Cutaneous and Aesthetic Surgery

Surgical smoke in Dermatology: Its hazards and management Saloni Katoch, Venkataram Mysore Journal of Cutaneous and Aesthetic Surgery 2019 12(1):1-7 Surgical plume with vaporized tissue particles, pathogens, and toxic gases emanating during dermatosurgical procedures is an occupational hazard to the dermatosurgeon, and protective measures must be taken to prevent their inhalation. Smoke evacuators are devices that capture and filter the plume generated during electrosurgical procedures or laser procedures, thereby maintaining a safe environment for the surgical team and the patient. A smoke evacuation system should be appropriately selected depending on the need of the facility. The objective of this article is to outline the health hazards of the smoke by-product of electrosurgery and lasers and provide details about safety measures and smoke evacuation systems.

Unconventional uses of laser hair removal: A review Saima Aleem, Imran Majid Journal of Cutaneous and Aesthetic Surgery 2019 12(1):8-16 Laser hair removal since its availability has been primarily used for aesthetic purposes. Over the years, it has emerged as an important therapeutic modality in various dermatological and surgical disorders, both as an adjuvant and as a monotherapy. Depending on the skin type, all laser hair removal systems have been used with good results and minimal complications. We hereby review the diverse range of unconventional indications of laser hair removal.

Efficacy of 308-nm monochromatic excimer light in the management of halo nevi: An open label, pilot study Swapnil D Shah, Amit Shah, Bhalachandra Ankad, Sharad Mutalik Journal of Cutaneous and Aesthetic Surgery 2019 12(1):17-24 Introduction: Halo nevus (HN) affects approximately 1% of the population. Presence of hypo- or depigmented lesion carries tremendous psychosocial disturbance in the mind-set of population in the Indian subcontinent. Hence, HN requires intervention by any modalities. Here authors attempted to evaluate the efficacy of monochromatic excimer light (MEL) in treating HN. Materials and Methods: A total of 29 patients with HN were included in the study. A xenon chloride lamp emitting noncoherent, monochromatic 308-nm light that represents the natural evolution of the excimer laser was used. The initial dose was 100 mJ/cm2, which was increased by 100 mJ/cm2 per session. All the patients were followed up for 6 months. Results: A total of 29 patients with 10 males and 19 females (male to female ratio of 1:1.9) completed the study. The age of onset of HN ranged from 5 to 47 years and the mean age of the patients was 23 years. HN was seen on the face, back, neck, chest, trunk, and extremities in 5 (17.2%), 6 (20.7%), 4 (13.7%), and 6 (20.7%) patients, respectively. Outstanding response was noticed in 14 patients (48.2%), whereas 6 (20.6%) patients showed excellent improvement. Only 2 (6.8%) patients showed no response after 10 consecutive sessions. Conclusion: HN causes apprehension in the Indian population because of the social stigma associated with depigmented patches on the body. Mere observation and only counseling in the treatment protocol are not sufficient. MEL is a noninvasive procedure, which results in excellent repigmentation of HN without scarring.

To study the outcome of three-flap technique in the management of pincer nail Kanathur Shilpa, Gorur Divya, Leelavathy Budamakuntla, Loganathan Eswari Journal of Cutaneous and Aesthetic Surgery 2019 12(1):25-30 Context: Pincer nail deformity is a transverse overcurvature of the nail. Though various conservative and surgical techniques have been described in the literature, very few studies are based on objective measurements. This study was undertaken to evaluate the outcome of three-flap technique in the management of pincer nail. Aim: To study the outcome of three-flap technique in the management of pincer nail. Settings And Design: Prospective interventional study. Subjects and Methods: Fifteen patients with pincer nail deformity, fulfilling inclusion and exclusion criteria were enrolled for the study. Routine X-ray was carried out for all patients to detect underlying bony abnormalities such as exostoses. Width and height indices were calculated before the procedure. A three-flap technique was performed on all affected toe nails and outcome was assessed at the end of 6 months and 1 year. Statistical Analysis Used: Paired t-test and P value. Results: Satisfactory cosmetic outcome and statistically significant improvement (P < 0.0001) were achieved in all patients. Conclusions: Three flap technique is an useful technique in the management of pincer nail.

Assessment of safe donor zone of scalp and beard for follicular unit extraction in Indian men: A study of 580 cases Kavish Chouhan, Rahulkrishna S Kota, Amrendra Kumar, Jyoti Gupta Journal of Cutaneous and Aesthetic Surgery 2019 12(1):31-35 Context: Hair restoration surgery for androgenetic alopecia (AGA) essentially involves various forms of hair transplantation. There is paucity of studies assessing donor area in Indian men and also no simplified guidelines are available for the safe donor area for follicular unit extraction (FUE). Our study is an attempt to study the donor area in Indian men.Aims: To assess the density of follicular units (FUs) in the donor area, that is, both scalp and beard in Indian men, and to propose simplified guidelines for FUE.Materials and Methods: The study design was cross-sectional and was carried out for 2 years. All the consenting male patients with male pattern hair loss Hamilton Norwood grading III or more who consulted for a hair restoration surgery were recruited. FU density was assessed in the donor area of scalp by drawing a rectangle with its lower border being a straight line joining two points, which are 27–28mm from the line drawn perpendicular to tragus, passing through external occipital protuberance. Three squares of area 1cm2 were drawn within the rectangle. Average of the FUs and follicles in the three squares was calculated to obtain mean density in the donor area of the scalp. Total number of FU was assessed, considering 25% extraction, total average number of extractable follicles was assessed. Total donor area was divided into three areas (areas 1, 2, and 3) and average number of extractable FU was assessed in each. Donor area in the beard, below the jawline, was divided into a triangle and rectangle. Average number of FU, total number of extractable FU was calculated similarly.Results: A total of 580 male patients were recruited in the study. Mean FU density in the scalp and beard was 78.2/cm2 and 49.7/cm2, respectively. The total available number of FUs for extraction in the areas 1, 2, and 3 and beard considering 25% extraction was 2064, 3097, 3612, and 824, respectively. We propose three types of donor areas in the scalp, namely, limited, standard, and extended donor area.

Cross-sectional study of dermatoscopic findings in relation to activity in vitiligo: BPLeFoSK criteria for stability Balakrishnan Nirmal, Belavendra Antonisamy, CV Dincy Peter, Leni George, Anu A George, Gauri M Dinesh Journal of Cutaneous and Aesthetic Surgery 2019 12(1):36-41 Background: Stability in vitiligo is an important concept in guiding patient management and a vital prerequisite before vitiligo surgery. Disease activity of vitiligo based on patient’s history is imprecise. It is practically impossible to perform biopsy from all lesions of vitiligo to ascertain stability. Dermatoscopy can be used to examine all clinical lesions in a patient of vitiligo. There is a need to validate many reported dermatoscopic findings for universal use. Aims: To analyze the significance of dermatoscopic findings in the activity of vitiligo and to devise a cutoff score for stable vitiligo. Materials and Methods: Dermatoscopic examination was performed in 85 patients clinically diagnosed with vitiligo. Six dermatoscopic parameters, namely, border, pigment network, perilesional hyperpigmentation, perifollicular pigmentation, satellite lesions, and micro-Koebner phenomenon (acronym: BPLeFoSK) were evaluated against Wood’s lamp findings as standard. Chi-square test was used to test association between categorical variables. Cutoff values for stability for these six parameters were plotted in receiver operating curve. Results: A total of 131 vitiligo lesions were analyzed with dermatoscopy. Absence of satellite lesions and absence of micro-Koebner phenomenon were the most sensitive parameters (96.7% and 100%, respectively). Sharp border and absent or reticulate pigment network within the vitiligo patch were the most specific findings (100% and 91.5%, respectively). Conclusion: A cutoff score of more than or equal to 1.5 using the “BPLeFoSK criteria” indicates stability in the vitiligo lesion.

