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Background: We report a case of a 54-year-old female patient with carcinoma of the left breast with persistent methylene diphosphonate (MDP) uptake in sclerotic osseous lesions. These lesions were finally declared treated osseous metastatic lesions due to non-avidity on the 18-fluorine-fluorodeoxyglucose positron-emission-tomography/computed tomography [F-18 FDG Positron emission tomography (PET-CT)] scan, normalization of CA-15.3, and resolution of bone pains. To the best of our knowledge, this has not been reported previously. Case Presentation: A 54-year-old woman with persistent backache was referred for further evaluation by a Tc99m MDP bone scan. A Tc99mmMDP bone scan showed wide-spread skeletal metastatic disease. Magnetic resonance imaging (MRI) showed extensive marrow disease involving the spine and iliac bones. A bone marrow biopsy revealed metastatic carcinoma with a tumor phenotype favoring breast primary. On further workup, the patient was diagnosed with invasive ductal carcinoma of the left breast and was treated with cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors along with hormone therapy and bisphosphonates, followed by radiation therapy for bone metastasis. The skeletal metastatic disease remains static on three consecutive Tc99m MDP bone scans, despite the clinical improvement and decreased tumor marker levels. The F-18-FDG-FDG-CT scan done for monitoring treatment response revealed multiple non-avid sclerotic osseous lesions, favoring treatment response. The patient was continued with the same treatment, and a follow-up Tc99m MDP bone scan after 6 months revealed no interval change in the reported lesions compared to the initial scan. However, a synergistically performed F-18 FDG PET-CT scan again showed multiple non-avid sclerotic osseous lesions suggestive of treated metastasis. Conclusion: This case highlights the importance of 18-F-FDG PET-CT in evaluating the treatment response, especially in patients with symptomatic improvement and falling tumor marker levels with static disease on repeated Tc99m MDP bone scans. [ABSTRACT FROM AUTHOR]

Background: Failure to treat persistent hypothyroidism despite the use of adequately prescribed doses of levothyroxine should be evaluated for malabsorption and nonadherence to medication. Previous literature suggested that orally administered levothyroxine showed maximum absorption at or near 2 hours. This rapid absorption suggests the use of a 2-hour levothyroxine absorption test as an alternative to long, cumbersome protocols. Limited data are available measuring free thyroxine (FT4) levels at 2 hours after oral administration of 1,000 mcg of levothyroxine. Case Presentation: Six patients who continued to have hypothyroidism despite taking ostensibly high doses of levothyroxine underwent a 2-hour protocol levothyroxine absorption test. All patients were given 1,000 mcg of levothyroxine, and serum levels of thyroid-stimulating hormone (TSH), FT4, and free triiodothyronine (FT3) were measured at 0, 60, and 120 minutes. All patients showed an increasing trend in FT4 in subsequent samples at 60 and 120 minutes, compared to baseline values, providing strong evidence of peak levothyroxine absorption at 2 hours. Five patients had raised baseline TSH levels, indicating nonadherence to treatment, and one had normal baseline TSH levels, indicating adherence to levothyroxine therapy on prior test scheduling, with increased FT3 and FT4 levels in subsequent samples at 60 and 120 minutes. Conclusion: We conclude that the rapid levothyroxine absorption test, using a 2-hour protocol, is a more convenient method to differentiate nonadherence from malabsorption. Moreover, scheduling the patient will result in adherence to levothyroxine therapy in some patients. [ABSTRACT FROM AUTHOR]

Prostate cancer (PCa) is the second most common malignancy in males and the leading cause of cancer-related deaths among men. In recent years, novel therapies have emerged for metastatic castration-resistant prostate cancer including immunotherapy, androgen-receptor signaling inhibitors, and radio-nuclide therapies. DNA Damage Repair (DDR) genes are frequently mutated in advance PCa and are useful biomarkers for targeted therapy such as poly ADP ribose polymerase inhibitors. DDR gene defects may affect tissue radio-sensitivity and could serve as biomarkers for therapy with alpha and beta-emitting radionuclides. Preliminary clinical reports suggest a potential trend toward longer survival in DDR+ subjects when treated with a-emitters, however, survival benefit was not significant in patients treated with β-emitting radionuclides. A comprehensive study regarding the impact of DDR genes in PCa patients treated with alpha emitters is vital. [ABSTRACT FROM AUTHOR]

Papillary thyroid cancer is the most prevalent and indolent thyroid cancer, but still, around 20% of cases will develop regional recurrence or distant metastasis. Isolated or coexistent BRAF V600E and telomerase reverse transcriptase promotor (pTERT) mutations in thyroid cancer are associated with poor clinical outcomes. The prior knowledge of BRAF V600E and pTERT mutation may help to identify the cases that may recur or become refractory to standard radioactive iodine treatment. Such cases could be treated initially with complete disease eradication through extensive surgery followed by maximum permissible high-dose radioactive I-131 ablation and vigilant follow-up. Conventional risk assessment coupled with genotype-based risk assessment can help in the precise management of aggressive thyroid cancers. [ABSTRACT FROM AUTHOR]

