Bile leak from gallbladder perforation mimicking bowel activity and a false-negative result in a morphine-augmented cholescintigraphy.

Cholescintigraphy of a patient with bile leak demonstrated intra-abdominal activity that mimicked normal bowel activity. Because the gallbladder was not visualized, morphine was injected intravenously. Gallbladder activity after morphine injection was misleading in the finding of chronic cholecystitis. Concurrent abdominal sonography and computerized tomography revealed a thickened gallbladder wall with a gallstone and pericholecystic fluid collection. Exploratory laparotomy confirmed acute and chronic cholecystitis, cholelithiasis, choledocholithiasis, and a pericholecystic abscess. The false-negative conclusion for acute cholecystitis in the patient's morphine-augmented cholescintigraphy resulted from an acceleration of bile leakage due to pre-existing gallbladder perforation.

Serum osteocalcin measurements in prostate carcinoma patients with skeletal deposits shown by bone scintigram: comparison with serum PSA/PAP measurements.

The correlation of technetium-99m-HMDP bone scintigraphic findings, serum osteocalcin as a measure of bone turnover and prostate-specific antigen (PSA) and/or prostate acid phosphatase (PAP) was determined in 19 men with bone metastasis due to prostatic carcinoma. Six of the 19 patients with metastases on bone scan showed elevation of osteocalcin. These patients had extensive metastatic disease. All 19 men with positive bone scans had high serum PSA and/or PAP levels. Serum osteocalcin measurement is less sensitive to detection of bone deposits than PSA/PAP measurements (p less than 0.0008).

Open rib biopsy guided by radionuclide technique.

When abnormally increased radioactivity is seen in a rib or ribs by bone imaging in a patient with suspected or known malignancy, it frequently is difficult to differentiate fracture from metastatic disease. Histological examination of the lesion is crucial for diagnosis, staging, and planning of therapy. To assess the value of external localization of the site or sites of abnormal uptake in a rib as a guide for open rib biopsy, 10 patients (7 men, 3 women; age range, 34 to 68 years) with known or suspected malignancy were studied. With reference to the oscilloscope image, a cobalt 57 marker was placed on the skin overlying the focus of increased uptake, and the area of increased activity was marked on the skin as a guide to surgical resection. Of ten resected ribs, four showed metastatic disease and five had fractures. (One patient underwent two external marking procedures and two surgical procedures.) Rib biopsy was not performed in 1 patient because prior to the surgical procedure, a small subcutaneous nodule adjacent to the skin marker was excised and confirmed to be carcinoma. Appropriate courses of management (operation, irradiation, chemotherapy) were taken after the biopsies. The surgeon responsible for the biopsy should be present during the skin-marking procedure, and the area beneath the scapula and the region adjacent to the spine should be avoided. Our results indicate that the technique is a very useful aid for approaching open rib biopsies more precisely.

Morphine-augmented cholescintigraphy enhances duodenogastric reflux.

Morphine intervention in cholescintigraphy decreases imaging time to diagnose acute cholecystitis. Not infrequently we observe duodenogastric reflux during scintigraphy with and without morphine intervention. To evaluate occurrence of duodenogastric reflux related to morphine, we reviewed 55 patients who underwent cholescintigraphy with (32) and without (23) morphine intervention. Morphine was injected when there was bowel activity with non-visualization of the gallbladder at 60 min. Duodenogastric reflux was identified by the appearance of activity in the area just below or immediately adjacent to the tip of the left hepatic lobe laterally. Among 32 patients with morphine intervention, 19 had acute cholecystitis and 13 chronic cholecystitis. Eleven of 19 (58%) with acute cholecystitis had duodenogastric reflux and 6 of 13 (46%) had duodenogastric reflux in chronic cholecystitis. The total of duodenogastric reflux in the group with morphine injection was 53%. Two patients' duodenogastric reflux occurred before morphine injection and was more apparent after morphine was given. In the without morphine group, 3 had acute cholecystitis and 20 had chronic cholecystitis; 2 (one acute and one chronic cholecystitis) of these 23 (9%) had duodenogastric reflux. Our results indicate: (1) occurrence of DG reflux in morphine augmented cholescintigraphy is not significantly different in cholecystitis from that in chronic cholecystitis; (2) duodenogastric reflux in morphine augmentation occurs significantly more often than without morphine intervention (p < 0.001). We conclude that cholescintigraphy with morphine enhances duodenogastric reflux. The degree of duodenogastric reflux in the acute cholecystitis patients has been more severe than in the chronic cholecystitis patients.

Axillary lymph node uptake of Tc-99m MIBI resulting from extravasation should not be misinterpreted as metastasis.

