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Background: Chronic inflammation has been linked to the development and prognosis of neuroendocrine tumors (NETs). The current study intended to evaluate the role of peripheral hematological inflam...

PURPOSE To compare the efficacy and safety of 177Lu-DOTATATE plus radiosensitizing capecitabine and octreotide long-acting release (LAR) as first-line systemic therapy in advanced well-differentiated gastroenteropancreatic neuroendocrine tumors (GEP-NETs). MATERIALS AND METHODS Data of consecutive patients of advanced inoperable or metastatic grade 1 or 2 GEP-NETs treated with first-line 177Lu-DOTATATE plus radiosensitizing capecitabine or octreotide LAR from September 2012 to December 2019 were collected and analyzed for response, toxicity, and survival outcomes. RESULTS Seventy-six patients (median age: 53 years; range 14-81 years) with treatment-naïve advanced grade 1 or 2 GEP-NETs were included. Thirty-six patients received a median cumulative dose of 27.3 GBq of 177Lu-DOTATATE intravenously at 8-12 weeks' intervals along with 1,250 mg/m2 oral capecitabine on days 0-14 of each cycle of 177Lu-DOTATATE, whereas 40 patients were administered 30 mg octreotide LAR intramuscularly every 4 weeks. Using response evaluation criteria in solid tumor 1.1, the objective response rate was 38% in the 177Lu-DOTATATE arm compared with 15% in the octreotide LAR arm ( P = .025), whereas the disease control rates were 88% and 67% in 177Lu-DOTATATE and octreotide LAR arms, respectively ( P = .035). The median durations of progression-free survival in the 177Lu-DOTATATE and octreotide LAR arms were 54 months and 16 months, respectively ( P = .017), whereas the median overall survival was not reached and not significantly different across both the arms. Of the treatment-related adverse events, no major difference was observed in the occurrence of grade 3 or 4 toxicities between the two treatment arms. CONCLUSION First-line systemic 177Lu-DOTATATE plus radiosensitizing capecitabine achieved better radiologic response and longer progression-free survival compared with octreotide LAR in patients with advanced grade 1 or 2 GEP-NETs. Future randomized controlled trials are, however, required to determine the best treatment sequence for the treatment-naïve patients with advanced GEP-NETs.

The aim of this study was to assess the utility of presynaptic dopaminergic imaging using 99mTc-TRODAT-1 SPECT/CT and 18F-FDOPA PET/CT and compare their performance in Parkinson's disease (PD), Parkinson-plus syndrome (PPS), and essential tremor (ET).A total of 103 patients (PD = 48, PPS = 19, and ET = 36) were enrolled prospectively. Hoehn and Yahr (HY) staging and MDS-UPDRS (Movement Disorder Society-Sponsored Revision of Unified Parkinson's Disease Rating Scale) were done for PD and PPS cases. All the patients underwent 99mTc-TRODAT-1 SPECT/CT and 18F-FDOPA PET/CT brain scan. The scans were analyzed visually and semiquantitatively. Average pixel count and SUVmean of the striatum were calculated in SPECT and PET images, respectively, to calculate the specific uptake ratio of striatum (SUR). Comparison of scan findings and SURs among different groups and correlation with clinical characteristics was done.Symmetrical comma-shaped uptake was seen in bilateral striatum in ET cases with mean SURs significantly higher than in cases of early PD (HY stage I and II, n = 37), PD and PPS both on SPECT and PET images (P ≤ 0.001). The mean SURs between PD and PPS showed no significant difference (SPECT, P = 0.17; PET, P = 0.61). Substantial agreement (weighted κ = 0.659) was found between 99mTc-TRODAT-1 and 18F-FDOPA for the detection of presynaptic dopaminergic dysfunction. Specific uptake ratio of striatum correlation between SPECT and PET was statistically significant (r = 0.67; P0.01). A negative but nonsignificant correlation was found between the SURs and HY staging/MDS-UPDRS.Both 99mTc-TRODAT-1 SPECT/CT and 18F-FDOPA PET/CT showed substantial agreement and proved to be potential imaging biomarker for the detection of dopaminergic dysfunction, thus assisting in differentiating early PD/PD and PPS from ET cases.

