Incidental Detection of Parathyroid Adenoma on 18F-PSMA PET/CT.

ABSTRACT: A 70-year-old man, diagnosed with prostate cancer, was referred to the Department of Nuclear Medicine for tumor staging with prostate-specific membrane antigen (PSMA) PET/CT. High PSMA uptake was observed in the prostate without PSMA-avid lymph nodes or distant metastases. Coincidentally, a PSMA-avid nodule was observed dorsal to the right thyroid lobe. A complementary 4-dimensional CT showed a round nodule of 18 mm with quick contrast enhancement well demarcated from its surroundings. Blood tests revealed elevated serum calcium and parathyroid hormone consistent with primary hyperparathyroidism. Subsequently, parathyroidectomy was performed, and histopathological examination of the nodule confirmed a parathyroid adenoma.

FDG-Avid Granulomatous Lymphocytic Interstitial Lung Disease With Common Variable Immunodeficiency.

ABSTRACT: A 26-year-old woman with known common variable immunodeficiency was referred for FDG PET/CT because of interstitial pulmonary abnormalities and enlarged mediastinal and hilar lymph nodes. FDG PET showed a combination of ground-glass abnormalities and pulmonary nodules, both displaying increased FDG uptake. In addition, multiple FDG-avid axillary, mediastinal, hilar, and inguinal lymph nodes were found. The abnormalities were diagnosed as granulomatous-lymphocytic interstitial lung disease. Cytology of mediastinal lymph nodes yielded only benign disease, without further specification, whereas histology of an excised axillary lymph node showed reactive changes, but no malignancy.

Distant embolisation in infective endocarditis: characteristics and outcomes.

BACKGROUND: Infective endocarditis is a severe and potentially lethal cardiac disease. Recognition of the clinical features of endocarditis, such as distant embolisation, and adequate treatment should be initiated promptly given the grim perspective of upcoming virulent pathogens. METHODS: We report on our registry-based experience with outcomes of consecutive patients with infective endocarditis with distant embolisation. We aimed to describe the patient characteristics of infective endocarditis complicated by distant organ embolisation and the safety aspects of continuing endocarditis treatment at home in these patients. RESULTS: From November 2018 through April 2022, 157 consecutive patients were diagnosed with infective endocarditis. Of them, 38 patients (24%) experienced distant embolisation, either in the cerebrum (n = 18), a visceral organ (n = 5), the lungs (n = 7) or the myocardium (n = 8). Pathogens identified in blood cultures were predominantly streptococcal variants (43%), with only one culture-negative endocarditis case. Of the 18 patients with cerebral embolisation, 12 had neurological complaints and most often discrete abnormal findings on neurological examination. Six of the 8 cardiac embolism patients experienced chest pain before admission. Visceral organ and pulmonary embolism occurred silently. Of the 38 patients with distant embolisation, 17 could be discharged earlier by providing antibiotic treatment at home without complications. CONCLUSION: This registry-based single-centre experience showed an incidence of distant embolisation in daily care of 24%. Cerebral and coronary embolisation provoked symptoms, while visceral emboli remained silent. Pulmonary emboli may present with inflammatory signs. Distant embolisation was not in itself a contra-indication for outpatient endocarditis@home treatment.

Performance of visual, manual, and automatic coronary calcium scoring of cardiac 13N-ammonia PET/low dose CT.

BACKGROUND: Coronary artery calcium is a well-known predictor of major adverse cardiac events and is usually scored manually from dedicated, ECG-triggered calcium scoring CT (CSCT) scans. In clinical practice, a myocardial perfusion PET scan is accompanied by a non-ECG triggered low dose CT (LDCT) scan. In this study, we investigated the accuracy of patients' cardiovascular risk categorisation based on manual, visual, and automatic AI calcium scoring using the LDCT scan. METHODS: We retrospectively enrolled 213 patients. Each patient received a 13N-ammonia PET scan, an LDCT scan, and a CSCT scan as the gold standard. All LDCT and CSCT scans were scored manually, visually, and automatically. For the manual scoring, we used vendor recommended software (Syngo.via, Siemens). For visual scoring a 6-points risk scale was used (0; 1-10; 11-100; 101-400; 401-100; > 1 000 Agatston score). The automatic scoring was performed with deep learning software (Syngo.via, Siemens). All manual and automatic Agatston scores were converted to the 6-point risk scale. Manual CSCT scoring was used as a reference. RESULTS: The agreement of manual and automatic LDCT scoring with the reference was low [weighted kappa 0.59 (95% CI 0.53-0.65); 0.50 (95% CI 0.44-0.56), respectively], but the agreement of visual LDCT scoring was strong [0.82 (95% CI 0.77-0.86)]. CONCLUSIONS: Compared with the gold standard manual CSCT scoring, visual LDCT scoring outperformed manual LDCT and automatic LDCT scoring.

