Diffuse Lung Uptake Research Articles

SAT581 Parathyroid Hormone Related Protein-induced Hypercalcemia In Medullary Thyroid Carcinoma In Pediatric Patient With MEN2A

Abstract Disclosure: S.A. Ackah: None. L.A. DiMeglio: None. J.C. Sanchez: None. G.C. Geddes: None. Background: PTHrp is a well-known cause of hypercalcemia of malignancy. Although PTHrp can often be detected in papillary, follicular and anaplastic thyroid cancers it does not always lead to hypercalcemia. Okotur 2007 described PTHrp in an adult medullary thyroid carcinoma (MTC). No pediatric cases have been described. Case: 8 year old female presented on transfer from hospital in Kenya where she had been admitted for three months with diarrhea and malnourishment (weight Z-score -6.5). She had been initially treated for aspiration pneumonia with negative testing for HIV, tuberculosis, stool cultures and parasites. At our facility, chest, abdomen and pelvis imaging were interpreted as an abscess from perforated appendicitis, bilateral hydroureteronephrosis, bilateral multifocal pneumonia and coronary artery ectasia. She experienced respiratory status decline requiring intubation. Further work up included consults and testing by infectious disease, genetics, immunology, cardiology, gastroenterology, pulmonology, and urology. In Kenya, the patient was initially normocalcemic and the calcium then slowly increased, so that on admission to our facility was found to have calcium 18.3 mg/dL (8.5-10.5), phosphorous 3.3 mg/dL (3.4-5.5), Creatinine 0.3 mg/dL (0.3-0.8), albumin 3.5 g/dL (3.5-4.7), PTH 5 pg/mL(10-65), TSH 1.9 mIU/ml (0.4-4.2), Free T4 0.8 ng/dL(0.6-1.5). IV hydration and pamidronate 0.5 mg/kg x 3 days administration resolved the hypercalemia. Rapid whole genome testing revealed a de novo pathogenic variant in RET (RET NM_020975.6 c.2753T>C; p.M918T) previously reported in individuals with MEN type 2A and 2B phenotypes. Thyroid ultrasound showed 2 nodules. FNA of both showed MTC; MTC was also present on lung biopsy. Screening labs obtained then showed PTHrp 301 pmol/L(adult range 0.0-3.4), Calcitonin 1433 pg/mL(0.0-5.1), VIP <13 pg/mL(0-60), Gastrin 45 pg/mL(0-100), Chromogranin A 4049 ng/mL(0-103), CEA123.7 ng/mL(0.0-2.5), metanephrine 0.91 nmol/L(0.00-0.49), normetanephrine 0.48 nmol/L(0.00-0.89). Bone scan showed diffusely diminished physiological uptake in the growth plates and diffuse bilateral lung uptake. Due to concern about ability to tolerate thyroidectomy, the patient was begun on selpercatinib, an oral chemotherapeutic agent specifically for tumors with disruption of RET gene. On day 11 of treatment, she was extubated to noninvasive respiratory support. Now, 3 months out from pamidronate and her hypercalcemia has not recurred. Conclusions: Hypercalcemia in pediatric patients with low PTH should prompt further workup including PTHrP measurement. In this case, we report a case of a child with MEN 2A and metastasized MTC with hypercalcemia attributable to PTHrp secretion.

Therapeutic Response and Long-term Outcome of Differentiated Thyroid Cancer with Pulmonary Metastases Treated by Radioiodine Therapy

