Impact of FDG-PET/CT fused imaging on tumor volume assessment of head-and-neck squamous cell carcinoma: intermethod and interobserver variations.

BACKGROUND: Although gross tumor volume (GTV) at the primary site can predict local control of head-and-neck squamous cell carcinoma (SCC) in patients who are treated with organ-preservation therapy, GTV assessment does not eliminate substantial interobserver variation. PURPOSE: To evaluate whether F-18-fluorodeoxyglucose positron emission tomography (FDG-PET)/computed tomography (CT) fused imaging provides additional information for GTV assessment. MATERIAL AND METHODS: We obtained FDG-PET/CT fused images on 20 patients with head-and-neck SCC. All had undergone preoperative conventional workup, including contrast-enhanced CT and magnetic resonance imaging (MRI). The GTV of the primary tumors was designed by two independent observers who used routine clinical data. Observer A was a radiologist and observer B a radiation oncologist. GTV1 and GTV2 were designed without and with FDG-PET/CT, respectively. For geometric interobserver comparison, we calculated the concordance rate as the ratio of the intersection (AxB) of the GTVs to their union (AxB). Intermethod (GTV1 vs. GTV2) and interobserver (A vs. B) differences in the GTVs were assessed by Bland-Altman analysis and the Spearman rank-correlation test. The interobserver concordance rates for GTV1 and GTV2 were compared using a two-tailed paired-samples t test. RESULTS: On FDG-PET/CT, all primary tumors were visualized. There was no systemic trend for a volume difference between GTV1 and GTV2. Although the 95% limits of agreement were wider for interobserver than intermethod differences, the 95% limits of interobserver agreement were narrower for GTV2 than GTV1. The mean interobserver concordance rate for GTV2 was higher than for GTV1 (54.5% vs. 39.1%, P=0.0002). CONCLUSION: FDG-PET/CT is a useful modality for consistent GTV assessment, which should not be used as a single modality but rather to obtain supplemental information in patients with head-and-neck SCC.

Role of adenosine in pathogenesis of syndrome X: assessment with coronary hemodynamic measurements and thallium-201 myocardial single-photon emission computed tomography.

OBJECTIVES: This study was performed 1) to examine the role of adenosine in the pathogenesis of syndrome X in patients with this syndrome and abnormal results on myocardial scintigrams during exercise, and 2) to determine the susceptibility to myocardial ischemia in this subset of patients with syndrome X. BACKGROUND: A role for adenosine in the pathogenesis of syndrome X has recently been postulated, but there are few clinical data supporting this hypothesis. METHODS: Exercise thallium-201 myocardial scintigraphy after intravenous administration of aminophylline, an adenosine receptor blocking agent, or saline solution and adenosine thallium-201 scintigraphy were performed in 26 patients with syndrome X. Hemodynamic variables during exercise and perfusion defect size after aminophylline and saline infusions were compared. At cardiac catheterization, coronary hemodynamic variables during separate infusions of adenosine and doubutamine were also examined and were compared among patients with abnormal or normal scintigrams and 10 control subjects. RESULTS: Perfusion abnormalities on exercise-thallium-201 scintigraphy occurred in 14 of 26 patients with syndrome X. Intravenous infusion of aminophylline suppressed the scintigraphic perfusion defect and prolonged the time to 1-mm ST segment depression in patients with syndrome X with abnormal exercise scintigrams. Intravenous infusion of adenosine induced a perfusion defect in the same myocardial area where the perfusion defect was observed at exercise in 7 of the 14 patients with syndrome X. At cardiac catheterization, patients with syndrome X with abnormal exercise scintigrams had lower coronary flow reserve and a greater frequency of myocardial lactate production and ST segment depression in response to the infusions of adenosine and doubtamine than did the other two groups. During adenosine infusion, great cardiac vein blood flow and oxygen content were significantly increased and myocardial oxygen consumption and lactate extraction were significantly reduced from baseline without a significant increase in rate-pressure product in this subset of patients with syndrome X. CONCLUSIONS: Patients with syndrome X with abnormal exercise scintigrams have high susceptibility to myocardial ischemia during exercise or pharmacologic stress tests, probably owing to reduced coronary flow reserve. A heterogeneous response to endogenous adenosine may contribute to scintigraphic perfusion abnormalities and myocardial ischemia during exercise in this subset of patients with syndrome X.