Correlation between clinical features, biochemical parameters, and histopathological findings in women with patterned baldness: Study from North India Sidharth Tandon, Pooja Arora, Ram Krishan Gautam, Minakshi Bhardwaj, Umesh Garga, Neera Sharma Journal of Cutaneous and Aesthetic Surgery 2019 12(1):42-48 Background: Androgenetic alopecia (AGA) is a non-scarring alopecia with a characteristic pattern in genetically predisposed men and women. Hormonal abnormalities namely hyperandrogenism, hair cycle defects, genetic predisposition, and follicular miniaturization have been implicated as the causative factors for AGA. Aim: To analyze women with patterned hair loss and correlate their clinical findings with the histopathology and biochemical parameters. Materials and Methods: Female patients between 18 and 45 years of age with a history of hair loss on the crown, temporal area, and recession of hairline were clinically examined. These patients were then subjected to histopathological examination, and on confirmation of diagnosis of female pattern hair loss (FPHL), they were included in the study. Their morning blood sample was taken on 3rd–5th day of the menstrual cycle for hormonal analysis. The study was carried out on 30 patients and 30 age- and sex-matched controls. Results: A statistically significant difference was observed between the mean values of dehydroepiandrosterone sulfate, prolactin, androstenedione, and free triiodothyronine of cases and controls. The most common histopathological finding in our study was an increase in the percentage of telogen hair. Conclusion: The biochemical findings in our study corroborate the role of hyperandrogenism as one of the major etiological factors in FPHL with the role of adrenal androgens being central, and therefore all female patients with FPHL should be evaluated for underlying hormonal imbalances. The role of histopathology in FPHL can be used as a prognostic marker.

Mini-punch skin excision: A newer novel approach for tattoo removal Jyoti Gupta, Kavish Chouhan, Amrendra Kumar, Ketan Garg Journal of Cutaneous and Aesthetic Surgery 2019 12(1):49-51 Q-switched Nd:YAG laser remains the gold standard for tattoo removal, but still some tattoos are not completely removed in a specified period as desired by the patient. Herein, we present a case report of 23-year-old patient who came to the outpatient department for tattoo removal. The tattoo measured around 20cm × 18cm and was located on the back. Nine to 12 sessions of 1064-nm Q-switched Nd:YAG laser were planned at 4- to 6-week interval. After the completion of nine sessions, all the shades of the tattoo disappeared, but the lines persisted. A trial of increased laser energy and multiple-pass R20 treatment was performed, which rather increased the scarring and no improvement in tattoo clearance was noticed. We tried mini-punch skin excision for clearing the remnant tattoo lines. The tattoo was cleared successfully without significant scarring. Mini-punch skin excision is a very promising technique, similar to the follicular unit extraction technique of hair transplant, for tattoo removal of the patients who want immediate results as compared to lasers that take almost a year, provided the patient accepts the risk of scarring.

A case report on use of cog threads and dermal fillers for facial-lifting in facioscapulohumeral muscular dystrophy Aman Dua, Bhawna Bhardwaj Journal of Cutaneous and Aesthetic Surgery 2019 12(1):52-55 Long-standing facial paralysis induces degenerative facial muscle changes on the involved side, thus making the individual seem older than their actual age. Furthermore, contralateral facial hypertrophy aggravates facial asymmetry (Sulamanidze MA, Fournier PF, Paikidze TG, Sulamanidze GM. Removal of facial soft tissue ptosis with special threads. Dermatol Surg 2002;28:367-71). The introduction of absorbable barbed thread has proved to be a good alternative for treating facial asymmetry. It also allows the association with other nonsurgical procedures, such as botulinum toxin use and/or dermal fillers in facial remodeling (Atiyeh BS, Dibo SA, Costagliola M, Hayek SN. Barbed sutures “lunch time” lifting: evidence-based efficacy. J Cosmet Dermatol 2010;9:132-41 and Kaminer MS, Bogart M, Choi C, Wee SA. Long-term efficacy of anchored barbed sutures in the face and neck. Dermatol Surg 2008;34:1041-7.). The aim of the treatment (threads) of the mid and lower third of the face was to promote the mechanical effect (lifting) and biological effect (neocollagenesis) with the improvement of the nasolabial folds, jaw, and jawbone contour.

Extended bifurcated superficial temporal artery island flap for the reconstruction of a periorbital burn: A case report Tarek M Elbanoby, Usama A Abdelfattah, Gaber M Aly, Mohab Abdulkafy, Amr M Elbatawy Journal of Cutaneous and Aesthetic Surgery 2019 12(1):56-59 A 47-year-old man with severe thermal burn injury to the face, including bilateral periorbital regions, presented with bilateral upper and lower ectropion with loss of both eyebrows. The periorbital area was reconstructed with the extended bifurcated superficial temporal artery flap with two islands extending out of territory to restore both eyebrows, lower eyelid, and add length to upper eyelid. After 12 months of the operation, the patient showed complete resolution of postburn sequels in addition to a high grade of satisfaction.

Clinical Nuclear Medicine,https://journals.lww.com/nuclearmed/pages/default.aspx

Editor's Note

In "Predicting Response to Immunotherapy by Evaluating Tumors, Lymphoid Cell-Rich Organs, and Immune-Related Adverse Events Using FDG-PET/CT", Nobashi and colleagues retrospectively investigate whether the evaluation of tumors, lymphoid cell rich organs, and immune-related adverse events (IRAE) with 18F-FDG PET/CT can predict the efficacy and outcome of immunotherapy in 40 patients (malignant melanoma, n = 21; malignant lymphoma, n = 11; renal cell carcinoma, n = 8) who underwent 18F-FDG-PET/CT  before and after therapy with immune checkpoint inhibitors.  Baseline and first restaging SUVmax for tumors, spleen, bone marrow, thyroid and pituitary glands were correlated with best overall response in the first year after therapy. Interval change between the baseline and first restaging PET showed that patients with a clinical benefit had a significant decrease in tumor parameters (P < 0.001). All patients with an increase of SUVmax in the thyroid of more than 1.5 (n = 5) on the first restaging scan had a complete response (CR) in 1 year. Patients with CR within 1 year (n = 22) were significantly associated with a favorable long-term outcome (P = 0.002). Nine patients with IRAE findings had CR at final evaluation. Among IRAE, thyroiditis was seen significantly earlier than arthritis (P = 0.040). Authors concluded that decrease of tumor parameters at early time-point PET was associated with favorable outcomes. Early development of thyroiditis is associated with a favorable early response indicator to immunotherapy.

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Pattern of FDG and MET Distribution in High- and Low-Grade Gliomas on PET Images

Takahashi, Miwako; Soma, Tsutomu; Mukasa, Akitake; More

Clinical Nuclear Medicine. 44(4):265-271, April 2019.

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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.

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Fast-track Radioiodine Ablation Therapy After Thyroidectomy Reduces Sick Leave in Patients With Differentiated Thyroid Cancer (FASTHYNA Trial)

Waissi, Farahnaz; Kist, Jakob W.; Lodewijk, Lutske; More

Clinical Nuclear Medicine. 44(4):272-275, April 2019.

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Background

Recombinant human thyroid stimulating hormone (RhTSH) aided radioiodine ablative therapy (RIT) is current-day practice in the treatment of differentiated thyroid cancer (DTC). It is often planned 4 to 6 weeks after surgery or sometimes even longer (standard protocol). The RhTSH-aided RIT, however, has the advantage that it can be planned shortly after thyroidectomy. The FASTHYNA trial was designed to test the hypothesis that RIT 1 week after thyroidectomy (fast-track protocol) results in a significant reduction of sick leave with lower societal costs and with a better quality of life (QOL) compared with the current standard treatment.

Methods

In a randomized, multicenter trial, we included patients with differentiated thyroid cancer, stage T1–3 N0–1 M0-x, who were treated with a total or completion thyroidectomy, with a paid job of at least 12 hours per week. The primary study end point was days of sick leave reported from time of surgery. Secondary end points were QOL and societal costs associated with absence from work.

Results

Twenty patients were eligible for inclusion between November 2013 and May 2016. Significant decreases in mean duration of sick leave in the fast-track group versus the standard care group (115 and 280 hours, respectively, P = 0.02) and in costs associated with productivity losses (€4070.77 vs €9202.90, P = 0.02) were found. There were no significant differences in QOL between both groups.

