The aim of our study was to compare dosimetry methods for yttrium-90 (⁹⁰Y) positron emission tomography/computed tomography (PET/CT). Twenty-five patients were taken to a PET/CT suite following therapy with ⁹⁰Y microspheres. The low mA, nondiagnostic CT images were used for attenuation correction and localization of the ⁹⁰Y microspheres. The acquisition time was 15 min, the reconstruction matrix size was 200 mm × 200 mm × 75 mm, and voxel size was 4.07 mm × 4.07 mm × 3.00 mm. Two software packages, MIM 6.8 and Planet Dose, were utilized to calculate ⁹⁰Y dosimetry. Three methods were used for voxel-based dosimetry calculations: the local deposition method (LDM), LDM with scaling (LDMwS) for known injected activity, and a dose point kernel (DPK) method using the MIRD kernel. Only the DPK approach was applied to the Planet Dose software. LDM and LDMwS were only applied to the MIM software. The average total liver dosimetry values (mean ± standard deviation) were 60.93 ± 28.62 Gy, 53.59 ± 23.47 Gy, 55.33 ± 24.80 Gy, and 54.25 ± 23.70 Gy for LDMwS, LDM, DPK with MIM, and DPK with Planet Dose (DOSI), respectively. In most cases, the LDMwS method produced slightly higher dosimetry values than the other methods. The MIM and Planet Dose DPK dosimetry values (i.e., DPK vs. DOSI) were highly comparable. Bland–Altman analysis calculated a mean difference of 1.1 ± 2.2 Gy. The repeatability coefficient was 4.4 (7.9% of the mean). The MIM and Planet Dose DPK dosimetry values were practically interchangeable. ⁹⁰Y dosimetry values obtained by all methods were similar, but LDMwS tended to produce slightly higher values.

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Lipedema is a chronic and progressive disease characterized by a symmetrical and bilateral swelling of the lower extremities. In general, the feet are not involved. Lipedema is believed to affect nearly 1 in 9 adult women worldwide. Despite this relatively common disease, lipedema is often confused with primary lymphedema or obesity. In clinically advanced lipedema stages, fat continues to build up and may block the lymphatic vessels causing a secondary lymphedema (Lipo-Lymphedema). We consecutively evaluated 54 women with a clinical diagnosis of lower limbs lipedema. Two doses of 99mTc-nanocolloid were injected intradermally at the first intermetatarsal space and in the lateral malleolar area. Two static planar scans were taken at rest immediately following the intradermal injection. Subsequently, all patients were asked to perform an isotonic muscular exercise (stepping) for 2 min. Then, post exercise scans were performed to monitor the tracer pathway. Subsequently, the patient was asked to take a 30–40 min walk (prolonged exercise) and delayed scans were acquired. In early clinical stages, the lymphatic flow is usually preserved and the rest/stress intradermal lymphoscintigraphy may visualize a normal lymphatic drainage with a frequent pattern (tortuous course) of the leg lymphatic pathway. In clinically advanced stages, lymph stagnation areas were observed. Unlike obesity, lipedema fat storage is resistant to dietary regimen, bariatric surgery, and physical activity. Surgical treatment (tumescent liposuction and reductive surgery) is the most effective treatment to remove adipose tissue. Complex decongestive therapies are helpful in reducing the lymph stagnation, especially in patients with advanced lipolymphedema.

