Purpose: Ac-225 labeled with prostate-specific membrane antigen (PSMA-617), a transmembrane glycoprotein which is highly expressed in prostate carcinoma cells, is presently being considered a promising agent of targeted alpha therapy for the treatment of patients suffering from metastatic castration-resistant prostate cancer. In the present study, we report an optimized protocol for the preparation of therapeutic dose of Ac-225 PSMA-617 with high yield and radiochemical purity (RCP). Methods: Ac-225 PSMA-617 was prepared by adding the peptidic precursor-PSMA-617 (molar ratios, Ac-225: PSMA-617 = 30:1) in 1 ml ascorbate buffer to Ac-225 and heating the reaction mixture at 90°C for 25 min to obtain the radiopeptide with high RCP and yield. The radiolabeled peptide was administered in patients who met the eligibility criteria and posttherapy assessment was done. Results: Ten batches of Ac-225 PSMA-617 were prepared following this protocol. The radiopeptide was obtained with an adequate yield of 85%–87% and RCP of 97%–99%. Conclusion: The current protocol allows single-step, successful, routine inhouse radiolabeling of Ac-225 with PSMA-617 with high yield and RCP.

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Radiopharmaceutical preparations are the important pharmaceutical dosage forms used for the diagnosis and therapeutic purposes. Various pharmacopoeias are having methods for the quality control of these preparations in the form of monographs. Indian Pharmacopoeia (IP) also included these monographs in IP 2014 first time with the help of an experts' group on radiopharmaceutical, drawing expertise from elite stakeholder institutions and the core team of Indian Pharmacopoeia Commission. Since then, these standards are regularly updated through the IP addendum and bringing out new edition of IP. IP is a book of official methods as per Drugs and Cosmetic Act, 1940. These standards can be used in government laboratories, private laboratories, or academia in India and abroad. This review provides an overview of the journey of radiopharmaceuticals' standard setting in IP. A comprehensive comparative information of regulatory perspectives of radiopharmaceuticals in different jurisdictions such as the US, EU, and India is also presented.

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Objective: This retrospective study aimed to investigate whether metabolic parameters of primary tumour i.e. maximum standardized uptake value (SUVmax), metabolic tumour volume (MTV) and total lesion glycolysis (TLG) predict overall survival (OS) in patients with advanced stage non-small cell lung cancer (NSCLC). Materials and Methods: SUVmax, MTV and TLG of the primary tumors were measured in staging ¹⁸F-Fluorodeoxyglucose Positron emission tomography- Computed tomography (¹⁸F-FDG PET/CT) scan of 97 NSCLC patients by gradient based tumour segmentation method. Prognostic ability was assessed for overall survival (OS) of the patients. Result: The median follow-up period of the study was 15.84 months (range 1.3 to 47.97 months).The estimated median OS was 11.29 months (range 1.37 to 38.63 months). Total of 40 (41.24%) patients had progressive disease and 21 (21.65%) patients died during the follow up period. Receiver Operating Characteristic (ROC) analysis showed that the area under the curve (AUC) for MTV was significant (area = 0.652 ± 0.065; 95% CI = 0.548 – 0.746; P = 0.020). Kaplan-Meier survival curves showed that the OS differences between the groups of patients who were dichotomized by the median value of MTV (38.76 ml, P = 0.0150) and TLG (301.69 ml, P = 0.0046) were significant. MTV (hazard ratio = 4.524; 95% CI = 1.244 – 16.451; P = 0.022) was found to be an independent prognostic factor for OS in multivariate analysis. Conclusion: MTV of the primary tumor is a potential prognostic parameter for OS in our population of advanced NSCLC patients independent of other risk factors.

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Introduction: [¹⁸F]-Fluorodeoxyglucose ([¹⁸F]-FDG) is the most widely used positron-emission tomography tracer used for imaging in clinical studies such as early detection of cancer or its malignancies, quantifications, staging, and restaging of several malignancies. For clinical application, routine production of this tracer is mandatory in compliance to regulatory guidelines. Several dedicated commercial synthesizers are currently used for producing[¹⁸F]-FDG for clinical usage. Being at hospital radiopharmacy, it is our responsibility and duty to support the clinical service with uninterrupted production and supply of [¹⁸F]-FDG. This document describes the production of [¹⁸F]-FDG using two different automated synthesizers in terms of its production yield, time of synthesis, and analyze the quality control (QC) of the produced [¹⁸F]-FDG. Materials and Methods: The precursor, mannose triflate ultra-pure, authentic nonradioactive standard FDG and [¹⁸O]-water were obtained from ABX, Germany. Solvents and reagents were purchased from Sigma Aldrich India Ltd. and Fisher Scientific India Ltd., (Mumbai, Maharashtra, India). Results: The protocol developed for the synthesis with MPS-100 synthesizer yield of [¹⁸F]-FDG is approximate about 45% End of Bombardment (EOB) with synthesis time of around 35 min, whereas with F300E synthesizer it is around 60% with synthesis time of 25 min. The quality of the tracer produced by both synthesizers is at par with the QC parameter for clinical applications. Conclusions: Finally, we have developed the production using two automated synthesis modules which have the capability to produce [¹⁸F]-FDG, to do the patient studies in good yield and purity. Our protocol is simple, reproducible, and robust.

