Evidence of Prostate-Specific Membrane Antigen Expression in Hepatocellular Carcinoma Using 68Ga-PSMA PET/CT Introduction Prostate specific membrane antigen (PSMA) expression has been demonstrated in tumor neovasculature of many solid tumors, including hepatocellular carcinoma (HCC). The purpose of this study is to evaluate PSMA expression in patients with HCC. Materials and Methods Nineteen HCC patients who underwent 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) as part of restaging procedure also underwent 68Ga-PSMA PET. 18F-FDG PET and 68Ga-PSMA findings were compared visually as well as quantitatively using maximized standardized uptake values (SUVmax). Results FDG was positive in 15 patients while 16 patients demonstrated PSMA expression. The only extrahepatic finding was one metastatic lymph node detected by both tracers. Mean SUVmax of liver lesions on FDG PET/CT was 8.3 ± 2.3 and mean tumor to background ratio was 2.3 ± 1.5. Respective values for 68Ga-PSMA PET/CT were 17.4 ± 9 and 3.3 ± 2.2. On visual and quantitative evaluation uptake was higher with PSMA in nine patients and higher with FDG in four patients. PSMA and FDG activity were similar in three patients. One of the FDG positive patients was PSMA negative whereas two patients were PSMA positive but FDG negative. Heterogeneous uptake pattern was observed in three patients. Comparison of mean SUVmax and T/B values between PET studies revealed no statistically significant difference (P > 0.1). The mean survival was 25 months (range: 18–32 months) and SUVmax of PSMA (P = 0.05) and FDG (P = 0.012) showed medium strength of correlation with overall survival. Conclusion PSMA expression in advanced HCC can be demonstrated by 68Ga-PSMA PET but is not superior to FDG PET however it could be useful for identifying patients with limited therapeutic options. Received for publication February 12, 2019; revision accepted May 24, 2019. Conflict of interest and sources of funding: none declared. Correspondence to: Serkan Kuyumcu, MD, Istanbul Tip Fakültesi, Nükleer Tip Anabilim Dali Millet cad. 34093 Fatih, Istanbul, Turkey. E-mail: serkan.kuyumcu@istanbul.edu.tr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Nivolumab-Associated Pulmonary and Bone Sarcoidosis in a Patient With Melanoma of Unknown Primary A 57-year-old man with stage IIIB malignant melanoma of unknown primary presented for pretherapy FDG PET/CT that demonstrated metastatic left cervical lymph node with no other site of involvement. Following left neck dissection, nivolumab was initiated. Follow-up FDG PET/CT 3 months after initiation of nivolumab demonstrated extensive radiotracer-avid chest lymphadenopathy and multiple bone lesions. Ultrasound-guided endobronchial biopsy of the mediastinal lymph nodes demonstrated sarcoidosis. Received for publication August 30, 2018; revision accepted June 2, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Mehrbod S. Javadi, MD, Division of Nuclear Medicine and Molecular Imaging, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Johns Hopkins Outpatient Center, Room 3235, 601 N Caroline St, Baltimore, MD 21287. E-mail: mjavadi@jhmi.edu. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Rapidly Progressing Renal Cell Cancer of the Left Native Kidney in a Renal Transplant Recipient With Unusual Sites of Metastasis Demonstrated in Serial 18F-FDG PET/CT An end-stage renal disease patient underwent renal transplantation 18 years back and was on triple immunosuppression for acute rejection. She presented with left-sided abdominal lump and underwent ultrasound and noncontrast CT scan, which revealed an exophytic mass lesion in atrophic left kidney (16.2 × 13.1 × 14 cm). Baseline 18F-FDG PET/CT revealed a large avid exophytic mass (SUVmax 23, 17 × 14 × 13) in atrophic left kidney, with multiple retroperitoneal lymphadenopathies and a suspicious lung nodule. She underwent left open radical nephrectomy. Follow-up PET/CT after 1 month revealed multiple soft tissue deposits in operative bed and other unusual metastatic sites. Received for publication January 28, 2019; revision accepted June 2, 2019. Author Contributions: K.R., the corresponding author, has taken efforts to obtain the clinical history of the patient in detail and follow him up for the second PET/CT scan. M.O., A.P., and A.S.S. have helped the corresponding actor with the necessary literature search, image editing, and legend placement. G.S., head of the department, has guided our work from the beginning and has given necessary words of advice from his experience of 30 years in nuclear medicine. Conflicts of interest and sources of funding: none declared. Correspondence to: Kasturi Rangan B K, MD, MBBS, SGPGIMS, Department of Nuclear Medicine, F Block, SGPGIMS, Lucknow, India 226014. E-mail: kasturi.rangan123@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Concomitant Prostate Carcinoma and Follicular Lymphoma: “Flip-Flop” Appearances on PSMA and FDG PET/CT Scans We report a case of a 75-year-old man with concomitant metastatic prostate cancer and progressive follicular lymphoma and the utility of molecular imaging in differentiating these 2 conditions. 