Clinical Nuclear Medicine

Unexpected Lymphatic Drainage of the Treated Breast This case highlights the use of lymphoscintigraphy with SPECT/CT in patients with previous chest and/or axillary surgery. A 67-year-old woman with a history of left breast carcinoma treated with lumpectomy and radiotherapy, and a second lumpectomy of the ipsilateral breast for a second breast carcinoma, underwent a lymphoscintigraphy for a new left breast lesion. Planar images visualized an alternative lymphatic drainage to the contralateral axilla and to the left paravertebral area. SPECT/CT confirmed sentinel nodes in both stations. Received for publication January 23, 2019; revision accepted May 26, 2019. Conflicts of interest and sources of funding: none. Correspondence to: Richard Raghoo, MD, Department of Radiology, Section Nuclear Medicine, C2-P, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands. E-mail: r.raghoo@lumc.nl. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Imaging Characteristics of Coexisting Primary Pulmonary Carcinoid Tumor and Multiple Myeloma on 18F-FDG and 68Ga-DOTATATE PET/CT A 69-year-old man with recurrent multiple myeloma underwent FDG PET/CT evaluation. A pulmonary nodule without higher-than-background FDG avidity was later biopsied as a low-grade neuroendocrine tumor. On further 68Ga-DOTATATE PET/CT evaluation of patient's neuroendocrine tumor, the lytic myeloma lesions revealed only mild DOTATATE avidity while the primary pulmonary neuroendocrine tumor showed intense DOTATATE uptake. The distinct imaging characteristics of different primary malignancies correlated with their underlying different pathology. Received for publication May 2, 2019; revision accepted May 28, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Dr. Yang Lu, Department of Nuclear Medicine Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1400 Pressler Unit Number: 1483 Houston, TX 77030. E-mail: ylu10@mdanderson.org. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Added Value of Myocardial Blood Flow Quantification and Calcium Scoring During CZT SPECT Myocardial Perfusion Imaging for Coronary Artery Disease Screening Dedicated cadmium-zinc-telluride cardiac cameras have been shown to provide accurate measurements of absolute myocardial blood flow and flow reserve when PET is not available. We report the case of a 66-year-old woman who underwent 1-day stress/rest myocardial perfusion imaging (MPI) for coronary artery disease (CAD) screening. Relative MPI analysis was normal, whereas low-dose CT showed high calcium score. Myocardial blood flow and flow reserve were strongly impaired in all territories. Coronary angiography confirmed extended CAD. Flow parameters derived from cadmium-zinc-telluride SPECT MPI acquisition and calcium scoring can improve diagnostic accuracy and confidence of CAD. Received for publication March 17, 2019; revision accepted May 27, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Matthieu Bailly, MD, Service de Médecine Nucléaire, CHR Orleans, 14 Avenue de l'Hopital, 45100 Orleans, France. E-mail: matthieu.bailly@chr-orleans.fr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Nivolumab-Induced Pneumonitis in Patient With Metastatic Melanoma Showing Complete Remission on 18F-FDG PET/CT A 49-year-old patient with metastatic melanoma was treated with nivolumab (Opdivo). An early 18F-FDG PET/CT after 2 cycles showed a progressive metabolic disease. A 4-month optimal follow-up 18F-FDG PET/CT showed a complete metabolic response. The treatment was stopped after 22 cycles because of immunotherapy-related pneumonitis. After discontinuation of treatment, PET/CT examinations demonstrated a metabolic complete remission during 2 years. The metabolic pattern on early PET was suggestive of pseudoprogression, which is a rare phenomenon reflecting an activation of inflammatory cells within the tumor microenvironment causing lesions to increase in size and to accumulate FDG until a sufficient immune response is developed. Received for publication March 13, 2019; revision accepted May 29, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Micheline Razzouk-Cadet, MD, Department of Nuclear Medicine, Centre Hospitalier Universitaire de Nice, Archet, 151, Route de Saint-Antoine de Ginestière 06200 Nice Cedex 3, France. E-mail: razzouk-cadet.m@chu-nice.fr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Incidental Finding of Acute Lymphocytic Leukemia in a Prostate-Specific Membrane Antigen PET/CT PSMA PET/CT is known to show uptake in various benign and malignant processes. The following PSMA PET/CT was performed for prostate carcinoma staging (Gleason 3 + 4 left apex; PSA 5.8). It shows incidental diffuse PSMA marrow uptake, not typical for prostate metastatic disease. No treatment had been commenced at the time of the scan. Serology and bone marrow biopsy showed B-cell acute lymphocytic leukemia. Focal PSMA uptake in the right ischium was correlated with a T1 hypointense lesion on a previous MRI and was convincing for a skeletal metastasis. Alternative diagnoses in diffuse skeletal PSMA uptake need therefore to be considered. Received for publication December 27, 2018; revision accepted May 31, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Christian Acksteiner, Dr Med, FRANZCR, South Coast Radiology, Locked Bag 1000, Mermaid Beach, Queensland 4218 Australia. E-mail: christian.acksteiner@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