Quantification of renal uptake of technetium-99m-DTPA using planar scintigraphy: a technique that considers organ volume.

We developed a method to estimate the radioactivity of 99mTc-DTPA within the kidney by planar scintigraphy. Phantom experiments and renal studies were used to compare our method with that of the Gates' method. Our method corrects for scatter and attenuation using the volume depth-independent buildup factor technique, after which background correction is performed with consideration for target organ volume. When the renal phantom-to-background activity concentration ratio (S) was changed from 5 to 80 in a water-filled container and the renal phantom depth was varied from 1 to 11 cm for each value of S, the renal phantom count rate calculated by our method was accurate under all conditions investigated. In contrast, the Gates' method was significantly affected by phantom depth and S values. In 40 patients, renal uptake in the image obtained 2-3 min after injection of 99mTc-DTPA was estimated by our method and the Gates' method, and the correlation between uptake and creatinine clearance was determined. When a ring background region of interest (ROI) around the kidney was employed, a good correlation was obtained by our method (r = 0.947) in comparison with the Gates method (r = 0.887). With both methods, a semilunar background ROI produced poor results than the ring background ROI. In conclusion, renal radioactivity levels that correlate well with creatinine clearance can be obtained by our method, which allows estimation of individual glomerular filtration rates.

Influence of exercise-induced coronary artery spasm on thallium-201 initial distribution and washout kinetics in patients with variant and classic angina pectoris.

Thallium-201 single-photon emission computed tomography was performed immediately, and 2 and 4 hours after exercise-induced anginal attack in 2 groups of patients with either exercise-induced coronary spasm or severe fixed stenosis on the isolated proximal left anterior descending coronary artery. All patients with variant angina had transient ST-segment elevation during the exercise-induced attack for thallium-201 scintigraphic study. Both perfusion defects and 4-hour washout abnormalities were significantly greater in patients with variant angina than in those with stable effort angina (p < 0.01). In patients with stable effort angina, thallium-201 activity in ischemic regions (as a percentage of initial count in the normal region) progressively decreased, whereas in patients with variant angina it increased from 38% (initial) to 48% (2 hours), and then declined to 42% (4 hours). The initial normalized thallium-201 activity in the ischemic regions was significantly lower in patients with variant angina than in those with stable effort angina (p < 0.001). In conclusion, perfusion and washout abnormalities during exercise-induced angina are greater in patients with variant angina than in those with stable effort angina. Exercise-induced coronary spasm seems to contribute to the profound reduction in initial thallium-201 distribution and delayed thallium-201 accumulation in the ischemic region.

Posttherapeutic intraaxial brain tumor: the value of perfusion-sensitive contrast-enhanced MR imaging for differentiating tumor recurrence from nonneoplastic contrast-enhancing tissue.

BACKGROUND AND PURPOSE: Differentiation of tumor recurrence from treatment-related changes may be difficult with conventional MR imaging when newly enhancing lesions appear. Our aim was to determine the value of perfusion-sensitive contrast-enhanced MR imaging for differentiating recurrent neoplasm from nonneoplastic contrast-enhancing tissue. METHODS: Twenty patients in whom new enhancing lesions developed within irradiated regions were examined prospectively with perfusion-sensitive contrast-enhanced MR imaging. Twelve of them also underwent thallous chloride Tl 201 single-photon emission tomography (201Tl-SPECT). Normalized relative cerebral blood volume (rCBV) ratios and thallium indexes were evaluated to determine whether the new enhancing lesions were recurrent or not. Five instances of tumor recurrence and one of radiation necrosis were verified histologically; in the others, tumor recurrence was distinguished by lesions that progressively increased in size on serial MR examinations over at least 5 months, and nonneoplastic contrast-enhancing tissue was distinguished by lesions that disappeared or decreased in size on serial MR studies over at least 9 months. RESULTS: When normalized rCBV ratios were higher than 2.6 or lower than 0.6, enhancing lesions were either recurrent (n = 5) or nonneoplastic contrast-enhancing tissue (n = 3), respectively. All nonneoplastic contrast-enhancing tissue had a low thallium index, whereas three of four recurrent lesions had a high index. CONCLUSION: An enhancing lesion with a normalized rCBV ratio higher than 2.6 or lower than 0.6 may suggest tumor recurrence or nonneoplastic contrast-enhancing tissue, respectively. In these cases, further examination with 201Tl-SPECT may not be necessary. However, when the normalized rCBV ratio is between 0.6 and 2.6, 201Tl-SPECT may be useful in making the differentiation.

