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Annals of Nuclear Medicine (v.26, #10)

Regional cerebral blood flow in patients with carbon monoxide intoxication by Yu-Yu Lu; Shih-Chuan Tsai; Chia-Hung Kao; Wan-Yu Lin (pp. 771-776).

Early detection of regional cerebral anomalies in acute carbon monoxide (CO) poisoning by ^99mTc-hexamethylprophylene amine oxime (HMPAO) brain single photon emission computed tomography (SPECT) imaging has been reported previously. However, SPECT findings varied in these studies because of their small population sizes. In this study, we included 96 patients with acute CO intoxication and analyzed the regional perfusion changes in these patients by means of HMPAO brain SPECT.Ninety-six patients, aged 4–80 years (mean age 32 years) with acute CO intoxication diagnosed by our emergency department were included in this study. Exclusion criteria included previous cerebrovascular diseases, brain injury, brain surgery and any known neurological and psychological disorders. All patients underwent a brain scan using a dual-head camera and fan-beam collimator 90–120 min after injection of ^99mTc-HMPAO. Brain SPECT images were obtained for interpretation.Our data suggested that 79 of the 96 patients (82.3 %) had abnormal HMPAO brain images. The predominant site of disease was basal ganglia (52/96 = 54.2 %), followed by temporal lobe (48/96 = 50.0 %), parietal lobe (44/96 = 45.8 %), frontal lobe (30/96 = 31.2 %), occipital lobe (21/96 = 21.9 %) and thalamus (8/96 = 8.3 %). No patients with acute CO intoxication had perfusion abnormalities in the cerebellum. In addition, there was no significant difference in serum COHb levels between patients with abnormal and normal HMPAO brain images. ^99mTc-HMPAO SPECT imaging is a useful tool to detect functional brain injury in acute CO intoxication.

Keywords: Carbon monoxide; Carbon monoxide intoxication; Regional cerebral blood flow; Brain SPECT; ^99mTc-HMPAO

Prognostic implication of thyroglobulin and quantified whole body scan after initial radioiodine therapy on early prediction of ablation and clinical response for the patients with differentiated thyroid cancer by Ilhan Lim; Seok-ki Kim; Seung-sik Hwang; Sun Wook Kim; Ki Wook Chung; Han Sung Kang; Eun Sook Lee (pp. 777-786).

To investigate predictors for successful ablation and disease-free status after high-dose radioiodine therapy in patients with differentiated thyroid cancer.We enrolled 173 consecutive patients with differentiated thyroid cancer between November 2001 and December 2004 retrospectively (female 145, 46 ± 12 years). All patients underwent total thyroidectomy and I-131 ablative therapy (IAT) (3.7–5.4 GBq). The success or failure of ablation was assessed 6–9 months after the IAT with reference to undetectable thyroglobulin (Tg) and negative I-131 whole body scan (WBS). Afterward, the decision for disease-free status was evaluated using Tg and WBS (follow-up period after 1st IAT 7–81 months, median 43 months, criteria of disease-free: less than 10 ng/ml TSH-stimulated Tg or less than 2 ng/ml TSH-unstimulated Tg and/or negative WBS). Clinical and tumoral factors such as sex, age, pathologic type, the size of tumor, quantified cervical uptake in WBS1, pattern in WBS1, ablative therapy dose, AJCC stage, lymph node (LN) stage, Tg just before IAT (Tg1), and ablation status were assessed using logistic regression analyses.There were 93 successful ablations (54 %). Significant predictors for the ablation failure were Tg1 (OR = 8.42; 95 % CI = 2.76–25.69; p < 0.0001), LN metastasis (OR = 3.05; 95 % CI = 1.11–8.37; p = 0.031), and quantified cervical uptake in WBS1 (OR = 4.95; 95 % CI = 1.07–22.88; p = 0.041). One hundred fifty-five patients were determined as disease-free after follow-up. All the eighteen patients with persistent disease were identified as ablation failure after first IAT. Significant predictors for the disease-free status were Tg1 (OR = 0.98; 95 % CI = 0.97–0.99; p = 0.028), tumor size (OR = 0.53; 95 % CI = 0.28–0.96; p = 0.044), and quantified cervical uptake in WBS1 (OR = 0.87; 95 % CI = 0.76–0.98; p = 0.024).The thyroglobulin and quantified cervical uptake in whole body scan are significant predictors for the successful ablation and disease-free status after follow-up.

