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Objevtive(s): Neuroendocrine tumors are a heterogeneous group of neoplasms that arise from the peptide-producing cells of the neuroendocrine system. Different functional imaging methods have been suggested to diagnose NETs. There is still not enough evidence to recommend 68Ga-DOTATATE as a standard diagnostic tool in NETs. Therefore, the aim of this study was to assess the value of 68Ga-DOTATATE scan in detecting NETs. Methods: This was a cross-sectional study. All patients with a pathologically confirmed NET tumor referred to Masih Daneshvari Hospital affiliated to Shahid Beheshti University of Medical Sciences entered the study. Patients underwent a 68Ga-DOTATATE PET/CT. All statistical analysis were performed by SPSS software version 18. Results: Forty patients with a mean age of 48.1±15.80 years entered the study. Twenty-one (52.5%) were male and 19 (47.5%) female. In the studied patients, neuroendocrine tumor was present in 19 cases (47.5%) in pancreas and gastrointestinal tract, 9 (22.5%) in lung, 3 (7.5%) in mediastinum and adrenal gland, 6 cases (5%) in liver and 3 other sites. There was no significant association between mean age and gender with primary location of the tumor. The mean SUVmax was 11.62±20.02 and the the mean tumor size was 38.25±31.35 mm. The mean size of the metastasis was 40.55±24.53 mm. The mean percentage of ki-67 was 12.54±18.40. There was no significant correlation between SUVmax of the lesion and age (r=0.063, P=0.701), tumor size (r=-0.63, P=0.067) or Ki-67 (r=0.011, P=0.960). In 20 cases, metastases were reported, of which 14 were (70%) in the liver, 3 in the lungs (15%), 2 in the gastrointestinal and cervical lymph nodes, and 1 in the bones and pancreas(%5). Conclusion: 68Ga-DOTA-peptide PET/CT could find the primary or metastasis sites of NETs with good quality images. In general, this modality can enhance the management in patients with NETs.

Background: Flourine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan is employed for initial staging and restaging of esophageal cancer patients. Objectives: The present study aimed to assess the value of a semi-quantitative parameter of 18F-FDG PET/CT scan, that is, maximum standardized uptake value (SUVmax), to determine its correlation with patient survival in two subtypes of esophageal cancer, including squamous cell carcinoma (SCC) and adenocarcinoma. Patients and Methods: This cross-sectional study was performed on patients with esophageal SCC and adenocarcinoma, undergoing 18F-FDG PET/CT scan for initial staging before any treatment. The 18F-FDG PET/CT semi-quantitative parameter (SUVmax) was determined by reviewing the PET/CT images. The patients were reevaluated using 18F-FDG PET/CT scan for restaging within 12 - 24 months. Results: No significant difference was observed in the SUVmax values of the primary tumor, metastatic lymph nodes, or distant metastasis between the adenocarcinoma and SCC groups, regardless of response to treatment. Similarly, no significant association was found between the short-term survival of patients with adenocarcinoma and the SUVmax values of the primary tumor, metastatic lymph nodes, or distant metastasis. Based on the survival curve, one- and two-year survival rates were estimated at 75% and 63.9% in patients with SCC and at 80% and 60% in patients with adenocarcinoma, respectively. In the SCC group, a significantly higher SUVmax was detected in deceased patients with distant metastatic lesions compared to cancer survivors. According to the area under the ROC curve, the SUVmax of metastatic lesions showed high potential for predicting the mortality of SCC patients. Conclusion: The assessment of SUVmax in distant metastatic lesions by 18F-FDG-PET/CT may help predict the survival of patients with esophageal SCC. However, 18F-FDG-PET/CT findings were not associated with the survival of esophageal adenocarcinoma; therefore, further evaluations on a larger sample size and a longer follow-up are required.

Immune checkpoint inhibitors are a new and different treatment option in many of solid tumors, but with many recognized immune-related adverse side effects. In this interesting image, we are presenting a 56-year-old woman with primary malignant melanoma who underwent nivolumab therapy for 5 months, and a posttreatment whole-body FDG PET/CT scan for treatment response evaluation demonstrated increased metabolic activity in the entire major joints of the upper and lower extremities. This was a new finding compared with previous FDG PET/CT scan and was interpreted as an immune-related arthritis complication.