Conclusions

The trial showed a significant reduction in sick leave and in societal costs in the fast-track group without a deterioration of QOL. Therefore, fast-track ablation is desirable.

Trial Registration: Netherlands trial register: NTR 3933.

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Tumor Identification of Less Aggressive or Indolent Lymphoma With Whole-Body 11C-Acetate PET/CT

Tsuchiya, Junichi; Yamamoto, Masahide; Bae, Hyeyeol; More

Clinical Nuclear Medicine. 44(4):276-281, April 2019.

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Purpose

The aim of this study was to investigate the diagnostic performance of whole-body [ 11 C]acetate PET/CT in less aggressive or indolent lymphomas, wherein [ 18 F]FDG PET/CT would exhibit limited sensitivity.

Methods

Between September 2016 and May 2018, we prospectively evaluated 17 patients (9 men, 8 women; mean age [range], 71 [45–87] years) with pathologically proven less aggressive or indolent lymphomas according to Non-Hodgkin's Lymphoma Classification Project, using both [ 18 F]FDG PET/CT and [ 11 C]acetate PET/CT (performed on the same day). Detected nodal lesions were recorded according to the Ann Arbor classification. Extranodal (EN) lesions were also evaluated. We compared whole-body lesion detection between [ 18 F] FDG PET/CT and [ 11 C]acetate PET/CT using the McNemar test.

Results

In all patients, significantly more nodal and EN lesions were detected using [ 11 C]acetate PET/CT than [ 18 F]FDG PET/CT (nodal: 84 vs 64 regions; P < 0.001; EN: 26 vs 19 regions, P = 0.039). Bone lesions were detected in 8 and 5 patients using [ 11 C]acetate PET/CT and [ 18 F]FDG PET/CT, respectively ( P = 0.25). Among the 14 patients (82.4%) who underwent bone marrow biopsy, bone marrow involvement was detected with sensitivities of 100% (6/6 patients) and 80% (5/6 patients) using [ 11 C]acetate PET/CT and [ 18 F]FDG PET/CT, respectively. Multiple areas of focal uptake in the spleen of 1 patient were exhibited on [ 18 F]FDG PET/CT but not [ 11 C]acetate PET/CT.

Conclusions

[ 11 C]acetate PET/CT exhibited greater sensitivity than [ 18 F]FDG PET/CT for lesion detection in patients with less aggressive or indolent lymphomas, thus promising applicability as a physiological tracer in the study of such lesions.

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Initial Versus Follow-up Sequential Myocardial 123I-MIBG Scintigraphy to Discriminate Parkinson Disease From Atypical Parkinsonian Syndromes

Ryu, Dong-Woo; Kim, Joong-Seok; Lee, Jee-Eun; More

Clinical Nuclear Medicine. 44(4):282-288, April 2019.

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Purpose

Previous single-center or meta-analysis studies analyzed myocardial 123 I-metaiodobenzylguanidine ( 123 I-MIBG) scintigraphy in a single image session and demonstrated low sensitivity and high specificity for discriminating Parkinson disease (PD) from atypical Parkinsonian syndromes (APS). This study aimed to assess diagnostic ability of myocardial 123 I-MIBG scintigraphy at 2 phases to discriminate PD from APS.

Patients and Methods

This hospital-based prospective study enrolled 162 PD and 26 APS patients who underwent 2 sequential 123 I-MIBG scintigraphy evaluations. Patients were stratified into normal and decreased 123 I-MIBG groups according to early and delayed heart-to-mediastinum (H/M) ratios. Patients with PD and normal 123 I-MIBG uptake (initial delayed H/M ratio, ≥1.78) were considered scans without evidence of cardiac norepinephrine deficit (SWEND). Early and delayed H/M ratios on the initial and 2-year follow-up scintigraphs were studied. The diagnostic sensitivity and specificity were calculated from these confusion matrices and were analyzed according to receiver-operating characteristic curve analysis. A repeated-measures general linear model was used to investigate differences among groups over time in H/M ratio changes and washout rates.

Results

Follow-up 123 I-MIBG scintigraphy analysis had a higher diagnostic sensitivity (89.5%) than the initial imaging (72.2%). The improved sensitivity was associated with a steeper decrease in H/M ratio in the SWEND group than in the APS group.

Conclusions

Follow-up 123 I-MIBG scintigraphy can identify cardiac sympathetic denervation and its progression in patients with PD and may be effective in discriminating PD from APS. A later decrease in myocardial 123 I-MIBG uptake in the group with SWEND meets the Braak staging threshold hypothesis for synucleinopathy.

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Predicting Response to Immunotherapy by Evaluating Tumors, Lymphoid Cell-Rich Organs, and Immune-Related Adverse Events Using FDG-PET/CT

Nobashi, Tomomi; Baratto, Lucia; Reddy, Sunil A.; More

Clinical Nuclear Medicine. 44(4):e272-e279, April 2019.

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Purpose

To investigate whether the evaluation of tumors, lymphoid cell-rich organs, and immune-related adverse events (IRAE) with 18 F-FDG PET/CT can predict the efficacy and outcome of immunotherapy.

Methods

Forty patients who underwent 18 F-FDG-PET/CT scans before and after therapy with immune checkpoint inhibitors from December 2013 to December 2016 were retrospectively enrolled (malignant melanoma, n = 21; malignant lymphoma, n = 11; renal cell carcinoma, n = 8). SUVmax of the baseline and first restaging scans were evaluated in tumors, spleen, bone marrow, thyroid and pituitary glands, and were correlated to best overall response in the first year after therapy; IRAE-affected areas were also evaluated.

Results

Interval change between the baseline and first restaging scans showed that patients with a clinical benefit had a significant decrease in tumor parameters ( P < 0.001). All patients with an increase of SUVmax in the thyroid of more than 1.5 (n = 5) on the first restaging scan had a complete response (CR) in 1 year. Patients with CR within 1 year (n = 22) were significantly associated with a favorable long-term outcome ( P = 0.002). Nine patients with IRAE findings had CR at final evaluation. Among IRAE, thyroiditis was seen significantly earlier than arthritis ( P = 0.040).

Conclusions

The decrease of tumor parameters at early time-point PET scans was seen in patients with immunotherapy who had clinical benefit within 1 year. PET-detectable IRAE was useful for prediction of a favorable outcome. Early development of thyroiditis may particularly represent an early response indicator to immunotherapy.

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Point Spread Function Reconstruction for Integrated 18F-FET PET/MRI in Patients With Glioma: Does It Affect SUVs and Respective Tumor-to-Background Ratios?

Rogasch, Julian Manuel Michael; Albers, Josefine; Steinkrüger, Ferdinand L.; More

Clinical Nuclear Medicine. 44(4):e280-e285, April 2019.

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Purpose

Semiquantitative 18 F-FET PET assessment using the tumor's SUV or tumor-to-background ratios (TBRs) can separate gliomas from peritumoral tissue or progression from pseudoprogression. This study investigated if point spread function (PSF) reconstruction of 18 F-FET PET data affects SUV-based dignity assessment.

Materials and Methods

This study is a retrospective analysis of 87 glioma patients (female, 36; male, 51; age, 48 [13–81] years) undergoing 18 F-FET PET/MRI for staging (n = 17) or restaging (n = 70). PET was reconstructed using ordered-subset expectation maximization with and without PSF. Lesions were delineated with semiautomated background-adapted thresholding relative to SUV max ; background was delineated contralaterally. Comparative measurements with a National Electrical Manufacturers Association International Electrotechnical Commission PET body phantom (sphere-to-background ratios, 8:1 and 4:1) were performed.

