Interesting images      Tawika, M.D.
Eur J Nucl Med Mol Imaging (2011) 38:412DOI 10.1007/s00259-010-1656-1 IMAGE OF THE MONTH                                  ...
•   A 39-year-old man, 14 years after splenectomy for injury    sustained in a road accident, a chest radiograph performed...
99m      Tc-labelled heat-denaturedgraphy was performed. Planar bral uptake in the chest and   left upper abdomen. Single ...
Tc-99m Heat-damaged RBC• Method of choice of non-intervention  evaluation of the accessory spleen/splenosis• In vitro labe...
waterbath 49-50 degree celcius for 15-20 min
•   Maintaining specified temperature throughout the heating    process is critical•   Overheating will lead to excessive d...
Clinical application•   To identify splenules•   To assess splenic number; asplenia, polysplenia•   To assess mass which i...
• searching for accessory splenic tissue, the  entire abdomen must be imaged• seeking for splenosis, thorax must be  image...
• The image acquisition can begin 30 min  after injection because of the rapid splenic  sequestration of damaged RBCs• Mor...
Other radiopharmaceuticals• radiocolloids   • about 30% of administered activity      accumulates in the spleen about 1 ho...
• Other labeled formed elements   • Labeled leukocytes and platelets
Splenosis vs Splenules• Splenules: Congenital accessory splenic  tissue• Splenosis: Autotransplanted splenic tissue  from ...
is specific for splenic tissue and quite sensitive given the highcontrast between splenules and surrounding tissues. A 99mT...
. However, small accessorypopulation, being present in  ortem studies. Consequently,w platelets even though theiroption fo...
e, and no further work-      nuclear medicine procedures and may serve as a referencee identified on anatomicMRI. However, ...
Eur J Nucl Med Mol Imaging (2011) 38:1586DOI 10.1007/s00259-011-1791-3 IMAGE OF THE MONTH123  I-Metaiodobenzylguanidine ‘s...
shed online: 29 March 2011 yearsgnosis   was                                       •   A 29-year-old man with a           ...
•   123I-MIBG whole-body scintigraphy (b) and                                             SPECT/CT showed marked uptake of...
earsnosis wasomy. log- IBG wedboneimal d in acer  and d a
Superscan on Bone scintigraphy•   Diffusely increased tracer uptake in axial skeleton      •   Homogeneous uptake      •  ...
Superscan• Renal osteodystrophy   • CA prostate : most                           common cause• Hyperparathyroidism        ...
• MIBG: Meta-iodobenzylguanidine • NE and guanitidine analoque • MIBG is taken up into the storage    granules of both nor...
• Normal distribution of MIBG   • salivary glands   • myocardium   • liver   • GI tracts   • urine
• Small percentage of patients show some  activity in...   • Blocked thyroid gland   • normal adrenal gland   • lung   • s...
• NO activity in........in normal populations   • bone   • bone marrow   • spleen
Figure 10            Figure 10: Anterior (left) and            posterior (right) planar MIBG            scans of 5-year-ol...
• Distant metastases of neuroblastomas are  located primarily in bone marrow (70%) or  bone (55%)• MIBG scanning is an acc...
Case 3                                                                  co                                                ...
•    a patient who had recently    undergone right lung surgery for    excision of metastases. A pleural    effusion devel...
continue to hold as still as possible for the                                                                  the acquisi...
ne: 6 April 2011                   Eur J Nucl Med Mol Imaging (2011) 38:1746                   DOI 10.1007/s00259-011-1793...
The End
Interesing images nov
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  • Interesing images nov

    1. 1. Interesting images Tawika, M.D.