Keywords: Thyroid; Differentiated thyroid cancer; Radioiodine ablation; Thyroglobulin; Whole body scan

Discrepancy of left and right hip bone mineral density (BMD) in Thai women: diagnostic agreement and misclassification by Sirianong Namwongprom; Sattaya Rojnastein; Ampica Mangklabruks; Suppasin Soontrapa; Potjaman Taya; Boonsong Ongphiphadhanakul (pp. 787-793).

To determine the diagnostic agreement and the degree of misclassification when using data from the left and right hips.The cross-sectional study of 1,943 perimenopausal and postmenopausal Thai women, who had bone mineral density (BMD) measurements at the left (non-dominant) and right hips for the screening of low bone mass (LBM) or osteoporosis (OP) in the Department of Radiology, Faculty of Medicine, Chiang Mai University from September 2008 to August 2010 was performed. The kappa statistic was used to assess diagnostic agreement. The prevalence of LBM and OP and the percentage of misclassification were reported.There was a significant correlation between the left and right BMD values for the femoral neck (FN) (r ² = 0.83; p < 0.001) and the total hip (TH) (r ² = 0.89; p < 0.001). The diagnostic agreement of the FN and TH regions was significant in all study groups ranging from 0.69 to 0.76 (p < 0.001). For the final diagnosis, which is based on the least T-score of the FN or TH regions, the diagnostic agreement was 0.73 for all women, 0.77 for perimenopausal women, 0.73 for postmenopausal women, 0.70 for postmenopausal women age less than 65 years and 0.71 for postmenopausal women age greater than or equal to 65 years. The percentage of misclassification for all women was 16.9 %, with 3.3 % being downgraded from normal to LBM and 3.4 % from LBM to OP.Despite the fact that good diagnostic agreement was demonstrated in this study, a significant number of diagnostic discordance between left and right hips (16.9 %) was also observed. BMD measurements of both hips are recommended for diagnosing LBM and OP in clinical practice.

Keywords: Bone mineral density; Discrepancy; Osteoporosis; Diagnostic agreement; Misclassification

Diagnostic performance of planar scintigraphy using ^99mTc-MIBI in patients with secondary hyperparathyroidism: a meta-analysis by Carmelo Caldarella; Giorgio Treglia; Alfredo Pontecorvi; Alessandro Giordano (pp. 794-803).

Parathyroid scintigraphy using ^99mTc-MIBI is not currently considered a valuable diagnostic tool for the localization of involved glands in patients with secondary hyperparathyroidism (SHPT). However, published data about its diagnostic accuracy are discordant and a meta-analysis about this topic is still lacking. The aim of our study is to meta-analyze the published data about the diagnostic performance of ^99mTc-MIBI parathyroid scintigraphy in patients with SHPT.A comprehensive computer literature search of studies published in PubMed/MEDLINE, Scopus and Embase databases through September 2011 and regarding the diagnostic accuracy of ^99mTc-MIBI parathyroid scintigraphy in patients with SHPT was carried out. Only articles in English language in which at least 10 patients with SHPT underwent planar ^99mTc-MIBI parathyroid scintigraphy were selected. Pooled sensitivity, pooled specificity and area under the ROC curve on a per lesion-based analysis were calculated to measure the diagnostic accuracy of ^99mTc-MIBI parathyroid scintigraphy in SHPT patients.Twenty-four studies comprising 471 patients were included in this meta-analysis. The pooled sensitivity and specificity of ^99mTc-MIBI parathyroid scintigraphy in detecting hyperplastic glands in SHPT patients were 58 % [95 % confidence interval (95 % CI) 52–65 %] and 93 % (95 % CI 85–100 %), respectively, on a per lesion-based analysis. Area under ROC curve was 0.75.In patients with SHPT and diffuse or nodular hyperplasia, planar parathyroid scintigraphy using ^99mTc-MIBI has demonstrated an inadequate diagnostic accuracy. Therefore, it should not be considered as a first-line diagnostic imaging method in the pre-surgical detection of hyperplastic parathyroid glands.

