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Annals of Nuclear Medicine (v.26, #8)

Reduced heart rate response to dipyridamole in patients undergoing myocardial perfusion SPECT by Gozde Daglioz Gorur; Esra Alkan Ciftci; Guliz Kozdag; Serkan Isgoren; Murat Alper Oc; Cagla Haksal; Muammer Gur; Hakan Demir (pp. 609-615).

A mild decrease in blood pressure and increase in heart rate (HR) are considered normal hemodynamic responses to dipyridamole. In this study, we tried to investigate HR response to dipyridamole and its predictors in patients undergoing gated myocardial perfusion single photon emission computed tomography (SPECT).201 consecutive patients undergoing dipyridamole stress Tc99m-MIBI or Tl-201 gated myocardial perfusion SPECT were prospectively enrolled. Dipyridamole was infused over 4 min and radiopharmaceutical was injected 3 min after the end of infusion. A reduced heart rate response to dipyridamole considered if the HR ratio (peak HR/rest HR) was 1.20 or less. Stress (sLVEF), rest (rLVEF) left ventricular ejection fractions, stress and rest motion (SMS, RMS) and thickening scores (STS, RTS) were derived automatically by QGS. Summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS) for myocardial perfusion were calculated. Patients were grouped according to HR response and groups were compared. A logistic regression analysis was used to determine independent predictors of reduced HR response.Reduced HR response was found in 78 % of patients. Patients with abnormal HR response were more frequently had a history of diabetes mellitus, chronic renal failure, and had lower high-density lipoprotein (HDL) levels. Peak HR, SSS, SRS, sLVEF and rLVEF were lower; rest HR, RTS, and the number of patients with ≤45 % sLVEF and rLVEF were higher in reduced HR response group (all p < 0.05). There was no difference between groups by means of gender, rest and peak systolic or diastolic tension, SDS, SMS, STS, RMS, history of hypertension, peripheral arterial disease, metabolic syndrome, coronary interventions, digoxin, calcium channel blocker or beta blocker usage. Multivariable logistic regression analysis demonstrated that the independent predictors of reduced HR response were HDL, rest HR and SSS. When HDL was removed from the model, chronic renal failure also emerged as an independent predictor.Reduced HR response to dipyridamole is associated with ventricular dysfunction, cardiac autonomic neuropathy. Low HDL levels also seem to be related with reduced HR response.

Keywords: Myocardial perfusion scintigraphy; Dipyridamole; Heart rate

Dual-time-point F-18 FDG PET/CT for evaluation in patients with malignant lymphoma by Takayoshi Shinya; Soichiro Fujii; Shoji Asakura; Toshitaka Taniguchi; Kotaro Yoshio; Aierken Alafate; Shuhei Sato; Tadashi Yoshino; Susumu Kanazawa (pp. 616-621).

The aim of this study was to evaluate the usefulness of F-18 fluorodeoxyglucose (FDG) dual-time-point (DTP) positron emission tomography (PET)/computed tomography (CT) with semiquantitative analyses for the initial staging in patients with malignant lymphoma.Forty-three patients had DTP PET/CT, with 60-min and 2-h scan [n = 8, Hodgkin’s lymphoma (HL); n = 12, indolent non-Hodgkin lymphoma (NHL); n = 23, aggressive NHL].A total of 524 lesions were evaluated (406 lymph nodes and 118 extra-nodal lesions). The maximum standardized uptake value (SUV_max) on 2-h delayed scan (SUV₂) was significantly higher than those on 1-h early scan (SUV₁) for all groups (P < 0.0001 for HL; P < 0.0001 for indolent NHL; P < 0.0001 for aggressive NHL). Significant differences were detected between HL and indolent NHL, between indolent NHL and the aggressive NHL for both SUV₁ and SUV₂ (each P < 0.0001). No significant differences were detected between HL and aggressive NHL for both SUV₁ and SUV₂ (P = 0.6891 for SUV₁; P = 0.8828 for SUV₂); however, significant differences were detected for the retention index of SUV_max between these groups (P = 0.0238).DTP F-18 FDG PET/CT with a semiquantitative technique may have the potential to provide the more accurate diagnoses for the staging of malignant lymphoma and the more important role in predicting the histological grades of malignancy compared with single-time-point F-18 FDG-PET scan.