    2. 2. Eur J Nucl Med Mol Imaging (2011) 38:412DOI 10.1007/s00259-010-1656-1 IMAGE OF THE MONTH 99mIntrathoracic splenosis: evaluation by Tc-labelledheat-denatured erythrocyte SPECT/CTCinzia Crivellaro & Grazia Cabrini & Emma Gay &Roberto Sara & Claudio RossettiReceived: 12 August 2010 / Accepted: 19 October 2010 / Published online: 11 November 2010# Springer-Verlag 2010In a 39-year-old man, 14 years after splenectomy for injury 38:412 Eur J Nucl Med Mol Imaging (2011) DOI 10.1007/s00259-010-1656-1sustained in a road accident, a chest radiograph performedfor dyspnoea showed an abnormal opacity. Computed IMAGE OF THE MONTHtomography (CT) confirmed a mediastinal left para-aorticmass suggestive either of confluent enlarged lymph nodes orectopic splenic tissue. Thus, 99mTc-labelled heat-denaturedred blood cell (DRBC) scintigraphy was performed. Planar 99m Intrathoracic splenosis: evaluation byimages showed left paravertebral uptake in the chest and Tc-la heat-denatured erythrocyte SPECT/CTmultiple little uptakes in the left upper abdomen. Singlephoton emission computed tomography (SPECT)/CT(Siemens Symbia) images confirmed 99mTc-DRBC left
    3. 3. • A 39-year-old man, 14 years after splenectomy for injury sustained in a road accident, a chest radiograph performed for dyspnoea showed an abnormal opacity. Computed tomography (CT) confirmed a mediastinal left para-aortic mass • DDx confluent LN or splenic tissue
    4. 4. 99m Tc-labelled heat-denaturedgraphy was performed. Planar bral uptake in the chest and left upper abdomen. Single tomography (SPECT)/CT line: 11 November 2010confirmed 99mTc-DRBC lefting to a solid mass from the aorta (a, b), consistent with lets of splenic tissue were alsoe left subdiaphragmatic region is defined as heterotopic tissue, usually occurring afteren or splenectomy. Although ing, a high index of suspicionnts with previous splenectomybeing followed up, as no more d unless symptoms worsen hy remains the method of Conflicts of interest None.onal evaluation of splenosis,PECT/CT has been demon- References for correctly identifying and
    5. 5. Tc-99m Heat-damaged RBC• Method of choice of non-intervention evaluation of the accessory spleen/splenosis• In vitro labeling of patient’s RBCs with Tc-99m pertecnitate
    6. 6. waterbath 49-50 degree celcius for 15-20 min
    7. 7. • Maintaining specified temperature throughout the heating process is critical• Overheating will lead to excessive damage of the RBCs, resulting in increased uptake by the liver and decreased uptake by the splenic tissue• Underheating will lead to insufficient damage of RBCs, resulting in decreased splenic uptake, along with increased activity in the circulating blood pool.
    8. 8. Clinical application• To identify splenules• To assess splenic number; asplenia, polysplenia• To assess mass which is suspicious of wandering spleen or splenosis• DDx LN vs splenules or hypervascular (pancreatic tail) tumor vs implanted splenule
    9. 9. • searching for accessory splenic tissue, the entire abdomen must be imaged• seeking for splenosis, thorax must be imaged • Diaphragm may have been violated during trauma
    10. 10. • The image acquisition can begin 30 min after injection because of the rapid splenic sequestration of damaged RBCs• More than 50% of HDRBCs localize in the spleen about 1 hour after injection
    11. 11. Other radiopharmaceuticals• radiocolloids • about 30% of administered activity accumulates in the spleen about 1 hour • splenule activity can be obscured by hepatic uptake • SPECT is helpful
    12. 12. • Other labeled formed elements • Labeled leukocytes and platelets
    13. 13. Splenosis vs Splenules• Splenules: Congenital accessory splenic tissue• Splenosis: Autotransplanted splenic tissue from secondary cause
    14. 14. is specific for splenic tissue and quite sensitive given the highcontrast between splenules and surrounding tissues. A 99mTc-sulfur colloid study is another nuclear medicine study thatmay be used to assess splenic tissue. However, the colloidis also taken up by the liver and bone marrow, and conse-quently this test is less sensitive and specific. The normal FIGURE 16. CT scan (A pancreas (arrowheads) and responding transaxial slicFIGURE 14. Heat-damaged RBC study assessing for pres- study demonstrates intensence of splenules in patient with ITP. Anterior MIP image (A) and it is simply an accessory stransaxial image (B) from SPECT acquisition demonstrate small depicts uptake in mass (arbut intense focus of uptake in splenic bed (arrow), consistent intense normal uptake in spwith splenule. MIP 5 maximum intensity projection. maximum intensity project142 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 3 • Septem
