Akiko Hara

Relative preservation of peripheral lung function in smoking-related pulmonary emphysema: assessment with 99mTc-MAA perfusion and dynamic 133Xe SPET

Abstract.In this study the cross-sectional functional differences between the central and peripheral lung in smokers with pulmonary emphysema were evaluated by lung perfusion and dynamic xenon-133 single-photon emission tomography (SPET). The subjects were 81 patients with a long-term smoking history and relatively advanced emphysema, 17 non-smoker patients with non-obstructive lung diseases and six healthy non-smokers. Regional lung functional difference between the peripheral and central lung was assessed in the upper, middle and lower lung zones by technetium-99m macroaggregated albumin SPET and dynamic 133Xe SPET. The distribution of emphysematous changes was assessed by density-mask computed tomography (CT) images which depicted abnormally low attenuation areas (LAAs) of less than –960 Hounsfield units. Two hundred and eighty-eight (59.2%) lung zones of 63 (77.7%) patients with pulmonary emphysema showed relative preservation of lung function in the peripheral lung, with a curvilinear band of normal perfusion (a stripe sign) and a significantly faster 133Xe half-clearance time (T1/2) than in central lung (P<0.0001). Of these lung zones, 256 (88.8%) showed central-dominant LAA distributions on density-mask CT images, but the remaining 32 zones did not show any regional preference in LAA distribution. Conversely, 117 (24.0%) lung zones of 19 (23.4%) patients showed periphery-dominant perfusion defects and LAA distributions, with significantly prolonged T1/2 in the peripheral lung area (P<0.0001). The remaining 81 lung zones of the patients with pulmonary emphysema and all the lung zones of the healthy subjects and patients with non-obstructive lung diseases did not show a stripe sign, and no differences were observed in T1/2 values and LAA distributions between the central and peripheral lung. Relative preservation of peripheral lung function seems to be a characteristic feature in smoking-related pulmonary emphysema, and may indicate a lower susceptibility of peripheral parenchyma to the development of this disease.

Alteration of myocardial metaiodobenzylguanidine uptake after treatment of phaeochromocytoma and neuroblastoma.

Abstract.The relationships between changes in myocardial uptake of metaiodobenzylguanidine (MIBG) and those in circulating catecholamines and cardiac function after treatment of phaeochromocytoma and neuroblastoma were evaluated. Iodine-123 or iodine-131 MIBG scintigraphy was performed before and after surgical resection and/or chemotherapy for primary tumours in nine patients with phaeochromocytoma and 13 patients with neuroblastoma. Changes in myocardial MIBG uptake after treatment were estimated by the heart-to-upper mediastinum (H/M) uptake ratios on the images obtained 24 h after MIBG injection, which were compared with serum levels of noradrenaline (NA) and adrenaline (A). Cardiac function was assessed by echocardiography, with measurements of the left ventricular ejection fraction (LVEF). Before treatment, eight patients with phaeochromocytoma and three with neuroblastoma showed poor myocardial MIBG uptake, with highly elevated circulating NA and A. Echocardiography, however, did not show cardiac dysfunction in these patients with the exception of two patients with phaeochromocytoma. With normalization of NA and A levels after treatment, all of these patients except for the two with persistent cardiac dysfunction showed restoration of myocardial MIBG uptake. The H/M ratios increased significantly after treatment in both patient groups, i.e. with phaeochromocytoma and with neuroblastoma (P<0.0001 and P<0.05, respectively), and these ratios correlated inversely with circulating NA and A before and after treatment. By contrast, there was no significant correlation between H/M ratios and LVEF in these two groups. These results indicate that suppression of myocardial MIBG uptake usually may not be related to cardiac dysfunction and may be reversible following normalization of excess catecholamine levels after treatment in patients with neuroadrenergic tumours. However, the suppression may persist in the presence of catecholamine-induced cardiac dysfunction. The assessment of myocardial MIBG uptake can be a helpful adjunct in monitoring the normalization of circulating catecholamine levels and also in identifying the presence of cardiac dysfunction in treated patients with neuroadrenergic tumours.

201Tl SPECT as an indicator for early prediction of therapeutic effects in patients with non-small cell lung cancer

This study retrospectively investigated the good parameters on thallium-201 chloride (201T1) SPECT for early assessment of the therapeutic effects in patients with non-small cell lung cancer.Based on tumor response as determined by chest CT scan about 9 weeks after the end of irradiation with adjuvant chemotherapy, the subjects were divided to the responder group (tumor regression > 50%, n = 13) and non-responder group (tumor regression < 50%, n = 13).201T1 SPECT was performed before and at the halfway through the course of therapy (average tumor dose, 27.4 Gy ± 4.5) in all the patients. SPECT was conducted twice 15 min (early scan) and 120 min (delayed scan) after intravenous injection of 148 MBq (4 mCi) of201T1. Tumor-to-contralateral normal lung tissue count ratios on both scans were calculated as early and delayed uptake ratios (EUR and DUR), and a retention index (RI) was also derived from these ratios.In the responder group, a significant decrease in DUR and RI halfway through the therapy was observed compared to pretreatment (2.6 ± 0.6 vs. 3.5 ± 1.0; p < 0.01, and -2.3% ± 25.5 vs. 37.4% ± 17.8; p < 0.001, respectively), even though EUR did not change significantly (N.S.). By contrast, in the non-responder group, there were no significant changes in any of these parameters (N.S.). When comparing DUR and RI for the two groups halfway through the therapy, DUR and RI were significantly lower in the responder group (both; p < 0.01), but no significant difference was noted in EUR (N.S.), and the percent reduction in tumor size did not correlate with the percent decrease in DUR or RI (N.S.).These results indicate that the extent of decrease in DUR and RI after therapy can be a useful parameter for early assessment of the therapeutic effects in patients with non-small cell lung cancer.

