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A Survey of the Standard Radiation Protection Practice in Radiography Departments of Some-Selected Tertiary Hospitals in South East Nigeria
Section: Research Articles Keywords: Radiation, Protection, Nigeria, Radiographers Background The radiation protection practices implemented in the radiology departments of tertiary hospitals in southeastern Nigeria have a significant impact on the safety of patients, healthcare professionals, and the general public. However, there is a lack of comprehensive understanding regarding adherence to standard radiation protection protocols in these departments. Objectives This study aimed to assess the standard radiation protection practices implemented in radiography departments within selected tertiary hospitals in Southeast Nigeria. Methods The study was a prospective cross-sectional survey. These hospitals include the University of Nigeria Teaching Hospital, Ituku Ozalla (UNTH), National Orthopedic Hospital Enugu (NOHE), Nnamdi Azikiwe Teaching Hospital, Nnewi, and Federal Medical Center Abakaliki. A total of 72 radiographers working in the abovementioned hospitals were included in the study. Results The quantitative findings revealed varying degrees of compliance with standard radiation practices. While all the hospitals employed appreciable shielding measures and demonstrated knowledge of radiation safety guidelines, the quality control measures and personnel/workplace monitoring were drastically low. The research also showed that little or no work has been done by hospital management and radiographers in updating their existing knowledge, as it pertains to standard radiation protection measures. Conclusions This research thus highlights the urgency of standardized radiation protection practices within radiography departments. Recommendations include the allocation of adequate resources to ensure the availability of essential protective equipment and infrastructure and the development of comprehensive formal training programs for radiographers and other healthcare personnel involved in radiological procedures. ---------------------------------------------------------------------------------------------------------------------------------------- A SURVEY of the STANDARD RADIATION PROTECTION PRACTICE in RADIOGRAPHY DEPARTMENTS of SOME-SELECTED TERTIARY HOSPITALS in SOUTH EAST NIGERIA Ezenwaka, Augusta Amarachi*1,ORCID; Ibe, Chijioke K.1; Ezugwu, Wisdom K.1; Ifeanyi, ThankGod O.1; Nwadike, Uchechukwu I.1 ¹University of Nigeria, Enugu Campus, Faculty of Health Sciences and Technology, Department of Medical Radiography and Radiological Sciences, Enugu State, Nigeria Swiss Journal of Radiology and Nuclear Medicine - www.sjoranm.com - Rosenweg 3 in CH-6340 Baar, Switzerland Introduction 1. Background of the study The increasing use of diagnostic radiology is unquestionably beneficial. However, per capita exposure to medical radiation has increased in the last two decades and appears to be still increasing (1, 2). Several studies carried out in Nigeria have shown that the level of adherence to and usage of radiation protection practices and devices is very low, resulting in unnecessarily high levels of ionizing radiation exposure for patients and healthcare workers (3, 4). Thus, the issue of medical radiation protection and its importance for the health of both patients and radiation professionals has gained increasing interest (5, 6). It is already well established that the effects of radiation are cumulative and lead to an increased incidence of cancer, cell death, genetic damage, and numerous forms of body tissue pathology; hence, ionizing radiation at any quantity is potentially detrimental to health (7, 8). Radiation damage can occur in many ways, inclu-ding skin erythema, hair loss, vascular damage, internal bleeding, cataracts, cancers, weakened immune systems, sterility, mutations in offspring, premature aging, and death. (3) During radiologic examinations, several factors are controlled by radiographers, which can maximize the diagnostic value of the image and minimize patient exposure (9, 10). Applying the principles of radiation protection can prevent the deterministic effects of ionizing radiation and decrease the related stochastic effects (11). Although several protective measures are considered significantly simple, radiographers’ proper observance of these measures eliminates most of the unwanted and unnecessary radiation hazards. The fundamental principles of radiation protection are justification, optimization, and dose limits (12, 13). These fundamental principles imply that only individuals who derive maximum benefits from such exposure to ionizing radiation are exposed (Justification); radiation dose as a result of medical exposure is enough only to achieve the needed diagnosis (Optimization); and the dose should also be set to ensure that no individual faces an unacceptable risk in normal circumstances (dose limit) (14, 15). Moreover, the use of lead aprons and protective equipment for patients and their companions when the presence of companions during radiographic examination is necessary is highly impor-tant (16, 17). Consequently, the availability and use of radiation protection measures, such as time, distance, protective shields (lead shielding devices), personnel dosimeters, and sound know-ledge of radiation protection, are essential (18, 19). To ensure the safety of patients, providers, and staff members, the healthcare community must become familiar with the terminology, common equipment, and standard practices used in radiation safety and monitoring. This has led to the urgent need for the radiology departments of tertiary hospitals in southeast Nigeria to abide by standard radiation protection practices for quality and efficient healthcare delivery. Yusuf et al. (20), in Damaturu, Yobe state, shed light on significant gaps in radiation protection measures among medical personnel. While certain protective equipment, such as lead aprons and shields, is accessible, this study reveals concerns about shortages of thyroid shields and, at times, lead gloves, heightening the risk of thyroid cancer. The absence of adequate monitoring devices leaves workers vulnerable to potential radiation overexposure. This research under-scores the vital necessity of complete safety compliance, urging the thorough implementation of quality assurance initiatives, consistent professional development programmes, and the incorporation of monitoring devices to ensure comprehensive protection. By addressing these issues, the study emphasizes the potential to minimize repeat exposures, enhance radiograph quality, and ultimately safeguard both patients and medical staff. The study conducted by Eze et al. (3) focused on radiation protection practices among Radiographers in Lagos, Nigeria. Radiographers generally had a good understanding of radiation protection, scoring an average of 73% in knowledge assessment, outperforming a similar study in England. However, the use of exposure charts was deemed crucial, especially in centers lacking modern equipment, to prevent unnecessary patient irradiation. The presence of obsolete X-ray machines without quality assurance tests and the absence of medical physicists raised concerns. Protective measures such as gonad shields were often ignored in government hospitals, possibly due to lax regulatory oversight. Discrepancies in radiation protection devices were observed between radiographers' claims and actual availability in government hospitals. The importance of wearing dosimeters was highlighted to avoid exceeding radiation dose limits. In the Association of Radiographers of Nigeria's journal, Skam et al. (21) examined radiographic room design and radiation protection in diagnostic facilities in Katsina State, Nigeria. The study showed that X-ray rooms in the surveyed centers lacked proper radiation protection for operators and others within the controlled area, potentially due to inadequate room dimensions. The authors highlighted the importance of the inverse square law, where radiation intensity decreases with distance from the source, emphasizing that larger room dimensions increase the distance between the X-ray tube and the control room, reducing radiation exposure. However, the diagnostic facilities did not adhere to the recommended guide-lines from the NNRA and IAEA in terms of room design. A study conducted in Rwandan public hospitals by Patrick et al. (22) revealed similarities between Nigerian and Rwandan hospitals regarding personal radiation monitoring. The study highlighted the inadequate enforcement of personal radiation dosimeter use and reading, which poses potential risks of radiation exposure to staff. The monitoring frequency of the dosimeters was far from the recommended standards, with only 3% being monitored monthly and 34% every three months. Al-sayyari et al. (23) carried out research in Saudi Arabia. Their research aimed to assess radiation protection practices among radiography students in Saudi Arabia. They carried out the study among 110 radiologic technologist students and discovered that all the students in the study made use of TLD cards. They also had good knowledge of the radiation protection practices that are necessary when taking radiographs. Fiagbedzi et al. (24) surveyed radiographers in Ghana to assess their radiation protection practices and discovered that while more than ninety percent of the radiographers had personnel dosimeters, only 25% of the radiographers made use of the dosimeters; however, the adherence to radiation protection practices was fairly satisfactory and was higher among the 35-45 years age group. Additionally, they discovered that radiographers who had worked for less than 5 years had a higher odds ratio of having completed some radiation training course. Abdelrahman et al. (25) carried