https://aojnmb.mums.ac.ir/ Asia Oceania Journal of Nuclear Medicine and Biology en daily 1 Thu, 01 Jan 2026 00:00:00 +0330 Thu, 01 Jan 2026 00:00:00 +0330 https://aojnmb.mums.ac.ir/article_26481.html Objectives(s): To report methodology that has been developed to provide real-time monitoring of radiation emissions from subjects treated with radionuclide therapies and summarise the radioiodine retention profiles of 250 subjects treated for differentiated thyroid cancer with 131I.Methods: A small ceiling-mounted radiation detector for continuously monitoring the exposure rate in the radiation isolation rooms has been developed. Measurements were made every minute after administration of 1-6 GBq of 131I over the one to three days typical inpatient admission. The data are saved in text format and have been fitted with a mono-exponential curve to measure retention half time.Results: The average effective retention half time (t½ (Eff)) for all subjects was 11.9±3.2 hrs (range: 5.0–23.1 hrs; n=250). Over 90% of the subjects had their serum TSH levels increased by injection of recombinant human TSH prior to treatment. Average retention half-time was found to be less in subjects lower than 55 year of age (t½ (Eff)=11.5 hrs) compared to those 55 or older (t½ (Eff)=14.4 hrs) (P=0.0007).Conclusions: Despite the subjects, being free to move around the isolation room during admission and thus changing the source-detector geometry markedly, the system has been able to characterise their retention profiles after radioiodine treatment. These real-time measurements have applications in planning therapy and monitoring the subjects during their admission to the hospital and can be used for “live” updates for all staff as well as providing insights into the fate of radioiodine in the body. https://aojnmb.mums.ac.ir/article_27003.html Objective(s): To establish normal ranges for [99mTc] Tc-Mebrofenin hepatobiliary scintigraphy (HBS) indices of liver function and the associated uncertainty in clinical measures due to region placement.Methods: 47 patients referred for gallbladder assessment with no history of liver disease were included in the study. Patients underwent dynamic HBS following injection of 200 MBq of [99mTc] Tc-Mebrofenin at 10 seconds/frame for 36 frames. Analysis was performed by 5 experienced technologists using in-house software (MIM Software, Cleveland, Ohio) to establish blood pool (BP) clearance rate (%/min), blood clearance half-time (min), mebrofenin liver uptake rate (MUR) (%/min) and MUR normalised to body-surface-area (MURBSA) (%/min/m2). Limits of normal ranges (95%) were established and correlation of functional indices with age was investigated. Analysis was repeated after a minimum of 4 weeks to establish intra-user variability and uncertainty associated with measures.Results: Data were collected for 27 women and 20 men, with an age range of 20 – 81 years. Twenty-seven patients were aged over 50 and 20 patients were aged below 50. The data were found to have a normal distribution. The mean values derived for the entire cohort for BP clearance rate, blood clearance half time, MUR, and MURBSA were 16.8±2.6 %/min, 4.3±0.7 min, 14.4±2.0 %/min and 8.0±1.5 %/min/m2, respectively. No significant difference in values was found between age groups and no correlation between liver function and age was found. The lower range of normal for MURBSA was established as 5.1%/min/m2, with clinical measures expected to have an uncertainty of ±0. 6 %/min/m2.Conclusion: The MURBSA value for a patient with normal liver function can be expected to be approximately 8.0±1.5 %/min/m2, with a lower limit of normal function at 5.1 %/min/m2. Patients receiving liver surgery or treatment that express MURBSA values below this may be at higher risk and should potentially be treated with caution. https://aojnmb.mums.ac.ir/article_26824.html Objective(s): This study aimed to systematically evaluate the diagnostic accuracy of hepatobiliary scintigraphy (HBS) for detecting bile leaks in post-traumatic and postoperative settings, given the increasing incidence of such complications following hepatobiliary surgeries and abdominal trauma.Methods: A systematic review and meta-analysis were conducted in accordance with the PRISMA guidelines. Literature searches of PubMed, Embase, and Scopus databases were performed through June 19, 2025. Studies were included if they assessed patients with suspected bile leak using HBS and reported sufficient data to construct diagnostic contingency tables. The quality of included studies was assessed using the QUADAS-2 tool. Pooled sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall diagnostic accuracy were calculated. Subgroup analyses evaluated diagnostic performance across clinical contexts such as post-trauma, liver transplant/resection, and cholecystectomy.Results: Sixteen studies with 673 patients were included. The pooled sensitivity and specificity of HBS were 0.882 (95% CI: 0.81–0.93) and 0.93 (95% CI: 0.83–0.97), respectively. The pooled PPV was 0.874 and NPV was 0.965, with an area under the SROC curve of 0.94, indicating excellent diagnostic performance. Subgroup analyses showed the highest accuracy in trauma patients, while specificity varied more in postoperative settings, particularly after liver transplant or resection.Conclusion: HBS is a highly sensitive and reliable imaging modality for ruling out bile leaks. While variability in specificity warrants cautious interpretation in complex surgical cases, HBS should be considered a valuable first-line, non-invasive diagnostic tool in evaluating suspected bile leaks. https://aojnmb.mums.ac.ir/article_26596.html Obgective(s): Reduced bone mineral density is often observed in breast cancer patients. Routine PET/CT scans can be used for detection of low bone mineral density. To evaluate prevalence of osteopenia, osteoporosis and fracture risk in pre and post-therapy breast carcinoma patients undergoing 18F-FDG PET/CT scans.Methods: In this retrospective study L1-L4 vertebral and femoral neck CT mean Hounsfield unit attenuation and their corresponding SUVmax values from initial staging and end of treatment FDG PET/CT scans performed in breast carcinoma patients were compared. Post chemo ± hormonal therapy FDG PET/CT HU values were also compared to DXA scan T- scores.Results: Significant increase in prevalence of post chemo ± hormonal therapy osteopenia, osteoporosis and fractures (62%, 18% and 16% vs baseline of 35%, 4% and 9% respectively). CECT mean attenuation values of ≤174.6 HU and ≤117.2 HU for detection of osteopenia and osteoporosis with sensitivity of 100% and specificity of 94.2 % for L1-L4 vertebrae, and ≤176.8 HU and ≤117.8 HU for osteopenia and osteoporosis with sensitivity of 100% and specificity 96.4% at femoral necks respectively were suggested. Furthermore, mean attenuation values of ≤125.9 HU with sensitivity and specificity of ~100% and 79% and ≤124.8 HU with sensitivity of 100% and specificity ~79.8% were suggested for increased L1-L4 vertebral and femoral neck fractures prevalence/ risk respectively. An associated post chemo ± hormonal therapy decline in vertebral and femoral neck mean SUVmax values in range of 14% was also observed.Conclusions: Baseline and post chemo ± hormonal therapy follow up FDG PET/CT scans allow opportunistic evaluation and can identify a significant number of patients with osteopenia, osteoporosis and patients at increased fracture risk with a high sensitivity and good specificity. They have potential to reduce need for DXA referrals, and also enable early initiation of prophylasix and therapy. https://aojnmb.mums.ac.ir/article_26937.html Objective(s): Due to its prevalence worldwide, osteoporosis is regarded as a significant public health issue. Numerous risk factors can contribute to the development of osteoporosis, leading to bone fractures. This study aimed to determine the association of parity, age, gender, origin, and pre-existing clinical conditions with low bone density of people residing in the Southeastern region of Bangladesh.Methods: This retrospective study included a cohort of 628 individuals seeking bone mineral density (BMD) assessments using Dual Energy X-ray Absorptiometry (DXA). Association of BMD with five contributing factors (age, gender, origin, parity of the female participants and pre-existing clinical conditions i.e., hypertension, diabetes) was studied.Results: This study included 84% female and 16% male participants. The mean BMD was found significantly lesser in older participants (aged >50 years) (P=.0.001)for both sites of lumbar spine (LS) and femoral neck (FN)). It also varied significantly in both skeletal sites, depending on the gender (P<0.001and P=0.027respectively). Rural participants were found with lower BMD than urban one (P<0.001and P=0.037respectively). BMDs of LS and FN were found to have significant negative correlations with age (-0.201 and -0.280) and parity (-0.317 and -0.236). Diabetic participants were found to have higher bone density in this study (P=0.002 and P<0.001) compared with the non-diabetic. Multivariate regression analysis also revealed statistically significant associations of BMD with gender (P<0.001), age (P<0.001), and origin (P=0.001) for the lumbar spine and with gender (P=0.002) and age (P<0.001) for the femoral neck. A significant decrease in mean BMD was also found in multiparous (parity ≥3) females compared to low parity (parity 1-2) and nulliparous (parity 0) females (P<0.001 and P=0.048 respectively for LS and FN).Conclusion: A proactive approach to prevent osteoporosis in the study population involves a meticulous investigation of its etiological factors and addressing them precedently. Therefore, it is recommended to consider BMD as a routine test for prevention, early detection, and to minimize the sequelae of osteoporosis. https://aojnmb.mums.ac.ir/article_26940.html Objective(s): This study aimed to evaluate the role of radioiodine uptake patterns and pulmonary nodule size in predicting progression- free survival (PFS) and overall survival (OS) in DTC patients with lung metastases only.Methods: A retrospective study was conducted on 189 DTC patients with pulmonary metastasis alone who were treated and monitored at the Department of Nuclear Medicine, Hospital 108, Vietnam from January 2004 to December 2018. They were categorized based on radioiodine uptake patterns on post-therapy whole-body scans (WBS) and CT-based pulmonary nodule sizes. Prognostic factors were identified by Kaplan-Meier survival and Cox regression.Results: The 5-year and 10-year OS rates were 96.83 % and 94.71 %. DTC-LM patients with diffuse radioiodine uptake and miliary metastases demonstrated significantly higher survival rates, with 5-year and 10-year PFS rates of 100% and 98.8%, respectively. In contrast, patients with nonavid metastases exhibited a markedly lower prognosis, with 5-year and 10-year PFS rates of 58.8% and 25.2%, respectively (p<0.001). Patients with nodules <5 mm had 5-year and 10-year PFS rates of 88.8% and 73.8%, respectively, while those with nodules 5–10 mm had rates of 79.8% and 52.7%. Patients with nodules ≥10 mm experienced the worst outcomes, with 5-year and 10-year PFS rates of 70.6% and 29.3% (p<0.001). Multivariate analysis confirmed that non-avid metastases, nodule size ≥10 mm, and age ≥55 were independent predictors of poor prognosis (HR:24.99, 5.96, and 6.58; p<0.001).Conclusions: Patterns of radioiodine uptake and pulmonary nodule sizes on CT imaging are crucial predictors of long-term clinical outcomes in DTC-LM. Diffuse iodine uptake and military pulmonary metastases are associated with favorable outcomes, while non-avid lung nodules and larger nodule sizes predict poorer survival. https://aojnmb.mums.ac.ir/article_26999.html Objective(s): To evaluate whether radiomic features extracted from 18F-NaF PET/CT scans, analyzed using machine learning (ML) methods, can improve the differentiation between true metastatic bone lesions (TP) and false-positive benign uptake (FP), thereby enhancing the diagnostic utility of 18F-NaF PET/CT.Methods: This retrospective study included 62 patients with known primary malignancies who underwent 18F-NaF PET/CT. Lesions were classified as TP or FP based on consensus interpretation including follow-up. Patients were randomly split into training (n=41) and validation (n=21) groups. Radiomic features were extracted from PET images using LIFEx software. Feature selection (ANOVA, RFE) and ML model training (SVM, Random Forest, XGBoost) were performed. Model performance was evaluated using accuracy, specificity, sensitivity, and AUC, initially with a train/validation split and subsequently with 5-fold cross-validation incorporating feature engineering and hyperparameter tuning. Feature importance was assessed using SHAP.Results: Significant differences in SUVmax (p=0.006) and SUVmean (p=0.034) were observed between TP and FP lesions. Initial validation showed XGBoost performed best (AUC=0.78). After optimization and 5-fold cross-validation on the combined dataset (n=62), the tuned XGBoost model achieved the highest performance (Mean Accuracy: 85.7% ±2.9%, Mean AUC: 0.86), outperforming Random Forest (AUC: 0.79) and SVM (AUC: 0.74). SHAP analysis identified SUVmax, SUVmean, Voxel Volume Num, GLRLM RLNU, and Skew.Conclusion: Radiomics-based machine learning classifiers, particularly XGBoost, demonstrated strong performance in distinguishing true metastatic from false-positive benign lesions on 18F-NaF PET/CT. Integrating radiomics and ML can potentially improve the diagnostic accuracy and robustness of 18F-NaF PET/CT for assessing bone metastases. Further validation in larger cohorts is warranted. https://aojnmb.mums.ac.ir/article_27000.html Objective(s): This study evaluates the utility of interim 18F-FDG PET/CT (iPET)-guided therapy in a Southeast Asian population, addressing gaps in region-specific data. Key outcomes included treatment response rates and progression-free survival (PFS) stratified by iPET results (Deauville score (DS) 1-3 vs. 4-5) across all clinical risk groups (including early-stage favorable/unfavorable and advanced-stage based on the International Prognostic Score (IPS)). Findings will inform optimal risk-adapted strategies in resource-aware settings.Methods: A prospective study was conducted of 100 patients with Hodgkin Lymphoma (HL) at the Vietnam National Cancer Hospital from March 2020 to March 2024. All patients underwent baseline clinical assessment and imaging (CT and/or PET/CT), followed by two cycles of ABVD chemotherapy. IPET was performed for early response assessment using Deauville scores (DS), with subsequent treatment adjusted according to NCCN guidelines.Results: A total of 100 patients with classical Hodgkin lymphoma (mean age: 32±13.8 years; range 9-73) were analyzed. Bulky disease and extranodal involvement were observed in 10.0% and 15.0% of cases, respectively. Early-stage disease (stage I-II) was present in 72.0%, and advanced-stage (stage III-IV) in 28.0%. After two cycles of ABVD, 78.0% of patients had a negative iPET result (DS 1-3), of whom 88.5% were DS 1, while 22.0% had a positive iPET result (DS 4-5), predominantly DS 4 (72.7%). In early-stage disease, the 3-year progression-free survival (PFS) was significantly higher in the favorable group than in the unfavorable group (95.7% vs. 81.2%, p=0.03). In advanced-stage disease, low-risk (IPS 0–3) patients achieved a 3-year PFS of 88.2%, whereas high-risk (IPS 4-7) patients had a markedly lower PFS of 42.9% (p<0.001). Overall, patients with negative iPET had substantially better 3-year PFS than those with positive iPET (93.6% vs. 40.9%, p<0.0001). The predictive performance of iPET for treatment outcomes showed a sensitivity of 72.3%, specificity 89.0%, PPV 59.0%, NPV 93.6%, and overall accuracy 86.0% (95% CI 0.78-0.91). Diagnostic accuracy remained high across subgroups, ranging from 84.0% in early-stage disease to 89.5% in advanced-stage, and was highest in favorable early-stage (90.8%) and low-risk advanced-stage (93.7%) patients. In multivariate analysis, iPET was identified as an independent predictor of PFS (p<0.05).Conclusion: In a real-world Vietnamese cohort with Hodgkin lymphoma, interim PET/CT guided by Deauville scoring after two cycles of ABVD chemotherapy showed strong predictive value for treatment response. The results advocate for broader integration of NCCN-consistent risk-adapted strategies in Southeast Asia. https://aojnmb.mums.ac.ir/article_26816.html Objective(s): Moyamoya disease (MMD) is a rare, progressive steno-occlusive cerebrovascular disorder characterized by impaired cerebral perfusion and an elevated risk of ischemic events.  Accurate cerebrovascular reserve (CVR) assessment is crucial for guiding surgical decision-making. This study evaluated the clinical utility of acetazolamide (ACZ)-challenged brain perfusion single-photon emission computed tomography (SPECT) in assessing CVR in patients with MMD.Methods: We retrospectively analyzed 10 patients (6 males, four females; aged 5–65 years) with angiographically confirmed MMD who underwent baseline and post-ACZ 99mTc-ECD SPECT. Regional perfusion across 12 brain regions per patient was visually graded and classified using Rogg’s criteria (Type I–III) to assess CVR.Results: At baseline, 78/120 regions showed normal perfusion; post-ACZ, this decreased to 72 regions, with an increase in severe hypoperfusion (from 16 to 26 regions). A total of 44 regions demonstrated improved perfusion following ACZ, indicating preserved reserve. According to Rogg’s classification, 63 regions showed Type I, 13 showed Type II, and 39 showed Type III responses. Three patients had infarcts, with two exhibiting crossed cerebellar diaschisis. In a patient who underwent revascularization, new postoperative perfusion defects developed in regions that corresponded to preoperative Type III responses.Conclusion: ACZ-challenged SPECT effectively characterizes regional CVR in MMD. Identifying Type II and III responses is a valuable predictor for ischemic vulnerability and guides the selection of surgical candidates. https://aojnmb.mums.ac.ir/article_26476.html Diagnosing gastrointestinal bleeding (GIB) can be especially difficult when endoscopic evaluation do not reveal a clear source. In this report, we describe 20 patients with suspected GIB in whom initial evaluations were inconclusive. All underwent dynamic planar 99mTc-RBC scintigraphy followed by SPECT/CT imaging. This combination proved valuable in either identifying active bleeding sites or clarifying non-bleeding causes of tracer accumulation. The added anatomical detail from SPECT/CT helped distinguish true bleeding from normal physiological activity, vascular landmarks, or postoperative alterations—areas where planar imaging is not enough. In some patients, imperfect red blood cell labeling introduced challenges in image interpretation, occasionally mimicking bleeding. Even so, the fusion of functional and anatomical data improved diagnostic clarity in most cases. This series emphasizes how hybrid nuclear imaging can provide critical insight when other diagnostic methods fail, enabling more accurate localization and better-informed clinical decisions. Our experience supports the broader use of SPECT/CT in evaluating complex or obscure GIB, offering clinicians a noninvasive yet highly informative diagnostic option. https://aojnmb.mums.ac.ir/article_26938.html The role of neoadjuvant therapy in neuroendocrine tumors (NET) remains an area requiring further advanced clinical exploration. 