Background: This paper is based on the initial findings from a prospective ongoing study to evaluate the efficacy of flourodeoxy glucose positron emission tomography-computed tomography (FDG-PET CT) in diabetic foot evaluation. Objective: The aim was to compare the diagnostic accuracies of three phase bone scan (TPBS) and FDG PET-CT (FDG-PET) in diabetic foot evaluation. Methods: Seventy-nine patients with complicated diabetic foot (osteomyelitis/cellulitis, Charcot's neuropathy) were prospectively investigated. TPBS (15 mci methylene di phosphonate [MDP] intravenous [IV]), followed by FDG-PET (5 mci IV) within 5 days were performed in all patients. Based on referral indication, patients grouped into Group I, n = 36, (?osteomyelitis/cellulitis) and Group II, n = 43 (?Charcot's neuropathy). Interpretation was based on intensity, extent, pattern of MDP and FDG uptake (standardized uptake value) along with CT correlation. Findings were compared with final diagnostic outcome based on bone/soft tissue culture in Group I and clinical, radiological or scintigraphic followup in Group II. Results: Group I: For diagnosing osteomyelitis, TP: TN: FP: FN were 14:5:2:2 by FDG PET and 13:02:05:03 by TPBS respectively. Sensitivity, specificity, positive predictive value and negative predictive value (NPV) of FDG-PET were 87.5%, 71%, 87.5% and 71% and 81.25%, 28.5%, 72% and 40% for TPBS, respectively. Group II: charcot's: cellulitis: Normal were 22:14:7 by FDG PET and 32:5:6 by TPBS, respectively. Conclusion: Flourodeoxy glucose PET-CT has a higher specificity and NPV than TPBS in diagnosing pedal osteomyelitis. TPBS, being highly sensitive is more useful than FDG-PET in detecting Charcot's neuropathy.

Objectives: A new method of interpretation of Three Phase Bone Scan (TPBS) scan based upon the normal physiological vascular endothelial related response. Materials and Methods: Fifty cases of TPBS were evaluated. Thirteen were normal. In remaining 37 positive studies, 20 showed localized hyperemic response. All localized hyperemic responses except one with vascular endothelial dysfunction were without infection (95.0%). Infection could be ruled out in absence of generalized massive flow and pool response. All 17 cases with generalized massive hyperemic response had infection, consistent with infection or CRPS/RSD. Micro-bacterial or histological confirmation of infection was obtained in 11 cases. All 11 cases with confirmed infection showed generalized massive hyperemic response (100.0%). Two were CRPS/RSD and 2 cases were of cellulitis (100.0%). Among remaining 2, one refused surgery and other was lost to follow-up. Additionally, 20 published cases in the literature of osteomyelitis were also analyzed. Nineteen cases of bone and joint infection, (osteomyelitis/arthritis/cellulitis) except one with endothelial dysfunction showed generalized massive increased flow and pool response (95.0%). All published cases of osteomyelitis in the literature showed generalized massive hyperemic response (100.0%). Results: The data clearly indicated that 100% of the cases of bone infection (osteomyelitis/arthritis/cellulitis) and cases of CRPS/RSD showed generalized massive flow and pool pattern. Infection could be ruled out in absence of generalized massive flow and pool response. All 100% published cases of osteomyelitis in the literature showed positive vascular endothelial response. Conclusion: By incorporating the concept of vascular endothelial related response causing massive vasodilatation in infection, the interpretation of the TPBS can be more précised as it is based upon the normal physiology. Larger studies are recommended.