Results

PSF showed significantly higher tumor SUV max (median difference, +0.1; interquartile range, 0.04–0.18), SUV mean (+0.05; 0.03–0.08), TBR max|mean (+0.1; 0.04–0.2), and TBR mean|mean (+0.06; 0.03–0.09) than non-PSF ( P < 0.001). Background SUV mean was unaffected. In patients and phantom, differences between PSF and non-PSF increased with TBR and decreased with lesion's PET volume. Differences only exceeded 0.2 SUV for SUV max or 0.1 SUV for SUV mean if TBR was greater than 3 and lesion's PET volume was less than 10 mL (d = 27 mm). Dignity assessment by PSF and non-PSF was concordant in all patients examined for staging (cutoff, TBR mean|mean > 1.6; positive, 14; negative, 3) and restaging (cutoff, TBR max|mean > 2.0; positive, 67; negative, 3).

Conclusions

PSF increased tumor SUV max and SUV mean compared with non-PSF 18 F-FET PET/MRI data, especially in small lesions with high TBR (>3). However, dignity assessment using established TBR cutoffs was not affected.

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Quality and Safety in Health Care, Part XLVI: Mindfulness, Meditation, and Burnout

Harolds, Jay A.

Clinical Nuclear Medicine. 44(4):289-291, April 2019.

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Some of the approaches to prevent and recover from burnout focus on the individual, and others focus on organizational initiatives. A common recommendation for the individual with burnout is to practice meditation and mindfulness. Mindfulness may be defined as focused awareness without judgment regarding the current instance in time. The practice of mindfulness and the outcome of various mindfulness courses will be discussed in this article. Other approaches on the subject of burnout regarding individual efforts and organizational changes will be discussed in subsequent articles in this series.

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Baseline Pancreatic Beta Cell Imaging After Pancreatic Transplantation Using Whole-Body 68Ga-DOTA-Exendin-4 PET/CT: A Spectrum of 2 Cases of Diabetes Mellitus

Gambhir, Aashish; Jain, Avani; Elangovan, Indirani; More

Clinical Nuclear Medicine. 44(4):292-294, April 2019.

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Whole pancreatic transplant and islet cells transplantation are currently available strategies aiming toward diabetes cure. Beta cell specific noninvasive functional imaging using novel PET radiotracers are now available and can be used for beta cell imaging and quantification. Herein we describe a spectrum of 2 cases demonstrating beta cell targeted imaging using 68 Ga-DOTA-exendin-4 PET/CT in patients with diabetes after simultaneous pancreas-kidney transplantation.

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Resolution of Hypoxic Tissue in Cerebellar Hemispheres After Arterial Bypass Surgery in a Patient With Symptomatic Bilateral Vertebral Artery Occlusion: A 18F-FRP170 PET Study

Oikawa, Kohki; Kobayashi, Masakazu; Beppu, Takaaki; More

Clinical Nuclear Medicine. 44(4):295-296, April 2019.

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A 48-year-old man experienced recurrent vertigo refractory to antiplatelet medications. Cerebral angiography showed occlusion of bilateral vertebral arteries with poor collateral circulation. PET using 15 O 2 gas showed reduced blood flow and metabolic rate of oxygen and elevated oxygen extraction fraction in bilateral cerebellar hemispheres. Subsequent 18 F-FRP170 (1-(2- 18 F-fluoro-1-[hydroxymethyl]ethoxy)methyl-2-nitroimidazole) PET, which depicts hypoxic but viable tissue, revealed elevated tracer uptake in the same regions. After superficial temporal artery-posterior cerebral artery anastomosis, 15 O-gas PET showed normalization of blood flow, metabolic rate of oxygen, and oxygen extraction fraction in bilateral cerebellar hemispheres. Abnormally elevated 18 F-FRP-170 uptake was also resolved in those regions.

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Multiple Myeloma of Testes and Spermatic Cord on 18F-FDG PET/CT

Velaga, Jyothirmayi; Liang, Huang Hian; Gopalakrishnan, Sathish Kumar

Clinical Nuclear Medicine. 44(4):297-298, April 2019.

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Extramedullary multiple myeloma (EM) has negative prognostic implications on the overall survival as well as progression-free survival. Testis is a rare site of EM, which can be a part of diffuse involvement in multiple myeloma or a site of recurrence in patients with remission. We present a case of EM of testes and left spermatic cord in an 80-year-old man who presented with painless progressive enlargement of the scrotum. 18 F-FDG PET/CT revealed tracer avidity of both testes and left spermatic cord. Bilateral radical orchidectomy was subsequently performed, and the diagnosis of multiple myeloma was confirmed on histopathology.

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Lymphadenopathy Due to Kimura's Disease Mimicking Lymphoma on FDG PET/CT

Yu, MingMing; Wang, ZhenGuang; Zhao, Jing; More

Clinical Nuclear Medicine. 44(4):299-300, April 2019.

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Kimura's disease is a clinically rare, chronic, benign lymphoproliferative disorder of unknown etiology. A 36-year-old man presented with painless axillary swelling, which was suspected as lymphoma. PET/CT was performed for staging. The images showed multiple foci of increased activity in bilateral axillary and right inguinal lymph nodes. Laboratory tests revealed an increased eosinophil ratio and eosinophil count. Pathological examination from dissected axillary lymph nodes was consistent with Kimura's disease.

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High-Resolution Brain 18F-FDG Images Provided by Fully Digital PET

Salvadori, Julien; Perrin, Mathieu; Marie, Pierre-Yves; More

Clinical Nuclear Medicine. 44(4):301-302, April 2019.

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Normal brain 18 F-FDG PET images, consecutively recorded on analog and fully digital PET cameras in an 85-year-old woman, are depicted herein with the reconstruction methods recommended for a 2-mm voxel size on each camera and with a high-resolution reconstruction additionally developed for digital PET with a 1-mm voxel size. An enhanced gray-to-white matter contrast was consistently documented for digital PET when compared with analog PET, and was associated with a further enhancement in spatial resolution at 1-mm voxel size, as evidenced by a much clearer delineation of cortical gyri. These high-resolution images could favor the identification of brain abnormalities.

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Dynamic Renal Ptosis Demonstrated on 18F-FDG PET/CT

Taylor, Justin; Prasad, Kalpna; Rohrer, Rebecca

Clinical Nuclear Medicine. 44(4):303-304, April 2019.

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Renal ptosis, otherwise known as nephroptosis or "floating kidney," is a condition of abnormal descent of the kidney, often asymptomatic with controversy over its clinical and therapeutic significance. The aberrant location of renal and renal collecting system activity associated with this condition may serve as a diagnostic pitfall in PET/CT interpretation. We report a case of dynamic renal ptosis demonstrated on 18 F-FDG PET/CT, identified as right kidney migration from an ectopic location on attenuation correction CT images, obtained immediately after upright positioning, to the right renal fossa on subsequent PET images, obtained after approximately 10 min of supine positioning.

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Pachymeningitis Demonstrated on Gallium SPECT/CT Scan

Wong, Veronica C.; Yung, Grace; Russo, Robert; More

Clinical Nuclear Medicine. 44(4):305-309, April 2019.

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A 34-year-old woman presented with a 3-month history of right-sided headaches associated with photophobia and pulsatile tinnitus. Investigations including lumbar puncture revealed elevated opening CSF pressure, increased protein, and presence of monocytosis consistent with an inflammatory/infective process. Brain MRI showed an area of thickened enhancing dura around the venous sinus posteriorly. 67 Ga scintigraphy demonstrated focal intracranial uptake in the posterior occipital region, and biopsy confirmed a chronic inflammatory infiltrate with no granulomas.

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Diffuse-Type Tenosynovial Giant Cell Tumor of the Shoulder Evaluated by FDG PET/CT

Tang, Kun; Zheng, Xiangwu; Lin, Jie; More

Clinical Nuclear Medicine. 44(4):310-312, April 2019.

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Diffuse-type tenosynovial giant cell tumor is a locally aggressive neoplasm that typically involves the knee and hip but rarely involves the shoulder. In this case, a 74-year-old woman presented a painless mass in the right shoulder. FDG PET/CT demonstrated intense FDG uptake with an SUVmax of 19.2 in the lesion. The mass was dissected and confirmed as diffuse-type tenosynovial giant cell tumor by pathology. Follow-up FDG PET/CT assessment revealed more extensive soft tissue infiltration and adjacent bone erosion 3 years after surgery. Thus, FDG PET/CT well demonstrated the hypermetabolic and local aggressive characteristics of the lesion.