177Lu-DOTATATE has demonstrated significant therapeutic efficacy in managing metastatic NET, with reports of notable tumor size reduction in specific cases. This report highlights the case of a young patient diagnosed with an initially inoperable hepatic hilum NET. The patient received two cycles of 177Lu-DOTATATE, resulting in remarkable tumor shrinkage on follow-up imaging, which facilitated surgical intervention. The patient underwent a complex left trisectionectomy resection, including anastomosis of the right portal vein, resection and interposition graft of the right hepatic artery, Roux-en-Y hepaticojejunostomy, and jejunojejunostomy. Due to residual involvement of the common hepatic duct and right portal vein margins, two additional cycles of adjuvant 177Lu-DOTATATE were administered post-surgery. Long-term follow-up imaging over a 20-month period has demonstrated stable disease, emphasizing the potential benefits of incorporating neoadjuvant and adjuvant 177Lu-DOTATATE in selected NET cases. https://aojnmb.mums.ac.ir/article_26939.html Neuroendocrine tumors (NETs) represent a heterogeneous group of neoplasms originating from neuroendocrine cells. Overexpression of somatostatin receptors is typically correlated with tumor differentiation.Localization and characterization of the primary tumor are essential, as radical surgery remains the treatment of choice for resectable disease. Additionally, identifying metastatic disease and assessing its extent are crucial for disease staging and monitoring response aimed at reducing total tumor volume.Radioguided surgery based on the ability to detect somatostatin receptor overexpression, is a valuable tool that aids in the identification of microscopic and occult endocrine tumors.In this context, we present three patients who achieved improved outcomes due to enhanced detection and  identification of previously indeterminate or undetected lesions on prior imaging or even the detection of tumors that were not easily visualized without radioguided assistance.Complete tumor removal is a key prognostic factor in patients with NETs, improving quality of life and reducing the risk of tumor recurrence or locorregional metastasis. Achieving R0 or R1 resections has been associated with better survival outcomes.The successful implementation of radioguided surgery for NETs requires a multidisciplinary approach, both surgeons and nuclear medicine specialists playing a relevant role, and who must be aware of its prognostic significance. https://aojnmb.mums.ac.ir/article_26367.html Objective(s): High levels of CXCR4 expression in patients with mantle cell lymphoma is associated with poor prognosis. Various molecular techniques used are unable to specify the metastatic disease burden. Cyclic pentapeptides act as CXCR4 antagonists hence are functional markers of in-vivo CXCR4 receptor expression. In this view, the theragnostic complex of radiolabeled 68Ga- and 177Lu-cyclic pentapeptides was developed to in-vivo target the CXCR4 receptor expression.Methods: Bone marrow aspiration and flow cytometry were performed to examine the fraction of lymphoid cells and immunophenotyping respectively. In-vitro CXCR4 receptor expression in the biopsied sample was determined using immunohistochemistry and flow cytometry molecular techniques. Diagnostic imaging using 68Ga-cyclic pentapeptide was performed to check the in-vivo CXCR4 expression in chemotherapy relapse MCL patient. Dosimetry studies in the same patient was performed with different time-point imaging to calculate the residence time and predict the critical organ.Results: Bone marrow aspiration indicated ~75% atypical lymphoid cells. Flow cytometric immunophenotyping revealed positivity for CD19, CD20, CD79b, Anti-kappa markers. IHC results showed high nuclear positivity. Approximately 86.11% of the cell population showed CXCR4 positive expression. Diagnostic imaging using 68Ga-cyclic pentapeptide showed high tracer avidity in the mesenteric mass at L4 level. The avidity of both 68Ga- and 177Lu- cyclic pentapeptide radiotracers was noted in the mesenteric mass at the L4 level. Dosimetry study using 177Lu-cyclic pentapeptide indicated kidneys as the critical organ with max residence time of 5.39 h.Conclusion: Theragnostic complex of radiolabelled 68Ga/177Lu- cyclic pentapeptides have the potential to in-vivo target the CXCR4 receptor expression. https://aojnmb.mums.ac.ir/article_26930.html Tuberculous pyomyositis is a rare and often under-recognized extrapulmonary manifestation of tuberculosis, presenting with non-specific symptoms such as fever and abscess, that may delay diagnosis. We report a unique case of disseminated tuberculous pyomyositis in a 56-year-old male with underlying chronic inflammatory arthritis. The diagnosis was confirmed using CBNAAT, line probe assay (LPA), and histopathology. Currently MRI is the standard imaging modality in use for imaging pyomyositis. 