Pelvic Kidney Mimicking Skeletal Metastasis on Bone Scan- Interesting Image

A 57-year-old female patient underwent left breast-conserving surgery with sentinel lymph node biopsy for Left breast carcinoma (stage IIA). The patient had hypertension and diabetes mellitus. Other findings include multiple hepatic cyst, bilateral renal cysts and uterine myoma. She had no significant renal symptoms and her liver &renal function test were normal.She was sent for Technetium-99m-methylene diphosphonate (99mTc-MDP) bone scan. There was a large area of intense tracer concentration in the region of right sacro-iliac (SI) joint which appeared like an osteoblastic metastasis at first glance. However, absence of uptake in the right renal fossa with the left kidney being normal in position contemplated the probability of right-sidedpelvickidneywhich was confirmed later by a contrast enhanced computerized tomography (CT) scan of abdomen that showed a pelvic right kidney overlying the sacrum. Bangladesh J. Nuclear Med. 22(2): 155-156, Jul 2019

Bulky Mediastinal Metastasis in Neglected Follicular Thyroid Carcinoma: A Case Report

Follicular carcinoma of thyroid usually behaves in an indolent manner with low metastatic potential. Distant metastases as initial presentation are rare in follicular carcinoma, especially in young patients. Blood borne metastasis is common with spread to lung, bone and other solid organs. However, metastatic mediastinal tumors are rare. Here, a neglected case of follicular carcinoma of thyroid (FTC) is reported. The patient is a 43 year old female who was referred to the Thyroid Division of NINMAS for radioiodine therapy for an inoperable metastatic FTC. She was presented with fever, shortness of breath and chest discomfort. 99mTc scan showed concentration of most of the isotope in the big metastatic mediastinal mass. Because of the sheer volume of the mass, a plan was undertaken to first reduce her tumor burden with external beam radiation therapy (EBRT) and then considered adjuvant therapy with radioiodine after manageable regression in size of the metastatic tumor. She had a history of thyroidectomy for FTC 14years back without radio iodine ablation. Negligence about proper management for FTC may result in poor outcome like huge mediastinal mass as in this reported case. Radioiodine therapy is usually the first line approach for functional metastasis, but in exceptional cases when the tumor size is very big, EBRT may be considered first. Radiotherapy (RT) is effective in relieving compression symptoms and may improve the quality of life in these patients. Bangladesh J. Nuclear Med. 22(2): 141-145, Jul 2019

Gated SPECT Myocardial Perfusion Imaging in female patients - an observational study

Background: It had been a general observation that the number of female patients undergoing SPECT myocardial perfusion imaging (MPI) is lower per week.This study was done to find out their proportionand association among their symptoms, history of (h/o) acute coronary syndrome (ACS) and corresponding myocardial perfusion. Patients and methods:This cross sectional retrospective study was conducted in 2017 on a group of patients who underwent gated SPECT myocardial perfusion imaging (GSMPI)from February 2005 to October 2016. Clinical record files and image files of all female patients were selected for analysis. The symptoms were retrospectively categorized according to New York Heart Association (NYHA) class while the patients were categorized according to their h/o ACS and myocardial perfusion in each patient was categorized as normal or perfusion defect. Data were analyzed using SPSS v.20. Results:Among 1347 patients undergoing GSMPI 196 (14.6%) were female with a 4.4-fold increase in number over 12 years. Mean age was 51.8 ± 10.1 (27-80). Symptom categorization assigned 84 patients in NYHA class I and 112 in NYHA class II. There was no h/o ACS in 143 while 53 had a previous h/o hospitalization due to ACS. GSMPI revealed normal perfusion in 156 patients with mean left ventricular ejection fraction (LVEF) of 66.6 ± 13.6. Perfusion defect was present in 40 patients with mean LVEF of 45.5 ± 15.8. NYHA class of symptoms was not associated with perfusion status (p > 0.05).H/o ACS was found to have association both with NYHA class of symptoms and with perfusions status (p < 0.05). Conclusions: Proportion of female patients undergoing GSMPI is low. Presence of perfusion defect in female was not associated with NYHA class of symptom. Bangladesh J. Nuclear Med. 22(2): 103-107, Jul 2019

Solitary Liver Metastasis from Follicular Variant Papillary Thyroid Carcinoma: A Case Report

Papillary and follicular thyroid carcinomas, together known as differentiated thyroid carcinomas (DTC), are among the most curable of cancers. Distant metastases are rare events at the onset of DTC. Sites of metastases from follicular thyroid cancer (FTC) are usually osseous, and those from papillary thyroid cancer (PTC) metastasize to regional nodal basins and the lungs. Visceral metastases are rare, but the involvement of multiple sites has been reported so far. Liver metastases from differentiated thyroid carcinoma (LMDTC) are rare.We present the case of a patient with follicular variant of papillary thyroid carcinoma (FVPTC) unusually involving the liver. Bangladesh J. Nuclear Med. 22(2): 146-149, Jul 2019

