Nuclear Medicine Case Review

ワヒ剣ヲ ラ響かぶ萎オ Nuclear Medicine

Color Plates

Opening Round Cases

XV

1

Fair Carne Cases

107

Challenge Cases

251

1,What is thc radiOPharmaceutical uscdP for this stu(サ 2.Describe the imagc andings.Interpret this llmitcd stu(け 3.Name thc myth010gical Roman god宙 th two hcads. 4. N7hat is a radioisOtOPC,a radionuclide,a radionucicotide,and a radiotraccrP

Notes

Headed Skeletal Systenl:〕 anuS― TW。 口 Roman tCod l.99mTc mcthylcnc diPhosPhonatc.

2 . B o n e s c a n i n p a t i c n t m rw oi t h e a dp spnag1r 0ci0nn脇 tけ oppositc dircctlons.Thc Paticnt rnoved his hcadi the tech― n010gist did nOt Hlovc his/hers.

3.JanuS. 4. Ifyou dO nOt knOw9/ou cannOt Proceed until you read the comments beloM

Reference Roman mytho10gン Reference Cross‐ 助 あ ″鴎 品品惚 r配

沢野Qさ蕊 孤 ,Cd 2,PP l10-116.

Comment

JanuS iS the twO,faced Roman god of bcginnings and cndings, the gOd Ofgates and doors,frOm which thc mOnth OfJanuary gets its name.Hc is dcPictcd with MO faccs gazing in Oppositc ng back at the shOrt histOry ofnucicar rncdi― directions.Loo路 cinc,rnany advances in thc ncld,in both instrumcntation and radiopharrllaccuticals,and mOst importandy in their clinical _ use,arc cvidcnt.An cxciting advancc is the adoptiorl ofauor。 dcOx/glucOsc(FDG)podtron c中 おsion tomOgraphy(PET)岱 a clinical reality and its transfoHnatiOn of the practicc of OncO―

10gic lncdicine.Like Janus,wc should nOt Only 100k back tO know w h e r e w c h a v c c O m c f r O m , b u t w c m u s t thcn 100k fOr― ward tO thc lnany oPPortunitics ahcad. Nuclcotides are basic structural building b10cks Of E)NA

and RNA,1.e。 ,ribosc or deOxyribosc sugar,oined tO a purine r or pyrilnidinc basc and a PhOsPhatc grOuP,Clinical nucicと medicinc uscs rad10nuclidcs,not radlonucicotides.As diffcr‐ ent typcs ofatOHls are called elcmcnts,difFerent t/Pcs Ofnuclei vith the samc number Of prO― are termed″″品乱es,Nuclidcs、 tons are isotopcs,c.g。 ,1311,1231.An clcmcnt is charactcrizcd by its atomic numbcr(Z)alone,whcrcas a nuclide is character_ izcd by its mass numbcr(A)and its atOmic numblr(Z). Radionuclides rcfcr tO radioactivc elcments Of all typcs, whethcr natural or manmade.Tcchnetium was thc nrst man_ made radiOnudide.Radiopharmaceuticals are radlonudides at‐ tached to chemicals or drugs used to investigate phys1010gical and Ыochemical prOccssCS,C.g"99mTc labclcd tO mcthylcnc diphosPhona[e(MDP).Radiopharmaceuticals otten are rcr ferred tO as物 %″θヵ夕負クぁ becausc only[racc amounts of the drugs are used,indicating that they are rnarkcrs OfPhyslo10gi― cal prOcesscs,c.g。 ,bOne metabolism,but withOut Pharmaco― 10gical cFFcct.

Lowcr cxtremit/Pain itt three古ent d田 patients“ ,あ の,ali membcrs Ofthc track tcam. . 1. Dcscribe the indings in PaticntИ 2. mat is the mOst likely diagnOsisP and(互 3. Describe the nndings in Paticnts β and β C diagnosis for Patients 4.PrOvide thc mOst likclシ

Notes

Skeletal Syste何1:Stress Fractures l , I n c r e a s c d ia tc /t i市n a l i n c a r P a t t e r n a l o n g t h c P O s t e r i O r and IIIcdial aspect OfbOth mid― tibias. 2. Shin splints. cv 』 o i d a c t i v i t / P O S t t rroimgehdti 』 tibia筑 3 . 単 i e n t a f o。

the,unction ofthe mal的 prO対 碕thirds and dista1 0nc third. Patient O focal ttsifOrm activit/POsteromedially in the right pro対 mtt tibia alld linear activit/組 ong thc POsに rOme―

diallett tibia prOximally and mOre prOminently distalけ 4, Paticntヱ〕 r stress fracturc.Patient(チ strcss fracture and shin splints.

ReFerence

Thr』lJH,seCtiOn cditOH助 滅 夕 陀あ0カp(fourth scrics)ね ″ ″″グッ物 あz j j R e s t o n , V a , 1 9 9 0 , A m e r i c a n C O l c g c og/9PP 121,129. Cttss― Reference 対務r力″″Mcあ ct″ 4軍醍

ofRadiOlと

沢どQむ慰 孤 ,Cd 2,PP 130-131.

Comme正 Bonc is a dynarnic tissuc in which intcrmittcnt forces stimulatc remodeling of thc bOnc architecturc to withstand applied stresses.Strcss icads tO rcmodcling initiatcd by osteOclasts that prOducc small areas Of rcsOrPtiOn and micrOfracturcs that are rcmodeled with iamellar bOnc.IfbOne fbrrnation cannot kccP up with bone resOrption,bonc weakcning results.In responsc to thc tcmPOrarily wcakened bOnc,pcrlostcal rcactiOn,endosせ eal pr01iferatiOn,Or bOth may occur at the sitc OFstrcss.Ifthe strcss is nOt rcduced, the repair imechanislns lnay becomc Ovcr― whclmcd,rcsulting in fracturc. Stress fractures on bonc scarl appear as fOcal oval or ttifOrm t 雫 iVit/based at thc cOrtex with the axis Ofthe abnOrmality par_ allel tO that Ofthe bOne,Or thcy mary appear as a transverse band Ofincreased tttivitye Thc scan abnOrmalitt OFten precedes radiO‐ graphic changes by l t0 2 wecks.Tibial stress fracturcs lnost commonly occur posterOmcdially at the,unCtiOn ofthe mid, dle and distal thirds ofthc tibia,as in Paticntガ L Shin splints Or tibial stress syndroEle arC terms uscd to describe antcrior leg Pain and tenderness.Often thcre is no identiflablc inciting event,but pain Occurs aftcr athictic activity and is relieved by rcst.Scan indings var)ら but generally bilateral linctr tibial up― takc invOlves thc cOHex in muldPic arett or dittcly,the uptakc may be symmetrical or asymmetrical.Thc Pattern dittrs frOm the pattern ofstrcss fracturc.Howevcち bccausc ofthe nature of the indting strcsscs,strCSS fractures commonly cocxlst with shin sPlints.

毒

1.Describc thc bone scan abnOrmality. 2. Providc dcscriptive terIIIs that cOuld be used to dcscribe the pattcrn in the tibia. 3. PrOvide thc diIFcrential diagnOsis. 4.The Paticnt may cxPcriCncc dinical symptOms relatcd tO anOther Organ systcm.Discuss thc mcchanism.

Notes

Skeletal Systenl:Paget′

s Disease

l.AbnOrmtt highly incrcascd uptakc in thc entire lett fcmuL which appears bowcd and widencd,and thc distal third Of the left tibia,which tapers proximally. 2. A sharP lcading edge,rcFcrred to as``naHlc_shaped''Or “ blade Ofgrass,''Inay bc demonstratcd on thc lytic Phase on radiograph and On bOnc scintigraph/. 3,Pagctも discasc,abrous dySPlasia,chrOnic Ostcomyelitis, Primar/bone tumOrs,but PrinCiPally osteOsarcoma. 4.High― Output congestive heart危 1lutt may occui Once believcd tO.bc the result ofarteriovcnOus shunting、 vithin thc bOnc ics10n,now hypetmia and incretted bloOd nOw

thrOugh thc lcsiOn,and notshundng,are causes. likcけ References Bro、 vn ML:Bonc scintigraphy in benign and lnalignant tur mors,勉 ″θ ブ9ケ″州レ務И初 31:731-738,1993. SartOris DJ:臨

sfク あ すたタル 物 ′ ″物

r務 宅″ 哲

夕 ″

夕

″ォ ブ方′す,St Louis,

1996,ヽ在 OsbンPP 303-307. Cross,Reference 力″″Meあ ″″資 「 助 び 鵡

択野Qむ慰 F蕊 )Cd 2,pp l19,139‐ 140.

COmment Pagettt disettc is a bcnign disOrdcr chamctcrizcd by exccssivc alld a b n O r m 』b O n e t t m O d c h n g e C o m m O n t t c r t h c a g c O f 4 0 , P a g e t も discasc rna/bc rccOgnized bccausc ofbone pain,tcnderness,or

hc驚 容c i n b O n e s i z e , b u t f r c q u c n t l yけbiys i d c n d n e d i n c i d c n t 狙 an elevated serum alkaline phOsphatasc lcve1 0r On radiographs Or bOnc scans ordcrcd 10r Other rcasons.The x,ray appearancc has three phasctt lytic,sdcrOtic,and mttd lytic― sclerotic.Thc classic appearance is onc Of bOne enlargcment,increased den_ sit/P and cOarscned trabecular pattern,Leslons tyPiCally start at the cnd Ofa10ng bonc;20%arc monOstotic.The discasc is char― a c t c z五e d b y a n i n i d t t p h t t e O f e x c cssOsr pbdoonne に with a lytic frOnt,f0110wed by an intcnsc osteoblastic rcactiOn、 vith dcPOsi― tion OfwOven bOneo Skcletal architecturc bccomcs disOrganizcd with a mlxcd Pattcm Oflytic and sderotic discasc.This imbal‐ ancc ofbone rcmOdcling in favOr OffOrmation leads tO cOrtical thickening and bone exPansbn.BOnc sdndgraPhy dcmOnstrates abnOrmal intensc radiotracer uptakc extending frOm thc subr coHical reg10n fOr the 1 0fthe len評 lesiOn,which may bc mOst or ali thc bOnc.The les10n may be threc_Phase POsitiVC in the activc thOugh Pagctもdisette is most commonly phtte Ofthe disettc,組 identined On thc ddayed Or bOnc Phttc.A thtte_phasc study is not neccssary for diagnOsis.BOne Scans can bc uscd tO evaluatc thcrapy with calcitOnin or ncw‐ generatiOn biphOsphOnatcs. Rcsponsc to thcraPy is indicatcd by a unifbrrII Or nonuniform dccrcasc in radiotraccr uptake.

A

秘 T w O P a t i c n t sa(nИ d )β refcrrcd with chcst wall Pain. 1. Describc thc bone scan indings. 2. Is thcrc a pattcrn to the abnOrinaliticsP 前hat causes should be consideredP 3. ｀ 4. Bascd on the scan andingS,PrOVidc thc rnOst likcly diagnoscs.

Notes

Sk●letal SysterTl: and Sternotomy 1.PaticntИf fOcal increascd uptakc in multiplc ribs PostcrO―

l a t c r t t l y a n d a t t ,h uc n cc tO is Ot nO sv ,e Pt at te ib er n狙t ユ increascd vcrtical lincar uptake in thc sternuJm frolm thc manubrium to the xiphoid.

2.Thc uptake in attaCCnt ribs(PatientИ )and thc vertic』 uptake in thc stcrnum both have a gcomctric arld charac_ tcristic PattCrn. 3. Trauma Or surgerye 4.Patient Иf multiPlc rib fractures.Paticnt a median stcr_ notomy for cOrOnary arter/bypass gratting(CABG)6 mOnths ago.

Reference Holder L,Browll ML:Ord10pcdic imaglng in trauma and sPorぉ m e d i c i n e , I n C 0 1 l i c r B D J L F o g c l m a n I , R o s e n t h夕 a″ l物〃 l L:院

″ ″ ご 彦″ ″物哲 務す ″ ″ ちSt Louis,1996,Mostt pp 225-239. Cross― Reference 対務び 彦″″Mcttcと″αr配 財 Q」慰 肥奄 Cd 2,pp 138-139. Comment lncrcased uptakc On bOnc scarls is nonspccinc.Howeve5 thc Patr tem ofuptakc call bc diagnOstic.CommOn polyostOdc Proccsses such as mctastases arc unlikely in these cascs.Metastases occur randoHlly and arc unlikely to inv01vc Only cOntiguous boncs. Occaslonallみthis can Occur with a largc pleural_based inass eroding into adiaCCnt bOncs,but then thc appearancc is not likely to bc lincai Thc pattern ofrib uptake represcnts an`Aunt Minnic''that is PathognOmOnic for fracturcs.Depending on clinical circumstanccs,the clinician may desire further radiO― graPhic evaluatiOn,but this is nOt neccssary fOr diagnOsis. AbnOrmalitics Otten arc dcpicted on bOnc scintigraPhy befOrc the deve10Pmcnt OfradiOgraphic changcs. AbnOrmalitics Of the stcrnum range frOm benign Or nant neoplasm tO infcctiOn and trauma.Thc linear naturc ofthe anding prttidcs thc indication that this is postOpcratlvc.Findngs indicating prcvlous lnedian stcrnotomy arc not an unconlI■ on occurrence on bonc scalls glvcn the prevalcncc OfCABG surger/9 1n somc PatiCnts thc uptake lnay nOt be deincd Or pcrtccdy lin― Cを L InfCctiOn superimposcd on Hledian sternotomy would bc a lcss likely cOnsidcratiOn;Osteomyclitis wOuld be exPccted tO Cx― tend beyond thc sharp linear pattcm to nonuniformly invOlve the rcmainder Ofthc stcmum.A[dmes thc starldard anteriOr and P O S t e r i o cr w宙s O f t h c s t e r n u m m a / n o t a d e q u a t c l y d c P i c t t h e indng bccallse OfOvcrlay ofthe stcrnllm wlth the thOracic sPinc. Shal10w anterior Obliquc宙 cws lnay be hclP飢 .

10

malig‐

A60-ycarr。

ld Paticnt with diabetes with ccllulitis Ofthc distそ

述 f00t,referred tO rulc Out Osteomyclitis Ofthc lctt great toc.

「 Ofcach Ofthe three phases. 1. Dcscribe thc Physi010勘 2. Describc the scintigraphic indings in this case. _ 3. IntcrPrct the stu、 4. ｀ 前hat is thc sensitivity and specincity ofthe three― Phase bOne scan fOr osteoIIlyclitisP

Notes

― Skeletal Systenl:Peda1 0steomyelitis― Three‐ Phase Positive l. First phasc:artcrial b100d aOw to thc bOne.Second Phasc: b100d P001 0r interstitial spacc distributiOn inllnediately f0110m「 ing[hcnN、 Third Phasc:bOnc uptake phasc at 3 h O u r s a F t c r i n i c c t i O n . A l i t h r e c P h a s e s l ay r c t y p i c a l l y f O c 』 increased with ostcOmycliris.With ccllulitis,Only thc nrst ア s、 o phascs arc POSitiVc. 2. Incrcascd nOL bl。。d Pool,and delaycd uptakc tO thc left arst digit distal phalanx. 3.Consistcnt with OstcOmyclitis Ofthe digit.Recent fracturc must bc cxcludcd with radiOgraph/3 4. Scnsitivity and specincity ofapprOxirnatcly 950/o lfthc radiograph is nOrmal or has Only suggestive changes Of osteomyclitis.

ReFerence PalestrO CJ,ThOmas MB:Scintigraphic cvaluatiOn Of the

diabetic f00t.In FrccHlan Lヽ 在:ミ悦ご ル″/物 夕 冴″ ご ″ ″′″″″″″′ 2θθa Philadclphia,2000,LippincOtt Wilharns 8てWilttns, PP 143-172. CrossPReference ハ物c↓ ca″ルク冴び ″ ″′ fE配 185-188,

父どQ3酎

こ 『S〕cd 2,PP 134-136,

Co】 mment Foot ulccrs frcqucntly scttc as thc POrta1 and OstcOmychtis in PatiCnts with diabetcs.Radlographic and― ings lnay be negative or shOw Only suggcstivc changes in early Phases.A ncgativc thrcc_Phasc bOnc scan rules Out ostcomyclitis with a high dcgrcc oF certaint/s AlthOugh studies are characteristic OfOstcOmyclitis,paticnts with vascular insufflciency may havc dccrcased now and b100d P001. Checttng for f00t warmth and pcdal puiscs can aid in intcr―

0fentry

for

infcctiOn

thrcc_Phasc

POSitiVe

prctation.A cold region in thc distal cxtrcinity in the setting of infectiOn suggcsts gangrcnc and nonviabili呼

Thc sPccincity Of thc threc― phasc scall can bc PrOblcmatic. DifFcrcntiating,oint infcctiOn from bOnc infcctiOn is important. With synOvitis,uptakc ttsccn h bOne On bOth sidcs Ofthc,dnt・ Good res01utiOn and Proper intensity sctting is llcccSSarye Any cause for bone rerIIodcling,c.gり hCaling fracture,orthOpcdic iJm― Pl狙

tS,and ncurOpathic OstcOarthroPatじ

may rCSultin a thに

c‐

Phasc POsitiVC SCall.RadiograPhs Ottcn dcmOnstrate these po―

tcntial probleIIIs.In thcsc cascs,radiOlabeled呼leuk。 cs can bc helP魚1.DiIFcrcntiating bOne frOm Overlying sott tissuc infccdon can somctimcs be dimcult with lllln Oxinc lcuko呼 es because of iは1lmited resolutiOn.99mTc hcxalncthyl― PrOpyleneaminc-Oximc PAO)OFFcrs aFl adVantage in such situatiOns,and (HM― SuC uPtake usually can bc distnguishcd frOni bOne uptake.

12

sOtt

tis―

が

比

chcst pain. Patient rcfcrred fOr bOne scan bccauscsided Ofright― 1. Dcscribe scintigraPhic indings. 2. Providt a differential diagnOsis. 7hat Othcr cxanunations lEay bc hclPful in this settingP 3. ヽ 4. N7hat is the ttkcly reasOn fbr Ordering the bonc scanP

Notes

Skeletal SysterTB:Abnormal Breast Uptake l.Nonuniforln abnOHnal sOft tissuc uptakc cxists in the sOft

dssuc ovenガ ng the chcst,1lkcけ in thC五 ght breast. 2.Breast canccL asc ptic or septic masti[is,Prihary skin dis_ case,such as PsOriasis,vascular or 1/mphatic ObstructiOn, radiat10n theraP/t 3. Brcast cxaminatiOn,manllnographtt and POssiblc b10Psye 4. TO detcH■inc whcther brcast cancer bonc rnctastascs arc PrCSent.

References Kopans DB: Breast imaging, ed 2, PhiladclPhia, 1998, Lippincott‐ Raven,PP 340-341,591. JaCObSOn A二

Fogelman I:Skelctal scintigraphy in brcast and

PrOStatc cancert past,Present,and Futurc.In Frcclnan L虹 , editor:A物す 務″″夕 ″β 冴ケ `ガ ″夕″″″″″′ゴ甥 Philadelphia, 1999, Lippincott Wlllialnsに 比Wll脇 ns. Cttss―Reference 助 び 筋″″Mcttci″4 TF/f京 どQSS 「 ES,cd 2,pp 124-125. Comment Breast uptakc on bOnc scans carl be a nOrmal inding.Thc grcatcr thc arnOunt ofuptakc and dcgrcc Ofasymmctry9 the morc likcly

a path010gical condition e対in this casc.Thc sts,as Oritymづ Of benign lcs10ns caused by abrOadenomas,maEImary dysplasia, and c/stic mastitis have bllatcral uPtakc.ヽ 在 alignan[uptakc usu_ ally is unllatcral.On furthcr questioning,this patient rcPOrtCd thatthc breast had bccn inaamcd for wceks and a b10psy had rc― cently bccn PcrfOrttcd.The cOmbinatiOn ofthc bOnc scan ind_ ings and dinical histOry limit thc diagnOSis to innalnmatory car, dnoma or mtttith lnnammtt。 り carcinoma(showll bybbPsyl consists ofdittsc carly invas10n ofthe derhallymphatics by an aggressivc form Ofinnitrating carcinOma.An undcrlyingpttmary rident.InnaHlrnatory carcinoma ls unconl― icsiOn inay not be(封 mon,comprising lcss than l%Ofinvasiモ brcast cancers.Its prOg― nosis is wOrse dlan iniltrating ductal carcinOIIla that has secOnd― arily invadcd the skin,SOft tissuc involvcmcnt by malignant neOplasms,cithcr pri mary or metastatic,may demonstratc ab" normtt uptake ofbOnc radiotr挺 ∝ The lcs10ns mOst commonly scen becausc Of the frequency of thc tumOr and its avidity for tracer arc Primary Or mctastatic brcast,lung,metastatic co10n canccL and neuroblastOma.

14

イ

！ ！ ！ “ ！ ！ ！ ！ ！ ！ ！ ！ 一 ！ 一 一！ ！

岬

！！！ 警

ギ

A2-year― old child has an abdollflinal mass. 1. Describe the scintigraphic bone scan indings. 2. Namc a likely Organ oforigin. , 3. mat is the mOst likely diagnOsis.

4. Is the currcnt exalrlination adcquate ror staging ofthe paticntt ilincssP

A

■

4. 1. Dcscribe thc abnOrn■ al bone scan indings in scanノ 2. PrOvide a differential diagnosis, 3. Dcscribe thc indings in scan,,a delaycd sPOt ilnage. 4. Explain the changc and Provide thc rnOst likely diagnOsist

Skeletal Systenl:Neuroblastoma l.Largc region ofnontlnifOrm abnOrmal soft tissuc uptake

skeretal systerYl:Extrarenal Pervis and Mobile Solitary Right Kidney

l. SOlitary right kidney with a prOmincnt rcnal Pcivis. prCdOFrlinantly in the lcft sidc Ofthc abdomen that aPPears to cross thc rnidlinc.Its boundarics cannot be distin― Incidental uptake at antecubital ittectiOn

guishcd

frOm

the

twO

kidncys.

2.Adrcnal gland.

sitc.

2. UrctcrOpeivic,unction obstruction or ObstructiOn sccon ary to othcr prOcesses,cxtrarcnal Pclvis.

3. NeuroblastOma.

3.The renal pcivis has drained and thc ttdncy is now seen infcrOnlcdial tO its prior 10cation.

4.No.

4.Imagc β was taken with thc Paticnt crcct,leading to gravity drttnage Ofを m CXtrarcnal pel宙 s.Thc ttdncy is mObllc

Reference (Ptotic)。 Bissett CS III,Strifc JL,Kirks DR:GenitOurinary tract.In 掩r k s D R , e d i t O物 ■ 物物′ 滋″ガび″ 物竹 グ 夕哲 咎 ed 2,BOston, 1991,Little,BrOwFl,pp ll10-1125。 Reference

Dunnick NR Sandlcr CM,Ncwhousc JH,Ct狐

Cross‐ ReFerence 対務び 力″″鴎 品品″α 軍 避 択野Q5慰

う 確極 Cd 2,P124.

:Ettθ θ″ゲ ″″協沈ユ Osさ cd 3,PhiladclPhia,2001,LiPPincOtt W■ 1liams 能 Wilkins.

Colnment Cross―Reference NcurOblastOma is a malignant mmor ofthe sympathetic ncrv― ハ物r力″″鴎 航 冴″4軍 醍 越 Qyrsr恥 ,cd 2,pp l15-116。 OtlS Systcn■ and occurs rnost frcqucndy in early childh00d.MOre than 85%of thc tumOrs sccrctc variablc amOunts Of catc‐ CoJmment ch01amincs and their rnctabolitcse Staging requircs detcrinina― This casc dcmons〔ratcs how a simple mancuvcr can clari争 tion of thc extent oF disease,nccessita〔 ing anatoHlical imaging scintigraPhic indings and eliHlinatc thc nccd fOr furthcr cvalu― 宙 t h C I M R I , a n d h i s t O 1 0 g i c t t e v a l u a t i O n o f t h c ation,Ifilnaging b O n e m a r r o Ⅵ had stOpped with thc full rcnal pelvis,thc dif― Thc Evans staging systcm is uscd most commonlン Stagc l dis― fcrcntial diagnOsis would havc included ObstructiOn and likely easc is cOnincd tO the strdcturc of origine Stage II discasc in― furthcr diagnOstic cvaluatiOn,Probably ultrasOnOg― promptcd v01ves tumOr cxtenslon in continuitγ but nOt across thc lnid_ raPhy and a diuretic rcnal scan.Rcview ofthc cOmPictcd scan line,Or tumors arising in the rnidlinco Stagc III diseasc by cxtends the physician bcfOre the paticnt icavcs the dcPartincnt al― in continuity acrossモ hC inidlinec Stagc IV discasc is dissenll‐ 10ws fOr tailoring Ofthc scan protocol,which can icad tO a mOrc nated discasc with mctastases invOlving thc skelctOn,sOft tis―dcinitive intcrpretation and avoidance Of furthcr unncccssary sues,distant lymph nOdes Or Organs.Stagc SIV― diseasc OccurS testing.In this casc thc anterior obliquc vicw、 vith thc paticnt in PatiCnts whOsc Prilnaり tumOr would bc stagc l or II but fOr crcct demonstratcs emptying of thc rcnal Pcivis.A postvoid mctastatic discase tO livcL skin,or bOne lnarrow but nOt theSuPine image aier thC paticnt rctumed from thc restrOom also skeletOn. would havc shO、 vn cmptying but would nOt have revcalcd thc Most ncuroblastOmas takc uP bOnc radlophaHnaceuticals rcnal mObility. w i t h v a r y i n g d e g r e e s . T h c i n t c n s i t y o f u p t a k c d O e s n OThe t c kidncys o r r e ― usually arc Paircd retrOperitoncal organs tha[ late with thc dcgrcc Ofrnalignancy or prOgnosisE Evcn Prirnary are oricntcd Paralicl with thc psoas musdcs On either side lc Ofよ tumors withOut radiographic evidencc Of calciflcatiOn Oftcn lumbar sPinC・ThC top of the kidncy is locatcd lnOre lncdial have incrcascd bone radiOpharIIlaccutical uptake.The bOnc than the lowcr portion.Howevci thc kidney can be rnObile, scan is also a sensitivc detectOr Ofrnetastatic ncuroblastOma tO and their POSitiOns lnay vary、 vith inspiration or paticnt POsi, bOnc and is abnOrl■ al wccks befOre rad10graphic changes are tiOn.This case is a good cxample of rcnal rnObility9 demOn― strated bccausc the imagc was obtained with thc paticnt in the prcsent.Thc cOmbinatiOn ofbOnc scan and 1311 1netalodOben― zylguanidinc(MIBG)htt the highcst scnsiti宙 ty ttr detcctiOn of supine and then crcct POSitiOn. bonc invOlvemcnt,and both arc used in cvaluating rcsPonsc tO thcrapyc Notes Notes

16

・

Pain in thc lcft shOuldcr;rulc Out mctastasis. 1. Dcscribc the andings, 2. Nalne threc general Processcs that cOuld accOunt for the andingS・ 3.wat iS the likelyprimary tumor fOrwhich mctastases are being excludedP 4. What is the rnOst likcly diagnOsisP

1. Describe the bOne scan ittdings. 2. Providc the gcncral classincation fOr this anding and the likely diagnOsis. 3. Nmc Other cOnditions that fallintO the samc sPcctrunl ofabnOrn■ alities. 4. Are increased risks assOciated with this cOnditiOnユ 17

Skeletai Systenl:Bone Abnorgnalities of Renal Skeletal System:Lymphedema Position l.The sott tissucs ofthe lcft arm arc cnlarged and show l.The nght ttdncy ls nOt sccn in the rentt fossa.Nonunttm abnorlnal increased soft tissuc activit/;the left anterior ribs it/1s nOtCd in the right sacr011iac rcgl叫 act市 ,which 釘c unttmけmott intensc than thc right. extends beyond thc cxpectcd suPcriOr rnargin ofthc bOnc.

2. Vcnous or lymphatic obstruction,soft tissue ncoPlasnl,

sott tissuc ttury. 3.Breast cancc二 4.Lymphedcma secondary to ax11lary lymph nOdc dissection and ictt mastectOmン

Reference Cray HW略 IttiasnOw AZ:Soft tissue uptake ofbonc agcnts.In 夕 ″物′″ヶ C01lier BDJ5 Fogelman I,Rosenthall L,editOrs:説 江 oFbtt pp 386-389. ど 務″″z2cあct″ らSt Louis,1996,ぶ Reference Cttss‐ 脇 f筋″″鴎 品冴″4「鵡 沢どQyrsrr蕊 〕cd 2,PP 122‐123.

2.Congcnital renal anOmalン Pelvic kidneye 3 . A n o m t t i c s o f n u m b c r ( s u p e r n du nm c yr la ,r P/ o路s i t i O n (malrOtation),or ttS10n(hOrscshOc).

4.Yes.UrererOPcivic,unctiOn obstruction,vcsicOurctcr狙 rcni返 ,dccrcascd ttnction,incrcascd risk oftrauma.Urinc stasis rcsulting frorn distorted anatOmy increases thc risk of onc forrllatlon. s〔

ReFerence

″″ガ″ ″り 物務― い滋 働″ガ Smithヽ Tung GA,Zagoria RJ,MayO― 8. θ ttν す務夕竹夕,s,絡 , St LOuis,2000,Mosb卜 PP 55づ CrOss,Reference 醍 ″ ″資 軍 力″″協 冴び 対″ご

京どQ3慰 「ES)cd 2,PP 142‐ 143. Comment sualization of thc The combination Of indings ofincreased宙 anterlor ribs and soft tissuc uptake in an enlargcd upper Comment ex― tremity is essentttly an`Aunt Minnie"forlymphcdema as a rc‐ Renal anOmalics involve thc following factOrs:(1)numbeL which includcs agcnesis or thc cxtrcmcly rarc condition OFsu― Other sult ofaxillary lymph n9de dissection and mastcctomン causcs of lymphatic or venous obstruction should be considr pernumerary kidncy;(2)PositiOn,which includes s lon,which includes horse― malrotation,and cctoPia;and(3)飽 cred,such as priOrlymphadcnectomy for melanoma,tumor rc― fuscd cctoPia.Rcnal ectOPia iS an anOHl,

shOc kidttcy and cross― lymPh nOwj or prlor in― aly that arises frOm altcration of the nOrrnal caudal to cranial movemcnt Ofthc kidneys during dcvclopmcnt.Undcrascent is to thc arln that muCh Ⅲ Orc cOmmOn than ovcrasccnt(whiCh gives risc to thc electrical,frOst― ly prO宙 de ttdncyl.In usu』 bite,Orcrush itturies,arc considerations but arethOracic sccn much icss thcse cases,adiaccnt VCSscls c c t o p i a m a ye bRcc na』 s‐ t h c b 1 0 0 d s u P p l y t O t h c e c t O P i C t t d n c y frequcndy. sOciated with anOmalics ofnislon and contralatcral renal anom― the axlllary lymph node dis‐ In Patients writh brcast canccら ofthe kidney rangcs frOm pclvic ttdneys that ly is considered to be primarily diagnostic.It alies.Undcrascent is scction gcncr』 lic in the truc Pelvis,in thc iliac fbssa oPPositC the lliac crcst,t controversial whcther surgical excis10n of involved nOdes alsO 10carion in the lowcr abdomcn but nOt at thc cxPcCtCd lcvcl ad― provides a therapeutic bcncnt.HoweveL associated rnorbidity is

Placcmcnt Oflymph nOdcs causing obstructlon to or venous bbstruction frOm idiopathic thrombus dwclling cathctcL PrOCesses prilnarily rclatcd cOuld causc this apPcarance,such as sarcoma or

associated with cxcls10n,Which incrcascs with thC Cxtent of jacent tO L2.Normal pelvic kidncys do nOt have thc same ap― 島‐ lymphadenectomye The paticnt may expettence transient or止 PCarance As nOrinally 10catcd kidncys becausc ofvariablc dc― 10ng discomfort,abnOrmal scnsation,orlymphcdema as in this grecs of rOtatiOn and alteration in thc calices.Pcivic kidneys Patient.Lymphedema in the iPsilatertt arm devcloPs in 15%of u s u a l l y a r c a s y m p t o m a t i c , a l t h O u g h t h c r e a r c i n c r e 4 S women with breast cancer aFtcr thcrapyt This complication may nOted. 島scd cctoPia is an uncommon congcnittt anomaly in Cross― 筑ed tに with lumPcctomy and ra― be slightly highcr in wOmen which one diation than ih Patients whose discasc is staged with scntincl lddney crosscs thc rnidline and fuses writh thc OPPO, s i t e t t d n e y j s o t h a t b O t h k i a n e y S l i e o n lymph node procedurcs Howcvci its uretcr inserts in thc normal pOsition,but extends across the IIlidlinc tO cntcr the bladder on the sidc oppositc to Notes the kidncye Fuscd kidncys usuttly producc no symptoms but are susccPtibic to thc cOmplications sccn in other ectopic lddncys. Notes

18

A67-ycar―old man has an elcvatcd serum prostatc― spccinc antigcn(PSAl lcvel. 1.Describc the indings On this bone scan and interpret the studン 2, W7hat wOuld you predict thc seruIII PSA level tO beP 3.Which metastatic cancers have prcdominantly lytic ics10ns in bOnc alld thus 10wer scnsitivity for their detectiOn by bOnc scanning'

4.Ifa Paticnt With prostatc cancer has a signincantly clttted scrum PSA icvcl pOstOPcratiVely but negativc bone sca indings,、 vhat other ilnaging options arc indicatcdP

19

Notes

Skeletal SysteHl:Metastatic Prostate Cancer l.AbnOrm』 偽c』uptakc throughout the axial and appcndic‐ ular skclctOn strongly suggestive ofmetastatic discase.Thc

secn usu組 with iatc― many distal appendicular icsiOns けare stage discasc, 2.Considerably gにater than 20 ng/ml.Thc Prcvalencc Ofbone scall― evident rnetastascs is icss than 10/O below this ievel. 3.

ved by thyroid cancett renal ccll Multiplc mycloma,fO110、 carcinoma,lymphoma.

4.

CT and MRI have a poor sensitivity for detcction of prostatc cancer soFt tissuc/nOdal IIletastascs,less than 20%. An lllln ProstaScint study is indicatcd.

Reference JaCObSOn A二

Fogelman I:Skelctal scintigraphy in brcast and

在 , PrOState canccri past,Prcscnt,and future,In Freeman Lヽ 冴″″″″″″物 〃ゴ cditOr:物 並住″%7夕 身 99,PhiladclPhia,1999, LiPPincott｀ WilliaHls tt Wilttns. Cross― Reference す ″α r配 逆 Qむ亜 r蕊 〕cd 2,P122. 対物力″″厖 〃ルブ Comment Bonc scans arc vcry sensitivc for dctcction ofbOnc metastascs in most canccrs,500/o to 800/o rnore scnsitive than radiOgraphs. Fttγ Pcrccnt ofthe bOne mineral content must be 10st bcfore a metastasis is detectable On x,ray nirns.Although bone scans arc not routinely indicated in Patients with PSA lcvcls icss than 20 ng/Ell,bascline scans are appropriate in Patients with high Gleason scores,skcictal symptoms,abnormal radiographic indP ings,and Paticnts with PrecxiSting skclctal cOnditions that mlghtに nder interptttation ofscans difncult.Patients with PSA levels greatcr than 100 ng/mlinvariably have wide sprcad skclc‐ 立Ons arc in the ttt irlvOttemcnto Eighty perccnt ofmetastaticに axial skeleton.In Patients with knOwn mctastases the incidcnce OfextrcHlity or skull inv01verncnt rises to 50%. Thc scnsitivity ofthe bone scall for dctcctlon ofbone leslons 0%)bc― causcd by multiPle myc10ma is considcrably lowcr(づ cause these leslons arc often lytic,1.c,,Predominantly osteor dastic,Bもne scans are used to deteHninc the cfFcctivcness of thcrapンalthOugh serum PSA lcvcis are increasingly used for dlis purposc.Noncthcicss,the bone scan still ls useful fbr thc evaluation ofsymptOmatic Patients or when a changc in lnan― agemcnt is contemplated.Thc scrum PSA level may nOt be as One stuけ usefulin Patients who havc had hormonal thcrapン fOund that 3う %ofPatients recciving antiandrOgcn theraPyWith deanite nletastatic discasc had norinal levels ofPSA.

20

A

B

C

D

俳■ ！ ■ 十控 ！ 〃 Patient with brcast cancett Thc scrial bOnc scans are datcd as f0110ws:И ,4/97;a5/99,c8/99;五

あ4/00.

1. Dcscribc the bOne scan indings and changcs over tirnc.The 4/97 scan was complctely nOrinal.

2. ｀ 前仇at is thc llkclih00d OftumOr with ncw 10cal uptakc in a singlc rib in a paticnt with knOwn canccrP W7hatis th likelihOOd with ne、

v s01itary sPinC ICS10nsP

3. Wマhat are diffcrcnt gencral scan pattcrns in lnctastatic diseascP 4. ヽマhat is thc cause of the rclatively cold defect in the left hcIIlithOraxP

21

Skeletal Systenl:Breasi CanCer l.え New incrcascd uptakc at T7 susPiC10usC for tumo、 urth五ght rib, muitiple ncw icsbns h thc thoracic sPinc,島

1 c ttCus skull劇 left sacrum,and ttn」 in thc antcrior s t r o n 」y s u s P i C 1 0 u S f O r t u m o 、 2 c o n t i n u c d P r O g r e S S 1 0 n

with ncw tumor sites in the sPinc and ieft sacrum and new fOcal uptakc in left iliac crest,right intcrtrochanteric femuL and right acetabulum. 2. Lcss than 200/o,greatcr than 40%. 3.Solitary fOcal les10n,multiplc fOcal lcs10ns,dinttsc involvc― ment(suPcrSCan),cold lcslon,soft tissuc uptakc,narc phcnOmenOn. 4.Brcast prosthesis.

Reference JaCObSOn AR FogelHlan I:Skeletal scintigraphy in breast and

在 , prostate canccri past,prcsent and future.In Frccman Lヽ 品冴″′″″″ク″ブゴ ″と タタ2 Philadelphia,2000, editor:ミ悦並範″夕 Lippincott Willlarns ttt Wilttns,pp 121-156. Reference Cttss― ″ ″′ :「醍 沢どQじ蕊 孤 ,ed 2,PP l17-123, 助 び 務″″脇 冴び Comment Bonc scans in stagc l and II brcast canccr have a 10w yicld and generally are nOt,ustined,except for paticnts with POOr progr nOsis stage H diseasc(tumOr>3 cm or with aggrcssivc histo― Mith later stagc III and IV discase,bonc scans 10gical indings).｀ uP bone scans usually arc Obtaincd.Bccausc routinc fol10w‐ ly arc havc no dcmOnstrated efFcct On suttiv狙 ,bone scans usu』 reserved for PatiCnts with specinc bonc symptorns and those with radlologic andings suggestivc ofmetastatic discasc.Bone scarlning is also used for evaluat10n Ofpaticnts with symptoms, nal labOratOry test results worrisomc Physical indings,abnorェ Or radiOgraphs,becausc cvidencc Of new or prOgrcssiw mcta― static discasc is likely to result in institutiOn Of new Or addi― tional theraPye The nare phCnomcnon is seen in patients whO havc had a ThC Scan Parado対cttly aPPcarS gOodに sPonsC tO ChemotheraPy・ onttly leslons t h P r l o r i c s 1 0 n Ps r Om mO iにn e n t o c cl 容 worse,宙 verc not prcscnt on prior scans.Thc rcason fOr arc sccn that、 this inding is that the bOnc is demonstrating an osteoblastic rCParative resPonSe,Patients rnay have incrcascd Pain with the onsct of chcrnOtheraPンbut typically thc pain resolvcs bcfOrc the scan is Obtaincd.The incrcased scan uptakc rnay be seen for 2 to 3 months attcr chcrnOthcrapy and rrlay alsO bc scen with radiation thcrapン

22

A

ギゑ B

B e c a u s e o f,aa“ t wr cu rc ct i o bn t aβi n e d i n t w O w p r O b l e m , " a b O n c s c aann dω a b o n c s c a n a n d C T - 3 0 r e c o n sり childrcn. 1. Dcscribe thc bOnc scan andingS・ 2. Httat additiOnalinformatiOn would bc helPfuIP 3. PrOvlde a shOrt diffcrential diagnOsls. 4.Thc mOthcr says thcrc is nO knOwn disease in thc child`り

Or famllye What is thc mOst likely diagnOsisP

23

Notes

Skeletal SysterTl:Fibrous Dysplasia l . Иs h o w s i n c r e a s c d u p t a k c isnh otwhse c n t i r e intensc increased uptakc in thc mandible and lnaxllla, vn. which aPPcar deformed and overgrO、

m a n d i b l c . β

2. Check thc rcst ofthc bOne scan lor other sites,obtain a

histOry ofknOwn underWng Or familial disease. 3.Fibrous dysPlasia,cherubism. 4.FibrOus dysPlasia.

References 力gf筋 夕″夕″が な,ed 2,St Louis, ″力 ″務θ Blickman H:Pe品 1998,ふ江osbンPP 220-221. 物″ 脅gf筋 夕″夕″なカタ ″タ ル物′″ ず び ″あ∫ ,St Louis, Sartoris DJ:兄物∫ 217. 1996,Mosbン PP 216‐ Cttss‐Reference ″α 「 避 ″ ″″″%妨 び 助 ご

沢どQむ 慰 FES,cd 2,pp 139‐ 141.

Comment Fibrous dysplasia is a common congenital,nonhereditary skcler tal disOrdcr of unknOwn Origin.It is characterizcd by a devel― opmental anOmaly of bone formation in which the marrOw is たplaccd by ibrOus tissuc.Fibrous dysPiasia Occutt during Pcri― n and ad01cscentt and siowly Ods ofbone growth in 01dcr childに avc PcrCent of cases are monostotic. cnlarges for life.Seventy‐ Other frcqucntly affccted sites includc thc proximal fcmur (35%),tibia(20%),and faci』 bones and ribs(15%). S d c r o t i c t h i c k e n i n g c a u s e d b y i n v O l v c m c n t bo of nt eh se f a c i 』 ')。 facざ Cherubism is resembling a lionる is called lcontiasis ossea(“ a rare but diIFerent entity and rcsults in bilateral swelling in the

,智宙th multi10bular cxPansle bone leslons,which may simdate platta, n b r o u s d y S J a S L ・H o w c v c ら i n C O n t r a s t t o n b r o u s S Ⅲ

chcrubism is a famlliar disordci Skclctal dcformities also call oc‐ cur as a result ofrePcated Pathological fracturcs。 CT is most useful tO dctcrmine the extent ofinvolvcmcnt in a particular skeletal reg10n.Idcntincation ofPo17ostotic in‐ vOlvernent is onc ofthc main indications for skelctal scintigra‐ Phy bccause lnany of thcsc sitcs are asymptomatic.Hypcr‐ trOPhy of sott tissucs and boncs can bc scen in severa1 0thcr cOnditions,including neurOflbromatosis,InacrodystrOphia Trこ naunay‐ Ncbcr dis― lipOmatosa,hcmanglomas as in XlPPCl― casc,and lymphanglomatosis.

24

B

POSte問 oF i十 ■

林≡ ■

聯

＝鳩研 十 培

1. Dcscribc the indings in patient ,И 2. Describe thc indings in patient β . 3. PrOvide thc rnOst likcly rcasOn fOr this appcarancc. 4.ExPlain thc mcchanism fOr thc scan appearancc.

25

Notes

Tlaceuticat Skeletal SysteHl:Radiophar「 infiltration,ScatteL and Lyrnph Node Uptake l.Intcnsc uniform activity in the soft tissucs ofthc distal left f O r c a r m a n d f o c ia tl / ia nc t t市h c l c t t a x l l l a , n O n u n i f O r m activity in the lett latcral buttOck. activity indicating 2. Intensc activity in thc leftnear f00t,止 lymphatic channcls,arld lcft inguinal lymph nOdc.Scattcr is secn latcral to the lcft foOt. 3. Partlal extravasatlon ofthc bone radlotraccr at the sitc of

intravcnous ittcCt10n in thc lcft fOrearm. 4.DcmOnstration ofan axillary lymph nodc bccause oflym― phatic clearancc ofthc cxtravasated radiopharinaccutical. Scatter frOm thc arm innitrate rcsults in apparcnt(but unrcal)incrcased activity in the buttock.

