Bangladesh Journal of Nuclear Medicine

Incidental Diagnosis of Prostate Cancer by 18F-FDG PET-CT Imaging in a Patient During Post-operative Evaluation for Cecal Cancer

Pupree Mutsuddy — 2023-01-31

Incidental high fluorine-18 FDG (fluorodeoxyglucose) uptake in well-differentiated prostate cancer is rare. We reported the case of a 75-year-old man who underwent a whole-body FDG PET-CT (positron emission tomography with computed tomography) scan for post-operative evaluation of caecal cancer and demonstrated no evidence of recurrence. However, a focal hypermetabolic lesion was detected in the right lateral lobe of the prostate. The patient’s prostatic biopsy from the right lobe revealed well-differentiated adenocarcinoma with a Gleason score of six and a raised serum PSA level. Incidental, focally intense FDG uptake in the prostate gland should be considered for further investigations to confirm the presence of prostate cancer.

Bangladesh J. Nuclear Med. 26(1): 51-53, 2023

Role of 18F-FDG PET-CT Imaging in a Patient with Renal Ewing’s Sarcoma: A Rare Case Report

Papia Akhter — 2023-01-31

Ewing's sarcoma (ES) is a bone-related tumor that typically affects young children and adolescents. Primary renal Ewing sarcoma (RES) is extremely rare. Sources of Ewing sarcoma in the kidney include invagination or migration of neural crest cells to the kidney. Here, a case of a young adult male with renal Ewing sarcoma is presented. A 28-year-old male presented with nausea, hematuria, and left flank pain for seven days with an unremarkable previous medical history. An ultrasound and CT scan revealed a massive lobulated mass in the upper and midsection of the left kidney. A radical nephrectomy was done. Histopathology and immunohistochemistry revealed Ewing’s sarcoma/primitive neuroectodermal tumor. The chest X-ray and chest CT scan were negative for metastasis. Initial staging was T2bNxM0. Before starting further treatment, the patient was advised to undergo a fluorine-18 FDG (fluorodeoxyglucose) positron emission tomography (F-18 FDG PET-CT) scan for the detection of occult metastases. A F-18 FDG PET-CT scan revealed peritoneal seeding, skeletal and abdominal lymph node metastases. A multimodality workup is essential for proper management of Ewing sarcoma of the kidney due to its rarity and unusual location. F-18 FDG PET-CT plays a critical role in the detection of occult metastases, staging, restaging, and treatment planning in patients with RES.

Bangladesh J. Nuclear Med. 26(1): 54-57, 2023

Investigating Unexpected Shortening of Height of A Middle-Aged Woman: A Case Report

Md Farhan Muhtasim — 2023-01-31

Osteitis fibrosa cystica (OFC) is a late sequela of untreated hyperparathyroidism caused by the autonomous secretion of parathyroid hormone (PTH). It is characterized by bone pain, skeletal deformities, and pathological fractures. OFC is caused by hypersecretion of PTH, leading to demineralization of bone and pathological fractures. We report a case of unusual presentation of OFC in a middle aged woman who noticed gradual shortening of her height within a particular period of time. Apart from height reduction, the patient had weight loss and pain in different parts of the body for over a decade. Despite being treated with analgesics and steroids initially, there was no significant improvement in her condition. Treatment history included surgical reduction of right elbow fracture and empirical anti-tubercular drug twice as there was a suspicion of disseminated tuberculosis. The patient developed lytic changes, skeletal deformities, and osteoporosis, and was diagnosed with a solitary parathyroid adenoma on the right side.

Bangladesh J. Nuclear Med. 26(1): 58-61, 2023

Scintigraphy Negative Ultrasound positive parathyroid adenoma in familial hypocalciuric hypercalcemia

Sumaiya Alam — 2023-01-31

Familial hypocalciuric hypercalcemia (FHH) is a rare, lifelong, benign condition with an autosomal dominant pattern of inheritance. FHH is clinically distinguished by mild to moderate PTH-dependent hypercalcemia and normal to significantly reduced urinary calcium excretion despite elevated serum calcium. FHH is usually caused by a heterozygous loss-of-function mutation in the calcium-sensing receptor gene (CASR). It should be differentiated from primary hyperparathyroidism (PHPT). The reported case of a 10-year-old girl presented with symptomatic hypercalcemia, elevated intact parathyroid hormone, and a vitamin D deficiency. ^99mTc-Sestamibi scan failed to detect any abnormalities, but high-resolution ultrasound (HRUS) of the neck revealed a right inferior parathyroid adenoma, which was excised with a focused parathyroidectomy. Although the patient’s calcium and iPTH levels normalized initially, they started rising within a few days.