Purpose Advanced inoperable/metastatic neuroendocrine tumors (NETs) pose a therapeutic challenge with limited treatment options. Peptide receptor radionuclide therapy (PRRT), being specific in targeting the somatostatin receptors, is a promising and viable option in this setting. In this study, we intended to evaluate the role of PRRT as the first-line systemic therapy in advanced inoperable/metastatic NETs. Methods Data of consecutive patients of advanced inoperable/metastatic NETs treated with first-line Lu-DOTATATE at our center, from September 2012 to August 2019, were collected and analyzed. Results Forty-five patients (median age, 50 years; range, 14-72 years) with treatment-naive advanced NETs received a median cumulative dose of 27 GBq (range, 13.3-41.3 GBq; over 2-7 cycles) Lu-DOTATATE and 1250 mg/m capecitabine from days 0 to 14 of each PRRT cycle. Three patients were lost to follow-up, 2 had nonmeasurable lesions on CT, and hence, radiological response using Response Evaluation Criteria in Solid Tumors version 1.1 could be assessed in 40 patients. Twelve of 40 patients (30%) showed a partial response, whereas stable disease was observed in 22 of 40 patients (55%). Disease progression was limited to 6 of 40 patients (15%). Treatment-related adverse effects were minimal with grade 3/4 anemia, leukopenia, neutropenia, and hepatotoxicity observed in 2%, 2%, 4%, and 4% of the patients, respectively. Median progression-free survival was 48 months (95% confidence interval, 34.7-61.3 months). Conclusions Our results indicate the efficacy and safety of first-line PRRT in advanced NETs. Future randomized trials, comparing PRRT and somatostatin analogs in treatment-naive patients, are required to identify the definite sequence of treatment options for these patients.

Prostate-specific membrane antigen (PSMA) PET/CT is a well-acclaimed imaging modality for prostate cancer (PCa). However, many reports have highlighted PSMA radioligand uptake in a variety of benign tumors and lesions. We report a case of PCa in which (68) Ga-PSMA-11 uptake was noted in the tracheal lumen. However, (18)F-PSMA-1007 PET/CT was done on a subsequent day, which demonstrated no abnormal radiotracer uptake or morphological lesion within the tracheal lumen. This case highlights an uncommon finding of PSMA ligand uptake in a tracheal mucus plug (non-prostatic benign uptake), which may be misinterpreted as a false-positive finding.

Objective To evaluate 18F-fluorodeoxyglucose (FDG) PET/CT in the assessment of disease activity, extent of the disease and response to therapy in relapsing polychondritis. Methods Twenty-five patients (9 men, 16 women) with a mean age of 38.2 years (s.d. 13.7; range 18–62), diagnosed to have relapsing polychondritis according to Damiani and Levine’s modification of McAdam’s criteria, who underwent PET/CT examination were included. Ten patients underwent a second PET/CT examination after therapy or during follow-up. Clinical symptoms and auxiliary examination findings were recorded. PET/CT findings were reviewed and correlated with the clinical symptoms. Results The major symptoms were aural pain (n = 21), nasal pain (n = 10), stridor (n = 5), cough (n = 9), fever (n = 8) and laryngeal tenderness (n = 8). The initial PET/CT was positive in 23/25 patients. PET/CT revealed involvement of auricular (n = 14), nasal (n = 8), laryngeal (n = 7), tracheobronchial (n = 6) and Eustachian (n = 3) cartilages with a mean maximum standardized uptake value (SUVmax) of 4.1 (s.d. 2.5; range 1.7–12.7). Fair correlation of aural/nasal pain/stridor with FDG avidity of cartilage involvement on PET/CT was noted. The key finding was detection of asymptomatic large airway involvement in seven patients (28%). Re-examination PET in 10 patients revealed complete therapeutic response (n = 5), partial response (n = 1), stable disease (n = 1), progressive disease (n = 1) and disease recurrence (n = 2). Conclusion FDG PET/CT is a useful tool for the assessment of the disease activity and extent. It identified activity in clinically inaccessible sites that are of clinical significance. It is also useful in assessing treatment response and finding relapse.

