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Annals of Nuclear Medicine (v.23, #4)

Cardiac hybrid imaging: state-of-the-art by Philipp A. Kaufmann (pp. 325-331).

The field of noninvasive cardiac imaging has experienced enormous advances including computerized tomography coronary angiography (CTCA). Invasive angiography remains the anatomic standard of reference but it is associated with a non-negligible peri-procedural morbidity and mortality which suggests confining its use to patients who will benefit from a revascularization procedure. Many factors that are beyond the simple quantification of diameter narrowing and therefore cannot be fully assessed with luminology will eventually determine whether or not a given lesion produces stress-induced ischemia. Myocardial perfusion scintigraphy by single photon emission computerized tomography (SPECT) is one of the most widely used and well established noninvasive tools for the diagnosis of ischemic heart disease. Although positron emission tomography (PET) offers a higher accuracy than SPECT its use is often limited to large centers. This article explains the great potential of cardiac hybrid imaging which allows a comprehensive evaluation of coronary artery disease as it combines both morphological and functional information by fusing either SPECT or PET with CTCA. SPECT/CT and PET/CT hybrid imaging can provide entirely noninvasively unique information which helps improving diagnostic assessment and risk stratification and also impacts decision making with regard to revascularization in patients with coronary artery disease.

Keywords: Hybrid cardiac imaging; SPECT/CT; PET/CT; Nuclear cardiology

Bioevaluation of ⁹⁰Y-labeled particles in animal model of arthritis by Usha Pandey; Ketaki Bapat; Haladhar Dev Sarma; Prem Singh Dhami; P. W. Naik; Grace Samuel; Meera Venkatesh (pp. 333-339).

The aim of the present study was to evaluate the behaviour of ⁹⁰Y-labeled particles when injected into an arthritic knee joint of Wistar rats with severe inflammation induced using Complete Freund’s Adjuvant (CFA). ⁹⁰Y-ferric hydroxide macroaggregates (⁹⁰Y-FHMA), ⁹⁰Y-hydroxyapatite (⁹⁰Y-HA) and ⁹⁰Y-phosphate particles (⁹⁰YPO₄) were prepared, subjected to quality control analyses and in vitro stability studies. Biodistribution studies were carried out by intra-articular injection into knee joints of Wistar rats induced with chronic inflammatory arthritis using CFA and by monitoring the radioactivity for retention and leakage.All the three preparations exhibited ~99% localization in knee joints even at 24 h p.i. with very small amounts observed in the liver and lungs, possibly due to leakage of the radiolabeled particles from the inflamed knee joint. Absence of any radioactivity in the femur indicated the in vivo stability of the particle preparations.The biodistribution patterns were very similar in the normal and arthritic rats and were associated with negligible leakage (up to 24 h) from the knee joint indicating the potential of all the ⁹⁰Y-radiolabeled preparations reported here, for use in radiation synoviorthesis.

Keywords: ⁹⁰Y-labeled particles; Radiosynoviorthesis; Complete Freund’s Adjuvant

A recovery coefficient method for partial volume correction of PET images by Shyam M. Srinivas; Thiruvenkatasamy Dhurairaj; Sandip Basu; Gonca Bural; Suleman Surti; Abass Alavi (pp. 341-348).

Correction of the “partial volume effect” has been an area of great interest in the recent times in quantitative PET imaging and has been mainly studied with count recovery models based upon phantoms that incorporate hot spheres in a cold background. The goal of this research study was to establish a similar model that is closer to a biological imaging environment, namely hot spheres/lesions in a warm background and to apply this model in a small cohort of patients.A NEMA phantom with six spheres (diameters 1–3.7 cm) was filled with ¹⁸FDG to give sphere:background activity ratios of 8:1, 6:1, and 4:1 for three different acquisitions on a Philips Allegro scanner. The hot sphere SUVmax and the background average SUV were measured for calculation of recovery coefficients (RCs). Using the RCs, the lesion diameters, and the lesion:background ratio, the SUVmax of 64 lesions from 17 patients with biopsy proven lung cancer were corrected.The RCs versus sphere diameters produced characteristic logarithmic curves for each phantom (RCs ranged from 80% to 11%). From a cohort of 17 patients with biopsy proven lung cancer, 64 lesions combined had a mean SUVmax of 7.0 and size of 2.5 cm. After partial volume correction of the SUVmax of each lesion, the average SUVmax increased to 15.5.Hot spheres in a warm background more closely resemble the actual imaging situation in a living subject when compared to hot spheres in a cold background. This method could facilitate generation of equipment specific recovery coefficients for partial volume correction. The clinical implications for the increased accuracy in SUV determination are certainly of potential value in oncologic imaging.

