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Introduction Nuclear medicine parathyroid imaging is important in the identification of hyperfunctioning parathyroid glands in primary hyperparathyroidism (pHPT), but it may be also valuable before surgical treatment in secondary hyperparathyroidism (sHPT). Parathyroid radionuclide imaging with scintigraphy or positron emission tomography (PET) is a highly sensitive procedure for the assessment of the presence and number of hyperfunctioning parathyroid glands, located either at typical sites or ectopically. The treatment of pHPT is mostly directed toward minimally invasive parathyroidectomy, especially in cases with a single adenoma. In experienced hands, successful surgery depends mainly on the exact preoperative localization of one or more hyperfunctioning parathyroid adenomas. Failure to preoperatively identify the hyperfunctioning parathyroid gland challenges minimally invasive parathyroidectomy and might require bilateral open neck exploration. Methods Over a decade has now passed since the European Association of Nuclear Medicine (EANM) issued the first edition of the guideline on parathyroid imaging, and a number of new insights and techniques have been developed since. The aim of the present document is to provide state-of-the-art guidelines for nuclear medicine physicians performing parathyroid scintigraphy, single-photon emission computed tomography/computed tomography (SPECT/CT), positron emission tomography/computed tomography (PET/CT), and positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with pHPT, as well as in those with sHPT. Conclusion These guidelines are written and authorized by the EANM to promote optimal parathyroid imaging. They will assist nuclear medicine physicians in the detection and correct localization of hyperfunctioning parathyroid lesions.

Purpose Diverse radionuclide imaging techniques are available for the diagnosis, staging, and follow-up of phaeochromocytoma and paraganglioma (PPGL). Beyond their ability to detect and localise the disease, these imaging approaches variably characterise these tumours at the cellular and molecular levels and can guide therapy. Here we present updated guidelines jointly approved by the EANM and SNMMI for assisting nuclear medicine practitioners in not only the selection and performance of currently available single-photon emission computed tomography and positron emission tomography procedures, but also the interpretation and reporting of the results. Methods Guidelines from related fields and relevant literature have been considered in consultation with leading experts involved in the management of PPGL. The provided information should be applied according to local laws and regulations as well as the availability of various radiopharmaceuticals. Conclusion Since the European Association of Nuclear Medicine 2012 guidelines, the excellent results obtained with gallium-68 ( 68 Ga)-labelled somatostatin analogues (SSAs) in recent years have simplified the imaging approach for PPGL patients that can also be used for selecting patients for peptide receptor radionuclide therapy as a potential alternative or complement to the traditional theranostic approach with iodine-123 ( 123 I)/iodine-131 ( 131 I)-labelled meta-iodobenzylguanidine. Genomic characterisation of subgroups with differing risk of lesion development and subsequent metastatic spread is refining the use of molecular imaging in the personalised approach to hereditary PPGL patients for detection, staging, and follow-up surveillance.

58-year-old female patient, who has been treated and followed-up for ovarian cancer and its colonic metastasis has also been on hemodialysis three times a week for 10 years due to chronic renal failure. Because of the right femoral pain, she underwent bone scintigraphy in order to evaluate the likelihood of developing metastatic disease. Diffuse Tc-99m MDP uptake in the heart was detected on her bone scan. This case was presented to highlight underlying reasons of this very rare and unexpected cardiac uptake in the patient without known heart disease.

BackgroundThe relationship between delayed gastric emptying and upper GI symptoms (UGI Sx) is controversial.ObjectiveTo assess association between gastric emptying and UGI Sx, independent of treatment.DesignWe performed a systematic review and meta-analysis of the literature from 2007 to 2017, review of references and additional papers identified by content expert. We included studies evaluating the association between gastric emptying and nausea, vomiting, early satiety/postprandial fullness, abdominal pain and bloating. Covariate analyses included optimal gastric emptying test method, gastric emptying type (breath test or scintigraphy) and patient category. Meta-regression compared the differences based on type of gastric emptying tests.ResultsSystematic review included 92 gastric emptying studies (26 breath test, 62 scintigraphy, 1 ultrasound and 3 wireless motility capsule); 25 of these studies provided quantitative data for meta-analysis (15 scintigraphy studies enrolling 4056 participants and 10 breath test studies enrolling 2231 participants). Meta-regression demonstrated a significant difference between optimal and suboptimal gastric emptying test methods when comparing delayed gastric emptying with nausea and vomiting. On evaluating studies using optimal gastric emptying test methodology, there were significant associations between gastric emptying and nausea (OR 1.6, 95% CI 1.4 to 1.8), vomiting (OR 2.0, 95% CI 1.6 to 2.7), abdominal pain (OR 1.5, 95% CI 1.0 to 2.2) and early satiety/fullness (OR 1.8, 95% CI 1.2 to 2.6) for patients with UGI Sx; gastric emptying and early satiety/fullness in patients with diabetes; gastric emptying and nausea in patients with gastroparesis.ConclusionsThe systematic review and meta-analysis supports an association between optimally measured delayed gastric emptying and UGI Sx.

