excluding 3 cases with epilepsy (n = 2) or hydrocephalus (n = 1) and 100 cases with incomplete follow-up) converted to AD within the observation period. Central image interpretation and automated ROI analysis predicted conversion to AD with 56 and 58 % overall diagnostic accuracy (sensitivity, 76 and 81 %; specificity, 39 and 37 %), respectively. Multivariate logistic regression analysis identified SPECT as a predictor, which distinguished AD converters from non-converters. The odds ratio for a positive SPECT to predict conversion to AD with automated ROI analysis was 2.5 and combining SPECT data with gender and mini-mental state examination (MMSE) further improved classification (joint odds ratio 20.08). Conclusions 123I-IMP-CBF SPECT with both automated ROI analysis and central image interpretation was sensitive but relatively nonspecific for prediction of clinical outcome during the 3-year follow-up in individual amnestic MCI patients. A combination of statistically significant predictors, both SPECT with automated ROI analysis and neuropsychological evaluation, may increase predictive utility.

As well as pre-operative roadmapping by (18)F-Fluoro-2-deoxy-2-D-glucose (FDG) positron emission tomography, intra-operative localization of the tracer is important to identify local margins for less-invasive surgery, especially FDG-guided surgery. The objective of this paper is to develop a laparoscopic Compton camera and system aimed at use for intra-operative FDG imaging for accurate and less-invasive dissections. The laparoscopic Compton camera consists of four layers of a 12-pixel cross-shaped array of GFAG crystals ([Formula: see text] mm(3)) and through silicon via multi-pixel photon counters and dedicated individual readout electronics based on a dynamic time-over-threshold method. Experimental results yielded a spatial resolution of 4 mm (FWHM) for a 10 mm working distance and an absolute detection efficiency of 0.11 cps kBq(-1), corresponding to an intrinsic detection efficiency of ∼0.18%. In an experiment using a NEMA-like well-shaped FDG phantom, a [Formula: see text] mm cylindrical hot spot was clearly obtained even in the presence of a background distribution surrounding the Compton camera and the hot spot. We successfully obtained reconstructed images of a resected lymph node and primary tumor ex vivo after FDG administration to a patient having esophageal cancer. These performance characteristics indicate a new possibility of FDG-directed surgery by using a Compton camera intra-operatively.

Background Myofibroma is a fibrous tumor of infancy that sometimes affects a single patient in a multiple fashion (infantile myofibromatosis). Its intracranial involvement is extremely rare, and its clinical picture has been poorly characterized. Here we report an interesting case of myofibromatosis with an intracranial lesion that behaved like an aggressive tumor and yet demonstrated very benign pathology. Case Description A 36-year-old man had never been diagnosed with infantile myofibromatosis despite his lifelong history of multiple tumors of various diagnoses. He presented with simple partial seizure and progressive right finger paresis. A series of brain magnetic resonance imaging scans revealed a rapidly growing lesion at his left frontal convexity, which corresponded to a high uptake area on a 18 F-fluorodeoxyglucose-positron emission tomography scan, highly suspicious of malignancy. He underwent complete tumor resection and his symptoms quickly resolved postoperatively. The pathological diagnosis was myofibroma with a MIB-1 labeling index of 1%−2%. A retrospective review of his previous tumors demonstrated the same pathology, which led to the diagnosis of myofibromatosis. Follow-up magnetic resonance imaging illustrated stabilization or regression of other preexisting lesions as well as formation of a new intracranial lesion. Conclusions The discrepancy between rapid tumor growth associated with increased uptake on metabolic imaging and benign pathologic findings with a low proliferative index is noteworthy and should be recognized in the management of an intracranial lesion in a patient with infantile myofibromatosis. Given de novo formation of a lesion in this adult patient, long-term follow-up is essential in this disease.