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Gummatous Syphilis Mimicking Malignant Bone Tumor on FDG PET/CT

Wang, Li-juan; Wu, Hu-bing; Zhou, Wen-lan; More

Clinical Nuclear Medicine. 44(4):313-316, April 2019.

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A 47-year-old woman suffered worsening pain in the waist and numbness in the right thigh for 1 month. MRI was performed to determine the cause, which detected an osteolytic lesion in the T12 vertebral body, suggestive of possible bone metastasis. FDG PET/CT scan was undertaken to detect the primary tumor, which only showed the same isolated lesion in the T12 without any other abnormal hypermetabolic lesion. The pathology following vertebrectomy revealed granulomatous infection. The diagnosis of osseous syphilis was eventually made following a subsequent positive Treponema pallidum serological test.

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A Case of Radioactive Iodine Uptake Found in Artificial Eye

Kim, Il-Hyun; Yoon, Joon-Kee; Lee, Su Jin; More

Clinical Nuclear Medicine. 44(4):317-318, April 2019.

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Radioactive iodine (RAI) therapy is widely used as an adjunctive treatment in patients with differentiated thyroid cancer. Although 131 I has high avidity in the functioning thyroid, and in differentiated thyroid cancer lesions, physiological and nonspecific uptake of 131 I in healthy or benign tissue may contribute to false-positive findings on an 131 I scan. Here, we present an interesting image of RAI uptake in the eye region post-RAI treatment, which has been identified as tear contamination in the artificial eye.

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Identification of Heterotopic Ossification Using 18F-NaF PET/CT

Seraj, Siavash Mehdizadeh; Al-Zaghal, Abdullah; Østergaard, Brian; More

Clinical Nuclear Medicine. 44(4):319-320, April 2019.

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Heterotopic ossification (HO) is a benign condition characterized by the abnormal formation of mature lamellar bone in extraskeletal soft tissues. Most frequently, HO is observed around the hip joint after fractures or surgical procedures such as open reduction internal fixation or total hip arthroplasties. We are presenting a case of HO as detected by 18 F-NaF PET/CT in a 68-year-old woman with multiple myeloma and a history of internal fixation of the right hip. Many previous publications have reported 18 F-NaF uptake portraying calcification in soft tissue; the present report demonstrates the feasibility of 18 F-NaF PET/CT to assess extraosseous calcification.

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Spontaneous Regression of Clinically Indolent Lymphomas Revealed by 18F-FDG PET/CT

Pan, Qingqing; Luo, Yaping; Cao, Xinxin; More

Clinical Nuclear Medicine. 44(4):321-323, April 2019.

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A 48-year-old man and a 55-year-old woman, who were diagnosed with follicular lymphoma and small B lymphocytic cell lymphoma, respectively, underwent initial "watch-and-wait" approach against lymphoma. The initial 18 F-FDG PET/CT of both patients showed multiple FDG-avid lymph nodes in the neck, mediastinum, abdomen, and inguinal regions. During their active surveillance, the follow-up PET/CT of both patients revealed spontaneous regression of lymphoma.

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Variable 131I Activity in Multiple Hepatic Cysts in a Patient With Thyroid Cancer

Shao, Fuqiang; Tang, Jiali; Lan, Xiaoli

Clinical Nuclear Medicine. 44(4):324-326, April 2019.

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Various etiologies could cause focal 131 I accumulation. Hepatic cyst is one of these etiologies. Here we present a 59-year-old man with a history of papillary thyroid cancer resection who received radioiodine therapy for three times. The images after the 131 I therapy of the second and third time showed variable activity uptake in the same hepatic cysts.

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Remarkable Response of Pulmonary Metastases Rather Than Remnant Thyroid in 131I Therapy of Follicular Thyroid Cancer

Tian, Tian; Chen, Yu; Xiang, Yongzhao; More

Clinical Nuclear Medicine. 44(4):327-329, April 2019.

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A 66-year-old man with follicular thyroid cancer after total thyroidectomy was referred for 131 I therapy. Thyroid function tests before 131 I administration exhibited severe thyrotoxicosis although the patient did not take levothyroxine after thyroidectomy. A 185 MBq 131 I whole-body scintigraphy and SPECT/CT revealed multiple iodine-avid pulmonary metastases with the largest tumor diameter of 1.4 cm and remnant thyroid. A diagnosis of thyrotoxicosis caused by hyperfunctioning pulmonary metastases was then made. The patient was administered 7.4 GBq of 131 I. Six months after 131 I therapy, a significant reduction of the pulmonary metastatic disease and thyroglobulin level was observed. However, the remnant thyroid was still visualized.

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Hepatocellular Carcinoma Mimicking Neuroendocrine Tumor Metastasis on 68Ga-DOTATATE PET/CT

Ulaner, Gary A.; Bodei, Lisa

Clinical Nuclear Medicine. 44(4):330-331, April 2019.

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68 Ga-DOTATATE is a radiolabeled somatostatin analog used for the detection and characterization of somatostatin receptor (SSR)–overexpressing tumors, particularly well-differentiated neuroendocrine tumors. We present a case of a 65-year-old man with well-differentiated pancreatic neuroendocrine tumor post–Whipple surgery and a new liver lesion on CT. 68 Ga-DOTATATE PET/CT was performed for SSR characterization and restaging, which demonstrated the lesion to be intensely SSR positive and interpreted as a neuroendocrine metastasis. However, subsequent pathology proved the lesion to be a hepatocellular carcinoma. This case adds hepatocellular carcinoma as a potentially DOTATATE-avid malignancy to be considered in the differential diagnoses of SSR-positive liver lesions.

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Diagnosis of Primary Clear Cell Carcinoma of the Vagina by 18F-FDG PET/CT

Fu, Zhanli; Chen, Xueqi; Yang, Xing; More

Clinical Nuclear Medicine. 44(4):332-333, April 2019.

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A 41-year-old woman presented with irregular vaginal bleeding, and a vaginal tumor was found and proved to be a clear cell carcinoma by biopsy. An 18 F-FDG PET/CT was performed to exclude its metastatic possibility, which showed the vaginal tumor was the only lesion with 18 F-FDG avidity. The vaginectomy and hysterectomy were performed to resect the lesion, and primary clear cell carcinoma of the vagina was finally diagnosed.

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Acral Involvement of Lymphoblastic Lymphoma Revealed on FDG PET/CT

Wen, Zhe; Zhuang, Hongming

Clinical Nuclear Medicine. 44(4):334-336, April 2019.

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Lymphoma rarely involves hand or foot. We presented the FDG PET/CT findings of lymphoblastic lymphoma in a 28-year-old man who had recurrent disease in many bones, including those of the hand and foot without any lymph node involvement 17 years after initial diagnosis.

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Superscan 18F-Fluciclovine PET/CT of PSA-Negative Prostate Cancer Bone Metastases

Chen, Bo; Macapinlac, Homer A.; Lu, Yang

Clinical Nuclear Medicine. 44(4):337-338, April 2019.

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A 76-year-old man presented with recently diagnosed prostate adenocarcinoma, Gleason score of 4 + 4, and a Super bone scan with concurrent PSA of 1.7 ng/mL. Approximately 3.5 months later, an 18 F-fluciclovine PET/CT was performed despite of a decreased PSA of 0.3 ng/mL. A Superscan fluciclovine PET/CT was identified, and bone metastasis were later confirmed at biopsy.

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Pericholecystic Rim Sign and Gallbladder Nonvisualization Indicating Acute Gangrenous Cholecystitis on 99mTc-MIBI Myocardial Perfusion SPECT

Qutbi, Mohsen; Ahmadi, Reyhana

Clinical Nuclear Medicine. 44(4):339-340, April 2019.

