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The aim of this study was to evaluate the incremental value of cocktail F-FDG/F-NaF PET/CT over F-FDG PET/CT alone for detection of skeletal metastases in breast cancer patients.Seventy patients with locally advanced/recurrent breast cancer were prospectively included. All patients underwent whole-body F-FDG PET/CT and cocktail F-FDG/F-NaF PET/CT within a span of 1 week. Both studies were evaluated to detect presence of skeletal/marrow metastases on PET/CT images by 2 nuclear medicine physicians. Clinical and radiological correlation/follow-up was used as criterion standard.Of 70 patients, 50 (71.0%) had locally advanced breast cancer, and 20 had recurrent breast cancer. On patient-wise analysis, both cocktail PET/CT and F-FDG PET/CT identified skeletal/marrow lesions in 23 (32.8%) of 70 patients. In 8 patients (11.4%), only cocktail PET/CT identified skeletal/marrow lesions, whereas F-FDG PET/CT was negative. In the rest of the 39 patients (55.8%), no skeletal/marrow lesion was identified on both scans. Good correlation was noted between cocktail PET/CT and F-FDG PET/CT results (r = 0.785, P0.0001). Cocktail PET/CT detected lesions in significantly more number of patients than F-FDG PET/CT alone (P = 0.007). On lesion-wise analysis, cocktail PET/CT detected more number of lesions in 20 patients as compared with F-FDG-PET/CT alone. Both scans detected same number of lesions in the rest of 11 patients with positive findings. A total of 32 additional lesions were identified on cocktail PET/CT imaging as compared with F PET/CT alone (P0.0001).Cocktail F-FDG and F-NaF PET/CT is superior to F-FDG PET/CT alone for the detection of skeletal/marrow metastases in breast cancer. It can be a better alternative to F-FDG PET/CT alone in facilities where both tracers are available.

Aim: Acute organophosphate (OP) pesticide poisoning causes substantial morbidity and mortality worldwide. Many imaging modalities, such as computerized tomography (CT), magnetic resonance imaging (MRI), and single photon emission computed tomography (SPECT) of the brain, have been used for quantitative assessment of the acute brain insult caused by acute OP poisoning. Perfusion defects on SPECT in acutely poisoned patients with OPs have been described, however, MR perfusion abnormalities have not been described in the literature. MR perfusion Imaging has the advantage of having higher spatial resolution, no radiation, and better availability. Materials and Methods:In this prospective study, 20 patients who ingested OP compounds were included. All the patients underwent brain SPECT on a dual head SPECT gamma camera and MRI brain on a 1.5T MR system. Neurocognitive tests were performed for all patients.Results: SPECT showed perfusion defects in 7 patients and total number of perfusion defects were 29. On MR perfusion, based on the cut-off values of normalized cerebral blood volume (nCBV) ratios and normalized cerebral blood flow (nCBF) ratios, the total number of patients showing perfusion defects were 6 and 8; and the total number of perfusion defects were 29 and 45, respectively. There was significant difference of the nCBV ratios and nCBF ratios between the control group (n = 20) and positive patients group (n = 6 and n = 8, respectively) (P > 0.05). All the defects seen on SPECT were well appreciated on nCBF maps (MRI perfusion) suggestive of 100% correlation. Conclusion: MR perfusion imaging can be used as an effective modality for evaluation in acute OP poisoning.

Ga-labeled prostate-specific membrane antigen (PSMA) ligand PET/CT is a rapidly evolving imaging modality for prostate cancer. However, with the widespread use of Ga-PSMA PET/CT, various reports of nonprostatic uptake of Ga-PSMA in both benign and malignant lesions have also appeared. We report a recently diagnosed case of prostate cancer demonstrating diffuse Ga-PSMA expression in both the lobes of thyroid gland, which on further clinical and biochemical investigations was established as hypothyroidism.