Objective The aim was to evaluate the diagnostic potential of Ga-ubiquicidin positron-emission tomography/computed tomography (PET/CT) in imaging patients with infection. Materials and methods Ga-NOTA-ubiquicidin (Ga-UBI) was prepared by addition of freshly eluted Ga-chloride from Ge/Ga generator into the NOTA-ubiquicidin vial and incubated at room for 15 min at 90°C. After compounding of the radiopharmaceutical, quality control using instant thin-layer chromatography, culture and endotoxin estimation was performed. Patients with suspected infection associated with diabetic foot, cellulitis and fracture were selected for the pilot study investigation to evaluate the ability of the tracer Ga-UBI in localization at infection sites. The PET/CT findings were compared with other diagnosis like microbial culture reports and bone scintigraphy to evaluate true positives or negatives in the study. Results The current study demonstrated the potential of kit-based Ga-UBI in localization of infection sites in most of the patients proven positive for infection on culture tests and bone scintigraphy. The kit could offer radiolabeling yield more than 95% in 15 min incubation at 90°C. Quality control rendered the kit as a clinical grade preparation with endotoxin content less than 10 EU/ml and sterility up to 14 days of culture incubation. Eight of 10 patients underwent culture test and showed positive results. Two patients had undergone three-phase bone scan as an indirect sign of active infection. Ga-UBI PET/CT showed tracer localization in four of eight culture-positive patients. Tracer localization was observed in one of two patients whose culture reports were not available. Ga-UBI failed to identify infection in four patients with culture-positive results. Conclusion The present study concluded that Ga-UBI prepared using NOTA-UBI kit is a potential agent in targeting infections associated with disease conditions including diabetic foot, cellulitis and fracture. The patient selection holds significance in accurate diagnosis using Ga-UBI PET/CT.

AIM: Premotor phase in Parkinson’s disease (PD) begins many years before the onset of motor symptoms. Despite advancement in the understanding of this common neurodegenerative disease, clinical diagnosis is still the gold standard. Various fluid- and tissue-based biomarkers have been postulated to play a role in the pathogenesis of PD. We aimed to study the role of serum DJ-1 and apolipoprotein A1 (Apo A1) in PD. SETTINGS AND DESIGN: A cross-sectional observational study was conducted in the Department of Neurology, in collaboration with the Department of Pharmacology. Cases of PD and healthy controls were recruited over 1 year with written informed consent from all the participants. The study was approved by the institutional ethics committee. SUBJECTS AND METHODS: All cases underwent detailed neurological examination, Hoehn and Yahr staging, and MDS-UPDRS (MDS-UPDRS (Movement Disorders Society–Unified Parkinson Disease Rating Scale) scoring. Serum of all the cases and controls were collected for the estimation of DJ-1 and Apo A1 by enzyme-linked immunosorbent assay. STATISTICAL ANALYSIS: Serum DJ-1 and Apo A1 levels were compared between cases and controls using Mann–Whitney test. Correlation of characteristics was carried out using Spearman correlation coefficient. RESULTS: The study cohort included 77 cases of PD and 69 healthy controls. Serum DJ-1 and Apo A1 levels were found to be significantly lower in cases compared to controls (P < 0.001). However, no correlation was found with age of onset, duration of disease, and severity of illness. A negative correlation was observed between DJ-1 levels and cognitive impairment and bladder dysfunction. CONCLUSION: Low levels of DJ-1 and Apo A1 are found in patients with PD of Indian origin. However, correlation of these biomarkers with progression and severity is needed to be explored in future randomized controlled trials with a large sample size.

Surgical resection followed by radioactive iodine (

Purpose of the report Tuberculosis (TB) is a major health problem. Activated macrophages in TB lesions show high metabolic activity and can be assessed using F-FDG PET/CT. This retroprospective study was done to evaluate the utility of F-FDG PET/CT in initial assessment and therapeutic response in patients with TB. Materials and methods Eighty-seven patients (male-to-female ratio, 46:41) diagnosed with pulmonary TB and extrapulmonary TB underwent whole-body F-FDG PET/CT for initial assessment and a follow-up scan 3 to 4 months after initiation of antitubercular therapy (ATT). Visual and semiquantitative (SUVmax) analyses were used for scan assessment. Treatment responses on interim scans were categorized as complete metabolic response (CMR), favorable response to therapy (FRT), stable disease (SD), and disease progression (DP). CMR, FRT, and SD cases were considered as responders and DP cases as nonresponders. Treatment response was correlated with clinical outcome (mortality) and ATT duration. Results Baseline F-FDG PET/CT scans were positive in all the patients and detected additional disease sites than suspected clinically in 72% patients. On interim PET/CT, 13 patients showed CMR, 43 showed FRT, 8 showed SD, and 23 showed DP. A longer duration of ATT was seen in nonresponders (P ≤ 0.001) than responders. During follow-up, 9/87 patients died, out of which 8 patients were of DP group and 1 patient belonged to SD. Nonresponders showed 35% mortality compared with 1.6% in the responder group (P ≤ 0.001). Conclusions F-FDG PET/CT is a valuable imaging modality for disease mapping and assessing therapeutic response. Treatment response in the interim PET/CT done at 3 to 4 months predicted the duration of ATT and clinical outcome of the patients.