Over the past few decades, the incidence of thyroid cancer, which was once a relatively uncommon aspect of oncology, has significantly increased worldwide. This tendency makes opening new horizons and finding new modalities for both its diagnosis and therapy all the more crucial. The concept of theranostics in thyroid cancer has shown potential in individualizing treatments, and tailoring therapies to the specific molecular characteristics of the patient's cancer. [ABSTRACT FROM AUTHOR]

Background: Osteopoikilosis (OP) is a benign, uncommon disorder that is inherited by the autosomal dominant gene. Multiple benign enostoses are present in this specific kind of sclerosing skeletal dysplasia, which can be mistaken for osteoblastic skeletal metastases. Case Presentation: We present here a case of a 50-year-old male patient with pain in the lower back for 3 months. His pelvic X-ray showed a few sclerotic rounded lesions in the ilium, acetabulum, and proximal femur. His magnetic resonance imaging (MRI) pelvis showed T1 and T2 weighted image hypo intense focal lesions in the ilium and acetabulum. His 99m Technetium methylene diphosphonate bone scan was done showing no focal abnormal uptake in the lesion reported on pelvic X-ray and MRI. These features are suggestive of OP, ruling out osteoblastic skeletal metastasis. Conclusion: OP is usually an incidental finding on radiograph. Both X-ray and MRI findings can mimic skeletal metastasis, but a normal bone scan can rule out metastasis and is useful if metastatic disease is thought to be a possibility. [ABSTRACT FROM AUTHOR]

Introduction: The condition known as scrotal cystocele occurs when the urinary bladder slides through the inguinal canal and fills the scrotum. It is a rare condition that typically affects obese male patients between the ages of 50 and 70. Massive scrotal cystocele in men younger than 45 or in the pediatric population is uncommon. Most people with scrotal cystocele are asymptomatic or present with the typical two-phase micturition with intermittent swelling that goes down after voiding. Presentation of the case: We present the case of a 44-yearold obese man who visited the radiology department with unusual symptoms, such as urinary frequency, urgency, nocturia, and suprapubic pain, along with scrotal enlargement. He was diagnosed as having a large scrotal cystocele based on his clinical history and radiological findings. Discussion: Rarely, reported cases include massive scrotal cystocele and left-sided ureter herniation. Preoperative diagnosis of IBH is important to lessen postoperative complications. Conclusion: Ultrasound, computed tomography intra-venous urogram (IVU), fluoroscopic cystography, antegrade IVU, and singlephoton emission computerized tomography aid to diagnose the scrotal cystocele or mimicking inguinal metastasis on bone scan. [ABSTRACT FROM AUTHOR]

Obtaining clear localization images in nuclear medicine can be challenging when radiotracers are administered locally. This lack of anatomical information can make it difficult to relate the scintigraphic findings to specific body structures. Various localization techniques such as point source, cobalt wires, transmission scans using Cobalt-57 (57Co) and Gadolinium-153 (153Gd), and hybrid imaging (single photon emission computed tomography) can be employed to overcome this issue. The primary goal of this communication is to summarize the available body contour outlining methods in nuclear medicine and provide a comprehensive guide for nuclear medicine trainees to obtain high-quality localization images that can facilitate the better evaluation of nuclear medicine scans. [ABSTRACT FROM AUTHOR]

Background: Hot kidneys had been reported on bone scan in few patients with hepatocellular carcinoma (HCC), but their cause is unknown. This study was conducted to compare the 99mTc-MDP renal parenchymal retention on bone scan in HCC patients with normal controls and chronic liver disease (CLD) patients and to correlate it in HCC patients with glomerular filtration rate (GFR). Methods: Fifteen normal, 15 CLD, and 85 HCC patients with normal serum urea and creatinine underwent bone scan. Renal parenchymal retention index (PRI) in terms of the kidney-to-lumbar vertebrae counts ratio was calculated, and its mean was compared between these three groups by using Student's t-test. Last consecutive 25 HCC patients underwent 99mTc DTPA dynamic renal scan, and mean PRI in patients with normal GFR (group I, n = 6) was compared with those with deranged GFR (group II, n = 19). Results: Mean PRI was 26.8% higher in CLD patients than control group (p = 0.000). Mean PRI in HCC group was 99.7% higher than control (p = 0.000) and 59.6% higher than that of CLD group (p = 0.004). GFR was deranged in 76% of HCC patients. Mean PRI was 36.9% higher in group II than group I at p = 0.023. Conclusion: Renal parenchymal retention on bone scan is significantly higher in HCC patients than normal control and CLD patients. In HCC patients, it was significantly higher in patients with reduced GFR than those with normal GFR. [ABSTRACT FROM AUTHOR]