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Rim sign is assumed as an ominous sign of gangrenous cholecystitis and mandates an urgent surgery. The main mechanism by which this phenomenon arises is increased regional blood flow as a result of an inflammatory process. Therefore, it is expected that this finding be visualized in varieties of scans with various radiopharmaceuticals, including myocardial perfusion scan with 99m Tc-MIBI as an extracardiac finding. Herein, we present a case of acute cholecystitis with a rim sign on preoperative myocardial perfusion SPECT using 99m Tc-MIBI, which posed the possibility of gangrene and perforation and thus the need for urgent surgical intervention.

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Safety and Efficacy of Combined Peptide Receptor Radionuclide Therapy and Liver Selective Internal Radiation Therapy in a Patient With Metastatic Neuroendocrine Tumor

Maccauro, Marco; Follacchio, Giulia Anna; Spreafico, Carlo; More

Clinical Nuclear Medicine. 44(4):e286-e288, April 2019.

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Nuclear medicine treatments of well-differentiated neuroendocrine tumors (NETs) are gaining increasing acceptance among clinicians. Peptide receptor radionuclide therapy (PRRT) is an effective systemic treatment, providing a significant survival benefit and improving patients' quality of life. Locoregional selective internal radiation therapy (SIRT) is a safe and effective treatment for unresectable NET liver metastases, providing good local tumor control and symptomatic relief. Few reports in literature examine the sequential use of PRRT and SIRT in metastatic NET. We report the case of a metastatic NET patient treated with sequential PRRT-SIRT achieving a long disease control interval without cumulative toxicity issues.

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Inflammatory Activity of Tumoral Calcinosis in a Patient With Fever of Unknown Origin

Gühne, Falk; Drescher, Robert; Seifert, Philipp; More

Clinical Nuclear Medicine. 44(4):e289-e290, April 2019.

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Unexpected inflammatory activity of tumoral calcinosis periarticular to the shoulders and hips in a man with recurrent fever of unknown origin and dialysis-dependent kidney insufficiency was revealed by FDG PET/CT. In absence of other pathologies, the calcinosis was deemed to be the cause of the fever. An infectious or malignant disease could be ruled out, so further therapeutic steps were enabled.

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68Ga-PSMA-11 PET/MR Can Be False Positive in Normal Prostatic Tissue

Ferraro, Daniela A.; Rupp, Niels J.; Donati, Olivio F.; More

Clinical Nuclear Medicine. 44(4):e291-e293, April 2019.

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Prostate-specific membrane antigen (PSMA) is a transmembrane glycoprotein expressed in the cytosol of normal prostate tissue and highly overexpressed on the membrane of prostate cancer, therefore increasingly used to image prostate cancer. We report a case of a 65-year-old man with two focal PSMA-positive areas on a 68 Ga-PSMA-11 PET/MR, one corresponding to a prostate carcinoma (Gleason score 4 + 3) and another region without any evidence of malignancy, but with corresponding high PSMA-expression on immunohistochemistry.

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18F-FDG PET/CT Demonstrates Renal Cell Cancer in a Transplant With Synchronous Intestinal Infection

Kavanal, Anwin Joseph; Bharati, Joyita; Vadi, Shelvin Kumar; More

Clinical Nuclear Medicine. 44(4):e294-e295, April 2019.

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We present a case of a 22-year-old man with history of allogenic renal transplantation on immunosuppression, who underwent 18 F-FDG-PET/CT to characterize a lesion in the transplanted kidney on ultrasonogram and contrast-enhanced computed tomography imaging. PET/CT revealed FDG avid lesion in the transplanted kidney and mural thickening involving the distal ileum, ileocecal junction, and ileocolic lymph nodes. Subsequent histopathological examination from the renal lesion revealed renal cell carcinoma in the transplanted kidney. Additionally, endoscopic biopsy from the ileal thickening revealed granulomatous inflammation, suggesting tuberculosis, which was missed on both ultrasonogram and contrast-enhanced CT imaging.

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Atypical Presentation of T-Cell Large Granular Lymphocytic Leukemia Mimicking Pleural Malignancy on 18F-FDG PET/CT

Senthil, Raja; Visakh R., Arun; Pratap, Thara; More

Clinical Nuclear Medicine. 44(4):e296-e297, April 2019.

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T-cell large granular lymphocytic leukemia is a rare form of leukemia, caused by clonal proliferation of cytotoxic T-cells, characterized by modest lymphocytosis and cytopenias of other lineage with hepatosplenomegaly and relatively rare lymph nodal involvement. Involvement of other organs is extremely rare. It is predominantly an indolent disease and most of patients remain asymptomatic for a long period. We present a rare case of aggressive form (CD56 positive) of large granular lymphocytic leukemia with atypical presentations mimicking pleural malignancy on 18 F-FDG PET/CT.

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18F-FDG PET/CT in Intramuscular Mantle Cell Lymphoma With Elongated Lymphomatous Neurovascular Extension

Hod, Nir; Levin, Daniel; Anconina, Reut; More

Clinical Nuclear Medicine. 44(4):e298-e300, April 2019.

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Skeletal muscle involvement by lymphoma is rare, particularly for mantle cell lymphoma. We describe a 65-year-old man who presented with a rapidly growing left thigh mass. FDG PET/CT characterized the mass as malignant. Interestingly, an unusual hypermetabolic elongated tumorous extension was demonstrated arising from the intramuscular mass disseminating alongside the neurovascular bundle of the thigh up to the groin. Histopathology revealed intramuscular mantle cell lymphoma. In this case, we aim to highlight this interesting FDG PET/CT imaging finding, which can serve as a clue allowing one to strongly suggest lymphoma as the leading diagnosis.

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68Ga-PSMA Uptake in Prostate Cancer Sciatic Nerve Metastasis

Gouveia, Patrícia Barros; Violante, Liliana Catarina Sobral; Teixeira, Ricardo Jorge Valpaços; More

Clinical Nuclear Medicine. 44(4):e301-e302, April 2019.

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Most prostate cancers spread to regional lymph nodes, axial skeleton and lungs. Perineural malignant involvement is very rare. We present a 68 Ga-PSMA PET/CT image of a sciatic nerve metastasis in a 65-year-old man with recurrent prostate cancer.

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Incidental 18F-NaF Uptake in Drug-Induced Gynecomastia

Kothekar, Esha; Raynor, William Y.; Al-Zaghal, Abdullah; More

Clinical Nuclear Medicine. 44(4):e303-e304, April 2019.

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Gynecomastia is not uncommon in men older than 50 years of age and is characterized by glandular proliferation of breast tissue. Non-physiologic gynecomastia is mostly caused by a variety of external medical interventions. Medications that belong to classes of antiandrogens, antipsychotics, or antibiotics alter the levels of estrogen and testosterone and are commonly implicated in patients with gynecomastia. We are presenting a case of bilateral 18 F-NaF uptake in the breast tissue of a 56-year-old man with known history of prostate cancer.

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18F-Choline PET/CT Imaging for Intracranial Hemangiopericytoma Recurrence

Jehanno, Nina; Cassou-Mounat, Thibaut; Mammar, Hamid; More

Clinical Nuclear Medicine. 44(4):e305-e307, April 2019.

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We report the case of a 50-year-old man, with previous history of grade 3 intracranial hemangiopericytoma with initial complete surgical resection, addressed for local recurrence. Surgical revision performed 18 months after initial surgery allowed only partial resection, leaving residual disease along the optic nerve. Complementary radiotherapy with proton was decided. 18 F-FDG PET/CT and 18 F-choline PET/CT were both performed for treatment planning. 18 F-FDG PET showed no uptake of the residual tumor, whereas 18 F-choline depicted highly metabolic residual disease uptake with excellent delineation of local recurrence. 18 F-choline PET/CT appears as a useful PET tracer for hemagiopericytoma imaging.

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Multifocal Small Bowel Carcinoid: Evaluation by 68Ga-DOTATATE PET

Clark, Michael; Nathan, Mark; Broski, Stephen

Clinical Nuclear Medicine. 44(4):e308-e310, April 2019.