Background Alice in Wonderland syndrome (AIWS) is a rare neuropsychiatric syndrome that typically manifests in distortion of extrapersonal visual image, altered perception of one’s body image, and a disturbed sense of the passage of distance and time. Several conditions have been reported to contribute to AIWS, although its biological basis is still unknown. Here, we present the first case demonstrating a clear concurrence of recurrent depressive disorder and AIWS. The clinical manifestations and pre- and post-treatment fluorodeoxyglucose positron-emission tomographic (FDG-PET) images provide insights into the psychopathological and biological basis of AIWS. Case presentation We describe a 63-year-old Japanese male who developed two distinct episodes of major depression concurrent with AIWS. In addition to typical AIWS perceptual symptoms, he complained of losing the ability to intuitively grasp the seriousness of news and the value of money, which implies disturbance of high-order cognition related to estimating magnitude and worth. Both depression and AIWS remitted after treatment in each episode. Pre-treatment FDG-PET images showed significant hypometabolism in the frontal cortex and hypermetabolism in the occipital and parietal cortex. Post-treatment images showed improvement of these abnormalities. Conclusions The clinical co-occurrence of depressive episodes and presentation of AIWS can be interpreted to mean that they have certain functional disturbances in common. In view of incapacity, indifference, devitalization, altered perception of one’s body image, and disturbed sense of time and space, the features of AIWS analogous to those of psychotic depression imply a common psychopathological basis. These high-order brain dysfunctions are possibly associated with the metabolic abnormalities in visual and parietotemporal association cortices that we observed on the pre- and post-treatment FDG-PET images in this case, while the hypometabolism in the frontal cortex is probably associated with depressive symptoms.

Inter-ictal (18)F-2-fluoro-deoxy-D: -glucose-positron emission tomography (FDG-PET) is widely used for preoperative evaluation to identify epileptogenic zones in patients with temporal lobe epilepsy. In this study, we combined statistical parametric mapping (SPM) with the asymmetry index and volume-of-interest (VOI) based extent analysis employing preoperative FDG-PET in unilateral mesial temporal lobe epilepsy (MTLE) patients. We also evaluated the detection utility of these techniques for automated identification of abnormalities in the unilateral hippocampal area later confirmed to be epileptogenic zones by surgical treatment and subsequent good seizure control.FDG-PET scans of 17 patients (9 males, mean age 35 years, age range 16-60 years) were retrospectively analyzed. All patients had been preoperatively diagnosed with unilateral MTLE. The surgical outcomes of all patients were Engel class 1A or 1B with postoperative follow-up of 2 years. FDG-PET images were spatially normalized and smoothed. After two voxel-value adjustments, one employing the asymmetry index and the other global normalization, had been applied to the images separately, voxel-based statistical comparisons were performed with 20 controls. Peak analysis and extent analysis in the VOI in the parahippocampal gyrus were conducted for SPM. For the extent analysis, a receiver operating characteristic (ROC) curve was devised to calculate the area under the curve and to determine the optimal threshold of extent.The accuracy of the method employing the asymmetry index was better than that of the global normalization method for both the peak and the extent analysis. The ROC analysis results, for the extent analysis, yielded an area under the curve of 0.971, such that the accuracy and optimal extent threshold of judgment were 92 and 32.9%, respectively.Statistical z-score mapping with the asymmetry index was more sensitive for detecting regional glucose hypometabolism and more accurate for identifying the side harboring the epileptogenic zone using inter-ictal FDG-PET in unilateral MTLE than z-score mapping with global normalization. Moreover, the automated determination of the side with the epileptogenic zone in unilateral MTLE showed improved accuracy when the combination of SPM with the asymmetry index and extent analysis was applied based on the VOI in the parahippocampal gyrus.

Background Gastric cancer exhibits various degrees of fluorine F-18 fluorodeoxyglucose (18F-FDG) uptake on positron emission tomography/computed tomography (PET/CT). We evaluated the relationship between 18F-FDG uptake and the presence/absence of metastasis in individual lymph nodes (LN) on a one-to-one basis. Methods We analyzed 21 patients with gastric cancer. We injected 18F-FDG intravenously in the morning, and gastrectomy with LN dissection was performed in the afternoon of the same day. Radiation doses were measured at each LN using a well-type counter, and we then compared 18F-FDG uptake, the shortest diameter, and pathological examination results for each LN. Results In our study, 906 LNs were analyzed, including 115 metastatic LNs. Metastatic LNs showed significantly higher 18F-FDG uptake (P

To identify a safe entry point for needle insertion in patients with idiopathic carpal tunnel syndrome (CTS), cross-sectional images of the wrist MRI of 45 normal volunteers and 180 consecutive patients with idiopathic CTS were reviewed. Insertion of the needle from the five different entry points into the carpal tunnel was simulated by drawing a 1-pixel line, and the incidence of contact with the median nerve was compared. In the CTS patients, the lowest incidence was 3% when inserted at one-third of the length between the FCR and FCU tendons on the ulnar side at the level of the distal part of the distal radioulnar joint and 4% at the mid point between the palmaris longus tendona and the flexor carpi ulnaris tendon. It was greater in the advanced stage of CTS than the less severe CTS. We recommend those two entry points.

