Ashwin Singh Parihar

Imaging-Guided Use of Combined 177Lu-DOTATATE and Capecitabine Therapy in Metastatic Mediastinal Paraganglioma

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.

18F-FDG PET/CT detects Metastatic Renal Cell Carcinoma Masquerading as Primary Breast Malignancy

We present the case of a 36-year-old woman who underwent 18F-FDG PET/CT with suspicion of a primary breast malignancy. However, PET/CT detected an occult renal cell carcinoma with metastases to the thyroid, breast, lungs and lymph nodes. Thyroid and breast metastases are atypical metastatic sites of renal cell carcinoma. Breast metastases from extra mammary tissue are extremely rare, more so from renal cell carcinoma. Histopathologic confirmation of the breast lesions is imperative to avoid unnecessary mastectomy and imaging can help in raising the suspicion of metastatic involvement versus primary breast malignancy.

Groove Pancreatitis Masquerading as Pancreatic Carcinoma—Detected on 18F-FDG PET/CT

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 18F-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.

Can 99mTc-labeled RBC-equilibrium radionuclide angiocardiography be an adjunct imaging biomarker for marrow hyperplasia in beta-thalassemia major patients?

Beta-thalassemia major (TM) is a hereditary disorder characterized by ineffective erythropoiesis owing to anomalies in beta-chain of hemoglobin and the peripheral anemia results in ineffective expansion and hyperplasia of the bone marrow. These patients require multiple tests to monitor the adequacy of blood transfusion and iron overload. Tc-labeled red blood cellequilibrium radionuclide angiocardiography (Tc RBC-ERNA) in these patients is used for monitoring of left ventricular ejection function (LVEF), along with prospect for whole-body marrow imaging as an indicator for adequacy of transfusion. CASE SUMMARY

Novel use of 177Lu-DOTA-RGD2 in treatment of 68Ga-DOTA-RGD2-avid lesions in papillary thyroid cancer with TENIS

Thyroglobulin elevation with negative I scintigraphy (TENIS) in patients with differentiated thyroid carcinoma (DTC) poses a unique management challenge to the physician due to limited treatment modalities. Treatment with chemo-radiation, redifferentiation therapy, tyrosine kinase inhibitors and peptide receptor radionuclide therapy (PRRT) using somatostatin analogues have shown very insignificant clinical benefits with high incidence of adverse effects [1]. Arginylglycylaspartic acid (RGD) tripeptide sequence, having very high specificity towards αvβ3 integrin, is over-expressed on the tumor vasculature, including DTC and can be used as a theranostic agent [2–4]. We present a 54-year-old woman with papillary carcinoma thyroid who developed TENIS syndrome after receiving 500 GBq of I in cumulative doses. She experienced significant adverse effects with no clinical improvement on sorafenib therapy for 1 year and presented with severe pain and a palpable hard mass in the pre-sternal region. GaDOTA-RGD2 PET/CT was performed to evaluate disease extent and for pre-therapy assessment. The maximum intensity projection (MIP) image (a) and transaxial fused PET/CT images showed increased tracer uptake in the thyroid remnant [maximum standardized uptake value (SUVmax) = 4.7] with cervical lymph nodes (b), mediastinal lymph node (c; SUVmax = 8.4), lytic skeletal lesions with soft tissue component in the sternum (c; SUVmax = 7.8) and left iliac bone (d; SUVmax = 8.4) and multiple lung nodules (e). The patient received 5.5 GBq of Lu-DOTA-RGD2 with post-therapy whole-body images in anterior (f) and posterior (g) views revealing the overall distribution of LuDOTA-RGD2 and transaxial fused SPECT/CT images (h–k) showing tracer uptake at sites corresponding to Ga-DOTA-RGD2 -avid lesions. The patient was followed up at 4 months post-therapy, with significant pain relief and reduced pre-sternal swelling suggesting clinical benefit. Post-therapy follow-up Ga-DOTARGD2 PET/CT MIP image (l) and transaxial fused PET/CT images showed tracer uptake in the thyroid remnant (SUVmax = 3.0 vs. 4.7) with cervical lymph nodes (m), mediastinal lymph node (n; SUVmax = 7.7 vs. 8.4), lytic skeletal lesions with significant reduction in soft tissue component in the sternum (n; SUVmax = 6.6 vs. 7.8) and left iliac bone (o; SUVmax 8.1 vs. 8.4) and multiple lung nodules (p), suggesting response to therapy. To the best of our knowledge, this is the first reported theranostics using Ga-DOTA-RGD2 and Lu-DOTA-RGD2 and can be a stepping stone for future studies.

Erratum to: Dual Pathologies of Parathyroid Adenoma and Papillary Thyroid Cancer on Fluorocholine and Fluorodeoxyglucose PET/CT

[This corrects the article DOI: 10.1007/s13139-017-0488-3.].

Hepatobiliary Scintigraphy Findings Lead to the Diagnosis of Spontaneous Common Bile Duct Rupture in an Infant

Hepatobiliary scintigraphy is a widely used functional imaging modality for diagnosis of a variety of liver diseases, as well as for detecting biliary tract abnormalities. Neonates or infants with persistent jaundice beyond the physiological period are usually evaluated with hepatobiliary scintigraphy. The authors present a 5-month-old girl with neonatal jaundice, ascites, and umbilical and bilateral inguinal hernias in whom spontaneous rupture of the biliary duct resulted in intraperitoneal bile leak with passage of tracer into bilateral inguinal hernial sacs.