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Carcinoid is a subtype of neuroendocrine tumor, a rare group of tumors that are known to express somatostatin receptor 2. 68 Ga-DOTATATE is a somatostatin analog that is specific for somatostatin receptor 2 and therefore allows visualization of neuroendocrine tumors. We present 2 cases of primary multifocal small bowel carcinoid evaluated using 68 Ga-DOTATATE PET/CT, along with contrast-enhanced CT corollary findings. Given the increased sensitivity of 68 Ga-DOTATATE PET/CT compared with CT and 111 In-octreotide scintigraphy, we expect multifocal carcinoid to become increasingly recognized.

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Primary Pulmonary Paraganglioma Revealed by FDG PET/CT

Shen, Guohua; Su, Minggang; Kuang, Anren

Clinical Nuclear Medicine. 44(4):e311-e312, April 2019.

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Primary pulmonary paraganglioma is a rare type of extra-adrenal paragangliomas arising from neuroectodermal-derived paraganglionic tissue. We report herein the case of a 49-year-old woman with a round-like well-defined nodule in the right middle lobe detected by chest CT. FDG PET/CT also revealed this homogeneous nodule with increased FDG accumulation. Finally, the patient underwent right middle lobe resection, and the pathological findings demonstrated the diagnosis of pulmonary paraganglioma.

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Hereditary Spherocytosis Presenting as Diffuse Bone Marrow Activation and Splenomegaly on PSMA-Targeted 18F-DCFPyL PET/CT

Gomez, Erin; Tran, Phuoc T.; Pienta, Kenneth J.; More

Clinical Nuclear Medicine. 44(4):e313-e314, April 2019.

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We present the case of a 71-year-old man with Gleason 3 + 3 = 6 pT2N0MxR0 adenocarcinoma of the prostate who presented with rising PSA level 16 years after radical prostatectomy. PSMA-targeted 18 F-DCFPyL PET/CT was performed, which demonstrated recurrent disease in the prostatectomy bed as well as splenomegaly and mild-diffuse bone marrow activation, consistent with the patient's history of hereditary spherocytosis. We briefly review the clinical characteristics of hereditary spherocytosis, its appearance on molecular imaging studies, the normal biodistribution of 18 F-DCFPyL, and the PSMA-RADS scoring system for characterizing findings on PSMA-targeted PET imaging.

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Meningeal Metastasis Relapse With Focal Involvement of Cranial Bone Flap: A Case Resolved by 18F-DOPA PET/MRI

Louarn, Nicolas; Dauta, Aurélie; Lechapt-Zalcman, Emmanuèle; More

Clinical Nuclear Medicine. 44(4):e315-e317, April 2019.

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A 63-year-old woman was referred to our PET/MRI platform to evaluate the possible relapse of a meningeal metastasis, complicating an invasive ductal carcinoma of the left breast. This metastasis was diagnosed on a left hemiparesis and treated by surgery and radiation therapy. One year later, the same symptoms led to another brain MRI examination that found a contrast-enhanced lesion in the operating site. We decided to perform a 18 F-DOPA PET/MRI to document this lesion, which confirmed the diagnosis of a probable relapse and revealed a focal uptake on the bone flap.

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 Collapse Box Letters to the Editor

Response Assessment of 223Ra Treatment: Should a Fluorocholine PET/CT Be Performed?: Reply

García Vicente, Ana María; Soriano Castrejón, Angel

Clinical Nuclear Medicine. 44(4):341-342, April 2019.

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Re: The Prognostic Value of 18F-FDG PET/CT in Monitoring Chemotherapy in Ovarian Cancer Both at Initial Diagnosis and at Recurrent Disease

Rubello, Domenico; Marzola, Maria Cristina; Colletti, Patrick M.

Clinical Nuclear Medicine. 44(4):342-344, April 2019.

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131I and 124I Accumulation in a Thymic Cyst: Reply

Freesmeyer, Martin; Kunze, Almut; Winkens, Thomas

Clinical Nuclear Medicine. 44(4):344, April 2019.

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• Tumor Identification of Less Aggressive or Indolent Lymphoma With Whole-Body 11C-Acetate PET/CT
• Baseline Pancreatic Beta Cell Imaging After Pancreatic Transplantation Using Whole-Body 68Ga-DOTA-Exendin-4 PET/CT: A Spectrum of ...
• Resolution of Hypoxic Tissue in Cerebellar Hemispheres After Arterial Bypass Surgery in a Patient With Symptomatic Bilateral...
• Multiple Myeloma of Testes and Spermatic Cord on 18F-FDG PET/CT
• High-Resolution Brain 18F-FDG Images Provided by Fully Digital PET
• Predicting Response to Immunotherapy by Evaluating Tumors, Lymphoid Cell-Rich Organs, and Immune-Related Adverse Events Using...

Cardiovascular Echography

Left atrial volume during stress is associated with increased risk of arrhythmias in patients with hypertrophic cardiomyopathy Giuseppe Limongelli, Vincenzo Fioretti, Marco Di Maio, Marina Verrengia, Marta Rubino, Rita Gravino, Daniele Masarone, Antonello D'Andrea, Quirino Ciampi, Eugenio Picano, Perry Elliott, Giuseppe Pacileo Journal of Cardiovascular Echography 2019 29(1):1-6 Introduction: In patients affected by hypertrophic cardiomyopathy (HCM), left atrial volume index (LAVi) is associated with an increased risk of tachyarrhythmias and major clinical events. To date, the clinical meaning of LAVi measured during exercise (stress LAVi [sLAVi]) has not yet been investigated in HCM. This study sought to evaluate the correlation between LAVi/sLAVi and clinical outcome (risk of arrhythmias and heart failure [HF]) in patients with HCM. Methods and Results: We enrolled a total of 51 consecutive patients with HCM (39 men; mean age: 39.41 ± 17.9 years) who underwent standard and stress echocardiography, following a common protocol. During follow-up (median follow-up was 1.82 years), the following composite endpoints were collected: ARRHYT endpoint (atrial fibrillation, paroxysmal supraventricular tachycardia, nonsustained ventricular tachycardia (VT), sustained VT, ventricular fibrillation, syncope of likely cardiogenic nature, and sudden cardiac death) and HF endpoint (worsening of functional class and left ventricular ejection fraction, hospitalization, and death for end-stage HF). Eight patients were lost at follow-up. ARRHYT endpoint occurred in 13 (30.2%) patients (8, 18.6%, supraventricular and 10, 23.2%, ventricular arrhythmias), whereas HF endpoint occurred in 5 (11.6%) patients. sLAVi (mean value of 31.16 ± 10.15 mL/m2) performed better than rLAVi as a predictor of ARRHYT endpoint (Akaike Information Criterion: 48.37 vs. 50.37, if dichotomized according to the median values). A sLAVi value of 30 mL/m2 showed a predictive accuracy of 72.1% (C-statistics of 0.7346), with a high negative predictive value (87.5%). Conclusion: These findings encourage future studies on sLAVi, as a potential predictor of arrhythmias and adverse outcome in patients with HCM.

StepWise protocols for scoring of mitral valve using three-dimensional transthoracic echocardiography in mitral stenosis Ashraf M Anwar, Wael M Attia Journal of Cardiovascular Echography 2019 29(1):7-13 Aim: This study aims to propose protocols that enable scoring of mitral valve (MV) in mitral stenosis using the three-dimensional (3D) scoring system. Methods: A two-staged study was conducted. The first stage was designed to select the best 3D images of MV leaflets and chordae through analysis of 471 images. The second stage was designed to organize the best 3D images into protocols for complete scoring of MV. It included 35 consecutive patients; 23 had sinus rhythm (SR) and 12 had atrial fibrillation (AF). Both single- and multi-beat 3D acquisition from apical and parasternal windows were focused on MV leaflets and chordae using all 3D modalities (live, zoom, and full volume). To propose the protocols, 1563 images were analyzed. Results: In SR with good apical window, 2 protocols were recommended for complete scoring of leaflets and chordae (4 zoom 3D images [1 image for leaflets and 3 images for chordae] and 1 full-volume 3D image) using single- and multi-beat acquisition. In AF, the same 2 protocols using single-beat acquisition were recommended. From parasternal window, complete scoring of leaflets was obtained by 3 recommended protocols (single- or multi-beat zoom 3D images from parasternal short axis [PSAX], multibeat live 3D images from PSAX, and single- or multi-beat full-volume 3D images from parasternal long axis) in SR and 1 protocol in AF (single-beat zoom 3D images from PSAX). Scoring of chordae was incomplete in all patients by all 3D modalities. Conclusions: The proposed 3D-transthoracic echocardiography protocols suit all patients regardless of echo window and heart rhythm and enabled complete MV scoring.

