Comparison of modified technetium-99m albumin and technetium-99m red blood cells for equilibrium ventriculography.

UNLABELLED: A newly developed modified form of 99mTc-labeled human serum albumin reconstituted from a kit (99mTc-dimercaptopropionyl-human serum albumin; 99mTc-DMP-HSA) was prospectively compared to 99mTc-labeled red blood cells (RBC) in patients referred for equilibrium radionuclide ventriculography at rest to evaluate its potential use as a blood-pool imaging agent. METHODS: A Paired comparison between 99mTc-DMP-HSA and either in vitro or in vivo 99mTc-labeled RBC was performed within 2 days in 20 patients'. For each study, two sets of images were acquired, starting at 15 min and 180 min postinjection, respectively. Each set consisted of a gated blood-pool cardiac study and a planar static image centered on the patient's thorax. All data were processed by two independent observers. Early and late postinjection parameters were calculated: ejection fraction (EF) value, activity within the main organs surrounding the left ventricle (LV), ratio of activity between the LV and these surrounding organs for each study separately, and temporal (late/early) evolution of the intraorgan activities and of the LV/organ ratios after decay correction. RESULTS: The images and the visual wall-motion analysis were of good quality with both agents in most patients, without significant image degradation at 180 min postinjection. Calculated EF values were highly comparable with the two tracers. Interobserver variability was 0.17% (RBC) and 1.08% (DMP-HSA) for the early EF value (EF1), and 0.62% (RBC) and 0.27% (DMP-HSA) for the late EF (EF2). Mean difference between EF2 and EF1 was 0.74% (Observer 1) and 0.28% (Observer 2) for 99mTc-RBC, and -2.88% (Observer 1) and -2.07% (Observer 2) for 99mTc-DMP-HSA. When comparing 99mTc-DMP-HSA to 99mTc-RBC the mean difference was 1.27% (Observer 1) and 0.36% (Observer 2) for EF1, and -2.35% (Observer 1) and -1.99% (Observer 2) for EF2. Also, the biodistribution and temporal evolution of the organ repartition of both compounds were stable and similar, with values of late/early activity ratios very close to one for all the studied organs [mean intraorgan ratio: 0.946 for 99mTc-RBC (range: 0.881-1.086) and 0.979 for 99mTc-DMP-HSA (range: 0.914-1.141); mean late/early LV/organ ratio: 0.964 for 99mTc-RBC (range: 0.919-1.016) and 0.967 for 99mTc-DMP-HSA (range: 0.912-1.035)]. CONCLUSION: Paired comparison of kit-prepared 99mTc-DMP-HSA to 99mTc-labeled RBC demonstrated that both agents were very closely related regarding as well the calculated EF value as the in vivo stability up to more than 3 hr postinjection. Technetium-99m-DMP-HSA may constitute a practical and useful replacement for 99mTc-labeled RBC.

Development and evaluation of a kit formulation for the preparation of 99mTc-DMP-HSA, a new tracer agent for radionuclide ventriculography.

This study presents the development of a kit formulation for the preparation of 99mTc-DMP-HSA, followed by a comparison of such kit-prepared 99mTc-DMP-HSA to 99mTc-RBCs in a volunteer. Reconstitution of the labeling kits with up to 5.55 GBq 99mTc afforded 99mTc-DMP-HSA preparations with a > 95% radiochemical purity for up to 8 h. Only minor differences were observed in the global distribution of both tracer agents, whereas the calculated ejection fractions were almost identical. The effective dose equivalent of 99mTc-DMP-HSA is 8.68 microSv/MBq.

99Tcm-dimercaptopropionyl-HSA prepared from a labelling kit: preliminary investigations as a blood pool agent.

The blood retention of 99Tcm-dimercaptopropionyl human serum albumin (99Tcm-DMP-HSA), prepared from a kit, was compared with that of five other 99Tcm-labelled blood pool tracers in two healthy volunteers. 99Tcm-DMP-HSA showed an almost identical behaviour to in vitro labelled red blood cells (RBCs), which are generally considered the reference standard for blood pool agents. The mean apparent blood mass of 99Tcm-DMP-HSA was 2.1% higher 10 min post-injection (p.i.) than that of in vitro 99Tcm-RBCs, 2.0% higher 30 min p.i., 4.7% higher 60 min p.i. and 2.3% higher 120 min p.i. In vivo labelling of RBCs yielded a labelling efficiency of 75-98%, depending on the stannous agent used. About 20 min after pertechnetate administration, the intravascular activity as a percentage of injected dose stabilized at levels close to that of in vitro labelled RBCs. One commercially available 99Tcm-HSA kit was found to be unsuitable as a blood pool tracer. As 99Tcm-DMP-HSA offers the same practical advantages as 99Tcm-HSA, but better biological characteristics, it shows promise as a new tracer for radionuclide ventriculography and further large-scale investigations are warranted.