Keywords: Parathyroid scintigraphy; Secondary hyperparathyroidism; Meta-analysis; Diagnostic accuracy

Efficacy of ^99mTc-sestamibi SPECT/CT for minimally invasive parathyroidectomy: comparative study with ^99mTc-sestamibi scintigraphy, SPECT, US and CT by Yong-il Kim; Young Ho Jung; Ki Tae Hwang; Ho-Young Lee (pp. 804-810).

We evaluated the efficacy of ^99mTc-sestamibi SPECT/CT for planning minimally invasive parathyroidectomy (MIP), comparing with dual phase ^99mTc-sestamibi scintigraphy, ^99mTc-sestamibi SPECT and conventional imaging (US and CT).Thirty-one patients (M:F = 10:21, range 35–78 years old) who showed high serum parathyroid hormone (intact PTH) level were included. ^99mTc-sestamibi scintigraphy was performed 15 and 150 min after injection of ^99mTc-sestamibi (555 MBq), and ^99mTc-sestamibi SPECT/CT was obtained just after the delayed scan. Comparison study between imaging modalities was done by patient-based and lesion location-based analysis. The location of the lesion was confirmed by the operative finding. An operation was performed in 24 patients. Seven patients had normal ^99mTc-sestamibi SPECT/CT, and followed for more than 6 months after SPECT/CT.Among 24 patients, parathyroid adenoma was detected in 19 patients and the other 5 had parathyroid hyperplasia (total 35 lesions). ^99mTc-sestamibi scintigraphy detected abnormal uptake in 15 patients with 24 lesions. Conventional imaging identified abnormal findings in 17 patients with 27 lesions. SPECT detected abnormal findings in 18 patients with 27 lesions. SPECT/CT identified abnormal findings in 24 patients with 35 lesions. SPECT/CT demonstrated 100 % sensitivity in a patient-based analysis. SPECT/CT exhibited significantly better sensitivity than ^99mTc-sestamibi scintigraphy, SPECT and conventional imaging (p < 0.05). All lesion location was correctly identified to perform MIP. The final clinical diagnosis of 7 normal SPECT/CT patients was secondary hyperparathyroidism on 6 months follow-up.We correctly identified the precise location of parathyroid adenomas or hyperplasia by ^99mTc-sestamibi SPECT/CT which was helpful to perform MIP.

Keywords: ^99mTc-sestamibi SPECT/CT; ^99mTc-sestamibi scintigraphy; Parathyroid adenoma; Parathyroid hyperplasia; Minimally invasive parathyroidectomy

¹⁸F-FAMT in patients with multiple myeloma: clinical utility compared to ¹⁸F-FDG by Atsushi Isoda; Tetsuya Higuchi; Sachiko Nakano; Yukiko Arisaka; Kyoichi Kaira; Tadashi Kamio; Momoko Mawatari; Morio Matsumoto; Morio Sawamura; Yoshito Tsushima (pp. 811-816).

l-[3-¹⁸F]-alpha-methyltyrosine (¹⁸F-FAMT) is an amino-acid tracer for positron emission tomography (PET), with uptake related to overexpression of L-type amino-acid transporter 1 and proliferative activity in tumour cells. This study evaluated the diagnostic performance of ¹⁸F-FAMT PET compared with 2-[¹⁸F]-fluoro-2-deoxy-d-glucose (¹⁸F-FDG) PET in patients with multiple myeloma (MM).Eleven patients with MM (newly diagnosed, n = 3; relapsed after treatment, n = 8) underwent whole-body ¹⁸F-FAMT and ¹⁸F-FDG PET within a 2-week interval. Magnetic resonance imaging (MRI) of the spine was also performed to assess patterns of bone marrow infiltration. Tracer uptake was semi-quantitatively evaluated using maximal standardized uptake value (SUV_max). Mean SUV was also determined for normal bone marrow and the aortic arch as mediastinal background SUV to calculate lesion-to-bone marrow (L/B) and lesion-to-mediastinum (L/M) ratios, respectively. Those values were statistically compared using Student’s t test.In 8 patients showing focal infiltration on MRI, 34 FDG-avid bone lesions were identified, with each showing increased FAMT uptake. Mean SUV_max and L/B ratio of FDG (3.1 ± 1.2 and 3.3 ± 1.9, respectively) were significantly higher than those of FAMT (2.0 ± 1.0 and 2.6 ± 1.1, respectively; p < 0.05 each). In contrast, the L/M ratio of FDG showed no significant difference to that of FAMT (2.2 ± 1.0 and 2.4 ± 1.2, respectively; p = 0.3).Clear ¹⁸F-FAMT PET uptake was seen in most ¹⁸F-FDG-avid lesions among patients with MM, and an equivalent semi-quantitative value was obtained using L/M ratio. Our preliminary data suggest that ¹⁸F-FAMT PET provides a useful imaging modality for detecting active myelomatous lesions.