Keywords: Partial volume correction; Positron emission tomography; Hot sphere/warm background phantom; Recovery coefficient

Adrenal masses: the value of additional fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) in differentiating between benign and malignant lesions by Masahiro Okada; Taro Shimono; Yoshihiro Komeya; Rina Ando; Yuki Kagawa; Takashi Katsube; Masatomo Kuwabara; Yukinobu Yagyu; Seishi Kumano; Izumi Imaoka; Norio Tsuchiya; Ryuichiro Ashikaga; Makoto Hosono; Takamichi Murakami (pp. 349-354).

To investigate whether integrated fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) can differentiate benign from adrenal malignant lesions on the basis of maximum standardized uptake value (SUV_max), tumor/liver (T/L) SUV_max ratio, and CT attenuation value (Hounsfield Units; HU) of unenhanced CT obtained from FDG-PET/CT data.We studied 30 patients with 35 adrenal lesions (16 adrenal benign lesions, size 16 ± 5 mm, in 15 patients; and 19 adrenal malignant lesions, 24 ± 12 mm, in 15 patients) who had confirmed primary malignancies (lung cancer in 23 patients, lymphoma in 2, esophageal cancer in 2, hypopharyngeal cancer in 1, prostate cancer in 1, and 1 patient in whom lesions were detected at cancer screening). All patients underwent PET/CT at 1 h post FDG injection. Diagnosis of adrenal malignant lesions was based on interval growth or reduction after chemotherapy. An adrenal mass that remained unchanged for over 1 year was the standard used to diagnose adrenal benign lesions. Values of FDG uptake and CT attenuation were measured by placing volumetric regions of interest over PET/CT images. Adrenal uptake of SUV_max ≥ 2.5 was considered to indicate a malignant lesion; SUV_max < 2.5 was considered to indicate a benign lesion. In further analysis, 1.8 was employed as the threshold for the T/L SUV_max ratio. Unenhanced CT obtained from PET/CT data was considered positive for adrenal malignant lesions based on a CT attenuation value ≥ 10 HU; lesions with a value < 10 HU were considered adrenal benign lesions. Mann–Whitney’s U test was used for statistical analyses.SUV_max in adrenal malignant lesions (7.4 ± 3.5) was higher than that in adrenal benign lesions (2.1 ± 0.5, p < 0.05). The CT attenuation value of adrenal malignant lesions (27.6 ± 11.9 HU) was higher than that of adrenal benign lesions (10.1 ± 12.3 HU, p < 0.05). In differentiating between adrenal benign and malignant lesions, a CT threshold of 10 HU corresponded to a sensitivity of 57%, specificity of 94%, accuracy of 74%, positive predictive value of 92% and negative predictive value of 65%. An SUV_max cut-off value of 2.5 corresponded to a sensitivity of 89%, specificity of 94%, accuracy of 91%, positive predictive value of 94% and negative predictive value of 88%. The T/L SUV_max ratio was 1.0 ± 0.2 for adrenal benign lesions and 4.5 ± 3.0 for adrenal malignant lesions. And T/L SUV_max ratio cut-off value of 1.8 corresponded to a sensitivity of 85%, specificity of 100%, accuracy of 91%, positive predictive value of 100% and negative predictive value of 83%.FDG-PET/CT with additional SUV_max analysis improves the diagnostic accuracy of adrenal lesions in cancer patients.

Keywords: Adrenal gland; Adrenal tumor; FDG-PET/CT; SUV_max ; CT attenuation value

Measurement of cerebral blood flow by the autoradiographic method with N-isopropyl-4-[I-123] iodoamphetamine: comparison of radiopharmaceuticals marketed by different companies in Japan by Toshiyuki Ogura; Hiroshi Ito; Kazuhiro Hida; Toshihide Masuzuka; Hiroshi Fukuda; Jun Hatazawa (pp. 355-361).