Background: Melanoma is one of the most serious types of skin cancer and one of the leading causes of cancer-related mortality worldwide. Objectives: This study aimed to investigate the association between 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography/computed tomography (PET/CT) scan findings and the pathological characteristics of primary tumors in patients with malignant melanoma. Patients and Methods: In this cross-sectional study, the baseline data of 103 patients with cutaneous or mucosal melanoma (stage III or IV) were recorded, and tumor characteristics and PET/CT scan findings were analyzed. The association between each pathological finding and PET/CT results was also investigated. Results: Patients without a free margin had a significantly higher mean standardized uptake value (SUVmax) of lung metastasis compared to patients with a free margin (3.12 vs. 1.69; P = 0.047). Also, patients with ulceration had a significantly higher mean SUVmax of lung metastasis compared to patients without ulceration (3.28 vs. 1.81; P = 0.041). Based on the results, increased primary tumor thickness was associated with a higher SUVmax of lung metastasis. However, there was no significant association between the metastasis type (single vs. multiple) and free margin, ulceration, or Ki-67 protein. The mean SUVmax of lung metastasis was significantly higher in mucosal melanoma compared to cutaneous melanoma. However, the mean SUVmax values of other metastases (bone, liver, and lymph nodes), even the primary lesion itself, were not significantly different between cutaneous melanoma and mucosal melanoma. Conclusion: The primary tumor margin status, ulceration, tumor thickness, primary tumor location (cutaneous vs. mucosal), and the presence of lung metastasis were significantly associated with PET/CT scan findings.

Background: The use of 68-gallium prostatespecific membrane antigen positron emission tomography/computed tomography (68Ga-PSMAPET/CT) scan has recently received particular attention in the evaluation of prostate cancer patients. Objectives: The present study aimed to evaluate the relationship between the prostate-specific antigen (PSA) level, Gleason score, and 68Ga-PSMAPET/CT findings in prostate cancer patients. Patients and Methods: In this cross-sectional study, 80 male patients with a definitive diagnosis of prostate cancer, who were candidates for 68Ga-PSMA PET/CT scan for both initial staging and restaging, were included. Restaging indicated biochemical recurrence, which refers to a detectable level of PSA after being documented undetectable following a definitive primary treatment. All prostate cancer patients, who were not initially treated with a definitive therapy, were excluded from the study. A cutoff value ≥ 4 was considered significant for maximum standardized uptake value (SUVmax) to differentiate benign from malignant 68Ga-PSMA-avid lesions. Any 68Ga-PSMA uptake outside the prostate bed, especially in the lymph nodes, bones, and visceral organs, was considered metastatic. Results: Comparison of the PSA level between two subgroups with and without metastasis demonstrated a higher PSA level in patients with metastatic abdominal lymph nodes and a slightly higher PSA level in patients with metastatic pelvic lymph nodes. No significant correlation was found between the Gleason score and the total PSA. There was also no significant association between the level of PSA and the type of Lymph node involvement (single or multiple) in different involved areas. Besides, there was no significant correlation between the SUVmax and the level of PSA and the Gleason score in different involved areas. Conclusion: The SUVmax value in 68Ga PSMA PET/CT scan provides a reliable predictor for neither the grade of prostate cancer, nor the metastatic status associated with cancer progression. The measurement of total PSA may predict metastasis to the abdominal and pelvic lymph nodes caused by prostate cancer.

Introduction: Rhinoplasty is one of the most common surgical procedures performed among Iranians. An important issue to be considered by nasal surgeons is anatomical variations between different ethnic groups. Working on Iranians with the existing ethnic variety encourages the need for an analysis of this particular population. Materials and Methods: The present cross-sectional observational study was conducted on Iranian patients who underwent primary open rhinoplasty at a university hospital in Tehran, Iran. The preoperative evaluations included routine aesthetic analysis as well as the measurement of the subcutaneous fat thickness (using ultrasound imaging) and the angle between the anterior nasal spine and the alveolar process of the maxilla. Intraoperative assessments were performed on the alar rim-inferior border of lateral crus distance, maximal width of lateral crus, connection pattern of upper lateral cartilage, and lower lateral cartilage. Alar cartilage thickness was measured with microscopic evaluation. Moreover, the similar studies conducted on other ethnic groups were reviewed as well. Results: In total, 66 cases were included in the study (41 females and 25 males) who were within the age range of 18-38 years old (27.82±5.51). According to the results, nasolabial angles were 93.68°±7.82° and 92.25°±6.98° in females and males, respectively. In addition, a significant correlation was found between the anterior nasal spine-maxilla angle and nasolabial angle (p