out a survey among radiologists in tertiary hospitals in Jordan to determine their level of compliance with radiation protection practices. They discovered that among the 62 respondents in the study, the use of lead aprons and thyroid shields was commonplace, whereas the use of lead-lined eyeglasses was very rare (3.2%), 93.5% of the radiologists always used a personal dose monitoring device, and 66.1% of the radiologists reported unnecessary exposure to the patient. Lewis et al. (26) carried out a qualitative study among South African radiographers to determine their adherence to radiation protection practices. The researchers found that most of the radiographers had good knowledge of radiation protection; however, compliance remained a personal choice, and some of the factors that made them less likely to carry out radiation protection included the rush to attend to emergency patients, patients’ knowledge of radiation protection, inadequate training during analog-to-digital migration, managerial support, imaging referrals, etc. The radiographers concluded that although the level of knowledge was high, the practice did not reflect the knowledge because the radiographers did not internalize the information that they had known properly; they proposed ways of improving compliance with radiation protection guidelines. The radiation protection practices implemented in the radiology departments of tertiary hospitals in southeastern Nigeria have a significant impact on the safety of patients, healthcare professionals, and the general public. However, there is a lack of comprehensive understanding regarding adherence to standard radiation protection protocols in these departments (2). This research aimed to identify the current state of radiation protection practices in the radiography departments of several selected hospitals in south-eastern Nigeria and assess their compliance with established standards. Although studies have been conducted across different geopolitical zones with respect to these growing concerns, as of the time of this study, no concrete survey has been carried out across the radiology depart-ments of tertiary hospitals in southeastern Nigeria. Hence, this research seeks to bridge this gap. 2. Methods A cross-sectional prospective study was conducted in four federal government-owned hospitals in southeastern Nigeria. These hospitals include the University of Nigeria Teaching Hospital, Ituku Ozalla (UNTH), National Orthopedic Hospital Enugu (NOHE), Nnamdi Azikiwe Tea-ching Hospital, Nnewi, and Federal Medical Center Abakaliki. A total of 72 radiographers working in the abovementioned hospitals were included in the study. The study was carried out between August 2023 and February 2024. The inclusion criteria included practicing radiographers in government-owned tertiary hospitals in south-eastern Nigeria and receiving a willingness to participate in the study. 2.1 Method of Data Collection A well-structured questionnaire was used for the collection of the data. All participants were provided with clear information about the purpose of the study, and informed consent was obtained prior to their participation. The questionnaire comprises three sections. Section A is based on the sociodemographic information of the respondents. Section B was concerned with assessing the integrity of the shielding used and the X-ray room design in reducing radiation exposure; section C was concerned with evaluating the level of radiation protection knowledge and its application, which was exhibited by radiographers. Finally, section D assesses the effectiveness of workplace and personnel monitoring and quality control. A total of 72 well-composed questionnaires were distributed to the sample for data collection. These were completed and returned, after which the information provided was extracted and analyzed. The questionnaire used for this study is provided in the Appendix. 2.2 Data Analysis The data were analyzed using the Microsoft Statistical Package for Social Sciences (SPSS) version 25, and the Pearson correlation coefficients were calculated for the study parameters. The demographic data were analyzed using descriptive statistics. The data were analyzed using a quantitative method. The quantitative data collected were analyzed using tables for frequency and percentage. 3. Results A cross-sectional study was carried out among practicing radiographers in several selected tertiary hospitals in southeastern Nigeria. A total of 72 questionnaires were administered to the respondents; the questionnaires were manually distributed and successfully completed and returned, for a response rate of 100%. The analysis in this research was performed using SPSS (Statistical Package for Social Sciences) version 25, where respondents’ answers were analyzed using both descriptive and inferential statistics and are presented in tables as follows Figure 3.1: Demographics of the Respondents. As depicted in Figure 3.1 above, a total of 46 males (63.9%) and 25 females (34.7%) participated in the study. Forty-six respondents (63.9%) were within the age range of 21–35 years, and 25 respondents (34.7%) were within the age range of 36–50 years. Thirty-four respondents (47.2%) were interns/corps members, 17 respondents (23.6%) were basic-level radiographers, 13 respondents (18.1%) were senior/principal radiographers, and 7 respondents (9.7%) were assistant chief/chief radiographers. Forty-three respondents (59.7%) had practiced for 1–5 years, 14 respondents (19.4%) had practiced for 6–10 years, 9 respondents (12.5%) had practiced for 11–15 years, and 5 respondents (6.9%) had practiced for 16–20 years. Fifty-six respondents (77.8%) had a B.Sc, and 15 respondents (20.8%) had an M.Sc. Twenty-one respondents (29.2%) worked at the University of Nigeria Teaching Hospital (UNTH), 15 respondents (20.8%) worked at the National Orthopaedic Hospital Enugu (NOHE), 18 respondents (25.0%) worked at the Federal Medical Centre (FMC) Abakaliki, and 18 respondents (25.0%) worked at the Nnamdi Aziki-we University Teaching Hospital (NAUTH). The detailed data are shown in Table 3.1 (see Appendix). As illustrated in Figure 3.2, the majority of the respondents affirmed (agree) that the X-ray room design is purpose-built for radiological procedures (91.7%), the lead-lined walls and doors in the X-ray room are in good condition (79.1%), the X-ray control room is adequately shielded to reduce radiation exposure to the operator (82.0 %), the availability of radiation shielding equipment (lead aprons, lead gloves, googles, gonads, and thyroid shields) is adequate (73.6%), the shielding devices (lead aprons, lead gloves, googles, gonads, and thyroid shields) are in good condition (68.0%), the calibration of the X-ray machine is accurate (61.3%), the X-ray machine is equipped with appropriate safety interlocks to prevent accidental exposure (68.1%), and the distance between the X-ray tube and erect bucky 180 cm from the focal spot (65.3%). However, the majority of the respondents were undecided as to whether the personnel dosimeters for radiographers were adequate and in good condition (mean value = 3.11± 1.37). The detailed data are shown in Table 3.2 (see Appendix). As depicted in Figure 3.3, the majority of the respondents strongly agreed that they understood the principles of radiation protection and the regulatory guidelines and local protocols related to radiation safety (94.5%), were aware of the appropriate safety measures to minimize radiation exposure to patients and staff (94.4%), were aware of the proper use and maintenance of radiation shielding devices and equipment (94.5 %), consistently applied radiation safety practices during radiographic procedures (95.5%), and encouraged patients to follow radiation safety guidelines during their examinations (94.4%). Additionally, they were advised that patients wear appropriate protective devices during radiographic procedures (94.4%), and they kept themselves updated with the latest advancements in radiation protection practices (86.1%). However, the majority of the respondents were not sure if the healthcare workers in their hospital received formal training in radiation safety and protection (mean value = 3.29±1.43). The detailed data are shown in Table 3.3 (see Appendix). As depicted in Table 3.4 (see Appendix), the majority of the respondents disagreed with the following: There are well-defined established radiation safety protocols and quality assurance procedures in your hospital (62.5%), the established workplace protocol is consistently implemented and followed (69.5%), the X-ray rooms are often assessed for structural integrity and radiation leakage (84.8%), the radiation shielding equipment is regularly assessed for structural integrity and radiation leakage (76.4%), there are mechanisms in place to address and rectify equipment malfunctions promptly (65.3%), the personnel dosimetry (e.g., badges) is provided to healthcare workers regularly exposed to radiation (65.3%), and the personnel dosimeters are frequently exchanged and analyzed for radiation exposure (70.8%). There is also a mechanism in place to raise awareness among healthcare workers about the importance of radiation safety (77.9%). However, regarding whether there are well-defined established radiation safety protocols and quality assurance procedures in your hospital, the majority of the respondents were not sure (mean value = 2.72±1.42). Discussion The findings of this study showed that while X-ray rooms are purposely built for radiological procedures with walls and control rooms adequately lead-lined to evert or reduce radiation exposure to people in adjacent rooms as well as to the operator (radiographer) in the cubicle, there is a slight lack of compliance in the area of personal radiation protective equipment (PPE). In the hospitals visited for this study, the lead aprons, gonads, and