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(<1.Ocm),bronchOalvcolar car― cinoma,and carcinoid tumOrs,Falsc― positivc indings can bc caused by benign tumOL and innaHIIIlatory or infec― tious discase,c.g.,histOPlasmosis,tubcrculosis.Typically innalninatory lesions havc lcss uptake than rnalignant tumors,but ovcrlaP cxiStS,

Reference Gould MK,W【 acican CC,Kuschncr WG,ct al:Accuracy PET fOr diagnOsis ofPulmOnary nOdulcs and mass ics10nsi a meta―

助2285;936-937,2001. analysis,ン Cttss‐Reference 巡 助 び 筋″″鴎 品冴″α 軍

逆 QSN孤

,Cd 2,pp 209-210。

Comment

OfapprOxilnately 130,000 pullnOnary lung nOdules diagnoscd annualtt onC third are malignant,CT scans can further char― 30%to C■ 40%are indc, acterizc the lcslon.HOweveh attcr tcrminatα50%ofthcsc ultimately arc malignant.Ifcharacter― v― risk lstic benign changcs arc not secn in Paticnt,InultiPle a lo、 f0110w‐ uP CT scans are performcd ovcr 2 years to conarm that thc lcs10n is benign.Varlous invasivc Procedures arc uscd to make the diagnOsis,including brOnchoscOptt PCrcutaneous assistcd thoracoscopy and thoracotomys bioPstt and videO‐ Rcsection of pulinOnary nodules has assOciated risk.A nonin― vasive mcthod to preOperatttly detcrmine which Paticnts rc― quire a morc invasive diagnOstic PrOCedurc would avoid un― Hlorbidit/1 and cvcn dcath fOr lnany Patients. nccessary surgcrン 18F FDG,PET can help difFercntiate benign from malignantic― slons.Data frOm 17 invcstigations and 588 PatientS ShOw 96% s e n s i t i v i t y f o r t h e d i a ig gn nO as ni cs y o if nm 』s i n g l c P u l m O n a r y nOdules,sPCCincity Of 880/o,and overall accuracy of 94%.A ncgative FDG―PET study result obviatcs the need for diagnos― dc surgery in PatiCnts at high risk fOr surgcrywho havc chrOnic Obstructivc Puimonary diseasc(COPD)Or othCr serious mcd‐ ical problcms and yOung patients atiow risk for malignancye

Notes

オ

A38,ycar―old lnan had a diagnOsis ofgradc I,II astrOcytoma and was trcatcd ll years ago.Hc has had a rcccnt onsct Ofseizurcs.MRI shOwed nO dcinite change frOm thc many prior studies役

1.matFDG―

抄.

PET scan indings arc cxpccted with a 10w_grade gliOmaP

2.matis the nnding On this FDG―PET scanにりP

3.Interprct ths stuⅢ 4.Nsuld 99mTc HM,PAO shOw a simllar appcaranccP

59

Notes

Prlmary Braln Tumor l . L o w ―g r a d e g l i o m a s t y p i c a l l y h a v c P o O r O r n o u p t a k c . 2.Intense uptake in thc large teinporoPariCtal rnass.

3.Transformation gradc ofa low― Jloma. to agradc high― 4.No.Malignant tumOrs usually do nOt have rcccPtorS fOr binding ofthc radioPhaHnaceutical,which is neccssary befOre intracclllllar incorporation.

References l Delbekc D,Mycrowitz C,LaPidus RL,ct ali Optimal cutoff 18 FDG uptakc in the difFercntiation gradc oflow‐ icveis OfF‐ カΨ 195%7島Om high…gmdc brain tumors with PE■ 勉 あク 52,1995. Langleben DB,Seg組 lGM:PET in diFFcrcntiatio4 0frccurrent

′ 瞳嵐41:1861び brain tumOr from radiation/A協 in,ur乃 1867,2000. Cttss,Reference 配 沢どQじ騒 FES〕cd 2,pP 314,316. ″ ″α 「 力″″%″ び 助 す Comment PET by Di Primary brain tumors were nrstimaged with FDG― Di ChirO in 1982.Thcsc tumOrs have increascd glucOse me, tabOlism demonstratcd by 18F FDG―PEI The degrec ofFDG uptake correlatcs with the tumor gradc and the paticntも prog― nosis.Lowrgrade tumors(grade I―II astrOcytomas)havc PoOr or no uptake.High,gradc tumOrs(gradc III anaplastic tttrocy― tomas and gradc IV glioblastoma multiformc)haVe uptakc ctabollsIIl is greater than gray mattctt Becausc gray mattcr l■ threc tO four times that ofwhite matteh white matter typically is scen as having no uP[ake on the scans.BloPsy iS invasive and Ottcn prOvides limitcd infOrmatiOn.Because g1lomas arc not ho― mogeneous and contain areas of nccrosis,biopsy is subiect tO samPling erro丘 stercotactic bloPsy in hCt FDG"PET has been uscd to direc〔 T also is hclPful in the diFFcrcntial e r o g e n c o u s t u m o r s . F DPGE‐ diagnosis of intracranial masscs in Patients with acquired im―

munOdcncicncySyndromc KAIDS).TumOrs,such aslymphoma, takc up the FDG,whcrcas infecdon,c.g.,toxOplaSmosis,usually PET also may be im― dOes not have signincant uptakc.FDG‐ ant in the evaluatlon of the cFFectiveness of therapy.Thc POrモ uptakc Or abscnce of uptake of FE)G aFtcr therapy can dcter― Hline whether thc tumor has resPonded to radiatiOn therapye

Areas ofradiation necrosis have very low JuCOSe metttb01lSm, ん by uPtakc.Finalも whercas ineffective thcrapy is indicatcd F D G ―P E T c a n b e u s e d t o d e t e c t t r a n s f o r m a t igorna docf a 1 0 w ‐ changcs att seen on MRI, tumorto a high― grade iumor befOに as in this casc. ￨

A

ANT

B

SdndmammograPhy in twO differcnt padentt ,a И mammOgraphicJly dctected right bttast 硝a m益 a pttPabic mass adiaCent to a right brcast prOsthesis.

1. W7hat is the radiOpharJnaceuticalP W7hat is its lnechanisrn Ofuptake: 2. Describc the imaging indings and givc an interpretation. 0・ What iS the accurac/ofCOnventiOntt mammOgraphy and scintimammography fOr brcast canccrP

4. N7hat arc causcs offalse― negative and falsc― POsitiVC nndingS On scintilnarlrnograPhyP

61

Notes

Oncology:Scintimammography l.99mTc scstamibi lipophilicity a1lows it to cntcr the cell where it is conccntrated in the mitochondrial tO charge. 2.Paticnt A has prominent foctt uptake in a right breast mass,Patient B has dcnnite focal uptake at thc PcriPhery Ofthe brcast prOsthcsis. 3.Accuracy ofcOnvention】 mammOgraphy:sensitivi財 70% 20%to 30%. to 9う %;PositiVC prcdictive value fOr canccち ity/Spcdnaty2 :se,血市 SdntimammOgraphy mddccntcr d狙 ity2 870/oi nonpalpablc 750/o/83%.Palpable icslon sensit市 icslon sensitivit/j71%. negat市c indings are in leslons lcss than l cm. 4.Most falsc― as and bcnign Falsc‐ PositiVC indings occur in abroadcnOn■ and malignallt tumors other than breast cancci

References :DiagnOstic ac― Khttkali I,Villancuva,Mcycr J,Edcll SL,et狙 sestamibi brcast imaging:multiccnter trial curacy of 99mTc―

A物〃ルをグ41:1973-1979,2000. resuits,メ sestamibi and Othcr cOnvcntional T狐1lefer R:The r01c Of99mTc― 物″ ″A物冴 rad10pharmaccuticals in breast canccr diagnOsis,S夕 筋 〃29:16-40,1999. Reference CrOss‐ 配 ″ ″α 軍 助 び 筋″″協 妨ど

越 Qむ蕊

蕊 『 )ed 2,PP 204-206.

Comment Ography has 300d SCnsitivity fOr dctcction of rnalig― ｀在 a宜11■ nancy;its scnsitivity is lowcr in paticnts with dense breasts,im‐ Plants,or aFtcr brcast surgery or radiotheraPye Of grcater con― vomcn rcquirc ccrn is its P00r positivc prcdictivc valuc.Many、 blopsy,ccauSC Ofthe limitations ofmammographic diagnOsis. onstrate Only onc third to onc lourth Of breast bloPsics dcl■ cancei UltrasonOgraPhy can diffcrentiatc a cyst froIIl a solld tumor but has limitations for solid masscs.MRI is quite sensi― t能 ,but its specinaty馬10M The r01c ofsdntimalnmography (SM)is evplving.Becausc its negatitt predictive valuc(10%to lう%)is nOt adequate tO exclude malignan(7 with conndencc, b10Psy is stili nccdcd.Bcttcr imaging devices,including dcdir catcd breast scanners,arc bcing dcvcloped with the gOa1 0filn‐ c s l o n s . S M i s c l i nli cftotrl y u s c 角 f o r 1 s ml 組 p r o v e d s c ni st iy t 市 paticnts with nondiagnostic rnaIIIInograrlls,thosc with dcnsc brcasts,PatiCnts with brcast implants,prcvlous surger/P nOdular etrofOsmin,a cardiac im… brcasts,and abrocyStic diseasc,99mTcモ aging agcnt similar t0 99mTc scstamibi,has been uscd for SM and has simllar accuracyt

62

rcglon

relatcd

A39,ycar―old wOman had acute upper abdOIIlinal paino Cholescintigraphy was rcquested. 1. W7hat patient preparation is requircd befOre ch01cscintigraphyP 2. W7hich hepatObiliary radiOPharinaccuticals are available in thc Unitcd StatesP 3. Mttat arc the rad10pharmaccuticals lnechanisllflS Ofuptakc and their difFerenccsP 4. Has acutc cholecystitis been ruled Out,With what degrec oFcertaintyP

63

Notes

Hepatobiliary Systenl:Cholescintigraphy― NorrTlal Study l.No oral intake for 3 to 4 hours beforc radiopharrnaceutical i早 )ect10n.

2.99mTc disofcnin(DISIDAj,Hepatolite.99mTc mcbrOfenin (BrIDAl,Cholctec. 3.Both are iminodiacetic acid(IDAl anttOgucs,cxtrttted excreted by hepatOctteS into the biliary systemo McbrOfenin h 杏駈g h c r h c P a t o c y t e c x t r a c t i o n ( 9 8 % v s . 8 8 % ) .

and

4. Yes,Acute cholecystitis(cystic duct obstruction)is rulcd ncgattt rate c ofcertainty.The falsc‐ out with a high dcgに is l%to 5%. References Ziessman IIA,Zcman RK,Akin EA:Cholcscintigraphy:cOr中 _ latiOn with othcr hepatobiliary imaging modalitics. In ど ″ ″ら ed 4, ″″物材″ J″す″″材夕 Sandicr M■ edito■ Dガ竹 ″θ 比Wllkins. Philadclphia,2002,LiPPinCOtt WilllaIIlsに l ln Murray IPC,Ell PH,editos Frcitas JE:CholcscintigraP町 物夕 竹″″ ″ちed 2, す か″″冴″ 物′温噂 θ ″ご ″″″ ル″″初妨 "″夕″ 対務び London,1998,Churchill Livingstone,PP 83-92. Reference CrOss― 醍 ズどQSNFES,ed 2,PP 229,231. 助 す 筋″″Mcttcと″α 「 Comment

iFasting for 3 to 4 hours is required bcfore initiating chole― the gttibladdcr ient htt caten rccentiレ SCintigraptt lfthc Pa〔 stimulatcd cholc― aybe COntractedas a rcsult ofendOgenOusけ Ⅲ .The time required bcfore gallbladder relax― C/StOkinin(CCЮ itiOn dcPends on the size and type Ofrrlcal and the ratc ofgas, tric emptylngo Convcrseけif thC Padent htt not catcn fOr 24 hOurs and thus has had no stimulus to contraction,the ga11bladdcr is likely to be full ofviscous concentratcd bile that can of thc radiOtracer and result in a POsitiVe falsc― prevent entlγ laddcr in a padcnt without chole― S t u Ⅲ( n o n i l i n g o f t h e lgb】 cystitis).A CCK anttOguc,sincttidc(Knevacl,slould bC in― 99mTc IDA is inJCCFed 30 min― fused to empty the galibladde■ u[es aFtcr cOmplctlon ofthe sincalide infuslon to a110w tiIIle for galibladder contraction and relaxatlon.

Hepatic ttnction is g00d,as dc― This casc is a normalstudン tcrmhed by the prOmpt backgrOund(heart blood,001)Cicar_ minutcs,Thc commOn ductis visualized by 5 min‐ ance byう utes,The galibladdcr bcgins alling at 5 to 10 Hlinttes and is nllcd by 60 minutes,at which time thc liver

to,bowcl clearance is seen by 19 minutes, Out.Normal biliary‐ on duct is cicaring by 50 to 60 Hlittutes. and the coHlI■ Gallbladder alling and commOn duct visualization by 60 min― utes is deaned as normal.

64

has

mosdywashcd

l min

2市 in

10 rnin

15 min

301nin

45 rYlin

601‐ min

180 mh

〕肺

A4う ― vOman with clinically suspected acutc cholccystitis. year-01d、

1.ス,Is the study nOrma1 0r abnormal at 60 minutcP a IS it diagnOstic Ofacutc ch01ccystitis at 60 minute diagnOstic ofacute chOlecystitis at 180 rlllinutesP 2. И,W7hat is the diagnOstic accuracy ofch01cscintigraphy fbr acute calculous ch01ccystitisP,,W7hat is the diagnOstic accuracy ofch01escintigraphy lor acutc acalcu10us chOlecystitisP 3. W7hat is thc relative accuracy ofch01escintigraPhy vcrsus uitrasOnographyP 4.mat are thc mOst common causcs for ttsc―pOsitiモcholescintigraphy rcsuits in thc cvaluat10n Ofacute 丈 itisP ch01cq澪

65

Notes

Hepatobiliary Systenl:Acute Cholecystitis 1 9

4

A b n o r Nm Oa il . Cュ Y e s .

2.4 ScnsitMt/98%,specincit/95%.a Greater thal1 90%. 3. The few direct comPariSOns publishcd havc shown ch01e― scintigraphy suPcrior to ultrasonograpけ 4. Pr010ngcd fasting,hyperalirnentation,serious concurrent illness,chrOnic cholccystitis,and hcpatic insuFncicncy・

ReFerences S a m u c i s

B I , F r e i t a s

J E , e t

a l : C o I I I P a r i S O n

o f

r a d i O n u c l i d c

time ultrasOund for thc dctcc― PatObliary imaging and rcal―

dOn Ofttute chdecysdd島 勉あ 牝ノ14ス207-210,1983.

Swaync LC:Acutc acttculous cholecystith scnsitMty in dctcc‐ tion using technctiuHl‐ 99m lininOdiacctic acid ch01cscintig―

rap町 筋妨θ 33-38,1986. 物 16位 Cross―ReFerence ″′ 脇 び ″″″%務 f″ r TF/J択野Qさ 慰

E「 S〕ed 2,PP 237-240.

Colnment NonvisualizatiOn ofthc gallbladdcr at 60 minutcs is abnOrrnal,

but it is nOt diagnostic ofacutc ch01ccystitis.Tradition】 け de― laycd images for up t0 3 to 4 hours havc bccn acquircd to rnakc o r c x c l u d c t h c d i a g n OOsriisげ O. fT Ph ac t im eづn t s w i t h d e l a y e d su― galibladder visualizatiOn(nonvisualizatlon at 4 hOurs,but宙 alizatiOn at 3 to 4 hours)havc chrOnic cholecystitis.Thc advan― tage of cholcscintigraPhyお that thc PathOphys1010gical abnOr― mality is detected,1.e,,c/stiC duct obstruction.UltrasOnOgraphy vall shOws sccOndary and less specinc andingS,e.g.,galibladder、 thickening,pcricholccystic nuid.Ifan imaging study is ordcttd to conttm acute chOlecysdtis,cholcsdnugraPhy is hdicatcd.If thc causc ofuppcr abdonlinal pain is icss ccrtaln,ultrasonogra― ― p h y m a / b e m O r c a p p r o p r i a t c a s t h c iA nc iu tt ic t ta c st tt uc du ヌ 1 0 u s clhe。 cysdtis occurs in sick hosPitaliZCd PaticntS,C.ge,thosc 宙 t h s c vtcrにa u m a , s e p s i s , o r s h o c k . I t h t t a h i g h m O r b i d i t y a n d mor〔狙ity.In many patientt the cystic duct is Obstructtd by in… spissated bilc and innamrnatory debris;hOweveL sOmetimcs thc galibladder is innalncd hcmatOgcnously frOm inttcdOn Or todns, but without ObstructiOn.Bccausc the cystic duct is PatCnt the i ty for dctectlon with cholescindgraphy might bc cx― scnsit市 calcu10us chOlecys― PeCted tO bC sOmcwhatlcss than withc acu〔 t i t i s . I f t h e g a l i b l a d d e r n l l s i nt ha aP ahtiigchn tc宙 l i sn ui sc ‐ 』 negative outcome is suspected, PiCiOn fOr chOlcc/stitis and a False― chOlecystottnin can bc administcrcd.Acutcly Or chrOnic劇 lンdiS― cased gallbladders do not contract.A radiolabclcd lcukOcytc study may bc hclpFul to cOnarm or exclude the diagnOsis,

66

h c ‐

1 5 rnin A

35 rnin

50 rnin

B

15 min

30 rnin

A53 ycar― old woman htt reccnt onset ofright upper quadrant Pain and suspccted acute chOlccystitis.И ,60rminutc chOlescintigraptt a 30-minutc PoStmOrphinc acquisition. 1. N7hy is rnOrphinc used as an alternative t0 3,to 4-hOur delaycd imagingP

2. In a paticnt with nOnvisualizat10n Ofthe gallbladder at 60 rninutcs,what rnust be deterttlincd bcfOre rnOrphine is adHlinistcredP 3. W7hat is the accuracy ofmorphine ch01escintigraphyP 4.Whatis the dOse OfmorPhine,and hOw 10ng after ittectiOn is the imagc obtaincdP 67

Notes

Hepatobiliary Systenl:Morphine‐

Augmented

Cholescintigraphy l. MOrPhinc PrOduccs contraCtion ofthc sPhinctcr OfOddi, which incrcascs intraluminal common bilc duct Pressurc. Bllc and cxcreted radiotracer then prcfcrcntially now thrOugh the cysdc duct hto the gttbLdder rhc cySdc duct is patent. 2.Excludc drug allergy.Do not give ifevidcnce OfcOmmOn duct obstruction,c.g.,dclayed illin3 0r clearancc ofthe to‐ bowel transit,cxists. colnI■ on duct or delayed biliary‐ he accuracy is at icast as good,ifnOt bcttctt than thc 3. i「 dclaycd imaging rncthod. 4.Intravenous administradon ofO.04 mg/kg mOrPhine,cogり kg paticnt.Images arc acquired for an 2.4 mg fOra 60‐ additiona1 30 rninutcs.

References K i m C ]K亀 e v i n 醐, c t a l i C h O l e s c i n t i g r a p h y i n t h e Ofacutc ch01ccystitis:Inorphinc augmcntation is suPcr10r to

diagnOsis

1870,1993. ミ韓r/%〃 34:1866‐ dclaycd imaging,ノ augmented Kisticr AM,Zicssman HA,Gooch D:Morphinc‐ 狙temativc to delayed cholescintigraPhy in acute cholccystit愚 〃%〃 16:404-406,1991. iinaging,Cど '″」 甲物び Cross―Reference 述 務″″%冴 び ″ ″含 『 助 び

京EQdS 「

ES〕ed 2,pp 238-239.

Comment

The 60-minute study(2りshows nOrlnlling Of the galibladde島 to― bowcl ncar― complcte washout 6fthc livch and nOrinal biliary― dOsc Of99mTc IDA was administered at transit.A rcPcat half― the samc timc as mOrPhinc infus10nにり.Notc the increasing hcPatic uptake at 5 t0 10 minutes.Thc galibladdcr prOmptly visualizes, ruling out acutc cholccystitis. With thc raPid washOut oftcn scen with IDA radiopharmaceuticals,delayed imtting can be prOblematic.In addition,a3-to hour 4‐ test is augmentcd chO― not optim』in a seriously ill Patient.Morphinc― lescintigraphy is rOutinely uscd in many nuclear medidne labロ oratorics to conflrin thc diagnOsis of acutc chOlecystitis. Howevctt thc handling ofnarcOtics requircs accountability and and nights at sOmc can be a logistical probleHl veckcnds on、 hOsPitals.Thc rciniec[10n ofthe radiOtracer at the time ofmor― Phine infus10n sometimes is ncccssary because thc llver often orPhine causcs a has washcd out by 60 1ninutcs.Bccausc l■ On duct obstruction,the diagnOsis of functiOnal partial 11■ co■ COHlinOn duct obstruction cannot be rnadc once it is givcn. Thus cOmmOn duct obstruction must be excluded befOrc mOr― Phinc adlninistration.Aftcr intravcnous infusiOn ofmOrphine ifthe cystic duct is Patent.Thus the gallbladdcr nlls prOmp[1乃 the entire study takes Only 90 minutcs.Nonalling Of the gall― bladder 30 1ninutes aFtcr mOrphinc adHlinistration is consistent M/ith cystic duct Obstruction and acutc cholecystitis. 68

lmrnediate

A

40 min

60

45

B

ピ

傷 120 min

RA0

LA0

A43-ycar―old worllan has a 10wrgrade fever and abdorrlinal discOmfOrt 2 days after chOlccystcctom/. 1. Describe thc ch01cscintigraphic indings.

2.Intcrprct the stuⅢ 3. ｀商hat arc POSSible causes fOr this prOblcHIP

4. Nマ hat unique infOrmation does ch01cscintigraphy prOvidc that is nOt obtainablc frOn1 0ther diagnostic imaging procedurcsP

Notes

Hepatobiliary Systenl:B:liary Leak l,F協呼北d bllc icakage probably Originating ttom thc reglon of he止 留平cd cysdc duct and cxtendng towad thc dght c010nic gutter and Mれ d■tiIIle,over thc dOme Ofthe livci 2. RaPid biliary lcak.

￨

On Cause is disruption Ofthc qttstic duct 3. The rnOst coHlI■ ligature aftcr ch01cc/stcctOmン Othcr causcs fOr leak include disruption Ofa surgical anastOmosis,blunt Or pcn― etrating trauma,interventiOnal radiOgraphic PrOcCdures, tumoL or innamrnatory processes. 4. COnnHn that nuid c。 1lectiOns sccn by anatOrrlical imaging mOdalities are biliary in nature.The rate Ofleakage alsO can be cstimated.

Reference Roscnberg DJ,BruggC WR,Alavi A Bile lcak fol10wing an elcc‐ tive laparOscopic cholec/stCCtOmy:the r01e of hcPatObiliary imaging in thc diagnOsis and managcmcnt Of bile leaks,メ ハあ″ び ′%〃 32:1777‐ 1781,1991. Ctts詞 降ference 対務び 筋″″丹々妨fガ 配 択どQ5蕊 ″α 『

r蕊 】ed 2,PP 244,245.

COmment Blliary tract iniury resulting in bile leakage Occurs in less than 10/o ofPatients undcrgOing cholec/stectOmye HoweveL the cOrFl‐ PttcatiOn can havc dire conscqucnces.A reduction in inorbidit/ and mortality can be achicvcd by carly dctcctiOn.Sterile s10w biliary lcaks Ottcn sctt sPontaneOus,whCrcas iarger and mOに raPid leaks Oftcn rcquire surgical intcrvent10n,Ch01cscin― tigraphy is a very scnsittt and sPccinc nOninvttivc method fOr dctect10n Ofa blle lcak and estimat10n ofthc leakage ratc.Bllc l c t t e c a n f c s u l t i n p e r i t o n i t i s , s u b h e p1altcicct iaOuni,da bc― 。 SCCSS,and istula fOHnatiOn. llectiOns UltrasOnOttaphy and CT can rehabけdCtCCt nuid C。 but Otten cannOt dctcrmine whcthcr thcy cOntain bilc Or tteely COHllnuniCate with the biliary trcc.Bccausc a frcquent causc of postopcrative bile lcakagc is incOmplete cystic duct ligatiOn,thc most common sitc ofbile c01lectiOn is in thc gallbladdcr fOssa, 狙thOugh subcapsdtt and intrapcritone』 locatiOns may be sccn, Bl10mas Oftcn aPPCar phOtOpenic initially;however with timc they nll in and bccorllc rnore ous.Multiple ob宙 vicws are often h c l P t t t O a c c u r t t c l y l o c a t e a n d c o n a r m tehwcs i c a k . D c l a y e d 宙 beyond thc routine 60-minute imagingPcr10d mttbe required tO dctect a siow leak Or One that is Obscurcd by cntcric activity. Ifimmediatc surgery is not dinically indicatcd,chOlescintigra― phy may be ttPcatcd On alater day to connm improvemcnt or rcs01ution ofthe biliary leak,

70

10bclc負 A59-ycar,01d man is reFerred with abdOminal pain.CT reportcdly shOwcd a lcsi9n Ofunccrtain origin in thc Ofthc livc丘 1,What is the radioPharmaccuticall Mttat is the studyP 2. W7hat are thc nndingS and the ttkely diagnosisP 3. Ho、v iarge rnust this lesiOn bc to be seen on Pianar scintigraphyP 4.mat are thc advantages/disadvantages and accuracy ofthe radiOnuchde studyP

ワ′

Notes

Hepatobiliary Systenl:Cavernous Hemangioma cf the Liver l.99mTc― labeled red blood cclls(RBCs).RBC liver scindgrap町 v nO dennitc abnormalitye Dclaycd 2.Immcdiatc images sho、 images show incrcascd fOcal uptakc in thc lcFt 10bc cOnsis‐ tent with a cavernous hcmangioma. 3. Atleast 2 cm. 4.Vcry

s P c c i n C )( f> o9 r9 0 h/ e。m a n g l o m a . P o O r

scnsitivity

sma11 lcs10ns.

ReFerence Birnbaum BA,VeignrcbJC,MCigibOwAJ,ct al:Deinitive di‐ agnosis of hcPatiC hamar[Omas:MR versus 99mTc labclcd RBC SPEC工 酪 あoれ。 176:95-101,1990. Ziessman HA,Silverman PM,Pattcrson J,ct al:ImprOved dc― tectlon of smali cavcrnous hemanglomas of thc livcr with high―rcsOlutiOn thrcc― hcadcd SPEC■ /ハ 物〃鴎 嵐32:20862091,1991. Reference Cross― 助 滋 ″Mcあ ct″ 4初

逆 QDttZttCd 2,pp 250,253.

Comment

CavernOus hcmanttOmtt arc the mOst common bcnign livcr tu… ncc onけ morj second h Occurに to hepatic metastases.They ttc composed ofabnOrmally dilated cndOthcliallincd vascttar chan_ ncis Ofvaり ing sizc scParatcd by ibrOus scPtac.HCmanglomas are not hyPcrvascular but havc incrcascd vascular space(blood Pool)comparedwith nOrmaltissuc.Thc cxPlanatiOn fOr thc char― actcristic changc in appcarance ttOm immcdiatcly aFtcr tteCtiOn unti1 1-to 2-hour dclaycd images is the time reqtired for the la―

lativcけ beled RBCs to exchange and equilibrate宙 th the largc,崎 Oma・ B100d nOw stagnant,nonlabdcd b100d P001 0fthe heman」 usually is nOrmal. UitrasOnOgraphy has poOr sPcCincity fOr thc diagnOsis of hemanglomas.Whcn strict CT criteria are used,sensitivity is only 550/oto 70%,With icss strict critcria,scnsitivity is higher but specincity iS cOnsidcrably Poorcr.MRI accuracy is high, vevett falsc― prObably greatcr than 900/0,ho、 pOsitive results Oc― cur becausc ofa variety ofbcnign and malignant tumors.Direct comparisOn studics ofM【 RI and SPECT havc shOwn simllar ac‐ hemanglomtt and c u r a c / P t t t h O u g h sMuRpIcお o五r f O r slm 』 o r v e S S C l s . T h c P O s i t i V C P r C d i Cvtailモ uc Of thOsc attacentto mり

thc RBC studyお highci Planar imagcs can dctcct hcmanttOmtt tO a size oFapprOxl‐ mately 2 cm,and smaller ifthey are suPCrnciale sPECT is suPcr― lor to planar imaging.ヽ 在 ultiheaded SPECT caIIIcras a1low dctcc―

tion of most hcmang10mas l.4 cm Or larger in size.A mttOr advantagc Of thc RBC technique is its vcry島rhigh sPccincけ hemangioma.Falsc‐ pOsitive results are rare.

72

fOr

B

30

35

40 min

TwO Patients undcrgo studies for gastrOintestinal biceding. 1.What radiOpharmaccuticalis usedP И・ 2.Detcrmine thc site ofblecding m stuけ 3,Dctcrmine the tttc ofblccding in studyユ 4.What is the s10west rate ofbleeding that can bc dctected with scintigraphy and with contrast anglographyP

Notes

Gastrointestinal Systenl:99mTc RBC Colonic Bleeding l.99mTcrlabcled RBCs。 2.ИけLett co10n,rcctOsigmoid regiOn. 3.ユ Right c010n,hepatic ncxurc.It moves raPldly to thc lc丘 c010n,

4.RBC scintigraphン 0。 l m1/1nini contrast angiograPhy(1.0 m1/min).

References Maurer AH:GastrOintestinal blccding and cine― scintigraphン S夕 ,物 ガ ″ハあ″ 〃%グ 26:43-50,1996. Guticrrez C,MarianO M,Laan TⅥetal:Thc usc OfTc_labclcd erythrOc/tC SCintigraphy in thc cvaluatiOn and trcatmcnt of 10wcr gastrointestinal hcmorrhage,」 4%2S″牲算64:989-992, 1998. Cross‐ ReFerence 助 び 力″″%冴 f″ ″貧 E醍 涼王文25慰

ES,cd 2,PP 280-287. 「

Comment The purposc ofthc rad10nuclidc gastrOintestinal biccding study is tO diagnOsc the apprOxllnate site ofblecding so that the an― giographer can IIlinilnize tiinc and cOntrast in PinpOinting thc cxact sitc.Thc apparent site Of activc bleeding usually is de― scribcd as at the cccum,hcPatic nexurc,transverse acxurc,。r rcctosigmoid reg10n.Thc angiographcr and surgeOn need to knOw whethcr thc bleeding sitc is in the distributlon Of thc ccllac,superio5 or inferiOr rnescntcric he arteryei「 radlonu‐ dide biccdng study狙 10ws ttr a mOre raptt and safcr anglo…

colon,splcnic

graPhic PrOcedure by thc tilne savcd in locating thc sitc and thus minimizing the alnOunt Ofcontrast media requircd. 99mTc sulttr c01101d also has been used tO diagnose gastrOin― tcstinal bleeding,Aftcr intravenous inicctiOn,it is dcarcd frOm thevascularsystcmwithin15to20rninutcsbecauscofraPidex― traction by thc reticu10endOthclial system(RES),Particularly thc l能randsJeeno With active biccdng,radiOtracer cxtravaslcs筑 the blccang sitc intO the bOwcl lllmcn.The targct/backgrOund ratio is high.HOwevett bccausc Ofhe intcmittcnt natutt ofgas‐ trointestinal biccding, cO1loid scintigraPhy has lirnitatiOns. Bleeding must Occur during thc 20-to 30-minutc study alld be detcctcd.D』ayed imtting is not possiblc,unicss the 99mTc sulttr cO110id iづ eCdOn is repeated.COmparathc studics Of99mTc_surur c01101d and 99mTc-labeled ctthrOtts havc cOnsistently shOwll thc supettority ofthc labeled cells.

74

■o‐ min

A

1垢 杭￨

B

RA0

A5-ycar―old girl is rcferred after PaSSage ofa b100dy stOOl. 1. ヽ 7hat is the radiopharrrlaccutical,its lnechanisln Of uptake,and study typcP 商/hat is thcir rnechanismP 2. ｀ 商/hich pharmacological drugs can be llscd tO enhancc dctcctabilityP｀ 3. PrOvide an interprctation. 4. ｀ 前/hy is biccding a coHllnon comPllcation Ofthis discasc cntityP

Notes

Gastrointestinal SysterTB:Meckel′ s Divert i c u l u m l. 99mTc Pcrtcchnctatc Mcckcltt scan.Thc radiOpharinaccuti― cal is takcn up and sccreted by gastric rnucosa. 2. Pcntagastrin incrcases rapidit/P intensityp and duration Of

uptakc.Itis uscd with JuCagOn,which htt an antiperi― staltic cfFcct that inhibits thc rapid disPcrsiOn cfFect of Pentagastrin.Cimetidinc,a histarnihc antagonist,incrcascs and pr010ngs uptakc bccausc Ofinhibi〔 10n Of99mTc PCrtCChnctatc sccrction fron■ gastric rnucosal celis,It is corninonly uscd bccausc ofits iack Ofsidc cffects. 3. Increasing FOcal uptakc in thc IIlidPabdomcn susPic10us IOr Mcckclも divcrticulurrl;hOwcveL at/Pical tilning ofuptakc lcsscns the certaint/e Thc uptakc shOuld bc cOincident with [cckclも divcrticulum.This may gastric uptake in cascs of臣 be a False― pOsitive scan. 4. Acid and PcPsin sccrct10n by thc gastric rnucosa produces innammation and ulccratiOn OfadiaCCnt bOwel mucOsa.

ReFerence

Treves S■Grand RJ:GastrOintestinal biccdinga ln Travcs S■ ta″ editOriみ沈 ガf″″び ル″″物夕 ι ″ご ″ ″らcd 2,Ncw York,1994, Vcrlag,PP 179‐ SPringer― 189. Cross‐ ReFerence 対務び 力″″%渉 す ″ ″α 軍 醍

京どQdSr蕊

,cd 2,PP 288-290.

COmment McckelもdivcrticuluH1 0ccurs in 10/O t0 30/o of the populatiOn. This mOst cOmmon gastrOintestintt congcnital anOmaly is callscd by failcd c10surc ofthc Ompha10mescnteric duct in thc cmbr/0, It is a truc divcrticulunl and arises on thc antilncscntcric sidc of the smali bowel,usually 80 to 90 cm prttmal tO the ileOcccal valvc.Gastric mucosa occurs in 10%to 30%ofcases,in 60%Of symptomati,PadcntS,arld in 980/o ofPaticntS｀ Vith blccding. Thc Pattem Ofuptake in this casc is atypical for a Meckclも di_ vcrticdum,which tticalけ demOnstratcs uptake dmdtaneOusけ with thc stOmach.In this case thc uptakc is dclaycd rclative tO gas― tric uptake and is nOt as intcnsc as usual.Falsc― pOsitive studics can occuL most commonly rclated to accumulatiOn Of tracer in thc udnary tract,c.gり CXtrarentt Pclvis,hydroncPhrOsis,使 nux,blad― der divcrdculumo Other callscs indude 10cal intcsdntt hypcrcmia and innaHllnation,c.g。 vcl diseasc,abscess, ,innalnlnatory bo、 appendicitis,and tumors,Gastric mucosa also may be fOund in Barrcttも csophagus,retお ncd gastric antrum,and gastrOintcstinal duPlicatiOns.These can bc disdnguished丘 。m Meckelもdiverticur l l l m b y d i n i c a l h i s t O t t a n dc cl Jo gc a st ti 五 t i v c― に O n . F anlesgca‐ sdはoccas10nallyOccur bccallse Ofthc raPid 99mTcwashOut Or lack O f s u F n c i c n t g a s ,t lr ei sc s m tu hc ao ns a 2, c c. mg .。T h c O v e r a l 0/O sensitivittr and 950/o sPccincity・ curac/is 8う

76

a c ―

A Patient With insulin_dcpcndent diabetes has chrOnic symptoms ofearly satictt PoStprandial b10ating,and abdominal cOnduct 90 minutcs tter a s01ld meal. 面scOmfOrt.A gastric empt/ing studyお 1, 対 マhat is the diagnOsisP 2.Wttat arc normal valucs for s01ld mcal gastric empt/ingP 3,恥

at is the advantage Ofa s01ld radiolabeled meal over a liquid mealP

4.Wtty is attcnuation corrcction rccommendcd for accurate quantincation ofgastric empt/ingP

77

Notes

Gastrointestinal Systenl:Diabetic Gastroparesis l.Consistent with scvcre diabctic gastroparesis.ObstructiOn cannot bc ruled out. 2.

Normal valucs arc mcギ and dcPcnd On its speCinc v01umc/cOmposition,thc methOd Ofacquisition,attenua, tion tOrrection,processing,and quantincatlon.Normal valucs must be determined in cach clinic Or results ofa published lnefhOd ShOuld bc f0110wcd ciOselye SOttd(meao or semisolid(cggl gastric emptying saに me』 more scnsitive rbr dctcctiOn OfHlild tO rnOderate dclay in emptying than studies cOnducted aFtcr a liquid Hleal,

4.

ActMty is dctccted宙th grcatest ettcicntt dosc tO the cam― cra.The antcriOr宙 cw alone undcrestmatcs cmpt/1ng,and thc POsterior宙 cw overestimatcs it bccause Ofvariabic attcn‐ uation as thc tteal movcs thrOugh the stOmach frOm the or gastric ttndus tO the more antcrior gastric arltrum. poste五

ReFerence Zicssman HA:KccP it SiHlplc一 ―ittt Onlγ gastric cmptying!In Frccman LM,cditoH助 能a″れ物妨す ″ ″夕И″″″ ″ブ2θθα Phila― dclPhia,2000,LiPPincOtt Williarns tt Wllldns,PP 233‐ 260. Cttss‐Reference 助 す 揚″″Mcttch′ f軍配

越 Q5横

切 吃u cd2,pp 273-279.

COmment

Diabetic gastrOParCSiS is a complicatiOn Of diabctes caused by vagal nerve damagc in a generalizcd autOnonlic ncuroPath/. SymptOHIs are nonspccinc and oftcn indistinguishable frOm Other diabetic PrObicms,c.gり P00r glucose cOntrol and inttc― tion.S01ld emptying can be undcrcstimated unless attcnuation correction is PerfOrrlled.This is a particular prObicm in Obcsc patients,bu1 0ccurs in nOnobesc Patients as wcll.Correction cannot be donc tter thc test.The geomctric mean mcthod is the mOst accuratc,rcqui五 ng bOth antcr10r and POsterior acqui― sition and then lnathematical correctiOn at each tilnc Ifa POint・ hCadcd camera is used,scquentitt anterior and POsteriOr Sin」e‐ 宙cws call be Obdned.Altcmttiモ 1ンthc study can be acquiに d in

ihe lcft anteriOr obliquc(LAO)prOjection.In this vicw thc StOttach contents movcParallCi roughけ tO thc dctcctOL thus compensating lbr attenuation、 vithout the need lbr rnathcmati― cal cOrrecrion.Accurac/ushg hc LAO PrOiCCtiOn cOmpares fa_ vOrablywith thc gcOmetric mcall.Timc― act市17 Curves att uscd to quantけ emptying.Thc pattctt ofsOlid empヴ ng iS Charac― tcrized by an initial lag phase f0110wed by lincar ettPtylng・ ThC lag phasc is thc tilnc requircd for the antrum tO grind uP s01ld foOd intO smttl enOugh Partidcs(lto2 mm)to Ptts through thc

sPOnsible ttr liquid emptying, Py10rus.Thc ttndtls isに primttiけ which Occurs rapidly(h狙 阜lifeし ]Of 10 t0 20 minutcs)in an CXPOnen[lal Pattern.

78

騨 A3-mOnth―

old infant was refcrrcd with symptOms OfgastrOcsOphagcal rcnlx.A radionuclide gastrOesophagcal renux

study(mlk studyl was PcrfOrmcd(POsterior viewl. 1. ヽ7hat arc coIIIInOn SymptOms and PrOblcHls in childrcn associatcd with rcnuxP

2. ヽ 7hat Other rnethod is used by pediatricians fbr detectiOn ofrenuxP 3.What ranolabcl and what mealis uscd ttr ths studyP 4.HOw frequently shOuld ilnages be acquired to maximizc scnsitivitt ofthis tcstP

79

Notes

′ Gastrointestinal Systenl:″ Milk′ Study― Gastroesophageal Reflux l. VoHliting,pullnOnary symptoHls,asthma,Pneumonia, sudden dcath,fallure tO thrive,ancmia. ２  

24‐ hOur pH mOnitoring.

３

9 9 m T c s u l f u r c O 1 1 0 i d ( l m C l ) i n tuhseu aclh ifledeも ding, fOHnula,Or nlilk.

4.

うto 10 secOnds/fraFne.

Reference P i e p s z A R e c e n t a d v a n c e s i n P c d i a t r i c n u″ cicar mcdicinc,最 物物 脇 す ′泌石″ 〃25:165-182,1995. Cross―Reference 助 び 彦″″%冴 び ″ ″α 「 避

越 Q5NFES,cd 2,PP 270-273.

COmment GastrOcsoPhagcal renux is a common clinical pediatric PrOb‐

lem.Although thお Occurs in thy hc』inttnts,itけusu狙 reSOttes by aPPrOximatcly 8 months and rarely causes serious medic狙 PrObicrrls.HowcvcL somC Childrcn have symptomatic rcaux that can persist intO adulth00do Symptorlls associated with re― nux can bc scr10us,including ttlurc tO thrive,csOphagitis writh stricture,anenlia,asPiratiOn,recurrcnt rcsPiratOry infectiOns, asthma,and suddcn dcath syndrOme. Thc 24‐hOur PH prObe rnOnitOring techhique Oftcn is cOn― sidered the gold standard.HOwcvcL COmparative studies ofthe t w o t e c h n i q u c s h a v c s h O w n s i m i l a r s e n s i t i v i t / f o r gastrocsophagcal rentlx by Scintigraphy(mllk study)and PH probe.The disadvantagcs of the pH PrObe are that children younger thanう /cars lnust be hOspitalized and POssible undcr_ estimation ofrentlx bccausc a smali v01umc Ofacid rentlx may adhcrc tO thc PrObc,PrcVenting subscquent cvcnts frOnl being recordcdo COnvcttctt thC mllkstudyis mOstsensitivewhen stomach is飽11,As it emptics,thc dctcctCd rcntlx cventS decline. The mllk study is a simple study to PerfOrm.After ingcsting thc milk Or fOrmula feeding,the study is acquircd for l t0 2 hOurs with thc child supinc On thc garrllna camera.Reflux events can bc dctcctcd casily On cOmPuter review ofthe stuⅢ Various quantitativc lnethods have been usedi the lnOst silnPic and stralghtfOward is counting thc numbcr Ofに ntlx cventt and CatC80rizing them as high(grcatcr than ftheh】 distance tO the mOuth)Or10w and shOrt(less than 10 seconds)or long events, This case study has frequent short and 10ng rcnlぷ cvchts.The paticnt htt many high and 10ng rccurrcnt ttallx cvents.

80

d e t e c t i o n

the

o f

か

微

A

ド

B

A35-year,old man has bccn cOmatose for 2 wccks since a reccnt severe hcad iniurン The cicctrOencepha10gram(EEG) is nat and hc is being considcrcd as an Organ dono丘 1. Ifthe EEG is a natlinc,why is anOthcr study indicatcdP 2. W7hat arc the clinicai nndings ofbrain dcathP

3 . L i s t w O d i f f e r c n t t / p e s o f r a d i O p h a r m a c c u d c a l s w i t h d f f c r c n t m c c h a ns it su m与s t h a t c O d d b c u s 4。W7hat arc the scintigraphic andingS and thc diagnOsisP

81

Notes

Central Nervous Systenl:Brain Death l. An isoelcctric nat EEG can bc caused by barbiturates, dcpressive drugs,or hypothermia. Dccp colna,no brain stcm renexes or spontaneous rcspira‐ tion,cxclus10n Ofreversible causes,and thc cause Ofthe brain dySfunction must be diagnOsed. 3.

99mTc diethylenctriaminepentaacctic acid(DTPAl or

99mTc pcrtcchnetatc can bc uscd tt a brttn aow stuけ (radlonuclidc angiOgram).HoweveL 99mTc HM‐ PAO and 99mTc cthyl― c/stCinatc dimcr(ECD)have thC advantagc of irrcvcrsibic ccllular binding on the arst pass,a1lowing fOr dclayed images.

4.

No blood nOw to the ccrebral cortcx.Brttn blood now study consistcnt宙th brain death.Thisis a99mTc DTPAstuⅢ 99mTc HM― PAO would show salivT uptake,With nOrmal bttn perttion,ccrcbral cor[ical activitywould be sccn.

Reference Кko亀ky RS,MasanOri I,Scibメ J■ et』:Functional brain SPECT imaging:1999 and bcyond.In Frecman LM,editor: ‐ ″夕″″″″ ″′ゴ 助 並住″″`冴た″ タリワI Philadclphia,1999,Lippincott WilliaFnS&Mlkins. Cttss― Reference 力α TrrF択どQdtt「 蕊 )Cd 2,PP 305-306,312助 f揚″″協 冴び 313. COmment Specinc critcria required to makc the diagnOsis ofbrain dcath havc been published and are listed above.The diagnOsis is Pri― marlly clinical.The nndingS Ofbrain dcath must bc Present FOr at least 24 hOurs.Ancillary tcsts are used to incrcasc the diag― nostic certaintt A single EEG does not adequately diagnosis.A[icast Onc additional cOnflrmatOry study is re‐ quired.Incrcascd intracranial Pressurc suFncicnt。vercOme t。 which is artcrial blood Prcssurc Prevents cercbral b10od n6Hら diagnOStiC of brain dcath.The radionuclidc study is ordered when the diagnOsis is uncertaln. Although 99mTc Pcrtcchnetate and 99mTc DTPA havc been used successhly for ycatt to evaluate for bttn death,they have limitations.Tcchnical prOblems,cag.,a bad boltls,or carllera or cOmptter failure duttng acquisition,can complicate interpret伊 tion.Howcve与 the new cercbral perttsion agcnts,99mTc HMP PAO and ECD nx intraccllularly in brttn cclls.A 為now stuけ not mandatorye Static ilnagcs ttRer the now showwhethPr the ra, is taken up by thebral ceにcortex.IfcOrdcal dlophttmaccudc』 mcd. the diagnosis ofbttun dcath is conarコ uPtake docs nor occuち labeled brttn Pcrtts10n agents This is the only use ofthe 99mTc‐ whcre SPECT is not rcquired.

conarm

the

A65,year―old man with rccent acute onsct ofrlght― sidcd hcmlParesis undcrgoes 18F FDG― PET scanning。 1.mat is thc radiOpharmaccutical used fOr metabolic ccrebralimaging wlth PE工 and whatis thc mechanism Of uptakcP ２

mat are the radiOphaHnaceuticals uscd fOr PET cerebral pcrFuslon iELagingP

３ ４

D e s c r i b c t h i s P a tPiEeTn tiも m a g i n g i n d i n g s ( a b O v c , t r a n smviedrdslα e,sagittal;bottOm,transversc)P 対Vhat is thc differcntial diagnOsisP

83

Notes

Central Nervous Systenl:Cerebral infarct l.18F PET―FDG is dcpendcnt on glucose mctab01lsm. 2.SPECT 99mTc HM― PAO ttd ECD are cercbral Pcrhs10n agcnts that are liPid solublc,distributc according to 3:l to 4:1),and cercbral blood nOw(gray tO whitc matte島 ax intraccllularlye 3.

Wcdgc‐shaped scvcre dccrcased lnctabOlisin in thc left POSterior parictal rcgiOn in a vascular pOsterial parictal distributlon.

4.

Ccrebral hcmorrhagc,infarct,and ncoPlasm.

References R a d i o P h a r m a c e u t i c a l s f o r S a h a G B , M a c l町n,tGyorIcこ ｀ ブ ″ミ悦び ′厖 〃24:324-349,1994. ,物 brain imaging,S″ V a n H c e r t u m R L , D r O c c a C , I c h i s c M , c t a l : S i n g l e cmission oF CT and PositrOn cmisslon tomograPhy in the

筋И物 ブ ″助 ″ ″ 冴冴 (財 evaluation of neurologic discase,沢 39:1007,1034,2001. CrOss‐ReFerence グ ″α E醍 ハ吻び 力″/舟々妨ど

沢どQdttrES,ed 2,PP 309-311.

Comment

nve perccnt Of ccrcbral strOkcs arc ischcrlic in naturc. Sevcnty― Ischemicinfarctions maybecmbolicoL more commontt throm_ bOtic.Emb01i may originatc frott the heart OL most commonけ frOm the carotid artcrics ttom thrOmbi causcd by athcrOmatous Plaques.HyPcrtenS10n is an importtnt knOwn risk facto丘 PAO and Ccrcbral perfus10n SPECT agents,99mTc HM― ECD,usually result in iniages similar to those obtaincd with mctabolism in most dis, F D G ―P E T b c c a u s c b l o o d 1n1O0ww sf 。 casc states.In acutc ccrcbral infarction,SPECT and PET dcmonstratc hypopcrfusion and hypometabolism,respcctiveけ within 24 hOurs,a perlod whcn CT and lにRI oFtcn still shOw noHnal indings.Thc carly phasc(3 to 7 days)after an acute strOke is an cxception in which blood nOw docs not rnatch rne― tab01ism.Blood now is prcscrved is the sctting of no lnctabO― 1lsnl becausc offallcd cerebrovascular autorcgulatiOn.Pcrfus10n may appcar normal in this PcriOd(“ luxury Pcrfusloぱ )。 ccrcbcllar diaschisis is a Possible nnding ttter strOkc fOr Crosscd― e side bOth PET and SPECI Thc cerebcllum contralateralto d■ Ofthe strOkc has dccreased uptakc becausc ofthc 10ss ofarcrcnt stilnuli.This lnay have accompanying clinical cerebellar symp― toms that may bc rcvcrsible.

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A5-ycar― old giri has had「 O 6内 urinary tract infectiOns in the Past 6 1nOnths. 1. W7hich radiOPharFIlaCeuticals cOInlnOnly are uscd 10r cystographyP

2.Whatお

thc advantagc ofradOnuchdc cystography Ovcr the contrast studyP

3.What is the differcnce bemrecn indrcct and dircct radionuclidc cystograPhyP 4. I― IOw is rcnux gradcd with radiOnuclide cystographyP

85

Notes

Radionuciide Cystography c two l.99mTc DTPA and 99mTc sulfur c01101d are mOSt d■ commonly uscd, 2.Radionuclidc cystograPhy is morc sendtivc in dctcction Of vesicouretcral ren旺 (VuRl and rcSultsin 50 to 200 times icss radiatiOn cxPostlrC tO thc gonads compared with thc

contrast stuⅢ 3.The drect method is commonly tlscd and rcquircs urin叩 cathctcrization and instillatiOn ofradiotracer into the bladdcr through a cathetci The indircct mcthod is PcrfOrmcd aFtcr 9 9 m T c D T P A 7 m c r c a p t y l a c―e t / 1 t 五 r o u t i n c t t n o g r a pthhy 宙 ,a prevoiding e r1お g l y c i n c ( M 嘔3 ) . W h c n t h e b l a d d 飢 image is obtaincd,fol10wed by dynamic imagcs during and 倒Rcr v01ding. 4.Grading critcria are similar tO those used with cOntrast cys―

s limitCd studプ rcsolu― tography;howevett the rad10nuclidc tlon does nOt pcrmit ttscssmcnt ofcalyccal mOrpholog/. Modcra〔e:rcaches thc Mild renux:conaned to thc urete■ distortcd collccting system PelvicOcalyceal systcm.Sevcrα and dilatcd tortuous uretci

References Eggli Di Tulchinsky M:ScintigraPhic 物″ ″ミ悦び ′脇 グ23:199-218,1993. urinary tract infectiOn,S夕

evaluation

of

CooPcrJA:Kidncy infcctiOn in childrcn:role Ofnucicar medi― 〃ゴ朔 , 冴ご グ ″′″″″物″ 能ぁ″物夕 cinc.In Frccman l回砿,editott A励 R avcn. Philadelphia,1998,Lippincott― Cttss―ReFerence

蕊〕Cd 2,pp 355-357. ルク冴 ″ び ″ ″ α冗″ど沢どQυtty「 ハ物ctta″ Comment VUR is caused by fallure Of Physlological valve function.Thc Ou3h the bladdcrwall and sub, obliquely血 llretr nomttypass岱 nc u五 nls thc bladdeL thc mucosa to its opening at the tigonc.As v a l v e s P t t s i V C l y d O s c , nP tr lc xv .e In ft ti hn eg にi n t r m u r a l w e t c r a l

thc valve dOcs nOt lcngtt is too shortcomparedwith itsぅ dialne使 abnOrmal_ dose and reniⅨ rcsdts,In mOrcthan 80%ofcascse d■ け

r C S O I V C S

a s

t h e

c h i l d

h r i ― g r o w s . U na tn rd e aP ty e dl o rn ec nP は

tis may result in rcnal scarrintt h/pertcnslon,and rcnal fttlurc. The cOmbination OfVUR and infcctcd urinc are required to producc iniurytO the ttdneys.The gOtt oftherapy is tt PrcvCnt re, ntt damagc undithe renは配solves spontancoLISly Or tt surgicay correctcd,In many ccntcrs,contrttt c/stOgraphy is reserved for 1,pardcur thc initial cvaluatiOn becausc ofbettcr anatomical det五 l a r l y t t r m t t c, tPot tcixecnlは udC POsterior urcthral valves.This c wl rcaching thc casc shows carly VUR on the ic丘 (Posterlor宙 rcnal pelvis during the later bladder iling Phasc and lcsser rcntlx intO thc right Pclvis.VURdccrcascs siowly over the voiding Phase withにsidual activity in thc Pelves,PartiCdarly thc leFt,at thc end ofhe stuⅢ RttOnudidc cystography is acquittd tttalniCalけ The 10べcconJframc acqulsitlon rate alows forvcリ on comp通 、 high scnsitMt/for αion dcに OfttR.

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dcmOnstrated On CT scanttng.

1. Describe thc scintigraPhic indings bcfOrc and after FurOsenlidc adIIlinistratiOn.

2. Interprct the study beforc lascr adrllinistratiOn. 3. Interprct the study after laser adHlinistratiOn. 4. List sOme lirnitatiOns ofdiurctic rcnOgraphy.