Objective: This retrospective study was conducted to assess the efficacy of radioactive iodine therapy (RAIT) and investigate the prognostic factors for patients with pulmonary metastasis from differentiated thyroid carcinoma (DTC). Materials & Methods: A total of 80 patients treated with radioactive iodine (131I)-avid pulmonary metastasis from DTC treated with 131I from 2001 to 2016 at National Institute of Nuclear Medicine & Allied Sciences (NINMAS) were enrolled in this study. Treatment response was mainly measured by serum thyroglobulin (Tg) levels, diagnostic 131I whole-body scan (DxWBS) and patients clinical response. According to the treatment response patients were classified in two groups-complete response (CR) and persistent disease (PD). Result: Among 80 patients; 53(66.25%) males and 27(33.75%) females. Six patients were lost to follow-up; this study was done on the rest 74 patients. Out of 74 patients according to histological pattern 65(87.84%) were PTC and FTC 09(12.16%). Among 74 patients 50 had LN metastases; lung metastases were in 18 cases and six patients showed both lungs and bone metastases initially. RxWBS revealed lung metastasis in all of these 74 patients. The average received a dose of 131I was 537 ± 17.6 m Ci. Average postoperative serum Tg level at the time of presentation at NINMAS was 97.3 ng/ml with a decline in serum Tg levels after RAIT to 90 ng/ml. In the case of CR 14 patients showed diffuse lung uptake and 13 showed focal uptake; among PD 40 patients showed diffuse uptake and 14 showed focal lung uptake (p-value-0.004). The average follow-up period was 06 years. We observed CR in 25 (33.78%) patients and PD in 49 (66.21%) patients. The patient with CR; their an initial Tg level average of 38.9 ng/ml and after receiving last therapy their follow-up average Tg was 1.9 ng/m (p value-0.001). For the patient who had PD, their initial Tg level was 126.2 ng/ml, follow up average Tg was150 ng/dl with rising Tg level. Conclusion: From this study, it may be concluded that patients with DTC with lung metastases, most of the patients showed persistence of disease (66.21%) even after giving repeated radioiodine therapy. DxWBS and serum Tg levels at diagnosis are both important factors to evaluate the therapeutic response. Patients presenting with high serum Tg at initial diagnosis and subsequent bony metastases are likely to show a poor outcome Bangladesh J. Nuclear Med. 24(1&2): 42-47, 2021

Implications of Unexpected Diffuse Lung Uptake on a 99mTc-Sestimibi Parathyroid Scan

Diffuse (99m)Tc-sestimibi uptake in the lungs is a sign of serious pathology and merits further work-up. We present a case in which diffuse lung uptake was incidentally found on a parathyroid scan.

Diffuse Lung Uptake of 111In Octreotide from Chronic Emphysema

A 62-y-old woman was found to have a lung mass and a brain mass. The brain mass was resected, and the histopathologic findings were suggestive of a gastrointestinal primary tumor with neuroendocrine features. She was referred for an 111In-octreotide SPECT/CT scan to evaluate for somatostatin-avid

Diffuse lung uptake in stress myocardial perfusion scintigraphy with Thallium-201 in a patient with sarcoidosis

Diffuse lung uptake in stress myocardial perfusion scintigraphy with Thallium-201 in a patient with sarcoidosis

Diffuse Iodine-131 lung uptake in bronchiectasis: a potential pitfall in the follow up of differentiated thyroid carcinoma.

Diffuse Iodine-131 lung uptake in bronchiectasis: a potential pitfall in the follow up of differentiated thyroid carcinoma.

Diffuse pulmonary uptake on FDG-PET with normal CT diagnosed as intravascular large B-cell lymphoma: a case report and a discussion of the causes of diffuse FDG uptake in the lungs

A 71-year-old woman was admitted to our hospital with asthenia, weight loss, fever, cognitive impairment and shortness of breath. Physical examination showed hemiparesis and cerebellar ataxia. There was no superficial lymphadenopathy. Blood tests showed raised levels of C-reactive protein and lactate dehydrogenase. Bone marrow aspiration and biopsy were negative. [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) showed intense uptake within a right apical nodule and intense and diffuse uptake of FDG in the lungs without corresponding structural CT abnormality. Lung biopsy showed intravascular large B-cell lymphoma (IVLBCL). FDG-PET findings in IVLBCL and causes of diffuse FDG lung uptake with and without CT abnormalities are discussed.