thyroid shields were fairly adequate. Additionally, approximately 70% of the radiographers did not have dosimeters, while those who had rarely worn them while on duty. Furthermore, the results also showed that the radiographers in the hospitals included in the study possessed sound knowledge and applica-tion of radiation protection measures, as they related to regulatory guidelines, the use of shielding equipment, and patient orientation. However, there is no formal training on radiation safety and protection for radiographers or other healthcare workers. Additionally, radiographers rarely update themselves with the latest advancements in radiation protection practices. This only means that, outside the formal school walls, little or nothing is done by the hospital or the radiographers to improve their knowledge, as it pertains to radiation protection knowledge. Again, the quality control measures and work-place/personnel monitoring in the hospitals used for this study were abysmally poor. First, there is no well-defined quality control procedure in hospitals. These findings show that diagnostic equipment such as X-ray machines, digitizers, and cassettes, among others, is not checked for functional integrity; thus, these devices are left to use until heavy and noticeable damage occurs before service engineers are consulted. This also means that personal radiation protective equipment (PPE), such as lead aprons, gonads, and thyroid shields, even the operator’s cubicle, are rarely assessed for structural integrity and replacement. Hence, no adequate radiation protection measures are put in place, and it puts the patients, radiographers or patient’s relatives in cases where it is required that they be present in the diagnostic room during radiological procedures. Conclusion In conclusion, this study revealed that in the area of optimal radiation protection practices among radiographers, there is much additional work to be done. From the study above, it is evident that while most radiographers demonstrate an appreciable level of knowledge in radiation protection, there is a large gap in the application of this knowledge. Therefore, hospital management and radiology unit leadership must take action to address the situation, starting by implementing the recommendations outlined above. Correspondence to: Ezenwaka Augusta Amarachi https://orcid.org/0009-0004-6732-5990 University of Nigeria, Enugu Campus, Faculty of Health Sciences and Technology, Department of Medical Radiography and Radiological Sciences, Enugu State, Nigeria Declarations Consent for publication: The author clarifies that written informed consent was obtained and the anonymity of the patient was ensured. This study submitted to Swiss J. Rad. Nucl. Med. has been conducted in accordance with the Declaration of Helsinki and according to requirements of all ap-plicable local and international standards. All authors contributed to the conception and design of the manuscript, participated in drafting and revising the content critically for important intel-lectual input, and approved the final version for publication. Each author agrees to be accoun-table for all aspects of the work, ensuring its accuracy and integrity. Written informed consent was obtained from the patient's legal guardians for the publication of this case report and any accompanying images. Competing interests: No competing interests. Funding: No funding resources. Ethical approval was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital (UNTH/HRC/2025/02/3036). The approval covered the use of data collected between August 2023 and February 2024. Participation was voluntary, informed consent was obtained from all respondents, and confidentiality of the data was maintained throughout. All participants provided written informed consent before completing the questionnaire. Participation was voluntary, and responses were treated with confidentiality. Conflict of interest: The authors declare that there were no conflicts of interest within the meaning of the recommendations of the International Committee of Medical Journal Editors when the article was written. Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of Swiss J. Radiol. Nucl. Med. and/or the editor(s). Swiss J. Radiol. Nucl. Med. and/or the editor(s) disclaim responsibility for any injury to people or property resul-ting from any ideas, methods, instruc-tions or products referred to in the con-tent. License Policy: This work is licensed under a Creative Commons Attribution 4.0 International License. This license requires that reusers give credit to the creator. 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Radiography [In-ternet]. 2022;28(2):387–93. https://doi.org/10.1016/j.radi.2021.12.008 Appendix Table 3.2: ASSESSMENT OF RADIOGRAPHER’S PERCEPTION ON THE INTEGRITY OF THE X-RAY ROOM SHIELDING Variables SD (%) D (%) N (%) A (%) SA (%) Mean±S.D Remark The X-ray rooms design are purpose-built for radiological procedures 00(0.0) 03(4.2) 03(4.2) 12(16.7) 54(75.0) 4.63±0.76 Strongly agree The lead-lined walls and doors in the X-ray room are in good condition 00(0.0) 07(9.7) 08(11.1) 24(33.3) 33(45.8) 4.15±0.97 Agree The X-ray control room is adequately shielded to reduce radiation exposure to the operator 00(0.0) 09(12.5) 04(5.6) 21(29.2) 38(52.8) 4.22±1.02 Strongly agree The availability of radiation shielding equipment (lead aprons, lead gloves, googles, gonad shields, and thyroid shields) are adequate 01(1.4) 15(20.8) 03(4.2) 35(48.6) 18(25.0) 3.75±1.10 Agree The shielding devices (lead aprons, lead gloves, googles, gonad, and thyroid shields) are in good condition 00(0.0) 09(12.5) 14(19.4) 34(47.2) 15(20.8) 3.76±0.93 Agree The personnel dosimeter for radiographers are adequate and in good condition 10(13.9) 21(29.2) 04(5.6) 25(34.7) 12(16.7) 3.11± 1.37 Neutral The calibration of the X-ray machine is accurate 02(2.8) 11(15.3) 15(20.8) 30(41.7) 14(19.4) 3.60±1.06 Agree The X-ray machine is equipped with appropriate safety interlocks to prevent accidental exposure. 02(2.8) 07(9.7) 14(19.4) 29(40.3) 20(27.8) 3.81±1.04 Agree The distance between the X-ray tube and the erect bucky is 180 cm from the focal spot 05(6.9) 07(9.7) 13(18.1) 26(36.1) 21(29.2) 3.71±1.19 Agree QUESTIONNAIRE Department of Medical Radiography and Radiological Sciences, Faculty of Health Sciences and Technology College of Medicine, University of Nigeria, Enugu Campus, August, 2023 Dear Respondent, This research questionnaire assessed standard radiation protection practices in the radiography departments of several selected tertiary hospitals in southeastern Nigeria. This research was carried out by the Authors. This study is being conducted for academic purposes, and the researchers will be grateful if you provide answers to the questions posed with the utmost sincerity. Please note that the strictest confidentiality will be assured with respect to the response given as facts are needed for academic purposes. Thank you for your anticipated cooperation. Yours faithfully, Authors SECTION A: SOCIO-DEMOGRAPHIC DATA Instruction: Kindly tick [√] against the option of your choice. Gender: a) Male [ ] b) Female [ ] Age: a) 21-35 [ ] b) 36-50 [ ] c)51 and above [ ] Rank: a) Intern/Corps member [ ] b) Basic radiographer [ ] c) Senior/Principal radiographer [ ] d) Asst Chief/Chief radiographer [ ] Years of practice: a) 1-5 [ ] b) 6-10 [ ] c) 11-15 [ ] d) 16-20 [ ] e) 21 and above [ ] Highest Qualification: a) B.Sc. [ ] b) M.Sc. [ ] c) Ph.D. [ ] d) Others specify [ ] Hospital of practice UNTH [ ] b) NOHE [ ] c) FMC Abakaliki [ ] d) NAUTH [ ] SECTION B: ASSESSMENT OF THE INTEGRITY OF THE SHIELDING EQUIPMENT USED AND THE X-RAY ROOM DESIGN IN REDUCING RADIATION EXPOSURE IN SOME SELECTED TERTIARY HOSPITALS IN SOUTH EASTERN NIGERIA. Please tick (√) in the appropriate box Strongly Agree (SA), Agree (A), Disagree (D), Strongly Disagree (SD), and Not Sure (NS). SECTION C: EVALUATION OF THE LEVEL OF RADIATION PROTECTION KNOWLEDGE—AND ITS APPLICATION—EXHIBITED BY RADIOGRAPHERS IN SOME-SELECTED TERTIARY HOSPITALS IN SOUTH EASTERN NIGERIA. Please tick (√) in the appropriate box Strongly Agree (SA), Agree (A), Disagree (D), Strongly Disagree (SD), and Not Sure (NS). S/N Measures to reduce the incidence of medical litigation among practicing radiographers SA A D SD NS 1. I understand the principles of radiation protection and the regulatory guidelines and local protocols related to radiation safety. 2. I am aware of the appropriate safety measures to minimize radiation exposure to patients and staff 3. I am aware of the proper use and maintenance of radiation shielding devices and equipment 4,. The healthcare workers in my hospital received formal training inradiation safety and protection 5. I consistently apply radiation safety practices during radiographic procedures. 6. I encourage patients to follow radiation safety guidelines during their examinations 7. I ensure that patients wear appropriate protective devices during radiographic procedures. 8. As a radiographer, I keep myself updated with the latest advancements in radiation protection practices. SECTION D: ASSESSMENT OF THE EFFECTIVENESS OF WORKPLACE AND PERSONNEL MONITORING AND QUALITY CONTROL IN SOME-SELECTED TERTIARY HOSPITALS IN SOUTH EASTERN NIGERIA. Please tick (√) in the appropriate box Strongly Agree (SA), Agree (A), Disagree (D), Strongly Disagree (SD), and Not Sure (NS). S/N Assessment of the effectiveness of workplace and personnel monitoring and quality control in some selected tertiary hospitals in south eastern Nigeria SA A D SD NS 1. There is a well-defined established radiation safety protocols and quality assurance procedures in your hospital 2. The established workplace protocol are consistently implemented and followed 3. The X-ray rooms are often assessed for structural integrity and radiation leakage 4. The radiation shielding equipment are regularly assessed for structural integrity and radiation leakage 5. There are mechanisms in place to address and rectify equipment malfunctions promptly. 6. The personnel dosimetry (e.g., badges) are provided to healthcare workers regularly exposed to radiation 7. The personnel dosimeters are frequently exchanged and analyzed for radiation exposure 8. There is a mechanism in place to raise awareness among healthcare workers about the importance of radiation safety
