Background: This study aimed to compare the recurrence rate of breast cancer between women treated with breast-conserving therapy (BCT) with/without radiotherapy and those treated with total mastectomy using 18F-fluorodeoxyglucose positron emission tomography/computed tomography18 (F-FDG PET/CT).Methods: The current study retrospectively included 588 patients suffering from breast cancer who had been referred to the PET/CT department of Masih-e-Daneshvari Hospital in Tehran between April 2013 and September 2019. Data of all female patients with breast cancer were extracted from the recorded hospital files. Based on the treatment plan, patients were divided into two groups: BCT with/without radiotherapy (n=168) and total mastectomy (n=420). Local, locoregional, and distant metabolically active lesions were determined in18 F-FDG PET/CT and compared between groups. Results: BCT and total mastectomy were comparable regarding local (28.5% vs. 25.7%, P=0.200) and locoregional (21.4% vs. 22.8%, P=0.712) recurrence, while distant recurrence was significantly higher with total mastectomy (88.5% vs. 64.2%, P<0.001). Also, lymph node invasion (42.9% vs. 60%m P<0.001) and positive PET/CT (78.5% vs. 88.5%, P=0.002) were significantly higher with total mastectomy. According to multivariate analysis, age, clinical stage, positive margin are independently correlated with the rate of distant metastasis. Conclusion: According to our analysis, breast-conserving therapy could be a suitable choice of surgery in selected patients since local and locoregional recurrence rate did not significantly differ between patients who underwent breast-conserving surgery compared to those who were treated with total mastectomy. Higher rate of distant metastasis in patients with total mastectomy seems to be influenced by many confounding variables such as age, higher stage of diagnosis and positive margin rather than type of surgery.
A 65-year-old patient with acute lymphoblastic leukemia presented for an 18fluoro-2-deoxy-d-glucose positron emission tomography computed tomography (18FDG PET) after several courses of chemotherapy for metastatic evaluation. Unexpectedly, on 18FDG PET scan, no discernible uptake was observed in the visceral organs, but instead, the skeleton/bone marrow showed homogenously intense metabolic activity. The distribution of 18FDG observed on the scan was remarkably similar to that on the NaF PET scan, indicating a superscan appearance.
Brain death is a state of irreversible loss of brain function in the cortex and brainstem. Diagnosis of brain death is established by clinical assessments of cranial nerves and apnea tests. Different conditions can mimic brain death. In addition, confirmatory tests may be falsely positive in some cases. In this study, we aimed to evaluate the role of positron emission tomography-computed tomography scan with 2-deoxy-2[18F]fluoro-D-glucose (18F-FDG-PET/CT) as an ancillary test in diagnosing brain death.
Neurologic manifestations are now being increasingly encountered in patients who are admitted for respiratory symptoms of COVID-19. A 67-year-old male with a recent history of Wernicke's aphasia was referred to the nuclear medicine department for risk stratification of malignancy in pulmonary nodule by 18F-FDG PET-CT scan. PET-CT revealed decreased metabolic activity in the left temporoparietal lobe of the brain consistent with recent CVA and excluded malignancy in the pulmonary nodule with low-grade metabolic activity. Incidentally noted, new bilateral pulmonary hypermetabolic ground glass opacities rising suspicious for covid-19 infection which was confirmed by PCR of nasopharyngeal mucosa sample. These findings highlight the value of 18FFDG PET-CT in the assessment of COVID-19 infection especially in non-pulmonary presentations like early neurologic manifestation.
The most common features of coronavirus disease-2019 (COVID-19) pneumonia on chest computed tomography imaging are ground glass opacity and consolidation. Mediastinal and hilar lymph node enlargement are less frequently observed. Herein, we present an unexpected finding of fluorodeoxyglucose (FDG)-avid hilar lymph node in an asymptomatic patient with COVID-19, and show that this is a transient phenomenon, subsiding on a follow-up FDG-PET/CT within 10 days.