A preliminary phantom study on a proposed model for quantification of renal planar scintigraphy.

A method for estimation of the absolute renal activity within background activity in renal planar scintigraphy will be presented. This method corrects for oversubtraction of background activity with consideration of background activity of the kidney volume, and employs the depth-independent buildup factor (DIBF) method for the correction of attenuation and scatter of photons. This method requires the depth and thickness of the organ and the thickness of background for a background activity correction. The transmission factor (TF) for a volume source is derived from integrating TF for a thin source over the thickness of the organ for the DIBF method. To validate this method, phantom studies with various uniform background activity concentrations were performed and the data were compared with conventional background subtraction that do not consider the organ's volume. The results showed that with the conventional background subtraction method at all depth activity was underestimated with errors of 5%-30% for organ/background concentration ratios of 5-40, while this method estimated the true count rate with errors of less than 5%. More accurate quantifications of renal functions such as renal uptake, glomerular filtration rate (GFR) and renogram may be obtained by this proposed method on the planar images.

Quantitative planar imaging method for measurement of renal activity by using a conjugate-emission image and transmission data.

We are proposing a method to accurately measure renal activity in renography using Tc-99m labeled tracers. This method uses a conjugate-view image and transmission data for attenuation correction, the triple energy window (TEW) method for scatter correction, and background correction techniques that consider the source volume for accurate background activity correction. To examine this method in planar imaging, we performed two renal phantom studies with various uniform background activity concentrations. One study used two ideal box-shaped kidney phantoms with a thickness of 2 or 4 cm in a water tank and the other study employed two real kidney-shaped phantoms in a fillable abdominal cavity. For these studies the kidney phantom-to-background activity concentration ratio (S) was changed from 5 to infinity. The transmission data were obtained with an external Tc-99m line array source. The anterior- and posterior-view emission images were acquired with a dual-headed gamma camera simultaneously and the TEW method was used to correct scatter for the emission and transmission images. The results showed that this method with both the accurate background correction and scatter correction could give depth-independent count rates and could estimate the true count rate with errors of less than 5% for all S values. However, if either accurate background correction or scatter correction was performed alone, the absolute error increased to about 50% for the smaller S values. Our proposed method allows one to accurately and simply measure the renal radioactivity by planar imaging using the conjugate-emission image and transmission data.

Direct 99mTc labeling of human immunoglobulin with an insoluble macromolecular Sn(II) complex.

An insoluble macromolecular Sn(II)(R-Sn) complex which strongly binds Sn(II) by chelation was applied to the direct 99mTc labeling of human immunoglobulin(IgG) to minimize the influence of Sn(II). 99mTc labeling was achieved at greater than 90% yield simply by the short-term mixing of IgGa containing > 2-SH groups per IgG molecule, 99mTc pertechnetate, and the R-Sn complex in pH 7 solution. The 99mTc-IgGa obtained by this labeling method has high stability based on the thiol-specific binding of 99mTc without transchelation from another weakly bound 99mTc-complex.

Synthesis and evaluation of hydroxamamide-based tetradentate ligands as a new class of thiol-free chelating molecules for 99mTc radiopharmaceuticals.