Copyright (c) 2025 Ibe, Chijioke K., Ezenwaka, Augusta Amarachi, Ezugwu, Wisdom K., Ifeanyi, Thankgod O., Nwadike, Uchechukwu I. https://creativecommons.org/licenses/by/4.0
A Case Report of a Non-Functional Ectopic Kidney in Crossed Fused Renal Ectopia on [99mTc] Tc-DMSA Renal Scintigraphy: A Rare Entity
Section: Case reports Keywords: Crossed fused renal ectopia, Congenital renal anomaly, Ectopic kidney, [99mTc] Tc-DMSA scintigraphy Introduction: Crossed fused renal ectopia is a rare congenital malformation, with an estimated incidence of 1 in 7,500 live births. It occurs more frequently in males and represents the second most common renal fusion anomaly after the horseshoe kidney. Case Report: Static renal scintigraphy with [⁹⁹ᵐTc]Tc-DMSA is considered the gold standard for confirming the diagnosis and ruling out the presence of a single kidney. We report the case of a 2-year-old child, born from a consanguineous marriage, followed for failure to thrive and recurrent episodes of pyelonephritis. The 99mTc-DMSA scan revealed a left pelvic ectopic kidney, fused with the right kidney at the mid-portion and upper pole. Relative renal function was almost entirely provided by the right kidney. Conclusion: Crossed fused renal ectopia is a rare congenital renal anomaly. Renal scintigraphy with [⁹⁹ᵐTc]Tc-DMSA remains the most reliable method for confirming the diagnosis and assessing renal function. Zakaria OuassafrarORCID1*, Abdel Amide GbadamassiORCID1,2, Halima BataniORCID1, Hafsa Bensimimoun1, Amal GuensiORCID1 1Nuclear Medicine Department, Ibn Rochd University Hospital Center, Casablanca, Morocco 2Laboratory of Mechanics and High Energy Physics, Faculty of Sciences Ain Chok, Hassan Second University of Casablanca, Morocco Introduction: Crossed fused renal ectopia is a rare congenital malformation, with an estimated incidence of 1 in 7'500 live births. It occurs more frequently in males and represents the second most common renal fusion anomaly after the horseshoe kidney. Case report: Static renal scintigraphy with [⁹⁹ᵐTc]Tc-DMSA is considered the gold standard for confirming the diagnosis and ruling out the presence of a single kidney. We report the case of a 2-year-old child, born from a consanguineous marriage, followed for failure to thrive and recurrent episodes of pyelonephritis. The 99mTc-DMSA scan revealed a left pelvic ectopic kidney, fused with the right kidney at the mid-portion and upper pole. Relative renal function was almost entirely provided by the right kidney. Conclusion: Crossed fused renal ectopia is a rare congenital renal anomaly. Renal scintigraphy with [⁹⁹ᵐTc]Tc-DMSA remains the most reliable method for confirming the diagnosis and assessing renal function. Keywords: Crossed fused renal ectopia, Congenital renal anomaly, Ectopic kidney, [99mTc] Tc-DMSA scintigraphy Introduction Congenital anomalies of the kidneys encompass a wide spectrum of conditions, ranging from essentially asymptomatic variants to severe and potentially life-threatening pathologies, and account for approximately 10–12% of malformations identified in adults [1]. Ectopic and fused renal anomalies are congenital urinary tract malformations resulting from disruptions in normal embryological renal migration. There are two main types of fused renal anomalies: the horseshoe kidney and crossed fused renal ectopia [2]. Crossed fused renal ectopia is a congenital malformation with an estimated incidence of 1 in 7'500 live births, showing a higher prevalence in males. It is considered the second most common renal fusion anomaly after the horseshoe kidney and is characterized by the presence of an ectopic kidney that crosses the midline, fusing with the contralateral orthotopic kidney and appearing as a single enlarged renal mass [3]. Static renal scintigraphy with technetium 99m-labeled dimercaptosuccinic acid ([⁹⁹ᵐTc]Tc-DMSA) is the gold standard for confirming crossed renal ectopia and ruling out a solitary kidney [4]. The aim of this study was to highlight the contribution of [⁹⁹ᵐTc]Tc-DMSA renal scintigraphy in detecting crossed fused renal ectopia, particularly in cases where ultrasonography was inconclusive. Case Report A 2-year-old child, born from a first-degree consanguineous marriage, was evaluated for failure to thrive and a history of recurrent pyelonephritis, which required multiple hospitalizations during the first two years of life. No other significant medical, surgical, or congenital history was reported by the parents. Initial abdominopelvic ultrasonography revealed a right ectopic kidney in the pelvic region, with no visualization of the left kidney. In this context, a renal scintigraphy with [⁹⁹ᵐTc]Tc-DMSA was indicated to confirm the suspected congenital anomaly and to assess potential cortical sequelae resulting from previous episodes of pyelonephritis. Examination Protocol Static renal scintigraphy was performed following the intravenous injection of 0.5 mCi of [⁹⁹ᵐTc]Tc-DMSA. Images were acquired using a dual-head gamma camera equipped with a low-energy high-resolution collimator (Siemens Symbia-Intevo), combined with a low-dose CT scanner (SPECT/CT). The study was conducted four hours after tracer injection, under the following condi-tions: patient in the supine position, matrix 128 × 128, and zoom factor 1. Static images were obtained in the posterior, anterior, right posterior oblique, and left posterior oblique projections, each lasting approximately 5 to 10 minutes. Imaging results (Fig.1) The analysis of the scintigraphic images obtained four hours after radiotracer injection focused on the number of kidneys visualized, their location, size, tracer uptake intensity, the presence of cortical abnormalities, and the calculation of relative renal function. The study revealed two renal formations located in the pelvic region, consistent with bilateral ectopia. Posterior oblique projections allowed better delineation of the two structures, showing a left ectopic pelvic kidney located below the right kidney (Fig. 1). The left kidney exhibited mildly homogeneous tracer uptake, indicating residual functional activity, with no obvious parenchymal abnormalities or focal defects suggestive of scarring or dysplasia. Furthermore, the images demonstrated a fusion of the left kidney with the right kidney at the mid-portion and upper pole, consistent with a crossed fused pelvic renal anomaly (Fig. 1). Relative renal function assessment showed that function was almost entirely provided by the right kidney (96%), indicating severely reduced function of the left kidney. Overall, these findings support the diagnosis of a congenital renal malformation combining pelvic renal ectopia and crossed renal fusion, with impaired functional activity of the left kidney. Complementary CT imaging revealed external rotation of both kidneys, and the left ureter crossed the midline before entering the bladder on the left side (Fig. 2). Discussion Crossed fused renal ectopia is a very rare congenital malformation. The exact incidence of crossed fused ectopia remains unknown, as most patients are asymptomatic; it occurs in approximately 1 in 1'000 live births. After the horseshoe kidney, crossed fused ectopia is the most common renal fusion anomaly, characterized by the abnormal migration of one kidney to the opposite side and its fusion with the contralateral kidney during development. This anomaly results from abnormal renal ascent during embryogenesis, with fusion occurring at the renal pelvis [5]. In this condition, as observed in our patient, both kidneys are located on the same side, usually fused, with two distinct ureters originating from each kidney. The ureter from the crossed kidney returns to the opposite side before entering the bladder. Imaging plays a key role in congenital renal disorders, facilitating accurate diagnosis. Ultrasonography is often used for initial detection and assessment due to its rapid ac-quisition, lack of radiation, low cost, and ease of use [5]. However, renal scintigraphy, particularly static imaging with [⁹⁹ᵐTc]Tc-DMSA, is the gold standard for confirming crossed renal ectopia and ruling out a solitary kidney [4]. Diagnosis can be challenging, especially in children, as ultrasonography has several limitations. Computed tomography (CT) or intravenous urography, although more sensitive and precise, are associated with significant radiation exposure [6]. DMSA renal scintigraphy provides a reliable method for diagnosing and characterizing complex congenital renal anomalies, offering functional information essential for appropriate clinical management [7]. It also provides crucial data for detecting cortical defects in children with vesicoureteral reflux or recurrent urinary tract infections, as demonstrated by Ditchfield and Nadel in a large cohort of 129 children [8]. Currently, DMSA scintigraphy is recommended as the reference technique to confirm the presence and localization of an ectopic or fused kidney, assess cortical function, and visualize the functional anatomy of fused kidneys, complementing other imaging modalities such as excretory urography and CT [7]. This information is essential for planning therapeutic management and clinical follow-up of children with congenital renal anomalies. Conclusion Crossed fused renal ectopia is a rare congenital renal anomaly. Renal scintigraphy with [⁹⁹ᵐTc]Tc-DMSA remains the most reliable method for confirming the diagnosis and assessing renal function.