Introduction: Samarium-153 (Sm-153)-EDTMP is routinely used for pain palliation in skeletal metastasis, however most patients report partial response. Many strategies have been contemplated to make radiation therapy for pain more effective, one of them being the use of radiosensitizers. Capecitabine is a chemotherapeutic drug and is routinely combined with external beam radiation to make the target more radio-sensitive. Aim of the study was to evaluate whether combining capecitabine in radiosensitizing dose with Sm-153-EDTMP produces superior analgesia compared to Sm alone. Materials and Methods: Forty-four patients with skeletal metastases from various primaries were randomized into two groups: The study group received 1 mCi/kg Sm-153-EDTMP plus capecitabine (1,650 mg/m ² ) orally for 8 days (equivalent to four t_½ of ¹⁵³ Sm-EDTMP) and the control arm received 1 mCi/kg Sm-153-EDTMP plus placebo for the 8 days. After treatment, the patients were followed up for 12 weeks to evaluate the degree and duration of pain palliation and hematologic toxicity. Results: All 44 patients reported different degrees of pain relief with none reporting complete pain relief for the entire duration of 12 weeks posttherapy observation period. However the level of pain relief obtained in study arm was significantly better than the control arm with mean posttherapy pain score being 1.29 ± 1.05 and 3.59 ± 2.77 respectively with P of 0.001. Transient and mild hematologic toxicity, as determined by World Health Organization criteria, was apparent in both arms without significant differences. Conclusion: The addition of a low-dose of capecitabine significantly enhances the analgesic effect of Sm-153 without any additional side effects.

Objectives: The rate and impact of thyroglossal duct remnant (TGDR) visualization in patients with hypothyroidism after total thyroidectomy for differentiated thyroid carcinoma (DTC) have not yet been fully determined. The aim of this study was to assess the rate of TGDR visualization in post total thyroidectomy whole body scan (WBS) for DTC and to evaluate its impact on the outcome of I-131 ablation. Methods: A total of 60 consecutive DTC patients (51 papillary thyroid Ca., and 9 Follicular thyroid Ca.), underwent total thyroidectomy, followed by WBS (using I-131 in 28 patients and I-123 in 32 patients), neck ultrasound (US), thyroglobulin (Tg) and Tg anti-bodies (TgAb) assay after 40 days and subsequent I-131 ablation. At 6 months later follow-up I-131 WBS, neck U/S, Tg and TgAb were performed following suspension of L-thyroxine for 1-month (thyroid stimulating hormone [TSH] >30 μIU/ml) in 53 patients and following recombinant human TSH stimulation in seven patients. Results: Of the studied 60 patients, 19/60 (31.7%) had a linear or focal radioactivity at the superior midline of the neck, suggesting TGDR (Group 1), and 41/60 (68.3%) had no uptake to suggest TGDR (Group 2). No significant difference regarding age, gender and histopathology between both groups. Neck US showed no evidence of thyroid tissue in the superior midline of the neck in both groups, and only a small or no residual thyroid tissue in patients of Group 1. There was a significant successful I-131 ablation rate among patients of group 1 compared to group 2 (79% in Group 1 vs. 41.5% in Group 2) (P = 0.007). Conclusions: Thyroglossal duct remnant visualization on WBS of hypothyroid subjects after total thyroidectomy suggests presence of only a small or no residual functioning thyroid tissue at the thyroid bed and can predict a good response to I-131 ablation.

Aim: To determine whether the predefined calibration factors of the dose calibrators can provide accurate radioactivity measurements of beta-gamma emitters used in routine therapeutic nuclear medicine procedures. Materials and Methods: Two models of dose calibrators were used in the present study for radioactivity measurements of ¹⁵³ Sm ethylenediamine-N, N, N', N'- tetrakis methylene phosphonic acid (EDTMP) and ¹⁷⁷ Lu (EDTMP). A known (precalibrated) activity of each of the two beta emitters received by us from our National Supplier for administration to the patients with extensive bony metastases for bone pain palliation, was used for experiments. Results: When we used the manufacturers' provided dial setting of 450 × 10, each of the dose calibrators underestimated the radioactivity of ¹⁷⁷ Lu by about 9.0%. Dial settings of 403 × 10 and 408 × 10 for ¹⁷⁷ Lu on CRC-15R and CRC-ultra dose calibrators respectively were calculated experimentally using an iterative approach. The radioactivity measurements made at these settings provided an excellent agreement with the specified values. Likewise, a dial setting of 230 for each of the two dose calibrators was calculated for ¹⁵³ Sm, which provided a good agreement between the experimentally derived radioactivity values and the certified values. A deviation of ± 5.0% was observed when radioactivity of ¹⁷⁷ Lu and ¹⁵³ Sm was measured over a wide range (4.0 MBq to 2.1 GBq) for time intervals equivalent to 4.5 half-lives of each of the two radionuclides. A deviation of ± 5% was observed when radioactivity was counted in different dilution volumes and in syringes of varying size. Conclusion: These variations could lead to a cumulative error of about 20.0% toward the inaccuracy in the radioactivity measurements of the beta-gamma emitters and thus predefined calibration factors of the dose calibrators may require experimental re-setting of these parameters and periodic checking to provide accurate radioactivity estimates of beta-gamma emitters in a given clinical setting.