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Stroke and other thromboembolic events in the brain are often due to carotid artery atherosclerosis, and atherosclerotic plaques with inflammation are considered particularly vulnerable, with an increased risk of becoming symptomatic. Positron emission tomography (PET) with 2-deoxy-2-[Fluorine-18] fluoro-D-glucose (¹⁸F-FDG) provides valuable metabolic information regarding arteriosclerotic lesions and may be applied for the detection of vulnerable plaque. At present, however, patients are selected for carotid surgical intervention on the basis of the degree of stenosis alone, and not the vulnerability or inflammation of the lesion. During the past decade, research using PET with the glucose analog tracer ¹⁸F-fluor-deoxy-glucose, has been implemented for identifying increased tracer uptake in symptomatic carotid plaques, and tracer uptake has been shown to correlate with plaque inflammation and vulnerability. These findings imply that ¹⁸F-FDG PET might hold the promise for a new and better diagnostic test to identify patients eligible for carotid endarterectomy. The rationale for developing diagnostic tests based on molecular imaging with ¹⁸F-FDG PET, as well as methods for simple clinical PET approaches, are discussed. This is a systematic review, following Preferred Reporting Items for Systematic Reviews guidelines, which interrogated the PUBMED database from January 2001 to November 2019. The search combined the terms, “atherosclerosis,” “inflammation,” “FDG,” and “plaque imaging.” The search criteria included all types of studies, with a primary outcome of the degree of arterial vascular inflammation determined by ¹⁸F-FDG uptake. This review examines the role of ¹⁸F-FDG PET imaging in the characterization of atherosclerotic plaques.

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Mucinous adenocarcinoma of the urachal remnant is a nonurothelial malignancy that may be asymptomatic until locally advanced or metastatic. We describe a 37-year-old woman with invasive ductal breast carcinoma who underwent ¹⁸Fluorine-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) computed tomography (CT) demonstrating a non-FDG avid pelvic mass, initially suspected to represent a pedunculated uterine fibroid. Magnetic resonance imaging revealed a mixed solid-cystic mass separate from the uterus, suspicious for urachal neoplasm, confirmed as mucinous adenocarcinoma on histopathology. Urachal tumors may not be FDG-avid and represent a potential pitfall on FDG PET/CT.

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Positron emission tomography/computed tomography (PET/CT) using ⁶⁸Ga-labeled prostate-specific membrane antigen (⁶⁸Ga-PSMA) became an important tool in the prostate cancer (PC) diagnosis. Despite its high sensitivity and specificity, this method may produce false-positive findings, as indicated by previous studies. This case report aims to warn nuclear medicine physicians, oncologists, and urologists about the possibility of false-positive findings using this imaging modality, especially in patients who have already been diagnosed with other malignancies. A 69-year-old man, previously treated for an extrapleural solitary fibrous tumor (ESFT), underwent staging tests after a new diagnosis of high-risk PC. ⁶⁸Ga-PSMA PET/CT imaging revealed an abnormal uptake in the prostate and in the right humerus. A biopsy was performed, and the pathology showed a lesion consisting of an ESFT metastasis. Diagnostic issues related to ⁶⁸Ga-PSMA PET/CT imaging should be disseminated to help physicians make appropriate treatment choices for each patient and avoid unnecessary procedures.