In Vivo Microbial Targeting of 99mTc-Labeled Human β-Defensin-3 in a Rat Model of Infection Objective Differentiation of infection from aseptic inflammation represents a major clinical issue. None of the commercially available compounds (labeled granulocytes, antigranulocyte antibodies, 67Ga-citrate, labeled immunoglobulin G, 18F-FDG) is capable of this differentiation, producing a nonnegligible false-positive rate. Recently, our group reported on a reliable labeling procedure of the antimicrobial peptide human β-defensin 3 (HBD-3) with 99mTc. The aim of this study was to evaluate in vivo 99mTc-HBD-3 uptake in a rat model of infection. Methods Recombinant HBD-3 was radiolabeled with 99mTc. Radiolabeling yield and specific activity of the compound were calculated. Chromatographic behavior and biological activity of 99mTc-HBD-3 were also assessed. An experimental model involving Staphylococcus aureus–induced infection and carrageenan-induced aseptic inflammation was performed in 5 Wistar rats. Serial planar scintigraphic acquisitions were performed from 15 to 180 minutes after 99mTc-HBD-3 intravenous administration. Radiotracer uptake was evaluated qualitatively and semiquantitatively as a target-to-nontarget ratio. Results Radiolabeling yield of 99mTc-HBD-3 was 70% with a specific activity of 6 to 8 MBq/μg. A significant and progressive 99mTc-HBD-3 uptake was observed in the site of S. aureus–induced infection, with a maximum average target-to-nontarget ratio of 5.7-fold higher in the infection site compared with an inflammation site observed at 140 minutes. Conclusions In vivo imaging with 99mTc-HBD-3 in a rat model of S. aureus–induced infection demonstrated favorable uptake in the infection site compared with sterile inflammation and background. These promising results, together with previous ex vivo uptake and toxicity assessment, suggest the potential of 99mTc-HBD-3 as a novel agent for specific infection imaging. Received for publication May 17, 2019; revision accepted May 31, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Giulia Anna Follacchio, MD, Nuclear Medicine Unit, Department of Radiology, Oncology and Human Pathology, AOU Policlinico "Umberto I," Sapienza University of Rome, 324, Viale Regina Elena, 00161, Rome, Italy. E-mail: giuliaanna.follacchio@uniroma1.it. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Quality and Safety in Healthcare, Part LV: Leadership to prevent burnout and increase joy Leadership is very important to reduce burnout and promote happiness in the healthcare workplace. Whereas burnout and unhappiness lead to doctor turnover, more errors, more accidents, and decreased patient satisfaction, joy in the workplace results in better patient care, enhanced engagement and productivity, and more profitability for the healthcare organization. Many leadership characteristics are critical including integrity, putting the well-being of others first, being fair, standing for important principles, being a good role model, being an excellent communicator, encouraging new ideas and adopting them when feasible, and loving people. Conflicts of interest and sources of funding: none declared. Received for publication May 27, 2019; revision accepted June 1, 2019. Correspondence to: Jay A. Harolds, MD, Division of Radiology and Biomedical Imaging, College of Human Medicine, Michigan State University, Advanced Radiology Services, PC, 3264 North Evergreen Dr. NE, Grand Rapids, MI 49525. E-mail: harolds112@cox.net. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.nuclearmed.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