87

Notes

Diuretic Renography:UnHatera1 0bstruction l.Good symttlctrical cortical uptake and prompt excretion

n市 h t o c o l l e c t i n g sけyRscttcemnsd obni lioatfttaecrit狙 lcft rcnal c011ecting systcnl,apparcnt cutoFFin the uppcr urctett and vcry poor rcsponsc to furOsclnidc.The right sidc shows a prOHlincnt collccting systenl but washcs out SPOntancOusly befOre FurOscrnidc adnlinistration. 2.H/droncPhrOsis ofthc l乱 路dneye Rulc out obstruction. 3。Consistent with signincant obstruction ofthc lcft lddncye 4.Dchydration,に ntt insufncicnc/2 inadcquatc diurctic dosc, large c01lecting systcm. 丘ェ 1l bladdcら

References Connolly LR Zurakowski D,Pctcrs CA,ct al:Variability lon duc to method Of Post― uresis renography interprcta〔 ination, tiine dcterl■ diurctic rcnal pclvic clcarancc half― メびTo′164:467,471,2000. Roarkc lMC,Sandler CM:Provocative imaging:diurctic rcnog―

r a p 町助 ′働 ″助 筋 И物2 5 2 2 7 - 2 4 9 , 1 9 9 8 . CrOss‐Reference fr配 ″夕 彦″″撮 品fグ 助 ご

逆 Qむ嘘 孤 ,Cd 2,PP 340-348.

Comment

The limitations Ofdiuretic renOgraphy must always bc consid― crcd,The patient must rcccivc a sumcient ttroscmide dosc.Thc diurctic dosc nccdcd is greater with rcnal insuttciency9 but thc cxact dose is only an cstimatc.Renalinsuttcicncy poscs a ma―

,Or prOblem in intcrPretation and is a common reason fOr an indetcrmhatc stu与 An Obstructcd kidncy shows vcry p00r or no washout(t%>20 血inutcs).A nonObstructed kidncy shows prompt washout. HoweveL somc PatiCnt studies show partial washOut,dcnned as indeterininatc for obstruction.An indetcrininatc resPonSe Oftcn is scen in patients who havc had Prcvlous intcrvention for obstruction but still havc a very dilated systcm.These patients can bc rnOnitored Over tllnc to cnsure that nO dcter10ratlon in rcnal function Or diuretic rcsPonsC OCCurs.Calculation Of a tiHlc can bc valuablc for scrial studics.Poor renal washbut half‐ function or dehydratiOn oftcn cOntributes to an intcrmcdiatc rCSPOnsc.A functiOnal bladdcr Oudct obstruction lnay be a fac‐ tbr ifthe bladdcr cannOt bc cmptied beforc FurOscnlide adrrlin― istration;in such cascs a urinary catheter lnay be ncccssarye Cathetcrization is routinc in lnany clinics in childrcn whO will not or cannot vold On instructlon.

88

Ofdi―

A

B

C

A35-ycar― o ld rcnal transPlant Paticnt has threc rcnal studies(scquentialimagcs Over 30 minutcs)using 99mT on one day and 9?mTc MAG3 and 1311 hippuran l week latc丘 1 . m i c h r e n a l r a d i O p h a r m a c c u t i c a l i s u s e d f O, ra ea an cd h c sP t u d y : И 2. N7hat is thc rncchanisllr1 0fuptakc Ofthe three rad10pharllrlaceuticalsP 3. mat are the advantages and disadvantages ofeach radiOPharmaceuticalP 4. Can a b100d nOw (radionuclide angiOgrarl)study bC dOne with ali threc agentsP対 7hy'

89

Notes

Renal RadiophargYlaCeuticals l.И,99mTc DTPA;a99mTc MAG3,C1311 hiPpuran. 2.

DTPA:glomerular iltratiOn,MAG3:tubular secretion; hippuran:20%ig10mcrulaL 800/o tubulai

3.

DTPA is inexPlnsive,providcs a good inlagc qualit/j bu[has 10w extraction cttcicncy(10%to 20%)and Poor quttit/ imagcs宙 th ttntt insuttcienc/6 MAG3 htt a high cxtraction ratc(60%),309d target to backgrOund,and good― qu】ity i m a g e s w t t h r c i a l i n s u m c i c n c y e H i p p u r a n to― background,POorimagc qu狙 ― tion cmcienc/9 high target― ity9 Poor cortica1/collccting systcm dircrentiation,and deliv― cncye e r s a h i g h r a d i a t i O n d O s ei n is nu t t tc ni 』

4.

Noo Thc admihistered dose of1311 hippuran is too low C i),limitcd by thc high radiation absorbcd (200 to 300卜 dOsc.A dosc of5 mCiis needed for 300d b100d aOw imagcs.

References TaylorA:Radionuchdc rcnOgraPhy:a pcrsontt apprOach,最物筋 ハあご ′昴々〃29:102‐127,1999. 0'Malley JR ZiCSSman HA,Chantarapitak N,ct al:99mTc MAG3 as an alternativcto 99mTC DTPA and I-131 hippuran

,″ミ悦r/丹々グ18:22-29, fOr rcnal transplant cvaluation,Cけ 1993. Reference Cross‐ 醍 貫FQ」 慰 r革 〕cd 2,pp 324-328. ガ ″劣 軍 州務材夕 ″″%妨 び COmment The 1311 hippuran study is casy to recognize becausc ofits Poor― ridc valuablc functiOnal rcs01ution imagcs.HowcvcL it does prぃ ivity curvcs(not ShOwn)simllar tO infOrmatiOn and timc―ac〔 99mTc MAG3.99mTc DTPA and 99mTcヽ AG3 studics look 在 res01udOn high― 99mTc argcnts.Both 魚iny similar bccauSc ofthe are superior to 1311 hippuran for discrinlinating cortex frOm c01th thc lccting system.UPtakc isatcr gに and backgrOund less宙 99mTc MAG3 than DTPA bccause DTPA has a nrst_PaSS ex― traction fractlon ofonly 100/O t0 200/O compared with 60%for MAG3.Thus MAG3 has an important advantage fOr PatiCnts This transplant PatiCnt has mOderate h rcnal insuFncicncy・ wi〔 renal dysfunction dcmOnstratcd by thc s10w cicarance.Both 99mTc agents result in a 10w radiation absorbcd dosc to thc Pa― ticnt comparcd with 1311 hippuran and a1low for a bloOd nOw studン99mTc MAG3 is thc agent most commonly used fOr renal scintigraphy in thc Unitcd States.99mTc DTPAresuitSin high‐ qualit/irllagcs and Provides useful lunctlonal infOrrlllation for vith norina1 0r rnildly decreased renal functiOn and Patients、 cOst. has a relativelyv 10、

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A 3 1 - y e a ro― ld man with a histOry ofcongenital ureterOpelvic junctiOn obstruction had surgical cOr ago.The rnOst rccent diurctic rcnOgram、 vas interpreted as right renal obstruction.This scan was obtaincd after thc second surgical cOrrection. 1. Describc the scintigraphic imaging indings bcfOre and after adlninistration OffurOsclnidc. 2.What is your interprctation Ofthc studyP 3. Can uretcropclvic vs.urcterovesical obstructiOn bc distinguishcd frOIrl this studyP 4. Whatis theヽ 商1littaker tcstP

91

Notes

Genitourinary SysteHl:Diuretic Renography/Nonobstruct,d HydrOnephrosis l. Bllateral prompt cortical uptakc and excredon into collecting m筑 30 min― COICCting sysに systcms.Rcttntion in the nghモ utes with good PostrttrOscmidc washout. c for 2.Good resPonse tO Surgical corrcction.Ncgat市 Obstructlon. 3. Not with ccrtainty.Urctcral nOnvisualization is not diagnos‐

tic Ofureteropeivicjunction obstruction bccausc a standing c01umn ofurcteral tine can PreVent radiotraccr entryt _ now relationshiPs and rcquires nuor。 4. It rncasurcs prcssurc― scopically guided trOcar Or sPinal nccdlc inscrtion into the rcnal pclvis.Basal and pressure mcasuremcnts slon ofa contrast solutiOn at a sct rate arc Obstrdction prcssure is deaned as greatcr than 15 cm watcちno obstruction asicss than 10 to 12 cHI watc丘

References

Mandell GA CooPcrJA,LconardJC,ct狙:Procedure guidelinc 助 〃%〃 3&1617偽r duredc rcnography h chttren,ノ 16う 0,1997.

, c t a rcnography l: P i e p s z A , ATronnedlc1u0r■ M E)luretic A励冴鴎 嵐39:2015-2016,1998, childrcn,メ CrOss‐Reference 助 あ ″鴎 温 ″α 初

越 QD町

鶴

in

ed 2,pp 340‐348.

COmment ultrasonograPhtt and convcn― Contrast intravcnous urographン raphy are nOt rettablc in dfFcrcntiating t i O n t t r a d i o n u dn dO cg に hydrOnephrOsis.Dllation,dc, Obstructivc ttom nonObstructiモ layed opaciflcation,and delaycd washout arc sccn with ob― struction on contrast urography but alsO may be sccn with nOnObstruct市c hydrOncphrOsiso Similartt ultrasonograPhycan depict hydroncPhrosis but cannOt distinguish bctwecn Ob― struction and nonobstruction.The Whittaker test is rarely uscd tOday becausc it is invasive and unncccssary;diurctic rcnogra― Phy htt simlar accurac/aFld iS now the standard dagnOstic tcst. The incrcascd urine nOw as a result offurOsemide diuresis pro‐ duces PrOmpt WashOutin a nonobstructcd systcmo With a nxcd Obstruction the capacity to augment outnow is limited,rcsuit, ing in prolongcd washout. An intermcdiate furOscmide rcnography rcsult may mdicatc somc compOnent Of Obstruction but is lnost inforinatively rc‐ POrtCd,Sincc obstruction cannOt bc excludcd.Thc maiority Of diuretic renographic studies are fOr Patien[s with incomplcte Obstructions(high‐ gradc dcaned as rcnal uptakc but no cxcre― tiOn into thc collccting system).The rapid washout with 血roseHlldc prOves that surgery was succcssful in rclieving thc Obstruction in this PatiCnt.

92

during infu― rccorded.

A30-ycarrold lddney transPlant rccipient has decrcasing PoStOpcrativc urinc Output,fullness and tenderncss around the graft,and scrotal swclling 24 hOurs aFter surgerye l. Dcscribe thc indings On the 25-ininute d/narrliC renal scintigraphy. 2. mat is the diagnOsisP 3.What are Other causcs OfPostOperative nuid c。

llcctiOns attacent tO the graftP

4. ヽ 7hat arc other cOHllnOn COmplicatiOns during thc irst wecks after transPlantatiOnP

93

Notes

Genitourinary Systenl:Transplant Kidney Urinary Leak l.Rapid icakage Ofurine,uSt inttriOr tO the transPlanted 脇dney and extravasating into thc scrotum。 2.Urinary leak caused by disrupdOn Ofthc surgical anastoIIloSiS.

3.Hematomas and abscesses occur in thc early PostOPcratiVe coursc,whereas iymphoceles gcncrally arc noted 4 to 8 wecksポ モ er surge字 4.Acute tubular nccrosis,acute reicctiOn,obstructiOno Cyclo― SPOrin toxicitt uSu組

け OCCurs months aFter transPlalltation.

Reference ChOykc PL,BcckcrJA ZiCSSman IIA:Imaging the transplantcd kidneンIn P01lack HM,McLennan BL:9ケ ″筋 〃″初駒 ed 2,Philadciphia,2000,WB Saundcrs,PP 3091‐ 3118. Reference Cross― 物 び 力″″脇 冴す ″ ″4『配 択EQd蕊

孤 ,ed 2,PP 351-3う3.

Comment Urinomas usuttly arc diagnOsed within the arst or second Post― OPCratiVe wcck.Thcy usually are 10cated betwecn the trans― Planted kidney and the bladdcL ttthOugh they may Occurin thc scrotum or thigh Urctcral breakdown is usually caused by vas― cular insuFncienc/1cading tO uretcral necrOsis but alsO caFl bC ructiOn. causcd by incrcased urinary prcssure From dista1 0bs〔 Largc urinOmas can rupture intraperitonettly tO prOducc uri― nary ascites,They can becOme infcctcd alld fOrm absccsses. ly develoP in the pOsttransplantatlon Urinary nstulas gener』 They are rllanaged by reilnplantatiOn of the urcter or PeriOd・ anOther recons[ructive procedure.Urinolmas result frOm the cOntinucd,s10w extravasation of urinc frOm thc renal pclvis, uretett or ureteroneocystostomy site.Large urinOmas and uri― nar/1caks can be a seriOus complicatiOn Of rcnal transPlanta‐ tion.Smallcr leaks Oftcn rcsult in collectiOns walled-0鮮 that may or may not produce symp〔oms and carl resOlvc sp9ntaneousけ Larger and more rapid leaks requirc Prompt intervcntion,An abrupt halt in urine output frOm a transPlant that was func― tioning initially atter surgery suggests a urinar/1cak.On ultra― s O u n d i m t t i n g , u r i n O m a s a r e w e l l , d c i n e d , a n e c h o i1c- n u i d c 。 lcctiOns.The radionuclide study can cOnflrin their urinary

Orittn.with a slowcr leak,dclayed images may be required to detcct thc urinary collcctiOn.

94

轟 一 一 A

B

81nin

Radionuclidc b100d nOw and carly dynamic imagcs at 24 h9urs after transPlantatiOn. 1. W7hat arc thc scintigraPhic indingsP 2. ｀ 前/hat is your phys1010gic intcrpretationP hat is the diffcrcntial diagnOsisP 3. Wマ 4. W7hat therapy would bc apprOpriatcP

95

Notes

Genitourinary System:Nonviable Kidney After Transplantation l.No blood nOw to the transPlanted kidneyt No rcnal uptake.A Photopenic rcglon in thc shaPc Ofthe trans― plantcd lddney. 2. Nonviablc kidney. or vcnous thrombOsis,scvere irreversiblc rcicctiOn, 3.Artcri』 acute corticai necrOsis. 4. RcmOval ofthe nOnviable transPlantcd lddncy.

References ChOyke PL,BcckcrJA,Zicssman HA:Imtting thC transPlantcd ″物 ブ″物物 路dnc卜 In P01lack HM,McLcnnan BL:働 2,Philadelphia,2000,WB Saunders,PP 3091‐3118.

cd

Russcll CD,Yang H,GastrOn RS,ct ali Prediction Of rcnal transplant survival frOnl carly pOstOPcrativc radioisotoPc

A物〃丹々〃41:1332-1336,2000. studics,メ CrOss―ReFerence 醍 ″ ″件 「 助 び 務″″脇 冴び

逆 Q3慰

孤 ,Cd 2,PP 349‐ 350,

Comment Amり or bcncnt oFscintigraphy is thtt radiOnudidc anttography can bc PerfOrined and b10oa nOw at thc caplllary lcvel demOn― stratcd.Acute artcrial thrombOsis is an uncoHllnon comPliCa― tion that prcscnts as anuria posttransPlantation.Itis an cmer‐ gency when it does occu二 Acutc kinking Of thc transPlanted Acu〔e venous thrombOsis may loOk artery may present similariン identical tO artcrial thrOmbOsis bccausc of the lack Of nOrrnal lymphatic drainage attcr transplantation.

Hyperacute rc,cctiOn is a rapidly progrcssive irrcvcrsiblc PrOCCSS flrst dctcctcd inllnediatcly after illtlplantation of the transplanted kidney.Thc kidncy turns bluc in thc oPcrating roomo Thc Precipitating factor is the presence ofPrcfOrmcd an― t i b o d i c s . I m m e d i a t c l y t t c r a n tatnttOimgoe― sni碇 s an antibody― action takes place in the graFt,lcading to rapid thrOmbOsis of thc vas,ular bcd and completc Funct10nal destruction within on bccausc of the Hllnutes to hours.HowcvcL this is uncoHlI■ current careful Prcscreening to determinc immun010gical cOm_ Patibilitye Rcnal arter/Stenosis can occur at any tilnc but usu‐ ally Occurs 3 months Or latcr aftcr transPlantation.

96

晦

A

帥

ぐ

簗

ふ

ほ

B

‖

i

ⅢⅢⅢ ⅢⅢ ⅢⅢⅢⅢⅢ Ⅲ‖￨■￨ A25-ycar―old lnan undergoes imaging 3 days after a rcnal cadaver transPlant. 1, Which POstOPcratiVe comphcatiOns occur in thc nrst week Ofrcnal transPlantationP 2.During which POstOpCrativc period docs acute rdeCtiOn ttpiCally OccurP 前/hat arc thc scintigraphic andingS in this caseP 3. ｀ 4. What is thc diagnosisP

97

Notes

Genitourinary Syste■ 1:Renal Transplant with Acute Tubular Necrosis l. Acutc tubular nccrosis,acceleratcd acutc rttcCtiOn,urinary leak,urinary obstructlon. 2.

The secOnd POstopcrativc wcck.Accelerated rdcctiOn may vhO havc had prcvi― occur during thc nrst weck in Paticnts、 ous transplants Or rcccivcd ultiPlc l■ transfus10ns.

3.

N o r m a l b 1 0 0 d略 vn co r、y p O o r t t i n c t i o n , n o c x c r c t i o n . B t t c OfPcnis sccn infcriOrlyB

4t

Thc pattern ofnorinal b10od now but pOOr Function dur― ing the nrstwcck aftcr transPlantatiOn is tyPiCal ofacutc tubular nccrosis lATN).

References Dubovsk/EM Russcll CD,BischottDclaloye A,ct組 :RcPort Of the radiOnuclides in ncPhrour010g/cOmmittCC for evaluatiOn Sを 初グ ″ハあご 〃 比 〃29:175,188,1999. OftransPlantcd ttdneン Brown ED,Chen ML Wolfman N工 ct ali Complicat10ns Of renal transplantatiOn:cvaluatiOn with ultrasOund and ra― と 0抑 カブ 付20:607-62222000. diOnuclidc imaging,動成 Cross― Reference 対″び 避 貫どQ3慰 ″″″Mcttct″客 「

『 ES,cd 2,pp 305-308.

Comment ATN occurs invariably aftcr transPlantation、 vith cadavcr a110_ grafts and frcqucntly with living related dOnOr grafts.An cx, tcndcd tirnc bcぃ げcen salvaging thc dOnOr kidncy and trans_ plantatlon incrcascs thc likelih00d and severity ofATN.Thc scintigraphic indings ofATN arc visiblc within 24 hours of transPlantatiOn. ATN usually rcs01vcs Ovcr l to 3 weeks. SOmetilnes ATN bccomcs suPCriinPoscd On Other postoPcra― tive cOmpllcatiOns,c.g.,acute rciectiOn,which bcgin thc scc‐ ond wcek aFtcr transPlantation.Acutc rdcctiOn usu組 け bcgins 5 to 7 days atter transplantatiOn and usually is associated scintig― raphically、 obstruction cannot bc vith dccrcascd b100d noMん excludcd tOtally in this casc.Howcvcr,the absencc Of initial photoPcnia rCpresenting a Full renal Pclvis docs nOt support obstructlon. 99mTc MAG3 1s the radiopharrnaccutica1 0f chOicc fOr rcnal On.13町hiPPuran』sO prOvidcs reliable infOrma― transPlant evaluaま don about function,but blood nOw studies callnot bc perfOrined Cl).99rnTc DTPA call bccausc ofthc 10wadministered dosc(300卜 prぃridc bloOd nOw information but callnOt dctcct improvcmcnt or deteriOration in ttmction whcn thc scrtlm crcatlnine concentra― 99mTc MAG3 alows don is dcvatcd,c.gり grCatcr than 2.5 mg/dl。 bloOd nOw and Function cven in thc setdng of evaluatiOn ofbod■ nctiOn.Thc r劇ほ very poor renal点 は Onudide study call be pardcu― larly valuable when rcnal ttmctiOn is dittcdt tO determinc dini― C江 性乃e・ gりin PatiCnts undcrgOing dialysis,Improvcmcnt in rcnd hollrs bc島 にchangcs h ttc hnction Oftcn carl bc dettcted 48 24的 sertlm crcatinine level, 98

A n 8 - y c a or l―d b o y h a s a c u t e o n s c t o f t t g h t tnc.s t i c d a r p ぶ 1, What is thc radioPharinaccutical and rnechanisnl ofdistributiOnP 2. mat arc thc mOst common causes ofacute tcsticular painP 3. W7hat is thc FnCChanisIIl oftcsticular torsiOnP

4. ヽ 7hat arc the imaging indings,and what is thc diagnOsis in thc cascP

99

Notes

Genitourinary Systenl:Testicular Torsion l. 99mTc Pertcchnctatc,initial b100d nOwP and thcn thc radlo― tracer distributes in the cxtracellular nuid sPace(intravas― cular arld interstitial)。 2.Acute epididymHs,tesdcular ular appendage.

torslon ofthe

3.

Developmental abnOrmality oftcsticular desccnt and attach― mcnt prcdisPoscs tO SPCrmatic cord torslon.Thc mOst com― mon anatomical abnOrmality is“ bell‐ daPper"tesds.

4.

Decrcased b10od aOw to the right testicle and a phOtopcnic right tcsticic consisttnt with acutc testicular tOrslon.

Reference Paldd HJ,COnnollyttAtttaA ct tt Acutc sctttalsymptOms h

bOys with an indetcrminatc dinical prcscntationi compttison Of c010r Dopple与 sOnOgraphtt and scintigraph乃 筋 冴θ 殉 207:223… 231,1998. Cttss‐ ReFerence 助 び 務″″協 妨す 醍 沢どQd蕊 ″ ″α 軍

孤 ,ed 2,PP 357‐362.

Comment Paticnts with a high likdih00d Oftcsticular ly tors10n usu』 un_ dcrgO iminediate surgerythout Hた diagnOsモ iC imaging.Testicular torslon is a surgical emergency bccause tcsticular atrOphy lnay occur as early as 4 hOurs after the acutc event and is inevitable by 10 hOurs.Howcvcr9 somc paticnts have an indctcrininate likelih00d Of tors10n bascd On symptoIIIS and clinical signs. ApprOximatcly 70%ofPatients have cOnditiOns othcr than tcs_ ticular tOrslon that do nOt rcquirc surger/.Imaging typically is PcrfOrHled in PatiCnts with equivocal clinical indings to help thc ur010gist dccidc whcthcr surgcry is indicatcd. The bcll clapper tcstis is a congcnitalalityj abnorl■ usually bilatcralltt in whiCh thc tunica vaginalis cOmPletely invests the tcstes.The nOrinal PostcriOr lncsorchial anchOr is absent,al― 10wing the testis to twist on its vascular pcdiclc. The rcPOrtcd accuracy of scintigraphy is aPProXilnatcly 95%.Rccentiン co10r DopPler ultrasOnOgraphy htt becOmc a commonly used imtting mOdality for evaluatiOn ofacutc scro― talsymptoms.Dircct comparison ofthe wO diagnOs〔ic studies dOcs nOt shOw a signincallt diFFcrcncc in interprctat市 e accurac/. Doppler often is IIlorc raPid and caslly obtained in thc acutc cmergcncy dePartinent scttingo ScintigraPhy may bc PartiCu― larly hcIPful whcn DoPplcr studies shOw cquivocai noM Potassium perchloratc may bc administcrcd to children beforc the scintigraphic study to prevcnt thyroid uptake CXPOSu崎

。Scintigraphy is nOt indicated fOr chrOnic Or PainlCSS

disOrders Ofthe scrOtum.

100

and

radiatiOn

A55,year―old wOman is referred fOr a thyrOid scan to evttuatc a pttPabic thyrOia nodule.Lctt to right vicws are ante‐ r10島right anterior obliquc,and left anteriOr oblique. livesPhalf― 1.WЪ at arc the wo radiOpharmaceuticals used fOr thyrOid scintigraphtt thcir photOPeaks,and Physical , 2.What is the likelih00d OfthyrOid cancer in this Patient. 3. WVhat wOuld you recollIIInend as the ncxt diagnostic or therapeutic PrOCedurcP

4. W7hat imaging rnethod is uscd hercP W7hat is its imagc res01utiOnP

弱 鞍tヽ ふ 縛 ギ 再 SS烏

A48-year―old wOman has recent onsct ofneck tcndcrness and hyperthyrOidism(thyrOid,stimulating hormOnes[TSH] 1%).Rttht sidCの すsuprastcmtt notch tSSN). <0.05 μU/ml);陀 31 scan uptakc(radiOactivc lodine uptake[RAIU])≦ 1.mat is the clinictt diffcrcntitt dittnosis ofhypcrthyrOidismP 2.Httat is thc clinical purpose ofthc thyrOid scan and RAIU tests in hyperthyrOidismP 3.How is thc RAIU calculatcdP 4.mat is thc likcly diagnosis in this PatiCntP

101

Endocrine Systenl:Cold Thyroid Nodule l.Intravcnous 99mTc Pcrtcchnetatc,140ぶ sodium 1231,159さ

,6 hOurs,Oral

)8 hours.

2.A singlc cOld nodulc has a 15%to 20%chancc Of malignanc/6 3. AsPiratiOn nccdle biOpsys

Endocrine Systenl:Hyperthyroidism/ Thyroiditis l. Gravcs'discasc,toxic nodulc(s),こ hyroiditis(subacute, silent,POstParturn),latrOgenic thyrOid hOrmOne ingcstion,

iodhe― induccd lJOd BascdOw),trOPhOblastic tumors cosis, ,HashitO対 (hydatidifOrm m01c and chOriOcarcinomう cctopic hypcrfunctiOning thyrOid tissuc(struma Ovaril).｀

4. PinhOlc c011lrnatOi 4 to 6 rnm.

2. Pttd in the diffcrcntial diagIIOsis ofhyPcrthyrOidism.

ReFerences FrcitasJE,Frcitas AE:ThyrOid and parathyrOid imaging,レ 物″ ″

3.A nonirnaging galnma probc obtains cOunts/timc frOm thc ncck and a phantOIn‐ containing activity cqual tO thc Orally adminis〔 crcd dosc(μ Ci)to convert thc gamma probc counts to μ Ci.%RAIU=ncck(卜 Ci)divided by the tOtal

ハあ″ ど ′丹々〃24:234-245,1994. Cases JA,Surks MII:The changing r01c Of scintigraphァ in thc evaluation of thyrOid nOdulcs,S′ 夕 物ブ ″」 物物〃30:81-87, 巾物す ブソ 2000。 ReFerence Cttss‐ 配 助 び 力″″陀 冴r″ ″α 軍

adm血おtered dOscは Ci)aFtcr backgrOund cOrrection. 4. Subacutc thyroiditis based On the histOry ofncck tcndcr― ncss,laboratOry anding,and RAIU.

越 Q占眼 孤 ,Cd 2,pp 364-375.

Reference Sarkar SD:Thyr01d PathOphys1010g/.In Sandlcr MB Colcman CoJmment RE,Wachcrs FJTh,ct狐 :Dブ竹 ″舛力 ″″び 彦″″物ettcれら cd 3, 1231 is trapped and Organincd by thyrOid lbllicular cclls.99mTc BaltimOrc,1996,Wllliams&Wilttns,pp 899-908. 99mTc has a simllar uptakc mcchanism,but it is nOt Organincd。 is advantageous fOr childrcn bccause Of its shOrt imaging tiinc Reference Cross‐ にl a t c d t O t h c c Oh ug nh t― r a t e a n d l o w m d i t t i O n a b s0O r b c d 助d oす s力e″〔 ″Mcttci″α r鵡 京どQ3s「 ES,cd 2,PP 368-378。 thc thyrOid.Thc adult administercd dosc is 3 to 5 mCi intra― venously vcrsus 200 to 300卜 Cl orally fOr 1231.1231 is uScd mostCOmment commonly in adults.Imagcs are obtained at 2 t0 6 hOurs and ThyrOiditis and Gravcs'discasc are the mOst cOmmon causcs of uptakes at 24 hours aftcr Oral adnlinistratiOn ofthc caPsule. hypcr〔 hyrOidism and Ottcn are difncult tO distinguish clinicallン PhOtOpenic reglons on thyroid scintigraPhy scan arc causcd Hyperthyroidism is diagnOscd by a suppresscd TSH icvcl. by various cOnditions,c.g。 ThyrOxinc(T4)and triiodothyrOninc(T3)may Or may not bc ,cysts,col10id nOdulcs,ncw Or old thyrOiditis,HashimOtOも diseasc,and hematOma.Thc incidence eicvatcd.Thc scan and RAIU aid in the difFcrential diagnOsis. OfthyrOid canccr is icss than 5%in a multinOdular 30itCr(mul―T h e s c a n c t t d i s t i n g u i s h n o d u l a r d i s c a s c f r o m G r a v c s ' tiple c01d nOdulcs)and lcss than 10/O fOr a hOt nOdulc. thyrOiditis.Thc RAIU difFcrentiatcs diseascs with incrcascd up‐ A pinh01c cOllilnatOr is uscd wlth thyrOid imaging for lnag― take,c.g。 ,Gravcs',hashitOxicOsis,from thOse with 10w uPtakes nincation.HOweveL it rcsults in distOrtion and magnttcatiOn.In(most othcr discascs listed in answer l,c.g.,th/rolditis).Thcsc the Obliquc imagcs thc lobc farthcr frOm the pinhOlc(lc丘 lobc in lattcr diseascs do nOt havc autonomous Function.Thc RAIU thc right antc五 〇r obliquc,五 ghtlobc in the ltt anterior obliquc) can bc lnisicadingly low bccausc Of ingcstion Of thyrOid hOr― is distOrtcd.Thc rcs01utiOn dcPcnds On the size Of the Pinh01c mone,stablc 10dine in f00ds,IncdicatiOns,vitanlins,and iodi‐ insert,usually 4 t0 6 mm(4t06 mm rcsOlutiOn)。 Size is dittcultnatcd cOntrast agcnts. tO,udge with a pinh01c c011lmatOr bccausc ofthe magnincation Subacute thyrOiditis is a granulomatOus diseasc that initially factOi Size markcrs are somctimcs uscd but are unreliablc m a n i bc― fests as hyperthyrOidism and neck tcndernes cause ofthc changing magnincation with dcPth.Ph/sical exam‐ roiditis has nO pain but a simllar clinical coursc.The patient his_ in証lon is thc cOmmon17 uscd methOd tO cstimttc size,組 thOugh tory can suggcst Postpartum thyroiditis.During thc acutc Phasc it is suttcctiVe and open tO intcrObsentr崎nccs. di徒 Ofth/rOiditis,hOrmOne is released&Om thc innalnc ducing symptorns of hyPcrthyroidism.Antithyr01d antibOdies Nctes arc clevatcd,AlthOugh HtthimOtOも discttc usu狐 けPにSents with 1lddlc― a ged wOmcn,a subgroup goitcr and hypothyrOidism in■ O f p a t i c n 6 h a v e a n a c u t t h y p e r t h y rc OO is di s P) h. aI sn c ( H a s h i t o thcse cascs the thyrOid scan and uptake arc indistinguishablc from Gravcs'discasc. Notes

102

A35-year,old woman、 vith hyPcrthyroidism.Radioactivc iodinc uptakc was 940/O at 4 hours and 810/O at 24 hours. 1. Describe the difference veenく beい ごravcs'discasc and euthyrOid scan appearance. 2. W7hat is the aPprOpriatc thcrapy IOr Graves'discascP 3. W7hat arc the usual adlninistercd dOses ofradiotracer fOr 1311 uptakes,1231 scans,and Graves'discasc therapyP 4. W7hat are thc shOrtrtcrn■

and long― term sidc cfFects Of 1311 thcraPy fOr hypcrthyrOidisIIIP

！ 側 Ｂ！

A

Ｎ

POST

￨‐ ■拠 ‐ RlGHT

鸞

軸 pた ま ふ

A39-ycar―old wOman 6 wecks prevlously undcrwcnt total thyrOidectomy for thyrOid canccre Scanning was donc 7 days atter theraPy for thyrOid ablation with 75 mCl of1311. 1. Describe and interpret the scintigraphic ilnages. P 2. W7hat is the rcason lor thc star artifact Pattern in thc ncck in scan И ′β 3.Mttat c011lmatOr was used for imagc 4.Why is the livcr scen in imagePИ

Endocrine Systenl:Graves'E)isease Endocrine Systerrl:131l star Artifact l. Scan aPPcarance may bc siHlilatt Witttl a large 30iter thc l . 孔P o s t t h c r a p y 1b 3O 1d 1y ws hc oa vln sc ― s ih nO t、c n s t t u p t a k e scan ottcn has a PlumPcr appearance with cOnvex bordcrs. in the neck with a“ star"artifact,ditthsc livcr activityp and Thc pyralnida1lobe ma/be seen,as in this casc. bladder dearancc.Thc mediastintlm is dittcult tO visualizc 2,Surgery ls seldom perfOrmcd bccausc Ofthe high五 sk. PrOpメ thOuradl(PTUl and methimazOle(Tapazdc)

bccausc Ofthc artifact.a Pinhole image Ofthc ncck with thrcc fOci Ofuptakc.

sometimes are used initially9 PartiCularly in PaticntS With2.Septtt pcnctradon ofhgh_energ/略 ll gamma ra/S thrOugh severc discasc whO requirc``c001ing down,''ン Oung chil― thc cOllirnatOr scPta. ientso Most ofthese arc trcatcd、 drcn,and Prcgnant pa〔 vith 3, Pinhole c011llnatOr centcrcd on thc thyrOid. radiOactive lodinc after 6 t0 12 1nOnths ofantithyroid lI. 4.Radlolabclcd thyrOid hOrmOnc is mctabolized in thc livc丘 medcadOn.Many padents att treatcd hhi』 け 宙 th略 This usuttly is scと n only On thc postthcrapy scans. μ 3.1311 uptakc(10卜Ci),1231 scan and uptakc(300 Ci), Graves'diseasc therapy:1311(5to 15 mCi) Reference 4.ShOrt―term:occaslontt cxacerbation ofhypcrthyrOidism, Tsui Bヽ 在 ∬ろGunter DL,Bcck RN,ct al:Physics Ofc011lmatOr cardiac symptorns in eldcrltt ver/rarc thyroid stOHn, design.In Sandicr MR COlcman RE,Wackcrs FJTh,ct』 , Long―[erin:hyPothyrOidism.Thcrc is nO increased inci― cditors:D″ ″ ω 力 ″ ″ び 力 ″ ″ 物夕 妨″ ″ ed 3,BaltimOrc,1996, ら dencc OfsecOndary canccrs,reduction in fertility9 0r cOn― 竹 W■11lams 6こ Wllkins,pp 67‐ 69. gcnital dcfccts in offsPring.

Cttss‐ Reference References ハ物ご 力″″ルク妨ご ″ ″α r配 越 QttsFttS,ed 2,PP 364-368, KaPlan MM,Meier DA,Dworkin HJ:TrCatmcnt ofhyperth/_ rOidism with radioactivc iodine,E″冴θ び ガ″θ′Mc物 あC″″ ″ Comment 州レ務И物 27:205-223,1998. The star artifact,mOst commonly sccn with 1311 scans,is sccn Wartottk/L:RadioiOdinc rhcrapy of Gravcs'diseasc casc sc― Only with highrdosc administration and intcnse focal uptakc, lectiOn and rcstrictions recoHllncndcd tO paticnts inc.g.,thyroid North remnants in PatiCnts with thyrOid canccr aFter thy― A m e d c ら 物 ″″ 乃2 1 3 - 2 1 6 , 1 9 9 7 . rOidcctOmンThe purpose for ncar― tOtal thyrOidcctomics for thy‐ roid canccr is to remove tumor and as much thyrOid tissuc as Cross‐ Reference POSSiblC,but tO lcave thc ParathyrOids,which rcquircs icaving 対務び 力″″鴎 品品″α r避 沢どQ5慰 孤 ,Cd 2,PP 369-374. some adiacent tiSsue.Thus thc paticntis madc hyPOthyrOid(Pa― tient has elevated TSH icvcls)tO ensure good therapeutic io― Comment dittc uptakc,TO enablc Paticnt r011。 w_up with rncasurements UPtake measurcmcnts with a gamma(nonimagingl Probc are of scrum thyrOglobulins and 1311 scans PostOpcratively is then madc at 4(2 to 6)or 24 hou応,Or bOth.MOst cOmmonly thcrc feasible. ∼ is a continualincrease in uptakc frOm 4 t0 24 hours.SOmetimcs Thc therapeutic 1311 dose is adnlinistcrcd to ablate the re― thc uptake platcaus bctwcen 4 and 24 hOurs;in Othcr cascs,the maining nornlal thyrOid,tO trcat any remaining thyrOid can― 24‐ hOur uptake is ver 10、than at hOurs 4‐ bccausc Ofrapid lodinc cett or both.In PatiCnts with thyrOid cancer the dOsc FOr abla― turnovci FOr therapy fOr Gravcs'disease,an arbitrar/dOSC,c.g。 tion ofresidual nOrmal tissuc rangcs frOm 30 to 100 mCi.Th , 1 0 t o 1 5 m C i , i s u s e d b y s o m c d i n i c i a n s o O t h c t t a d i u S thァ t FrOid O r tcanccr hc thcrapy dosc in patients with rnetastases rangcs 研 o variables that detcrinine the radiatiOn dOse tO thefrOm gland: 10o t0 200 mCi.Highcr dOses sOmetimcs arc adminis― gland size and the RAIUo SOmc usc an equation to calculatc thctcrcd but usually Only aFter dOsiinctric studics that ensurc no theraP/dOsα graHl size of」 and× 50t0200 μ C〃gm di宙ded CXCCSS radiatiOn tO thc bOnc lnarrOMら thc critical organ. by the RAIU.With iOwer μ Ci/gm dOscs the radiatiOn dOse is Thc star artifact lnakcs interpretation Of thc ncck and uP‐ minimized,but thc rccurrence rate is high∝ With highcr per chest dilncultt The pinh01c c011llnatOr rnagnines bccause Of 卜Ci/gm dOscs thc nced for retrcatment is 10w2 but Onsct ofhy―its geOmetr/6 RcsolutiOn is better with the pinhOle c011linator Many endocrino10gists than thc high,cnergy collimatOr used for whOlc bOdy imaging. POth/r01dism is earlier and mOrc likcけ 危r the higher dOscs bccausc ofthe Lck Ofser10us ttdc cFFccほ Thus thc PinhOle c011linatOr inakcs inte,pretation Of the neck P陀 and thc incvltability of hypoth/rOidism.Doses of 33 mCl or possible,but thc upper chest reglon can still bc prOblcmatic. grcatcr can be used routinely On an Outpaticnt basis Pcr revised Nuclcar RegulatOry Commisslon(NRC)regulatiOns. Notes Notes

104

l and Old man with hypcrcalccmia has an cicvatcd scrum PTH level.Images arc taken at 5 minutcs and at A5う ― year― 2 hours. 1. W7hich rad10pharinaccutical is bcing uscd,and what is the ratiOnalc lbr this techniqucP 2. W7hat is the diagnosisP 3. N7hat is thc accuracy ofthis studyP 4.Whatis the mOst common causc for a ttse,pOsk市c study rcsultP

ld hOrmOne leveis and nOrmal indings on neck cxamination. A Patient has elevated serum calcium and Paratttr。 1.What othcr prOtocolin addition to dual― Phasc(early and dclaycd)99mTC Sestamibiimaging can bc uscd tO cvaluate fOr ParathyrOid discascP 2. Dcscribc how that prOcedure is perfOrJncd. 123L nghtt subtraction. :99mTc sestamibi middlα 3.Dcscribc thc andngs.Lc丘 4. List thc diffcrential diagnOsis and thc rnOst likely diagnOsis.

105

Endocrine Systenl:Hyperparathyroidism

Endocrine Systenl:Parathyroid Adenoma

l.99mTc sestarnibi(MIBI)is taken uP by thc thyrOid and Para― l. Dual― isOtOpc imaging with subtraction,in the past using thyr01d tissuc,but washcs out mOrc raPidly ttom thc thyrOid. 201「 Fl and 99mTc Pertechnctatc,and lfnorc rcccndy using 1231 and 99mTc scstamibi(MIBI). 2.Parathyroid adcnOma in thc rcglon ofthc lctt 10wcr 10bc Of thc thyrOid. 2. 1231 by lnOuth.After a delay of2 to 3 hours,an anterior 1231 thyrOid scan is Obtained.WithOut rnOving thc paticnt, 3.Greater than 90%predictive value for prcOpcrativc local‐ an imagc is obtaincd aftcr intravcnous ittcctiOn of99mTc izatiOn OfparathyrOid adcnOma,lowcr tcst accurac/fOr MIBI.Thc 1231 imagc is computcr subtractcd from thc hyPcrplasia and smali tumOrs. 99mTc MIBI ilnage.

4.Thyroid f01licular adcnOma.

3.Thc修

31 thyrOtt scan apPcars nomal,althOugh thc lcft

iObc cxtcnds mOrc infcriOrly移 ″,冴 冴↓ り.The MIBIimagc

References 佐ル)ShOWS an asymmetrical bulbOus cOniguration in thc rcglon Ofthc right 10wcr polc Ofthc thyrOid.SubtractiOn Taillcfcr R,BOuchcr L Potvin C,ct al:DctcctiOn and iocaliza― demonstrates focal radlotraccr cOmpatiblc with Parathy‐ tiOn Of ParathyrOid adcnomas in patients with hyper―

rOid adcnOma at thc 10wcr polc Ofthc 炒 right thyrOid侮 ″. 4.ParathyrOid,thyrOid adcnOma,ParathyrOid,thyrOid carci―

Parathyrottism using a single radonudidc imaging proccr

Aあ〃鴎 嵐 dure with 99mTc scstamibi(dOubic― Phasc study),メ

33:1801,1805,1992. Rauth JD,Sessions RB,Ziessman HA:COmparisOn of99mTc MIIBI and 201T1/99mTc fOr diagnOsis of primary hypcr― ,″ハ吻び ブルク〃21:602-608,1996. Parathyroidism,Cと

Reference

H a n e y T ■e d i t o t t R e h m P K R : N u c l c a r m c d i cOinncα 010g/― convcntional tumOr imaging,Rcston,■ 生, 1997,ミ悦ご ″ 夕 ″″

Cross‐ReFerence 物 び ″″″Mであcれ ″α 軍 避

noma,rnctastatlc carcinoma.

京どQδ慰 恥 ,Cd 2,PP 384_387.

物 財 ″び″″タ ャ //―∫物

カ

タ

ト 6督 船

rr unit 2,SOcicty of Nucicar

Medicine,pp 32-34. Comment BefOre the avallability Of99mTc MIBI,201Tl and 99mTc Pcrtcchnc_ 201Tl is taken up by tate were uscd for parathyrOtt sdntigrapl平

Cttss―Reference

助 び 力″″通 抗 ″″4『 醍 bOth nOmttth/rOid arld hyperuncdoning ParadlyrOid dssuc,but

沢どQ5眼

孤 )Cd 2,PP 363,384-387.

9 9 m T c b y t h c C tO hm yp ru Ot ic dr s Ou nb け t r a c t i o n wComment as pcrfomed. Thc mcthOd has limitatiOns,c.g。 ParathyrOd sdntttraphy may be perfOmed successfully ttng stics Of ,poor imtting Characte五 201Tl,paticnt movement,and cOmputer subtractlon artifac低 . a varicty of diffcrcnt protocols.Bascd On P001cd 在 IB1/ data,ヽ 99mTc MIBI is a nOnsPccinC tumor_lrnaging agcnt taken uP thyrOid scanning subtractiOn tcchniqucs havc grcatcr ity scnsit市 by avaricty ofbcnlgn and mttignanttumo附 .F01licdtt adcnOma than 201T1/thyrOid subtraction imaging(870/o Of the thyrOid is the mOst cOmmon falsc_POSitiVc nnding,but Of the better image resolution Of 99mTc MIBI cOmparcd Other tumOrs,c.gり lymphOma,may havc similar uptakc.99mTc with 201Tl.Thc lattcr has subOptimal imaging characteristics MIBI htt a highcr accuracy for dctcction ofparathyrOid bccausc tumors Ofits 10w cncrgy(69 to 83 keVl and low administered than Other imattng modalities,c.g.,201T1/99mTc,ultrasOnOgr伊 dosc(3 mCi).Either 99mTc Or 1231 can bc uscd fOr the thyrOid irnaging portion Of thc subtractiOn tcchnique.1231 haS thc ad― Ptt or MRl.In additiOn tO thc superiOr imaging characteristics Of99mTc cOmparcd with thOsc Of201Tl,MIBI has usctti phar― vantagc of a differcnt photoPcak(159 kcヽア )comparcd with 99mTc-labeled]VIIBI,Some variability in、 「 macokinctic characteristics,1.e.,it washes Out ttOm parathyrOid vashOut Occurs、 ith 、 tumors at a slowcr ratc than th/rOid tissuc,益 seen in this ctte.It the nvO― phasc MIBI tcchniquc.Thc addition Of thc thyrOid 』s o O 丘 c n h t t h i g h c r i nuipttia】 k c c o m p a r c d w i t h t h c t h / r O iscan d . and subtraction imagcs oFFers some advantages.It can cOn‐ A variet/ofrechniqucs have bccn uscd,including cOmputcr sub― arm the th/rOid rathcr than Para[hyrOid Origin of thc uptake, traction宙th遊31 arld SPECI The simplc carly― late methOd sc‐ c.g。 , follicular adenOmas,and can be helPful in Patients with anatoHlical variants,Prior thyroid surgertt or thOse receiving quence uscd in this casc oftcn is adequatc lor 10calizatiOn. ThyrOid imaging may bc hclP的 l occasionttly in Patients withthyrOid hOrmonc causing thyrOid supprcsslon.HowcvcLざ ub― anatoHlical abnorinalitics Or thyroid adenOmas,Preoperative traction tcchniqucs sOmetilnes PrOduce artifacts because ofPa― tient motion or misregistration of imagcs.COmputer subtrac― parathyrOid scintigraph/can save operatlve timc.IntraoPcratiVC tion images should always bc intcrprctcd as an adiunct tO image gamma probcs currcntly arc uscd by many surgcons. analysis,nOt in is01atiOn. Notes Notes

106

v

Fair Came Cases

A

澱 B

祓

C

欝赫附

鞘館 ＝

D

A12-ycar―old boy has recent bnsct ofback pain.The rcPOrt OfOutside rad10graphs was equivocal. 1.Dcscribc thc bone scan indings On the planarimages像

り and reprOjcctiOn SPECTに

り images,

2.Dcscribe the nndings on thc transvcrse and cOrOnal SPECT sliccs(Cand D). 3. PrOvidc a differential diagnosis and the IIlost likcly diagnOsis. 4.This

cntity

may

be

associatcd

with

an

abnormalitt

Ofalignment.Describc

109

Notes

Skeletai SysterrB:LS Pars interarticularis lDefect l,The bOnc scan demOnstrates focalincreascd uptakc in thc latcral aspcct OfLう vcrtcbra. 2. The nnding is better dernOnstratcd and bcttcr localizcd On the SPECT imagcs,where the abnOrmal uptakc is dcarly

sccn in thc rcglon ofthe lctt pars interarticularis/facct,Oint. 3. L5unilatcral pars intcrarticularis dcfcct,dcgcncrative or posttraumatic facct discase.Pars dcfect is thc mOst likcly diagnosis in this age group. 4. Spond/1olisthcsis Or slippage Ofthc vertebrac Out ofnor‐ mal alignlncnt can Occur ifthc deFect is bilateral.

Reference C01licr BD,Krasnaw AZ,Hcllman RS:Bone scanning.In C01lier BD,FOgelman I,Roscnthall L,cditOrs:S″ ′ ″物ブ%″― r筋″″物″ β 冴,c,″ ち St Louis,1996,MOsbtt pp 51‐ 56. Cross‐Reference ″夕 fr遼 ハ吻び 彦″″Mcあ c″

京どQdS孤

,Cd 2,pp 128-132.

Co】mment Spond/101ysお is a ttacturc Ofthe ncurtt arch Ofthc vcrtcbra in― vOlving thc Pars intCrarticularis.Currendy it is bclicvcd tO rcP―

rcscnt a strcss fracturc causcd by rcpctitive in,ury bCWCCn in― Fancy and carly adult lifc,rathcr than a singic trauma,althOugh

thc latter may occui SPondyloぃ isis mOSt frcqucnt h thc lum― bar sPinq thc mttOrity Ofcases invOlvc thc ntth vcrtcbra,as in this casc.It may bc unilateral or bilateral and ma/bc assOciatcd with sllppagc,Or spond/101isthesis Of thc vertebra with resPcct tO adiaccnt vcrtebrac. SPOndyiolysis may cause symptoms,prompting an imaging diagnosis,but it Fna/bC asymptomatic and discOvcrcd incidcn― tally On radlographic studics.LOcalizatiOn of increascd uptake on Planar imagcs is often difncult,SPECT a110ws fOr dctcr― mining whcthcr abnOrmal uptakc is in the bOdン Pedicic,Or posteriOr clcments,SPECT has signincantly higher sensitivity than planar imtting(85%vs.62%)for dctcctOn Ofa Pars dC― fcct.Thus SPECT shOuld be perfOrmcd evcn aftcr ncgativc pla― nar study indngs whcn the diagnosis is susPccted,particdany in yOung Paticnts with iOw back Pain.An abnorrnality sccn on bOnc scintigraphy has signincant paticnt rnanagclncnt ilnplica_ tions.Inappropriatc carly lnanipulatiOn Or too carly a rcturn to sports could cOnvcrt the strcss― rclatcd parts defcct intO a Frank fracturc,POSSibly leading tO unstablc sPOndylolisthcsis.

110

A

ｉ■

ぢ

A5-/car Old boy With low― phase bOnc scan. gradc fcvcr and pain in the right knce was refcrrcd fOr a three― 1. Dcscribc thc thrcc,Phasc scintigraphic indings. 2, Provide a differential diagnOsis. 3. Do thcsc indings suggest a scPtiC arthritisP 4.What Othcr radonudidc study codd conirm Or exdudc inttcdOnP

Notes

Bone:Tibia1 0steomyelitis― Three―Phase Positive Bone Scan l. Incrcascd bloodv(ク ao、 リ,blood poolめ,and uptakc On delayed imagesに of )in the prOximtt mctaphyscal reglo■ thc right tibia, 2.OstcOmyelitis,bone tumott fracturc/OstcOtOmye 3. No.A bonc scan with scPtic arthritis shOws incrcascd uptake at the tnd Oflong bOncs symlnetrically on bOth

StteS Ofthe,Oint・ An asymmttrictt appcarancc ma/bc seen ifosteOHlyelitis and scPtic arthritis cOcxist;howcvcL this study rcvcals nOrmal indings on the femOral sidc. 4.99mTc HM‐ PAO― labeled leukocyte study in a child.

Reference

PalcstrO CJ,TOrrcsヽ 色代:Radionuclldc imaging in OrthOPedic infectiOns,レ ク″″,W物 び ブ 脇 〃27:334‐ 343,1997. Cross― ReFerence 助 す 彦″″Mcttct″αr醍 択野Q5慰 189.

恥 ,ed 2,pp 134-138,186‐

Comment Bonc infcctiOn is usually bactcrial in origin(most commonly staphylococcal)and rcachcs thc bOnc by hematOgenous sprcad, dircct cxtcnslon fron■ a cOntiguous skin sitc OfinfcctiOn,or dir rect introduction by surgcry or trauma.In acutc hematOgenous OStCOmyclitis,infectiOn involves the red rnarrOw Oflong bOncs as a rcsult of the relatively s10w b100d nOw in mctaPhysctt si― nusoidal vcins and thc rclativc lack OfPhagocytcs.In adults thc 10ng bOncs rarely are afFected becausc adipOsc tissuc has re‐ Placed red inarrOM InfectiOn inost oftcn Occurs in the spinc with scPticCmia as the initiating event.Direct cxtcnsion frOm cOntiguOus sitcs ofinfcctiOn is a vcry coHllnon causc of os― teomyelitis,usually as a rcsult of sOft tissuc infectiOn after trauma,radiatiOn thcrapンburns,Or pressurc sorcs.Dircct in‐ trOductiOn of bactcria rna/oCCur durin3 0PCn fracturcs,oPcn SurttCal rcductiOn,Or Pcnctrating trauma by foreign bOdics. Thc bOnc scan is very scnsitivc fOr Fnaking thc diagnOsis. Howeveち a positive dlrec― Phase bone scan is not spcciflc for Os― teomyclitis.Fracturc,tumoL and CharcOt,Oints may bc thrcc― Thc sPccillcity ofthc bOnc scan is cvcn P00rCr in Phasc POsitiVC・ PatiCnts with underlying conditions such as previOus bone in_ fcct10n,fracturcs,orthopedic implants Or dcviccs,alld ncurO― Thc PatientもhistOry9 rad10graphs,rad101abclcd pathic,OintS・ icukocytes,争 nd blopsy frcqucntly are nccessary to rnake a de‐ anitive diagnOsis in nonvirgin bone.Thc bOnc scan has a high negative predictive valuc and thus a ncgative study result can rule Out bonc discasc.

112

読

十 1+,1,11,1,十

嵐 An ll― inonth― old infant has a hcpatic FnaSS Oh ultrasOund.Bonc scan ordcred tO cxclude bOnc rnetastases. 1. Dcscribc thc scintigraphic indings. 2. Bcsides a neOPlastic PrOCCSs,、

vhat Othcr cOnditions cOuld be assOciated with the nndingSP

3. Name anothcr likcly Origin Ofthe tumOr Othcr than the livc■ 1 4. What is thc rnOst likely diagnosisP

113

Notes

Skeletal Systenl:Hepatoblastoma l,NOnunttrm abnomtt stt tissue right uppcr quadrant up― takc thtt callnOt bc dcarly separttcd ght ttomttdncyc the五 2. Trauma to soft tissue Or organs,in this casc,thc liveL

resulting in contuslon or hcmatoma,ischcmic ittury lalthOugh the pattcm appears round rather than suggcstive Ofa vascular distribution),chronic abscess. 3.Adrenali ncurOblastoHla. 4.Glて n thatit is a hcPatic mass,hcpatoblastoma is most likely bascd on thc Paticntt age and uptakc ofbonc radiotracei

ReFerences Buomono C,Taylor GA,SharcJC,ct al:GastrOintcstinal tract. ご "物 〃夕c品残″ ご物 ″ 咎 Cd 3, In Kirks DR,editoR物 Philadclphia,1998,LiPPinCOtt Ravcn,PP 960 969。 s,cd 2,St Louis, 脇あoれP務 ′″ク ,s,姥 Blicttan H:petta滋 江osbンPP 137-138. 1998,ぶ ReFerence CrOss‐ :Ett Rど Q5蕊 ル″″丹々″″″夕 助 び 124-125.

E「 S,cd 2,PP l12-115,

Comment Bccausc this is a hcPatiC rnass,hcPatOblastoma is rnost llkcly age and uptake ofbonc radiotracett Aftcr based on thc Paticntも the kidney and the adrenals,the livcris thc third lnOst common site ofabdominal malignancics in infants and children,Ofwhich One third arc benign.In many cases,imaging callnot rcliably de― Cal study is rcquircd.In terminc the tumor typc and Patholo夢 childにn yOunger thanうycars Ofagc the most likcly tumors arc hePatoblastoma,mesenchymtt hamartoma,arld hemangloma. On Prilnary hepatic tumor HcPatoblastoma is thc rnost coHll■ Ofchildhood;wo thirds ofcascs occur in Children youngcr than 2 ycars ofagco Similar tO paticnts with ncuroblastoma,abdom― inal radlographs of Paticnts with hcpatoblastolna show calcin_ cation in up to 500/o ofcascs,which accounts for the deposition Ofbone radiopharrnaceutical.The bonc scan is uscd to diagnosc metastascs. In adults,bonc radioPharmaccutical uptakc in tumOrs most comm6nly is sccn in mctastascs from colon,breast,and lung. HcPatic nccrosis,mctastatic calcincation,and amyloidosis are Other rcPorted causcs.