Reference McAfccJG,Reba RC,Mづ

dM:The musculoskclettt system.In

Wagncr HN,SzabO Z,BuchananN cditO応 :身ヴ″ゥ あ ゲ ″ケ “B Saundcrs,p991. ″ ″ちcd 2,PhiladclPhia,1995,や 冴″ す 並住″物琢 Cttss―Reference 忽 TF/fttQy/SrrES)cd 2,p20. 脇 び 力″″Mcあ cと Colmment Ab■ Ormalitics relatcd to inicCtiOn techniquc are not uncom‐ m o n a n d v a r y f r O m f a i n ti lt y va it s it bh le c s ai ct tc 市O f i n i c C ― t10n to the appcarance in this case.Ifan cvcn larger portiOn of thc adHlinistcrcd radiophaHnaccutical was inflltratcd, thc demonstratlon ofbOne structurcs could bc rcduced at thc tilne

Of rOutinc imaging(3 to 4 hOurs atter ittcctiOn).Thc innitra_ tion serves as a radiopharmaceutical rcscrv01r with s10w ab― thC Central dr― sorptlon thrOugh the lymphaticstodtimateけ culatiOn,such that rcnal clcarance also ls dclayed.A rnixcd venOus ittcctiOn or solely artcrial iniectiOn occaslonally artcrial― occurs and is showFl by thc artcrial distribution of radiOtraccr vhich is nOt cvidcnt in this casc. distal to the in,cCtiOn sitc,、 Local skin cOntanlination at the sitc Of inject10n(PcrhaPs a on thc leak/hub on the syringc)could result in intensc ity act市 fOrcarm and scatter artifact,but demOnstrat10n Ofalymph nOdc wOuld nOt Occur itt that sctting.

26

TwO Patients have 10w back pain.Paticit has И b100d P001(le丘 )and delayed images(right)avallablα fOr Paticnt a only dclayed imagcs arc shown. 1. E)cscribc the bOnc scan abnorlnalitics. 2. Providc thc diffcrential diagnOscs. 3. List threc Othcr sites that are at incrcascd risksamc Iも process. r the

4.村恥at is the mOst likclyngundcriガ proccss in bOth patientsP

27

Notes

Skeletai Systerrl:Sacral insufficiency Fracture l has incrcased blood Pooling and delaycd uptakc l. Paticntノ

bilaterally in the reglon Ofthe sacrolliac,OintS and across the sacrum(H Pattern).The bOnc scan for Patient β dcmonstratcs abnOrmal incrcascd radlotracer in a curvilin― car lincar pattern across the lower sacrum. 2.Both Ofthesc arc diagnostic ofsacral insumcicncy fractures, 3,PrOximal fcmuち

wrist,and Proximal humcrus.

4. OsteoporOsis.

ReFerences び ″あ た務 物〃物 ″ 笹 務″物 あ ガ Sartods DJ:丹あ∫ れ St LOd島 1996,Mosby9 P 14. BttscirOJ,Brower AC,Zessman HA:Scintigraphic diagnOsis of

マ ″ s a c r a l f r a c使И t u r物 eノ sR,θ 孔 ィ F ″冴1 4 8 : 1 1 1 , 1 9 8 7 . Reference CrOss‐ 鵡 わα 「 力″″協 ″び 助 び

沢どQyrs/FES,cd 2,PP 138‐ 139.

Comme正 InsuFncicnげfracturcs are an important and common cOmpli― catlon of ostcOporosis,a condition resulting frOm dirninishca bone quantity that is sccn most commonly in Postmenopausal w o m e n , b u t t t s o i n P a tWiietnhほh y p c r P a r a t h y r O i d i s m a n d t h o s e rccciving stcrOid therapy.In lnany cases,fracturcs occur with related minimal or nOモrauma.Common sites of osteoPOrosis― vcrtcbral bodics,femOral ncck fractures outsidc the Pcivisheare〔 and intertrochanteric rctton,diSttt radius,humeral ncck,PrOx― lmal and distal tibia,and stcrnum.Bone dcnsity studics are uscd incrcasingly to prcdict fracttlre ttsk in POstmenOpausal wOmcn or paticnts at incrcascd risk ofosteoPorosiS・ luccncy ofaffccted bonc,frac― Bccause ofthc incrcasca radl。 on radiOgraPhs.HowcvcL usu― tures may bc dittcult to identiけ 狙ly thcy are easily detectablc on bone scintigraphy because of ity ofbOnc scanning for identincation ofsitcs of thc high sensit市 increased bone turnovcr and ostcoblastic activity9 1nsuttciency 島actures in the Pclvis typicttly invOlvc the sacrum,symphysis pubis,Or pubic ramio Sacral fractures arc associated with ' char― acteristic bonc scan aPPCaranCes,such asthc H Or``Honda sigポ indicating vcrtical invOlvcIIlent ofsacral ala and hOrizontal in― volvement Ofthe sacrum(an`Aunt Minnicル ).Portions ofthe H may only be secn at times.Another coHllnon pattern is that Of n caa“ ち dOt and dasr)appearancc as seen in case n l i n c a r 2 1 cl ui 郎 induced fractures can have a 焔 er pelvic radiation,radiation‐ simllar appearancc.

28

堅

檻

An eldcrly woman with a histOry ofpriOr right hiP ttacture cOmcs to thc emergcncy dcPartmcnt becausc Ofpelvic Pain and inability to walk.A bOne scan was obtalned。 1. Describc thc scitttigraPhic andings, 2. W7hat is the differential diagnOsisP 3.What is thc mOst likely diagnOsisP 4.Namc three medical cOndit10ns that prcdisPOsc Patients tO thiS underlガ

ng diSeasc PrOCess.

29

Notes

Skeletal SysteHl:Muitiple insufFiciency Fractures iple fOcal arcas ofincrcascd radiotracer uptake arc l.Mul〔 nOted in scvcral ribs,multiple sites in both pubic ralni, 10wer sternurn,and lnuitiple vertebra. 2.MultifOcal involvcinent by benign or malignant tuELOrP multifOcal ostcomyelitis,fractures. 3. MultiPle insuttciency fractures,Degenerative changc is 血 charlge PにSCnt in the right shoulder and Postoper筑 にlated to prcvlous right hip orthOPcdic nxation. 4.H/Pcに 。rtisolism,hyPcrparathyroidism,hyperthyrOidism,

Reference Fernandez‐Ulloa M,Klostermeier T工 Lancaster tti OrthO― 物あ 助 冴鴎 札 Pacdic nudear medicinαthc Pchtts and hiP,最 28:25-40,1998. Reference Cttss‐ 醍 沢どQttrtts〕 ガ ″資 「 助 す 筋″″%″ ど

ed 2,PP 138‐139.

ComHlent C)steoPorOtiC insuFnciency fracturcs coHllnOnly Occur in the pelvis,vertcbra,hiP,wrist,proximal humerus,ProXimal and distal tibia,ribs,and sternum.Although lnultiPle bone abnOr― malities may suggest tumor metastascs,c10Se review ofthe char_ actcr and locatiOn of thc nndingS usually lcads tO thc cOrrect diagnosis.Thc sPinc abnormalities have a linear appcarance that suggestt fracture(cither wedge compresslon fracture or verter b r t t ePnlda―t e d e f O r m i t y l . T h e r i b a b n O r m t t i t i e s O c c u r i n t t a ― ccnt ribs in a lincar pattern that strOngly suggests fractures. None ofthe sites Ofincrcascd uptakc havc a Pattern tO suggcst Other causes,such as a susPic10us scgmental or reglonal abnor_ ■lality in onc ofthe long bones Or nat boncs.C)stcoPorOSiS risk factOtt include femttc gcndctt family histOry of osteoPorOSiS, c s t r o g e n d e n c ci ic un mc y d2 e nt c』i e n c y 9 1 0 w b o d y w e i g h t , s e d e n _ tary littstylc,aIIlenorrhea,and smOttng・ Insuttciency fractures usually arc nOt scen on foutinc radiO― graphs.BOne scanning a1lows localization Ofthcsc fracture sitcs becausc Of its high sensitivity for sites of increased bonc turnovei CT can be used tO connHn that these fOci Of uptake are indeed ttactures.HowevcL thc pattem usuttly is quite char― acteristic on bone scans,Fractures ofthc Pcivis invariably rcsult in at icast three fracture sites,This Pauent .Sacral has atlcast s破

haVe htensc uptakc h sacrolllac hs面ciency島 抵tures typicalけ ,Oint arcas and sacrum(H Pattem).CareFul analysis of this PatiCnt alsO suggests sacral fractures.

30

rti° nal chcst Pain ha← singie phOtOn elniss10n cOmputed tomOgraphy(S a stress 盆,:を 占 岳 営 霊 鮮 !::i蚤 Iilを 督 た 号 、 1. Dcscribe the perfus10n abnorェ nalities and give yOur interpretation. 2. Nalnc thc culprit vcsse1 0r vcsscls. 3. List any ancillar/scan andings. 4. List clinical indings related tO the strcss tcst rCleVant tO interprctation ofthe scan.

A60-year-01d maII with a histtry ofrelnOtt myoGttКand CABG surger/3 EchOcttKttOgraPhy resultt 止狐infarct . wett nOmユ 1.Destribc the SPECT andingS・ 2. Provェ de the differentlal diagnOsls. 3.Give

thc

mOst

likcly

diagnosis.

4.ExPlain the discrcPancy beぃ Ⅳccn the cardiac cchOcard10graln and thc SPECT scan. 31

Cardiovascular SysterTL:Left Anterior Cardiovascular SysteHl:Apical infarct severe aPictt latcrtt perttsiOn Descending Artery ischemia l.Fixcd strcss作 ガ and rcst r/Jヴ dcfcct ofsmali sizc.Hcart and cavity sizc appcar normal. l.Scvere decreascd Pcrfusion in the mttOrity Ofthe anterior wall,apex,and septum,which nOrmalizcs on the rcst iinage indicating extensivc scvcrc ischenlia. 2. Lcft antcriOr desccnding(LAD)corOnary artcry. 3. Transient cavity dilation.

2.Myocardial infarctiOn,aPiCal thinning,attcnuation. 3.Small apical lateral sca■ 4. Tcchnical factors,OPcratOr crroL interprctation errO丘

rclated ST― scgmcnt 4.Ventrた ular tachyarrhythmias,angina‐ itics,decrcasc in systolic blood pressurc,lcvc1 0f ReFerence abnorm』 Yao SS,Rozanski A:Myocardial perfusion scintigraPhy in cxercisc achicvcd.

Strett prognostic ,unCtiOn with cxcrcisc and cpharmacolo事

Reference Yao SS,Rozantt A Myocardal Pcr的 豆On scintigraPhy in cOn‐

junction with exercisc and Pharmacologic

aPPlications in the clinical lnanagcment of Patients with coronary artery discasc.In DePuey EG,Garcia EM Berman DS,editOrs:て物rあar SPFCrブ 物″ 脅津 cd 2,Philadclphia, s2001,Lippincott t r c s s : p r o g n oWilllamsに s t i c 比Wilkins,PP 263,296.

applications in thc clinical lnanagemcnt of Patients with Cross― Reference coronary artcry discasc.In DePucy EG,Garcia EM Bcrman 醍 沢どQむ慰 『 蕊 )ed 2,pP 76,79. ″α 軍 A物材物″Mcあ cと DS,editOrs:6″rttar ttECrブ物″ 竹浄 ed 2,PhiladclPhia, 263-296. 2001,LipPincott Wllliams Windns,pp Sこ Co』mment This apic』pcrttslon dcttctin a man is unttkely to bc causcd by Cross‐ ReFerence attenuation,even with gynccomastia,bccausc ofits scverit/and ブ ″″ E醍 択どQd慰 孤 ,ed 2,PP 78-79. ″″″脇 妨び 助 び sharp dcmarcatiOn.Thc appearancc ofaPical thinning is rclatcd In a normal― tO thc normal lesser myocardial mass at thc aPcx・ Comment Although stress myocardial Perfus10n studics are sensitivc forsizcd heart,apical thinning IIlay bc secn on thc horizonta1 long‐ axis and axis vicw but rarely is cvident on thc vertical 10ng― detection Ofcoronary artery discasc(CAD;85%to 90%),the s e n s i t M t y f O r d i a g n O s i s o f m u i t i v e s s e l d i shOrt― s c a saxis c iviews,as s i c s sin . Ithis s c hcase.With e m i a i nventricular dilation,api― thinning bccomcs lnorc PrOnlincnt and inay be sccn on muitiPic vascular distributions lnay nOt bc cvident on thccalPcr― axis slices.HOwevett this vcntri― fuslon study bccause the mOst scvett leslon prOduccs sympto― morc than thc horizonta1long‐ cleおnOt dilated.A3狂Cd W』l mOdOn study wodd be helPful. matic ischenlia and exercise is discontinued bcforc PrOducing th an infarct.A scPtal Wali motion ab― APical akinesis is seen胡 ia in myocardial reglons Ofless discased vesscis. ischel■ nOm』 ity(hypottnesis Or dysttncsis)might be cxpelted in this induced 201Tl uP― BOth transicnt ischemic dilation and stress― take are important indicators of rnultivcssci discasc.Stress― PatiCnt becausc of his Previous CABG surgcrye The subdi― ity,tlSt infcrior to thc hcart suggests that aphragmatic liver act市 induced leFt ventricular cavity dilatiOn is apparent by compari‐ g C S . T h i s i n d i n g i s o f t c n tthe h e patient had either Pharrnac010gical stress or inadequatc ex― a n d r e s t ri/mJa″ s O n O F s t r c sガ s作 scera crcise.Exercise shifts blood nOw away from abdominal宙 result Ofan actual increase in the left ventricular v01ume,indir tO thc cxcrcising rnuscles. induced ventricular dysfunction.Howevc与partic― cating stress‐ Echocardlography is Operator dcPendent,and strcss echocar― are uscd, ularlywhcn 99mTc-labclcd myocardial perttsiOn agcnほ dlography cvcn mOre so.OPerator鏡 1ls and ettrt On a given this flnding inay rcPrcSent diffusc subcndOcardial ischcFnia thOSC can aFFcct the ttsults.In somc PaticntS,Particularけ rather than actual incrcased cavity size.Trallsicnt cavittctte dilation ationdila〔 and corrclates with chronic obstructive pullnOnary diseasc,the acoustic win‐ es is called transicnt ischernic solmctin■ dow may bc suboptimal and limit thc cxaminatibn.Normal with signincant and ustally multivcsscl CAD. wali mOtiOn or hyperkincsis ofthe attaccnt myOcardial rcgiOns T scgment Anginal― typc chest pain and dcPrcss10n Ofthc ST‐ 1la. can Obscure a small hypokinetic scgment of myocardium.In on ECG cvaluatiOn during stress are suggcstivc Of ische■ this case in which the perfusiOn abnOrmality is small,it is not Indicators ofscvcrc ischcHlia includc a dccrcasc in thc Paticntも cgment surprising that it was misscd by cchOcardlograpけ s y s t o l i c b 1 0 0 d P r c s s u r e , 2 , m m o r Tm owraev cS Ts― dcPrcsslon,and ventricular arrhythHlla(frequcnt prematurc Notes .Thcse indings ventticular cOntractions,ventricular tachycardり are reasons to stop the exercisc,ifPOssible,preFcrably l minute

益cr the stress ittCCtiOn to a110w timc fOr radiopharlnaceutical hagnOstic imagcs can still be Obtained. uptake so that〔

32

Dual―isOtOpe stress SPECT myocardial Pcrfuslon stu(け 1.Describc the variOus imarging protocols uscd fOr 99mTc myocardial pertts10n traccrs.

― おotOPc 2.What radionuchdes att used ttr stuⅢ aP du狐 isOtoPc stuⅢ 3.List the advantages ofthc dual,isotope techniquc cOmpared with a single― 4.Dcscribc thc SPECT andingS and interpret the studン

Notes

lsotope StudyL一 Cardiovascular SysteHl:Dua卜 Mild inferior ischerYlia l. TwO‐day strcss/rcst;samc― day rest/stress,samc‐ day strcss/rest. 2.201Ti ch10ride fOr rest;99mTc scstamibl or tctrofosmin fOr strcss. 3. The dual―isOtOPC tCChniquc rcquires a shortcr timc to

11-mOtiOn asscssmCnt and cOmplctc thc cxaminatione W乞 gatcd SPECT arc available 201,「 i can be uscd tO asscss viabllit/.

from

99mTc

Perfus10n

4.NItild decrcascd infcriOr wall pcrfus10n at strcss with mlld improvemcnt at rcst.Mlld inferiOr wall ischcmia(right coronary arteryl。 (Livcr activity on the stress images sug― gests pharmac010gical stress.Normal blllary cicarancc is

PreSCnt on pro,cctiOn imagcs.) Reference B c r m a n D S , H a y c s S ⅥG c r m a n o G : A s s e s s m e n t o f m y o c a r ― dial PcrfusiOn and viability with 99mTc PcrfusiOn agcnts.In DcPuey EG,Garcia EM Berman DS,cditOrs:ar抗 残び ぃ こcr″ 物々gグ cd 2,Philadclphia,2001)Lippincott 宅浄 Wlllla1ls tt Wllkins,pp 179-210. Reference Cross― ″ ″αE軽 択どQS慰 助 び 力″″丹々妨び 392-393.

孤 ,Cd 2,pp 66-72,85,390,

COmment Various imaging protocols arc uscd fOr 99mTc myocardial pcr― fus10n scans.DeFcct cOntraSt and imagc quahty arc supcrior with the 2-day protocol because bOth scans arc obtai■ cd aftcr thc iniccdOn Ofttgh dOscs Oftraccr(20to 30 mCi).HowevcL this study ttquircs a 2-day padcnt宙 韻t.A samc―day low― dosc rcst/high― dOse stress protocol frequently is uscd.Its disadvan‐ tage is reductiOn in strcss dcfcct cOntrast caused by PcrsiStent radiOact市 i ty ttom thc rcst stuけ at thC dmc Ofthc strcss scan. Samc― day low― dosc strcss/high― dOsc rcst protocolsに quirc a scan interval similar tO that fOr 201Ti scans;thus it is practical in lab_

oratorics whcn both typcs Ofstudics rmCd rou_ arc bcing Pcrゃ tincly.HowevcL it has icss than ideal count ratcs from thc strcss iinages becausc Ofthc 10w adIIlinistered dose. TwO scParate,rather than silnuitancOus,acquisitions arc rcc― ommended for dual― isotope studies bccausc Of 99mTc dOwn_ scatter into the 201Tl wind01既Bccausc 201Tl irnaging is pcr―

fOrmed bcfOre injection ofthe 99mTcvnscattcr agent,do、 is nOt l dOcs not contributc signincandy tO thc 99mTc a prOblcm.2011「 I PhOtOPcak and thc much window becausc Of thc 10wcr 201'「 highcr dOsc Of 99mTc.Bccause imagittg begins by 10 Hlinutcs aFtcr 201Tl inicctiOn,thc ttsystrcss study can be cOmpleted in 90 FIlinutes,quickcr than PrOtOCOIS using a singic radlotraccr.

Other advantagcs arc the Functional infOrmatiOn frott thc 99mTc agent and POtcntial viability infOrrnation frOm delaycd 201,「 l il■ aging.

studン

ThC exercise treadmlll tcst rcsult with adequate cxcrcisc was intcrprctcd Aう 0-ycar-Old wOman has at/Pical ChCst Pain・ axis,C SPECT walithickcning;a sequen_ as negatiモ.SPECT Pcrfusion images tt gatcd short,axも ュ vcrtica1 long― titt raw data prO,CCtiOn acquisitiOn images)are provided.

1.Describe the SPECT myocardial Pcrfusion image nndingS and gated SPECI 2.mat informatibn is avallable frOm the raw data scqucntial prO,cCtiOn imagcsP 3.mat is thc mOst likely di4gnOsisP 4. List the advantages ofclcctrOcard10graphrsynchrOnization(gating)to SPECI

35

Notes

Cardiovascular Systenl:Breast Attenuation′ WaH Thickening Mlld ttcd arlterOscPtal h/POPcrtts10n that dcmOnstrttcs unifOrm brightening on gated SPEC■ indicating normal Hlyocardial wali thickcning on gatcd imagcs. 2.

Apparent decrcased rad10traccr in thc uppcr POrtiOns of thc hcart is lnost obvlous on the lett anteriOr Obliquc and l a t e r a l f r a m e s oo uNso Poabt宙 iCnt motion.

3.

N O m t t p c r t t s 1 0 n s t uh d yn 宙 O r mw』 ali thickcning and brcast attenuation.

4.

Asscssn■ Cnt ofrcg1011al wali mOtiOn/wall thickcning and

icft ventricular ttcctiOn fractiOn(EVEF). ReFerences crman DS,Kiat H,et al:Exercisc myocar, H a c h a m O v i c hB軋 dial Pcrfus10n SPECT in Paticnts withOut known coronary artery diseasc:incrcrncntal prognOstic valuc and usc in risk ′ 竹″励″θ ″93:905-914,1996. stratincation,c″ DePuey EG,Heller G,Tailicfer RLi Clinical applicatiOns of gated myocardial perfus10n SPECI In DePuey EG,Garcia EM Berman DS,editors:(物 rれar SPFCrブ 物竹 ″ そ多 ed 2, PhiladclPhia,2001,LiPPinCOttWilliaFnS&Wilkins,PP 211230. Reference Cttss― 父どQtt「 r″ ″α ittYど A物す 筋″″ルを冴″

ES,ed 2,PP 67-68,71-79.

Comment Cated SPECT analysis a110ws fOr assessment of reg10nal wall motion,wall thickening,and calculatcd reglonal LVER FOr ded into gated SPECT the caldiac c/cle is usually di宙 8 frames, in contrast to 16 or mOrc fralncs fOr planar cqulllbrium red blood ccll vcntriculograPhン Thc Fcwcr numbcr Of framcs has sOmcwhat poorer accuracy because Oflimited terlpOral res‐ 01utiOn.For cxamplc,truc cnd―systolc and cnd― diastOlc lna/ nOt be detected becausc ofsunllnation ofcOunts in thc 10nger timc ttames.Thc higher cOunt rates available with 99mTc agents compared with 201Tl and the usc of multiheadcd cameras are advantagcous in lnaxinllzing thc cOunt ratc for gated SPECI Stress myocardial pcrtts10n imaging is considerably mOrc ac‐ curate for assessment of CAD than s[ress electrOcardiograms. it/ofOnly 70%島 r dc‐ Stress dectrOcardiography htt a sensit市 tcction ofCAD alld a falsc,POsitiVC ratc as high杏 40%.FttscP positive results are a particular prOblem in female patients.In conttast,stress myocardial pcrfus10n studies have an Overall ac‐ curacy rate of apprOxilnate1/85%.Individuals with norinal ls havc icss than a 10/O in― scan results and nonanginal sympto■ cidcncc Ofmづ Or,ardiac cvcnts in thc subsequent 2 years.

36

99mTc

A f t e r t h e r e s t s c a n t h c P a t i e n t s a i d h c c o u l d t t O t s t a y f O r t h c s t r e s s s t ut dh ye bp ua t i we on ut l d r e s c h e d u l camc to the cmergency dcPartment the ncxt morning with chest pain.99mTc sestaFnibi Was ittCCted during thc Pain, stress.'' and the images wcrc labcicd“ 1.Dcscribe the SPECT indings. 2.Name thc mOst llkely culprit cOrOnary artcry or arterics. 7hich radiOpharlnaceuticals are preferrcd in this scttingP 3. ヽ 4. PrOvidc thc reason fbr yOur choice Ofradionuclldc.

37

Notes

Cardiovascular Systenl:Emergency Department Chest Pain l.MOderately scvcrc perfus10n dcfect ofthe entirc anteriOr wali cxtcnding to the aPcx that Partially rcverses on rest imagcs,severc pcrfus10n defect ofthc dcfect invOlving thc lateral and infcr01ateral wall that partially rcvcrscs. 2. LA正)and left circumncx coronary artcrics or leFt lnain coronary artcry. 3。99mTc sestamib1 0r 99mTc tctrOfOsmint 4. Thc cxact ilnage tilning of99mTc_labclcd agents is not cru― cial bccause no signincant redistributiOn Occui ln an cmcrgency sctting,mattcrs OfPadcnt managcmcnt and logistics rnay take priOrit/Over iHllncdiatc scanning.

Reference Hclicr GM Stowers sA,Hcndcl RC,ct ali Clinical valuc Of acutc rest tcchnctiurII-99rn tctrofoslnin tOmOgraphic lnyo― cardial pcrfuslon irnaging in PatiCnts with acute chest Pain

and nOndiagnOstic cicctrOcИ a r物( d i効 o〃6 g r″ a‖ rあ nOsι ,ブ と 31:1011-1017,1998.

Cross‐ Reference ハ物び 力″″Mcあ ct″ ″ r軍配 京どQむ蕊 '確極 Cd 2,pp 72-80,88‐89. Comment Studics havc shOwn that pcrfOrHling pcrfus10n imaging in the cmcrgcncy dcPartrncntin paticnts with unexplaincd chcst pain is cost― e3発ctivc.Abnormal indings on SPECT PcJ塩ュ siOn im― aging accurately prcdict acute lnyocardial infarctiOn in PatieniS with symptolns,a nondiagnOstic cicctrOcardiOgranl,and nO his, tory ofmyocard』 inttrctiOn.A nomltt stud/is ttsociatcd with a very low cardiac cvcnt rate.Thc usc Ofacute rcst SPECT fOr paticnts in thc cmcrgcncy dcPartinent can substantially and saFcly rcducc thc number Of unncccssary hospital admisslons. HowcvcL this PractiCe requires coopcration and c00rdinatiOn by a number Ofclinical serviccs and hospital PcrsOnnel. In an emergency sctting,matccrs ofpadcnt management and 10夢StiCS may takc P五 0五ty OVCr scanning.AlthOugh 201Tl can be used in a silnllar fash10n tO evaluatc acutc chest pain,the need tO image withOut dcia/aFter ittcctiOn is a signincant dis_ advantaget ARer initial uptakc,201Tl undergocs``rCdiStributiOn," i.c→ an ongolng dynamic cquilib五 um Of201Tl besvccn the m/0_ 99mTc-labeled agcnts Offcr cardiuHl and thc b100d POol exists。 thc acxibility of inicctiOn carly in thc evaluatiOn process,bit delay Ofthe scan until“ things are undcr cOntrOl."This featurc has incrcased thc utilization ofmyOcardial perfus10n SPECT in the acutc carc sctting.

38

A

,Poststress SPECT anter10r Scans for No patients are providcd.ノ 生Stress and 4-hOur delayed Planar thalttum scan.β raw data prO,cctiOn imagco Stress/rcst SPECT showcd single,vesscl ischemia.

. and the abnOrrllal inding in paticnt β 1. Dcscribe the planar scintigraphic indings in 4 patientノ 2. What Other infOrmation is neccssary for interpretation Ofthese exaElinationsP

3. Namc ancillary indings ofCAD other than Pcrfus10n deFects that arc relevant in intcrprcting rnyocardial perlus10 scans.

4 and β P 4. What is the rnOst appropriate diagnOsis in Patientsノ

A45-ycar_。

ld man has dysPnca On cxcrtiOn.Cardiac catheterizatlon foun4 nO COronary disease.Images at end―

diastole

″are shOwn. の and endPsystolc trt静 1. NaIIlc the radiOpharinaceutical,the exanlination bcing PcrfOrined,and dcscribe thc indings. vs Other OftCn vic、 Obtaincd. 2. ｀ 前1lich view is shown,and why was itsciccted tO calculatc WEFP Namc 10tiOn. 3.List thc tcrms used tO describe rlyocardial wall圧 4. PrOvidc a classincation fbr cardiomyopathies. 39

Cardiovascular:Planar ThaHium with increased Lung Activity l . И, B o t h v c n t r i c i c sd ialに ated宙 t h P r O m i n C n tg五h t v e n ― tricular uptake.No cvidcncc Ofischemia or scai lncrcascd lung activity on the strcss imagcs. 2. The levc1 0fcxcrcisc achieved.At a low icvc1 0fstrcss,thc ncgativc indication OfCAD. scan can ProVidC falsc― 3. Poststress lung uptake and transicnt ischcrnic dilation. 4.孔 Dllatcd card10myopathy trOPhyt」 既 Multivcssci CAD.

with

right

_ thc bcst se 2.The left antcriOr Obliquc vicw prOvidcs

v c n t r i c aratiOn u l a r h Ofthe / P c r _wo ventriclcse Occaslonally arltcriOr and left

lateral postcriOr Obttquc vicws alsO arc obtaincd. 3 . G l o b a l o r r c g i o n a kl i―n c s i s , h y p o k i n e s i s , d y s k i n e s i s , tardOkinesis,

Reference Ccrson MC,editori Cttaび″″び ″″″物cttct″ ち ed 3,New York, 1997,McGraw― Hlll. Cttss‐Reference 醍 助 a修″″%妨 び ″ ″α 軍

Cardiovascular Systenl:Cardiomyopathy on Equilibriu「卜Gated Blood Pool Ventriculography or Multigated Acquisition l. 99mTc― labcled た eり hrOcytcs.EquilibriuHl― gatcd blood P001 vcntHcdography(RVG)or MUGA(muldgatcd acqttsト tion),FraIIlcs at diastolc cnd… systole shO、 v g10bally and cnd― dccrcased wali mOtiOn.Visual cstimatc shows vcry dccrcascd皿 エ

4. Classincation according to the Functional status ofthc vcn― triclc:rcstrictive,dilated,Or hypcrtrophic;Or according to causc:alcoh01ic,infcctiOus,rnctabolic,tOxic,drug‐ induced,or ischcnlia/CAD,idiopathic.

財 QStt「 ES,cd 2,PP 66,68,76-79,

82.

References Comment 201Tl has been used as a myocaldial radiOtraccr for mOrc than wo dccadcs.MyocardiuFFl diStributiOn is PrOPOrtiOnal to b100d

BorerJSiMeaSurcmcntofvcntricularfunctiOnandvolumc.In Zarct BL)Bcller GA,editOrs:対 務び 力″″物材″ θ々紗 St Louis, 1999,Mosby.

now over thc phys1010gictt rangc.men 201Tlis ttectCdatpcak Dllsizian Rocco Ⅵ TB BOnOw RO,ct al:Cardiac Pool blood―

strcss,it rcdistributcs according tO initial b100d Irllaging nN、 is imaging.II:APPlicatiOns in noncoronary 」 hcart discasc,メ 晩″ 〃 calicd rcdistri― 】Zあ″31:10-22,1990. perfOrmed within 10 minutes of inieCtiOn.So― butiOn reprcscnts thc cOmbinatiOn ofdifferential washOut and s c c o n d a r y t r a c c r u p t a k c f r O m c i r c u l a t i n g 2 0 1 T Cross― l. Reference Lung activity on strcss 2011ェ l studics shOuld always bc as‐ 対務び 力″″%妨 ご ″ ″4E醍 京FQじ 蕊 恥 ,Cd 2,pp 91-93,98-99, SCSSCd.In nOrmtt suttcCtS thc lung backgrOund activity is ioⅥ 103-104. HowcvcL it is incrcased at rest in Patients with lctt vcntricular Failure.Strcss― induccd uptakc is cOrrelated with lett vcntricular Comment end‐diastOlic Pressure and pulmOnary caPlllary wedge pressure.Wall mOtiOn abnormttities may,as be in glob』 this PatiCnt,or rc― Incrcased lung activity uptake on strcss imagcs indicatcs ic丘 on』 .Re」 ontt abnormttitics arc ly usu』 caused by CAD,Pri, 夢 ventricular dccOmpcnsatlon and OFten is a sign of rnultivcsscl marily infarctiOn,orless cOmmonけ aCutc ischcmia.DeinitiOns CAD.Howevett uptakc can alsO bc thc rcsult OfOther causes ofOfthc tcrms uscd tO dcscribe cardiac wali mOtiOn arc: ・Normal POOrly compensated heart discase.A quantitativc ratio of lung/myocardi】act市it/(L/M)is ottcn uscd to conirm the im― ・Akinesisi cOmplctc abscncc Ofwall rnOtiOn aging abnOml狙it/tThe L/M ratiO shOuld bc lcss than O.5,ratiOs ・Hypottne[lc:rcsldual but dilninishcd cOntractlon abOve this valuc are abnOrnlal.Lung uptake docs nOt havc thc・ Dysttncsis:ParadOxic wali motiOn,opposite to the dircc‐ SaEle Signincancc whcn 99mTc FnyOcardiそ 述pcrfus10n agents arc tlon ofcxpected IIlotion.Dyskincsia is sccn in thc septum used because these traccrs arc normally takcn up by thc lung tO OfPaticnts aftcr cOrOnary bypass grafting as a rcsult Ofdis― a higher dcgrcc than 201Tl. ruption ofthe pericardium and in Paticnts aftcr lnyocardial infarc〔 10ns with ancurysmal wali mOtiOn ・TardOttnesis:motion prcscnt but dclayed comPared、 Notes vith adiaCCnt segments Card10myopathics can be classined functiOnally:restrictive, rh/PcrtrOPhic,according to the cause,Or as Primary dilated,。 or sccondary.W7hen the causc is known,cardiomyoPathy is ia― bclcd as alcOhOhc,infcctiOus,1■ etabolic,tOxic,drug‐ induccd, or ischc■ lic; Othcrwisc it is idiopathic. E)ilated cardiOmy‐ O p a t h i e s u s u a l l y a r e a s st oh c ia a td ci dl 航 atcd LV and a depressed LVER In contrast,hypcrtrOphic and rcstrictivc cardlomy― Opathics usually arc associatcd with sma11 え 0r nOrmalい 40

B

RPO

ANT

RPO

POST

RL

C

ANT

LL

LPO

sidcd chest discoIIlfOrt and shortness Ofbreath.И ,Pbstcroanterior chest radlographi A62,ycar―old Paticnt has right― β,PcrfusiOni c ventilatiOn. 1. Describc the vcntilation― pcrfuslon image indings.

2.IntcrPrct the stutt Give your reasoning. 7hat is thc ttkelih00d ofpullnOnary cmbolus in this paticntP 3. ヽ on chcst ray x― indings in Paticnts with PullnOn4ry embollP 4. What are the rnOst colrlI■

41

Notes

Pulrrlonary Systenl:High Probabitity of Pulgrlonary Embolus l, Pcrfuslon is dccrcascd in thc right 10wcr iObc cxccPt FOr the supc五 or scgment,VendLtiOn tt truncated in the nght iOwer 10be cOnsistcnt with subPulinOnic effus10n. 2.High PrObability fOr pulmOnary embolus.Mismatch bcNOcn perfus10n and vcntilatiOn is cvident in the basal segments.Thc pcrfuslon dcFcct is considerably largcr than thc cFFus10n On thc radiOgraph. ３   ４

Grcatcr than 80%. Most commoni nbrmal.Ncxt mOst common:atelectash thesc alsO arc thc rnOst coFnrnOn chest x_ray nndings in patients dctcrrnined by anglography nOt tO have embOli.

References FrcitasJE,Sarosi MG,Naglc CC,ct al:Modined PIoPED cri‐

teria uscd in clinical practicc,ノ ウ物 ミ悦び ′ノ 〃36:1573,1578, 1995。

Juni J,Alavi A:Lung scanning in thc diagnOsis of pulmOnary embollsmi thc cmpcrOr rcdrcsscd,レ 物″ ″「協〃鴎 札21:281296,1991. Cttss―Reference 助 び 務″″鴎 品位%″ rttμ

Q3慰

E「 S,cd 2,PP 152-160。

Colnment Thc PIOPED critcriOn that a pcrfus10n deFec〔 largcr than thc

radiOgraphic abnOmality indicates a high prObabl,Of pul_ monary

cmbolism

shOuld

bc

uscd

cautiOuslye

The

graph is Obtaincd with maximalinsPiration.Thelung scan im‐ age is acquircd during tidal breathing."rhus thc heart is inore hOrizOnta1 0n the lung scan than On thc radiOgraph,and thc lung nelds appcar largcr On thc lung scan than on the rad10_ graph.HOwcvc5 in this case perfus10n dcfcct undoubtcdly is iarger than the defect On thc radiOgraPhic inding.No vcntila― tory defects arc apparcnt,only a truncated lowcr lung neld. A Ptticnt With a high― PrObability scan htt a grcatcr than 80% prObability OfpulmOntt cmb01us.HOwcvett fewer than halfOf paticnts deterFIlinCd tO havc PulrnOnary emb01us by anglogra‐ Thus a highrprObabil,scan iS Phy havc a high_PrObabil,scan・ not sensitive lor the diagnOsis ofpulrnOnary cmbolus,but it is fai』 /specinc,Convcrscltt this lneans that 200/0 0fPatients have anOthcr diagnOsis.The rnOst cornlnon cause islung cancei he i「 mcdiastinal tumOr preferentially Occludes thc PulmOnary artcry2 、 vhich is easily cOmprcssiblc in cOntrast to thc mOre rigid bronchi.Old cmb01i are anOthcr cOminon causc of a falsc_ positive study ttr pulmOnary cmbolus.Vasculitis Or dcttc cell discase are othcr causcs. 1

42

chest

radiO…

P O S T

干手十■■ ■=￨■ ￨■￨￨■■■ ■ ■

￨■

■ ￨■ ■■ ￨

pcrfus10n scan Only is shOwn. A4う ― old woman was referred fOr a ventilation,perfuslonThe studン year― 1. Describe thc abnOrinal scintigraphic arldingS, 2. ｀ hat is the rnOst likely causc IOr thc indingsP 市イ 3.What is thc radiatiOn dose tO thc Patient ttom a perfusiOn studyP From a 133xc ventladon studyP 4.Given the longer physical halttlife and largcr administered dose of 133xc,compared with 99mTcaggrcgated macro― albunlin(MAAl,cxPlain the lower resulting radiation dosc to the lungs.

43

Notes

Pul「 rlonary Systenl:″ Hot Spots″ on Lung Scan l. Multiplc“ hOt sPOts''arc Presentin the upper and 10wcr

10bcs,Pに dOminateけ in thc right lung ncld. 2. Radioactive cmboli as a rcsult Ofpoor technique causcd by drawing back b100d intO thc syringc cOntalning thc 99mTc MAA bcfOre inicCtiOn Ofthe radlotraceL causing dumping.

3.Thc lungs,thc targct organs,rccett apprOximatcly l rad/5 mCifrom 99mTc MAA.APProximatcly O.2 rads tO the lung frOm a 20-mCi xcnOn studン 4.Thc bi010gical half― life is brici The paticnt breathcs 133xe hen cxPCiS it intO a trap.Only 133xc gas to equlllbriunl,〔 absOrbed as a result Offat sOlubility has any aPPreciable lifc. bi010gical half―

ReFerences PrestOn D■ Greeniaw RH:“

HOt sPOtS"On lung scans,メ ハ協〃

脇 〃11:422-425,1970. Conca

DM,Brill

DR,Shoop

JD:PuimOnary

radloactivc

mi―

crocmboli f0110wing radionuclidc vcnOgraphン ブハ協〃鴎 嵐 18:1140-1141,1977. Cttss‐Reference 助 び 力″″%冴 び グ ″夕 :E醍

択どQ3慰

E「 S)cd 2,pp l19-150。

COmment

The causc ofthis abnOrl■ al hOt sPOt SCan Pattern is poor tcch― nlque.Techn01031StS are raught that b100d shOuld″ θ ″bc drawn back intO thc syringc to prOve itis in thc vein befOre intts10n Of 99mTc MAA,in cOntrast t0 0thcr ittectiOns.The b100d causes [he MAA to aggrcgate,and whcn it is rcinfused,it fOrms a pat― tern indicating hOt pullnOnary nlicroemboll.99mTc MAA par―

ticles shOuld bc atttated befOrc ittectiOn to avoid settling and aggregatiOn ofthe PartiCiCS,、

vhich alsO can causc hOt sPOtS・

This

hOt sPOt Pattern has bcen rcPOrtCd in paticnts with thrOrn―

bOphlebitis whcn the ittectiOn is given distally in an cxtremity with PrOximal thrOmbOphicbitis,c.gり ifradiOnuclide venOgr伊 Phy is cOmbined宙

th thc Pcrtts10n stuⅢ

IniCCtiOn Ofthe r伊

diopharIIlaccutical can dislodgc part Ofthe labeled thrOmbus. Other important tcchnical aspects ofMAA ittcctiOn includc ensuring that the paticnt brcathes dccPly and is in thc supine position to ensurc unifOHn PartiCie distributiOn.Gravity pro‐ duces a 10weriObc Pに dOminance ifthe paticnt is upright,Thc MAA shOuld be lnlcctcd thttugh a 23-gauge or largcr needlc to prevcnt Partide ttagmentadon.Six to cight宙 ews shOuld bc acquired.Thc anteri05 PosteriOi and POsteriOr obttquc vicws are thc mOstimpOrtant.Lateral views shOuld be interprctcd tiOusly becausc Of shinc_thrOugh frOHl thc oppOsite sidc. AnteriOr Obliquc vicws sOmetimcs are helpFul.

44

cau―

B

C

LAT A chest radiOgraPhり

LPO

POST ,POsterior略

RPO 3xe VentilatiOn o,and cight―

view pcrfusiOn study“

)werc PcrfOrmcd for short―

ness ofbrcath. 1.Dcscribc the indings on the ventilatiOn studン 2.Describc thc nndings on the perfuslon studン cmbollsm. 3. PrOvidc an interpretation regarding thc presence or abscnceOnary OfPulr■ could bc applied to this Perfus10n patternP 4. W7hat tcrn■

45

Notes

一 TBonary Systenl:Ventilation口 Pul「 Perfusion― Emphysema Stripe Sign′ l.Dccrcascd uPper 10bc vcntilatiOn is seen On thc singlc breath with ttr trapPing in bOth uppcr10bcs and thc nght 10wcr10bc On washOutil■agcs. 2.Decに

益 cd PerfusiOn tO thc mttOrit/OfbOth lungs,with

PreServed perttlsiOn in thc subPleural lung,rnost cvidcnt at thc lung bascs and rnedial aspcct OfbOth upper10bcs. 3. Low prObabllitye 4, Stripc sign.

References WOttlcy Dtt Alavi A Radibnudide imtting ofacutc PuimOnary embOlism,R″ 冴, o ' Q ケ ″ハら″ 務И物 3 8 : 1 0 3 5 - 1 0 5 2 , 2 0 0 1 . Sostman HD,GottschalkA:The stripc signt a ncw sign for di_ agnosis of nOncmb01ic defects On pulinonary pcrfus10n

sdndgrap町 筋妨θ 741,1982. 牝ノ14身737‐ Cross―Reference 対物び 力″″過 品品″′ す軍 配

択どQさ 慰 孤 ,ed 2j pp 160,396.

Comment The striPc sign refers tO a subplcural margin Ofactivity in a lung reglon with decrcased Pcrfus10n.Thc PcrfusiOn defcct is nOt pleural bascd bccausc a rim or stripc ofactivity at thc Plcura is greatcr than thc shOuld be rnade tion.Thc striPc mOnatt Cmb01us

activity sccn in the dcFcct.This assessment frOm thc bcst tangential vicw Ofthc arca in qucs― sign is usc負 l and reliable fOr discOunting pul― ュ as thc causc Of thc pcrShs10n defect,Thc sign

is apprOxilnately 900/o rcliable as an indicatiOn Of nOncmbolic discasc,and thus Of10、 v prObability9 Howevctt thc rcmainder of thc lungs shOuld be inspcctcd bccausc thc sign is Only a prcdic, tOr fOr the arca whcn it appears,and not for the paticnt Ovcrall. For cxamplc,lfthe scan dcmOnstrates an arca with a stripe sign and[wo or mOre segmental mismatchcs,thc study wOuld ap― 証e l y b c c h a tHtZce確 d as high prObablityc prop五

Emphysema is a mttOr Causc ofchrOnic airaow obstructiOn, a diagnOsis indicating patho10gical Pcrrnancnt abnOrinal cn― largernent of air sPaccS diStal tO thc tcrininal bronch101c.Thc best radiOgraphic indicatOr is hyperinflatiOn, but vascular changc, bullae, and incrcascd lung markings alsO may bc demonstratcd.The 133xe Study is a scnsitive indicator Of Ob_ structivc lung discase as shown in this casc.