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Aim: Radionuclide therapy may produce a significant radiation exposure risk to the patient's caregivers. The study aims to assess the radiation exposure rate to caregivers after the patient's discharge from the isolation ward. Materials and Methods: Patients of the well-Differentiated thyroid cancer (DTC) were given high-dose radioiodine therapy as an inpatient. Their radiation exposure was measured daily, and they were discharged once the exposure rate falls as per standard guidelines. Detail counseling of the patient and caregiver about radiation safety was done before admission and at the time of discharge. Caregivers were given thermoluminescence dosimeter (TLD) to wear as a locket for 7 days. Radiation exposure received by the caregiver was measure after that. Results: A total of 22 patients (8 male and 14 female) of DTC were recruited in the study. The mean age was 39.0 ± 14.5 years. Patients were treated with 3.79 ± 1.07 (102.4 ± 28.9 mCi) (1.85–5.55 (50–150 mCi) GBq of radioiodine. They were discharged from the isolation ward at a radiation level of 0.028 ± 0.015 mSv/h (3.193 ± 1.71 mR). The mean effective dose received by the caregiver was 14.60 ± 3.43 mSv (1460 ± 343 mR) (9.73–24.25 (973–2765 mR) mSv. Conclusion: Our study denotes that the caregivers of DTC patients receive a significant radiation dose. It was well above the caregiver's annual dose-limit constraints regarding the rationales well as international guidelines of 5 mSv/yr. These could be related to the long travel in public transport and housing conditions. There is a need for patient-specific discharge criteria rather than following standard guidelines to minimize radiation exposure to caregivers.

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Radiopharmaceuticals are used in the diagnosis and management of various diseases. There are several reports of adverse reactions related to the use of radiopharmaceuticals, though it is not as common as conventional drugs. Adverse reactions related to radiopharmaceuticals have been not widely reported and documented. In this review, we have tried to summarize the adverse reactions associated with some of the commonly used radiopharmaceuticals.

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Background, Aims and Objectives: Cisplatin is extensively used in chemotherapy for treatment of a broad range of cancers. But its undesired side reactions with biomolecules that lead to severe side effects especially on kidney and nervous system, are limiting its clinical utility. To reduce its side effects, the kinetically inert Pt(IV) prodrug was recognized as an alternative approach from satisfactory results of preliminary experiments. But, its approval as anticancer drug for clinical use requires detailed investigations of its anticancer action and pharmacological pathways by employing its analogue which can be traced by a suitable technique. As a step closer towards translation of Pt(IV)-based prodrug from research to clinical level, a protocol for efficient synthesis of ^195mPt-radiolabeled Pt(IV) prodrug was devised. Materials and Methods: In order to achieve the aim, we started synthesis from elemental platinum avoiding lengthy steps. The synthesis protocol was standardized on its cold analogue, as [PtCl₂(NH₃)₂(OCOCH₂CH₂COOH)₂] which has been characterized with nuclear magnetic resonance (¹H, ¹³C{1H} and ¹⁹⁵Pt{1H}) spectroscopy, microanalyses and cyclic voltammetry. Also, cytotoxicity of [PtCl₂(OCOCH₂CH₂COOH)₂(NH₃)₂] was evaluated against MCF-7 human breast cancer cell lines using cisplatin as test control. Results: Intrinsically, ^195mPt-labeled analogue of prodrug was obtained with high radionuclidic and radiochemical purity. It was confirmed by chromatography and γ-ray spectrometry. Conclusion: The ^195mPt-radiolabeled prodrug was synthesized in a facile manner. It can be utilized in evaluating the mechanism of anticancer action and pharmacokinetics by enabling synergistic use of molecular imaging and targeted drug delivery.