Copyright (c) 2025 Zakaria Ouassafrar, Abdel Amide Gbadamassi, Halima Batani, Hafsa Bensimimoun, Amal Guensi https://creativecommons.org/licenses/by/4.0
The Diagnostic Accuracy of 18F-NaF PET/CT versus 99mTc Bone Scintigraphy for Detection of Skeletal Metastases: A Systematic Review and Meta-Analysis
Section: Research Articles Keywords: 18F-NaF PET/CT, Bone scintigraphy, Skeletal metastases, Meta-analysis Objectives: To compare the diagnostic accuracy of 18F-sodium fluoride (NaF) PET/CT (Positron Emission Tomography/Computed Tomography) and 99mTc(Technitium-99m) bone scintigraphy for detecting skeletal metastases across malignancies using head-to-head, patient-level studies. Methods: A systematic search of PubMed, Embase, Scopus, Web of Science, and Cochrane Library was conducted up to March 2025 following PRISMA 2020 guidelines. Eligible studies directly compared NaF PET/CT and 99mTc scintigraphy in the same patients and provided extractable 2×2 data. Quality was assessed with QUADAS-2 (quality assessment of diagnostic accuracy studies). Pooled sensitivity, specificity, and diagnostic odds ratios (DORs) were calculated using a bivariate random-effects model. Narrative synthesis was performed for studies without full 2×2 tables. Results: Six studies met inclusion, with four eligible for meta-analysis (prostate, breast, thyroid, renal, and nasopharyngeal cancers; n=468 patients). Pooled sensitivity and specificity of NaF PET/CT were 0.96 (95% CI, 0.91–0.99) and 0.93 (95% CI, 0.88–0.97), respectively, compared with 0.72 (95% CI, 0.63–0.80) and 0.81 (95% CI, 0.71–0.89) for 99mTc bone scintigraphy. The pooled DOR for NaF PET/CT was 342.1 versus 23.5 for bone scintigraphy. Heterogeneity was low-to-moderate. Narrative synthesis of two additional studies confirmed consistent superiority of NaF PET/CT. Conclusions: NaF PET/CT demonstrates significantly higher sensitivity, specificity, and overall diagnostic accuracy than 99mTc bone scintigraphy for detecting skeletal metastases across malignancies. Supported by multiple head-to-head studies and meta-analyses, NaF PET/CT is well positioned to replace bone scintigraphy as the reference standard in oncologic practice. Future work should assess cost-effectiveness, multicancer prospective validation, and integration with PET/MRI platforms. Introduction Bone metastases represent a frequent and serious complication of advanced malignancies, especially prostate, breast, lung, thyroid, and renal cancers, and are associated with significant morbidity, pain, and skeletal-related events that negatively impact survival and quality of life (1). Accurate and early detection of skeletal metastases is therefore essential for appropriate staging, prognostication, and treatment planning. For decades, 99mTc-methylene diphosphonate (MDP) bone scintigraphy has served as the reference standard for detecting osseous metastases. While widely available and cost-effective, its diagnostic performance is hampered by limited spatial resolution and suboptimal specificity, particularly in differentiating malignant from benign degenerative or inflammatory changes (2). The addition of SPECT or SPECT/CT has improved localization, but sensitivity remains modest for small or early lesions (2, 5). NaF PET/CT has emerged as a powerful alternative owing to its favorable pharmacokinetics, rapid blood clearance, and high affinity for hydroxyapatite crystals at sites of active bone remodeling (3, 4). These properties provide markedly higher bone-to-background ratios and superior image quality compared with 99mTc-based tracers. The integration of PET technology further enhances lesion detection through higher spatial resolution, tomographic capability, and quantitative assessment. Multiple head-to-head studies have demonstrated the superiority of NaF PET/CT over conventional scintigraphy. Even-Sapir et al. (5) showed significantly higher sensitivity in patients with high-risk prostate cancer, while Ota et al. (7) reported similar findings in differentiated thyroid carcinoma. Abikhzer et al. (8) extended these observations to breast cancer, and Gerety et al. (9) found that NaF PET/CT detected all lesions in renal cell carcinoma compared with only 29% by bone scintigraphy. More recently, Wang et al. (6) confirmed the superior diagnostic accuracy of NaF PET/CT in nasopharyngeal carcinoma. Jambor et al. (14) further validated its performance against MRI, demonstrating NaF PET/CT as the most accurate modality in high-risk prostate cancer. Early studies by Schirrmeister et al. (20) also highlighted its potential in breast cancer patients. Systematic reviews and meta-analyses corroborate these findings. Sheikhbahaei et al. (1) and Perera et al. (16) demonstrated pooled sensitivities exceeding 90% and specificities above 95% for NaF PET/CT in prostate cancer, markedly outperforming bone scintigraphy. Evangelista et al. (18) and Fan et al. (12) extended these observations across multiple malignancies, confirming consistently superior diagnostic accuracy. Reviews by Langsteger et al. (11), Mick et al. (10), Bastawrous et al. (4), and Lindenberg et al. (15) emphasize NaF PET/CT’s role in routine oncologic imaging, while Beheshti et al. (12) published EANM (European Association of Nuclear Medicine) guidelines formalizing technical protocols and clinical applications. Despite robust evidence, most prior reviews included lesion-based analyses or heterogeneous designs, limiting their direct applicability to clinical decision-making. To address these limitations, the present systematic review and meta-analysis focuses strictly on patient-level, head-to-head comparisons of NaF PET/CT versus 99mTc bone scintigraphy, providing pooled estimates of sensitivity and specificity across multiple cancer types. Methods Literature Search Strategy We conducted a systematic literature search of PubMed, Embase, Scopus, and Web of Science from inception through March 2025 to identify studies comparing NaF PET or PET/CT with 99mTc-based bone scintigraphy (planar or SPECT) for detection of skeletal metastases. Search terms combined synonyms for “sodium fluoride,” “PET/CT,” “bone scintigraphy,” “skeletal metastasis,” and cancer-specific keywords (e.g., prostate, breast, lung, thyroid, nasopharyngeal, renal cell carcinoma). Reference lists of retrieved ar-ticles and relevant reviews were also screened. The review process followed PRISMA-DTA guidelines, and a flow diagram is shown in Figure 1. Eligibility Criteria Studies were included if they: - Enrolled patients with histologically confirmed or clinically suspected malignancy at risk of bone metastasis; - Performed both NaF PET/CT (or PET alone) and 99mTc bone scintigraphy in the same patient cohort or in contemporaneous comparative cohorts; - Reported sufficient per-patient diagnostic data to construct a 2×2 contingency table (true positive, false positive, true negative, false negative). Studies were excluded: - if they only reported lesion-level data; - did not include a direct comparison, or duplicated previously published cohorts; - Studies without extractable patient-level data were retained for narrative synthesis only. Data Extraction and Quality Assessment Two reviewers independently extracted study characteristics, patient demographics, technical details of imaging protocols, and diagnostic accuracy outcomes (Table 1). For eligible studies, 2×2 contingency data were extracted to calculate sensitivity and specificity for each modality. If raw 2×2 data were unavailable but sufficient secondary data were provided (e.g., reported sensitivity and denominators), reconstructed values were derived and flagged accordingly. Studies lacking such reconstruction were included in the narrative-only table. Risk of bias was assessed using the QUADAS-2 tool, evaluating domains of patient selection, index test, comparator test, reference standard, and flow/timing. Statistical Analysis Sensitivity and specificity with 95% confidence intervals (CIs) were calculated using the Clopper–Pearson exact method. Forest plots were generated for each modality (Figures 2–3). Pooled estimates were obtained using a random-effects model (DerSimonian–Laird) applied on the logit scale. Summary results are provided in Table 2. A ROC scatter plot was constructed for NaF PET/CT (3) to illustrate study-level performance distribution. Narrative-only studies were synthesized descriptively to contextualize findings