Iodine-123-labeled N-isopropyl-4-iodoamphetamine (IMP) is used as a tracer for the measurement of cerebral blood flow (CBF) by single-photon emission computed tomography (SPECT). Two IMP products, IMP_A (Nihon Medi-Physics Co., Ltd.) and IMP_B (FUJIFILM RI Pharma Co., Ltd.), produced by different radiopharmaceutical companies are marketed for clinical use in Japan. Although no significant difference in whole-body distribution between the two products has been reported, a significant difference in the radioactivity of the octanol-extracted fraction in whole blood between the two products has been reported in humans. In this study, CBF values obtained by the autoradiographic (ARG) method obtained from both IMP_A and IMP_B were compared in the same human subjects.SPECT studies were performed on 6 healthy subjects with the use of both IMP_A and IMP_B. Standard input functions used in the ARG method were obtained for both IMP_A and IMP_B from 5 additional healthy subjects.Significant differences were found between CBF values when SPECT data with IMP_A was combined with the standard input function for IMP_B (37.7 ± 3.7 mL/100 g/min at a mid-scan time of 30 min) and SPECT data with IMP_B was combined with the standard input function for IMP_A (50.7 ± 8.9 mL/100 g/min). Nearly the same CBF values were found when SPECT data with IMP_A was combined with the standard input function for IMP_A (43.1 ± 4.4 mL/100 g/min) and SPECT data with IMP_B was combined with the standard input function for IMP_B (44.2 ± 7.6 mL/100 g/min).Our results suggest that the appropriate standard input function should be used, according to the IMP product used, in the calculation of CBF by the ARG method.

Keywords: IMP; SPECT; CBF; ARG (autoradiography)

Influence of residual oxygen-15-labeled carbon monoxide radioactivity on cerebral blood flow and oxygen extraction fraction in a dual-tracer autoradiographic method by Katsuhiro Iwanishi; Hiroshi Watabe; Takuya Hayashi; Yoshinori Miyake; Kotaro Minato; Hidehiro Iida (pp. 363-371).

Cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO₂), oxygen extraction fraction (OEF), and cerebral blood volume (CBV) are quantitatively measured with PET with ¹⁵O gases. Kudomi et al. developed a dual tracer autoradiographic (DARG) protocol that enables the duration of a PET study to be shortened by sequentially administrating ¹⁵O₂ and C¹⁵O₂ gases. In this protocol, before the sequential PET scan with ¹⁵O₂ and C¹⁵O₂ gases (¹⁵O₂–C¹⁵O₂ PET scan), a PET scan with C¹⁵O should be preceded to obtain CBV image. C¹⁵O has a high affinity for red blood cells and a very slow washout rate, and residual radioactivity from C¹⁵O might exist during a ¹⁵O₂–C¹⁵O₂ PET scan. As the current DARG method assumes no residual C¹⁵O radioactivity before scanning, we performed computer simulations to evaluate the influence of the residual C¹⁵O radioactivity on the accuracy of measured CBF and OEF values with DARG method and also proposed a subtraction technique to minimize the error due to the residual C¹⁵O radioactivity.In the simulation, normal and ischemic conditions were considered. The ¹⁵O₂ and C¹⁵O₂ PET count curves with the residual C¹⁵O PET counts were generated by the arterial input function with the residual C¹⁵O radioactivity. The amounts of residual C¹⁵O radioactivity were varied by changing the interval between the C¹⁵O PET scan and ¹⁵O₂–C¹⁵O₂ PET scan, and the absolute inhaled radioactivity of the C¹⁵O gas. Using the simulated input functions and the PET counts, the CBF and OEF were computed by the DARG method. Furthermore, we evaluated a subtraction method that subtracts the influence of the C¹⁵O gas in the input function and PET counts.Our simulations revealed that the CBF and OEF values were underestimated by the residual C¹⁵O radioactivity. The magnitude of this underestimation depended on the amount of C¹⁵O radioactivity and the physiological conditions. This underestimation was corrected by the subtraction method.This study showed the influence of C¹⁵O radioactivity in DARG protocol, and the magnitude of the influence was affected by several factors, such as the radioactivity of C¹⁵O, and the physiological condition.