Radiosynoviorthesis: almost seventy years of experience but still somewhat fameless.

Radiosynoviorthesis (RSO) or radiation synovectomy has been practiced for more than half a century, but in many parts of the world, it is still relatively unknown and not used to its full potential in the standard care for chronic, persistent or recurrent synovitis. The working mechanism of RSO is simple yet elegant. Radiopharmaceutical particles are, after injection in the affected synovial joint, gobbled up by phagocytizing subsynovial inflammatory cells. As a consequence, the synovium will be irradiated locally resulting in synovial cell necrosis and inhibition of cell proliferation, which eventually leads to a decrease in the inflammatory response in the joint cavity. In this review RSO is once again brought to the attention and common indications for RSO are discussed. Also, appropriate activities of the administrated radiopharmaceuticals and coadministrated glucocorticoids are provided. Furthermore, a detailed database-assisted chronological overview of published literature of RSO in inflammatory and non-inflammatory diseases, like rheumatoid arthritis, psoriatic arthritis, osteoarthritis and osteochrondomatosis, hemophilic hemarthrosis and pigmented villonodular synovitis (PVNS) is provided. Based upon the published literature an indication of level of evidence of RSO is discussed. There is evidence that RSO is effective in persistent synovitis in patients with a variety of causes for synovitis, although the effectiveness seems to decrease over time. In these patients, RSO may not be used to its full potential in many parts of the world. Results in of RSO in hemophilia patients with hemarthrosis are favourable, however the evidence for the effectiveness of RSO in these patients is less firm and mainly based on case series. The evidence for the efficacy of RSO as adjuvant therapy in PVNS is, at best, of very low quality.

Athletic Osteitis Pubis Detected on 18 F-FDG PET/CT.

ABSTRACT: A 37-year-old male personal trainer presented with debilitating groin pains, fever, and night sweats. Enlarged inguinal lymph nodes were noticed during physical examination, and blood tests showed elevated erythrocyte sedimentation rate and C-reactive protein. 18 F-FDG PET/CT excluded lymphoma and other malignancy but showed intense FDG uptake at the pubic symphysis and cortical erosions of the pubic bones on CT. The patient was diagnosed with osteitis pubis, an inflammatory condition of the pubic symphysis commonly seen in athletes. Treatment with anti-inflammatory drugs was initiated. Within several weeks, pain decreased, and inflammatory markers normalized.

Multi-task Deep Learning of Myocardial Blood Flow and Cardiovascular Risk Traits from PET Myocardial Perfusion Imaging.

BACKGROUND: Advanced cardiac imaging with positron emission tomography (PET) is a powerful tool for the evaluation of known or suspected cardiovascular disease. Deep learning (DL) offers the possibility to abstract highly complex patterns to optimize classification and prediction tasks. METHODS AND RESULTS: We utilized DL models with a multi-task learning approach to identify an impaired myocardial flow reserve (MFR <2.0 ml/g/min) as well as to classify cardiovascular risk traits (factors), namely sex, diabetes, arterial hypertension, dyslipidemia and smoking at the individual-patient level from PET myocardial perfusion polar maps using transfer learning. Performance was assessed on a hold-out test set through the area under receiver operating curve (AUC). DL achieved the highest AUC of 0.94 [0.87-0.98] in classifying an impaired MFR in reserve perfusion polar maps. Fine-tuned DL for the classification of cardiovascular risk factors yielded the highest performance in the identification of sex from stress polar maps (AUC = 0.81 [0.73, 0.88]). Identification of smoking achieved an AUC = 0.71 [0.58, 0.85] from the analysis of rest polar maps. The identification of dyslipidemia and arterial hypertension showed poor performance and was not statistically significant. CONCLUSION: Multi-task DL for the evaluation of quantitative PET myocardial perfusion polar maps is able to identify an impaired MFR as well as cardiovascular risk traits such as sex, smoking and possibly diabetes at the individual-patient level.

