PET/CT analysis of 21 patients with breast cancer: physiological distribution of ¹⁸F-choline and diagnostic pitfalls

Objectives: ¹⁸F-choline is a useful tracer for detecting tumours with high lipogenesis. Knowledge of its biodistribution pattern is essential to recognise physiological variants. The aim of this study was to describe the physiologic distribution of ¹⁸F-choline and pitfalls in patients with breast cancer. Methods: Twenty-one consecutive patients with breast cancer (10 premenopausal and 11 postmenopausal women; mean age, 52.82 ± 10.71 years) underwent 18F-choline positron emission tomography (PET)/computed tomography (CT) for staging. Whole-body PET/CT was acquired after 40 minutes of 18F-choline uptake. Acquired PET images were measured semiquantitatively. Results: All patients showed pitfalls unrelated to breast cancer. These findings were predominantly caused by physiological glandular uptake in the liver, spleen, pancreas, bowels, axial skeleton (85%-100%), inflammation and benign changes (4.76%), appendicular skeleton (4.76%-19.049%), and site contamination (61.9%). In <1%, a concomitant metastatic neoplasm was found. The breast showed higher physiological uptake in premenopausal compared with postmenopausal woman (¹⁸F-choline maximum standardised uptake values [g/dL] of the right breast = 2.04 ± 0.404 vs 1.59 ± 0.97 and left breast = 2.00 ± 0.56 vs 1.93 ± 1.28, respectively). Conclusion: ¹⁸F-choline uptake was higher in premenopausal women. Physiological ¹⁸F-choline uptake was observed in many sites, representing possible pathologies

Diagnostic dilemma of reactive arthritis aided by multimodality imaging using MRI, CECT and 18F-FDG PET/CT scans

Reactive arthritis can be an elusive diagnosis especially in the elderly. A 77-year-old lady, presented with recent history of hip pain. She had been treated for urinary tract infection caused by Chlamydia sp. and had associated weight loss. She was also investigated for possible tuberculosis and occult malignancy. CT scan abdomen/pelvis and MRI revealed peri-articular muscle inflammation. Biopsy of her hip joint failed to find the causative factor. Whole-body 18F-FDG PET/CT scan revealed increased FDG uptake at bilateral hip and shoulder joints. She recovered after an intensive course of antibiotics. Thus, she was diagnosed with reactive arthritis. Reactive arthritis is usually a diagnosis of exclusion made by a high index of suspicion and positive serology test. Molecular imaging can be an alternative investigation for joint pains in the elderly, which enables excellent anatomical and functional information to exclude more sinister conditions such as malignancy

Pain interference level and its effects on patients' quality of life and depression: a study on breast cancer survivors in Hospital Kuala Lumpur, Malaysia

Introduction: Cancer pain is a complex experience and is one of the most common and distressing symptom of breast cancer which affects patients’ functioning in daily activities, their quality of life (QOL), and mood. Yet, there is a great lack of data on breast cancer and pain in Malaysia. Methods: A cross-sectional study using the Breast Cancer Patient Version of Quality of Life (QOL) Instrument (translated into Malay) and Depression Anxiety and Stress Scale (DASS) were conducted on 87 female breast cancer patients to investigate the impact of pain interference level on their quality of life and depressive level. Results: The patients were divided into 4 groups based on their rating of how pain and aches have been a problem to them (i.e not a problem [n=18 (20.7%)], mild[n=29 (33.3%)], moderate [n=18 (20.7%)] and severe [n=22(25.3%). Pain and aches ware reported to be the most severe interference problems in QOL physical domain by patients (mean=5.8, SD=2.8), followed by fatigue (mean=6.0, SD=3.1) and sleep changes (mean=6.2, SD=3.5). Patients who reported that pain and aches had severely affected them showed significantly lower score on many aspects of quality of life (Fs > 5, p < 0.005; p < 0.0001) and patients reported pain was not a problem at all demonstrated highest score on all aspects of QOL. Patients with most severe pain interference level showed highest depressive score [F (3, 84) =3, p < 0.05]. Conclusion: The study underscores the impact of pain interference on patients’ quality of life and depressive level. The pain assessment deserves significant attention and therefore a comprehensive biopsychosocial assessment of pain to rule out any related underlying issues is warranted in the management of breast cancer to ensure appropriate intervention given to the patients

Syringomyelia secondary to thoracic intervertebral disc protrusion: a rare condition

Spinal spondylosis is an extremely common problem among the middle-aged and elderly population. However, it is an extremely rare cause of syringomyelia in clinical practice. The differentiation between syringomyelia and hydromyelia is not always straightforward and rather exhaustive. Spinal cord compression and instability are the proposed mechanisms of injury-causing syringomyelia. Symptomatic presentation depends primarily on the location of the syrinx within the neuraxis, be it motor, sensory or autonomic disturbance. There were abundant of successful cases in the past, whereby surgical interventions can regress the appearance of syringomyelia in magnetic resonance imaging. However, there was a mixed result in terms of patients' symptom. There were only 6 reported articles of syringomyelia secondary to cervical spondylosis found worldwide. We describe a case of T11/T12 thoracic intervertebral disc protrusion causing long segment syringomyelia till conus medullaris

Spontaneous thrombosis of non-tuberculous pulmonary artery mycotic pseudoaneurysm in prolonged childhood pneumonia