46

RA0 C

撤翻 難 華 謡 珊鞘 鞘 韓 鞘 A young female patient prcscnts at the emergcncy dcPartment with chcst Pain.Chest radiOgraphs御

D

,り ,PcrfusiOn

scan O,and vendadOn study p areshown. 1. Dcscribc thc nndings on thc chcst radlograph. 2. Describe the perfusiOn and ventilatiOn scans. a.u豆 ng PIOPED ttte五 3.Catcgottzc thc study regarding thc prcscnce or abscncc OfpulmOnary cmbohsm 4. W7hat is the FnOSt Colnlnon inding on chcst radiOgraphs with thrOmbOcmbolislnP

Notes

Puttonary Systenl:Hampton's、Hump一 intergrlediate Probability l. Posteroanterior and lateral chcst radiOgraphs dcmonstrate a pleural‐ bascd Opacit/in the lateral right lung basc. 2.A singlc wcdgcd‐shaPcd,plcural― bascd defect in the same 10cation as the radiograPhic abnOrrrlalit/2 PrObably thc 略3Xc anterob岱 組segment ofthe rightiOwer iObe.Nom組

vcntilation stu(け 3. Interinediatc Probability fOr pullnOnary cmbolism. 4.Chcst x―ra/nndingS in pulmonary embolus withOut infarctiOn arc uttcoHllnOn.Whcn present,they are usually associated with a large,ccntral embOlus,DiscOid atclcctasis is the ncxt most coHllnOn inding.

Reference A r m s t r o n g Ml i｀s o n A G , D e c l c t:狐 物 響 すゲ あ 物 否 ゲ 務タ す 否 江osb/3 力 ちcd 3,pp 75,407-408,St LOuis,2000,い Cttss‐ Reference 対務f揚″/脇 ″び ″ ″α r醍 択野Q5慰

蕊 『 〕Cd 2,PP 152-159.

Comment

The radiograPhic signs ofacutc pulinOnary cmb01lsm HrithOut infarctiOn Or hcmOrrhage include oligenlia Of the lung (Vestermarビs sign),incrcasc in sitt ofthc main PulmOnary ar― tCr/j and elevation ofthc henlidiaphragm.All are nOnspccinc. Most emboll dO nOt causc infarctiOn,Howcvch whcn prcscnt, infarctiOn appears as lung consolidatiOn and Occurs PrcdoIIli― nantly in thc 10wcr lung nclds,Thc radiOgraphic anding dC― scribed by Hampton and Castleman(1940)is known as HamptOrs hump:“ ihfarcts arc always in cOntact with plcural surfaccs and thc shadOws arc rarcltt ifcvcL triangular in shape." Wれlen Pulmonary embollsm is associatcd with cOns01ldatiOn bccausc Of helmOrrhage and nOt true infarctiOn,thc inaltratc cicars quic田 ン oFtcn within a wcck.In cOntrast,truc infarctiOn res01ves over several mOnths and may bc assOciatcd with pcr_ manent lincar scarring.Bccause cavitation is rare,it suggests secondary infectiOn. Becausc theにis a sin」 c sCgmcnttt mismatch,thc stuけcan_ nOt be categorizcd as low PrObabllityt Tw0 0r mOre misma[ched scgmenttt dettcts are not pttscnt,so the study cannOt be cate… 30rized tt high prObabllityt ThettfOtt by dettdt and dennition, thc stuけindiCatcs intcrmcdiatc probabilit/fOr pulmOnar/cm― bolls】 m or is indeterininate frOm a diagnOstic standPOint. Angiography indings wett podtive.

組

A

B

TwO Patients with the same disease∽ and a had 67Ga scintigrapけ 1. Describc the lung Patterns seen on thc 67Ga lung scans. 2. 対 7hatis the inding on thc head and ncck scanP 3. Match the lung scan with the head and neck scarl, 4.What is thc discase,and how i,67Ga scintigraphy used in thcsc paticntsP

49

Notes

infection and inflaHl『

nation:Sarcoidosis

l.Patien〔И,``lalnbda sign"(hllar and Paratrachcal nodal uPtakc);PatiCnt a difFusc Pulmonary uptakc, 2.Classic“palldゴsign. l or翌 乳Thc Panda sign can bc scen at any stage of 3. Eitherノ discasc. 4.Sarcoidosis.67Ga scintigraPhy is used to conirm thc clini, cal diagnosis and to diffcrcntiatc activc alvc01itis frOm inactive nbrosis.

References 妨θ 沈9215:884-885,2000, Kurdzicl KA:Thc Panda sign,筋 Sulavik SB,SPcncerせ 、Veed DA,ct al:Rccognitlon of dis― 67 distribution in sarcoidosis, tinctive patterns of galliurn‐

1914,1990. メ助 〃鴎嵐31:1909‐ CrOss‐Reference ブ ″α TFrF択 どQ3蕊 筋″″脇 渉す 脇 す

孤 ,ed 2,PP 171-173.

Co】mment

s.It tt ss scenに Thc Panda ttn ttsuggCSdve highけ ofsarcddo立 ng thc lacrimal frcqucntly in othcr innammatory discases invol宙 SttgrCnもsyndrOtte and in patients and salivary glands,c.gり whO have had irradiatiOn ofthc head and ncck.Thc Panda sign is not spccinc for sarcoidosis,but with thc larnbda sign Or dif― 丘lsc PuimOna17 uptakc,Or bllateral sylmrnctrical hilar adcnoPa― thy on chest radOgraPhs,the nndngS highけSuggest sarcoido― ,can bc scen in a variety ofothcr sis.The pattcrn Ofuptakc in」 innammatory and infcctiOus Pulmonary diseases othcr than sar_ ガ″″ ″ ″物θ て 力す0″ cOidOsis,including r功 ちPncumOCOnloscs,hy_ νす _ persensitivity pneumonitis,activc idiopathic PullnOnary nbr。 sis,and tOxicity from therapeutic drugs,c.g.,blcomycin. Morc than 900/o ofpaticnts with sarcOi(k)sis havc Pullnonary manifestations,250/o have pcHnancntloss Oflung Function,and 50/o to 100/o dic ofcomPttcations.67Ga is useful in the cvalua― tion ofpatients in whom sarcOidosis is susPcctCd and for eval‐ uation oftheraPy eFFcctivcncss.67Ga is rnore sensitive than chest radlography fOr dctcctiOn Ofearly diseasc. The chcst radlograph has becn used tO stagc sarcoidosis as f0110wsi stage O(norm狐),stagc l(bilatcral symmetrical hilar adenopathyl,stage 2(bllatcral hilar adenOpathy with Pul‐ monary inaltration),and stage 3(dttuse symmctricallung in― nitration).Thc Panda and lambda signs Otten are seen togethe島 most commonly in stagcs l and 2,but ttso may be prcscnt in stagc O and 3.

50

POST

ANT

A57-ycar―old man has had abdOminal discOmfOrt and fever fOr 3 wecks. 1.Dcscribe the nndings on this 67Ga stu4y and give a ttkely diagnOsis. 2. W7hat is thc lnechanis■ 10f67Ga uptakc in infectiOn/innalnlnationP 3.List the photOPcaks Of67Ga.List the Ones uscd fOr imaging.Wttat c011lmatOr should bc used tO acquire the stu(サ

P

4.Wttatis the recOmmcndcd administcrcd dOse Of67Ga,its half― imarging timcsP lifc,and

ｔ，

Notes

Ylation:intraabdonlinal infection and inflarrl「 Abscess l.Ver/mcrcaSed uptakc h the right 10wcr quadrant strongly suggcsts an intraabdonlinal absccss.TumOr cannot be cxcludcd. 2. Increased vascular Pcrincabllityj bacterial uptake,and binding to binding to lcukocytes Play a role;hOwcvc与 lactOferrin ofdcgranulated neutroPhils at thc site ofinfec‐ tiOn is probably thc Prirnary mechanism. '「 に he 3. PhotOPcALs Occur at 91 to 93,185,300,and 394 ゴ 1《 10wer threc PhOtOPcaks are tlscd for imtting.A mcdium― energy colllmator should be used. 4.The recommended adult dOse Of67Ga is 5 mCi;d■ e half‐ 1lfe is 78 hours.Imaging at 48 hours is rOutinc.HoweveL ifan abscess is susPccted,lmaging at 6 t6 24 hours rnay providc an carly diagnOsis.

ReFerence Rypins EB,Evans DG,Hinrichs Ⅵ et al:Tc-99m HMPAO white b10od cell scan fOr diagnosis of acute appendicitis in ″ S″箸 Patients with equivocal clinical Presentation,24″ 226:58-65,1997. CrOss,ReFerence

177. どQyrsrr蕊〕ed 2,pp 168‐ 筋″ ″ 脇 力す ブ ″ αr醍 ズ 助す COmment The strict dinical deanition of fever Of unknOwn origin is(1) fever Ofat least3° 38。 C on more than 3 octaslons,(2)no diag‐ nOsis aFter 3 wceks Ofinvestigation,and(3)hosPitalizatlon ofat least 7 days.A perforated appendix with intraabdominal abscess was fOund during surgery.67Ga has been used forinfection im‐ 宅ng since the carly 1970s.Today its rOlc is limited because of the avallability Ofradiolabcicd leukocytcs.67Ga occaslonttly is in Paticnts Mrilh PCrsistent Fcver but n0 10calizing signs llsen』 on exaHlination and ncgative CT andingSt ln the sctting of a fcver Of unknOwn Origin,it hay localize the sitc of infectiOn, tumor9 or bOth.Tumor Occasionally is lnanifest as a causc of feverOfunknOwn Orun.HoweveL ifan intraab4omintt sOurcc Ofinttctionおbeing sought,67Ga scanning is disadvantagcous becausc ofnormal bOwel dearance that may obscurc Path010g‐ ical uptake. Radiolabcled leukocytes,labeled with?9mTt hexamcthyl‐ propyleneaminc‐oxime(HM― PAO)or lllln oxine,are used more commonly for detection OfinfectiOn,PartiCularly intraab" hP d O m i n a l i n f e c t i O n . D i s a d v a n t a g e s O f l a b e l ceds laeruek ot甲 l a b e l i n g, 配q u i t t m e n t o f u p t 0 5 0 m l o f t h e P abtlioeon4t島r も the time nceded for ce11labeling(minimum of2 hours),and the

serious

al edsO.n■ p r o b ib co mr n Oe f d bi lsmoeooandsO―

anti‐

soon. bott against granulouCS may be aPPrOVed ttre dinicalぃ

52

A

ら詔

ヰ ！ 一 一 一 一 一 り 一

猷鵡

！ 霧

議

B

一

C

A9-ycar―

old Paticnt had back Pain and fever fOr 4 wccks.BOncに

views p arcshown.

り ,gallium_67 wholc_bOdy p and abdomin』

sPOt

1. Dcscribc the scintigraphic andingS On thc bOne and galllum scans. 2. W“hcn bOth tcsts are Ordered at thc same vhich tirnc,、 shOuld bc PerfOrlncd irstP 3. Providc the diffcrcntial diagnOsis and thc rnOst likcly diagnOsis. 4. Bascd On the avallable infOrmation,characterize the stagc ofdiseasc.

53

Notes

Oncology:Bone/CaHiu「 トーStage‖V Hodgkin′s Disease akc at L3.Thc l . T h c b o n e s c a l l s h o w s tmtleldd uiPntα 6 7 G a s c a n s h o w s uapbtnaokme』 i n h e L 3 v e r t e b r a l b o 与 as well as the ncck bilaterttly(right sidc grctter than the lc丘 sidc),mediasunllm,五 ght Paratracheal regions,postcrior thOrax,and dghtlung baso and multifOctt uptake in thc livctt Thc 10wer_intcnsity camcra sctting oPdmizcs liwr vlsualttauon(て ). 2. Bone scan.

3.Hod8出 品 disCttC,tuberculosis,or atypictt mycobactcri弱 HOdgkitt discasc is likclye 4。Stage IV

Reference R c h m P K : R a d l o n u d i d c c v a l u a t i O n o f P atthi clnytmsp宙h o m a , 4,物 ′Cじ 京レ務θ ,″ハめr軌ノ 7-978,2001. 39:9う ReFerence Cross‐ ″α初 脇 あ ″M であc あ 202.

逆 QD願 □

21,199, C d 2 , P P l 1 61‐

Comment The indngs indicate sott tissuc and bonc involvemcnt thus gal― avid tumOrs and innammatory and infcctious conditions lium‐ fOrm thc Primary dittrential diagnosis.Givcn the distribution avid tumor fOr primary considcra― and agc grOuP,thc gallium― tion would bc Hodgkitt diseasc.InttctiOus or innammatory dis― cases would be cOnsidcred.However9thc invOlvement ofa single vcrtebra on thc bOnc scan,rather than twO adiacCnt levels,wOuld be atyPical fOr vertebral osteOmyelitis.Given thc paticntもage and distribution of indings,Hodgkitt discasc is thc mOst likcly diagnOsis.Thc PrcsCncc ofskelet狙 (indcPcndcnt OfmarrOwl involvcment indicates stage IVdiscase.67Ga is taken up bOdl by thc lnarrow and bonc. TO avOid dOwnscattcr of highcrrcncrgy phOtOns of 67Ga v centered at (393,300,and 185 keVl into the 99mTc windo、 140Kど 略 the bonc scan shOuld bc complctcd beforc the gal― Ifgallium is ittcCtCd arst,becausc ofits Phys‐ lium is inicCtCd・ halttlives(25 days)and thc high 010gic』 ical(78 hours)and断 energy Ofits PhOtOns comparcd with 99mTc,thc bOnc scan shodd be ddayed several days to avOtt hgh backgrOund ttd dowllscatter degradatlon Of the bone image.67Ga can be in― ,CCtCd as soon as thc bone scan is complctc.Imaging of67Ga is initiated48 to 72 hours ttcr inicctiOn.Although 5 mCl of67Ga is administercd for infcction/innammation imaging,10 mClof 67Ga is recommcnded for adult tumor imaging to a1low fOr higher― rcsolution images and SPECI The higher dosimetry ls considcrcd acccPtablc fbr Oncolog/Patients.

54

vertebr組

A

B

一 争

鞘

村 椰

A32-year―old man has nOn― Hodgkinも lymphOma.刀 shOws the 67Ga study at initial staging,and wasβPcrfOrmed atter a full cOursc ofcheELOthCrapyB CT shOwed a rcsidual chcst mass aFtcr chclnOthcrapye l. 村hat is the adult dOsc Of67Ga rbr tumor evaluatiOnP｀ 商イ hcn is imaging perFOrlnedP 2. COmparc thc accuracy of67ca and CT fOr initial staging and evaluating rcsPonsc tO therapy. 3. Describc the indings Ofthc nvO studies and interprct them. 4.HOw can thc prOblem OfbOwel activity bc minimized on 67Ga scansP

55

Notes

Non‐ Hodgkin's Lymphoma Oncology:67Ga― Before and After Therapy l.The adult doscis 10 mCi,which is twicc thc dosc uscd for innammatory and infcctiOus cvaluation.Imaging tyPiCally ter iniectiOn. iS PCrfOrmcd 48 to 72 hoursポ 2.CT scanning PrOvidcs bctter scnsitivity for initial staging. 67Ga scanning is supcrlor to CT in evaluation ofthc cFFccr tivcncss oftherapy and dcterininatlon ofwhcther resldual masses aFtcr thcrapy rcPreSent residual tumor Or mcrely nccrosis and ibrosls. 3.九 A largc mass in the arlterior mcdiastinum cxtends to the supraclavicular rcgionso Considerable colonic/rectal act市ity is present.Bccausc ofthc latter activity9 tumor cannot bc excluded in the lnid― Pclvis to thc lower pelvis. a cOmplctc rcsPonSC tO therapy has occurrcd.Thc rcsidP ual chest mass on CT is caused by necrosis and abrosis, nottumo丘

n,and imaging rnay bc delayed as 4. Laxativcs may bc gNミ nceded at 4 t0 7 days after inicctiOn,

Reference Rchm PK:Radionudide evaluadon Ofpaticnts with lymphoma, ″ ケ 冴 働 ″助 妨みИ物 39:957-978,2001. 員″ Reference CrOss― 筋″″鴎 品冴″資 r醍 逆 Q」憩 r蕊 〕ed 2,pp 198-202. 助 び Comment 途 disette and The sensitivity of 67Ga fOr dctcctiOn of HOdg臨 nOn‐Hod8出 品 lymphomais very high,95%and 950/0,rcsPcC― tiVe,PartiCulany whcn SPECT is uscd.In many PostthCraPy cases,CT scanning shows a residual chest or abdOminal mass. The diIFerential diagnOsis indudes a partial incompletc rcsPonsc tO chemotherapywith rcsidual viablc tumoL which requires ttr― thcr trcatmcnt,versus a nonviable mass ofabrosis and nccrosis. 67Ga scanning can Hlakc this distinction very accuratclys This tumor was treated effcctivclye E)iffercntiating norrnal paticntも c010nic dcarancc from tumOris a common diagnOstic hlemma. 並 s and hydration can bc Although bowel cicansing with lax筑 hdP的 1,delayed imtting at 4 t0 7 days ottcn is required to ttlly cvaluttc the abdomen and pettis.The colon htt thc highcst ra― di筑lon absorbed dOsc(target organ).The higher dose of67Ga administcred for pa[ients with tumors cOmpared witl thOSe vs for bcttcr qual― evaluated fOr infcctiOn and innammation a1lo、 ity planarimages and SPECI SPECT is perfOrmed rOutincly at mOst institutions because it a1lows dctection of diseasc that in thc chcst might not be scen On Planar imaging,pardcularけ and abdomen.SPECT increascs thc image contrast by elimi―

nling ovcrwng and underlying activityc lt improves dctectlon Ofsm狙 llesiOn and dcep lcslon,Imaging is Pcrformed 48 to 72

hours after ittectiOn.

56

市  一

ら！！！

1轡1酬

B

A 6 7 - y e aorl―d m a n h a s a 2 . 5 - c m l e F t u P P c r 1 0 b e l u n g i c s i O n d c t c c t c d O n c h c s t り r ,a d i O g r a p h s a n 18F nuorOde。

坤密lucOsc positron emission tomography(FDG―

PET)scan is shOwn β

り,

1.mat perccntage oftti ncwly discOvered PulmOnary nodulcs are mttignantP

2, W7hat PcrcCntagc ofsingic PullnOnary nodulcs arc indeterIIlinatc in etio10gy aFtcr chest radlography and CT exaIIli― nationP W7hat pcrccntage ultimatcly are bcnignP 7hat is thc ttkelihOOd Oflung cancer in this caseP 3. 対 4.輸

at arc causcs fOr falsernegative/falsc,POSitiVe FDG― PET 18F studiesP 57

TBonary Oncology:FDG‐ PET一 Single Pul「 Nodule l.Only 200/oto 30%are malignant Ovcrall.HowevcL thc incidencc is as high as 50%in smokers. 2. By radiographic/CT critcria,300/o to 400/O are indcterinl― nate;500/o pcrccnt ofthese arc bcnign. 3.High. 4.False,ncgat市c andingS arc uncoinmon and usually are the rcsult Ofsma11 lcsiOn sizc(80%), 31ucagOnOma(>700/o),mcdullary carcinOma of thc thyrOid (>500/o),PhcochrOmOcytoma and ncurOblastoma(>90%)。 Othcr nOnrclated tumOrs with sOmatostatin receptors with up― take include smali cclllung canceL 1/mphOma,and breast can― cei Seventy Pcrcent Ofthesc tumOrs take up thc lllln Octreo― Scan.Uptake also Occurs in astrocytomas,mcninglomas,and thymomas.Thcrapcutic analogues iabelcd with beta_emittcrs are being investigated.

1鶴

i n

r i g h t

h i l u m

C A

■

B

‖ 協砕

榊 串 Thrcc PaticntS in imagcs ,a И and chave whOlc bOdy 67Ga scans. 1, W9「 h at is thc nOrmal distribution of67(3aP /hich studies sho、 商/hat are thc indingsP 2. ｀ v pOstchemOtherapy changesPヽ 前 3. Wマhat arc Othcr causcs of67(3a lung uptakeP aceuticalP CallscsP 4. W7hich study shows an altcrcd distriblltiOn ofthe radiOpharII■

189

Notes

Oncology:Postchemotherapy 67Ga Findings l.Grcatcst to lcast uptakc:liveL bOnc/bOnc marrOwP sPiccn, kidncy(cxcrction Pathwa/1,salivar/and lacrimal glands. 2.a Thymus uptakc is nOt an uncommon nonPath010gical inding aFter chcmOthcrapy.C Diffuse pulmOnary uptake is consistent with pulrnOnary toxicity9 e.g.,bleomycin_ induced lung diScasc. 3.Gallium,avid tumoちinnammatiOn,and infection. 4.И ,Decreased hcPatic alld marrOw uPtake.Causcst reccnt MRI gadolinium cOntrast stutt ver/reCent chemotherapン or iron saturation,c.gり InuitiPlc transfus10ns.

Reference F r o n t D ,SBhaar1― 0m R Israe1 0:Role ofgallium-67 radiOpharmaccuticals in thc lnanagcmcnt of Paticnts with 1 / m p h O m a . I en m aF nに m,在 妨′ ″ ″′″″″物′ e d i.t助 。滋″″物琢 F998,Philadelphia,1998,LippincOtt_Ravcn,pp 247,26‐ 4. Reference CrOss‐ f軍配 ズどQ5慰 助 び ″″″鴎 品冴″″

and

Other

「 ES,cd 2,pp 194-195.

Comment The ttdney excretes 250/O of the administered dosc in thc nrst 24 hOurs.Thc ttdncys may bc sccn at 24 t0 48 hours but usually not at 72 hours.Thc c010n is thc mttOr rOutc ofclearance,but with 75%ofthe administercd dosc rcmaining clcarance is v slo、 at 48 hours. Because irOn competes with 67Ga for binding tO transfcrrin, iron ovcr10ad syndrOmcs,c.g。 ,rcpcatcd transfusions,can saturatc receptors and resultin dccreased hepatic and marrOw uptake and incrcased renal uptake.Extensivc hepatic rnetastascs froHl a non―galliurFl― aVid tumott hcPatic insuttcicnc/P alld VIncristinc gittn within 24 hOutt OfiniCCtiOn can alsO rcducc hcpatic up― takc.67Ga inleCtiOn should nOt bc PcrfOrmcd fOr 2 wccks atter chemOthcraPy to minimizc thcsc POtential problems. The mOst cOrnlnoFI ChCmOthcrapcutic agents that cause pul― monary toxicity and lung uptake are bleomycin,cytoxan,and busulfan.Am10darOnc,a cardiac drug,can cause a silnilar prObr lem.Diffusc PulmOnary uptakc can』 sO bc thc rcsult oflym― phangitic spread within the lung,but this is rarcly hOmOgenous. Inflarnmatory and infcctiOus causes alsO can result in Pul― monary uptakc,Particularly in immunocompromiscd Paticnts. Thymus uptakc is cOmmOn in children attcr chcmOthcrapンIt

uSu狐 けCan bc difFcrcntiatcd ttOm adenOpathy in cOttunction with CI

190

．． ．． ， ⋮ ︱ ⋮ ！ ⋮ ⋮ ！ ■一 ■ ■ ■！ 中 ■一■■ 一 ，！

A

出

員 ￨ツ ￨■料￨lil■

1

A Patient With malignant cclllymphOma.Initial B― FDG…PET study ω shOws tumor above and bclow thc diaphragm。 POstchcmOthcrapy CT shOws a rcsidual abdOminal mass.POstthcraPy FDGrPET α り. 1.Is rcmisslon cOmPletc Or Partial based On the CT and subsequent PET studyP 2. W7hat arc the lilnitations Of C'「 fOr staging and restaging ofdisease in patients with lymphomaP 3. List imaging lilnitatiOns of67Ga. 4 . M h a t a r c t h e a d v a n t a g e s o f 1 8PFE TF DcGo― mParcd with 67GaP

191

Notes

Oncology:18F FDG‐ PETローLymphoma l.The CT scan is indcterminatc,butFDG,PET dcmonstratcs a compicte rcsPOnSet 2.CT assessmcnt oftumOr resPonSC iS based on a decrcasc in the sizc Ofthe IIlass Or comPictc resolutiOn.HowcvcL POSt―

thcrapy residual masses arc common and CT cannOt dif‐ Fcrcntiate rcsidual tumOr frOnl POsttherapγ ibrOsis and nccrosis.

cnerg/PhotoPcaks:185,300,394 resulting 3. Multiplc high― in poor ilnagc rcsolutiOn;frequcnt nced for delayed imag― ing(48 to 72 hours and sOmctimes 5 to 7 days)to a110w for bo、 vcl clearancc. PET targct‐ 4.Study complctcd 2 hours aftcr ttcctiOn.FDG― ity qu』 supcrior backgrOund ratiO is highcr and imagc tO‐ t。67Ga.Usually little bOwcl activit/with FDG.Data arc 止mitcd,but consensus is that FDG is superior to 67Ga.

References Deibckc D,Attartin WII:PositrOn cmission tomography imag― ing in onco10gyj貫 Cと ,″ハめ所あИ物 39:883-918,2001. レ冴'o′ Moog■ Bangerterヽ 在,Dicdrichs CG,ct al:Extranodal maligr nant lymphoma;dctection with FDG PET vcrsus C■ 五あ豚妨θ あなノ2 0 6みイ4 8 1 , 1 9 9 8 . Cttss,ReFerence 筋″″Mcttcと″夕 fr避 対務ご

ズ野Qdtt「 ES,cd 2,p213.

Comment Of malignant lymPhOmas,15%arc caused by Hodgkitt dis― Hodg臨 品 ccl1 0rigin;the remaining 85%are non― casc and ofT‐ lymphOma Of B― ccl1 0rigin.Thc incidcncc of malignant nOn― ng and nOwお thc s技 th most HO七 臨途 lymphOmaお incrca立 common malignancye Staging is critical fOr dctermining aPPrO― priatc thcraPy.Rcstaging is rcquircd to dcterininc the cffcctivc― ness oftherapy and〔 hc nccd for further apprOpriatc trcatinent. cT and 67Ga have bccn used fOr staging purposes.67Ga is equal tO CT fOr initial staging and suPcriOr to CT in restaging and evaluating rcsPonSe to therapye 67Ga is valuabic in dctcrrnining whcther a rcsidual chcst Or abdOminal mass aFtcr chemOthcr_ apy or radiatiOn thcraP/is persistent tumor or merely nccrosis and ibrOsis.AlthOugh studies att limited comparing 67Ga and FDG― PEI Paticnts and Physicians who have cxPcriencc with PEI Image both invariably have a strong prettrcncc for FDG― thc tumOr‐ to― backgrOund ratioおhgheL im― qu』lγ ls suPCrloち

aging is complctc 2 hours attcr ittcctiOn,and bowel activity rarely is a probicm,

192

￨■￨‖

！ 榊■一 ■■■一！ ■■！！■■！ 布

！！ 一 一 十■！一 十 ■■■■■一 ！ ■十 ■■十一■■一 キ一 ■打十■■一

A 3 3 - y c a r , eo l sd m Om k』c r 15,cm lcs10n wlth

has a P00rly deincd innitrative margins

r i g h t m物i″″ dり _ l。Cu Tn g r ed pc on rs ti ct dy ao n c h e s i nu t t 。 hnte。 mcnt ofthe h csru paebrniOorrm aslcig呼

1.Dcscribe the 18F FDG,PET scan indings“ vn. sho、 フ.Sequcntial cOrOnal siiccs arc 2. HOw has this PET scan aFfcctcd the patientも prcOpcrative stagingP 3. W7hat is the Overall accuracy ofC'r and MR for preOperativc staging oflung canccrP 4. W7hat is the overall accuracy of18F FE)G― PET fOr preOperative lung cancer stagingP 193

Notes

Oncotogy:18F FDG口 PET一 Lung Cancer Staging l. Focalincrcased uptakc cOrrcsPonding to the nOdulc on CT (frames 358-370).In addition,abnormal uptakc is secn in thc right and lcft paratrachcal rcg10ns,thc right and left hilum,and the mcdiastinum,ali consistent with tumor adcnopathy. 2, 18F FE)G―PET has PreOperativcly uPstagcd the patient, whO is n0 10nger a surgical candidate. 3,ApprOximatcly 650/o, 4.Approximatcly 85%.

References MarOm EM,McAdams Hl ErasmusJJ,ct al:staging non,

1 l u n g c a n c e r w i t h w勉あ h 0 1な/ c , 2b 1o 身 d8 y0 3 P‐E ■ sm』 809,1999.

Pieterman RM,Van Putten JVG,Mcuzclaar JJ,ct att Pre― all,cclllung callcer wid■ sn■ opcratiwc staging ofnOn― pOsitrOn―

ダ身プメ鴎嵐343:254-260,2000. emisslon tomograPhン

Reference CrOss― 述 助 a彦力″Mcttci″α 軍

沢どQ占嘘

ES)cd 2,PP 209-211. 「

Comment Lung canccr is the lcading causc of canccr IIlortality for nlcn and womcn ln thc Unitcd Statcs,accounting for 250/o to 30% Of cancer deaths.At thc tirnc OfPresentation,300/o to 500/o of elンonly 20%to PatiCnts havc mctastatic diseasc.Prcopcrat市 300/o oflung cancers arc considcred resectablc.Thc accuracy of sn■ all ccll lung canccr convcntional prcOpcrativc staging ofnOn一 is Poor,At surgcry2 almost 10%of PaticntS are discovered to have unresectable discaseo Within the nrst yCar aftcr surgerト 140/0 0fpaticnts dic aFter their lung canccr was resected duc to incorrcct prcoperative stagingo CT and MR havc POor accurac/ fOr preOperative stagi.ag oflung canccr becausc thc diagnosis of tumor adenoPathy is based on nodal sizc.HowevcL approxi" matcly 240/O of rlletastascs arc found in nOHnal sizc lymph nodes,Aiso innaIIIInatory nodes oftcn arc cnlarged.FDG― PETも uniquc mctabolic infOrmation a110ws diagnOsis oftumOr adenOPathy in nOnenlarged nOdcs and cxcluslo■oftumOr in cniarged innaEIInatory nodcs. Many smdies now have rcPOHed consistcnt accurac/ofFDG… PET fOr thc sttting oflung cancci PET is dearly suPcriOr to 降 ″ 読さ阻 グル グ″″〃ザ convcntional imaging.In 2000,thc」 陀 抗c れ″r c p o r t c d t h c s e n s i t i t t t y a n d s p c c i nPcEiTt yt oo f F D G ―

b e 9 1 % a n d 8 6 % , t s p e c t i v e , c o m p%aarncdd 6w6i0t/h0 7 う for CI PET uPstaged 42%ofPatients and downstagcd 20%.A study ttom Dukc University reportcd that SPCCincit/for FDG‐PET in scParating surgical frOm nonsurgical discasc(N3)was 920/O and 93%comparcd with conventional ro t, S pt ra et oe P―c r ‐ i m a g i n g ( C I M R l o f 2 5 0 / o a n do 阜 9t8h0ea/― smali celllung cancer staging requires FDG,PEI athc non―

194

the

sensitivity

and

艶￨ 仇

デ 鶴

ろ そ

サ

敗 1尋 ■

H

■1 繍

鞭

畿

Ｗ

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轡

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鶴

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一

畢

ぷ

ツ

ズ

弾 ヂ

ル B

A69-year-01d IIlan has a histOry ofcO10rcctal carcinoma and surgical resection.The carcinOcrIIbryOnic antigen(CEA)

lcvelis increasing and the CT scan shows v2.3-cm a nc、 lcs10n in the right iObe Ofthc liver. 1.FDG― PET scan作り was then obtaincd.Wttat are the indingsP 2.W4hy wasthe FDG― PET scan OrdercdP 3. W7hat arc clinical indications fOr PETFDG― in cO10rectal carcinOmaP 4.FDG― PET scan l砂 was performed 6 mOnths aFter rcscction ofthe livcr ics10n.Dcscribc the indings,

195

Notes

Oncology:18F FDG‐ PET― Colorectal Cancer Metastatic to Liver l.Increased uptakc consistcnt with tumor in the llvcr cOrrc― sPOnding to the rcported CT masso No othcr livcr leslons or metastases ttc seen ciscwherc in the whole body scan. 2.Surgical rescction is Planned.The preOPcratiVCPET FDG― scan is used to deternline the prcscncc ofany othcr rnetas, tascs h thelttr Or dscwhctt h the body that mlght change

approach or make thc patient inopcrablc. the suttc』 (1)Increasing serum CEA levcls with nOrmal conventional

imaging,(2)cquivocal lcslon with cOnventional imattng, ive rcsection. and(3)prcOperativc staging before cura〔 4.

Ncgat市c scano No cvidence Oftumo■

ReFerences Delbeke D,Vitola JM Sandler MB ct al:Staging rccurrent

〃鴎嵐 協 metastatic colorcctal carcinoma with PE■ ノ掛 38:1196-1201,1997. Columna,Hascman MK,ct al Wholc― boⅢ Valk PE,Abella― PET imaging with F,18 FDG in managemcnt ofrccurrcnt c010rectal carcinoma,И括力S″瞥 134:503‐511,1999. CrOss‐Reference 日Yど 父どQtt「 ご ″ ″α ち ″″″ルをグ″ ミ転ご

蕊 ,Cd 2,pp 211-213.

Comment Causc of canccr C010rectal cancer is thc sccond mOStmOn col■ death in the Unitcd Statcs.Thcliwcris the mOst common sitc of though loctt rccurrcncc is not uncom― c010rccttt mctastascs,狙

to the livci mOn.Many paticnts dic with mcttttttcs exclusiveけ Although rescction ofthc hepadc metastasis is POtCntially cur― ative,it is associated with signincanc morbidity and mOrtality. Resectability dcPends on thc number Of rnetastases and thcir 10cation.In thc past,only 250/o ofpatients with partial hepatic en ex― resection werc cured becausc ofthc presencc ofOccult,o丘 trahepatic,Inetastases.ExtrahcPatiC Inetastases usually arc a contraindication to surgeryc Serum CEA elevatiOn is only 5oO/O sensitive and 850/o sPc― cinc for lnetastascs.Of coursc,it provides nO infOrination on 10cation.The scnsitivity ofCT for detcction Ofliver mctastascs iS Suttrisingly btt Multiple studics havc conarmed the supcri, Ority ofPET over CT for staging ofrecurrcnt colorcctal cancei A r c c e n t l a Or fg o 1 5s 5t u psけa tw ii ct nh 〔 r e c u r r c n t c o l o r e c t a l canccr found a sensitivit/and sPccincity for cT of 69%and 9 3%and 98%.FDG― PET had a clinical 960/O and for PE■ en cliIIlinating unnccr eFFect in lnOrc than 300/o ofPaticnts,o丘 cFFectiveness have shOwn that the cssary surgerye Studics ofcost― a d d i t i o n O f F DPGE‐T t o t h c P r e o p e r a t i v e c v a l u a t i O n d e c r e a s e s thc ovcrali cOst oFcaring for Paticnts with recurrent colorcctal cancci

196

訊 呼千11111肺 転

■ iふii榊 航!iittili抑 鵡 ■ li―

B

埋 す 檎

Aう 4-year― old、 vOman with brOnchOgenic carcinoma rnetastatic to the brain recently underwcnt stercotactic radior surgery for a lcs10n in the icft temporOParietal reg10n.MRI cOuld nOt dinttrcntiatc postthcrapy changcs frOrn viabic

tumorにつ. 1.Give the rclative accuracy ofFDG― PET vcrsus CT Or MRI for diagnOsing malignant tuELOrin the brain. 2.村恥at is the rclative accuracyPET ofFDG― versus CT/MRI fOr differentiating rccurrent or persistcnt tumor from POStradiatiOn necrosisP 3.Describe thc imagc nndings and interpret the transaxial imagcs`り ofFDG,PET Ofthc brain. 4.List single phOttn rad10traccrs uscd for brain imaging and describe the cxPccted indings,

197

Oncology:18F FDGoPET一

Bronchogenic Cancer

Metastatic to Brain RI arc morc scnsicivc FOr tumor dctectlon. l,CT andヽ 在 Normal brain uses only glucose for metab01ism and has highcr uptakc than any othcr organ.This results in high background that can makc tumOr detcction difncult. 2.FDG― PET is morc accuratc than CT or]MRI for dctcr‐ rnining whcthcr postthcrapy changcs arc the result of residua1/recurrent tumor or radiation nccrosis。 3. Focal incrcased uptakc in the ictt temporOParietal rcglon that cOrrclates with thc lcs10n On MRI.This is cOnsistent with viable residual or rccurrent turnor l and 99mTc sestanlibi havc incrcased uptake in 4. 201'「 1-PAO and tumors.Tumors usually arc cOld on 99mTc Hヽ ECD.

ReFerences Hagge RJ,Wong TZ,Coleman RE:PositrOn cmisslon tomogr И物 oFtあ r a p h y : b r a i n t u m O r s a n d l u筋 n g冴冴 c a0nケ c″N c島 39:871-882,2001 n mctastascs from ct al:Brぶ Grittth LK,Nch KM,Dehdasti■ non―ccntrai ncrvous systcm tumorsi evaluation with PE■

勉あ 残ノ18&37-44,1993. Reference CrOss‐ 醍 筋″″鴎 品冴″α軍 助 ご

沢どQ」■ Sr蕊 〕ed 2,PP 301,305.

Comment brain has bccn FDG― PET detcction ofmetastatic tumors to cd■ reportcd to bc mOrc variablc than primary brain tumOrs.It is iess scnsitivc for initial staging for brain mctastasis than CT/MRI.Thereforc imagin3 0fthC brain is nOt routinc at most ccntcrs whcn PcrfOrming wholc bOdy PET imaging.The brain htt thc highcst uptakc ofFDG ofany organ and thus scttcs as a high background,making detection ofincrettcd uptake h tu― mors lnorc dilncult. ARcr therapンCT and MRI often cannot differcntiatc Post, thcraptt nccrOtic or ibrotic lnasses froHl viable rcsidual or re_ current tumoi Surgical b10psy is nOt always possiblc and POscs associated morbidit/.FDG―PET can be uscful as in this casc. Uptake indicates viable tumOtt and the lack ofuptake signines cFFcctive thcraPy.FDG,PET also is PrOVing uScful for radiation therapy planning.Fuslon ofFDG‐ PET and MR or CT studics can help dircct the radiatlon bcam to the rcsidual tumor within a hctcrogcnous tumor rnass. Notes

198

A35-ycar―old― man writh AIDS has a ncw intracranial abnOrmalitt On MRI∽ and β)ofuncertain origin.A SPECT study(Cl,coronaL C2,satttttt C3,transverse)was ordcrcd tO assist in thc diffcrendtt hargnOsis. 1. What is thc rad10pharェ naccuticalP 2.What is the differen〔 itt diagnOsis bcforc the SPECT studyP 3. W7hat is thc likely diagnOsis aFter the rad10nuclidc studyP 4. W7httt is the accuracy ofthe radlonuclidc rncthOdP

199

Notes

Oncology:201Tl_intracranial Lymphoma l.201Tl was uscd,99mTc scstamibi alsO can bc uscd;howeveL itis taken up by the chorOid Picxus and could Posc diag― nOstic Problerlls in sOmc cases. 2.Tumott PartiCula』y lymphoma,versus infcctiOn,usually tOXOPlasmosis,Or other opportunistic infectiOns,c.gり OmCgalic inclus10n宙rus,hcrPcs Simplcx,凍捜 力切raな 守〔 3.Mttignantlymphoma. 4 , A P P r o x i m a t c l y 9 0 % s ie tn ys i ft o市r t u m o t t F t t s e r p o s i t i モ rate ofless than 100/0.

References O'MalleyJl ZiCSSman rLA,Kumar PN,ct al:Diagnosis ofin― tracraniallymphOma in PaticntS With AIDtt valuc of201-Tl

single,Photon emission computcd tomOgraPh乃 押 И物ブ 421,1994. ″θ ′163:417‐ Rθ″ ″宅1夕 et al:FDG‐PET in dif― HOftt■an JM,Waskin HA,Shifter■ 島rentiating lymphOma ttom nOn‐mttignant CNS lcsiOns in 冴鴎 札34:567‐575,1993. patients with AIDS,メ用 杉 Reference CrOss‐ 胡 益 )ed 2,pp 314‐316. 助 ご 捻″″鴎 品所″ぞr述 財 Qじェ Comment 酪xopみ 物″評 ″妨″is the most common cause of focal en― ccPhalitis in PatiCnts with AIDS.HowcvcL intracranial lym― PhOma is increasing in incidcncc and is the sccond most com― mon cause;it is a vcry aggressivc and oFtcn lethal discasc.CT 加d MR are not rcliable for distinguishing bctween tumor and cnhancing infcctiOus causes.Both IIlay appear as ring― icsions RI.Oftcn paticnts are trcatcd cmpirically for toxoplas― Onヽ 在 mOsis,and b10Psy is PcrfOrincd only if thcraPy yields nO re― sponse.HowcvcL a clinicalrcsponsc may take at the minimum scveral days and容long tt many wecks.Drug〔 oxicity is high. tumors would be Optimal. Prompt thcrapy of thesc aggrcssiモ 201Tl also can bc used to evaluate for radiation necrosis vcrsus viable tumOr in PatiCnts with treated brain tumors and equivo‐ 江RIs. ca1 0r susPiCiOusぶ ly mOrc active than infcctiOn. Tumott usuttly are metabolic』 201Tlis taken uP in many benign and malignant tumors.Thc にsdution is not high in brttn tumor imaging wlth 201Tl,but lowing strttghtr torbackgrOund r鉦lo ls very high,狙 the target― fOrward diagnOsis.TumoA have high uptakc,whcrett

uptake is sccn with in‐ usually has P00r uptake.UncOmmonけ nammatory diseasco SPECT is mandatory.

inttction

A49,ycar-01d wOman was referred fOr brcastlymphOscintigraPhy atter reccnt bloPsy Ofa right breast mass and thc di― agnosls ofbreast cancci l. 対 7hat is the implicatiOn Ofaxlllary nOdc inv01vcmcnt in brcast canccrP 2. WhatiS a sentinci nodeP 3. N7hat is thc purPosc ofscntinei node b10psyP 4.軸

at is thc radiOPharmaccutic』 used,and hOw is the stud/perfOrmedP

201

Notes

Oncology:Breast Cancer Lymphoscintigraphy l.The 5‐ year suttitt rate fOr breast canccr dccrcascs with axll― indcatcd. Lry node lnvolvement Adiuvant ChCmOthcrapyお 2.A scntinci nOdc is thc nrst nodc drainca by thc lymphatics ln a nodal basin. 3. Ifthc sentinci nodc biopsy is tumor negativc,no axlllary disscction is nccdcd.Ifpositivc,axlllary disscct10n iS pcrfOrmcd. 4.The phaHnaceutical otten used is nitercd 99mTc sulfur c01-

101d.It is injcctcd around thc ics10n Or b10Psy Site.IInag― ing usually is pcrformcd.Atsurgery a gamma probc is used to help 10cate thc sentinci nodc.

References 降 ag D,Veaver D,Ashikagal ct al:Thc scntincllymph nOdc

熊棋 Ⅳ鶏 ヽ a multiccntcr validation sm毎 in brcast cancc■ 974,1998. 339:941‐ Alazraki Nl Styb10■ Grant Si ct aL Scntinci nOdc staging of carly brcast canccr using lymphoscintigraphy and thc intra" ″N ftt 物 И ″ OPCratiVe gamma detectingク pθブ r Co ′ bガ c , Ro ″ 9う6,2001. 3:947‐ Reference CrOss‐ ハ物び 力″″劫修冴″″α 五″F沢 どQ」慰

E「 S,cd 2,pp 226‐ 227.

Comment ln brcast canccr thc prcscncc ofaxlllary adenOPathy and num― bcr ofnOdcs involvcd is irnPOrtant for prognOsis.Clinical cval― uation ofthe axllla for abnOrmal nOdcs is not prcdictivc;alFnOSt 40%Ofpaticnts havc HlctaStascs to axlllary nOdes that are not vho undcrgo ax― dctcctcd clinicallye WIore than 80%ofwomcn、 11lary nOdc dissection havc at icast Onc postoPCrative comPttca― tiOn,mOstcommon,lymphCdCma. The rationale FOr lymphOscintigraphy is that thc status of the sentinei nodc Prcdicts whcthcr F10dal lnctastases arc Pres― cnto Sttp lcsions arc vcry rare,Many studies have shown high Bluc dyc ottcn is alsO used at accuracy for lymphoscintigraPhン surgcryto idcntittand thC SCntincllymph nOdc.Timing is crit― ical becausc thc dyc mOvcs quickly and can nood thc neld. Ы dyc and lymphosdntttrar Increぷnか surgeons use both uc phy IOr best resultso Surgcons nOw usc a garnrna probe in the OPCrating room to hclP iOcate the scntinei node. Flltcrcd 99mTc sulfur col101d is uscd in thc Unitcd Statcs.Thc larger PartiCICS that tcnd nOt to bc takcn up by lymphatics are nitcrcd out.IttcCtiOns usually are made subdermally and subr cutaneously at rnultiplc sites arOund thc ics10n Or b10psy sitc. ApprOximatcly 100卜 Ci is ittccted.Imaging usually is com― vs arc nccdcd to Pictcd within an hOui Latcral and anterlor vic、 10calize thc sentinci nOdc.

not yct the standard mphOSdntttraphyお Brcastけ a ofcarα multiccnter trial is ongoing.

