Lung Perfusion Scintigraphy in Eisenmenger Syndrome Due to Patent Ductus Arteriosus Eisenmenger syndrome refers to the elevation of pulmonary arterial pressure to the systemic level caused by an increased pulmonary vascular resistance with right-to-left shunt through an intracardiac or aortopulmonary communication. A 36-year-old woman with Eisenmenger syndrome due to patent ductus arteriosus underwent 99mTc-MAA lung perfusion scintigraphy to evaluate right-to-left shunt. Whole-body imaging visualized extrapulmonary activity in both kidneys, spleen, and intestinal tract, confirming the presence of right-to-left shunt. Accumulation in the brain was visible but much weaker compared with that in the body trunk and was limited to the left cerebral hemisphere, which reflected the location of the shunt pathway. Received for publication March 9, 2019; revision accepted June 2, 2019. Conflict of interest and sources of funding: none declared. Correspondence to: Department of Radiology, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami-ku, Sagamihara, Kanagawa 252–0374, Japan. E-mail: km19901004@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

18F-DCFPyL Uptake in an Incidentally Detected Follicular Lymphoma by PET/CT Performed for Biochemically Recurrent Prostate Cancer A 75-year-old man, treated with curative intent for histopathologically proven prostate cancer (initial prostate-specific antigen, 27 ng/mL; Gleason 4 + 5 = 9) through external beam radiation therapy in 2010 in combination with 3 years of androgen deprivation therapy (leuprorelin), underwent 18F-DCFPyL PET/CT for biochemical recurrence with a prostate-specific antigen of 4.1 ng/mL in February 2019. Multiple pelvic and some para-aortic lymph nodes showed highly increased 18F-DCFPyL uptake, suspicious for metastases. Incidentally, a solid mesenteric mass and mesenteric lymph nodes with moderately increased 18F-DCFPyL uptake were found. Upon histopathological evaluation, this proved to be a low-grade follicular lymphoma. Received for publication May 20, 2019; revision accepted June 4, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Dennie Meijer, BSc, ORCID 0000-0002-8298-575X, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands. E-mail: d.meijer2@vumc.nl. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Diffuse Pulmonary Metastases From Prostate Cancer on 68Ga PSMA PET/CT A 63-year-old man, recently diagnosed with carcinoma of the prostate (Gleason’s score 4+4), with serum prostate-specific antigen 189.2 ng/mL, underwent 68Ga PSMA PET/CT scan for pretreatment staging. The study revealed abnormal tracer uptake in the prostatic bed region, the pelvic, abdominal, and mediastinal lymph nodes and diffuse metastases to the bilateral lungs. The lung metastasis was proved to be metastatic adenocarcinoma from analysis of bronchoalveolar lavage. Received for publication April 9, 2019; revision accepted June 16, 2019. Conflict of interest and sources of funding: none declared. Informed consent was obtained from the participants included in the study. Correspondence to: Nikhil Seniaray, DRM, DNB, Department of Nuclear Medicine and PET/CT, Mahajan Imaging Centre, Sir Ganga Ram Hospital, Old Rajinder Nagar, New Delhi-110060, India. E-mail: nikhilmamc89@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

68Ga-PSMA Uptake in Escherichia coli Spondylodiscitis In a patient with recently diagnosed intermediate-risk prostate cancer, 68Ga-prostate-specific-membrane-antigen (PSMA) PET/CT for primary staging discovered increased 68Ga-PSMA uptake in spondylodiscitis in the thoracic spine. The bacteria Escherichia coli was found both in blood cultures and bone biopsies from the thoracic lesion. This case presents spondylodiscitis as a potential benign pitfall to be aware of when interpreting PSMA PET/CT in prostate cancer patients. Received for publication May 2, 2019; revision accepted June 16, 2019. Conflict of interest and sources of funding: none declared. Correspondence to: Søren Klingenberg, BSc (Med), Department of Nuclear Medicine & PET-Centre, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus N, Denmark. E-mail: soekli@rm.dk. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Physiologic Uterine Uptake of Radioiodine During Menstruation Demonstrated by SPECT/CT A 35-year-old woman with papillary thyroid cancer underwent 131I therapy after thyroidectomy. Post-therapy whole body scan revealed increased activity in the pelvis, in addition to the activity in the neck. On SPECT/CT images, the radioactivity in the pelvis was localized in the rectum and cervix. Further inquiry discovered that the patient was menstruating. We concluded that abnormal radioiodine uptake in menstrual uterus might be an exceptional finding mimicking a metastasis. Received for publication May 12, 2019; revision accepted June 17, 2019. Lina Liu and Yu Chen contributed equally to this work. Conflicts of interest and sources of funding: none declared. Author contributions: All named authors have agreed to the submission and have participated in the study to a sufficient extent to be named as authors should accompany the submitted manuscript. Lina Liu, Yu Chen, and Tian Tian wrote the manuscript and collected the data. Rui Huang and Bin Liu designed the study and edited the manuscript. Correspondence to: Bin Liu, MD, Department of Nuclear Medicine, West China Hospital, Sichuan University, No. 37 Guo Xue Alley, Chengdu 610041, Sichuan, China. E-mail: binl@foxmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Progressive Hydrocephalus Due to Ventriculoperitoneal Shunt Infection: Detection With FDG PET CT Ventriculoperitoneal shunt malfunction is common in patients after shunt surgery. Imaging is done to reveal the underlying cause and confirm the diagnosis. Shunt infection is one of the common causes of shunt malfunction. FDG PET CT is an accepted infection imaging tool and can be used to diagnose shunt infection accurately in a patient with high clinical suspicion. Received for publication June 20, 2019; revision accepted June 21, 2019. Conflicts of interest and sources of funding: none declared. Correspondence to: Nilendu C. Purandare, DNB, Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Parel, Mumbai 400012, India. E-mail: nilpurandare@gmail.com. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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.