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¹⁸F fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography (PET) can be used to image synovial inflammation in patients with rheumatoid arthritis (RA). Recently, clinical application of novel therapies for RA, such as tumor necrosis factor-α (TNF-α) inhibitor and anti-interleukin-6 receptor antibody, has been introduced. The radiological assessment of disease activity changes of patients who underwent these therapies will help the clinicians to obtain more information about the patients and to decide drug withdrawal or change of medication. It is considered that ¹⁸F-FDG PET scan is generally very expensive; however, the information from ¹⁸F-FDG PET about patients during biological treatments helps discontinuation of these treatments with incomplete response despite its high costs and with possible side effects such as malignant lymphoma. In this study, we evaluated if the 18F-FDG uptake of the affected joints represented by standardized uptake value (SUV) correlated with the clinical assessment of patients with RA. In addition, we would like to evaluate if there was a correlation between the difference of SUV and improvement of clinical findings in RA patients undergoing anti TNF therapies. RA patients who underwent anti-TNFα therapies in a tertiary care hospital were assessed using whole-body ¹⁸F-FDG PET/computed tomography (CT). PET assessments were performed on hip joints, knees, shoulders, wrists, ankles, MCP, and PIP for a total of 28 joints in each patient. The ¹⁸F–FDG uptake was then quantified using the maximum SUV (SUVmax) prior to, and 6 months after the initiation of treatment with anti-TNF-α drugs. Disease activity score (DAS28 and DAS28-C-reactive protein [CRP]) were recorded and white blood cell, matrix metalloproteinases (MMP-3) and rheumatoid factor (RF) were examined in all patients. The average of SUV_max among measured joints, or the sum of these joints (total SUV_max), correlated with DAS28 (r = 0.671, P < 0.001), DAS28-CRP (r = 0.623, P < 0.001), ESR (r = 0.542, P < 0.001), CRP (r = 0.411, P = 0.002), MMP-3 (r = 0.399, P = 0.006), and RF (r = 0.447, P = 0.002). There were correlations between ΔSUV and ΔDAS28 (r = 0.651, P < 0.001), ΔSUV and ΔDAS28-CRP (r = 0.682, P < 0.001), ΔSUV and ΔESR (r = 0.449, P = 0.023), and ΔSUV and ΔMMP-3 (r = 0.457, P = 0.027), respectively. The number of PET-positive joints and the cumulative SUV significantly correlated with the DAS₂₈, which is a composite disease activity score (DAS) that combines the swollen and tender joint counts, the erythrocyte sedimentation rate (DAS₂₈-ESR) or CRP serum levels (DAS₂₈ − CRP) or RF (DAS₂₈ − RF) or metalloproteinases-3 (DAS_28-MMP-3). At baseline and at 6 months' post-treatment with anti-TNFα drugs, there was a significant correlation between the PET results, either visual, the cumulative SUVs or the composite SUV index, and the comprehensive clinical assessment (DAS₂₈), the CRP levels and the number of joints positive for RA, and cumulative synovial thickness. By reflecting inflammatory activity, ¹⁸F-FDG PET may enhance the diagnostic performance and expectation of disease prognosis in RA, especially with early synovial inflammation. The intensity of uptake varied from mild to intense (SUV_max values from 3.10 to 6.0). Overall, these values correlated well with the clinical evaluation of involved joints. ¹⁸F–FDG PET imaging data provided a distribution of joint involvement with varying degrees of severity and phase of disease activity (moderate, low, and remission) in the same patient. PET/CT imaging with ¹⁸F-FDG shows better image quality, provides more confirmative diagnostic information, and will be promising imaging modality in diagnosis and management of RA.

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Gallbladder involvement in lymphoma is rare, with only a few cases reported in the literature, predominately in the pre positron emission tomography (PET) era. ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) PET/computed tomography (CT) has now become the modality of choice in the staging of lymphoma. We report a case of gallbladder involvement by high-grade B-cell lymphoma detected by PET/CT.

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Van Neck-Odelberg disease or ischiopubic osteochondritis, is a rare cause of pain in the pediatric pelvis due to late closure in synchondrosis ischiopubic, whose main symptom is an asymmetric pain that can cause a limitation in movement or limp. The different characteristics by images from simple radiography, computed tomography, MRI and bone scintigraphy scan will increase certainty diagnosis and will allow the correct differential diagnosis with fractures, posttraumatic osteolysis, infections or tumors, that leads to unnecessary invasive procedures, this being a benign disease with an evolution and improvement that occurs in weeks or months with conservative treatment. A case of a 15-year-old boy who consulted our hospital with an extra-institutional diagnosis of right ischiopubic fracture. After being evaluated by different imaging methods, a diagnosis of Van Neck-Odelberg or ischiopubic osteochondritis was made.

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Scanning oncological patients with ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) for their disease staging, evaluation of treatment response, and monitoring/management has become a standard of care. The use of the radioactive fluorine in the FDG molecule helps establish cell/tissue lines high on glucose consumption and hence metabolically active. Abnormalities are detected on the scan as areas of increased uptake. However, these areas of increased (hot) uptakes do not necessarily translate into a pathological finding. A comprehensive knowledge of the uptakes of the tracer and the potential “pitfalls” that may be associated with them should be known and kept in mind during scan reading. One such pitfall is the “hot clot” or “pulmonary emboli,” and we report two such cases encountered at our setup and discuss their causes and how they should be identified and avoided.