Focal PSMA-Positive Pleural Lesion in a Patient With Stage II Prostate Carcinoma.

ABSTRACT: A 70-year-old man with histopathologically proven prostate carcinoma (Gleason, 5 + 5; prostate-specific antigen level, 6.2 µg/mL) was referred for an 18F-PSMA-1007 PET/CT scan. The scan revealed bilateral PSMA uptake in the prostate, representing the primary tumor, but no evidence of PSMA-positive lymph nodes. However, a left-sided ventral pleural thickening showed focal PSMA uptake. Lesion biopsy showed no signs of malignancy, and prostatectomy was performed. The 1-year follow-up CT thorax showed growth of approximately 20% of the pleural lesion. Subsequently, video-assisted thoracic surgery of the lesion was performed. Histopathology showed a solitary fibrous tumor, a rare mesenchymal tumor.

Löfgren Syndrome on 18F-FDG PET/CT: An Acute Manifestation of Sarcoidosis.

ABSTRACT: A 58-year-old man presented with fever, erythema nodosum, and arthralgia of knee and ankle joints. Laboratory data showed signs of inflammation, and chest x-ray revealed bilateral hilar lymphadenopathy. 18F-FDG PET/CT was acquired to analyze the underlying causes and revealed FDG accumulation in thoracic lymphadenopathy and in subcutaneous lesions and periarticular uptake. This typical triad is known as Löfgren syndrome, an acute manifestation of sarcoidosis and which, as this case shows, can be visualized on 18F-FDG PET/CT. It is important to recognize this syndrome and to discriminate it from the classic presentation of sarcoidosis because of its different diagnostic and therapeutic consequences.

Matched-Pair Comparison of 18F-DCFPyL PET/CT and 18F-PSMA-1007 PET/CT in 240 Prostate Cancer Patients: Interreader Agreement and Lesion Detection Rate of Suspected Lesions.

Over 20 different prostate-specific membrane antigen (PSMA)-targeting radiopharmaceuticals for both imaging and therapy have been synthesized. Although variability in biodistribution and affinity for binding to the PSMA receptor is known to exist between different PSMA-targeting radiopharmaceuticals, little is known about the clinical implications of this variability. Therefore, this study analyzed differences in interreader agreement and detection rate between 2 regularly used 18F-labeled PSMA receptor-targeting radiopharmaceuticals: 18F-DCFPyL and 18F-PSMA-1007. Methods: One hundred twenty consecutive patients scanned with 18F-PSMA-1007 were match-paired with 120 patients scanned with 18F-DCFPyL. All 240 PET/CT scans were reviewed by 2 readers and scored according to the criteria of the PSMA Reporting and Data System. Interreader agreement and the detection rate for suspected lesions were scored for different anatomic locations such as the prostate, prostatic fossa, lymph nodes, and bone. Results: Great equality was found between 18F-DCFPyL and 18F-PSMA-1007; however, some clinically relevant and statistically significant differences were observed. 18F-PSMA-1007 detected suspected prostatic or prostatic fossa lesions in a higher proportion of patients and especially in the subcohort scanned for biochemical recurrence. 18F-DCFPyL and 18F-PSMA-1007 showed an equal ability to detect suspected lymph nodes, although interreader agreement for 18F-DCFPyL was higher. 18F-DCFPyL showed fewer equivocal skeletal lesions and higher interreader agreement on skeletal lesions. Most of the equivocal lesions found with 18F-PSMA-1007 at least were determined to be of nonmetastatic origin. Conclusion: Clinically relevant differences, which may account for diagnostic dilemmas, were observed between 18F-DCFPyL and 18F-PSMA-1007. Those findings encourage further studies, as they may have consequences for selection of the proper PSMA-targeting radiopharmaceutical.