Objective: Accuracy of in vivo activity quantification improves after the correction of penetrated and scattered photons. However, accurate assessment is not possible with physical experiment. We have used Monte Carlo Simulation to accurately assess the contribution of penetrated and scattered photons in the photopeak window. Materials and Methods: Simulations were performed with Simulation of Imaging Nuclear Detectors Monte Carlo Code. The simulations were set up in such a way that it provides geometric, penetration, and scatter components after each simulation and writes binary images to a data file. These components were analyzed graphically using Microsoft Excel (Microsoft Corporation, USA). Each binary image was imported in software (ImageJ) and logarithmic transformation was applied for visual assessment of image quality, plotting profile across the center of the images and calculating full width at half maximum (FWHM) in horizontal and vertical directions. Results: The geometric, penetration, and scatter at 140 keV for low-energy general-purpose were 93.20%, 4.13%, 2.67% respectively. Similarly, geometric, penetration, and scatter at 140 keV for low-energy high-resolution (LEHR), medium-energy general-purpose (MEGP), and high-energy general-purpose (HEGP) collimator were (94.06%, 3.39%, 2.55%), (96.42%, 1.52%, 2.06%), and (96.70%, 1.45%, 1.85%), respectively. For MEGP collimator at 245 keV photon and for HEGP collimator at 364 keV were 89.10%, 7.08%, 3.82% and 67.78%, 18.63%, 13.59%, respectively. Conclusion: Low-energy general-purpose and LEHR collimator is best to image 140 keV photon. HEGP can be used for 245 keV and 364 keV; however, correction for penetration and scatter must be applied if one is interested to quantify the in vivo activity of energy 364 keV. Due to heavy penetration and scattering, 511 keV photons should not be imaged with HEGP collimator.

Sarcoidosis is a multisystemic disease presenting with well-defined, bilateral, symmetric hilar and right paratracheal lymph node enlargement. Recently, fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (F-18 FDG PET/CT) has been used to stage and detect occult site of active inflammation in sarcoidosis. F-18 FDG PET/CT has become a cornerstone imaging modality in the modern lymphoma management, which can present with generalized lymphadenopathy including mediastinal. We present a case series, which shows how sarcoidosis can be a "great mimic of lymphoma" on F-18 FDG PET/CT and how histopathology is essential in diagnosing sarcoidosis and ruling out lymphoma.

18-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) is an integral part of imaging in the follow-up of head and neck malignancies. Very often distinguishing inflammatory/infective from malignant recurrence cannot be made confidently with standard uptake value (SUV) alone, as inflammatory lesions have shown to have a very high SUV, and in some cases both can co-exist. In such doubtful cases, dual time PET-CT (3-5 h delayed) is of paramount importance in confidently differentiating inflammatory/infective from a malignant cause.

Angiosarcoma is a malignant vascular tumor that originates from the mesenchymal cells which have undergone angioblastic differentiation. Pulmonary angiosarcomas are invariably (>90%) metastatic tumors form primaries of the skin, bone, liver, breast, or heart. Primary pulmonary angiosarcomas are exceedingly rare, with just about 20 cases being reported in the literature. We report an additional case with a brief review of the literature of a primary pulmonary angiosarcoma in a 26-year-old lady who presented with intractable hemoptysis. In addition, we highlight the potential of fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography as an important diagnostic tool in the evaluation of this tumor and thus contribute to the existing sparse literature on this fascinating yet devastating disease.