Introduction: Opioid medications are an established cause of delayed gastric emptying. Given this known association, gastric emptying scintigraphy (GES) is typically performed after a 72-hour opioid withholding period to prevent detection of opioid-induced gastroparesis. It is unknown if opioids contribute to gastric emptying delay even when withheld for 72 hours. We reviewed a scintigraphy database to examine the associations of opioids on solid (GES-S) and liquid (GES-L) gastric emptying after a 72-hour withholding period. Methods: Retrospective analyses were conducted of GES results from November 2009 to August 2017 of patients with an active opioid prescription at the time of GES. Patients withheld opioids for 72 hours prior to GES testing. GES was performed after ingestion of dual-labelled meals (1 mCi 99mTc sulfur colloid in egg substitute/toast, 0.075 mCi 111In DTPA in water). Delayed GES-S was defined as greater than 10% retention at 4 hours post-meal ingestion. Delayed GES-L was defined as greater than 50% retention at 1 hour. Drug formulation, route of administration, and dosing (PRN vs scheduled) were recorded. Results: 1,417 patients were included in the analysis. The mean age was 48 + 16 years, and 71% were female. Delayed GES-S prevalence in patients with an active opioid prescription was 33.6%, versus a historical 23.4% institutional prevalence in an unselected population (p < 0.001). Delayed GES-L prevalence in patients with an active opioid prescription was 29.8%. Among oral opioid users, the prevalence of delayed GES-L was associated with increasing age (OR 1.01, p = 0.02) (Table 1). There was also a trend between increasing age and delayed GES-S, but statistical significance was not reached (p = 0.06). These findings were independent of opioid formulation, route of administration, or dosing schedule (PRN vs scheduled). Conclusion: Despite a 72-hour withholding period, opioid use is associated with an increased prevalence of delayed solid and liquid gastric emptying when compared to historical control data. The difference in prevalence of delayed gastric emptying between the opioid-user cohort and the historical control cohort suggest the standard 72-hour opioid withholding period may be insufficient in duration. These results should prompt further studies that investigate if the opioid withholding period should be extended beyond 72-hours to prevent detection of prolonged opioid-induced gastric neuromuscular dysfunction.

Background: Accurate diagnosis of transthyretin amyloidosis cardiomyopathy (ATTR-CM) and its differentiation from light-chain (AL) cardiac amyloidosis (CA) cases (AL-CM) are of paramount importance. Surprisingly, comparative imaging data based on concurrent cardiovascular magnetic resonance (CMR) and bone scintigraphy in the same patients with biopsy-proven diagnosis of CA are still rare. Methods: This was a real-world retrospective single-center study based on a local clinical care pipeline and we carefully analyzed clinical, laboratory, CMR, and bone scintigraphy data (and if necessary additional endomyocardial biopsy [EMB] data) in patients with suspected CA. As a major inclusion criterion, we only looked at those patients who underwent both a CMR study and a bone scintigraphy—with a clear-cut imaging finding detected by at least one imaging method. Results: One hundred twenty three patients in whom the final diagnosis was obtained either non-invasively based on combined findings from bone scintigraphy and monoclonal protein studies or invasively based on additional EMB findings were included. A positive CMR result indicating the presence of CA was found in 121 patients—suggesting a CMR sensitivity of 98.4% for the diagnosis of any CA. Bone scintigraphy identified 18 patients with low to moderate uptake (Perugini score = 0–1) and 105 patients with high uptake (Perugini score ≥2)—resulting in a sensitivity for bone scintigraphy of 85.4% for the diagnosis of any CA. There was an agreement (“diagnostic match”) between CMR and bone scintigraphy results in 103 patients (84%) of the total study cohort, while a discrepancy (“diagnostic mismatch”) was observed in 20 patients (16%). In 18 out of these 20 diagnostic mismatch cases, CMR correctly diagnosed the presence of CA despite a negative or inconclusive result on bone scintigraphy (8 with AL-CM, 8 with ATTR-CM, and 2 with EMB-proven but unspecified CA). Conclusion: CMR shows a substantially higher diagnostic yield for the diagnosis of CA compared to bone scintigraphy, if a real-world cohort of patients comprising different subtypes of CA is looked at, since CMR does not only detect ATTR-CM but also depicts other CA subtypes such as AL. In case of a clear-cut positive CMR result unequivocally indicative of CA, there is no incremental diagnostic value of an additionally performed bone scintigraphy.