HER2/neu is over expressed in 20–25% of breast cancers. HER2 breast cancers are aggressive and are associated with poor prognosis. The aim of this study was to develop the clinical grade Lu-177-trastuzumab and its preliminary evaluation for specific tumor targeting in HER2 positive breast cancer patients. Trastuzumab was conjugated to bifunctional chelator, DOTA, and characterized for integrity and the number of molecules conjugated. Radiolabeling of DOTA-conjugated trastuzumab was optimized using Lu-177. Quality control parameters including radiochemical purity, stability, sterility, pyrogenicity and immunoreactivity were assessed. A preliminary pilot study was conducted on breast cancer patients (n = 6 HER2 positive and n = 4 HER2 negative) to evaluate the ability of Lu-177-trastuzumab for HER2 specific tumor targeting. The conjugates were efficiently labeled with Lu-177 with high radiochemical purity (up to 91%) and specific activity (6–13 µCi/µg). Lu-177-trastuzumab was stable up to 12 hr post labeling. The radioimmunoassay demonstrated good antigen binding ability and specificity for HER2 receptor protein. The patient studies showed the localization of Lu-177-trastuzumab at primary as well as metastatic sites (HER2 positive) in the planar and SPECT/CT images. No tracer uptake was observed in HER2 negative patients that indicated the specificity of Lu-177-trastuzumab. The study demonstrated that in-house developed Lu-177-trastuzumab has specific targeting ability for HER2 expressing lesions and may in future become a palliative treatment option in the form of targeted radionuclide therapy for disseminated HER2 positive breast cancer.

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

Neoplasms arising from the urachus are extremely rare. We present a case of a young woman with mild abdominal pain and a palpable swelling in the mid abdomen with incidental detection of a subumbilical mass. Repeated fine-needle aspiration cytology failed to reveal the true nature of the lesion. F-FDG PET/CT showed tracer uptake in the cranial end of urachal remnant lesion. Core biopsy from the site with maximal FDG uptake turned out to be lymphomatous involvement in urachus, which is extremely rare and previously unreported.

Ga-prostate-specific membrane antigen (PSMA) ligand is a well-known tracer used in prostate cancer. Nevertheless, there are reports of unusual Ga-PSMA uptake in variety of benign lesions. We report a case of prostate cancer in which Ga-PSMA PET/CT revealed tracer avidity in the enhancing walls of cystic lesions in the brain consistent with the features of neurocysticercosis. The uptake of Ga-PSMA in neurocysticercosis is not known and may be attributed to angiogenesis occurring at the periphery of these lesions.

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

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

Primary adrenal lymphoma (PAL) is a relatively rare disease entity with only fewer than 200 cases reported till date. PAL frequently presents with bilateral adrenal involvement and shows male preponderance. We here present a case of PAL in a 65-year-old female with a relatively uncommon unilateral adrenal involvement. The present case depicts that 18F-fluorodeoxyglucose positron emission tomography/computed tomography had decisive role in the treatment management of this patient suggesting its potential utility in the management of this rare disease.

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

Patients with multiple endocrine neoplasia type 1 usually have a combination of endocrine disorders due to lesions in the pancreas, parathyroid gland, and pituitary gland. Functional imaging using different tracers in addition to conventional imaging are applied in localizing the primary sites, determining the disease extent, and characterizing the lesions. We present a diagnosed case of multiple endocrine neoplasia type 1 with interesting incidental imaging findings showing 99mTc-sestamibi and 18F-fluorocholine uptake in addition to 68Ga-DOTANOC uptake in metastatic mediastinal and cervical lymph nodes arising from gastroenteropancreatic neuroendocrine tumor. This case shows the possibility of imaging the neuroendocrine tumors with 3 different tracers, namely 68Ga-DOTANOC, 99mTc-sestamibi, and 18F-fluorocholine.

Although 18F-fluorodeoxyglucose (FDG) is the most extensively used tracer in oncological positron emission tomography/computed tomography (PET/CT) studies, various physiological as well as benign pathological conditions are known to cause false-positive results. This report describes 18F-FDG PET/CT done in an elderly man with primary hepatocellular carcinoma, revealing a metastasis mimicking lesion in the left inguinal canal, which was identified as the herniated portion of the urinary bladder. Though rare, bladder herniation, especially with a narrow neck, can be a pitfall in the evaluation for metastatic disease. The study also highlights the utility of delayed imaging in the evaluation of pelvic pathology.