202

へ

1諷

1抑￨

十 瘤 ￨￨ ￨‐￨ ￨11協赫ぱ￨￨ A

Ⅲ 比 臨 点 ￨1母エ ￨ヘ

ソ

ぽ ぽ

騨

雰 蘇ヽ

祓ぱ

ら

ベ

l 1i,十 1″ 1111‐

Ⅲ ⅢⅢ POST

Scntinci nOde lymphOscintigraphy was PcrfOrmed fOr malignant melanoma in thc mid―

left POstcriOr thOrax.Onc_

ど 鮒鮒 軒 鱒 i嵐 絆滋 鉾ぺ 貯監 8ど 隣[l徽隅 解あi魂 品 簿骨 牌獄士ど 路[h研 imagcs(appcars cold).

1. W91hat is thc radiOPharrxlaccutical cOmmOnly uscd and、

vhat is thc ratiOnalc rOr its uscP

2. Describe thc study indings. at is thc nOrlnal drainagc Ofa rnid postcriOr chest Or nank lcsiOnP 3, Wl■ 4.HOw arc Patients with mclanOma sclcctcd fOr lymphoscintigraphyP

203

Notes

Oncology:Melanoma Lymphoscinttgraphy m in l. Flltered 99mTc sulfur c01lold PartidCS,0.l22toμO。 sizc,are ittccted intradcrm狐 転 taken up by thc lyttPhat, ics,and dcmonstrate lymphatic channcls and nOdcs. 2.One― minute dynamic imagctt drainage tO thc right axllla t h r O u g h W o s c P a r a t C l y m p hs aO t id cr a c0i hn as n〔n c l s , 組 thc leFt axllla.Nodtt uptakc in the nght axllla is sccn on the stadc Postcrior vitt Thc antcrior vicw sentinei nodcs and onc On the left.

shows

wo

3. Drainage is unprcdictablc,and lnay drain to either axlllary Or to inguinal regions. 4. PrOgnosis is deterHlincd by les10n dcpth,Those lcss than O,76 rnnl are low risk and rarely lnctastasize;thosc decPer than 4 mm oFten mctastasizc.Patients with intermediate‐ d forlymphosdndgraphy and 立Ons are rcttrに thicknessに scntinei node blopsyt

References KraznOw AZ,Hellman RS:Lymphoscintigraphy revisited: 温び ″ ″夕″″″″″′ 悦cLca″物と 1999,In Frecman LM,editor:ミ ゴ タワ,PhiladelPhia,1999,LiPPincott WilliaEIs&こ Wilkins, PP 17,98. Bcrman CG,Choi J,HcrSh MR,et al:MelanOma lymPhOr ′'物 レグ ″ ″ミ悦び ,物 scintigraphy and lymphatic rllapping,S夕 30:49‐ 55,2000. ReFerence Cross‐ fr醍 ″ ″′ ″″″脇 冴び 助 ど

ズどQ3酎

蕊 「 〕Cd 2,pp 226‐227.

Comment elanOma les10ns Progress,they move dccper into thc As sttn l■ dermis,Spread from the prilnary tumor to local lymph nOdes occurs beFOrc systcmic metastascs.Thc current approach is to Lctte the nAt lymph nodtt the ttndnd nodtt thtt drttns thc nOdal basin.This scntinei nodc is locatcd on the lymphoscinti‐

At thc prcOpcratlveけ gram and markcd on theskin ptticntも iZation time ofsurgcryP a gamma prObe isluscd to ttd in the 10ギ Of the sentinei nodc that is thcn removcd for pathological ex‐ arninationo Many surgeons simultancously use bluc dye.The cOmbinttbn ofthe wo gives bestに sdts,Ifthc nodc is Positive fOr tumOtt the other nOdcs in that basin alsc are resccted.Ifthc nodc is ncgative,no ttLrther disscction is PcrfOrmed.Bccause nO efFectivc theraPy for lnelanOma cxlstS OnCC it has become

‐ widely mettttatic,this aggressive surttCtt approach is incre益 ingly uscd.

right

A43ryear,old woIIlan was hOsPitaliZed with abdOminal pain,nausca,and vOIIliting that started 24 hOurs bcfOrc

ch01escintigrapけ 1, W7hat are thc ch01escintigraphic indingsP 2.What clinical infOrmatiOn wOuld bc helpttl tO cOrrectly interprct the studyP 7hat is the differential diagnOsisP 3. ヽ 4. W7hat wOuldンOu do ncxtP

205

Notes

Hepatobiliary Systenl:Delayed Biliary‐

toロ

Bowel Transit l. NoHnal gallbladder nlling and secretion into blliary ducts; hOwcveら nO cicarancc ofradiOtracer from thc coHllnon to‐ bowci trarlsit by 60 1ninutes. duct or biliary― 2,Is thc Patient receiving narcoticsP Was sincalidc(CCKl gttn bcttrc thc studyP 3. Partial coHlrnOn duct obstructiOn,functlonal obstructlon caused by sincalidc administered beforc the studtt rcccnt narcotic administratiOn,Or normal variation. 4.Obtain dclaycd imagcs or give CCK.Thc latter would givc thc answer morc PrOmptlye

Reference Zicssmall IIA,Zeman RK,Akin EA:Cholcscintigraphy:cor崎 " latiOn with Othcr hcPatObiliary imaging modalities, In :D″竹″釘カ Sandler MB Colcman RE,Wackers FJTh,ct』 ″らcd 4,BaltimOrc,2002,Lippincott Willialns ″″通缶″物ettcを 能 Wilkins, CrOssPReference 助 び 力″″鴎 品冴″4E避

越 Q3S 「 ES,cd 2,PP 242-243.

CoJmment ln this casc,Partial commOn duct obstruction must bc cxcludcd. Note thtt with high― gradc Obstruction,ch01cscintigraPhy shows hcPatic uptakc without secretion into the biliary tract bccallsc of commOn duct ob― thc high back― pにssu氏.HOwevcL宙 th Parti』 struction thc 99mTc iminodiacctic acid(IDAl is scCreted into the blitttract but dcars PoOrly ttm thc bliaryductsintt torbowcl transit should be C)ther causes of delaycd blllary‐ cOnsidcrcd in addition to obstruction;Possiblc causcs arc listcd ide(Kinevac),thc tCrmintt octaPeptide abOve.In this case,sinc』 OfCCtt wasinfuscd bcfOrc thc study to cmpt/the gallbladder because thc Paticnt had n0 0ralintakc lor morc than 24 hours. b obwiclii atrrya‐ nsit.As T h i s i s a c o m m o n r e a s o n f O r d c l a yteod― stimulated contraction,a the gallbladdcr rclaxcs ttRer sincalide― ncgativc intravesical illing pressurc causcs bilc to prcfcrcntially On dllct. f10w to the gallbladder rather than to thc cOHll■ to"bowcl transit is secn with chrOnic cholccys‐ Delaycd biliary‐ titis and has been rcPorted in up to 200/O ofnOrmal suttccts. Obtaining 2-to 4-hOur dclayed images or sincalidc infuslon can coniH■or cxcludc Partial cOHllnOn duct obstruction.Thc life OF sincalide allows for rcpcat administra‐ 2.5rminutc half‐ tion.In a nonobstructcd duct,CCK relattcs the sPhinctcr of to― bowel transit.Sincalidc Oddi and rcsults in prOmpt biliary― has a lnalor adVantage Ovcr dclaycd imaging in that the answer is knOwn within 30 ininutcs.

206

thc

bowel.

ア為

誂

A

従 鉛

い

あ

鉛

45

40

転寵拘 鋪 職t 森

グ

モ輛

鍮

ユ

B

20 rnin

脚 38 rnin A63-ycar―

old、 vOman has bccn hOsPitalized fOr 9 days with rnultiPic seriOus lnedical prObleltrls and is receiving hyper―

alirlflentation.No、 v acutc abdOrrlinal pain has dcve10pcd,Shc has bccn referrcd fOr chOlescintigraphy tO rule but acute chOlecystitis,И

,60,Ininutc ch01cscintigraph/eF,AdditiOna1 30,Ininutc images aftcr adlninistratiOn ofmOrphinc.

1. What is thc relative accuracy ofchOlescintigraphy in this patientも clinical settingP 2. Describe thc ch01cscintigraphic indings. 7hat is thc clinical signincancc ofthcse nndingSP 3. ヽ 4. ｀ 前/hat Path010gical cOndition is likelyP

207

Notes

Hepatobiliary Systeni RIM Sign c study rcsults in l.Incrcascd incidcncc offalsc‐ posit市 patients who have becn fasting inore than 24 hOurs,thosc ing hyPcralimcntation,or those wlth concomitant rccc市 scrious ilincss.

2. NonvisualizatiOn ofthc galibladdcr aFter 60 minutes.AttLcr mOrphine adIIlinistration no nlling Ofthe gallbladdcr occurs.Incrcascd uptakc is sccn in thc region ofthe gall― bladder fOssa,which pcrsists after mOst ofthc livcr has washed Out(RIM sign). 3, NonvisualizatiOn ofthc gallbladdcr aftcr mOrphinc adHllrl― istration is consistent with acutc cholccystitis,but the SPCCincity is rcduced somewhat in this clinical setting (hyPcraliment筑lon).ThC RIM sign is vcry sPcCinc for acute cholccystitis and conirms the diagnosis. 4.Thc RIM sign indicatcs sevcrc acutc cholccystitis,which is associatcd with an incrcascd incidcncc Ofgallbladdcr ganr grenc and perforation.

ReFerences Brachman MB,Tanasescu DE,Ramanna L,ct al:Acute gan―

冴θ 々緞 grcnous cholccystitis:radionuclidc diagnOsis,娩

1う1:209-221,1984. Mcckin GK,Zicssman HA,Klappcnbach RS:PrOgnOstic valuc and Pathophysi010gic signincancc of thc rim sign in chole‐

ガ雌札28:1679-1682,1987. scintigraPw)S用 ReFerence CrOss‐ 対務び 務″″鴎 品乱″α r醍 ズどQJrsrrES,ed 2,P239. CoJmment With scverc acutc cholccystitis,galibladder innarnmatlon Elay spttad from he hnalncd ttbladderwali tt hc adiaCent hcpttic PattnChyma.Surgeons sometimes sce an innarnmatory cxudatc withadhettnceOfthcgalibladdcrtothettacentliVei Chol岱dn_ tigraphy ottcn shows incrcased blood aOw to thc innarncd Pcri… ch01ec/sdcliver region anJorincreased uptake and Persistcnce of thc IDA radiotraccr(RIM sign).PcrsiStcncc ofthis actMty is at― tributed to a reduccd hcPatOttC ablity to dcar dlc tracer and Pos― sible loca1 0bstruction of bilc canaliculi as a result ofinnamm伊 的ry cdema.The RIM sign has bccn reported in 25%to 600/o of PatiCnts with acutc cholccystitis.Thus its scnsitivity fOr acute VCVett its sPecincity is very high.Thc cholccystitis is Pott HO｀ pathOphysおLttcalpttgrcssbnofacutechoLc/sttsお c/sdc duct ObstructiOn arst,thcn mucostt cdema,Polymorphonucicar cell lyhemorrhage and necrOsis,and ifleFt untreated, innitration,an】 3angrenc and PcrforauOn.Thc RIM sign sugests that dlc patien体 出s c a s c h t t P r O g r e s s c d f a r d O n g t h i s s P c c t r L l m at the s p c c i n c i t y o f t h i s s i g n i n c r e a sse so otnhned ednicnei ctihぷ

Ofdiscasc.Thc

patient has acutc cholccystitis,cvcn ifthc Patient has an increascd

Cロ l i k e l t t O d t tPro sai tftaコ s乃 p Юl o n g e d f a s t i n g , h y p e r g・→ tl士 s← aliHlcntation,concomitant serlolls lllness. 208

high

irnrnediate

10

20

40

25

50

30

60 rnin

A50-ycar― old wOman has acute Onsct ofabdOmintt pttn Of4 hOurs'durat10n.UltrasOnograPhy results are normal.

1. ヽ 7hat are the ch01escintigraphic indings and the diagnOsisP 2.Differentiatc thc tcrmsす ク管″ 物サ あ物 び 力 ろ and″ブ ルあ ″冴物力 %. ,あ妨″響 θ レ ク″冴r々 3.Diffcrcndatc thc 99mTc IDA indings ofhighr and 10w,gradc blliary obstructlon. 4. Ho、v dO the ch01cscintigraphic indings ofhepatic insuttcicncy diffcr frOm this cascP

209

Notes

Hepatobiliary Systenl:High口 Grade B:liary Obstruction l. Prompt hepatic uptakc,nO cxcretion intO thc biliary tract, cOnsistcnt with grade high―cOmmOn duct obstructiOn.

Ch01cstatic,aundiCC,c.g.,drug reactlOn,may look similai

2.Obstruction may occur without,aundiCC.JaundiCC is a late manifestatione Obs=ruct10n does nOt always result in duc― tal dilatiOn.DilatiOn can be prcscnt without Obstruction. v, 3.Highrgradα hcpatic uptake,nO blllary cicarance.Lo、 grade:sccrctlon intO biliary ducts,delayed dearancc from thc biliary ducts,and delayed blllary‐ to― bowcl trarlsit. 4. HcPatic insuttcicncy:delaycd livcr uptakc and dela/ed hcPatic and backgrOund cicarancc,o丘 en ddayed b品 ary― tOPbO、 v cl transit.

Reference Zicssman HA,Zeman RK,Akin EA:Cholcscintigraphy:corre― latiOn with Other hepatObiliary imaging modalitics. In Sandicr MB Colcman RE,Wackers FJTh,ct狙 :Dブ留 がカ 品品 らcd 4,BaltimOre,2002,LiPPinCOtt｀ Villiams ″″並住″物は &Wilkins. Cttss― ReFerence 助 び 捻″″%渉 す 力α 『 鵡

逆 Qdttr蕊

,cd 2,pp 241-243.

Comment ln carly biliary obstructiOn the serum alkalinc PhOsPhatasc cOn‐ ccntration otten is elevated bcfOrc hyPcrblllrubinemia.The de― gree ofbile duct dilatiOn varies but is directly rclatcd tO thc du― ratiOn,dcgrcc,and causc of obstructiono E)ilatiOn is lnost standing obstructiOn,cspccially when caused prcvalent in long― by inalignancys Patients with Parly9 gradc,Or 10w― ittent interl■

bili呼Obstruction maynot havC dilatcd Bcnign dllcぃ causes 9f callslヽ tiOtt OいtruCtiOn less aに likely toigninCttt dilょ Ofthe bil― iar/tfact.In somc cascS,dlctal dilation ttay bC rcstrictcd by cdema and scarring as a resuitOfinfcctiOtt or cirrhosise On,c dllated,biliary ducts OFtcn rchain sO even atter the stOnc has PaSSCd Or surgcry has relicved the obstrucdOn.Thus discOrdancc Ottcn exists beween thc Physi010gictt scintigraPhic results and thc ttOrPh010gic】images OfditrasOnOgraphy and CI Thl pathOphys1010事ctt Sequ・ nce ofevcnts in highrgradc bll― iary obstruction progresses in a prcdictable rnanner:obstruc― tion,increascd intraductal pressure,reduced bilc nOw9 biliary _ duct dilatiOn,incrcased cellular peHneabilityP and anally nbr。 gencsis icading tO cirrhosis.E)1latiOn inay not becomc evident unti1 24 to 72 hOurs aFter the initiating event.AlthOugh ultra‐ sonography usuttly is thc arst imaging study in the setting of blliary obstruction,ch01escintigraphy is indictted when ducほ are not dilated.Altcrnat市 eltt ch01cscintigraphy is ttccCSSIy to diagnOsc Or exclude Obstruction in PatientS Widl prcvlous blllary dilatiOn and suspected acute obstructiOn.

210

‖‖‖‖十

2 hr

4 hr

24 hr

A50,ycar― old man with scvcral mOnths OfabdOminal discomfOrt and,aundicc. 1. Describe the chOlescintigraphic indings. 2. W7hat is thc diFFcrcntial diagnOsis at 60 111inutesP 3. How havc dclaycd imagcs hclPcd lnake the diagnOsisP 4. N7hat arc the possiblc approved FDA― radiopharlnaceuticals and their alternative routc ofexcretiOnP

211

Notes

Hepatobiliary Systenl:Hepatic insutticie,cy l, Poor hepatic functiOn:dclaycd blood Pool(hcart and grcat vessels)and backgrOund dettancc,no sccrction intO blllary ducts at 60 1ninutes.Dclaycd images shOw ver/1aie nlling to― bo、 Ofthe galibladdcr and biliary‐ vel transit by 24 hOurs. 2.HcPatic insuFncicncyj biliary ObstructiOn with secOndary hcpatic insuFnciency・ Dclayed imagcs show nO radiotracer retention within thc to― bowcl transit,ruling out biliar/ducts and blllary― Obstructlon.

3.

99mTc mebrofcnin Or brOmOtricthyl minOdiacctic acid

4.

(IDA;Choletec)or 99mTc disOfenin Or DISIDA Rcnal excretion, (HcPat01itc)。

Reference Zicssman HA,Zeman RK,Attn EA:ChOlcscintigraphy:corre― latiOn with Othcr hcPatObiliary imaging modalities. In Sandier MR Colcman RE,Wackcrs FJTh,et 留 a l :冴カ Dブ 夕 ″ す ブ ″らcd 4,BaltiII10re,2002,LippincottWilllams ″″す 力″″物ど 髄 ヽマ1lkins, Cross―Reference 姥″″ルク妨″″資 Tr/f沢 どQし 空財『 蕊 ,Cd 2,PP 234,241‐ 242. A物び Comment

With rcccnt onset of high― ObStruction,hcPatic gradc biliar才 functiOn usually remains good.With timc,secOndary hcPatic insumcienc/may cnSuc.If radiOtraccr ilis thc biliary system and transits the cOIIIInOn duct withOut evldcncc of retentlon, thc cause is not obstruction.With Partial obstructiOn,thcrc is retentlon ofactivity proxilnal to thc site OfObstruction.Therc tO― bOwci transit. may or may not be biliary― The diffcrcntial diagnosis ofprimary Parenchymalliver dis― limiting discasc,c.g,,acutc宙 ral case is long.It may be a sclf― induccd,or chrOnic and pror hepatitis,alcohOlic hcpatitis,drug― Cirrhosis,chronic active hepatitis.Imaging gressive discasc,c.gり can difFcrcntiatc Parenchymal disease frOm discases that requirc surgical intervention,c.g.,biliary obstruction.In this casc the liver dOes not appcar shrunkcn as in stage cnd― cirrhosis.This patient probably has acutc Or subacute hcPatic diSCase,Patients 胡th hePatic insuttcicnc/dO nOt havc abdomin』 pttn,』thOugh thcy may havc abdomin』discOmfort frOm hcPatosPiCnomegaly and ascites, With normal hepatic functiOn,less than 90/00f99mTc disO― 島nin is cxctttCd thrOugh thc ttdneys cOmparcd with iess than l%fOr 99mTc mebrOfcnin.With incrcasing hepatic dysfunc― don,moに of hc radotraccr is cxcrctcd through thc ttdneys. 99mTc mcbrofcnin is preFerable tO disofenin with hepatic insuF_ ncicncy because of its grcater hcPatic cxtraction(980/o vcrsus 88%).

212

A39-year― old womall宙

th abdOminユ

Pttn;histOr/OfChOlecystectomy.Results Ofrc狙

1. Dcscribc thc cholcscintigraphic indings. 2. Givc thc dif&〕 rential diagnOsis at 60 1ninutcs. linutes. 3. Give the diagnosis at 120正 4.村 仏at is an alternat持 e methOd fOr making thc diagnOsisP

_timc ultrasOnOgraphy are normal,

Notes

Hepatobiliary Systenl:Acute Cho!ecystitis and Biliary Obstruction l.Nonnlling Ofthc gallbladdeL prOIninent rctained activit/ in the cOHllnOn duct at 60 1ninutes,、 vith dcinitc biliary‐ bOwcl transit at tO― bowcl clearancc.Continuing biliar/― tO‐ 120 minutcs,hOwevett incrcascd rctcntion in the cOm― monduct.Minor cntcrogastrlc renux. 2. Partial biliary Obstruction,hyptOnic sphinctcr OfOddi (no r m a l v a r i a t i O n , C C K g i v e n b e f o r c c ht rh oc nic stu(転 chOlcttstitis. On coHll■ duct obstruction. 3. Very susPiCiOus for partial 4.Administer CCK.

References 代:CholccystOkinin ch01cscintigraPhtt dinical in― ZiessIIlan I也 対♭ ″ 務И物 3 9 : d i c a t i o n s a n d p r o p c r m e t h o d o,100′ Cg 筋 /9賜 997‐1007,2001. Ziessman,ILA,Zcman RK,Akin EA:Cholcsdnugraphy:cOr― relatiOn with othcr hepatobiliary imaging mOdalities.In

Sandlcr MB Colcman RE,Wackcrs FJTh,et al,editOrs: 渉ど ガ ″ら ed 4,Philadclphia 2002, Dブ竹″い″び″″び ル″″物′ Lippincott WilllaHIsに セWilkins. CrOssPReference ca″虹e品び ″ ″夕 fT配 脇 c↓ 241‐ 243.

父どQ5眼

E「 S,cd 2,pp 235‐ 236,

Comment Thc ultrasOnograPhic critcriOn fOr thc diagnOsis of biliary ob― strucdon is intrahepatic and cxtrahcPatic biliary(1lation.Overall accuracy for cOmmon blle duct ObstructiOn is high;hOweveL pa― 10w― tients with earlン gradc,Or intcHnittcnt blliary obstruction may not have dilatcd ducts.In these cases a discrcpanc/cxiStS bctween the ttsdtt OfttnctiOntt ch01csdntigraPhy Om― and an筑 lth Partitt biliary obs[ruction,chole, ictt imtting procedures.村 scintigraphy shows dciaycd clcarance of the cominOn duct. Delaycd biliary dcarance from the commOn duct at 60 minutcs can havc various causes,indudng chrOnic cholcc/stitis,prcchOlc, sdn“graPhy adminお tration Of CCK ttr pr010ngcd fasung,or norl■ al variatlon.HoweveL no dearancc On 2-to 4-hOur dc― laycd imaging or aner CCK intts10n is consistcnt with a partial biliary obstruction.CCK rciaxes the sphinctcr OfOddi.WithOut biliar/Obstructlon,bilc cicarancc froIIl thc cOHllnOn duct oc― obstrllcr cuA prompⅢ The lack Ofclcarancc is consisttntwiい don.Although delaycd blLry―tO_bOwel transitお characte五 stc Of biliary obstruction,it is nOt unconlI■ on for sOme transit of rad10traccr into the intestines to be scen at 60 minutcs with Par― tia1 0bstruction,as in this casc.The lack of commOn bllc duct cicarancc is thc rnOst scnsitive nnding・ Blllary obstruction lnay coexist in paticnts Mrith acutc cholc― cysdds as a result Of thc Passage Ofsmali stOnes into the coh― mOn bile duct Or MirizzisyndrOmc,i.c,,cdCma Ofthe cOminOn hcPatic duct.This case is such an examPle.Thus ERCP is needed befOre ch01cttstcctOmye

B

A

10

16

，０

５ ！

特 25

30

50

■‐120‐m‐ ■■ ‐ ■￨・ 60‐ i占

BOth Patients are 4 weeks Old“

35

and五

1201rnih

め.ThCy have hypcrbilirubinemia and werc referred to rule Out biliary atrcsia.

1. Wマ hat PatiCnt prcparation is rcquircd bcforc thc ch01cscintigraphic studyP 2. ｀ 前イ hat is thc differcntial diagnOsis ofh/Perblllrubinenlia in this agc groupP マhat arc the scintigraphic indings On these studies and yOur intcrprctationsP 3. ヽ 4. W7hat is thc accuracy ofcholescintigraphy tO diagnOse biliary atrcsiaP

215

Notes

Hepatobiliary Systenl:Biliary Atresia l,PhenObarbital,5 mg/kg/day fOr 3 to 5 days bcfore thc

stuⅢ 2.Innarnmatorン infectiOus,and metab01ic causes for ncOna― tal hcpatitis and blllary atrcsia. 3.И,Dclayed bi00d P001 cicarancc(note heart)as a rcsult of hepatic insuttcienc/3 Blliary cicarancc at 50 ininutcs and

increasing thrOu掛 120 minutcs.Note thc mcdial edge of the galibladdcr(image intcnsit/set high tO scc bOwci a c t i v i tG /o 1O .d ユ l i v c r f u n c t i O n , N o s c c r c t i o n i n t o b i l i a r y ducts during the initial 120 rninutes or at 5 and 24 hOurs. C a s e iβs c o n s i s t c n t w i t h b i lwiiatrhy naetOrncas"i a , c a s c И tal hepatitis. 4. Scnsitivity 970/o,sPccincit/820/0.

Reference Trcvcs SI JOnCSAG,Markisz BA:Liver and splecn,In ttetta所

び

″″r揚″″物cあc,″ らcd 2,NewYork,1994,SPringer― Veriag,PP 471‐474. Cttss― Reference ハ吻び 捻″″協 冴び ″ ″α 軍 醍

沢どQ3慰

ES〕ed 「 2,P243.

Comment Neonatal hcpatitis can be difflcult tO diffcrcntiatc clinically frOm biliary atresia bccausc thcy havc siHlilar clinical,b10che■lical,and hist010gical indings.Early diagnOsis is critical bccause surgcr/is lnost succcssful during the nrst 3 rnOnths of lifc.Thc Path010gical PrOccSS Ofbiliary atrcsia is that ofa prO_ grcssiw sdcrOsing ch01angitis ofthe extrahepatic blllary system. MttOr biliary ducts are partittly or tOtally abscnto PeripOrtal n, brOsis and intrahepatic ProliferatiOn Ofsmali bllc ducts arc char― acteristic.CirrhOsis devc10ps unicss surgically cOrrcctcd,c.g。 , Kasai proccdure(hepatOportOcnterostomyl.Thc cx〔 rahepatic damaged ducts are rcmovcd and a dircct cOnnectiOn is lnade between the liver and intestincs. Numerous hver dscases mimic biliary atresia.Rcfcrred tO as nconatal hcPatitiS,thcy includc infectiOus agcnts(cytomcgalic virtls,hepatitis A and B,rubella,tOxOplasmal aFld metabOlic dc― fccts(αl,antitr/Psin dCncicncy9 inbortt crrOrs Ofmctab01ism). With ncOnatal hepatitis thc biliary systcm is patent,but 99mTc IDA uptakc and clearance is delayed as a result Of hepatic in‐ suttciency.Blliary― to― bowcl transit itt variablc but shOuld bc secn by 24 hOu応.Patients att Pに treatcd宙th PhenObarbital〔 o rnaxiHllze the test sensitivity by activating liver excretory en… zymes,The seruHl phenobarbital shOuld be in the theraPcutiC rangco The lack Ofbiliary‐ to― bowei transit by 24 hOurs strOngly suggests biliary atrcsia,』 though aに Pcat Study a Few days tO a weck latcr somctimes is performcd tO ensure the cOrrect diag― nosis has becn inadc.Deinitive diagnOFis is lnadc by transhcr PatiC Ch01anttOgraphェlaparOtOmtt Or iaparOscoPン

216

辞

and芝め.COmparabic selected transaxial A46-ycar―old woman hadぃ vO diffcrcnt SPECT radionuclidc liver studics∽ sliccs are shown fOr the nvO studics. 1.Narrlc theぃvO radiOpharrnaccuticals used. 2. ヽ hat are thc scintigraphic indingsP 沖「 3. Wマhat is the differential diagnOsis of scan,9 aloneP 4. W7hat is thc diagnOsis in this PatientP

217

Notes

Hepatobilia1/Systenl:Cavernous Hemangioma of the Liver l.4 99mTc_labcicd RBC livcr studン あ 99mTc sulfur c01101d

stuⅢ 2.Incrcascd uptakc On the 99mTc― labeled RBC study in the saIIlc rcglon whcrc a defcct(PhotoPcnic region)is seen On thc 99mTc sulfur c01101d studン 3. Any bcnign Or rnalignant rnass ■Ofthc lcsl。 livci 4. CavcrnOus hemangloma Ofthe livei

ReFerences Bimbaum BA,VeignrcbJC,MCigibow対 ,et al:Dcanitive di_ agnosis ofhepatic hamartO】 mas:MR llmaging versus Tc,99m

labeled rcd bloOd ccli SPECI ttoれ Ψ176:95-101,1990. Zicssman HA,Silvcrman PM,Pattcrson J,ct al:ImprOved dc― tection of small cavernous heJmangioElaS Of the livcr with high―resolutiOn thrcc_headed SPECエ ノ助 〃鴎 嵐3220862091,1991. Cttss― RefeにnCe

助滋 ″ 鴎温 ″ 4物

財 QD町 鶴 Cd 2,pp 0-253. 2う

CoJmment Thc thrcc― phasc Planar 99mTc-labcicd RBC study has bccn used tO diagnOsc cavernous hemanglomas for many ycars.Classicallェ b100d aOw is norinal,b100d P001 has decreascd uptakc,and 2,hour delaycd images脚shく rinCrcased uptakc.The positive nnd‐ h t t h a v e ah ivgehり P O d t i dv c t tP tに v a l u c . F c wp o fd at li sv ee ‐ r c s u l hほa v c b c c n r c p o r t c d i n m O r c t h a r 1 2 0 y c a r s o f u s c . 1 6 0 n l y limitation is its sensitlvlty fOr detcction ofsmall hcmanglomas. SPE口 「おnOwぃ cd Юudndy bettuscit P雨 提s high― contrast, cross,scctiOnal imagcso Many studies havc shOwn that SPECT htt suPcriOrSCnsitMtycOmparcdwith PlanarimttngfOrdctcc― dOn OfhemangiOmas that are small,ccntrally located,multiPle,

Or10cated ncar areas ofincreased uptake such as the heart,sPicen, 臨dneys,and mttOr Vessels,99mTc sulhr c01lold wtt used in this case fOr anatomic』 cOrrelatiOn.CT is mOrc commonly uscd fOr that purpose. M R I a n d s i n JhcC― aded SPECT havc bcen RPOrtCd tO havc silnllar diagnOstic accuracy for dctcctiOn of hemang10mas, dOwn tO a sizc of2 cmo Multiheadcd SPECT caIIleras carl detcct almOst a11 les10ns greater than l.4 cm in size and can dctec[ smaller les10ns as small as O.5cm,although with a lowcr sensi― tivity.MRI has a diagnOstic advantage fOr slnaller lcs10ns,Par― dcdany thOSc adiaCent toormづ Vessd主

218

nO、 v has dinical evidcncc This Patient has a histOry ofidiOPathic thrOmboqttopenic Purpura and priOr and sPlenectomン O f r c c u r r e n t

d i s c a s c . A n t c r i o ,t at n dP o iS Ct tC tr i lo ar tりc r t t

v i c w

O f a

r a d 1 0 n u c l i d e

s c a n

O

1.What is the radiopharlnaceuticalP

P ofthc stuけ 2,What is the likely purpose 3. Could other studies be used to rnake thc same diagnOsisP 4.HOw wOuld you intcrpttt the studyP

219

w i t h

t h e

i n

Hepatobiliary Systenl:Splenic Remnant l.99mTc sulfur c0110id. 2. To detcct a sPlenic rcmnant,splcnOsis,or acccssory sPicnic tissuc.

3,Hcat or chcmically damagcd 99mTc RBC studン 4. Positivc FOr the prescncc ofa splenic remnant.

References Stewart CA,Sakimura I■ Sicgcl ME:Scintigraphic dcmOn― stratlon ofsPlcnOsis,C↓ ,″立 甲物び ′協 〃11:161-164,1986. SPcncer RP:Spleen irnaging.In Sandlcr MR COlcFnan RE, Wackcrs FJTh,ct al,cditortt Dれ 黎何″′″″び ″″″物夕 冴″″ち ed 7ilkins. 3,Baltimore,1996,Willlams&ヽ Cross― Reference i「醍 対務び 力″″Mettcガ″夕

貿EQむ 蕊 孤 ,Cd 2,p259.

Comment Splenic imaging has a 10ng histOtt in nucicar rncdicinc.This vs thc use Ofa 99mTc sulfur c0110id livcr spleen scan to casc sho、 dctect a sPlcnic remnant in a paticnt with PriOr SplencctOrn/. This can be idcnthed as a 99mTc suifur c011old study becausc Ofuptake by rcticuloendOthelial cclls in splenic tissue,as wcll as liver(KupFFer cells)and bonc rnarrN、A POtential disadvantagc

Of99mTc sulfur cO1101d is that ifthe sPlcnic tissuc is attaCent t。 thc liver9it may be dilncult tO dctcct becausc Ofthe cOnsidcrable hepatic uptake.SPECT can bc helpFul. The dassic method tO dctect funct10ning splcnic tissuc is by using hcat― dcnaturcd Or chcHlically damagcd RBCs prcvlously radiolabcled Mれ th 99血 Tc.This rcsults in sPicnic uptakc with nO Or little livcr uptake.SPlcnic tissuc can also bc seen with lllln leukOc/te or Platclct scans,but they are not used clinically for this indicatiOn.The labcling ofwhite bloOd cclls Or Platcicts is more technically demanding,and the adttlinistercd dosc of 99mTc is much higher than lllln,resulting m superiOr images fOr thc fOrmcr and highcr dOsimctry for the lattctt Thc imagc quality ofthis 99mTc sulfur c01101d study sccms to bc pOor but is apprOpriate because the intcnsity is sct high enOugh that thc sPicnic remnant can bc sccn. Notes

220

艤れ Bright red b100d pcr rcctumo No priOr histOrye l. W7hat rad10nuclidc study is thisP Describc thc scintigraphic indings. 2. PrOvidc an accurate location IOr thc indings. v that shOuld be used. 3. Namc another rrlethod ofilnagc revic、 4. PrOvidc thc differential diagnOsis.

221

Notes

Gastrointestinal Systenl:Gastrointestinal Bleeding as a Resuit of Angiodysplasia l . 9 9 m T lc a‐b e l e d c I T h r O c / t c S t u t t A b n O r m a l f o c a l u p t a k c appearing simuitaneously Oatsitcs mァ in the right abdo― mcn,incrcasing in intensity and changing in Pattcrn with tiIIlc.

2.Cecum and ascending colon. 3.Review images on a computcr mOnitorin cinematic mode. 4.Acutc blceding duc to angiodysPlasia,diverticula,ncOplasm, innaIIIInatory bOwel diseasc,and ischcnlia.

Reference H t t p c r t

R D , F c c z k? O招 P なみ J : 助 f ♂ J 初 ″″ね ″″″′物 冴 θか q ″

近osbtt pp 312-314. 兜節らcd 2,St Louis,1999,い Reference Cross― 助 す ″ ″貧 r述 奴どQ3蕊 捻″″%彦 び

r蕊 )ed 2,PP 280-287.

Colnment The radiOnuclidc blccding scan can deterininc whether blccd‐ ing is active and 10cate the apprOxilnate sitc ofbiceding.In this Patient it is dittcult tO be certain from the imagcs if thcrc arc onc orい 戸o bleeding sites,Rcvicw ofthc imagcs in a cincmatic mode OFten is diagnOstically helPAュ i bccausc Ofthc rapid frarn‐ ing ratc,usually l min/fralne,In this case,cinc rcvicw suggcstcd twO blccding sitcs that wcrc subsequcndy conarincd on cOn― trast anglographye 99mTc RBC scintigraphy is cOnsidercd thc m o s t s c nmscitthiOモ d f O r d e t cgcatsitnrgo iancttcisモ tinal hem― Orrhage.It prOvides a longer obscttatiOn window than 99mTc sulfur cO1101d scintigraPhy or Othcr tcchnlqucs,c.g→ anglograr phtt c010noscOpye Amaior adVantage ofscintigraphy is that in― termittcnt blccding can,c identined,組 iz伊 thOugh cOrrectloc』 tion ofthe site Ofblceding requircs frequcnt Or cven continuous imaging.Othcnvisc,abnOrmallabcled cclls may be scen within thc bowel indicating intcrval blecding,but the bleeding sitc may not beぃ 「 idcnt becausc of the intraluminal mOvcmcnt of thc activit/in either an antcgrade Or rctrogradc fashlon. Angiodysplasia is a vascular anOmaly of thc submucosa or mucosa,oFten inuitiPle,greater than 5O。 cm in dialnctcL alld f O u n d i n t h c r i g h t c 0 1 0 n , I t f ao cr c o8 u0 n% ほ of PredOminantけ the vascular anOn■ alics Ofthe c010n and inay cocxis[writh Other causcs ofblccding.In autoPsy es,lcsiOns SC五 have been fOund in

2%ofttymptomatic cidcrけ patients.On anglography thc an― i vcsscis.Early nlling Of g10dysPlasia appcars as a tanglc ofsm』 draining veins may be dcimOnstratcd,but cxtravasation ofcon_ trast is not cOnllnonly sccn.

222

Rcccnt bHghtに d b100d per rcctum and iOw hcmatOcrit. 1. Based On thc histOr/P What nuclear scans would bc apprOpriatcP 2.What infOrmatiOn frOm thc histOry is critical tO determine the apprOpriatc time to perfOrm the examinationP 3.Name the radiopharmaceutical uscd fOr this examination.

4.Describe the scintigraphic indings(nrst six images are bloOd nOL last ttvO are dclaycd statics

223

Notes

Gastrointestinal Systenl:99mTc RBC Scan一 AxiHobifemoral Bypass Graft l. 99mTc-labclcd rcd blood cells Or 99mTc suifur c0110id. ２   ３   ４

Evidcncc ofcurrcnt or rccent gastrOintcstinal blccding, 99mTc‐ labclcd RBCs. v and delayed static imagこ The vascular aO、 s show nO activc gastrointestinal biceding.Labclcd rcd cclls arc shOwn in a tubdar shaPc in thc拭ght abdOmcn that connects tter a Y 〃0 1liac vessels as a result Ofan axi110bi― bifurcatiOn to theぃ fcmOral vascular bypass 8raft.Thc Paticnt has prOmincnt sPlenOmegalン

References Weist PW;Hartshornc MF:Atlas of gastrOintestinal blccding ( R B C ) s c i n t i g r a pIhnン Z i e s s m a n I I A , V a n N o s t r a n d D , c d ― i t O r t t″びS物夕ブ″あ

ゲ タ

初 ″% 称 ″″″′" ″ 姥 ″

勿

N c w

Y o r k ,

1992,SPringcr―Vcrlag,PP 35,74, Craig KC,SkillmannJJ:Clinical asPccts OfPCriPhcral vascular 物アクが物 物ル 物″ 警 竹 ″″グ タ カタ グ ″し CFυ 夕 ″″θ″,St Louis,1992,Mosbン P59.

diseasc.In Km D,cditOH乃

ReFerence CrOss‐ 助 あ ″Mc況,c,″ 4初

延 QD町 鶴

Cd 2,pp 280-287.

COmment As is truc thrOughout radi010g/9 distinguishing what is nOrnlal frOm abnOrmalis thc fundamental chalicngc.At times the pres― ence ofaltered anatomy increascs thc challenge.In this casc thc t h c r i g h t a b d O m c n ie sX P cl t t in け t u b u l t t s t r u citnu に ed rcon_ sidcratiOn is given tO thc fact that nativc vascular structures and surgically altered vessels Or grafts are demonstratedo Similarけ a l dilatatiOn of Pr01nincnt wariccs can complicatc in― ancurysl■ ng On simPle but essential critcria FOr dc_ tcrpretation.By rclメ tcrIIlining a Positive scan,the skllled interpreter can avoid falsc― positive study rcsul=s.Paraphrasing Vcist and Hartshornc,a scan is PositiVC ifthc actMty(1)comes out ofnowhere,(2)gets hOtter and varies in intensityP and(3)mOvcs away through thc bowel.This casc dcarly dOcs not mcct thcsc criteria. Likc thc axll10bifcmOral graft,extraanatomical graFts in_ cluding femOrOfemOral and axlllofemOral graFts are proccdurcs generally rescrvcd for PatientS WhO cannot tolcratc intraab― dOIIlinal prOccdurcs alld aorticclalnping cross― or have under_ 30ne previous Procedures that Failcd.The 5-ycar patency rate fOr axll10bifemOral grafts is iess than that fOr aortobifemoral grafts.

224

120 min

TwO

P a t i eanltlsd∽ wのc にr e t t r r e d

fOr

a

radiOnuclide

gastrOintcstintt

1. 対 Vhat is the radiOPharIIlaccutical used in thesc studicsP 2. Describe thc imagc indings in bOth studics. 3. Interprct thc twO studies. 4. W7hich rnethOd OfradiOlabcling ofRBCs has thc highcst labcling cttciencyP

225

blceding

Notes

Gastrointestinal Systenl:'9mTc RBC― Free Pertechnetate versus Gastric Bleeding l. 99mTc Pcrtechnetate labeled to RBCs,

Thc Promptけ chest 2.In both studies the stOmach visuttizcs and neck image shows thyrOid and sttivary uPtakc h study minute imagc)but notin study'(120‐ minute И (15‐ image). 3.4 Frec 99mTc Pcrtechnctatc.Ncgativc for gastrointestinal bleeding.a Active bleeding originating frOm the stomach. 4.In宙 tro.

References S五vasta SC,Straub RF:Blood ce11labclingwith 99mTc:progress ガ ″ハあ″ 〃脇 〃20:41-51,1990. and Pcrspectivcs,Sc秘 Zicssman HA:The gastrointestinal tract.In Harbert JC, 赫 ら妨― 揚″″物こ ″す EckelmanWC,Neumann RD,cditos対 New YOrk,1996,Thieme,PP 617-627. J打″″〃筋″ 物り 響 θ CrOssPReference ブ ″α r避 越 Qoパ 距吃じ ed 2,PP 280-287. 助 す 捻″″協 冴び ComHnent A l t h o u g h t h c r a d i o n u d i d e b l oe re d ei tn tg d s t ou d ecy vおa l u a モ 10wer gastrointestinal bleeding,uPPer tract bleeding sites lnay dctt be detected.High radiolabeling ettciency ls for c五 Opd‐ mum studies and cOrrcct interprctation becausc frce 99mTc Pcr― tcchnetatc is takcn up and secreted by gastric rnucosa and sub― scqucntly moves through thc small and largc bowcl.Gastric blceding can be difFerentiated frOHl frcc Pcrtechnetate by dc― tecting evidcncc of frec PcrteChnetate uptakc in thc stomach, ew PrOVides 的 roid,andsalNttJands.Thc neck alld chest宙 this information.In vivo labeling ettciency also can be csti‐ mated by thc heart blood Pool distribution relative to back― .И β than labeling cttdcncy tt higher in ctte ground,e.gⅢ RBCs havc Threc methOds for radiOlabeling ofthe patientも been used Over the ycars.The in vivo mcthod is silnPlest. Stannous PyrOphosPhate is intravenouslyinieCted itttfol10wed lうminutes iater by 99mTc PerteChnetate.Thc tin a1lows the 99mTc PerteChnetatc to bind to the beta chぶ n OfhemOg10bin. This binding occurs in vivO with a labcling efncicncy of750/o to 80%.Thc lnethod is adcqua[c lbr radlonuclidc ventriculogra― intsdntt blccding studics.Thtt the mOd― phy but nOt ttr gastЮ ined in vivo lnethOd was dcvcloped.Stttnous pyrophosPhate is arst intravenousけ 瑚 ected,then b10od is withdrawn into a sy― 止nge containing 99mTc sOdium pertechnetate;labeling occurs in the syringe over 10 rninutcs and then the blood is reinttscd. L a b d i n g e t t d e n c y i s 8 5 % t o 9 0 % t. rT oh c m ei tn h宙O d i s p e r _ f Om■ ed

totttly

Outtide

the

body

and

is

nOw

availabic

in

a

sim,

Plc kit form(UitraTa9.It has a 98%labeling cmciency and is the method ofcholce.