in additional cancer populations. Results The initial search identified 750 records (732 from databases and 18 from other sources). After removal of duplicates, 600 records were screened by title and abstract, of which 40 full-text articles were assessed. Ultimately, 7 studies were included in the quantitative synthesis and 2 were retained for narrative-only analysis (Figure 1). The 7 quantitative studies comprised 476 patients across diverse malignancies: prostate (two studies), lung (two studies), nasopharyngeal carcinoma (one study), differentiated thyroid carcinoma (one study), and breast cancer (one reconstructed dataset). Five were head-to-head comparisons, and two were reconstructed data-sets based on published accuracy values (Table 1). The two narrative-only studies evaluated renal cell carcinoma and a multicenter mixed cohort of prostate and breast cancer. Diagnostic accuracy results are presented in Table 2. Across individual studies, NaF PET/CT demonstrated consistently higher sensitivity than 99mTc bone scintigraphy. For instance, in prostate cancer cohorts, NaF PET/CT achieved sensitivities of 0.95–1.00 compared with 0.60–0.75 for bone scintigraphy. Similar patterns were observed in lung and nasopharyngeal carcinoma studies. Specificity was also generally higher for NaF PET/CT (typically 0.90–1.00) compared with bone scintigraphy (0.70–0.90), although greater variability was noted when equivocal scintigraphy scans were classified as positive. When pooled using a random-effects model, 18F-NaF PET/CT achieved a sensitivity of 0.96 (95% CI 0.91–0.99) and specificity of 0.93 (95% CI 0.88–0.97), whereas bone scintigraphy achieved a pooled sensitivity of 0.72 (95% CI 0.63–0.80) and specificity of 0.81 (95% CI 0.71–0.89). Forest plots illustrate the per-study accuracy estimates for sensitivity and specificity of both modalities (Figures 2 & 3), while the ROC scatter plot demonstrates that NaF PET/CT results clustered tightly in the upper-left quadrant, reflecting both high sensitivity and high specificity across studies. The narrative synthesis reinforced these findings. In renal cell carcinoma, NaF PET/CT detected all 77 malignant bone lesions compared with only 29% detected by bone scintigraphy (Gerety et al. 2015). The multicenter MITNEC-A1 trial similarly confirmed the superiority of NaF PET/CT over 99mTc SPECT/CT in prostate and breast cancer, although raw 2×2 patient-level data were not available for pooling. Together, the pooled and narrative data highlight the consistent diagnostic advantage of 18F-NaF PET/CT over conventional bone scintigraphy in detecting skeletal metastases across multiple cancer types. Discussion This meta-analysis demonstrates that NaF PET/CT provides substantially superior diagnostic performance compared with 99mTc-methylene diphosphonate (MDP) bone scintigraphy in detecting skeletal metastases across malignancies. Our pooled results showed that NaF PET/CT achieved markedly higher sensitivity and specificity, consistent across cancer types and sensitivity analyses. These findings confirm that NaF PET/CT can overcome the limitations of conventional scintigraphy and offer improved staging accuracy, with significant implications for patient management. Comparison with Previous Literature Our results align closely with prior systematic reviews and meta-analyses. Sheikhbahaei et al. (1) reported pooled sensitivity of 91.9% and specificity of 97.1% for NaF PET/CT in prostate cancer, compared with 47.0% and 94.1% for bone scintigraphy. Evangelista et al. (18) also found pooled sensitivity exceeding 90% across malignancies, while Perera et al. (16) confirmed similar advantages in prostate cancer biochemical recurrence. More recently, Fan et al. (12) extended these findings in a contemporary meta-analysis, reaffirming the consistently higher diagnostic odds ratio of NaF PET/CT relative to scintigraphy. Collectively, these meta-analyses strengthen the evidence base and corroborate our pooled results. Head-to-head studies provide further support. Even-Sapir et al. (5) demonstrated that NaF PET/CT detected more metastases than scintigraphy in high-risk prostate cancer, while Gerety et al. (9) reported that NaF PET/CT identified all lesions in renal cell carcinoma compared with only 29% for scintigraphy. Ota et al. (7) confirmed these advantages in differentiated thyroid carcinoma, and Abikhzer et al. (8) found superior lesion detection in breast cancer. Wang et al. (6) extended the evidence to nasopharyngeal carcinoma, and Jambor et al. (14) prospectively compared NaF PET/CT with planar scintigraphy, SPECT, and MRI, demonstrating NaF PET/CT as the most accurate modality in prostate cancer. Early work by Schirrmeister et al. (20) also highlighted its diagnostic superiority in breast cancer. Together, these studies provide robust evidence across diverse malignancies. Biological Rationale for Superiority The diagnostic advantage of NaF PET/CT is grounded in its biological and technical features. 18F-fluoride exchanges with hydroxyl groups in hydroxyapatite, localizing rapidly at sites of osteoblastic activity and enabling high lesion-to-background contrast (3). PET technology adds higher spatial resolution, tomographic capability, and the potential for quantitative analysis (10). Compared with 99mTc-MDP scintigraphy, which can be limited by low resolution and nonspecific uptake (2), NaF PET/CT allows earlier detection of subtle or small-volume metastases and more accurate delineation of disease extent. These features are particularly important in cancers such as prostate and breast, where early identification of osseous involvement may change treatment intent (5, 8, 11). Clinical Implications The importance of these results in a clinical context is substantial. Accurate detection of skeletal metastases informs staging, guides systemic therapy initiation, and influences radiotherapy planning. In prostate cancer, NaF PET/CT can distinguish patients who remain candidates for curative therapy from those requiring systemic treatment (11,16). In renal cell carcinoma, Gerety et al. (9) showed that reliance on bone scintigraphy alone risks understaging and suboptimal management. In thyroid and breast cancers, NaF PET/CT has demonstrated value in identifying clinically relevant metastases that may alter management (7, 8, 20). For nasopharyngeal carcinoma, Wang et al. (6) confirmed improved detection, highlighting its broader oncologic applicability. NaF PET/CT may also be valuable in treatment monitoring. Mick et al. (10) and Evangelista et al. (18) suggested that its quantitative capabilities can track therapeutic response more reliably than scintigraphy, which is subject to the “flare” phenomenon. This could make NaF PET/CT an important biomarker in clinical trials and routine practice. Guidelines and Consensus Statements Expert reviews and guidelines endorse the use of NaF PET/CT in oncologic imaging. Langsteger et al. (11) concluded that NaF PET/CT should be considered the preferred modality for detecting bone metastases in prostate cancer, and the European Association of Nuclear Medicine (EAN-M) has published procedural guidelines standardizing imaging protocols and clinical use (12). Bastawrous et al. (4) and Lindenberg et al. (15) emphasized its integration into routine clinical practice, while Hutchinson (13) highlighted its value in renal cell carcinoma. Together, these publications indicate a growing consensus that NaF PET/CT is poised to replace scintigraphy as the gold standard in many clinical contexts. Limitations Several limitations should be acknowledged. First, although we restricted our analysis to patient-level 2×2 data, some breast and lung studies required reconstructed tables, which may introduce bias (8, 20). Second, reference standards varied, often relying on composite imaging and follow-up rather than histopathological confirmation. Third, heterogeneity in imaging protocols exists across studies, though recent guidelines (12) provide standardized approaches. Finally, NaF PET/CT is not universally available, and cost, reimbursement, and radiation exposure remain barriers to adoption (11, 15). Future Directions Future research should focus on large, prospective, cancer-specific trials directly comparing NaF PET/CT with SPECT/CT and whole-body MRI. Jambor et al. (14) provided a model for such studies, integrating multimodality imaging in a prospective cohort. PET/MRI platforms incorporating NaF may further enhance diagnostic performance while reducing radiation dose. Health-economic evaluations are also needed to support policy decisions, as broader access will depend on demonstrated cost-effectiveness. Conclusion In summary, this meta-analysis confirms that NaF PET/CT significantly outperforms 99mTc bone scintigraphy for detecting skeletal metastases, offering higher sensitivity, specificity, and clinical utility. Supported by multiple head-to-head trials, meta-analyses, and international guidelines, NaF PET/CT is well positioned to become the reference standard for evaluating skeletal metastases across malignancies. Wider adoption into oncologic imaging pathways could improve staging accuracy, optimize treatment strategies, and ultimately improve patient outcomes. Correspondence to: Haroon Rashid Department of Radiodiagnosis Sher-i-Kashmir Institute of Medical Sciences, Srinagar, J&K, India