114

A

B

カ

一 べ

品響

！ 鞠

！

  ！

！ ！！    ！ ！！！

支

算

醐

≡ 告 苑 轟騨

ｔや揮 ！ ！ ！ ■ ！ ！ ・ ！ ！ ！ ！！！！ ぷ ！！

ゾ■低

餡ぽ

A13ザ ear― old girl adOlcsccnt with sicldc ccll discasc,low― gradc fevett arm,lcg,and back Pain was rcfcrrcd fOr a bOne scan像 り.The scan was rcPCatcd 1/carlateri thc Paticnt nOw has arm and back pain り. α 1. Dcscribe thc scintigraphic bonc and sOtt tissuc indings. 2. W7hat is thc likcly diagnOsisP

3 . W / h a t O t h e r n u c l e a r m c d iア cCiannc dscttucも ct SiCkle infarctsP 4.HOw can OstcomrlitiS bc differentiatcd frOm bOne inttrctP

115

Notes

Skeletal SysteHl:Sickle tCeH IDisease l.乳 AbnOrmalincreased uptake in thc Proximal righ〔 humerus,left distal femuL multiplc sites in thc thoracic and l u m b l s p i n e . a u P t a k e i n t h c r i g h t uina and ictt Pos― terior ninth ttb.Subde soFt dssuc uPtake is Prescnt in thc reglo■ofthc sPleen. ２   ３   ４

Sickle cell criscs with infarcts. 99mTc sulfur c。 1101d bOnc rnarrow scan. COmbincd 99mTc bone scan and marrow scan carly in the acute crisis.

Reference Al航 ん Heyman s,Tsc KM,Munz D:Bonc marrow imaging. In Sandicr MB Coleman RE,Wackcrs FJTh,c[狙 ,Cdito職 ″らcd 3,BaltimOre,1996,Willlams 筋″″物cれcと Dブ響 ω力 ″″す るこWilldns,pp 845-864. CrOss,Reference ガ ″夕 r「醍 脇 rル″″擁 妨び 186-189.

Rど QSNFES〕

cd 2,pp 134‐ 138,

Comment

Bonc and,oint COmplaints are quitc commOn in Paticnts wlth sicklc ccll hemOg10binoPathies.Symptoms may bc transicnt, bu[they arc related tO marrOw infarctiOns that Occur as Part Of a sicklc crisis.OFtcn thesc rcsolve writhOut radiographic changes. Radionuclide scans are the lnost sensitive imaging techniquc of daHlage.A fOr carly detection and cvaluatiOn of the cxtcn〔 99mTc sulfur collold bone rnarrow scan can detcct bonev rnarro、 infarctiOns carlys thc leslon appears as a cold deFecte Convcrscけ mid― sPine, in〔 marrow scanning otten mnOt cそ detcct infarcts he 10wer ribs or stcrnum.Thus bone scanning is thc techniquc most coHllnonly used.During thc nrst few days aFtcr a vasooc‐ dusitt crisiS with infarctiOn,decrcascd uptakc IIlay bc seen On thc bone scan.Soon incrcased uptakc is cvidcnt,starting as a rim Of increased activity arOund thc infarct.Oftcn only in‐ creased uptake will be scen becausc thc bone scan usually is not obtalncd during thc acute phase.Avascular necrOsis ofthc hcad Ofthe femur is the mOst disabling bonc icslon,and carly diagr nosis is important.Combincd bone scans and marrow studies, if Obtained carly in the cOurse,rnay be used to differcntiatc aSCPtiC OSteonccrosis and osteOmyclitis.With infarction thさ v‐ IIlarrow defcct is iargcr than the bonc scan abnormality;ho、 ever9 with httctiOn the marrOw study results positive aに only aFtcr 5 to 6 days,wherctt the bonc sctt iS pOsitive carけ

116

″li丁 ￨￨‐ ￨

A

TwO paticnts have knee pain,with no fevcr Or ca10tt Paticntノ 年bOnc scan and radiOgraph.Patientf β bOne scan, 1. E)cscribe the abnOrIIlal threc_phasc bOne scan indings fOr patients and B. И 2. W7hat Other gcneral infOrmatiOn abOut thc Patients is evidcnt frOIIl the bone scansP

3. Provide a differential diagnOsis and the rnOst likcly diagnOses for each Patient. 4. W7hat term is corllnonly used tO dcscribc thc Pattcrn scen on delaycd images in β ′

Notes

Skeletal Systenl:Osteosarcoma θ ol l . えI n c t t t e d b lぁ o″ o ad n dn O bw l物o o dあ物PJoヮ

ψ

tO the right distal ttmur and increased uptakc on ddaycd femOrtt mctaphysis extending to the imagcs in the dist』

d uptake in thc M l l d itntccК ,Oint Surf物 a c″ e ヴ p.ぁ pro対mtt tibia prObably the rcsult ofh/Peremia.a Radlo‐ 危mur with sclcrodc leslon ofthc dist狙 graph mixed lytic‐ cortical dcstrucdon and indistinct margins.No periostcal rcaction.C Abnormalincrcascd now and blood Poolto the lett distal femur with dclayed increascd uptakc in sPiculatcd Pattern cxtending beyond thc fcELOral Contoui 2.Thc Paticnts arc skeletally immature but near thc mature stage.Physes arc seen faintly On delaycd imagcs,indicating that fusion is immincnt.Thcse are tcenagcrs. 3.И ,ヽlonOstotic Primary ncoPlasm,c.g.,osteosarcoma,sec― Ondary ncOPlasm,or Ostcomyclitis.a Charactcristic sun― burst pattcrn ofostcOsarcoma. 4. Sunburst pattcrn.

Refelence Rchm PK:Nucicar medicine scif― study program IM unit 2.In θG総 ― :θ″び 力″″夕 M″f″ ″ ″″物″ Haney TR Rchm PK,cditors:」 Rcston,Va,1997,Socicty of ″″ ″ 物 び 0″%″ ″θ″″′物物θ 宅ノ咎 9 ,20,22. Nucicar Medicine,PP 7‐ CrOss―Reference 述 力″″鴎 品冴″α 「 助 び

沢野QdttFES,cd 2,pp 125‐

127,136.

CoJmment Osteosarcoma(ostcogenic sarcomal is thc most common malig― nant prilnary tumor in childrcn and adolesccnts.The in_ traosseous mmor usuttly arises in the mctaphyses Of10ng bones, the distal femur(44%),ProXimal tibia(22%),and PrOximal

hysiS,Or s,cPゃ It Can extcnd into the diaphy立 humcrus(9%)。 vithsccn、 a largc rneta― both.Two thirds Ofpaticnts initially arc physcal tumor as thc Primary fOcus.Radlographically the lcsion may bc predominantly ostcOscierotic(25%),oste01ytic(25%), Or mixed(50%).A cocxistcnt sott tissuc mass characterizcd by the prOduction OfOstcOid Or bone usually is prcscnt.A periostcal reactlon ofintcrruptcd or sPiculatcd type frcquently occurs. Bonc scintigraphy is indicated beforc initiation ofthcrapy to dctect skiP icsions,multicentric osteosarcoma,or a prilnary lc― slon with lnultiPic FnetaStases.In the prescncc of rnultiPlc lc‐ slons,lirnb aFnputation is no longcr aPPrOpriate.On boncscan, OStCOSarcoma avidly accumulatcs the radlotraccr with or with, out extcnslon into adiaCent sott tissuc.Occaslonally an cxtended or augmcntcd Pattem may imply extensive marrOw extension or transarticular involvement.Bonc scinagraph/is poorin deining intraosscouS tumor icngth.The cxtendcd Pattem iS attributcd oblas‐ to circulatory changes in bonc that simulate rcgional ost色 v bascd on MRI. ity.PrcoPcratiVe asscssment is no、 tic act市

118

A

B

鵡

墨

批

！ 比

ギ端磐誹

書

TwO yOung adults werc rcFerred fOr a bOne scan.Paticntノ 4 has thOracic Pain,and Patient翌 〕has hip pain. 1. Dcscribe thc scintigraPhic indings in bOth Patients. 2. W7hat is thc diagnOsis and causc fOr this Pattcrn Ofuptake in thcsc PatientsP 3. W7hat is the rnechanisII1 0fradiOpharIIlaceutical uptakcP 4. Wマhat are other causes ofuptakc in muscicP

119

Notes

Skeletal System:Musde iniury muscles bilatcr狐 l.乳 Uptakc in tcresormづ けa Bllatcr』 uptakc h thc adductor magnus musdcs Ofthc thighs.

veight strcss;、 2,Soft tissue muscic ittury Caused by rcpetitivc l i f t i n g ,iann dИ s t a i r c l l r n b e r c x c r t i o n i n a 3. Soft tissuc dcposition Of99mTc-labelcd diphOsphonatcs is

causcd bybinding to microcalcincations at sitcs ofittury immature collagcn. and POssibly bindingurcd to l可 iOn,Polymyositis,myo‐ 4.Rhabdomyolysis,lron dcxtran ttcα rcct trauma. sids ossincaFIS,iSchemia,dectrical initlries,乱

ReFerence Brill DR Radionudide imaging ofnOnneoPl益 tic sOtt tissuedis‐ ″'W物び ′%〃 11:277-288,1981. ″ orders,S夕,物 Cross‐Reference 醍 彦″″鴎 品冴″α 「 州力び

蕊 〕cd 2,PP 130‐ 13o. 財 Q占 酎 『

Comment

A300d gcncral rulc when rcvitting bonc scans is to nrst scru_ tinizc thc scan fOr rcnal and soft tissuc abnormalitics bcfOre fO‐ alitles arc rnore cusing on thc boncs.Although iddncy abnorn■ commonly notcd,sott tissuc abnormalities arc not uncommon. r cxclude bonc abnor― Patients usually are referrcd to 。 conarl■ malities,c.g.,stress fractures and shin splints;hOwcvcL the bOnc scan occaslonally prOvides sPccinc soft tissue diagnosis,as in thcse cascs.Ovcrcxcrtion iniuricS tO thc musculoskelettt systcm arc common,Many are associatcd with overexcrtlon rcPctitiVe strcss inluries. The proPoscd HICChanisln Of uptake is absOrption to dcnar turcd prOteins or binding to nlitochondrial calciun■ ,which is increascd in ischcmic tissucs,The causc ofmuscic localizatiOn is bclicvcd to bc rhabdOmy01ysiso Muscle localization of bonc ter a varicty ofexerciscs.In downhill traccrs has been rcPortCdポ runners,uptakc occurs in thc buttocks,halnstrings,and quadri‐ uPtakc in thc thigh 益 uphill runnctt havc 杏ed incに CCPS,Whe崎 adductors.Uptake in thc thighs can bc sccn in bicycic riders uP cOntcsts.Bllateral and in the abdOminal musdes attcr push― it/Posteriorly in the tcrcs maior muSCiC has bccn rcPorted act市 in weight crs. ll丘

120

1. Dcscribe the bOnc scan indings. 2,Name structures whcre thC traccr could be dcPOsited. 3. PrOvide the difFcrchtial diagnOsis. 4.村 イ hat Othcr infOrmation would bc helP飽 lP

121

Notes

e Skeletal System:Pleural Upta“ l. AbnOHnal soft tissuc uptake in the antcr10r left hcinitho‐ rax,scoliosis and lnild arthritic changcs in bOth hips. ward:in thc lung vorldng ouぃ 2. Starting on thc insidc、 parenchyma,in a priFnary Or sccondary tumOrin the lung〕 in thc pleural or Pleural cttusion,in thc sOFt tissuc ofthe chcst wa11. 3. Extcnsivc Pleural calcincation,nbrothorax,prior radiation. 4. Historンchcst radiograph,orSPECI

Reference Gray]Hヽ に IGasnOw AZ:Soft tissue uptakc of bOnc agcnts.In ル物〃″ヶ タ Fogclman I,Rosenthall L,cditors:Sを C01licr DBJち 務″″らSt Louis,1996,Mosbtt p 383. ι び ″″″物夕 Reference Cross― fr配 ブ ″夕 助 材″ ″″%妨 ご 142-143.

沢どQ3蕊

rES〕 cd 2,PP l12-115,

Colmment The curvilinear infcriOr margin fol10ws thc contour of thc di‐ aphragm,suggcsting that thc llptakc relatcs to pleura.The ind… indicating it is located ing is cvidcnt on thc anteriOr vicw onlン こ slon is unlikely unless it is 10c‐ anteriorly;thcreforc Picural e衛 ulatcd anteriorlys Prlor radiatlon is unlikcly to involvc the an― terior and spare postcrior structurcs,or have a rOundcd supcriOr uptakc in a soft tissuc mass margin,as in this casc.Simllarlレ within the thOrax or arising frOrFl thc chcst wall is unlikcly to havc an inferiOr rnargin that parallels thc diaphragm.This Pa― ticnt had a history ofPrior lett cmpycina and subscquently dc― vc10Pcd a nbrothorax. In gcncralthc mOst common rcason for unllateral uptakc in sOft tissues within thc thoratt is malignant plcural cffusiOn.If nOwing,thc scintigraPhic Pattern can changc thc cttLslon is frcc― with changcs in Paticnt PositiOn,as it does whcn radlographs are taken with thc paticnt crcct and supinc or in thc dccubitus posltlon.

1. What arc possiblc cxPlanatiOns IOr the change in thc Patientも bOnc scan ttrom И tO」 伊′ 2. List threc questions that wOuld bc helPfui tO lilnit thc differential diagnOsis in勉 3. Describe thc bOne scan indings in patient(五 Ignore the rectangular rcglon ofintcrest. 4, PrOvide thc rnOst likely diagnOsis lor the 勾 scansノ 程〕and C

123

Notes

Skeletal Systenl:Hot Kidneys′ Radiation Nephritis,and Spinal Photopenia l.Incrcascd radiotracer is PrCSCnt in both renal corticcs in a up study that bilateral symmctrical Pattem On thc f0110w―

狙stュ was n6tseen on thc h血 毎 2.Has thc Paticnt becn trcatcd with a new mcdicatlon in the intcrval sincc thc PriOr bOnc scanP Has thc PatiCnt had recent intravcnous contrast rncdiaP Has thc patient had rcstricted nuid intakcP 3. Incrcascd activity in the uPPcr portiOns ofboth lddncys aFla COld lowcr thoracic sPinc. 4.〃 ,ChcmOthcrapy‐ induced interstitial nephritis,C Prior radiation theraPy to thc sPine With radiation ncPhritis,

ReFerence Siddiqui AR:Incrcascd uptake Of technctiurrl,99rn-labelcd 物物グ12:101‐ V力〃ソ 形″タ ブ ″プ bOnc irnaging agents in thc ttdncy9さ 102,1982. Cross‐ Reference fr醍 筋″″鴎 温冴″′ 対務す

逆 Qdtt「 ES,cd 2,P l15,

Co】mment

hOt"臨 dneys on bonc scan that resOlves Dchydration can causc“ On ttPCI Study with 800d hydration.It may be sccn transicntけ in patients with acute tubular necrosis.Most common,it is causcd by rcnal tOxicity as a rcsult Of rnedications such as chemOtherapン ncPhrOtOxic antibiotics,or radiOgraphic cOn, trast.The ttdneys rcturn to a normal appcarancc on subscqucnt scans.Thc pattern may bc PcrsiStCnt in chrOnic conditions,such as iron overload and rnultiplc mye10ma. RadiatiOn can lcad to ParCnchymal ischelnia as a rcsult Of slna11-vesscl artcritis,which can bc followed by renal atrOphye Radiation ncPhritis is secn icss cOIIlinOnly with inodern radiar tion therapy techniqucs but rnay occui Effects in bOnc are re― lated to dosc,Patient age,sitc,and specincs Of the radiatiOn iS rcfers tO a varicty ofappcarallccs, techniquc.Radiation Ostciを including growth arrest,Pcr10Stitis,and abnoHnalitics of Hlin― in the rad体 10n.Whcn immatuに bonc is inadvertentけ eraliz証 tcrin Outcomc lnay include scoliosis tion treatinent neld,long― and undergrowth ofirradiatcd bonc.Although somc dcbtte ex― ng meChanism fOr bonc lsts,vascularitturyiS thC likelyundcrlガ iniurye lncreased radiotraccr uptake in bonc associatcdwith hy‐ w eeer魅r a d t t b n g r e a t e r 「C r C m i a ぉP r c s e n t d u i n g t h c n r s t 益 than 30 Gy(3000 rttds),This phase usually is missed bcdausc thc diagnOsis is known and trcatinent under wayj and no clini‐ cal nccd cxists for a scan,With tiEIC the scan pattern cvolvcs to PhOtOpenia that usually resolves cOmplctely or remains at most slightly decretted comparcd with nOmtt adiaccnt bOnes,

124

1.Describc the advarltagc ofwhole bOdy imaging for the techn010観 st cOmpared宙 th spot imaging,which wtt uscd in this casc. 2.Describe thc advantagc ofwhole bOdy imaging for thc Physician. 3.Dcscribe thc abnOrmali呼 4. PrOvide thc differential diagnOsis.

Notes

Skeletal SysteHl:Splenic Uptake l.Lcss camera repositioning and time FOr thc tcchnologist, 2. Easicr for thc physician to check for quality assurancc and 1 ぃ、 fOr intcrpretive rc宙 al uptake in a structurc that appcars to bc 3. Intense abnorn■ an enlarged sPlecn by its location and connguration. 4.Blood dyscrasias,including sicklc ccll discasc,sicklc tha―

extcnsive sub, lassemia,thalasscmia hemosidcrOsh mtto、 capsular sPlcnic hematOma.

ReFerencc ″ Silberstcin EB,McAfee JG,SPasottAP:D″ 竹″何カ タ″ル物∫″ グ び ″ ″ ″ ″物′ グ ″″び ″ ″ ら Reston,Va, 1998, Socicty of Nuclcar Mcdicine,P228. Reference Cross‐ ″″″鴎 品冴″4「醍 京野Qむ慰 FES,ed 2,pp 133‐ 134. 助 ご Comment WhOle bod/images aに casicr for thc Physician to rcvitt When st bc t h e s t u d yPお c r f O r m c d t t m u l t i J c s P o t S , t hdca nP hmyu立 carenli to ensurc that nO gaps betwcen the scanned regions cx― ist whct aleslon may be mおscd.Thc ttholc bOけ format cn_ surcs that thc whole arca has bccn imagcd,and the whole bOdy study is casier for the tcchn01ogist to PerfOrm.Thc technolo― 31St posidons the padcnt and sets up thc wholc body scanttch VithOut Furthcr tcchn010gist inter― which then dOcs a``swccP"ヽ vention.In contrast,the tcchn010gist inust rcPositiOn thc pa― tient Fbr cadl ofthc rnultiplc sPots uSing thc othcr tcchniquc. Thc lnost coHllnon causc oFsPlcnic uptakc ofbonc traccr is sickle ccll discasc,HoweveL the sPiccn would bc cxPeCted tO bc shrunken,as a resuit ofautOinfarctiOn,in a paticnt who is skele― ta■ y mature,as in this casc.In a child with sicklc cell discasc thc sPlcen lnay not bc small.BOnc nndings suggesting bone infarcts though dc― wOuld support thc dagnOsis ofsictte cell discasc,狙 Pcnding on thc agc ofthc bonc infarct,they may be difncult or impossiblc to idcntitt lfmultiple iacturcs or uptakc in sOtt tis‐ suc contusions were dcmonstrated,sPlenic trauma would be a likely possibilityb Becausc of thc Pcrfcct connguration of the tracer in a sPlccnlike appearallcc and thc lack Ofothcr indings, subcapsular hcmatoma would sccm unlikclys ThcrcfOrc sickle thalasscmia,thalasscmia malo5 or hCmosidcrOsis arc the bcst dl‐ argnoses.This Patient had sicklc thalasscmia.

126

Thc bOne scan image and rad10graph ofa paraPlegic Patient are provided. 1. Describc the bOne scan indings. 2. PrOvidc a diffcrential diagnOsis, entions cOuld be pcrforlrled ifartifact is susPectCdP 3. W7hat intcnァ 4.Radiograph ofthe right hip was ncdobtぶ atter the bOnc scan.Whatお the mOst hkcly diagnOsisP

Notes

Skeletal Systenl:Heterotopic Ossification l, Radiotraclr in a Full urinary bladder Obscurcs the central portlo■ofthe bony pelvis.Intcnsc activity is scen Overiy‐ ing the right acetabulum with a slParate area ofuptakc Overlying the p:oXimtt right ttmu丘 2.Urinar/contalninatlon;fracturc with exuberant callusi ft tiSSuc heterOtOpic ossincation or myositis ossincans,,。 iniury(COntuslon). 3. Ifurinary contanlination is susPCCtedi remOvc clothing skin in thc and overlying bed shcets,wash the paticntも arca ofsuspected cOntarllination. 4. HctcrotoPiC OSSincation.

ReFerence ″筋ブ?″ ″筋, r物 冴θ々gf″ P物 す 務?タ ググ GrecnsPan A O″ 蛇Wll臨 ns,P648. Philadelphia)2000,Lippincott Willlarnsに Cttss‐Reference ″ %α r醍 脇 す ″″″丹々妨び

沢どQじ 憩 rES,ed 2,pp 124-125.

Comment す ″ あθ ∬冴筋″すand力み 物力 ″ザ 響 θ The temsル ″″,η″ pjf炉

物″ ″θ ″島cquently are used intcrchangeablン θ ″ ′ 夕 ″方 力″ ワ″あ θ ∬夢 C ″打 t O C t t C S i n w h i c h n e w S o m c r e s t r i c t t h c t c r m s 't あ tθ

bone ariscs as a result of innaIIlination of rnuscic and rescttc ″す ″′ヵ 物 ″力 ″″ r%夕″ あθ カタ ″″ ″体 炉ィヵθ″Orみ秘 ″η ″ げ deancd cause.Thc ProPosed lncch" 成ss″ 夕in the absencc ofwell― anism is that primitive mcscnchymtt cclls diffcrcntiatc tcOblasts that dcposit rnatrix that ossines.Thc radiograPhic ap― PCarancc in this paticnt is t/Pical.The leslon frequcndy is sccn adiaCent to the cortex of a long bonc or nat bonc.It shows nizcd bone at thc pcripherywith less d e n s c , wocrlgla― A wcll― d enned scParation ofthe lcsion frOm bOne at thc ccnte■ the cOrtex Of thc ad,acent bOnc is prcscnt.Alternativc,the cOnditiOn appear as a vell-1lkc lcsion that is icss wcll delineated. B10Psy ofmyOsitis ossincans/heterotoPiC OSSincation carly aFter onsct can lcad to histo10gical confus10n with sarcoma. APprOpriatc correlation with thc rad10graPhic appearancc is lon if critical to avoid unneccssary biopsy or furthcr intervcn〔 b10psy is inadvcrtently pcrfOrmcd.

128

into

organized

os‐

Elevated alkalinc PhOsPhatase level. 1. Dcscribe the bOnc scan indings. 2. NaIIlc two othCr nonOsscous systeIIIs that shOuld be cvaluatcd On thc bbnc scan. 3. Dcscribc any Other indings. 4. ヽ Vhat terIII can bc applied to this cascP

Notes

Sketetal Systerrl:Superscan Secondlry tO Metastatic Prostate Cancer l,Incrcascd rad19trtter in the largc mttOrit/ofthc visualizcd bOnes,、 rith nonunifbrm inv01vement particularly evident in bOth feFnurS,both humcri,and skull. ２   ３

4.

SOtt tissues and genitOurinary tract. Thc k i d n c y s a r e n O t v i s u a l i z e d , b u t f a i n t activity is scen in the urinary bladdci Litdc sOtt tissuc activit/is seen. Superscan.

References Sicgel BA,Chang A:OsteoPorotiC insuFncicncy fracturcs,In ThrallJH,sCCtiOn editO■

ハ 物す力 ″″ 物 ″θ駒

(fourth series)豚

Colcgc ″ガ ル あら R c s t o n , V a , 1 9 9 0c,aAlmlc 五

″

ofRadido排

P230。 McAfceJG,Rcba RC,Mづ dM:The musculoskcicttt system.In 力a″″ W a g n e r H N , S z a b O Z , ″ Bウ uあ c hザ a″″ nび n J W 筋 Satlndc馬 艇赫 ちed 2,PhiadclPhia,り9う,Ⅷ ,PP 991'994. Reference Cttss‐ 鵡 助 f彦″/Mettci″α 軍

択どQ3慰

rES)ed 2,P121.

Comment The term J夕′ おCa″rcFcrs tO a bonc scan pattern with increased radiOpharmaccutic』uptakc rclative to sott tissuc background and renal activitye SoFt tissuc,kidneys,and bladdcr aPpear tO have decreased uptakc.Thc superscan can occur in any diIFuse h tracer uptakeお markcdly incに岱cd h skeにttt dsOrder h whた the skcictOn.Bccause lcss Ofthc traccr is avallablc fOr rcnal cx" cretion, faint Or no visualizatiOn of thc kidneys results. Optimization ofthe imaging Parametcrs fOr the skeletal activ‐ it/1evel cOntributcs to thc apparcnt nOnvisualizatiOn Of renal activitye WidesPrcad metastatic discase is the most frequent causc of a superscan.The prittlary tumors responsible indude carcinor mas Of the brcast,lung,and PrOstatc,組thOugh it may occur with lymphoma and bladder canc∝ Supcrscan o,curS in latc, stage mctastatic discase OfbOnc wlth dinttse invOlvement.This Patient had prOstatt callctt USually somc inhOmogeneity or hot tern suggest tumor as thc causc.A singic radio― spots in the pa〔 graph Of an inv01ved bOnc sudl as thc Pelvis Or femur usually lrinatiOn of rnetastatic involvement.The PrOVides easy con「 Other mttOr Causes ofa superscan are metabolic bbne diseascs, c.g.,rcna1 0steodystrophtt Osteomalacia,and hyperParathy, roidism.Myclonbrosis and systemic mastotttoSiS lan result in a sinnllar pattern.In this casc,additional clinical inforlnation such as thc abscnce ofchrOnic rcntt failure and prinar/hyper― Parathyroidism incrcasc thc likelih00d Ofmctastatic disease as the likely diagnOsis.

130

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額1坑 41臨

せ

A56-ycar_01d was adIIlittcd aftcr a seizurc and fall.Brain CT dcmOnstrates rnultiplc Vholc ccrebral bOdyrnasscs.対 bOne scan像りand multiPle transverse SPECT images ofthe chcst浄 り arc shOwn, 1, Describc the skcletal abnOrlnalitics. 2. Describc any Othcr abnOrmalities. 3. W7hat is thc II10St likely diagnOsisP 4. Name 3 1iver priFnary Or rnctastatic tumOrs that have incrcascd bOne traccr uptakc.

131

Skeletal SysteHl:Soft Tissue Uptake ln Lung Mass l,Foctt abnormぶ uptakc in the right and ictt anterior ribs, right upper posterior rib,and stcrnum. 2.Abno r m ぶ d i f f u s c r a d i o t r a c c r u p t a k c i n the right upPcr chest On the antcrlor and Poster10r vlcws,WhiCh dOcs not cOnfOrm tO normal bOnc cOniguratiOne Sclcctcd SPECT images dcmonstratc the uptakc to bc in a largc ovoid Hlass 宙 thin the right lung. 3.Lung cancer with brttn EICtaStascs.The bOnc scan abnor― mttities arc likcly traumatic becausc ofthe distribution and history ofa fall. 4.A high percentage ofncuroblastomtt invotting thc liver havc bonc tracer uptake,and a rnuch aller sn■ perccnt of metastases from lung,brcast,and colon cancch esPccially mucinous canccrs.

ReFerence Pcllcr PJ,HO VB,KransdorfMJ:Extraosseous Tc-99m MDP 冴 ,慨 んね 13:715uptakei a pathophyslo10gic aPProaCh,筋 734,1993. Reference Cross‐ ″夕 f『醍 脇 す 彦″″%″ f″

沢FQyrSrrES)ed 2,PP 124‐

125.

Comment Bone scintigraphy inay dcrnonstratc abnoHnal sOtt tissuc up― vidc varicty of nonosscous disordcrs,induding nco― take in a、 Plastic,hOrmonal,innalnmatory9ischcmic,traumatic,excrctoryp and artifactual cntities,ThOracic uptakc on bOnc scans often is seen in PatiCnts with cancer Ofthc lung.Howevett in contrast to c― this stutt it is mOre commonly the result Of plcurtt invo障 rllcnt and malignant pleural cffus10n.The distribut10n charac‐ teristically extends to the diaphragmatic costal margin,PartiCu― larly ifthc Paticnt iS Standing or sitting uP.On thc other hand, benign eFFusions typically causc attcnuation and thus dccrcascd uptake is scen on that sidc.Ascitcs can result in silnllar indings in the abdOmen,with incrcascd or dccrcased uptakc dcPcnding On whether thc Peritoncal proccss is rnahgnani or bcnign. Mctastatic tumOrs to thc sPleen Occaslonally show uptake On bOne scanning.Paticnts with sickle cell discasc Oftcn have sPlenic bone traccr uptakc until thc sPiccn atrophies.Prirnary b崎術t cancers mtthave uptake,particula』 y ifthcy are large or innamlnatorys Prclirninary studics suggest that thc scnsitivity fOr detcction OfPrilnary breast canccr with bone radiOtracers is similar t0 99mTc sestamibi.Bllatcral uptakc is mOrc ttkely thc result Ofibrocystic discasc and othcr bcnign catses. Notes

132

A55-ycar―old lnan hasiO、 v back Pain and no prior histOr/・ BOne scm iinagcs,antcrior and PostcriOr views. 1. Provide a general distributiOn fOr thc bOnenalitics. abnOrェ 2. Describe Fhe indings. 3. List three factOrs that help lilnit the diffcrcntial diagnOsis. 4. W7hat is the rnOst ttkely diagnOsis'

Notes

Skeletal Syste‖1:Prostate Cancer Bone Metastases′ Axial Distribution l・SPine and Pcivis. 2.AbnOrmal focal and regional activity is secn in multiplc sitcs in the sacrunl,both iliunl,both inferiOr pubic raHli, right superior pubic ramus,mid― thOracic and 10wer tho― racic sPinc・ Note thc incidcntal calcincation ofcOstOChOn― dral cartilage. 3, MultiPic lcsiOns,axial prcdOHlinancc,oldcr adult man. 4.Multiplc skcletal merastases from prOstate cance■

Reference JaCObSOn AF:BOnc scanning in mctastatic discasc.In Collicr BD JL Fogelman I,Roscnthall L,editors:せ 影タ ル物ブ″″び 力″″

物″ あ″ %Ncw YOrk,1996,MOstt pp 90,108-109. Cttss,Reference 対物び 力″″%″ び ″ ″α 『 配

京どQ5慰

rES〕cd 2,PP 121-122.

Comment ln this case thc nndingS ofmultiPic lcs10ns that arc distributed in thc axial skeletOn,and not at sitcs that suggcst dcgcncrativc change,suggcst skclctal rnctastatic discasco With Patient infOr_ mation(oldcr mall)and a knowlcdgc ofthc mOst prevalent can‐ cers,thc most likely diagnOsis can be determincd.Thc PattCm Of bOne mctastascs of most tumors(cxccPt primary lung can_ cers)shows a predominancc in thc axialskclctOn and Pcivis,al― thOu3h nOt cxclusivcけ ThC diStributiOnおnot h PrOPOrtiOn tO arterial b100d nOwp Suggesting that this is nOt the likely mOdc Of disscminatlon of tumOr cmboll.General agrccmcnt cxists that the vertebral vcnOus Plcxus is an important factor in the prcdilcctiOn Of bOnc lnctastascs to thc axialOn.TumOr skeleせ cclls Originating bclow thc diaphragnl can mOve through the vcrtcbral venOus Picxus tO thc pclvis,abdOmcn,and chest whilc bypassing thc infcr10r vcna cava.Intcrconnecrions bctwccn Batson's Plexus and thc intcrcostal veins prOvidc a rOute of spread to五 監 RctrOgrade now thrOugh the valveless Picxus can occur from hcreased Pに ssuにrcsddng frOm cOughing or strttn― ing.In this case,radiographs ofthe pelvis revealcd multiple sdc― rotic leslons,and prostate bloPsy conarIIled the diagnOsis.

134

軽褻ガ鮒 一 轄 一

静

！ ！ ！ ！一 一

一

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A53-year―old wOman with hyperc』cemia was rcfcrrcd tO rulc Out mctastatic bone discase. 1. Describe thc bOnc scan indings. 2.Givc a dittrential diagnosis. 3, PrOvidc thc rnOst likely diagnOsis. 4. COuld this pattern be causcd by frcc 99mTc PcrtcchnetateP W7hyP

135

Notes

Skeletal SysterTl:Hyperparathyroidism 1. AbnOrrllal diffusc uptake in the lungs and stomach.PoOr visualizatiOn Ofsmall kldne/s and bladdcr9 increased uptakc in thc shOuldcrs,hips,knccs,and anklcs. 2.

HyperParathyroidism,metastatic calchcatiOn caused by hypcrcttcemia,氏ntt failutt Or bOth,mctab01ic bonc discttc.

3.

This Particular Pattcrn ofmctastatic calcincation is charac― standing hyperparathyrOidism.Although teristic of10ng‐ alacia Othcr causes ofmctabolic bone discasc,c.g。 ,osteon■ result in abnOrmal bonc scans, and rcna1 0stcOdystrOPhン they do nOt have this characteristic Pattern.This scan pattcrn is scen in hypcrparathyrOidism.

4.

ar/ sal市 Fttc 99mTc Pcrtcchnctatc hasc,thyrOid,and gttt五

」and uptake.The latter tto are not secn in this Patient, whO alsO shows iargc uptakc.

Reference 挽 野 l B A , e d t o H 助あ ″″あ 物 はメl a b u t t s c c o n cd s ,s c 拭 Rcston,Va,1978,Amcdcan Colegc OfRadio10排PP 410-424. CrOssPReference 醍 助 f捻″″Mcttcttα 軍

沢野Q」 慰 「ES)ed 2,PP l12,121,138.

COmment Thc rncchanisHl of altcrcd bOne radiotracer uPtake in h/Per― ParathyrOidism is rclatcd tO the increasc in bonc resoFptiOn and sccondary incrcascd bonc turnovch causing increased os‐ teoblastic activity in the skeleton with less radiOtraccr avallable fOr renal cxcrctiOn.Thc bOnc scan in prirnary hypcrParathy, rOidism Oftcn aPPCars norma1 0r may havc subtle abnOrmalitics Of diFFuse increased bone uptake dctectable only by quantita… Vhen prcscnt,bonc scan abnorinalitics usur tive techniqucs.対 ally cOrrcsPond tO arcas with radlographic demineralizatiOn eroslon,e.g.,in the calvaria,mandible,acrOrnioclavicular areas, sternum,1筑 er』humcrtt cPicOndyles,and hands.IfbrOwn tu, ly show uptakc.As the discase ad― mott arc PreSent,thcy tyPic』 vances,extraskeletal rrlineralization ofsoft tissues can occur in

the cOrnca,cartilage,,Oint CapSuics,tcndOns,and PcriartiCular standing hy‐ regions.Bonc scans in Patients with scvcrc,10ng‐ ake,charactcristi― PCrparathyrOidism may have sOtt tissuc up〔 cally in the lungs,stOmach,and often kidncys as a rcsult of mctastatic calcincation.Intcrcstin」 乃 組l these Organs with up― base mctabolism. In additlon, takc are involved with acid‐ 脇scけincreascd uptakc in bOnc,10w scintigraphy may shOw d問 sctt dssuc,and renal activityP and Prominent uptake in the skull〕

acromiodavicular,oiniS,mandible,slcrntlm,and the Pcriartic― ular arcas Oflargc,OintS・

136

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A

B

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An initial bonc scan(ク . iatcr rコ リand rcpeat study 2 ycarsノ 1. Describc the bone scan abnOrrllalities On thc initial. study(2り 2.Dcschbe the skclcttt abnOrmattties on the島110w― uP studyの . 3. List thc diffcrential diagnOscs. 4. PrOvidc the rnOst likcly diagnOsis.

137

Notes

Bone:Osteosarcoma Metastatic to Lung l.И,Abnormal dccreascd and increascd uptakc in the leFt humerus(Proximtt and mid,rcsPcctiVelyl. 2. 2乳Irregular uptake in the chcst antcrior and Postcrior cn in the lung vicws indicatcs locatiorl lnidwa/bcNミ ParenChyma.Uptakc is nOdular and masslikc.Rib abnor‐ malities cannot bc cxcluded,but thc path010gical cOndi― tion cxtends acrOss thc rib sPaces.Lcft shOuldcr arthrO― Plasty is shOwn by photOPcnia. 3.The dittrential diagnosis fOr abnormallung activity in a fOcal pattern indudcs primary lung tumOrs and metastascs, CSPCCially for turr10rs with calcinc or Ossinc corIIPonentS・

For abnormal lung activity in a rcttonal pattcrn,not evi― dcnt in this case,thc differenfial diagnosis indudes malig‐ brothOrax,or radiation thcrapy― nant PiCural cfFusion,丘 induced PneumOnitis. 4.Ostcosarcoma ofthc lcft prOximal humcrus,status/ arthrOplast/9 with lung mctastases. POSt‐

References Link MR Eilbcr F:OstcOsarcoma,In Pizzo PA,Poplack DG, e品住″ル θ″御殉 PhiladclPhia,1989,Lippincott, cditors:踏 PP 706-707. Sartoris DJ:ル

方 夕 ∫ 物 ″ 宅gr務 ′″夕″オブ 物∫ f″あJ″タル″ 〃″ ,St Louis,

1996,ふ江osbtt PP 244-254. CrOss‐Reference 醍 ″ ″α 軍 捻″″%冴 び 助 び

ズどQyrSrr蕊

)ed 2,PP 126,207.

Comment Distant mctastases are fOund at initial staging ofostcOsarcorna in Only 2%of Paticnts.C)sscous rnctastascs occur at a ratc of 10/o per rnOnth betwccn 5 and 29 1nonths aftcr diagnOsis,with

Bc島陀the advcnt ofattllvant a decreasc h the rate thcrcaFtc■ otherapン bonc IIlctastases LISually wcre detectcd bcfore chel■ pulmOnary IIletastascs.Howcvc島the natural coursc ofthe dis― easc has been altcrcd;bOne mctastascs now appear bcfOre pul― monary rnetastascs in only 150/o oF cascs.Mctastases to othCr cL臨 dncyp and lymph nOdcs,occaslonally arc sites,including l市 demonstrated by skelettt scintigrapけ Thc primary tumOr and metastases avidly producc ostcOid thatにsults in bOne traccr uptakc.Although bOnc scintigraPhy Ottcn can demonstratc lung metastascs,bOth planar and SPECT imtting are less scnsitivc than CT fOr dctcction oflung mctas‐ tascs from ostcosarcoma.Thc incrcasing usc of surgical resec― contributcd tions oflung rlletastascs,cSpeCially in n,has childた to imprOvcd suttival.Thc mOst widely used excisional procc‐ dures for lung mctastases arc for ostcosarcomat Thc surgery is stasis is cxciscd with r a t h c r u n i q u ci id u ta hl c m ie nt da 市 mal margin Of surrOunding lung tissue with thc goal of Pre‐ serving the rnaxirnunl amount oflung tissuc.

138

a

minl‐

一イ ．

ぶ鞄 拗

のま

，

■■ｉぽ督轡十

紡

一 鶏 十

！

帆 機 お丁 剖

︼

一 ・ 

ぱ麟

Diffusc upPcr extrernit/pain Was notcd 3 months aftcr thOracOtOmye Hand radiOgraphs shOw nOrmal indings.Thc re_

mainder Ofthe bOnc scan is norlnal. 1. Dcscribc the scintigraphic bonc scan indings in this casc(pallns dOwn On the camera). 2. Provide thc differcntial diagnOsis. 3. W7hat is thc likely diagnOsis in this cascP 4. DiscLISS thc pathOgcncsis.

139

Notes

Skeletal SysteHl:Reflex Sympathetic Dystrophy l.Thrcc―phasc study dcmonstratcs abnormal incrcascd blood n o w a n d b。 ld。P o o l o f t h e d i s t a l r i g h t u P P c r C X t t t m i t y e The dclaycd bonc Phase shOws incrcased activity in thc boncs in thc same distribution,with a striking increase in

PCriarticular activity causing the,OintS tO Stand Out. 2.Rcnex sympathedc dystЮ phy syndrOme(RSDS),diSusc of t strokc or immOblllzatiOn a l i m b o f n c w o n s c t ,rce.cge.n〕 by orthopcdic cast or sPlint. hand syndrome,a frcquendy cncountcred form 3. ShOuldcr― ofRSDS. vith 10ss Ofsympathetic autonomic 4. NeurOgcnic origin、 though nOt ly accepttd cxplanadOn,狙 tOne is thc gcner』 irlnly cstablished.

References Sartoris DJ:批

物 ∫び″わ 影 タル 物 ′″物 牲 ,れなf務 ′ 打タタ″オブ方夕す ,St Louis,

1996,い 江osbンPP 290-292. Fournier RS,Holder LE:Rencx sympathctic dystrophr diag― ブ丹々グ28:116-123,1998. 物ブ ″ハ協ご ■ostic controvcrsies,S′ ReFerence CrOss‐ ″ ″4「配 京どQdSFES,cd 2,pp 136-137. 筋″″脇 妨び 助 ご Comment C)ther causcs of incrcascd Pcriarticular uptake include innam― matory osteoarthritis,c.8。 ,rheumatoid,carly postarthroplast/ changcs,or ProsthCSiS cOmplicatcd by infcctiOn Or 100scning. Howevctt thcsc cntitics generally do nOt inv01vc thc cntirc limb, sO they would bc inapprOpriatc considcrations in this case.Also s atrOphンOr cauSalgia,rcncx symPathctic rcfcrrcd to as Sudccぱ dystrophy syndrOme is an entitt that indudes Pain,swclling, osteoPorosiS,and latc atrOPhy ofthc limb.Thc causc is thought trauma,sur― tO be neurOgenic,and ottcn it is associatedhwi〔 gerンor ilincss. Radlographs lnay demOnstratc soFt tissue swclling and ostco― porosis.Bonc scintigraphy oftcn demOnstratcs abnorIIlalitics bcfOre clinical or rad10graphic indings.Classically thc cntirc distal cxtremity demonstratcs scintigraphic abnOrmalitics.Thc typical pattcrn Ofrcncx sympathetic dystrOphy is increascd Pcr― fus10n,blood Pool,and uptakc On delaycd imagcs in thc af‐ ly promincnt and charactcristic dittse fccted cxtrcmitye Typic』 vcver,thc pcrfus10n and PCriarticular uptakc is prescnt.Ho、 b10od pool phascs arc nOt as rcliable as thc delaycd imagcs. mately 50%of Increased now and blood P001is sccn in appro対 Patlents with RSDS,whcreas lnorc than 950/o are abnOrinal on dclaycd imagcs.

140

A

An cidcrly paticnt has had right kncc pain 10r 3 1■ onths.Radlographs at Onsct、 vere reported as nOrIIlal. 1. Dcscribe the bone scan indings.乳 ″あθ ク ″ タ fnOw;/4,あ′ あク f b100d POOl and delayed images. 2. Based On the scan andings,providc a differential diaghosis.

3.A radiograph thcn was Obtained.Given lり all available infOrmatiOn,what is thc most likely diagnOsisP 4.ミ＼at are common causcs for this cOnditiOn in the FemOral headP

A patient has back Pain aFld elCvatedalkalinc scrun■ PhOsPhatasc concentration. 1. W7hat is thc rncchanisn1 0fuptake OfbOne scan agentsP 2. Describe the bOne indings.Describc any Other sOft tissuc indings. 3.What is thc mOst likcly diagnOsisP 4. List three POSSiblc Prilnary ncoPlasHls. 141

Skeletal Systenl:Spontaneous Osteonecrosis

Skeletal Systenl:Metastases to Bone and Liver l. Uptakc is dcpcndcnt On blood nOw and adsorption to thc . Crrt』 l . I n c r c a s c d a c t i v i t y i n t h e m e d i a l f e m O r a l c O n d y l c o n hydrox/aPattt all

of Distal Femur

threc Phases Ofthc bOnc scan.

2. Abnorinal focal uptakc in thc skull,scapulac,ribs,spinc,

2. Osteonctrosis,fracture,Osteoarthritis,prilnary bonc ncO― Plasm(uhlikely With priOr nOrmal radiOgraph).

pelvis,and ictt fcmui Dinttse uptakc in thc mttOrity or entirc livc丘

3.SPontanebus ostconccrosis Ofthc mcdial fcmoral condylc.

3. Malignant rnetastascs to bonc and livc丘

4.Trauma,StcrOid thcrapェvasculitis,infarct10n(sicklc ccll, Gauchcrもdisease),alcOh01lc,caissOn discasc.

4. Brcast,co10n,lung.

ReFerence

ReFerences 物導 機讐 筋夕解夕″方″ 姥す Sartois DJ:批 物す び ″あ影タ ル物〃″ ,St Lottis, 1996,ふ江osbンP25.

″ Silberstein EB,McAfcc JG,SpasottAP:D″ 竹 ″ωカ タ″姥 物∫″ ″ ググ び ブ ″ら Rcston,Va, 1998, Socicty of Nuclcar ″″rけ ca″,物 臣【 edicinc,P227.

O〕出Iara RE:Bcnign bonc discasc.In Sandlcr MR Colcman RE,

冴ガ ご ガ ″らcd 3, す ″f″グア タ ″ ″物夕 Wackcrs FJTh,editOrs:D″ θ 竹″ BaltirIIore,1996,Willlams&Wilttns,pp 669-705。 Cross‐Reference 鵡 助 び 力″″%冴 び ″ ″α 『

CrOss‐Reference 力″″鴎 品び ガ ″夕 :『配 ハ吻び

沢どQ3騒

孤 ,ed 2,pp l17-125.

Comment

a― 耽T U p t a k c O n b O n c s c a n s i s v c r y d e p e n d e n t O0n、 b lh oe O dr 且 diOpharrnaccutical must be dclivcrcd tO thc bone surfacc before 「 Fhc amOunt Ofuptake dependssOn■cwhat On uptakc can Occu丘 COmment thc amOunt OfЫ ood att Thc grcatcrthc nOw9thc hか er the JllXtaarticular ics10ns that arephasc threc― POsitiVC On scintigra― uptake."mTc PhOsPhOnatcs bccOmc adsorbcd On the h/drO聯 scicrOds and dcttrmit/ofthc ar― phy and ttsdtin subchondr』 apatitc rnatrix of thc bOnc,The radiopharinaccutica1 localizes ticular cOntour on radiOgraphs includc OstcOnccrosis and osteO― in thc lnincral Phasc of bOnc at activc sitcs of bOne fOrination chondritis desiccans.Most bOncs have a dual b100d supply that larly at thc Osteoid mineral intcrfaccs,and indudes a nenvork OfPcriOstcal vcssels and One or mOrc ( r nutricnt e m o d c l i n g ) , piacru〔 is incorPoratCd into thP crysta1linc structurc.Thc binding sites arteries thatsⅢ ,ly thC marrow9 the trabccular bOnc,and an en_ diPhosphonatcs can bc saturated by adnlinistration of dOsteal pbrtiOn Ofthe cOrtex.Boncs that lack thc Pcriosteal fOr sup… diphosPhonatcs. aに with articular cartilagc or cnc10scd PけbeCause theycOvcrcd Thc POlyostotic distribution Ofmultiplc fOcal abnOrmalities within thc,Oint capslllc are more vuinerabic tO ischcmic insults strongly suggests skclctal mctastascs.To ascribc Osteonecrosis and Ostconccrosis(also called avascular nccrosis)。 ality shOuld bc consid― ng cauSC・ This Pa― to onc discasc cntity9 thc liver abnorl■ can bc idioPathic or rcsult frOm an undcrlガ crcd as an additional site ofinv01vcmcnt.IIl addition,thc 10ng tient demonstrates idioPathic Ostconccrosis,a sPontaneous dis― order Ofthc kncc that occurs with suddcn Onset in older Pa―list Of tumOrs that rnctastasizc to bone and livcr can be short― vhose soft tissuc rnctastases arc cncd by considcring only those、 tients.It usually inv01vcs thc medial femOral cOndylc.BOnc scan abnOrmalitics may prcccdc the developmcnt OfradiOgraPhic ab― likcly to shOw uptake of bOnc radlotraccr,Many of thcse are normttities,狙 thOugh thcywcrc prcsent in this Paticnt,PrObably adenocarcinottlas.ThcrcfOrc thc shOrtened differcntial diagno‐ On l■alignancics such as brcast,colon, sis list includes coIIII■ because Of thc duratiOn of symptOIIls.C)stconccrosis resulting f r O m a n u nn gd c Cr al uメs c s u c h a s s t e r o i d u s clung,and c a n lcss c r ccorIIInon a t c a lnalignancics s i m i l a r such as Ovarian,and ade― nocarcinomas arising frOIIl othcr gastrointestinal organs,c.g。 , pattcm,but it usually invOlves multipic sitcs,including thc mcr dtt and Lter』島mOral cOnd/1cs,humeral and ttmOr』 hcads, pancreas,gastric. and taluso C)stcOchOndritis dcssicans ls a conditlon that Occurs in Notes childrcn and adultss it usually inv01vcs thc lateral surfacc Of med胡 島mOr】 condylc,狙though it may lnvolvc Othcr bones, including thc talus and capitcllum. Notes

142

財 Q占 亜 孤 ,Cd 2,PP 32‐ 34.

A bOne normal.

scan

was

ordcred

b c c a uhsuer tasn ac1l1d c0rvlcyr mTahnc“ r c m a i n i n g

bonc

scan(notshown)wa

1. Describc the 99mTc disphOsphonate bOnc scan indings. 2. In terIIIs ofanatOIIliCal 10catiOn,whcrc is thc abnOrIIlal radiOtracer uptakcP

マhat Other radiOpharmaccutical wOuld give a siIIlilar appearanceP 3. ヽ 4. ヽ 7hat is thc differcnfial diagnOsisP

143

Notes

Skeletal Syste口 1:Myocardial Uptake 'PattCrn Ofuptake in thc anterlor l. Curvllincar``horseshoc〕 al bony allatOmy chcst that does nOt corresPond tO norn■ and thcreforc is ost I■ likcly abnOrFnal SOft tissuc uptake. 2. Cardiac uptake,cithcr the rnyocardiunl or pcricardium. 3. 99mTc PyrophOSphatc. due tO car_ 4口Id10pathic Or sccondary cardlomyoPathtt c.gり dlotoxic drugs,myocarditis,cardioverslon in)uryj myocar― dial contuslon,vcntricular ancurysn■ ,infarction,severe vith or without calcincation, unstable angina,Pericarditis、 amy10idOsis.

ReFerence Gray Hや 後 Soft tissuc uptake of bonc agcnts.In Colier BD, わら ″″″物`冴び 物′″クび Fogclman I,Rosenthall L,cditorsi SLc稔 osbtt p 383. St Louis,1996,ヽ江 Reference CrOss‐ ブ ″α 盈材 財 QttSrtts,ed 2,PP 105-107, 助 あ ″%冴 び 124-125. Comment Bone scanning agents have cvolvcd over thc past 40 ycars. bascd radiopharrnaceuti― rcnt 99mTc-labcled phosphorOus― Dif&〕 cals have bccn dcvcloPcd.Thcy can bc classined on the basis Of their phosPhate linkage,c.g。 ,polyphosphatc(P‐ O―P),lrni― doPhosPhates(P‐N―P),PyrophOsPhates(P―P),and PhOsPho― natcs(P― C―P).The imagc qualitt ofpOlyphosphatcs was limitcd .Thisicd tO the usc Ofthc mOrc sta― bccause Ofin vivO hydrOlysお C―P linkage compounds.Thc diphosphonates, N‐P or P― blc P― v thc rnost coFn, P grouPing,arc no、 which incOrporate P,C‐ mOnly used skeletal agcntsc PyrOphosPhate(P,P)iS uscd When the qucstiOn sPccttCally rclatcs to myocardial nccrOsis bccausc though the radiopharmaceutictt has moR sott tissuc uptakc,』 P is used the andingS can bc sirnilar with both radiotracers.P― when the electrOcardiogram and enzyme study resdts are in― cOnclusivc.Large ccrcbral or intcstinal infarcts also vJmay sho、 bonc tracer uptakc. Norinal uptakc in nonOsscous structures oftcn is sccn on bOne imaging,including uptake in thyrOid cartilage,cttchca― tions in blood vesscls,and calcincd costal cartilagcs.AbnOrlnal uptakc occurs in Patients with heterotopic calcincation,rhab, domyolysiS,and sott tissuc calcincatlon seen in sclerOdcrma and dcrmatomyositis,in addition to morc diffuse lung uptake causcd by metastatic calcincation,c.g.,hyPcrparathyroidism, mllk― alkall syndromco Some prilnary and inctastatic tumors charactcristicttly take up bonc radlotracers,c.gⅢ mctastatic os― tcosarcoma to thc lung and ncuroblastoma,

1名

A

B

紘滞

鹸

C

Patient has knownast bにcanccr metastatic tO bOne.Initialand bOnc scan lり scan 6 mOnthsiater(β and c)arc submittcd. 1. Dcscribe any interval changc. 2. Describe thc indings in(互 前/here is thc skull abnOrrrlalit/mOst likely 10catcdP 3. ｀ 4. W7hat is thc lnOst likcly cxplanatiOnP 145

Notes

Sketetal Metastases:Metastasis to Clivus n in the nasal rcglon on l . I n c r c a s e d i n t e n s iitty/ iosf ascctc市 thc anteriOr vicw and lnidlinc occiPut on thC POstcrior

view and lett sixth and scventh costOchOndral,unctions attd lcFt radial head uptakc(nOt ittcCtiOn sitc). prOicCtS OVer thc 2.The skull abnormally incrcased ty acti宙 t e m p o r o m a n d i b u l a r ) O i n t t t g l o n o ng htth ca nrdェl e 丘 latcral skull lmagcs. 3. Skull basc in the midlinc. 4. Metastasis to clivus;othcr skelctal mctastases appcar stablc.

