Tekchand Kalawat

Role of lymphoscintigraphy in diagnosis and management of patients with leg swelling of unclear etiology

Background: To study the utility of lymphoscintigraphy in detection of lymphatic obstruction in patients with leg swelling of unclear etiology, selection of site for nodo venous shunt procedure, and follow-up lymphoscintigraphic documentation of improved lymph flow in surgically treated limb. Materials and Methods: Twenty four consecutive patients with leg swelling, 10 male, 14 female with mean age 47 years, range from 13 years to 74 years underwent lymphoscintigraphy. All patients were referred from Department of Plastic Surgery, after initial work-up, and routine investigations to rule out the other causes of leg swelling. Both clinical and scintigraphic staging performed for all patients. All clinically and scintigraphically positive patients treated with decongestive lymphatic therapy (DLT). In addition to the DLT, those patients positive for unilateral or bilateral lymphedema, consented for surgical intervention, nodo venous shunt (NVS) in their only affected or one of the two affected lower limbs. Follow-up lymphoscintigraphy performed in operated cases after 3 months to 6 months of surgery, lymphoscintigraphy images of each patient in pre and post-surgery compared. Results: In 20/24 cases (83%) of clinically positive leg swelling were found to be positive for lymphedema on lymphoscintigraphy and remaining, 4/24 were scintigraphically normal. Based on the clinical and lymphoscintigraphy staging, 03/20 cases (15%) had Grade I lymphedema, 01/20 (5%) Grade II lymphedema, 06/20 (30%) Grade III and remaining 10/20 (50%) had Grade IV lymphedema. 11/20 cases of Lymphedema (55%) were managed conservatively by only DLT and in remaining 09/20 cases (45%), who were case of Grade IV, lymphedema (five patients with unilateral and four patients with bilateral disease) initially treated with DLT, and on completion of DLT, undergone for NVS procedure, in their unilaterally affected lower limb or one of the two diseased lower limbs. All nine patients showed remarkable clinical improvement in leg swelling and their follow-up lymphoscintigraphy showed normal visualization of lymphatic channels. No patient developed any recurrence. Conclusion: Pre-operative functional evaluation of lymphatic channels using lymphoscintigraphy, is a widely available, simple imaging test and highly useful for documentation of lymphedema in patients with leg swelling of unclear etiology and also for exact localization of inguinal lymph nodes to perform the NVS procedure. Further, it can play important role for follow-up of patients receiving DLT or DLT with surgical intervention that provides early relief from clinical symptoms.

Assessment of early response to treatment in extrapulmonary tuberculosis: Role of FDG-PET

1. Sekhri V, Sanal S, Delorenzo LJ, Aronow WS, Maguire GP. Cardiac sarcoidosis: A comprehensive review. Arch Med Sci 2011;7:546-54. 2. Mostard RL, Prompers L, Weijers RE, van Kroonenburgh MJ, Wijnen PA, Geusens PP, et al. F-18 FDG PET/CT for detecting bone and bone marrow involvement in sarcoidosis patients. Clin Nucl Med 2012;37:21-5. 3. Kim SK, Im HJ, Kim W, Kim TS, Hwangbo B, Kim HJ. F-18 fluorodeoxyglucose and F-18 fluorothymidine positron emission tomography/computed tomography imaging in a case of neurosarcoidosis. Clin Nucl Med 2010;35:67-70.

Intracranial meningioma, mimicking brain metastasis on 18F sodium fluoride bone scan in a case of carcinoma cervix

Bone scintigraphy (BS) is a well--established commonly used imaging modality for staging and follow--up evaluation of cancer patients. Occasionally, BS may show asymptomatic unusual extraosseous lesions in the body which may or may not be related to primary disease. We here present an interesting case of carcinoma cervix in whom 18F sodium fluoride positron emission tomography-computerized tomography (PET-CT) bone scan detected an intracranial lesion. Initially, this lesion was suspected as brain metastasis; however, later on, combined PET--CT images and contrast-enhanced CT confirmed this lesion as calcified falcine meningioma in the right posterior parietal region.

Utility of bone scintigraphy in diagnosis of post- traumatic osteitis pubis

Minor musculoskeletal injuries usually heal within few weeks with conservative treatment, but in pelvic injuries, symptoms may persist for long duration and patient need medical attention to get relief from disturbing pain symptoms. We present a case of post-trauma osteitis pubis in a 58-year-old female, who reported with lower abdominal and left side hip joint pain since 2 months, after an episode of trivial trauma to her pelvis. Technetium-99m methylene diphosphonate bone scintigraphy was performed, which confirmed the site of injury in symphysis pubis and left hip joint, by increased radiotracer localization at both of these symptomatic sites.