Keywords: Malignant lymphoma; F-18 FDG; PET/CT; Dual-time-point (DTP); Delayed scan

Computer-aided diagnosis system for bone scintigrams from Japanese patients: importance of training database by Hiroyuki Horikoshi; Akihiro Kikuchi; Masahisa Onoguchi; Karl Sjöstrand; Lars Edenbrandt (pp. 622-626).

Computer-aided diagnosis (CAD) software for bone scintigrams have recently been introduced as a clinical quality assurance tool. The purpose of this study was to compare the diagnostic accuracy of two CAD systems, one based on a European and one on a Japanese training database, in a group of bone scans from Japanese patients.The two CAD software are trained to interpret bone scans using training databases consisting of bone scans with the desired interpretation, metastatic disease or not. One software was trained using 795 bone scans from European patients and the other with 904 bone scans from Japanese patients. The two CAD softwares were evaluated using the same group of 257 Japanese patients, who underwent bone scintigraphy because of suspected metastases of malignant tumors in 2009. The final diagnostic results made by clinicians were used as gold standard.The Japanese CAD software showed a higher specificity and accuracy compared to the European CAD software [81 vs. 57 % (p < 0.05) and 82 vs. 61 % (p < 0.05), respectively]. The sensitivity was 90 % for the Japanese CAD software and 83 % for the European CAD software (n.s).The CAD software trained with a Japanese database showed significantly higher performance than the corresponding CAD software trained with a European database for the analysis of bone scans from Japanese patients. These results could at least partly be caused by the physical differences between Japanese and European patients resulting in less influence of attenuation in Japanese patients and possible different judgement of count intensities of hot spots.

Keywords: Computer-aided diagnosis; Bone scintigram; Bone metastases; Artificial neural networks

Comparison of diagnostic ability between ^99mTc-MDP bone scan and ¹⁸F-FDG PET/CT for bone metastasis in patients with small cell lung cancer by Jeong Won Lee; Sang Mi Lee; Ho Sung Lee; Yong Hoon Kim; Won Kyoung Bae (pp. 627-633).

The aim of this study was to compare the diagnostic ability of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) with that of ^99mTc-methylene diphosphonate (^99mTc-MDP) bone scan for bone metastasis in staging patients with small cell lung cancer (SCLC).Ninety-five patients with SCLC who underwent both ¹⁸F-FDG PET/CT and ^99mTc-MDP bone scan for initial staging work-up were retrospectively enrolled. All ¹⁸F-FDG PET/CT and bone scan images were visually assessed. Bone metastasis was confirmed by histopathological results and all available clinical information.Of 95 patients with SCLC, metastatic bone lesions were found in 30 patients, and 84 metastatic lesions were evaluated on a lesion-basis analysis. The sensitivity of ¹⁸F-FDG PET/CT was 100 % on a per-patient basis and 87 % on a per-lesion basis, and there was no false-positive lesion on PET/CT images. In contrast, the sensitivity of the bone scan was 37 % on a per-patient basis and 29 % on a per-lesion basis. The bone scan showed 11 false-positive lesions. The bone scan detected two metastatic lesions that were not detected by PET/CT, which were outside the region scanned by PET/CT. On follow-up bone scan, 21 lesions that were not detected by the initial bone scan but were detected by PET/CT were newly detected.In patients with SCLC, ¹⁸F-FDG PET/CT showed higher detection rate of bone metastasis than ^99mTc-MDP bone scan. Thus, ¹⁸F-FDG PET/CT can replace bone scan in staging patients with SCLC.