Objective Inoperable and metastatic pheochromocytomas and paragangliomas (PPGLs) present a therapeutic challenge with current treatment options being limited to radiolabelled meta-iodo-benzyl-guanidine (MIBG) and systemic chemotherapy. Peptide receptor radionuclide therapy (PRRT) seems to be a promising option for these patients with few studies reporting favourable response. This systematic review was conducted to evaluate the efficacy and safety of PRRT in patients with advanced PPGLs. Methods This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Searches in PubMed, Scopus and Embase were made using relevant keywords and articles up to May 2019 were included. Data on efficacy and toxicity were extracted from the individual articles, and pooled estimates were generated using meta-analysis. Results Twelve articles consisting of 201 patients with advanced PPGLs were included. Overall, treatment with PRRT achieved an objective response rate of 25% (95% CI: 19%-32%) and a disease control rate of 84% (95% CI: 77%-89%). Clinical and biochemical responses were seen in 61% and 64% of the patients, respectively. Among the PRRTs, similar tumour response rates were noted for 90 Y-yttrium- and 177 Lu-lutetium-based agents. Treatment-related adverse effects were minimal with grade 3/4 neutropenia, thrombocytopenia, lymphopenia and nephrotoxicity observed in 3%, 9%, 11% and 4% of the patients, respectively. Treatment discontinuation was noted in five out of 102 patients. Conclusions Peptide receptor radionuclide therapy is a safe and efficacious treatment option for advanced PPGLs and may be considered a viable alternative to chemotherapy and I-131 MIBG.

F-FDG PET/CT imaging is an important diagnostic tool for accurate staging and assessment of response to neoadjuvant chemotherapy (NACT) in patients with locally advanced breast carcinoma (LABC). However, F-FDG being non-specific marker, it also accumulates in inflammatory conditions, leading to false positive results. Angiogenesis, an essential characteristic for tumor development, intrusion and metastasis can be imaged using Ga-labeled RGD tripeptide. We here depict a series of clinically staged LABC patients who underwent both Ga-DOTA-RGD2 and F-FDG PET/CT imaging for staging and illustrate the similarities and significant differences between the two tracers.

Purpose To study the role of 18FDG- PET (Flourodeoxyglucose positron emission tomography) in a) determining the extent of cranial and extra-cranial disease and b) diagnosis as well as prognosis of CNS TB (central nervous system tuberculosis) including TBM (tuberculous meningitis). Patients and methods This prospective observational study (n = 70) was carried out at a tertiary care institute in Northern India from 1.1.2017 to 30.6.2018. Diagnosis of TBM was made according to modified Ahuja's criteria. All patients were evaluated in detail and treated as per standard guidelines. All patients underwent 18FDG-PET scanning of brain and whole body at baseline. Results Mean age was 35.2 ± 14.8 years. There were 37 men. Majority of patients (n = 47; 67.1%) were below 40 years of age. 43 (61.4%) patients were in stage II TBM. The mean duration of illness was 77 ± 101.9 days. Majority of patients presented with fever (94.3%), headache (90%) and vomiting (84.3%). MRI was abnormal at baseline in 67 (95.7%) of patients, most common abnormalities being meningeal enhancement (68.6%) and tuberculomas (57.1%). PET was abnormal in 66 (95.7%) of patients. All these patients had either lung lesions (n = 62, 88.6%) or lymphadenopathy (n = 61; 87.1%). 18FDG-PET revealed evidence of brain lesions in 52 (74.3%) patients. It revealed vertebral involvement in 19 (27.1%) and genitourinary lesions in 9 (12.9%) patients. PET evidence of lymphadenopathy correlated significantly (p = .04) with good outcome in CNS TB. Conclusion 18FDG-PET does seem to have a promising role in initial evaluation of patients with CNS TB.

We present a case of endometrioid carcinoma metastasis in the bladder mimicking as the second primary of urinary bladder on 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18F-FDG PET/CT). The presentations of bladder lesions on 18F-FDG PET/CT are varied, and rare presentations of common malignancies can pose a significant diagnostic challenge as in the index case and highlight the importance of histopathological examination to confirm any unusual FDG uptake confounding the diagnosis.