Copyright (c) 2025 Dr. Tosif Quazi MD, Dr. Haroon Rashid MD, Dr. Aamir Majeed Shah MD, Elena Khalid https://creativecommons.org/licenses/by/4.0
The Ectopic Thyroid in the Anterior Mediastinum Coexisting with a Normally Positioned Thyroid Gland in Neck
Section: Case reports Keywords: Ectopic thyroid, anterior mediastinal mass, mediastinal thyroid Introduction: Ectopic thyroid gland is a developmental anomaly resulting from abnormal migration of thyroid tissue from its embryologic origin at the base of the tongue to its normal location in the neck. The coexistence of normally located thyroid tissue with an ectopic thyroid in the anterior mediastinum is an exceptionally rare finding. Most patients with ectopic thyroid tissue are asymptomatic; however, when the ectopic tissue enlarges, it may produce compressive symptoms, including tracheal or esophageal compression. Case presentation: We report the case of a 50-year-old woman who presented with an insidious onset of dry cough for one year which was unresponsive to conventional treatment. Imaging revealed a superior mediastinal mass along with a normally positioned thyroid gland in the neck. Initially based on imaging a provisional diagnosis of germ cell tumor vs lymphoma was made. An ultrasound guided biopsy through sternal notch was performed with histopathological examination confirming benign, enlarged thyroid tissue without evidence of malignancy. Conclusion: This case underscores the importance of considering ectopic thyroid tissue within the anterior mediastinum in the differential diagnosis of anterior mediastinal masses, which more commonly include thymic tumors, germ cell tumors, and lymphomas. ------------------------------------------------------- Introduction Ectopic thyroid is a rare but well known condition in which thyroid tissue is located at a site other than its normal anatomical location within the neck. It can be present anywhere along its path of descent from foramen cecum to anterior lower neck which may occur as a result of abnormalities in development or migration from primitive foregut to pre-tracheal region. Rarely, thyroid tissue may be found beyond this path or away from midline within the trachea, mediastinum, heart, or even the abdomen (1, 2). The presence of an ectopic thyroid with a normally located thyroid gland in neck is extremely rare (3, 4) Although the incidence varies among the cases reported in literature, the most common type is the lingual thyroid located at the base of the tongue (3). Mediastinal thyroid accounts for less than 1% of ectopic thyroid and often co-exists with a normal orthotopic thyroid tissue (5,6). The condition is mostly asymptomatic and is often diagnosed incidentally when a person is evaluated for some unrelated condition. Not infrequently, it may give rise to symptoms based on its location secondary to mass effect, or symptoms related to hypothyroidism and rarely, hyperthyroidism. We report a case of a female patient with an ectopic thyroid co-existing with a normally located thyroid where the diagnosis was established on histopathology. Case presentation A 50-year old female patient, with otherwise no co-morbidity, was referred to us for evaluation of chronic cough that she was experiencing on and off from past one year. The cough was non-productive and mild initially. She had sought medical consultation couple of times but was never evaluated for the same. A respiratory, cardiovascular and ENT examination was done by the treating physician which was unremarkable. Because of persistence of symptoms, a chest X-ray was ordered that revealed an abnormal widening of superior mediastinum with sharply demarcated margins (Fig. 1). The right and left para-tracheal stripes are significantly widened. No other abnormality was found. Baseline lab investigations were undertaken that revealed normal blood count, and renal and liver function tests. Serum C-reactive protein and ESR were within normal limits. Thyroid function test revealed a TSH level of 1.4mIU/L. A contrast enhanced CT scan of neck and chest was ordered which revealed a well-defined 6.8x 4.6 cm rounded mass within the superior mediastinum with heterogeneous enhancement pattern. The mass was separate from the thyroid gland. No definite communication was found between the mass and orthotropic thyroid (Fig 2). Further evaluation on ultrasound using a high frequency linear transducer showed a well circumscribed fairly homogenous mass lesion in retrosternal location with vascularity upon Doppler analysis (Fig 3). Thyroid gland was seen at its normal location. A preliminary radiological diagnosis of germ cell tumor vs. lymphoma was made and patient was advised biopsy of the lesion. An ultrasound guided biopsy of the lesion was performed using 18G biopsy gun with co-axial assembly. Histopathological analysis revealed normal thyroid follicles filled with colloid with maintained basal polarity of nuclei (H&E stain) (Fig 4, 5). No signs of malignancy were seen. Discussion Ectopic thyroid tissue can be present anywhere along its path of descent from the floor of tongue to pre-tracheal location in lower neck. Rarely, it may be seen beyond this course anywhere from neck up to abdominal cavity or away from midline within salivary glands. It is not uncommon to find an ectopic thyroid tissue with a normally positioned orthotopic thyroid gland. Increase in size in times of physiological stress which may or may not be associated with hyper-or hypothyroidism may lead to mass effect producing symptoms based on its location. Mediastinal thyroid with a normal thyroid in neck is exceedingly rare and patients may present with cough, stridor, dyspnea, dysphagia or signs of thyroid dysfunction. Careful analysis of history and physical examination along with basic laboratory investigations are important. Ultrasound helps in confirming the diagnosis of normal neck thyroid. It also aids in detection of retrosternal extension of thyroid from a purely mediastinal ectopic thyroid. Ultrasound is also useful in guiding biopsy if the mass is visible through suprasternal notch. Contrast enhanced CT aids in establishing attenuation and contrast characteristics of normal and ectopic thyroid. MRI is another excellent modality to assess similarities between normal and ectopic thyroid. Scintigraphy is also very helpful in localizing ectopic thyroid, however, can be negative incases of necrosis or malignant transformation (7). Despite all these radiological modalities, the definitive diagnosis is often established only after histopathological analysis of biopsied tissue. Despite most patients being euthyroid, surgical intervention in case of ectopic thyroid may be required especially when symptoms of airway compression exist and rarely in cases of malignant transformation (8). Conclusion Mediastinal ectopic thyroid is a rare form among the various ectopic locations of thyroid especially when a normal orthotopic gland coexists. This case underscores the importance of considering ectopic thyroid tissue within the anterior mediastinum in the differential diagnosis of anterior mediastinal masses, which more commonly include thymic tumors, germ cell tumors, and lymphomas. Our aim was to highlight the fact that despite advancement in the radiological methods, definitive diagnosis may still depend on the analysis of cellular structure and any mediastinal mass should always point towards the possibility of the mass being ectopic thyroid tissue.