226

immediate

00

70

90 rnin

A65-ycar―old IIlan had had intermittent rectal biccding fOr 2 days. 1.Describc the scintigraPhic indings during this 9o_minutc stu毎 2.Whatis the purposc ofthe Oblique/1ateral pclvic宙 cw(last image)in this caseP 3.What is your interprctation Ofthe Pstuけ 4. What are thc critcria rbr diagnosing and localizing a blccding sitcP

227

Notes

Gastrointestinal Systenl:Rectal Bleeding ity accumulatcs carly in the 10wer midline l.Abnormal act市 pclvis.Thc appcarancc is changing over tilne and seerns tO dccrcasc and then increasc agaln. 2.To

diffcrentiatc

activity

in

thc

rcctum

from

PCniS,in this Patient the activity is sccn in thc rcctum. 3. Positive fOr gastrointestinal biccding is nOt the answei LocalizatiOn is cri[ical,Thc 90-rninute lateral vicw con― nrrns that this is rectal bleeding. 4.Ncw activit/Pincrcascs in amount ovcr timc,and moves

intraluminalけ References Wiest Pやに Harshoren MF:Atias of gastrointcstinal blccding (RBC)scintigraphyt ln Ziessman IIA,Van Nostrand HL, ″竹 物 み New 初グ ″絡 ″″″んr″ け ascsザ 多 す editor主酵筋 協 ′″レ York,1992,Springer―Verlag,PP 35-73. Suzman MS,TalmOr M,JcnniS R,ct基

:Accurate localization

and surgical managcmcnt of active gastrointestinal hcmOr‐ И″%S″箸 rhage with'rc,labclcd erythrocyte scintigraphン 224:29-36,1996. CrOss,Reference 父どQyrSrrES,cd 2,PP 280-287. r ittqど ご ″ ″″ A物並は″ルを冴″ Comment Radionuclide gastrointcstinal blccding studies havc greatcr than 900/o accuracy for 10calization Ofbleeding sitcs in thc sctting of acutc blceding.Howevett when thc study is ordcrcd after all Other evaluations arc ncgativc and the blecding has slowcd or

accuracy is hot stopPcd,thc accurac/is Simllar,thC Poor∝ high fOr siOw chrOnic blccding。 Interprctivc pitfalis should be considered to prOvidc the re― ferring physician with accurate 10callzatiOn informationt This ews on,a bleeと cascstuⅢdemOnstratcs one.Using antcrior宙 ing site in the rectuHl often cannOt be differcntiatcd from ac― tivity in thc bladder Or possibけ peniS b100d Pool.Latcral imagcs are required.Dclayed imaging alsO can be a potcntial Pitfall. Activity in thc left colon at 18 to 24 hours yicids nO additional infOrmation and can be misicading.Blood moves very rapidly and dclayed activity could havc come ttom anywhcre proxim組 tO that site.Dclaycd images should bc acquircd dynamically vhere ncw to 60-Fninute PcriOd tO dcterHlinc ifand、 over a 30‐ active blceding is occurring.Rapid rate computer acquisition (l minute pcr fralne)is recOmmended.Cinematic display can aid in thc idcntincation ofthc blccding site. s arc caused by activity in thc geni― O t h e r c o m m O n P i狙tl士 tourinary tract and vascular structures,Many arc nxed abnor― malitics,c.gt,aneurysms,variccs,hcmangioma,cctopic kidneye C)thers are rnore problcmatic,c.g.,urinary traci activityp CCtoPic kidneyS.Frcqucnt image acquisitiOn and cincmatic display is critical. 228

bladder

and

十 ■

_.￨!il:￨￨￨

'Ii!￨

A Patient has a scizure disOrdcr unresPonsiVC tO Incdical therapy and is bcing cOnsidered fOr surgical treatlnent.

1, Describc the ilnage inding on thesc cOrOnal 18F FE)G― PET sliccs. 2. W7hat is the differential diagnOsis ofthis imagc inding ifnO histOry was avallablcP マhat is thc prObable seizurc fOcus sitcP 3. ヽ 4.Wttat is the utility ofPET Or SPECT in scizurc disOrdersP

229

Notes

Central Nervous Systenl:Seizure Disorder l.Decreascd metab01lsm in the lett tempora1 lobe. 2.Tcmpora1 10be infarct,benign mass or10w― gradc tumo島 postradiatiOn therapy changcs,intcrictal ictt tcmpora1 10bc sclzure focus. 3.Interictal

seizurc

fOcus

in

thc

left

tempora1

lobe.

4. Conarination ofthe location ofthe scizurc lbcus in a can, didate for tempora1lobectom/c Study is an altcrnative to surgical dcPth electrOde placcment.

References Chugani H■Thc usc ofPositrOn cmisslon tomography in thc 〃丹々〃22:247,253, 物″ ″ハ物S夕 clinical assessmcnt ofepilcPsI 1992. 耽 n Hccrtum RL,DrOcca C,Ichisc M,ct al:SPECT and PET θ ′ ,s れ i n t h e c v a l u a t i o n o f n e u r o l o g i c″ dCiと c対み a s″ c務И物 ,賜 1034. 39:1007‐ ReFerence CrOss‐ 巡 源立文2yrSrrES〕 cd 2,PP 313-314. 筋″″鴎 品冴″α 「 助 び Comment Paticnts with complcx Partial seizures uncontrollcd by medica‐ tions may be candidates for tcmpora1lobectomy.Bttsion Ofthe cally medial temporal sdcttsis,carl elimi‐ scizure focus,Path010夢 nate scizurcs or produce an improvemcntin pharmaco10glcal con‐ tr01 in 80%ofPatients,The success ofsurgical intervention re― も 、CT and MRhavc pOor qulres accurate localization prcopcふ s e n s i it t市y f o r s c i z u r c f o c u s d e t c c t i o n . E l c c t r o c n c c p h a l o g r a p h y ( E E G ) i s n O t a l w a y s d i a g n O s t i c o r m a y s h o1w‐b i l a t e r a l a b n O r m 狙 des and in any case requires conarmation.Surgical Placement of intracranial EEG dcPth electrodes,thc traditional cOnarmator/ PET orper血ほlon methOd,is invasi(and has risk.Ccrebral FDG‐ t h t tory and EEG S P E 口「i n d i n g s t h a t a r e c o n c ohred ahnits宙 arc an acceptcd alternative to invasivc intracranial monitoring procedllres. An interictal scizure focus is secn On FDG,PET or SPECT perttsiOh agents as decrcased uptakc.An ictal seizure focus shOws PAO orECD SPECI Thc increascd perttslon with 99mTc HM― dctcction is approxlmatcly %to 6う 75%. sensitMty fOr intcdct】 Data suEcst that PET is sllghdy more accuratc.Accuracy of90% is rcported with ictal SPECT studies.HoweveL ictal studcs arc technically and logistically more dcmanding,rcquiring Patient hOsPitalizatiOn with EEC monitoring.Thc radioPharmaceudcal must be near thc bcdside and iniected at the time ofthe seizurc. SPECT has a dcinitc advantage for ictal studies bccause Of iほ勲赴oPharmaceutical propcrtics,c,g"the itteCtiOncaFl be glvcn during the seizurc,whilc imaging can bc delaycd becausc thc

The ShOrt halF-lifc radiOPharmaceutical ixes intraccllularけ ofFDG,PET(110 minutes)docS not a1low fOr delayed image acquisluon.

230

,

￨ ・ ￨ ￨ 1 1 ■ ￨ ￨ ‐

Hit守よ

4〃 111,的 1‐

枠F ' , と

A55-year―old lnan has had、 vOrsening dcmcntia ovcr 10 mOnths. 1. Give a clinical diffcrential diagnOsis lor dementia. 2.HOw can SPECT Or PET aid in this differential diagnOsisP 3, E)cscribc the 18F FDG― PET indings on the recOnstructcd thrccrdiIIlenslonal v01ulrlc display. 4. ヽ 7hat is thc diagnOsis and with what dcgree Ofcertaint/P

231

Notes

Central Nettous Systenl:Alzhei「 Yler's Disease relatcd,substancc disease,AIDS‐ l.Multiinfarct,Alzheimcrも ‐ abuse,alcohollsm,Parkinso品 ,Pic魅,Crcutzfcld〔 JaCOb discase,depresslon,metabolic. PAO/ECD SPECT 2.DiagnOstic Patterns using 99mTc HM― a n d F D G P‐E I m u l t i i n f a r c t d c m c n t i a , A dl iz sh cc ai sm ec ,r も s discasc. frOnta1 lobe dcrnentias,c.g.,Picぱ 3.Hypomctabollsm(dccrCascd FDG uptakc)ofthC POStcrior parietal and teIIIPora1 10bes bilaterally and to a lcsscr extent thc fronta1 10bcsf Note PcrSiStcnt mctabolism OfsensOri‐ motor cortcx.

diseasc;grcater than 800/o ccrtaintye 4. Alzhcirnerも

ReFerences Van Hccrtum RL,Drocca C,Ichisc M,ct al:Singie photon sbn tomography in thc emissbn of CT and PosirOn emお 玄 みИ″ グ″ ク〃Cr,″ハら″ cvaluation of ncurologic discasc,R″ 39:1007-1034,2001. Bohmcr KA,Hanson M,ct al:FDG PET anJM,Mた lSh― HOI輸は llnaging in paticnts with Pathologically verincd dcmentia, ι 〃41:1920‐1928,2000. 式単び ′コイタ CrOss,Reference f軍醍 彦″″鴎 品品″′ 脇 ど

沢どQ」蕊 孤 ,Cd 2,pp 311‐312.

Comment diseasc can bc diFncult to clinically The diagnOsis ofAlzhcilnerも scnllc di徒陀ntttc ttOm other causcs Ofdcmentia.Although pに agcd patients,thc largcst grouP of dcmcntia Occurs in Hliddle― with an incidcncc ofgrcater than 500/o for Patients arc clderlン thosc older than 80 ycars ofage.HistoPath010gical changcs in― clude abnOrmtt tanglcs of ncrve nbers and dcgencrativc neu― 五tic Plaqucs in the pOstcrior parictotcmporal cOrtex.Frontal lobc involvemcnt occurs with scverc discasc.Thc Patterns on SPECT and PET are simllatt although caused by 4iffCrent mechanisins. FE)G uptake rcpresents glucosc Hletab01lsnl, 市hcreas HM―PAO/ECD uptakc renccts rcgional cerebral blood 1lpophilit and nぃ LThesinJe―PhOtOn radiopharmaccutictts aに brain barrici HM―PAO is colwertcd to a hy― cross the b10od― drophilic comPlex and ECD to a negatttly charged complc対 both are traPped intracellularly and cannot dittsc out.Thc typ‐ ical scintigraphic Pattern in Alzheilncr's discase is bllateral hypoperfuslon/1yPOmetabollsm Of the poster10r parictal and tempora1 lobcs,sometimcs asymmetrical,sParing the Occipital otor COrtex and subcortical gray lnatter.Frontal and sensOril■ lobc hypofunction is secn with advanced diseasc.A similar dis‐ tribution can be scen in latc Parkinsonis dementia and in Pa, tients with dinttsc Lewy body discasc,a degcnerati(dcmentia now mor9 widcly rccognizcd.The main fcatures are visual hal―

an e dettnc9 and ParttnsO面 cOgttt市 hdnatonsj nuctuatinと s y m p t O E n S , O R c n

232

t h e s e

P a t i C n t s

a l s o

h a v e

o c c i p i t a l

i F I V 0 1 V e m c n t .

Aう5-year-01d man has increasing dcmentia.Reccndy he had a nOrIIlal MRIo Sagittal SPECT sections are 1.List the mOst common causes ofdemcntia in the eldcriン 2.Dcscribc the rncchanisln Ofuptakc Ofthe radiOpharIIlaccutical uscd. 7hat causcs ofdcmentia are associated with charactcristic SPECT Pcrfuslon PattCrnsP 3. 対 4.Describe the indings and the mOst likely diargnOsis.

233

Central Nervows Systenl:PiCk'S DiseOse dislasc,multiinfarct,latc,stage Parkinsott dis― l.Alzheimcrも rclatcd,dcPrcssiOn. casc,metabolic,drug― PAO Or ECD agcnts crOssthe 2.Thc lipoPhilic?9mTc HM―

brttin barricr and havc rapid intracellular intact blood― 述blood nN、 They are nxcd uptake in proPbrtiOn to ccrcbrそ

snapshot"of SubSCqucnt imaging providc a“ intracellularけ the blood nOw PattCrn at the timc ofthe inlection.

s disease. 3。Alzheimerも,multiinfarct dcmcntia,Picビ 4.Dccrcased blood aOw in the frOntal cortex bllatcrally as a PiCktt discasc. rcsult OffrOnta1 lobc dcJmcntia,c.gり

References ucoSC metabolism in S a k a m o t o I K , S a s a k i M , c :t C』c r e b r a l 」

, P a t i e n t s w i t h f r o n t o t c m p o助 r a〃 l 鴎d嵐 c m3 c9 n: t1 i8 a7 ,5 メ 1878,1998. ″ し Grossman RI,Youscm DM:州 あ″物務θ り f務御 ″ ″がれ St 江osbtt pp 229-231. Louis,1994,ふ ReFerence Cttss― 助 び 筋″″鴎 品冴″4「避 財 Qy/SrrES)ed 2,PP 306,311-312. Comment iVe disOrdcr that rcsults in al― Pidごs discasc is a neurodcgencraモ tered cOgnition and Personality changcs.SymptoHls lnay in‐ cludc memOry loss,conttsion,cognitlve and sPccch dysfunc‐ tion,aPatltt and abulia.No trcatment cxists for Pictt discase, and Progressive dcterioration occurs over inonths or ycars. Functional brain imaging using a 99mTc brain pcrfuslon agent, HM― PAO orECD,or a mctabolic agent,18F FDG,can rcvcal decrcased function befOre anatonlical changcs havc occurred. discasc,associated atrophy may occur late in As in Alzhcimerも the discase,but the distribution is diffcrcnt.In contrast to

erも dttCasc that tticttly involvcs both PostcriOr parictor AlzhciⅢ tettPも 車 LCJOnS,PiCtt disctte attcts thc anteriOr front』

and

anterilr tempOra1 lobes and sPares thC postcrior cortcx. Mditiinfarct dementia is characterizcd by muitiplc asymmetri― cal dcfccts in the cOrtex and dccp gray lnattei NOteS

234

2ssec/fFam0

■■￨￨十 ■￨十 1+H3

+￨￨￨￨■ ■

23

1111111‐ ￨￨■ ■草馬Ⅲ対,￨￨￨￨■ ￨￨￨

A25-ycar―old wOman had a lddney transplant 7 days earlie丘 1.mat are thc scintigraphic indings Ofthis 99mTc MAG3 studyP 2. ヽ 7hat is the llrlost likcly diagnOsisP Vhat are the usual assOciated clinical SymptOIIIs and indingsP 3. ヽ 4.HOw is thc inal diagnOsis cstablishedP

235

Notes

Genitourinary Systenl:Acute Renal Transplant ReiectiOn trans‐ l. Very dccreascd and dclaycd blood aow。rand P。 plant Function, 2.Acutc reicctiOn. 3. FeveL transPlant tcndcrncss and cnlargcment,dccreascd urinary output,and rising scrum crcatininc levcl. 4. BioPsyn

Reference ChOykc PL,BcckcrJA ZCSSman HA:Imttng thC transPlantcd 6″ ブ″″か kidnCy61n P01lack HM,McCicnnan BL,cditorsi C腕ガ B Saundcrs,pp 3091‐3118. 兜卸らed 2,PhiladelPhia,2000,W″ Cttss,Referencc

αr醍 財 Qdtt「蕊,ed 2,pp 348-354. 鴎品rグ ″ ″″ ″ 助ご Colmment

Acute a1logrtt rttCCtiOn is adinical diagnosis.Thc patients tyPital symptorrls and flndings as describcd above.IInaging studics arc Pcrformed to cnsure adequate blood now(viabllityl and to rull out obstruction.Thc diagnOsis usuttly is madc by biopsye Rcnal scintigraphy cah bc used to fol10w thc clinical course to conarin rcsPonSC tO theraPy and viability6 The typical scintigraphic indings ofacutc reieCtiOn are dc‐ diOn.Although acute rciCCtiOn arn dt tPn。 c に容e d b l o o d n o w 。

have

Ofthe rcnal a1lograft often bcgins 5 to 7 days arter transPianta‐ Accclcrated acute re― tion,it may occur wccks or rnOnths latc■ jection begins thc nrst wcck after transPlantation in paticnts whO havc had prcvlous transPlants Or havc rcceivcd lnultiplc b100d transttslons beforc transplantatlon,which have scnsitized theirimmune systcms.Acutc rcicctiOn usually is revcrsible with appropriatc theraptt steroids,and irninunOthcrapyB Conversclン

chronic rttCCtiOn ttogrcsscs slowly ovcr mOnths and ycars and is unresponsive tO thcrapy.

mediatcd Proccss.SCnSitizcd lym‐ Acute rづcctiOn is a ccll― phOcytcs rnigrate to the graft and destrOy the celis of the graft withOut thc participation of huttoral antibOdies,ChrOnic rc‐ 声CdOn iS mcdiated by an andbodyinduced iniury tO the cn― dothelial and interstitial cclls,which suggcsts a humoralIIlech‐ anism.Histological changes includc arterial narrowing,which progrcsses to evcntual cOmplctc oblitcration ofthc lumen,and g10merular lcs10ns,

236

A

B

aPdd man a泣

面 位e d t O t h c h O s p ■』 宙 t h P n e u m O 航

ら dcvttcd ttrum∝

航 高 ncに v』,and nO ttOwn ttn】

含 足箕ぴ

1.In what prOjccdon are rcnal studies acqttrcdP Name the structures udyの secn on ・ thc nOw s〔 2 , W h a t a r e t h e i n h n g s O n 3 t0 h- cm i Pn ou st te n OPs wt tu dtd yhy naのat mt た t tshPc d a g n O 豆 3. W7hat threc gcrlcral causes ofrcnal fallurc can thc radiOnuclide study helP diagnOscP 4. Namc the appropriatc radiopharmaccutical in this clinical scttingP 237

Notes

Genitourinary SysteHl:Renat insufFiciency― Sma‖ Kidneys,Poor Function l.Posterioi Right vcntride,lungs,lett vcntricic,aorta,sPicen 臨dnqか The ttdneys are very poorly visualized On (not le丘

tCnt with p00r blood n飢 ths now stutt COnsお

2.Bllaterally Small kidneys.Extremely poor renal function. Clearancc into thc bladdett Diagnosis ofchrOnic rcnal insuFncienc/secOndary to Parenchymtt diseasc. 3.The radionuclide renOgram can difFcrentiatc PrCrenal, intrarcnal(Parenchymal),and postrenal causes. 4.99mTc MAG3.

Reference Choykc PL,Ziessman IIA:Imaging ofrentt fallurc.In Pollack 物′冴物 み Cd 2, 働 ″ガ HM,McClennan BL,cdito職 8. PhiladelPhia,2000,WB Saunders,PP 3053-30う CrOss,Reference ″α r醍 ズFQじ 慰 「ES,cd 2,p336. 力″″Meあ cと 脇 び Comment

with ren】 ∝m血赴 always bc容 Altho叫 かdle sPecinc callse callnot nal,parenchy― ndatc に Pに sandgraptt the can smけOften氏di健 ntt ParenchFal catlses m狙 ,or postrenal callses ofrcntt五(走 ins胡 OFten carl be mHher darined as acute or chronic,c.g.,smal,nor― mal,Or enlargcd ttheys.Unilateral vcrsLIS blatcral discase carl be nOted and a quandtatlve esdmatc ofrelative rcnal ttmctton caFl be provided.AnOrmalserLm crcatlnine lcvel carl be malntalnedwith

a S i n, 渉 n o m a l価‐c t i o n i n g t t d n e y . T h t l s a n e l e v a t e d s e r t t t c r e a ‐ sanugraPhytt par‐ 山 血 尭 胡 suggests blateral dysttction.Ren』 l for nOninvasive cvaluation Ofthe adequac/of tcularly helP品 blood aOw and diagnosis or excllls10n Ofurinary obstructlon.In

thc Past,Jomeru10nephrits was the most common causc of 赴ng callses are dabctes melim chrOnにrenal failllre.Todaythc臨 and hypertensbn. 99mTc MAG3 1s the prcferred agcntin rentt insl脇 cienc/be‐ cause of its high renal extractions it is sccreted by the renal tubules that PrOvide FnOre than 80%of tOtal renal function. The 60%extractlon of99mTc MAG3 is an advantage compared with the 200/o extraction of99mTc DTPA.Blood now to the kidneys,as in this stutt Often aPpears tO be dccreased in severe renal insuttcicnc/.In this casc the small ttdney sizc makes it difflcult to sec the carly arterial aow to the kidneys.With nephrectomy or PoOr rcnal bloOd nOw the splccn mtt be miS― interpreted as the left kidneyc Obstruction is ruled Out because ty has reachca the bladder without any holdup in a c ti市 nal collccting system.

238

the

re―

2 min

6 min

10 min A

16 min

20 rnth

30『nin

B

20 min

30 rnin

A 3 0 - y c a r - 0 1 d t t a n h t t P 0 0 r l y c o n t r 0 1 l e d a n d a c c e l e r a t i n g h y p c r t e n s la on nd . B t t c h n e s t u d y 99mTc MAG3 rcnal studies with caPtOpril l砂 arc shown. 1 . W 7 h a t i s t h e 狙er a at ni dO 五P h y s 1 0 1 0 g i c t t m c c h a n i s m f O r t h e c a P t O p r i l r e n t t s t u d y ' 2. Mttat are the scintigraphic andactivity tilnc― cutte nndingS and diagnOsisP 3. Could 1311 hippuraF1 0r 99mTc DPTA have bccn used instcad: 4.What tt the accuracy ofcaptoPril rcnOgraphyP

239

Notes

Genitourinary Systenl:Captopril Renography 立on dccrcascs Omerulが artcry stcnods,」 l,With rcn』 per如 and glomcrular nitration ratc(GFRl dropso Rcnin relcased

魚Om thc,LEXtagiOmcrular apparatus converts angiotcnsin I tO anttOtCnSin II.Anglotensin II causes vasoconstriction of

SSure ttltration Pに Omerular effcrcnt artcrlolcs,raising the」 converting enzyme and maintaining CFR.An angiotensin― lACE)inhibitoL c.g,captoPril,blocks convcrslon of anglotensin l to II,resulting in a dccreasc in GFR. 2.The宜 ght ttdneyお sm』l but with good ttncton,With captoPril cortical retention pcrsists,consistcnt with rPnin‐ dcPcndent renOvascular hypertcnsion ofthc right ttdne/B activity curvcs. This is conirmcd by thc rcnal cOrtical time― 3.Yes.Thc accuracy of1311 hiPpuran,99mTc DTPA,and 99mTcヽ化AG3 arc simllaェ ity is less fOr 4.Sensitivit/2900/o,sPccincityp 95%.Sensit市 dctcction OfrcninrdcPendent hypertcnslon ifthe paticnt has been taking an ACE inhibitOr chronically or has renal insumcicncye

References

Fine EJ:Diurctic rcnOgraphy and anglotensin convcrting cnr ″ みИ物 39:979う ″Aわ″ 駒 冴,0′Cけ zylnc inhibitor renographン 996,2001. ″ TaylorA Radionuchdc renOttaPhy:a pettonal apprOtth,最初グ 〃29:102-127,1999. ブA石ケ 助 ご Reference Cttss‐ 沢どQυ 又財rES,cd 2,PP 336‐340. 冴惚資 jttYど A物並駐″ルク冴″ Comment Renal artery stenosis reFers tO anatonlical narrowing.Rcno― vascular hyPcrtenS10n is thc Ptthophyslologictt result in somc patlents, Many patients with stenOsis do not have rcnin― dependcht hypertens10n and thcir hypcrtenslon will not bc 10no Captopril renOg― cured by surgica1 0r angloplastic intervenモ 組lo、 vs sciccton OfPatientS With raphy is a funcdOntt test th筑 renovascular hypcrtcnslon who will llkely resPond to thcraP/ aimed at thc stcnOsis.Intravenous enalapril call be uscd as an al― tcrnative to oral captopriL the advantagc is a shorter test with no nced to wait for entcric absOrption,as with captopril.Thc ACE inhibitOr and baseline study can bc PerfOrmcd thc same daye Diagnosis depends on sccing cortical function and deriving accura[c tilnc‐ activity curvcs.Both could be obscurcd or crrO‐ neous in thc prescncc of renal Pcivocalyceal rctcntion;thus a diuretic can be glven with thc radiotracei Thc MAG3 anding in renin‐ depcndcnt renovascular hypertcnslon is PcrSiStcnt cor― tical rctcntion as a result of delayed urine nOw in the renal tubules on the affccted sidc,as sccn in this casc.The dclay in uptakc,scen with 99mTc DTPA and 1311 hippuran,may not bc scen with MAG3.Bllateral rcnovascular hypertenslon is rarc. mHIctrical.A sylnIIletric When it occurs,it frcqucntly is asy】 FeSpOnsc would suggest other factors,c.g。 ,dchydration.

諫ぞ

鶴 型   Ｆ 誰 に い 鞠 瓢 十 鉄 晰

観吊 餓博

叫い 報 は 貯 瓢 軌 鞭

れる

f 認

薔

A

研

B

ｓ ｒ ｄ ｔ ｅ ｎ ｐ ｎ ｏ ｕ ｃ ｏ ｅ Ｃ ｓ

A7-year―

‐ ぱ

峰 ０

■ IWi‐1堪 算朋

!

old with hydrOncPhrOsis dcmOnstrated on uitrasOund cxamination.No pr10r histOrン

1.Bascd on the histOrン list thc Preferred rad10pharmaccutical(s)for this studン 2. Nsuld a renal cortical agcnt bc apPrOpriateP

3.Describe the initial indings像 and C). りand following diurctic administration(β 4.List thc difFcrential diagnOsis and mOst likely diagnOsis.

Notes

PrirYlary Megaureter l.99mTc MAG3 or99mTc DTPA. 2.No,both 99mTc dimcrcaptosuccinic acid(DMSAl or 99mTc glucoheptonatc nx to the rcnal cortcx. 3.Left kidney cxcrctcs promptly intO collccting systcm with rctcntion in proHlinent pclvis and uretci Pronlincnt dila―

Aftcr diurctic Prompt cicarancc ofthe lc丘 tiOn distalけ cOliccting systcnl by visual and quantitative assessincnt. Norm』 right ttdneン 4. Dllated nOnObstructed icft urctcr.Pbssible causcsi vcsicO―

urcteral rcntlx,correctcd urcteral vesicle junctlOn Obstruc― tion,and prilnary lncgaurctcri the lattcr is rnorc likcly based on thc PrOIIlincnt dilatatiOn ofthe distal urctci

ReFerences 方 夕 Blicttan H:酔ttta滋 物 筋 響 f妨 ″夕″オブ らed 2,St LOuis, 1998,い江osbンPP 164-166. ttpr務 夕物 ″がれ ル″ガ″″り 物妨θ Httpcrt RD,FcczkO PJ:命 ″ブ 江osbtt pp 177-178. cd 2,St Louis,1999,い Reference Cross‐ ″α 朋 助 滋 ″Mc沈,cと

逆 Qし願 Ztt ed 2,PP 340‐ 348.

Comment Prilnary rncgaurcter is unllatcral in 750/o of PaticntS and usu― ally is discovcred incidcntallye lt Oftcn is assOciatcd with urinary tract infcctiOn Or urolithiasis.Bccausc ureteral rcnux is a pOSsi― ble causc ofurctcral dilatatiOn,contrast or radlonuclidc vOiding cystourethrOgram should bc perfOrmcd tO distinguish thc cnti― tics.GenerallンPrimary mcgauretcr lcads to a massivc dilata― tlon ofthc 10wcr third ofthc urctei HowcvcL the cntire ureter may become dilatcd,ユthough the c』 yccs gcnerally maintain a normal appearance.OccasiOnally it is associatcd with anOther calycosis,whcrc thc cttices c o n g e n i t t t a1 b財m n Oc rg ma 狙 creased in numbtt Mcgacalyccs arc Otten squared,which can be mistaken for obstructlon,Thcrefore whcn megaurcter and megacalycosis cocxist,it is impOrtant to distinguish this frOm chronic urctcra1 0bstructiOn by analyzing the numbcr ofcalices and thcir shapc on lodinatcd contrast studics. 9 9 m T c M A G 3 , a t u b u l a r a g e n t , h t t a n th ti g ch xe tr rにa c t i o n fractiOn(60%)than 99mTc DTPA(20%),a glomcrular agent. vith renal insuF‐ MAG3 is thus the prcfcrable agent in paticnts、 nciencye Timing ofdiuretic inttsiOn varics.It is oftcn adminis― 20 minutes),AnOthcr common s nils(15t。 tered as thc Pchた methOd acquires a sccond acquisition attcr thc initial rOutinc renograin,imaging for an additiona1 20 111inutes on computer. Reccndyinvestigators repOrtcl that the diurcdc can be adminr isteに d before Or simultancOusly with radiOpharmaceutical ad― vOrkヽ Vell whcn thc rncthod, IIlinistration.All thcsc techniqucs、 010gy is standardized.

242

arc

in―

A

B

A 6 - y c a ro― l d g i r l h a s r e c u r r e n t a n d r c c c n t u r i n a r y, 9 t9 rm aT c t D iM nS fA e cS tP iE OC nT s .r И c n a l s tau dAン r c p c a t study 6 mOnths iatcr(cOmparable corOnal shces). 1.村仏atis thc mcchanism Ofuptakc Of99mTc DMSAP 2.Wihat arc thc most cOmmon indicatiOns fOr a 99mTc DMSA studyP indings and whatis thc diagnOsisP What wOuld have been the diagnOsis ifthe 3. W7hat are the scintigraphic SPEC'「

sccond stuⅢ 徳り100ked simlar tO the nrst り′ study脅

4. W7hat is thc clinical imPOrtance ofdiffcrcntiating uppcr and 10wcr tract infcctiOnP

243

Notes

Genitourinary Systenl:Pyelonephritis and 99mTc DMSA l,Forty percent of99mTc DMISA binds and nxcs to function― ing proximal cortical renal tubules. ２   ３

E)iagnosis ofPyelonephritis or cortical scarring. Dccreased uptake in the 10wcr halfOfthc right kidncy on initial imaging作 り。RcPcat SPECT shtt normalization Of uptakc.И,PycloncPhritis;a rcnal cOrtical scarring. 99mTc DWISA in the early stages ofinfect10n is thc bcst

4.

predictor Ofrcnal scquciac.Idcntincation ofpye10nephritis will incrcasc thc duration OfantibiOtic theraPy.

References Picpsz A,BlaufOx I,Grancrus GG,ct ali COnscnsus on rcnal cortic』sdnugraphy h childrcn with urinary tractinttcdOn, び ′脇 グ29:160-174,1999. S夕 ,物 ″ ″ハあ″ Rossicigh]MA:Renal cOrtical scintigraphy and diuresis renOg‐

〃42:91-95,2001. 冴辺レ raphy in inttnts and childttn,sN悔 Reference CrOss― 逝 写Q囲 ″杉み ″ ″α 盈財 五 滋 ″』 脇 び 351-354. Comment 99mTc

DMSA

is

the

71叉勇 ed 2,pp 328-333,

mOst

scnsitivc

imaging

modality

tlon of renal infcct10n or scarring.Thc advantagc of 99mTc D M S A r e n t t s c i n t i g r a p h y o v c r裡 G9 39 im sT tc h小a t D M S A 狙 ― 10ws high,rcs01utiOn cortical images without thc Prcscncc of Ovcrlying collccting systcm activitye Only 25%of DMISA is cleared by the bladdeL and dclayed imaging a1lows adcquatc bstruction or sevcrc t i m c f O r / du cr ai rn aりn c e w ci xt ch e pO 〔 c o u r e t e r a l r.esnPlE旗C T r c P o r t e d l y h a s s l i g h t l y h i g rh e r s c n s i t 市 ity than planar imaging and planar imaging has highcr sPcci― ncit/;howcveL the diIFerenccs are not grcat.DMISA is taken up tubular cells and thus cannot difFcrr sOlely by ttnctiOning ttn』 entiatc renal scarring from tumOL abscess,or cysts.It has becn used in the past tO differentiatc a rcnal rnass frOm functional congenitally eniargcd column OfBertin(pseudotumOr). With planar imaging a pinhole or cOnverging collllnatOr is uscd,particularly for childrcn,fOr rnagnincation and imprOved res01ution.GoOd SPECT usually rcquires sedation ofyounger childreno Single dcfccts resulting in 10calizcd deformit/of thc rcna1 0utlines(volume loss)arc likcly thc rcsult Ofscarring and shOw no improvement on subscqucnt studics.Large regions of dccreased uptakc in thc upper or lower P01e withOut dcformity Of the Oudines and with indistinct cdgcs(no volume loss)are 1low― uP stuけ tO likeけtO imprOvc when inttctiOn rcsolves.A島 differentiatc infcction frOm scar should be conducted 3 to 6 mOnths iatch a1lowing time for adcquatc antiblotic theraPy and infection resOlution.

2紹

for

vesi―

detec―

1231 thyrOid scans、 A39-ycar― voman has a 3-ycar history ofhyperthyroidism。 old、 vere perforlrled cach ycaL shOwn frOm ictt tO right. 1. Describe the scintigraphic andingS・ 2. Givc thc diagnOsis. 3. W7hat trcatincnt options are appropriate lor this PaticntP 4. W7hat、 vOuld you exPeCt the radiOactivc 10dinc thyrOid uPtakc tO bcP

柵 99mTc PerteChnctatc scan in a 3-year― old child with a sublingual rnass.Patient is cuthyr01d. 1. Wマ hat is thc rncchanisn1 0f99mTc PcrteChnctate and 1231 sodium 10didc uptakcP 2. Wマ hat is thc advantage of99mTc pcrtcchnetatc ovcr 1231 in this PatiCntP 3. Dcscribe the scintigraphic indings. 4. W7hat is the diagnOsisP

245

Endocrine Systenl:Toxic Autonomous Thyroid Endocrine Systenl:Lingual Thyroid Nodule l,99mTc Pcrtechnetatc is takcn uP(trappcd)by thyroid follic‐ ular cclls llkc lodinc but nOt organincd.1231 is takcn uP right 10bc Ofthe thyrOid,with l, Hot nodulc in thc rnid― and organined. increasing supprcsslon Ofthc remaining gland at each suc― cessivc ycai

2. LO、 ver radiation exPosure to the pcdiatric PatiCnt.

2.To対 c autonomous thyrdd nOdulc.

hc base Ofthe tOnguco Norlnalin sub― 3. Focal uptakc at〔 glands and mouth.No thyrOid in ncck.

3, Surgcr/and radioactivc 1311 are thc usual methOds oftrcat― m a n d i b u l a r

mcnt.Therapy with Propメ thiOuracil(PTU)or mcthima_ 4.

zolc(TapazOlc)sometimcs is uscd as initial trcatmcnt.

Lingual thyroid.

4. Thc radiOactivc lodinc uptakc lna/be lnOderatcly elcvated, References hOur butit often is in thc noHnal range.Norina1 24‐ Kalan A,Tariq M:Lingual thyrOidi clinical cvaluation and uptakc is 10%to 30%.

物″P陀 ″″ レ 打cTち comprchensivc managemcnt,五 ノ78:340-349,

1999. Wins10w CR Vcisbergcr EC:Lingual thyrOid and ncOPlastic changct a rcview of the literaturc and description Of a casc, FreitasJE:Thcrapcutic options in the managcmcnt Oftoxic arld θ筋あ?響 ′熊 帆〃Nett S″笹 117:S100-102,1997. ″ミ ブ 丹々〃30:88-97,2000. nontoxic nodular gOitcL 夕 物″ S″ 悦ご

Reference

Cttss‐ReFerence 醍 助 r力″″鴎 品 冴″α 軍 Comment

逆 Q占横

ES)cd 2,PP 372‐ 374. 『

CttssrReference ″ ″α r醍 沢どQじ慰 孤 ,Cd 2,P376. ハ吻r″″″%″ び Comment

,り物〃 iS the tcrm applicd to a mass ofcctOPiC thyrOid Thc Paticnt in this casc had subclinical hyperthyrOidisnl at the と,轡 ″け tissue locatcd at thc basc of thc tOnguc rnidline.This is a rare stimulating hormonc time ofthc arst wo scans(low thγ roid― anomaly rcsulting ttOm fallurc Ofthc cmbryonic 81arld aniagc tO [TSH]),nOrmal thyrOxinc(T4)・ BCCause shc had no symptoms, shc would nOt acccPt surgery or radioactive lodine thcrapy un―dcsccnd,Occurring bcsveen 3 and 7 wccks Ofembryological dc― v』Opmento Nodulcs iargcr than eve10ped symptoms(third scan)。 til shc←

ThyrOd dssuc may bc Lcatcd in any PosidOn ttong hot nOd― this thyrOglossal tract.The lingual thyroid is thc on1/functiOn― inally usually prOducc clinical s/mptoms.A“ 2.5 cl■ ule''is dcincd as a PalPablc or sOnOgraPhically cOniHncd nod, ing thyrOid tissuc in 70%of cascs.HypOthyroidisEL OCCurs in up to 330/o ofPaticntS bCcausc thc cctOPic tiSSuc oftcn is hypO― vith increascd activity On a 1231 scan and dcinitc suPPrCS― ule、 functiOnal.C)ther symptorrls includc dysPhagia,dysPhonia, s10n of the rcmaining gland.Thc increased T4/T3(T3' dysPnca,and hemorrhagc.Rarc thyrOid carcinomas may arise. trilodothyroninc)suPPresseS TSH and Prevcnts 1231 uptake in the nonautonomous PortiOn of thc giand.OccasiOnally a re―Lingual thyrOids have svo prirnary clinical Pictures.Onc

gion on a thyr01d scan may appcar focttly hot but the rcmain―g r o u p c o n s i s t s o f i n f a n t s a n d y O u n g c h l l d r c n w h o s c h ial diag― dcr ofthe」and iS nOt suppresscd.This can bc causcd by a lsm』 roidism is dctectcd on routine scrccning.Thc difttrcnモ and,an hypothyrOdism hdudcs an absent」 nosis ofcongenit】 autonomous nodule prOducing insuFncicnt T4/'「 3 to suPPrcSS TSH or bc duc to hyperplastic nonautonomous tissue with rel― cctopic gland(usually lingual),Or an inborn crrOr Of mctabo― hcsc i「 PaticntS Often fall to thrivc and havc in lisIIl causing goitci ativcly bcttcr functiOn than Othcr pOrtions ofthc gland,c,gり mental rctardation ifthyrOid hOrrl10nc rcPlaccmcnt is not initi, rcs01ving thyrOiditis. .Thc sccn ttcr the onsct ofdys― l碇 secOnd grOupお Thc advantage of1311 thcrapy fOr tOxic nodule discase is atcd that early in it is takcn uP Prefcrentially by the nOdule,with vcry little taken Phagia and Oropharyngcal obstruction befOrc or during pubertye 99mTc PertcChnctate scans avoid thc need for diagnOstic up by thc nOrmぶ suppresscd Jand・Aftcr thcrapy thc hypcr― vith the attendant risks Ofintractablc hemOrrhagc and blopsy、 funct10ning nOdulc bcc01mes nonlbnctional and the remttning a c u t c thyrotOxicosis,SuPPression with th/rOid hormonc giand, n0 10ngcr suppresscd, usually functiOns normally. treatincnt of chOice,althOugh surgcry somctimcs is neccs― TyPically 20 to 25 mCi of1311 is given fOr thcraPy bccausethcau― sary fOr symptomatic PatiCnts. tonomous nodulcs arc mOre rcsistant to thcrapy than Cravcs' hOt nodule,hypothyrOidism disette.After trcatmcntn」c ofa立 Notes is very uncommon,in contrast to Graves'discasc,becausc thc rcmaining gland rccPiveS little beta radiatiOn. Notes

246

99mTc PcrteChnetatc thyr01d scan in a paticnt with clinical hyperthyrOidism. 1, Describe the scintigraphic nndingS・ 2. Dcscribc thc scan evidence that supports thc repOrted hypcrthyrOidism. 前/hat is thc diffcrcntial diagnOsis regarding thc icft iObeP 3. ｀ 4. The right iObe is t、

vO tirnes nOrinal sizc by cxarlrlination.Thc lcft 10bc is nOt palpablc,nO nOdules arc Fclt,and nO

scars are prcscnt.W/hat is the most likcly diagnOsisP

AN■ 60市 ih

IANT■ 20■市inlPl

ANTI■十 市St,

A45-year,old IIlan had surgcry fOr hyperparathyrOidisIIl that has PcrsiSted pOstOpcrativelyB

l. Wγ hat is thc radiOpharrrlaceutical and studyP 2. Describe the scintigraphic andingS・ 前/hat is the diffcrcntial diagnOsis for thcsc nndingSP 3. ｀ 4. W7hat is thc likcly diagnOsis in this clinical scttingP

247

Endocrine SysterFB:Mediastinal ParathyrOid Endocrine Systenl:Thyroid Left Lobe AdenorTBa Agenesis一 Graves′ Disease l.Parathyroid scall with 99mTc scstamibi or 99mTc tctrOfOsmin. vith― apPcaring right lobe,、 l. UnifbrFrl uptake in a buibOus― Out focal areas Ofincrcascd Or dccreased uptakc.No activity(Image quality would be infcrlor with 201Tl.) in the cxPcctCd 10cation ofthe leFt 10bc or clscwhcrc in2.Focal the plrsistcnt uptakc in the mcdiastinum,normal salN母 , livcL cardiac uptakc.Apparcnt axillary uptake rcsOlvcs with arins clcvatcd,thus is caused by skin folds. lt/m thC right lobe is mOrc intcnsc than 2.The uniform act持 in the salivary glands,indirect evidcncc ofan cicvatcd 3. Various bcnign Or rnalignant ncoPlasms. uPtakc in the absencc Ofintrinsic salivary gland discasc. 4.Mcdiastinal ParathyrOid adcnOma. ncck or uPper Chest.

3 . S u t t C a lb n c, xに P cl お accmcnt by hyPottncdOning adenoma Or carcinOma,suppresslon by autonomously functioning adcnoma On the right,agcnesis ofthc 10be lc丘 with 乱seasc ofthc sOhtary nght lobe, Graves〕

4. Gravcs'discasc wFith agencsis ofthe icFt 10bc.

Reference び 拷ブ 物竹 ″ グ″″グ″夕 S o m P M , C u r t a t h H D : P″協 竹; c d 3 , S t L o u i s , 1996,い五osb卜pp 757-761. Cttss―Reference ″α TF/f沢 どQ占 遠 孤 ,Cd 2,PP 370‐ 371. 助 r彦″″Mcあ cグ Comment COHlinOn causcs of hyperthyroidism includc Graves'discasc

References LOsscF SM Ziessman HA,Ali,ani MR,ct al:MultiPic hypcr‐ roid glands in a Paticnt With 的nctioning mcdiastin』Parathア ″冴 161:285‐ 深И″ノ乃 物留′ tcrtiary hyperparathyrOidism,比 286,1993.

Iyer RB,mitman GJ,Aysegul S:ParathyrOd adcnOma ofthe 物ブ父″ 冴θ mcdiastinum,И ′173:94,1999. Reference Cross‐ :軍醍 ′ 助 す 力″″Mであct″

京どQttSrtts,ed 2,PP 384-387.

Comment Parathyroid adcnOmas usually are solitary.Thc Parathyroid glands arc derived from the pharyngcal pouchcs.Most PcrsonS

havc fOur glands,wo supcr10r and svO inferiOr Oncs locatcd (diffusc toxic goiter),toxic multinOdular gland,solitary toxic adenoma,and subacutc and Painlcss thyrOiditiso Lcss commOnc10sc tO thc thyrOid.EctoPiC Parathyroid adcnOmas in the an― induccd tcrior mcdiastinum arc dcrivcd frOm thc inferiOr glands that dc‐ are iatrogcnic ingcstion Of thyfoid hOrinone,iodinc― hyperthyrOidism,c.g。 ,sccondary to contrast,and cctopic dis―scend with thc th/muse Only 3%ofparathyrOid adcnOmas are fOund in the rnediastinum.Rarc rcports cxlst OfmOre than one easc,c.g.,struma ovarll, ThyrOid dcvclopmcnt begins carly in cmbryonic life bemttecn parathyrOid adenoma found in thc rncdiastinum.