Keywords: PET; OEF; CBV; Carbon monoxide

Prognostic value of myocardial perfusion and ventricular function in a Japanese multicenter cohort study (J-ACCESS): the first-year total events and hard events by Kenichi Nakajima; Hideo Kusuoka; Shigeyuki Nishimura; Akira Yamashina; Tsunehiko Nishimura (pp. 373-381).

To determine the prognostic value of myocardial ischemia, function and coronary risk factors on total and hard cardiac events using myocardial perfusion imaging in a Japanese population.A prospective cohort study was performed in 117 Japanese hospitals, each with a nuclear cardiology facility. A total of 4,031 patients with suspected or confirmed ischemic heart disease were registered. The patients were followed up for a year to investigate total and hard events, and those who had any events were followed up for 3 years to evaluate subsequent hard events. A stress-rest gated myocardial perfusion study was performed with ^99mTc-tetrofosmin using gated single-photon emission computed tomography (SPECT) and analyzed by semi-quantitative scores.During the 1-year follow-up period, 263 (6.5%) patients had total events comprising all-cause death, non-fatal myocardial infarction (MI), heart failure, unstable angina, angina pectoris and coronary revascularization. Cardiac death occurred in 23 patients (0.6%) and non-fatal MI in 11 (0.3%). Among patients with ejection fraction (EF) of <45% and a summed difference score (SDS) of ≥2, 18.7% (2.4% for cardiac death and 0.6% for non-fatal MI) experienced total events compared with 3.9% (0.3% for cardiac death and 0.2% for non-fatal MI; P < 0.0001) of those with EF ≥ 45% and SDS < 2. Multivariate analysis identified EF, SDS, age, history of revascularization and diabetes as significant predictors of all events, while the significant predictors were age and EF for hard events. When the patients who had heart failure in the first year were followed up, 9 of 41 (22.0%) experienced cardiac death in the subsequent 3-year follow-up period.Myocardial ischemia defined by SDS and ventricular function were the main predictors of total events despite the relatively low incidence of hard events in this Japanese population. In patients with cardiac events in a year, closer attention should be paid to subsequent hard events particularly in patients with heart failure.

Keywords: Myocardial perfusion imaging; Gated SPECT; Prognosis; Multi-center study; Cardiac events

Factors associated with myocardial salvage immediately after emergent percutaneous coronary intervention in patients with ST-elevation acute myocardial infarction by Susumu Yoshida; Seishi Nakamura; Tetsuro Sugiura; Yoshiaki Tsuka; Hirofumi Maeba; Fumio Yuasa; Takeshi Senoo; Kazuya Takehana; Masato Baden; Toshiji Iwasaka (pp. 383-390).

The amount of myocardial salvage after percutaneous coronary intervention (PCI) is reported to be a major determinant of functional recovery in patients with ST-elevation acute myocardial infarction (MI). However, factors related to the amount of myocardial salvage remain unknown. The goal of this study was to investigate the factors related to the amount of myocardial salvage after emergent PCI in patients with ST-elevation acute MI by incorporating pre- and post-treatment indices and adjunctive treatments.Technetium-99m myocardial imaging was performed before, immediately after, and one month after emergent PCI in 161 patients with ST-elevation acute MI, and the defect score was serially evaluated. A good myocardial salvage was defined as ≥4 change (before minus immediately after PCI) of the defect score.Good myocardial salvage was observed in 89 patients. Based on nine clinical variables, logistic regression analysis was performed to determine the important variables related to myocardial salvage. Multivariate analysis revealed that earlier time from onset to PCI (χ ² = 6.55, P = 0.01, odds ratio = 2.78), larger defect score before PCI (χ ² = 7.29, P = 0.01, odds ratio = 1.13) and administration of nicorandil before PCI (χ ² = 9.88, P = 0.008, odds ratio = 4.42) were independently associated with good myocardial salvage. Thrombolysis In Myocardial Infarction (TIMI) flow grade <2 before PCI (χ ² = 4.91, P = 0.03, odds ratio = 0.36) and TIMI flow grade ≤2 after PCI (χ ² = 4.82, P = 0.03, odds ratio = 0.31) were independently associated with poor myocardial salvage. In contrast, the number of asynergic segments before PCI, infarct-related artery, adequate collaterals before PCI and stent implantation were not determinants of myocardial salvage.This study demonstrated that patients with a greater improvement of ^99mTc tetrofosmin myocardial uptake immediately after PCI had better recovery of left ventricular function and smaller final infarct size. Reperfusion time and TIMI flow grade ≤2 after PCI were important determinants of myocardial salvage, and nicorandil was a major determinant of myocardial salvage.