Ipsilateral axillary lymph node visualization due to extravasation of Tc-99m MDP intravenous injection has been well documented. A patient with suspected angina underwent Tc-99m MIBI myocardial SPECT who had extravasation of Tc-99m MIBI in the antecubital region resulting in ipsilateral axillary lymph node uptake. This finding should not be misinterpreted as lymphatic nodal metastasis in a patient with breast cancer or lung cancer.

A mural thrombus of an infrarenal aortic aneurysm demonstrated as photon deficiency in a radionuclide study.

Radionuclide angiogram (RNA) and aortogram may underestimate external aneurysmal diameter. Photon deficient areas are not uncommon along the abdominal aortic aneurysm (AAA) on RNA. To determine whether or not photon deficient areas along the aneurysm could represent a large thrombus, we studied radionuclide aortic angiography in thirty-eight patients during a preoperative cardiac gated study. All the patients (men, ages from 60 to 78) had CT, US, and/or aortogram for comparison. The presence of a thrombus was determined by CT, US, and/or surgical findings. Twelve of 38 (32%) patients' RNA and blood pool images showed photon deficient areas along the aneurysmal walls having a large concentric or eccentric thrombus of the AAA. A large photon deficient area could be detected along the narrowing calibre of the aorta lumen. This finding results from a large mural thrombus being interposed between the left or right bowel/mesentery activity and the activity of the aneurysms functioning patent lumen. We concluded that a photon deficient area along an inferorenal aortic aneurysm may indicate a large thrombus of either eccentric or concentric type within an AAA.

Lymphoscintigraphy of melanoma: lymphatic channel activity guides localization of sentinel lymph nodes, and gamma camera imaging/counting confirms presence of radiotracer in excised nodes.

UNLABELLED: Lymphoscintigraphy has become a standard preoperative procedure to map the cutaneous lymphatic channel for progression of nodal metastasis of melanoma of the skin. Lymphoscintigraphy was employed to visualize lymphatic channels as a guide to identify sentinel lymph nodes (SLNs). Excised tissue was imaged with a gamma camera to verify the findings of presurgical lymphoscintigraphy. Percent counts of SLN(s) among the total counts of the excised melanoma tumor or scar tissue and SLN(s) were calculated. METHODS: Eleven patients with cutaneous melanoma received four to ten intradermal injections of Tc-99m sulfur colloid at elual distances around the melanoma site. Images were made immediately after injection: 1 minute per image for 15 min; and then 5 minutes or 1,000,000 counts per image for 30 min. After surgery, the excised melanoma tumor or scar and SLN(s) were imaged/counted with a gamma camera. Percent counts of SLNs among the total counts of the excised melanoma tumor or scar tissue and SLNs were calculated. To validate the specimen count accuracy, an experimental phantom study was done. RESULTS: Linear lymphatic channels were identified between the injected sites and the SLNs in each patient. Gamma camera images demonstrated radioactivity in the SLNs of all patients, verifying the lymphoscintigraphy findings. Uptake in the SLNs of ten of the eleven patients ranged from 0.4 to 7.2% (mean 2.2%) of the total counts in excised tissue. We noted that a node with lower uptake should not be ignored because a lower percent of SLN activity does not necessarily rule out existing metastasis. In two of eleven patients, histopathologic showed metastases. One patient's melanoma on the middle back had lymphatic channel activity directed to both axillae. The results of the phantom study validated accuracy of our specimen counts. CONCLUSIONS: Because linear lymphatic channels existed between lymph nodes and the injected sites in all eleven patients, these lymphatic channels could be used as a guide for localizing SLNs. The SLNs indicated by presurgical lymphoscintigraphy were verified by postoperative gamma camera imaging, and radiotracer localization in the SLNs averaged 2.2%.

A quadriplegic patient's cholescintigraphic findings: delayed gallbladder visualization and common bile duct dilation.

A Tc-99m DISIDA cholescintigraphic study of a 37-year-old patient with a 20-year history of quadriplegia demonstrated dilation of the common bile duct and delayed gallbladder visualization. A concurrent sonographic study showed an enlarged gallbladder with stones and dilation of the common bile duct. These findings were proved by autopsy. Quadriplegia secondary to a high level of spinal cord injury may result in gallbladder dysfunction.

Prostate adenocarcinoma using Gleason scores correlates with prostate-specific antigen and prostate acid phosphatase measurements.