"Skull on Fire": Monostotic Paget Disease of the Skull Bone.

An 81-year-old woman was evaluated for a stroke. CT showed no intracranial abnormalities but diffuse patchy aspect of the neurocranium. An MRI and F-NA PET/CT were performed to differentiate between metastases, Paget disease, hyperostosis frontalis interna, and primary malignancy. MRI yielded no additional findings. F-NA PET/CT showed diffusely increased uptake in the skull and 4 spots with intense uptake. No other suspicious skeletal foci were seen elsewhere. Low-dose CT showed no sign of malignancy elsewhere. Image findings together with elevated serum alkaline phosphatase levels, slightly increased calcium levels, and normal phosphorus levels were interpreted as pathognomic for monostotic Paget.

Clinical verification of 18F-DCFPyL PET-detected lesions in patients with biochemically recurrent prostate cancer.

PURPOSE: Radiolabeled Prostate-Specific Membrane Antigen (PSMA) PET/CT is the current standard-of-care for lesion detection in patients with biochemically recurrent (BCR) prostate cancer (PCa). However, rigorous verification of detected lesions is not always performed in routine clinical practice. To aid future 18F-radiolabeled PSMA PET/CT interpretation, we aimed to identify clinical/imaging characteristics that increase the likelihood that a PSMA-avid lesion is malignant. MATERIALS AND METHODS: 262 patients with BCR, who underwent 18F-DCFPyL PSMA PET/CT, were retrospectively analyzed. The malignant nature of 18F-DCFPyL PET-detected lesions was verified through any of the following metrics: (1) positive histopathological examination; (2) additional positive imaging; (3) a ≥50% decrease in Prostate-Specific Antigen (PSA) following irradiation of the lesion(s). RESULTS: In 226/262 PET scans (86.3%) at least one lesion suspicious for recurrent PCa was detected ('positive scan'). In 84/226 positive scans (37.2%), at least one independent verification metric was available. PSMA PET-detected lesions were most often confirmed to be malignant (PCa) in the presence of a CT-substrate (96.5% vs. 55.6% without CT-substrate), with SUVpeak ≥3.5 (91.4% vs. 60.0% with SUVpeak<3.5), in patients with a PSA-level ≥2.0 ng/mL (83.7% vs. 65.7% in patients with PSA <2.0ng/mL) and in patients with >2 PET-positive lesions (94.1% vs. 64.2% in patients with 1-2 PET-positive lesions; p<0.001-0.03). CONCLUSIONS: In this study, the clinical verification of 18F-DCFPyL PET-positive lesions in patients with BCR was performed. Diagnostic certainty of PET-detected lesions increases in the presence of characteristic abnormalities on CT, when SUVpeak is ≥3.5, when PSA-levels exceed 2.0 ng/mL or in patients with more than two PET-positive lesions.

Relation between pharmacological stress ECG, 13NH3-PET/CT outcome and the occurrence of cardiac events during follow-up in women with chest pain.

AIM: Evaluation of major adverse cardiovascular events (MACE) in women referred for NH3-PET/CT in relation to scan outcome and pharmacological stress ECG (PxECG) results. PATIENTS AND METHODS: Six hundred twenty-four women, referred for NH3-PET/CT between 2012 and 2016, were included. Demographic data and MACE during follow-up (407 ± 207 days) were retrieved from electronic patient charts. NH3-PET/CT was scored as either normal or abnormal. PxECG was scored as negative, non-diagnostic or positive. PxECG was compared with NH3-PET/CT and related to MACE. RESULTS: The NH3-PET/CT was normal in 482/624 (77%) and abnormal in 142/624 (23%). PxECG was negative in 234/624 (38%), non-diagnostic in 365/624 (58%) and positive in 25/624 (4%). NH3-PET/CT was normal in 87, 71 and 72% with normal, nondiagnostic and positive PxECG, respectively. 41/624(7%) experienced a MACE, 38 with abnormal NH3-PET/CT versus three with normal NH3-PET/CT (P < 0.001). MACE occurred in 5/234 (0.9%), 31/365 (8%) and 5/25 (20%) with normal, non-diagnostic and positive PxECG, respectively (P < 0.001). No MACEs were seen in 204 with both normal PxECG and NH3-PET/CT versus 5/30(17%) with normal PxECG but abnormal NH3-PET/. No MACE occurred in 3/260(1%) with non-diagnostic PxECG and normal NH3-PET/CT versus 28/105(27%) with non-diagnostic PxECG and abnormal NH3-PET/CT. 0/18 with positive PxECG and normal NH3-PET/CT showed MACE versus 5/7(71%) with a positive PxECG and abnormal NH3-PET/CT. CONCLUSION: Normal NH3-PET/CT is most prevalent in women with normal PxECG. The occurrence of MACE during follow-up is more frequently related to an abnormal NH3-PET/CT than to PxECG. Furthermore, in women with positive PxECG but normal NH3-PET/CT no MACE are to be expected.