Influence of Age, Estrogen receptor (ER),Progesterone receptor (PR) and Epidermal growth factor -2 (HER-2) in Breast Carcinoma Patient in correlation with Radionuclide Bone Scan – Single Institute Based Experience

Background: Breast carcinoma is a common type of malignancy in women worldwide. Radionuclide bone scintigraphy is recognized choice of investigation for the detection of bone metastases both in asymptomatic and symptomatic patients. Biomarkers like Estrogen Receptor (ER), Progesterone Receptor (PR), Human Epidermal growth factor -2 (HER-2) also play important role in the management and prognosis of breast cancer. The study was aimed to find out the relationship between the MDP bone scan findingsand hormone receptor and HER-2 status of breast carcinoma patients referred to the Institute of Nuclear Medicine and Allied Sciences (INMAS), Mitford, Dhaka. Patients and Methods: This cross sectional study was conducted among 301 breast carcinoma patients between January 2018 and December 2019. Planar bone scan and SPECT (if needed) was done to all the patients after intravenous injection of 99mTc-MDP. Receptor status (ER, PR and HER-2) were documented from the patient’s medical records. Breast tumors were classified as (a) Triple positive- HER2-, ER-, and PR-positive) (b) Triple negative- HER2-, ER-, and PR-negative (c) Hormonereceptor (HR) positive (ER+/PR+) with HER-2 negative and d) HR negative (ER-/PR-) with HER-2 positive.Patients were broadly grouped according to age as A. less than 50 years (n = 59) and B. more than 50 (n = 260 ) years. Results: The mean age of the patients enrolled for this study was 59.02±9.3 with range of 32 to 81 years. Out of the 301 patients, positive bone scans were found in 105 (34.8%) and negative bone scan were found 196 (66.2%). Patients of group A (<50years) with triple negative and HR+/HER-status had no bone or bone with visceral metastases. Triple positive subtype had 2 bone metastases, and HR-/HER-2+ subtype had 2 bone metastases and 1 had bone with visceral metastases. Group B (> 50years) patients having HR+/HER2- receptor status showed 16% solitary metastases, 53.2% multiple metastases, 33.3% extensive bony metastases, 13.6% bone with visceral metastases. Triple negative subtype showed 36.0 % solitary metastases, 19.1% bone with visceral metastases. Triple positive subtype group had 40.0% solitary metastases, 34.0 % multiple metastases, 66.7% extensive bony metastases, and 13.6% bone with visceral metastases. HR-/HER-2+ subtype group had 8% solitary metastases, 12.8% multiple metastases, and 18.2 % bone metastases with visceral involvement Overall relationship between bone scan and hormone receptor subtype, showed that most of the patients had HR+/ HER-2-(35.2%) subtype and 25.6% patient had triple positive, 23.3% patient had triple negative and 15.9% patient had HR-/HER-2 – receptor subtype. This study showed the visceral involvement with bone metastases (13 % in HR+/HER-2- 52.2 % in triple negative, 13 % in triple positive, 21.7 % in HR-/HER-2+subtype). Highest bone only metastases (35) in triple positive and HR+/HER-2-(31) subtype. Most of the patiens who had bone metastases with visceral involvement belong to triple negative (52.2%) and HER-2 subtypes -HR-/HER-2+ (21.7%). The result was significant (P<0.001). Conclusion: It is observed from this study that triple positive and HR+/HER-2- were more likely to develop bone metastases than triple negative and HR-/HER-2-. Patients with bone scan negative and HR-/HER-2- or triple negative receptor status most likely develop visceral metastases Bangladesh J. Nuclear Med. 22(2): 114-118, Jul 2019

Primary Hyperparathyroidism with Multiple Fractures and Brown Tumors in a 14-year-old Girl: Case Report & Review of Literature

Primary hyperparathyroidism (PHPT) presenting as pathological fractures with brown tumors is very rare in children. The rarity and variable presentation of PHPT can make its diagnosis a challenge – especially in the developing countries where malnutrition may mask hypercalcemia. We report a case of a 14–year-old girl who presented with muscle pain, multiple fractures and bone pain. Laboratory tests revealed normocalcemia with vitamin D insufficiency. Subsequent biochemical, radiographic and scintigraphic findings were consistent with primary hyperparathyroidism due to a parathyroid adenoma. Tumor resection was done in a local hospital and histopathology confirmed parathyroid adenoma. Following parathyroidectomy, fractures were treated conservatively with supplementation of calcium and vitamin D. We found her quite capable of self-care and walking in good health at 1 year follow up. Though rare, PHPT-causing brown tumors related skeletal fractures is an important differential diagnosis in the evaluation of patients presenting with multiple foci of radiotracer uptake in bone scintigraphy. Bangladesh J. Nuclear Med. 22(2): 130-136, Jul 2019

Biochemical Outcome of Repeated Radioactive Iodine Therapy in Patients with Primary Hyperthyroidism– Follow Up of a Decade