While fever, cough, and dyspnea are the main symptoms of coronavirus disease-2019 (COVID-19), nonrespiratory presentations have been increasingly recognized, including neurological manifestations (1Galougahi M.K. Ghorbani J. Bakhshayeshkaram M. et al.Olfactory bulb magnetic resonance imaging in SARS-CoV-2-induced anosmia: the first report.Acad Radiol. 2020; Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar, 2Karimi-Galougahi M. Yousefi-Koma A. Bakhshayeshkaram M. et al.18FDG PET/CT scan reveals hypoactive orbitofrontal cortex in anosmia of COVID-19.Acad Radiol. 2020; Abstract Full Text Full Text PDF Scopus (73) Google Scholar, 3Cooper K.W. Brann D.H. Farruggia M.C. et al.COVID-19 and the chemical senses: supporting players take center stage.Neuron. 2020; Abstract Full Text Full Text PDF Scopus (218) Google Scholar). Herein, we describe the first report of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced facial nerve palsy assessed by 18fluoro-2-deoxy-d-glucose (18FDG) positron emission tomography-computed tomography (PET/CT). A 60-year-old healthy man with COVID-19, confirmed by polymerase chain reaction assay performed due to close contact with a COVID-19 case, developed sudden-onset right-sided facial nerve palsy. The patient had no systemic, respiratory, or auditory symptoms, nor facial pain. He was subsequently admitted with fever, cough, and dyspnea, and received remdesivir, dexamethasone, and oxygen. There was peripheral right-sided facial nerve palsy, involving mouth, eye, and forehead, consistent with Bell's palsy. Electromyography revealed decreased compound muscle action potential (∼60% axonal degeneration) in the right facial nerve. Given the likelihood of neuropathic impact of SARS-CoV-2(3), we performed 18FDG-PET/CT to assess the metabolic activity of the facial nerve and the related processing neurons. The study was approved by the Institutional Review Board of our institution and the patient provided written consent. 18FDG-PET/CT was performed after 6 hours of fasting, in a semidarkened, noiseless, and odorless room with the patient's eyes covered for 20 minutes, subsequent to which 18FDG was administered intravenously (4.6 MBq/kg, Masih Daneshvari hospital, Tehran, Iran). Whole body PET/CT was performed after 60 minutes by sequential TOF-PET/CT (Discovery 690 PET/CT, GE Healthcare, USA). The imaging data were acquired in the 3D mode with scan duration of 10 minutes for brain and 2 minutes per bed position for whole-body scan. Low-dose CT with shallow breathing was used for attenuation correction and diagnostic purposes. Scan parameters were as follows: tube voltage 120-140 kV, tube current with automated dose modulation 60-440 mA/slice, field of view 50 cm. Images with a transverse pixel size = 0.625 and a slice thickness = 3.75 mm were reconstructed in axial, coronal, and sagittal planes. The images were reviewed by a nuclear medicine physician and a radiologist with substantial experience in PET/CT imaging. Brain PET/CT in axial and coronal planes identified decreased 18FDG uptake in the right facial nerve compared with the contralateral side, spanning from the cerebellopontine angle to the internal auditory canal (Fig 1). Maximal standardized uptake value in the right facial nerve was 5.1, which was significantly (ie, >10%) lower than the standardized uptake value in the left facial nerve (5.9). Additionally, hypermetabolic areas colocalizing with the ground-glass opacities were identified in the lung field (Fig 1). Bell's palsy is the most common etiology of facial nerve palsy. The condition is idiopathic in most cases, and less commonly is secondary to trauma, or viral or bacterial infection (3Cooper K.W. Brann D.H. Farruggia M.C. et al.COVID-19 and the chemical senses: supporting players take center stage.Neuron. 2020; Abstract Full Text Full Text PDF Scopus (218) Google Scholar). It is typically self-limiting, with recovery occurring within 2-8 weeks in the majority of cases (4Bleicher J.N. Hamiel S. Gengler J.S. et al.A survey of facial paralysis: etiology and incidence.Ear Nose Throat J. 1996; 75: 355-358Crossref PubMed Scopus (114) Google Scholar). If clinically indicated, neuro-imaging is performed to exclude other causes of facial nerve palsy, for example, space occupying lesions. A reduction in the metabolic activity in the facial nerve in the affected side compared with the contra-lateral side in the present case may suggest a reduction in the blood flow to the nerve secondary to microthrombosis in the perineural arteriovenous plexus—a phenomenon that occurs due to SARS-CoV-2-induced endothelial injury in the pulmonary and several other microvascular beds (5Ackermann M. Verleden S.E. Kuehnel M. et al.Pulmonary vascular endothelialitis, thrombosis, and angiogenesis in Covid-19.N Engl J Med. 2020; Crossref PubMed Scopus (3797) Google Scholar). In addition to vascular injury, an alternative or concurrent mechanism may be the neurotropathic effects of SARS-CoV-2 by infecting the neurons or supportive non-neural cells such as glia, as suggested by expression of the cellular entry proteins for SARS-CoV-2 in these cell types (3Cooper K.W. Brann D.H. Farruggia M.C. et al.COVID-19 and the chemical senses: supporting players take center stage.Neuron. 2020; Abstract Full Text Full Text PDF Scopus (218) Google Scholar). In conclusion, to the best of our knowledge, this is the first description of the hypometabolism of the facial nerve on 18FDG-PET/CT in COVID-19-induced Bell's palsy. Further research is warranted to elucidate the putative neuro-vascular underpinnings of the SARS-CoV-2-induced peripheral facial nerve palsy. No M.K, M.B, N.R and A.Y have provided the case and images and M.K and S.H. have written the article. M.K, M.B, N.R, A.Y and S.H report no conflict of interest or funding sources.