Complexes of technetium-99m with tetrapeptides containing one alanyl and three glycyl moieties.

Recently, we have shown that tetrapeptides can be efficiently labelled with technetium-99m by direct labelling at alkaline pH. Tetrapeptides can be considered derivatives of mercaptoacetyltriglycine (MAG3) in which the mercaptoacetyl moiety is replaced by an amino acid residue. In view of the interesting biological properties of some C-methyl substituted derivatives of 99mTc-MAG3, we have now synthesised and evaluated the complexes of 99mTc with tetrapeptides containing three glycyl (G) moieties and one D- or L-alanyl (A) moiety. In mice, 99mTc-L-GAGG, 99mTc-D-GGAG and 99mTc-L-GGAG showed a rapid and high renal excretion, comparable to that of 99mTc-MAG3. Renal handling was somewhat reduced for isomers d and l of 99mTc-AGGG and 99mTc-D-GAGG and markedly inferior for 99mTc-L-GGGA and 99mTc-D-GGGA. In the baboon, 99mTc-L-AGGG, 99mTc-D-AGGG and 99mTc-L-GAGG showed a comparable or even higher 1-h plasma clearance than 99mTc-MAG3. 99mTc-D-GAGG, 99mTc-L-GGAG and 99mTc-D-GGAG were characterised by a lower plasma clearance and the clearance of 99mTc-L-GGGA and 99mTc-D-GGGA was remarkably low. The three 99mTc-labelled tetrapeptides with the highest plasma clearance in a baboon were compared with 99mTc-MAG3 in a human volunteer. 99mTc-L-AGGG and 99mTc-L-GAGG had a roughly similar plasma clearance as 99mTc-MAG3. The clearance of 99mTc-D-AGGG was significantly lower and liver uptake was clearly visible with this compound. Left kidney renograms of 99mTc-L-AGGG and 99mTc-D-AGGG indicated moderate kidney accumulation. On the other hand, the renogram obtained after injection of 99mTc-L-GAGG had an excellent shape and the maximum kidney concentration was slightly higher than for 99mTc-MAG3. These results show the importance of the position of the methyl substituent on the 99mTc-tetrapeptide with respect to its biological behaviour.

Complexes of technetium-99m with tetrapeptides, a new class of 99mTc-labelled agents.

Tetrapeptides are a class of N4-tetraligands that can efficiently bind 99mTc. In fact, tetrapeptides can be considered as derivatives of mercaptoacetyltriglycine (MAG3) in which the mercaptoacetyl moiety is replaced by a more stable and easier to handle aminoacyl group. Direct labelling of tetrapeptides with 99mTc in alkaline medium (pH > or = 11) in the presence of stannous ions gave a high yield (> 95%) of one or two (probably isomeric) radiochemical species. Exchange labelling at different pH values in the presence of stannous tartrate resulted in lower yields of the same 99mTc-labelled products as those formed during direct labelling. In addition, other radiochemical species were formed of which one was characterized as an oxotechnetium-complex with the cyclisized tetrapeptide. Tetrapeptides with a chiral centre in the first amino acid yield upon labelling with 99mTc two radiochemical species, probably the two diastereomers with an oxotechnetium core respectively syn and anti with respect to the substituent on the amino acid. Only one diastereomer was observed when the chiral carbon atom is located in the second or third amino acid. Electrophoresis indicated that these new 99mTc-labelled complexes are neutral in acidic medium and negatively charged in neutral and alkaline conditions. This correlates with a complex in which an oxotechnetium(V) group is bound to the ligand through three deprotonated nitrogen atoms of the amide functions and the free electron pair of the amine nitrogen atom. Biodistribution in mice showed for all studied 99mTc-labelled tetrapeptides a rapid clearance from the blood mainly by the renal system. The presence of a methyl substituent in the tetrapeptide increased the urinary excretion. 99mTc-labelled L-glycylalanylglycylglycine showed in mice a urinary excretion comparable to that of 99mTc-MAG3. Further rise of lipophilicity by introduction of a dimethyl, isopropyl or isobutyryl group leads to increased hepatobiliary handling. It is concluded that tetrapeptides are an interesting group of technetium complexing agents which can easily be labelled with 99mTc at room temperature in alkaline medium. This class offers the possibility of a wide variety of derivatives, just by substituting one or more amino acids. This group of ligands thus opens a new research field of 99mTc-complexes with potential usefulness in several areas.

First experience in healthy volunteers with technetium-99m L,L-ethylenedicysteine, a new renal imaging agent.