Kemik Sintigrafısinde Bilateral Akciğerlerde Difüz Tc-99m-MDP Tutulumunun Gözlenmesinin Ardından Sol Akciğerden Küçük Hücreli Dışı Karsinom Tanısı Alan Bir Olgu

Kemik Sintigrafısinde Bilateral Akciğerlerde Difüz Tc-99m-MDP Tutulumunun Gözlenmesinin Ardından Sol Akciğerden Küçük Hücreli Dışı Karsinom Tanısı Alan Bir Olgu

Fixations extra-osseuses du 99mTc MDP dans le cas d’un cancer du sein métastatique à l’os

AimTo report and discuss an unusual visceral uptake on bone scan in a case of breast cancer with bone metastases. Patient and methodsA 40-year-old woman, with untreated bilateral breast cancer was referred to our department for a bone scan. ResultsThe bone scan evidenced multiple metastases over the axial skeleton. Uncommonly, visceral uptake was noted associating diffuse bilateral lung uptake and intense myocardium, stomach and kidneys uptakes. Serum calcium level was high: 4.08 mmol/L (normal: 2.38–2.70 mmol/L). ConclusionThe incidental observation of metastasic calcifications on bone scan is often related to severe hypercalcemia. Such pattern should alert the physician on the existence and the severity of calcium metabolism disturbances that had not been suggested before.

Author's reply

Drs Celik and Karacalioglu raised interesting points concerning our study published in a recent issue of the Journal, which showed that lung uptake of radiotracers was a single best parameter in the identification of left main trunk (LMT) disease among 508 patients with suspected or known coronary artery disease (CAD) [[1]Shiba C. Chikamori T. Hida S. Igarashi Y. Tanaka H. Hirose K. Ohtaki Y. Usui Y. Miyagi M. Hatano T. Yamashina A. Important parameters in the detection of left main trunk disease using stress myocardial perfusion imaging.J Cardiol. 2009; 53: 43-52Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. The questions they raised concerned a potential effect of concomitant pulmonary disease on lung uptake of radiotracers and reliability of a 20-segement scoring system on myocardial SPECT imaging. In patients with chronic pulmonary disease, diffuse lung uptake of radiotracer is often observed on SPECT image both after stress and at rest [[2]Pham R. Bellezuoli E. Diffuse pulmonary uptake of Tc-99m sestamibi due to chemical pneumonitis.J Nucl Cardiol. 2006; 13: 127-129Crossref PubMed Scopus (5) Google Scholar]. In contrast, lung uptake of radiotracer in patients with extensive and severe CAD such as LMT disease is observed only after exercise or pharmacologic stress [1Shiba C. Chikamori T. Hida S. Igarashi Y. Tanaka H. Hirose K. Ohtaki Y. Usui Y. Miyagi M. Hatano T. Yamashina A. Important parameters in the detection of left main trunk disease using stress myocardial perfusion imaging.J Cardiol. 2009; 53: 43-52Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar, 3Choy J.B. Leslie W.D. Clinical correlates of Tc-99m sestamibi lung uptake.J Nucl Cardiol. 2001; 8: 639-644Crossref PubMed Scopus (24) Google Scholar]. Lung uptake of radiotracer disappears on the delayed SPECT image. The definition of lung uptake has been clearly stated in our study [[1]Shiba C. Chikamori T. Hida S. Igarashi Y. Tanaka H. Hirose K. Ohtaki Y. Usui Y. Miyagi M. Hatano T. Yamashina A. Important parameters in the detection of left main trunk disease using stress myocardial perfusion imaging.J Cardiol. 2009; 53: 43-52Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar]. In addition, patients with severe valvular heart disease were excluded from the study. Thus, potential confounding effects due to pulmonary or valvular disease seem negligible. In the evaluation of myocardial SPECT image including a 20-segment scoring system, two cardiologists with vast experience of this methodology contributed. In addition, our institution has been involved in the J-ACCESS study, in which inter-institutional reproducibility of SPECT imaging has been affirmed [[4]Nakajima K. Kusuoka H. Nishimura S. Yamashina A. Nishimura T. Normal limit of ejection fraction and volumes determined by gated SPECT in clinically normal patients without cardiac events: a study based on the J-ACCESS database.Eur J Nucl Mol Imaging. 2007; 34: 1088-1096Crossref PubMed Scopus (55) Google Scholar]. Nevertheless, we concur with Drs Celik and Karacalioglu in that before applying our study in clinical practice, a learning curve should be taken into consideration to avoid pitfalls of this technique.