Bangladesh J. Nuclear Med. 26(1): 62-65, 2023

Papillary Thyroid Carcinoma Arising in Thyroglossal Duct Cyst and Locally Infiltrated to Hyoid Bone: Issue of Individualized Management

Shahnaj Hossain Dinu — 2023-01-31

Thyroglossal duct cyst (TGDC) is the most common developmental anomaly of the thyroid gland, while TGDC carcinoma with local infiltration to the hyoid bone is extremely rare. The reported case of papillary thyroid carcinoma (PTC) was diagnosed in TGDC along with local infiltration to the hyoid bone and needed individualized management. A 70-year-old male patient presented with a history of PTC arising in TGDC and locally infiltrated to the hyoid bone followed by total thyroidectomy and radical sistrunk operations and was referred to National Institute of Nuclear Medicine and Allied Sciences (NINMAS) for radioactive iodine therapy (RAIT). His post-operative ultrasound of the neck revealed an irregular shaped, fungating, grossly non-homogenous mixed echogenic mass lesion invading the hyoid bone, measuring about 25 X 28 mm. Radioactive iodine(¹³¹I) of 150 mCi was administered because the residual hyoid bone mass was inoperable and he was on thyroxine suppression therapy. The post-therapy ¹³¹I scan (RxWBS) showed two intense foci of radiotracer concentration (RTC) in the upper area (above the thyroid bed) and an intense focal RTC in the fundal region of the stomach. The activity in the stomach region was evaluated by ultrasound imaging, which revealed a soft tissue mass or thickening of the mid-region of the posterior wall of the stomach (3.3 cm X 1.6 cm). A CT scan of the chest was also performed to rule out metastasis, and it revealed multiple nodular lesions in both lung fields (most likely secondary) as well as tiny subcentric lymphnodes in the lower pre- and right paratracheal regions after nearly one month of RAIT when the patient was stable for examination. EBRT is still under consideration as adjuvant therapy. Tyrosine kinase inhibitors (TKI) may be considered in cases of refractoriness to radioiodine and disease progression.

Bangladesh J. Nuclear Med. 26(1): 67-70, 2023

Radioiodine Therapy in Patient with Differentiated Thyroid Cancer and Chronic Kidney Disease on Maintenance Hemodialysis: First Case of Bangladesh

Jasmin Ferdous — 2023-01-31

The conventional course of differentiated thyroid cancer (DTC) treatment requires surgical resection followed by radioactive iodine (¹³¹I) therapy (RAIT). Patients are advised to drink plenty of water, as ¹³¹I gets eliminated through the kidneys and the burden of extra radiation is reduced. Treating a case of DTC with chronic kidney disease (CKD) by RAIT is challenging. As a result, when planning hemodialysis in a DTC patient with CKD, the dose of 131I, the timing of the dialysis, and radiation safety must all be carefully considered. Because ¹³¹I is dialyzable, a standard Geiger counter can observe and detect it. A post-thyroidectomized case of DTC with CKD was successfully treated with ¹³¹I while continuing scheduled peritoneal hemodialysis (HD) simultaneously during hospital isolation, as reported here. This case report was aimed at sharing the HD management procedures, challenges to any adverse effects, and exposure doses of ¹³¹I-treated DTC patients in their immediate post-ablative days. Geiger counter measurements in the patient after HD following ¹³¹ I administration revealed levels of less than 4.20 Sv/h on the fifth day, allowing safe hospital discharge in this case.

Bangladesh J. Nuclear Med. 26(1): 71-74, 2023

Abstracts of 26th National Conference of Society of Nuclear Medicine, Bangladesh 10th March 2023 BRAC Learning Center, Dinajpur

Editor in Cheif — 2023-01-31

Abstract not available

Bangladesh J. Nuclear Med. 26(1): 75-96, 2023

Evaluation of Physiochemical and Microbiological Stability of 2-[18F] Fluoro-2-Deoxy-D-Glucose, [18F]FDG: Synthesized in the Cyclotron Facility of National Institute of Nuclear Medicine and Allied Sciences