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Anorectal malignant melanoma (ARM) is a rare variant of malignant melanoma and even more rare among all anorectal cancers. ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography–computed tomography (CT) scan is valuable in staging, restaging, treatment response evaluation, and long-term follow-up of malignant melanoma. Here, reporting two cases of anorectal melanoma with a variety of FDG uptake pattern and CT-based features and reviewed a few articles to evaluate the pattern of FDG uptake.

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Vascular graft infection (VGI) is a rare and severe complication after vascular surgery associated with significant morbidity and mortality, but the diagnosis is not always straightforward due to its variable and nonspecific clinical signs. Computed tomography (CT) scan is considered to be the diagnostic tool of choice for advanced VGI, but there is a high incidence of false-negative results, especially in low-grade infections. ¹⁸F-Fluorodeoxyglucose positron emission tomography with contrast-enhanced CT (¹⁸F-FDG PET-CT) imaging can serve as an effective alternative tool for assessment of suspected VGI and also provide accurate anatomic localization of the infective focus. Here, we describe three cases of VGI with various clinical presentations where the site of infection was diagnosed, confirmed, and documented with the help of ¹⁸F-FDG PET-CT imaging.

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Second primary malignancies (SPMs) are known to be associated with neuroendocrine tumors (NETs). The association necessitates a careful assessment of the dual-tracer positron emission tomography–computed tomography (PET-CT) imaging findings to identify these malignancies earlier. Such early diagnosis can provide incremental benefit for screening these SPMs apart from their known applications in the management of NETs. A case of incidentally detected metachronous triple-negative breast carcinoma on dual-tracer PET-CT imaging is presented using ¹⁸fluoro-2-deoxy-D-glucose (FDG) and ⁶⁸Ga-DOTATATE that showed a high uptake on FDG but no uptake on somatostatin receptor-based imaging.

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Gastrin-secreting tumors, hypergastrinemia and severe ulcer disease form the trademarks of Zollinger-Ellison syndrome (ZES). We report a case of gastrinoma, in a patient who was misdiagnosed for almost five years. The case emphsizes the the special role of functional imaging in the personalized approach to the patient with suggestive symptomatology for NETs. Taking into account that in 80 to 100% of cases of gastroenteropancreatic (GEP) NETs are expressing somatostatin receptors, the functional imaging with radiolabeled somatostatin analogues can be used in order to improve its diagnosis, respectively the treatment of GEP NETs. In the approach to the patient with tremendous digestive symptomatology, physicians from different specialties should evaluate NETs specific markers and then insist on structural-functional complementarity, avoiding the waste of time and high cost of repeated structural investigations. The conclusion of our study is that functional imaging is mandatory in the diagnostic algorithm of gastrinoma.

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We describe the case of a 75-year-old patient who progressed over a 12-year period from localized to symptomatic metastatic prostate cancer (PrCa) with lung as the sole organ of involvement. In this case, the specific sequence of positron emission tomography (PET)-based next-generation imaging with ¹⁸F-sodium fluoride-, ¹⁸F-fluoro-2-deoxy-D-glucose-, and ¹⁸F-DCFPyL PET/computed tomography and biopsies allowed illustration of the pathway of disease progression from nonglycolytic hormone-sensitive PrCa to glycolytic castrate-resistant PrCa without neuroendocrine features. The observations provide a unique insight into the timelines of anatomical and metabolic progression of metastatic PrCa. They highlight the value of close radiographic surveillance of metastatic PrCa with modern imaging to guide early treatment interventions.

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Pilomatricoma, also known as calcifying epithelioma of Malherbe, is a rare skin tumor originating from the hair follicle matrix. We report a case of pilomatricoma in a 50-year-old woman, presenting as a rapidly growing pretibial mass. Malignant pilomatricoma is associated with potentially fatal metastases and are clinically and histologically indistinguishable from benign pilomatricoma. Thus, an ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸F-FDG PET/CT) scan was requested for staging, revealing marked FDG uptake restricted to the primary lesion and no evidence of separate disease. The purpose of this report is to demonstrate the importance of PET/CT in the staging of this FDG-avid tumor; the malignancy of which is often first revealed by metastases. Our case also demonstrates that pilomatricoma should be included in the differential diagnosis of a rapidly growing peripheral soft-tissue mass; conventionally, the domain of sarcoma.