Malignant melanoma is a highly aggressive tumor and surgical resection is the primary treatment. However, the chances of recurrence are quite high despite complete resection. The aim of study was to evaluate the 18F-fluorodeoxyglucose(18F-FDG) positron emission tomography–computed tomography (PET/CT) in detection of recurrent melanoma after curative surgery and its prognostic value. Fifty-four melanoma patients (32 women) with prior primary lesion resection were evaluated with 18F-FDG PET/CT for clinically suspicious recurrent disease. The diagnostic accuracy of 18F-FDG PET/CT (visual interpretation as well as semi-quantitative parameter) was determined on the basis of subsequent imaging and clinical follow-up. Melanoma-specific survival and risk of progression (hazard ratio [HR]) were assessed using Kaplan–Meier method and Cox regression analysis. 18F-FDG PET/CT detected recurrent diseases in 36 (66%) patients including distant metastases in 13 patients and second synchronous malignancy in 2 patients. Overall, the sensitivity, specificity, positive predictive value, and negative predictive value of 18F-FDG PET/CT were 91.2%, 80.0%, 88.6%, and 84.2%, respectively, with area under the curve of 0.86 (95% confidence interval: 0.74–0.97; P < 0.05). Positive 18F-FDG PET/CT study was associated with a significantly shorter overall survival than negative study (30.8 ± 4.6 vs. 64.5 ± 6.9 months, P < 0.05). Apart from positive 18F-FDG PET/CT scan, maximum standardized uptake value (SUVmax) >2.7 and combination of both were independently associated with an increased risk of disease progression (HR = 7.72, 21.58, and 11.37, respectively; P < 0.05). 18F-FDG PET/CT showed enhanced diagnostic performance in patients with suspicious recurrent malignant melanoma leading to appropriate management. FDG positivity along with SUVmax >2.7 provides important prognostic value in predicting the survival outcomes and assessing the risk of disease progression.

Radiolabeled Arg-Gly-Asp (RGD) peptide derivatives have immense potential for non-invasive monitoring of malignancies overexpressing integrin α

Multiple-myeloma (MM) is a malignant plasma cell proliferation disorder and the second most common blood malignancy after non-Hodgkin lymphoma. The chemokine (CXCR-4) receptor analogues are the newer agents being postulated for myeloma imaging and have shown good diagnostic performance. We report a case of plasmacytoma with suspicious renal cell carcinoma, in whom Ga CXCR-4 PET/CT revealed tracer-avid lesion in the left perinephric region. PET/CT-guided biopsy from the tracer-avid lesion revealed plasmacytoma. PET/CT-imaging and guided biopsy using Ga CXCR4 receptor ligand, proved its usefulness for accurate localization of the culprit lesion and helped in definitive management of the patient.

To study the prevalence and characteristics of Sensory processing abnormalities (SPAs) in children with autism and to study if there is any correlation between sensory processing abnormalities with FDG-PET findings in children with severe autism. One hundred children, aged 3–12 y, diagnosed as Autistic spectrum disorder; ASD (DSM-V) and 100 age and sex matched controls were studied. SPAs were detected using Short sensory profile (SSP) questionnaire. Children with progressive neurological diseases, active epilepsy and structural brain abnormalities were excluded. On Childhood Autism rating scale, 30 children had severe and 70 had mild-moderate autism. The pattern of sensory processing abnormalities in children with severe ASD was compared with mild-moderate ASD. FDG-PET scan was done in children with severe autism and correlated with SPAs. All children with severe autism had sensory processing abnormalities as compared to only 40% children with mild-moderate autism. Underresponsiveness/seeking-sensation was affected in all children with severe ASD and 82% had movement sensitivity. In children with mild-moderate ASD, 45% had auditory filtering, 30% had movement sensitivity and 27% had underresponsiveness/seeking-sensation. FDG-PET was abnormal in 17% of children with severe autism. Diffuse cerebral/ temporal lobe hypometabolism, increased bilateral frontal lobe uptake and moderate reduction in parietal lobe (Lt > Rt) was observed. All patients with severe autism had SPAs. However, they did not correlate with FDG-PET findings.