Keywords: Small cell lung cancer; ¹⁸F-fluorodeoxyglucose; PET/CT; Bone scintigraphy; Osseous metastasis

Novel method for quantitative evaluation of cardiac amyloidosis using ²⁰¹TlCl and ^99mTc-PYP SPECT by Yasushi Yamamoto; Masahisa Onoguchi; Masuo Haramoto; Nobuhiro Kodani; Akio Komatsu; Hajime Kitagaki; Kazuaki Tanabe (pp. 634-643).

The degree of myocardial technetium-^99m-pyrophosphate (^99mTc-PYP) accumulation in cardiac amyloidosis is conventionally evaluated by the PYP score. This method involves qualitative visual evaluation on two-dimensional images. Here, we performed three-dimensional quantitative analysis using software developed in our laboratory.We performed dual myocardial imaging using thallium-²⁰¹-chloride (²⁰¹Tl-Cl) and ^99mTc-PYP in cases of suspected cardiac amyloidosis and calculated the PYP accumulation rates of all myocardial pixels showing ^99mTc-PYP accumulation. We defined this procedure as quantitative evaluation of the degree of ^99mTc-PYP accumulation in the myocardium. Patients were divided into two groups with and without a diagnosis of cardiac amyloidosis, and we examined the PYP accumulation rates in both groups. In addition, we examined the PYP scores of the two groups by conventional qualitative evaluation.The PYP scores of the cardiac amyloidosis group were significantly higher than those of the other group. The PYP accumulation rates of the cardiac amyloidosis group were significantly higher than those of the other group. There were significant differences in the PYP accumulation rate and PYP score between the two groups. There was considered to be a threshold between the two groups in the case of the PYP accumulation rate.When the threshold of the PYP score was defined as 3+ and that of the PYP accumulation rate as 41.5 %, the sensitivity of the PYP score and PYP accumulation rate was 84.6 %. However, the specificity of the PYP accumulation rate was higher than that of the PYP score. Quantitative evaluation by the PYP accumulation rate of the degree of ^99mTc-PYP accumulation in the myocardium may be useful in the diagnosis of cardiac amyloidosis.

Keywords: Cardiac amyloidosis; PYP scores; ^99mTc-PYP; Dual myocardial imaging

F-18 fluorodeoxyglucose uptake and water-perfusable tissue fraction in assessment of myocardial viability by Hidehiro Iida; Ulla Ruotsalainen; Maija Mäki; Merja Haaparnata; Jörgen Bergman; Liisa-Maria Voipio-Pulkki; Pirjo Nuutila; Kazuhiro Koshino; Juhani Knuuti (pp. 644-655).

¹⁵O-water-perfusable tissue fraction (PTF) has been shown to be a potential index for assessing myocardial viability in PET, an alternative to ¹⁸F-fluorodeoxyglucose (FDG). This study aimed to directly compare these two independent methods in assessing myocardial viability in patients with abnormal wall motion.PET study was performed on 16 patients with previous myocardial infarction, before coronary artery bypass graft operation (CABG). The protocol included a ¹⁵O-carbonmonoxide static, a ¹⁵O-water dynamic and an ¹⁸F-FDG dynamic scan, during the euglycemic hyperinsulinemic clamp. Echocardiography was performed at the time of PET and 5–12 months after the CABG, and the wall motion recovery was evaluated on segmental and global bases. Consistency between PTF and ¹⁸F-FDG was evaluated visually and also in a quantitative manner. Predictive values for the wall motion recovery were also compared between the two approaches.The image quality of ¹⁸F-FDG was superior to that of ¹⁵O-water. The qualitative PTF showed significantly smaller defects than ¹⁸F-FDG, and the quantitative PTF showed slightly greater values than ¹⁸F-FDG in the infarcted region. The two methods were, however, consistent visually and also quantitatively. The predictive values of the wall motion recovery were almost equal between the two approaches. The absolute ¹⁸F-FDG uptake was varied in normal segments, and predictive values for the wall motion recovery by the absolute ¹⁸F-FDG was less (accuracy: 80 %) compared with those by the relative ¹⁸F-FDG (accuracy: 87 %) and the quantitative PTF (accuracy: 89 %).Despite the small sample size, PTF appears to give consistent results with the ¹⁸F-FDG approach, and might be an alternative viability assessment.