Pulmonary tuberculosis (PTB) is common in tropical country like Malaysia. Prolonged PTB infection may lead to mycotic pulmonary artery pseudoaneurysm (PAP). We report a case of childhood non-tuberculous pulmonary infection causing mycotic PAP which resolved spontaneously after antibiotics therapy. A 1 year 6 months old girl underlying Down syndrome presented with prolonged fever for two weeks , cough and breathlessness. Her leucocytes count were elevated and she developed several hypotensive episodes secondary to septicaemia. Chest radiograph showed loculated right sided pleural effusion. Ultrasound revealed complex pleural collection and initial aspiration revealed a thick stale blood. Thinking of possible vascular cause, ultrasound able to locate a well-defined rounded structure with high flow velocity seen on Doppler ultrasound consistent with pseudoaneurysm and CT thorax confirmed the findings. Pulmonary artery angiogram prior to embolization revealed no evidence of abnormal vasculature or contrast blush at the region of interest. Complimentary ultrasound showed evidence of spontaneous thrombosis within the pseudoaneurysm. Non-tuberculous PAP is a rare but possible life-threatening sequela of pneumonia. Pleural drainage in a haemothorax with concomitant mycotic thoracic pseudoaneurysm may cause loss of pressure tamponade and will end up with devastating consequences. Careful ultrasound image acquisition must be made by the attending radiologist prior to pleural drainage

False negative bronchial artery caliber on multi-detector computed tomography in predicting outcome of bronchial artery embolization in patient with haemoptysis

Bronchial artery embolization was first performed in 1973 by Remy et al with widespread acceptance since then. Multi-detector computed tomography (MDCT) CT angiography (CTA) is currently the gold standard imaging modality used to identify the site and cause of bleeding in patient presented with haemoptysis. Bronchial artery anatomies and precise location can be obtained by scrutinizing CTA prior to interventional procedures. CTA has the advantage of not only can preclude the need of digital subtraction angiography (DSA) in inappropriate cases, but also can shorten the intervention procedure timing. We present a case of false negative bronchial artery caliber seen on MDCT which was abnormal in DSA

Prevalence of ultrasound-diagnosed non alcoholic fatty liver disease among rural indigenous population in Malaysian and its association with biochemical and anthropometric measures

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease worldwide, especially in the Western world and Asia-Pacific regions. This study was designed to determine the prevalence of NAFLD detected by sonographic assessment among the rural indigenous population in Peninsula Malaysia and its association with anthropometric and biochemical factors. Methods: A cross-sectional survey was carried out from January 2014-February 2016. Subjects were recruited among indigenous peninsula Malaysia population in rural villages, aged ≥18 years old. The survey was questionnaire-based followed by anthropometric and blood parameters measurements. All subjects underwent abdominal ultrasound assessment to screen for the presence of NAFLD. Semi-quantitative visual grading was performed to assess for mild, moderate or severe NAFLD. Results: A total of 270 subjects underwent the screening program (mean age 43.3 ±14.0 years). Approximately 53 subjects (19.6 %) were identified with NAFLD. Of those with NAFLD, approximately 83% had moderate grade of fatty liver and the remainder were diagnosed with mild grade. NAFLD was closely associated with age, body mass index (BMI), central obesity, hypertension, total cholesterol (TC), triglyceride/high density lipoprotein-cholesterol (TG/HDL-C) ratio. On multivariate logistic regression, a high BMI (≥23.0 kg/m2), central obesity, and raised TG/HDL-C ratio were independent risk factors for developing NAFLD. Conclusion: This pioneer study defines the prevalence of NAFLD among rural indigenous population in Peninsula Malaysia. Lifestyle-related diseases, such as NAFLD can affect both rural and urban communities with equal severity. High BMI, central obesity, and elevated TG/HDL-C ratio were independent risk factors for developing NAFLD

Sonographic assessment of renal size and its correlation with anthropometric measures among indigenous population in Peninsular Malaysia

Introduction: Renal size measurement using ultrasound is a valuable parameter in the diagnosis of renal function and its diseases. This study is aimed to determine the differences of mean and correlation between the renal length (RL), renal width (RW) and renal parenchymal thickness (RPT) with age, gender and anthropometric measurements among indigenous population in Malaysia. Methods: A prospective cross-sectional study was carried out in this survey. Abdominal sonography was performed on 240 subjects. Sonography of the renal size included measurements of RL, RW and RPT. A portable ultrasound machine (Mindray DP-50, Shenzen, China) with a 3.5 MHz convex probe was used in this study. An independent-samples t-test, one-way ANOVA and Pearson's correlation coefficient test were performed in statistical analysis. Data were analyzed using SPSS program version 22.0. A P-value of <0.05 was considered significant. Results: The mean left RL was significantly decreased after the age of 54 years. RL of both kidneys was positively significant correlated with height (P<0.001), weight (P<0.001), waist circumference (WC) (P<0.001) and hip circumference (HC)(P<0.001). Similarly, a significant positive correlation was found between right RW and right RPT with weight (P=0.007 and P=0.003, respectively). Left RPT was significant correlated with height (P=0.006), weight (P<0.001) and HC (P=0.035). There was a significant positive correlation between left RW and height (P=0.048). A significant difference was also reported between right RL (P<0.001), left RL (P<0.001) and left RPT (P=0.040) with BMI. Conclusion: The normal values of renal size measurements are related to age, gender, height, weight, BMI, WC, and HC