Keywords: Multiple myeloma; Amino acid; ¹⁸F-FAMT; ¹⁸F-FDG; PET

Time course of bone metabolism at the residual ridge beneath dentures observed using ¹⁸F-fluoride positron emission computerized-tomography/computed tomography (PET/CT) by Hanako Suenaga; Masayoshi Yokoyama; Keiichiro Yamaguchi; Keiichi Sasaki (pp. 817-822).

Excessive pressure due to wearing mal-adapting dentures is well known to cause residual bone resorption beneath the denture. X-rays have been commonly utilized to evaluate the changes in the bone beneath the denture. However, X-ray images merely detect bone density and relatively large changes in the bone shape and structure, whereas nuclear medicine imaging can detect functional changes, which occur prior to structural changes. This article aimed to describe the time course of the bone metabolism at the residual ridge beneath the denture following denture use by ¹⁸F-fluoride positron emission computerized-tomography (PET)/computed tomography (CT) scanning.Three subjects, who had a free-end edentulous mandible, were treated with a denture replacing the edentulous region of the dental arch. The metabolic changes in the residual bone beneath the denture were assessed by ¹⁸F-fluoride PET/CT imaging. ¹⁸F-fluoride PET/CT scanning was performed at baseline, and 4–6 and 13 weeks after denture use. A volume of interest (VOI) was placed on their mandibles at the edentulous region beneath the denture on the PET/CT image. CT value and mean standardized uptake value (SUV) of the VOI were calculated. The difference in the time variation between the CT value and SUV was analyzed.The adaptation of the denture base to the residual ridge was successful, and there was no trouble such as pain at the residual ridge beneath the denture. The SUVs of each VOI significantly increased at 4–6 weeks after denture use and then decreased at 13 weeks in all three subjects (P < 0.05; two-way ANOVA, Dunnett test). On the other hand, the CT images showed no obvious changes in the bone shape or structure beneath the dentures, and the CT values of each VOI remained static after denture use in all three subjects.This study indicates that in the present first-time removable partial denture (RPD) users, wearing of a well-adapted RPD initially increased bone metabolism beneath the denture and then decreased it at around 13 weeks after RPD use without any bone structural changes detectable by clinical X-rays. These metabolic changes are a mechanobiological reaction to the pressure induced by RPD use.

Keywords: Bone metabolism; Denture; Mechanobiology; ¹⁸F-fluoride PET

A comparative study of breast-specific gamma imaging with the conventional imaging modality in breast cancer patients with dense breasts by Bom Sahn Kim; Byung In Moon; Eun Sook Cha (pp. 823-829).

The aim of this study was to evaluate the value of breast-specific gamma imaging (BSGI) as compared with mammography (MMG) and ultrasonography (US).This study retrospectively enrolled 121 women with breast cancer (45.0 ± 8.1 years) and dense breasts (breast density >50 %). All patients underwent preoperative BSGI, MMG, and US, and the results were correlated with the biopsy results.In the 121 patients, 153 breast lesions were malignant tumors and 75 lesions were diagnosed as benign tumors. The sensitivity and specificity of BSGI were 92.2 and 89.3 %, while the values of MMG and US were 53.6 and 94.7 and 91.5 and 53.3 %, respectively (p < 0.0001 and p < 0.0004). In breast lesions ≤1 cm, the sensitivity and specificity of BSGI were 80.6 and 91.5 %, which were different from MMG and US, respectively (p < 0.0001 and p < 0.0003). Of 28 patients with 59 multiplicities, BSGI and US found 49 lesions and 51 lesions correctly. However, MMG detected only 26 lesions as malignancies.Given the results of this study, women with dense breasts are not evaluated with MMG at all and went straight to US or MRI in order to minimize radiation exposure. Due to the high false-positive rate of these modalities, BSGI could then be utilized if the US or MRI are positive.