Keywords: Myocardial viability; Chronic myocardial infarction; ¹⁸F-FDG; Water perfusable tissue fraction; Positron emission tomography

Correlation between neuropsychological tests and hypoperfusion in MCI patients: anatomical labeling using xjView and Talairach Daemon Software by Hyun Jin Yoon; Kyung Won Park; Young Jin Jeong; Do-Young Kang (pp. 656-664).

Statistical analysis of brain perfusion SPECT images has shown mild to severe abnormalities, consistent with cortical dysfunctions in the brain. Recently, functional brain imaging such as fMRI, PET and SPECT is increasingly used for diagnosis of MCI. In this study, we calculate the correlation with perfusion of brain SPECT and neuropsychological test scores of patients by SPM analysis to evaluate the relationship with cerebral hypoperfusion and cognitive dysfunction in MCI patients. Anatomical labeling was performed automatically using the Talairach Daemon (TD) and xjView.Ninety-three patients (mean age 67.2 ± 7.42 years; 59 women and 34 men) with MCI were selected and examined by the comprehensive neuropsychological test. Tc-99m-HMPAO brain SPECT images were acquired on the patients using a two-head gamma camera. We analyzed the brain image of MCI patients by SPM8 software, and observed the anatomical correlated region, between the neuropsychological tests and cerebral hypoperfusion. The SPM8 tool provided correlation between neuropsychological score and brain perfusion by simple regression method. The neuropsychological test included attention, language function, visuospatial function, memory, frontal executive function, depression score and general cognitive function.Percentage of voxels with correlated area to the whole brain was calculated and the values by Rey complex figure test (CFT) copy score, MMSE score, Seoul verbal learning test (SVLT) immediate recall score and Rey CFT delayed recall score were 15.3, 12.33, 10.59 and 8.45 %, respectively. Rey CFT copy score was correlated with perfusion in the left middle temporal gyrus (BA 21), right inferior frontal gyrus (BA 45), right lingual gyrus, left lingual gyrus (BA 18), right postcentral gyrus (BA 40), right cingulate gyrus (BA 31) and left thalamus (pulvinar) with p < 0.01 FDR. The correlation related to MMSE included left parahippocampal gyrus, right fusiform gyrus and right middle frontal gyrus (BA 46). SVLT immediate recall score was correlated with left superior temporal gyrus and Rey CFT delayed recall score was correlated with left inferior frontal gyrus (BA 47), right inferior frontal gyrus, and left lentiform nucleus. Visuospatial and general cognitive dysfunctions in the patients with MCI were most correlated with cerebral hypoperfusion.Rey CFT copy and MMSE scores were more strongly correlated with blood perfusion of the brain than with other neuropsychological test scores. xjView was a useful tool to find out the anatomical name of the selected voxel or clusters and to display the cluster’s anatomical information and list all cluster information and could be used instead of TD Client.

Keywords: SPECT; Mild cognitive impairment (MCI); SPM8; xjView; Neuropsychological tests; Hypoperfusion

Is there a correlation between symptoms and bone scintigraphic findings in patients with complex regional pain syndrome? by Abedallatif AlSharif; Alaa Y. Akel; Rasha F. Sheikh-Ali; Malik E. Juweid; Ziad M. Hawamdeh; Jihad M. Ajlouni; Ameer S. Abdulsahib; Fadi A. AlHadidi; Shaher T. ElHadidy (pp. 665-669).