Tc-99m MIBG imaging in a huge clinically silent pheochromocytoma with cystic degeneration and massive hemorrhage

I-131 metaiodobenzylguanidine scintigraphy showed marked accumulation in the walls of a clinically silent, huge cystic adrenal mass with a prominent hemorrhage in a 48-year-old man. Although a careful reexamination of the histologic specimen finally lead to a diagnosis of pheochromocytoma, the appearances of this mass on computed tomography and magnetic resonance imaging were not specific for this neoplasm, and even pathologic analysis initially indicated, incorrectly, that this lesion was a hemorrhagic hemangioma. This case shows that I-131 metaiodobenzylguanidine scintigraphy is useful for correctly diagnosing an adrenal mass with prominent cystic or hemorrhagic degeneration.

Tc-99m colloid and Ga-67 imaging of splenic inflammatory pseudotumor: Correlation with ultrasound, CT, and MRI

Splenic inflammatory pseudotumor is extremely rare and may mimic splenic neoplasms, such as lymphomas or hamartomas, clinically and radiologically. A case of a surgically proved splenic inflammatory pseudotumor is presented in which Tc-99m colloid SPECT and Ga-67 scintigraphy characterized the changes in the spleen, but the findings of ultrasound and unenhanced CT and MRI were nonspecific. This report indicates the utility of radionuclide imaging for diagnosing splenic inflammatory pseudotumor.

Abnormal lymphatic flow demonstrated by lymphoscintigraphy in chylothorax correlation with lymphography.

Lymphoscintigraphy may be useful to identify the lymphatic leakage site in some patients with chylothorax. A 60-year-old woman had lung cancer that was complicated by massive chylothorax after radical surgery. Dynamic lymphoscintigraphy after injection of Tc-99m HSA in both feet showed abnormal tracer accumulation in the subcarinal area of the medlastinum after visualizing the lower level of the thoracic duct, indicating a thoracic duct disruption in the inferior mediastinum. Scintigraphic findings were well correlated with lymphographic findings. Subsequent thoracoscopic ligation of the thoracic duct in the inferior mediastinum successfully terminated chyle leakage.

Respiratory failure and pulmonary hypertension associated with Klippel-Feil syndrome

A 28-year-old woman with a deformed thorax and kyphoscoliosis associated with Klippel-Feil syndrome developed respiratory failure with pulmonary hypertension. Pulmonary133Xe ventilation and99mTc-MAA perfusion scintigraphies showed maldistributions of lung ventilation and perfusion, and noticeably delayed133Xe washout from the lungs. Dynamic breathing MR imaging showed poor and/or asynchronous respiratory movements of the chest wall and diaphragm. These findings indicate that the perfusion-ventilation imbalance, the decreased ventilatory turnover, and expiratory flow from the alveolar space partly derived from the impaired respiratory mechanics may be responsible for the respiratory complications in this patient.

Ga-67 and I-131 adosterol scintigraphic findings of bilateral primary adrenal lymphoma.

The authors report a rare case of clinically silent bilateral primary adrenal lymphoma (PAL) as imaged by Ga-67 and 1-131 adosterol scans. A Ga-67 scan showed symmetric and intense uptake in the masses without abnormal extra-adrenal uptake. After chemotherapy, the scan effectively predicted the subsequent growth of the residual masses despite temporal regression on an abdominal computed tomographic (CT) scan. An 1-131 adosterol scan showed positive uptake in both adrenal glands, indicating well-preserved adrenocortical function despite the bilateral masses. Symmetric intense uptake of Ga-67 confined to both adrenal glands seems to suggest this disease, and a Ga-67-avid residual mass after treatment should be carefully managed and will depend on changes in mass size. The assessment of adrenocortical function by an adrenocortical scan seems indispensable in bilateral PAL, because this disease is often associated with adrenocortical insufficiency.

Resolved splenic accumulation of Tc-99m HMDP after recovery of disseminated intravascular coagulation in a patient with rhabdomyosarcoma.

Unusual, intense splenic radioactivity was seen on bone scintigraphy with Tc-99m HMDP in a 14-year-old boy with alveolar rhabdomyosarcoma complicated by disseminated intravascular coagulation. Abnormal splenic radioactivity was resolved after recovery from the disseminated intravascular coagulation. During treatment of disseminated intravascular coagulation and tumors, the patient received repeated blood transfusions, resulting in iron overload, but this did not prevent the abnormal splenic uptake from resolving. This case indicates that disseminated intravascular coagulation may be a cause of splenic accumulation of bone-seeking agents, and that abnormal splenic uptake can be resolved.

Abnormal brain perfusion demonstrated by Tc-99m MAA total-body scan in two children with complex congenital heart disease.

This paper describes abnormal brain perfusion unexpectedly demonstrated by Tc-99m MAA total-body imaging in two children with intracardiac right-to-left shunt (RLS) associated with complex congenital heart disease. One child was a 12-year-old girl with asplenia cardiac syndrome and multiple cerebral infarctions caused by thromboembolism in the internal carotid artery, and the other child was a 6-monfh-old boy who developed focal cerebral infarction following shunt operation. In both children, the total-body imaging depicted the brain due to RLS, where radioactivity decreased unilaterally in the cerebral hemisphere. In the first patient, radioactivity also decreased in the contralateral cerebellum, suggesting the crossed cerebellar diaschisis phenomenon. These abnormalities in brain perfusion were confirmed by Tc-99m HMPAO brain SPECT. Careful review of the distribution of the radiotracer in the depicted brain on Tc-99m MAA total-body imaging may provide important information regarding brain perfusion in some patients with a high risk of stroke complication associated with RLS.