Reference McAfee JG,Reba RC,Mttd M:The musculoskelettt systcm. みガ ″? み ザ I n W a g n c r H N , S z a b O Z , B L I C h a n a ncJdⅥ i t O:応 び ″ ″らcd 2,Philadclphia,1995,WB Saundcrs,PP ″″ご 揚″″物琢 冴″ 991_994. CrOss―Reference r軍醍 対物び ″″″鴎 品冴″″

越 QyrSrrES,cd 2,P121.

Comment Recognition of the t/Pical appcarancc and distribution Of bc― nign indings(eag.,dcgencrative and arthritic changcs)is irn_ POrtant fOr the cOrrcct idcntincation ofmctastatic leslons.The nndingS in thc cttvus on thc arst scan were not initially intcr‐ prcted as susPiciOus for mctastasis.HowcvcL thC lesion bccame morc obvious on the subsequent exaHlinatlon and was associ‐ atcd、vith symptoms.Failurc OfresPOnsC tO therapy commonly is associated with an interval incrcase in thc cxtcnt or intcnsitγ narc"causcd Of a mctastatic icsiOn,as in this casc.HOweveL“ by hcaling of rnetastascs secondary to therapy can rcsult in an increase in the intcnsity or extent ofprcv10usly dcmonstratcd ic― 'lcsions that、 verc scintigraPhically Occult nポ slons,or revcal“

on Prior scans:Many benign icsiOns,c.g.,fractures,show a de‐ crcasl on serial cxanlinationst Dcgcnerative les10ns frequcntly remain stable,althOugh they can incrcasc in intensity if thcy ‐ progrcss.Howeveら thc distribution and aPpcarancc of degc五 crative les10ns is usually helPFul but not always dcanitivc. This case is a good cxalIIPlc ofhOw triangulat10n Ofindings frOn1 0rthogOnal vicws is necessary fbr accurate locatiOn using Planar images.This important principle alsO applics in interr pretation ofradiOgraphs,thc Prcvalencc OflrOss,seCtiOnal tech‐ r thi早 臨早g.￨ 早iqucs,￨.g.,CI SPECtt shOu!d not dul1 0ぃ

146

鶴舶 静

べ辮 T w O p a t i e n t s a r c sA l1 o0 w, ny .c 乳 aorl― d b O y w a s r e f e r r e d f o r a b o n e s c a n bAc6c0a-uyscea rO-f0b1adc km aPna i n . ユ with ncw iung cancctt Bonc scan and CT scan are provided. 1. Describc the bOnc scan indings in bOth Patients. 2.Givc a diffcrcntial diagnOsis for thesc abnormalities. 3.Dcscribc the cxtraosscouS SOft tissue abnOrmality in a 4. What are the ttЮttOst likcly causcs for the soFt tissuc abnOrllrlalityP 147

Notes

Skeletal Systerrli Cold Spine Defects Dccrcased activity at approxl― l.И,Cold dcfect in Tll.ユ matclyT6. 2. Bcnign or malignanttumo5 osteomyelitis,avascular necro― sis,congcnital or surgical dcFcct,artifact,radiation thcrapye 3.Intcnsc rcnal cortical uptakc(cortical stainingl. 4. NcPhrotOxic antib10tics or chemOtheraPcutiC agcnts asso― ciated with intcrstitial nephritis.

References

SoPov M LibersOn A,Gorcnbcrg M,ct ali COld vcrtcbrac on 冴%〃 31:82-83,2001. Sタ タ 物グ ″ハ協″ bonc scintigraphン わ れνf務′,7″崩施 ed 2,St Louis, Blickman H:Pettattr″ ι 1998,小江osbンP234. Cお ss― Reference 助 あ ″鴎 品物 4「避 沢どQど慰 船 ,ed 2,pp l15-135。 Comment Paticntノ l had leukcHlia,thc causc ofthe cOld defcct in this case. P a t i c n t hβ ad a hemangiomao CommOn causcs for a c01d dc― fect On bOnc scan are avascular nccrosis,c.g.,Posttraumatic, malignant tumors, sicklc cell discasc,but also radiation thcrapみ sbns,c.g"multiPle myc10ma, PItiCdarけoStCOClaStic Or lyticに renal ccll and thyrOid cancci C)stcomyclitis lnay appear as a cold dcfcct,particularly in childrcn.ChordOma,PlasmOcroma, and PriOr Orthopcdic surgcry arc other causcs Of cold dcfccts.

bclt buckles,c10thing Attcnuation may bc caused by,eWClrみ snaps,coins,or barium in thc gastrointcstinal tract. lerIIothcraPy or nCphrO― Rcnal cortical uptake as a result ofよ toxic antibloticsis a cOmmon inding on bOnc scans,PartiCularly in Patients rccciving nephrotOxic chemothcraPy or antibiOtics. Highrgradc bllater』 rcn狙obstruction may show this rcn』 Pat― tcrn.In that casc,no activity would be secn in the bladder and backgttund wodd bc high.Paticnts with sicklc cell anemia may have increascd cortical uptakc as a result OfmicrOcalcincations. The CT shO、vs an intact vertebrtt bOdywith PrOmincnt trar beculac,widely sPaccd and scierOtic without sott tissue compO― nent.Hcmangiomas oFten cause nO s/mptoms and usually rcP― resent an incidcntal inding.On bOnc scans,they disPlay thc 的1l sPcctrum ofuptakc,mOst commonly are isointcnse,and are unrecognized,howevcL they ina/bc photopcnic(as in』r)or cven havc incrcascd uptakc.Intraosscous hemanglomas arc most commonly found in the spinc(75%)but alsO occur in skull and facial bOnes.

148

モ

距 ‖

キ

= ■

品 A patient has abnOrl■ al blood cheHlistry tcst results.Sclectcd imagesa frOn■ bOne scan are subllrlittcd Printed in norlnal and dark lnOdes. 1, Describe the indings. 2. Name ttvo Fcaturcs that hclp tO narrow the diagnOsis. 3, List othcr indings Outsidc the chest that can hcIP tO narrow the dif&〕 rential diagnOsis. 4. PrOvide thc FnOSt likcly diagnOsis。

149

Notes

Skeletal Systenl:Metastatic Calcification in Lungs and Kidneys l.AbnOrmal bilatcral lung activity,incrcascd activity in thc r c n a l P a r e n C h y m a t t d n e y s a P p e a r e n i a r g c d . 2.The indings are bilatcral and uniform.TwO differcnt organs are involvcd. vould suggcst 3. Traccr uptake in thc stOmach、 hypcrParathyrOidism. 4.Mctastatic calcincation caused by hypcrcalccmia associatcd with rcnal insutticicncy.

Reference 抗 Aldcrson PO,cdito■ 対″滋″/物あθ 町ン(sct 20,third scries syl― labus),ChicagO,111,1993,American Collcge of Radiology9 PP 564-579. CrOss‐ Reference ″ ″′ fr亜 助 び ル″″れ修冴び 142‐ 143.

父どQyrsr「 ES,cd 2,PP l12-115,

Colnlnent Rcnal cOrtical uptakc greatcr than the sPine uptake is abnOHnal. ncct It can be secn ttcr rattadon thcrapy and is thought toに induced vascular Oc― ischcnlic dssuc dalnagc causcd by radiation― dus10no Rcnal uptakc alsO FXlay bc sccn atter theraPy with Cy― c10phOsphamidc(CytOXan),vincristinc(Oncovin),or dOxOru― bicin lAdrimycin)and issccn mOstcommonけ within 7 days of therapy.It rnay bc caused by a transient nephrotOxic responsc to the drugs.Abnorinal rctcntiOn Hlay bc sccn in sicklc cell anc― mia,othcr hemO」 OЫnoPathics,and iron Ovcdoad syndromes. In Patients with dittse lung uptake of 99mTc bonc traccrs duc to hypercalccmia,calcium prcciPitates in thc alvcolar scPta・ Mctastatic calcincation occurs in thc prescnce of renal failurc when the s01ubilit/PrOduct for calciunl and Phosphate is cx― cccded.This prOccss is reversiblc with the correction Of thc callse for hypcrcttccmia.Thc differenttt diagnOsis for abnor‐ brothorax, mal lung activit/includcs lnctastatic calcincation,丘 mctastascs,pleural cffus10n,priinary lung tumOrs,radiation therapン and alve01ar micr01ithiasis,Bccausc the abnormality is dittse,bilatcral,and symmctrical,causcs that tyPiCally arc fO― ca1 0r unilateral can bc discountcd,narrtting thc difFercntial diagnOsis to:metastatlc calcincation,alveolar micr01ithiasis,and radiation theraPyc HowcveL ofthosc POssibilitics,only mctas[a― tic calcincation would cxplain thc nndings in both the kidneys and thc lungs.

150

A

C

PrOvidc the prObablc causc and give your rccommendatiOns fOr thc abnOrmal gamma camcra quality cOntrol nOods.

1 . A . 2. B. 3. Co Overnight change. 4. D.Changc since prlor patient that daye

Notes

Quality Control:Gamma Camera Fioods l.Cracked crystal(buy a ncw crystal)。 2. NonfunctiOning phOtOmultiPttcr tubc(cali scrvicc).

3.Distortcd(not circulaO and nOnuniform imagc.ElectrOnic tu航ng requircd.Thc power wcnt orovcmlght.Cttl thc scrvice reprcscntative. 4.ContaminatiOn ofcrystal with radloPharmaccutical. livcs.) (Cican camcra or a1low rad10tracer to dcca/10 halユ

References Alderson PO,Colcman RE,GrOvc RB,editOrs,ct al:A物

ご 彦″″

83,American labus,third scries),ChicagO,111,り 姥あo沈 盟 (sガ Collcgc ofRadiolog/ppp 18-31. Patton JA:Quality assurancc.In Sandicr MB Colcman RE, 揚″″物cあct″ Wackers FJTh,ct al,edi的職 D物 探 崩 ′″クす ちcd 3, ｀ 岡1lkins,PP 18‐ BaltimOre,1996,Willlarns 8こ 31. Cross‐ Reference 助 あ ″M c あ c t ″ 4初

延 QD町

露 見C d 2 , P P 2 7 - 3 0 .

COmment The gamma camcra consists Of a sOdium lodinc crystal opti― cttly couPled tO an array ofPhOtOmultiplicr tubcs.Gammarays cntcr the crystal,undcrgo phOtOcicctric and COmpton intcrac― tions,and are absorbcd.The garnlna camcras rcsPonsC ShOuld bc uniforin acrOss thc neld,Ho、

vcvCh thC resPOnSC iS inhercndy

nonuniform bccause OfsPatial diStortiOns,systcmic errors in 10_ catiOn dcterminatiOn,variatiOn in light transit efncicncyp and so one Digital micrOprOcessors corrcct for this inhcrcnt nOnunl― fOrmitye Thc Output of thc Photomultiplicr tubcs arc thcrcby adiuStCd tO yield maximum uniformit/. GalEnma camcra quality cOntr01 noods arc PCrformed On a dally basis cach inorning bcfOrc Patient studics.The rncthod ds arc obtained cithcr by placing a 99mTc used varics.Daily 。 n。 source at a standard distancc(3 to 5 fcco frOm ally hanging from abOve)with thc colllmatOr off(intrinsic nood).Altemativclン with the c011lmatOr On(cxtrinsic nood), thc n。。d source is Placcd directly on thc camcra.57c。 (122 が ,half‐ life 270 days)nxed in Plcxiglas Ottcn is uscd or ttter_ nativcly 99mTc is mittd in watcr and placcd in a nllablc Plcxiglas disk. tuned gamma camcra with Thc n。。d imagc frOm a wcll― wOrking photOmuitiPlier tubcs and uni10rrrlity corrcction cir― cuitry should have a uniforin appcarance.Thc。dn。image cvaluatcs the crystaL Photomultiplier tubes,prcampliflers, Pulsc hcight analyzcL position clectrOnics,and display systcm. Thc fOur―quadrant icad bar PhantOm(lmagc C)is usca tO cvaluatc linearity and sPatial rcs01utiOn;wcckly asscssinent is adcquate.Thc bar phantom is Placcd bcween thc sOurce and the c011lmatO丘

152

thc

Camera(usu―

/O ofmaximum60° agcrPredicted A50,ycar― o ld Patient With diabctes achieved 4.O METS(metab01ic equivalent)and hcart ratc(MPHRl on thc exercise treadmlll stress tcst. 1. W7hen shOuld thc cxercisc trcadII111l strcss test bc discontinuedP 2.Describe the myocardial strcss and rcst perfus10n SPECT image nndingS・ 3. Providc the differential diagnOsis and likcly inv01ved vesscl(s). 4. Discuss any other factOr important to the interpretation ofthc scan.

153

Notes

inferior Lateral

Cardiovascular Wa‖ infarction

Ifthc Paticnt dCVcloPs scvcrc anginal chest pain,a dccrcasc in b10od Prcssure,frcqucnt prcIIlaturc vcntricular cOntrac― tions(PVCs),or sIT wave CiCVatiOn suggestivc ofacutc infarct.Alsoェ f`hc Patlenせ can walk nO Furthcr On thc fatiguc,lcg Pain,Or dysPnca. trcadmlll bccausc ofgcncr』

1.

Scvcre stress and rest ixed dcFcct in thc basal lateral, infcrioL and infcrOlatcrを 述walis,sParing thc apcx. 3.

Myocardial infarctiOn or POsSibly hibernatiOn.Circumncx artcrye

4.

Thc cxercisc stress icvel.

Reference Mayo

Clinic

CardiOvascular

WOrking

Group

on

Strcss

Tcsting:

Cardiovascular stress testing:a description of the variOus 中

CS OfStrcss tcstS and indicatiOns for their use,切

C ιう れカ

P/pr 71:43-52,1996. Cross‐ ReFerence 対務び ″″″Mcttct″α E遼 沢どQむ逮 「ES)cd 2,pp 73-75。 COmment Thc inal rcpOrt shOuld includc thc qualincr that thc Paticnt had a10w cxcrdse thrcsh01d(4 METSand 60%MPHRl.Inadcquate excrcise can decreasc the sensitivity of the examination fOr dc_ tetting ischemiao Thc PrinciPle underlying stress PCrtts10n im― aging is that thc dcgrcc ofcardiac wOrk must bc suttcient tO un― mask ischcmia abnOrmalitics.Thc adcquac/Ofcxercisc and thc arnount ofcardiac wOrk is indicated by thc b100d pressurc hcart ratc rcsPonSC・ Adoublc PrOduct lhcartratc×systolic b100d pressurc1 0fgrcatcr than 25,000 1s an indicttOr Ofadcquate cxer‐

cise.Another is achieving greatcr than 85%ofthc 姐,ustCd agc― MPHR(220-PatiCntもagc)。 Indirect mcasurcs ofox/gcn con― S ―P d O n

frcquendyare

llscd

bccatlsc

ox/gcn

uptakc

d i a c w o r k . A tsに t a h te h』y s u t t C C t C O n s u m C s a Pm Pt rt Oc 対 け3 . 5 m 1 / k g / m i n O r l M E I A g o o d c o r t t l a t i OanH 1c0xnigs ほ ox/gcn

uptakc,METS,and exercisc duration on the starldard Brucc cx― erclse protocole Selecting a sPccinC Stress tcchniquc depcnds On 10c』experdsc and On the stttngths and limit狂 10ns Ofthc tech‐ niqu岱容they rclttc tO thc Pttent・ Becatlsc cxcrcise provldes valu‐ ablc cardiOpulmOnt均 /infOrmatiOn,trcadmlll stress testing gen‐ crally is prcFcrred tO PharmacOlogical strcss.Thc Brucc PrOtOCOl is the mOst common excrcise protOcol.However2 othersecxcR筑 protocols arc avallable that use difFercnt work10ad incrcments. Excrcisc tcsting is usually n■ aximal,1.c.,discOntinued becausc of Physicalsymptoms,or may bcsubmttmal,whcn exercisc is dis‐ continued at a lower work load because of cOncerns ofPaticnt saFety9 c.g.,aFter myOcardial infarctiOn.

154

Paralds

car_

and

SPECT study bcfOrc A53-year,old man whO had a rcccnt myocardtt infarctiOn had a diP/ridam01c stress myocard』 hOsPitJ disChargeo SPECT short― axisの and vertic狙 long― axis α ,images are shOwn. 1.Dcscribc thc SPECT indings. 2. Namc the ttkely corOnaりartery or arterics involved. 3. Providc thc difFercntial diagnOsis. 4. W7hat prOgnostic infOrmation docs the scan providcP

155

Notes

Cardiovascular Systenl:Dipyridamole口induced Reversible inferior WaH ischenlia l.A pertts10n defect inv01ving thc cntirc infcrior wall extcnding tO thc apex shOws partial rcvcrsibilitye 2.Right cOrOnary arterン 3.InfcriOr wall ischemia with incOmplctc rcvcrsibilitye The latter may rcprcscnt scar(infarct)Or hibernating myocar― dium. 4.Thc Paticnt is at risk fOr a further cardiac event,cithcr myocardial infarct Or dcath.

Reference Brown KA,Heller GM Landin RS,ct al:Early dipyridamolc Tc-99m scstamibi SPECT imaging 2 to 4 days aftcr acutc myocardial infarctiOn Predicts hOspital in― and POstdischarge cardiac cventsi comparison with submaximal exercisc imag― ing,(助 打 働″ あガθ″100:2060-2066,1999. Cross,Reference 施 す 醍 貿どQさNFES,ed 2,pp 85,392. ″″″肋物筋物α 「 Comment The SPECT images shO、v reversibilit/9 but a POrtiOn ofthc ab― normalit/does nOt normalizc.This raiscs thc POssibility that ischernic rcglons lnay coexist with arcas Of ibrOsis or cvcn hi― bernating myocardiunl,1.ec,viabic,but dysfunctional inyo― 叱Thc amOunt ofviablc myO― cardium with reduccd bloOd nO、 cardiuni cOuld bc furthcr evaluatcd with FnCtab01ic imaging using FDG,a201Tl rcst,rest studェ or gatcd SPECT sestamibi ilnages.Although FE)G― PET is considcred thc gold standard, the Other techniques can providc a gOOd indicatior1 0fmyocar_ dial viability. Thc nOrmal malc Pattcrn ofmyocardial perfuslon shOws de― creased inferiOrwall uptakc,which is attributcd tO diaPhragmatic attcnuation,FnCaning attcnuation by sott tissuc and organs be" 10w the diaphragm.This appcars as a nxed defcct and cannOt al― ways be differcntiated frOm an infcriOr wall infarct.A gatcd SPECT study showing wali mOtiOn and myocard』thickcning 、 vOuld cOnnHn that it is causcd by attcnuation and not infarct. MyOcardial pcrfus10n scintigraphy can bc PcrfOrmcd saFcly early aftcr myocardial infarctiOn using subHlaximal excrcisc

trcadmlll stress or vasodilatOrs.DipyridaIIlolc can risk strati争 PatiCnts bcttcr than submaximal cxcrcisc trcadmlll.Thc SPECT scan providcs PrOgnOstic infOrmation for this pa[icnt.AttultiPle studies havc shO、 vn that any rcst perfus10n abnOrn■ ality and any induced Pcrfus10n abnorl■ stress― ality arc indePcndcnt advcrsc PrOgnOStiC indicators.This Paticnt iS at risk fOr an advcrsc in―

evcnt(e.gり m yOcardial infarct Or death).ConsideratiOn Ofrevas― cularization is warranted.

156

SPECT adcnOsine stress/rest myoc4rdial Pcrfus10n imagcs.SPECT short,axis lり long― axisの ,and horizontal ,vertica1 10ng_axisに,images are shown. 1. Describc thc prOcedure for adenosine stress(al,adcnOsincも duratiOn OfactiOn(b),and the prOcedure to deal with side cIFccts OfadCnOsine(c). 2. List contralndicatlons to the use OfintravenOus adcnosinc. 3. Describe thc SPECT indings and thc diagnosis. 4. W7hat are dinical indicatiOns for adcnOsinc stressP

157

Notes

Cardiovascular Systenl:Adencsine Stress/ Lateral lschemia Apical infarctt Anterior‐ l.(al Adcnosinc is infuscd intravcnously fOr 6 minutcs (140 μg/kg/min).Aftcr 3 minutcs the radiotraccr is iniCCted and adcnOsine is continued fOr 3 mOre minutes. (b)Adenosinc is dcared rapidly frOm thc circulation (tz<10 scconds)。Return to basclinc blood now icvcis occurs in 2 to 3 minutes aftcr stOpping thc infusiOn。 (c) Stop the inttsiOn. 2. Sints nOdc discase,sccond― Or third‐ dcgrec atriOvcntricular lAp block,brOnchosPastiC lung disease,adcnOsinc alicrre ali to rnOdcratcly scvcre nxed dcfcct at thc apex on bOth 3, Sn■ strcss and rcst images consistcnt with infarct,Mil』 y improvcd perfusiOn Ofthe antcriOr and latcral walis at rcst compared with stress consistcnt with mlld anterolatcral ischcmia. 4. Whencvcr adcquatc cxercise strcss is not possible.

Reference Botvinick EH,cdit鉱

2み″物 ″切 牝 ブrJ″琢す す"%サ ?η

, り ″″グ が

何 (Nuclear Mcdicinc Sclf‐ Study Program III, す θ ご 筋″グ方 ヮブ Cardi010gy unit 2),Rcston,Va,1998,Socicty of NuclcaF ヽ江 cdicine,pp 8-32. Reference Cttss―

どQど慰 蕊 ″ ″ 鴎品rあαr配 ズ 『〕cd 2,pp 76-79,85-86. 助 r″ Comment Adcnosine,a POtent COrOnary artcry vasodilatott dcmOnstratcs reglonal disparity ofcOrOnary bloOd nOw in paticnts with CAD. Partially occludcd vcsscis cannOt dilatc to the sarnc dcgree as mal vesscls,thus PrOducing nonuniform traccr distributiOn.The resuldng imagcs are similar tO thOsc Obtttncd with exercisc;how― evcL the physi010g/is quitc different.Exercise ss stに maximizcs cardiac wOrk to bring out ischcmic regions ofthc hcart.The ac― curac/of`hc svO tCChniques is sirnllai Pharinacological strcss is uscd in Paticnts unabic to cxcrcisc,c.g.,thOse with claudica― tion,scvere arthritis,gcneral fatiguc,physical deconditiOning, and so lbrth. ThcOphメ linC‐ type drugs and caffcinc b10ck thc effect Of nosinc and diPyridam01c and arc thus PrOhibited beforc thc adこ studヌSide cffccts Of adcnOsinc and diPyridam01c arc similar becausc both agcnts act through the stimulation Ofthc adcno― sine reccPtOrso Common side efttcts arc chcst Pain,headachc, and dizzincss.The frequcncy of sidc cffects is greatcr with adenosine,but their duratiOn is shOrt_lived and thus lnOrc eas― 1ly contr01led comparcd with diPyridamOle.Conduction ab― normalities may occur with adcnOsinα irst― dcgree AV block in 10%Of patients,transient seconⅢ dCgrcc block in 4%,and third― degrec block in less than l%.Again,because ofits shOrt nO[ dc cffccts arc trandent and generalけ duration Of actiOn,立 scrious.

158

noP

A55-ycar,old man with CAD but nO histOry or ECC cvidencc Ofmyocardialinfarction.SPECT short―axisに 4えvcrti… cal 10ng― axisの ,and horizontaHOng―axis p areshown. 1. E)cscribc the indings on thc SPECI 2. Provlde the diffcrcntlal diagnOsis.

,

3, Dcscribe the b100d now and functiOnal state Ofhibernating rnyocardium. 4. Describe thc b100d nOw and functional statc Ofstunned myocardium.

159

Notes

Cardiovascular Systenl:Viabili町 Fixed LAD Defect l.Extcns市 e nxcd dcfects involving thc alltcrlor wall,apcx, scptum,cxtcnding tO thc latcral wali. 2.Myocardial infarctiOn versus hibcrnating myocardium v and function,c.g., 3. In hibcrnating rnyocardiunl,blood nO、 contractiht/9 arC ChrOnically rcduccd. 4. B100d nOw is nornlal,reccndy restorcd aftcr an acute Occlusivc state;functiOn is rcduced。

Reference Botvinick EH,editO■a物 妨 ″びゴ 冴r物 竹 グ 笹 (Nuclear Mcdicinc SclF_Study PrOgram III,Cardlolo3/unit 3),Rcston,Va, 1998,Socicty ofNuclear cdicinc,pp l砿 32-49. Cross‐ Reference ″α 軍 醍 助 nル″″Mをあ,cと

京どQ3慰

「ES,cd 2,pp 89,92.

Comment Hibernating myocardium is chrOnically and sevcrcly ischcrnic tissuc that is viable,but has nxcd reduccdlsion Per負and is non_ functiOnal on gated SPEC■cchocardiOgraphtt or IMRI. 卜Iibcrnation rnay PcrsiSt FOr a PrO10ngcd Pcriod,until prOgrcs― sion to infarctiOn,Or prcFcrably rcvascularization,occurs.E)if‐ ferent radloPharmaccuticals can bc used to cvaluatc fOr thc prcs_ cncc ofviablc muscic.Thc nOnischcmic hcart uses frcc fatty acids for its mctabollsm,whcreas the ischcmic hcart uses glu― COSC.ThuS FE)G,a glucOse analogue,PrOVides an idealincthOd fOr making this distinction.W【 cthOds using FDG includc im― aging with dedicated PET cameras,hybrid SPECT‐PET coin― cidcnce systcms,or cvcn noncoincidcncc SPECT using high― 五ethods using singlc phOtOn cnlittcrs cnergy colllinatOrs.い includc 201Tl rcst‐ restimaging and gated SPECT using 99mTc‐ labelcd Perfuslon agents to evaluatc wall rnOtiOn. Stunned myocardium is viable ln/Ocardium in thc iHllnedi― 狙け is SCCn aFter acute intcr― 筑e postocclttOn phasc and typた ventiOn to lmprovc blood nOw in the sctting ofilnpending in― farctiOn,c.g.,paticnts who have rcccndy reccived thrOmb01ytic thcrapy or acutc angioplasty.Norma1 0r incrcased radiophar‐ thc stunned scgmcnt has maceutical uptakc is sccn;howcveら dccreased function.DcPcnding on thc severit/and duration of the Occlusive cvcnt,thc arca lnay return to al norl■ or be Pcr‐ manently damaged.Thc PeriOd of stunning usually is shOrt, gencrally a pcriOd of a few wccks,Stunning is not commonly seen on Perfus10n imaging becausc it is rccoIIIInendcd that a myocardial pcrfusiOn study should nOt be perfOrmed until scveral wccks aftcr angioplast/8

160

_eye fOrmat for SPECT ttyOcardial perfus10n studies. 1.Dcscribe thc bullも ,cye quantitative analysis tcchnique tO myocardial per飽 _ 2.List possiblc crrOrs that may occur whcn applying a bullも slon SPECI 3 . D c s c r i b c t h e n n d i n g s a n d t h c l i k e l y c u l P r i t c O r O n a r y a r t― e yr cy Po 1r 0 ta r ct Oc nr i re ms . tD hO e s i mt ah ge e b u l l も indingsP 4. List the characteristics Ofperfus10n scan abnorrrlalities that shOuld be includcd in any rcport.

161

Notes

′ Eye′ Cardiovascular SysteHl:Bu‖s― Reporting Results l. A Polar p10t is cOnstructed by layering short,axis sliccs Onc on top ofthc OtheL wlth the apex forming the ccnter and the basc Ofthe heart being thc OuteHnost portion. 2.Misregistratlon/misalignmcnt,usc ofinaPPrOpriate refcr‐ cnce database. 3.

Stress:h/pOPcrfuslon ofthc anteriott latcral,and infcrior walis.Res〔 ,normalized Pcrfus10n Ofthc antcriOr and latcral walis and incomplete nOrmalization ofthe infcriOr wall. Most consistcnt with ischemia ofthe leFt circumacx and ― cyc Connms infarct Ofthc right corOnary artery.Thc bull七 the lFnagc andings.

4.

Include location and extcnt,severityP and reversibllity for each perfus10n abnOrmality.Ifgated SPECT is PcrfOrmcd, include LVE■wali motion,with or wlthout wali thicken‐ ing fractiOns.Note ancillary signs ofsignincant(LAD,c.g。 , induced dilation of increased 20rrl lung activity2 or stress― the lett vcntricic,ifprcsent.

References Cooke CD,Fabcr TL,Arecda JS,ct al:Advanced computcr

mcthOds in cardiac SPECI In DcPuey G,Garcia EM Berman DS,editors:て 物rれar SPECrガ 物好 々多 ed 2,Phila― 蛇Wilkins,PP 65,80。 delphia,2001,LiPPincott WilliaEISだ 物筋 掛協〃鴎 嵐 Watson DD:Qualltitative SPECT tcchnlqucs,シ 29:298‐ 3 18,1999. Cross― Reference 配 ズどQyrSrrES,ed 2,PP 78-79. 脇 す 筋″″協 冴す ″ ″α 「 Cor― ent Plays were devcloped to lllustratc P 0 1 a r m a P s ,Ocry eb udlilsも normalized stress and rest data Of the entirc lctt ventride in a axis singlc Picturc.The disPlay is PrOduccd by layering short― slices One on top ofthe othcr wttth the apcx forttling thc ccnter arld the base ofthc hcart the Pcriphcrye Circumfercntial count inlagc, lm ali slices are combined intocOded a co10r― pronles fr。 a110wing for a quick and comprehcnsive OvcrvicM Thc POints of each circumferential prOnic are assigncd a color bascd on nor― ■lalized count values,AbnoHnal areas can bc ldentincd at a The bull`eyc is most uscttl ifit indudes quantincation 」anCC・ of〔he degrcc ofPcrttsiOn dcfccts and Pcrccnt change frOm rcst to stress(not shown herc).Howeve島 this requires a normal database for cOmparison,which is supPicmentary software avallabie for purchase from commercial vcndOrs.Rcfercncc normal databases should be gencrated in each institutiofs iab― vith silnllar equipmcnt,tech‐ oratory or another iaboratory、 niquc,and Paticnt poPulation.As in all arcas ofnucicar rnedi" cine,quantitative data should be uscd only as an adiunCt tO image analysis and not interpreted in is01ation.Now9 thrccP dilnens10nal quantitatiⅥ e disPlays alsO are avallable. 162

the

A Paticnt had atri狙丘brillatiOn and high baselinc resting hcart ratc.The patient cxercised for only 3.5 minutes, achieved Only 3.O METS,but rcached 100%Ofage― predicted maximum heart rate.SPECT shOrt_axis砕 りand hori― zOnt組 long―axis perfusiOn imagesの . 1.Dcscribc any pcrfus10n abnormalities。 2. Describe any Other indings. 3.mat is thc mOst likely culPrit cOrOnaり artCりP 4. Discuss the signincance of最 近lurc tO achievc adequatc exercise.

163

Cardiovascular Systenl:inadequate Stress l.Severc axcd defect involving thc cntire lateral wall. 2. Dilated icft vcntricular cavity at bOth stress and rcst. 3. Lcft circumncx coronary arterye 4.Falsc‐negative studics fOr ischemia may rcsult.

Reference Yao SS,Rozanski A:Myocardtt pcrttsiOn scintigraPhy h cOn―

j u n c t i o tn h宙 t t c r c i s c a n d P h a r m a c 0 1 o g i c s t r c s s : p r o g n o s t i c aPPlications in the clinical rnanagemcnt of Paticnts with coronary arter/disease.In DcPucy EG,Garcia EM Bcrman ar ttECrグ 物″ 咎 Philadelphia,2001, DS,cditorsi C滅 と こWilttns,pp 263-296. LipPincott Willlalnsる CrossPReference rr述 彦″″鴎 品冴″夕 ハ物ど

京FQ5亜

E「 S)cd 2,p75。

COmment Failurc to achievc adequatc cxcrcise stress can rcsult in falsc― negativc studies for ischeHllao Signincant coronary stcnoscs in― vOlving icss than 90%ofvesscl diametcr rnay appear as normal reglonal perfuslon undcr rcsting conditions.Bccausc now re_ sclve across a nxed stenosis is lilnitcd,augmentation of b100d now by cxcrcise or pharrnaco10gicalintcrvcntion is nccessary to unmask blood nOw heterogcncity caused by corOnary artery stcnosis,Evcn ifischemia is dcmonstratcd,it may be undcrcsti‐ matcd in extcnt or scvcritt withOut adcquatc strcss,Therefore the dictatcd rcpOrt should includc a qualincation indicating that excrcisc thrcsh01d,which cOuld dc‐ thc Patient rcachcd av lo、 crcase thc scnsitivity of thc cxamination for dcmOnstration of ischenlia.In this paticnt with rapid atrial ibrillatiOn,thc fact that hc achieved grcatcr than 85%ofagc‐ predictcd rnaximum heart rate is not an indicatOr ofadequate cardiac workload bc― tent c a u s c i t w a s i n c r e a s e d a t b a s c lEiTnSc .iTsh cc1O0nws iMs【 vorldOad and short excrcisc duration. with 10w、 BloCke附 negatiw scan.β― Medications can rcsult in a ttse― can prevcnt thc achicvemcnt Ofmaximunl heart rate during cx… ercisc.Nitrates or calcium channcl b10ckcrs lnay rnask Or pre― vcnt cardiac ischemia.In some cases,it may not bc fcasiblc for the paticnt to stop thC rncdications.At other tilnes,rncdications arc deliberatcly cOntinued to asscss thc adcquacy ofdrug thcr― aPy in b10Cking ischeIIlia.In thOsc circurIIstanccs,dctection of CAD is notthe goal,as thcsc PaticntS are already bcing treated mcdically fOr CAD. Notes

164

A60-ycar-01d Paticnt with diabetcs has severe chronic Obstruct市 e puimOnary diseasc(COPD)and uscs a walkc、 he d c n i e s c h c s t p a i n . S h o r t)raanxdi sh向 orizOnta1long_axis a)SPECT myocardial Pcrfuslon images arc PrcscntCd・ 1. W7hat fOrII1 0fstress is indicated lbr this Paticnt and whyP 2.Dcscribe thc pcrfus10n abnormalitics. 3.輸

at is the likely culprit cOronary arteryP

4. ExPiain the discrcPancy bCtWCen thc indings and Patientも lack Ofsymptoms.

165

Cardiac:Silent Lateral Wlall ischenlia l. Dobutanlinc.The need ofa walkcr prccludes adcquate cxcrcise stress,and COPD is a contraindication to adeno― sinc or dipyridamolc usc. 2.Modcratcly scvcrc PerttS10n defect involving thc entirc lat― cral wall extending to thc antcr01atcral,infcrolateral rcgions,and apcx on thc stress images that ncarly normal― izes on thc rcst images.IncOmpletc rcvcrsibllity oFsmall POrtiO■OfinferiOr wall. 3. Lctt circumncx coronary artery. 4.Silent myocardial ischernia.

Reference lskander S, Iskandrian AE: lRisk asscssinent using singlcr 99m liSS10n computed tOmographic technctium‐ photott e■

62,1998, И″(筋 〃C滅 'o↓ 32:57‐ scstamiblimagmg,メ

ReFerence CrOss‐ ″ ″4 rF/fttEQStt「 助 ど ″″″脇 冴び

蕊 】Cd 2,PP 85-86。

Comment Sllcnt rnyocardial ischeIIlia is dcincd as thc PresenCe oFsignin, cant CAD without anginal symptoms.Thus cOronary discase may go undetected until scverc conscqucnccs have Occurred, such as massive myocardial infarctiOn,ischemic cardlomyopa“ t h みo r d e a t h o P a t i c n t s w i t h d i a b e t e s a r e a t i n c r c a s c d sllcnt ischernia as a result of autonOrrlic ncuroPathye Studics havc shown that any pcrfus10n abnorinality or any strcss― induced perfus10n abnoHnality is an independcnt adversc PrOg― Based on thc scan andings,this paticnt is at nOstic indicatO■ risk fOr an advcrse cvcnt(c.g.,acute myocardial infarct,or dcath)in sPitc ofthe lack ofanginal symptOms,Consideration rranted. Offurther revascularizariOn■is対 In this casc,coronary vasodilatOr stress with dipyridam01c Or adenOsinc is contraindicated bccause of the sevcre COPD bccausc the drugs rnay inducc brOnchosPasln,Dobutanlinc is a synthetic catcch01aHline that increascs cardiac workload by in_ patient is a tyP― creasing the heart rate and b100d This Pttssure・ lcal candidate fOr dObutaHlinc,1.c.,one who cannOt excrcisc and has brOnchospastic Puimonary discasc.BcfOrc stress,a pa― tient should be checked fOr rclative contraindications to dobu, talninc such as rcccnt rnyocardial infarction or unstablc angina, hemOdynanicttly signincant ictt ventricular outaOw tract ob… モ aChyarrhythmias,ventricular tachycardia,un‐ struction,atri狙 controlled hypertenslon,aortic disscctions,or largc aneurysms, Notes

166

risk

fOr

A55-year―old woman with abnOrmal bascline ECG and left bundle branch b10ck(LBBB)is scnt for a strcss dual― isOtOpe SPECT studン LVEF and walithickcning by gated SPECT arc nOrmal. 1. Narle the apprOpriate strcss tcchnique. 2. List stress lncthods that would bc disadvantageous in this Paticnt and state thc rcasOn. 3.Discuss thc physlo10gical advantagc ofadcnOsinc Or dipyridarlole cOmpared with Other stress methods. 4. Describc thc scintigraPhic indings.

、

Gated rad10nuclidc ventricu10grarn(RVG or MUGAl was ptrfOrmed. 1.Name the rad10pharmaccutical used. 2. List rncthOds fOr preparation Ofthis radioPharェ naccutical. 3. Describe thc lnethOd010gies Ofrad101abeling. 4. List the advantagcs and disadvantages ofthcrcnt digお iabcttng lnethOds. 167

Cardiovascular Systenl:LBBB l. E)ipyridaFn01C Or adcnOsine.

Cardiovascular Systenl:RBC Labeling for RVG/MUGA

l,99mTc-labcled RBCs, 2. Excrcisc or dObutaFrline.MethOds ofstrcss that result in 2. In vivo,rnodined in vivo,and in vitrO FnethOds, Vith falsc‐ incrcascd hcart rate can bc associaFCd｀ positivc andingS OfScptal rcvcrsibilit/(ldentical to is01atcd scPtal3. In vivo:stannOus PyrophOSPhate is adHlinistcrcd intraロ ischcmlal in patients with LBBB. f ol10WCd in 15 to 30 minutcs by 99mTc vcnousけ

pertc

4odincd in vitroi stannous pyroPhosPhate is adrninis― tate.ヽ 3. ThcsC agCnts do not rcsult in an incrcase in hcart ratc. tcrcd intravcnously and 15 to 30 minutesiatch 3 to 5 ml 4.Thc mlld decreascd activity in thc anterior wall appears Ofblood is writharawn into an attachcd shicldcd syringc ixcd and likcly is caused by brcast attcnuation in light Of contalning 99mTc pertcchnctatc and arl anticoagulant,cithcr thc rcPorted normal wall mOtiOn. citrate― dcxtrOsc lACD)Or heparin.Thc b10od is incu― acid― batcd for 10 minutcs and PeriOdiCttly agitated,then inttscd The syringe is icft attached tO thc indwclling intravcnous ReFerence line during the proccdure so that thc cndrc s/stCm is dosed. DcPucy EG:Artifacts in SPECT myocardial Pcrfuslon imag― al In vitrO:b10od is withdrawn and Placcd in a dosed宙 ing,In Gordon EG,Garcia EM Berman DS,lditorsi Ca妨 ″び condning stannous chloridc and spdum hypOchloritc t。 SPfてヽ「力%を そ多 Cd 2, Philadclphia, 2001, Lippincott Oxidizc cxceSS CXtraccllular stannous lon and prcvent cxtra― Williams&EW■ 1ldns,PP 232-262. cellular rcduction Of99mTc pcr[cchnctate.Labeling occurs whcn 99mTc Pertechnctatc is added,followcd by a 20,minute Reference CrOss‐ ハ物び 力″″蝿 品冴″α E醍 京どQ占慰

蕊 『 ,ed 2,pp 66‐86.

incubation bcforc rcittectiOn oflabelcd cclls.

4. Thc in vivo lncthOd is simplest and icast cOsdtt but has the CoJmment he in vitrO ldt rncthod 10wcst labcling ettcicncye'「 Excrciscrinduccd revcrsiblc pcrfusion dcFects involving the scP―( U l t r a T a g ) h t t t h c h i g h c s t l a b c hnncgy cbfuntc た ttqdres ng scPtalischeHlia arc sccn in 30%to 900/o ofpa, tum Hlinlldほ morc tirnc,techn01ogist cffOrt,and cost. ticnts with LBBB.One thcOry PoStulates that thc dccrcasc in nOus relaxatlon of SCPtal b100d nOw occurs bccausc ofasynchrも the septum rclatcd tO this conduction abnoHnalitye CorOnary ReFerence vt。 b100d aOw occurs prirnarily during diastolci thcrcfOrc no、 ChiltOn HM,Cttlahan RJ,Thr劇 lJH:RadloPharmaccutictts for the scPtum iS COmprorrlised by its asynchrOny and by thc short‐ cardiac imaglns myocardial infarct10n,Pcrttslon,metab01lsm, ″ ″″″″物み″ and vcntricular function(blood Pool).In筋″物ワ thc hcart ratc ening ofdiastolc at high heart rates.At vhcn rcst、 450. 442‐ i s n o t i n c r e a s c d , n o r c g l o n a l d i s P a r i t y i n r a d i O t r a c e物品 r a駐 c tル物 i v留 i t咎 y iNcwYork,1990,Macmlllan,pp s rfus10n dcfccts aPParent,so thc defcct appears rcvcrsibic.Pと CrOss,Reference causcd by LBBB without cOrOnary artery discasc sParC the apex ″rr配 沢野Q5慰 寛 s,Cd 2,pp 93,94. ″ 力″″脇 冴び 助 び and antcrior wall. BOth excrcisc and dobutaIIlinc incrcasc cardiac work by in, Comment crcasing myocardia1 0xygcn dcmand as a rcsult ofincrcasing the With thc in vivo approach,labcling cttciency rangcs bewcen hcart ratc and systolic b100d Pressure and contractilitys ThercfOre thcsc strcss methods should nOt bc used in Paticnts 600/O and 80%.Thc Prcsence offrcc 99mTc PcrteChnetate cOn, ay bc Falsely positivc fOr scPtal tributcs to incrcttcd backgrOund activity and crrOncous calcu‐ with LBBB because the scan l■ ischcHlia.However,rcgardlcss of the strcss incthod,stress― lation Of the LVER With thc rnodined in vivo tcchniquc,lar induced Pcrttision abnorinalities outsidc thc septuHl havc thcbeling cfncicncy is aPprOXimately 90%,and with the in vitrO mcthOd,950/o to 98%.VariOus causes exist FOr Poor RBC la― same signincancc as in Patients without LBBB and indicate 'Thc mOst comlnon are drug― drug interactions,c.g。 ,覇rith bcling。 coronary artery discasc.AbnormalscPtal wali mOtion On gated heparin,doxorubicin,methyldopa,hydralazine,iodinated con― images almost invariably is seen aFtcr CABG surgery as a rPsult trast media,and quinidinc,C)thcr causcs include circulating an― ofdisruption Ofthe Pcricardium in thc absencc ofLBBB. tibodics frOnl prior transfus10ns,transPlantation,and somc an― tiblotics.Finaltt insumcientor too grcat adose oFstannous ion, Notes t00 shOrt a``tinning"intcrval,and too short an incubation pe― riOd fOr reduction oftcchnctium(VII). Notes

168

1.Describc and cxPlain the prOccssing pcrfOrmed On this cqullibrium gatcd RVG or MUGA stu与 2.How arc the regions ofintcrcst(ROIs)selectedP 11ft vcntricular Function call bc asscsscd. 3. List thc nucicar medicine tcchniqucs by whic止 4. Provide thc cquatiOn for deterIIlinatiOn OfLVER

Rad10nuclidc Plallar gated b100d P001 stu(け Sequential gated image ttaIIles are shown。 1.Estimate the lett ventricularづ ectiOn fractiOn(LVEF)based on thc submitted images and exPlain thc decrcased

intcnsity ofilnage No.16. ２

Discuss the importance Ofpatient positioning on calculatiOn Ofthe LVEn

３

List factors that may result in rcduccd accuracy ofthe LVEF calculation.

４

Describe thc cffcct On the LVEF ifrtt no backgrOund is )a subtractett backgroundαreg10n is used that includes the spleen.

169

Cardiaci Calculation Of LVEF for RVG(MUGA) 1.Lctt antcriOr obliquc cnd,diastOlic systolic and cnd‐imagcs t ular and background(bkgl ROIs drawn shOw itt vcnt五 on computcr for calculatiOn Ofthe LVER

Cardiovascular System:RVG/MUGA Technique l.LVEF appears normal(>5う ° /o).End―systolic at Framc 8. Framc 16 shows dccrcascd intcnsity comparcd with othcr heart ratc, frames,resulting from variability in thc PatiCntも c.g.,frequcnt PVCs.

2.Acquisition in thc lcft anterior obliquc(LAO)vicw with and l乱 right ventricle.ROI for grcatest separation ofthe 2.Thc lctt antcriOr Obliquc(LAO)position sclcctcd is that diastOle,and the lett vcntricle at end,systOlc,at end― fOr which PrOvidCS thc best scparation ofthc lcFt and right adiaCCnt backgrOund. ventriclcs,approximatcly a 45-degrec LAO vieL but varies 3.Equlllbrium gatcd b100d P001(RVG)対 rst― Pass radionu― anatomy(bcst scptal vicwl. dcpcnding on thc paticntも 乱de ventricu19graphy;gatcd pcrfusiOn SPECI relatcd factOrst arrhythrnia,inability tO gait,subOp― 3. Paticnt― 4. 皿 F=cnd― diastolic cOunts一 c nd,systolic counts/ timal RBC iabeling,e.g.,concomitant drugs.Techniquc― ctcd for bkg counts). cnd― diastollc counts(corに rclatcd:POor LAO positiOning,suboPtimal RBC labcling, incorrect ROI ttr ictt ventricic or background. ReFerence Borgcs― N e[oS,Colcman RE:Radlonuclide ventricular func_ 冴ク ′(9ケ 筋И物 31:817-830,1993. tion analysis,勉 ″かめ″

4.乳Fttsely low;a high・ falseけ References

Reference Cross― 1,103-104. あす ″ ″α; 岡T 」 U Q t t r t t s , c d 2 , P P 9130‐ 脇 滋 ″財あ

BorcrJS:McaSurcmcnt ofvcntricular functiOn and volu θo轡〕St Louis, び ル″″物物ケ Zarct BL,Bellcr GA,editors:用 ″ 1999,い江osbtt pp 201-215,

Borgcs― Ncto S,Colcman RE:Radionuclidc vcntricular func― Comment 務 И物 31:817-830,1993. ″ハら″ O n t c c h n i q u c t o a s s c s s v c n t r i C u l a r f u n c t ition o n analysis,勉妨θ′こ材″ T h c l n O s t c o1n■ ■ withOut perfuslon imaging is the equilibrium gated RVG or MUGA.Thc Paticntも hcart rhythm is clcctrically gatcd.Each Cross―Reference c a r d i a c c / c i C i S d i v i d c d i n t O a t i c a s t 1 6 f r a助 I I n修 l e″ s″鴎t o品物 m aぞ x iTr/JttQstt「 m i z e t e m ― 蕊 ,cd 2,pp 93-101. d i a s [ o l i c a n d c n d , s y s t o l i c f r a m c s c a n pOral resolutiOn so that end― bc ldentincd for LVEF quantincatlon.T00btain suttcicnt Comment interval was Thc imagcs rcPrcsCnt the framcs intO which thc RR― counts for high― quttit/images,approximatcly 300 cardiac c/― cics are acquircd aFtcr 99mTc RBC cquilibratiOn in thc b100d。dividcd using simultancOus cardiac gating.By宙sual cstimatlon The nrst,PaSS radiOnullidc anglocardiogram(RNA)method the LVEF aPpearS normal(calculated to be 650/o).The radionu― clidc cqullibrium gatcd blood Pool and irst― PaSS tCChniqucs arc quantincs ventrictlar function during radiotracer bolus transit thrOugh thc hcart, aPprOXirnatcly six cardiac cycics.Thcsc accuratc methods fOr measuring thc LVEF bccausc calcdatlon is v01ume‐bascd mcth9ds(radioactivc counts arc Proportional to based on v01lHne changcs and not geomctric assumptions ofcar―

nd cchocardiOgrapけ d a c s h a p c t t a r c ccounltorgarsatpvheyn ta五 c mcthods ventricular volumo arc more accurate than geomet五 Alimitation ofthc gatcd b100d Pool techniquc is ograpけ c,g"echocardiOgraphy Or cOntrast vcntric』 R interval is mia,The LVEF becomcs less reliable when the R― an ROIis drawn around the ventri― For calculatiOn OfLVE■ occurin morc highly irrcgdtt Whcn vcntricular prcmature bcaほ dein end―diastole and end― systole.A background ROI is Placcd bctwccn the lctt vcitridc and thc sPiccn.NOrIIlal LVEF rangc than Onc Of evcry six beats,quantincation must be suspcct. f r o m 5 5 % t o 7 5 % . M a n y l a b O r a t O r i e s t l sOveに c 5stimation 0 % a s ofbackgrOund t h e l o w cactMty r l ifalseけ m i tdevates the B電■ sstt the LVE■ and undcにstimation OfbackgrOund activity dcPに Of nOrmal.CalculatiOn of right ventricular eieCtiOn fractiOh Thc crrOr in LVEF that rcsults frOm mild arrhnmia is not sig‐ (RVEF)using thc gatcd blood P001 tcchniquc is subicct tO Crror nincallt becatlsc most ofthc beat length variablity occutt at the callscd by overlaP Ofthe atria alld ventridesi nrst― Pass RNA issu― arc R intcrval varics,fcwcr cOunほ cnd ofthc c/clc.Whcn thc R― perior bccause RVEF is calculatcd using only c/clcs that thc bO― vn in thc terminal frarnes.Thc droproIFin thc intlnsity may lus rcsides宙 thin thc right ventridco SPECT is POtentittly mOrc shO、 appear as a nicker when viewing the gatcd images in dnematic accurate than thこ planar MUGA bccause selccted ROIs minimizc 出splaye tO just,thc ovenap Ofthe atria and vcntttdes,but it is dittcult

cxtra proccdurcwhen Planar imttngPCrforms sOwell. Notes Notes

170

鑑 盤

A35-year―

薇

ヤ

old man with increasing dyspnca was refcrrcd for ventilatiOn―

cicar bfinnitrate,Inass,or pleural disease.

PCrfusiOn(V/Ql stu(け

1. Nalne the three phases Ofa 133xc vcntilatiOn scan. 2. Describc thc Phascs. 3. Describe the indings on the ventilatiOn and Pcrfus10n scans.

4.PrOvidc an intcrpretation O郎 こ r aand diagnOsis for the ng undcriガ diScasc.

The ChCSt ilm was

Notes

Pul「Y10nary Systenl:Emphysema Caused Antitrypsin Deficiency by α l‐ l.Singlc brcath or wash,in,cqulllbrium,and washout Phascs. 2.Single breath:Patient brcathcs in and holds a single maxl‐ muHl dccP inSpiration while a 100,000,count ilnagc is acquired.Equilibriunl:paticnt breathes a lnixturc ofair vhilc serial imagcs are obtained cvcry 60 to 90 and xcnOn、 seconds for 3 minutcs.Washout paticnt brcathes r00m air and exhalcs xcnOn whlle serial inlages arc obtaincd. 3. VentilatiOni nOnunifOHn in the uppcr lung zones bilatcrr

all,Initially ncar abscnt at the bascs.As uppcr lobcs wash out,xenon nlls and is retaincd in both bascs indicating severc air trapping.Perfus10n:heterOgcncous to both uppcr lung zoncs that match the carly ventilat10n images. lung alitics in bOthver lo、 The cxtensivc Pcrfusion abnOrl■ zoncs are matched with areas ofwashOut air trapping. 4.Low probability dcnciency・

for

p u ilma― On nt ai rt yr y cp ms bi on l l s m , α

ReFeたnce Armstrong l Wilson AG,Dcc l et組

溶否 ザ 筋 タ :物 竹 否 ザ 滋 F琢

9み 否ちcd 3,St LOuis,2000,い江osbン P932. Cross―Reference 助 ど あ ″姥 冴冴″件 五材 財 Qyrs/zs,cd 2,pp 147-148, 154‐157. Comment 133xc,an incrt gas,dcmOnstratcs thc abnOrmal phys1010g/OfOb‐

ased and dclayed xenon structivc aittay discasc.Initi』 け dCCに n is f0110wcd by siow washout or trapping w a s hi ― wash―in phase distribution corrcsponds to 99mTC aCrOsOI Partidc irnagcs.The advantage of133xc is that the washOut phase is vcr/ scnsitive for Obstructive airway disease.Disadvantages of 133xc

of

in One宙 ew(wor WO, are thtt images can bc obtaincd onけ hcadcd camera).The study is bcst donc befOre thc Perfus10n 3xc energ/PhOtOPcak(80 kcn,Em― study becausc ofthe 10w略 p h y s e m a i s a l u n g d i s c a s c ccthtalrya cbtyc raibzncOdr ‐ Patho10夢 mal Pcrmancnt cniargement of air spaccs distal tO thc terminal brOnchial accOmpanied by destructibn of the walis without obvlous abrosis.Panlobular emphysema is associated with thOugh it may occur in smokers and αl,antitrypsin dencienc/P』 elderly ptticnts.Uppcr lobc ttr trapplng is sccn with thc morc common chronic obstructive pulmOnary disease.Lower 10bc ttr stiVe ofα trapplng is野s叫 l Antitrypsin lrantitrypsinncienc/.α tに is a scrum protein that inhibits lysOsOmal protcascs released dur‐ ing innarnIIlatory rcactions and Prcvents their damaging cFFccts. antitrypsin arc at risk for vith rcduced icvcis of α Patients、 l― emphyscma.Smoking further incrcascs this risk.

172

gas.The

Post

RP0

R Lat ■十

RA0 ■￨￨■

A

ANT

ととat

とpO

臨

Ｐｉ 弔 ！

P o s t i

ILA0

にチ

騨

rLat

聯 岬ぴ

A N T I I

lぶ

B

I窯

ld inan has reccnt Onsct ofshortncss ofbrcath.Theray chest A64-yearr。 was x― clea丘 1.Dcscribc thc image nndings律 ,perfusiOn;a ventilation)and givc an intcrprctation.