Complex regional pain syndrome (CRPS) is characterized by pain in combination with sensory, vasomotor, sudomotor, trophic and motor abnormalities. The diagnosis of CRPS is based primarily on clinical criteria and the presence of distinct signs and symptoms. The role of bone scintigraphy in the diagnosis of these patients has been limited by its variable sensitivity. In this study, we aim to look if the presence of specific symptoms or symptom subgroups in patients with clinically diagnosed CRPS correlates with scintigraphic findings in bone scan.We retrospectively reviewed clinical records of patients referred for bone scintigraphy with the clinical diagnosis of CRPS during the period December 2006 until February 2011. Patients were classified into 4 distinct subgroups according to the presence of specific symptoms namely sensory subgroup, sudomotor and/or edema subgroup, vasomotor subgroup and finally motor and/or trophic changes subgroup. We looked specifically for the correlation between these specific symptoms and scintigraphic bone findings.37 patients were referred for bone scintigraphy with the clinical diagnosis of CRPS and were enrolled in the study. The presence of vasomotor symptoms and (motor and/or trophic changes) was significantly higher in patients with positive bone scintigraphy (P value 0.0133, 0.018 respectively). There was no other statistically significant correlation between the presence of specific symptoms or symptom subgroups on one hand and the result of bone scintigraphy on the other hand.The probability of positive bone scintigraphy increased significantly in patients with vasomotor symptoms and in patients with motor and/or trophic changes. This may contribute to the reported variability of the diagnostic performance of bone scintigraphy in CRPS patients.

Keywords: Bone scintigraphy; Complex regional pain syndrome; Symptoms

Imaging characterization of benign and malignant pheochromocytoma or paraganglioma: comparison between MIBG uptake and MR signal intensity ratio by Simone Maurea; Alberto Cuocolo; Massimo Imbriaco; Teresa Pellegrino; Mario Fusari; Renato Cuocolo; Raffaele Liuzzi; Marco Salvatore (pp. 670-675).

We compared metaiodobenzylguanidine (MIBG) uptake and magnetic resonance (MR) signal intensity ratio in differentiating benign and malignant disease in patients with pheochromocytoma or paraganglioma.Eighteen patients (9 men, mean age 37 ± 8 years) with pheochromocytoma or paraganglioma underwent MR imaging and iodine-131 MIBG scintigraphy. MR signal intensity ratio was measured on T1 and T2-weighted images using region of interest analysis and intensity ratio of MIBG uptake was calculated for each tumor lesion on 48 h images.A total of 28 tumor lesions was analyzed of which 12 were benign and 16 malignant. MIBG uptake intensity ratio was significantly higher in malignant lesions compared to benign (5.2 ± 2.4 and 2.9 ± 1.4, respectively, p < 0.01). On the contrary, no significant difference in tumor size and MR signal intensity ratio between malignant and benign tumor lesions was observed.In patients with pheochromocytoma or paraganglioma, iodine-131 MIBG uptake is able to differentiate between benign and malignant disease, while MR imaging is not useful for this purpose. The higher MIBG uptake observed in malignant lesions could reflect major tumor storage of catecholamines compared to benign lesions.

Keywords: MIBG; MR; Benign; Malignant; Pheochromocytoma; Paraganglioma

Higher scrotal uptake ratio of ^99mTc-MDP on bone scans in newly diagnosed prostate cancer: a reliable indicator of pelvic node metastasis by Maseeh uz Zaman; Nosheen Fatima; Zafar Sajjad; Ibrahim Hashmi; Khalil Khan (pp. 676-680).