PET cancer screening is performed widely in Japan as opportunistic screening, but no study has focused on the correlation with various cancer risk factors and the seeking bias of examinees and cancer detection rate. Analyzing our large series of PET cancer screening data, correlations with cancer detection rates according to general cancer risk factors and PET detection survey were reviewed, and the selection bias of the medical examinees was determined. 19189 examinees who underwent PET cancer screening were enrolled. Using logistic-regression analysis, we analyzed correlations between smoking history/drinking history/cancer family history and detection rates of thyroid cancer/breast cancer/colorectal cancer/lung cancer, which are the main malignancies detected in PET cancer screening. In addition, we evaluated seeking bias of examinees, analyzing correlations between the presence of cancer risk factors and prior screening checkups at other institutions to our PET cancer screening using a matched case–control study. Cancer detection rates by FDG-PET were 1.17% (224/19189), being much higher than those of standard cancer mass screenings. In males, statistically significant correlations were seen between lung cancer and smoking, and between prostate cancer and a family history of prostate cancer, but not between the detection rates of three other types of cancer (thyroid cancer/lung cancer/colorectal cancer) and other cancer risk factors. In females, detection rates of four types of cancer (thyroid cancer/lung cancer/colorectal cancer/breast cancer) were significantly higher in the examinees without cancer risks, and subgroup analysis according to types of cancer did not indicate significant correlations either. The matched case–control study evaluating seeking bias indicated that a significant proportion of the examinees with cancer risks had undergone prior cancer screening at other institutions. Our study indicated that there was significant seeking bias for prior screening of examinees, with this accounting for the fact that this study did not find a significant correlation between cancer risks and cancer detection rates. The results of our study indicated that PET cancer screening can provide high cancer detection rates.

BackgroundThe Patient-Rated Wrist Evaluation is a regionspecific, self-administered questionnaire consisting of a pain scale (PRWE-P) and a functional scale (PRWE-F), with the latter consisting of specific function (PRWE-SF) and usual function (PRWE-UF). The PRWE was cross-culturally adapted from the original English version by the Impairment Evaluation Committee, Japanese Society for Surgery of the Hand (JSSH). The purpose of this study was to test the reliability, validity, and responsiveness of the Japanese version of PRWE (PRWE-J).MethodsA consecutive series of 117 patients with wrist disorders completed the PRWE-J, the JSSH version of the Disabilities of the Arm, Shoulder, and Hand (DASH-JSSH) questionnaire and the 36-Item Short-Form Health Survey (SF-36). Of the 117 patients, 71 were reassessed for test-retest reliability 1 or 2 weeks later. Reliability was investigated by reproducibility and internal consistency. To analyze the validity, a factor analysis (principal axis factoring) of PRWE-J and correlation coefficients between PRWE-J and DASH-JSSH were obtained. Responsiveness was examined by calculating the standardized response mean (SRM) (mean change/SD) and effect size (mean change/SD of baseline value) after open surgery in 50 patients.ResultsCronbach’s α coefficients for PRWE-P, PRWE-F, and PRWE were 0.90, 0.95, and 0.95, respectively. The intraclass correlation coefficients (ICCs) for the same were 0.86, 0.93, and 0.92, respectively. Unidimensionality of PRWE-P was confirmed. Bidimensionality of PRWE-F was confirmed and separated clearly into PRWE-SF and PRWE-UF. The correlation coefficients between PRWE-P and PRWE-F or DASH-JSSH were 0.63 or 0.63, respectively. The correlation coefficient between PRWE-F and DASH-JSSH was 0.80. The correlation coefficients between DASH-JSSH and PRWE-SF or PRWE-UF were 0.76 or 0.73, respectively. Moderate correlation was observed in “physical functioning” for SF-36 and PRWE-SF (r = −0.46), PRWE-F (r = −0.46), or PRWE (r = −0.46). The SRMs/effect sizes of PRWE-P, PRWE-F, or PRWE were respectively excellent: 1.7/2.2, 1.2/1.3, 1.6/1.9.ConclusionsThe PRWE-J has evaluation capacities equivalent to those of the original PRWE.