FDG PET/CT scan is a diagnostic imaging modality for oncologic patients, but with false-positive findings in inflammatory diseases. In this interesting case, we present a 24-year-old woman with history of giant cell tumor of the bone (lumbar vertebrae) who underwent whole-body FDG PET/CT scan for treatment response evaluation. FDG PET/CT scan demonstrated a large hypermetabolic tumoral mass lesion in segment VI/VII of the right hepatic lobe. A range of malignant versus benign lesions should be considered as differential diagnoses, including metastasis, primary cholangiocarcinoma, hepatocellular carcinoma, focal nodular hyperplasia, and infection. Final diagnosis of "steatotic hepatitis" after CT-guided biopsy was established.

We present a 37-year-old man with cough and progressive dyspnea for the past 3 years. According to inconclusive chest CT scan and lung biopsy histopathology findings, the patient referred for 18F-FDG PET/CT scan for further evaluation. Classic pulmonary manifestations of Langerhans cell histiocytosis were seen on CT images with intense FDG uptake on PET scan. Moreover, PET/CT revealed multiple hypermetabolic subcutaneous foci throughout his body. Finally, the patient was treated with corticosteroids. Follow-up chest CT images demonstrated improvement of lung lesions in accordance with improvement in the patient's symptoms. We are briefly discussing differential diagnoses in this patient.

Gallium-68-labeled prostate-specific membrane antigen (68Ga-PSMA), as a relatively new positron emission tomography (PET) radiotracer, can be used to evaluate tumors other than prostate cancer, including renal cell carcinoma and probably non-small cell lung cancer, as discussed in our case. We present the case of a 65-year-old man with a history of lung adenocarcinoma diagnosed in 2015 and a subsequent diagnosis of renal cell carcinoma in 2018, treated with a right lower lobectomy and a left partial nephrectomy, respectively. Both conditions were evaluated using 18F-fluorodeoxyglucose (18F-FDG) PET/computed tomography (CT) scan before surgery. A rise in prostate-specific antigen (PSA) was detected in the follow-up in September 2020, and the patient was referred for a 68Ga-PSMA PET/CT scan following pelvic magnetic resonance imaging (MRI). The 68Ga-PSMA PET/CT scan demonstrated avid lesions in both lung and kidney surgical beds. The 68Ga-PSMA PET/CT scan can be potentially used in patients with recurrent renal cell carcinoma to detect metastasis. This modality may also detect non-small cell lung cancer lesions; however, further investigation is needed.

Most primary small cells carcinoma develop from the lung, and extra-pulmonary small cell carcinoma accounts for less than 5% of all small cell carcinoma cases. In the head and neck region, the most common sites are the larynx and salivary glands; however primary involvement of the palate is extremely rare. The extra-pulmonary small cell carcinoma is similar to its pulmonary counterpart regarding morphology, immunohistochemistry, and electron microscopy features and derives from pluripotential stem cells that develop neuroendocrine features. There is growing evidence regarding the ability of extra-pulmonary small cell carcinoma to arise from pluripotent basilar cells capable of divergent differentiation with the consequence of arising neuroendocrine phenotype as a trans-differentiation phenomenon in the progression of an organ-specific carcinoma. The differentiation between primary and metastatic extra-pulmonary small cell carcinoma is challenging. There is also no standard guideline for treatment as it is a rare occasion, and there is no consensus between radiation oncologists and cancer surgeons about the best treatment strategy. In this study, a very rare case of hard palate small cell carcinoma with neuroendocrine pathology features is presented. To our best of knowledge, this is the third case report of extra-pulmonary small cell carcinoma involving the palate in the literature review. Knowing the clinical presentation and pathology characteristics of such rare tumor in addition to follow-up outcome can be highly useful to establish a reliable guideline for hard palate small cell carcinoma management.