Keywords: ST-elevation acute myocardial infarction; Technetium-99m tetrofosmin; Antegrade flow; Nicorandil; Myocardial salvage

Significance of ¹⁸F-2-deoxy-2-fluoro-glucose accumulation in the stomach on positron emission tomography by Hiroshi Takahashi; Kunio Ukawa; Nobuhiko Ohkawa; Kaoru Kato; Yuuko Hayashi; Kazuhito Yoshimoto; Akiyoshi Ishiyama; Nobuko Ueki; Kensuke Kuraoka; Tomohiro Tsuchida; Yorimasa Yamamoto; Akiko Chino; Naoyuki Uragami; Junko Fujisaki; Masahiro Igarashi; Rikiya Fujita; Masamichi Koyama; Takashi Yamashita (pp. 391-397).

To explain the accumulation of ¹⁸F-2-deoxy-2-fluoro-glucose (¹⁸FDG) on positron emission tomography (PET) in the stomach and differences in its pattern, we focus on the accumulation pattern in association with endoscopic findings of the gastric mucosa and Helicobacter pylori (Hp) infection.Of 599 cases undergoing ¹⁸FDG-PET examinations, we retrospectively analyzed the pattern of ¹⁸FDG accumulation in the stomach, findings of upper gastrointestinal endoscopy, and Hp infection. The pattern of ¹⁸FDG accumulation was classified into three groups: localized accumulation only in the fornix (Group A, 32 patients), diffuse accumulation throughout the entire stomach (Group B, 49 patients), and no accumulation (Group C, 191 patients).Regarding the relation between Hp infection and ¹⁸FDG accumulation, Hp infection was positive in 56.3% of Group A, 73.5% of Group B, and 24.1% of Group C, with significant differences (p < 0.001). Regarding the relation between ¹⁸FDG accumulation and gastric mucosal inflammation, when Groups A and B were compared with Group C, nearly half of the cases in the former groups had papular redness with a significantly higher frequency of redness and erosion. Three cases found to have malignant tumor were limited to the former groups. One MALT lymphoma case was also found in the same group. Accumulation of ¹⁸FDG largely corresponded to mucosal inflammation including superficial gastritis and erosive gastritis, and therefore the main cause of non-specific ¹⁸FDG accumulation was considered to be inflammatory mucosa (mainly redness). The accumulation pattern was not associated with atrophic changes of the gastric mucosa or with Hp infection, but with mucosal inflammatory changes, including redness and erosion localized to the fornix.Accumulation of ¹⁸FDG in the stomach suggests a high probability of the presence of inflammatory change in the gastric mucosa forming a background for the development of cancer or malignant lymphoma, and thus requires further endoscopic examinations.

Keywords: Positron emission tomography; Endoscopy; Gastritis

Differentiation of FDG-avid loco-regional recurrent and compromised benign lesions after surgery for breast cancer with dual-time point F-18-fluorodeoxy-glucose PET/CT scan by Kazuyoshi Suga; Yasuhiko Kawakami; Atsuto Hiyama; Naofumi Matsunaga (pp. 399-407).

To evaluate the ability of dual-time point F-18-fluorodeoxy-glucose (FDG) PET/CT scans to differentiate FDG-avid loco-regional recurrent and compromised benign lesions after surgery for breast cancer.A total of 64 FDG-avid recurrent lesions (local tumor recurrence or lymph node metastases) in 52 patients and 38 FDG-avid compromised benign lesions after surgery in 37 patients were included in the study. FDG PET/CT study was performed at 60 and 120 min after intravenous injection of 3.5 MBq/kg FDG. The maximum SUV (SUVmax) on the early and delayed scans and the percent change of SUVmax (%ΔSUVmax) between the two time points were measured. The optimal differential parameter was determined by receiver-operating characteristic curve analysis.The average early SUVmax, delayed SUVmax and ΔSUVmax% were 4.9 ± 2.6, 6.0 ± 3.6 and 18.2% ± 18.8 in FDG-avid recurrent lesions, and 2.1 ± 0.8, 1.8 ± 1.0 and −17.8% ± 21.3 in FDG-avid benign lesions, respectively. Delayed SUVmax was significantly increased compared with early SUVmax in recurrent lesions (P < 0.0001), while it was decreased in benign lesions (P < 0.0001). All the three parameters in recurrent lesions were significantly higher than those in benign lesions (P < 0.0001). The highest diagnostic accuracy of the differentiation was achieved by the combined use of the optimal parameter of delayed SUVmax > 2.5 and %ΔSUVmax > 0%, with a sensitivity of 90.6%, specificity of 81.5%, accuracy of 87.2%, NPV of 89.2%, and PPV of 83.7%, which were better than the respective values obtained with the use of delayed SUVmax > 2.5 alone or %ΔSUVmax > 0% alone (P < 0.005 and P < 0.05, respectively), and the use of the traditional parameter of early SUVmax > 2.5 (P < 0.005).This approach with SUVmax estimation appears to improve the differentiation between FDG-avid loco-regional recurrent of breast cancer and compromised benign lesions after surgery, since delayed scanning significantly enhances the difference in FDG uptake between these lesions.