Dear Editor, Olfactory dysfunction is a well-known complication of coronavirus disease-2019 (COVID-19) and includes quantitative (hyposmia or anosmia) and qualitative (parosmia or phantosmia) olfactory dysfunction. Parosmia is defined as alteration of olfactory perception in the presence of real olfactory stimulation. Patients with parosmia often describe perceiving the smell of something that is burned, foul or rotten (1Bitter T Siegert F Gudziol H et al.Gray matter alterations in parosmia.Neuroscience. 2011; 177: 177-182https://doi.org/10.1016/j.neuroscience.2011.01.016Crossref PubMed Scopus (34) Google Scholar). Few mechanistic and imaging studies have been performed to evaluate the pathophysiology of parosmia, and none in parosmia due to COVID-19. We have previously reported the findings on MRI of the olfactory bulb (2Galougahi MK Ghorbani J Bakhshayeshkaram M et al.Olfactory bulb magnetic resonance imaging in SARS-CoV-2-induced anosmia: the first report.Acad Radiol. 2020; https://doi.org/10.1016/j.acra.2020.04.002Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar) and cortical metabolic patterns on PET/CT imaging in anosmia of COVID-19 (3Karimi-Galougahi M Yousefi-Koma A Bakhshayeshkaram M et al.18FDG PET/CT scan reveals hypoactive orbitofrontal cortex in anosmia of COVID-19.Acad Radiol. 2020; https://doi.org/10.1016/j.acra.2020.04.030Abstract Full Text Full Text PDF Scopus (73) Google Scholar). In this study, we assessed the findings with multimodality PET/CT and MRI in parosmia secondary to COVID-19. We included a 28-year-old healthy right-handed woman with COVID-19, confirmed by polymerase chain reaction assay 6 months ago, which was complicated with anosmia. While anosmia was gradually improving, she developed parosmia, which has persisted for the past 3 months. For PET/CT imaging, the patient fasted for 6 hours before receiving intravenous 2-deoxy-2-[18F]-fluoro-D-glucose (18FDG, 4.6 MBq/kg). We performed the scan in a semi-darkened, noiseless, and odorless room, with the patient's eyes closed for 20 minutes. The brain PET/CT was performed with sequential TOF-PET/CT (Discovery 690 PET/CT, GE Healthcare). We performed MRI to assess the olfactory bulb and tract volume and signal changes. We used the PMOD Neuro Tool (PMOD Technologies Ltd., Version 4.2) to segment the cortex and the basal ganglia from the T1-weighted MRI. On MRI, the olfactory bulb and tract volumes were normal, and no signal changes were detected. There was a reduction in the maximal standardized uptake value (SUVmax) in the left insula, left inferior frontal gyrus, left hippocampus, and left amygdala compared with the contralateral side (Fig 1, Table 1).Table 1Maximal Standardized Uptake Value (SUVmax) in the Olfactory Cortices in Parosmia of COVID-19RegionSideSUVmaxReduction (L vs. R)Insular cortexR5.623%L4.3HippocampusR4.312%L3.8AmygdalaR4.212%L3.8Inferior frontal gyrusR7.211%L6.4 Open table in a new tab Two working hypotheses exist for parosmia—the peripheral hypothesis indicates incomplete regeneration of olfactory neurons while the central hypothesis implies malfunction of the olfactory centers in the brain (1Bitter T Siegert F Gudziol H et al.Gray matter alterations in parosmia.Neuroscience. 2011; 177: 177-182https://doi.org/10.1016/j.neuroscience.2011.01.016Crossref PubMed Scopus (34) Google Scholar). A reduction in the volume of primary olfactory centers, most importantly the olfactory bulb, has been reported in parosmia (4Rombaux P Mouraux A Bertrand B et al.Olfactory function and olfactory bulb volume in patients with postinfectious olfactory loss.Laryngoscope. 2006; 116: 436-439https://doi.org/10.1097/01.MLG.0000195291.36641.1ECrossref PubMed Scopus (147) Google Scholar), nonetheless we did not find structural or metabolic abnormalities in this region in parosmia; findings that are consistent with our observations in anosmia of COVID-19 (3Karimi-Galougahi M Yousefi-Koma A Bakhshayeshkaram M et al.18FDG PET/CT scan reveals hypoactive orbitofrontal cortex in anosmia of COVID-19.Acad Radiol. 