Animal studies have indicated that technetium-99m L,L-ethylenedicysteine (99mTc-L,L-EC) may be a promising tracer agent for renal function studies. We have performed a paired study with 99mTc-mercaptoacetyltriglycine (99mTc-MAG3) and 99mTc-L,L-EC in six male volunteers. In both cases, iodine-131-labelled o-iodohippurate was co-injected as an internal biological standard. The analog images between 0 and 30 min p.i. were of identical diagnostic value for both tracer agents. The two renograms were similar in all volunteers. The mean 1-h plasma clearance for 99mTc-MAG3 and 99mTc-L,L-EC was significantly different, respectively 382.9 +/- 17.1 ml/min per 1.73 m2 versus 460.2 +/- 47.7 ml/min per 1.73 m2 (P < 0.003). The urinary excretion after 30 min p.i. was 69.4% +/- 5.6% of the injected dose for 99mTc-MAG3 versus 66.5% +/- 2.5% for 99mTc-L,L-EC (P > 0.05) and after 60 min p.i. respectively 83.1% +/- 3.9% versus 79.8% +/- 4.3% (P > 0.05). 99mTc-L,L-EC has a very low plasma protein binding (31% +/- 6.8%) as compared to 99mTc-MAG3 (88% +/- 5.2%) and a larger volume of distribution. Although the exact mechanism responsible for the high plasma clearance of 99mTc-L,L-EC is not yet fully known, we conclude that this new agent merits further clinical evaluation in patients to establish its value as a renal radiopharmaceutical.

Technetium-99m labelled human serum albumin for ventriculography: a comparative evaluation of six labelling kits.

In this study we have compared the characteristics of six labelling kits for the preparation of technetium-99m labelled human serum albumin (99mTc-HSA) and evaluated the usefulness of the various 99mTc-HSA preparations as blood pool tracer agents. The amount of the principal ingredients, i.e. HSA and stannous ions, varies largely between the studied kits and this is probably a reason for the observed differences in the labelling rate. Analysis of the reaction mixtures after labelling of the respective kits with 99mTc showed in each preparation the presence of four to five radioactive components in variable relative amounts. The retention time of the main component on size-exclusion high-performance liquid chromatography (SEC-HPLC) was identical for all preparations. Biodistribution of the HPLC-isolated fractions was studied in mice. The components with the shortest and longest retention times on HPLC show poor retention in the plasma. The three intermediate fractions, including the principal peak, are initially retained relatively well in the blood (60%-70% of the injected dose after 10 min), but clearly to a lower degree than iodine-125 labelled HSA. Moreover, they diffuse out of the vascular compartment at a much higher rate than 125I-HSA. The biological behaviour of the main component of the various preparations was clearly different, despite the identical retention time on SEC-HPLC. Study of the total preparations in mice and a rabbit showed that two of them are cleared rapidly from the blood and cannot be considered valuable blood pool tracers. Diffusion of the other preparations out of the blood is slower but also considerable and compromises their use for ventriculography.

Technetium-99m mercaptoalbumin as a potential substitute or technetium-99m labelled red blood cells.

Technetium-99m labelled red blood cells (99mTc-RBCs) are far superior to 99mTc-labelled human serum albumin (99mTc-HSA) for radionuclide ventriculography, but their labelling is more complex, time consuming and risk bearing (in vitro labelling) or suffers from interference by some medications (in vivo labelling). We have now modified HSA by the introduction of mercapto groups with the purpose of preparing stable and practical 99mTc-mercaptoalbumin with long retention in the vascular system, that could replace 99mTc-RBCs. HSA was incubated with N-succinimidyl S-acetylthioacetate (SATA) or N-succinimidyl 2,3-di(S-acetylthio) propionate (SATP) to introduce a chain containing one or two protected sulfhydryl groups on some of the lysine amino groups. After purification by size-exclusion chromatography (SEC), the mercapto groups were deprotected by incubation at alkaline pH or by treatment with hydroxylamine. The reaction products were used with or without SEC purification for direct or exchange labelling experiments with 99mTc at neutral pH. SEC-HPLC was used to determine labelling yields and to isolate pure 99mTc-mercaptoalbumin. Stable 99mTc-mercaptoalbumin complexes could be formed in 90%-95% yield after coupling albumin with SATA or SATP in all molar ratios used followed by deacetylation in one of the mentioned conditions. The most favourable results were obtained after reaction of SATA or SATP with HSA in a 25:1 ratio and deprotection with NH2OH. The stability of the resulting 99mTc-mercaptoacetyl-albumin (99mTc-MA-HSA) and 99mTc-dimercaptopropionyl-albumin (99mTc-DMP-HSA) and their retention in vivo in plasma of mice and rabbits are clearly higher than that of conventional 99mTc-HSA preparations. 99mTc-DMP-HSA approaches the behaviour of 125I-HSA quite well in both animal species. A preliminary study with 99mTc-DMP-HSA in a volunteer showed a retention in the vascular compartment almost identical to that of 99mTc-RBCs and clearly higher than that of a common 99mTc-HSA preparation. The results indicate that these 99mTc-mercaptoalbumins and especially 99mTc-DMP-HSA are very promising as a practical alternative to 99mTc-RBCs.