18F-FDG PET/CT can play a crucial role in detecting widespread metabolically active lesions involving multiple skeletal muscle groups and lymph nodes, which are not fully appreciated on conventional imaging and prove to be a sensitive imaging modality in such cases. This imaging modality provided a comprehensive assessment of disease burden, helping to map the full extent of involvement and guide clinical management. Early identification and treatment are essential, especially in atypical or disseminated cases, to prevent further complications and improve patient outcomes. Here we present a rare case presentation of such extensive muscular involvement in tuberculosis, highlighting the diagnostic utility of PET/CT in extrapulmonary TB. https://aojnmb.mums.ac.ir/article_26941.html Tumor necrosis factor-alpha (TNF-α) inhibitors, such as adalimumab, are integral in the managing refractory ankylosing spondylitis (AS). However, their immunosuppressive effects elevate the risk of reactivation of latent tuberculosis (TB), especially extrapulmonary TB (EPTB), which can present with non-specific symptoms and mimic malignancy.We report the case of a 40-year-old man with ankylosing spondylitis who had been on long-term adalimumab therapy. He presented with a low-grade fever and weight loss. An 18F-FDG PET/CT scan revealed intense FDG uptake in the peritoneum, omentum, and mesentery. There was no ascites or visceral involvement; however, a few FDG-avid retroperitoneal, mediastinal, and right cervical lymph nodes were noted, along with a right pleural effusion and no lesions in the lung parenchyma. Despite a negative microbiological workup, empirical anti-tubercular therapy (ATT) was initiated due to strong clinical and imaging suspicion of tuberculosis. The patient showed significant clinical improvement, and a follow-up PET/CT scan six months later indicated complete metabolic resolution of the lesions.This case underscores the diagnostic challenge of peritoneal TB in immunosuppressed individuals. It highlights the supportive role of FDG PET/CT in guiding empirical therapy and monitoring treatment response without microbiological confirmation. https://aojnmb.mums.ac.ir/article_27001.html Chronic Recurrent Multifocal Osteomyelitis (CRMO) is a rare autoinflammatory bone disorder characterized by episodic bone pain, swelling, and radiologic evidence of sterile osteolytic lesions. We report the case of a 55-year-old woman with breast cancer as well as a long-standing history of rheumatoid arthritis who presented with chronic pain and radiologic findings of bilateral, metaphyseal-diaphyseal tibial lesions evolving over an eight-year period. The bone lesions appeared spontaneously, remained for variable durations, and regressed without specific treatment, paralleling pain severity. Laboratory data showed elevated inflammatory markers, while biopsy ruled out infection and malignancy. Bone scintigraphy and MRI confirmed multifocal active bone lesions, consistent with CRMO. The case highlights the diagnostic challenges of CRMO in adults, especially in the presence of other autoimmune conditions, and emphasizes the importance of long-term imaging follow-up. This case also illustrates that CRMO may mimic malignancy or infectious osteomyelitis, yet respond well to anti-inflammatory therapy alone. Early recognition can prevent unnecessary interventions. https://aojnmb.mums.ac.ir/article_27002.html Esophageal cancers predominantly metastasize through direct invasion, lymphatic dissemination, or hematogenous spread. Frequent metastatic locations comprise the liver, lymph nodes, lungs, and bones. However, direct bronchial metastases are extremely rare and present significant diagnostic challenges. We report the case of a 50-year-old male diagnosed with esophageal squamous cell carcinoma who underwent neoadjuvant chemoradiotherapy followed by esophagectomy with gastric pull-up reconstruction. Two years after surgery, routine follow-up imaging revealed a suspicious endobronchial lesion. On 18F-FDG PET/CT, the lesion demonstrated only mild uptake, potentially leading to underestimation of its malignant potential. Subsequent bronchoscopy and histopathological examination confirmed metastatic squamous cell carcinoma, consistent with the patient’s primary esophageal tumor. This unusual presentation highlights the limitations of relying solely on metabolic imaging in rare metastatic patterns. It further underscores the importance of a multimodal diagnostic strategy, integrating clinical evaluation, radiological findings, endoscopy, and tissue biopsy to achieve accurate diagnosis and guide optimal management in complex cases. https://aojnmb.mums.ac.ir/article_27027.html Transthyretin cardiac amyloidosis (ATTR-CA) is increasingly recognized as a cause of heart failure in elderly patients. Noninvasive diagnosis with technetium-99m pyrophosphate (99mTc-PYP) scintigraphy has become established, but quantitative approaches for therapy monitoring remain under investigation. We present a case of wild-type ATTR-CA in an 82-year-old man treated with tafamidis. Baseline echocardiography showed concentric left ventricular hypertrophy with preserved ejection fraction, impaired global longitudinal strain, and elevated B-type natriuretic peptide (BNP). Planar and SPECT/CT imaging with 99mTc-PYP demonstrated diffuse myocardial uptake (grade 3, H/CL 1.97). Quantitative analysis with GI-BONE software yielded SUVmax 4.2, amyloid deposition volume (AmyDV) 122 cm³, and total amyloid uptake (TAU) 313. Endomyocardial biopsy confirmed wild-type ATTR. After 18 months of tafamidis therapy, symptoms persisted with further GLS impairment and BNP elevation, while echocardiographic wall thickness remained increased. In contrast, repeat PYP imaging showed reduced uptake (grade 2, H/CL 1.64) with markedly decreased quantitative indices (SUVmax 2.3, AmyDV 2 cm³, TAU 4). This case demonstrates that volumetric indices can capture substantial therapy-related changes, although discordance with functional and biomarker findings highlights the need for integrated assessment. Quantitative 99mTc-PYP SPECT/CT may serve as a promising tool for therapy monitoring in ATTR-CA. https://aojnmb.mums.ac.ir/article_27291.html OBJECTIVE The Philippine Journal of Nuclear Medicine, the official publication and peer-reviewed journal of the Philippine Society of Nuclear Medicine, serves as a primary repository of research articles by Filipino nuclear medicine physicians. Despite rapid global developments in nuclear medicine, local research output remains underexplored. With 20 volumes and multiple articles published, the PJNM best reflects the situation of nuclear