Copyright (c) 2025 Dr. Arshed Parry, Dr. Zahia Shabir, Dr. Pirzada Suhaib, Dr. Irfan Yousuf, Dr. Wajahat Un Nazir Mir, Prof. Shabir Bhat https://creativecommons.org/licenses/by/4.0
A Case of Ovarian NIFTP Treated with Iratherapy
Section: Case reports Keywords: Struma ovarii, ovarian NIFTP, iratherapy Struma ovarii is a form of mature monodermal teratoma, a rare germ cell tumor containing more than 50% thyroid tissue. Its transformation into a malignant tumor is rare. NIFTP (non-invasive follicular thyroid neoplasm with papillary nuclear features) is an entity characterized by a completely encapsulated follicular proliferation with papillary nuclear features, but without invasion or high-risk criteria. It has an excellent prognosis when located in the thyroid gland. Its presence in the struma ovarii makes its prognosis uncertain. We report a case of ovarian NIFTP treated with complementary iodine-131 isotope therapy. The patient was a 50-year-old woman who consulted for a pelvic mass appearing on pelvic ultrasound as a large, double-component, cystic and fleshy mass measuring 109×100 mm. Pelvic CT scan, performed in addition to pelvic ultrasound to better assess the characteristics of the mass, revealed a solid-cystic pelvic mass affecting the left ovary, measuring 106x117×74 mm. Left adnexectomy was indicated based on these results. The pathological examination of the surgical specimen concluded that it was a NIFTP developed on a struma ovarii. A total thyroidectomy was performed. Histology concluded lymphocytic thyroiditis against a background of multi-hetero-nodular thyroid hyperplasia, with the presence of a follicular adenoma. She underwent complementary irathérapie treatment at 1.11 GBq. The originality of this observation lies in the rarity of this histopathological entity, and the lack of international consensus on treatment opens the way for an approach aimed at codifying the classification, treatment protocol, and prognosis of ovarian NIFTPs. --------------------------------------------------------- Struma ovarii is a form of mature monodermal teratoma, a rare germ cell tumor containing more than 50% thyroid tissue [1]. Its transformation into a malignant tumor is rare [2]. Non-invasive follicular thyroid neoplasm with papillary nuclear features (NIFTP) is an encapsulated or clearly defined, noninvasive tumor with a follicular arrangement and nuclear features of papillary thyroid carcinoma (PTC), but without well-formed papillae or psammomatous bodies, and without the typical signs of aggressive subtypes of PTC or poorly differentiated carcinoma [3]. This lesion is considered "borderline" or "pre-malignant" [4]. The presence of NIFTP in a struma ovarii is an exceptional entity, described only twice in the literature [5]. To our knowledge, no author has yet addressed the value of complementary iratherapy in the management of ovarian NIFTP. We present a case of ovarian NIFTP in a woman in her fifties who had received iratherapy treatment in the nuclear medicine department of the Hassan II University Hospital in Fez. Being individualized: Iodine therapy may be justi-fied in the presence of risk factors or uncer-tainties regarding progression, particularly with the aim of optimizing prognosis and preventing recurrence. The case we have reported highlights the importance of an international registry and multicenter studies to define harmonized recom-mendations for the management of this extremely rare entity. Case presentation This is a 50-year-old female patient, third preg-nancy, third delivery, with no history of radiation exposure during childhood, no family history of goiter, and no other notable medical or surgical history, who consulted for a pelvic mass unrela-ted to pregnancy. A pelvic ultrasound performed as part of the investigation of the mass revealed the presence of a large, dual-component cystic and fleshy mass measuring 109×100 mm on the left ovary. To better assess the characteristics of this mass and its relationship to neighboring organs, a pelvic CT scan was performed. This confirmed the presence of a solid-cystic pelvic mass measuring 106x117×74 mm in the same location, with no other abnormalities detected. She underwent a left adnexectomy, the patholo-gical examination of which was consistent with a NIFTP developed on a struma ovarii (Figures 1 and 2). PCR sequencing confirmed the presence of the C.1801 A>G. p. K601E mutation in exon 115 of the BRAF gene (Figure 3). Furthermore, the thyroid ultrasound was normal. The patient un-derwent a total thyroidectomy, the pathological examination of which was consistent with lym-phocytic thyroiditis against a background of multi-hetero-nodular thyroid hyperplasia, with the presence of a follicular adenoma. She was there-fore referred to the nuclear medicine department for further treatment with iodine therapy. Given this clinical picture and ultrasound findings showing a thyroid gland that appeared essentially normal, a diagnosis of NIFTP developed on a struma ovarii was made. The patient underwent ablative radioiodine therapy at 1.11 GBq six weeks after total thyroidectomy. The peri-radioio-dine therapy assessment performed during defre-nation noted a well-stimulated ultrasensitive thy-roestimulin (TSHus) at 116.1 mlU/L; tumor marker levels were 2.65 ng/mL for thyroglobulin (Tg) and anti-thyroglobulin antibodies (anti-Tg Ab) were positive at 21.7. The whole-body scan with iodine-131 performed on day 3 after the iodine-131 treatment found two areas of iodine uptake in the thyroid bed (Figure 4) associated with thyroid remnants (Figures 5a and b), with no other areas of pathological uptake, particularly in the pelvic region. The post-treatment course following radioactive iodine-131 therapy was favorable. The patient was declared "cured" on the basis of satisfactory morphological, functional, and biological criteria: a low thyroglobulin level during perithyroid therapy, whole-body scanning with iodine-131 showing two thyroid remnants, and a cervical ultrasound scan 4 months after total thyroidectomy showing no abnormalities. She is currently receiving lifelong hormone therapy with L-thyroxine at a suppressive dose and undergoes annual clinical and biological monitoring. Discussion NIFTP is a newly defined, low-risk tumor entity [7]. It is characterized by a completely encapsulated follicular proliferation with papillary nuclear features, but without invasion or high-risk criteria. It has an excellent prognosis when located in the thyroid gland [3]. In this context, the standard treatment is generally limited to lobectomy without the need for radioiodine therapy or other adjuvant treatments, the aim being to avoid over-medicalization of indolent forms [8]. However, in the context of NIFTP developed on a struma ovarii, little data is available in the literature. The therapeutic approach therefore remains controversial due to the exceptional nature of this location and the lack of long-term follow-up data [9]. Our patient underwent a left adnexectomy and total thyroidectomy, followed by complementary iratherapy treatment at 1.11 GBq. This was due, on the one hand, to the uncertainty surrounding the biological behavior of NIFTP in the ovary; and on the other hand, the presence of risk factors such as tumor size not indicated by the pathologist and the presence of specific molecular alterations, in particular the C. 1801 A>G. p. K601E mutation in exon 115 of the BRAF gene. Furthermore, there is currently no international consensus or published recommendations regarding the indication for iratherapy in this specific case. Most authors recommend a multidisciplinary approach, considering the individual profile of the patient, including age, comorbidities, the molecular specificity of the tumor, and local extension [5,10]. What appears to be the first case of NIFTP within a struma ovarii was diagnosed at the Fernando Fonseca Hospital in Portugal and reported at the European Congress of Endocrinology in Milan, Italy, in 2022 [10]. The patient was a 32-year-old woman admitted to the emergency department with acute painful abdominal distension, in whom a well-defined right ovarian NIFTP measuring 1 cm in diameter was found. She had no associated thyroid ultrasound or histopathological abnormalities and had not received additional treatment with radioactive iodine-131. In terms of follow-up, it is advisable to monitor patients clinically, radiologically, and by measuring thyroglobulin levels over the long term in order to detect local or distant recurrence at an early stage, even though the risk remains theoretically low due to the indolent nature of NIFTPs [11]. In the case we are reporting, the patient was declared "cured" based on satisfactory morphological, functional, and biological criteria, then placed on a suppressive dose of L-thyroxine with a target of 0.3< TSHus < 2, as she was classified as having a low risk of tumor recurrence according to the 8th edition of the UICC/AJCC classification. She is under clinical and biological surveillance and undergoes annual ultrasound scans according to clinical guidelines. According to some authors, complementary treatment with radioiodine therapy should be reserved for cases presenting risk criteria such as association with classic thyroid carcinoma, large ovarian NIFTP, or in cases of doubt about invasion or in the presence of molecular alterations (BRAF mutation) [12]. In the absence of consensus, the choice of therapeutic adjunct with radioactive iodine-131 in our patient was essentially based on a "precautionary" approach, given the absence of an indicated size for the ovarian NIFT and also the presence of the C. 1801 A> G. p. K601E mutation in exon 115 of the BRAF gene during sequencing by Polymerase Chain Reaction (PCR). Conclusion NIFTP developing on struma ovarii is an exceptional entity, with only two cases reported worldwide. Although thyroid NIFTP has an excellent prognosis, its progression in the ovarian context remains uncertain. In the absence of consensus, the management of ovarian NIFTP must be individualized. Iodine therapy may be justified in the presence of risk factors or uncertainties regarding progression, particularly with the aim of optimizing prognosis and preventing recurrence. The case we have reported highlights the importance of an international registry and multicenter studies to define harmonized recommendations for the management of this extremely rare entity.
Copyright (c) 2025 Dr Esso-Mada Kpekpeou, Dr Arnauld Muhoza, Dr Sofia Chkikar, Dr Mehdi Goudira, Dr Aïcha El Boukhrissi, Prof. Nadia Ismaili Alaoui https://creativecommons.org/licenses/by/4.0