18F-FDG PET/CT can offer accurate staging in many cancers, although its role in prostate cancer is limited. The role of 18F-DCFPyL (PSMA) PET/CT in prostate cancer is evolving and has been demonstrated to have a higher sensitivity than conventional bone scan and CT scan. Together, FDG and PSMA PET/CT studies may offer a noninvasive approach to individually characterize concomitant malignancies, aiding optimization of management and follow-up. Received for publication February 12, 2019; revision accepted June 2, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Nattakorn Dhiantravan, MBBS, MBA, Department of Nuclear Medicine, Prince of Wales Hospital, 320-346 Barker St, Randwick NSW 2031. E-mail: nattakorndhiantravan@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Quality and Safety in Healthcare, Part LVI: Wellness Leaders All members of the healthcare system should make positive contributions to improve the overall level of wellness. However, leaders should have certain specific responsibilities to prevent burnout and increase happiness and wellness at work. It has been proposed that a chief wellness officer direct the initiatives to improve wellness, in collaboration with many others including those in the executive suite. Part of improving joy in the workplace is improving efficiency, quality care for patients, safety for patients and workers, meaningful work for the workers, and respect and fairness for all. Received for publication May 27, 2019; revision accepted June 1, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Jay A. Harolds, MD, Division of Radiology and Biomedical Imaging, College of Human Medicine, Michigan State University, Advanced Radiology Services, PC, 3264 North Evergreen Dr NE, Grand Rapids, MI 49525. E-mail: harolds112@cox.net. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal’s Web site (www.nuclearmed.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Influence of Biological Parameters Assessed in [18F]FDG PET/CT on Overall Survival in Cervical Cancer Patients Aim The aim of this study was to estimate the influence of biological parameters assessed in [18F]FDG PET/CT on overall survival (OS) in cervical cancer patients. Methods Retrospective analysis was performed on a group of 371 patients with newly diagnosed and histologically confirmed cervical cancer. PET biological parameters in primary tumor including SUVmax, SUVmean, total lesion glycolysis (TLG), metabolic tumor volume (MTV), heterogeneity, and parameters referring both to primary tumor and metastatic lesions: SUVtotal, TLGtotal, and MTVtotal, were analyzed. Results Based on PET/CT results, 3 subgroups were identified: cervical only—with disease limited only to the cervix (38%), +regional nodes—where increased glucose accumulation in addition to the cervical area was also observed in regional lymph nodes (36%), and +distal metastases—where PET scan showed a disseminated disease (26%). Depending on the stage of the disease, in the cervical-only group, 5-year survival rate was 86%; in the +regional nodes group, it was 80%; whereas in the +distal metastases group, 5-year survival rate was only 55%. However, based on Cox regression model, significant influence on OS was found only in heterogeneity of primary tumor; more inhomogeneous tumors suggest worse prognosis (0.25 ± 0.04 vs 0.16 ± 0.09, P < 0.001), SUVtotal (76.6 ± 130.1 vs 45.4 ± 73.4, P = 0.002), and MTVtotal (79.03 ± 88.27 vs 63.00 ± 83.80 cm3, P = 0.03). For heterogeneity, cutoff point suggesting worse prognosis was 0.18; for SUVtotal, 52.3; and for MTVtotal, 66.55 cm3. Conclusions Stage of disease assessed in [18F]FDG PET/CT significantly influences survival rate in patients with cervical cancer. SUVtotal, MTVtotal, and heterogeneity of primary tumor are independent prognostic factors on OS in cervical cancer patients. Received for publication March 25, 2019; revision accepted June 2, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Paulina Cegla, PhD, Department of Nuclear Medicine, Greater Poland Cancer Center, Garbary 15, 61-866 Poznan, Poland. E-mail: paulina.cegla@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Uptake of Pineal Gland Visible on 18F-DOPA PET/CT With Last Generation of SiPM PET/CT A 17-year-old girl underwent an 18F-DOPA brain PET/CT on a new high-resolution digital