medicine research in the country. This study analyzed and described local research productivity through a bibliometric analysis of PJNM from 2002 to 2025. METHODS Full-text research articles were retrieved from both physical and online sources. Eligible articles were classified by study type. Bibliographic data such as authorship and institutional affiliation were extracted. Descriptive statistics and bibliometric mapping using VOSviewer were employed to evaluate publication trends, collaboration networks, and keyword occurrences. RESULTS A total of 134 full text articles were included. Publication output peaked during 2010-2012, followed by stable but modest productivity in subsequent years. Observational studies (53%) comprised the majority of publications, followed by case report/series (40%), and meta-analyses/systematic review (7%). No experimental studies were published. JM Obaldo was the most prolific author (n = 24), while GFL Goco demonstrated the strongest collaborative links (37). St. Luke’s Medical Center-Quezon City produced the highest research output and linkages. Keyword mapping revealed seven thematic clusters, namely: bone imaging, cardiac and parathyroid scintigraphy, radioactive iodine therapy for thyroid cancer, pediatric scintigraphy, prostate cancer and theranostics, MPI SPECT image quality, and renal scintigraphy. The more recent articles focused on oncology, PET/CT, and theranostics. CONCLUSIONS PJNM reflects the growth and evolving focus of nuclear medicine research in the Philippines. While research output is diverse and increasingly aligned with international trends, there is a need to strengthen experimental and translational studies, foster broader collaborations, and achieve international indexing to enhance visibility and global impact. https://aojnmb.mums.ac.ir/article_27365.html Background: Primary leiomyosarcoma of the ovary is extremely rare, accounting for only 1% of ovarian tumors. Myxoid leiomyosarcoma (MLMS) is one of the subtypes. As far as we know, only few cases have been reported, and there is no imaging report of ovarian MLMS. This paper reports a case of primary MLMS of the ovary with multiple complex predominantly cystic masses and mild metabolism on PET/CT, and reviews the literature. Case presentation: A 70-year-old woman was admitted to the hospital due to intermittent abdominal distension accompanied by edema of lower limbs for 3 months. Abdominal CT showed multiple irregular complex predominantly cystic masses in the abdominal and pelvic cavity, with unclear lesion boundaries, and patchy mild to moderate enhancement. PET/CT showed inhomogeneous low uptake of FDG, SUVmax:2.2；In the cystic area, there are multiple flocculent flotations with no FDG uptake. The patient underwent tumor debulking and omentectomy. Intraoperative exploration revealed that the tumors were complex, predominantly cystic masses accompanied by multiple solid septa, which originated in the right ovary. Finally, ovarian MLMS was histologically confirmed. Conclusion: Due to extensive myxoid degeneration, MLMS of the ovary is mostly manifested as large complex predominantly cystic masses on imaging, with uneven and mild uptake of glucose. In this paper, enhanced CT and FDG PET/CT findings of ovarian MLMS were reported, which made up the gap in the imaging of this disease. https://aojnmb.mums.ac.ir/article_27366.html Background: Accurate staging, including detection of nodal and distant metastases of gastric carcinoma is essential for treatment planning. 18F-FDG PET/CT has important limitations in gastric cancer, especially in diffuse and mucinous histologic subtypes. Fibroblast activation protein inhibitor (FAPI) PET/CT targets cancer-associated fibroblasts and may improve lesion conspicuity. Objective: To systematically review and meta-analyse the diagnostic performance of 68Ga-FAPI PET/CT for staging of gastric carcinoma and to compare it with 18F-FDG PET/CT. Methods: The protocol was prospectively registered in PROSPERO (CRD420251056976). PubMed, EMBASE, Web of Science and Cochrane libraries were searched from January 2016 to December 2023 for clinical studies evaluating 68Ga-FAPI PET/CT in histologically confirmed gastric carcinoma. Two reviewers independently screened records, extracted data, and assessed risk of bias using QUADAS-2. Pooled sensitivity, specificity, positive and negative predictive values and accuracy were estimated using random effects models. Summary ROC (SROC) and hierarchical SROC (HSROC) curves were generated. Comparative analyses with 18F-FDG PET/CT were restricted to studies with head to head data in the same patient cohort, and areas under the curve (AUCs) were compared with DeLong’s test. Results: Fourteen studies (681 patients) were included; eleven provided head to head comparisons with 18F-FDG PET/CT. For detection of primary gastric carcinoma with 68Ga-FAPI PET/CT, pooled sensitivity and specificity were 95-96% and 93% respectively, with an AUC of 0.96 (95% CI ~ 0.89-1.00). For metastatic disease, pooled accuracy for lymph node, omental, visceral and skeletal metastases ranged from ~ 89% to 97%. In head to head studies, 68Ga-FAPI PET/CT showed higher AUCs than 18F-FDG PET/CT for primary tumors (0.96 vs 0.76; p = 0.001) and omental metastases (0.97 vs 0.78; p = 2.6×10⁻⁵). Heterogeneity was moderate for most outcomes. Funnel plots and trim and fill analyses suggested possible small study effects, but adjusted pooled diagnostic odds ratios remained high. Conclusions: 68Ga-FAPI PET/CT demonstrates high diagnostic accuracy for staging of gastric carcinoma and appears to outperform 18F-FDG PET/CT in many settings, particularly for omental and some visceral metastases and for histologic subtypes with low FDG avidity. These findings support the use of 68Ga-FAPI PET/CT as a promising complementary imaging modality for staging and restaging https://aojnmb.mums.ac.ir/article_27418.html Introduction: Secondary and tertiary hyperparathyroidism (HPT) are common complications in patients with end-stage renal disease (ESRD) and may result in renal osteodystrophy. While [18F]-FDG PET/CT is primarily used to evaluate malignancy, it may occasionally reveal metabolic or endocrine abnormalities. Case presentation: A 45-year-old male with ESRD on hemodialysis presented with generalized bone pain and radiologic suspicion of malignancy. [18F]-FDG PET/CT demonstrated diffusely increased skeletal uptake and multifocal lytic bone lesions, consistent with metabolic bone disease secondary to renal osteodystrophy. Incidental findings of soft tissue nodules in both tracheoesophageal grooves suggested parathyroid pathology. Subsequent [99mTc]Tc-sestamibi SPECT/CT confirmed parathyroid adenomas/ hyperplasia. Laboratory tests revealed elevated calcium (10.8 mg/dL), phosphorus (7.2 mg/dL) and markedly increased parathyroid hormone (3120 pg/mL) levels. Discussion: This case highlights that diffuse skeletal [18F]-FDG uptake in ESRD may mimic malignancy but actually represent metabolic bone disease due to secondary or tertiary HPT. The [18F]-FDG PET/CT findings of parathyroid lesions were incidental, while [99mTc]Tc-sestamibi SPECT/CT accurately localized the hyperfunctioning glands. Conclusion: FDG PET/CT can incidentally demonstrate metabolic bone disease and parathyroid-[18F] abnormalities in ESRD, but [99mTc]Tc-sestamibi SPECT/CT remains the preferred modality for parathyroid localization. Awareness of this potential finding may prevent misinterpretation and guide appropriate management. https://aojnmb.mums.ac.ir/article_27419.html Background:Adrenal histoplasmosis is a rare presentation of disseminated fungal infection that can mimic malignancy or granulomatous disease. Case Presentation: A 51 year old immunocompetent man with no significant past medical history was referred for evaluation of five months of progressive unexplained weight loss (7 kg), anorexia, intermittent low grade fever, and right shoulder pain. An 18F-FDG PET/CT scan showed moderate grade FDG uptake in left suprarenal region with central photopenic area and high grade FDG uptake in right supra renal region and moderate grade FDG uptake at bilateral scapular regions. No additional sites of abnormal uptake were noted. On CT guided biopsy and microscopic examination fungal elements were detected. Oral itraconazole 200 mg twice daily and hydrocortisone replacement therapy were initiated. Clinical and biochemical improvement on follow up at 6 months supported treatment response. Conclusions: 18F-FDG PET/CT is a valuable imaging modality for incidental detection of adrenal histoplasmosis and for guiding biopsy in metabolically active lesions. Early diagnosis paired with antifungal and corticosteroid therapy optimizes patient outcomes in immunocompetent adults presenting with bilateral adrenal masses. https://aojnmb.mums.ac.ir/article_27420.html Hyper-IgE Syndrome (HIES) is a rare immunodeficiency predisposing patients to infections, inflammation, and occasional neoplasia. We report a 17-year-old boy with HIES who presented with severe right thigh pain. FDG-PET/CT demonstrated a right adrenal mass (SUVmax 5.4), multiple pulmonary nodules, and a lytic-sclerotic femoral lesion (SUVmax 4.6), initially suggesting disseminated malignancy. Biopsy confirmed acute osteomyelitis and a benign spindle cell tumor of the adrenal gland. Two months later, persistent fever and elevated ESR prompted re-evaluation, revealing intense FDG uptake in the thoracic aorta (SUVmax 20.5) consistent with large vessel vasculitis, later confirmed by angiography. The combination of infection, benign tumor, and vasculitis illustrates the broad FDG uptake spectrum in HIES and the risk of misdiagnosis as malignancy. Integration of clinical, imaging, and histopathologic data was critical for accurate diagnosis. This case highlights FDG-PET/CT’s value in detecting inflammatory vascular disease and monitoring therapy, while reinforcing the importance of biopsy for definitive diagnosis. In immunodeficient patients, a multimodal diagnostic approach is essential to distinguish between malignant and benign FDG-avid lesions. https://aojnmb.mums.ac.ir/article_27421.html The planar whole body iodine scan (WBIS) has traditionally been used as the primary imaging technique for assessment of patients with thyroid cancer. This case report examines the imaging findings of a 61-year-old male with follicular thyroid carcinoma who underwent total thyroidectomy and received adjuvant radioactive iodine (RAI) treatment. A planar post-ablation WBIS revealed the commonly seen pattern of multiple foci of iodine uptake in the central neck region suggesting postsurgical thyroid remnant, thyroglossal duct remnant and central lymph node metastasis. However, single photon emission computed tomography (SPECT) / computed tomography (CT) imaging excluded lymph node metastasis and revealed iodine contamination over the mentum superimposed on the thyroid bed. This case report highlights the importance of utilizing SPECT /CT even for patients with apparently central neck uptake to prevent incorrect staging and treatment planning. In this report, we also present a review of the literature highlighting various pitfalls that can affect the interpretation of the WBIS and potentially result in false-positive findings in the neck region. https://aojnmb.mums.ac.ir/article_27422.html Introduction: Currently, the treatment of prostate and endocrine cancers with radiopharmaceuticals derived from lutetium-177 is the focus of many radionuclide therapy centers. One of the reasons for turning to lutetium radiopharmaceuticals is their favorable dosimetry and stability. Directly excreting the urine of patients treated with these radiopharmaceuticals into the hospital's waste water and consequently into the city's waste water and finally into agricultural fields causes indirect radiation exposure. This study aims to calculate the radiation exposure of people in Tehran due to the presence of this radioactive material in the wastewater of urban areas. Materials and methods: First, the activity concentration in wastewater was estimated, and then, the dose received by people was estimated via a mathematical model. Results: The amount of public dose of lutetium in wastewater from nuclear medicine centers in Tehran is 8712.9 nSV/year. Conclusion: The direct release of patients' urine into the wastewater of nuclear medicine centers in Tehran does not have a significant effect on the radiation exposure