Background: Patients with differentiated CA thyroid are treated with surgery followed by radioactive iodine-131 therapy. Pregnancy and lactation are absolute contraindications to radio-iodine therapy. Lactation after radio-iodine therapy results in thyroid dysfunction of infant which may lead to hypothyroidism. Case presentation: We describe a case of 24-year old male who developed permanent hypothyroidism at the age of 2 years after breast feeding from mother treated with radio-iodine for CA thyroid in spite of proper advice. Conclusion: Lactation should be stopped in patients treated with radioactive I-131 therapy through maternal education and counselling. It is necessary to avoid radio-iodine induced hazards to infants and close follow up is needed if lactation is not ceased after radio-iodine therapy. [ABSTRACT FROM AUTHOR]

Background: Dual phase parathyroid imaging with Tc99m methoxyisobutylisonitril (MIBI) is well known for the detection of parathyroid adenomas. We describe a unique case of brown tumor and double parathyroid adenomas in the neck. Case presentation: A 56-year-old female visited the Nuclear Medicine Department for parathyroid scanning. She underwent left parathyroidectomy 4 months ago and histopathology confirmed the diagnosis of parathyroid adenoma. However, her parathyroid hormone levels (2213 pg/ml) were consistently raised, even after the surgery. The patient was again referred to the Nuclear Medicine Department for parathyroid scanning. The second MIBI scan showed an abnormal area of radiotracer retention in the neck, near upper pole of right lobe of thyroid gland, favoring parathyroid adenoma with a focus of increased uptake in the chest on left side. Conclusion: This report emphasizes the importance of dual phase Tc99m MIBI scintigraphy in persistent hyperparathyroidisim following the parathyroid surgery. It also highlights possibility of double parathyroid adenoma or the ectopic parathyroid adenoma. [ABSTRACT FROM AUTHOR]

Background: Hepatocellular carcinoma (HCC) is the 5th leading cancer which metastasizes to bones in 3%-20% cases. The routes of metastasis from HCC include hematogenous, lymphatic, or direct invasion/dissemination/seedlings into the surrounding cavities. The 99mTc-methylene diphosphonate (MDP) bone scintigraphy is a sensitive imaging technique for early detection of skeletal metastasis. Methods: Bone scans of 220 patients with HCC from 1st January 2012 to 31st December 2017, referred to Nuclear medicine department for evaluation of skeletal metastasis, were analyzed. About 70% presented with backache followed by rib cage pains (25%). Results: Out of total 220 patients, 40 patients (18%) had skeletal metastasis on 99mTc-MDP bone scans, with solitary to multiple metastasis ratio was 1:9. Vertebrae were the most common site of metastasis (27/40 patients, 67%). Most striking characteristic of bone metastasis of HCC was the presence of soft tissue element in vertebral metastasis. This soft tissue element is responsible for compression symptoms in these patients. These soft tissue components were poorly outlined on routine planner bone scans due to poor99mTc-MDP uptake but were better diagnosed with Single Photon Emission Tomography / Computed Tomography.- Conclusion: Skeletal metastatic distribution of HCC follows an unusual pattern on 99mTc-MDP bone scan with a unique feature of soft tissue component, especially in larger lesions involving spine. During radiotherapy planning, these soft tissue lesions must be included in the field of irradiation to improve post radiotherapy outcome and may play a vital role in determining progression or regression of the disease. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal (GI) tract duplication, or GI duplication cyst, is a rare congenital abnormality that may arise anywhere from the GI tract. We present a unique case of a 2-year-old girl having a large GI duplication cyst with ectopic gastric mucosa (EGM) diagnosed on 99mTc pertechnetate single-photon emission computed tomography-computed tomography (SPECTCT) scintigraphy. Case Presentation: A 2-year-old girl with a history of fresh bleeding per rectum and abdominal distention was referred to the nuclear medicine department for Meckel's scanning to rule out Meckel's diverticulum. Meckel's scanning along with SPECT-CT showed abnormal radiotracer accumulation in the dilated gut loops in the right side of the abdomen simultaneously with that of the stomach, indicative of EGM in GI duplications cyst. Conclusion: We conclude that although GI duplication cyst with EGM is a rare entity, it should be kept in mind while interpreting the Meckel's scan. 99mTc pertechnetate SPECT-CT scintigraphy is a useful modality though not commonly used for the preoperative diagnosis of GI duplications cyst with EGM. This case report emphasizes the use of 99mTc pertechnetate SPECT-CT scintigraphy while evaluating the patients with lower GI bleed. [ABSTRACT FROM AUTHOR]