SiPM PET/CT (Vision600 Siemens) to explore a suspicion of recurrence of a pilocytic astrocytoma. This study showed a local recurrence, but a second intense focal uptake was visible above, more intense than striata. On fused MRI, this was the pineal gland considered as physiological. This physiological uptake, due to a pineal DOPA decarboxylase activity, has also been observed with this PET system in other patients with 18F-DOPA to explore movement disorders. New high-resolution PET can show uptake of small structures by being less dependent to partial volume effect. Received for publication May 6, 2019; revision accepted May 28, 2019. Conflict of interest and sources of funding: none declared. Correspondence to: Pierre Decazes, MD, Department of Nuclear Medicine, Henri Becquerel Cancer Center, Rue d'Amiens, 76000, Rouen, France. E-mail: pierre.decazes@chb.unicancer.fr. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

18F-FDG PET/CT in Metastatic Extramammary Paget’s Disease Extramammary Paget's disease (EMPD) is a rare disease with an estimated prevalence of 0.1 to 2.4 per 1,000,000 person-years. Metastatic EMPD has a poor prognosis with a 5-year survival of approximately 7%. Local therapy is the only curative option with surgery being recommended for resectable disease. It is therefore crucial to be able to stage such patients appropriately. The utility of 18F-FDG PET/CT for this disease is not well established. We share a case on how 18F-FDG PET/CT was used to stage metastatic EMPD. Received for publication March 14, 2019; revision accepted June 5, 2019. The manuscript has not been published before or is not under consideration for publication anywhere else and has been approved by all co-authors. Conflicts of interest and sources of funding: none declared. Ethical Statement: The study was approved by an institutional review board or equivalent and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The subject in the study gave written informed consent. Authors' Contribution: Khoo proposed and co-wrote the manuscript. Yeoh co-wrote the manuscript. Both reviewed the final manuscript. Correspondence to: Alex Khoo Cheen Hoe, MBBS, MMed, FANMB, Department of Nuclear Medicine, Penang Adventist Hospital, 456, Jalan Burma 10350 Georgetown, Penang, Malaysia. E-mail: dr.alexkhoo@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Unilateral Absence of the Basal Ganglia on 123I-Ioflupane DaTScan This 33-year-old man presented with hemorrhagic stroke manifesting with left hemiparesis and right ptosis. Angiography revealed no patent carotids. The anterior and middle cerebral arteries were filling collaterally through the posterior vertebrobasilar pathway. The presumptive diagnosis was moyamoya disease. The etiology of the bleeding was right basilar tip aneurysm that subsequently had partial coil placement. Months later, the neck of the aneurysm perforated and second coiling was performed. Later on follow-up, patient developed left hand tremor. A radionuclide DATscan revealed total absence of right-sided basal ganglia activity. A possible etiology was occlusion of the middle cerebral artery’s lenticulostriate branches. Received for publication May 22, 2019; revision accepted May 23, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Leonard M. Freeman, MD, Divisions of Nuclear Medicine, Montefiore Medical Center, 111 E 210 St, Bronx, New York 10467. E-mail: lfreeman@montefiore.org. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Dynamic FET PET Imaging of a “Butterfly” IDH-Wildtype Anaplastic Astrocytoma A variety of neoplastic and nonneoplastic conditions involve the corpus callosum, which may result in a “butterfly” appearance on conventional MRI. Typically, that pattern shows a bilateral and heterogeneous contrast enhancement of the lesion, occasionally with central nonenhancing areas indicating intralesional necrosis. In contrast, anaplastic gliomas may show only minimal or even a lack of contrast enhancement on MRI. We here report neuroimaging findings in a 69-year-old man with a “butterfly” pattern on dynamic FET [O-(2-[18F]-fluoroethyl)-L-tyrosine] PET and the diagnosis of an anaplastic astrocytoma (WHO grade III; IDH-1/−2 wildtype, no 1p/19q co-deletion) but without typical MRI contrast enhancement. Received for publication February 18, 2019; revision accepted June 5, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Norbert Galldiks, MD, Institute of Neuroscience and Medicine, Research Center Juelich, Leo-Brandt-St. 5, 52425 Jülich, Germany and Department of Neurology, University Hospital Cologne, Josef-Stelzmann St. 9, 50937 Cologne, Germany. E-mails: n.galldiks@fz-juelich.de; norbert.galldiks@uk-koeln.de. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.