Both N,N'-ethylene bis(benzohydroxamamide) [(C2(BHam)2)] and N,N'-propylene bis(benzohydroxamamide) [(C3(BHam)2)] were designed as new thiol-free chelating molecules for 99mTc radiopharmaceuticals. Synthetic procedures using oxadiazoline intermediates were developed for C2(BHam)2 and C3(BHam)2. Both C2(BHam)2 and C3(BHam)2 formed 99mTc complexes with high yields over a wide pH range (pH 3-12) at room temperature. Complexation yields of over 95% were achieved at ligand concentrations as low as 2.5 x 10(-6) M. Reversed-phase HPLC analyses indicated that both C2(BHam)2 and C3(BHam)2 formed 99mTc complexes as single species with stabilities much higher than those of 99mTc-BHam. Selective complex formation of 99mTc with the two ligands was observed in the presence of human IgG. No decomposition with low protein binding were demonstrated when the two 99mTc complexes were incubated in murine plasma. Although further structural studies are required, these findings implied that the Ham-based tetradentate ligands would serve as new chelating molecules for 99mTc radiopharmaceuticals.

Development of macromolecular Sn(II) complex for preparation of 99Tcm radiopharmaceuticals.

Macromolecular Sn(II) complex (R-Sn) was developed using a chelating resin containing aminophosphonic acid groups as a reducing agent of 99Tcm(VII) in the preparation of 99Tcm radiopharmaceuticals. Since Sn(II) was bonded strongly to the resin by chelation, release of Sn from R-Sn was rarely observed in saline solution. 99Tcm labelling with a yield greater than 90% was performed by mixing R-Sn, 99Tcm pertechnetate solution and a ligand, such as human serum albumin and diethylenetriamine pentaacetic acid, for a short time. The 99Tcm radiopharmaceuticals were almost free from Sn(II) and the reducing activity of R-Sn was quite stable despite long-term storage without any special care.

Hydroxamamide as a chelating moiety for the preparation of 99Tcm radiopharmaceuticals (I).

Hydroxamamides contain a nitrogen and an oxygen as donor atoms, and can be synthesized by the simple reaction of nitriles with hydroxylamine. Benzohydroxamamide (BHam) was investigated as a new ligand for 99Tcm. The yield of the 99Tcm-BHam complex was determined by thin-layer chromatography using cellulose strips. A high yield of the complex was obtained at room temperature over a wide pH range, even at BHam concentrations as low as 5 x 10(-7) M. Cellulose acetate electrophoresis indicated that the complex was uncharged. When the 99Tcm-BHam complex was injected into mice, it was cleared gradually from the blood by means of the hepatobiliary system with low urinary excretion. Uptake by the stomach and the spleen was low. These results demonstrate the high affinity of BHam for 99Tcm and the high stability of the 99Tcm-BHam complex. The hydroxamamide group may be a promising chelating moiety for designing new 99Tcm radiopharmaceuticals.

Quantitative evaluation of the regional hepatic reserve by 99mTc-GSA dynamic SPECT before and after chemolipiodolization in patients with hepatocellular carcinoma.

99mTc-DTPA-galactosyl human serum albumin (99mTc-GSA) hepatic scintigraphy was performed in 32 patients with hepatocellular carcinoma before and after chemolipiodolization, which was performed from the right hepatic artery (RHA) in 15 patients and the proper hepatic artery (PHA) in 17 patients. Following a bolus injection of 99mTc-GSA, dynamic SPECT was performed with 1 minute rotation for 16 minutes. Data analysis was conducted by setting a region of interest (ROI) on the right liver, left liver and heart and then their time-activity curves were generated. The regional hepatic accumulation index (LHL15) and the regional uptake constant index (KU) were also calculated from the time-activity curves. In the RHA group, regional LHL15 and KU of the left lobe significantly increased, but they did not significantly increase in the PHA group. In the right lobe, no significant change in regional KU or LHL15 was observed. In the poor prognosis group, all indices in both regions decreased after chemolipiodolization, especially the value for regional KU had a poor score before chemolipiodolization. A decrease in each index in both lobes after chemolipiodolization is considered to be a sign of a poor prognosis. 99mTc-GSA dynamic SPECT scintigraphy is a useful method for evaluating the changes in regional hepatic reserve before and after chemolipiodolization.

Evaluation of persistence of ductus venosus with tc-99m DTPA galactosyl human serum albumin liver scintigraphy and I-123 iodoamphetamine per-rectal portal scintigraphy.