Acute bilateral non-obstructive bacterial pyelonephritis with acute kidney injury in the elderly: role of non-invasive studies in its diagnosis

Nine elderly patients who presented with features suggestive of acute pyelonephritis were studied with the help of laboratory and imaging investigations. All patients had acute kidney injury of variable severity at presentation. Renal imaging helped us in revealing bilateral involvement and the findings are discussed. The infection was treated with appropriate antibiotics. Because of severe renal failure, five patients were supported with hemodialysis, of them, three became dialysis independent. The remaining two patients were dialysis dependent at discharge. However, none of them came to us for follow-up.

Prostatic abscess as a cause of pyrexia of unknown origin in posttransplant recipient detected on F18 Fluorodeoxyglucose positron emission tomography/computed tomography

Renal transplant recipients are at an increased risk for opportunistic infections especially in the first year post transplant. Ascertaining the cause of infection requires an extensive clinical and diagnostic evaluation. Here we report a case of pyrexia of unknown origin (PUO) in a renal transplant recipient, who after extensive conventional evaluation was negative. Later F18 FDG PET/CT detected the cause of fever focus as prostatic abscess. This case has been reported to highlight the utility of F18 FDG PET/CT in post renal transplant setting to evaluate the cause of fever.

Role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography in detecting posttransplant lympho proliferative disorder

Context: Hair is said to gray prematurely when a minimum of five gray hairs occurs before the age of 20 in fair skinned, 25 in Asians, and 30 in Africans. It may be genetically associated with autoimmune syndromes or certain environmental factors. Aims: The aim of this study was to evaluate the serum level of iron, copper, and calcium and to assess their role in premature hair graying. Subjects and Methods: This study was carried out on 60 patients with premature hair graying (PHG) and 30 age- and sex-matched healthy individuals served as a control group. The severity of PHG was assessed by the hair whitening scoring system. Serum iron, copper, and calcium concentrations were measured using Beckman Coulter instrument and spectrophotometric method. Results: There was a reduction in serum levels of iron, copper, and calcium in patients with PHG in comparison with controls. There was a statistically negative significant correlation between the severity of PHG and serum iron and calcium levels. There was a negative nonsignificant correlation between body mass index and serum iron, copper, and calcium levels. Conclusions: Serum iron, copper, and calcium levels were reduced in association with PHG and correlated with its severity. Premature graying may be an indicator that hair is not getting enough nutrients and minerals, and supplementation with these trace elements might reverse and is expected to prevent progression of canities; however, further studies are needed to find the underlying mechanism of this relationship.

Whole-body 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) for staging locally advanced breast cancer: A prospective study from a tertiary cancer centre in south India

Background & objectives: Locally advanced breast cancer (LABC) is associated with substantial risk of occult metastases. The patients with LABC have high rate of systemic relapse, suggesting inadequacy of the current conventional staging in detecting the occult metastatic spread. 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET/CT) is a new modality in the staging of breast cancer patients. Hence, this study was conducted to evaluate the role of 18F-FDG PET/CT in initial staging of LABC and to compare it with conventional methods. Methods: This prospective study included biopsy-confirmed female patients diagnosed with LABC meeting the selection criteria and attending surgical, medical and radiation oncology departments of a tertiary care centre in south India, from April 2013 to December 2014. Conventional workup included serum chemistry, mammogram, bone scan, contrast-enhanced CT (CECT) chest and upper abdomen and ultrasound abdomen and pelvis. All patients following conventional workup underwent 18F-FDG PET/CT. Results: In this study, 61 women with LABC underwent both conventional workup and 18F-FGD PET/CT. The 18F-FDG PET/CT, in comparison to conventional workup, revealed unsuspected N3 nodal disease in 11 more patients, revealed distant metastasis in seven more patients and also detected extra sites of metastasis in five patients. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT to detect distant metastasis were 95, 98, 95, 98 and 97 per cent, respectively, whereas the sensitivity, specificity, positive predictive value, negative predictive value and accuracy of conventional imaging to detect distant metastasis were 65, 93, 81, 84 and 84 per cent, respectively. Interpretation & conclusions: The 18F-FDG PET/CT was found to be more accurate than conventional imaging for staging and modified stage and treatment in 30 and 38 per cent of patients, respectively. It was particularly useful in detecting occult distant metastasis and N3 nodal disease with an added advantage of examining whole body in single session. However, CECT chest was superior over 18F-FDG PET/CT for detecting pulmonary metastasis.

