PMC5314667_01
(a) 99m-Tc Sestamibi (99m-Tc-MIBI) parathyroid scintigraphy showing tracer avid foci in multiple parathyroid gland indicative of multi-glandular parathyroid disease. (b and c) 68-Ga-DOTATATE PET CT (Fig 1bi and 1c) showing solitary SSTR positive liver lesion and a peri-pancreatic node. The skeletal lesions do not any evidence of SSTR expression. 18-NaF PET-CT (1b iii) showing diffusely increased tracer uptake in the entire skeleton with faintly visualized kidneys bilaterally akin to superscan, while FDG-PET (1b ii and 1c) does not show any uptake in the skeletal lesions
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F1
Multiple lytic lesions were noted involving right third rib, bilateral iliac bones, and bilateral sacral ala suspecting them to be brown tumors secondary to parathyroid pathology. 99m-technetium (Tc) sestamibi (99m-Tc-MIBI) scan [Figure 1a] was undertaken for the evaluation of the parathyroid pathology that showed tracer avid foci in multiple parathyroid glands and was indicative of multiglandular parathyroid disease. Brain magnetic resonance imaging (MRI) was negative for any pituitary pathology. 18-NaF positron emission tomography-computed tomography (PET-CT) [Figure 1b] showed diffusely increased tracer uptake in the entire skeleton with both the kidneys being not visualized. The skull showed prominent tracer uptake with CT showing marked thickening of the skull bones. 68Ga-DOTATATE PET-CT [Figure 1b] showed solitary somatostatin receptor (SSTR) positive liver lesion and a peripancreatic node. Follow-up 68Ga-DOTATATE PET-CT showed no change [Figure 1c].
PMC5314667_02
(a and b) 68-Ga-DOTATATE PET CT (Fig 2ai and 2b) showing single SSTR expressing lesion in the D6 vertebrae of Krenning score 2. The other skeletal lesions or the anterior mediastinal lesion do not show any SSTR expression on the scan. 18NaF fluoride PET-CT (Fig 2aiii and 2b) showing diffusely increased tracer uptake in the skeleton, with prominent tracer uptake in the skull with evidence of costochondral beading all suggesting the features of metabolic bone disease. Also a single osteoblastic lesion involving the D6 vertebrae is noted in the fused transaxial image. (c) 99mTc-MIBI parathyroid scan demonstrating multiple tracer avid foci in delayed scan in multiple parathyroid glands indicative of multi-glandular parathyroid disease
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F2
The MRI showed multiple lesions in the dorsolumbar vertebrae, sternum, bilateral pelvic bones, and bilateral femora. 68Ga-DOTATATE PET-CT [Figure 2a and b] was undertaken, which showed one single SSTR expressing lesion in the D6 vertebrae that was of Krenning score 2. D6 vertebrae was noted. Due to the scan suspicion of metabolic bone disease, a serum PTH level was undertaken which was found to be substantially elevated [Table 2]. 99mTc-MIBI parathyroid scan [Figure 2c] demonstrated tracer avid foci in multiple parathyroid glands indicative of multiglandular parathyroid disease.
PMC5314667_03
(a and b) 68-Ga-DOTATATE PET-CT scan (Fig 3ai and 3bi)showing multiple SSTR avid liver lesions and a SSTR positive pancreatic body lesion. The skeletal lesions show no SSTR expression. FDG PET-CT study (Fig 3aii and 3bii) showing multiple low grade FDG uptake in the liver lesions and a FDG avid lesion arising from the distal body of pancreas and multiple low grade sclerotic skeletal lesions which are FDG avid.18F-NaF PET-CT (Fig 3aiii and 3biii) show diffusely increased tracer uptake in the entire skeleton and non visualization of the kidneys bilaterally consistent with superscan features. The skull showed prominent tracer uptake with observation of costochondral beading
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F3
Fluorodeoxyglucose (FDG) PET-CT study [Figure 3a] showed multiple low grade FDG uptake in the liver lesions and a FDG avid lesion arising from the distal body of pancreas and multiple sclerotic low grade FDG avid skeletal lesions. 68Ga-DOTATATE PET-CT scan [Figure 3a] showed multiple SSTR avid liver lesions and a SSTR positive pancreatic body lesion. The patient had elevated serum chromogranin A level, elevated serum calcium, and low vitamin D3 levels [Table 3]. 18F-NaF PET-CT [Figure 3a] was done that showed diffusely increased tracer uptake in the entire skeleton and both the kidneys not being visualized.