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The COVID-19 pandemic has now reached most countries. However, the referred patients to a nuclear medicine department will be primarily the asymptomatic ones. We report the case of a patient (84-year-old male) who was sent for¹⁸F-prostate-specific membrane antigen positron emission tomography computed tomography (PSMA PET-CT) with suspicion of recurrent disease after prostate cancer and total prostatectomy 2 years prior to the examination. He suffered from COVID-19 pneumonia 4 weeks prior to PET-CT examination. The¹⁸F-PSMA PET-CT revealed moderate elevated uptake in the area of previous pneumonia in the right lung. The radiological findings showed ground glass changes in this area indicating possible residual inflammatory disease even weeks after infection.

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This study aims at prospectively evaluating the difference in the effect of cholecystokinin (CCK) and half-and-half milk (HHM) administered in the same patient on gallbladder contractility and correlation with clinical outcomes. Upon gallbladder visualization during standard hepatobiliary imaging, 0.02 μg/kg of CCK was injected over 3 min, and additional 30 min of dynamic imaging was obtained. Patients with gallbladder ejection fraction (GBEF) <35% after CCK were administered 8 oz of HHM followed by 30 min of imaging. The GBEF was recalculated. The number of patients whom GBEF changed from below 35% (abnormal) after CCK to above 35% (normal) after HHM was recorded. Follow-up of the clinical outcome at 6 months was performed. Fifty patients with abnormal GBEF were prospectively included. The average GBEF after CCK was 14.7% ± 8.5% and after HHM was 30.7% ± 20.8%. The average increase in GBEF with HHM was 16.0% ± 22.2%. The GBEF changed from abnormal to normal in 17 patients (34%). The remaining 33 patients remained abnormal. Clinical outcomes at 6 months were available in 47 patients. Cholecystectomy was performed in 60% of patients with abnormal GBEF with CCK and HHM with resolution or improvement of pain. Two of 16 patients (12%) with abnormal GBEF after CCK but normal after HHM had cholecystectomies with pain improvement, while 8 out of these patients (50%) were diagnosed and treated with other disorders and improved. Hepatobiliary imaging with HHM stimulation is a superior physiologic test which can lower the number of unnecessary cholecystectomies and misdiagnoses as functional cholecystitis.

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In the present study, the last stable version of Monte Carlo Geant4 code known as Geant4.10.3 has been used for measuring internal dose ratios to the whole body for about 40 organs. This, by performing a Monte Carlo model of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) inside different organs of medical internal radiation dose male phantom, mimics a human male adult of 70 kg. A dedicated Geant4 user code has been developed in the top of one offered by Geant4 Monte Carlo toolkit and so-called human phantom. Several Monte Carlo simulations have been carried out, and in each of them, we have taken up such organ as source of ¹⁸F-FDG with a small amount of radioactivity, evenly distributed across its volume, and we measure ratios of absorbed doses deposited in organs to the whole body. The results have shown that there are radiation dose contributions from surrounding organs and their gravities are so variable; some organs have near-local character; thus, almost all radiations are locally deposited, which generally do not affect surrounding ones mainly including adrenals, thyroid, clavicles, thymus, testes, bladder, pancreas, scapula and upper spine; whereas, it is not the case for many other organs in which radiation doses are deposited outside of their parent volumes. In addition, absorbed doses in some organs that have high-tissue weighting factors, namely colon, lungs, stomach, bladder, thyroid, and liver are seriously affected by radioactivity of surrounding muscle organs, the gravity of such affectation is mainly growth when a patient is identified as having hyperglycemia or undergoing a hard physical activity.

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Muscular metastases (MMs) form an infrequent entity, and their physiopathology is still not well-defined. In this study, we estimated the incidence of MMs that were detected by ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography and also specified their metabolic characteristics. This study includes 13 patients with MMs from a remotely located primary tumor. The results of this study showed an incidence of MMs at about 1%, with the most frequently involved muscles being iliopsoas and paraspinal. Lung cancer seems to be the most common tumor that causes MMs. Furthermore, these MMs vary in size and physiological uptake; they seem to be out of the ordinary and easily detected. They are often associated with other extra muscular locations and frequently involve the trunk muscles. Their detection in the course of the evolution of a specific neoplasia testifies to their aggressiveness and portends an unfavorable prognosis. The data in our series confirm that in the literature regarding the underlying primary tumors and anatomical sites involved by MMs.