    15. 15. . However, small accessorypopulation, being present in ortem studies. Consequently,w platelets even though theiroption for therapy in this caseaccessory splenic tissue. The he most effective method ofFigure 14 is such a study in ae platelet levels were falling splenectomy. A solitary in-onstrated in the splenic bed. e is overestimated on theseolution) it could not be iden- trospect. The patient went onused intraoperatively to locate emoved. d female patient also under-sing platelet counts in the FIGURE 15. Anterior MIP image demonstrates no concentra- no accessory splenic tissue tion of heat-damaged RBCs within accessory splenic tissue. This onstrates that in the absence negative study depicts distribution of damaged RBCs through- nic tissue, the distribution of out blood pool when there is no significant functioning splenic tissue to sequester them. MIP 5 maximum intensity projection. e circulating blood pool.other indication for the heat- 65-y-old male patient, a CT spleen takes up only about 10% of injected 99mTc-sulfured reason identified a 3.1-cm colloid, versus 90% of heat damaged RBCs (28). as. The concern was that this
    16. 16. e, and no further work- nuclear medicine procedures and may serve as a referencee identified on anatomicMRI. However, as indi-ties are neither sensitiveat-damaged RBC studysensitive given the highnding tissues. A 99mTc-ar medicine study that . However, the colloidne marrow, and conse-d specific. The normal FIGURE 16. CT scan (A) revealed mass (arrow) near tail of pancreas (arrowheads) and spleen (double arrowhead). (B) Cor- responding transaxial slice from heat-damaged RBC SPECTudy assessing for pres- study demonstrates intense uptake in mass (arrow), confirmingnterior MIP image (A) and it is simply an accessory spleen. (C) Anterior MIP image furthersition demonstrate small depicts uptake in mass (arrow) near splenic hilum. There is also bed (arrow), consistent intense normal uptake in spleen and faint uptake in liver. MIP 5 ty projection. maximum intensity projection.
    17. 17. Eur J Nucl Med Mol Imaging (2011) 38:1586DOI 10.1007/s00259-011-1791-3 IMAGE OF THE MONTH123 I-Metaiodobenzylguanidine ‘superscan’ in an adultpatient with neuroblastomaVíctor Andrés Marín Oyaga & Juan Ignacio Cuenca Cuenca &Juan Luis Tirado Hospital & Rosa Fernández López & Isabel Borrego Dorado &Ricardo Vázquez AlbertinoReceived: 24 November 2010 / Accepted: 7 March 2011 / Published online: 29 March 2011# Springer-Verlag 2011 Eur J Nucl Med Mol Imaging (2011) 38:1586Neuroblastoma is extremely rare in patients over 10 yearsold [1]. 123I-MIBG has 10.1007/s00259-011-1791-3 DOI a high sensitivity for the diagnosisof primary and metastatic neuroblastoma [2]. IMAGE OF THE MONTH A 29-year-old man with a neuroblastoma IIB wasreferred to us for an extension study after adrenalectomy.Bone scan with 99mTc-HDP (a) showed several patholog-ical lesions suggestive of metastatic spread.123I-MIBGwhole-body scintigraphy (b) and SPECT/CT showed 123marked uptake of the radiopharmaceutical in the bone I-Metaiodobenzylguanidine ‘supemarrow throughout the axial skeleton and in the proximalhumeri and femora compatible with metastatic spread inthe bone marrow and an abnormal distribution of tracer
    18. 18. shed online: 29 March 2011 yearsgnosis was • A 29-year-old man with a neuroblastoma IIB was tomy. referred to us for anholog- extension study afterMIBG adrenalectomy. Bone scan owed with 99mTc-HDP showed bone several pathological lesions ximal suggestive of metastaticead in spread tracer r andwed amerate These superscan’ study due to the extensive involvement of the
    19. 19. • 123I-MIBG whole-body scintigraphy (b) and SPECT/CT showed marked uptake of the radiopharmaceutical in the bone marrow throughout the axial skeleton and in the proximal humeri and femora • 18F-FDG PET/CT (c) showed a hypermetabolic retroperitoneal adenopathic conglomerate with involvement of the bone and bone marrowue to the extensive involvement of the
    20. 20. earsnosis wasomy. log- IBG wedboneimal d in acer and d a
    21. 21. Superscan on Bone scintigraphy• Diffusely increased tracer uptake in axial skeleton • Homogeneous uptake • Heterogeneous uptake• Total absence of soft-tissue activity• Lack of or faint kidney activity
    22. 22. Superscan• Renal osteodystrophy • CA prostate : most common cause• Hyperparathyroidism • CA breast : 2nd most• Osteomalacia common• Fibrous dysplasia • CA lung• Paget’s disease • CA bladder • Lymphoma
    23. 23. • MIBG: Meta-iodobenzylguanidine • NE and guanitidine analoque • MIBG is taken up into the storage granules of both normal and abnormal neural crest cells
    24. 24. • Normal distribution of MIBG • salivary glands • myocardium • liver • GI tracts • urine
    25. 25. • Small percentage of patients show some activity in... • Blocked thyroid gland • normal adrenal gland • lung • skeletal muscle
    26. 26. • NO activity in........in normal populations • bone • bone marrow • spleen
    27. 27. Figure 10 Figure 10: Anterior (left) and posterior (right) planar MIBG scans of 5-year-old girl with left retroperitoneal neuroblastoma. MIBG uptake in primary tumor (arrow), as well as diffuse osteomedullary metastases in cranial vault, skull base, sternum, spine, humerus, ribs, pelvis, femurs, and tibias, is visible.