Drug-induced pneumonitis detected earlier by 18F-FDG-PET than by high-resolution CT: a case report with non-Hodgkin’s lymphoma

Drug-induced pneumonitis is a serious and an unpredictable side effect of chemotherapy in patients with malignant lymphoma. We present the case of a 51-year-old man who developed drug-induced pneumonitis during chemotherapy for non-Hodgkin's lymphoma in which pneumonitis was detected earlier by 18F-fluorodeoxyglucose positron emission tomography (18F-FDG-PET) than by high-resolution computed tomography (HRCT). After five courses of chemotherapy, 18F-FDG-PET was performed for assessing residual lesions, and diffuse lung uptake was incidentally observed. No symptoms were present, and HRCT performed immediately following PET revealed no abnormalities. Mild dyspnea appeared 3 days after PET, and additional HRCT revealed patchy ground-glass opacities disseminated with the appearance of interlobular septum thickening. Drug-induced pneumonitis was finally diagnosed, and treatment was initiated. 18F-FDG-PET can be an imaging modality for detecting drug-induced pneumonitis at an extremely early stage in which HRCT is incapable of revealing any abnormal changes.

FDG-PET in patients at risk for acute respiratory distress syndrome: a preliminary report

To compare the pattern of lung uptake of 18F-fluorodeoxyglucose (FDG) by positron emission tomography (PET) imaging in patients with lung contusion that developed or did not progress to acute respiratory distress syndrome (ARDS). Prospective, observational study. Trauma Center (academic urban hospital). Eight patients with blunt thoracic trauma and pulmonary contusion, confirmed by computed tomography (CT) on admission, underwent repeat CT and FDG-PET (on the same day) 24-72 h after admission. No subjects met the criteria for ARDS at the time of the PET and second CT. Four subjects subsequently developed ARDS 1-3 days after the PET scan; the other four did not develop the syndrome. Three of the four subjects who subsequently developed ARDS showed diffuse FDG uptake throughout the entire lungs, while those who did not develop ARDS showed significant FDG uptake only in areas of focal lung opacity (non or poorly aerated lung units) on CT. FDG uptake in normally aerated lung regions was higher for those who subsequently developed ARDS than those who did not, approaching statistical significance. The normally aerated tissue:liver ratio was significantly higher in subjects who developed ARDS than in those who did not (P = 0.029). In this small series of patients with thoracic trauma, diffuse lung uptake of FDG was detected by PET imaging 1-3 days prior to clinically determined ARDS.

Systemic Tuberculosis Presenting as an Epiglottic Mass Detected on F-18 FDG PET/CT

A 32-year-old man presented with asthenia, weight loss, cough, and dysphagia following a recent stay in Morocco. Endoscopy showed a bulky mass of the epiglottis suspected of being a malignant tumor. The patient underwent jointly an F-18 FDG PET/CT and a biopsy of the tumor. Against all expectations, biopsy revealed granulomatous inflammation with epitheloid giant cells and caeseating necrosis. These findings associated with the presence of acid-fast bacilli in the sputum smears were highly suggestive of laryngeal tuberculosis, which was confirmed later after cultivation of mycobacteria. F-18 FDG PET showed diffuse pharyngolaryngeal and lung uptake with bilateral cervical and abdominal nodes, but also one thoracic vertebral uptake. Lung CT could have revealed carcinomatous dissemination, but cavitary lesions in some pulmonary segments were more evocative of tuberculosis. Moreover, cerebral MRI showed brain tuberculomas not visualized on F-18 FDG PET/CT. The patient was treated with a 5-antituberculosis drug regimen, which improved clinical symptoms with epiglottis mass regression, and lung CT image reduction, clinching the systemic tuberculosis diagnosis. A control F-18 FDG PET/CT performed 5 months later showed disappearance of the pharyngolaryngeal and node uptake, with an improvement of lung uptake without normalization, arguing for persistent disease. Unexpected pathologic findings may be present in more than 3% of neck dissections. Although this is usually indolent, with the underlying SCC remaining the main prognostic determinate, it may significantly complicate postoperative management.