2020; https://doi.org/10.1016/j.acra.2020.04.030Abstract Full Text Full Text PDF Scopus (73) Google Scholar). Moreover, we did not detect structural or metabolic abnormalities in the secondary olfactory cortex, notably the pririform cortex. In contrast to anosmia of COVID-19, where the metabolic activity of the left orbitofrontal cortex was reduced (3Karimi-Galougahi M Yousefi-Koma A Bakhshayeshkaram M et al.18FDG PET/CT scan reveals hypoactive orbitofrontal cortex in anosmia of COVID-19.Acad Radiol. 2020; https://doi.org/10.1016/j.acra.2020.04.030Abstract Full Text Full Text PDF Scopus (73) Google Scholar), we did not detect a change in the 18FDG uptake in this tertiary olfactory center in parosmia. We observed decreased 18FDG uptake in several other tertiary olfactory cortices, most prominently in the left insular cortex, compared to the contralateral side (Table 1). The insular cortex functions as an integrative center for multimodality convergence of inputs from the gustatory and olfactory cortices, and processes the odor quality (1Bitter T Siegert F Gudziol H et al.Gray matter alterations in parosmia.Neuroscience. 2011; 177: 177-182https://doi.org/10.1016/j.neuroscience.2011.01.016Crossref PubMed Scopus (34) Google Scholar). The reduction in metabolic activity of the left insular cortex in the present study is consistent with previous reports of structural remodeling of this region in parosmia (1Bitter T Siegert F Gudziol H et al.Gray matter alterations in parosmia.Neuroscience. 2011; 177: 177-182https://doi.org/10.1016/j.neuroscience.2011.01.016Crossref PubMed Scopus (34) Google Scholar). Nonetheless, we did not detect volume reduction on MRI in this cortical region in this patient with a 3-month history of parosmia. The relative hypometabolism in the left inferior frontal cortex, involved in odor identification and semantic association, and left hippocampus, involved in odor quality discrimination and olfactory memory processing (5Goodrich-Hunsaker NJ Gilbert PE Hopkins RO. The role of the human hippocampus in odor-place associative memory.Chem Senses. 2009; 34: 513-521https://doi.org/10.1093/chemse/bjp026Crossref PubMed Scopus (26) Google Scholar), are consistent with previous reports of structural remodeling in these cortices in parosmia due to other etiologies (1Bitter T Siegert F Gudziol H et al.Gray matter alterations in parosmia.Neuroscience. 2011; 177: 177-182https://doi.org/10.1016/j.neuroscience.2011.01.016Crossref PubMed Scopus (34) Google Scholar). Last, we detected hypometabolism in the left amygdala that is involved in emotionally aversive response to odors (1Bitter T Siegert F Gudziol H et al.Gray matter alterations in parosmia.Neuroscience. 2011; 177: 177-182https://doi.org/10.1016/j.neuroscience.2011.01.016Crossref PubMed Scopus (34) Google Scholar). To the best of our knowledge, this is the first report of combined PET/CT and MRI assessment of parosmia in COVID-19. Decreased metabolic activity without volume reduction in the tertiary olfactory cortex involved in the quality processing and affective response to odors in the present report suggests functional rather than structural impairment, and put emphasis on the central hypothesis in pathogenesis of parosmia. The observed changes might be a consequence of neuro-invasion by COVID-19 (6Butowt R Bilinska K. SARS-CoV-2: olfaction, brain infection, and the urgent need for clinical samples allowing earlier virus detection.ACS Chem Neurosci. 2020; 11: 1200-1203https://doi.org/10.1021/acschemneuro.0c00172Crossref PubMed Scopus (248) Google Scholar). Nonetheless, further studies are warranted to evaluate the mechanisms of parosmia in COVID-19. None. A.Y., M.B., N.R., and M.K. have provided the case and images and M.K and S.H. have written the article. The authors report no conflict of interest or funding sources.
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