In the era of coronavirus disease 2019 (COVID-19) pandemic, many cases may be misdiagnosed based on their semiology, laboratory tests or chest computed tomography (CT) images and further evaluation might be helpful in appropriately selected cases Methods:We are discussing usefulness of fluorodeoxyglucose (FDG) positron emission tomography PET/CT scan in appropriately selected suspicious cases of COVID-19 infection We are discussing two interesting cases on how18F-FDG PET/CT scan might be helpful to avoid COVID-19 infection diagnostic error Both cases had clinical symptoms suggestive for COVID-19 infection with nonspecific chest CT scan findings including lung nodules, ground glass opacities (GGOs), consolidations, and mosaic perfusion patterns This case series was approved by our institutional review board and informed consent obtained from both patients Results: In one case,18F-FDG PET/CT images demonstrated hypermetabolic mostly peripheral GGOs and nodules in both lungs with subsequent evaluation confirming COVID-19 infection The second case demonstrated right perihilar consolidation, not well appreciated on noncontrast chest CT images in addition to GGOs and further evaluation confirmed diagnosis of poorly differentiated squamous cell carcinoma of the lung Conclusion: During COVID-19 pandemic, many cases might be misdiagnosed by either clinicians or radiologists In appropriately selected cases, FDG PET/CT scan may be helpful during COVID-19 outbreak to avoid diagnostic errors © 2020 Biomedical and Biotechnology Research Journal (BBRJ) ;Published by Wolters Kluwer - Medknow

Background Various studies showed the usage of epidermal growth factor receptors (EGFRs) gene mutations in the therapeutic plan of patients with advanced lung cancer. This study aimed to investigate the frequency and types of EGFR gene mutations among Iranian patients with lung cancer referred to a specialized lung diseases hospital from 2014 to 2019. Results The study was included 570 individuals, with an average age of 58.74 years old, of which 51.6% were men and 48.4% were women. Gene mutations were present in 113 of the 570 (19.8%) participants. There was deletion, replacement, and deletion and replacement in 65 (57%), 48 (42.1%), and (0.9%) cases, respectively. The mutation was significantly higher among women (P = 0.001); in detail, deletion was higher among female participants, although the replacement mutation was the same in male and female groups. There were no significant differences in mutation among different age groups (P = 0.05). Conclusion EGFR gene mutations, associated with lung cancer and could help patients' therapeutic plan, had the frequency of about 19.8% among Iranian patients with lung cancer.

Background: An initial evaluation of non-small cell lung cancer (NSCLC) patients with 18F- fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scan can modify treatment planning. We investigated the clinical significance of FDG PET/CT quantitative parameters (QPs) in NSCLC patients. Materials and Methods: We included 125 NSCLC patients for initial staging FDG PET/CT scan. The primary tumor (T), regional lymph node metastases (N), and distant metastases (M) were evaluated on FDG PET/CT images. QPs, including standard uptake value (SUVmax), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were calculated separately for each T, N, and M lesion and also for the whole body. Statistical analysis through SPSS version 22 was used to evaluate the clinical significance of PET/CT QPs concerning primary tumor pathology characteristics, initial tumor stage, and patient’s prognosis. Results: We followed the patients for 19.28 (±11.42) months. Considering primary tumor pathology, there was a significant difference in FDG PET/CT QPs, including primary tumor SUVmax (p=0.00), metastases SUVmax (p=0.014), whole-body MTV (p=0.045), and whole-body TLG (p=0.002). There was also a significant difference in QPs, including primary tumor SUVmax (p=0.00) and regional lymph node metastases SUVmax (p=0.048) when accounting for tumor initial stage. There was a significant prognostic value for the whole-body TLG (p=0.01) and a cut-off point of 568 was reached to differentiate better versus worse survival outcome. Conclusion: We demonstrated a statistically significant difference in FDG PET/CT QPs when accounting for primary NSCLC pathology characteristics and initial stage, as well as patient’s prognosis, and recommend incorporating QP values into clinical PET/CT reports.

Hypersensitivity pneumonitis (HP) is an immune-mediated diffuse parenchymal lung disease induced by inhaled antigens. High-resolution computed tomography (HRCT) is widely used in the diagnosis and follow-up of patients and determining the progression and prognosis of the disease. In this retrospective study, 45 consecutive patients with the final diagnosis of HP, seen at a large tertiary care center during a period of 4 years, were included and their HRCT findings were evaluated. The most common HRCT findings were ground glass opacity and reticulation. Some HRCT patterns were detected more severely in bird fanciers in comparison with other etiologies. There is no “gold standard” for the diagnosis of HP. HRCT findings play an important role in hypersensitivity pneumonitis diagnosis and CT scan also help to define the severity of hypersensitivity pneumonitis injuries. In our study, reticulation and ground glass opacity were the most common findings in HRCT of patients with HP. We also find that patients with avian contacts had a significantly higher rate of fibrosis.