Dynamic 18F-fluorocholine PET/CT for parathyroid imaging in patients with primary hyperparathyroidism.

OBJECTIVE: In the past few years, F-fluorocholine PET/CT has been established as a promising imaging technique for preoperative localization of parathyroid adenomas, but the optimal time point to start PET/CT acquisition after tracer injection is yet unknown. The aim of the present study was to assess the optimal time frame to acquire the PET/CT images and to evaluate the ability of dynamic imaging to differentiate parathyroid adenomas from active lymph nodes, a common cause for false-positive scan results. PATIENTS AND METHODS: Patients with primary hyperparathyroidism who had undergone a dynamic F-fluorocholine PET/CT positive for parathyroid disease and who subsequently underwent successful parathyroidectomy were retrospectively included in this study. On the 20 minutes dynamic images, standardized uptake value measurements were acquired per 1 minute frame for the parathyroid adenoma, the thyroid gland, blood pool activity, and, if present, lymph node activity. RESULTS: A total of 101 patients were included in this study. Time-activity curves showed a decrease of activity in parathyroid and thyroid glands, with faster wash-out from the thyroid gland and on average a stable, lower activity in lymph nodes. Blood pool activity was particularly present in the first 2 minutes. Differentiation of a parathyroid adenoma from active lymph nodes was best before 5 minutes, but no definitive cutoff value could be determined. Differentiation of a parathyroid adenoma from the thyroid gland was best after 10 minutes. CONCLUSION: Dynamic imaging starting at the early time point of 2 minutes after injection of F-fluorocholine is useful for characterization of hyperfunctioning parathyroid glands.

Incidental Breast Carcinoma Detected With 13N-NH3 Cardiac PET Imaging.

A 78-year-old woman with chest pain and a history of pacemaker implantation for arrhythmia underwent myocardial perfusion imaging by means of N-NH3 cardiac PET/CT. N-NH3 cardiac PET showed no signs of ischemia or infarction. Incidentally, a nodule with increased N-NH3 activity was observed in the right breast. Histopathologic examination revealed invasive ductal carcinoma.

18F-DCFPyL Uptake in an Incidentally Detected Follicular Lymphoma by PET/CT Performed for Biochemically Recurrent Prostate Cancer.

A 75-year-old man, treated with curative intent for histopathologically proven prostate cancer (initial prostate-specific antigen, 27 ng/mL; Gleason 4 + 5 = 9) through external beam radiation therapy in 2010 in combination with 3 years of androgen deprivation therapy (leuprorelin), underwent F-DCFPyL PET/CT for biochemical recurrence with a prostate-specific antigen of 4.1 ng/mL in February 2019. Multiple pelvic and some para-aortic lymph nodes showed highly increased F-DCFPyL uptake, suspicious for metastases. Incidentally, a solid mesenteric mass and mesenteric lymph nodes with moderately increased F-DCFPyL uptake were found. Upon histopathological evaluation, this proved to be a low-grade follicular lymphoma.

Ventricular synchrony is not significantly determined by absolute myocardial perfusion in patients with chronic heart failure: A 13N-ammonia PET study.