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Background: One of the treatment modalities for thyroid cancer and hyperthyroidism is radioiodine-131 (I-131) therapy. The use of this therapeutic modality is not completely safe and can lead to oxidative stress, eventually DNA damages. However, these radiation-induced damages can be reduced by antioxidants. This study aimed to investigate the potential radioprotective effects of melatonin and selenium nanoparticles (SeNPs) on DNA double-stranded breaks (DSBs) caused by I-131. Materials and Methods: After obtaining informed consent, 6 ml blood was taken from each volunteer. The samples were divided into two general groups of control (without I-131) and with I-131. Each group was also divided into three subgroups, including without antioxidant, melatonin, and SeNPs. The samples of control group were incubated for 2 h after adding the antioxidants. The samples of I-131 group were first incubated for 1 h with the antioxidants and then the samples re-incubated for another 1 h after adding the I-131. Then, the samples were prepared for γH2AX assay. Results: The findings showed that after 1 h of incubation with 20 μCi I-131/2 mL, the DSB levels increased by 102.9% in comparison with the control group. In the I-131 group, there were significant reductions of the DSB levels after incubation with melatonin (P < 0.001) and SeNPs (P < 0.001) in comparison with the without antioxidant subgroup. Furthermore, the DSB levels at the melatonin + I-131 and the SeNPs + I-131 subgroups decreased to 38% and 30%, respectively, compared to the I-131 subgroup. Conclusion: According to the obtained findings, it can be concluded that the use of melatonin and SeNPs (as radioprotector agents) can reduce the DSB levels induced by I-131 in peripheral lymphocytes.

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Objective: An image processing pipeline can have more than one image processing technique in sequence, and the output of the first technique becomes input for the next technique and so on. In this study, we have designed and compared the performances of image processing pipelines for enhancement of I-131-metaiodobenzylguanidine (mIBG) images. Materials and Methods: Five different image processing pipelines (A [Gaussian filter, normalization], B [histogram specification (image 1), Gaussian filter, normalization], C [histogram specification (image 2), Gaussian filter, normalization], D [{histogram specification (image 3), Gaussian filter, and normalization], and E [histogram specification (image 4), Gaussian filter, normalization]) were designed and their performances were evaluated on I-131-mIBG images (n = 122). The image quality was assessed objectively using Perception-based Image Quality Evaluator (PIQE) score and subjectively (on scale 1–4) by two nuclear medicine physician. Sign test was applied to find the statistically significant difference between the image quality obtained using image processing pipelines. We applied test of proportion to compute difference in proportion of image quality score assigned to images obtained using image processing pipelines. Results: Based on PIQE score, the quality of images obtained using all the five image processing pipelines were significantly better than that of input images (P < 0.001). The highest image quality score (=4) was assigned maximum number of times (n = 90) to the images obtained using image processing pipeline D and was significantly different from that of the second best image processing pipeline E (P = 0.015). Conclusions: The image processing pipeline D was found to be better for enhancement of I-131-mIBG images.

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Melanomas are the malignancies that can affect any anatomic region where melanocytes exist (such as the epidermis, eyes, nasal cavity, and anus). Anorectal melanoma is a rare mucosal melanocytic malignancy, comprising 0.8% of all anorectal malignancies. Here, we report a case series of three patients of anorectal melanoma and role of positron emission tomography/computed tomography in diagnosis and follow-up to evaluate the local recurrence and distant metastases. Of three patients, two presented with rectal bleeding and one with obstruction. One patient had recurrence after 10 months, other after 24 months, and third remained disease free post surgery till 9 months.

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Chondroblastic osteosarcoma is an uncommon subtype of osteosarcoma, constituting about 25% of all osteosarcoma cases. It has shown high propensity for developing tumor thrombi and thromboembolism, with poor overall survival rate. Differentiation between tumor thrombus and bland thrombus is an important factor in making treatment decisions. 18 F fluorodeoxyglucose positron emission tomography/computed tomography plays a very important role in detecting and differentiating bland thrombus from tumor thrombus.

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This article briefly describes the event of a defective detector block in a daily quality assurance scan/blank scan and insists on implementing guidelines to scan or not to scan in such a scenario. The nuclear medicine physicist should have a clear understanding of the blank scan graph, which shall help rectify the right cause of problem and give confidence to the physician in reporting the acquired study. A routine blank scan in positron emission tomography signifies various parameters of the crystal (coincidence count rate, single count rate, dead time, and coincidence time along with energy response) and in some respect is analogous to the daily uniformity flood image for gamma cameras, providing an overall assessment of detector response. We encountered a bad detector block in our routine quality assurance scan/blank scan and analyzed the root cause behind such an error which was finally restored to normalcy by replacing the defected part with a new one and an error-free blank scan was established. The analysis was carried out by performing various possible checks and discussing the issue with service engineer to help identify the defects much before service engineer actually arrived in our department. This allowed us to take the correct decision and enabled us to get the scanner repaired faster. Hence, a good understanding of the daily quality control test and proper analysis of the same may result in swift decision-making and faster repair of equipment leading to minimal disruption in the clinical workflow as well as avoidance of suboptimal scanning leading to the wrong diagnosis.

