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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.

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.

Introduction/BackgroundSentinel node (SN) biopsy is a safe staging method in patients with vulva cancer (VC). Near-infrared fluorescence (NIRF) imaging using indocyanine green (ICG) has recently been introduced to improve the visual intraoperative SN identification. The purpose of this study was to evaluate the feasibility of fluorescence tracer imaging for SN detection in conjunction with conventional radio-guided technique.MethodologyProspective study of patients with primary VC planned for vulvectomy and SN procedure. Bimodal tracer (ICG-99mTc-Nanocoll) was injected peritumorally and followed by lymphoscintigraphy and SPECT/CT to define the SNs. Intraoperatively SNs were detected with a hand-held gamma-probe and NIRF camera. The detection rate was defined as the proportion of patients with at least one SN detected in at least one groin on scintigraphy or perioperatively (using gamma-probe and NIRF camera).ResultsSN procedure was performed in 36 patients (14 uni- and 22 bilaterally), corresponding to 58 groins. At least one SN was detected in 52 of 58 intended groins (90%) on scintigraphy, while perioperatively SN was identified in 54 of 58 groins (93%). In 14 patients with lateralized tumor and in 22 patients with midline tumor (<1 cm from midline) the unilateral SN detection rate was 100%. In patients with midline tumors the bilateral detection rate on scintigraphy and perioperatively was 77% and 82% respectively. In one patient with a midline tumor and no-detectable SNs bilaterally on scintigraphy and in three of four patients with midline tumor and no-detectable SNs in one side on scintigraphy, the SN was detected perioperatively by NIRF only. In 11 of 58 groins (19%) the SN could only be identified by NIRF.ConclusionA combined fluorescent and radioactive tracer for SN procedure is feasible, and the additional use of NIRF imaging may improve the accuracy of SN identification in VC patients.DisclosureNothing to disclose.

Abstract The lack of a standardized cut-off value in the quantitative method and an inter-observer disagreement in the evaluation of the semiquantitative score in 99 mTc-DPD scintigraphy leaves several patients with cardiac amyloidosis (CA) undiagnosed (grade 1 and H/CL: 1–1.49). This study aims to increase diagnostic productivity of 99 mTc-DPD scintigraphy in CA. This is a retrospective study of 170 patients with suspicion of CA. A total of 81 (47.6%) were classified as transthyretin CA (TTR-CA) and 9 (5.3%) as light-chain CA (LC-CA) applying the visual score. An enhanced quantitative method and cut-off point were attempted to reclassify inconclusive patients and reduce inter-observer variability. Applying the proposed quantitative method, of the 19 patients with grade 1 uptake, 2 became grade 0 (none-CA), 2 were reclassified as grade 3 (TTR-CA), and 2 were regrouped as grade 2 (1 TTR-CA and 1 LC-CA). Adjusting the quantitative method’s cut-off value to 1.3, four patients previously inconclusive were reclassified as TTR-CA, the diagnosis was confirmed in 3 and rejected in 1. When a 1.3 threshold is compared to 1.5, the sensitivity increases to 94% without reducing its specificity. The quantitative method improves the visual interpretation, reclassifying doubtful cases. The optimization of the cut-off value from 1.5 to 1.3 reclassifies a higher percentage of patients as TTR-CA with a higher sensitivity without reducing its specificity.

The relationship between delayed gastric emptying and upper GI symptoms (UGI Sx) is controversial. To assess association between gastric emptying and UGI Sx, independent of treatment. We 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. Systematic 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. The systematic review and meta-analysis supports an association between optimally measured delayed gastric emptying and UGI Sx.

Aims Post-traumatic osteomyelitis (PTO) is difficult to diagnose and there is no consensus on the best imaging strategy. The aim of this study is to present a systematic review of the recent literature on diagnostic imaging of PTO. Methods A literature search of the EMBASE and PubMed databases of the last 16 years (2000–2016) was performed. Studies that evaluated the accuracy of magnetic resonance imaging (MRI), three-phase bone scintigraphy (TPBS), white blood cell (WBC) or antigranulocyte antibody (AGA) scintigraphy, fluorodeoxyglucose positron emission tomography (FDG-PET) and plain computed tomography (CT) in diagnosing PTO were considered for inclusion. The review was conducted using the PRISMA statement and QUADAS-2 criteria. Results The literature search identified 3358 original records, of which 10 articles could be included in this review. Four of these studies had a comparative design which made it possible to report the results of, in total, 17 patient series. WBC (or AGA) scintigraphy and FDG-PET exhibit good accuracy for diagnosing PTO (sensitivity ranged from 50–100%, specificity ranged from 40–97% versus 83–100% and 51%–100%, respectively). The accuracy of both modalities improved when a hybrid imaging technique (SPECT/CT & FDG-PET/CT) was performed. For FDG-PET/CT, sensitivity ranged between 86 and 94% and specificity between 76 and 100%. For WBC scintigraphy + SPECT/CT, this is 100% and 89–97%, respectively. Conclusions Based on the best available evidence of the last 16 years, both WBC (or AGA) scintigraphy combined with SPECT/CT or FDG-PET combined with CT have the best diagnostic accuracy for diagnosing peripheral PTO.