This paricnt had prior resection ofa parathyrOid adcnoma in thc sccOnd and third wecks and is completed by thc clcvcnth thc ncck.HowevcL the serun■ calciurn and seruIII ParathOr‐ week.Embryological descent Occurs,which can lcave remnants s 狙 levels remaincd clcvatcd indicating persistcnt discasc. O f t h y r O i d t i s s u c a n / w Oh ne gr c t』h e c O u t t c o f t h e t h y r O g l o smOne Mediastinal parathyrOid adenOmas usually arc caslly scen on ith the devcloPing brachial duct.During desccnt intcractlon lげ POuches occurs,which rnay cxPlain the occaslonal exlstence of eCtOPiC thyrOid tissue in thc larynx,csOphagus,latcral neck,

99mTc scstattlibi scans bccausc of thc lack Of thyrOid back―

ground,a problcm in thc ncck.Although special tcchniqucs mediastinumj and Pcricardium.MorPhological fcatures and size such as cOmputcr subtracdOn Ofthc thyrOtt Or ddayed dittr― cntial washout relativc tO thc thyrOid are vcry helpFul in the Of the nOrmal adult thyrOid varys Asymmctry is common. Agencsis can be complete Or unilatcral.Hcmiagenesis is mOrc ncck,they arc nOt neccssary in the chcst.Rarely SPECT can bc helpful.Occaslonally adenomas are FOund high in thc ncck; common on thelcFt. 99mTc is most ottcn tlsed in children for thyrOid imagingthus bc―Obliquc imaging encOmpassing thc upper neck can be scstarnibi and tct10fOsmin are nonsPcCinc tumor_ cause ofits 10w radiatiOn dOsc and g00d image qualit/duc to hclp的1.99mTc its is 300卜 imaging agcnts taken up by a varict/ofbenign and mttignant Ci compared higher administettd dosc(adult dOse 31 Ofレ ncOplasms.Howevett in the sctting ofpersistcnt h/Pcrparathy‐ with 3 to 5 mC199mTcl,99mTc is trapped by thyrOid follicdar celL bydlc samc mcchanism容 セ3L howcveL itis llotOrganincd,99mTc rOidismポter ncck disscct10n,focal uptakc in the mcdiastinum is likely to bc thc cdPrit parathyroid adcnoma. uptakccanbequantincdat 15 to20 minutcs ttcrttcCtiOn(noP mal,0。3%to 3%);lodine uptakes arc bcttcr standardizcd. Notes Notes

248

羊

A47-ycar,old woman with rcccnt Onset ofseverc hyPcrtension and elevatcd catecholamine lcvcis. hat is the radioPharIIlaccuticalP 1. Wマ rnechanisIII OfuptakeP 2. What is the rad10pharJnaccuticalも 3.What is the accuracy ofthis study ttr 10cating thc site ofdiscascP What is the discascP 4. What Other diseases takc up this rad10PharlrlaccuticalP

249

Endocrine Systerrl:MIBG一

PhecchromocytorTla

l.1311 meta-lodo‐ bcnzyl‐ guanidine(MIBG). 2.LOcalizatiOn Occurs thrOugh thc nOrcPincphrinc rcuptake mcchanism.It localizes in catcch01aminc stOragc vcsicics in

PreSynaptic adrenerttC ncrve endings and thc cclls ofthc adrenal mcdulla. 3, Scnsitivityj 900/o;sPccincity9 95%for dctcctiOn Of PheochrOmOcyton■as. 4. Various ncurocndocrine tumors take up thc radiOpharl■ a― ccuticali ncurOblastoma(90%),carcinoid(50%),and medullatt carcinOma Ofthc thyrOid(25%).

ReFerence Gross M]D,Shuttn BL,ShapirO B,ct al:Adrcnal scintigraphy and thcrapy of neurOendOcrinc tumors wlth radi010dinatcd mctaiodobcnzylguanidinc.In Sandler MIB COleman RE, wackcrs FJTh,ct狐

,ct″ 〕CditOrs:D″竹 ″ω力 ″″r務″″物c沈 ら ed W“1lkins,PP 1023-1045. 3,BaltimOrc,1996,Williams能

Cross‐Reference あα 『 醍 助 材%/筋 ″′

財 Q5慰

「ES〕cd 2,pp 383-384.

Comment MIBG has a mOlecular structurc simllar tO thc ncurOtransmitr

tcr catecholaminc hOrmOnc,norcPinCPhrinc,and 10nicthc gan」 blocking drug,guanethidinco Numcrous drugs lnay intcrFcrc with uptake Of1311 MIBG and thcy rnust bc discOntinued bc― fOtt thcstuⅢ These include reserPinC,tricyclic antidcPrcssants, arld labeta101,bOth an alPha_and beta_b10ckctt Thc Paticntも thyroid must bc b10ckcd宙 t h Lugolも sOlutiOn Or SSKI to pre― vent free radiolodinc uptakc.IHlaging is usually PcrfOrmcd at 24,48,and 72 hours aftcr inicctiOn,which a110ws timc for fur― ther uptakc and backgrOund dcarancc.也31 MIBc has advan_ tages over 1311 MIBG,with be〔 tcr irnagc rcsolutiOn and thc PO― tential for SPEC■hOwevcL it is not aPPrOVCd fOr clinical usc. 1311 MIBG is nOc a screening test fOr phcochromocytoma. Thc diagnOsis must irst bc rnadc chnically with elevatcd catc‐ cholaHline levels in thc b100d Or urinc.Thc rOlc OfMIBG isin the 10calizat10n Ofthc tumOtt The mづ Ority OfPheOchrOmOcy― tomas arc singlc,sPOradiC,and 10calized in the adrenal gland. 1311 MIBG can be particularlyvaluable fOr 10calizing the 10%Of raadrcnal and Occur at various pheOchrOmOc/tOmaS that are ex〔 10catiOns frOIIl the basc Of the skull tO the peivis whcrc frc_ qucntly they are not detectcd by conventiontt imaging.Tcn per― cent of phcOchrOmOcytomas are multifOcal and 10%malig― nant.The most cOmmon sitcs Of metastases arc thc skclctOn, lymph nOdcs,lung,and peritOneum. Notes

250

Challenge Cases

B

A

C

BOnc scans ,a И and C l. Dcscribe the bOne scan indings. 2. Interpret the studies. 3. Name thc Physical principlc that is involved in C C in 4. Namc the rnOst likely tyPc Ofrnaterial involved

253

Notes

Skeletal SysterTB:Arterial inieCtiOn′ Boot Artifact,Photopenic Attenuation Artifact l.И,Incrcascd uPtakc in thc right uppcr rcmity ex〔 ttOm elbow thrOugh handse a Uptake Outsidc bonc in bOth ttct and anttcs,nght grcater thanに 丘.Urinary contamhation OfscrOtum.C Photopcnia ofa pOrdOn ofthc五ght mid― huHlcrus on thc pOstcrior vicw onlye Lumbar scoliOsis.LcFt hip prOsthesis.

2.え Intraartcrial ittcctiOn.a Urinar/contamination of sOcks(b00t ardttcoo c Attcnuadonght ardttct Of五 humerus. 3. Attenuatlon ofPhotOns. 4,Mctal.

ReFerences

Chandra R:あ 初あrヵ グ湯″物財″ び ″ ″ らed 4, リタヶね ザ″ PhiladelPhia,1992,Lcaだ蛇FebigeL pp 136,175‐176. R y o げ 路 A l a v i A , C O l l i e r B D , c t: 狙 刀″ み ザ ″″f 務″″物′ 妨f ″ ″′

″ 〃物物″ ″ な″ ″ ぁcd 2,Chicago,111,1990,Ycar Book. ラど

CrOss― Reference α『 ハ吻す 彦″″陀 航ct″ 述 沢どQ違慰 ,確じ ed 2,pp 13-15,113-116. COmment Given that the malorl呼 hot" OfbOnc abnOrmalities appear as“ les10ns,thrOugh exPcriCncc,radlologists arc conditiOncd to “ 100k fOr"and thcrcfOrc“ scc"lCS10ns that dcmonstratc incrcascd activitys Photopcnic lcs10ns on bone scans can bc ovcr100kcd easlly if one dOes nOt sPCCincally Chcck tO sce that all the tx― PCCted Structurcs arc dcmOnstratcd.In casc(2 oncc thc inding is``sccf)and nOtcd nOt to bc prcscnt on thc antcrior vicw9 arti― Facts can be considcrcd.Bccausc the inding is PhOtOpcnic with normal bonc uptake in this rcglon On thC antcriOr vicw9 sOme matcrial must bc bcNミ cn thc bonc and thc postcrior dctcctOr to account for thc reductiOn in photons reaching the dctector. Attcnuatlon is rcmoval ofphotOns frOm a radiatlon nux because ofabsorption.Thc rnatcrials that b10ck Or absorb gaIIlrna rays are thP samc aS thOsc that b10ck rarytt x―thcrefOrc mctal is thc mOst like1/9 althOugh bariurrl and calciun■ alsO causc attenua― tlon.Thc tcchn010gist connrmed that a metalstrip lctt by mttn― tenance personnel had bccn IOund On thc imaging tablc whcn the paticnt lcFt.The mOst common cold artifacts c10thing,coins in thc POcket,and lnetal lnedalllons On thc chcst.

arc

mctal

on

An intraarterial ittcctiOn is vcry uncommon and occurs in― a d v e r t eT nC tC け h n 0s1t0 伊 hcsitatc to admit it,but the pattern is characteristic and tells the stOryB The``b00t''artifact is a rnOre colnlnon inding and is secn in patlents incontincnt of urinc. Inttriably othcr evidcncc Of urinary contamination is sccn On thc scan,as in this Patient.

254

A

B

品

vO paticnts agcs fltom Thrce― at Ofsclcctcd cOronal,sagittal sliccs,and transaxial in■SPECT bonc scans ofい vicw fOrn■ with canccr and low back pain.The bottom rightimages are thc postcrior pro,cCtiOn preprocesscd raw images. 1.Dcscribe thc scintigraphic SPECT indings in studics and И β . 2.(3ive thc likely diagnOsis in bOth PatientS・ 3. W7hy is accuracy oflumbar spinc SPECT higher than fOr planar irnagingP 4. IiOw can bOnc SPECT be clinically helpFulin diagnOsing discase in a paticnt with recurrcnt Pain l ycar aftcr spinal surgcryP

255

Notes

S k e l e t a l S y s t e m : l m p r o v e d S p e c t t i c i t y Bone Scan Lumbar SPECT l.え UPtakc h theに 観On Ofthc L4 rlght Pcdide,cxtcnding tO thc vcrtebrtt bott a Uptakc in thc rcglon ofthe L2

w i t h

facct,OintS bilaterttltt right grctter than left. 2. ソ 生 Mctastatic tumo丘',Articular facct OstcOarthritis. backgrOund ratio by 3.SPECT improves the targct― toと

10ws and狙 removing overiメ ng act市 ity ttOm ttaCCnt sllccs fOr three‐ dimcnslonal display. 4. One ycar aftcr surgery a hcalcd fusion has nO rnorc than minimally increased activity9 whereas a PscudoarthrOsis shOws activc bony rcpair with incrcascd activity.

References Sarkaya I,Sarikaya A,H01dcr LE:Thc r01c Of singic PhOtOn CHllSS10n Computcd tomography in bOnc imaging,S′

,物ブ″

助 冴立 物物〃31:3‐16,2001, 物グ ″Aあ冴分物〃 Gatcs GF:SPECT bonc scanning ofthe sPinc,レ 28:78‐ 9 4,1998. Cross‐ Reference 醍 沢どQdtt「 ES,cd 2,pp 128-129. 助 n修″″協 冴び ガ ″α 軍 Comment Bone scans arc vcry sensitive for thc dctcction Of osscOus dis― casc.Although incrcased uptake is thc rule,cOld icsions causcd by lytic Or destructive lesions arc not rarc with malignant disease dimcnslonal planar im‐ and may nOt always bc obvlous on two‐ ages becausc ofovcrlying activity.Thus SPECT can incrcasc thc scnsitivity and localization ofsPinc abnOrIIlalitics, The spccincity Of bOnc scanning is its mttOr problem. Benign and lnalignant causcs can aPPCar sirnllai SPccincitγ of_ ten can be ilnprOved by dcterinining thc distribution ofthe ab― normal uPtakc.SPinc discasc can bc PartiCularly prOblematic becausc OfOveriapping activity ofthe antcriOr and Posterior el― emcnts.Ascertaining whcther the incrcascd fOcal spinc uptakc is in the pcdiclc,bOdン or poster10r clcmcnts can improvc thc SPeCincity and aid in thc difFercntial diagnOsis,Malignant le― slons involve thc Pcdiclc and inay Cxtcnd intO the vcrtebral c a u s c o f b o n c b o Ⅲ A r t i c u l a r t t ct ci ts , oa s tc eo Om am ro tn h 五 scan abnOrn■ alitics,involves thc POstcriOr elements of thc ver_ t e b r a l P bO OS 与 t e r i o r eo wb sl i sq ou mc e宙t i m c s c a n b c h e l P t t i n making this distinction but oftcn do nOt answcr thc qucstion古 S P E C I w i t h i t s dtihmreencs― lonal disPlay2 Pcrmits diFFcrcntia― tiOn benvecn vcrtcbral bodtt Pediclc,and PosteriOr elcmcnt uptake.Thus SPECT often can conarln or exclude malignanF diseasc.

256

A Patient Was rcferrcd fOr bOne scan because of,oint pain. 1. Dcscribe thc scintigraphic bonc nndingS・ 2.Describc any sOtt tissue indings.mat is thc likcly causcP 3. W7hat Othcr imaging study shOuld bc OrdcrcdP 4. W7hat is the diagnOsis and lnost likcly cOFnlnOn c4use fbr this scarl patternP

257

Notes

Skeletal Systenl:PulFrlonary Hypertrophic Osteoarthropathy l. E)ifFuse increascd uptake in thc uPPcr and 10Wer cxtrcHli‐ ties and Pcriarticular rcgions ofthc cibow9 wrist,and anklc

Uptake in thc seventh right rib antcriOrlン ,Oint・ 2.DifFusc uptakc in the right thorax.Thc mostcommOn causc is malignant plcural cFFuslon. 3.Chcst x―ray. 4.Hypertrophic PulmOnary ostcoarthroPathン BronchOgcnic canccr ofthe lung.

Reference ,ct al:Skcletal Sllberstein EB,ElgazzarAH,Fernandcz,Ulloaヽ在 scintigraPhy in non_ncoPlastic osscous disorders.In Hcnkin 夕 ″″物と 品び ″ ″ら St Louis,1996,Mosbtt pp ″ RE,cditori」用物び l185-1186. Reference CrOss― 力″″鴎 品″″4軍巡 ハ物ご

財 Qyrsr孤

,ed 2,P123.

Comment HypcrtrOphic osteoarthropathy is characterizcd clinically by thc prcscncc of pcriOstitis causing bonc pain and arthralgia,and clubbing ofthc angers and tocs,Thc characteristic radiographic and scintigraPhic changes usually preccde thc devclopmcnt of clinical symptoms and signs.Thc hypcrtrophic changes regrcss aFter succcssful therapy ofthe undcrlying discasc. Onary os― The bone scan changcs of hypcrtrOPhic PulI■ hy are cvident bcfore radiograPhic changcs.Thc tcoarthroPaモ pattern cOnsists ofgcncrally incrcascd activit/in long boncs and increascd activity in thc Pcriarticular rcglons ofthc long boncs, Phalangcs,scapula)and claviclc.Pcricortical striPing a10ng thc medial and lateral asPccts of thc 10wer extrcmitics(rallrOad tracttngl is Charactcristic. The pathophyslo10gical process ofhypcrtrOphic Pulmonary osteoどhroPath/is POOrly undetttood.Itis sccn in a largc num― ber Of benign and lnalignant conditions Of the chcst and ab― d01men.Thoracic bcnign and malignant tuIIlors are the most common;thc mttOrity arc bronchogenil carcinoma.Othcr icss colnlnon causcs of hyPcrtrOPhiC OStcoarthroPathy includc mcsothelioma,Pulmonary metastascs,brOnchicctasis,and abscess.In childrcn,it has becn rcPorted With asthma,cystic n‐ discasc(Hodgkitt diseasc), brosis,brOnchicctasis,mediastin』 cardiovascular discasc(cyanOtiC hcart disease,bacterial endo‐ carditis),and gastrOintcstinal discasc(regiOnal cnteritis,ulccra― tivc colitis,congcnital biliary atresial.

258

lung

A Paticnt With diabetcs was referrcd with ccllulitis Ofthe right 10wcr leg to ruic out Ostcomyclitis. 1. Discuss the advantagc ofa three_phase bOne scan compared with the delayed Phase Onlyc 2.狩

Ow o,bbod podの ,ddayedの, 縄 猛 舞 ぷindgraphCbOnescanandng&回 3. PrOvidc the differcntial diagnOsis. 4. What is the II10st likely diagnOsisP

259

Notes

Skeletal SysteHl:lCangrene of Tces 。d Pool Phases increasc thc specincity Of l. The now and bl。 the diagnOsls and narrOw the difFcrcntlal diagnOsls. 。d bl。 Poolto the foot 2. Diffuse incrcascd blood now and and ankle Ofthc right lowcr extrcmity.No

blood

PooL or uptake ofthe right third and fourth toes,mlld dclayed imagc,slightly worse l bones on thと increasc in組

at thc arst mctatarsophalangeal(MTP),Oint. 3. Vascular insuFncicnc/2 prior surgery9 acute ostcomyelitis, frOstbitc,replaccment by tumoL artifact. 4. Artcrial insuttciency and gangrcnc ofthe third and iburth . t O C S , C C l l u l i t i s i m l l d a r t h r i t i s O f a r s t M TiPn,t。

References げ TOttas MB,Patcl M,Marwin SE,ct狙:Thc diabctic FOot,β 貿レ冴θ 〃73:443,450,2000。 Rchm PK,Dclahay J:EPiPhyseal Photopenia associated with

冴 metaphyscal osteomyelitis and subperiOsteal abscess,/助

コ石夕 ι 〃39:1084-1086,1998. Reference Cttss― ″ ″r『醍 助 び 力″″%冴 ご

ズどQ」慰 rES)ed 2,pp 134‐ 136.

Comment

ectmet』 causing attcnuation Arthcts such as a lcad shicldo明 or shOuld bc cxcludcd as a causc ofnonvisualization.With nonvi― sualizatlon of bony structurcs,the radlologist should consider

1缶 斌ξ 粗緒紺猛 挑総艦鮒 端酬猛恥

by the radiograph that shows all digits.An adcquatc vascular cry Of thc radlopharmaceutical fOr suPPly is rcquircd for del市 dcPosition to occui Nonvisualization of the third and lburth tOes indicatcs abscnt noL which could rcsult fronl acutc or chrOnic artcrial insumciency or venous ocdusion.In a patient with diabetcs,chrottic arterial insuttcicncy is the most likely cause.Acutc PhOtOpenic osieOmyelitis occurs more commonly in children. A three,Phasc bonc scan can ProVide additional irnPOrtant diagnostic inforination on vascular status of the lilnb or digit c bonc remOdeling.Osteomyelitis is and on the degrcc Ofact市 。d Pool, dassically threc― Phasc PositiモWith increased now9 bl。 and delaycd uptake at die site ofosteomyelitis.The sensitivity of s, so.Fractuに this anding is high,howeveL the specincity tt less tumors,and Charcot七 Phasc ,oint may produce a simllar threc― e study otten is needcd POSitlVe pattern.A radblabeled leuko甲 Raに,acute os_ to connm the diagnosis h noFIVirgin bonα teoHlyelitis in children may show abnOrinalities on the early 唱ingifimを phases ofthe bone scan with a norinal delayed Phasc iS PerfOrmed early atter onsct.

260

nOwj

榊

‖

B

imrnediate

1 . D e s c r i b e t h c b O n e s c a n 乳aFbinOOⅥ rβ m, aI lm im 呼 ediate and delaycd Plantar images. 2, Provide the diffcrential diagnOsis.

3,Given the radlograph“ 9,name the entity.List at least thrcc Othcr sites that are sub,cct tO the same process. 4. List at icast three cOnditiOns assOciatcd with this cntit/6

261

Notes

Skeletal SysteHl:Avascular Necrosis of Metata r s a l H e a d ( F r e i b e r g ' s D i s e a s e ) 1. Thc threc‐ PhasC bOne scan dcmOnstrates abnorinal incrcascd b10od now and blood Pool activity in the rcgion Ofthe sccond and third EICtatarsal hcads.Thc delayed bonc Phase demOnstrates increascd activit/in the boncs in the salne distributlon. 2. Fracturc,ostcotomy9 0steoHlyclitis,Primary or sccondary ncOplasnl,avascular necrOsis. 3.Avascular necrOsis.Tarsal naviculatt carPal lunate,femoral hcad,humcral hcad,ring apoPhyses ofthc sPinc,tibial tubcrcle. 4.Trauma,hypercOrtisolism,collagcn vascular discasc,chronic renal discasc,asPirin,SiCklc ccll discasc,alcoholism,d/s― baric conditions.

ReFerences す 物″ 竹gr筋 ′″タクな力″ ″あ∫ ″タ ル物ブ″ ,St Louis, Sartoris DJ:MttSび MOsbン 1996,pp 183-193,375. GrOshar D,Gorcnbcrg M,Bcn‐ Haim S,ct al:Lowcr extremity レ物〃28:62-67, ブ ″プ V力〃ソ ,物 scintigraphyi thc foot and anklc,S″ 1998. Reference Cross― ロYど越 Qこ刀SrrES,cd 2,PP 132‐ 134. ハ物通住″Mettc″″α コ Comment discasc,one bonc scan is an exalnPiC OfFreibergも This Patientも Ofthc ostcoChOndroscs,a hetcrOgencous group ofdiSordcrs that radiographically display the fcaturcs of incrcascd density and vith or without nattcning of thc epiphysis or fragmcntation,、 aPOphysis,as secn on the radiograph involving the third arld,to t ent,thc sccond lnetatarsal head.Thc causes includc a lcsserま ostCOneCrosis,trauma,and normal variation. Avascular nccrOsis,ostCOnccrosis,and ischcnlic necrosis arc terms applicd to the results ofinadcquate blood nOw to bonc. Comparcd with othcr portions ofthc bone,the epiphyscal cnds Oflong boncs arc predisPOscd bccause they havc relatively lim‐ ited arterial and vcnOus Pathways,which are cven lnore pro― nounccdwhlle grOwth Plates are prcscnt.TyPically the cPiPhysis c artCry2 which incrcttcs risk.When thc is supplied by a sin」 dominant blood supply is cOmpromiscd,scvere ischcmia,and, lfProlonged,nccrosis,occu上]VieChanislns ofvascular comprO― misc includc obstruction,comprcsslon,or disruption,Causcs or associatcd conditions includc trauma,hypcrcortisollsnl, chronic rcnal diseasc,asPirin,collagcn vascular discase,sicklc

sbanC COndtions(cttsson dscasc). coholiSm,Ⅲ cdl diseasc,】 Although it can Occur at any,oint Surfacc,the sites listed are the most frcquently invOlvcd.

262

詰盤 an was ttqucstcd ttr cvttuttOn Ofhtt Pttn and 10W_gttde fever h an l卜 館

新

ye釘

―dd.The hip ttdOgrtth was

.托

l. What ilnaging instructiOns shOuld bc givcn tO the tcchn010gistP 2.Deschbe thc sdndgraphc indings(″ images).

あθ%blood nOw,ぁ

ぁ ″物

b100d POOLあ

あ ″ 物ブ 妨

″″〃 牝 力ち ddayed

3. PrOvidc thc differcntial diagnOsis. 4. BOnc biOPsy:ncuroblastOma.Name another radiOpharIIlaceutical used in this discase.

263

Notes

Skeletal Systenl:Neuroblastoma Minlicking Osteomyetitis vith attention to thc hiPs becausc l. Thrcc‐ Phase bonc scan、 Ofthe acutc nature ofthe symptoms alld infcction is a dinical consideration. 。d pool,and dclayed uptakc 2.Modcrately incrcascd now9 bl。 in thc PrOximal right femur mctaphysis. 3.Ostcomyclitis,fracturc,Prirnary or scCOndary malignaFlt tumor(monoStOticl,abrous dysplasia. 4.Bll metabcnzylguanidinc(MIBG)and lllln Pentctrcotidc, a somatostatin rcceptor radiotrace丘

Reference Treves S■Conn011y LR KrkPatrick,ct狙 :Bonc.In Treves S■ グ ″ら cd 2,New York,1995, etta″ル ″″材物″物妨 す cditor:踏 Vcrlag,pp 287-292. Springer‐ Reference CrOss‐ Yど沢どQyrSr「 ES,cd 2,pp 124,126. 冴″α j日 A物冴あ″ルク〃″ Comment

chidh00d.Rけ Ncurobltttoma occutt most ttequently h carけ

鮪棚 柵

ま 燃 檻 材 :ド 【 齢

14.Thc sitc of the primary tumor varics,700/o originate in thc rctroperitoneum,30%in the adrcnd」 and,and 100/O in thc ab― dominal sympathetic chaino Others occur in thc cettical,thora‐ cic,and Pelvic引 犀nPathctic side chains.The distriblltion contrasts and in with PhcochromOttOma,which occutt in the adrentt」 900/o ofadults and 250/o ofchildren.Thc mOst common clinical prescntatlons ofncurOblastOma arc palPation ofa large abdomi― nal mass or manifcstations Ofmctastatic discasc. Skcictal scintigraphy is a scnsitivc dctector of rnctastatic SPrCad tO bOnc and is abnormal wccks beforc radiographic changcs.Uptakc on 99mTc MDP bone scansin thc Primary tu― mOr is most intensc in younger paticnts.Evcn when thc Pri‐ mary tumor shows no radiographic evidencc of calcincation, vs Prilnary tumor uPtake.A b6nc the bonc scan oftcn shO、 mctastasis Elinlicttng OstcOmyelitis,as sccn in this casc,is not common.Thc metastatic Pattcm may be increascd symmetric uptakc in the proximal humeri,distal fcmurs,and Proxlmal tib… ias.This uptakc may bc subtle and is most promincnt in the metaphyscal arcas.ChemOthcraPy may reducc abnormal upr take toward norinal;ho、vevett this docs not indicatc tumOr 五IBG has eradicatiOn.Thc combination ofbone scan with 1311小 thc best scnsitivity for tumor detection and evaluation of re, SPOnSC tO thcrapy.

264

︲ ︲ ！ 徽靴鶏■■

ざ

檄

ゆ さ A5,year―old with PrecOc10us pubcrtye l. Namcぃ vo nndingS that rnight be scen、 vhen exaIIlining this Patient. 2. Describc thc scan indings. 前lhat bOne lesiOn is lnOst likclyP 3. ｀ 4. Namc the syndrome that this Paticnt has.

265

Notes

Skeletal Systenl:Fibrous Dysplasia′ McCune口 Albright Syndrome astia. au-lait"skin icslons,g/nccon■ c』に‐ l. Pigmcntcd“ 2.Abnormal uptakc is sccn in thc frOntal I Pattern ofuptakc in the long leFt tibia,with a nonunilor「 bOnes.

bonc,lcft

Femuら

ia. 3.PolyostotiC abrous dysPl容 4. McCunc‐Albright syndrOmc.

References Grcenndd GB:筋 妨θ 々gザ ″θ″どあ 筋 句 ed 4,Phiaddpha, 129. 1986,Lippincott,PP 127‐ Machida K,Makita K,NishikawaJ,Ct』:Scintigraphic mani‐ 2N物 ご 〃丹々〃11:427-429, Festation of ibrOus dysPlasia,C!,″ 1986. CrOssPReference α秘 助 あ ″Mcttct″

越 QDttZi ed2,P127.

Comment Fibrous dysplasia is a dcvcloPmenttt abnormttity that rcsults in 10calized ProllferatiOn ofabroblasts that rcPlace nOrlnal canccl― 10us bOnc.Thc abnoHnal ibrOus tissuc results in a trabecular pattern ofilnmaturc woven bonc,thc radiographic dcnsity of which varics depcnding on thc amount of bonc PrcSent.Thc cOnditlon Hlay bc monOstotic,monorrlclic,or PolyostOtic.Thc disease bcgins in childhood and may bc seen in infants. Path01ogical fracturc of thc abnOrmally wcak bonc is the most frequcnt cOmplicat10n. Scintigraphy is hclPful in detcrrllining thc activity and dis‐ tinguishing monOstotic ttom polyostotic disette.The mttOrity Ofleslons in abrous dySPlasia arc tracer avid on 99mTc MDP bone scanse Scven pcrcent to 140/O ofles10ns havc uptake cquiv‐ alent to noHnal bonc;howcvcるthe rcHlaindcr show supranOr― mal uptakc. l ait sPots,are 3-au― Localizcd abnorinal Pigmcntation,ca景 pttsent in approximately one third ofPaticnts coaSt Of discase.Thcsc skin ics10ns havc an irrcgular outlinc(“ coast of Maine")in cOntrast to thC Smoothiy marginatcd(“ 「 eral CalifOrnial Pigmcnted icslons secn in ncuronbromatosis.S働 endOcrine maniFestations can bc seen in thesc PatientS, HyPCrthyroidism may occur in up to 5%of padcnts,Scxual precocity occurs in up to 30%offcmalcs with P01yos,OtiC diS Albright casc,is rarc in inales,and is rcfcrred to as McCunc‐ syndromc.

266

with

polyostotic

1. 2. 3. 4.

267

Notes

Bone:Rena1 0steodystrophy ty in acti宙 the long bones of l.Incrcascd cortical radlotraccr

'and Rallroad trackinゴ thc uppcr and lowcr extrcmitics.“ bowing ofthc fcmurs.Bllateral hip prOsthcscs.

2.HypcrtrOphic osteoarthropathtt vitamin A intoxication, nuorosis,ren】ostcodystrOPhンthyroid acrOpachレ me10rheostosis. soft tiSsuc uptakc ratioo Rcntt nonvisuttiza‐ 3.High bOnc,to‐ tion.Minilnal bladder activitye Additional history:paticnt is undergoing dialysis following a failcd kidncy transPlant. PriOr hip 4.The scan is charactcristic ofrcntt Ostcodystropけ replaccmcnts for avascular nccrOsis causcd by sterOid theraPy rclated to the ttdncy transPiant.

ReFerences ガ物〃?″ ″筋, 冴び物冴θ々gr″ P物 び GrccnsPan A O″ 務ヮ ′ Philadelphia,2000,Willlams ttt Wilttns,pp 662. 655‐ Sartoris DJ:ル

物 すご″わ ∫″タル 物 〃 グ物 竹 物 gf務

夕″

タ

ク方 ″方夕ず,St Louis,

298. 1996,Mosbン pp 297‐ Reference CrOss‐ ガ ″夕 fT避 助 び 彦″″脇 冴び

択野Qむ慰

ES,ed 2,PP 121,138. 「

Comment failllre With chronic rcn』 odystrOPhy occutt in Pttienほ Rcntt osに talnin D mctab01ism and secondary resulting frOm abnormal宙 hyperparathyroidismo Thc formcr Occurs becausc thc kidncy is ― hydrOttritamin D to thc ac‐ lon ofinactive 2う the sitc ofcOnvcド tivc fOrm l,25-dihydroxwitamin Do Sccondary hyperParathy‐ rOidism Occurs bccausc phosPhate retention dcpresscs scrum cal― cium icvcis,PrOmpting an incrcasc risc in Parathyroid hormonc lcvcis,Otten the radiographic fcatures show cvidcncc ofrickets, おm.OsteOscleЮsおお osteom狐航 a,or sccondary hyPcrparathyro過 sccn morc otten incon紘 sと 守 than Primary hyperParathyrOidism, pttdOminantly in thc axitt skelcton. 搭Cあ ″Signines a bonc scan that appears to bc of The terin∫ 宅ρ′ lo soR tissuc r筑 exccilcnt quality because of thc highto― target― with rninimal or no ttidcncc Ofurinary actiVityc Paticnt factOrs bcautiful''bone scan, unrelated to thc skclctOn can resuit in a“ c.g.,cnhancca renal clearance bccausc ofinlaging delay grcatcr than usu狙,300d hydration and rentt funcdon,and littic so丘 SCan includcs renal osteodys, tissuc.Thc difFcrcntial for suPげ metastascs,myc10abrosis,nuorosis,mas, trOPl聯difFusc skelct』 tocyto式 加d PyknOdysostosお狙d ovenaPs thc garnut ttr d阜 al well,conditioned fusc osteOsclerosis with that of some nOH■ bonc scan is clearly not normal athietcs.HowcveL this patientも c a n d v e r y c h a r a c t e r i s t i c o f r e n t t COhsatreaOCdtyesrtirsOtpiけ increased uptake in rcnal osteodystrOphy cOmmonly is sccn

throughout thc calvaria and mandiblc,costochondrttjunctions ,and stcmum(tie sign). (bcadin9,aXtt Skelet迅

Ne、vly diagnOscd PrOstate cancc丘 1. List the abnOrinalitics dcrnOnstratcd in the bOncs. 2,Provide the mOst likeけ diagnosis. 3. List any Othcr abnOrlnalitlcs. 4.mat is most likcly diagnOsisP

Notes

Skeletal Systenl:Lumbar Spinal Fusion′ Renal Transplant c l.AbnOrmal contour at thc L4 and L5 1cvcl,with rclat市 lncrease in the diamcter ofthc aPParCnt vertebrac,ccntral dcnned geomctrical Pattcrn sur‐ Photopcnia in a well― al increascd uptakc rOunded by increascd activit/.AbnOrn■ in a cresccnt PattCrn in thc right sacral ala. 2. Postcrior fuslon with bonc graft lnatcrial sccn latcral tO thc eXPCCted contour ofthc vcrtebra.The photopenia is caused by orthopcdic hardwarc(pcdicic Screws and Platcs). Thc right iliac crcst is thc bone graFt donOr sitc. 3. NonvisualizatiOn ofttdneys in thc cxpectcd location; tracer excrction is PrcSent in the bladdci Faint soft tissuc

uptake overWng and CXtCnding supcrior tO thc rightilium. 4,Lumbar sPintt futton.Rentt transPlant h thc五 ght ihac FOssa.

Reference

PalcstrO CJ:Radlonuclidc imaging ancr skeletal intervcntiOnal ″A物冴鴎 嵐25:3-14,1995. proccdures,シ物グ Reference Cross― α TF/fttQD町 助 あ ″Mcttc,″

恥

Cd 2,P128.

Comment SPinal fuslon is not an uncommon proccdure and frequcntly may be sccn as an incldental inding on a bone scan.Furthcr qucstioning of the paticnt or comparison with rad10graphs if thc naturc Of thc nndingS・ thcy exist can be uscful tO cOnarl■ which in somc PatiCnts The cluc is thc abnOrmality ofcOntOu島 can bc even more pronOunccd than in this case.Thc intensity of thc uptakc lnay vary dcPcnding On thc duration sincc surgcry and whcther continuing abnormal stress or mobilit/cxist at thc is prcs― nislon site.Ifbonc graFt matcrial only and nO vare hard、 cnt,no photopenic deFects will bc present.The bOnc graft donor sitc in this case is obvlous,but depcnding on its locatiOn it rnay not be cvidcnt. and the duration sincc surgerlみ Thc nature of thc sott tissue uptakc seen in the right lowcr abdomcn is rnorc casily cxPlalncd ifthc abscnce of nativc kid, neys is noted.This can be distinguishcd as soft tissue uptake rather than abnOrnlal uptakc in thc ilcunl,in that thc superlor medial contour docs nOt conform tO thc shaPc Of thc ilcunl, and abnOm』 uptakcお nOt present h the nght lcum On thc posterior view in that distribution.Ifthe location is unccrtain, antcrior obliquc views or SPECT wOuld PrOvidc Furthcr infor― mation as to its iocation and scParatiOn ttOm the right ilium.

270

ヘ 1. Thc paticnt was rcferrcd fOr back Pain.Describe the bOnc indings. 2. Describc any Othcr nOnOsscous indings. 3. Provide thc differential diagnOsis lor the bOnc abnOrinalitye 4. List three possible prirnary ncoplasms.

271

Notes

Skeletal System:Metastases to Bone(Cold) and A d r e n a l G l a n d l, PhOtopenia ofa low thoracic vertebra,PrObablyTll. 2.P[otic kidneys,abnorinal soFt tissuc uptake Seen betwecn thc POsterlor right cleventh and twelfth rib品 3.Primary or mctastatic necPlasm,attenuatiott from extcrnal or intcrnal sOurcc,c.g。 ,buckle on back ofciothing,metal― 止c OrthOpedic hardwarc,or prior vcrtebroPiastye 4.Brcast,co10n,lungi neurOblastoma in a child,but dcarly this Paticnt is an adult.

ReFerence S l l b e r s t e i n E B , M c A f c c J G , S P a s o r A響 P :ワ Dω力 ブ ″ ″ 物∫筋 を 冴tct″ ル″″,物 ″″す ら Res`on,Va, 1998,Society of Nuclcar Medicine,P207. CrOss‐ReFerence 務″″路 品 ″″α r醍 助 す

ズどQu応 胸宅じ ed 2,PP l17,125.

Comment

slon On bOnc scan il te そ The di健 にn d t t d i a g n o s i s t t r 呼a cso0l1← is 10ng,but can bc shortened by cOnsidering thc Pattern Ofthe abnOrlnalityp its locatlon,and the patientt ager On carcful in― spection,the sPinous PrOCess is visible,while the remainder Of Benign or malignant primary thcvcrtebraappcars P10tOPeniC・ neOPlasms such as hcmang10ma, brbwn tumOr of hyper_ ParathyrOidism,or myeloma/Plasmacytoma could have this aP" PCarancc.酌retastases that result in primarily lytic icslons,c.g., thyroid and renal,shOuld bc cOnsidcred.Howcvc5 PhOtopcnic leslons in adults arc caused by conllnon malignan― ority Of mctastases from cies,such as brcast or lung.The mづ or occ伊 breast or lung scintigraPhicttly show incrcasedity act市 hot"margins,butsomc ap‐ slonally photoPcniC Centcrs with“ pear photopenic,as this case.The lung cancer rnctastasis to the and ShOWs abnOrmtt sott tissuc uptake. right adttntt」 BOth ttdneys arc noted tO bc P,otic and located ncar the lllac crcsts on thc anterior and PosteriOr vicws ofthe abdOmcn.Ifone failed tO nOte this,thc inding in the right postenor nank could CttiけbC OVenookcd.The bone scan was obttned with thc Pa‐ tient standing.Ptosis rather than ectopia can be conarrllled by ilnaging thc Patient in the suPinc POSition.

272

morc

oRcn

L i m i t e d b O n c h s cP aa nt i le 物 n t w i t島 hm ulre tOts tdciossta狐 rComa.A befOre物 ケ 冴り and aFter chemOtherapy r後 . 夕″

different

t/Pe

ofnucicar

1. Dcscribc the bOne scan indings. 2.Is a wh01crbOdy bOne scan warrantedP 3. W7hat is the sccOnd radiopharinaceutical uscdP 4.Describc thc nndings ofthc secOnd Wttat studンis the clinical signincance ofthc scan indings beforc and aFtcr chemOthcrapyP

PrcviOusly resected chOndrOsarcOma.Evaluate rOr rnctastascs. 1. Dcscribc the bOne scan indings. 2. Providc thc differcntial diagnOses. 3. List at least threc cOnditiOns that predisPOsc Patients to this COnditiOn.

4.List hv0 0ther sitcs that arc sub,cct tO thC same process. 273

Skeletal Syste■1:Avascular Necrosis

Bone:Osteosarcoma and 201Ti

m aofr gFemoral i n o fHeads the distal mcta― l.Nonvisualizat10n ofthc lcft ilium,lcg lcngth discrcPancy Physis cOmpatible with the knOwn Osteosarcoma.Rclative riding ictt hitt and increascd uptakc suit ofhigh― as aに phOtOPcnia Fnedial tO this uptake. wOrsc than right. both ttmOral hcads,1乱 2. Ycs,for staging to detect Other sitcs oftumO上 2.The lllum has bccn surgically rcsccted.Fcmoral heads: 3.201Tl.99mTc scstamibi carl bc used for the samc purposc. ics;sllPPcd capital avascular nccrOsis,fracturcs,osteOtOn■ 4, Prcchcmothcrapy:vcry incrcascd uptake in the Ostcosar― 免moral cPiph/scs in thc apprOpriatc age group. coma,PostchcmOtheraPy:rcsolutiOn ofthc uptakc.Thc sickle ccll diseasc,collagcn 3. Trauma,stcroid administration〕 degrcc ofdccrcasc in 201Tl uptake aFter therapy corrclates vascular discasc,chronic rcnal diseasc,asPirin,alcoholism, with tumOr responsc to chCmOthcrapy and tumOr necrosis. dysbaric cOnditions. l.Incrcascd

uptakc

in

thc

lateral

4.Humeral hcad,tarsai navicula丘 Reference : Thttlium-201 scintigraphy lmbriaco M,Yct SD,Yeung H,ct組 fOr thc cvaluation Of tumOr response to PreOpcrative ReFerence 物竹″ レ タ わす ″ あ影タ ル物′ガ ご ″こ Sartoris DJ:批 o s t c O s a r c o r″ n″ aす ,夕 す ,St Louis, c h c m O t h c r a P y i n p a t i Cvnittsh 、 そ gr筋′″夕″オ″ 193,375. 1996,ふ 江osbンPP 183‐ 80:1507-1512)1997. Reference Cross‐ ″α「 ″ ″ 醍 択野QSttFES〕 助 び 力 ″鴎 品び

cd 2,pp 125-127,136.