2.W7hatis thc vendLdon study ranopharmaceudc狐 m OfhstribudOnP What arc the ttkcけ ,and whatttits mcchanお rcasons for thcir appearancc on this studyP 3.Is thc vcntilat10n Or perfus10n study usually perfOrmed irst and whyP 4. ｀ used,and、 前仏at is anothcr cOrrllnonly uscd vcntilatiOn radiOpharinaccutical that cOuld be vhat are the advantagcs and disadvantagcsP

173

Notes

Puirnonary Systenl:99mTc DTPA Ventilation Study with Aerosol Clumping Multiplc Perttlslon dcfccts in uPPCr and lowcr lung nelds, nght Many appear scgment』 ,c.g"the lateral 狙ofthe b容 lower 10bc,suPcriOr segElent Ofthe leFt lower 10bc.Vcnti‐ ladOn study shows extcnstt d胡温e“dumpinゴ Within the 筑rways thrOughout both iung nclds mttng determinatiOn ofmatching Or mismatching dittcult.Thc smdy wasinter― preted as intcrmcdiatc prObabilit/since the ventilation study could not be interptttct howcver9 the scgmental n defect pattem is susPiclouS fOr emb01us. pera暉1。 2.

3.

99mTc DTPA aerosol Partides(0.l to O。 うぃm in sizc)nOr‐ 宙 thin thc alveoli.With m組 け diStributc On arst impac〔 airway turbulencc,c.g.,asthma or COPD,Partides imPact proximally宙 thin brOnchi and aPPcar as focal hot spots. 99mTc DTPA acrOsol ventilatiOn stu(け usually is performcd arst.The Paticnt brcathcs in less than l mCi at tidal vol― ume until an adequate cOunt rate is obtaincd(3,000 counts/scO.The sixf01d iarger 99mTc MAA perfus10n dOsc (5-mCi)Overwhelms thc rctaincd ventilatiOn dOsc,allow― ing fOr wO consecutive 99mTc studics, 133xc,an inert gas,is advantageous fOr Patients with

4.

COPD and asthma.Dclaycd alling and dcarance(air traPPingl in reglons OfObstructive discase can bc sccn. Disadvantage:only posteriOr views are possible because of rapid exhalatiOn.

Reference Truill10 NB PrattJR TahiSani S,ct al:DTPA acrosolin vcntila― tlon/PcrttsiOn scintigraphy ttr diagnOsing pulmonary cm…

A励冴鵡ふ38:1781-1783,1997. bolism,メ Reference Cross― ガ ″α E職 越 Q5醸 助 材%″協 渉び

「ES,cd 2,PP 146-162.

Comment 133xe mimics ttr exchange within dle lung.Xcnoだ s disadvan_ tages are its low energ/(81 kcW and therefOre low resolutiOn 10wing only pos― and ttpid tcmporal changes in distributiOn,狙 hcaded camemお uscd.レ偽 もhぶ er 使ior宙 ews,unltts a twO― PhOtOpeaks al10w fOr postperttslon images;howeveL it is cx‐ Good ttrnOw and a negatlve― penstt and nOt avallable gcncralけ PreSSure rOom are required,otherwisc xenon,a hcav/gas,la/ers .A xenon“tttP"iS required to absorb and tttttn out on the no。 exhaled gas.81mI缶 ( 81Rb宙 th 190 kcn a1lows POstPCrfus10n il■ aging,but it is exPenSiVe and generally nOt avallablc,99mTc `化 "cOnsists ofvery smali carbOn Parddes tha[do not cchncg容 scttic Out in thc lung.Itis used in rnany parts Ofthe world but not apprOved by the U.S.Food alld Drug Administration。

174

A

Perfus,on

崚

革

Ventitatton

A 5 4 - y e 4 r , 0 1 d m a nt宙 h k n O w n c a r d i o p u l m O n a r y d i s e a s es cbOfmipnlcatlt■ a s i n g d y乳 s P nChest c a ・ r4d10graph; S10n scaniて β,Pcrrも みventilatiOn scan. 1. W7hat arc the scintigraphic indings and intcrprctationP 2. W7hat is thc likelihOOd OfpullnOnary cmbolus in this paticntP

「

3. W7hat is the likelihOOd OfpullnOnary cmbolus in a Patient with a nOrIIlal scanP

4.HOw are perfus10n dcfccts claSSined as to sizeP

175

Notes

Pulmonary System:Low口

Probability

VentilationコPerfusion Scan l. Bllatcral inhomOgcncous distribution.Matchcd Pcrfus10n alitics thrOughOut thc uppcr and and ventilatiOn abnOrn■ 10wcr 10bcs,csPcCially in thc right lower iobe basal seg― mcnts.Minimal atelectasis in the 10wcr 10bcs On chcst x― rays LOw prObabilit/fOr pulmOnary cmb01us, 2. Less than 200/0。 3. Lcss than l%. 4.Largc(segmental):greatcr than 75%ofa scgmcnt. MOderatc(subscgmcntal):2う %to 7う %ofa scgment. Small(smali subscgmental):icss than 250/o ofa segmcnt.

References WOrsicy DR Alavi A:Radionudidc imaging ofacutc Pulmonar/ 筋И物 39:1035-1052,2001. emb01ism,酪 沈,o〃(9″ ″拘 ″ Stcin PD,GOttshalk A:Rcvicw ofcriteria appropriatc for a very onary emb01lsin On ventilat10n― 10、 v prObability Of Pull■ ″冴Q算7″カブ 岱20:99perfusiOn lung scans:a PositiOn PaPch沢 105,2000. Reference Cross‐ ″ fr醍 脇 材物″Mであci″

択どQdtt「 ES〕ed 2,PP 145-161.

Comment Onc Ofthc ncw indings ofthc PrOsPcctiVe lnvestigation Ofthc PulmOnary Emb01ism DiagnOsis(PIOPED)study was that a V/Q Study ShOwing cxtcnsivcけdCCrcttcd Pcrfus10n h a lung ncld with rrlatching vcntilatiOn should be interpreted as iow prObabllity as long as some perfus10n cxists to that lung ncld. BcfOre thc PIOPED studtt this Pattcrn was called indctermi― natc.AnOthcr inding was that if thc reFerring clinician has a high clinical suspiciOn for puimOnary cmbolus,but thc scan is 10w prObabilityj thc likclih00d Of prOvcn pulinOnary embolus incrcascs to 40%.COnditions cOmmonly associated with V/q matchcd abnormalities includc COPD,brOnchicctasis,alvcO‐ lar Pull■ Onary cdcma and Plcural effus10n,asthma,Inucus plugs,and tumO丘 Critcria have bcen prOPOSCd to dcnnc a vcr/1ow‐ prObability categoり ろ1.e・ ,lCss than 100/o.Thcy include nOnscgmcntal perfu― s 1 0 n d c f c c t s , m a ti cn h Ocm d「o rd e tf he rc cはc z o n e s i n a s i n g l c lung Ontt and thC Strlpe 島 srlsg nt.OT hacc tsMttryi p c s i g n に that Othenvisc appcars secn along thc plcuralsurface Ofa scgmen〔 hypOpertted.Thc stripc sign lessens the likclihoOd ofpdmOnary

cmb01us for thtt lung氏 夢On bccausc pcrtts10n dcttcts causcd by vascdar Occlusion shOuld cxtcnd tO the Pleural surface.

176

RPO

RL

RA0 A

A29-ycar―old pregnant wOman has a histOry ofasthma and recent onset ofdyspnea. 1. Is any paticnt preparation indicatcdP 2.瑚

る uld thc Paticntも

pregnancy changc the V/QprOtOCOIP

3,Describe thc perfus10n ω 夕imagcs and vcntilatiOn α and radiOgraph andings rCP. 4.Givc your in,crprctation ofthc stu毎 177

Notes

Puimonary System:intermediate Probability and Pregnancy l.BrOnchodilatOr thcraPy bcFOrc V/Qstudy tt arl ttthmatic

therapeutic trial. 2.PulmOnary emboli arc life thrcatcning to the patient and fctus,The radiation dOse to the patient and fctus is 10w high.No changc (lcss than 2 rads).The bencnt/risk ratiOお in PrOCCdure is rcquircd.In young,nonsmottng paticnts withOut car出 opulmonary disctte,Onc might rcducc the

perfusbn stutt or both. dOsc,cOnducta onけ 3. H/PoPCrfus10n Ofthc lc丘10wcr 10bc,cxcept the supcrior segment.Bcttcr vcntilation than perfus10n with inislnatch‐ ing,in thc anteriOr basal and Part OfthC latcral basal seg‐ ments.No ventilatiOn in the posterior basal and Part Of thc iateral basal.COstoPhrenic anglc loss sccn in lCft iateral and LPO viewso Radiograph:atclectasis/inttltratc with cle― vation ofthe lcft diaphragm. 4.Intermediatc probability for pulmonary embolus.One large/Onc rnodcratc segmcntal rllisrnatch and Onc largc and onc lnoderatc scgmental lnatch cOrrcsPOnding toray thc x‐ atclcctasis/iniltratc.

Reference ヽ後】sicy DR AlaviA:Radionuclide imaging ofacute pulmonary ″助 /筋И物′ rtca39:1035-1052,2001. embolism,路 あoブ(9ケ Cross,Reference 筋″″鴎 品び ″ ″′ f軍醍 脇 び

沢どQyrSr孤

,cd 2,pp 128-129.

Colmment A noml』 V/Qscan cxcludcs the dagnOsis ofpulmOnar/cmbO― lus.Paticnts with iow― PrObabilit/scallS and a 10w dinical likeli‐ h00d dO nOt rcquirc anticoagulation Or further cvaluatiOn. Patienほ宙 th low‐ probabilけ scans,but an intermcdiate or high dinical likelihOod ofdiscasc,shOuld havc lower extremityvenOus studies.Ifrcsults arc ncgative,andcoagulatiOn Or angiography is unnccessary.IfpOsitive,thc patient requircs trcatmcnt.Patients 航 th an intermediate‐ PrObabilityV/Qscan rcquire a noninvas血 venous study Ofthc 10wcr extttmides.IfPOsit統 ,trcatmentおin― dcated.Ifncgatlve,CT anttOgraPhy Or pulmonar/anttOgraPhy is indicatcd,Patients with a high‐ probability scan and high likc_ lihOOd Of discase rcquire trcatment.Those with a low Or intcr― mediate likclihoOd need nOninvasive evaluat10n.Undcrstanding Ofthe apprOpriate usc ofCT for cvaluation ofpulmOnを り/embOr itls is evolvingo At ptscnt,CT anttography is considered sensit統 and sPccinc for diagnOsing central pulinOnary cmboll,but in_ scnsitivc fOr dagnosing subsegmental emb011,The safct/ofwith― h01ding anticoagulant treatlncnt in paticnts with negativc CT results is uncertain.Furthcr PrOspective studies to evaluate thc s e n s i t i v i t y a n d s P e cfiCnTc iatn/g。 lography are rcquircd.

178

A

B

￨■■ 柵

T w O

p a t i e n t s

m w ai nt dh の s i m i l a r

h i s t O r i c s

O f a

s O f t

t i s s u c

i n f c c t i O n

O v c r l y i n g

studics wcrc ordcred tO cOnirm Or exclude undcrlying OstcOmyclitis. 1.Would a bonc scan bc useful as the initi』 study in these casesP 2. When wOuld a bOne rnarrow study with 99mTc sulfur c01101d bc uscful in this clinical scttingP

3.Wbuld an lllln Oxine icukOcytc studybeorprettrableP 67Ga stuけ 4. Describe the nndings.w7hat arc thc diagnOscsP

179

t h e

t i b i

Notes

infection and infiaHl「Tlation:99mTc HM口 PA0 Leukocytes and Osteomyelitis l. A negativc bone scan rules Out Ostcomyclitis with a high dcgrcc ofccrtalntyt 2.A bonc marrO、v study can imprOvc the sPcchaty ofa lcukocytc study ifthcre is displaced nOmtt marrow (orthOpedic hardwarc).This is mOst hclpFul in thc hips and knces. 3.11lln icukOcytes can makc thc sarnc diagnosis.The suPcriOr imaglng rcsolutiOn Of99mTc HM―PAO often bcttcr diFFerr entiatcs soFt tissuc and bone infcction.67Ga is less spccinc vith bonl rcmOdeling becausc incrcascd uptakc occurs、 f r O m a n y c a u s e , 空 4. Paticntノ r soft tissue uptake.No bonc uptakc rules Out r sott tis― osteomyclitisi cOnsistent with cellulitis,Patient β 10n consistcnt with osteOrnyclitis. suc and bonc 10calizaを

References lontt cvolv― ElgazzarArI,Abdcl― Daycm M:ImttngSkelctalinttα 揚″″″死″物"″″ ing considerat10ns.In Frccman LM,editonハ協す ″″″ク″′F999)Philadclphia, 1999,Lippincott Willlarns枇 Vllkins,PP 157-192. PalcstrO CJ,TOrres MA:Radibnuclide imaging in orthOPcdic infectiOns,S夕 物物 A物冴雌 札27:334-435,1997. CttssPReference 彦″″鴎 品"″α 軍 述 助 ど

沢どQS慰

蕊 『 〕ed 2,pp 184‐189.

Comment Thc most common causc for Osteomyclitis in adults is direct cxtension frOn■ a soft tissue infcctiOn.Although hcmatogcnous SPrCad OCCurs in adults,it is seen more commonly in chlldren. Long bone metaphyses cOmmonly are attctcd in childrcn be― cause ofthc relativcly s10w b100d now in metaphysctt sintlsoid狙 vcins and thc paucity ofPhagocytcs.Adult hcmatOgcnous acutc OStCOmyelitis rarely inv01ves thc 10ng bOncs.In adults,Os― teolnyclitis is Oftcn the result Ofdircct introductiOn Ofbactcria frOm sOft tissue wounds,compound fracturcs,contarninatiOn OfbOne during surgerye A n c g a t i v e t ph hr ac sc c― b o n c s c a n r u l e s O u t o s t c o m y e l i t i s w i t h a high degrcc Ofaccur軒 ,in― /in addほ 宙 thOut previous fractuに FectiOn,or Orthopedic hardwarc.A99mTc sulfur cO1101d bOne marrow study is mOst uscful for cvaluating Proximal marrOw illed bOnes,c.g.,hiP or knec PrOsthesis Or Orthopcdic hardwarc causing marrow disPlaccment.11lln oxinc and 99mTc HM,PAO leuk09Acs have sirnilar accurac/fOr diagnOsis ofosteornychtis. PAO and thc radiatiOn Image qualit/is bettcr with 99mTc HM‐ dOsc is 10wc5 which is an advantagc in children.Howcvci both have a high falsc_negative ratC ttr OstcOmyelids Ofthe 67Ga may be preFerablc in thOsc cases.HoweveL 67Ga may bc positive in thc Prcsencc ofbone remodeling.

180

spinc

thus

物ダ ″ク″冴Sepsis. A49,ycar-01d man was配 島rttd for99mTc HM,PA0 1eukO呼 e study to 10ctte the sOurcc″物 of最 切ど 1. W7hat arc the scintigraphic indingsP 2.What is your interpretation ofthe study:

3. What arc thc rnost common causcs lor falsc― POsitiVC radiolabcicd icukOcytc studiesP 4.や7hat is the optimalimaging Pcriod for 67Ga,11lln oxinc lcukOcytcs,99mTc HM,PA0 1eukOcytes for infcctiOn imagingユ

181

￨

Notes

lrrlation:99mTc HM‐ infection and lnfta田 P A0 Leukocytes―free'9mTc pertechnetate l.Activity in the salivary glands,thyrOid,stOInach,bOwcl, and bladdci 2.Frcc 99mTc pertechnctate,NondiagnOstic studン 3.GastrOintestinal blccding,swa1lowcd icukocytcs from OrOpharyngcal,csOPhagcal,Or lung innaHlrnation/ infcctiOn,accessory spleen,uninfected POstoPcratiVe surgical wounds,intestinal stOmas,and cathctcr sitcs. 3. 67Ga,48 hours,11lln Oxinc lcukOcytes,24 hOurs,99mTc HM― PAO lcukocytcs,l to 4 hOurs.

Reference Datz FL,Tay10r」衛R Ccll labcling:tcchniqucs and clinical util_

ity.In Frceman andJOhnsott clinical radiOnuclide imaging, ed 3,updatc,Ncw YOrk,1986,Grunc在 蛇Stratton,PP 1785‐ 1847. Reference Cttss― ハ協死協物″Mcあ cを ″夕 f軍亜

沢どQむ慰 孤 ,Cd 2,PP 177-190。

Comment Frce 99mTc Pertechnetate is caused by Poor CCll labeling.It is more coHllnonly seen with bOne scintigraph/c PbOr cell labcling rcsults in a suboptimal scan,thus lilniting infcctiOn dctcction bccausc Of thc rcduccd numbcr Oflabclcd lcukocytcs,Poor count densitywhcrc it mattcrs,aFld intraabdominal

dearancc

of

pcrtechnctate,which cOmPlicates dctcction OfintraabdOminal infectiOn.むality COntrol ofradiOlabeled lcukocytcs bcforc in― ,CCtiOn is limitcd tO micrOscoPic cXamination ofthe lcukocytcs cH■ining labcling pcrcent cttciency since thc radlola‐ and de〔 bcled cclls must bc inicCted Promptly to cnsurc ccll viability. Lcukoqtte viabilit/is difncult to cvaluate but critical to diag‐

n o s t i c a c c u r a cc t/ t. M CO hr ap rh a0 c1 t0 e夢r i s t i c s a r e croscoPically.HOwcvch the ultimate tcst ofviability is in vivo 血nctiOn.Little b100d Poolls noHnally seen On leukocyte stud‐ ics.The presencc ofincreased blood Pool indicatcs a high por‐ tiOn ofthc labelis On the red celis,platelets,Or bOth,Pr010nged lung uptakc indicatcs cellular dalnagc.Usually thc sPlccn has

c h c c k e d

hiか eSt uptakc.Ifthe ittr sJCenれ ratoお rcvetted,thお suggcsほ ccll dalnagc.Because bOthけhave Organs high norm』 uptake, this is nOt a sensitive parameter ofcell viabilityg

182

m i ―

A25-ycar―old lnan has fcvcr and abdOIIlinal pain.99mTc HM,PAO-labclcd leukOcytc imagcs. 1. ｀ ▼lLiCh lCukOcytes arc labeled with the nvO radiopharmaceuticals used IOr leukOcytc scansP

2. N7hat is thc cxPianatiOn for thc PrOnlincnt skclctal uptakcP labclcd leukocytes and 99mTc HM,PA0 1cukOcytesP 3.Wttat is thc Optimalimaging timc fOr lllln oxine― 4. Givc an imagc intcrprctation and diagnOsis in this case.

183

NOtes

nation:intraabdonlinal infection and infiaHl『 Abscess l.99mTc HM‐

PAO binds only tO neutrophils.11lln oxine

binds to rllixed leukocytcs. 2.

Normal bOnc rnarrOw distribution Ofthe radiOlabcled leukoqttcs. Abdominalimaging:99mTc HM_PAO images are acquired at l to 2 hours bccausc hepatObiliartt intestinaL and renal clearancc Occurs subsequcndtt compliCating interprctation. 11lln leukocytcs:24 Extrcnlity ilnaging:2t06 hOurs。 hours.Four‐hOur imtting fOr innammatory bOwel diseasc because sloughing ofintcstinal mucosa lcukocytes may occur and 24-hOur rnay be lnisleading,

4.

Infection in thc right 10wer quadrant ng theOvcJメ sacr011‐ iaC ttht in the anteriOr宙 五ght Ofthc sPine・ ew and latcr狙 Thc Patient had a pcrfOrated appcndix.

References C O l a k G■u n g o r i O z u g u r S , c t a l Hi M PV Aa Ol u e O f 9 9 m labeled whitc bloOd ccll scintigraphy in acute appendicitis ″ ノA物〃 paticnts with an cquivocal clinical Presentation,動

Tc―

】石あ″28:575-580,2001. Stahibcrg D,Veress B,Mare K,ct al:Lcukocytc acutc colonic innarllrnatOry bowel diseasci comparison Ofhis― t 0 1 0 g i c a l a s s c s s m C9 n9 tm aH nM dP TA cO ‐l a b e l e d l e u k o c r e

migration

in

″夕 ″ ″″〃 288,1997. scan,И 物ダ物 ″ 92:283‐ Cttss― Reference ブ ″α 軍 鴎 助 び ″″/鴎 品び

沢どQど玉 胡 蕊 ,Cd 2,pp 184‐190.

Comment 99mTc HM― PAO initially was uscd for cercbral pcrtts10n imag‐ ing.Its lipOphilicity a1lows it tO cross the b100d brain barricr and becomc nxed intraccllular1/E This prOpcrty is uscd to tralls― port the 99mTc int0 1cukOcytes.99mTc HM_PAO and lllln Ox" ine label RBCs,Piatcleis,and lcukocytes.HOwever9 cells Other than icukocytcs are removcd during thc labeling prOccss.ExccPt fOr rcnal and biliary clearancc,thc distributiOn Of_PAO Hl砿 lcukOcytes is silnilar to that Of lllln oxine,labeled leukocytcs. Grea[est uptake is in thc spleen,10110wca by liVcr and bonc marrN、 i「 he splccn has the highcst radiation dOsc, 15〔 o20 rads with lllln Oxine arld 2 rads with 99mTc HM― PAO.Thus 99mTc HM,PAO is the prcferred agcnt in childrcn.Additional lon.A advantages of99mTc HM_PAO is its better imagc rcsolu〔 disadvantagc of all radi01abclcd cells is the12‐ lninilnu■ hour bOrne discasc. preparatlon tiine and the prObleHl of bloOd― 99mTc lcukocytcs arc used for patients with innammatory bowcl discase as an altcrnatitt tO rcPcat GOOd cOrrclatiOn cxists脚 bcぃthc amounモ cen and sitc Ofuptakc ofr鉦 五olabeled leukoO花

Cndoscopy

es cOmpared Mrith endOscOpy and radio―

10gical 10calizatiOn fOr paticnts with uicerativc cOlitis and CrOhtt diseasc(granu10matOus or rcgional cntcritis). 184

or

contrast

studies,

An 8-ycar―

old girl with juvenile rhcumatoid arthritis and Persistent fcvcr aFtcr resolutiOn Ofreccnt PneumOnia,Shc has

no current symptorls ofarthritis. 1.Dcscribe the indings on 67Ga sequcntial coronal SPECT chcst imagesの diagnosisP intenslty is high.W恥 at is thc diffcrent』 2. ヽ 7hat is the advantagc of67Ga Over indiurl―

and a sclected cnlarged imagc神 り.ImagC

or tcchnetiuIII-labeled icukocytcs for fever OfunknOwll originP

3.Whtt is the target organ(highcst radiation absOrbcd dOsc)for 67GaP v increascd 67Ga uptakeP 4.Which pulmOnary infcctiOns or innammatory discases sho、

185

Notes

infection and infranl「

Tlation:Peritarditis-67Ga

l.AbnOrmal uptake in myocardium,pcricardium,Or both cOnsistent with Pcricarditis or rnyocarditis.Thc paticnt deve10ped a pcricardial frictiOn rub thc day aftcr thc 67Ga scan.Incidcntal notc OfnorIIlal livcr uptake and transverse and lcft colon clcarance. 2.67Ga shOws uptakc not Only with innammation and infcc― tlon,but als0 1n tumors that can sOmetimes bc the cause of pcrsistcnt Feve5 c.g.,lymphoma. 3. Large bowcl,apprOxllnatcly 4.5 rads. 4. MOst pulinOnary innalnlnatory and infectiOus diseases. UptakcおnOnsPcanq】 though thc pattcrn Ofuptakc and thc clinical setting,c.g.,AIDS,may bc hclPfulin dctcr― mining thc diFFerential diagnOsis.

References Dcsai SR Yuillc DL:Thc unsuspcctcd cOmplicatiOns ofbactcr―

ial endOcarditis imaged by gallium_67 scanning,メ A励〃鴎 嵐 34:955-957,1993. Shulkin BL,Wahi RL:SPECT imaging oflnyocarditis,Cι ハ協″ び ′舟々〃12:841_842,1987. Cross‐ Reference ″α E配 択どQ3眼 脇 す た″″陀 冴f″

,″

孤 ,Cd 2,PP 171-175.

Comment ln cardiOvascular disease,67Ga has bccn used to dctect infcc‐ tion ofsynthctic vascular grttRs,mycotic ancurysms,Inyocardi― tis,and Pcricarditis.E)istinctiOn besvccn thc lattcr MO can bc difncuit becausc oflinlited res01utiOno Scnsitivity for endOcar‐ 67Ga has a larger rOlc in evaluating the causc and ditis is P00■ cffcctiveness ofthcrapy ofPullnOnary innaHllnatory and infec― t i o u s d i s e a s c , c .夕 g物θ .ヮ ,す S a物″ rグ cあo bi ld eO os mi /s c, iあn ″ 力 ″ toxicityj inttrstitial lung discasc. Bccausc 67Ga is cxcrcted by thc c010n,thc radiOpharrrlaceu― tical generally is nOt uscd to evaluate fOr intraabdominal infcc_ tion.Bowel cicansing with iaxatives is uscd tO better visualize thc abdomen,but delayed imaging is ORcn necessarye lllln ox, inc leukocytes are preferablc fOr abdOminal infcctiOn becausc ― there is nO colonic dcarance.99mTc Hヽ 宝 PAO byprOducts are clearcd through thc biliary and renal systcm,rendcring it ttso subOPtimal fOr intraabdOminal infcctiOn.Imaging bcfOrc 2

hOurs after rein,eCtiOn can prevcnt this PrObicm.Thc usual adult dosc of67Ga is 5 mCi.Highcr dOcs(7 to 10 mCD arc uscd fOr tumorimaging with SPECI Nttth smali children,67Ga is not an idcal imaging agent and oFten resuits in subOptimal imagcs becausc Ofthe 10w administercd dosc,P00r crystal scn‐ sitivity for 67Ga becausc Ofits multiPlc high PhOtOPcaks(185, cncrgy collimatOi 300,394 keVl,and the need for a medium‐

186

B

的 SiF

ANT

HIAAl,and a diag, И,70-year― old man宙 th recent Onset ofnushing,diarrhea,elevatcd 5-hydrox/indoleacetic acid(チ nosis ofcarcinoid syndrOmc.ヨ ,う6ryear_old Paticnt with Past histOry ofmedullary carcinoma Ofthc thyrOid and recent increasc in serum calcitOnin icvcls. 1. Provide thc lnechanisn1 0fuptakc Oflllln PcntCtrcotidc(OctrcoScan). 2. List the category oftumOrs fOr、 vhich this rad10Pharmaceutical is PartiCularly useful. 3.Describe the iIIlagc indings on thcsc wO studieS:И (abdomina1/pelvis viewl and (β chcst views),and givc your intcrprctatlon. 4. Name the Organs that nOrmally havc greatest uptake ofthc radiopharmaccutical.

187

Notes

Oncology:Neuroectoderrrlal Turmors l・ PCPtidC ana10guc OfsOmatOstatin and octreOtidc.Binds to

tumors Mrith somatOstatin rcccPtorS・ 2. NcurOcndocrlnc tumors. Tw0 1argc 3. ノ 宅 AttultiPie rnetastascs to bOth lobcs Ofthe live二 fOci and Onc sn■ all fOcus Ofuptake cOnsistent with ParaaOr― t i c

t u m O r

a d c n O P a t t t

P O s s i b l e

s m t t l

t u m O r

PrOmincnt irregular uptakc in

(conarmed by later CT).ユ the attlterior mcdiastinurn and focal uptake in thc lcft 10wcr lung POstcrlorlyc 4. Kidncys and sPleen.

ReFerences Krenning ER Kwckkcb00m DJ, Bakker wH, ct al: Somatostatin rcccPtor SCintigraPhy with[111-in,DTPA― DPhc,1]and[1231-Tyr-3]― octreOtidci the Rotterdam cxPc―

ricnce with mOrc than 10oo patients,』 ″ ″ノ「 協〃進 棋 20:716-731,1993. G 品 五l ■ R c y n o l d s J C , L u b c n s k / 1 A :, Ae bt l組i t y O f s O t t a t O ―

statin receptor scintigraPhyPaticntS宙 tO identiけ th gastric carcinOids:a prOspcctive 杉 〃鴎札41:1646-1656, /用stu毎 2000. Cross‐ ReFerence 師朔物″Mettci″α r醍 沢EQさ s「 ES)ed 2,pp 223‐225. Comment Neuroendocrinc tumors lAPUDomas)arc dcriモ d from ncural crest cells,Thcy can synthcsizc amincs frOm prccursors and Pror itters. ducc PcPtides that act as horFF10neS and ncurOtransl■ Many neurOendocrine tumOrs can be difncult to detect on con― ventional iIIlaging because ofthcir smali size.All havc incrcascd somatostatin rcccPtorS tO Varying dcgrccs,and rnany have a high tumOr uptakc ratlo on lllln Octに oScan.SPECT can hcip detect smali tumOrs and imprOvc localizatiOn comparcd with Planar scans, Sensitivity for t!mOr detection varics dcPending on the neu_ ■ oendocrinc tumo■ gastrinOma(9う %),carcinOid(>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.

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‖ 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

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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

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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

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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―

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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

18054 Fourier Bkg

16048 14042 12036 10030

B

8024 6018 ED ES ED ES

4012 2006

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５ ８ ８

５ ４ ６

４

3 7 8

０

3 3 6

４ ６ ２

2 9 4

４ ２ ０

２ ６

４

１ ６ ８

１

８

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0

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

Time(ms)

16700 C O 15030 u n 13360 t S 11690 P 10020 e 8350 r R e g i O n

C

6680 5010

ED ES ED ES

3340 1670 ７

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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<180仰 g/dL. 3. Insulin drives glucose and FE)G intO Inuscle and lNttr cclls.

Poor 4.九

diabctic

contr01

and

insulin

ion.a Good diabctic con― b c f o r c 1 8 F F D G a d m i nriastせ tr01.Insulin given morc than 2 hours beforc 18F FE)G adnllnlstratlon.

References body PEI Physio‐ Engel H〕Buck A,Bcrthold■ et att Wholc― 10gic』and artifactual nuOrOdcox/glucOsc accumulations,メ グ37:441-446,1996. ハ協″ び ′Л石タ Shrcve PE),Anzai L Wahi RL:Pitfalis in Onc01ogic diagnosis with FDG PET lmaging:Physio10gic and benign variants, 勉 冴'慨 みね 19:61-78,1999. Reference Cross‐ N蕊 :「配 択どQど■ 州初協″ 鴎 品冴″″

)ed 2,pp 207-209.

Comment

F a s t i n g b e F O r e am aFXDiGm iszteusけt u m o r u p t a k c a n d m i n ― imizes hcart uptakc,a1lowing fOr bctter tumor visualization in the

chest.High

OSe s c r uumC」

levels

h iに n t宙 c rt島

FDG

tumOr

faSting uptakc because OfcOmPctittt inhibition.Unfortunttcけ does not always cnsure 10w cardiac uptakc,sugges[ing that othcr mechanis1ls bcsidcs glucosc competition arc at work. In PatiCnts with hyperglyccmia,image quttity is Poor2 hCart んInSulin can rcducc thc uptakc high,and tumOr uptakc lo税 Serun1 31ucosc lcvcl,but it alsO drives glucosc and FE)G into livcr and lnuscle cells,thus dcgrading image quality and hin― dcring tumOr detcction,as seen in this casc. A fasting blood glucose icvel shOuld bc dctcrnlined bcfore FE)G inilslon in all Paticnts with diabetes.In this Paticnt the ucosC COnccntration was 276 mg/dL.Insulin was ad― serum」 Hlinistered,and thc scruH1 31ucose levcl dccreascd to 120 mg/dL。 18F FDG was administcttd and imaging was performcd rcsultcd.The patient was instructed to re― an hour latcr,studyИ tum another day under bcttcr diabetic control.Study is β the rcpeat study with the patient in good diabctic control(blood glucOse concentration 120 mg/dLl.

324

administration,ust

i

銃il■1

肺

勢 i ti

門

村

1巾Ⅲ Ⅲ 怖 市 れ わ 赫 怖 市 i市 品 加 輸 品

！” ！ ！ ！

帥

ト

ぺ

A51-ycar― old man with AIDSo MRIscan(nOtshown)showcd a cystic mass

a rlsing

l. W7hat is thc differential diagnOsis in this clinical scttingP 2.What a r e t h c F DG ― P E T i m a g i n g i n d i n g s P T ransvcrse物 みθι り,sagittal 3. W7hat is your interpretatiOnP 4.Can this diffcrcntiatiOn oftumor versus infcctiOn bc madc using singl

325

Notes

Oncology:Brain Lymphoma Versus infection in AIDS l.TumoL csPeCially lymphoma,vcrsus infcctiOn,c.gり tOXOPlasmosis. 2.Incrcascd FDG uptakc in tle medullaOblongata. 3.Consistent with malignancy. 4.Yes,with 201Tl or 99mTc scstaHlibi.

References O'MttlcyJl Ziessman H限 ,Kumar PN,ct tt Diagnosis ofin― tracran』 lymphoma in PttiCnts宙 th AIDSi valuc of201 Tl‐

163:417‐ '0〃 И物ブ脇冴 single photon computed tomograPhン 421,1994. ct al:FDG― PET in dif― HormanJM,waShkin IIA,Schifter■ fcrentiating lymphoma frOm non― malignant central ncttous ′鴎 嵐 34:567system icslons in PatientS With AIDS,メ ハ物び う75,1993. Cross‐ReFerence 醍 ″α 『 ″ 助 す ″″″脇 妨び

逆 Qy/Sr孤

,ed 2,pp 314‐ 316.

Comment lntraccrcbral rnasscs in Patients with AIDS arc causcd by a va‐ riety of infectious and ncoPlastic prOcesscs.COnVentional im― aging with CT orヽIRI is not rcliable for distinguishing tumOr and infcctious causes,Thc most common causcs arc toxoPlas―

though other opportunistic mPhOma,狙 mosis and mttignantけ infcct10ns and multifocal leukoencepha10pathy must bc con‐ sidcred.Radiographic Features suggcstivc oflymphoma include a centra1 locatlon,lack ofmultifocalityp SiZe grcater than 2 cm, and a lcs10n crossing midline.Howcvett diagnOsis frcqucntly is 在 alignant lymphonlas in pa― uncertain and blopsy is rcquircd.ヽ Early trcat, ssive and survival is poo二 th AIDS arc aggに tients Hた Inent is optimal;howcveL thcsc Patients oftcn arc trcatcd cln_ PiriCally for toxoplasmosis bccausc it is common and treatable. Using this apprOach a bloPsy iS perfOrmed only when therapy rcsPonse tO antitoxoplasmOsis thcrapy can take fails.HOwcvcち weeks. FDG― PET and 201Tl sPECT alsO havc been used to make vith good succcss.InCrcascd uptakc rcntiation,both、 this dif&ラ malignan[tumott whereas no or very of201Tl is consistenth wi〔 10w uptakc is mOst consistent with an infectiOus prOcess,with a 9 0 % a c c u r a c y s A P o s i t i V e tveosutl dr eas1ullotw、 f O r c a r l y b l o P s y and dennitive treatincnt.99mTc scstaHlibi could be used in a simllar rnannci lt offcrs thc advantage ofthc 99mTc radiolabcl and highcr administettd dose,rcsulting in suPCrlor image qual― ity.A Potential disadvantage of sestarnibi is noHnal uPtakc in thc chorOid plcxus.

326

A

B

釘 ago and 豆 nOw tt a ng i溺i盤 金 瀞[::盟 繊描科鮮歌継言 『 品群:戦就i播 濫紺.1汗 発電 l. Describe thc scintigraphic indings and give/Our interprctation. 2. Mttat is the rclativc accuracy ofthis study comParcd With CTP 3.List clinical indicatiOns fOr a 99mTc CEA studン 4. WVhat other radiOPharrnaceuticals havc bcen uscd t0 10calize c010rectal carcinOmaP

327

Notes

Oncology:99mTc cEA Colorectal Carcinoma Recurrence l. Large abnorlnal reglon Ofincrcased uptakc in thc Pcivis cOnsistcnt with recurrcn[tumoL A large tumor is prcsent

in the leFt peivis attaCCnt to thc bladder in addition tO multiplc smali sites oftumOr uptakc. 2.99mTc CEA is supcr10r to CT in the extrahcPatiC abdomcn and Pcivis but equalto CT in detecting tumor in the livc丘 3.Rising scrum CEA level with negativc CT andings. ly in the erP l市 Potcntially rcscctable rccurrcnt diseasc,usu』 dOne to excludc othcr metastascs that would Predudc surgcry. 4.11lln OncoScint and 18F FDG,PEI

ReFerences Bcndcr H,Bangard M:FDC PET and im― Willkomm■ abeled andbody 8agmcnts munoscintigraphy with 99mTc■

fOr dctection of the recurrcnce oF colorectal carcinoma,メ ′卦石あ〃41:1657-1663,2000. 助 ど Hughes K,Pinsky CM,Petrclll NJ,ct狙

:USe Ofcarcinoembry―

onic antigen radlolrnmunodetection and computcd tomog― raPhy fOr predicting the resectabllity of recurrent colorectal cancctt ″ И″S″役ζ226:621-631,1997. CrOss‐Reference ガ i「亜 ″夕 対務び 彦″″筋 冴ご

択野QyrsrrES,ed 2,pp 214‐

219.

Comment 99mTc is radiolabclcd to a 丘 Fab′ agmcnt ofthC CEA arltibody IMMU-4.Thc remOval ofthc Fab′ fragmcnt from the Fc Por‐ hc immunogcnicity scen tlon of thc lgG elinlinatcs lnuch of〔 dcrived whole antibOdies.Another advantage of with lnOusc― the antibody ttagment is its rapid clearance frOm thc ttdnc/s

tumor,to background ratio and im― 組10wing for anhigh carけ Ctal car‐ agingon the day ofinicctiOno Mott thal1 95%ofcoloに cinomas exPress CEA on the ccll surface.It is shcd intO thc b100d strcarn and is dctcctabic in aPPrOxllnatcly 650/o ofpa‐ tients.The serum CEA lcvel docs not have to be clevatcd for thc scan resuit to be Positivc,OfPaticnts Mrith rccurrent tumoL One third dO nOt havc cicvated serum CEA levels,99mTc cEA has better imagc quality and highcr tumor dctectability than lllln OncoScint,particularly in thc livei i「 radlolabcl hc 99mTc ls a distinct advantage.Uptake ofthe radloPharmaceutical in a patient with increasing CEA lcvcis can 10calizc thc Prev10usly undetectcd tumOL in a paticnt with an indeterminatc livcr ler slon can conarin or cxcludc tumOr9 and in Paticn,s with a po‐ tcntially rescctablc lhcr tumor call cxcludC Other mctastases that PET is used increasingly to providc sim‐ prOhibit surgerye FDG‐ mousc ilar information.Thc incidencc ofclevated human an[i‐ SCANお less than l%. antibOけ(HAMAllevclS With CEA‐

328

A64-ycar_01d man had prOstatectomy for prOstatc canccr 3 years v thc ago.No、 scrum prostatersPccinC antigCn(PSAl level is increasing.Bone scan and CT indings are ncgative.11lln PrOstaScint scan is shown. 1. W7hat is thc rncchanisn■ OfuptakcP 2. COmpare thc accuracy ofCT and MRI with lllln ProstaScint fOr detecting prOstatc cancer EletaStases aFter prostatcctoIIlye 3.mat are the abnOrmtt imaging indings On this studyP Give your interpretation. 4.HOw dOcs thc PrOstaScint study arect thetherapy patientも planP

329

Notes

Oncology:11lin ProstaScin卜 Prostate Cancer l.11lln-labclcd monOdOntt antibody dirccted against the spccinc membranc antigen,a glycoPrOtein prostate― al and prOstatc canccr cells. eXPrCSSed by nOrn■ 2.CT and MRI sensiti宙 ty ranges from 5%to 20%.Ovcrall rcported accurac/of lllln ProstaScint is 70%。 3, Paraaortic uppcr abdoHlinal uptakc consistcnt with tumor adenoPa的 _Focal uptakc in the lcft uppcr chest consistcnt with tumO丘 4. Rccurrcnt tuttor limited to thc PrOstate bed Or rnctastatic Pelvic lymph nOdcs rcquirc differcnt radiatiOn PortS・ Extrapeivic mctastases rcquirc systemic therapン

References ManyakMJ,Hinklc GH,01scnJO,Ct狙

:ImmunOscintigraphy

with ln-111-capromab pendetidc:cvaluatiOn bcforc denni―

th prOstate canceL助 e therapy tt pttcnts宙 t市 物 54:1058-1063,1999. Blcnd MJ,SodCe DB:PrOstascint an updatc.In Frecman LM,

妨ど ブ ″′″″″″″ブ2θθF,Philadelphia,2001, 申物を 彦″″物′ cditor:」 Lippincott Raven,pp 109-138. CrOss―Reference あ″ f軍醍 力″/比 妨ご 助 す

択どQ3眼

r蕊 〕cd 2,PP 220,223.

Comment E x a m i n a t i o n , h i s t O P a t h 0 1 0 g i c a l G l c a s o f s s c o r e , a n d level are uscd to stage prostatc canceL AFtcr Prilnary theraPy for

s e r u m

P S A

prostate canccr thc paticnt is inonitored with thc seruHl PSA lcvcl as a marker oftumOr activitye An increasing PSA lcvel sug― gcsts recurrencc oftumOi Bccause bOnc mctastases are common in inetastatic PrOStatc canceL the 99mTc bonc scan is obtained arst.Ifbonc scan resuits arc negativc,CT or MRI may bc per― f O r m e d ; h o w tc hv ec i島r S c n s i t i v i t y f o r d c t c c t i o n 砿 11lln ProstaScint(capromab pende‐ prostatc cancer is vcr/10｀ antibody dircctcd against intact prostate tidc)is a monoclon】

o f

r e c u r r e n t

celis.It is a murinc immunoglobulin rcactivc with prOstate, SPeCinc mcmbranc antigcn(PMSAl,a glyCOprotein cxprcssed by morc than 95%ofPrOstatc cancers.It is clinically dctec[lon Ofsoft tissue mctastascs,Extrapclvic mctastases in thc abdomcn sOmctimcs can be diagnoscd with planar imaging,as HOwcvctt SPECT is mandatory to dctcct seen in this Patient・ int is icss p r o s t a t e b c d a n d P c t t i c t u m O r aP dr eO nS ot Pa aS tc け sensitivc for bOnc mctastases than thc 99mTc bonc scan.Images are intcrpretcd in conillncdonwithblood Poolimagingto aid in anatomic』 loc』ization,cithcr by imttng On the day ofiniec‐ dOn when bbOd Pod tttM呼 おhigh or uttng 99mTc RBCs tt a du■ isotoPc Study on imaging day 4 to 6.

330

indicatcd

for

ndocrinc di的 記cr and Pd地価 と器 射灘 .a ttw∝ l. W7hat radiopharmaceuticals are apPlicableP

n拭m主 n ttghtctt CT ttudyshOwsa mass h乱

銅 かt

2. Based On the biOdistribution,what agcnt was uscdP 3. Dcscribe thc nndings in the hcad and neck. 4. PrOvidc the rnOst likcly diagnOsis and a differential diagnOsis.

331

￨

Notes

Oncology:OctreoScanロ ーGlomus Tympanicum l.11lln OctrcoScan(octrcOtidc),1311 MIBG. vith 2. ProHlincnt liveL sPlccn,and iddncy uptakc is scen、 lllln OctreoScan. 3.Focal abnOrm』 uptake in thc right temporal bOnc that corrclates with CT rcPort. 4.ParagangliOma(giomus tympanicum)considCring thc history,also lncningioma or ncuroendocrine patientも tumor mctastasis.

References 形 ″″″妨θttgf務 夕′ れ St GrOssman RI,Youscm DM:夕 ″ ″カガ Louis,1994,Mosbン P345. ustil10 A,Whitcman ML,ct al:Octrcotide scintig‐ T c l i s c h i FB ■ r a p h y f O r t h e d e t c c t i o n o f P a r a g″a物 n g後 l算 i〃二 o m形 a″ s〃 ,θ 掛形す ″S″箸 122:3う8-362,2000. CrOss―Reference ″′ f ruこ 越 Qむ 蕊 「ES,cd 2,pp 223‐ 州物`協″″筋 冴rグ 383‐384.

22う,

Comment

Glomus t/mpanicum and glomus,ugularc arisc ttom Paragan― Glomus tympanicum,associ― gliOma tissuc in thc middle ca■ ated with thc ninth cranial ncrve,usually manifcsts as pulsatile

e.g"high though othcr entitics can prescnt simllarけ tinnitus,』 dural artcr10venous mal― ,ugular bulb,abcrrant carotid arterン fOrrnation,cavernous carotid Flstula,Incningloma.Glomus tympanicum usually PrOduces syJmptoms carly in thc clinical coursc as a smali sOtt tissuc mass bchind the tympanic mcm‐ brane that inarkedly cnhanccs.It is critical in PreoPCratiVe as, sessmcnt to distinguish amOng thc variOus vascular tympanic masses to avoid a paticnt with a vascular abnormality being in‐ advertendy scnt to thc operating room without thc surgeon's fOreknOwledgc. 11lln Pcntetrcotidc(OctrcoScan)is a sOmatostatin analoguc that binds to somatostatin receptors on ncuroendocrinc tumors and nurrlerous othcr malignancies,c.g.,bFeaSt CanceL smali cell scnsi… lung cancett and lymphoma.The radiopharmaccuticalも tiVitt fOr dctcctiOn ofmmOrs varics by mttignancyt lt htt a very high accuracy for carcinoid,gtttrinoma,smttl cell lung cancer (80%to 95%),but the accuracy is 10wer for insulinoma and medullary carcinoma ofthe thyrOid(30%toう 00/o).ThC Sensi‐ ti宙 ty for Paragangliomas has becn rcPorted tO be 86%. 10ws for delaycd imaging at 24 to 48 The lllln radlolabel狐 .This is to― backgrOund ratio is optim』 hOurs whcn the targct― an advantagc bccause Ofthc high uptakc in thc lttr and kidneys otcct) (sec ittages).A99mTc-labclcd somatOstatin anttoguc(Nこ 五 canα has becn approved for smali ccll and non,smali celllung Simllar analogucs labelcd with therapcutic radionuclidcs are bc‐ ing invcstigated.

332

2 0 A

25

30

RLAT C 601赫

せ A10-year-01d girl has acute abdOminal Pain.A ch01escintigraphy scan takcn at 60 minutes lり by 30, was fol10wcd minutc chOlecystokinin(CCK;sincallde)infuslon作 . り 1, Describc the chOlescintigraphic indings. 2. W9「 hat is thc likcly diagnOsisP 3. Wマhat Othcr clinical prcsentations are colrllnon in paticnts with this prObicrnP 4. W“hat is thc cause,Path010gical cOndition,and apprOpriate therapy fOr 〆 this entiり P

333

Notes

Hepatobiliary Systenl:Choledochal Cyst l. И ,G00d hcpatic uptakc and clcarancc into the galibladdeら common hepatic,and proximal m i n u t e s . N o tb oi ,l bi oa wr cy contracts with sincalidc

common bllc duct at 60 i‐ t r a n s i t e a T h c g a l l b l a d d c r infuslon;howeveL focal increasing

accumulation Ofradlotracer occurs,ust medial to thc prOx― imal pOrtiOn ofthc common bilc.Thc PrOximalcommon duct activity cmptics into thc duodcnum.Notc cnterogas― tric renux. 2.Likcly choicdOchal cysto Partial blllary obstruction also wOuld result in radiotraccr retention within the FnOre proximal biliary ducts. 3. Cholangitis,scPsis,pancrcatitis,or obstruction. 4. Congcnital anomaly.Localizcd dilatiOn ofthe biliary[ract, or diverticular outpouchingo Surgcry is thc either fusifoH■ appropriatc therapy6

References CamponOvo

graphic E , B u c k J L , D: rS ac ni cn t Wi れ

featurcs

of

〃30:622-628,1989. ″ あ ハ物〃コ ch01cdOchal cyst,メ Kim OH,Chung HJ,ChOi BG:Imaging ofthc chOicdoChal

87,1995. 9‐ c y s t彦 , 響″ 娩 あ1 5 お

Reference CrOss‐ 醍 助 ご 彦″″鴎 品所″α 「

沢どQ5眼

FES,cd 2,P243.

Comment A c h o l e d o c hc』y s t i s a c o n g e n i t t t a n o m a l y c h a r a c t c r i z e d b y s a c ― cular dllation of the extrahepatic blllary tract.It is nOt a truc cyst.Thc most common form is charactcrizcd by a fusifOrm dl― latiOn Ofthe common blle duct.A sccond type is a erticular d市 outpouching Ofthe cOHllnon bllc duct,and the third is aall sn■ saccular dilation ofthc distal coHllnon bile duct.Less coHllnon intrahcPatic ductal dilation is reFerrcd to as discasc. CarOliも cnt of a cholc― Rccognition and apprOpriatc carly trcatl■ dochal cySt arc critical bccause ofthe risk oFsevere cholangitis, ObstructiOn,and adenOcarcinOma(10°/o occurrcnce ratc)ifthC cyst is icFt unattcndcd.Thc diagnosis is rnadc prcOpcratively in only 270/o to 80%ofPaticnts in differcnt PubliShed rcPorts.A vith a prcoperativc diagr 10wer strgical rnOrbidit/is associated、 n O s i s . U l t r a s o n O g r a p h y i s t h c b c s t s c r c c n i n g m e 1t h o d f o r s m 』 has bcen advocated lbr older childrcn and adults. children,C'「 ly conarm thc diag― Ch01escintigraphy is uscd to noninvasiモ nOsis,1.c.,to cnsure that thc cystic structure connects with the

b i l i a r y t r a c t a n d s o m c ttihmee st DytepoaC n・ hietliPv ci d e n t i け diagnosis is made by ECRID or intraopcrativc chOlangiographン

334

1いい瑚 a崎 A

30 Fnin

fmm● diate‐

B

TwO paticnts∽ andの have a simllar histOry of recurrent,colick/upper abdomin』 Pain and negativc test rcsults. Thcy、vere rcfcrrcd fOr CCK ch01cscintigraphy to cOnarm thc clinical diagnOsis OfchrOnic acalcu10us ch01ecystitis (CAC).ImagCS Werc acquired during sincalide infus10n. 1. W“ hatis CAC,and hO、 v dOcs it differ frOn■ chrOnic calculous chOlccystitisP 2. W7hy is sincalide chOlescintigraphy rcquircd to lmakc the diagnOsis OfCACP 3 . T h c c a l c u l a t e d g a l l b l a d d e r W7hat are thcir diagnOscsP

e i c c t i O n

f r a c t iaOnnd( Gf1Bo0Er0F/)p。 waa.tsi cgnrtc aβt e r

4. ｀ 前イ hat is thc accurac/of CCK chOlescintigraphy for cOnarIIling the diagnOsis Of CACP 335

Notes

Hepatobiliary Systenl:Chronic Acalculous Cholecystitis l. CAC is chnically and Patho10gically identical tO chrOnic calcu10us cholccystitis,cxccpt fOr thc abscnce ofgalistOnes. 2. AnatoIIlical ilnaging diagnOsis dcPends heavlly on visuali‐ lows quan‐ zadon ofg狙lstoncs.CCK cholescintigraPhy組 tincation ofgallbladdcr cOntraction.E)iscased gallbladders dO not contract. 3. Findings consistCnt with chronic acalculous ch019cystitis in . but nOtИ patient β 4.A lo、v GBEF has a positivc PrcdiCtive valuc ofmOrc than symp‐ 9o%that cholecystcctomy、vili cLlre the paticntも tOHlS and that the diagnosis will bc conarmed by patho― 10gical gallbladdcr cxaFnination.

Reference Zicssrnan ltIAi Cholccystottnin cholescintigraphy:clinical in‐ 務 И物 ″P θ d i c a t i o n s a n d p r o p c r m c t h o d″ o冴 l″ o′ g C/ ′ P″ 父 協″ 39:997-1006)2001. ReFerence CrOss‐ 醍 グ ″α 軍 び 助 び 力″″%冴 ″

越 Qむ慰

益 「 )ed 2,pp 240-241.

Comment Thc symptoms of chronic cholecystitis overlap with many causcs ofabdominal Pain.BefOrc thc avallability ofCCK cho‐ clinicians had nO ob,cctlVC incthod to diagnOse lcscintigraphン CAC bcfore surgcrye CCK cholcscintigraphy should bc pcr― fOrFrlCd Only in the prOpcr clinical sctting,1.c.,in outpatients with recurrent symptoms suggestive of thc disease whO have of bccn evaluated to cxcludc othcr diSCases and with uP follow― many months'duration to a1low time for othcr diseascs to man― ifcst.The test shOuld not bc pcrformed in acutcly lll paticnts, and Patients should nOt be taking drugs that inhibit gallbladdcr contraction,e.g.,progcstcrone,nifedipinc,atrOPinc,Phento‐ lamine,and lnOrphine. Propcr methodも10勘アis important.CCK administcred as a bolus results in spasin of thc galibladdcr neck and incfFcctive contraction.Onc―to 3-Hlinutc infusions using O.01 or O,02 en rcsult in inettcttt contraction in one third of kg ttso o丘 卜g′ normal subjects.HowcveL intts10ns of30 to 60 minutcs using thc sarne total dose rcsult in gOod contraction in these salnc sub― minute infuslons,up to halfOfpatients havc to 3‐ jcctso With l― abdOnlinal cramps and nausca as a result ofthe rapid ratc oFin― fus10n and not because Ofa gallbladder pathological cOnditiOn. o adverse symptoms occui Hlinutc intts10ns,■ With 30‐to 60‐ ReprOduction ofthc PatiCntも pain with CCK is not diagnostic of thc discasco With a 30-minutc inttslon an abnOrmal GBEF is iess than 30%and with a 60-minutc infuslon is lcss than 40%.

1 20 rnin

A46-year,old woman 8 1nonths aFtcr ch01ecystcctOmy and rcmova1 0fcOHllnOn blle duct stOnc has rccurrent upper ab― dOIIlinal pain. 1. Describe thc ch01escintigraphic indings. 2.Provide a diIFcrenti』 diagnOsis at 60 minutes.Wttat is the likely diagnOsis at 2 hOursP 3.Give the diffcrential diagnOsis for the postch01ecystcctOrlly syndromc. 4.村 恥at is sPhinctcr ofOddi dysfunctiOnP

Notes

Hepatobiliary Systenl:Postcholecystectomy Syndrome l.Prompt hcPatic uptakc(b10od Pool dearance by 5 minutts), dcarancc into biliatt ductt t030 by lう minuにs,retendon of hCPttc and aCtMtt in ducts,apparcndy ttlatcd Proxlm』

common ducts,bil■ b OWCl dearance by 60s.At minuに 汁tO― 120 minutcs,飽 rther smali bOwel dearance but prOmincnt

rctcndon in corIInon duct with 述stalけ apparent cuto鮮 2. 60 1ninutes:Partial cOrllnon duct obstruction vcrsus PoSt― biliary duct Obstruction surgery with nOnObstructed Pcr― sistent bilc duct dilatiOn.120 rninutesi suspectcd Partial Obstructlon. ・ 3,Common ductstone,innammatory stricturc ofthc cOm― mon duct,sPhincter OfOddi dysfunctiOn,innamcd cyStic duct rcmnant. 4.SPhincter ofOddi dysfunction is a partial ruc‐ biliary obs〔 tion at the level ofthc sphinctcr OfOddi not caused by stones or stricturc.