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The aim of this study is to simulate GE Discovery 690 VCT positron emission tomography/computed tomography (PET/CT) scanner using Geant4 Application for Tomographic Emission (GATE) simulation package (version 8). Then, we assess the performance of scanner by comparing measured and simulated parameter results. Detection system and geometry of PET scanner that consists of 13,824 LYSO crystals designed in 256 blocks and 24 ring detectors were modeled. In order to achieve a precise model, we verified scanner model. Validation was based on a comparison between simulation data and experimental results obtained with this scanner in the same situation. Parameters used for validation were sensitivity, spatial resolution, and contrast. Image quality assessment was done based on comparing the contrast recovery coefficient (CRC) of simulated and measured images. The findings demonstrate that the mean difference between simulated and measured sensitivity is <7%. The simulated spatial resolution agreed to within <5.5% of the measured values. Contrast results had a slight divergence within the range below 4%. The image quality validation study demonstrated an acceptable agreement in CRC for 8:1 and 2:1 source-to-background activity ratio. Validated performance parameters showed good agreement between experimental data and simulated results and demonstrated that GATE is a valid simulation tool for simulating this scanner model. The simulated model of this scanner can be used for future studies regarding optimization of image reconstruction algorithms and emission acquisition protocols.

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Majority of patients with unilateral hydronephrosis (HN) detected on ultrasound do not require pyeloplasty. The measurement of the cortical transit time (CTT) has been demonstrated by several authors to predict the need for patients who may require pyeloplasty. The study aimed to assess if CTT would have predicted a drop in differential renal function (DRF) in patients with unilateral HN on the affected side and to assess whether CTT would differ on the first renogram between those patients who had a pyeloplasty and those who did not have a pyeloplasty. Sixty-eight patients with at least two renograms with unilateral HN with a normal contralateral kidney were observed retrospectively. The CTT was recorded for each kidney. Renograms were processed three times to measure the DRF. The mean of the three DRF measurements was used for analysis. The mean CTT of the left and right hydronephrotic kidneys was 6.0 min and 6.7 min, respectively. The relationship between CTT and DRF as well as CTT and anterior posterior diameter in the first renogram of those patients who did not have a pyeloplasty was statistically significant (P < 0.05). In the 20 patients who had a pyeloplasty, there was a drop of more than 10% in the DRF of three patients. No significant difference was found in CTT or DRF when comparing the group who had surgery against the group who did not have surgery. The current study was unable to demonstrate in our series of patients that CTT can predict a drop in DRF in those patients who would require pyeloplasty.

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Ectopic thyroid (ET) is a developmental anomaly of the thyroid gland with the presence of thyroid tissue at sites other than the normal cervical location anterior to second and third tracheal ring due to abnormal migration of the gland. It may be found along the path of descent of the developing thyroid primordium from the foramen caecum to the isthmus of the thyroid and up to the base of the diaphragm. Dual thyroid ectopia, where ET tissue is simultaneously present at two different abnormal locations, is a very rare developmental defect. Only a few cases have been reported worldwide. ET is predominantly seen in females and during puberty when the hormonal demand is high. Patients with ET may remain asymptomatic or present with swelling in the neck, symptoms such as dysphagia, dysphonia, dyspnea, and features of hypothyroidism. The diagnosis is usually made on clinical examination, laboratory tests, imaging studies, and cytology. Careful clinical evaluation is essential as ET may be the only functioning thyroid tissue. Thyroid scintigraphy is an important imaging tool and the gold standard for the diagnosis of ET tissue, as it has high sensitivity and specificity. Early and accurate diagnosis of ET is essential to start hormone replacement and avoid unnecessary surgery. The authors report here a series of four patients with dual ET tissue, diagnosed on thyroid scintigraphy.

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