Pheochromocytoma of Urinary Bladder in a Dialysis PatientPheochromocytoma of Urinary Bladder: Pheochromocytoma of urinary bladder

A 43-year-old gentleman underwent bilateral nephrectomy for bilateral renal cell carcinoma in 2011. It was part of vonHippelLindau (VHL) disease. He was on thrice a week haemodialysis. He was on amlodipine, telmisartan and ramipril. After four years of haemodialysis he presented with uncontrolled hypertension and intradialytic hypertension. He required addition of three more antihypertensives. Clonidine, metaprolol and prazosin were added. Patient was specifically evaluated for the causes of hypertension while on regular haemodialysis. There was no paedal odema and facial oedema suggestive of volume overload. The lowering of dry weight produced cramps; therewas no reduction in blood pressure. The echocardiographic volume parameters did not change before and after haemodialysis. The volume reduction during dialysis was carefully matched to weight gain, so as to avoid excess stimulation of the renin-angiotensin-aldosterone system associated with intravascular volume reduction. To avoid removal of antihypertensive medications during dialysis that could precipitate intradialytic hypertension amlodipine, telmisartan, prazosin were prescribed before dialysis and clonidine and metaprolol were prescribed after haemodialysis. Dialysate sodium levels were adjusted to maintain serum sodium at 135mEq/L. Ionized calcium was maintained between 4.4-5.4mg/dL. The dose of erythropoietin was also adjusted to maintain haemoglobin less than 11.0 g/dL. Despite all these measures there was no reduction in blood pressure. An I-131 MIBG (Metaiodobenzylguanidine) scintigraphy was done. I-131 MIBG is taken up by chromaffin tissue anywhere in the body and useful in localizing small tumours. The I-131MIBG scintigraphy revealed abnormal uptake in urinary bladder (when both kidneys removed) and it persisted for 96hours. It suggested the diagnosis of urinary bladder pheochromocytoma (supplementary figure). Cystoscopic biopsy of the lesion showed, polygonal to spindle-shaped chromaffin cells, also called chief cells, clustered with the sustentacular cells into small nests or alveoli (zellballen) by a rich vascular network. The cytoplasm on silver stain has a finely granular appearance, suggesting the appearance of granules containing catecholamines. Partial cystectomy was performed. On follow up he required only two antihypertensives. Urinary bladder pheochromocytoma constitutes less than 0.05% of urinary bladder tumours and less than 1% of all pheochromocytomas. There is no sex predilection, and the mean age of incidence was fourth decade. The common presenting features are episodes of sweating, hypertension, and haematuria and postmicturition syncope. Clinical hallmarks of VHL disease include the development of retinal and central nervous system hemangioblastomas, pheochromocytomas, multiple cysts in the pancreas and kidneys, and an increased risk for malignant transformation of renal cysts into renal cell carcinoma. There was only one published report of pheochromocytoma of urinary bladder in association with VHL disease.

Parathyroid adenomas: A case series and clinicopathological study from a tertiary care center in South India

Background: The incidence of primary hyperparathyroidism (PHP) in India is 2.5/1000 individuals. The major cause for PHP is parathyroid adenoma. To arrive at the correct diagnosis, clinical setting, biochemical and radiological investigations, the status of other glands assessed intraoperatively and finally histopathologic confirmation is essential. Materials and Methods: We carried out a retrospective analysis of the last 5 years of operated cases of parathyroid adenomas. Diagnosis was based on histological confirmation. In all the cases clinical data, details of biochemical, radiological, and other investigations including histopathological findings were recorded. Results: There were four operated patients of parathyroid adenoma at our center in the last 5 years. Out of four operated cases of parathyroid adenomas, three were symptomatic and one case was detected incidentally. The symptoms were varied and included skeletal, renal, neuromuscular, and neuropsychiatric manifestations. Two of the patients had diabetes mellitus at the time of presentation. They showed improvement in glycemic control after surgery. Histopathologically, all the parathyroid adenomas were of clear cell type without any evidence of capsular or vascular invasion to suggest the possibility of malignancy. Conclusion: Majority of our patients were females who showed symptomatic improvement after surgery. Histopathologically, all the cases were parathyroid adenomas and in one case of papillary carcinoma of thyroid, the parathyroid adenoma was incidentally detected.