Background: Whileradioactive iodine therapy (RAIT) in patients with primary hyperthyroidism results in euthyreosis or hypothyreosis, requirement of repeated therapy in a proportion of patients is a clinical reality. This study describesbiochemical outcomeof patients requiring repeated RAIT and the dose profiles across the demographic traits. Patients and Methods: The study retrospectively included the patients who underwent RAIT for Primary hyperthyroidism from January to December of 2006, using a modified fixed dose protocol following an institutional guideline which was adopted as the national guideline in 2007. Persistence of biochemical features of hyperthyroidism six months after RAIT was an indication for repeated therapy. Follow up data of eligible patients till December of 2016 was included in the descriptive statistics. Results: One, Two, three and four instances of RAIT were given to 83%, 14%, 2% and ≤ 1% of patients resulting in hypothyroidism to 58%, 67%, 67% and 100% of patients after each instance of therapy with incremental dose. Apparently more females than males ended up as biochemically hypothyroid, though not significant (OR 1.15, p=0.56).Younger females became significantly hypothyroid (p = 0.03).Patients with euthyroid outcome received higher dose-1of RAIT (P=0.007) which was found significant in females (p=0.005), in patients with Graves’ disease (GD) (p=0.018) and in patients receiving two instances of RAIT (p=0.03). Among the patients with GD, Single Toxic Nodule (STN) and Multi-Nodular Goiter (MNG), the proportion of hypothyroid outcome were 61%, 67% and 35%, at ten years following first dose. GD and STN required RAIT for up to four instances.MNG received an apparently higher mean of dose -1 and apparently less steep increment of doses, in comparison to GD and STN. Conclusion: Thisobservationof patient outcome over a decade was a scope to compare the mentioned guideline’s performance with the targets set by influential guidelines and recent reports around the globe. Bangladesh J. Nuclear Med. 22(2): 119-124, Jul 2019

Congenital left lobe megaly of liver resembling splenic pathology: a diagnostic dilemma confirmed bySPECT-CT of liver-spleen scan

Liver scintigraphy is a specialized nuclear medicine imaging technique used to diagnose hepatic pathological conditions as well as to assess the function of the liver. Itis also used to follow the progress of treatment of certain diseases. This procedure may be referred as liver-spleen scan because the spleen is alsoevaluateddue to its proximity and close functional relationship to liver.SPECT-CT correlation along with planar images increases the specificity of the test and can guide the physicians to rule outdiagnostic dilemma regarding certain hepatic & splenic diseases. Here, we present a case where the patient was initially suspected tohave splenomegaly with splenic hematomabut finally confirmedas unusuallyenlarged left lobe of liverand normal sized spleen with SPECT-CT of liver-spleen scan. Bangladesh J. Nuclear Med. 22(2): 161-165, Jul 2019

Experience and Challenges during Establishment of a Cyclotron and PET-CT facility at National Institute of Nuclear Medicine & Allied Sciences (NINMAS)

not available Bangladesh J. Nuclear Med. 22(2): 137-140, Jul 2019

Individual Monitoring of Internal Exposure for Nuclear Medicine Workers in NINMAS through In-Vitro Bioassay Techniques

Internal radiation monitoring of occupational radiation workers is essential for protecting them against the risks of incorporated radionuclides. More than 400 workers in Bangladesh are working with unsealed radioactive sources and most of them are employed at different nuclear facilities. Among the 18 Nuclear Medicine Centers in the country, the National Institute of Nuclear Medicine and Allied Science (NINMAS), Dhaka was selected for this study where workers get internal radiation exposure while processing and labeling of the liquid sources. The aim of this study was to estimate the activity concentration and committed effective doses from bioassay sample, namely urine samples of Nuclear Medicine (NM) workers due to handling of radioactive Iodine (131I), Technetium (99mTc) and Fluorine (F-18). Total 86 urine samples were collected from 17 occupational workers of NINMAS during the year 2017 and analyzed using High Purity Germanium (HPGe) detector. The radioactivity of 131I and (99mTc) was found 2.21±0.44 BqL-1 to 444 ± 39.91 BqL-1 and 5.53±1.12 BqL-1 to 603 ± 72.36 BqL-1 respectively. Due to low activity of the unsealed F-18 sources and for appropriate shielding, radioactivity of F-18 was found below the minimum detection level in the urine samples of the workers who handled it. The effective doses of occupational workers have also been calculated using the radioactivity concentration and the dose coefficients given in ICRP publication 78. The highest and lowest effective doses due to handling of the unsealed source of (99mTc) were 28.2 and 0.0258μSv for working with 780 and 36mCi of radionuclide respectively. On the other hand, the highest and lowest effective doses due to handling of 131I were 8.73and 0.045μSv, for working with 1425 and 55 mCi respectively. Both the doses are found to comply with ICRP annual dose limit of 20 mSv. Bangladesh J. Nuclear Med. 22(2): 125-129, Jul 2019