Parkinson's disease (PD) and Parkinson plus syndromes (PPS) are neurodegenerative movement disorders caused by loss of dopamine in the basal ganglia. The diagnosis of both PD and PPS is complex as it is made solely on the basis of clinical features, with no established imaging modality to aid in the diagnosis. Technetium-99m-labeled tropane derivative (Tc-TRODAT-1) binds to the dopamine transporters present in the presynaptic membrane of the dopaminergic nerve terminal. The aim of this prospective study was to investigate the potential usefulness of Tc-TRODAT-1 imaging in the diagnosis of PD and PPS.Fifty-eight patients with a clinical diagnosis of idiopathic PD or PPS were recruited. The severity of the disease was assessed using the Hoehn and Yahr scale. Patients in stage I and II were considered as cases of Early PD. Twenty-five apparently healthy volunteers served as controls. Brain single-photon emission computed tomography/computed tomography in all the participants was performed 3-4 h after an injection of Tc-TRODAT-1. Specific uptake ratios (SURs) of striatum were calculated for both the left and right striatum, and the values were compared between PD, PPS, and healthy volunteers.A significant lower uptake of tracer activity was found in either of the striatum in PD and PPS cases compared with the control group, which showed a symmetrical comma-shaped striatal uptake. This was also reflected in the SUR values, which were significantly higher in the control group in comparison with the PD and PPS patients (P0.001). A significant difference was also found in the SUR values between the cases of early PD and control group (P0.001).No significant difference was noted among the SUR values in different Hoehn and Yahr stages.For clinical practice, both the visual analysis and the quantitative parameters of Tc-TRODAT-1 single-photon emission computed tomography/computed tomography showed usefulness in distinguishing cases of PD and PPS from the healthy individuals.

The aim of the study was to analyze the diagnostic and prognostic utility of F-FDG PET/CT to predict the disease-specific survival (DSS) with FDG uptake and tumor grade in recurrent chondrosarcoma.Retrospective analysis of FDG PET/CT findings in 31 previously treated patients (46 studies) with mean follow-up period of 40.7 ± 23.9 months (range, 3-77 months) from the date of first PET/CT study was done. Kaplan-Meier DSS analysis was made with respect to tumor grade, FDG uptake at the recurrent primary sites, and a combination of grade and FDG uptake as parameters.Recurrence (local and distant) was shown in 28 (60.8%) of 46 FDG PET/CT studies with sensitivity and specificity of 88.9% and 78.9%, respectively. The median SUVmax at the recurrent primary sites differed significantly (P = 0.008) among 3 tumor grade groups, with higher median SUVmax in higher grades. There was significant difference in median SUVmax among different grade groups except between grade II and grade III. Recurrent primary site SUVmax cutoff at 6.15 derived from the receiver operating characteristic curve yielded significant difference (P0.001) in mean DSS time. Significant difference in survival was noted between 3 different tumor grade groups (P = 0.016). The combination of SUVmax and grade improved the survival prediction than with grade alone.In recurrent chondrosarcoma, the recurrent primary site FDG uptake and grade were found to be reliable prognostic factors with respect to DSS. PET/CT in recurrence setting has the potential to predict tumor grade and survival and may assist in clinical management.

Persistent hyperinsulinemic hypoglycemia in adults is most commonly caused by insulinomas, which pose a diagnostic challenge to physicians, surgeons, and radiologists and require multimodality imaging for precise localization and staging. PET tracers such as F-FDOPA and glucagon-like peptide 1 receptor analogs have been used for imaging insulinomas. Glucagon-like peptide 1 receptor analogs have recently shown promising results in preoperative localization of these tumors, as all insulinomas express glucagon-like peptide 1 receptors. Ga-DOTA-Exendin PET and MRI done in the present case helped in precise localization and management of the culprit lesion, whereas contrast-enhanced CT and F-FDOPA PET failed to do so.

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.

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.

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.

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.

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.

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.