To evaluate a relationship between Gleason scores of histopathology of prostate carcinoma and concurrent serum prostate-specific antigen (PSA) and prostate acid phosphatase (PAP) values, 65 men with prostate carcinoma were studied. These patients' cumulative Gleason scores were obtained by totaling the primary and secondary patterns, resulting in two groups: 42 patients received high (6-10) and 23 received low (2-5) Gleason scores. Serum PSA and PAP values were measured by radioimmunometric assay 1 to 7 days before surgical procedures or biopsy for prostate carcinoma. Mean serum PSA for patients in the high Gleason score group was 134.39 ng/mL (normal range: 0 to 4), and the mean serum PSA for patients in the low Gleason score group was 23.62 ng/mL. Mean serum PAP for patients with high scores was 28.08 ng/mL (normal range: 0 to 5), and the mean serum PAP for patients with low scores was 18.19 ng/mL. Patients with high Gleason scores showed significantly greater elevation of serum PSA than those with low Gleason scores (P = .047), using two samples to test for groups having unequal variants. Prostate acid phosphatase levels of patients with high scores were not significantly higher than the levels in patients with low scores (P = .60). These results indicate that PSA levels but not PAP levels correlate with Gleason scores.

Giant cell carcinoma of the lung exhibiting a large, well-circumscribed photon deficiency in ventilation/perfusion scintigrams.

Giant cell carcinoma is a specific clinicopathological entity because of its fulminating clinical behavior and peripheral location in the lung. We present two patients with rapidly fatal giant cell carcinoma; each 99mTcMAA and/or 133Xe ventilation scintigrams showed a large, discrete, photon-deficient area in the lung. This unique scintigraphic finding may result from the peripheral location and rapid grawth of the giant cell tumor. Since giant cell carcinoma is a specific clinicopathological entity and of definite significance in establishing the prognosis of patients with lung cancer, 99mTcMAA and/or 133Xe scintigraphic findings may be useful in revealing such a tumor.

Tc-99m HMDP bone scintigraphic findings in association with concurrent serum osteocalcin measurements.

Osteocalcin is a noncollagenous bone protein produced by osteoblasts. Increase in serum osteocalcin level reflects osteoblast activity with acceleration of bone formation. To evaluate the correlation of Tc-HDP bone scintigraphic findings and concurrent serum osteocalcin, serum osteocalcin values of 40 consecutive patients were measured by radioimmunoassay at the time of initial referral for bone studies. These patients, all males aged 23-93, were studied for various disease entities, including prostate carcinoma. The results of the assay were categorized into three groups (gp) as follows: 17 at normal (1.8 to 6.6 ng/ml) level (gp 1), 21 low (gp 2), and two high (gp 3). Only one bronchogenic carcinoma patient with a high level had a right iliac lesion suggesting metastasis. The bone scans of nine patients with normal or low levels showed positive metastases. Two patients with stress fractures as shown on bone scans had normal levels. The images of patients with disparity between serum osteocalcin and positive bone lesions may be interpreted as follows: Instead of osteoblastic activity resulting in the synthesis and/or release of osteocalcin, area(s) of increased uptake in the bone scan may be predominantly reflecting increased regional blood flow and decreased sympathetic tone, resulting in an increase in bone-agent deposition.

Radioactive contamination of packing materials from a xenon-133 shipment.

OBJECTIVE: We report on radioactive contamination of packing materials from a 133Xe shipment. METHODS: A 2-vial 133Xe shipment was monitored using a survey meter before opening. Both vials were immediately assayed in a dose calibrator. The packing materials were monitored and contamination was detected. RESULTS: The maximum surface reading of the shipment was 7.0 microSv/h. This was higher than previous shipments (1.1 +/- 0.3 microSv/h). One vial was 544 MBq while the other vial was only 474 MBq. Previous shipments were 565 +/- 13 MBq/vial. Monitoring and imaging revealed 133Xe contamination within the packing materials. Xenon-133 escaped from the packing materials over time. The lower activity vial continued to leak 133Xe over time. CONCLUSION: Careful monitoring of 133Xe shipments before and after opening along with assaying vials on receipt can indicate vial leakage and radioactive contamination so steps can be taken to minimize radiation exposure to the staff.

Nonuniformity intrinsic flood artifact caused by point-source syringe needle.

UNLABELLED: The purpose of this study was to investigate the cause of a nonuniformity artifact seen on an intrinsic flood. METHODS: Intrinsic floods were acquired on three different cameras using a point source in a 1-cc syringe, with and without a needle attached. Floods were obtained with the syringe placed perpendicular and parallel to the camera face. RESULTS: A nonuniformity artifact was evident if a syringe with a needle was placed perpendicular to the crystal face. CONCLUSION: If a syringe is used as a point source during the acquisition of an intrinsic quality control flood, the needle should not be placed perpendicular to the camera face.