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Prosthetic valve endocarditis (PVE) is a sinister complication, with high morbidity and mortality. Diagnosis is conventionally based on modified Duke Criteria. 18F-Fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography-computed tomography (PET-CT) has shown high accuracy in diagnosing PVE. Positive ¹⁸F-FDG uptake in prosthetic valves on PET-CT is now considered major criteria for diagnosis of PVE. We share our experience of ¹⁸F-FDG PET-CT imaging as a problem solving tool in a case of suspected PVE and review the relevant literature.

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Krukenberg tumor (KT) is a rare clinical entity with a mysterious origin. It originates most commonly from adenocarcinoma of the stomach. We present an interestingly rare case of this entity in renal cell carcinoma, revealed by ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT) scan. Ovarian cancers with diffuse peritoneal metastasis were considered the differential diagnosis of the disease, based on PET/CT. The potential efficacy of this functional imaging for KT is still in the exploratory phase, but its applications in diagnosis, disease prognostication, therapeutic response monitoring, and follow-up recurrence detection are superior than other imaging modalities.

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Immunoglobulin G4 (IgG4)-related kidney disease is a relatively rare clinical entity and usually occurs as an extra-pancreatic manifestation of IgG4-related autoimmune pancreatitis. We describe here the imaging findings of a patient who presented with recurrent multiorgan IgG4-related disease, involving bilateral kidneys/ureters, proximal small bowel, and multiple abdominal and extra-abdominal lymph nodes.

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Extraadrenal paragalionoma at multiple sites and its association with GIST is a rare finding. Although ¹⁸F-FDG PET-CT is not a modality of choice for primary diagnosis of paraganglioma, and its use is restricted for detection of metastases/multiple sites and disease staging. However, in this case that we describe here, its role in an already-proven/recurrent case of paraganglioma is emphasized by its simultaneous assessment of disease at several different sites.

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Hyperfibrinolysis caused by abnormal over-activation of the fibrinolytic system can be associated with occult cancer. We present an interesting case of a 48-year-old man with paraneoplastic hyperfibrinolysis, where ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography-computed tomography (PET-CT) was able to detect occult prostate-specific antigen-negative metastatic prostate cancer as the underlying etiology. This shows that while ¹⁸F-FDG PET-CT has overall poor sensitivity for prostate cancer, it can be useful in certain clinical situations.

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This pictorial essay depicts normal appearances, complications, and findings of residual and/or recurrent disease on fluorodeoxyglucose positron emission tomography/computed tomography (18F- FDG PET/CT) studies in the postsurgical setting. Reading and reporting 18F- FDG PET/CT in the postoperative scenario is demanding due to the multiple false positives seen during this period. This article which contains two parts will familiarize the readers with the normal appearance and pitfalls seen in 18F- FDG PET/CT studies during the postoperative period so as to avoid misinterpretations. This pictorial will discuss 18F- FDG PET/CT in the postoperative scenario in head and neck cancers.

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We describe the Ga-68 DOTATATE positron emission tomography/computed tomography (PET/CT) findings of a 51-year-old man, operated for right esthesioneuroblastoma. Postoperative Ga-68 DOTATATE PET/CT revealed focal uptake anterior to sphenoid ostium on the right paramedian side, suspicious for residual disease. Magnetic resonance imaging showed an enhancing lesion in posterosuperior nasal cavity on the right side extending into the right sphenoid sinus. He underwent re-surgery and adjuvant chemoradiotherapy. The histopathology revealed residual olfactory neuroblastoma. The follow-up Ga-68 DOTATATE PET/CT was negative. This case emphasizes the role of Ga-68 DOTATATE PET/CT in the management, especially in residual or recurrent disease and potential radiotheranostics for these rare tumors.

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Positron emission tomography-computed tomography (PET-CT)-guided biopsy is being increasing practiced worldwide with indications in sampling of lung, abdominal, bone lesions, and among others. Training for PET-guided Interventions at select centers is carried out under supervision of an expert on real patients, similar to training for interventional radiology procedures. Simulation center training has been shown to be useful in improving efficiency of resident trainees. We report the development of concept, design, and practical application of a simplified humanoid training phantom for PET-guided interventions.