Pulmonary Alveolar Microlithiasis Scintigraphic Features

A 35-year-old female patient presented with a history of nonspecific chest pain and cough for one year. Spirometric studies excluded an obstructive ventilatory defect . Lung volume study findings were consistent with a moderate restrictive ventilatory defect with Total Lung capacity of 2.15L (51.6% of predicted). Diffusing capacity for the alveolar volume ventilated was reduced. Plain chest radiograph showed sand-like opacities, diffusely scattered, bilateral, micronodular areas of radioopacity of calcific densities throughout the lungs with the classic “sandstorm” pattern throughout both lungs predominantly in the lower zones (Fig: 1). Figure 1 Figure 1: Plain chest radiograph showing sand-like opacities, diffusely scattered, bilateral, micronodular areas of radioopacity of calcific densities throughout the lungs with the classic “sandstorm” pattern throughout both lungs predominantly in the lower zones. Computerized tomographic scan revealed diffuse bilateral calcified fine nodular pattern with extensive septal thickening (Fig: 2). Pulmonary Alveolar Microlithiasis Scintigraphic Features 2 of 4 Figure 2 Figure 2: Computerized tomographic scan showing diffuse bilateral calcified fine nodular pattern with extensive septal thickening. Figure 3 Figure 3: Tc-99m methylene diphosphonate (MDP) Bone scintigraphy showing intense bilateral uptake of the radiopharmaceutical in the lungs. Bone scintigraphy along with chest radiography and computerized tomography contributed to the diagnosis of Pulmonary Alveolar Microlithiasis in this patient. DISCUSSION Pulmonary alveolar microlithiasis is a rare disease of unknown etiology, characterized by the presence of calcific concretions in the alveolar spaces, intra-alveolar development and deposition of microliths or calcispherytes consisting of calcium phosphate1 The progression of the disease is generally very slow. Study of the calcium metabolism in many reported cases, however, reveals no derangement of serum calcium levels as in this patient who was normocalcemic, though elevated serum calcium and renal stones have been recorded in some cases.2, 3 Pulmonary function studies demonstrate a tendency toward a restrictive pattern. Chest roentgenography, high-resolution computed tomographic, and technetium-99m lung scan are useful in the diagnosis. Bone scintigraphy can be useful in the detection of early pulmonary calcifications, which have been associated with impaired pulmonary function and, due to their size, are generally not detected by X-ray. Bone scintigraphy may add helpful information in the case of nonspecific CT findings. Bone scan usually shows intense bilateral uptake of the radiopharmaceutical in the lungs.4 Differential diagnosis of diffuse lung uptake in bone scans includes patients with hyperparathyroidism, Hodgkins lymphoma, Sarcoidosis, Wegener's vasculitis, Primary amyloid, renal failure and Pneumocystis carinii.5 CORRESPONDENCE TO Dr Regi Oommen MD, Professor and Head, Department of Nuclear Medicine, Christian Medical College, Vellore - 632004, India. Email ID: regi@cmcvellore.ac.in Fax: 0091-416-2232103

Lung Uptake in a Young Patient With Hypercalcemia Who Was Found to Have Systemic Lupus Erythematosus

We report the case of 19-year-old woman with severe hypercalcemia who was evaluated with a bone scan to exclude bone metastases. Increased uptake in both lungs was detected on the bone scan. The patient's final diagnosis was systemic lupus erythematous (SLE). There is no reported pattern of bone scanning in SLE, and diffuse lung uptake has not been reported in these patients.

Difuse bilateral 67Gallium pulmonary uptake in a patient with Hodgkin's lymphoma and Pneumocystis carini infection

We report the case of a 12-year-old boy with chemoresistant stage IV Hodgkin's lymphoma. A 67Gallium scan was performed when his fever did not diminish following intensification of therapy. Apart from a known bone lesion, it showed diffuse bilateral lung uptake which could well be interpreted as an extension of his disease. But further investigations brought evidence of a Pneumocystis carinii infection. Because of the underlying disease, it was an important pitfall with clinical implications.