Intractable drug-resistant magnetic resonance imaging (MRI) negative epilepsy in one of the complicated issues in neurology. Epilepsy surgery is beneficial treatment of intractable seizures, but precise localization of epileptogenic zone is a major concern. Thirty-four MRI negative drug-resistant epilepsy patients underwent video electroencephalography (EEG), positron emission tomography (PET) scan, and voxel-based morphometry (VBM) MRI from 2014 to 2019. Then, the findings of PET scan and VBM were compared with semiology and long-term electrophysiology. Cohen’s kappa-coefficient (k) test was utilized to measure the agreement between our modalities. Among 34 patients with age ranging from 8 to 49 (mean: 29.00 ± standard deviation: 10.35), 19 were male (55.9%) and 15 were female (44.1%). Twenty-one patients (61.76%) had right temporal, 12 patients (35.3%) had left and one patient had bilateral temporal ictal focus according to video EEG. Inter-rater agreement analysis showed that the kappa index between video EEG and PET scan was of almost acceptable (more than 0.4) and there was poor agreement between video EEG and VBM (kappa index = 0.099). PET is highly concordant with video EEG in temporal lobe epilepsy (TLE) and has a considerable agreement in localizing epileptogenic zone while VBM is less.

We present a highly suspicious case of COVID-19 infection, incidentally found on 18F-FDG PET/CT images. Patient was scanned on February, 25, 2020, when COVID-19 outbreak was unrecognized in our country. She admitted having recent occasional dry cough and fever. A retrospective review of her clinical and laboratory data was strongly suggestive for diagnosis of COVID-19 infection. PET/CT images demonstrated hypermetabolic diffuse ground glass opacities in both lungs with bilateral nodules. There was no evidence of pleural effusion or prominent mediastinal or hilar lymphadenopathy. Radiologists must be aware of COVID-19 presentations on PET/CT scan images during COVID-19 outbreak.

Sarcoidosis is a multi-organ disease and is characterized by sarcoidal noncaseating granuloma comprised of T-helper/inducer (CD4+) lymphocytes and scant cytotoxic (CD8+) T-lymphocytes. CD4+:CD8+ T-cell elevated ratio is a characteristic diagnostic parameter for sarcoidosis. This is the first report from Iran evaluating the CD4:CD8 ratio capability in differentiating pulmonary sarcoidosis from other interstitial lung diseases (ILDs) on a large cohort. Fifty pulmonary sarcoidosis patients and 50 non-sarcoidosis interstitial lung diseases (nsILDs) patients were included in the current study. Bronchoalveolar lavage (BAL) was performed using flexible fiberoptic bronchoscopy and flow cytometer. Non-sarcoidosis group was established by 50 components that were classified into eight subgroups. Fifty-two percent of sarcoidosis patients and 62% of non-sarcoidosis interstitial lung disease patients had normal spirometric results. The CD4/CD8 ratio was significantly higher in sarcoidosis than in non-sarcoidosis interstitial lung diseases (p < 0.001). The CD4/CD8 ratio was found to be > 3.5 in 33.3%, 2.5-3.5 in 7.1%, 1.5-2.5 in 20.2% and < 1.5 in 39.4% of the entire study population. The best cut off point was 1.1 with the sensitivity of 92% and specificity of 80% for distinguishing sarcoidosis from other interstitial lung diseases. Performing bronchoalveolar lavage as the safe and rapid first step confirms the diagnosis of sarcoidosis in 92% of cases (current study sensitivity). Hence, performing an invasive procedure was required in a few patients only. Bronchoalveolar lavage flow cytometry in the assessment of clinical and radiological findings supplies an appropriate diagnostic adjunct for discriminating sarcoidosis from non-sarcoidosis interstitial lung diseases.

Background: A few studies have evaluated the predictive value of fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) in patients with head-and-neck squamous cell carcinoma (HNSCC). Methods: We performed a retrospective study on 32 HNSCC patients, undergoing PET/CT after completion of planned treatment. The PET/CT volumetric parameters measured separately for primary tumor site and nodal or distant metastases. The primary outcome measure of the study was overall survival. Results: There was significant difference between alive and dead patients regarding some of volumetric parameters. Univariate and multivariate Cox regression analyses demonstrated association between metabolic tumor burdens with survival outcome. There was also significant difference in time to survival between patients with metastatic metabolic tumor burden and metastatic total lesion glycolysis (TLG) above and below 50th percentile. Conclusion: PET/CT volumetric parameters including metabolic tumor burden and TLG are significant prognostic markers for overall survival of patients with primary HNSCC after treatment.