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The case of a 39-year-old woman presented with symptoms of progressive cerebellar degeneration for few months preceding by the diagnosis and treatment of breast cancer. The causative association was revealed with the strong positivity of antineuronal antibody. Because of the multidisciplinary team approach with surgery and adjuvant endocrine treatment, the patient did improve symptomatically and she is alive without any evidence of disease after 22 months following the initial diagnosis of the neurological disorder. Interestingly, neurological symptoms regressed partially after surgery. Early recognition and appropriate combined modality treatment of this rare presentation of breast cancer are imperative as it may be crucial for the disease outcome.

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Myeloid sarcoma is a rare extramedullary manifestation of acute myeloid leukemia (AML) that often presents during remission or disease relapse. The most common site of relapse being, however, many rare sites has been reported in the existing literature. We are herewith presenting the case of a 27-year-old patient of AML who showed an unusual site of relapse on fluorodeoxyglucose positron emission tomography/computed tomography scan.

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Primary angiosarcomas of the breast are rare tumors, with a fatal outcome. We present a rare case of an operated primary angiosarcoma of the right breast in a 20-year-old female who showed disease recurrence in the right posterior arm subcutaneous tissue on ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography after 1 year of surgery without any other visceral metastasis.

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Diffuse osteoblastic activity in the ribs on bone scan is seen in association with pleural thickening. Irrespective of the pleural pathology, this represents benign finding caused by pleural hyperemia or reactive periostitis, with preserved cortical integrity. However, malignant involvement of the ribs can occur by local invasion of pleural malignancy causing cortical lysis. Herein, we describe the ¹⁸F-fluoride positron emission tomography/computed tomography findings of reactive periostitis of the ribs in pleural metastasis and emphasize the advantage of hybrid imaging in detecting local malignant tumor invasion superimposed in such condition.

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Tuberculosis (TB) is a common bacterial infection in developing countries. Solid-organ and hematopoietic stem cell transplant recipients are more prone to this infection. Reactivation from previously acquired infection is the most common mode. It has to be ruled out in cases of pyrexia of unknown origin (PUO) before ruling out the other possibilities. We present two cases of incidentally detected TB in the posttransplant patients referred for the evaluation of PUO.

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Prostate cancer usually metastasizes to regional lymph nodes and bone. Laryngeal cartilage metastases are very rare and only few cases have been published so far describing thyroid cartilage metastatic lesions from prostate cancer. Here, we describe 5 cases of carcinoma prostate, 3 staging and 2 follow-up, where ⁶⁸Ga-prostate-specific membrane antigen positron emission tomography/computed tomography (PET/CT) scan revealed multiple skeletal lesions along with thyroid cartilage metastasis. Initially, laryngeal cartilage metastases remain asymptomatic and in later stages patients present with symptoms. These metastatic lesions to thyroid cartilage are rare entities and can often easily be missed on conventional imaging. PET-CT imaging has overcome this diagnostic problem due to its ability to provide for both anatomical and functional imaging.

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Hepatocellular carcinoma (HCC) usually metastasizes to the regional abdominal lymph node, lungs, and bones. Nonregional lymph node involvement by HCC in the absence of regional lymph nodes is rare. We describe the ¹⁸F-fluorodeoxyglucose positron-emission tomography-computed tomography findings of an HCC patient with histopathologically proven inguinal lymph nodal metastasis in the absence of regional lymph nodal metastases.

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Excessive abnormal tracer uptake in active tracer avid organ(s) with the suppression of physiological background tracer distribution is termed as super scan. Herein, we present an ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (FDG-PET/CT), where the metabolic pattern of skeletal super scan with coexistent parathyroid tumor was seen giving rise to the suspicion of primary hyperparathyroidism. It was subsequently diagnosed as a case of parathyroid carcinoma. Very high levels of serum parathormone in parathyroid carcinoma lead to accelerated bone turn over resulting in metabolic skeletal superscan in FDG-PET/CT which is seldom observed in parathyroid adenoma.

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Testicular metastases from solid tumors is a rare entity. We describe one such case where a patient on treatment for prostate cancer presented with a right scrotal swelling. For restaging, whole-body 68-gallium prostate-specific membrane antigen positron emission tomography/computed tomography (PET/CT) was performed. Fused PET/CT images demonstrated intense uptake in the testicular lesion. Unique anatomic and functional information provided by hybrid PET/CT helped in reliably establishing the testicular mass as the site of metastases from prostate cancer, which had a major impact on patient management.

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Cardiovocal syndrome or Ortner's syndrome is hoarseness voice due to left recurrent laryngeal nerve palsy secondary to nerve compression caused by enlarged cardiovascular structures in the mediastinum. We present here an interesting positron-emission tomography/computed tomography image of a patient suspected to have Takayasu's aortoarteritis and presenting with hoarseness of voice.

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