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

Infection of aortic valve-tube graft, although rare, is associated with high morbidity and mortality. Early identification of site and extent of infection is not only challenging but also crucial for adequate patient management and prognostication of disease. Combined clinical, laboratory investigation and imaging modalities assist in the identification of aortic valve graft infection. Molecular imaging techniques like PET/CT using F-FDG and F-FDG-labeled autologous leukocytes (LALs) have improved the sensitivity for detection of infection, resulting in better outcome for these patients. F-FDG-labeled autologous leukocyte PET/CT in our patient after Bentall procedure accurately localized the site and extent of infection.

Paraneoplastic syndromes are symptom complexes that cannot be readily explained by local or distant spread of the tumor. They can occur due to hormone production, autoimmunity or other biologically active products produced by the tumor, etc. Tumor induced osteomalacia is a rare paraneoplastic syndrome in which the manifestation is mainly musculoskeletal such as bone pain, fractures and muscle weakness as a consequence of elaboration of fibroblast growth factor 23 (FGF23) by the tumor. Most of these tumors are solitary and small and hence localization of these tumors is often challenging. This review summarizes the various anatomic imaging modalities such as plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI) and nuclear medicine imaging techniques in the evaluation of these tumors.

F-Fluorocholine is a relatively new, extremely versatile radiotracer for detecting proliferative or mitogenic activity. Its diagnostic potential has been explored in cancers of the prostate, liver, esophagus, breast, brain, and lung, as well as lymphoma, sarcoma, melanoma, and parathyroid adenomas. The authors present a case where fluorocholine PET/CT performed for characterizing a space-occupying lesion in the brain revealed intensely tracer-avid skull lesions with intracranial soft tissue component and multiple other skeletal lesions. Fine-needle aspiration cytology from the skull and chest wall lesions confirmed the diagnosis of plasma cell neoplasm.

Thick-walled gallbladder is difficult to characterize on conventional imaging. 18F-FDG PET was used to differentiate benign and malignant wall thickness and compared with histopathology. Thirty patients with gallbladder (GB) wall thickening (focal > 4 mm and diffuse > 7 mm), underwents uspected on ultrasound, or CT scan, and underwent 18F-FDG PET. Histopathology of the specimen was compared with imaging findings. The mean age was 48.22 ± 31.33 years with a M:F 1:4 ratio. Twenty patients had diffuse and 10 had focal thickening. On 18F-FDG PET, lesion was benign in 12, malignant in 13, and indeterminate in 5. Histopathology was malignancy in 12; benign in 18-chronic cholecystitis in 11, xanthogranulomatous in 4, IgG4 related in 2, and polyp in 1. The mean GB wall thickness was 7.79 ± 3.59 mm (10.34 malignant and 6.10 in benign, p = 0.001). At a cutoff of 8.5 mm, the sensitivity and specificity of detecting malignancy was 94% and 67%. The mean SUV uptake was 7.46 (benign 4.51, malignant 14.26, p = 0.0102). At a cutoff of 5.95, the sensitivity and specificity of detecting malignancy was 92% and 79%. For 18F-FDG PET, overall sensitivity was 91%, specificity 79%, PPV 77%, NPV 92%, and diagnostic accuracy was 84%. 18F-FDG PET is a reliable method of differentiation between benign and malignant thickening of the gallbladder particularly when wall thickness and SUV value is taken into account.

68Ga-labeled prostate-specific membrane antigen (PSMA) ligand positron emission tomography/computed tomography imaging (PET/CT) is a rapidly evolving imaging modality for prostate cancer. Many studies have proved its superiority in staging, restaging, and detecting the recurrent prostate cancer. However, case reports describing the incidental tracer uptake in benign and nonprostatic malignancies are also reported in the literature, thus questioning the specificity of the tracer. This pictorial assay illustrates the nonspecific tracer uptake encountered during PSMA PET/CT imaging, knowledge of which can increase the confidence of interpreting physicians and may also open a new path for peptide receptor radionuclide therapy in nonprostatic malignancies.

Osteogenic sarcoma is an aggressive malignant bone tumor arising from primitive mesenchymal bone-forming cells. Ossification is the characteristic feature of the metastases in osteosarcoma which aids their detection on 99mTc-MDP bone scintigraphy. Although lung is the most common site of metastasis in osteogenic sarcoma, pleural involvement with effusion and skip metastases are rare. Herein, we report a case of osteogenic sarcoma of distal femur with diffuse calcified pleural thickening leading to malignant pleural effusion, calcified lung, lymph node, and bone metastases illustrated on bone scan.