Reference ZiessIIlan rIA,Zeman RK,Attn EA:Cholcscintigraphy:cOrrc‐ latiOn with Other hcPatObiliary imaging modalitics. In Sandler MB Colcmall RE,ct』 ,editortt D″ 響 何力 ″ク筋″″ 物琢 冴び ″ ″らed 4,BaltimOrc,2002,Williams&ヽ 7ilttns. Cttss― Reference 力″″脇 冴ビ ルタ rr縄 助 び

択どQ3職

船 ,Cd 2,PP 245‐246.

Comment Severe recurrent abdominal pain symptoms occur in up to 10% Ofpatients aFtcr chOlccystcctomye The mOst common causes arc conll■ on duct stOncs and innaIIIIIlatOr/nbrosis causing biliary Obstruction.TyPical chOlcscintigraphic nndingS arc a partial bil‐ iary duct Obstruction and noncicaring of the cOIIIInon duct. B l l lI狙 bOwel transit may or may not be delayed.As many as tO― 500/o of Patients with Partial cOInlnon duct obstructlon have bユiar/― tO‐ bOWeltransit by 60 minutes,In this casc,nonclearance Ofthe cOmrnon hcPatic and coHllnOn bile duct at 2 hoursis cOn― sistent with Partial obstructioni dcarancc wOuld havc cxcluded ObstrucdOn.An altcrnative to obtaining dclayed be administration Ofsincalidc.With n0 0bstructiOn thc sphinc― ter OfOddi relaxes and the cOmmOn duct drains.An Obstructcd duct has cOntinued rctcntiOn,The diagnOsis ofsphincter OfOddi dysttmctiOn usually is cOnsidered when a stricture or stonc is ex― duded and delayed cOntrast dralnagc is sccn on cndoscopic ret‐ rogradc cholanttOPancrCatography(ERCP)。SPhincter of Oddi manomctry dcmOnstrating clcvatcd prcssure is more sPcdic fOr making the diagnOsis.HoweveL manomctry gcncrally is nOt avallabic and is technicttly dcmanding.Cholescintigraphy has been tlscd to rnakc dlis diagnosis,and the andingS are thosc Ofa ptttial biliary obstructiOn`Cholecystokinin has becn used dur‐ ob― 容e bile nOw“ strcss"a pttti』 いg Cholesdntlgraphy to 14Cに stricdon,thus imprOving the sensitivity for ch01esdntigraphic detcction.Trcatment is sPhinctcrotomy. !

imaging

would

A patient has a histOry ofbiliary diversiOn OfunknOwn type and nO、

1. Describc the scintigraphic indings. 2. What is thc blllaり /divers10nP 3. Arc thc study resuits nOrinal or abnOrinalP 4.COuld ultrasOnograPhy have prO宙 ded the same informat10nユ

v has abdOIIlinal Pain.

Notes

Hepatobiliary Systemi Cholecysto,e,unOStOmy l,Prompt hcpatic uptakc and rapid biliary― tO― bowcl dcar, ancc through the galibladdc■

2.CholecystoduodcnOstomy or cholccystoittunOStOmy. 3.Normtt pOstOPcratiVe study rcsulほ 4. NondiagnOstic exallinations are frequcnt with ultrasOnOg― raPhtt occurring in up to 670/o ofPaticntS,usually as a result Ofgas in the anastoII10tiC bOwcl segrrlent.Pcrsistcnt biliary dllation is oftcn prcscnt without Obstruction.

ReFerence Ziessman IIA,Zeman RK,Attn ttA:Cholescintigraphy:cOr, relatiOn with Othcr hePatobillary imaging inOdalitics.In Sandlcr MB Coleman RE,ct al:Diagnostic nuclear medi― cine,ed 4,BaltimOrc,2002,LiPPinCOttやmilialns&wilttns. Cross,Reference ガ 助 び 力″″脇 冴ど ″α rF/JttQさ 慰 明

ed 2,PP 243-244.

Comment arybⅢ ChdcscintlgraPhyお uscd to evaluate thc POstOPCrativc cnteric anastomosis.EvaluatiOn tract aFtcr crcatiOn ofa blllary‐ Of acutc and early cOmplications OF surgery and terl■ 10ng― f0110w― up fOr biliary pttentt iS possible.Knowlcdgc ofthe post― operative anatomy of thc Patient is important when imaging thc POstOperativc biliary tract.Blllary scintigraphy commOnly is used tO ttluatc a cholcdochojciunoStOmtt WhiCh is a direct On bile anastomosis of thc cxtrahepatic Portion of the cOHll■

― Ya Ofjづ cn― u num. duct or the cOmmOn hepatic ductto Rolぷ I t t t s O i s u s c d t o e v a l u a t c i n t r a h c P a t i c c h o l a n可 g iu句 nOStOmics.

Thc latter is morc comPlex,requiring direct anastomosis bc― tween smali bOwcl and intrahcPatic ducts that must be dissected out decP with the livei CholedOchOduOdcnostom/9 cholccys― tOduOdenOstomy9 and cholecyst句 づunOStOmy alsO can bc stud― i e d . T h c l a t t c r ts w of r pc rq ou ce en dt ul に y are used h benign ease statcs. Many comPlic筑

10ns can Occur postoPCrat血

け 益 er cttatiOn

Ofbil血りdiversiOn.Bll血 りlcakageis amOng thc most commOn. Recurrcnt blliary ObstructiOn is or a mづ prOblem and is wcll suited lbr cholescintigraphic cvaluatiOn.Ch01cscintigraphy is the Only noninvasive tcchnique that can distinguish Obstructcd dilated ducts frOm thOse that arc PcrSiStently dilatcd.

340

dis‐

30

A

A35-ycar―old woman has abdOminal pain.ChOlescintigraphy移 り り imagCs at 30 to 120 minutes.Thc CT scanゎ shOws a large,circumscribcd icslon atuncturc theチ ofthc right and lcft iobes. 1. Dcscribc the cholescintigraphic andingS・ 2. ｀ 商hat is the differential diagnOsisP W7hat is the diagnOsis in this cascP 前hat is thc approPriate therapy fOr cach ofthese diagnOsesP 3. ｀ 4. N7hat othcr radiopharrllaceutical could cOnirm the diagnOsis in this cascP

Notes

Hepatobiliattr SyStenl:Focal Nodular Hyperplasia(FNH) 1. Increased radiOPharl■ accutical uptake that cOrresPondS tO t h c i c s 1 0 n s c c n o n C I T h e u p t発cark el iivsc rr e t t t n c d 』 washOut. 2. Benign and lnalignant tumOrs that have hcPatOCytes,c.g。 , hcpatic adcnoma,hePatOma,fOctt nOdular hypcrplasia. Thc latter is the cOrrect diagnosis. HcPatiC adenoma 3.FNH usually requires nO sPCCinc thcraPン requires discontinuation ofOral contraceptives and surgical rcmoval,and hcPatoma requires resection. 4. 99mTc sulfur c01101d.

ReFerence BOulahdOur H,Cherqui D,Char10tte■

et al:Thc hOtspo[he‐

ハ物〃雌 嵐 patObiliary scan in focal nOdular hyPcrPlasia,メ 2110,1993. 34:2105‐ Cttss‐ Reference 助 ど ″″″蠅 品品″4軍醍

沢EQど 慰 孤 ,ed 2,Pp 246-247.

COmment FNH and hepatic adcnOma are benign liver tumors as s01ld intrahepatic les10ns in young and aged rniddle― wOmen. The nttural histOry ofthc twO is quite difFeren[.AlthOugh hc_

that

Occur

PatiC adcnOmas may manifest as a mass,oFten thc initial Prcs― cntatlon is an abdOnlinal crisis because ofin[raperitoneal herll_ orrhagc. HcPatic adCnOma has a strOng association with contraccptive usc.Path010gically adcnOrnas consist oFsheets Of hepatOttes宙thOut structurc,bilc ducは ,or KuPIFer cclis.FNH has Only a wcak assOciation with cOntraccPtlvc uSC,usuttly prO― duces nO symptoms,and usually is discovered incidcntallye Path010JcallyFNH tllmotthave asdlatenbrous cOrc(scc CT) and cOntttn ali three liver cell t/Pcs. 99mTc SC is taken up by livcr KuPfFer cells.TwO thirds Of FNH tumOrs takc up 99mTc SC tO varying degrecs.HcPatic adenOma and hePatoma do nOt have uptake becausc they do not usu狙け haVe Kupffcr cclls.On cholescindgraptt FNH h容 a characteristic appearancc:lncreascd nOwj norinal or increased uptakc,and delayed clearance compaにd宙 th attaCent unin― vOlved l持 c島PrObably as a result ofimmature biliary caIItticuli, Hepatic adcnOmas have nO uptakei the reason is unccrtain. With hcPatoCCllular carcinOma,imagcs during thc nrst hour demOnstrate a cold defect,hOwcvett delayed imaging at 2 to 4 hOurs shOws uptake within thc tumOr as the nOrmallivcr washcs Out,This pattcrn occurs becausc hcPatocCllular carcinoma cclls aに hypOfunctiOntt cOmParcd with nOrmtt liveL With dclaycd uptakc and clearance.Thc 10w― lcvcl uptakc alsO is casicr to vir sualizc whcn the nOrmal liモ r has washed out.Scnsitivity for detcctiOn OfFNH with ch01escintigraPhy is greaに r than 900/0.

342

A

RA0

B

99mTc sulfllr c01101d liver― spleen scans vo in PatiCnts.И t、 ,A50-ycar old with abnorrnal liver Function and hc―

a A59-year-01d with a livcr mass on CT in the quadratc 10bc.Antcr10r ttp an patosPienomcgaけ を Oblique vicws「 き″in both studies. ヽ つ uptake. 1. ヽ マhat is thc rncchanisrl1 0f99mTc sulfur c01101d 2. ヽ 7hat is the nOrIIlal distributlon Ofthis radloPharIIlaccuticalP

3, W7hat arc thc image nndingS and diagnOses in thcsc httrO paticntsP 4. List threc Othcr causes fOr hOt sPOts 99mTc sulfur cO1101d sPiccn scans.

Notes

Hepatobilia■ /Systenl:Hot Spot'9mTc Suifur CoHoid imaging l.UPtake by the reticu10endOthcllal system. 2. More than 85%of99mTc suifur c0110id is takcn uP by the Kupffer cclls Ofthc livch 100/o by the sPlecn,and 50/o by thc bOnc lnarroⅥ 3。九 Thc centr組 ,large cold rcttOn may be caused by an intrahepatic lnass,but thc pattern has bccn stable and CT shOws cirrhOsis.There is col101d shift tO the spleen and bOne m a r r O Ⅵ T h e r c l a t i v c l y i n c r e a s e d u p t akc in the in― liverお 島rior a s P c c t O f t h e r i g h t l o b e a n d d O m c t ofthe hc bcst hnctiOning POrtiOn Ofthc liver2 related to prcFcrcntial

damage morけ e ocre』 tnCtrrn狐 atittltt POsSibly areas of regenerat10n.互 Increased uptakc in thc rcglon ofthc quadrate 10be,consistent with FNH.

4.Superior vena catt syndromc(arm ittcctiOn),inferiOr vena cava obstructiOn(leg iniectiOn),Budd_Chiari syndromc,

Reference Welch

T J , S h C C d y J Ho ■ hnSOn

Foctt M , c t: 狙

n9dular

hyPcr―

Plasia and hcPatiC adenOma:cOmparison Ofang10graphtt Cエ US,and sdndgraphン 勉あ 牝ノ156593‐ 5 95,1985. Cttss,Referencc 助 す 筋″″脇 渉す ″ ″α E鴎 択どQさ蕊

ES,ed 『 2,pp 256‐258.

Comment 99mTc Sulfur col101d livcr imtting is uncommOn since thc ad― vent ofCT scannintt hOwevcL it Occaslonttly is Ordered to cval― uate the degrcc ofhepatic insumcicncy in patients with cirrhO― sis,c.g.,collold shift indicatcs portal hyPcrtenslon.A liver tumor rnust havc KuPffer cells tO takc up 99mTc sulFur ld. c011。 With cirrhOsis the liver is abrotic and PoOrly ttnctional,scen as dccrcased uptakc in a shrunken liver and incrcased uptakc in the spleen and bOnc 〔 m斑.FNH,with ali three littr ccil typcs 碑 (hcPatocytes,biliary ducts,and Kupffer cclls)Often takes up 99mTc sttlfur c0110id.APProximatcly ott third Ofpatients with FNH havc increased,One third dccrcased,and Onc third uptake cquivalent tO attaCentlivciThus in wO thirds OfPttientswith FNH the diagnOsis can be made.HcPatic adenomas have fcw Or五O KupfFcr ccllsi nOr d0 0thcr prilnary or secondary liver tu― mors.With the Budd― Chiari(hepatic vein thrombOsis)syn― drOme, POOr liVCr functiOn is causcd by impaired venOus drainage frOm thc liveL cxccPt fOr the cauda[e lobe,which cOn― nccts scParately tO the infcriOr vena cava.In supcrior vena cava syndrOme,collatcral thOracic and abdOnlinal vessels conllnunir catc with the recanalized umbllical vein,dclivcring incrcased b100d nOw and radio[raccr to the reg10n Of thc quadrate lobc thrOugh the lett POrtal vein whcn thc radioPhamaceudcalお iniCCtCd in thc arm.With a lowcr cxtremity inicCtiOn the dis― tributiOn is normal.

3紹

20

30

35

45 min

A46-ycar,Old rnan has a secOnd cpisodc ofrcctal biccding. 1. W7hat is the radioPharrrlaceutical,and what rnethod oflabcling was likcly uscdP cding 2.Describc the sdndgraphic bに study andngS・ 3. PrOvlde a diagnOsis. 4. List colrllnon causcs lor bleeding from this portion Ofthc gastrOintestinal tract.

345

Notes

Gastrointestinal Systenl:99mTc口 labeled RBCs一 Smali Bowel Bleeding l.99mTc-labclcd RBCs.Thc in vitrO mcthOd Oflabcling was cthOd wOuld bc an acccPt‐ u s e d . T h e m O d i n e dv o i nm 宙 able alternative. rst scen atう 2. Evidencc fbr active biceding,丘 Hlinutcs,start, ing in thc lcFt uPPer abdOmcn and lnoving in a scrPiginous Pa[[ern across the mid to lower ibdOmen tO the nght 10wcr and thcn Hght mid abdOmen.

3。Small bOwcl bleeding originating frOm thc rcttOn OfthC )eJunum. 4.ArteriovenOus malfOrmatiOns and tumors,

References Lcwis BS:Small intcstinal bleeding,Gみ レ ″夕 ″″″〃Ctt F協筋 И物 29:67,9う ,2000.

Ziessman HA:The gastrOintcstinal tract.In Harbert JC, Eckelman WC,Ncuman RD,editors:対

務す 彦″″物じ 脇 ∫ オ ″″グ 務夕 ″ 宅″θ ηり Ncw YOrk,1996,Thicme Medical Publishers,pp 617‐ 627. CrossrReference ″含 r醍 対物び 力″″筋 妨f″

京FQsN『

ら 渉―

蕊 〕ed 2,PP 280-287,

Comment

MttOr blCCding frOm thc smallintestine is uncommon and of― 1。 ten diFncult t。 calize becausc Ofthc Orgars iength,its frec in― traPCritonca1 location,and the nature Ofthe les10ns that biccd in thc small bowcl.Causes include artcriOvenOus malformatiOns (C● gりangiOdysPlasia),tumors(c.g"le10myoma,lc10myosar― coma,and adcnOcarcinoma),Mcckelも diverticulum,and CrOhtt disettc.In aPPrOXimatcけ 50/o Of狙 l Paticnts宙th gas― troiniesdnal bleeding,nO causc for thc blccding is cvident aftcr an extensivc cvaluation and is referred to as gastrOintcstinal blccding ofObscure origin.AlmOst 300/o ofthcsc Patients have leslons in the smali bOwel. The pattern ofmovemen[ofradiolabcled RBCs in this casc is characterisdc ofsmali bOwel bleeding.It is important to dis― ting叫 lsh this Pattern丘 。n■c01onic bleeding.Frequcnt ilnagc ac― line the sitc Of blccding. quisition is important to deter■ Although the case images are taken cvcry 5 to 10 minutes,the studywas acq配配d on thc cOmputtr tt a Framing rate ofl minu使 颯ng the dncmatlc disPlay On the cOmputer Pcr frame.Thtls revi倒 h elPtt in cOnnming hc 夢 O五 can be veり n Ofthe bleeding. The in vitro method Ofradi01abding eり Optimal. 油 rOwesis Labeling eFncienc/is greater than 98%。 The mOdined in vivO methOd,PcrfOrincd by dralwing the patientも b100d back intO a syringe containing 99mTc pertechne[ate after intravcnolls iniCCr tion of stannOus chloride or pyrOphOsPhate,is an alternative methOd with labcling emcicncy Ofappr∝ imately 85%to 90%.

346

A54,ycar― old lnan with a histOry ofcirrhOsis and ascitcs has shOrtness Ofbreath and a right pleural efrusio cal settce ttqucsts a rahonudttc stu毎 1. 対 マhat question can nucicar rncdicine address rcgarding thc cffuslonP 2. Dcscribc thc PrOcedurc. 3. mat radiotraccr is preferredP naccutical carl be uscd tO dcmonstrate the pcritOncal nuid nowP 4. W7hat Other radloPharェ

347

Notes

Gastrointestinal Systenl: Peritonea卜 Pleural Scan l. Is thcrc a cOnnectlon bcMeen thc Picural ettusion and the ascitesP

IniCCt radlotracer into thc peritOncum in an area whcrc ascitcs is present.Uitrasound guidance may bc hclPful. IHlincdiate and dclayed imagcs are obtaincd tO evaluatc transit from the PcritOneum to thc Pleural sPace,cOnnrrn― ing transdiaphragmatic ao、 、 1

2.

3. 99mTc sulfur c0110id. 4. 99mTc MAA is the tracer ofchOice to estabttsh thc patcncy

Ofa peritOncal― venous shunt cathctci such as a Lc Veen or Denvcr shunt,Uptake in thelungs Ofthe 99mTc MAA cOn― irlns PatenCy ofthe shunt.

ReFerences Armstrong,Wilson AG,Dcc l ct』

,cditors:物 宅 否 げ 冴'SttScs

ザ滋筋句 ed 3,St Louis,2000,Mosbン p749.

Sing A:PcritoncOvenous shunts:Patency studies,In Hcnkin RE,Boles MA,Dlllchay GL,ct al,cditors:メ M杉並住″物召 妨ど ″ ″ち St Louis,1996,Mosbtt pp 1041-1052. Cttss‐ ReFerence 州務ど 力″″鵡 品品″α r配 京どQ3慰

a吃じ ed 2,PP 253,261.

COmment Pleural cffusiOn in a Patient with cirrhOsis is not unconllnon. W7hcn Other causes for plcural cFusiOn havc been cxcluded,c.g。 , cardiac,pulmOnary9 or pleur』 徳 iS ,thc tcrm力?″カ ル 務θ打 used lbr thc transudativc cttus10n in PatiCnts with cirrhOsis.The effus10n varies in size,is mOrc cOmmon on the right,but can occur on the ieft sidc alone Or bllatcrallye Transdiaphragmatic PaSSagc ofnuid is the mOst impOrtant mcchanism cxPlaining a hcpatic hydrOthOrax.Thc dcvcloPmcnt Of picurtt cffuslon by this mechanism dcPcnds On the prcscnce ofascitcs.POstmortcm exaHllnatlons havc shO、 vn that deFects cxlst in the diaphragrl, usually in thc tcndinOus Part Of thC diaphragHl,and PrObably arc tears resulting frOm stretching causcd by abdOminal distcn_ tion by ascites.Thc right― sidcd Prevalencc Of hcPatic hydrO_ thOrax may bc bccausc thc tcndinOus diaphragm is more exPosed On thc right side while it is cOvered by thC heart On the lcFt. 99mTc sulfur c0110id can bc used fOr this investigation be― cause thesc Pardcles dfFusc PoOny through peritonca1 s. 0r宙 certt surfacゃ s(slow systcmic absOrption may occur),and tt ap‐ PCarance abOve the diaphragnl cOnttrins a Picural― PcritOneal connection.99mTc MAA Partides cannOt be absorbcd syste■ 11‐ cttly blcause thcy are considerably larger PartiCles(10to m 90 μ vcrsus O。 l to l.o卜m).Thcsc arc advantagcous for pcritone組 vcnous shunts becausc uPtake in the lungs cOnarins vcnous ac‐ cess and Patency.

348

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salivagram'(esophageal transit studyl to diagnOsc suspected asPiratiOn(antcriOr imag― A2-ycar―old was referred for“ ')Study was PO立 for asttraton. mlピ tiVC for renux but cnegat市 ing).The result ofa gastrOcsoPhagett renux(“ 1. W`/hat are thc clinical symptOIIIs ofPullnOrlary asPiratiOnP

vhat is thc rncthOd ofadlninistrationP 2. W7hat radiopharinaccutical is uscd fOr the salivagraln,and、 hat are the scintigraphic indings in this cascP 商子 3. ｀ 4.Whatお

the advantage Ofthe salivagram Ovcr the mlk studyP

349

Notes

Gastrointestinai Systenl:PuirY10nary Aspiration l.Rccurにnt pncumonia,cough,asthma,ゑ lurc tO thr血 , aPnea,Sudden infant dcath. 99mTc suifur c0110id in a slnali volurle Ofnuid Placcd On

2.

thc tOnguc arld a1lowed tO mix with oral secrctions and swa110、 ved. Poor b01us PrOgrcsslon noted in the dynalnic csophagcal swa110w study with entrancc into the main bronchi bilater― 狙け and then intO thc right 10wcr 10be,

3.

4. Thc mlk studyお

very senttt市

c fOr rcnLEX;hOWeveら

止 is

inscnsitiモ for asPiratiOn.Thc salivagram is sensitivc for small amOunts ofpulrnOnary asPiratiOn,

References Hcyman S,Rcspondckヽ 在 :Detection ofpulinOnary asPiratiOn

in children by rad10nudidc“ ivttraIIl,"ゴ s』 脇 cと 臨 嵐3位667679,1989。 Bar― Scvcr Z,COnn01ly LR Trcvcs STl Thc radiOnuclidc saliva― th PulmOnary discttc and a high risk Of g r a l n i n c hni lwdiに aspira[lon,酵 e品駐″勉 冴冴24(Suppl l):S180‐ S183,1995. ReFerence Cttss― 助 す 捻″″協 冴ご ″ ″4『醍 沢どQdtta吃 じ ed 2,PP 272‐273. Comment The aspiration Ofgastric contcnts can result in brOnchOsPasin and severe brOnchOpneumonia that can be life‐ threatening. AsPiratiOn OFten is assOciated with Patients who have ncur01og― ical dysfunctiOn Or gastroesophage』 rentlx or attcr surgery to the uPper airway or digestivc tract, RadiOnuclide rnilk studies arc cOnsidcrably lnOrc scnsitivc for diagnOsing rcntlx than thc barium swa1low studン HOwevc与 t h e s e n is ti tt 市f O r d i a g n O s i s o f a s p i r a t i o n i s s i g n i n c a n t l y 'scan and the diagnOsis is rarely rllade on the basis Of a``rnllぱ cven in Patients with signincan[renux.Many paticnts with as― PiratiOn have associatcd esophageal motOr abnorinalities and gastrocsophageal renllx.Thc csOPhagealswa110w POrdOn Ofthc sttivagram stud/is acquired in a raPid dynamic mOde(15‐ to 30,sccond frarncs)that vs宙sualizatiOn a1loヽ OFcsOphagcal swal― 1 0 w i n が g o Pl Ⅲ o gT /O ・ P e r f O r m t h eC 1t9e9smtT,c2 5s0u卜 l f u r c01101d in lo rnL of、 va[er is placed On the tOnguc or POStCrior pharynx.once the transit stuⅢ is cOmplCted,thc rcmttning mcal v01ume is fcd and further imaging can be obtained. Esophageal swa1low studics alsO have been uscd to diagnOse Or f0110w the cffectivencss of therapy in paticnts with achalasia, esOphageal sPasm,Or sderOderIIla.

350

10weL

venOus shunt fOr intractable ascites ycars ago is nOw cxperiencing incrcasing ascitcs. A patient who had PcritOneal― Images obtaincd 30 minutes aRcr itteCtiOn arc submitted. 1. N7hat is the clinical qucstion tO be addressedP 2.mat tracer(s)could bc uscd,alld what was usedP 3.Dcscribe the iniectiOn proccdurc. 4. Dcscribe the indings and PrOvidC a conclus10n.

351

Notes

Gastrointestinal Systenl:Peritoneal Scan― ―Patent Denver Shunt l. Is thc peritOncal― venous shunt Patcnt,or occludcd and causing the increased ascitesP 2.99mTc MAA Or sulfur c0110id;99mTc sulfur col101d. 3. The radiotraccr is)ected i早 intO thc Peritoneal cavitye 4.UPtakc ofthc radiotraccr is sccn in thccrl市 and spleen (which aPPears enlargcd),indicating shunt Patencyt Thcrc おtransdaphragma〔ic trandt hto the五 ght hemtthOrax.

Reference Stewart CA,Sa瓶 mura II Applebaum DM,ct al:EvaluatiOn Of peritOncovenous shunt patency seen by intraPcritOncal 物 Tc‐99m macroaggrcgated albumini clinical exPcricncc,И

タ ″ 冴1 4 7 : 1 7 7 - 1 8 0 , 1 9 8 6 . ノR ク 々 軍″ ReFerence Cttss‐ 助 び 務″″脇 冴″″4軍醍 財 Q5眼

蕊 「 〕ed 2,PP 253-254.

Comment Le Vecn or Dcnvcr― type PcritOncovcnous shunts arc uscd to dc― toncal cavity in Paticnts with signincant ascites comprcss the pe五 rcfractOry to medical management.Thc shunt drains into a large vein in the neck Or thOrax.The caudal end is 10cated within thc valvc that oPcns whCn peritoneal cavity and cOntains away onc― incrcasing ascitcs rcsults in incrcascd intraPcritOncal pressurc. Fibrinolls dcPositS at thc valvc in thc PcritOncal sPacc rnay cause shunt obs[ructlon,which is lnanifcst as increasing ascites in a patient writh a shunt.Patency can be demOnstrated by intraperi“ toncal ittcCtiOn of99mTc sulfur col10id or MAA,subscqucnt idcntincation ofOrgan extraction Ofthc radiOtraccr(11確 r for sul― fur c01101d,lungs fOr MAAl.Flow thrOugh the shuntに qulにs suFncicnt pressurc to open the valvc.Therefbre paticnts who he forモ teSt.In Patients have liHlited ascitcs are inapprOpriatc whO havc had therapeutic ParaCentesis,shunt patenc/evaluar tion should be postPOned until rcaccumulatiOn of adequate nuid,A nOrinally functiOning shunt results in lung uptakc w i t h i n 1 0 m i n u t e s . T h e s h u n t t u b i n g ussiubailcl.yI nド icsα s宙 in which Organ extraction does nOt Occur within thc nrst 30 ■linutes,delayed images lnay bc uscful tO distinguish Partial frOm cOmplete shunt Obstructlon.99mTc MAA oFFers am advan, tage in that the sitc Ofuptakc(lungs)is ttrther remOved frOm the site ofinieCtiOn(Pcritoncum)than sulfur c0110id,which demOn, strates uptake in the liver and splcen.HOweveh ifbilateral enRL‐ slons arc PreSent,99mTc MAA rnay cnterthe[horax by transdia‐ Phragmatic now9 which can cOmplicatc intcrpretation.

352

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A SPECT 99mTc HM,PAO cerebral perfus10n studンSinglc transverse sliccs frOm ttO separatc SPECT acquisitions Of the samc patcnt are shown.И ,mdalstutt a Rcpeatstu毎 1. Iinage quality is very poore What arc questions that shOuld bc askedP 2, WVhat camera quality cOntrOl should be perfOrmcd dally for all gamma camerasP 3.輸 at sPccial qualitt cOntrOl is requircd for SPECTP 4. ヽ 7hat is the differencc bcnveen an intrinsic and extrinsic noodP

353

Notes

Central Nervous Systenl:GaHwna Camera Quality Control l, Was the carnera set at thc corrcct PhotoPcakP Did thc Patient rnOveF What did the nood and sPatial rcsolution orningP tCStS 100k ttkc in the r■ How do they look nowP 2. Field unifoHnitye A nood source ofradioactivity is used to test gamma camcra uniforinity ofresponsc across its neld Of宙。M Spatial resolution and lincarit/2 using a four― quadrant bar phantom,is acquircd wecklyt /nood acquircd fbr 30 rnill10n counts fbr 3. UnifOrIIliり

SPECT(l mllllon to 5 mllliOn cOunts for planao,centcr OfrOtatlon. 4. An cxtrinsic nood is acquircd with the collilnator on,an i n t r i n s i c。d n 。 is donc with the colllmator o宜

Reference ル″″″冴θ Siegel BA,editOH対 ″ご 々翌 (third scries),Chicago, 1993,Amcrican College ofRadlology9 pp 31. 22‐ Cross‐ Reference あ′ fr醍 助 す 筋″″脇 渉す

沢野Qttrtts,cd 2,pp 27-30,42-43.

Comment Routinc gmma caFnera quality cOntrolls mandatory to ensure quttity diagnOsdc images.In ths cttc proper ttncdon and high― st fOrgOt to changc thc gamma calnera PhOtOpcak the ttchnolo夢 to 140 keV from 122 keV used for the cObalt flood source s ntttstudy Ofthc mOmhtt thiSis a com‐ a c q u i s i t i o n b ctfhoiに mon crroL Floods arc PcrfOrmcd in the carly lnOrning before the star〔 Of dinical studies,A commOnly uscd a00d sourcc is one with 57co cmbedded in a s01ld Plastic encascment.It is 7co is commonly used be‐ う Placcd directly on the colllmato丘 causc ofits long halttlife(122 days)and cncrg/PhotoPcak(122 keW is dose,組though nOt identical to 99mTc(140 ken.The alternative lnethod uscd in some laboratories is insertion of 99mTc PerteChnctatc mttd with waterin a Plasdc renllabic disk. Its disadvantage is the nced fOr dally rcl11ling bccause Of99mTc低 u r l p h y s i c a ll i fh ea .l Bf o―t h m c t h o d s a r e r e f e r r e d t o a s s h O r t (h6o‐ An intrinsic 。ds,1.c.,cxtrinsic to the c011llnato■ cxtrinsic n。 n。。d is perforIIled by placing a hot sourcc at a distance from t h e g a H l m a c a m e r a w i t h t h e ct ou ln lc id m ac ta Ol rn _ o t t A w e l l ― era with prOpcr PhOtOmultiplicr tube and correction circuitry perfOrmance should aPPcar uniFOrm.PhotomultiPlicr tube It d‡ Crackcd Or failure can be seen as arl area ofdccrcasedtye acti宙 crystals and collllnator damagc can be detectcd.Floods should bc Pcrformed on a daily basis.

354

市 納

輸

A29-ycar,old lnan with reccnt Onsct offever and hcadache has nO prlor rnedical prObicIIIs. 1.Describe the 99mTc HM,PAO SPECT rcconstructed v01umc disPlay in this Paticnt.Angic O is thc anterlor prttecP tiOn,angic 90,thc ieft iatcral and vieMら sO fOrth. ２

N7hat is the physi010gical correlatc Ofthis imaging patternP

３

What is thc differential diagnosis Ofthis scintigraphic Pattcrn in this Patient,

４

What is the likcly diagnOsis considcring the paticntも histOryP

355

NOtes

Central Nervous Systenl:Herpes Encephalitis l.Incrcascd uptake in thc lett ternPOra1 10be. 2. Incrcascd blood now to this rcgion. 3.Seizure focus(ictal iniectiOn),infcctiOn,tumoi 4.Hcrpcs cncephalitis.

References :Sequcnti』PositrOn emis― Mcyer Mh,Hubncr q RaiaS,Ct組 sion tomography cvaluations Of brain IIlctabolism in acutc ″ro'物 herPcs enccphalitis,A彦 れ算そg4:104-105,1994. Ackerman ES,Tumeh SS,CharOn M,et ali Viral cncephalitis: imaging with SPEC工 働 ″助 〃鴎 嵐13:640-643,1988. CrOssPReference ガ″夕 ,E配 冴虎 助 aル″″コ″核

越 QyrsrrES,cd 2,PP 300-301.

Comment Bccausc of its poor prognosis and rapid Progresslon,carly di― agnosis and trcatlncnt ofhcrpcs enccPhalitis is critical.The dis‐ easc is lifcrthrcatening and may result in Pcrmanent mcmory and cognitive brain dysfunctiOn fOr thosc who survivc.Thc clinical diagnOsis is based on nOnspccinc ncurological signs in, dicating tcmpora1lobc dysttnction and fOcal EEG abnOrmali― tics,MRI is thc initial diagnOstic ilnaglng mcthOd bccause Ofits high sensitivity and anatonlical res01ution Oflimbic structurcs. Howcvch when incOndusivc,brain pcrfusiOn SPECT or FDG― PET inay be diagnOstic.Increascd tracer accumulatiOn in thc rlledial and latcral portiOns ofthe tempora1 lobe is charactcris― tic Of herpcs cnccphalitis,althOugh cxtratemporal sitcs somc― times may bc sccn, Priinary and secondary brain tumOrs generally havc in― crcascd metabollsm that can bc sccn on FDG,PET imaging. Although blood flow usually fol10ws metabOlism and is in_ creased with mOst tumOrs,99mTc HM_PAO SPECT ccrcbral pcrfus10n studies rarcly show incrcascd uptakc with tuttors. ―perhaps a lack of rcccptors.Seizurc The reasOn is unccrtain一 PET and brain PCrfus10n fOci have incrcased uptakc on FE)G‐ SPECT during thc ictal phase but have decreased uptake duing the intcrictal phasc.

356

A65-ycar-01d rrlan was referred fOr radiOnuclide cisternOgraphye CT showed enlargcd cerebrOsPinal SPaces. 1. W7hat is thc rad10pharIIrlaccutical and rOutc OfadIIlinistratiOnP

2.Dcscribe thc indings On thesc images acquired at 24 hours afterク inieCt10n.多 物″f anterior and right lateral. βθ ′ 殉物物タ ォlcft lateral and POsteriO丘 3. W7hat is thc diagnosisP 4. や7hat arc the paticntも likely symptOmsP

357

Notes

ma卜 Pressure Central Nervous Systenl:Nor口 Hydrocephalus l.11lln DTPA administered intrathccally by lumbar puncturc. 2. Ventricular renux and coFIVeXlt/block with nO nOw over the ccrcbral hcmisPhercs above thc sylvian issure. 3.Communicating hydrOcephalus,in this case nOrmal‐ prcssurc hydrOcephalus. 4. Triad ofdcmentia,ataxla,and incontinence,

Reference Harbcrt JC:Radionuclide cisternography.In Harbert JC, 切物″物c赫 ち冴― Eckclman WC,Ncumttn RD,cditors:脚 ″ す オ ″″〃 務レ ηり New York,1996,Thiemc Mcdical 宅″θ 400。 Publishcrs,PP 387‐ Reference Cttss‐ 彦″″Mcttci″4r避 助 す

財 Q3慰

蕊 「 〕Cd 2,pp 317‐318.

Comment CcrebrOsPinal nuid(csF)is sccrcted by thc chorOid Plexus Of the ventricies,then drains frOIn the latcral ventricles thrOugh the intcrventricular fbramcn ofthe third and fourth ventricles and diffuses intO the subarachnoid sPace that surrOunds the brそ 述n and sPinal cOrd.It then is absorbed by the pacchionian granulations of thc Pia arachnOid vllla and entcrs the suPcriOr

sagittal sinus.Wlhcn in,CCtCd intrathccally intO thc lumbar SPaCC,11lln DTPA,a smali molecuic,fol10ws the nOw OfcsR

NoHnally it rcachcs thc basal cistcrns by l houL thc frOntal P01es and sylvian nssure by 6 hOurs,the cerebral convcxities by 12 hours,and the sagittal sinus by 24 hOurs.It docs nOt nor― mttly cntcr thc ventricular systcm(cxccPt tranSiCntly in somc nOmtts)becaい C PhysbLttcal nowぉ h he oppttte血 陀cton. Norm迅 ‐ prcssutt hydrOccPhttus is a communicating hydro― ccPhalus associated with dilation ofthc vcntricular systcin but normtt cerebrOsPintt Pressure.The pattems ofcerebral atrOphy u s overlap On MRI.Surgical and nomal‐Pにssutt hydroccPh』 shunting(vcntricular pcritoneal,vcntricu10atrial,or lumbar can reverse the prOgressive dysfunctio叫 peritoneal shuntinθ vith surgery.Radlonuclide hOwcveL nOt all Patients improve、 mCn' indings,c.gり cistemography in combinatiOn with clinic』 比er remOval ofcerebrospinal nuid,is used to con― tal cicaring剣 arm the dinical diagnOsis and tO predict rcsPonSC tO Shunting. ″ith Thc Pattern of Prolonged ventricular renux is associated、 improverllent aFter ventricular shunting.

358

A33-ycar― old man with ncur010gical disorder was referred fOr aPET 18Fbrain FDG―scan. 1.Whatisthe FDG― PET scan abnOrmaliげ P 2. What symptoms are likelyP 3. W7hat is thc Path010gical conditiOnP 4. W7hat is thc diagnOsisP

Notes

Central Nervous Systenl:Huntington'sE)isease l.Hypomctabolism ofthc basal ganglion. 2.

ェ oreiform Progressivc motor abnormalities ofinvoluntaryよ movements andを出述nctic rigidity with progrcssivc cognitive dctcrloratlon.

3.

Ncuronal degencration in the striatun■ ,with thc caudatc mOre involvcd than the putamcn.

4.

Huntingtons discasc.

References BOccker H,Kuwert工

Langcn KJ,ct al:SPECT Mttth HMPAO

comparcd to PET with FDG in Huntingtontt disease,メ 働 物,グ‰ Fル 動物呼 18:524-528,1994. VanHccrtum RL,Tikofsky RS,Rubcns AB:Dementia.In ″θ″″′● 夕 ″あ″ど ″ど r鋭 V a n H c c r t u m R L , T ki /k Ro S亀, c d i t o励 々 遡 cr″ ″〃財 r″物竹 グ 警 ed 3,New York,2000,Lippincott こWllldns,pp 165-169. WilliaHlsる ReFerence Cross‐ α r醍 奴どQ5蕊 助 び 彦″″Mcれ ci″

ES,cd 2,P314. 「

Comment Huntingtons discasc is an autosomal dominant disorder Ofun― k n o w n o r i g i n t h a t m a n i f c s t s i n m i d d l c discase with symptOHls and Signs Of inv01untary chorciforin movcments andそ ndnctic rigidityj behavloral changes,and dc― mentia.CT and MRIscans Often shOw no changes carly in thc thOugh in iater stages,atrophy of the coursc of thc discasc,狐 hcad Ofthc caudate and frOntal cortex lnay bc scen.PET stud― ies shOw hypometabollsm in the caudatc and Putamcn nuclcl, which as gray mattcr should have uptake simllar tO the cOrtex. These changes oRen prccede atrophy sccn On CII Studics havc fOllnd hypomerab01ism in thc caudatc nudeus mately ofapprO対 One third ofPaticntS gcnctically at risk fOr the discase. Parkinsonもdiscase is anOther mOvemcnt disOrdc5 onc that is caused by loss ofthc Pigmcntcd ncurons in thc substantia nigra and is characterizcd by bradykincsia,tremor,and rigiditye Dementia occurs in latcr stages in 20%to 300/o ofPatients.No consistent characteristic SPECT or PET imaging Pattern has HOwcvctt PatiCnts with scvere Paridnson's dc― becn rePOrtCd・ mentia late in the disease cOurse may have scintigraphic indings diseasc,1.e., indistinguishabie frOIIl thOsc Of latc Alzheilncrも lsiOn and hyPometabolisrn of the postcrior bilatcral hypoPcr負 parictotcIIIPOral and frOntal reglons.

360

a g c . I t

i s

a

p r O g r c s s i v c

A53-ycar―

old wOman has a histOry ofhead trauma,headachc,and rhinOrrhea.LcFt latcral vic、

vs OVer l hOu丘

1.NaIIlc the apprOpriate radiOpharmaceutical(s). 2. ItIOw is the radiOpharIIlaccutical adIIlinistcrcdP

3, W7hat is the imaging inding and interprctatlonP 4. HOw can the site Ofleakage be rurther dcnncdP

361

Notes

Central Nervous Systenl:CSF Leak l. 11lln or99mTc DTPA.

2.Intrathecal ittPCtiOn・ 3. Activity in the region Ofthc nOsc,indicating CSF leak, Probably at the cribriform platc. 4.Anterior宙 cws.Nヽth thC use Ofnasal pledgets placcd in thc superioL middle,and infcrior nasal turbinatcs.

References

Harbcrt JC:Radlonuclide cistcrnographye ln Harbcrt JC, 温 ″ち冴み Eckelman WC,Neumann RD,editos対 務滋″″物と 宅紗 N c w Y O r k , 1 9 9 6 , T h i e m c P u b l i s h c r s , p p 響 赫 ″″グ務夕 398. 396‐ Lawrence SK,Sandlcrヽ 在 ,Partain CL,ct ali CcrebrosPinal ndid imaging,In Sandler Ml Colcman RE,Wackers FJTh, 紙 ″ちed 3,BaltimOrc,1996, editOrtt Dガ れ攣ω″び″″能彼 物し こWilldns,PP l163-1176. Willlarns愚 Cross― Reference fr醍 ″ ″′ 力″″%″ び 助 び

M蕊 財 Q」玉

〕Cd 2,PP 318-320.

Comment

CSF rhinorrhca and Otorrhca can bc difncult diagnOstic PrOb' l volume lems.MOst leaks produce a sm狙 Ofauid arld icak in― Somc PaticntS have rcpcated bouts ofmeningitis, termittentけ and patient recognition of nuid drainagc rnay be Hlinirnal or absent.OFten irnaging is requircd to conirin the CSF origin of rhinorrhea.MultiPle mOdalitics,c.g.,CT with metrizamidc and MRI,are also uscd for this purPOse,Thc rad10nuclidc Hlethod is an old,cstablishcd tcchnique alld still useful in rnany cascs. Trauma and surgery are thc most common causcs for CSF rhinOrrhca.HydroccPhttus and congenital dcttcts are less cOm― mon nontraumatic causeso CSF leak may occur at any site from thc frOntalsinuscs to thC temporal bOnc.Thc cribriform plate is the mOst susccPtiblC tO fracturc.CSF otorrhca is a faricsF cOm mon causc of CSF lcako PerfOratiOn ofthe dura with commu‐ nicatiOn through the petrOus bonc is the usual causc of otor―

rhca,組though diversiOn through thc eustachian tube ttso has been Obscrved. Th e s t u d y i s p e r f O r m c d w i t ho fpcloetdtgocnほP l aced in the i d d l e , a n d i n f e t t O r n a s a l t u r b ienraa■ tes supe r i omら ンThebilaモ

to中免rcntiatc ttontal,cthmOidユ ,and sphenoid狐 purPoseお sinuslengc.The pledgcほ

are collntcd in a well cOunter rather

d thuS dctecdon ofに than imaged Ⅲ more scnsttive ttrakage ough lateral ttd antriorimagingis done for than imaging.AIⅢ rhinorrhea,postcriOr imaging is performcd for otorrhca.

362

A55,ycar―old wOman with a histOr/Ofrenal stOnes is cvaluated fOr rcccnt Onset ofnank Pain.99mTc DTPA 30-minute dynamic rad10nuclidc renOgramの and 24-hOur delayed imagc a)are shown. 1. W7hat arc the scintigraPhic indingsP 2.Explain thc changing imaging indings. 7hat is the diagnOsisP 3. 対 4. N7hat is the ttkcly causcP

363

Notes

Genitourinary Systenl:Urinoma l.A Photopenicに gion,best secn On carly images,involvcs most ofthe left rcnal fossa.Only thc vcry upper pole is rinar/clearance into lctt rcnal pelvis 血nctioning.1」 appears displaced rnedially by thc photopenic deFcct.Thc 。r right pettis and uPPcr wO thirds ofthc uttter nil.P。 dearance bilatcrallye Dclaycd imagcs show incrcascd radio― tracer uptakc in thc reglon ofthc initial cOld dcFcct and ェ nfcr10r t0 1t. 2.The cOld dcfect is a urinoma with an attcnuating mass e urinc cnters this sPace cfFcct.Over timc thc radloact市 and mixes with thc nonradioactive urinoma.Activity in the reglon Ofthc urinOma increascs over tilne whilc the carlier scen ttdney and background actMt/have clcattd. 3. Active urinary lcak and urinOma. rinary tract obstruction. 4. 1」

Reference Talner LB:Urinary obstruction.In Pollack HM,McCicnnan BL,cdito応:働 ″筋 ′ws督韓 物 ed 2,Philadelphia,2000,WB Saunders,pp 1944-1952. Reference Cttss‐ ″α E醍 ズどQ」酎 r蕊 〕cd 2,PP 351-353. ″″″陀 冴,fケ 助 す Comment RuPture Of the wcakcst PortiOn of thc collecting systcm,thc calyccal fornix,occurs when rcnal Pcivic PrcsSurc cxcccds a crit‐ ical level.Lcss commOnly thc tcar may afFect the pclvis or urete丘 This lnay occur during a bout ofacutc uretcral obstructlon,rct― rogradc Pyelographtt intravcnous urography with abdoHlinal compresslon,and inassive vesicotrcteral renux.spontancous cxtravasation(not caused by trauma,instrumcntatlon,or sur‐ geryp usually is caused by a ureteral calculus and alIIlost alWays is bcnign and sclttlimited.Continucd icakage of urinc in the prescncc ofObstruction rnay lead to the fOrmation ofan encap‐ sulated retroPcritOncal urine collcction,a urinoma.In adults, as arc conaned to thc Pcrinephric sPace・ SPOntaneods urinon■ Urinomas generally do not result from small perforations un, lcss the lcak is accompanicd by Obstruction distal to thc cxit point.Undithey bccomc very large,winOmas ottn are dinically ly a pttpable tcnder mass may devcloP in cOn― silent.Evcntu』 航sc,welght loss,nausca,and vaguc abdomin』 th m狙 )unCdOn航 pttn or back discomfort.The urinOma may worsen the obstrucP tiOn becausc ofits mass ettct.TreatHlcnt consists ofrepair Ofthe Obstructlon and cxcls10n and dralnagc ofthc urinoma.

301品h Furosemide

A51-year-01d wOman with metastatic ccrvical canccr and new hydrOnephrOsis On CI l. Dcscribe thc scintigraphic indings. 2.Wttat is the diagnOsis bcfOrc and after thc administration ofdiuretic(furoscmide)P 3. W7hat ilnaging inding should you sce befOre adlninistering FurOscIIrlidcP 4. HOw dO you calculate diffcrcntial renal functiOnP

Notes

Genitourinary Systenl:Diuretic Renography― Bilatera1 0bstruction l,LeFt kidncy:dclayed and dccrcased cortical uptakc,no dear_ anccinto the dyctt Or pcMs.Right ttdney:prOmpt uptakc a n d d c a r a n c c i n t o t h e c o l l e t t n g s y s tue― m,faint Pcttistentお 組 ization Ofthe hgh[uに

tcL and Poorに

SPOnsC tO ttrOsemidc.

highrgrade obstruction on the left and 2.Befott furOsemidα hydronephrOsis On the right,susPiC10us for obstruction. high― AFter furOscmidα gradc obstruction on thc ictt and Obstruction on thc hght. 3.Fllling ofthe renal collecting systcm. 4. Pcrcent radiopharrnaccutical uptake by each kidney divided by total renal uptakc beNeen l and 3 rrlinutes (bcforc cicarancc into the calyces and Pelvis).

References

converdng enz/mc tic renography and angiotensin‐ FincEJ:Diuに 脇 0とC脇 刃み7筋И物 39:979‐ 99う,2001. inhibitOr renograph乃 Tay10r AL:Radionuclide renOgraPhr a perSOnal aPPrOaCh, 脇 〃29:102-127,1999. レ″2″ ″」 申物f′ Reference Cross‐ 逮 ブ ″α 軍 助 並磯″鴎 品す

択好Qy/S/『 蕊 〕cd 2,pp 340-348.

COmment T h e a d m i n i s t r a t i o n o f a d i u r e d c i s n o t h d c a tgerda dien h i g h ― xliotraccr Obstruction bccausc therc is no collecting systcm rそ to chttlengc.Diuretic rcnograPhy is usettlin PatiCnts with 10wer_ grade obstructions,1.c.,urinary cxcrction into thc c611ecting system but retcntion in the renal Pclvis.Ifdle c011ecting system drains with diuretic,it is nOt obstructcd,c.g.,PatiCnts with cOn‐ gcnital hydrOncPhrosis Or hydrOncPhrOsis caused by uretero― Pcivic renux.Another grOup ofPatientsin whOm this techniquc is valuablc are thOsc who havc had surgical correctiOn for ob, struction but have PcrsiStent dilatiOn.Finall乃 PatiCnts with knOwn partial obstruction,ctg.,those with Pelvic tumor com― pressing the uretcrs and ncw hydrOnephrOsis nOted on CI Thc question is not whether an Obstruction cxists.Rathcr thc qucs― tiOn is whether urgent intclvention is nccdcd,c.g.,stenting,to save the ttdney and its renal ttnction.Drainagc aFter adminis, tration Ofa diurctic in thesc pttients suggests that rcnal ttnctiOn will nOt dctcriOrate in thc short tcrm. dlo, M a n y n u c l e a r m e d i c i n e t dh ie n ir ca st e q uo af n tr ia け traccr washout after furOscmidc.A commOn mcthod is to cal― culate a half‐ time Of cmptying.As in all nuclear medicine, quantincation must bc interprcted in cOniunctiOn with image analysis,NOrmal values fOr the ratc Of cmptying dcpcnd to some cxtent on the mcthOd01og/uscd.In sOme dinics,diuretic is administeに d aS SOon as the rcnal pelvis has alled.othcr clin‐ 30- 25‐ lcs adIIlinister thc diurenc at thc end Of the to initla1

minute stutt Stil1 0theA administer it befOk ThC the stuⅢ techniquc should be standardized fOr thc PartiCular rnethOd. 366

B

Thrcc PaticntS∽ ,a and c)prescnt with acute scrotal Pain.All had testicular scans with now static imagcs Ft齢 →. 1. W7hat are the scintigraphic indings in each cascP 2. ヽ 7hat is the rnOst likcly diagnOsis in each PaticntP 3. What is thc PathOphys1010gical cOnditiOn lbr PaticntS И ,ど,and{gP 4. N7hat is the incidcncc Ofthe rnOst frequent inal diagnOses in Paticnts referrcd 10r acute scrotal painP

367

Notes

Genitourinary Systenl:Tbrsion of Testicular EPididynlitis,Delayed Torsion Appendage′ l.4 Mildly incrcascd now and mlld focal lcFt uPper scrOtal uptakc On thc static imagc.a lncrcascd now and increascd distribution tO thc lctt hemiscrOtumo C Increascd now and d e l a y e d h t t o s i g n gOhftt hhce五 mlscrOtum. Acutc cpididyml, 2.И,Torslon Ofa testicular appendagc.ユ tis/orchitis,c Dclayed tcsticular torslon. 3.九 Loss ofblood supply to the appcndage ofthc tcsticle.ユ Infection,vira1 0r bactcrial.C InfarctiOn Ofthe testiclc causcd by torsiOn FnOrC than 24 hOurs'duration. 4. Tcsticular torslon ,350/o;tors10n ofthc aPPcndiX tcstis, 35%;acute cpdidymids,25%,but varies with ins[itution.

References Mcl10ulヽ在,Paz A,Las D,ct al:Thc Pattern of radlonuclidc

″ eSticular scrotal scan in tOrsion Ofモ aPPcndagcs,あ メA物〃 コ石レ 〃23:967-997, 1996. Sたgd MJ:Thc aCute scrotum,筋 あ 〃働 ″助 筋 И物 35"9976,1997. Cross―Reference 脇 す 筋″″脇 冴び わα Tr/fズ どQむ 眼 rES,cd 2,pp 3う 7‐362. COmment

AfFected TO応lon Ofthe testicular aPPendage is trcatcd medicalけ PatiCnts(6 to 12 ycars of age)havc acute pttn 10calized to thc superior polc of the testis.Thc classical physical exanlination anding iS a small,arm paratesticular nOdule exhibiting blue dis― c010ration through overlying sttn.Atrophy Of outcome,Sanugra2Phy and RsolutiOn ofsymptoms tt the usu』 ed images as scen in may bc nOrmal,show focal uptake on dclaン this case,or have aOrc I■innarninatory apPcarance with in‐ crcased now9 usually localizcd tO thc upPcr polc. Acutc cPididymitis most commonly aFFects adolescent bOys, It usu』 ly is caused by scxuttly transmittcd organisms such as chlamydia and gonOrrhca.This sevcに ,acute hnammationお visualized on scintigraphy as incrcascd now and increased dis‐ tribution to thc innarned sidc.It lna/bc fOcal and localizcd to thc cPldidymits or mOrc dittsc in Orchius. Tcsticular torslon is the rcsult Of the testis and sPcrinatic A con― i stin3 0nc or morc tirncs,obstructing blood nN、 cOrd s〃 cxists as a result Of the dapper bell‐ defOr‐ 野航d predにcdonimacuteto附 おnお susPcCtCd are taken im‐ mitt Padcnほ h wh:y h an attempt to mぶ ntttn tcsdcdar mediately tO surgel viabilitye The salvagc ratc is 100%at 6 ,70%frOm hou応 6 t0 12 hOurs,and 20%、vithin 12[o24 hours aftcr the onset OfPain. AFtcr 24 hOurs thc testis rarcly is salvageabic.The increased now seen on this studtt C is caused by thc hyperemic dartOs ofthc scrotunl;the cold ccntral reglon is nOnviable testicic.