Increase in radiopharmaceutical uptake is an indicator of progression of disease. Paradoxical increase in the radiopharmaceutical uptake also occurs during favorable response to therapy, which is designated as flare phenomenon. Flare phenomenon is well documented on bone scinitgraphy when initially noted lesions show increased radiotracer uptake after therapy is instituted. This happens despite favorable response to the treatment. The osteoblastic activity associated with healing response of bone tumors is the cause of flare phenomenon. Recently, metabolic flare phenomenon has been described in patients with breast cancer who undergo hormonal therapy. Changes in the hormonal level during initial part of the treatment is the cause of metabolic flare. We describe a patient with bilateral breast cancer who underwent second line chemotherapy along with bevacizumab. Serial positron emission tomography scans done showed interesting phenomenon of metabolic flare.

Multi-modality positron emission tomography/computed tomography (PET/CT) with 18F-fluoro-deoxy-glucose (FDG) depicts the enhancement pattern and metabolic intensity of lesions. Benign lesions with multiplicity, like neurofibromas often mimic similar appearing malignant neoplasms. We, report, a similar case where FDG PET/CT shows imaging hallmarks for diagnosing benign neurofibromas, in a patient with clinical presentation of lymphoma.

Paget's disease of bone is a benign disease, of uncertain etiology, characterized by an accelerated turnover, that is, bone resorption and formation. Paget's disease may be present in up to 5% of the population, and the majority of cases are asymptomatic. We report the imaging findings of Paget's disease of pelvis discovered incidentally in patient with lung cancer evaluated by fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) for staging. FDG PET-CT scan showed intense uptake in the right lung lower lobe primary and mediastinal lymph nodes. Furthermore, increased uptake noted in left hemipelvis suggestive of Paget's disease. He underwent follow-up FDG PET-CT after chemotherapy showed decrease in lung mass and mediastinal nodes. However, the uptake in left hemipelvis remains same confirming Paget's disease.

We are presenting two cases that illustrate nonosseous localization of 99mTc-Methylene diphosphonate (MDP) in hepatic metastases arising from varied primary pathology and review of the literature. This series emphasizes the evidence of MDP localization in hepatic metastases arising from adenocarcinoma of rectum and infiltrating duct cell carcinoma of the breast.

The American Society of Clinical Oncology guidelines recommend sentinel lymph node biopsy (SLNB) for all patients with melanoma tumors of intermediate thickness (between 1 and 4 mm). In case of patients with thick melanoma tumors (>4 mm), SLNB may be recommended as well, for staging purposes and to facilitate regional disease control. We report a case of an 82-year-old man, undergone excision of a cutaneous melanoma of the right thigh, which shows some limitation of SLNB in thick melanoma. Lymphoscintigraphy, performed as single-photon emission computed tomography/computed tomography (SPECT/CT), failed to identify the real sentinel lymph node, as tracer uptake was seen in A right inguinal node. Due to the presence on CT co-registered images of another suspicious node (with no radiopharmaceutical uptake) in the crural region, and considering the "high-risk" pathologic features of the removed primary lesion, a 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) staging scan was planned. PET/CT showed high metabolic activity in the suspected crural lymphadenopathy. Histopathology demonstrated massive invasion of the crural ("sentinel") node and no metastatic cells in the inguinal node. This report highlights both the higher accuracy of lymphoscintigraphy, when performed as SPECT/CT and the potential utility of 18F-FDG PET/CT in regional staging.

Primary malignant melanoma most commonly originates from the skin; other less common extra cutaneous sites include squamous mucous membranes, uvea, retina, leptomeninges, genitourinary tract, digestive tract, biliary tract, and upper respiratory tract. Primary melanoma of the gastrointestinal tract is exceedingly rare. We are reporting a histo-pathologically proven rare case of primary malignant melanoma of the esophagus and its findings on fluorodeoxyglucose positron emission tomography and computed tomography.