Diffuse lung uptake of Ga-67 after treatment of lymphoma: is it of clinical importance?

To determine if diffuse lung uptake (DLU) of gallium-67 at scintigraphy in patients with lymphoma is indicative of lymphomatous involvement of the lungs. Thirty-eight patients (24 male, 14 female; aged 15-76 years) with DLU were examined. The relation between DLU and lymphoma was investigated. Radiographic and computed tomographic findings and the persistence of Ga-67 uptake were investigated to detect lymphomatous involvement of the lungs. The relations between chemotherapy and radiation therapy, previous lung or heart disease, and DLU were also examined. DLU appeared only during or after chemotherapy. No clinical, radiologic, or follow-up evidence indicated that patients with DLU had active lymphomatous involvement of the lungs. The difference in survival between patients with persistent and patients with transient DLU was not statistically significant. No statistically significant correlation between DLU and any possible inductive factor was indicated at multivariate analysis. DLU after treatment does not indicate lymphomatous involvement of the lungs.

Diffuse lung uptake of Ga-67 citrate in treated lymphoma: another milestone on the road to understanding.

There are approximately 51,000 new cases of non-Hodgkin lymphoma and 7,800 new cases of Hodgkin disease reported yearly. Combined, these diseases account for 23,000 deaths. As medical oncology advances, the probability of curing cancer will increase because of improvements in diagnostic and therapeutic interventions. Anatomic diagnostic studies such as computed tomography (CT) and magnetic resonance (MR) imaging are generally used to identify and stage lymphoma; however, when the involved nodes are of normal size, CT and MR imaging are incapable of helping to distinguish between normal nodes and those involved with either Hodgkin or non-Hodgkin lymphoma. The problem of differentiating active lymphoma from scar or necrosis in residual masses after radiation therapy and/or chemotherapy, especially in the thorax, has been well documented in the medical literature. Whether gallium imaging is useful in this situation has been the subject of controversy over the years, and there have been many important detours and milestones on the road to our understanding of the role that gallium-67 scintigraphy should play. 22 refs.

Tc-99m DTPA diffuse pulmonary uptake in patients with coronary artery disease and renal insufficiency.

Diffuse bilateral lung uptake was observed in 10 patients undergoing Tc-99m DTPA renal scanning, referred for the evaluation of rising serum creatinine levels. All 10 patients demonstrated renal insufficiency (RI) as shown by both decreased bilateral renal tracer concentration and elevated background activity. Nine of the patients were known to have coronary artery disease (CAD) and six of these nine patients were in congestive heart failure (CHF), at or around the time of scanning. However, Tc-99m DTPA lung uptake was not observed in five other patients whose scans demonstrated RI, in whom there was no CAD or other cardiac disease. Diffuse lung uptake of Tc-99m DTPA in patients with RI therefore is highly suggestive of cardiac dysfunction (i.e. CAD and/or CHF).

Ga-67 lung uptake in patients with adult respiratory distress syndrome. Association with lung infection and patients' prognosis.

Nine patients with adult respiratory distress syndrome (ARDS) were studied with Ga-67 imaging in search for a site of infection. Different degrees and two patterns of Ga-67 lung uptake scoring in comparison with liver uptake were demonstrated. All patients had diffuse lung uptake, whereas five of them also showed additional focal lung activity. In only one patient was an abdominal focal uptake detected. Chest radiographs of all patients revealed diffuse and focal lung infiltrates that correlated with the Ga-67 uptake patterns. Therefore, Ga-67 imaging was unhelpful in differentiating patients with ARDS with lung infection from patients without lung infection. The intensity of Ga-67 uptake, as expressed by Ga-67 scoring, correlated with the course and outcome of ARDS. Patients exhibiting a high Ga-67 score had long periods of hospitalization and eventually died (four patients), whereas those who had low Ga-67 scores had a short disease course and survived (five patients). It is concluded that Ga-67 imaging in ARDS patients is unable to detect lung infection; however, it may be useful in the assessment of patients' prognosis.