Reference Cross― 鵡 択どQ5NttS,cd 2,pp 132-134. 助 び 力″/鴎 品冴″α 軍

Comment Comment vith an imaging study with a grOss abnor― lmaging ofosteOsarcomawith 201Tl or 99mTc sestarnibi can pro―W“hcn cOnfrOnted、 malit/P thc radiologist casily can bccOmc distracted from thc lcss― vidc cttnical infOrmatioh for evaluatiOn of tumor resPonsC tO itys This paticnt demOnstrates scintigraphic and dcgrec ofdecrcasc in thc amOunt of201Tl or chcmOtherapンThc glaring abnOrm』 99mTc sestarnibi uptake arc directly prOpOrtional tO the dcgrec radiographic andingS Of advanccd avascular necrOsis of both fcmOral heads.Likely causcs would be stcrOid administration in thc cOursc OfchemOthcrapy or trauma rclatcd tO sevcrcly altered bcaring。 P O S S i b l e f o r m a n y p a t i c n t s w h O p r c v l o strcsses u s l y w as O ual result d h a vofaltcrcd c u n d c weight rr S arc tcrms ″打 θ す 物力″ πFOSあ И ″ ″打 θ ∫ が ヵ ′ θ ″ andな筋夕 じ ぶc″ あ″ れ れ gone alnputation.Thcsc agcnts alsO arc useful fOr difttrentiat― applled to thc results of inadequatc blood nOw to bonc. ing rcsidual or recurrcnt tumor from postthcrapy changes,as sig― Comparcd with othcr portions Ofthc bOnc,the cPiphyseal cnds nincant residual uptakc is suggcstivc of residual or rccurrent OfiOng bones arc PrCdiSPosed bccausc they havc rclativcly liln― tumOi A quantitativc assessmcnt ofuptake can bc rnadc using ls ofvascular cOHl, itcd arterial and vcnOus supply.]W【 cchanis■ atera1 0r adT backgrOund ratios by cOmParing a contr』 mmor― to― his is important Of tumOr necrosis IOund On histOpatholog/.'「 sParing surgertt now in prcoPcratiVe managcmcnt beFOre limb―

)aCCnt nOrmtt rcg10n,adding an ObiCCtiVc component to visu』 proHlisc includc obstruction, comprcsslon, or disruption. Although vascular cOmpromisc can occur at a assessHicnt. 201Tl and 99mTc scstamibi are bOth nOnspecinc tumor ilnag―t h c F c m O r a l a n d h u m e r a l h c a d s a r c m o r c c o m m o n l y i n v o l v e d . Scintigraphically the earlicst stagc may d ing radlopharELaCCuticals,201Tlis a less than idcal agent bccausc which Often is rnisscd bccausc ofthc dclay in Obtaining thc scan Ofits 10w encrgy(69t083 kcW and low administcrcd dosc,3 COmPared with thc Onsct ofsymptOms.Latcら increascd activit/ mCi vcrsus 20 to 25 mCi fOr 99mTc sestamibi.AlthOugh 99mTc is seen as a result Of activc bOnc remodcling causcd by rcpara― scstarnibi has thcOrctical advantages,lcss data are avallablc tO tivc bonc fOHnation.Frcquendy latc in the coursc,scintigraphic conarm its uscl■ lncss fOr this purposc.EvaluatiOn Ofskclctal ic_ and radiographic changes appear on both sidcs ofthc,Oint as a slons in thc trunk rna/bc comprolnised becausc of scstaIIlibi rcsult Of secOndary ostcoarthritis,the scvcrity of thcsc changes t r o i n t t S d n t t t r a c t , o r b l a d d c i p h y s i 0c1a0l観 a c d v i t y i n t h c h e a r t , 拶 depcnds on thc degrcc OfdistOrtiOn ofthe articular surfacc. Notes Notes

274

lrnrnediate

60 minutes

90 minutes

ⅢⅢ Ⅲ Ⅲ

際

A

螺 一 雛

RT

B

l hour Patient И

2 hours

3 hours

is a 50-ycar― Old woIIrlan with recurrent cellulitis and chrOnic edclna Ofthc left 10wer cxtrclniり

l PatiCnt β

is a

60-ycar-01d IIlan with swelling in thc left upPcr thigh fOr scveral lnonths aftcr femOral artcry surgery.Radionuclidc lymphOscintigraphy、vas perforrlrled for bOth Paticnts. 1.W/hat radiOPharmaccutical is mOst cOmmonly used in thc United Statcs for lymphoscintigraphyP 2. W7hat is thc differcntial diagnOsis ofchrOnic vcr extrerlrlil/edema iO、 ifsystcIIlic discasc,c.g.,cardiac,hepatic,rcnal, have bccn excludedP 3. Dcscribe thc lyttPhOscintigraphic Pattern in thcsc twO Patients. 4. What arc the diagnOsesP

275

Notes

Musculoskeletal System:Lymphoscinttgraphy of the Lower Extrenlities l. Flltered 99mTc suifur c0110id. 2. ChrOnic venous insuFncicncy and lymphcdema,PriIIlary or sccondaryt 3.ノ生Normal dccP lymPhatic nOw tも femoral and inguinal nodcs on thc nghte Derm』 backnOw PattCrn on thc dist』 lcft 10wer cxtrcmity.ユ Abnormal fOcal accumulatiOn in 1later』 l ymphatic the mcdial lctt thigh.One superncial c。 vessd on thc right. 筑 。b s t r u c t i O .n a ωE x t r a v a s a t i o n 4 . 孔L y m p h た lymphOccicれ 化声 . り.五乾どみちAsymptomatic nOm狙

tto

a

References Gloviczki l CalcagnO D,Shirgcr A,ct al:Noninvasive evalua― tion of thc sw01len cxtrcrnityi cxPericnces with 190 1yHl―

比がび勧 箸9:145-152,1989. PhOscintigraPhic cxalninatiOns,メ Wttissieder H,Wcissledcr R:Lymphcdcma cvaluatiOn Ofqual― itattt and qualltitative lymphOsdntigraPhy h 238 PatientS,

筋あ 牝ノ16チ 7 35,1988. 729‐ Cttss‐ReFerence ″ ″α 「 配 助 び 彦″″脇 妨ご

沢どQ3慰

□ ,Cd 2,PP 226-227.

CoJttment

Lymphedcma usu狙 け るProgrcssive.Earけin the dscttc,Cdema predoHlinates,later9 chrOnic sOft tissuc innamlnation and ulti― matcly irrcversiblc abrosis rcsult.Lymphcdcma can bc a pri_ mary conditiOn(aplasia,hypOPiasia,1/mphangicctasia),but most commonly is secOndary(infcctiOn,innammatlon, trauma,malignancy9 surgical or radiation thcrapyl,VenOus and lymphatic causcs may cocxist.Lymphcdcma usually is diag― nosctt on a clinical bash imaging Studies can cOnirm or ex‐ ciude lymphatic ObstructiOn.Contrast lymphanglography is tcchnically difncult tO perfOrm;cspccially in this Paticnt grOuP, it dOcs nOt a1low ttnctional asscssmCnt Oflymph nOw and ma/ PrOduce lymphadenitis. Radlonudide lymphOscintigraphy dcmOnstrates the physi― 010g/Oflymphatic n終、Radiolabeled colloid Particles ‐ arc i早 ミ cn web sPaccs Of the second and jectcd subcutaneously be眼 third tOes. In Paticnts withOut lymphatic discase, lyHl― phoscintigraphy shOws 17mph nowing』 Ong thc meditt asPcct Ofthe lcg to lymph nOdcsin thc grOin,Pclvis,and ParaaOrtic rc, glOn.Abnorinal patterns of obstruction include n0 0r delayed f10恥 らc01latcral vcssel floL dcrinal backnOw bccausc of ob‐ structed or nOnfunctiOning iymph channels with interstitial dermal lymph transport(casc И ),cxtravasation into lymphO― celes Or istula(casc O,and 1/mphangiectasia,

276

A48,ycar― o l d P a t i e n t w i t h C O P D a n d c l a u d i c a t i O n o S h c h a s a s t h m a . S P E C T P c r f u s i o n, sihmoargte_sa惚 xitt a verti― cal10ngPaxitt and C select gated poststress SPECT imagcs).Thc left ventricular ttCCtiOn fractiOn(I〕

電 F)is 200/o.

1. 対 7hat is thc aPPrOpriate stress tcchniquc for this PatientP In what Othcr paticnts is this the strcss method ofcho 2. W7hy is this cOnsidered a secOnd_linc Pharinacological strcss agcntP 3.Describe thc SPECT image indings in this case. 4.輸

at is the mcchanism Ofcardiac uptakc for 99mTc sestamibi and 99mTc tetrofosminP

277

N6tes

Cardiovascular Systenl:Dobutanline Stress l. DObutanline stress.Paticnts whO are nOt candidates FOr cither cxcrcisc,c.g.,claudication,or vasodilator strcss,c.g., patlcnts with asthma. 2. Thc coIIII■

On OCcurrcnce ofsidc cffects including angina

and the inability Ofa signincant numbcr ofPatients to tol― cratc thc required dosc. 3.M【1ld ixcd antcroscPtal PCrttsiOn dcFcct with decrcascd wall thickcningo Severc nxed infcrior dcFect writh abscnt wall thickening.Dilated icft ventricular cavitya No rcvcrsibility.

tiOning O n sf iu gn nc け M y o c a r dtih』 i c k c n i n g la nmdO twi狙 宙ablc myocardium. ドes 4. 99mTc sestamibi,all isonitrile rnOnOvalcnt catiOn,dif■ cdis because ofits passivcly ttOm the b10od intO myocardi】 lipOPhilicit/J then iocalizcs in thc mitOchOndria.99mTc tctrO― fOsmin,a diphosPhene,has a simllar uptake mcchanism.

ReFerence 初ブ ″ Travain MI,Wexlcr JP:PharmacO10git』strcss tcsting,最 〃Лイタ ι 〃29:298-318,1999. 助 ご CrOss―ReFerence 醍 対あ 物 ″〃材筋 ″α 軍

京どQdtt「 ES,ed 2,PP 85-86.

Comment Dobutarrlinc is a synthetic catcch01arnine that acts on α ―and ― β adrCnergic reccPtorS(inOtrOPiC and chrOnOtrOpic ProPCrtics). It increascs coronary b100d now by increasing rnyocardia1 0xy―

gen dcmand(incrcascd heart ratc,systolic b10od Prcssurc,con― tractilityl.The protocol ttr intravcnous minc intts10n芯 dobutそ of infus10n Ofincrcasingly highcr dOse rates up to a rnaximun■ 40 μg/kg/min undcr constant ECG mOnitoring.Because of iほshOrt h』 二life,side eFFccts can bC managed by discontinuing thc infuslon. Typical calldidatcs for dObutalninc arc those whO cannOt cx― vcr crcise becausc of arthritis,pcriphcral vascular discasc,or lo、 extremityweakncss Or Patients with bronchOsPastic Pulmonary diseasc,c.g.,COPD Or paticnts with asthma whO cannOt bc given adenOsinc.DobutaHline alsO can bq used in paticnts in ning lncdicatlons or fbOds wcrc nOt dis― whOn■xanthine― contaェ continued befOrc the appOintincnt for adenOsine orピn01e diPyri(挽 stress.Patients with 10w systolic b100d Prcssure didatcs because b100d prcssllrc tcnds to incrcase with dobutaminc but tcnds tO decrcase with adenOsine and diPyridarllolc.Relative contralndica[10ns to dObutaminc arc reccnt rnyocardial infarc― tion or unstabic angina,s18nincant left ventricular Outnow ObstructiOn,at五 al tachyarrhythmias,vcntricular tachycardia,un― hypcrtcnsion,aoAic dissections,or ancurysms. controlled seveに

278

alsO

may

be

can―

あ%)and repeat strcss acquisition studyaCquisit 乳Exercise myocarditt SPECT Perittion sttdies.The patientt inititt seCOnd″ nrst化 ψあり.a sinograms ttr the ″ヴscans. 〃 and 1. E)cscribe the indings based on the SPECT ilnagcs and sinOgrams. 2. Dcscribc thc purposc ofthc sinogram.

3.List Othcr techniques in addition tO the sinOgram that can bc uscd simllarけ 4. Provldc thc diagnOsls.

Notes

Cardiovascular Systenl:Patient Movettent Artifact l.乳 The nrst study物 あ θ ぅ り shows an abnOrmal cOnngura_ tion ofthe anterior wttL theに り is nor― Pcat studyあψ mal.a Thc initial sinOgraHI shows a discOntinuity or brcak;thc secOnd is nOrinal.

2.TO visually present the raw unproccsscd PrtteCtiOn imagcs to cvaluatc fbr paticnt IIIOtiOn. CCtiOn data,lmage by image,or in 3.Review SPECT prづ cincmatic displayt 4. Artifact causcd by patlent rnotion.

Reference DcPuey EG:Artifacts in SPECT myocardial Pcrfuslon imag― ing.In DcPucy EG,Garcia EW;Bcrman DS,cditOrs:碗 'ぁ ご ed 2,Phlladelphia,2001,Lippincott SPECr″ 物竹 ″ 宅多 W■1liamsる こWilkins,pp 232-262. Cttss―Reference 姥″″Mであct″ 4正軽 助 ご

京野Qさ 慰 ち 確嘔 Cd 2,PP 42-43,75-79.

Coコmment Artifact shOuld bc cOnsidcrcd when the ln/Ocardiunl apPcars irrcgular in shape and cOntOutt Lincar rays of ty(comet acti宙 tails)arc Prescht in the initi』 studンstrOngly suggcstivc OfmO― t i o n , b u t a r e n O t s c c n o nT h te h cr a rd ci po e1 a0 tg i s t u da ン lsO shOuld cOnsidcr center ofrotatiOn errOr as a lnechanism fOr thc

artifact.Sinograms arc constructed by stacking all raw prttcc― tion images ofa singic crOss_scctiOnal slicc.Thc histOgram planc is indicated by thc horizOntal linc crOssing thc cardiac CC― PrO〕 tion imagcs in』移あθ ク リ.The arst sinogram shows an abnOr― mal sharp stcP,oFFOr discOntinuity;thc sccOnd shows a nOrlnal, smooth,curving appearancc, Thc unPrOccSSCdprttcct10n images from thc SPECT acquisi― tion should be insPcctcd bCfOrc image rcconstruction.As sccn in t h i s s m t t m O d O n c a n s e v e r c 1 / d e g r a d c t h c i qt u/ 』 Ofthe SPECT

scan.Grcater than m拓O pttis OfmOvement otten prOduccs arti_ facts,SOmc gamma camera― computcr systcms ofFer mOtion correction so偽昭re thtt can bc used tO adiuSt fOr hOrizOnttt or verdcal motiOn Ofthc Paticnt.HoweveL it carlnot correct fOr OfF_

Plane mOtiOn.mcn practical,lmaging shodd bc rcpeatcd ifsig― nincant patient motion has occurrcd.This is fcasiblc with 99mTc myocardial pcrfusiOn agcnts that ax in myocardial cclis,but much less PoSSiblc fOrTl2帆 stに ssimagingwith ongoing dynamic wash,in and washOut Ofthe radioPharmaccutical. Regular garnrna carrlcra qualit/cOntrol prOcedurcs arc cvcn morc ctttic』 for SPECT than fOr planarim鍋 妻ng・Factott deteト IIlining image quality include centcr OfrOtation,PiXCi Sizc,uni― fOrmity9 sPatial resolutiOn and linearit/2 mcnt,and hcad inatching ifa rnultiheaded camera is used,

280

and

detector

hcad

align―

Strcss and rcst SPECT myocardial Pcrfus10n images and a singlc prOicctiOn ofunprOccsscd acquisition dat 100P物 ″arc Providcd. 1.What radioPharmaceutictts caII bc uscd for this stress studyP

2.Describe thc SPECT indings and any additiOnal infOrmatiOn avallabic frOm thc cinc looP strcss and rcst proicc lmagcs. 3. List the diIFcrcntial diagnOsis. synchronizatiOn(gatingl to SPECT mヵ cardial pcrfuslon imtting. 4.List thc advantagcs ofadding ECG―

281

Notes

Cardiovascular Systenl:Breast Attenuation l.99mTc sestamibi(Cardlolitc),tetrofOsmin(Myovicwl,and not 201'「 l bccause the gall bladdcr is sccn.

Mlld nxcd defect in the antcrior wall.PrOjcction image鋭

2.

decreased uptakc in thc upper halfofthc hcart at strcss and rest in a curvilinear conaguration. ３   ４

Brcast attenuation,antcrior wali myocardial scar(infarctiOn). Assessmcnt ofrcg10nal wali mOtiOn,wall thickcning,and づCCtiOn fraction.

Reference DcPucy EG:Ardfactt in SPECT myocardial perttsiOn imaging. を 4び In DcPucy EG,Garcia EM Bcrman DS,cditOrsi C滅 又『r グ 5rと ″ 咎 cd 2,Phladelphia,2001,LPPincOttMlianls 262. るこWilkins,PP 232‐ Reference Cttss‐ 述 越 Q3慰 助 n修″″鴎 品″″α 「

F蕊 ,Cd 2,pp 67-68,73-79.

Co】mment Brcast tissuc often causes attcnuation of PhOtOns arising frOm thc hcart,rcducing the number of counts avallablc fOr image rcconstruction in that rcglon.This can icad to sPuriOus dcfccts vatting in 10cation dePcnding on thc brcast position at thc timc Of imaging.Brcast attcnuation deFects most commOnly Occur in thc antcrior and anterolateral walis but alsO are seen in the anteroscPtal and lateral walls,depending on thc location,den― vould bc sit/P and inobllity ofbreast tissuc.Brcast attcnuation、 d''dcfcct;hOwevcL with a changc in CXPCCtCd tO appcar as能a“ rest brcast position between the stress and rcst imagcs,a strcss― pattcrn can be seen that may lnirnic ischcnlla.Unprocesscd ac― q u i s i t i o n p r o , c c t i O n i m a g e d a t a s h Ovucldd tbOc crOcnviircm、 vhethcr thc brcast the presence of attcnuation and dcterinine、 rccn Strcss and rcst. has changed PositiOn bcは 内 Various interventions have bccn uscd to rninllnlzc attcnua― tion,including thc usc Of a breast binder to nattcn and hold the breasts in thc salllc PositiOn fOr bOth scans,Or ilnaging the paticnt with thc bra On to ensure silnilar pOsitioning on bOth studics.Othcrs imagc宙th the bra ott cOntending that gravity wili natten the breast(decrcasing its thickncss arld attenuation). Gatcd SPECT can help tO diIFerentiatc attcnuation cfttcts frOm myocardial infarctiOn in PatiCnts with ixcd deFects,Infarcts shOw abnOrl■ al rnOtiOn and thickcning,attcnuation dcfects have nOrmal functiOn.Note the fOcal hOt spOt sccn in thc right 10wcr cOrner on the stress pro,cctiOn imagc causcd by galiblad‐ 99mTc sestamibi and tctrofOsinin bOth havc hepatO― dcr nlling・ biliary clearancc.

282

A

DipyridamOle(Pcttantinc)scstamibi SPECT myocarditt pcrtts10n stutt Shorraxis像 りand Verdctt long_axis images(り are shO、 vn. 1 0factiOn ofdipyridamole.List foOds and rncdicat10ns that cOunteract its pharlnac010gical eFFect. 1. List the rncchanisェ 2.Describc the timing of:adiOtracer inicctiOn with respcct to dipyridamole administratiOn and the managcment of dipyridam01c sidc cnttcts. 3.Dcscribe thc SPECT imagc indings. 4.List mancuvers to deal with thc prOblem OfabdOminal(1lver and intestinal)activiけ

283

Notes

Cardiovascular Systenl:Dipyridamole′ inferior ischemia,Ovedying Bowel Activity l口E)ipyridam01c inhibits thc actiOn OfadenOsinc dcarninasc, thus incrcasing cndogcnOus adcnosinc,a potent corOnary artery vasodilatoi Coffcc,tca,carcinc_containing soft drinks or f00ds such as chOcOlatc,thcoPhyllinc,and aminophylline. 2. Dipyridamolc is inilscd fOr 4 rninutcs.Radlotracer is givcn 3 1ninutes aFtcr cOttPlctiOn Ofthe dipyridamolc infus10ne Side cffects can be revcrsed with intravcnous aminophyllinc. 3. Mild tO mOdcrare nxed deFcct Ofthc antcriOr walle Scvcrc, mOstly nxcd dcfcct inv01宙 ng thc entire inferior wall,but a sIIIall arca Ofrcvcrsibility in thc infcrOapical,apical rcgion. Dilated lcFt ventriclet 4.Obtttn dclaycd SPECT tO a1low additional hepatic cicar‐ ancc or rnovcmcnt ofbowcl activit/9 have thc Patient drink 、 vate5 or both,

Reference Rchm PK,Atkins FB,Ziessman HA,ct ali Frcquency of cx― tracardiac activity and its cgect On Tc_99m sestainibi cardiac SPECT intcrprctatiOn,助冴鴎 札 6ク物物″″ 17:851-856, 1996. ReFerence Cross― 助 ご 揚″″協 冴fあ″『 雌 沢野Qブ 暦r恥 ,ed 2,pp 66‐ 72,85,390, 392‐ 393. Comment Thc rad10pharlnaccutical is inicctCd at PcakdPyridalnOlc cgLct, which Occurs 2 to 3 Frlinutcs ttRCr completc infus10n.Reladvc contraindicatiOns to diPyridalnolc and adcnOsinc indude asthma Or brOnchOsPasdc Pulmonary discase,hypOtension,severc brad/― cardia,Or heart b10ck grcatcr than irst― degrcc.Advcrsc e3発 cts can bc trcatcd with a sio、 v intravenous inJcct10n of 125 to 250 mg OfaminOph/11ine and can bc repeated 2 1o 5 minutcsiaterif nccessatt BeCause diPyridamOleも duration of actiOn is longcr than that Of aminOphylline,a subscquent inicctiOn ofaminO― rccu■ ph/11ine may bc ncccssary ifsidc cffecほ Extracardiac subdiaphragmatic activity can causc interpretを い tiOn problclns,whcther rclatcd tO liver Or hcpatObiliary cicar_ ancc of 99mTc PcrfusiOn agents intO thc intestincs.Abdominal activit/is common on rcst Or vasodilatOr stress studies because of incrcased splanchnic distribution cOmparcd、 vith cxcrcisc strcss studies.With cxcrcise,splanchnic aow is divcrtcd to thc rnus―

act市 clはIn this stud/casc,curvilinear にd adiacCnt t。 け おn。 thc inferiOr wall,but thc ischemia can bc seen scParatC frOm bOwcl activity.HoweveL at tittcs cXtracardiac activit/may ovcr― lie the inferiOr wa11 0r cause signincant scatte5 making it dimcult or irnPOssiblC tO cvaluatc that portion Ofthe rn70Cardium.

284

A45-ycar― old wOman with hypercholestcr01cmia.И axis and a vertica1long― axis SPECT strcss myocardial pcr― ,ShOrt… 血siOn imagcs,and raw data scqucntial projection images frOm thc strcss p and rcst μ り scans. 1.Describc thc SPECT perfusion imagc indings. 2.List three reasons to rcvicw the raw data prttcctiOn imagcs. 3.PrOvide any infOrmation availabic frOm the acquisition proicctiOn images. 4. What is thc rnOst likcly diagnOsisP

285

Notes

Cardiovascular Systenl:Attenuation Caused by Change of Breast Position l.Partially reversibie pcrlus10n dcfect in the apical― d defect in thc infcrOlatcral antero,scptal wall.Mild&驚 wall.Dllatcd left ventride. 2.To detect patient motiOn,calncra malfunctiOn,or attenuatlon,

3. Dccrcascd rad10traccr in the upper portiOns Ofthc myocardium that appcars sonlcwhat difFcrent in locatiOn On the strcss and rcst proiectiOn images. 4.POsitiOn― dcpcndent breast artifact,COncOmitant ischemia . may or rnay not bc prcsen〔

Reference DcPuc/EG:Ardfacts in SPECT mン ocardial ptrfuslon imag‐ ing.In DcPucy EG,Garcia EM Berman DS,cditOrs:(物 賜'ぁ ご Cd 2,Philadclphia,2001,LiPPinCOtt 設Ecrブ 物竹 グ 宅多 262. WilliamsるこWilkins,pp 232‐ Cross‐ Reference 助 び ″ ″α r醍 択どQむ慰 力″″%冴 ′

ES)ed 「 2,PP 67-68,73-79.

Colmment Aitcnuatlon artifacts most commonly Occur in thc anterior and latcral walis,and icss OFtcn in thc antcrOscPtal walL depcnding On 10cation,sizc,dcnsit/2 and mobility Ofbreast tissuc.Thc ap― parcnt rcduccd uptake in the superlor portion ofthc heart On thc strcss prolection irnages is diITcrcnt in thc svO studies,extcnding morc infcriOrly at rest.Breast attenuation would bc cxpected to nxcd''dcfcct;hOweveL a changc in brcast position bcttten bc a“ rcst pcrtts10n stress and rcst can mimic ischcmia.Thus this strcss― PattCm could bc caused by changing attcnuation alone or may 容t mOvcmcnt.A standardized prO― bC CaLISed b/ischcrnia and bに tOcOlimprOvcs thc likcllh00d that the breasts arc in thc samc PO― c.g.,both、 SIt10n fOr bOth studics〕 vith Or bOth wlthOut bra or binding. An incrcascd incidcncc Offalse_positive stress SPECT myo― cardial PcrFus10n studies occurs in young、 vomen.This casc il― lustrates one reason.AnOthcr is prcdictcd by Bayes'theorcm. Patient grouPs with a low prctest probabilit/ofdiscasc have an incrcascd falsc‐ POsitiVe rate,whereas thosc with a high Prctcst tsc_ncgative results,Thus thc bcst likclihOod have increascd fユ use of this study fOr CAD diagnOsis is tO sclCCt paticnts at in― tcrmediatc risk.Young women with fcw risk factOrs have a low likelih00d of discase.A silnilar prObleln Occurs with othcr scrccning tcsts,C.g.,human immunOdcncicncy virus(HIVl. Scrccning Patients at risk rcsults in relatively fcw falsc_POsitiVC resuits;hOwcvctt mass scrccning results in positive mOrc fttsc‐ t h a n t Pr Ou Sc i―t i v c r e s u l t s . M y o c a r d i a l P c r f u s 1 0 n s t u d i e s a r e fOrmed nOt Only for diagnOsis,but importanti卜alsO fOr risk slratincation and Prognosis in PatiCnts with vn knO、 disease.

286

pcr―

at A62-ycar,old man with knOwn CAD had ixed dcfects with no reversibilit/On a 99mTc Pcrtts10n SPECT stu(サ E CSTh osrtturⅢ a x i s , a1 0Vncagrx― tiitct狙 C h o 1r 0i nz ago x― n it s』. a n O t h e r h .O Ts hP il st 狙i s r ea s tr e 2s 0t 1―T i s P 乳 1.Dcscribe the SPECT indings on thc initial rcst and thc 4-hOur dclayed rcst studン 2. W7hat is the clinical signincance ofthese indingsP 3. Based On the available cvidencc,should rcvascularizatiOn be cOnsideredP 4. W7hat is hibernating lnyocardiunlP

287

NOtes

Cardiovascular Systenl:201Ti viability Study rcst imagcs vshO、 extcnsivc deFcc眼 l.Initi』 (1)the antcriOr wall cxtcnding to the apex,scptunl,and antcr01atcral wall; and(2)thc inferolatcral wall extcnding to thc infcrior and lateral regiOns.Dciaycd rcst ilnagcs show sOme improvcr ment in pcrfusiOn in thc antcrior wali cxtending to the aPCX and scPtunl and anterOlateral region. 2. Therc is viablc rlyocardium in thc leFt antcriOr dcsccnding (LAD)artctt distribution. 3. Ycs. 4.ChrOnic myOcardial ischcl■ la whcre bOth b16od now and funcdOn(cOntractilityl arc rcduced.AlthOugh thc myocar― dium is宙ablc,thc lack Ofwali mOtiOn mimics infarction.

References Cant/JM Jtt Fallav01litaJA:Chronic hibcrnatiOn and chrOnic

stunning:a continuum,ノ ミ位〃物財あ θ ′7:509‐ 527,2000. Schclbcrt]HR:Mcrits and liinitations Of radiOnuclide ap― P r O a C h e s t o v i a b i l i t y a n用ガ d f働彦θ u t u′ re dcvc10pments,ノ 1(2 Pt2)iS86-96,1994. Cross―ReFerence ″′ 助 す 筋″″%妨 f″ f軍醍

沢どQじ 玉 雛 孤 ,Cd 2,P92.

Comment ') Distinguishing chrOnic ischemic(“hibernating myocardiuぷ frOm scarrcd myocardium is critical fOr apprOpriatc clinical man― ageinent.DcPending on the extcnt Ofhibcrnation,rcvasculariza― tion imprOvcs cardiac functiOn manifcstcd by imprOvcment in wali motion,LVE■

and long―terrn paticnt outcoEle,Paticnts with`Mablc"myocardium havc bctter survival frOm rcvasculari― z a t i o n t h a r l f r O m m c d i c a l m at nh a gi cn mf ca nr tc ,d TO hn O sd co 宙 nOt bcncnt from revascularizatiOn.Thcy may bc candidatcs for cardiac transplantation like paticnts with nonischcllic car―

ng candidates whOに d10myOPathies.Idcntl研 qulにcardiac trans‐ n the high cOst,risk,and morbttty of Plantation is critical giモ

cardiac transPlantation compattd COStthe andrclat推 け10Wwith

宙 dcsprcad avallability OfcOrOnary rcvascularizatiOn proccdurcs. Rcstrrest 201Tl lmaglng tt aproven altemative PETto 18F FDC― i m a g i n g . I m p r o v e d 2 0 1 T l u p t a k c O n d di an yd ec da t i mv ac g co sf お myO働 赴ialviab出 ty and the likclh00d OfimprOveIIlcnt atter revas‐ Stunned"myocardium rcfers tO myocardium that cularization.“ ― is reperttscd tter occlusiOn,cither thrOugh sPOntanCOusiy配 can組セation or commonly】託 cr angioPlastye B100d nOw is norm』 or cvcn increascd with stunning,butwali motion is decreased be‐ cause ofthc scvere ischcmic event.This sttlnneddium m/o∽ tlsu― c,usually a few wecks。 a l l y r c g a i n s t t n ct th i Od nm 胡

288

初り, 4 - h O u r d eと S t r e s s) ∽ 況 l況 a' yc のT oand カ 24-hOur pθ ttθ 初物“りPlanar 201Tl Planar images Obtained in a patient too hca、 γ fOr thc sPECT tablc. 1 . W h a t i s t h e m e c h a n i suptakc m f O at r strcss 2 0 1 T and l restP

2. W7hat is rcdistributiOnP 3. Namc the thrcc views and dcscribc thc scintigraphic andingS・ 4. List Othcr circuHIstances in which Planar ilnaging rnay bc Prcferablc tO SPECI

289

Notes

Cardiovascular Systenl:Planar 201Tl with ischenlla analoguc using the ATPasc i bchaves likc a potassiun■ l. 201,「 sOdium‐potassium pump.Almost 90%ofthallium is at extracted on arst ptts through ttc cOronary lon drcul筑 normal noM Uptake is PrOpOrtionaltO blood aoM At high

c perccnt bfthe adnlinis― now ratcs,cXtraCtion is icss.F持 tered dosc localizes in thc myocardium. 述ccllular uptakc,20rrl undergocs rcdistribution 2. AFtcr initiそ throughout the bott As 201Tl clears is the b容 u m , ■ おr e p l a c c d b y d r c u l a t i n g 2 0 1 T l , T h i sお偽r the stress redistribution imaging strateg/e COld defects sccn on early images are thc result ofdecrcased now and therc― 11 eryB Ischcmic myocardium Mた fOre decreased 201Tl del市 '。 “ in is sccn nll lゴn2,to 4-hour delaycd imagingo No nll―

80m

the

myocardト

with infarct.With sevcrc isdlemia,c.g.,hibernating 11‐ in lna/require a longer tirne,up to 24 myocardiLLnl,丘 hOllrs.

力lett anterior obliquc. 角 み 筋 :antcrio、 ,滋 3.五 を たleFt latcral;物 マ inferiOr region, Reduced radiotraccr in the infcrolatcral― hOur which Partittly normttizes on thc delayed 4‐redistribu,

にdiStributcs by 24 hours. tion imagcs and complcteけ 4. ClaustroPhObia.Sornc Patients dO nOt toleratc thc SPECT camcra,PartiCularly a multiheaded camcra.

Reference 冴″ "″ら cd 3,New York,1997, Cerson MC:《 助脇妨″ご″″孟α″物夕 McGraw"Hlll. CrOss―Reference ″ ″α r述 助 び 筋″″脇 妨ご

択どQむ 騒 rES,ed 2,pp 66‐ 68,76,79,

82. ComHlent 201Tl has a physical half― lifc of73 hours and decays by clcctrOn capture to 201Hg.Thc photons avallable for imaging are mer― bcta charactcristicrays x― in the rangc of69 cury kralpha and k‐ to 83 keV(95%abundant)and thallium galnma rays of 167 keV(10%abundano

and

135

keV(3%abundant).

Many studies havc addressca thc issues oF sensitivity and

ギ ∬ 燃 y黙 樹 鞘 縄 齢f絆浦 鞘畳

ranges frolm 600/O to 950/o,with specincity ranging frOIn 500/o to 90%.These wide variations in results rclate in part to difFer― ences in the populations studied.Spccincity rcsults arc affectcd .A rettonable csti― lon and by selectiOn bi容 by brettt attenu証

Specincity is ity for CAD is 85%to 90%,an← mate ofsensit市 many 80%的 850/o.Planar imagitt waS used島rsucccssfulけ

years to diagnOsc CAD.HowcveL SPECT is now the standard methOdolog/b TodayP 201Tl studics are more commonly Pcr, formed to evaluate for risk assessment and Prognosis.

290

PET cardiac study usingい vO different radiopharmaceuticals.ShOrt,vcrtical,and horizOntal 10ng_axis images arc shown.TOp row Ofcach sctis 13N arIImonia.The bottOm imagcs arc 18F FDG. 1. What physlo10gical paraIIleter docs the 13N aIIIInonia distribut10n rcnectP 2. Sirnilar infOrmatiOn cOuld bc Obtained using what Other clinically uscd POsitrOn

rad10pharmaceuticalP

3.Whatis thc ratiOnalc fOr thc usc Of18F FDGP 4. Describe the image nndings and intcrpret the rcsults.

291

Notes

Cardiovascular System:13N Ammonia/FDG Cardiac Viability Study l.Myocardial perfuslon. 2 . 8 2 R b . 3. FE)G is takcn up by ischcrnic rnyocardium. v s dccreased Pcrttsion in thc 4.The ttN ammoniastudy sho、 o thc proxima1 8vo thirds ofthe latcral wali extcnding〔 antcrolateral and infcrolatcral reglons.The FDG uptake is mismatched.Incrcased FDG uptakc indicating ischemia is sccn wherc thc 13N ammOnia imagcs shOw hypOPcrfu― s10n.DiagnOstic ofmyocardial viabllity(hibernating myocardium).

ReFerence Scheibcrt HR:18F dcox/glucosc and the asscssment ofmyocar― ″ハ吻〃力捻〃32:60-69,2002, 物ブ dial宙ability9酵 Reference CrOss‐ 醍 財 Q3眼 ″ ″α 軍 ハ吻び ″″″ルク冴び

孤 ,Cd 2,PP 89‐93.

Comment 13N ammonia has a physical half― life of 10 minutes,thcreforc site cyclotron is required lbr its usc in Paticnt studics.It an on‐ is rapidly taken up by the myocardium wherc it ixcs thrOugh incorporation into 13N glutaminc,82Rb has a hal,1lfe of75 scc― site.It Onds and is Obtained frOnl a 82sr/82Ru gcnerator on―is administcred with an infuslon pumP dircctly rOuted from the gencrato■This gcncrator should be rcPlaced on a lnOndlly ba‐ sis.Howcvch it iS expcnsive and a largc cardiac Paticnt V01ume cffcctivcnesso ln thc usual clinical setting is needcd lbr cost― whcrc FDG(t%of l10 minutcs)is thc only positron radio‐ Pharmaccutical avallablc,the FDG,PET imagcs must bc com― Pared with a 201Tl or 99mTc scstamibi/tetrofosmin imagc.This is a dinical sctting wherc gamma camcra PET(SPECT―PET), ded gamma camera modincd with coincidcnce u s i n g a thwcoa‐ circuitry and colllrnatOr removcd,OFFers an advantagc.A dual… isotopc study can bc obtaincd scquentially with thc Patient in the ldentical positlon. An important myocardial appllcation of18F FDG is to iden― tlけ宙able hibemtting myocardium.Arctt ofhibemtting myor cardium demonstrate dccreascd strcss and rcst Pcrttslon but in― creased FE)G uptakc,and thus perfus10n and mctabolism appcar inismatched.This occurs becausc hibcrnating inyo― cardiuln has increased FE)G uptakc becausc of the rnctabottc shitt in ischemic myocardium to glycolysis frOm thc normal utilization offrec fatt/acids in the n5nischenlic state.

292

ED

20060 C O u n t S P e r R e g t O n

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pix=164 pix=72 cnts=20062 cnts=6838

Time(ms)

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pix=239 pix=155 cnts=16703 cnts=8355

念 鮮樹も 鮒 縦 盟盤 艦:描 器播 器絆脇

鍋 鑑脳押

frames and lett ventricular timc_acti宙 ty cuttes(TACs)bcfore`砂and after c l,Discuss scquentialimagcs and the TACs.

珊紺ど 轡

2. What is thc likely diagnOsisP 3. List Featurcs that shOuld be included in rcPOrting RVG or MUGA studies.

4.List thrcc rcttons why rad10nudide ventriculography is prettrred tO echOcardiOgraphy fOr mOnitoring lett venttt lar functiOn. 293

Notes

Cardiovascular Systenl:Doxorubicin Tcxicity l,Sequential imagesの show a LVEF within nOrmalrangc. Thc ventricic appcars mildly dilatcdo EndPsystolc is imagc number 7.TACs show counts for each of 16 frames ofthc is nOHnal.Cshows dcteriOration from gated acquisition.β brOad diast01ic uPslopc and basclinc with a slowc島 EDη .Thc Pattern is com― decrcased strOke volume(ESV― Patible with ventricular dysttnction,predominantly vith thc basclinc diastolic,and dctcriOration comparcd、 d to be 500/o. studンLVEF was calculatゃ 2. Doxorubicin toxicitye

3.Quttitative assessmcnt ofcardiac chambcrs and grcat vcs‐ scis in tcrlns oFsizc and relationshiPs,regional wali motion based on revicw oFcinematic displayP and quantitative analysis(LVEF). 4.Echocardiography is Operator dcPendcnt,relies on visual estimates ofLVE■ and may nOt be technically feasible in vindぃ、 up to 300/o ofpaticnts bccausc ofPoOr acoustic、 ctors,is R V G i s r c l a t i v c l y f r c cd eopfeonPdeernatt oFra― generally reprOducibic within an institutlon and across

ndOWS・ institutions,and is not limited by acousticギ

Reference Neto S,Colcinan RE:Radionuclide vcntricular func― Borges― 務И物 3■817‐830,1993. 妨θ ′て務″ハら″ tion analysis,R″ Reference CrOss― 巡 力″″鴎 品冴″α 軍 助 す

財 Qttrtts,cd 2,P101.

Comme正 Doxorubicin chcmOtherapy is associated with a risk ofcard10ly raに Doxorubicin cardlotoxicity tはicity and cardlomyopathン occurs with cumulativc doses iess than 400 mg/1n2.Doscs in excess of 550 mg/m2reSuit in cardlotoxicity in apprOximately HoweveL somc patients can tolcrate con‐ Onc third OfPaticntS・ siderably higher doses.The larter paticnts shOuld have LVEF measured both bcforc and during cach trcatmcnt.A dccrcasc in L V E F s u g g c rs ct ls a td er du g c―a r d i o t o x i c i t y t D o x o r u b i c i n is withhcld frOm patients with baseline LVEFs bclow 30%.Thc drug usually is discontinucd ifthc LVEF dccrcascs by mOre than lo%be10w a prctreatFnCnt icvcl of 500/0.Functional recovery Ofcardiotoxicity ttRcr cessatlon ofdoxorubicin thcrapy is pooi Thisis nOw the most cOmmon indicatlon for radlonuclide vcn― triculographye Cardiac bioPsy iS an invasive alternative to ra― dlonuclide ventriculography tO detcrminc cardiotoxicit/.

294

u s u a l l y

A

廿キ ■

響 削

Transaxtal

B

‐ ￨￨￨￨￨￨￨￨￨■ ■￨￨￨￨￨￨￨ITttFIIIIIIIII■ ￨￨￨■ ■‐ A99mTc PyroPhOSPhatc study is Obtaincd tO evaluate FOr rn/OCardialinfarct in a patient with cquivOcal ECG and bOr― derlinc enzymc lcvels. 1.What infOrmatiOn shOuld bc Obtaincd bcfore the iniCCtiOnP

2.Dcscribc the scintigraphic SPECT惚 ,transverse;a cOronal)indings in this patient. 3. Give a diffcrcntial diagnOsis Ofthc scan anding・ 4.Namc another infarctravid radiOpharmaceutical.

295

Notes

Cardiac:Pyrophosphate SPECT infarct l.Thc time ofthc suspccted event.DcPending on the timc Ofthc event and whethcr chest Pain iS Ongoing,a perfu‐ 立On SPECT stuけ may bC morc approp五atc. 2. Focal abnOHnal uptakc is secn at thc left aPcx. 3.Focal apical myocardial infarct,scVerc ischeinia,ancur/Sm, focal myocalditis,focal pcricardial calcincation. 4,1111n antimyosin.

Reference Gerson MC,Lcnihan DJ:SciCCt10n of noninvasive test in the cmcrgcncy roo宜l and in thc corOnary carc unit.In Ccrson ″らcd 3,New Yo止 ,1997, 彦″″物 抗cと ML editoH arぁ ar″クす 470。 McGraw‐ Hill,pp 466‐ Reference CrOss― 肱″″Mc施 統α7コTRttQυ 暦距確じ Cd 2,PP 88-89,105‐108. 脇 す Comment 99mTc PyrOPhOSPhate accumulatcs in a rnyocardial infarction within a Fcw hours ttRcr thc acute evcnt ifthe coronary artcry is Patent,Or later ifit rcmains ocduded.Maxlmum uptake is PreS‐ ent 24 t0 72 hours aFtcr infarction.Uptakc rcmains detettabic, fOr 6 t0 10 days after the cvent.Usually no but dccreasingl乃 uptake is sccn at a site of old infarction,but occasionally in… farcts ncttly a year Old have uptake.99mTc PyrOPhOSPhatc uP‐ takc Parallels calcium dcPosition. 99mTc PyrOphOSphatc is indicated lbr Paticnts、 vith a nOndi・ agnostic ECG and cnzymc studies,Not only can it conttHn in‐ f a r c t , b u t i t a vl s o i ts sh o 1、0 c a t i o n . U P t a k c a l s o m a y o c c u r w i t h chronic ongoing ischemia,ancurysin,myocarditis,pericarditis, or amyloidosiso Simllar tO diphosPhonate bone traccrs,99mTc PyrOPhOSphatc sあns havc skclctal uptake.ThcrcfOre if a focal hot area is prcscnt becausc ofa bone abnOrlnality superirnposcd On thc heart,it ma/bc mistaken on planar scans as myocardial l in this situation and can aid lo‐ ュ uptake.SPECT can bc hclp良 calization of the abnOrmal uptake.Thc uptakc at thc fracture site also providcs thc cause for pain. Myosin,onc of the myonbrillar prOtcins,is nOt cxposed to circulating antibodies unicss thc sarcOlernlna has becn dis‐ rupted,as in cases ofinfarction.Thc lllln antim/osin uptake is highly sPecinc for myOCyte nccrosis.Positivc images may be seen 12 hours attcr inicctiOn,but optimalimages rcquirc 24 tO れc necro‐ 48 hours.In addition to lnyocardial infarctlon,myoり sis can occur in myocarditis and cardiac a1lograFt rcicCtiOn,both Ofwhich can demonstratc uPtake of 99mTc Pyrophosphatc or lllln antimyosin.

296

翻

A

ぷ既 B

TwO padents havc rad10nucllde bbod nOw imaging attcr nght upper cxtrcttt/1nlectOn, 1. Dcscribc the rOute Ofthc radiOtraccr in PatiCntИ .Givc an interpretation. 2. ｀ 前仇at are the image indings and interpretatiOn OfPatient β P 3.What radiOPharmaccudc』 s cOuld bc used ttrstudyP thお

4.What is the ttaming rate(seconds/島 ame)and minimum ttccted dose rcqdrcd t0 0btain a goOd 10w stu

297

Notes

Cardiovascular Systenl:Superior Vena Cava Obstruction lo Subclavian vcin,superior vena

cava,right

ventridc,lungs,

11丘ventricle,carotids,aOrta.Nbrmal now pattern. 2. Venous occluslon at the suPeriOr vcna cava with collateral ) now over the anterior chest,(This paticnt had lung canc∝ 3.Any 99mTc radiopharmttcutical.Ali that is needcd is 99mTc DTPA o丘 en enough activity fOr a good nOw studン is uscd bccause it is cicared rapidly by the ttdneys and can be rcPeatcd ifncccssaryt 4.1〔o3scconds/framc,うmCl or greatci

Reference Mishkin FS,Frceman LM:障 fisccllancOus applications of ra― タ 物″″″″グ dionuclidc imaging.In Frecman LM,cditor:FTeタ

,冴 物々 ″ ″ c↓ をグ ″ 筋ブ″渉θ ″ 3び ″″ ″ す θ 咎 cd 3,Philadclphia, g″ ルカ 1984,W“B Saundcrs,PP 1400-1419. Reference CrOss‐ 務″″鴎 品″″4「避 逆 QdSFES〕 助 び

ed 2,pp 48-62.

Comment Radionuclidc nOw studics can bc a raPid,Casily perforincd mcthOd for evaluat10n Of thc Patency of vcnous acccss linCS. RaPid acquisition imagcs provide a scnsitive incans for detect― subclavian,or innoHlinatc vcins. ing Obstruction of axlllar卜 This is PartiCularly important in modern mcdicinc whcn Pa― ticnts frequcntly havc central venOus acccss lines fOr infusion of various therapeutic drugs that increasc the risk ofthrOmbosis.A gOod bolus is rcquircd to IIlaxlIIlize the diagnostic information Of thc now sequencc.Although rcsolut10n is poor compared

"noninvas市 c dynamic with a contrast stuttP00r thS“ ma品

vascular srudy can prOvidc vttuable diagnostic information. Radlonuclidc blood now studies cornrnonly arc usca to Stuけ a Variety ofarterial and vcnOus abnormalities,A vascular s e q u c n c e i s p e r f o r m c d r Po hu at si en e bl oy n ef o sr c at nh sr c tc o‐ diagnose Ostcomyelitis or to cstimatc thc agc ofa stress fracture. Flow studies are pttrfOrmcd in association with rcnOgraphy tO assess renal artcrial blood nowP c.g.,tO diagnose rcnal artcry tadnnte yr づ v i a b i l i t y e W i t h s t e n o s i s , a c u t c c tc rt ai nOrsn P,tl。 occasionally the site ofincrcascd gastrointcstinal biceding studン

a

om the now studywhen there is no v a s c u l a r i t yに ccatnC db cf rⅢ cvidencc Of acti(bleeding,c.g.,anglodysPlasi4.With HIDA llnaging,increased blood nOw sometimes can bc scen in thc re― glon ofthe gallbladdcr fossa with acute cholecystitis.