Groove pancreatitis is a rare form of chronic pancreatitis that affects the groove area adjacent to the second part of the duodenum. Clinical and biochemical features often overlap with other subsets of chronic pancreatitis, while the imaging features resemble that of carcinoma of the head of pancreas. We present a 38-year-old man with abdominal pain, nausea, vomiting, and loss of weight who underwent (18)F-FDG PET/CT to rule out a pancreatic malignancy. PET/CT imaging features of groove pancreatitis are distinct from the other subsets of chronic pancreatitis, such as alcoholic and autoimmune pancreatitis, and helpful in the diagnosis and planning further management of the patient.

Primary signet ring cell adenocarcinoma of the breast is a rare neoplasm. Similar to other mucinous neoplasms, it has low FDG avidity and poor prognosis compared with the traditional ductal/lobular carcinomas. We present a case of a 40-year-old woman with signet ring cell adenocarcinoma and skeletal fluorosis showing higher uptake of Ga-prostate-specific membrane antigen in the primary lesion and the metastatic sites compared with F-FDG on PET/CT imaging. Additionally, diffuse increased prostate-specific membrane antigen uptake was noticed in the entire skeleton, likely due to skeletal fluorosis.

Graft versus host disease (GVHD) is the most frequent and serious complication of allogenic hematopoietic stem cell transplant. Polymyositis is a rare neuromuscular manifestation of GVHD, which often responds well to corticosteroid and immunosuppression therapy. We present a case of a 38-year-old man with a known case of mixed-phenotype acute leukemia after hematopoietic stem cell transplant presenting with GVHD-associated polymyositis. F-FDG PET/CT done in this case not only helped in the detection of the muscle involvement but also helped in obtaining precise muscle sample for histopathological diagnosis using PET-guided biopsy.

We present a case of a 19-year-old woman with Ewing sarcoma of the iliac bone in whom Ga-PSMA-HBED-CC PET/CT showed high radiotracer activity in the primary tumor. The present case documents the in vivo expression of PSMA in Ewing sarcoma family of tumors and adds on to the list of nonprostatic malignancies showing PSMA expression.

Extraskeletal osteosarcoma is a rare, high-grade soft tissue malignancy, accounting for approximately 1% of all soft tissue sarcomas. Despite the histologic resemblance to osteogenic osteosarcoma, it is considered as a distinct entity because of the differences in clinical behavior and response to treatment. Hence, imaging plays a vital role in establishing the nonskeletal origin of the tumor, differentiating it from osteogenic osteosarcoma. We present F-FDG PET/CT findings in a case of isolated primary extraskeletal osteosarcoma confirmed on histopathology.

Technetium-99m sestamibi MPS is a commonly employed imaging study for myocardial perfusion; however, incidental extracardiac sestamibi uptake requires further evaluation, and the tracer uptake in the thorax/mediastinum may be pathological. The authors present a case of significant extra-cardiac uptake seen on stress MPS images helping in the incidental detection of bronchial carcinoid.

TENIS (thyroglobulin elevation with negative iodine scintigraphy) syndrome in patients with differentiated thyroid carcinoma is not a rare finding. In such patients, F-FDG PET/CT can help in disease evaluation. RGD tripeptide, used for imaging angiogenesis, may also help in disease detection in patients with negative radioiodine whole-body scan. We present 1 such case in whom Ga-RGD tripeptide imaging was helpful in disease detection in the setting of negative radioiodine whole-body scan.

We report a case of clinically asymptomatic patient of prostate cancer who was previously subjected to radical prostatectomy presenting with a rising serum prostate-specific antigen level of 6.6 ng/mL. Whole-body PET/CT with Ga-labeled prostate-specific membrane antigen ligand was performed to assess for disease recurrence, which revealed an intense tracer uptake in a soft tissue mass in left hemithorax mimicking lung metastasis; which later turned out to be splenic tissue.

Biotechnological improvement of monocots is often hampered by the lack of efficient regeneration systems, requisite wound responses and low cell competence. Despite these limitations, the biolistic and Agrobacterium methods have been successfully used to produce several transgenic monocots by adjusting the parameters that govern efficient delivery and integration of transgene(s) into plant genome. It is now possible to transform even difficult monocots using tailor-made gene constructs and promoters, suitable A. tumefaciens strains and a proper understanding of the entire process. This success has been reviewed in the present article and a special emphasis was laid on the measures that were taken in overcoming the difficulties that arise due to the differential responses of monocots and dicots. This information is necessary for biotechnological improvement of still newer monocotyledonous plants that have been hitherto difficult to transform.