Technetium-99m-L,L-ethylenedicysteine: a renal imaging agent. I. Labeling and evaluation in animals.

L,L-ethylenedicysteine (L,L-EC) can be labeled efficiently with 99mTc at pH 12 to obtain a highly pure and very stable tracer agent (99mTc-L,L-EC). The biological behavior of 99mTc-L,L-EC was studied in mice and a baboon. In mice, 99mTc-L,L-EC demonstrated a more rapid urinary excretion and less retention in the kidneys, the liver, the intestines, and the blood than did 99mTc-MAG3 at 10 and 60 min p.i. Urinary excretion decreased in probenecid pretreated mice, which indicates active tubular transport. In the baboon, the renograms for 99mTc-MAG3 and 99mTc-L,L-EC were comparable. Plasma-protein binding of 99mTc-L,L-EC was lower than that of 99mTc-MAG3 while its distribution volume and 1-hr plasma clearance were clearly higher. The promising results of the animal experiments suggest that 99mTc-L,L-ethylenedicysteine may be a useful alternative to 99mTc-MAG3 for renal function studies in humans.

Evaluation of the renal excretion characteristics of technetium-99m mercaptoacetylglycyl-D-alanylglycine in healthy volunteers.

During a study of C-methyl derivatives of technetium-99m mercaptoacetyltriglycine (99mTc-MAG3) it was found that the isomer of 99mTc-mercaptoacetylglycyl-D-alanylglycine (99m-TC-MAGAG-DA) is superior to 99mTc-MAG3 with regard to its renal excretion characteristics in both mice and the baboon. We have now compared the renal handling of 99mTc-MAGAG-DA and 99mTc-MAG3 in 6 healthy volunteers in a paired study. Renograms of 99mTc-MAGAG-DA show a shorter time to renal maximum and a lower residual renal activity at 30 min post-injection (p.i.). The urinary excretion of 99mTc-MAGAG-DA is higher at both 30 and 60 min p.i. The plasma concentration of 99mTc-MAGAG-DA is lower than that of 99mTc-MAG3 at each moment up to 60 min p.i., and the plasma clearance is accordingly higher. It is concluded that 99mTc-MAGAG-DA is excreted more efficiently than 99mTc-MAG3, but the preparation of 99mTc-MAGAG-DA requires a HPLC purification step, and this limits its practical clinical usefulness.

Mediastinal parathyroid localization: possible pitfall in technetium-thallium subtraction scintigraphy.

Two cases of mediastinal localization of parathyroid adenoma are presented, in which technetium-thallium subtraction scintigraphy yielded a positive result. Both patients had already undergone a negative surgical neck exploration. We suggest that, in case of negative subtraction scintigraphy and negative surgical exploration in proven primary hyperparathyroidism, subtraction scintigraphy should be repeated with emphasis on the superior mediastinum, and in all cases, the use of a non-zoom, large field of few procedure is recommended for technetium-thallium subtraction scintigraphy.

Reflections on the etiology of hot spots on liver scans.

Liver scintigraphy demonstrated areas of increased radiocolloid uptake in three cases with obstruction of the superior vena cava and extensive collateral circulation through the veins of the thoracic wall. The pattern of the hyperactive zones is indicative of predominant vascularization of the liver via the umbilical vein, with high colloid particle deposition in the quadrate lobe and adjacent part of the right lobe. These liver regions vascularized by the first intrahepatic branches of the umbilical vein as demonstrated by postmortem angiography, probably extract a great portion of the tracer dose, resulting in localized hyperactivity. An identical liver scan image was, however, found in a fourth case without evident superior vena cava syndrome. In this patient, presenting with a bronchus carcinoma with paratracheal metastatic lymph nodes, there is no explanation metastatic lymph nodes, there is no explanation (collateral circulation without vena cava obstruction?) for the abnormal tracer distribution within the liver.

Critical appraisal of angioscintigraphy as a diagnostic procedure in cerebrovascular disease.

In order to assess the diagnostic usefulness of combined functional and morphological isotopic investigations of brain vascularization after intravenous injection of a bolus 99mTc pertechnetate, the authors explored, besides a control group, patients with acute cerebrovascular disease, angiomas, aneurysms and intracerebral hematomas. Combined flow evaluation and visualization of the intracerebral bolus transit was highly effective in patients with cerebrovascular disease. Angiomas with a diameter of 2 cm or more are always visible, the abnormal vascularization of the affected hemisphere being correctly evaluated. Cerebral aneurysms are frequently missed by angioscintigraphy. Intracerebral hematoma generally gives false negative results.