Keywords: Breast cancer; Breast-specific gamma imaging; Mammography; Ultrasonography; Dense breasts; Tumor size

Tracheal involvement in ulcerative colitis: clinical presentation and potential interest of 2-deoxy-2[¹⁸F]fluoro-d-glucose positron emission tomography (¹⁸F-FDG PET) for the management by Youenn Jouan; Yann Venel; Bertrand Lioger; Christophe Monegier du Sorbier; Luc Gaucher; Sylvain Marchand-Adam; Patrice Diot; Elisabeth Diot (pp. 830-834).

Ulcerative colitis (UC) is an inflammatory bowel disease that can on rare occasions affect the respiratory tract. We report the case of a 32-year-old woman suffering from UC, for whom 2-deoxy-2[¹⁸F]fluoro-d-glucose positron emission tomography (¹⁸F-FDG PET) was useful, both for diagnosis and management of tracheal involvement. She presented with severe cough and fever, and bronchoscopy revealed inflammation of the trachea. Infection, vasculitis and relapsing chondritis were first ruled out. Lymphoma was then suspected, and ¹⁸F-FDG PET was performed, but revealed only a moderately increased uptake on the posterior wall of the trachea. Histological findings revealed non-specific inflammation. Systemic corticosteroids were prescribed and symptoms improved rapidly. After 3 months, bronchoscopy showed a significant reduction of the local inflammation, and ¹⁸F-FDG PET did not reveal the previous abnormal tracheal ¹⁸F-FDG uptake. Management of tracheal involvement of UC requires close monitoring. However, repeated bronchoscopies can be harmful in these inflammatory situations, and non-invasive techniques could be useful. ¹⁸F-FDG PET is used for the follow-up of digestive involvement of UC, but extra-intestinal locations have not been evaluated. Our case highlights the potential interest of ¹⁸F-FDG PET for tracheal involvement of UC, allowing a non-invasive assessment of local inflammation.

Keywords: Ulcerative colitis; Respiratory tract; Tracheal inflammation; ¹⁸F-FDG PET

A case of pulmonary choriocarcinoma metastasis with unusual FDG-PET and CT findings: correlation with pathology by Yasuhiro Maruoka; Koichiro Abe; Shingo Baba; Takuro Isoda; Yoshio Matsuo; Yuichiro Kubo; Shinji Ogawa; Tokujiro Yano; Masayuki Sasaki; Hiroshi Honda (pp. 835-839).

A 26-year-old female who had had a hydatidiform mole at 20 years of age showed high levels of serum human chorionic gonadotropin. Because pelvic ultrasound did not show any gestational sac in her uterus, she was suspected to have had an extrauterine pregnancy and a spontaneous abortion. About 6 months later, a pulmonary nodule in the patient’s right upper lung field was found on a routine chest X-ray film. Contrast- enhanced CT scans revealed a solitary lobulated nodule 2.0 × 1.3 × 3.0 cm in diameter in the S2 segment of the right lung. CT suggested a vessel malformation. Positron emission tomography using 2-deoxy-2-[¹⁸F]fluoro-d-glucose (FDG-PET) was performed and showed weak FDG accumulation (SUVmax = 2.0) in the nodule, which did not positively indicate malignancy. Because a follow-up CT showed a rapid increase in the size of the nodule, partial resection of S2 segment in the right upper lobe was performed. The histopathological diagnosis was a metastasis from choriocarcinoma. The tumor consisted largely of necrosis and hemorrhage, and it was considered to be a major cause of the unusual FDG-PET and CT findings.

Keywords: Choriocarcinoma; Pulmonary metastasis; FDG-PET/CT; Weak FDG accumulation

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Annals of Nuclear Medicine (v.26, #10)

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Annals of Nuclear Medicine (v.26, #10)