Pelvic lymph node dissection (PLND) is the gold standard procedure for nodal staging in prostate cancer (PC) but less commonly used due to its invasiveness. More commonly computerized tomography (CT) and magnetic resonance imaging (MRI) are used although these have limited sensitivities and specificities. The aim of this study was to find out the correlation between higher scrotal uptake ratio (SUR) of ^99mTc-methylene diphosphonate (MDP) on bone scan and pelvic node metastasis in patients with PC at high risk for nodal metastasis.This was a retrospective study which included 68 biopsy proven newly diagnosed PC patients who had bone scan from January 2008 till January 2012. MRI of the pelvis, prostate specific antigen (PSA) and Gleason’s score were available in all patients. Whole body bone scan was performed in all patients and SUR was calculated by dividing mean counts over scrotum and soft tissue over lateral aspect of right thigh. PLND was carried out within 2–3 weeks of MRI study in these patients.Mean age of studied males was 71 ± 07 years with a mean PSA level of 65 ± 162 ng/ml. Prostate biopsy revealed adenocarcinoma in all patients with mean Gleason’s score 7 ± 1. Mean SUR was 2.786 ± 0.496. MRI was positive for pelvic lymphadenopathy in 32/68 (47 %). PLND revealed evidence of nodal metastasis in 16/68 (24 %) patients. Receiver operating characteristic analysis revealed good diagnostic strength of SUR for nodal metastasis with a cut off value of >2.99 with an area under curve (AUC) 0.708 (95 % CI 0.533–0.847, p value <0.05) and a mean sensitivity of 68.75 % and mean specificity of 80 %. Diagnostic strength of MRI for nodal metastasis was found to be low (AUC 0.566, 95 % CI 0.047–0.657, non-significant p value). No significant correlation was found between SUR and PSA in nodes positive and nodes negative patients.We conclude that in newly diagnosed PC patients, higher SUR on bone scan has a high diagnostic accuracy for pelvic node metastasis. Furthermore, a bone scan with a SUR <2.99 and negative for bone metastasis can stratify newly diagnosed PC patients as low risk.

Keywords: Carcinoma prostate; Pelvic node metastasis; Bone scan; Scrotal uptake ratio

Bronchial anthracofibrosis: a potential false-positive finding on F-18 FDG PET by Hong Yoon Choi; Yu Kyeong Kim; Jong Jin Lee; Sang Eun Kim (pp. 681-683).

Bronchial anthracofibrosis characterized by bronchostenosis associated with anthracotic pigmentation in bronchoscopic finding without a relevant history of pneumoconiosis or smoking has been recently described as a clinical entity. Radiologic finding of bronchial obstructive lesion and mediastinal lymph nodes in bronchial anthracofibrosis can be mimicking cancer. However, the metabolic characteristics of bronchial anthracofibrosis have hardly been reported. Here, we report a case of bronchial anthracofibrosis which showing hypermetabolism on F-18 FDG PET.

Keywords: Anthracofibrosis; FDG; FDG PET/CT; Positron emission tomography; Bronchostenosis

Unusually increased metaiodobenzylguanidine uptake in a gastrointestinal stromal tumor of the stomach by Kazuki Fukuchi; Makoto Suzuki; Shinsuke Sato; Jouji Iseki (pp. 684-687).

A 70-year-old woman with a submucosal gastric tumor was referred to our hospital for surgical treatment. Upon examination, it was found that she had hypertension, and abdominal computed tomography revealed swelling on both adrenal glands. The patient was examined with gamma camera imaging and iodine-123 metaiodobenzylguanidine (MIBG), because her hypertension was thought to be due to a suspected adrenomedullary tumor. The planar image showed an unexpected abnormal uptake of MIBG in the upper abdomen. On single-photon emission computed tomographic images, the area of abnormal tracer uptake was thought to correspond to the known gastric tumor. The surgical procedure and histological assessments revealed that the gastric tumor was a gastrointestinal stromal tumor (GIST). MIBG can accumulate in GISTs as well as in neuroendocrine tumors of the medulla of the adrenal glands. Although the cause of radiolabeled MIBG uptake in GISTs is uncertain, further studies are necessary to establish the significance of MIBG scintigraphy in GIST imaging.

Keywords: Iodine-123 MIBG; Gastrointestinal stromal tumor; Scintigraphy; Gamma camera

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Annals of Nuclear Medicine (v.26, #8)