BACKGROUND: It is thought that heart failure (HF) patients may benefit from the evaluation of mechanical (dys)synchrony, and an independent inverse relationship between myocardial perfusion and ventricular synchrony has been suggested. We explore the relationship between quantitative myocardial perfusion and synchrony parameters when accounting for the presence and extent of fixed perfusion defects in patients with chronic HF. METHODS: We studied 98 patients with chronic HF who underwent rest and stress Nitrogen-13 ammonia PET. Multivariate analyses of covariance were performed to determine relevant predictors of synchrony (measured as bandwidth, standard deviation, and entropy). RESULTS: In our population, there were 43 (44%) women and 55 men with a mean age of 71 ± 9.6 years. The SRS was the strongest independent predictor of mechanical synchrony variables (p < .01), among other considered predictors including: age, sex, body mass index, smoking, diabetes mellitus, dyslipidemia, hypertension, rest myocardial blood flow (MBF), and myocardial perfusion reserve (MPR). Results were similar when considering stress MBF instead of MPR. CONCLUSIONS: The existence and extent of fixed perfusion defects, but not the quantitative PET myocardial perfusion parameters (sMBF and MPR), constitute a significant independent predictor of ventricular mechanical synchrony in patients with chronic HF.

13N-ammonia PET/CT stress myocardial blood flow compared to fractional flow reserve in coronary artery disease.

AIM: In this retrospective study, fractional flow reserve was compared to stress myocardial blood flow derived by -ammonia (-NH3) myocardial perfusion PET/CT. METHODS: From a large cohort of patients referred for -NH3 PET/CT, patients who also had fractional flow reserve-measurements within 6 months of the PET study were selected. These fractional flow reserve measurements were compared to PET/CT derived stress myocardial blood flow of the corresponding coronary territory. Results were categorized as concordant or discordant. Patients with discordant results were subdivided into a group with reduced fractional flow reserve but normal stress myocardial blood flow (group A) or into a group with normal fractional flow reserve but reduced stress myocardial blood flow (group B). RESULTS: From September 2013 through July 2016, 46 patients examined with -NH3 PET/CT also had fractional flow reserve-measurements within 6 months. A total of 66 measurements were used for comparison. Discordance was found in 32% of the measurements. Group B showed a significant reduction in stress myocardial blood flow of all coronary territories compared to group A (P = 0.000). During follow-up (median 3.96 years), group B showed more visits to the emergency department and newly developed heart failure. CONCLUSION: Discordance with stress myocardial blood flow in the corresponding flow territory was found in 32% of the fractional flow reserve-measurements. Patients with reduced stress myocardial blood flow but normal fractional flow reserve showed significantly reduced stress myocardial blood flow in all coronaries and a trend towards more cardiac adverse events.

Machine learning in the integration of simple variables for identifying patients with myocardial ischemia.

BACKGROUND: A significant number of variables are obtained when characterizing patients suspected with myocardial ischemia or at risk of MACE. Guidelines typically use a handful of them to support further workup or therapeutic decisions. However, it is likely that the numerous available predictors maintain intrinsic complex interrelations. Machine learning (ML) offers the possibility to elucidate complex patterns within data to optimize individual patient classification. We evaluated the feasibility and performance of ML in utilizing simple accessible clinical and functional variables for the identification of patients with ischemia or an elevated risk of MACE as determined through quantitative PET myocardial perfusion reserve (MPR). METHODS: 1,234 patients referred to Nitrogen-13 ammonia PET were analyzed. Demographic (4), clinical (8), and functional variables (9) were retrieved and input into a cross-validated ML workflow consisting of feature selection and modeling. Two PET-defined outcome variables were operationalized: (1) any myocardial ischemia (regional MPR < 2.0) and (2) an elevated risk of MACE (global MPR < 2.0). ROC curves were used to evaluate ML performance. RESULTS: 16 features were included for boosted ensemble ML. ML achieved an AUC of 0.72 and 0.71 in identifying patients with myocardial ischemia and with an elevated risk of MACE, respectively. ML performance was superior to logistic regression when the latter used the ESC guidelines risk models variables for both PET-defined labels (P < .001 and P = .01, respectively). CONCLUSIONS: ML is feasible and applicable in the evaluation and utilization of simple and accessible predictors for the identification of patients who will present myocardial ischemia and an elevated risk of MACE in quantitative PET imaging.