368

thc

appendagc

卿

A44-year― old wOman had tw0 1231 thyrOd scans perttrmed l ycar apttt.

hyperthyrOid. 1.What is the likeけ diagnOSiS in the irstPThe scanpaticntis ω 2. What has happened in the intcrvening tiFnCP

.

thyrOid function and diagnOsis at the tilnc Ofthe secOnd scanP 7hat is the paticntも 3. ヽ 4.Thc Patient has a suppressed thyrOid,stimulating hOrmonc(TSH)level but normal thyrOxine lT4)level.wttat is the diagnOsisP

369

Notes

Endocrine Systenl:Therapy of Tbxic Nodule l.TOxic autOnOmOus thyrOid adenOma in he right10be, 2.The patient has bccn treated with radiOattive lodine 1311. Thc autOnOmous nodulc is still hyPcrfunctiOn』 with cOld areas,1lkcly rcpresenting hemOrrhagc,nccrosis,or bOth. Howcvctt it is n0 10nger fully suppressing thc rcmaining thyrOid.

hyperthン 3.Thc Padcnt may bc cuthyrOtt Ormndly possibけ rOid.The thyrOid scan suggcsts Partial suppression ofthc normal th/rOid.Determination Ofthc scrum TSH lcvcl wOuld answer the qucstion. 4.Persistcnt hyperttnctiOning autOnOmous adcnOma(nod― ulc),inadcq■ a tely treated.

Reference

Bcckcr DⅥ Huricy JR:Radlolodine trcatment of hypcrthy― rOidism.In Sandler MB Coleman RE,Wackcrs FJTh,ct al, editOrs:Z)湯 を″″a修″″物と 縄 ″ら ed 3,BaltimOre,1996, 名″`u力 Williams tt Wilttns,PP 943-958. Cross‐ ReFerence 助 す 務″″%冴 び ブ ″α r配 財 QttFttS,cd 2,PP 272,274. Comment This Paticnt bccarne clinically euthyrOid aFtcr 1311 thcrapy ttter the arst scan.She rcturned for a rcPCat thyrOid scan bccausc of iSttnt right10wer10bc Ⅲ a PCお 10n arld yroidnOdulc On exalYlin征 a supPに sscd scrum TSH lcvcl.The sccOnd stud/shOws that thc Pttpablc nOdulc is still hyperfunctiOning but tO a lesser extcnt than bcfore therapy.The patient rcccived additiOnal radlolodine thcraPye Thc cfFectiveness of radiOactive iodinc therapy fOr single autOnomous nodules is quite high;hOwcve5 0ccaslonttly a second thcrapy is needcd.Effectivc thcrapy wollld have re‐ suited in a tOtally c01d(nOnfunctioningl nOdule. ShOrt―and 10ng‐ tern■ adversc c3発 cts frOm radioactive lodine are tt Radoact市 e bdinc thcrおy htt bCen」vcn fOr hyper_ thyrOidism for mOrc than 50 ycars.It is saFc and cffective.The usua1 1311 dose for autOnOmous nodule(s)is20to 30 mCi.This dOse is t/PiCally greater than fOr patients with Graves'discasc b e c a u s e t h y r O i d n O d u l c s a r e m o r c r e s i Ms at na yn [ t o t h c r a p ン studics have sOught to nnd advcrse efFccts,C.g。 ,second tumors, lcukemia,infcrtility9 abnOrlnal offsPring;howevcL no signin― can[incrcast in thcsc prObleIIIs has becn fOund in trcatcd

paticnts.Transient worsening of hyperthyroid symptOms and 10cal Pain inay be nOted in a lninOritγ Of Patients in the days

― aFter therapy.Thcse arc easlly cOntrolled b10Cking with and β

antiinnaHlrnatory drugs.1311 therapy is cOntraindicated if thc Patient is Pregnant.Iodinc crosscs thc Placenta.Thc fetal thy‐ roid traPs and Organines iodinc after 10 wceksi thercfOrc cOn― result if 1311 is administcred to thc g c n i t t t h y p O t h y r O i d i1slm 宙 mOthei

370

ld woman was rettrrcd ttr rccent cniargement ofthc right10wer bbc Ofa knOwn muldnOdular t A 5 3 - y c a ro― giand and a suppressed TSH levcl.Thc Patient had radiation thcrapy for acne as a teenager. 彦″ 佐 カカantcrioL 1.Describc the scintigraPhic indings ofthis 99mTc PcrteChnetate scan O物lett anter10r obttquc,right anterlor obliquc). 2. Givc the likcly diagnOsis. マhat arc the thcrapeutic optionsP 3. ヽ 4. W7hat is the likclihOOd OfthyrOid canccr in this PatientP

ラ′ ，Ｄ

Notes

Endocrine Systenl:Toxic Nodular Goiter and Thyroid Cancer l.MultiPlc hOt alld c01d rettOns throughOut both lobcs with aPParCnt supprcssion ofnonnOdular gland. ２   ３

MultinOdular tOxic gOitci BloPsヌIfbcniか,thCn 1311 thcraP/Or Surgery for multi― nodular goitei Thc likclihood OfthyrOid cancer is lcss than 5%in

4.

Patients with a lnultinOdular goitei A dolninant nodule increascs the susPic10n fOr cancci A histor/OfradiatiOn t h e r a p y t o t h c h c a d a l l d n c c k s i g n i n c a n t l y PatiCntもrisk ofthyrOid cancei

i n c r c a s e s

t h i s

Reference Cases JA,Surks MI:Thc changing role Of scintigraphy in the 物修〃30:81-87, ″ 物″ ″】 甲物び ′ソ cvaluation of thyrOid nOdules,S′ 2000. Cttss‐Reference ″ ″α 『 配 脇 す 筋″″脇 妨′

財 Qじ 慰 孤

Cd 2,PP 369‐374.

Comment This Patient not only had a tOxic rnultinodular goiter writh a ra― dioactiw iodine uptakc(RAIU)of36%but also had Paplllary f011lcular thyrOid cancci She subscqucntly had a ncarrtot』 thy‐ roldectOmy and radioactivc 10dinc theraPye The incidcnce Of thyrOid canccr aPProachCS 30%in a Ptticnt With a histOry of

radiation theraPy tO the neck and a nodular gland.Patients 〔 r e a t e d w i t h r a d i a t i o n t o t h e n e c k f O r slllar eniargcrnent OFten reccivcd a radiatiOn dOsc Of 10 t0 50 rads to the thyrOid.The scan has the apPcarance of a inulti_ nodular tOxic goitci This is a Tc 99血 Pcrtechnctatc scarl.Note

a c n e , r i n g w o r m , a n d

the sttNtt」 ands above the thyrOid and the high backgrOund, 31.Norm狙 ncithcr Ofwhich is seen with貶 けthyroid uptakc and salivary uptakc are simllar with 99mTc Pcrtechnctttc.The high thyroid uptake cOmpared with salivary uptake hcre is cOnsis― tent with hyperthyrOidism.1311,10卜 Ci,was adminis[ered The RAIU was OrallェfOr thc rad10actiw iOdinc uPtakc studン 38%.The usual administered dose fOr thcraPy OfmultinOdular nodular goiter is lnore re‐ tOXiC 80iter is 20 to lCi.Toxic 30■ sistant to 1311 theraPy than Gravcs'discasc.Oncc the nOdules arc egLctivcly[reated,which Fnaン rcquire 3 to 4 Onths,the 1■ functiOn Of the remaining suppressed giand will return. Hypothyroidism as a result ofradioactive 10dine thcrapy is un‐ common bccausc the suppに sscd」and dOes nottake up the r伊 diOactivc iOdinc.HOwevcL in this case thc Pa[ientも b10Psy shOwed canccL so shCにCettd a thyrOid cancer ablatiOn dose af‐ tcr a ncar‐ total thyrOidcctOmye

372

t O n _

A

B

POST

total thyrOidcctomン near― A53,ycar―old wOman with papillary,folllcular thyrOid cancer attcr 恥 at is the rad10pharmaccudcalP 1.What is thc studyPヽ 2. Describc thc Pattern ofuptake and your intcrpretation. andgoitcrの fOr a r thyrOid uptakc and scan for a paticnt writh suspcctcd substernal 3. W7hat dOse of1311 is uscd Iも

after thyrOidcctomyP thyrOid canccr paticnt`砂 4.ExPlain why 1311 therapy but nOt 1231 is effectivc fOr Gravcs'hypcrthyrOidism,toxic nodulcs,and thyrOid canc銚

373

Notes

Endocrine Systenl:Thyrcid Cancer Whole。 Body Scan lIお scan.略 l.レ31 wholc,bOdy thyrOtt cancer mostcOmmonけ used,but the excellent imagc quality and similar b10dstd― butiOn indicate this is 1231. 2.Abnormal diffusc uptakc in the lungs,uptake in the mid_ line ncck,left suPraciavicular and iOwcr cervical,ali cOnsis― tent with mctastatlc tumor 3,Uptake,10卜 Ci scan,50 μCt thyrOid callccr scan,2t04 mCi.Bc careful to distinguish besvccn millicuries(mCi) and micrOcuries(μCi). 4.The beta particic cmisslons of1311 are takcn uP by thyr01d f01licular cells and arc rcsPOnsibic lbr its thcrapeutic cttect.

References

FにitasJE:Therapy ofdifFcに ntia[ed thyrOid cancctt emanln Fに Lヽ在 吻材物″Mcttic筋′И物 ″″′ノ998,Philadelphia) ,cditOr:2内 1998,Lippincott‐ Ravcn.

Hurley JR,Bccker DV:Treatmcnt of thyrOid canccr with ra‐ d1010dine(131-I).In sandler ML COlcman RE,Wackcrs FJTh,ct al,editOrs:Dブ θ J″ び″″ご み″″物′ 力冴″ら ed 3, 宅r″ BaltimOre,1996,Willlams位Wrilkins,PP 959-989. Cttss‐ ReFerence 対務す 彦″″Mcあ ct″ 夕 f rF/f沢 どQ3慰

恥 ,Cd 2,PP 379‐ 380。

CO】mment 1311 is mOst cOmmonly used fOr wh01c_bOdy thyrOid cancer scintigraPhtt howcvc5 there is a high tOtal bOdy radiation dosc (0.5 rads/mCi)and the pOtcntial for thyrOid stunning,1.e.,de― crcased uptake Ofthe subscqucnt theraPcutiC dOsc.PreliFninary rCPOrtS Suggest that 1231 is nOw being uscd as an alternativc tO 1311 with simllar diagnOstic infOrmatiOn.Disadvantages of 1231 arc its short physical hal二 life(13 hours),which limits dclaycd imaging to 24 hOurs,and is higher cxPensc.The admi面 stcにd dose for th/rOid cancer scans is approximately l.5 mCi,com_ Ci for routinc thyrOid scans. Pared with 200 μ The Only acccPtcd clinical indication fOr a 1311 thyroid scan Other than thyrOid cancer is substem』 80■e■The higher en_ crgy photoPcak(364 kcn a11。 ws fOr better dctectability cOm_ ″ith POssiblC attenuation of 1231(159kも ヽO by thC ster― Parcd、 nuIIl,Thc radiation dOse tO thc normal thyrOid frOm 1311 is h g h , l r a dC/iμ ,resddng in aPprOXimatcly 50 rads tO the thy― rOid.MOst patients reFerred for this indication arc eldcrly pa‐ ticnts with gOitci Many clinics usc 1231 nrSt and rescrve 1311 aS a sccond-line cvaluatiOn fOr a substcrntt gland.

374

〃o1311receivedぃ A Patient has a histOry ofPaplllary thyrOid canccr and has undcrgolle thyrOidcctoIIly.Thc Patient lc― bwh。 Ody sCan werc O bdin levelおelcvated.Findings Ofa rccent 1311 treatmcnts,150 mCicach.The scrum thyrO」 ncgativc. 1.Wttat is thc Purposc ofa serum thyrOglobulin icvcl determinat10nP PET studyP 2. W7hat arc the scintigraphic indings and interpretation Ofthc FE)G― veen the 1311 study and thc 18F FDG studyP 3.Why is thcrc a dscrcPanCy beぃ 4 . M u s t t h c p a t i e n t b e w i t h d r a w n f r O m t h y r O i d r e p l a c e m e n t / s u p p r e s s i o n t h e rP aE pT y s bt eu fd Oy rP c t h c F D G ―

375

Notes

Endocrine Systenl:FDG― PET and Thyroid Cancer t l.Scrum th/rO」 Obulinぉ used tt a thyrOid canccr scrum markei AFter」 and ablatiOn,detec[10n indicatcs PCrsistcnt tumoi lt is increased with activc discasc. 2.FOctt uptakc in thc right hilum and mcditttinum consis― tent writh tumOr adcnopathy. diffcrentiatcd thyrdd 3.The tumOr htt diIFerendated.Vcll―

tumors usu組 町uptake.P00rけ diffCrcntiatcd けhavc略 tumors arc likcly tO be 1311 negative,FE)G PositiVC・ 4 . N o . F D G u p t a k e i s n O t T Sd He ― pendcnt;thus Patients dO nOt haveモ o bC Withdrawn frOm supprcssion.

ReFerence 歌 ng Wる]MacaPinlac H,LarsOn SM,ct al:[18F]FDG PositrOn cmission tomography localizes rcsidual thyrOid cancer in pa‐

tients with negativc dagnOsdc略 町whOle bOけ scanS and el― evated serum thyrOglobulin leveis,メ 働″助あfガ θ 〃 ノ ″ 降物″ 84:2291‐ 2302,1999. Cttss,Reference 揚″″"々冴f″ 助 す ″′ f『選

択どQ」 ISr蕊

〕ed 2,pp 376-378.

Comment

APPrO対ma[cけ 85%of dfferendated thyrdd cardnOmtt take uP略 lI.HowcveL somc uncommon thyrOid cancers arc knOwn tO havc incOnsistent 1311 uptakc,e,g.,Hdrthlc ccll tumO島 anaplastic thyroid canceR ThC Currcnt clinical indicatiOn fOr FDG‐PET in thyrOid canccr is for paticnts with ncgativc nnd‐ intt on崎町wh01c_bOdyscans but clevatedserum thyroJObulin levels.FDG localization a1lows fOr POssible tumOr resection and serves as a baselinc fOr evaluating rcsPonSC tO therapye Treatmcnt Of thesc Patients with high― ftcn PrOduces a decline dOsc 1311。 of the serum thyrog10bulin icvcl,組 thOugh Patients arc rarcly cured.TumOr response indicates tumor uptake,albcit very low (not scen On 2 mCi diagnOstic scan,butseen on scan 7 to 10 days atter high‐ dOse thcrapガ ,201Tl and 99mTc sesiamibi have been used for thyrOid tumOr localizatiOn;howeveL FDGttPET is considered supcriOi ThyrOid metastascs that trap 1311。 ften do nottakc up FDG,whercas FDG― avid metastases often have 10st their ability tO trap lodine.Dcdiffercn[iated tumOrs lose thcir norinal ttncdOnal ability to conccntrate lodine but tcnd tO havc inctased」 ucOSC metabolism typic』 Of highcr‐ grade tu‐ mors.Thc sensitMt/OfFDG―PET for dctecting mctastascs in all patients with differentiated thyrOid canccr is Only abOut 50%,but thc cOmbined usc Of FDG and 1311 scan has a 95% scnsiti宙 t/.HOwevctt fOr Patients with ncgativc 1311 scans and cicvated serum thyrOg10bulin lcvels,the scnsitivit/ofFDG― PET is cOnsidcrabけhigher(70%to 90%).

376

Three PaticntS With Cushingも

syndromc were refcrred for an 1311 1。 dOcholcstcrol study(NP-59)。

CT and NPづ

9 ψ ω,

vs arc a bonus. ″″θ ″ク ル物ジstudiCS arc shOwn.Arro、 c the indings and g市 have a similar history ofnewly ercOrtisolism.Describc diagnosed hお 1.Paticntsand И β interpretatlons. syndrOme but continues to have hypcrcortisolism.Describe thc 2.Paticnt Chad Prcvlous adrenttcctomy fOr Cushingも indings and givc an interpretation. 3. W7hat is thc lncchanisnl ofuptakc ofthc rad10pharIIlaccutical, 4. W7hat other discases besidcs Cushings syndrome can be diagnOsed with NP-59P 377

Notes

Endocrine Systenl:Adrenocortical Scintigraphy l.乳 Unilatcral NP-59 uptake cOnsistent with iett adrcnal adenOma COncordant with thc CT studン あ Bllateral adrenal h/PcrPlasia;discOrdantwith CT stuⅢ 2.Uptake in thc nght adrcnal bcd rettOn hdicating adrcnal rcmnant.Discordant with thc negatiw CI 3. Transport and rcccPtOrS Systcrns cholester01 for scrun■ account for adrcnal uptake.Ch01csterOl is rcquired fOr the productiOn ofadrcnal hOrinOncs. 4.HypcraldosterOnism(adrcntt adenOma Or hyPcrplasia)and h/PcrandrOgcnism.

ReFerences GrOss MD,Shulkin BL,ShaPirO B,ct』:Adrentt scintigraPhy and thcrapy of neurOcndOcrinc tumOrs with I-131 lV[IBG. In Sandler MB COlcman RE,cditors:Dル 務″″ 抑 西″び″″び 物″ 冴r″ ″ら cd 3,BaltimOre,1996,Villiams使 WFilkins,pp 1023‐ 1045. Yu KC,Alexander HR,Zicssman ltIA,et al:Thc rOlc Of pre― operative lodOch01estcr01 scintiscanning in PatientS underr going adrcnalectOmy for CushingもsyndrOmc,S″ 警 7118: 。 981,987,199う Cross― ReFerence 脇 す 彦″″%冴 び ″ ″4『述

沢どQStt「 ES)cd 2,pp 380-383.

Comment 1311_6β -10dOmethyl_19_iOdOch01ester01(NP-59,“ new Pharma― ccutical,"invcstigatiOnai number)is not approved by thc FDA but available frOm the Univcrsity ofMichigan On an investiga, 'drug.HowcveL its clin_ tional new drug basis.It is an``Orphポ ical utittty is Proven.It can prOvidc impOrtant functiOnal infor― mation cither nOt avallablc Or in cOntradictiOnhcto〔 nndingS suggested by the anatOmical imaging studン 瑚袖cn used tO di― agnosc hyperaldOstcrOlism or hyperadに nttism,the pttent must be prctreatcd with dcxamethasOnc to suppress adrenocOrti" cotropic hOrmOnc lACTH)sccretion and inhibit adrcnal up‐ take by thc zOna fasciculata and zOna rcticulosa.NP-59 1s used t010calize discasc PrOVed to bc hypcrfunctiOnal by b10chemical 〔 esting.It can determine whethcr the discase is unilateral or bi‐ “ lateral,The mOst cornrnon indicatiOn is Cushingも syndrOme," “ Or hypercOrtisollsm.cushingも disctte"is caused by excess Pl― tuitary ACTH,the mOst cOmmon causc for Cushingも syn‐ drOmc.In these patients bllateral uptake is sccn.With autOnO― mous cortis01 PrOductiOn frOm an adrenal adenolna,unilatcral uptake is sceno With adrenal cOr〔 ical carcinOma,no uptake is seen.Thc tumOr is hypottnction』 and thus dOes nOt take up enough radiOtracer in mOst cases to be detected scintigraphi―

calけ No uPtake is sccn on the contraltteral normtt side bccausc it is sLIPpreSSed.

378

叫■ヒ

一 ！蘇 料！ ！

A

養

フ

‖

A3-ycar―old boyヽvith a rcccntly diagnoscd retrOPcritOneal tumOr. i n g S O f t h c 9 9 m T c M D P b o n c s cル a n n“d t h c 1 3 1 1 M I B G s t u d y o . 1 . D e s c r i b c t h c i m a g i n gd “ vO StudicsP 2, W7hat is your interprctation of thc t、 3. W7hat are thc rnost cOIIIInon tumor causcs for cxtraosscouS uptakc ofbOnc_sccking radiopharlrlaceuticals in this agc

groupP 4. ｀ 前hat is the rnOst scnsitivc imaging IIlcthod fOr dctection ofbOne rnctastases in this diseascP

Notes

Endocrine Systenl:Bone Scan and 1311 MIBG口 Neuroblastoma l.Bone scan shows uptakc symmetrically in the distal 1311、 femurs,cranial,and facial bOncs。 在IBG study shOws a largc area Ofntidlinc abdOttlinal uptakc.Inspection Ofthc bOne scan in the samc area suggests a sott tissuc ictt Perire― nal dcnsity9 bes〔 sccn in the antcrior vi漁 、In addition,dif‐ fusc marrOw/bonc uptakeissccn on thc MIBG stuⅢ The prOmincnt midlinc uptake On thc MIBG study is cOn_ sistcnt writh neurOblastOma.Subtic bOne uptakc is seen in that region,The symmetrical bOne uptakc in the distal Femurs,crand,and facial bOnes is very suggestiVC Of tumoi Thc MIBG study cOnirms metastatic disease with cxtcnsitt tumor in the marrOw/bone frOm skull tO fcct. 3.

First,primary neuroblastOma.Ostcosarcoma metastatic to the lung is anothcL Attetastases ofvariOus tumOrs occaslon― 狙l y a r e s c e n o n b o n e s c a n s , l u n g , c 0 1 0容t n , .a n d b 陀

4.

CombinatiOn of99mTc bOne scan and 1311 MIBG.

References Shulldn BL,ShaPirO B:Current cOnccPts On the diagnostic usc ofMIBG in children,メ Aあ冴瞳 札39:667‐688,1998. G c i f a nり d小 M c t t t O d O b c n z y l g u a n i d i n c 物グ i″ n 対務 c〃 hildren,S″ Л石夕 〃23:231-242,1993. Cross‐ Reference 助 ど 務″″脇 妨rブ ″α 「 醍 沢どQS慰

孤 ,ed 2,pp 383-384.

Comment NeuroblastOma cOmmonly manifcsts at an advanced stagc and bOne scans are uscd routincly fOr dctcction ofmetastatic lcs10ns. Becausc thc metastatic icsions OfncurOblastOma originate in thc bOnc lnarrOw cavityj bonc scans lnay undcrcstimatc thc carly stages of sprcad.The prOpcnsit/of rnctastatic ncuroblastOma to 10cttizc h metaphysctt regiOns adiacent tO hOt grOwth Platcs can alsO hinder carly detectiOn.The relativcly subde bOne scan changes in this case contrast with the very abnOrinalい 五IBG

StuⅢBO品 Studics arc ttqdred ttr he hghest detecdOn rate of mctastascs.

1311 MIBG is taken up alld localizcd in presynaptic adrenergic nerves,adrenal mcdulla,and neurOblastic tumOrs.On scintigra― sOtt tissue,and Phtt nOmtt MIBG uptake is seen in the Ll統 blood P001 but nOt in normal boncs Or bonc marrN、 NOrl■al uptake alsO ma/bc seen in Organs宙 th adrcncrgic intcrvention, C● gりhear[,s』Ntt JandS,SPleen.NOrIIl』 bilatcrtt adrentt up‐ takc is scen in 10%OfPatien体 .MIBG commOnlyis Ordcに d fOr staging and lnOnitOring thc egttctivencss Oftherapy.RcsPonsc tO therapy is sccn on the MIBG study bcfOtt thc bOnc scall.

380

l 2 3 4 5

37 Skeletal Systcm:JanuS―TWOrHcadcd Roman God,2-4 Skeletal System:Stress Fractures,5-6 38 Skcictal System:PagctもDiscase,7‐8 39 Skeletal Systcm:Rib Fracttlrcs and StcrnOtOmy9 9-10 c POsi― Skeletal System:Pcda1 0st二 eTOhmryeccl,iPthiass一

40 tivc, 11-12 6 Skeletal Systcm:Abnormal Breast Uptakc,13-14 41 7 Skeletal System:Neuroblastoma,15-16 8 Skelctal Systcnl:Extrarenal Pelvis and Mobilc Solitary 42 43 路 ght Kidneン 15-16

HcPatobiliary System:MorPhine― tigraph乃67‐68

Augmentcd Cholescin,

HcPatobiliary SystcIII:Blllar/Lcak,69-70 HcPatobiliary Systclni CavcrnOus Hemangloma of thc I″ ivc5 71-72 GastrOintcstinal System:99mTc RBC Colonic Blceding, 73‐74 GastrOintcs[inal Systcm:Mcckclも Divcrticulum,75,76 Gastrointcstinal Systcm:Diabetic GastrOparcsis,77-78 Gastrointestintt Systcm:“Mllr'Study― GastrOcsoPhage劇

Renux,79-80 9 Skelettt System:L/mphcdema,17-18 alities of Rcnal Position, 4 4 C e n t r a l N c r v o u s S y s t e m : B r a i n D e a t h , 8 1 - 8 2 10 Skcictal Systenl:Bone AbnOrl■ 4 5 C e n t r a l N e r v O u s S y s t c m i C c r c8b4r a l l n f a r c t , 8 3 ‐ 17-18 46 Radionudide CystOgraP町 ;85,86 1 l Skeletal System:Mctastatic Prostate Cance島 19‐20 47 Diutttic RenOgraphy:Unllatera1 0bstructiOn,87-88 12 Skcictal Systcm:Brcast CanccL 21-22 90 48 Renal Radiopharrnaccuticals,89‐ 13 Skeletal System:Fibrous DysPlasia,23-24 n a r y S y s t e m : D h r e t i c R c n O g r a P h y / N使odn o b s 皿 14 Skeictal Systcm:Radlopharmaccutical lnnitration,Scattcら 4 9 G c n i t O 耐 HydronephrOsis,91,92 and Lymph Node UPtake,25-26 28 50 GenitOurinattr Systcnl:TransPlant ttdney Urinary Leak, 15 Skeletal Systemi Sacral lnsutticiency Fracturc,27‐ 93-94 m:MultiPlc lnsuttcicncy Fracturcs,29,30 16 Skeletal Sysに 51 Gcnitourinary Systcm:Nonviable Kidney ARcr Transplan‐ 17 Card10vascular Systcm:Left Anterior Desccnding Artery tation,95-96 lscheHlia, 31-32 52 GcnitOurinary Systcm:RcnalTransPlant withAcuteTubu― 32 18 Cardiovascular System:APical lnfarct,31‐ lar NecrOsis,97-98 19 Cardiovascular Systcm:Dual‐ IsOtOpe Study― Mlld ln― 100 53 GenitOurinary Systenl:lesticular TOrslon,99‐ feriOr lschcmia,33-34 54 EndOcrinc Systemi Cold ThyrOid Nodulc,101,102 20 Cardiovascular System:Brcast Attenuation,Wall Thick‐ 55 Endoc五ne Systcm:HyperthyrOidism/ThyrOttitis,101-102 cning,35‐36 う6 Endocrinc Systcm:Gravcs'Discase,103‐ 104 21 Cardiovascular System:Emergcncy Departmcnt Chcst 57 Endocrinc System:1311 star Artifact,103,104 Pain,37-38 with lncrcased Lung 58 Endocrine Systcm:Hyperparathyroidism,105‐ 106 22 Cardiovascular:Planar irhalllun■ 59 Endocrine Systcm:Parathyroid Adenoma,105,106 40 Activity9 39‐ 60 Skcictal Systcm:L5Pars lnterarticularis Dcfect,109-110 23 Cardiovascular Systcm:Card10myoPathy On Equilibrium― 61 Bonc:Tibia1 0steomyelitisttThree,Phasc Positivc Bonc culogttPhy or MulugatedAcqul‐ Cated BLod P001 Vent五 Scan,111,112 sition,39,40 62 Skclctal Systcm:HcPatoblastoma,113‐ 114 24 PulI■Onary Sysrenl: High PrObabllity of Pullnonary 63 Skeletal Systemi Sicklc Cell Discase,115-116 Embolus,41,42 64 Skcictal SystcHl:OSteosarcoma,117-118 44 Hot Spots''on Lung Scan,43‐ 25 PullnOnary Systenl:“ 65 Skelettt System:Muscle lniury9 1リ ー120 Stripc Sign, Pcrfusion_― :ヽLntilatiOn― 26 Pulr■Onary Systen■ 66 Skelcttt System:Pleural Uptake,121,122 Emphysema,45,46 is,and 67 Skcletal System:Hot Kidneys,RadiatiOn Nephri〔 27 PullnOnary Systcrn: Hamp〔 onも Hump― 一Interlnediate SPinal PhotOpenia,123-124 48 Probability9 47‐ 68 Skelctal Systemi SPlcnic UPtake,125-126 28 1nfectiOn and lnnaHlination:Sarcoidosis,49,50 69 Skcletal System:HcterotoPiC OSSincatlon,127-128 29 1nfectiOn and lnflaIIIInatibn:Intraabdonlinal Abscess, 70 Skcletal Systenl: Superscan Sccondary to Metastatic 51‐52 Canccら 129-130 S t a g e I V H o d g k i t t D i s c t t cProstate , 30 0nc01ogy:Bone/Gttlium一 71 Skeletal Systenl: SoFt Tissuc Up[akc in LLLng Mass, 53-54 131-132 n d H o d g k i t t L y m p h o m a B c f O に N o n ― 31 0ncolog/:67Ga― 72 Skeletal System:Prostate Canccr Bone臣 Ictastases,Axial 6 Atter Therap乃 55,う ― Distribution,133,134 PEET一 Singlc PuimOnary Nodulc, 32 0ncolog/:FDG―

33 34 35 36

57-58 Primary Brain TumoL 59‐ 60 61-62 0nc01og/:ScintimammograP町 N9rmal Stud乃 SyStemi CholescintigraPhy― HcPatobilhり 63‐ 64 66 HcPatobiliary System:Acutc Cholccystitis,65‐

73 Skeletal System:Hyperparathyroidism,135‐ 136 74 Bonci Osteosarcoma l砿ctastatic to Lung,137,138 139‐140 75 Skcletal System:Rcnex Sympathctic DystrOph乃 76 Skeictal Systenl: SPontaneous Ostconecrosis of Distal FemuL 141-142 77 Skelctal System:IMctastases to Bonc and Liver9 141-142 381

78 79 80 81

Skeletal Systcm:Myocardial Uptake,143-144 Skclctal Mctastascs:Metastasis to Clivus,145-146 Skcletal System:Cold SPine Dcfccts,147‐ 148 Skelctal Systcrn:Mctastatic CalciflcatiOn in Lungs and Kidne乃 149_150

84

CardiOvascular Systcm:DiP/ridamOlc― Induccd Rcvcrsible lnfcr10r Wali lschcmia,155-156

120 GastrOintestinal Systcm:99mTc RBC Scan―

Cardiovascular System:AdcnOsinc Strcss/Apical lnfarct, Antcrior― Latcral lschcIIlia,157-158

121 GastrOintcstinal Srtem:99mTc RBC一

115 HcPatObiliary Systeln:」 Acutc Cholecystitis and Blllary ObstructiOn,213-214 116 HcPatObiliary Systcm:Biliary Atrcsia,215‐ 216 117 Hepatobiliary Systcnュ :CavcrnOus】 Hcmangloma of the LivcL 217-218 8 2 Q u a l i t y C O n t r O t t G a m m a C a m e1r5a2 F 1 0 0 d s118 , 1 5HcPatobiliary 1‐ Systenl:SPlenic Remnant,219-220 83 Card10vascular Systcm:InfcriOr Lateral Wall lnfarctiOnぅ 119 Gastrointcstinal Systc■ 1:CastrOintcstinal Blccding as a 153-154 Rcsdt ofAnttodySPL立 ら221-222

86

CardiOvascular Systcmi Viabilittt Fixcd LAD Dcfcct, 159-160

Axll10bi_

femOral ByPass Graft,223-224 Frcc Pcrtcchnctatc vcrsus Gastric Blccding,225‐ 226 122 Gastrointcstinal Systcrn:Rcctal Blccding,227-228

123 Ccntral Nervous Systcrn:Scizurc DisOrdcら 229-230 Cardiovascular Systcrn:Bull's_Eyc,Reporting Rcsults,1 2 4 C c n t r a l N e r v O u s S y s t c m : ADlizshccaismcc,r2も 31-232 161-162 125 Ccntral Ncrvous Systcm:Pictt Discasc,233-234 88 Cardiovascular SystcIIl:Inadcquate Strcss,163‐164 126 Gcni[Outtnary System:Acutc RcnalTransPiant Rcject 89 Cardiac:Sllcnt Latcral Wall lsche■ 1la,165-166 235‐236 一Small Kid― 90 Cardiovascular SysteFnt LBBB,167-168 127 Gcnitourinary Systcnl:Rcnal lnsuFncicncy一 91 Card10vascular Systcm:RBC Labcling for RVG/MUGA, ncys,Poor Function,237-238 167-168 128 Gcnitourinary S/stcnl:(じ aptopril RcnograPhェ239-240 87

92 Cardiac:CttculatiOn OfLVEF fOr ttC(MUGAl,169‐ 170 93 CardiOvascular Systcmi RVG/M【 UGATechniquc,169-170 94 PulmOnary Systcm:Emphyscma Causcd by al_AntitryPsin Dcnciency9 171-172 9 5

P d m O n a r y S y s t e m : 9 9 m T c Acrosol Clumping,173-174

D T P A

97 PulrnOnary Systcnl:Intcrincdiatc PrObability and Prcg― nancy9 177-178 cukocytcs 98 1nfcctiOn and lnnammation:9在 9_mPTAcO HLヽ and OstcOmyclitis,179-180 99 1nfectiOn and lnnammation:99mTc HM【 ― PAO Lcukoqttes_ frcc 99mTc Pertcchnctatc,181-182 100 1nfectiOn and lnfla町 llnationt lntraabdonlinal Abstcss, 183‐184 -67Ga,185-186 101 1nfcctiOn and lnnaFrlrnatiOni Pcricarditis一 102 0nco10gy:NcurOcctodcrmal TumOrs,187-188 103 0nc01ogγ :PoStchemOthcrapy 67Ga Findings,189-190 104 0nc010g/:18F FDG― PET一 Lymphoma,191-192 105 0ncolog/:18F FDG_PET― Lung Canccr Staging,193-194 106 0nc010gy:18F FDG― PET一 C010rcctal Canccr Mctastatic tO LiveL 195-196 107 0nc010野 :18F FDG― PET一 BrOnchOgcnic Cancer Mcta― static tO Brain,197-198 108 0ncolog/:201Tl_Intracranial L/mphoma,199-200 203-204

11l HcPatobiliary System:Dclaycd Blllary― to― Bowcl Transit, 205-206 1 12 HcPatObiliary Systcn■ :RIヽ江Sign,207-208 Gradc Blliary Obstruction, 209‐210 1 14 HcpatObiliary Systenl:HcPatic lnsuFncicnc乃 211-212

382

132 Endocrinc Systenl:Lingual Th/rOid,245_246 133 Endocrine Systcm:Thyroid Lcft Lobe Agcnesis―

Gravcs'

E)iseasc,147-248 134 Endocrinc Systcm:Mediastinal ParathyrOid AdcnOma, 147-248 135 EndOcrinc System:W【 IBG_PheOchrOInOttOma,249_250 136 Skcletal System:Arterial lnjcctiOn,B00t Artifact,PhO― tOPCniC Attenuation Artifact,253-254 137 Skclctal Systenl:Improvcd Speciflcity with BOnc Scan

Lumbar SPEC■ 255-256 138 skelctal systcm:Puimonary HypcrtroPhic OsteOarth― ropathン257-258 139 Skcletal Systenl:Gangrcnc ofTOcs,259-260 140 Skeletal Systcnl:Avascular Nccrosis ofコ 砿etatarsal Hcad Discasc),261_262 (Frcibergも 141 Skclctal Systern:NcurOblastOma lV【 irnicking OsteOmy― clitis,263-264 142 Skcletal SysteHl:Fibrous Dysplasia,McCune―Albright Syndromc,265‐266 143 Bonα Rcn』OsteOdystrOp聯267-268 144 Skcletal Systcm:Lumbar SPinal Fusion,RcnalTransPlant,

109 0ncolog/:MelanOma Lymphosdndgrap町201-202

113 HcPatOblliary System:High―

243‐244

131 EndOcrinc Systcm:Toxic AutonOmous Thyroid Noduic, V e n d l a d O245,246 n S t u d y w i t h

96 PulrnOnary Systcrn:LOw_Probabllit/VcntilatiOn―PcrltsiOn Scan,175-176

110 0ncology:Breast Cancer L/mphoscintigraphン

cgaurcteL 241-242 129 Prilnary l砿 130 GenitOurinary Systcm:Pye10ncPhritis and 99mTc DMSA,

269-270 145 Skclctal Systcm:Mctastascs to Bonc(Cold)and Adrcnal Gland,271-272 146 Bonc:OstcOsarcoma and 201'「 1,273-274 147 Skclctal Systenl:Avascular Nccrosis of FemOral Hcads, 273-274 148 Muscu10skcictal Systcm:LymPhoscintigraphy of thc LOwer Extrcmitics,275-276

149 Cardiovascular Systcnl:DobutaHlinc Stress,277-278 150 CardiOvascular System: Paticnt IMovcment Artifact, 279-280 151 Cardlovascular Systcm:Breast Attenuation,281-282 152 CardiOvascular Systenl:E)ipyridamolc,InfcriOr lscheHlia, C)vcrlying BOwel Activity9 283-284 153 Card10vascular Systcm:Attenuation Caused by Challgc of Breast Position,285-286

175 0ncO10gy:11lln ProstaScint一一PrOstatc CattceL 329-330 176 0ncO10gy:OctreoScan一 Glomus T/mpanicum,331-332 177 HcPatoblliary Systemi CholcdOchal Cyst,333-334 178 Hcpatobiliary Systcm:Chronic Acalcu10us Cholccystitis, 335,336 179 HcPatobiliary Systcrn:Postcholecystcctomy Syndrome, 337-338 180 HcPatobiliary Systcm:CholccystojttunOStOm乃

339,340

154 Card10vttcular Systcm:201Tl viabilit/Stu毎287-288 th lschemia,289-290 341-342 155 Cardiovascular Systcm:Planar 201Tl宙 182 HcPatobiliary Systcm:Hot SPot?9mTc Sulfur C01101d 156 Cardiovascular Systcm:13N AmmOniarFDG Cardiac Via‐ 11■ aging,343-344 bilit/Studン291-292 183 Gastrointcstinal System:99mTc‐ labeled RBCs― 一Small 157 Caldiovascular System:Doxorubicin TOxicity9 293-294 BOwcl Bleeding,345-346 1う8 Cardiac:PyrophosPhatc SPECT Infarct,295-296 Plcural Scan,347-348 184 Gastrointestinal System:Pcritoncal― 159 Cardiovascular Systcm:Supcr10r Vcna Cava Obstructlon, onary AsPiratiOn,349-350 185 GastrOintcstinal Systenl:PulI■ 297-298 一Patcnt 186 Gastrointestinal Systcm:Pcritoneal Scan― Dcnver 160 Pulmonary Systcm:High PrObability of PulmOnary Em― Shunt,351-352 b01us,299-300 187 Ccntral NcrvOus System:Gamma Camera Quality COn_ 161 Pullnonary SystcHl:StriPc Sign,301-302 troL 353-354 162 Pullnonary Systcnl: Unllateral Matchcd Vcntilation‐ 188 Ccntral Nervous Systcm:Hcrpcs EnccPhalitis,355,356 Pcrfusion AbnOrmalit/J303-304 189 Ccntral Ncrvous System:Normal,Pressurc H/droccPha‐ t o‐ Ltt Shunt Dcmonstrated by 163 PulmOnary Systcm:Right― 99mTc MAA,305-306 lus,357-358 190 Central Ncrvous Systcnl:Huntington's Diseasc,359,360 164 ThrOmbophlebitis:AcuTcct(99mTc apcitidc),307-308 191 Ccntral Ncttous System:CSF Lcak,361-36 Cs一 Right 165 1nttction and lnnammatioE lllln Oxinc Ⅷ 192 GenitOurinary Systcnl:Urinoma,363-364 llcum C)stcoHlyclitis,309,310 1 6 6 1 n f c c t l o n a n d l n n a m m a t i o n i O s t c o m y c l i t i s O193 f GcnitOurinary t h c S P i n c , Systcnl:E)iurctic Renography― Bllatcral Obstruction,365-366 311-312 194 GenitOurinary System:TOrSiOn OfTesticular APpendage, 167 1nflarnmation and lnfcctioni FDG一 PET―ParasPinal EPididymitis,Dclayed TOrslon,367‐368 lnfcction,313-314 :ThcraPy ofTOxic Nodulc,369-370 195 Endocrine Systen■ 1 6 8 1 n f e c t i O n a n d l n n a m m a t i o n : K n c c A r t h Rr uO lp cl a s t y ― 196 EndOcrine Systcm:Toxic Nodular Goiter and ThyrOid Out lnfection,315‐ 316 CanceL 371-372 169 0nc01og/:FDG― Hodgkitt Diseasc and Musdc TcnsiOn Body Scan, 197 Endocrine Systernt'rhyroid canccr Wholc‐ Artifact,317-318 一 373-374 170 0nc01og/:18F FE)G一 心江clanoma,319-320 ET and ThyrOid CanceL 1 9 8 E n d O c r i n c S y s t c l n : F D GP― PE■ 321-322 171 0ncology:Gamma Canlcra FDG― 一 v ith Diabctcs,323,324 375-376 172 0ncolog/:18F FE)G一 Patient、 199 Endocrine Systcnl:Adrcnocortical Scintigraph乃 377‐378 173 0nc01og/:Brain LymPhoma Versus lnfcction in AIDS, ,326 NeurO― 200 Endocrine Systerlli Bonc Scan and 1311 MIBG‐ 32う blastOma,379-380 1 7 4 0 n c 0 1,09観 9mTC CEA Colorectal Carcinoma Rccurrencc, 327-328 181 Hepatobiliar/Systemi Focal Nodular HyPerPlasia(FNH),

383

A

Angiod/sPlasia AbdOminal Pain gastroinrestinal biceding as result dh01escintigraphy for cvaluatiOn oi 333,335,341 small intestinc bleeding associated with,346 sphincter OfOddi and,338 Anglograrn,radlonuclide,82 Absccss,intraabdoFninal,う 2,184 灼尊Ography Acquired immunOdenciency SyndrOme computed tomograptt pulmOnary embOlism evaluated brttn lymphOma and,326 with,178 dementia differentiatcd frOm,232 radiOnuclide,96 intracranial mass assOciatcd with,60 Antitrypsin dcnciency9 emphyscma associatcd with,172 m a g n e t i c r e s O n a n c c i m a g i n g f O r c v a l u a t 1 0 n O i 3 2 5APnca,Pulmonary asPlratiOn assOc比 忙ed with,350 Acute tubular necrosis,98,124 APPcndicitiS,Meckel`dttrticulum and,76 AcuTect.∫′ ′99mTcchnctiunl aPcitide imaging APUDomasesを で恥 moL ncuroendocrinc AdenOcarcinoma Arrhythmia,ventricula与ischemia and,32 ch01cdOchal cyst and,334 Artery in liveL 142 lett antcriOr descending,32 small intestine blccding associatcd with,346 . mcsente拭c,gastrointestinal biceding and,74 AdcnOma obstruction oi radionuclide bloOd nOw study fO島 298 hepatic,342 PulmOnar/Pincrease in sizc Oi 48 Parathyroid,106,248 thyrOid,370 thyttid f01licula5 1o6 toxic,hyperthyrOidism caused 248bン Adcnopathy hilaら304 prostatc bed,330 AdenOsinc b100d pressure decreascd 278 bン cardiac stress induced bン 168 contraindicat10ns to,284 side cIFccts Oi 158 stress induccd、 vith,158 Adenosine strcss/に st m/OCardi』Pcrfuslon imaging,157 Ad01cscent,osteosarcoma in,118 Adrcnal gland bOne scan arld,272 malignancy in,114 鮎 ncsis,dcanitlon oi 40 AlcOh01isln i dcmentla diFFerentlated frOn■ ,232 osteonccrosis associated with,142,262 Alkalinc PhOsPhatasc,cicvated levc1 0i 129,141,210 Alierg/P adenOsine contraindicated b乃 158

A110grancction,cvalua[lon rづ Oi 236 AlvcOlar microlithttis,abnOrm』 lung activiけ 陀ntiatcd di徒 fro血,150 Alveolitis,nuorOdcox/glucOsc uptakc and,314 AlzhciFnerも discasc,232 AminOphyllinc,diP/ridamOlc attd,284 Am10daronc,67gallit■ l uptakc affectcd 190 b乃

rcnal,stenosis bi 96,240 Arthnds,nuorodeoxyglucOse uptake and,314 ArthrOPlast/2 knce,316 Artifact boot,254 causes oi 254 muscle tension as causc oi 318 PhOtOpcnic attcnuation,254 Ascitcs evaluation Oi 351

managemcnt oi 352 Aspergi1losis,nuorodcOwglucOsc uPtakc and,314 AsPiratiOn,pulinOnar乃 350 AsPirin,OStconccrosis assOciatcd with,262 Asthma

dipridarnolc cOniraindicatcd町 284 dysPnea and,177 gastrocsophageal rentlx associated with,80 PullnOnary asPiratiOn assOciated with,350 pulmOnary hypcrtrophic OstcottthrOPathy ttsOciated with, 258 vendlatiOn/Pcrfuslon matchcd abnormalitics associatcd with,176 Astrocytoma,59 1 dctection Oi 188 ATN.secAcute tubular necrosis AtriOventicular b10ck,adenOsine cOntttndicated町 158 Avascular nccrOsis,142,274 cause oi 262 cOld sPine dcfect and,148 Axll10bifemOral graft,224

Amメ01dOSiS,myocardd uptake and,144 Ancmia,gastroesophageal renlx associated with,80 B A n e u r y s m , v c n t r i t u l a t t m y o c a r d i a l u p t a k c a n d , 1 4 4 Back Pain

Anttna infarctiOn indicated b,154 中yOCaldial uptake and,144

bOnc scan fbr evaluatiOn O二 109,271 evaluation Oi l10,311 Barbiturate drugs,nat electrOencepha10granl causcd by9 82 385

oi

2

Baycs'theorcHl,286 Bcll‐ claPpcr deforIIlity9 368 negativc scan rcsulting frOm,164 Bcta blocker drugs,falsc―

Bonc gr五 丘,bone scan and,270 Bone rnarrow cvaluatiOn oi 180 67galliuFn uptakc in,190

Bllc,lcakagc oi 70 Bilc duct

infectiOn in,310 1cukocytc uptakc in,184

飽siform dilation oi 334 0bstructlon oi abdonllnal Pain caused by9 338

neuroblastoma OrittnatiOn in,380 Bonc scan

stoncs in,214 Blliary atrcsia,215-216 Blliary divcrs10n,339-340

agcnts fb島144 artifacts in,254

Blllary duct,obstruction oi 210

breast cancer diagnOsis with,22

Blliary lcak,70 bo、vel transit,dclaycd,206 Blliary― to―

breast uptakc in,14 cold icslon on,272 cOld sPinc defcct dctccted with,148 Freibergもdiscasc and,262

Blliary tract cyst in,334 in)utt tO,70

gallium uscd atteh 54 hyperparathγroidism and,136 1311。 dinc mctalodobenzylguanidinc foL 264 kncc arthrOplasty and,316 multiPle rnyeloma diagnosis、vith,20

0bstruction oi 210,214 Bladdcr carcinoma oi supcrscan associatcd with,130 auorodeox/glucosc and,318

ncuroblastoma evaluated with,380 fOr Onc01og/954 vith,180 osteomyelitis cvaluatiOn、

0bstructlon oi 88 SuPCrSCan and,130 urinary lcak and,94

Pagetもdiscasc and,8

Bladdcr divcrticulunl,Mcckclも divcrticulurn arld,76 BlastOmycosis,IluorOdcOx/glucose uptakc and,314

PhOtOpcnic icslon on,254

Blceding

PrOStatc canccr and,20 rib fracture appearancc on,10

gastrlc,cvaluation Oi 226 gastrointestinal,73 cvaluatlon oi 222,226 radionuclidc scan for cvaluatiOn Oi 222

sickle cell discasc diagnOsed with,116

-256 on computcd tomOgraphy島 Sh」 e phOtOn emi雨 島25う SPina1 0Steomyclltis cvaluated with,312

rcctal,227-228

stress fracturcs on,6

cvaluatiOn oi 345 frOm smali bOwcl,346

SuPCrSCan effccts in,268 thrcc― phasc,112 vascular status cvaluatiOn with,260

190 BleOInycin,67galliurn uptakc affcctcd b乃 BleOmycin toxicityj cvaluation Oi 186

Bonc sdntigraphy insuttcicncy fracture and,28 Pagctもdiscase and,8 rcncx sympathctic dystroPhy syndromc and,140

B10od nOwjto bonc,274 B100d glucOsc icvel,fasting and,324 B10od prcssure

sOtt tissuc uptakc and,132 Bowcl

dObutaHllnc cffccts on,278 excrcise and increasc in,154

activitt oi card10vascular system imaging and,284 bleeding in,evaluation oi 226,346 cckeltt diverticulum and,76 small,ヽ在

systolic,ischernia and,32 Bone avascular nccrOsis oi 262

BOwcl discase,cvaluatiOn Oi 184

blood aOw tO,274 cnlargement oi Pagetも discasc and,8 fOrmatiOn Oi stress and,6 67galliu】 m uptakc in,190

Bradycardia,dipyridamole contraindicatcd bン 284 Brain brOnchogenic carcinoma rnetastatic to,197‐198

infection,oint O二 infectiOn differentiated from,12 10ng,cpiphyscal ends Oi 262 mctastases in,134,142

‐

metastasis in,prostatc canccr and,330 0StCOSarCOma in,274 rcmOdeling oi Pagctもdisease and,8 resorption oi stress and,6 stress on,cfFect oi 6 BOne discase,mctabolic,suPCrscan associatcd with,130 386

llnagin3 0二233‐234 1ymphOmain,326 mctastases in,132

tumorin,60 Brain dcath,82 Brain iHlaging,dcmentia cvaluatcd with,234 Brain pcrfusion studンcnccPhalitis diagnosis and,356 Brain scan,18Fluorinc nuorodeoxyglucOsc POSitron emisslon tomography foら359

Brain tumoL 60 Breast abnOrmal uptake in,14 attenuation causcd bンsingle phOtOn emiss10n cOmputcd tomography and,282)286 attcnuatlon oi 36 carcinoma oi supcrscan associated with,130 mctastatic,bOnc scan uptake and,14 Brcast cance5 18,21,22 bone traccr uptakc and,132 dctectiOn Oi 188 1/mphOsdntigraphy ttr cv』 uadOn Oi 201-204 scintimammOgraPhy for detectiOn Oi 62

Captopril renOgraph乃240 CarcinOcFnbryOnic antigcn icvcl,327 CarcinOid syndrOme,187 CarcinOma.∫″″筋 Cancc、 Tumor brOnchOalvc01a島 diagnOsis Oi 58 brOnchOgcnic,197-198 PulrnOnary hypertrOphic OstcOarthropathy assOciatcd with,258 cervical,87 c010rectal,195,327 99mTcchnctium irnaging Foら 328

dctectiOn Oi 188 csOphagcal,321 stagcs oi 22 hepatOccllula島 324 Brcath,shOrtness oi radlograph for diagnOsis oi 45 innallllinator/2 bOnc scan uptakc and,14 Bronchicctasls thyrOid,376 40 P u i m O n a r y h y p e r t r o p h i c O s t c O a r t h r O p a t h y a s s O c i a t e d w CardiomyoPathン ith, 2う8 dOxOrubicin assOclated with,294 vcntilation/pcrfusiOn matched abnOrmalitics associatcd myocaldial uptakc and,144 with,176 Card10〔 Oxicity9 dOxOrubicin assOciated with,294 Bronchiolitis,POStinfcctiOus obliterativc,304 CardiOvascular discasc BrOnchOpncumOnia,PulinOnary asPiradon and,350 cvaluation oi 186 BrOnchOsPasln,pulinonary asPiratiOn and,350 Bruce exercise prOtOcOl,154 Budd―Chiari syndrOmc,99mTechnetium sulfur cO110id uptake in liver a3拾 cted bン343-344 Bullもeye singlc PhOtOn emisslon computed tomOgraP町 161‐162 Busuifan,67Gallium uptakc aFFccted bン190

Puimonary h/pcrtroPhic OsteoarthrOPathy assOciatcd with, 258 Cardiovascular s/stenl,31-40,153‐ 170,277-298 breast attenuatlon and,282 Patient mOvcment artifact and,280

CardiOverslon ittury9 myOCardial uptake and Caroliも discase,334

Causaltta,140

C CABG.J″ COronar/artcry bypass grafting CAC.scc ChrOnic acalculous chOlec/stitis CAD.j夕 ′COrOnary artery disease CaissOn disease

`

CCK.Jタ タCholccystOkittin CEA level.J″夕Carcinocmbryonic antigcn levcl Cellulitis bOnc scan fOr cvaluation oi 259 0StCOm/clitis diagnOsis and,12

osteonccrosls assoclatcd wlth,262

Central ncttOus systenl,229-234,353-362

SPOntancous osteonecrosis assOciated with,142

Ccrebral infarct,84 Cerebral perfusiOn studン99mTcchnctium hcxanlcthyl,

Calclncatlon heterOtOpic,rnyocardial uPtake and,144 ctas atic

in lddney9 150 in lung,150 Calciun■channcl b10ckcr drugs,false― ncgativc scan resulting from,164 Ca1/ccal fornix,urinoma and,364 Cancciす″″沈フCarcinOma;Tumor ″ Breast canccr) brcast(す ccttical,365 c010rcctal,196 18Fluorine nuorodcox/glucOsc POSitron emission tOmog, raphy fbr evaluatiOn Oi 196 prostate,20,130,134,269,329-330 rcnal,c01d spine defcct and,148 thyroid,372,373‐374,375-376 c01d sPine defect and,148 incidence Oi 102 Capromab Pcndetidc,330

proPylcnamine‐ oximc fOL 353 CcrcbrOsPinal nuid leakage oi 362 secretlon oi 358 ChcmOthcrapy doxorubicin f05 294 ,190 g a l l i u m u p t a k c f ovli1n0g、 Cherubisnl,descriptiOn Oi 24 Chest pain diagnosis Oi 47 infarctiOn indicated bン 154 lschemla associatcd with,32 SinJC PhOtOn emissiOn cOmputed tomography島

島 38

Child ibrOus dysplasia in,266 67gallium dOsage fO島 186 1iver malignanc/in,114 neuroblastOma in,264 387

Child―contu OStCOSarcoma in,118 pdmonary hypertroPhic Osteoarthropathy h,258 thyroid imaging in,248 tumorsin,114 Chlangitis,choledOchal cyst and,334 uated with,334 Cholanglographtt choledOch組守st ev』 ChOlecystectomy1 337-338 Ch01ccystitis acutc,66,67,214 diagnosls oi 68 chdescindgraphy島 ぁ65,66 chronic acalculous,335-336 to,bowci transit associatcd with,206 delaycd biliary― 208 galbLddcr hnammadon caused bン Ch01ecystoduodcnOstomン 340

unoStOmン 340 ChOlec/stojづ Cholecystokinin to― bowci transit and,206 blllary― ch01escintigraphy and,64