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

Purpose of the Study: Radioiodine (I-131) is used as an effective noninvasive treatment for thyroid malignancies. Salivary gland is one of the most affected nontarget organs. The present study aims to perform early quantification of salivary gland function after I-131 therapy (RIT) for thyroid cancer considering I-131 down-scatter in the Tc-99m window. Materials and Methods: A total of 20 patients (6 males and 14 females) with differentiated thyroid carcinoma were enrolled in the study. Baseline dynamic salivary scintigraphy was performed in all patients using 185–370 MBq (5–10 mCi) Tc-99m pertechnetate. Posttherapy, salivary scintigraphy was performed 10–25 days after RIT in the range of 1.85–7.4 GBq (50–200 mCi). Time–activity curves obtained from the pre- and posttherapy dynamic salivary scintigraphy were used for semi-quantitative analysis. Uptake ratio (UR), ejection fraction (EF%), and maximum accumulation (MA%) were calculated by drawing regions of interest of individual parotid and submandibular glands over a composite image, after correcting for down-scatter from I-131 in the Tc-99m window. A paired t-test was used for comparison of the parameters obtained. Results: Significant changes were observed in UR and EF% of both parotid and submandibular glands (P < 0.05). No significant changes were found in the value of MA% of left parotid gland and both submandibular glands in the posttherapy scans in comparison to pretherapy scans (P > 0.05). However, significant difference was observed in the MA% of the right parotid gland (P = 0.025). Conclusion: Salivary gland function was found to deteriorate after RIT, with the parotid glands affected more than the submandibular glands.

Insulinomas are rare neuroendocrine tumors which occur predominantly in the pancreas. Although majority of the insulinomas are benign, over-secretion of insulin by the tumor leads to debilitating hypoglycemic symptoms. The diagnosis is based on clinical and biochemical findings. After the diagnosis is made, the principal challenge lies in locating the tumor because most tumors are solitary and small in size. Locating the tumor is of paramount importance as complete surgical excision is the only curative treatment, and incomplete resection leads to persistence of symptoms. Different preoperative and intraoperative imaging techniques have been used with varying success rates for the insulinoma imaging. Besides localizing the tumor, imaging also helps to guide biopsy, detect metastatic lesions, and perform image-guided therapeutic procedures. This review will discuss the role of different Cross sectional and nuclear medicine imaging modalities in insulinomas.

Objectives This prospective study was aimed to determine and quantify the change in mandibular condylar hyperactivity over a period of time by using a fluorine-18 (18F) fluoride PET-computed tomography (CT) scan. Materials and methods Sixteen patients (age 19.50 ± 2.58 years) with noticeable faciomandibular asymmetry caused by unilateral condylar hyperplasia (UCH) were included in the test group and underwent an 18F-fluoride PET-CT scan at the beginning of the study (T0); these patients were then followed up for a minimum of 12 months, after which the 18F-fluoride PET-CT scan was repeated at first follow-up (T1). An age-matched control group consisted of 10 patients with apparently symmetrical faces whose PET-CT scans were acquired for some other medical conditions. Statistical analysis of maximum standardized uptake values (SUV max) obtained through 18F-fluoride PET-CT was performed using the paired t-test. Results Mean SUV max of the affected condyle at T0 and T1 was 9.18 ± 4.07 and 9.18 ± 3.88, respectively. The mean SUV max of the contralateral condyle at T0 and T1 was 6.21 ± 2.30 and 6.66 ± 2.64, respectively. The mean right-left difference in tracer uptake between the test and control groups both at T0 and T1 was statistically significant. Right-left percentage difference of isotope uptake of the test group was 16.87 ± 15.75% at T0 and 14.97 ± 12.72% at T1. Right-left percentage difference of isotope uptake of the control group was 5.51 ± 5.72%. Although these differences were statistically significant, their clinical relevance was insignificant. SUV max of the higher uptake side and the lower uptake side of the control group was 5.63 ± 1.85 and 5.09 ± 1.83, respectively. Conclusion Great diversity exists in the clinical presentation of UCH. The growth trend of UCH is highly variable because of the age and sex of patients. The results of the present study show that the 18F-fluoride PET-CT scan may guide us in determining the right time and in making the right choice of surgico-orthodontic intervention in UCH patients. The clinical presentation and SUV max of PET-CT of UCH patients were in agreement with each other. The baseline values of the control group indicated that these could also be used to differentiate normal from abnormal condylar growth in potential class III skeletal pattern cases - that is, patients having sagittal skeletal dysplasia resulting from either maxillary deficiency or mandibular protrusion, or both in combination, thus resulting in a concave facial profile.