Md Jashim Uddin — 2023-01-31

2-[¹⁸F]Fluoro-2-Deoxy-D-Glucose ([¹⁸F]FDG) is very effective and the most successful radiotracer for the assessment of glucose metabolism in the brain, heart, and lungs. It has also been used for imaging different tumors in oncology. The purpose of this study was to evaluate the stability and quality of [¹⁸F]FDG synthesized by the newly installed 18MeV Cyclotron facility at the National Institute of Nuclear Medicine and Allied Sciences (NINMAS). [¹⁸F]FDG was synthesized by nucleophilic fluorination of Mannose-triflate followed by basic hydrolysis with an IBA Synthera® auto synthesizer. [¹⁸F]FDG solution was collected in a sterilized vial after the filtration by a vented Millex®-GS 0.22µm syringe-driven hydrophilic filter. An aliquot of [¹⁸F]FDG solution was taken 0, 2, 4, 6, and 8 hours after the synthesis. All quality control parameters were measured in the first evaluated period, immediately (i.e., 0 hours) after synthesis. Radiochemical purity (RCP) was measured for all [¹⁸F]FDG samples and for all time points. The radiochemical and radionuclidic purity was more than 95% and 99.99% respectively. The [¹⁸F]FDG was physiochemically & microbiologically stable over 8 hours.

Bangladesh J. Nuclear Med. 26(1): 44-50, 2023

The “National Integrity Strategy (NIS): Shuddhachar Koushol” and the “Annual Performance Agreement (APA)” for Sustainable Excellence in Quality Nuclear Medicine Service

Shamim Momtaz Ferdousi Begum — 2023-01-31

Abstract not available

Bangladesh J. Nuclear Med. 26(1): 11-12, 2023

18F FDG PET/CT Scan in the Evaluation of Metabolic and Morphologic Change of Breast Cancer after Neoadjuvant Chemotherapy

M Mezbah Ahmed — 2023-01-31

Background: Breast cancer remains the most commonly occurring cancer among women across the world and accounts for 69% of cancer deaths. Neoadjuvant chemotherapy (NACT) has been effective in downstaging a primary tumor before surgery. In this study, a fluorine-18, 2-fluoro-2-deoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan was used to determine the metabolic and morphological changes of breast cancer after therapy. An 18F-FDG PET/CT scan was done before and after NACT. The change in maximum standard uptake value (SUVmax) ultimately reflects the metabolic status of tumor cells, and the change in tumor diameter represents the morphology of the tumor.

Objective: To determine the therapeutic response by assessing metabolic and morphologic changes in breast cancer patients using an 18F-FDG PET/CT scan after NACT.

Patients and methods: The study was conducted at the National Institute of Nuclear Medicine and Allied Sciences (NINMAS), Bangabandhu Sheikh Mujib Medical University (BSMMU) campus, from March 2020 to June 2021, on biopsy-proven female patients diagnosed with breast cancer (stage II to stage IV as defined by the AJCC). A total of nine patients were enrolled in this study. Before and after NACT, a PET/CT scan was performed in accordance with the IAEA CRP guidelines (in a prone posture with breast hanging supported by a breast cushion) and following the NINMAS protocol. Morphological and metabolic data were recorded and analyzed to ascertain the tumor's metabolic and morphologic (as per RECIST 1.1) outcomes. A follow-up 18F-FDG PET/CT after NACT was done using the same dose and the same number of beds (1 minute per bed) as done before NACT.

Results: About 89% of patients showed a reduction in tumor size following NACT. The mean tumor size reduction rate was 23.66±22.19 (%) and the difference was statistically significant between prior and after NACT (P < 0.05). Only 11% of patients developed higher SUVmax following NACT. According to RECIST 1.1 criteria, 11.11% of patients had progressive disease, 44.44% had a partial response, and 44.44% were stable. In PET/CT scans, approximately 66.67% of patients responded to NACT.

Conclusion: 18F-FDG PET/CT can be used as a potential state-of-the art imaging approach in breast cancer patients before and after NACT. Following NACT, metabolic and morphological changes are visible in the 18F-FDG PET/CT scan, distinguishing responder and non-responder, which must be compared with pathologic response.

Bangladesh J. Nuclear Med. 26(1): 13-18, 2023

An Iterative Based Motion Correction for SPECT with Simulated Data

Md Nahid Hossain — 2023-01-31

Purpose: Single Photon Emission Computed Tomography (SPECT) is one of the important imaging modality in nuclear medicine used for diagnostic imaging of different organs of human body. Patient movement during the acquisition time is a well-known cause of artifacts in reconstructed SPECT data. These motion artifacts may significantly affect the diagnostic accuracy. Therefore, the motion correction of patients in tomography images is very much essential for more accurate diagnosis and hence achieves the quality of the images.

Objective: The aim of this project is to develop and evaluate a data driven approach to motion correction without necessity for motion tracking system.

Methods: It has been proposed a method to iteratively estimate and compensate this motion during the reconstruction. The rigid motion was estimated view-by-view in every iteration and then used to update the system matrix. The initial reconstructed image is motion contaminated; it can be used to generate a first rough motion estimate. This motion is taken into account in a reconstruction process to generate a motion-corrected image at the first iteration. Then the motion-corrected image and the motion estimate are alternately updated to increase the likelihood, the iterations are stopped when the updated motion seems to have converged. The image update is done by applying multiple iterations of the OSEM algorithm. A final iterative reconstruction was performed with the last motion estimate.