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.

Peptide receptor radionuclide therapy (PRRT) either using Lu-177 or Y-90 peptide radiopharmaceuticals has emerged as promising treatment modality in patients with inoperable metastatic neuroendocrine tumour (NET) including medullary thyroid cancer, because of overexpression of somatostatin receptor 2 (sstr-2) on these cells. The several investigators have used PRRT in non-iodine avid differentiated thyroid cancer patients with limited success, where other treatment modalities have failed, probably due to faint sstr-2 expression in these lesions. However Hurthle cell neoplasms being predominantly non-iodine avid lesions have shown sstr-2 over-expression. The present case of inoperable NET patient imaged and treated with radiolabelled somatostatin analogue showed incidentally detected thyroid lesion highlighting the its importance in imaging and treatment in these type of thyroid malignancies.

Purpose of Study: Loss of dopamine neurons in the brain is a characteristic feature of Parkinson's disease (PD). TRODAT-1 is a tropane derivative that binds to dopamine transporter (DAT) receptors. It can be used for noninvasive in vivo imaging of DAT receptors leading to the early detection of PD. The present study aims to optimize the in-house radiolabeling of TRODAT-1 with Tc-99 m in hospital radiopharmacy set up along with performing single-photon emission computed tomography/computed tomography imaging in patients with PD. Materials and Methods: Radiolabeling was performed through transchelation method. For optimization studies, varied amount of glucoheptonate (GHA) and stannous chloride was incubated with Tc-99 m for 10 min at room temperature. TRODAT-1 was added to the reaction mixture followed by incubation at 95°C for various time intervals. Phosphate buffer saline was added to maintain the pH of the final product. After performing the quality checks, whole-body imaging was performed to check the biodistribution in 4 patients at 1 h postinjection of 20–25 mCi (740–925 MBq) of Tc-99 m-TRODAT-1. Regional brain imaging was performed at 3–4 h. Clinical evaluation was done in control (n = 5) and in patients with PD (n = 5). Results: Radiolabeling yield of 100% was achieved by incubating TRODAT-1 with Tc-99 m GHA. All the quality control indicated the suitability of radiopharmaceutical for the intravenous administration. Good uptake of Tc-99 m TRODAT-1 was observed in the striatum of normal patients. However, decreased uptake was seen in patients with PD. Conclusion: Tc-99 m TRODAT-1 is a potential radiopharmaceutical for the diagnosis and staging PD which can be radiolabeled in-house with good yield leading to its easy availability.

Background Methotrexate (MTX), a mono-glutamate, by addition of 2–6 more glutamate moieties, is converted to methotrexate polyglutamates (MTX PGs) intracellularly. These are the active compounds mediating folate pathway inhibition and increase in adenosine. Erythrocyte polyglutamate levels (RBC MTX PGs) are surrogate markers for levels inside lymphocytes and hepatocytes.Variability in RBC MTX PGs formed intracellularly (despite similar MTX dose) may be one of the factors determining variability in efficacy of MTX. Previously, contrasting results have been found on their association with efficacy and few prospective studies exist. Objectives To assay levels of erythrocyte methotrexate polyglutamate (1–5) levels in patients with rheumatoid arthritis and assess their relationship to efficacy and adverse effects. Methods Prospective study that included patients of RA (fulfilling 1987 ACR), aged 18–65 years with active disease (DAS28–3v>3.2) and not on methotrexate. Oral MTX was started at 15 mg/week and increased to 25 mg/week at 8 weeks. Disease activity measured using DAS28 (3 variables), and at 24 weeks patients classified into responders (EULAR good or moderate response) or non-responders. MTX-PG levels (PGs 1–5) assayed in deproteinised packed RBCs by HPLC using reverse phase (C18 column) and post-column derivitization using UV photo-oxidation followed by fluorescent detection (ex 274; em 470 nm). Results Included 117 patients, with mean (±SD) age of 42.7±11.9 years, disease duration 2.0±1.7 years, 71.8% RF+ and 85.7% CCP+. At 24 weeks, there were 57 responders and 33 non-responders with no significant difference in mean (±SD) MTX dose (21.7±3.9, 22.7± 4.1mg/week, p=ns), age, disease duration, but with lower BMI (21.7±3.9, 24±4.5 kg/m 2 , p=0.02) and higher baseline DAS28(3) (6.5±0.7, 6.1±0.9, p=0.02). There was an early and sustained gap between the curves of DAS28(3) between responders and non-responders (Figure, left upper quadrant). Methotrexate PG levels increased till 24 weeks (mainly PG3 and PG4), with reasonable correlation between dose and MTX PG levels (r=0.38, p Conclusions Our study suggests that MTX-PG levels is not a determinant for response to MTX or their adverse effects. This is different from a previous prospective study, we think the differnce lies in MTX dose and clear classification as reponder and non-responders in our study. Disclosure of Interest None declared