The present study is aimed at carrying out a comparative performance evaluation of different types of (68)Ge/(68)Ga generators to identify the best choice for use in (68)Ga-radiopharmacy. Over the 1 year period of evaluation, the elution yields from the CeO2-based and SiO2-based (68)Ge/(68) Ga generators remained almost consistent, in contrast to the sharp decrease observed in the elution yields from TiO2 and SnO2-based generators. The level of (68)Ge impurity in (68)Ga eluates from the CeO2 and SiO2-based (68)Ge/(68)Ga generator was always

PET with fluorodeoxyglucose F 18 (FDG)/computed tomography (CT) imaging has significantly improved the management of head and neck cancer. FDG, however, is not tumor-specific and various image interpretation pitfalls may occur because of false-positive and -negative causes of FDG uptake. Routine imaging examination of head and neck malignancies does not yield all of the necessary data, even with the most advanced imaging technique. Specific interventions, such as use of different dynamic maneuvers and pharmacologic interventions, may provide useful information about the lesion. This article reviews the use of special techniques in FDG PET/CT imaging and whole-body FDG PET/CT imaging for evaluation of head and neck cancer.

Introduction The present article demonstrates a ‘mix-and-use' approach for radiolabeling RGD peptide derivative with 68 Ga, which is easily adaptable in hospital radiopharmacy practice. The radiotracer thus formulated was successfully used for positron emission tomography (PET) imaging of breast cancer in human patients. Methods The conditions for radiolabeling NODAGA-coupled dimeric cyclic RGD peptide derivative [NODAGA-(RGD) 2 ] with 68 Ga were optimized using 68 Ga obtained from a 68 Ge/ 68 Ga generator developed in-house with CeO 2 -PAN composite sorbent as well as from a commercial 68 Ge/ 68 Ga generator obtained from ITG, Germany. Preclinical studies were carried out in C57BL/6 mice bearing melanoma tumors. The radiotracer was prepared in a hospital radiopharmacy using 68 Ga obtained from ITG generator and used for monitoring breast cancer patients by positron emission tomography (PET) imaging. Results 68 Ga-NODAGA-(RGD) 2 could be prepared with high radiolabeling yield (>98%) and specific activity (~50GBq/μmol) within 10min at room temperature by mixing 68 Ga with the solution of the peptide conjugate. In vivo biodistribution studies showed significant uptake (5.24±0.39% ID/g) in melanoma tumor at 30min post-injection, with high tumor-to-background contrast. The integrin α v β 3 specificity of the tracer was corroborated by blocking study. Preliminary clinical studies in locally advanced breast cancer (LABC) patients indicated specifically high tumor uptake (SUV max 10–15) with good contrast. Conclusions This is one of the very few reports which presents preliminary clinical data on use of 68 Ga-NODAGA-(RGD) 2 and the developed ‘mix-and-use' holds tremendous prospect in clinical PET imaging using 68 Ga.

Tamoxifen is the most prescribed anticancer oral drug for increasing overall survival and decreasing recurrence and the risk of contralateral disease. However, some side effects, such as endometrial and liver tumors, thromboembolic disorders, and drug resistance, are associated with long-term tamoxifen treatment. We assessed the hematologic and organ toxicity after oral administration of three different doses of nanotamoxifen formulations. We also performed biodistribution studies of Technetium-99m (99mTc)-nanotamoxifen after intravenous administration. The results demonstrated that nanotamoxifen was well-tolerated, with no adverse effect on biochemical parameters of blood and at the cellular level. Nitric oxide (NO) levels indicated no free radical formation. Oral nanotamoxifen is well-tolerated, with no hepatic or renal toxicity. Intravenous nanotamoxifen has potential to escape the liver, and is known for producing the harmful metabolite 4-hydroxytamoxifen (4OH-tamoxifen), which can cause uterine cancer.