Results: The method was evaluated on simulations phantom study. From the simulations phantom data, we produced the several simulated motion induced data. Motion correction algorithms were applied with the simulated motion induced data. The quality of the reconstructed images was improved substantially after the compensation. Mean structural similarity was increased. In the simulation studies, most of the motion blurring in the reconstructed images disappeared after the compensation.

Conclusions: The proposed method effectively eliminated motion-induced artifacts in SPECT scans. Since only measured raw data are needed for the motion estimation and compensation, the proposed method can be applied retrospectively to SPECT scans affected by motion.

Bangladesh J. Nuclear Med. 26(1): 19-24, 2023

Association of Excess Dietary Iodine Intake with Papillary Thyroid Carcinoma

Sutanu Roy — 2023-01-31

Background: Papillary thyroid carcinoma (PTC) is the most common type of differentiated thyroid carcinoma and accounts for 70–80% of all thyroid carcinomas. After the global iodine fortification of salt and food, the incidence of PTC has been increasing throughout the world in recent years.

Aims: To determine the relationship between excessive dietary iodine intake and PTC.

Patients and methods: This cross-sectional study was carried out at the National Institute of Nuclear Medicine & Allied Sciences (NINMAS), Dhaka, from March 2020 to June 2021. A total of 111 patients were included in this study, of whom 53 were pre-operative papillary thyroid carcinoma patients and the rest, 58, were age- and sex-matched healthy individuals. Their urinary iodine concentrations were measured in the laboratory of the Bangladesh Reference Institute for Chemical Measurements (BRICM). Urinary iodine concentration is a good marker of dietary iodine intake. Statistical analysis of the results was obtained using Windows-based computer software devised with Statistical Packages for Social Sciences (SPSS) version 23.0.

Results: The mean urinary iodine concentration was 223.54±55.78 microgram/liter in the PTC group and 154.29±61.83 microgram/liter in the healthy group. A remarkable number of participants in both the PTC group 42 out of 53 (79.3%) and the healthy group 18 out of 58 (31.0%) had biochemical evidence of excess iodine intake. Excess iodine intake significantly (p<0.05) increased with 8.48 times odds (95% CI 3.30-22.33) in PTC patients.

Conclusion: This study revealed that a significant number of participants in the PTC group had evidence of excess iodine intake compared to that of the healthy group, which suggests that excess dietary iodine intake may be related to the occurrence of PTC.

Bangladesh J. Nuclear Med. 26(1): 25-30, 2023

Complementary Role of Thyroid Scintigraphy, Neck Ultrasonography and Biochemical Assay to Delineate Thyroid Disease Pattern in Southern Part of Dhaka

Afroza Naznin — 2023-01-31

Thyroid disorders are among the most common endocrinopathies, and a wide array of patients are referred to Nuclear Medicine (NM) institutes for different thyroid-related investigations. In this study, we analyzed the findings of thyroid scintigraphy, high-resolution thyroid gland ultrasound, and thyroid hormone assays of 279 referred patients in the thyroid division of the Institute of Nuclear Medicine and Allied Sciences (INMAS), Mitford. The complementary role of the aforementioned investigations not only helped portray the pattern of thyroid disease in the historic southern part of Dhaka but also once again emphasized the importance of multidisciplinary diagnostic tools in disease management.

Bangladesh J. Nuclear Med. 26(1): 31-33, 2023

Association of High TPO Antibody Titer with Differentiated Thyroid Carcinoma: A Case-Control Study

Umme Salma — 2023-01-31

Background: The most common well-differentiated thyroid carcinomas are papillary thyroid carcinoma (PTC) and follicular thyroid carcinoma (FTC). PTC accounts for 80–90% of all thyroid cancers, and follicular carcinoma accounts for 10–15% of all thyroid cancers. Common established risk factors for thyroid carcinoma are head-neck irradiation, a positive family history, and a few genetic disorders. High anti-thyroglobulin antibodies (TgAb) have already been established as predictive markers for thyroid carcinoma, but anti-thyroid peroxidase antibodies (TPO Ab) have not been established as predictive markers till now.

Objective: To find out the association of high TPO Ab titer with differentiated thyroid carcinoma (DTC).