    28. 28. • Distant metastases of neuroblastomas are located primarily in bone marrow (70%) or bone (55%)• MIBG scanning is an accurate method for detecting osteomedullary metastases with sensitivity and specificity estimated at 90% and 100%, respectively• Bone scan has a reported sensitivity of 70%– 78% and a specificity of 51% for the detection of bone metastases
    29. 29. Case 3 co the lat FIGURE 15. Anterior im- sin age from lymphoscintigra- phy study in same patient inc as in Figure 14, extending ph from neck to upper pelvis. dy Abnormal accumulation of jui radiopharmaceutical is seen dy throughout right side of tho- rax (arrowheads), confirming un lymphatic leak. Appropriate ad uptake is seen in abdominal gla and superior mediastinal cre lymphatics and within liver ula (L) and spleen (S). ca(2). The patient is asked to lie supine in the Water’s position be(chin and nose touching collimator face), and approxi- ac
    30. 30. • a patient who had recently undergone right lung surgery for excision of metastases. A pleural effusion developed after the operation, and it was suspected that this may have arisen from damage to the thoracic duct, resulting in leakage lymphatic fluid into the pleural space (chylothorax)•
    31. 31. continue to hold as still as possible for the the acquisition. Static images in the right la lateral positions are acquired as needed. Al FIGURE 15. Anterior im- single longer dynamic acquisition may a • age from lymphoscintigra- Anterior image from lymphoscintigra- phy study in same patient incorporating both the prestimulus and as in Figure phy extending phase. For example, one may choose to 14, study, extending from neck to upper from neck topelvis. Abnormal accumulation of 40 min and adminis upper pelvis. dynamic acquisition for Abnormal accumulation of juice via a straw to the supine patient 20 radiopharmaceutical is seen dynamicisacquisition. It is important to kee radiopharmaceutical seen throughout throughout right side of tho- thorax (arrowheads), right side of unaware of the lemon juice stimulation unt rax (arrowheads), confirming confirming lymphatic leak. Appropriate lymphatic leak. Appropriate administration, to prohibit psychologic stim uptake is seen in abdominal glands. Normal and superior exhibit a s uptake is seen in abdominal glands should and superior mediastinal lymphatics activity almost immediately after mediastinal crease in and within liver lymphatics and within liver ulation, with a resultant increase in activit (L) and spleen (S).and spleen (S). (L) cavity (Fig. 16). During the prestimulus phase, an increase i(2). The patient is asked to lie supine in the Water’s position be due to local inflammation or infection.(chin and nose touching collimator face), and approxi- acute sialadenitis on scintigraphy displays amately 555 MBq (15 mCi) of pertechnetate are adminis- blood flow, resulting in marked uptake andtered intravenously. A dynamic blood flow study is pertechnetate within the entire gland. On the
    32. 32. ne: 6 April 2011 Eur J Nucl Med Mol Imaging (2011) 38:1746 DOI 10.1007/s00259-011-1793-1 IMAGE OF THE MONTH
    33. 33. The End

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