18 F-FDG PET/CT has made it possible to identify many unsuspected lesions such as isolated intramuscular metastases because of its ability to detect abnormal metabolic activity in an early stage even without clinical symptoms or morphologic changes. We need to modify our routine techniques for performing biopsies of such lesions because they may not be visualized on morphologic imaging. We describe a technique in which fused PET/CT is used to guide the percutaneous biopsy needle for sampling isolated intramuscular metastatic lesions in a patient whose intramuscular metastases were identified only on PET/ CT, not on CT or ultrasound, and were clinically occult. Wereportapat ient in whom intramuscular metastases were identified on PET/CT but not seen on CT or ultrasound and were clinically occult and, hence, in whom we used PET/CT to guide the percutaneous biopsy needle for sampling the lesion. CASE REPORTA 35-y-old woman presented with difficulty in swallowing. Esophagoscopy revealed a large mass with significant narrowing posterior to the cricoid region. The scope was not negotiable beyond the stricture. Biopsy samples from the mass had revealed squamous cell carcinoma.The patient was referred to our department for a staging PET/CT scan, which was performed with a 16-slice PET/ CT scanner (GE Healthcare) after intravenous injection of 370 MBq of 18 F-FDG. A diagnostic CT scan of the neck, chest, and abdomen with intravenous iodine contrast administration was also performed.The mass at the postcricoid region was well delineated and appeared to extend into the thoracic esophagus and left tracheoesophageal groove, causing left vocal cord palsy.There were foci of increased 18 F-FDG accumulation within the skeletal muscles of the right lateral chest wall and axilla and the erector spinae muscles (Fig. 1). These were not apparent on contrast-enhanced CT images. A few lower neck and mediastinal metastatic nodes were present. No other metastases were identified. MRI was not performed.A probable diagnosis of skeletal muscle metastases from postcricoid esophageal cancer was made. An image-guided biopsy of the intramuscular lesions was planned.The lesions were not well appreciated on high-frequency ultrasound. Because the lesions were also not visible on contrast-enhanced CT scans, 18 F-FDG PET/CT was again used for localization of the lesions. Fused images of CT and PET were obtained, and a biopsy sample was obtained of one of the lesions in the left erector spinae muscle (Fig. 2). CT images with the needle in place were fused with PET images to accurately position the needle into the metabolically active lesion. The diagnosis of metastasis was established. DISCUSSION

The use of magnetic resonance imaging (MRI) is the current standard for the delineation of target volumes for high-grade gliomas (HGG). While the peritumoral edema as per T2-weighted (T2W) imaging is utilized as basis to delineate the initial borders of the clinical target volume (CTV), those areas enhancing on T1-weighted (T1W) images with gadolinium contrast (T1-Gd) are considered for treatment with further boost. However, recent data has emerged concerning the use of positron emission tomography (PET) with 11 C-methionine, which seemingly provides additional information beyond MRI. We present the case of a gentleman with an inoperable HGG which was imaged with 11 C-methionine-PET ( 11 C-MET-PET)/CT as well as MRI as part of the radiotherapy treatment planning (RTP) process. The differences noted between the MRI and the PET defined volumes are presented. This being a patient who was not operated, the potentially confounding issue of surgery-induced PET-avidity is absent.

Internal gold fiducials are necessary for tracking the translational and rotational movements of target lesions during stereotactic radiosurgery. The fiducials are generally placed under image guidance in and around the lesions by interventional radiologists. Specific challenges are encountered during the procedure. This article discusses the basic principles and techniques as well as the specific complications.

Breast cancer (BC) is a heterogeneous disease. Numerous chemotherapeutic agents are available for early stage or advanced/metastatic breast cancer to provide maximum benefit with minimum side effects. However, the clinical outcome of patients with the same clinical and pathological characteristics and treated with similar treatments may show major differences and a vast majority of patients still develop treatment resistance and eventually succumb to disease. It remains an unmet need to identify specific molecular defects, new biomarkers to enable clinicians to adopt individualized treatment for every patient in terms of endocrine, chemotherapy or targeted therapy which will improve clinical outcomes in BC. Our study aimed to identify frequent hotspot mutation profile in BC by targeted deep sequencing in cancer-related genes using Illumina Truseq amplicon/Swift Accel-Amplicon panel and MiSeq technology in an IRB-approved prospective study in a CLIA compliant laboratory. All the cases had pathology review for stage, histological type, hormonal status and Ki-67. Data was processed using Strand NGS™. Mutations identified in the tumor were assessed for ‘actionability’ i.e. response to therapy and impact on prognosis.

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