Patients and Methods: This case-control study was carried out at the National Institute of Nuclear Medicine & Allied Sciences (NINMAS), Dhaka, from September 2020 to November 2021. A total of 52 cytologically diagnosed DTC patients who underwent thyroidectomy were selected as cases. Another 52 age- and sex-matched healthy individuals who had sonographically normal thyroid glands and a biochemically euthyroid state were selected as controls. The total number of participants was 104. Written informed consent was obtained from each of the participants. A detailed history was taken, and a thorough clinical examination was carried out on each patient. High resolution ultrasonography (HRUS) of the thyroid gland, serum thyroid-stimulating hormone (TSH) level, and fine needle aspiration cytology (FNAC) report of the thyroid nodule of each participant were collected. Serum TPO antibody levels were measured in patients with DTC prior to thyroid surgery, as well as in the control group, in the NINMAS laboratory using the CLIA method. After the collection of all the required data, analysis was done by SPSS 24.0.

Results: The mean age of the cases was 35.8 ± 13.3 years and 34.6 ± 13.0 years in the control groups. Female patients were predominant in both the case and control groups (63.5% and 69.2%, respectively). Both groups were statistically almost similar in terms of age and sex. Around 46.2 % (n=24) patients in the case group had high serum TPO Ab levels and 15.4 % (n=8) of participants in the control group had high serum TPO Ab levels. The mean serum TPO Ab level in the case group was 306.77± 452.57 U/mL, and the mean serum TPO Ab level in the control group was 75.85±181.47 U/mL. Serum TPO antibody level was significantly higher in the case group compared to the control group (306.77±452.57 vs 75.85±181.47 U/mL, p = 0.001).

Conclusion: There was a significant association of high TPO Ab titer found with DTC

Bangladesh J. Nuclear Med. 26(1): 34-38, 2023

Successful Treatment with Radioiodine for Antithyroid Drug-Induced Agranulocytosis in Graves' Disease

Jasmin Ferdous — 2023-01-31

Background: Graves’ disease (GD) is an autoimmune disorder and the leading cause of hyperthyroidism. Antithyroid drugs (ATDs) are available treatment option. Agranulocytosis is a rare but potentially fatal complication of ATD in hyperthyroidism management. The study's objectives include clinical symptoms of ATD-induced agranulocytosis in Graves' illness and the difficulties in clinical care in addition to radioactive iodine therapy (RAIT).

Methods: Twelve patients with ATD induced agranulocytosis referred to NINMAS between 2021to 2022 for RAIT therapy were included in this study. All the patients with hyperthyroidism and agranulocytosis or leukopenia were taken in this study.

Results: The age of the 12 patients (female: male = 10:3) was 26 to 56 years (mean SD: 38.41±13.9 years). Among the twelve patients 10 were treated with carbimazole and two with PTU for Graves’ disease. Initial dose of ATD was 15-30 mg daily. The most common clinical manifestations were fever (100%), sore throat (41.6%), oral ulcer (16%), rash (41.66%), loose motion (16.66%) and atrial fibrillation (8.33%) with deep vein thrombosis (DVT). Agranulocytosis developed between 7th and 547th days after initiation of ATD; all of them developed early onset except one who developed agranulocytosis after 1.5 years of initiation of ATD. All 12 patients were treated immediately after diagnosis of agranulocytosis following prompt discontinuation of ATD, they were treated with antibiotic with 12 cases, G CSF in one case, KI in one case, glucocorticoid in two cases, and beta blocker in all cases. After intensive and supportive treatment in hospital, all the patients recovered with absolute neutrophil counts of more than 500/mm3 in 5 to 15 days (mean SD: 7.6 3.4 days). Nine patients were treated with lithium carbonate supplement to reduce FT3 level. Average dose of lithium carbonate was 600 mg. After that patients were referred for RAIT. TRAb were positive in seven patients and average were 4.2 U/L. Plasmapheresis was done in three patients and one patient in two times due to high FT4 level before RAIT. Lithium carbonate supplementation reduce thyroid hormone level but not to the optimum level. All the 12 patients were treated with RAIT. Average dose RAI 10.9 mCi, average follow up period 2.3 years. Two patients required second dose of RAIT due to persistent hyperthyroidism. Six patients became hypothyroid, two were in hyperthyroid state (on plan for second therapy), four patients are euthyroid at present and they are on follow up. No fatal condition was found in this study.

Conclusion: The most cost-effective method of managing agranulocytosis induced by thionamide-derived ATD is that all patients with thyrotoxicosis must be informed that their white blood cells and differential counts should be checked immediately whenever the “common cold” symptoms occur during treatment, especially within the first three months of medication. Contraindication to ATDs; RAI is a safe and effective alternative.

Bangladesh J. Nuclear Med. 26(1): 39-43, 2023