Colitis,uicerativc,cvaluatiOn Oi 184 C01lagcn vascular discase,Ostconccrosis associatcd with,262 C011llnatoL cxtrinsic nood and,354 C01101d nOdule,thyrOid,102 C010n

bleeding in,74 evaluatlon oi 222 metastatic,bone scan uptakc and,14 Coma,brttn dcath and,82 CoHllnOn duct,obstruction oi 206 Computcd tomograph/6J″ ″みθSingic PhOton emisslon com‐ Puted tomOgraphy nuid icakage detectcd with,70 pulmOnary cmbollsm evaluatiOn with,178 rhinOrrhea cvaluatcd with,362 Congcnital biliar/atreSia,pulmonary hypertroPhic ostCOarthrOpath/assoCiated with,258 Congcstivc heart Fallurc Pagetもdiscasc and,8 vcntilation/Pcrfuslon lnatched abnOHnalitics associatcd with,176 Coronary artcry bypass grafting,10 Coronary artery discasc,32 lung uptakc and,40 silent latcral wall ischernia and,166 wali mOtiOn abnormalitics associated with,40 C O u g h , p u l m O n a r / a S P i r a t i O n a s s o0c i a t e d w i t h , 3 う

pharmac010gical ettects Oi 213 sPhincicr OfOddi and,214 ChOlccystokinin intts10n,333 Ch01cdOchal cyst,334 Ch01edochoduodenostomン 340 Ch01cscintigrap町64 abdorninal Pain cValuated with,333,335,341 rcntiatcd frOm,232 Crcutzfcldt― blllary obstruction evaluatcd with,214 JacOb diSeasc,dementiaと di麟 Crohl途 discasc blliary tract cvaluated with,340 cvaluation oi 184 biliary tract obstruction evaluated with,210 small intcstine blecding associatcd with,346 66 chOlec/stitis dctected with,65‐ CSRャ タCercbrOsPinal nuid cholccystokinin,cholecystitis evaluatcd with,335-336 立on com‐ CIャ Computcd tomographys Sh」C PhOtOn cmお vith,334 chOlcdochal cyst cvaluatcd、 COHllnOn duct obstructlon and,206 putcd tomOgraPhy Cushingもdiscasc,378 examplc oi 63,207 CushnぶsyndrOmc,377,378 mOrphine―augmcntcd)68 Cyc10PhOsPhamide,renal uptakc and,150 cvaluated with,338 sphincter OfOddi dysfunctio■ Cyst ChOndrOsarcoma,resected,273 hal,334 ch01edoこ Chronic acalculous chOlecystitis,33う ,336 thyrOid,102 ChrOnic obstructive pullnonary discase,165-166 Cystic duct obstruction,66 cchocがdiograPhy and,32 diagnosls oi 68 10n Oi 301 radlography ttr evalu征 Cystic ibrosis,pulmonary hyPcrtrOphic OsteoarthrOpathy ventilatlon/Pttrtts10n matched abnOrmalities associatcd atcd with,258 assocェ with,176 Cystic mastitis,bone scan uptakc and,14 ventiladon/perfusion study島 島176 CystograPhy scan alld,76 Cimetidinc,Mcckclも cxamplc oi 84 CirrhOsis radlonuclidc,86 biliary atresia and,216 m,radlonuclide voiding,242 CystourethrOgrそ biliary obstruction and,210 Cytoxan,67Gttlium uptake afFccted bン190 parenchymal livcr discasc and,212 Picural eFFuslon and,348 D lradionuclidc,イ 3う8 Cisternographン 357‐ DchydradOn,hot ttdncy ttsOciated with,124 clarrs icvel,320 Dementia,231‐232 Ci市us,metastasis to,146 causes oi 234 ed with,258 Clubbing,hypertroPhic OsteottthrOpathy ttsoci■ dif&:rential diagnOsis oi 232 231‐ COld sPine defect,148

SinJe phOtOn emission cOmputed tomography oi 233

3鶴

￨

Dcprcsslon,demcntia diffcrcntiated from,232 Dcprcssivc drugs,nat clcctrocnccPhalograln caused bン 82 Diabetes,11‐12 18nuOrine scall for cvaluatiOn oi 323,324

Endocarditis,puimOnary hypcrtrOphic osteOarthrOPathy assO― clatcd wlth,258 EndOcrine systcnl,101-106,24う‐ 250,369-380

EndoscOpic retrograde ch01ang10Pancreatograp町 ;338

Ente五 ds,pulmOnary hypcrtrOPhiC OSteOarthroPathy ttsOciated gastroparcsis and,78 、 vith,258 glucOsuria and,318 insulin― dependcnt,77,323 E P i d i d / m i t i s , 3 6 8 spontancOus osteonccrosis assOciated with,142 ERCn∫ タ タEndoscOpic retrOgradc cholangiOpancrcatography Diabetic gastrOparesis,78 E均れhro。たe,labeling oi 310 E)iP/ridamole Esophagcal swa110w studン350 action oi 283,284 EuthyrOid,graves'discase and,103 b100d Prcssurc dccrcased bン 278 Evans staging systcnl,16 cardiac strcss induccd bン 168 Excrcise contralndicat10ns to,284 cardiac wOrk incrcased bン 168 m/OCardial Pcrfus10n arld,156 inadequatc,llnaging affected b乃 164 sidc effects Oi 158 strcss PcrfuS10n imaging and,154 strcss induccd with,158 Exercise treadmlll stress test,153 Dobuta11lne Extrinsic nood,garnlna camera qttality cOntrOl and,354 cardiac wOrk incrcascd b卜 168 F c a r d i a c w O r k l o a d i n c 1r 6e 6a s c d b ン description Oi 278 Facc,boncs in,abrous dysplasia in,24 Dobutanlinc stress,278 Fallure tO thrive DOppler ultrttOnograptt testiCdar tOrslon evaluatedwith,10o gastroesoPhagcal renux associatcd with,80 DoxOrubicin PullnOnary asPiratiOn associated with,350 lymphOma treated wi[h,293 Fasting,nuorodeox/glucOse study and,324 red blood cell labcling affected168 bン Fasting blood glucOsc lcvcL 324 toxicity to,294 FDG―PEI tt nuorodcOx/glucOsc PositrOn emtton DTPA.∫″ 99mTcchnetium dicthylcnctriamincPCntaacetic acid tomography

Duct obstructlon,diagnOsls Oi 68 Dysttncsis dennitlon oi 40 lnfarct10n and,32 DysPlasia nbrous,266 mam■ lar/9 bOnc scan uptake and,14 D/sPnca,asdllna and,177 E Echocard10graphy OPCratOr skill and,32 rad10nudide ventricu10gram compared to,294 EctoPia cross― fuscd,18 rcnal,18 EEG.ャ タElectrOcnccPhalogFam ElcctrOenccPhalogram,braln dcath diagnOsis and,82 Emcrgcncy dePartmCnt,PCrfusiOn imaging in,38 Emphyscma alrnow obstructlon caused bン 46 causcs oi 172 diagnOsls Oi 46 Empycma,nuorodcox/glucOsc uptakc and,314 Enalapril,lntravenous EnccPhalitis,herpes,356

Fcl■ ale,POstrncnoPausal,OSteoPOrOSiS in,28

Fcmur avascular nccrOsis oi 274

abrous dyS」 aSL h,24 SPOntancOus osteonecrosis oi 142 Fever 10w grade,cvaluatiOn Oi 311 0funknOwn Origin,deinitiOn Oi 52 FibrOadenOma,bOnc scan uptakc and,14 FibrothOrax,122 abnOrmal lung activity differentiated frOm,150 lung tumOr difFcren〔 iated frOm,138 Fibrous dysPlasia,24,266 Finger clubbing,hypertrophic OstcoarthrOPathy assOciated with,258 Fistula,urinar卜 94 F100d,extrinsic,gaHIIna carncra quality cOntr61 and,354 18Fluorine nuorodcowglucOse,292,320 18Fluorinc nuorodeoxyglucOsc POSitron emisslon tomograPhェ 57,58 brain cancer evaluatcd wid■ ,198 brain scan wlth,359 brain tumOr diagnOsed wlth,60 cercbral strOke diagnOsis with,84

HOd鎖 品 diSCase and,317‐ 318 1ymphOma detccted with,192

389

18Fluorinc nurodcox/glucOsc PoSitron emission tomographン cxamplc oi 323 FluorodcOxyglucose cxcrction oi 318 uPtakc Oi iFlfCCtiOn indicatcd314 bン 57,58 FluorOdeoxyglucosc positron enlission tomograph乃 brain lymphoma cvaluated with,326 brain pcrfusiOn study and,356 vith,321 csOphageal carcinoma cvaluated、 gamrna camcra,322 infcriOr wa11 lschemia and,156 ParaSPinal infectiOn cvaluated with,314 vith,230 selzurc disorder cvaluated、 thyrdd cancer cvaluatcd with,376 Fluorosis,suPcrsCan associatcd with,268 FNH.∫ ″ Focal nOdular hyPcrplasia Focal nOdular hypcrplasia,342 6 b乃 Focal oval,strcss fracturc indicatcd Foot,diabctcs with ccllulitis Oi l l Fracturc insufnclcncy9 28 multiplc,30 oStCOneCrOsis diffcrcntiated fron■ ,142 rib,10 28 sacral insuttcicncン タStress fracturc) strcss(ャ Frcibergも discasc,262 Frostbitc,spontancous ostconeCrosis associatcd with,142 FurOscnlldc radiotraccr washOut attch 366 renograPhy and,82 scintigraphy and,91 6 Fusiforrn activityJ strcss fracturc indicatcd bン

67Gallium一― contu sarcoldosls diagnoscd with,50 uptakc oi following chemothcrap卜 190 67Gallium scintigraphtt sarcOidosis evaluatedwith,49-50 Gamma camera,quality control fOL 354 Gamma camcra nood,152 Gangrcnc,bonc scan and,260 Gastric bleeding,cvaluation oi 226 Gastrinoma,dctectlon Oi 188 80 GastrOcsoPhagcal rcnux,79‐ pulmonary asPiratiOh and,350

349-350 1 GastrOesophagctt rcntlx stu(転 GastrOintcstinal discasc,puimonary hypcrtrOphic OStCOarthrOpathy associatcd with,258 -352 GastrOintcstinal systcm,73-80,34う blceding in,226 radionuclidc b10od nOw study for blecding in,298 GastrOintcstinal tract,biccding in,cvaluat10n Oi 222 GastrOParcsiS,diabctic,78 Gated radionuclidc vcntricu10grarn,167-168

1cft vcntricular ttcctiOn fraction and,170 〃ith, Gauchcrも discasc,spontaneous osteonccrosis associatcd、 142 J G″a l l b l a d d c r c i c c t 1 0 n f r a c t i o n 2 44,363-368 GcnitOurinary systcHl,91-100,235‐ GBER

Gingivitis,nuorodeoxyglucosc uptake and,314 Glcason's score,330 Glioma high‐ gradc,60 10、 v― gradc,60 Glomus tymPaniCuIIl,332 GlucagOnOma,dctcction oi 188 Glucosc,mctabolism Oi 318 Glucosuria,diabetes and,318

G

Goltcr

Gallbladdcr chOlecystitis and,66 ch01cscintigraphy and,64 208 innammation o二 mOrphine infuslon and,68 nonnlling Oi 214 normai nlling Oi 206 Gallbladder clectiOn fraction,335 67Gallium

substcrnal,374

toxic nOduic,372 Granu10cytc,labcling oi 310 o島314 Granu10cytc,stiFnulating Fac〔 Gravcs'discase,104,248,370,372 cuthyrOid and,103 hyperthyrOidsm assodatcd with,102 H

abdOminal discomfort diagnOsed with,51 adult dosc oi 52 bone marrOw study with,180 bOnc scan prior to,54 vith,186 cardiovascular discasc cvaluatcd、

1tIAMA icvcl.マ Human andmurinc andbody lcvcl Hamartoma,mescnchymal,114

dosage Oi 186 nuorodeoxyglucOsc POsitron cllisslon tomography cOHl―

Hcart,nOrinal,sizcd,apical thinning in,32 Hcart block,dipyridam01c contraindicatcd b乃 284

Pared tO,192 infcctiOn cvaluated with,310 non,Hodgkitt lymphoma and,56 0StCOmyclitis cvaluated with,312

Hcart discase,pulinonary hypertrophic OstcOarthrOpathy assor

390

1tlarnptonis hump,48 HashilnOtOも discasc,102 HashitOxicosis,102

ciatcd with,258 Hcart ratc

cxercise and incrtase in,154 maximum age― prcdicted,153‐154

Hemangioma cavernous,oflivcら218 in child,114 cold spinc dcfcct and,148 止veも72 60ft tissuc hypertrOphy associated with,24 ultrasOnOgraphy fOr diagnOsis oi 72 Hcmatoma,thyroid,lo2 HenlithOrax,bOnc scan and,132 HemOsiderosis,sPlcnic uptakc and,126 Hcparin,red b100d ccll labcling affected 168 bン HIPatic adcnOma,342 HCPatitiS,ncOnatal,216 HcPatObiliar/systcnl,63‐ 72,205-220,333‐344 dysttnctiOn Oi 212 HcPatOblastOma,114

HyperchOlestcr01cmia,cvaluation oi 285 HypercortisOlisnl,378 0StConccrosis assoclated with,262 Hypcremia,Mcckclも diverticulum and,76

Hyper」 ycemia,image quttity and,324 HyPcrparathryrOidism,renal ostcOdystrOphy and,268 HypcrParathyrOidism,106,136 myocardial uptake and,144 osteoporosis assoclatcd wlth,28 SuPCrSCan associatcd with,130 HyPcrscnsitivity pneumonitis,sarcoidosis differcntiatcd frOm, 50 Hypertension ccrcbral strOke and,84 renovasculaち 240 Hyperthyrottism,101,102 causcs oi 248

HcPatOportocnterostom,216 Herpcs cnccPhalitis,356 nuorodcox/glucOsc uptakc and,314 HctcrOtOpic bone fOrinatiOn,128 HeterOtOpic ossincation,128 Hcxameth/1-prOpylcnaminc-Oxime braln dcath diagnOsls and,82 cercbral Pcrfus10n and,84 osteom/clitis cvaluated with,12 Hibcrnating rnyocardiunl,160,288 Hip multiple insuttcicncy fracturcs in,30 263 Paln ln,bOnc scan lo島 HistOcytosis,nuorodcOx/glucOsc uptakc and,314 HistOPlasmOsis n u o r o d e o x y g l u c O s c u p t a k e

PolyOstOtic discase and,266 ・ radiOactivc lodinc uptakc and,103,372 99mtCChnetェ unl pertcchnctatc scan fo島 247‐248 thyrOid scan fbr cvaluatiOn Oi 245 trcatmcnt oi 370 HyPOkincsis deinltiOn Oi 40 lnfarct10n and,32 HypOtcns10n,diP/ridamOlc cOntraindicated b乃284 HypOtherrnia,nat clcctrOenccPha10grarn caused 82 bみ HyPOthyrOidism congcnital,difFcrential diagnOsis oi 246 rad10active lodinc thcrapy and,372 thyrOid hOt nOdulc treatmcnt and,246 a n d , 3 1 4

pulrnOnary nodulc and,58 HM― PAO.彫 Hexarncth/1,PrOP/1enarninc-Oximc Hodgkitt discasc,54 nuorodeox/glucOsc POsitrOn cmissiontomograPh/scan Oi 317 lymphOma associated with,192

I 1nlinOdiacetic acid,ch01cscintigraphy with,64 11llnditnl,dOsagc Oi 184 11llndium antimyOsin,uptakc Oi 296 mttndum dcthylenetialnhcpcntaacedc add,hydrOccPhalus

cvaluated with,358 11llndium OctreOSttn,188 PullnOnary hypcrtrOphic OsteOarthropathy assOciated with, 11llndium OncOScint,328 258 11llndiuH1 0xinc Human andmu五 ne antibOdy levcl,328 Humerus,InultiPlc insuttcicncy fractures in,30 infectiOn detectcd with,う 2 Huntingtonis disease,360 infectiOn evaluatcd、 vith,310 Hurthic ccll tumOら 376 1eukOc/tc study with,312 11llndiunl PcntctrcOtidc,332 Hydralazine,red b100d cell labeling affcctcd168 b乃 11llndiunl PrOstaScint,330 HydrOcephttus ccrebrOsPinal nuid rhinOrrhea associated with,362 1nfant norinal‐ ibrOus dysPlasia in,266 Prcssurc,358 H/drOnephrOsお ,241,365,366 1ivcr rnalignancy in,114 Meckclもdivcrticulunl and,76 1nfarctiO五 nonobstructed,92 adenOsine stress/apical,158 HyPCradrenttism,diagnOsis Oi 378 aPiCal,32 HyperaldOstcr01lsm,diagnOsis Oi 378 inferiOr latcral wall,154 HyperbilirubineHlia myocardial G″ Myocardial infarction) biliary tract obstruction alld,210 myocardial uptake and,144 ch01escintigraPhy for evaluatiOn Oi 215 spontaneous ostcOnccrosis assOciatcd with,142 Hypercalcemia,105 391

186,309-316 Infection,49-52,179‐ abdominal,evaluation oi 186 unodcaciency syndrome and,326 acquired iHll■ bohe,112 dctcctlon Oi 52 nulrodeoxyglucOsc uptake and,314 intraabdominal,cvaluation oi 310 intraccrebral mass and,326 ostlomyelitis associated with,180

一contu Ischemia‐

osis oi 32 diag■ perfuslon for stuけ rcvcrsiblc inferior wa11,156 silent lateral wall,166 vesscl,39 singlc― 291Thallium imaging fo5 290 1sotope,deinition oi 4

J

JaundiCe,blliary tract obstruction and,210 ParaSPinal,314 in prosthesis,316 JOint infcctiOn Oi bonc infcctiOn difttrentiatcd from,12 Pulmon狐 卜 evaluatiOn oi 186 septic,sPontancous osteonecrosis associated with,142 rcnal,244 sOft tissuc,179 JOint pain,bonc scan fOr evaluatiOn oi 257 urinary tract,242,243 K 1nferior ttcna cawa obstruction,99mTechnctium sulttr c0110id Kasai procedure,216 uPtake in liver aFFected343-344 bン Kidney 1nnitration,radiopharinaceutical,26 bone scan and,272 1nnamrnation,49‐52,179-186,309‐ 316 dysfunctiOn oi 212 nuorodeox/81ucose uPtakC and,314 CCtOPiC,18 1nnammatory bowcl disease,Meckclも diverticulum and,76 67galliurn uptakc in,190 1niCCtiOn arterlal,bone scan artifact and,254 glucosc excreted by9 318 hOrseshoc,18 techniquc oi abnormal uptakc associatcd with,26 hot,124 1nteStine,small,bleeding from,346 and uptake in,136 hyperParathyroidisn■ 2 1ntraabdoIFlinal abscess,う infectiOn oi 86 camera quality control and,354 1ntrinsic 。d,gamma a。 malignancy in,114 10dine,radioactive,advcrsc cFFccts Oi 370 1231。 rrletastatic calcincatlon in,150 dine mObile solitary right,16 uated宙th,246 thyroid nOdule cv』 nOnviable,aFter transPlantation,96 body scan with,374 wholc― 1311。 0bstructlon oi 88 ・ dinc 370 contralndicatlons fo島 POOr functlon oi 238

obdin iCVel and,376 high― dosc,serum thyro」

POSitiOn Oi bonc abnOrinalities and,18 rcna1 0stcOdystroPhy and,268

hyperthyrOidism evttuated with,370

small,238 supernumcrary2 18

pttathyroid imaging with,106 siar artifact and,104 thyroid scan wlth,102 1311。 dinc hiPPuran,90 renal transplant evaluation with,98

supcrscan and,130 transPlant oi 236 transPlantcd

距■0出nc bdochdestcrd stu毎 377 1311。 dine mctalodobcnzylguanidine,16,380 bOne scan wlth,264 PhcOchromOcytoma evaluatlon wlth,250

1311。 ‐ -lodOmcthメ 19-10dOCholester01,378 6β dine‐ 1231。 dintt thyrOid scan,369 1schemia acute,40 anterior-latcral,158 chest pain as indicatiOn oi 32 chrOnic,288 drugs and masttng oi 164 inferiOL 284 1eFt antcrlor descending artery9 32 mild inferioL 34 nchymal,radiation arld,124 Parど 392

acutc tubular necrosis and,98 urinary lcak and,94 tumors oi 188 unllateral obstruction oi 88 uptake in,366 Kippcl‐Trcnaunay‐Wcber discttc,sOtt dSsuc hypertroPhy associated wlth,24 Knec

arthroPlasty oi 316 ostCOneCrosis 142 o二 thrce,Phasc bone scan Oi lll KupFFer ccll,342 L ty L/M.∫″Lung/myocardial acti宙 Lambda sign,50

LBBB,∫″ 夕LeFt bundic branch b10ck Lc Vccn peritoneovenous shunt,352 Lctt bundlc branch b10ck,167-168

Lung― contu right― tO― left shunt in,306 StriPC Sign iA,46 Left ventricularづ CCtiOn fractiOn,36,169-170 uptakc in,abnormal lung activity alld,150 Lcgg―Calve― Pcrthes discasc,spOntancOus osteonecrosis assOci― vcntilation,PcrttlS10n scan oi 303 133xcnOn ventilation imtting oi 304 ated、 vith,142 Lciomyoma,small intestinc biccding assOciated with,346 Lung cancc5 132 LclomyOsarcoma,small intestine blecding associated with, dctectiOn O二 188 18nuOrittc nu6rodeox/glucOsc POSitrOn cmisslon tomogra‐ 346 Lcontiasis ossca,24 Lcs10n on bone scan,272 malignant,in sPine,256 PhOtOPcnic,254 Lcukemia cOld spinc deFect and,148 SPOntarlcous ostconccrosis associated with,142 Leukocyte labcling oi 310 oxinc,186 99mtcchnetium studics Oi 181,184 Lcukocytc stutt radiolabeled,312 Lewy body discasc,232 Lingual thyrOid,246 Livcr benign tumOr in,342 blccding in,74 cavcmous hcmangioma in,72,218 c010rectal canccr and,196 d y s f u n c t i O n 2O1二 2 67galliuin uptake in,19o infcctiOn in,310 lcs10ns in,71 lcukOc/tc uptakc in,184 malignanc/in,114 mctastascs to,142 neuroblastOma in,132 99mtechnetium sulfur c0110id scan220,343‐ O二 344 99mtechnctium sullur 11。 c。 id uptake in,causes oi 343-344 tumorin,72,188 uptake in,radiatiOn thcrapy and,150 Liver diseasc biliary atrcsia and,216

rlMduatiOn Oi 194 Phy∼

1

nuorodcox/glucosc POsitrOn cmiss10n tOmOgraphy ttr dctcction Oi 193 lung scan fOr diagnosis Ot 42 pcrfusiOn defcct assOciatcd with,304 PullnOnary cmbolisin cvaluatiOn and,300 Lung discase adcnOsine cOtttralndicated bン 158 diagnOsis Oi 46 cvaluation Oi 186 Lung/inyocardial activit/240 Lung scan hOt spOts On,44 pulinOnary cmbolisll diagnOscd with,42 Lupus crythcm4tOsus,sPOntaneous ostconccrosis assOciated with,142 LVER J“ 夕Lctt wntricularづ

eCtiOn fractiOn

Lymph nOde brcast cancer and,18 uptakc in,26 L/mphan夢 OmttOSiS,sott tissuc h/pertrOPhy ttsOdattd with,24 L/mPhcdcma,18 breast cancer and,202 dcscription Oi 276 Lymphocyte,labeling oi 310 L/mphoma brain,326 brain tumor and,60 detectiOn Oi 188 18nuOrine nuorodcox/glucOsc POSitron cmiss10n tomogra‐

Phy ttr detecdOn Oi 192 intracranial,cvaluatiOn Oi 200 malignant,293,326 malignarlt B― cell,191 non‐ Hod8出 ,212 品 parenchym狙 ,55,う6 LobectOmyP temporal,230 superscan associated with,130 1ッ ung LymphoscindgraPhy l a b n o r m a l a cttyi 宙 o i d i f F e r c n t i a l d i a g n O s i s o i 1 5 0 breast,201‐ 202 cancer oi 132 10wer extremitics cvaluated with,276 mclanOma evaluatcd with,204 pullnOnary embolisnl and,42 carcinOma oi superscan associated with,130 M hypcrparathyrOidism and uptake in,136 10weL hypoPα ttOn Oi v8 M A A . ″M a c r O a g g r e gb au tm ei dn 』s t u け ,306 metastatic,bone scan uPtakc and,14 30う MaCrOaggrcgated ttbumin stu毎 mctastatic calcincation in,1う 0 MaCrOdyS,Ю 9sa,sott dssuc hypcrtrophy Phia lipom■ 01igemia Oi 48 with,24 0StCOSarcoma in,138 393

ttsOdated

Myocardial infarctiOn,32,155 Magnctic resonance imaging cvaluatlon oi 29う breast tumOr detcctcd with,62 cOmPared tO,160 hibernating lnyocardiun■ CnCCPhalitis evaluatcd with,356 hemangloma cvaluatcd with,72,218 pcrfus10n imaging for diagnOsis oi 38 99mtCChnctium pyroPhosPhatc study for evaluatiOn Oi 296 Mammograp町 ,COnvcntion狙,62 Myocardial pcrfus10n,single photOn emisslon cOmputcd Mandible,abrous dysPiasia and,24 tomography fOr9 281-284 Mastitis,nuorodcoxyglucosc uPtake and,314 Myocardi』 Mastocytosis,suPcrscall associatcd with,130,268 perfus10n study brcast attcnuatlon and,286 Maxllla,abrous dysPlasia and,24 rcst― rcst,287 Maxilnunl agc― prcdictcd hcart rate,153-154 Myocardial singic PhOtOn cmisslon comPuted tomography McCunc‐Alb怠ght syndromc,266 99mTechnetium mcthylcnc diphosPhonatc 279 MDRす ′ ′ pcrfuttOn stu毎 Myocardial uptakc,144 Mcckelもdivcrticulunl,76 Myocardial wall,thickening oi 36 Mcdiastinal diseasc,pulmonary hypertrophic osteOarthrOpa, Myocarditis,myocarditt uptakc and,144 thy assoclated wlth,258 Myocardium,hibcrnating,160,288 164 MedicatiOn,ischerlllia masked bン Myosin,infarction and,296 Medulla ob10ngata,325 ヽ在 ヽ在 egacalycosis,242 yositis ossincans,128 MegauretcL primarン 242 N MelanOma Nccrosls imaging oi 320 acute tubula島98,124 1ymphOsdndgraphy ttr dctccdon Oi 204 avasculah 142,274 in thOrax,201 causc o二262 Mcningloma,dctcctlon oi 188 ischeHlic,274 Mcningitis,rhinOrrhca and,362 causc oi 262 MCnOPause,osteoporosls assoclated with,28 Ncoplasm Mesothclioma,pullnonary hypertroPhic OstcOarthrOPathγ bOnc,ostconCCrosis difFcrentiatcd frOn■ ,142 associatcd with,258 SPOntancous osteonecrosis associatcd with,142 MEIす ′ ′Mctabolic cquivalcnt Ncphritis,radiation,124 ふ江etabolic cquivalcnt,cxcrcise strcss tcsting and,154 ntral ncttous systcm N e r v o u s s y s t c mC.eマ Metatarsal bOne,avascular nccrOsis oi 262 Ncuroblastoma,16 Mcthiinazole,Gravcs'discasc and,104 bonc scan uptake and,14 M【ethyldopa)rcd blood cell labcling affcctcd168 bン 1311。 dcscription oi 380 dine rlletalodobcnzylguanidine MIBG。 す タ タ 1ivci bone tracer uptakc and,132 ヽ江 1lk,alkali syndrOrnc,Inyocardial uptakc and,144 osteomyclitis and,264 Mlk stu毎 349-350 gastrocsophageal rcnux and,80 Mirizzi syndromc,214

Monocyte,labcling oi 310 MOrphine as alternativc to dclaycd iHlaging,67 ch01cscintigraphy augmentcd with,68 M P H R . ャ ″M a x i m u m a g c r p r c d i c t c d h e a r t r a t c alitics Mucus plug,ventilation/Pcrfuslon inatchcd abnOrl■ associatcd with,176 MUGA.す ″Gatcd radionuclidc ventricu10gram Multigatcd acquisition,cardiomyopathy and,40 Muscic,1可 ury tO,120 Muscle tenslon,artifact frOm,318 M[usculoskclctal system,275-276 Myc10nbrOsis,suPcrscan associated with,130,268 Myc10ma

co14 sPinc dCFcct and,148 multiplc,bone scan【 br diagnOsis oi 20

394

NcurOendocrine disordcr9 331 Ncurttbromatosis,son tissuc hypcrtrOphy ttsOciated with,24 ncgat市e scan rcsulting frOm,164 Nitrate drugs,falsc‐ 13NitrOgcn,half‐ life Oi 292 13Niモ rOgen/nuorodcOxyglucOsc cardiac viabilit/studン 292 N o n ―H o d g 臨 ポs l y m p h o m a , 5 5 , 5 6 , 3 1 3

,19-iOdOCholcster01 ― iodOmcthメ dine-6β NP‐ マ 1311。 59。 Nucicotidc,dennition oi 4 Nuclidc,description oi 4 O 0bstructive airway discase,172 0ctrcoScan.∫″ 11llndium pcntctrcotide Oncologyj 53-58,187,204,317-332 C)rchitis,368 ossincation,hetcrOtopic,128 C)stcitis,radiation,124

OstcOarthritis articular facct,256 inaaHIInatory9 138 0StCOneCrosis difFcrcntiatcd丘 。n■ ,142 0steoarthrOpathェpulmonary hypcrtrOphic,258 C)stcochOndritis desiccans,142 0stcOchOndrOsis,bOnc scan fOr evaluatiOn Oi 262 0steOdystrOphン rcnal,268 0stcOmalacia,supcrscan associated with,130 C)stcOII1/elitis,180 acutc hcmatOgcnOus,112 bOnc scan fO島 112 cold spinc dcfcct and,148 cvaluatiOn Oi 311 67gallium imaging fOr cvaluatiOn Oi 312 neuroblastOma and,264

Pentagastrin,Mcckclもscan and,76 Pcrfus10n dccrcase in,striPc sign and,46 m/OCardial,35 Pcrfus10n imtting,in emcrgcncy dcpartment,38 Pcrfus10n scan,dyspnca cvaluated with,175 PerfusiOn study dual― isOtOpe,34 shortncss Ofbrcath diagnOsこ d with,45,46 Pcricarditis,186 myocardial uptakc and,144 Pc五ostids,hypcrtrOPhic Osteoarthropathy ttsOciated宙 th,2う8 PcritOncal Plcural scan,348 PcritOncal scan,352 PH Probc,gastrOcsophageal renux diagnoscd with,80 PheOchrOmOcytoma,250

Pcdal,12 sPinaL 312 threc_phasc bOnc scan fOr9 260

PhOtOpenia,avascular nccrOsis and,274

tibial,112

dcinentia diffcrcntiatcd frOm,232 Pigmentation,abnOrl■ al,polyostOtic discasc and,266 Pinh01c c011llnatO島lo4

0stcOnecrOsis,274 causc oi 262 diffcrcntial diagnOsis oi 142 SPOntaneous,142 0stcOPOrOsiS

PhOtOPcnic attCnuation artifact,254 Picrs discase,234

PIOPED stu(け

彫 Prospectivc lnvcstェ gation Ofthe PulmOnary Emb01ism Diagnosis stud/ Platcict,labeling bi 310

insuttcienc/fracturc associated wlth,28 Pleural effusiOn,347-348 m u l t i p l c i n s u F n c i c n c y f r a c t u r c s a s s o c i a t e d w i t h , 3 0 a b n O r m a l l u n g a c t i呼 宙d i f f c r c n t i a t e d f r o m , 1 5 0 0stcOsarcOma,118,274 malignant,138 fcmu5 273 lung tumOr diIFerentiatcd frOm,138 in humerus,138 thOrax and,122 imtting oi 274 lung,138 C)stcoscicrOsis,diIFuse,supcrscan associated with,268 0tOrrhca,diagnOsis oi 362

vcntilation/Pcrfusion matchcd abnOrmalitics assOciated with,176 PMSA.す ′ ′Prostatc― sPCCinc rncmbranc antigcn PneumOcOnlosis,SarCOldosls diffcrcntlatcd frOnl,50 拘夕 ″物θヮF 力骸ガ″あ 5 0 Pneumonla

P Pagctもdiscasc,8 Panda sign,50 ParagangliOma,332 Paraspinal infectiOn,314 ParathyrOid adenOma in,106 99mtcchnetium scstamibi uptake bン 106 Parathyroid hOrinOne,elevatcd,105

nuorodcoxyglHcOsc uptakc and,314 rith,80 、 gastrocsophageal rcnux associatcd、 pulrnonary asPiratiOn associated with,350 PneumOnltis auorodeox/glucosc uptakc and,314 lung tumOr diffcrcntiated froIIl,138 Polar plot,dcscription oi 162 P01yOstOtic discasc,266

ParkinsOポs disease,360

PositrOn decayj dcscription oi 314

dementia diffcrcntiated from,232 Pars articularis dcfect,1lo

酌S i t r o n e m i s s i o n t O m o g r a p h y c a r d i a c s t u t t

Patent Dcnver shunt,352 Patient,movcmcnt oi artifact caused bン 280 Pclvic tumOr aden6Pah乃330 PcMs cxtrarenal,16 Meckclも diverticulunl and,76 insuttciency fracturc in,28 multiPic insuttciency fracturcs in,30

Positron emission tOmOgraphy― nuorodeox/glucbsc,thyrOid cancer evaluated wid■ ,375 PostchOlecystectomy syndromc,337-338 PostinfectiOus oblitcrativc bronchi01itis,304 POstphicbitic syndrome,308 Prcgnancy radioactive lodinc thcrapy contrttndicatcd町 370 ventilation/perfuslon study and,178 Prcmature vcntricular cOntraction,ischemia and,32

Primary lnegauretcL 242 Propylthlouracll,Graves'discasc and,104 Prospectivc lnvestigation ofthc Pulinonary Embollsin

stu毎176 DiagnOsお Prostatc cancer oi 20,130,134,269,329-330 carcinOma oi superscan associatcd with,130 Prostate bcd adcnOPathy9 330 specinc antigcn Prostatc― bOnc scan interpretation and,19 pFOStatc canccr diagnOsis and,20

Radiograph chest,pulinOnary cmbollsin cvaluation and,300 shOrtncss ofbreath diagnOsed with,45 RadionuclcOtidc,dcscription oi 4 Radlonuchdc,dcscription Oi 4 Radionucttdc anglocardiogranl,170 Radlonuclidc blccding scan,222 Radlonuclidc bleeding study gastric biceding cvaluatcd with,226 rcctal blecding cvaluated with,228 Radlonudidc biood now st式 〕vena Cava obstruction evaluatcd with,298 358 Radlonuclide cistcrnograph/9357‐ Radlonudidc now stud>vcna cava obstructiOn evaluated with,298 Radionuclidc gastrointestinal blceding74stud乃 276 Radlonuclide lymphOscintigraphン 350 Radionuclidc milk stud卜 Radionuclidc rcnOgranl,363 168,293 Radlonuclide ventricu10granl,167‐

specinc antigcn icveL 329,330 Prostatc― ProstatcrsPccinc rnembranc antigcn,330 Prosthcsis,infcct10n in,316 sPCCinc antigen PSA.scc Prostate‐ PTH.ャ P釘狂hyrOid homOne Pubert/2 PreCOClous,265 PulmOnary asPiratiOn,350 Pulmonary diseasc diagnosis oi 50 echOcardiography cOmPattd to,294 284 ridamOle cOntraindicated bン dipγ equilibriuln gated,170 lslon lnatchcd abnOrinali― Pulinonary edema,ventilatiOn/Pcr負 1cft vcntricular ttcctiOn fractiOn ties associated with,176 Radionuclldc voiding cystourcthrograrn,242 PulmOnary embolism,42,178 RadiotraccL dcscription oi 4 diagnosis oi 48,178 ″ Radioact市c lodine,uptakc of RAIU。 す prObabilit/oi 300 RBC.ャ タRcd blood cell sources oi 308 RDRS.J″ Rcncx sympathetic dystrophy syndrOme striPc sign and,302 Pullnonar/nbrosis,sarcoidosis dif&,rcntiatcd fronl,50 PulttOnar/hyPcrtrophic Ostcoarthropath乃2う8 PullnOnar/mCtastasis,pulrnonary hyPcrtrOphic osteoarthroPathy ttsociated with,258 Pullnonary nodule,diagnOsis oi 58 48,171-178,299-306 Pullnonary systcHl,41‐ PVC.∫′ ′Premature ventricular cOntraction Pye10ncPhritis,244 Pyknodysostosis,suPcrSCan ttsodated with,268

Q Qualit/COntrol,152 gaHlrna camera and,354 Quinidinc,rcd blood cc11 labeling afFcctcd羽.168 R Radiatlon ParenChymal ischcmia associated with,124

whdc―bo毎 374 Radiatlon ncPhritis,124 Radiation Ostcitis,124 Radiat10n Pneumonitis,nuorodcoxyglucosc uptakc and,314 Radiatlon therapy abnormal lung activit/differentiatcd0 frOm,1う rcnal uptakc and,150 thyrOid tanccr associated with,372 Radloactive lodine,uptake oi 101,372 Gravcs'diseasc diagnOsis and,104 396

and,170

Rcctum

blceding in,227-228 cvaluation oi 223,345 radionuclidc study oi 221 Red blood ccll labcling oi 310 for radlonuclidc ventriculogranl,168 1ivcr sdntigraphy and,72 labcled,72 tcchnetiuHl‐ Rencx symptthctic dystrophy syndrOmc,140 Rcnal artcry stenosis,240 Rcnal discasc,ostCOneCrosis associated with,262 Rcntt failure,ostcodystrOphy and,268 Rcnal insutticicncy9 evaluatiOn Oi 242

268 Renal ostcOdystrOp町 h,130 supcrscan associatcd wi〔 Rcnal Pclvis,urinary rctcntlon in,366 Renal systcm abnormalitics in,120 lnsuttcicncy oi 238 90 radiopharmaccuticals fOち Renal transPlant bOnc scan and,270 rttCCt10n oi 236 RcnOgranl,radiontlclidc,363 RenOgraphy captopril,240 diuretic,88,92,366 radionucllde,hydrOncphrOsis diagnOsis宙 th,92

RES.J″ Rcticu10endOthllial systcm

Rcst/stress stuttt iSChcmia diagnOsis and,34 Reticulocndothelial systcm,74 Rhabdom/Olys志 muscle localizatiOn and,120 myocardial uptakc and,144

RhcumatOid arthritis,テ uVenile,185 RhinOrrhca cerebrOsPinal auid,362 lmaging for cvaluatiOn oi 361 Fub ibrOus dysPlasia in,24 fracture o二 10 multiPle insuttciency fracturcs in,30 RIM sign,208 RNA.マ 路 dOnu胡 dc anttOC醐0野a缶 RVG.す ″ ′Gated radiOnudidc venticulc 加 ;Radbnu乱 de vcntriculogram S Salivagraln,350 Sarcoidosis,50 evaluation O二 1 86 nuorodeoxyglucosc uptakc and,314 Panda sign as indicatOr oi 50 Sarcoma,osteogenic,118 Scatte与 radiOpharinaceutical,26 ScintigraPhy adrcnocOrtical,378 biliaryD 340 bOne,OsteOsarcoma diagnOsed、 vith,118 c01101d,gastrOintestinal blccding diagnOsis with,74 ibrOus dysplasia cvaluated with,266 gastrocsoPhageal rcnux diagnOsed with,80 myocardial Pcrfus10n,156 nonviable lddney and,96 ParathyrOid,lo6 vith,72 planatt hcmangloma detected、 renal,93,236,238 skcletal,metastascs to bone and,264 testicular tOrslon evaluated with,100 thallium myOcardial,290 t h / r O i d , l o 2 ScintimammOgrap町 61‐62 Selzurc disordcら 229,230 ScPticcllia,in spine,112 Serum ttkalinc PhOsPhatasc lcvel,Paget`diseasc arld,8 Serum crcatinine,levc1 0二 238 Serum thyrOg10bulin level,375 Shin splints,6 Shunt,right‐ tO‐ lcFt,306 Sickle cell discasc,116 bOne scan and,115 bonc tracer uptake and,132 c01d sPine deFect and,148 osteonecrosls assoclated wlth,262

Sickle ccll discasc― cOnt祖 PullnOnary cmbollsin evaluatiOn and,300 pulrnOnary embolisnl false diagnOsis and,42 splenic uptakc and,126 spontancous ostcOneCrosis assOciated、 vith,142 Sickle thalasscmia,126 Sincalide.ャ タChOlccystOttnin Singlc PhOtOn emisslon computed tomographン 31-40 adcnOsine stress/rest imtting and,157 bOne scan with,255-256 braln perils10n,356 brcast attcnuatlon and,282 bull`― eyc fOrmat foら 161-162 dipyridamOle strcss myocardial,155 dual,isOtOpe stress,33 36,36,156 gated,35‐ hemangloma cvaluated with,72,218 hyPcrchOlester01eHlia and,285 intracranial abnOrmality cvaluatと d with,199‐200 myocardial Pcrilslon,3う ,38,279,283 attenuatlon in,286 stress and rest,281 ncuroectodcrmal tumOrs evaluatcd with,188 1 non― Hodgkitt lymphoma diagnOsis and,56 patient mOvement artifact and,280 POSitrOn cmitton tomOgraPh/camcra and,322 pyrophosphate,myocardial infarctiOn cvaluated with,296 selzurc disOrder evaluatcd with,230 spine abnOrmalitics evaluated with,256 spond/1olysis evaluttcd宙 th,110 stress/rest,39 9 9 m t C C h n e t iPuAmO HcMe‐ r e b r a l p e r 3f 5u 3s 1 0 n two‐ headed,exalnplc Oi 321 Sinus nOde disease,adenOsinc cOntraindicated158 b乃 Shuttdtt nuorodeOxyglucOse uptakc and,314 朝6gに途 SyndrOme,50 Skelctal mctastatic disease,134 Skcictal sysiem,3‐ 274 30,109-150,2う 3‐ SOtt tissuc abnOrnlal uptakc in,14 abnOrinalites in,120 calcincation in,myocardial uptake and,144 hypertrophy Ot 24 infcctiOn in,12 infc,tiOn Oi diagnosis oi 179 Picural uptakc in,122 superscan and,130 unilateral uptake in,122 1 uptake in,causcs oi 132 SPECI J′′Single photOn emisslon computed tomography Spermatic cOrd,testicular tOrs10n and,368 SPhincter ofOddi,214 dysttnctiOn oi 338 mOrphine for cOntraction oi 68 Sphincterotomン338 SPinal PhOtOpenia,124 397

stud乃

Supcrscan causcs oi 268 dcinition Oi 130 mctastatic disease as causc oi 130 SurgerンcerebrosPinal nuid rhinorrhca associatcd with,362

SPinc dcFect in,148 fusiOn Oi 270 intraosscouS hCmangioma in,148 lumbar

Swcr― Jamcs SyndrOme,304

bonc scan Oi 256 fracturc Oi l 10

Synovitis,diagnosis oi 12

0StCOmyelitis oi 312

T

evttuatlon oi 311

TAC.ャ ′Timc―activity curve Tardokinesis,dcinit10n Oi 40 Tcchnctiunl,description oi 4 99mTechnctium

scpticcrnia in,112 SPlccn bleeding in,74 67galttum uptakc h,190

vith,34 Pcrfus10n scan、 rcd blood cclls iabclcd with,346 thyroid imaging with,248 99mTcchnctiunl apcitide imaging,303 99mTcchnetiunl bonc scan,PrOStatc cancer andす 330 99mTechnetlum brain scan,234 99mTcchnctium diethylenetriamincpcntaacctic acid,82,90

infectiOn in,310 1eukocytc uptakc in,184 metastatic tumor oi 132 99mtechnetium sulfur c01101d scan o二 220 tumors oi 188 uptakc in,126 Splenic imaging,220 SPOndylolysis,dcanition oi l10 SPot imaging,wholc bOdy imaging comparcd to,125 Stannous PyrOphosPhate,gastric bleeding cvaluation and,226 勧 ?り

あ 御 ″ 舛 ″″″ 勿

OStCOmyelitis causcd b乃

312

dinc and,104 star artifact,1311。 Stcrnotomtt COronary artery bypass grafting and,10 Stcrnum abnOrmttitics oi 10 multiplc insuttcienc/fracturcs in,30 Stcrold therapy oStcOpOrosis assoclatcd with)28 vith,142 SPOntaneous osteonccrosis associated、

cystography with,86 renogram with,363

99mTcchnetium dicthメ cnCtriamincpcntaacetic acid vcntila" tion,174 99mTcchnctiuHl disofenin,cholescintigraPhy with,64 99mTechnctium Dヽ 在 SA,rcnal infection cvaluatcd with,244 99mTcchnctium cthyl― c/stinatc dmci brttn nOw stud/with,82 99mTcchnetium hcxamcthyl― prOPメcnCamine―oxime,12,52 bttn now study with,82 ccttbral pcrttdon study with,353 cerebral strokc diagnOsis with,84 にukocytc study with,181-184 ostcOmyclitis evaluatlon with,180

Stomach,hyPcrparathyrOidism and uptake in,136 Stress PrOSthesis infcctiOn cvaluated with,316 selzurc disOrder cvaluated with,230 cxcrcisc trcadHlill foL 153 99mTechnedum hcxamcthyl― eneamineroximc Lukocytc, inadequatc,imaging and,164 prOPメ infcctiOn cvaluated with,310 8 Pharmac01ogical,1う 99mTcchnctium ilnaging Strcss echocardiograPhtt oPcrator skill and,32 carcinocmbryonic antigen lcvel and,328 Stress fracturc,6 c010rcctal carcinoma evaluated with,328 tibial,6 99mTcchnetium― cvaluatcd labeled ttd bloodhemangloma stu4乃 lsion imaging,154 Stress Pcr負 w i t h , 2 1 8 Stripc sign,46,302 99mTcchnetium macroaggrcgated albumin dcinitlon Oi 302 ascitcs managcment and,352 description oi 176 S u b l i n g u a l m a s s , 9 9 m T e c h n e t i u m p c r t c c h n e t a t e s c a n fPleural o r c v a cttslon l u a ‐ cvaluatcd with,348 99mTcchnctium macroaggrcgatcd ttbumin 305-306 stt毎 t10n oi 245 99mTcchnetiunl MAG3,90 Substancc abusc,dcmcntla difFerentiatcd frOnl,232 rcnal irnaging with,238 Suddcn infant dcath syndrOmc gastroesophageal rcntlK aSSOCiated with,80 pullnOnary asPiratiOn associatcd with,350

rcnal insumciency cvaluated with,242 vith,98 renal transPlant cvaluation、 99mTcchnctium MDP bone scan,316 99mTcchnetium mebrofcnin,cholescintigraphy with,64

Sudcctt atrop町 140 1 ″ 298o二 ‐ Superior vena cava,obstruction SuPcrior vcna cava syndrome,99mTcchnctium sulfur colloid 99mTechnetium mcthメ enC diphosPhonatc,dcscription oi 4 99mTcchnctiunl Pertechnetatc uptake in livcr aFfccted 343-344 bン brain now study With,82 1eukocyte study with,181-184 398

99mTechnctiunl PCrtechnetatc一 一cOntu Parath/rOid imaging with,106 scan、vith,371 th/rOid scan宙 th,lo2,372 99mTechnetiunl PyrOphOsphate,bOnc scan、 vith,144 99mTcchnctium P/roPhOsPhate stud乃 285 myocardial infarctiOn cvaluatcd with,296 99mTcchnctium red b100d ccll scan,224 pertechnctatc,226 99mTechnetium rcd b100d cell scintigraphン gastrOintcstinal blccding evaluatcd with,222 99mTechnctium scstaHlibi,38

201Thallium ch10ride,34 201Thttlium singlc photOn emisslon computcd tomOgraP町 brain lymphOIIla evaluatcd with,326 ThOrax mclanOma in,201 unilatcral uptakc in,122 ThrOmbOphicbitis,308-309 evaluatlon oi 307 lung scan hOt sPOtS and,44 PulinOnary embolism associatcd with,308 ThrOttbOsis,arterial,96 ThymOma,dctcction Oi 188

cardiac uptakc oi 277 dittuslon oi 278

Th/mus,67Gallium uPtakC in,19o

osteosarcoma cvaluated with,274

ThyrOglobulin icvcl,375 ThyrOid cancer oi 372,373-374,375-376 c a r c i n o m a o1二8 7 cOld nOdulc in,lo2 cyst in,102 dcvcloPment Oi 248 f01licular adenOma O二 106 hOt nOduic in,246 lcft 10be agencsis in,248 1ingual,246 radioactivc lodine uptakc in,372 scan oi 101 99mtcchnctium scstarnibi uptakc by9 106

ParathyrOid imaging宙 th,106 thyrOid scan宙 th,248 thyrOid tumOr cvaluated with,376 thyrOid uptakc Oi 106 201Tcchnctium sestanlibi,34 99mTedhnctium sOdiunl pcrtcchnctate,gastric bleeding evalu― ated wlth,226 99mTechnctium sulfur c01101d ascites managcment and,352 bOnc lnarrOw scan with,116 bOnc marrow study with,180 c y s t o g r a P h y 航t h , 8 6 examplc oi 315 fOcal nOdular hyperPlasia cvaluated with,342 gastrointestinal blccding diagnOsis with,74 livcr scan、 vith,220,343-344 lymphOscintigraphy with,202,204,276 Pleural cffusiOn evaluated with,348 vith,350 PullnOnary asPiratiOn evaluatcd、 sPiccn scan with,220 99mTcchnctium tcchncgas,174 99mTcchnctlum tetrofosinin,38 cardiac uptake oi 277 u p t a k c m c c h a n i s m o2二 78 Tcsticular scan,367 Testicular tOrsiOn,100,368 T e s t i s

bcllて ユappe5 10o testicular tOrsion and,368 torsion oi 100

T h a l a s s e m i a mo 巧 も1 2 6 201Thallium cardiovascu14r systcm evaluatcd with,288 half_life oi 290 intracranial lymphOma evaluatcd with,200 lsche■ 1la cvaluated wlth,290 myocardial tracing with,40 0StcosarCOma cvaluated wlth,274 rest― rest,287-288 thyr01d tumOr evaluated、 vith,376 uptakc Oi 200,289

ThyrO」 Obdh,thyttd canccr cvaluadOn and,376

tumors in,dctection oi 188 ThyrOid canceL c01d sPinc dcfect and,148 ThyrOid scan,tOxic nodulc cvaluatcd with,370 ThyrOid_stimulating hOrmOnc,101 hyperthyrOidism and levc1 0二 102 ThyrOiditis,102 nuorodcoxyglucOse uptake and,314 hyperthyroidism assOciatcd with,102,248 Tibia bOne scan Oi 6 nbrous dySPlasia in,24 multiple insumciency fracturcs in,30 stress fracturc oi 6 Tibial strcss syndrome,6 Timと― activit/curve,293 Tinnitus,pulsatile,331 TOe,gangrcnc in,260 TOe ciubbing,hyPcrtrOphic ostcOarthropathy assOciated 258 TOxic nOdule,therapy oi 370 ■bxic nodulc discase,246 物赫 留 %あ 326 %族 Trauma

cerebrOsPinal nuid rhinOrrhca associated with,362 osteonecrosls assoclated with,262 SPOntancOus osteonecrosis associated with,142 Trcadilill stress tcst,1う 3,154 TSH.j夕 ″ThyrOid―stimulating hOrmOnc 399

Tuberculosis nuorodcowglucOsc uptake md,314 pullnOnary n9dule and,58 Tumor l breast,scintittaHImOgraPhy fOr dctcctiOn Oi 62 carcinoid,diagnosis oi 58 nuorodcox/glucOse uptake md,314

ga11lum,avid,1,4

Vasculitis_Ontu SPOntancous osteonecrosis associated with,142 Vein,obstruction oi radionuclide b10od aow study f05 298 Vena cava inferiOL 343-344 SuPCriOL Obstruction oi 298 Venograptt cOntrast,thrombOphiebitis evttuatcd with,308 ヽ砲ntilatlon― perfusion scan,304 examplc oi 303 high― prObability9 304 10w‐ PrObabilityj 176

Hurthle cell,376 1iveL 72,342 lung,abnOrttal lung activity differentiated frOm,150 Ventilation pcrfuttOn 171,299 stu毎 malignant,cold sPine defect and,148 intermediate― Mcckelもdivcrticulunl and,76 probability9 178 ncuroectodermal,188 Pregnancy and,178 Ventilation scan,dyspnea evalutted with,175 neuroendocrinc,188 Vcntilation stuⅢ retroperitoncal,379 shOrtncss ofbrcath diagnOscd with,45,46 skelctal IIletastaric discasc and,134 small intcstine blceding associatcd with,346 ?9mtcchnetium dicthylcnctriamincPcntaacctic Vcntricle SuPCrSCan associatcd with,130 assessmcnt offunction oi 170 uptake Oi fasting and,324 1 e ,丘p 0 1 a r m a p1 6 f2 o 島 vcntilation/perfuslon rnatched abnOrnlalitics associatcd Ventricular systcm,hydrOcephalus and,358 with,176 Ventriculograrn,radionuclide,293 U VcntriculograPh/9 cquillibriuHl― gated blood pool,40 Vertebra,IIlultiplc insuttcienc/fracturcs in,30 Uiceratlvc colitis,Puimonar/hypcrtrophic ostcoarthroPathy Vesicourcthral renux,86 assoclated with,258 Vomiting,gastrocsophagcal rentlx associatcd with,80 UltrasOnOgraphy brcast tumOr detectcd with,62 cholcc/stitis detectcd with,66 cholcdochal cyst cvaluatcd wvith,334 Dopplerj testicular torslon evaluated with,100 duplcx,thrOmbOPhicbitis cvaluated with,308 nuid icalagc dctectcd with,70 hemangloma dctccted with,72 hydrOnephrOsお diagnOsis with,92 Urinary le』 も94 Urinary tract,infcctiOn Oi 242,243 Urinoma,364 urinary leak associated with,94

Urograptt cOntrast htravenous,92 Ur01ldliasis,242 V ヽ

V/QヤVCntilation Pertts10n study Vasculitis

pulinonary cmbolisin evaluatiOn and,300 f alsc diagnOsis and,42 Onary embollsl■ pull■

400

W Vestermartts sign,48 Whittakcr test,92 WhOle body imaging,126 spotimaging comPared to,12う Wrist,multiple insumcicncy fractures in,30 X 133xcnOn advantages oi 174

description oi 172 lung discase diagnosis and,46 ventilation/Pcrfuslon study 133xcnon ventilation imaging,304

with,172

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