A normal technetium-99m-DTPA renogram in renal cell carcinoma: a case report.

A 64-yr-old man with a renal mass had a preoperative 99mTc-DTPA renal flow study and renogram. An area of minimally relative increase in flow in the upper half of the right kidney was thought to reflect the high vascularity of the renal mass. A subsequent renogram showed no mass defect in the area of relatively high flow of the right kidney. The patient had a right nephrectomy. The removed kidney showed an extrarenal mass measuring 6 x 5.5 x 5 cm at the upper pole of the kidney. The mass was confirmed to be a renal cell carcinoma, clear cell type. There was no renal tissue invasion. These finding suggest an extrarenal mass pattern may be difficult to identify with a normal appearing renogram.

An unusual case of a tibial metastasis as the clinical presentation of bronchogenic adenocarcinoma.

A patient with initial complaints of leg pain and difficulty walking was found to have a large right tibial metastatic tumor and poorly differentiated adenocarcinoma of the lung. Findings from total-body bone scintigraphy include a large area of increased uptake in the proximal half of the right tibia with a photon-deficient area medially, and focal areas of uptake in a right rib, in the femoral neck and the left ileum. An irregular area of increased uptake in the left lung mass was shown by thoracic bone SPECT. This is an unusual case of a tibial metastasis as the first clinical presentation of bronchogenic adenocarcinoma.

Bone agent localization in hepatic metastases.

We present the bone scintigrams of two patients, which demonstrate diffuse extraosseous uptake of a bone agent in metastatic masses in the liver, one from a primary lung tumor and one from a primary breast tumor. The bone imaging agent did not localize in the brain metastases in these patients. CTs of the abdomen in both patients showed massive metastases in the liver with multiple areas of tumor necrosis. The CT of the abdomen of the breast cancer patient showed multiple small hepatic calcifications. Autopsy revealed massive tumor necrosis with calcifications in the enlarged liver. In routine bone scintigraphy, diffuse uptake of bone agents in the liver of a patient with a known malignancy should be considered suggestive of massive hepatic metastases.

Localization of (99m)Tc HMDP in an extraskeletal myxoid chondrosarcoma: a case report.

Extraskeletal myxoid chondrosarcoma of the lower extremity is rare, and slowly progressive. The authors of this article present the case of a man with progressive enlargement of the right thigh that underwent bone scintigraphy. The bone images showed a diffuse, moderate increase in uptake in the swollen right thigh. Despite chemotherapy, the patient died 28 mo later. At autopsy, it was confirmed that he had extraskeletal myxoid chondrosarcoma of the right thigh, which had metastasized to the upper arms, left scapula, lungs, pleurae, and right lower quadrant of the abdomen. The myxoid chondroid matrix, a major feature of the extraskeletal myxoid chondrosarcoma, is thought to account for the localization of the bone-imaging agent.

Localization of a bone imaging agent in a calcified hematoma.

A patient with chronic renal failure and secondary hyperparathyroidism had iliac bone biopsy. The procedure was complicated by a soft-tissue hematoma, which had calcified. A 3-4-cm palpable mass was visible in the lower left abdominal wall. Intense uptake of 99mTc-HMDP corresponded with the location of the calcified hematoma in this patient.

Demonstrable photopenic lesion in Tc-99m pertechnetate thyroid imaging after recent contrast radiographic procedure.

Iodine-contained contrast media of a recent arteriogram can block normal thyroid uptake of Tc-99m pertechnetate or radioiodine, resulting in virtual nonvisualization of the thyroid gland and showing a prominent salivary activity. In Tc-99m pertechnetate thyroid imaging, however, diffuse soft-tissue uptake in the anterior neck surrounding a fluid containing (cystic) lesion may standout as photopenia. The authors present two patients with recent contrast radiographic procedures who underwent Tc-99m pertechnetate imagings that demonstrated photopenic lesions: one was a thyroid cyst and the other confirmed an abscess.

Malunion of a femoral fracture mimicking osteomyelitis in three phase bone imaging.

A case of greatly increased blood flow in the region of a fracture with malunion of the left femur, both in the flow and immediate blood pool studies during three phase bone imaging, is presented. The sluggish left femoral artery flow resulted from the greatly increased regional perfusion and is similar to the findings in acute osteomyelitis. The sluggish left femoral artery flow and greatly increased regional perfusion of the site is probably best explained as a regional "neurovascular flush" resulting from the pain caused by the malunion of the fracture and/or hyperemia in the area of the malunion responding to inflammation.