of people, and septic tanks are not necessary for these radiopharmaceuticals. https://aojnmb.mums.ac.ir/article_27423.html Oncocytic thyroid carcinoma (OTC) and tenosynovial giant cell tumor (TGCT) are rare neoplasms with distinct clinical and pathological presentations. This case report presents an unusual occurrence of these two tumors in a single patient. A 45-year-old male with a history of recurrent OTC developed a rapidly growing soft tissue mass in his left ankle. Initial imaging studies, including 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG) show intense hypermetabolic bilateral thyroid bed focal lesions as well as hypermetabolic infiltrative soft tissue lesions involving left ankle and ventral surface of the foot with multiple lytic bone lesions and cortical distribution of the calcaneal and few tarsal bones. However, subsequent biopsy confirmed a diagnosis of TGCT. This case highlights the value of FDG PET/CT in the diagnosis of both OTC and TGCT. FDG PET/CT is a powerful imaging modality that can detect metabolically active lesions, such as these two tumors. Its high sensitivity allows for early detection and accurate disease staging. FDG PET/CT has limitations, as it may lack specificity in distinguishing benign from malignant lesions. Thus, combining clinical assessment, histopathology, and additional imaging is vital for accurate diagnosis and patient care. https://aojnmb.mums.ac.ir/article_27424.html Purpose: Diabetic patients are at high risk for developing diabetic cardiomyopathy, often initially presenting as left ventricular diastolic dysfunction (LVDD). While echocardiography is the standard for diagnosing LVDD, Gated SPECT (GSPECT) offers simultaneous assessment of perfusion and function. This study aimed to evaluate the diagnostic value of diastolic parameters derived from GSPECT for detecting LVDD in diabetic patients without known heart disease, using echocardiography as a reference. Materials and Methods: In this cross-sectional study, 60 diabetic patients without a history of cardiac disease underwent both GSPECT myocardial perfusion imaging and echocardiography within a two-week period. Diastolic function was assessed on GSPECT using peak filling rate (PFR) and time to peak filling rate (TTPFR). Echocardiography served as the gold standard for classifying diastolic function as normal, grade 1, or grade 2 dysfunction. Diagnostic accuracy, sensitivity, and specificity of GSPECT parameters were calculated. Results: Based on echocardiography, 51.7% of patients had LVDD (45% grade 1, 6.7% grade 2). The PFR derived from GSPECT demonstrated a sensitivity of 87% and a specificity of 48.2% for detecting LVDD, with an overall accuracy of 68.3%. TTPFR showed high sensitivity (90.3%) but low specificity (17.2%). A significant correlation was found between the ischemia pattern on GSPECT and the presence of diastolic dysfunction (p=0.01). Lower PFR values were significantly associated with male gender, age >60 years, and smoking. Conclusion: Gated SPECT, particularly the PFR parameter, shows high sensitivity for the detection of LVDD in asymptomatic diabetic patients. Incorporating diastolic function analysis into routine GSPECT reporting can provide valuable incremental information for the early diagnosis and risk stratification of diabetic cardiomyopathy. https://aojnmb.mums.ac.ir/article_27630.html Cardiac metastases are uncommon, particularly in the left ventricle, where lesions often remain asymptomatic and can be easily overlooked on conventional imaging. Lung cancer, a leading cause of global cancer-related morbidity and mortality, accounts for approximately one-third of all cases of cardiac metastases among various malignancies. We present a 62-year-old male with stage IV squamous cell carcinoma of the lung, who exhibited widespread systemic metastases. Staging Fluorine-18 Fluorodeoxyglucose (¹⁸F-FDG) Positron Emission Tomography/Computed Tomography (PET/CT) revealed a hypermetabolic cavitary left upper lobe mass with a metastatic process involving multiple nodal, adrenal, hepatic, osseous, and cerebral deposits, along with an incidental focal FDG-avid lesion in the left ventricle that was not detected on initial CT. Echocardiography confirmed preserved cardiac function with a normal ejection fraction. Given uncommon nature of left ventricular involvement by squamous cell carcinoma and the limited number of similar reported cases, our findings contribute to the growing evidence supporting the critical role of ¹⁸F-FDG PET/CT in detecting clinically silent occult cardiac metastasis. https://aojnmb.mums.ac.ir/article_27631.html Background: Primary myoepithelial carcinoma (MEC) of the breast is exceptionally rare and diagnostically challenging. The role of 18F-FDG PET/CT in its evaluation is not well defined. Case presentation: A 52 year old woman with history of right breast ductal carcinoma, post MRM and chemo-radiation therapy followed by tamoxifen 14 years back, had now presented with a 1.8 x 1.6 cm, firm, non tender, mobile left breast lump and a right neck lump.USG guided FNAC of the right lobe lesion of thyroid gland revealed metastatic carcinoma. Core biopsy of the breast lesion showed a biphasic neoplasm with predominant malignant myoepithelial differentiation. Preoperative 18F-FDG PET/CT demonstrated high grade FDG uptake confined to the primary tumor (SUVmax 9.8) in the left breast with high grade FDG avid contralateral ( right) thyroid lesion, infraclavicular lymph node and moderate grade FDG avid subcentimetric right internal mammary lymph node. Histopathology and immuno-histochemistry of breast lesion confirmed myoepithelial carcinoma; the myoepithelial component stained strongly for p63, S100, CK5/6, and lacked ER/PR/HER2 expression; Ki-67 was ~20%. Subsequently patient was planned for systemic chemotherapy and radiation therapy and has received 2 cycles of chemotherapy so far. Conclusions: Breast MEC is a rare, aggressive neoplasm requiring meticulous histopathologic/IHC work up. 18F-FDG PET/CT can complement conventional imaging by providing whole body staging and a quantitative baseline for follow up in selected cases. Multidisciplinary discussion remains essential given limited high level evidence.