Rural schoolchildren between the ages of 6 and 18 years were screened for residual paralysis following poliomyelitis; 503 (0.85%) out of a total of 58,592 were victims. Of these, only 16 (3.8%) had received poliomyelitis vaccine, while the remainder had not been immunised. The disease had occurred before the age of 4 years in nearly 90%, the lower limbs being affected (98%) more often than the upper (2%). In the lower limbs, the quadriceps, hip adductors and tibialis anterior were frequently affected. The muscles supplied by the L4 and L5 spinal segments were most commonly involved, while those supplied by L1 and S3 were least. Some order does exist in the apparently irregular distribution of paralysis after poliomyelitis.

Background Strategies to reduce toxicity of Methotrexate (MTX) have been receiving increasing attention. One strategy backed by good evidence is folic acid supplementation. However, its optimum dose is not known. Although guidelines suggest 5-10mg per week; this is based on weak evidence.1 Indeed, only one clinical trial has compared different doses; but was done 20 yrs ago using low MTX doses.2 Also, effect of folic acid on efficacy of MTX unclear. Objectives To compare the effect of folic acid at dosages of 10 or 30 mg per week on MTX toxicity and efficacy in patients with rheumatoid arthritis. Methods Patients included in this double blind randomized controlled trial were started on MTX at 10mg/week which was escalated every two weeks by 2.5 mg till 25 mg per week till 24 weeks. This escalation was based on ongoing disease activity and absence of toxicity evaluated every 8 weeks. They were randomized in a ratio of 1:1 to receive either folic acid 10 mg or 30 mg per week. Patients in the first group recieved two tablets of 5mg folic acid (and four tablets of placebo) and in the second group recieved six tablets of 5 mg folic acid for each week of the study. Patients took one tablet daily except on the day they took MTX. Co-primary endpoints were incidence of toxicity and change in disease activity at 24 weeks. Toxicity included undesirable symptoms (by questionnaire) and laboratory abnormalities including cytopenias (thrombocytopenia or leucopenia) and transaminitis (twice upper limit of normal). Secondary outcomes were change in level of RBC (and serum) folic acid levels at 24 weeks (from baseline) and change in the functional status of patients. Trial # NCT01583959 Results This study included 100 RA patients (F:M=86:14) with mean age 44.3 (±10.9) yrs, disease duration 4.8 (±4.7) yrs, RF+ in 73 and anti-CCP+ in 84. Among these, 51 received folic acid 10 mg per week (FA10) and 49 received 30 mg per week (FA30). By 24 weeks, there were 6 patient withdrawals in either group. Mean methotrexate dose at 24 weeks was 22.8±4.4 and 21.4±4.6mg in FA10 and FA30 respectively (p=0.1). There was no singificant difference in occurrence of undesirable symptoms between groups, although they were numerically higher in the 30 mg folic acid group (Figure 1). There was also no difference in frequency of transaminitis (42.6, 45.7%, p=0.7) or cytopenias (4.3, 4.3%, p=0.9). At 24 weeks, DAS28(3) declined in both groups by a similar extent (-1.1±1.0, -1.3±1.0, p=0.2) and EULAR good or moderate response occurred in 56.9 and 67.4% in FA10 and FA30 (p=0.3). Serum folic acid levels increased in both groups. At 24 weeks serum folic acid levels were higher in the 30mg group (20.4±17.1, 45.1±39.7ng/ml, p Conclusions Our results suggest that supplementation of 5-10 mg folic acid is sufficient when using MTX in RA even at currently used dosages. However, apart from there being no additional benefit of a higher dose of folic acid; it also did not lead to reduction of efficacy of MTX. References Ann Rheum Dis 2009;68(7):1086-93. Ann Intern Med 1994;121(11):833-41. Disclosure of Interest None declared