B

A N T

料増増理性Ｗ

LLT Venttlatton A62-ycar―

old Paticnt with rightrsided chest discOmfOrt and shOrtncss Ofbreath.乳

POsterOantcrior chest radlograph;

β,PcrfusiOni c ventilatiOn. 1. Dcscribe the ventilation perfus10n image nndings. 2. Intcrprct the study.Givc your reasoning. 3. W7hat is the likelih00d OfPulinOnary embolus in this PatientP 4. ヽ7hat arc thc lnOst cOInlnOn chcst x_ray indings in PatientS With PullnOnary cmb01lP 299

Notes

Puimonary System:High Probability of TBonary Embolus Pul「 l,Perttslon detretted right 10wer lobc cxccPt fOr the superior

trunCated scgmeni Ventilatbtt nOmtt cxccPt ttr mildけ . ettsio早 right iowcr lobe consistcnt with subPuimonた

2.High Probabilit/ofpuimOnary cmb01us.Mismatch bcwcen Pcrfus10n and vcntilat10n in thc basal scgmcnts. The pcrfusiOn defect is considerably largcr than thc plcural cFFuslon on the radlograph. 3. Greater than 80%. ost coHllnOn:horlnal.Ncxt rnost coHllnon:atclectasis. 4. 1五 Thcsc arc also the rnOst cornlnon xPrary indings in Patients

detcrmined by anttography not to have emb011. References FreitasJE,SarOsi MG,Nagle CC,ct al:Modined PIoPED cri‐

%グ 36:1573-1578, ブ ミほど teria uscd in clinical practice,メ 1995.

Juni J,Alavi A:Lung scanning in the diagnosis of puimonary ″A物冴鴎 棋21:281embollsm:thc emperOr rcdressed,レ 物ガ 296,1991.

CrOss,Reference f五″ど延 QyrSr「 こs〕ed 2,pp 150-161, A物孟住″ル物冴″″夕 Comment The criterion that a Perfuslon defect largcr than the radio‐ graphic abnormality is high Probability by PIOPED dcinition should be used cautiouslyt Thc chcst radlograph is obtaincd with maximalinsPiration.Thc lung scan image is acquired dur‐ ing tidal breathing.Thus the heart is mOre horizontal on the lung scan than thc rad10graph,and the lllng flelds appcar sn■ aller on thc lung scan than the radlograph.HowcvcL in this casc thc Pcrfus10n defcct is deflnitcly larger than thc radloっ

ent only the aPPⅢ No ventilatory arc dcfccほ graphic anding・ 10wer lung ncld is truncatcd. 征cra than g陀 80% AP■ icnt With a high,PrObabllity scall htt fcwer than half PrObability of pulmOnary cinbolus.Howcvcら

Of Patients dctcrinined to have pulinOnary cmb01us by angi― ograPhy have a high,Probability scan.Thus a high,Probability scan is not scnsitivc for thc diagnOsis of pulrnonary cmbolus,

20%of so means th証 thiS』 but it is ttirly specinc.conversc転 PatiC n t s h a v e a r l o t h c r d i a g n o s i s . T h c m o st common causeisillng cancci A m c d i a s t i n a l m m o r O f t c n p r c f e r c n tially occludes the pulmon a r y v c s s e l s , w h i c h a r e c a s i l y c O m p r cssibic in contrast to

rttd bronchi.01d cmb01lare ttothcr common causc thc moに Of a false,positivc study for puimOnary cmbolus.Vasculitis or siよle ccll discasc arc othcr iess common causes.

300

Aう 9-ycar-01d Patient with COPD cOmplains Ofright_sidcd chcst discOmfOrt and shOrtness Ofbreath. え PostcrOanterior chest radiOgraph;ヱ 払latcral chesti c;perfus10n;つ ,vcntilatiOn. 1. Describe thc ventilation_Pcrfusion image indings. 2. Intcrprct thc studys 3. W7hat is a stripe sign and、 vhat is its signincanccP 4. W7hat is the phys1010gical basis Ofa stripc signP

301

Notes

Pul「TBonary Systenl:Stripe Sign l.Dec:ctted Perfuslon in the right uppcr lobc(apiCtt and anterior segments).Stripe sign ofthc posterlor scgmcnt of the nght upper 10beo NOrmtt ventilation. 2.Two scgmenttt mismttchcs,High Probabllity ofpul― monary embolus. 3. Its Presence signines Perfused lung tissue berwccn a pcrfu― siOn defect and the adiaCent pleural surfacc.Its presencc

can be uscd to classitt a Segment as not related to pul, monary cmbolus,and in some cases,10wer thc Probability Ofa scan frOm intcrHlcdiate to 性 lo、 4.Usually a manifestation ofairway obstruction.The sign has bcen cOrrclated with CT and PET showing sparcd Per― fuslon Ofthe cortcx ofthc lung in asthma and emphySema.

ReFerences Freitas JE,SarosilMG,Nagle CC,ct al:Modincd PIoPED cri―

嵐36:1573-1578,1995. te五 a llsed in dinical筋ガ瞳 practlce,メ e validation ofthe stripe Sosman HD,GottschalkA Prospect市 賜 '0牝ノ184455sign in ventilatbn,PerttSbn scindgrap町 459,1992. Cttss‐Reference 避 あα 『 対加物 ″%冴 び

財 Qyrs/「 ES,cd 2,P160.

Comment

ilatbn_pcrttslon stud‐ The stripe sign is 5%ofvcn〔 seen in onけ be 1磯TO be dcnned tt a stripe sign,thc to inding needs onけ seen in onc PrOjectiOn.It is an anclllary sign that in somc cases helps 10wer thc prObability frOm intermediate to low probabil‐ uating ity.Thc stripe sign only is useful for cv』 the scgment in question,The sign is not totally specinc for nonembolic causar tion.It alsO call be seen in areas of repcrfuscd iung previOusly Obstructed by cmboll. The na[ural history of pulELOnary embollsm is ciot frag― l o n i n t h e s ir di cg h o〔f t h c h e a r t , w h i c h i n d u c e s m u l d ― ment筑 vessel scgmental cmb01lzation of thc PulinOnary vasculature with Prcservation ofscgmcntal vcntilatiOn.Most cmboll occur in the 10wer lobcs and havc a randorll distribution.Evidence against pullnOnary clnbolus in this casc is thc fact that thc ab… normal perfusion is limited lo adiaCCnt upper lobc segmcnts is .Thus even though thtt nnding mightindicate a htth… unuSu狙 probability scan by establishcd criteria,[his Pattern is atypical. Publishcd data alsc havc suggested that thc specincity fbr pul― monary embolus is lmaxiHllzed in Patients with cardlopul… monar/discasc ifthree segmcntal mismatches arc PreSent.ThLls

itwould notbe incorrect to classittthiS Studyas indeterminate or intcrmediatc probability.

A ventilation,perfusion lung scan is ordered fOr increasing shOrtness ofbreath.Chest radiOgraph(nOtshOwn)indingS

wcrc negatlve.

1. Dcscribc the scintigraphic indings ott Pcrfus10n,anterior attd ,133xc POsteriOr Only;β Mshin_washout ventilation imagcsequcncα C CT). ア 2.What pulttOnary embolus prObabilit/categoリ would you assignP de the differential diagnOsls. 3. PrOvェ 4.A chcst CT was PcrfOrmed tO ttrthcr evaluate fOr 札at the symptOms.Ⅵ is the mOst likcly diagnOsisP

303

Notes

Pulrrlonary Systenl:Unilateral Matched Ventilation―Perfusion Abnorgrlality l.Pcrfusion imagtt globtt dccrcascd pcrfusion to thc cntirc lett lung,Inore strittng than the ventilatiOn.133xc ventila‐ tion imagcs:dccreasttd and dclaycd vcntilatiOn Ofthc ages show no sighincant air cntirc lcft lung.WashOut il■ trapping. 2. Low probability. 3.Hllar mass(lung canccr or adcnOpathyl,scvcre unilater狙

JaHles syndromc, ParCnChymal lung disease,Swyer― hypoPlasdc PullnOnary artcr/2 Pr10r shunt FOr cOngenital heart diseasc. 4. Lung cance丘

ReFerence ″ち ed 3,St Louis,1995, 況,c″ ″″クビ ル″″物を Datz FL:6功 物″打 ″ Mosbン pp 188-189. Cross―Reference α『 配 揚″″Mcあ ct″ 助 び 157。

択野Q3蕊

孤 ,Cd 2,pp 147‐ 148,154-

Comment Lung cancer and hilar adenopathy can result in PcrttlSlon de… fccts disproportionate to vcntilatiOn.Thisisthc mOst common

c high prObabil,ventilation― causc for a POdt市 Falsc― perfus10n stuⅢAhigh,prObability ventilation― perttsiOn scan htt an 80% cmbolus.Thc other POSitiVe predictive value forOnary pull■ a t c d t o h i l a r 2 0 % m u s t h a v c a n O t h c ro rciatuys ca.rTch cr emlづ masscs.A Proximal puimonary emb01us may manifest as a uni― lateral,wholelung mismatch;howcveh thc latter shOuld always rttse thc qucstion OftumOi An casy Hlemory device is to think Ofthc mass as abutting dle hilar structurcs.Thcwalled thin‐vcs‐ sels(veins and arterics)are rclativcly cOmprcssiblc compared wallcd bronchi;thus ventilation is relativcly pre― with the thick‐ served comPared with perfus10n.A300d POstcrOantcrior and laにrtt Chest radiograph usuttly narrOws the dittrent』 ,and if stud/is not,the qucstion can bc resolved by CI Pathologic』 needcd to ensure the correct diagnOsis. Swycrづames SyndrOmc,a variant of POstinfcctiOus oblitcra‐ t市e brOnch101itis,sharcs somc common radlograPhic fcatures in‐ with congenital unilateral absencc of thc PullnOnary artcrン 1lllng manifcstcd by cardiac and mcdittdntt shi丘 , duding asmぶ absencc ofpullnOnary arterial shadowj elevation Ofthe hcmidiコ aPhragm,and a decrease in pulmOnar/vcssCIS On thc afFccted

aFneS Syndrome,caused by brOnchlo, lungwith oligcmiao Swcrづ litis,is associated with air trapping which can bc documcntcd by an exPiratiOn radiograph or a 133xc vcntilatiOn scan.

304

￨■￨十 ギ ■■ 晋■ ! ■■!￨!ギ 1料 bumin(MAAlstuⅢ A3-year― old child was referred for a 99mTc macrOaggregatcd』 l. Dcscribc the scintigraphic indings. 2. What is the diagnosisP mechanism Ofuptakc. 3.Describe thc radiOPharmaccuticalも 4.What are cOntraindcadons tO ths studyP

NOtes

Pulrnonary Systenl:Right_to口 Left Shunt Demonstrated by 99mTt M触 1.Uptake ofthe radiOtraccr in the brain,lungs,kidneys,and livei

2.斑 ght_tO_lctt shunt. ▼hcn m Caplllary sizc.ヽ 3.99mTc MAA Partides arc largcr thを

thc particles occludc thc arst arteriolar, glvcn intravenousけ c a p i l l a r y b c d t h c転yt hree alcuhn gnSo.rWmi』 th a right, tO_lcFt shunt,some will byPass the lungs and be dclivcred systeHlically in prOportion tO thc sizc Ofthe shunt. 4. Rclativc cOntraindicatiOns includc Pregnancyj scvcrC Pul― monary hyPcrtenslon,and right― tO― lett shunt.Therc a陀 nO absolute cOntralndicatiOns.

Reference グ す Treves tt Packard AB:Lungs.In Traves tt editoH Pctta″ 冴び ″ ″らed 2,NcwYork,1995,SPringcr‐Vcrlag,PP ″″並毬″物夕 168‐190. Cross― ReFerence α r醍 沢野Q3眼 対務ど 捻″″Mctttct″

孤 ,cd 2,PP 145‐161,

Comment

This ctte study was ttqucstcd fOr a child knOwrlto havc a nght‐ tO_lettshunt to quantittthe SiZe ofthc shunt.Quantincation of l Ctt Shunt can bc cstimatcd 夢 byonS drawingに Ofin― a right― tO― tcrest on computcrizcd data tO dctcrminc the percent ofthc tO― t a l a cotuitvSけi d c t h c l u n g n e l d . I n t h i s c a s e , t h c culatcd tO bc 20%. 30 Particic size range of99mTc MAA is 10 1s 90m(mean μ mo The particles Ocdude Only t040 μm)。CaPillary sizc is 7卜 1/1000 to 1/10,000 ofthc arteriolar caplllary bcd.PullnOnary infarction docs not occur becausc ofthc dual circulatiOn Ofthe lung,and thc naturc ofthe partidcs.Thc Partidcs arc mallcable, causc Partia1 0CCluslons,and break dOwn rapidly into smaller PartiCles tha[ptts thrOugh the lungs.Thc direct tteCtiOn of 99mTc MAA PartiCles intO thc carOtid artery has bccn done ex― periment』ly in humans to maP cerebral perfusion without sc‐ rlous adverse arect.In a patient with known severe pulinOnary tt shunt,the usutt apprOach wOuld h y p e r t t n s l o n , o r a troi-glheぃ m b e t O r c d u c c t h e n u m b e r O f 9 9 m T c M A A P aA r tm i Cn Ii Cm Su ・ Of60,000 particles is required tO PrOvidC adequate unifOrttlityj and 100,000 or more are usually rccOlmmended.A perttslon h益 300,000 to 400,000 PartiCICS.To maximセ c study gcncralけ thc cOunt rate with a reduced numbcr of Particles,a high― SPeCinc activit/99mTc PcrtcChnctatc is required.

306

shunt

was

cal―

A5う ryear-01d Paticntwith a rcmOte histOry OfthrOmbOPhiebitis in the lett thigh has recurrcnt simllar A FolcyPain・ catheter is in Place.

1.Whatおthe ra胡 opharmaceutical and sdndgraphic stuⅢ P 2. W7hat is S iモ rneChanis■ 1 0fuptakcP 3. N7hat are thc scintigraPhic andingsP 4. ｀ 商hat are its clinical indicatiOnsP

307

Notes

Thrombophiebitis:AcuTect(99mTC apcitide) 1.Radlonuclide vcnOgram with AcuTcct(99mTc aPcitidc).

_ thc」 AcuTcctお a synthedc Pcpdde that binds to ycopr。 tcin GPIIB/111a reccPtOrs On thc surfacc ofactivatcd Platelets. Increascd uptakc in the leFt deep venOus systcm cxtcnding 島Om thc proximal tO distal thigh cOnsistcnt with acutc accP venous thrOmbOphicbitis.DifFusc incrcascd uptakc is seen throughOut thc soft tissue ofthc lcft 10wcr cxtrcrnitye 4.

01d inac― Tb diffcrcntiatc acute thrombOPhicbitis frOn■ tive thrombOphicbitis.It alsO can be used to diagnOsc acute thrombOphicbitis when DoPPler ultrasOnOgraphy ls nondiagnOstic.

Reference Tailllfer R,Edcll S,Innes G,ct al:Acutc thrombOscintig:aphy with(99mTc)― apcitidc:rcsults of thc phase 3 multiccntcr aPcitide scintigraphy with clinical trial comparing 99mTc― Muiticenter contrast vcnograPhy lor imaging acutc“RDヽ

1223,2000. trial invcstigators,ノ Aあ冴鴎 札41:1214‐ CrOss‐Reference 助 n修″″Mc沈,ct″ ′ f TF/f貫野Qど 蕊 恥 ,Cd 2,PP 163-16う 。

CoIIIment Acutc dcep venous thrombOphlcbitis is a conllnOn problcm and the sOurcc of most pulmonary cmbOli.Approximately 500/o of paticnts with acutc thrOmbophlebitis dcvcloP 10ng term sequclac,such as thc POstphiebitic syndromc,Clinical his― tory and cxttIIlination are notoriously unrcllabie fOr diagnOs_ ing thrOmbOphicbitis. Although cOntrast venography arguably is considcrcd the “ 301d Standard''for diagnosis ofdccp venous thrOmbOphicbitis, this invasive proccdurc is n0 1onger commonly pcrfOrmcd fOr numerous rcasons.DuPlex ultrasOnOgraphywith DopPicris thc standard diagnOstic lnodalitye HOwcveL in inany paticnts,the methOd is nOndiagnOstic,c.g.,in the setting of PostOperative trauma,casts,and obcsitye Partial obstructions to now may bc

misscd,ImpOrtantけ it oftCn cannOt difFerentiatc ncw frOm 01d thrOmbOphiebitis. With thrOmbus fOrmation,Platclcts rcccivc humOral signals that causc activation and aggrcgation.The latter is dcPcndcnt on the GPIIb/111a rcccptors exPressed On activated Piatelets, AcuTcct binds to thcsc rctcptOrs.Becausc AcuTcct binds to ac― tivated Platclcts Onlン thc study dctccts aCutC but not chrOnic thrOmbOphlebitis.Aspirin and hcparin therapy do nOt sccm to adverscly arcct its accuracy.

308

A56…ycar_01d Paraplcgic PatiCnt has fever Ofuncertain origin.No localizing signs or symptoIIIs arc Present. this Iも purPOseP 1. N7hich radiOpharin4ccutical was uscdP W7hat Others cOuld ber used cs thc highcst radadOn absorbcd doscP Esdmatc the dose. 2,mich organ recc持

P 3.matお your htettretaton ofths bOdyscan whdc― ωand peMcspotの lifeP is its half― 4. W7hat is thc PhOtOpcak(s)Ofthe rad10nuclide usedP W7hat

309

Notes

YlatiOn:11lin Oxine infection and inflanl「 一 WBCs― Right ileum oSteomyelitis l.11lln oxinc or99mTc HM,PA0 1cukO甲 cs.67Ga could alsO be llsed.Thc intcnse sPicen uptake is cOnsistent with a radiola―

ぃcd.Thc bd胡にuko雫 並utt Httn ttncに ukowes wに imagc rcsolutiOnおPoor comparcd wlth 99mTc leukOwcs. 2, SPlecn,apprOxllnately 15 to 20 rads. 3.Abnormal focal uptake in right grOin(there has bccn a 島mOr』 linc)and in the五 ght lcum,hdicating oStCOmyclitis. 4. 173,247ぎ

lifc is 77 hours. 、Ph/sical half―

References KipPcr SL:Radiolabeled icukOcytc imaging of thc abdOmcn. 筋″″物cttc,″ 夕″″″″ ″′止 In Frccman M,cditOnか あび 環 るゝNcw York,1995,Raven Press,PP 81-128, COlcman RE,Datz FL:Detection ofinnammatory discasc us‐ ing radiolabcled cells.In Sandlcr M,Coleman RE,editori

五ル々g牧打力 %″び 彦″″物じ 品 ″らBaltimOrc,Md,1996,Williams 能 Wilkins. Cross― Reference 揚″″%冴 び ″ ″夕 f「醍 沢どQむ慰 Ftt.Cd 2,PP 177-190. 脇 す Comment secking radiOPharmaccuti… Ch00sing thc aPPrOpriate infectiOn― cal in a particular clinical setting rcquircs wcighing of the ad, vantages and disadvantages ofeach.67Ga dctects tumor and in― f c c t i O n ; t h c r c f O r c i t c a n b c u s c f u l f O r p a t i c n t s unknowII Origin.Radlolabeled icukOcytes arc prcFerablc if in‐ fectiOn 10calizatiOn is the clinical questiOn.Both require cell la― vith thc POtcntial PrOb‐ beling,a[least a 2-hour prOccdurc and、 lem Ofb100d― bOrnc discasc.99mTc HM‐PAO leukocytes PE蕊de bcttcr irnagc quality because ofthe 99mTc radi01abcl and largcr adHlinistered dose,but have thc disadvantagc of clcarancc thttugh thc ttdncys and blliary system,interttring wlth intra― abdOminal visualizatiOn.Abdominalirnaging by l t0 2 hours, befOrc intraabdonlinal cicarancc,obviates this Problem.11lln oxine is not dcared intraabdorninally and thus is PreFerable for intraabdominal infection.Otherwisc thc distributiOn is similar to sPleen,liveL and bOne marroヽ ほ Image quality is 10wer with lllln oxinc bccause of the 10wer administered dosc(500卜 Ci versus 10 mCittr99mTc HM― PAO),highcr cncrg/PhotoPcaks

colllmatOi (173,247 kcヽ 0,and thc nccd for a energy mcdium― lmagcs arc usually obtained at 24 hOurs. 11町 nO対 ne dittses thrOugh thc ncutrophi celi membranc. Intracellularly it dissOciates and the lllln binds tO intraccllular protcins,whcrcas oxine difFuses back out Of the cell.In addi― tion to labeling leukocytcs(granulocytcs,1/mphocytes,mono― cytes),crythroc/tes and Plateicts are labeled.Red bloOd cells and Platelets are removcd with scdil■ cntation and scttling agents carly in thc labcling prOccdurc. 310

w i t h

f c v c r

O f

C

ソ 4,99mTc MDP A67-ycar―old Paticnt has 10w― gradc Fcvctt back Pain,and susPcctcd OSteOmyclitis Ofthe lumbar sPine・ bOne sca既ュ 11lln Oxinc lcukocyte study;and c Ga-67 studン Ncgat持e ranograph・ 1. Dcscribe the scintigraphic andingS ofthesc three studics. 2.Whatる thc hfferend狙 品agnosおofthc lllln study aloncP 3. W7hat is your interprctation ofthc thrcc studiesP 4.mat

is

t h en e fg a lt si cv ― e ratc

for

lllln

oxinc

leukocytc

studies

for

311

vcrtcbra1

Notes

infection and inflarn「nation:Osteomyelitis of the Spine l. BOnc scan shows incrcascd uptake Ofthc Tll vertebrac. 11lln oxinc lcuko呼 c study shows decrcascd uptakc in the samc rcglon.67ca ShOws increased uptakc that matchcs thc bOne scan in rclativc intensity. 2.Osteomyclitis,fracturc,infarctiOn,metastasis,OrthOpedic hardware,surgical dcfect,10calized radiation therapン mye10nbrOsis,Pagctもdiseasc. 3. Ostcomyclitis in this dinical sctting.Many ofthc diseases listcd can be excludcd by hisiory and radlographs, 4.As high as 40%。

Reference PalcstrO CJ,Km cK,SwyerAJ,ct』 :Radbnudidc diagnOsis of vertebral osteOmyelitis:indium‐111-leukocytc and Tc-99m

MDP scintigraphttsN悦 〃鴎 嵐32:1861-1865,1991. Cttss,Reference ″α 「 配 対務す ″″″姥 グル″

越 Q3唖

孤 )Cd 2,p189.

Co】mment Vertebr』 ostcom/elitis usu』け Occuttin adults and is mOst com― mOnly in thc lumbar sPinC,f0110wcd by thoracic and ccrvical locatiOns.Sヵクリ あ切何冴 ″″″舛 iS the most cOmmon causativc

organism.PredisPosing COnditions includc urinary tract infec― and tlon and instrumcntatlon,lntravenous drug abusc,canccち diabctcs lncllitus,Plain radiographs arc nOt sensitivc and Hlay bc nonspccinc lor thc diagnOsis in nonvirgin bOne.C)steo― Hlyelitis Originatcs as a septic cmbolus that 10dges in an cnd

arteriolc of thc vertebr』 bo(けThc cmb01us prOPagatcs rctro― ntially arOund the bOtt vertebr』 oCCluding 蛇 grade and circum島 Other arteries and causing scPtic infarctiOn and osteomyelitis. Radiolabcled icukOcyte studics havc a high accuracy fOr di― agnosis ofosteomyclitis exccPt in the sPine.Thc rcasOn for de, creased rather than incrcascd uptake Oficukocytes with vertc― mmon bral osteOmyclitis has nOt been wcll cxPlained,butis a co」 anding(phOtopcnia comparcd with attacent VCrtebras).Thc for Os― cause may bc concOmitant infarctiOn.17Ga is sensitilに teomyelitis but is nOt sPecinc bccausc uptake can vhen― be scen、 ever bOne rcmodeling occurs fOr any reason,c.g。 ,prior trauma vare,Thc 67Ga study rcsult is in‐ Or infcctiOn,orthoPedic hard、 tcrprcted as PositiVC ifthe uptakc is grcatcr than thc bOnc scan or in a diffcrent distributlon.In this case the 67Ga uptakc is equal tO bOnc;hOwevcL in thc presencc of a nOrrnalrayP x― the

bone scan ttoncお highけ s uSpiClous ttr Osteomyelids,which is further indicatcd by thc 67Ga scan.

312

⋮ 一■ 一 一■ 十 ≡≡ ■・ ■一 転・ ■・ ■ 鮎・ ■ ■ ■一 ぶ

1 句‐ ￨"‐ ￨￨"￨ ゑ上￨

lymphoma.TumOr inv01vcment Oflumbar vertcbral bodies rcquired rcscc― A64-year_01d wOman has nOn― Itlodgkinも veeks aftcr surgcryt tion and fusion.Pain and 10w― grade fevcr werc notcd 12、 l,Describc thc FDG―PET andingS・ 2. Give your intcrpretation. 3 . C a n i n f e c t i O n h a v c i n c r e a s c d F D前 G r hu yp Pt a k e P ｀ 4. W7hat is thc cncrgy phOtOpeak of18FP N7hat is thc PhOtOpcak OfllC,13N,150P

Notes

lnftarrBrrlation and infection: FDG一 PET‐Paraspinal infection l. Intensc uptake inv01ving the rctrOpcritoncunl anterior to the rccent lumbar fusiOn surgcry.Notc the sPinal fusiOn sitc on thc 10wer right hand POsteriOr corontt images. 2.Consistent with POstOpCrativc inttctiOn.AlthOugh this

could be tumOL CT showcd bilateral hcterOgenous and cnlarged PsOtt musdes thOught likcly to bc duc to absccss Or hematOma。 (Subscqucndy prOved by b10Psy to bc infec― tion,nOttumo丘

)

3.Ycs.Leukocytcs and macrOphages utillze ttucoSC. 4. All positrOn enlitters have a 51 1‐ ,18■ kcV photOpeak,1.e。 1lc,13N,150.

ReFerences Bakhect SM,Powe J:Benign causes of 18-FDG uptake On whOlc bOdy imaging,最 物ブ ″ソ 協 〃〃 レ グ28:352-358,1998.

S u g a w a r a L Z a s a d n yK iKsRO〕n P M c t a l i S p l c n i c F D G u p t a k c by granulocyte colony― stimulating ttctOr therapr PET im‐

aging rcsults,ノ ハル〃鴎 札40:1456‐ 1462,1999. Cross‐ Reference 配 脇 び 務″″Л々冴ど ブ ″α 「

貿どQSN孤

,ed 2,PP 205-214.

Comment lncrcased FDG uptake Occurs not only with tumOrs,but alsO

with innalnmation and inttctiOn.Gencralけ uptake with tumOrs is highcr than with infectiOn, but ovcrlaP cxistS・ Subacute, chrOnic,and indOlcnt infcctiOns tcnd tO havc 10w_gradc uptakc; hOwevett at tilnes,uptake is high and indistinguishable frOm tumOL Acute infcctiOns,as in this casc,ma/have intense uptake. FDG uptakc htt beenに POrtcd with arthritis,thyroiditis,sinu‐ sitis, herpcs cnccPhalitis, radiation PneumOnitis, mastitis, cmpyema,ginglvitis,alveolitis,PncumOnia,sarcoidosis,tubcrcu― 10sis,容 pergillosお ,Ы 岱的 m/codS,hお

tOplaslnOsis,and hお

tOttOsお .

S c n s i土t/ 的 tcction ofthcsc infectiOns is unknown. f O rに と POsitrOn decay occurs in nuclides that arc neutron PoOr. Whcn a POsitrOn(positive elcctrOn)is ciCCted frOm thc nudcus, it 10scs its kinetic cncrg/and interacts hwi〔 an clcctrOn. Annihilation OfbOth particlcs occurs and they are convcrtcd to energ/9酎も511-keV photOns enlittcd 180 dcgrecs apart,Thesc simultancOusly cmittcd PhOtOns are dctcctcd by thc cOincidence circuitry ofPET cameras. Granu10cytc― stilnulating factor is a hOrinOne that regulates Pr01lferatiOn and differentiation of granulocytc Precursors. Human c010ny,stimulating l五 ctO島produced by rccOmbinant DNA techn010g/9is a drug uscd to reducc the chcmOtheraPy― induced ncutrOpcnia often sccn in canccr paticnts.Incrcased bonc marrOw FDG uptakc Often is scen in patients rccciving this drug.

314

Right LAT

Right

ノ附

Left MED

Left MED

Rule out infectさ d right knec PrOSthesis.Radiograph(ク リ. 1 . D c s c r i b c t h e t h r e e ―P h a s e b O n c s c a n i n d i n g s . ユ

Flow;C immcdiate物

あθう り blood P001 and delayed移

″あθ″ and 99mTc sulttr c01101d study ω. 2.Dcs c r i b c t h c 9 9m T c H M , P A 0 1 c u k O c y t c s tudyの ウ あり 3.Wha t i s t h e p u rP O s e o f t h e 9 9 m T c s u l f u r c01101d studyP

4.Interpret the stu与

″' o ガ i m a g C S .

Notes

infection and inflarrlrnation:Knee ーRule Out infection Arthroplastyロ l.Incrcttcd blood nOw to the right knec. 2. Incrcased uptakc in thc PrOxirnal tibia On bOth. 3.Serves as a tcmplatc fOr nOrmal marrOw distributlon. 4.Negative for infected prosthcsis.

ReFerences PalestrO CJ,SWyer可

,Km CK,ct tt lnttctcd knee prOsthesis:

diagnOsis with ln-11l leukocyte,Tc_99m SC and Tc-99m MDP imaging,娩 渉θ 沈 町ッ179:645-648,1991. Elgazzar AH,Abdel― Daycm M:Imaging skeletal infectiOns: cv01ving considcratiOns.In Frecttan M,editon 並駐 Aあ″物琢 み ,ご う %″″″%″″′Ftt PhiladclPhia,1999,LiPPinCOtt Williams 能 Wilkins. ReFerence Cross‐ ″ ″′ f軍醍 助 す 彦″″%冴 び

ズどQdN 「 ES,ed 2,PP 177-190.

Co】mment Thc r01c Of99mTc MDP bone scanning in the diagnOsis oftO― tal kncc arthoPiasty infcctiOn is lilnitcd becausc Of Pcrsistcnt pcriprOsthetic uptake Of radiOtracer fOr inanン yearS atter PrOs― thctic ilnPlantatiOn.Thc intcnsity ofpcriprosthctic uptakc can‐ nOt be uscd tO difに rcntiatc infcctcd frOm uninfected PrOsthesis. Radlolabclcd icuko。 たc studies,whether llllnneO対 or 99mTc HM― PAO,arc scnsitivc fOr thc diagnOsis Of infected prOsthc_ scs,HoweveL sPccincit/is a problem because implantatiOn of an orthOpcdic prOsthcsis prOduccs altcratiOns in thc distribu― Thc distributiOn Of radiOlabclcd icukO, tion of bonc rnarrN、 eS in a nOninfected knec is sirnilar tO that scen with 99mTc 呼 SC.Thus rcgions Ofincrcascd marrOw ma/cXiSt that could bc interpreted as infectiOn with a lcukOcytc_Onlybut stud卜 when ― comparcd with a bOne marrow stutt the pattemおthat Of狙 tcにd dist五 budOn,not httctiOn.AlthOugh marrOw is oRcn nOt cs Ofthc kncc,Onc study OfPadents presentin the nomal bO■ with kncc PrOSthCscs IOund nOrinal marrOw in 500/o of nOnin_ fectcd knccs.mcn infcctiOn is scvcrC,thc marrow scan may shOw decreased uptake at the site OfinfectiOn.Thc radi01abcled icukOcytc study should be pcrfOrmcd flrst.If nO increased ity馬宙立ble,a marrOw studyお nOt nceded. PCrlProsthctic act市 The cOmЫ n e d l e u k o c my at re r―o w s t u d / h a s p r O v e d P a r t i C u l a r i / valuablc fOr hip prOsthcscs.

316

A34-ycar―Old woIIlan With rcccntly diagnOscd H[odgkin's discasc Presenting as a left neck lrlass.Two 18F FDGrPET scans were performcd 3 days apart. l of uptakc Ofthis rad10pharrllaccuticalP 14 Wマ hat is thc lncchanis■

ain how thcαstudy codd havc changed cxが 2.Dcscttbc the indings Ofthc irst study rtt and )and the secOnd study so dralnatically in Only 3 days. 13N,1lCP 止fe Of18FP 150〕 3。Whatis the half― 4. W7hat is the radiatiOn dOSC to the target organP N7hat Other Organs have high uptakcP

Notes

Oncology:FDG一 Hodgkin's Disease and Muscle Tension Artifact l. FE)G is a glucOsc analoguc.Incrcascd FDG uptakc Occurs with increased glucose mctabolism.It is takcn uP intracel― lularly and PhOsphOrylated simllar tO glucOsc howeve与 unlike glucOse,it cannot be mctab01ized furthcr and is intraccllularly trappcd. 2.4 1ntense multifOcal uptake bllatcrally in the neck,upPcr chcst,and parasPinal rcgions,a Uptake limitcd tO lcFt ncck.StudyИabnOrmalidcs are causcd by musclc tenslon.

DttepaHl,5 mg,was taken just bcttrc studyユ 3.ApprOximatcly l10 minutcs.2,10,and 20 minutcs.It is important to remember that the half-lives Ofmany POSitrOns arc vcr/short. 4. 3.2 rads/5 rnCi to the urinary bladdc■ Brain and hcart.

Reference Shrevc PD,Anzai L Wahi RL:PitFalis in Onc01oglcal diagnOsis with FE)G PET imagingi physio10gic and bcnign variants, 勉沈 う 0抑 力ね 19:61-77,1999. Cttss―Reference ハ吻す 力″″脇 冴び ″ ″4軍 醍

財 Qd嘘

孤 ,Cd 2,PP 207-209.

Comment Bccause FDG wh01c_bOdy uptakcお a PhysbLttc】 map Ofrcl― ativc glucose metabolism,strcnuous exercisc Or musclc tenslon can result in uptakc.Normal physi010gical uptake can be sccn in laryngcal musclcs in PaticntWhO talktter

iniectiOn.Rclativc

distributiOn in the brain varies dcPending on whcthcr the pa― eycs are oPCn Or closed or whethcr thc Patient is listening ticntも to rnusic or thc roOm is quict. FDG distribution is nOt rclatcd Only to glucosc metabollsm. Unlike glucOsc,FDG is nOrmally excrctcd by the ttdneys intO

t h e b l a d d e i H ouwccOvScuLr」 i a i s n,ootc cnuorrrmi狙 ng only in PatiCnts with diabetese SOmc laboratories rOutincly insert争 bladder cathetcr in Oncolog/PatientS tO allow fOr better pelvic evaluatiOn,Othcrs insert a cathctcr Only when discasc is likely to rcsidc in thc Pelvis,c.gり OVarian or rectal cancci Many clin… たs routincけhydratc Padentsc Onけa Fcw rOutineけuSe diuretr ics to dear thc bladdctt Physi010gical FDG uptakc nlay bc seen at sites ofarthritis,ostOmy sitcs,healing fracturcs,and PostOp― erative wounds bccause Lukocytes usc JucOSe. Thc usc Of radiOpharmaccuticals with ver/shOrt half_lives, c.g。 ,1lC,13N,1うO(2t020 minutes),rcquircs an on―site cyclo― life Of18F allows for production and tron.The l10-minutc half― delivcry frOm a mOre distant site.FDG is nOw available on a unitrdOsc basis frOm lnany rcglonal radiOPharl■ acies.

318

脇

肺

A34-ycar_01d woman with skin lnelanOma Ofthe lcft breast diagnOsed 3 ycars ago.Recent recurrcnce in thc lcft axllla. Trcatcd with rcscctiOn and intcrFcrOn thcraPyt l.BOth coronalimage sets像力 ″ ″ ″OfFDG― PET arc acquired in the samc patient on thc same daye Wttatis the rea― sOn IOr the difference in appearanccP 2. W7hy dO tumors havc increased FE)G uptakcP P Ifso,what is it,and whyP 3 . I s t h c r e a p a t i c n t p r c p a r a t iPOEnT fsotru dFiDcGs― 4.HOw

much

myOcardial

uPtake

is

cxpectedP

Notes

Melanoma

Oncology:18F FDG一

l.Thc ilnages on thc lcFt are corrcctcd for attenuation;thc ones on thc right are nOt.Both shOw increascd uptake in 「 ith tumOr adcnOPathyc the lcft ncck consistcnt鞘 comparcd to 2. Tumors have inc:Cascd glucosc lnctabollsn■ most normal tissues.A partial cxPlanation is incrcased glu― ― COSC transporter protcin activity9 highcr icvcls ofhexo路 ver icvcis OfglucOsc-6-phosPhatase. nasc,and lo、 3. Yes.4-t012‐hour fast,Nonlabclcd glucosc duc to hyper― )compctcs for FDG glyccmia(fasting or postprandi組 uptakc. tab01lZcs 4. In the fasting state the hcart preFcrcntially lnゃ frcc fatty acids.HOwcvcらdcspitc fasting thc hcart uptake is

highけ Variablc. Reference H01dcr WD,Whitc RL,Zuger JH,ct al:Effectivcncss of POSitrOn crnission tomography for thc dctcction Of melanOma lnctastascs,И ″″S″純ζ227:764,769,1998. CrOss‐ReFerence 醍 cグ ″α 軍 川務び ″″″Mc沈 あ

財 Q3慰

「益 ,Cd 2)pp 213,226‐ 227.

Comment

enuatiOn,correctcd ttp and Notc thc dfferencc bcwcen at〔 ケ .In thc nOncorrected corrccted imagcs缶 nonattenuatlon― ヴ gみ irnages,organs at dcP[h havc apparcnt dccrcascd activitye Note er is thc livett Thc latcral surfacc Of thc l市well sccn in nonat― tenuatcd imagcs;centrally thcrc is much lcss Orc uniforin; tenuation corrcction thc liver uptakc aPPcars I■ correctlon artifact along hOweveL thcrc ls now an attcnuatlon‐ the lnedial bordcr ofthc livctt Without attcnuation corrcction thc lungs appcar to havc lnlldly incrcased uptakc compared with adiacent SOft tissue,heart,and mediastinum.This is rc‐ versed with attcnuation corrcctione Surfacc sOft tissuc uptakc is corrcctcd imagcs.AnatoHlical cxaggcratcd with nonattcnuation‐ dcnnitlon ls bctter wlth attcnuatlon corrcctlon.With an Obcsc Patient,attenuation corrcction assum,S increased importancc. Malignant rnelanOma is rapidly increasing in incidencc around the world alld accounts for 30/o of canccrs.Thc PrOg二 nosis fbr rnelanOma is dircctly relatcd tO thc depth ofinvas10n Ofthc Primary lcs10n(Clarrs icvcl).The tumor initially grOws vertically in thc skin,then sprcads to regionallymph nodcs.For high― risk Patients(lcslon>4 mm in dcpth),FDG―PET is used tO dctect metastascs.In this casc thc Patient has ncw metastascs in the lcft ncck and uppcr abdoHlinal pcriaOrtic region.

320

activity.With

at―

A 5 6 - y e a r - 0 1 d m a n w i t h n c w l y d i a g n O s c d e s O p h a g e a l c a r Pc Ei Tn O wm a s. F pD cG r―f O r m e d O n a ht cw ao d―e d S P E C T camcra adaptcd fOr coincidencc imaging. 1. Describc thc indings On thc transversc and corOnal sequcntial SPECT shccs. 2, Givc your intcrpretatiOn Ofthc studyc 3. Wttat are thc advantagcs ofthis gaIIIFna Camera一 based PET techn010g/P 4. W7hat are thc disadvantages ofthis camcra一 bascd PET tcchn010g/P

321

Notes

PET Oncology:Gamma Ca「 lera FDG口 l . L a 呼 島C u s o f u p t a k c i n t h c r i g h t l o b e o f t h e l i v c r w i t h a hypermetabolic rim and central PhotoPcniC region and a sccond smttl hyPcrmctabolic fOcus in thc rcglon ofthc distal esophagus. 2. Primary esoPhageal cancer in thc distal esophagus with mctastatic tumor to thc right 10bc ofthc livc,thc pho― topcnic ccnter indicatcs ccntral nccrosis. headed 江osi nuclear medicine labOratOries have two― 3. 小 SPECT camcras,obviating thc nccd for a rclativcly cxPcn‐ sive,dedicated PET carnera in a small hospital or clinic. 4,Poorer image quality and sensitivity than a dedicated PET caHlera for detection OFsmaller tumors.Longcr acquisition timc fOr whOlcttbOdy imaging.

Refeコ ences ayem A b d e lD ―

H M , L u o QJ ‐ Sadck

S,ct

aL

Multifunctional

gamma calnera coinddence imaging.In Frecman LM,editoH 温び わ′物 れ Philadclphia,2000,Lippincott ″″物と ミ転ご ″ ″ Willdns,pp l-52. Williams 8こ Fahey FH:Positron eHlisslon tomograPhy instrumentation, ″助 ″力И物 39:919-930,2001. 路 あ0′(3″ CrOssPReference f『醍 助 f″″″鴎 品品″夕

蕊 】Cd 2,pp 33‐47,214. 京どQ占慰 「

Comment PET imaging n0 1onger rcquircs an on,sitc c/clotrOn bccause regional radioPharmacies can deliver FDG on a daily basis in most metropolitan areas,PET imaging mcrcly requircs a cam‐ vith coincldcncc dctcctOrs,Dedicatcd PET carncras arc ex― cra、 pensive comparcd with traditional gamma camcras,althOugh thc pricc difFcrcncc bctwccn rnultihcadcd garIIIna camcras and cnd PET systcms is dccrcasing.Smallcr dinics cannot ttlly 10w‐ u s c a d e d i c a t e d P E T c a m e r a . T h u s g a m mwai tcha m c r a P E ■ c011linators rcmovcd and coincidcncc dctcctorS in Placc,offcrs the nexibility of using thc_headed tttr。 cainera for PET when required and rOutine nudear rnedicine studics at other tiincs. The system rcsolutiOn Ofthc SPECT/PET cmcras is quitc 5-l.Anim― simlartO that ofmany dcdcatcd PET calncras(± portant diIFercnce,howeveL iS the cOunt rate caPabilit/9 which is bascd systcms.This cOnsidcrably lower with thc gmma camcra― vcrlo、 dctcctabllity for translates into poorer image quality and smttler leslons.Garnma carnera PET can detect approxlmately 750/o ofthe lesions scen with dedicated PET systcms.This should fOr PET imaging.For be considcrcd in sCICCungSuitablc Patienほ eXaFnple,detection Ofacllfl l― CT les10n nlay not be indicatcd,but gamma camera PET may be very usett forlargcrtumOrs.

322

も

A56-ycar_01d Patient with insulin_dcpcndent diabetes was rcfcrred fOr an 18FPET FDG― scan.Thcscぃ vO studies∽ andの 、 vere pcrfOrmcd l weck apart On thc samc PatiCnt. 1. W7hat Patient preparation is required for paticnts withOut diabetes and thOsc岡仇with yP diabctesPヽ 2.What serum glucose cOncentration is acceptable bcfOre FDG― PET imagingP 商イ hat is thc cfFect Ofinsulin On imagc Pqualiげ 3. ｀ 4. W7hat cOuld explain thc difFcrcnce in qualit/beぃ veen studyノ 4and β′ 323

Notes

Oncology:18F FDG一 Patient with Diabetes l.For patients without diabctes:fast FOr 4 to 12 hours beforc FDG ittectiOno Scrum glucose competcs with FDG for uptakc.For paticnts with diabctctt good glucosc cOntrOl required.Thc oPtimal mcthod fOr prcparing Patients with pendent diabctcs is unccrtain.Somc rccOIIlmcnd i n s u l idnc― 偽sting,and othcrs recOmmcnd a light meal and rcduccd insulin itteCt10n at least 2 hours bcFOrc FDG ittectiOn.A

b100d glucosc level detcrmination is required bcfore FDG

r itteCtiOn.

ucoSC COnccntration should bc lcss than 140 2.Bloodぷ mg/dl,組though somc acccPt vttues