A 58-year-old woman, diagnosed as a case of mycosis fungoides (MF), underwent [18F]-fluoro-D-glucose positron emission tomography/computed tomography (FDG PET/CT) examination. The study revealed intense FDG uptake in a large ulceroproliferative right thigh lesion, indurated plaques in the chest wall and left thigh, along with multiple sites of cutaneous involvement, axillary and inguinal lymphadenopathy. The patient underwent chemotherapy with CHOP regimen, radiotherapy for the right thigh lesion, along with topical corticosteroids and emollients for the disseminated cutaneous involvement. Repeat [18F]-FDG PET/CT study performed a year later, showed near complete disease regression specifically of the ulceroproliferative lesion and indurated cutaneous plaques, no change in lymphadenopathy, and a subtle diffuse progression of the remaining cutaneous lesions. A multidisciplinary approach to the diagnosis, staging and treatment of MF has long been suggested for optimizing outcomes from management of patients with this disease. This case highlights the potential role of incorporating PET/CT as a single modality imaging technique in the staging and assessment of response to therapy.

Differentiated thyroid cancer is, usually, associated with an excellent prognosis and indolent course. Distant metastases are rare events at the onset of thyroid cancer. Among these presentations, metastasis to the axillary lymph nodes is even more unusual. Only few cases of papillary carcinoma with axillary nodal metastasis were previously reported in the literature. We present a 38-year-old female who underwent Iodine-131 whole-body scintigraphy, after total thyroidectomy and bilateral neck lymph node dissection for papillary carcinoma of thyroid, showed intense uptake in the remnant thyroid, lung metastasis, left cervical and left axillary lymph nodes. Excision of left axillary lymph nodes confirmed metastatic papillary carcinoma.

Osteosarcoma (OS) is the most common nonhematolymphoid primary bone malignancy characterized by osteoid or new bone formation. Lungs and bones are the most common sites of metastases. We report a case where unusual sites of the soft tissue recurrence from OS were detected on restaging fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography scan done post 6 years of disease free interval.

The authors report an extremely rare occurrence of a massive aneurysm of a major pulmonary artery branch vessel caused by adjacent necrotizing aggressive squamous cell carcinoma metastatic mediastinal nodes. Despite the huge size, there was no hemoptysis due to the walling off effect by the necrotic nodes.

Post operative chylothorax is a known complication of various thoracic surgeries. It needs identification of precise site of leak in the thoracic duct. Lymphosicintigraphy can identify chyle leak but cannot delineate exact site of leak. SPECT-CT is precise in anatomic localisation and hence SPECT-CT should be combined with every lymphoscintigraphy in evaluation of clinically suspected case of post operative chylothorax. We report such a case.

Ectopic thyroid tissue primarily occurs along the course of the embryologic migration of the thyroid gland. Mediastinal thyroid may be differentiated into primary and secondary form. Primary mediastinal goiters are quite rare, occurring in <1% of all goiters. We present findings of 29-year-old female, case of papillary carcinoma of the thyroid who underwent iodine-131 whole body scintigraphy after total thyroidectomy showed a primary mediastinal mass lesion along with residual thyroid. She underwent mediastinal mass excision through sternotomy and biopsy confirmed as ectopic nodular colloid goiter with no malignancy.

In general, there are five lumbar vertebras in normal human subjects. But occasionally there are six. In such a situation, a radiologist need to discern between lumbarization of S1 (S1 vertebra becomes segmented and mimics L5) or due to hypoplastic 12 ^th ribs, hence the T12 vertebra is wrongly assumed to be L1. These interesting images serve a multimodality approach to right aplasia/left hypoplasia of 12 ^th rib, injury of left 11 ^th rib and subluxation of left 11 ^th Costovertebral joint in a patient with lumbar back pain.

Corticobasal degeneration is a rare neurodegenerative disorder that often eludes clinical diagnosis. The present case shows the F-18 fluoro-d-glucose positron emission tomography/computed tomography (PET/CT) of a 62-year-old man with a progressive movement disorder with asymmetric features. PET/CT examination showed a markedly right-brain hemispheric hypometabolism also involving basal ganglia.