Keywords: PET ; ¹⁸F-FDG; Breast cancer; Operation scar; Dual-time point PET scan; Differential diagnosis

^99mTc-TRODAT-1 and ¹²³I-IBZM SPECT studies in a patient with extrapontine myelinolysis with parkinsonian features by Yi-Chung Wu; Giia-Sheun Peng; Chun-An Cheng; Chun-Chieh Lin; Wen-Sheng Huang; Chun-Jen Hsueh; Jiunn-Tay Lee (pp. 409-412).

Osmotic demyelination syndrome can result from the rapid correction of hyponatremia, and is categorized by central pontine myelinolysis and extrapontine myelinolysis (EPM). Magnetic resonance imaging (MRI) is currently the most useful modality for visualizing EPM lesions. However, MRI is unable to delineate the severity of involvement in the nigrostriatal dopaminergic pathway. The authors describe the case of a 48-year-old woman who developed isolated EPM with predominantly right-sided parkinsonian symptoms after rapid correction of hyponatremia. MRI revealed symmetrical demyelinating lesions in the bilateral striatum without central pontine involvement. ^99mTc-TRODAT-1 and ¹²³I-iodobenzamide (¹²³I-IBZM) single-photon emission computed tomography (SPECT) images showed unequally decreased uptake in the bilateral striatum. Treatment with carbidopa/levodopa improved the clinical parkinsonian symptoms. ^99mT_C-TRODAT-1 and ¹²³I-IBZM SPECT images provide presynaptic and postsynaptic molecular information of the nigrostriatal dopaminergic pathway. The lesions demonstrated in the ^99mT_C-TRODAT-1 and ¹²³I-IBZM SPECT images show higher correlation with the severity of clinical features in EPM than MRI, and the modalities may be useful in the evaluation of patients with parkinsonian symptoms.

Keywords: Extrapontine myelinolysis; ^99mTc-TRODAT-1; ¹²³I-IBZM; Single-photon emission computed tomography (SPECT)

Findings of hepatopulmonary syndrome on breath-hold perfusion SPECT-CT fusion images by Kazuyoshi Suga; Yasuhiko Kawakami; Hideyuki Iwanaga; Osamu Tokuda; Naofumi Matsunaga (pp. 413-419).

Pulmonary perfusion SPECT-CT fusion images were used to characterize CT manifestations of intrapulmonary arteriovenous communications (AVC) causing right-to-left shunt and hepatopulmonary syndrome (HPS). After scanning the whole body and obtaining multiple view images of the lung, deep-inspiratory breath-hold (DIBrH) SPECT was obtained in 2 patients with HPS, which was automatically and three-dimensionally co-registered with DIBrH CT. In both patients, the whole body scan depicted systemic organs and confirmed the existence of right-to-left shunt. DIBrH SPECT-CT fusion images showed that perfusion defects were predominantly located at subpleural reticulo-nodular opacities and/or dilated vessels in the lung base. Subpleural reticulo-nodular opacities and/or dilated vessels in the lung base appear to be characteristic CT manifestation of intrapulmonary AVC in HPS.

Keywords: Single photon emission computed tomography (SPECT); Pulmonary perfusion; Hepatopulmonary syndrome; Right-to-left shunt

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Annals of Nuclear Medicine (v.23, #4)