68Ga–Prostate-Specific Membrane Antigen-11 PET/CT: Incidental Finding of a Vestibular Schwannoma A 77-year-old man with newly diagnosed prostate adenocarcinoma with a total prostate-specific antigen level of 6.4 ng/mL and Gleason score 7 (4 + 3) was referred to 68Ga–prostate-specific membrane antigen-11 (PSMA) PET/CT for initial staging. An intense focal PSMA uptake was shown in the right peripheral zone of the prostate gland consistent with the primary tumor. Additionally, PET/CT demonstrated a PSMA-avid soft tissue mass in the left cerebellopontine angle. The patient had a history of left-sided sensorineural hearing loss. Received for publication March 15, 2019; revision accepted June 2, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Göksel Alçin, MD, Istanbul Egitim ve Arastirma Hastanesi, Nukleer Tip Kliniği, Org. Nafiz Gurman Cad, Samatya, Kocamustafapasa, Fatih 34098 Istanbul, Turkey. E-mail: gokselalcin@hotmail.com.tr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

18F-Fluorocholine PET/CT in the Prediction of Molecular Subtypes and Prognosis for Gliomas Aim To study the association of metabolic features of 18F-fluorocholine in gliomas with histopathological and molecular parameters, progression-free survival (PFS) and overall survival (OS). Methods Prospective multicenter and nonrandomized study (Functional and Metabolic Glioma Analysis). Patients underwent a basal 18F-fluorocholine PET/CT and were included after histological confirmation of glioma. Histological and molecular profile was assessed: grade, Ki-67, isocitrate dehydrogenase status and 1p/19q codeletion. Patients underwent standard treatment after surgery or biopsy, depending on their clinical situation. Overall survival and PFS were obtained after follow-up. After tumor segmentation of PET images, SUV and volume-based variables, sphericity, surface, coefficient of variation, and multilesionality were obtained. Relations of metabolic variables with histological, molecular profile and prognosis were evaluated using Pearson χ2 and t test. Receiver operator caracteristic curves were used to obtain the cutoff of PET variables. Survival analysis was performed using Kaplan-Meier and Cox regression analysis. Results Forty-five patients were assessed; 38 were diagnosed as having high-grade gliomas. Significant differences of SUV-based variables with isocitrate dehydrogenase status, tumor grade, and Ki-67 were found. Tumor grade, Ki-67, SUVmax, and SUVmean were related to progression. Kaplan-Meier analysis revealed significant associations of SUVmax, SUVmean, and multilesionaly with OS and PFS. SUVmean, sphericity, and multilesionality were independent predictors of OS and PFS in Cox regression analysis. Conclusions Metabolic information obtained from 18F-fluorocholine PET of patients with glioma may be useful in the prediction of tumor biology and patient prognosis. Received for publication March 21, 2019; revision accepted June 2, 2019. All the authors confirm that the article is not under consideration for publication elsewhere. All ethical standards were complied with. Conflicts of interest and sources of funding: JPB and VMP-G were partially funded by the Ministerio de Economía y Competitividad/FEDER, Spain (grant number MTM2015-71200-R), Junta de Comunidades de Castilla-La Mancha (grant number SBPLY/17/180501/000154) and James S. Mc. Donnell Foundation 21st Century Science Initiative in Mathematical and Complex Systems Approaches for Brain Cancer (Collaborative awards 220020560 and 220020450). All other authors declare no conflicts of interest. Research involving human participants and/or animals: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent: Informed consent was obtained from all individual participants included in the study. Correspondence to: Ana María García Vicente, MD, PhD, Nuclear Medicine Department, University General Hospital, C/ Obispo Rafael Torija, s/n 13005 Ciudad Real, Spain. E-mail: angarvice@yahoo.es. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

FDG-PET/CT Demonstrates Splenic Angiosarcoma Bone Marrow Metastasis Some patients with splenic angiosarcoma initially manifest thrombocytopenia owing to hypersplenism or tumor-related bone marrow fibrosis. The diagnosis of bone marrow metastasis in patients with splenic angiosarcoma is challenging, as the presentation mimics idiopathic thrombocytopenic purpura or primary myelofibrosis. Our case showed diffuse FDG uptake in the vertebral bodies, sacroiliac bone, humerus, femur, and clavicles. It was pathologically diagnosed as bone marrow metastasis of splenic angiosarcoma. We believe that the heterogeneous FDG accumulation in the bone marrow, although nonspecific, can be useful for the diagnosis of the bone marrow metastasis in patients with splenic angiosarcoma. Received for publication March 13, 2019; revision accepted June 2, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Hiroaki Takahashi, MD, Faculty of Medicine, Department of Diagnostic and Interventional Radiology, University of Tsukuba, 1-1-1, Tennoudai, Tsukuba, Ibaraki, 305-8575, Japan. E-mail: h.1982.takahashi@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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