Background: Primary hyperparathyroidism (PHPT) is characterized by inappropriately elevated serum parathyroid hormone (PTH) level despite elevated serum calcium. Insulin resistant is the basic pathophysiology, behind the higher prevalence of diabetes mellitus in patients with PHPT. However, the improvement in insulin resistance (IR) after curative parathyroidectomy (CPTX) has not been established yet, as the study results are conflicting. Materials and Methods: In this prospective interventional study, ten patients with mild PHPT (Group 1) and another ten patients with moderate to severe PHPT (Group 2) were undergone CPTX. The IR was assessed by homeostasis model assessment-IR (HOMA-IR), quantitative insulin sensitivity check index (QUICKI), fasting plasma glucose (FPG), and fasting serum insulin (FSI), before and 3 months after CPTX. Results: There was no significant change of FPG and FSI, before and after CPTX in Group 1 (P = 0.179 and P = 0.104) and Group 2 (P = 0.376 and P = 0.488). Before surgery, HOMA-IR was higher, and QUICKI was significantly lower, in both Group 1 (P = 0.058 and P = 0.009) and Group 2 (P = 0.023 and P = 0.005) as compared to published normal reference mean, with no significant difference between the groups. Three months after surgery HOMA-IR increased further and QUICKI remained unchanged as compared to baseline, in both Group 1 (P = 0.072 and 0.082) and Group 2 (P = 0.54 and 0.56), but statistically insignificant. Conclusion: IR remained unchanged after CPTX in mild as well as moderate to severe PHPT. Asymptomatic PHPT with abnormal IR should not be used as criteria for parathyroidectomy.

Bronchobiliary fistula (BBF), a rare complication of liver disease, is an abnormal communication between the biliary tract and bronchial tree. BBF may occur as a consequence of local liver infections such as hydatid or amebic disease, pyogenic liver abscess or trauma to the liver, obstruction of biliary tract, and tumor. As such management of liver disease with BBF is very difficult and often associated with a high rate of morbidity and mortality. Therefore, timely diagnosis of BBF is imperative. Hepatobiliary scintigraphy along with hybrid single photon emission computed tomography/computed tomography using Tc99m-mebrofenin is a very useful noninvasive imaging modality, in the diagnosis of BBF.

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

Primary neuroendocrine tumors of the liver are a diagnostic challenge. We present a rare case of primary hepatic neuroendocrine tumor in which Ga-DOTATATE PET/CT imaging played an important role in the diagnosis and follow-up.

Tracheal metastases from renal cell carcinoma (RCC) are extremely rare. Most common primary malignancy metastasizing to this unusual location usually comes from lung region while it is rare to have tracheal metastases from nonpulmonary malignancies such as breast, thyroid, colorectal carcinoma, and melanoma. The lesions detected on fluorine-18 fluorodeoxyglucose (F-18 FDG) positron emission tomography/computed tomography (PET/CT) scan, especially in the head and neck region, soft tissue, and muscular compartment during follow-up of RCC patients raise the possibility of metastatic lesions in these regions, though rarely encountered. F-18 FDG PET/CT proved to be a valuable noninvasive imaging tool in detecting the very unusual distant metastases and multisystem involvement many years after nephrectomy in RCC in a single session in the present case.

Ga-labeled prostate-specific membrane antigen ligand PET-CT has emerged as a promising technique to evaluate the extent of disease in patients with prostate carcinoma. We are reporting a 63-year-old man with prostatic carcinoma subjected to Ga-prostate-specific membrane antigen ligand PET-CT for initial staging. In addition to the radiotracer uptake in known primary site (prostate), focal increased radiotracer uptake was also noticed in the left breast. Subsequent biopsy of the breast lesion revealed PASH (pseudoangiomatous stromal hyperplasia), which is a benign mesenchymal proliferative lesion that may present clinically as palpable mass requiring further evaluation to rule out malignancy.