Three-dimensional echocardiographic imaging of a Gerbode defect complicating transcatheter aortic valve replacement Hani Al Sergani, Domenico Galzerano, Olga Vriz, Jehad Al Buraiki Journal of Cardiovascular Echography 2019 29(1):14-16 We describe a case of a 77-year-old male who underwent transcatheter aortic valve implantation (TAVR) with Edwards SAPIEN XT size 26 mm for severe aortic stenosis. Postprocedural transesophageal echocardiography (TEE) showed left-to-right shunt between the left ventricular outflow tract just below the bioprosthesis and the right atrium across the atrioventricular septum (Gerbode defect). Three-dimensional echocardiography (3DE) allowed a detailed anatomical imaging of the shape and the location of a small, circular, atrioventricular defect that was a type II, direct, supravalvular, Gerbode-type defect. This is the third report of a Gerbode defect after TAVR whose diagnosis has important implications on clinical decision-making. TEE plays a key role; its diagnostic ability is enriched by the additional value of 3DE.

Ventricular Septal Defect Complicating Inferior Acute Myocardial Infarction: A Case of Percutaneous Closure Donatella Ferraioli, Giuseppe Santoro, Michele Bellino, Rodolfo Citro Journal of Cardiovascular Echography 2019 29(1):17-19 Ventricular septal defect (VSD) is one of the most serious mechanical complications of acute myocardial infarction (AMI). Despite the incidence of post-AMI VSD in reperfusion era has reduced from 1%–2% to 0.17%–0.31%, it is a still life-threatening condition with poor prognosis. Surgical VSD closure is considered the best treatment approach since conservative management carries an extremely high mortality rate. Over the last decade, percutaneous transcatheter closure has emerged as an alternative therapeutic strategy for a patient with post-AMI VSD, with outcomes similar to cardiac surgery (30-day mortality 14%–66%). We present a case of inferior AMI complicated by posterobasal VSD and cardiogenic shock successfully treated with percutaneous closure. The role of echocardiography in diagnosis, management, and percutaneous procedure guiding has been emphasized.

Amniotic fluid embolism in a grown-up congenital heart disease patient Elena De Angelis, Costantina Prota, Rosanna Matturro, Rodolfo Citro Journal of Cardiovascular Echography 2019 29(1):20-22 Amniotic fluid embolism (AFE) is a rare but potentially lethal obstetric condition affecting women during labor, delivery, or also in the immediate postpartum period, when amniotic fluid, fetal cells, hair, or other debris could enter the maternal circulation. We present the first case of AFE described in literature in a 33-year-old patient with a complex history of congenital heart disease, where the crucial points for successful course were the prompt recognition and treatment of the disease and the use, for the first time, as diagnostic tool for AFE, of right ventricular free-wall longitudinal speckle-tracking strain.

Dual coronary-pulmonary fistula firstly found at routine doppler echocardiogram Grazia Casavecchia, Stefano Zicchino, Matteo Gravina, Alessandro Martone, Andrea Cuculo, Luca Macarini, Matteo Di Biase, Natale Daniele Brunetti Journal of Cardiovascular Echography 2019 29(1):23-25 Congenital coronary-pulmonary fistulas (CPFs) are defined as an abnormal direct communication between one or more coronary arteries, with a cardiac or thoracic structure bypassing the capillary network. We report the case of a 73-year-old male, with a history of hypertension, asymptomatic for angina and dyspnea, who was referred for routine clinical control. Echocardiogram unexpectedly showed the presence of diastolic flow from the pulmonary trunk in parasternal short-axis view. Pulsed-wave Doppler confirmed the presence of diastolic flow and displayed the typical coronary flow pattern. Coronary angiography hence showed the presence of dual CPFs originating from the second segment of the left anterior descending coronary and the right coronary arteries. Careful routine Doppler echocardiograph examination may raise the suspicion of CPF in case of otherwise unexplained symptoms and may represent a simple, easy, repeatable tool for the first suspected diagnosis and follow-up of CPFs.

A rare case of left subacute atrial dissection: Multimodality imaging approach Alberto Lavorgna, Carmine Villani, Donatello Fabiani, Cosimo Napoletano Journal of Cardiovascular Echography 2019 29(1):26-28 Today, left atrial dissection is described as a rare complication of cardiac surgery, particularly after a mitral valve replacement. We report a rare case of left subacute atrial dissection occurred as a result of a domestic accidental fall. Transesophageal echocardiogram, angio-computed tomography, and magnetic resonance imaging showed an intramural formation with clear margins and a seamless cleavage with the posterolateral wall of the left atrium, which determined an obstacle to the ventricular filling. The patient was then operated in order to empty the hematoma and reattach the atrial wall.

Giant right coronary artery aneurysm detected by transthoracic echocardiography Matteo Pernigo, Marco Triggiani, Samuele Pentiricci, Graziano Montresor Journal of Cardiovascular Echography 2019 29(1):29-31 Coronary artery aneurysms (CAAs) are rare findings caused by atherosclerosis in about 50% of cases. They are usually diagnosed using coronary angiography, cardiac computed tomography, or magnetic resonance imaging. In this report, we present a rare case of giant, isolated right CAA, detected by transthoracic echocardiography in an adult patient with unstable angina. Diameters of the aneurysm were 3.6 cm × 2.7 cm. Anterior-septal hypokinesia of the left ventricle was also noted. A comprehensive echocardiographic examination, including contrast study, excluded alternative diagnoses and supported the hypothesis of a coronary ectasia. The coronary angiography confirmed the diagnosis of giant coronary aneurysm and revealed a severe three-vessel disease. The patient was treated with cardiac surgery a few days later: two coronary artery bypass grafts and exclusion of the aneurysm by surgical legation were successfully performed.

A nonfatal massive pulmonary embolism in a very old patient: The protective filter-effect of the Chiari Network Andrea Sonaglioni, Gian Luigi Nicolosi, Michele Lombardo, Claudio Anza Journal of Cardiovascular Echography 2019 29(1):32-34 The Chiari network, a net-like structure within the right atrium, has been described as an embryonic remnant of no clinical significance. Its role in facilitating paradoxical arterial embolic events and as a potential site for thrombus formation has been reported in the literature. This case illustrates the protective filter-effect of the Chiari network in a 92-year-old women who presented with the clinical signs and symptoms of acute cor pulmonale. Transthoracic echocardiography revealed a large, S-shaped, and extremely mobile right atrial thrombus within the Chiari network. Here, the authors describe how the Chiari network may have prevented the occurrence of a fatal pulmonary embolism acting as a protective factor.

Never too grown-up for a congenital heart disease: Diagnosis of transitional atrioventricular canal in a 50-year-old male Francesca De Angelis, Ketty Savino, Alessandro Colombo, Mariagrazia Sardone, Giuseppe Ambrosio Journal of Cardiovascular Echography 2019 29(1):35-38 Transitional atrioventricular (AV) septal defects are uncommon congenital heart defects, and diagnosis is usually made in childhood. We present the case of intermediate AV canal diagnosed in a man referring to cardiological examination for the first time in his life at the age of fifty for exertional dyspnea. The absence of medical examination or execution of electrocardiogram or echocardiogram in childhood or in youth and the very late appearance of symptoms lead to a late diagnosis of this congenital heart disease (CHD). This case underlines the importance of including CHD in the differential diagnosis of symptoms such as chronic dyspnea, also in adulthood.