Tc-99m DTPA galactosyl human serum albumin (Tc-99m GSA) hepatic scintigraphy was performed in two patients with patent ductus venosus before and after operation. To evaluate the portosystemic shunt flow, per-rectal portal scintigraphy with I-123 N-isopropyl-p-iodoamphetamine (IMP) was undergone in the same period. The portosystemic shunt indices (PSS index) were decreased from 67.9% to 7.3% in the patient 1, and from 77.3% to 22.7% in the patient 2, respectively. Quantitative indices of Tc-99m GSA hepatic scintigraphy improved dramatically in both patients. Under microscopic examination, nearly all the hepatic cells showed signs of severe fatty degeneration. After the operation, the severe fatty degeneration was alleviated and all the hepatic cells appeared normal. I-123 IMP per-rectal portal scintigraphy and Tc-99m GSA hepatic scintigraphy were useful in evaluating the quantitative shunt flow of the persistent ductus venosus and its hepatic functional reserve.

Correction of scattered photons in Tc-99m imaging by means of a photopeak dual-energy window acquisition.

We are proposing a new method for correcting of scattered photons in technetium-99m (99mTc) imaging by means of photopeak dual-energy window acquisition. This method consists of the simultaneous acquisition of two images and estimation of a scatter image included in the symmetric energy window (SW) image by the difference between these images. The scatter corrected image is obtained by subtracting the scatter image from the SW image. In order to evaluate this method, we imaged a planar and a SPECT phantom with cold lesions and calculated the contrast value with and without the scatter correction. In addition, we performed asymmetric energy window (ASW) imaging to compare with this scatter correction method for planar images. In the planar image with the tissue-equivalent material of 10 cm, the scatter correction method removed 32% of the counting rate of the SW image and improved from 0.81 to 0.94 of the contrast value for a 4 cm-diameter cold lesion, while the contrast value with the ASW was 0.87 for such a cold lesion. The scatter corrected SPECT image had a reduction of 18% of the counting rate of the SW SPECT image and improvement of approximately 11% in contrast for cold spot sizes larger than a 3 cm-diameter, compared with the SW SPECT image. In addition, a perfusion defect could be well visualized by this scatter correction method on 99mTc-HMPAO regional cerebral blood flow SPECT of a patient. Our proposed scatter correction method can improve both planar and SPECT images qualitatively and quantitatively.

Usefulness of reinjection image for evaluating viable myocardium in the infarcted zone on exercise thallium-201 SPECT.

Reinjection images were obtained in 23 patients with myocardial infarction by the additional injection of 37 MBq of thallium-201 after obtaining 4 hour delayed images on exercise thallium-201 SPECT (TSPECT). A redistribution index (RI) was derived of the changes in perfusion defects between immediate and 4 hour delayed images as well as immediate and reinjection images on polar bull's eye maps. The RI of reinjection images (46 +/- 27%) was significantly greater than that of 4 hour delayed images (26 +/- 26%) in patients with myocardial infarction (p less than 0.01). Significant redistribution after reinjection occurred in 4 of 9 patients (44%) without significant redistribution on 4 hour delayed images. Improvement in redistribution on reinjection images correlated significantly to the small extent of coronary artery disease and collateral development. The appearance of redistribution from 4 hour delayed imaging to reinjection imaging also might reflect the function of collateral development in the resting state in patients without significant redistribution on 4 hour delayed images. It has been demonstrated that underestimated viable myocardium on 4 hour delayed images in the infarcted zone can be better assessed on reinjection images. This reinjection technique is recommended in patients with no or partial redistribution on 4 hour delayed images.

A new method for crosstalk correction in simultaneous dual-isotope myocardial imaging with Tl-201 and I-123.

We have developed a new method of crosstalk correction in simultaneous dual-isotope imaging with Tl-201 and I-123 by using crosstalk ratios and a blurring filter. Single isotope myocardial studies (10 for Tl-201 and 7 for I-123) were performed with a dual energy window acquisition mode and two low energy general-purpose collimators. Then two planar images acquired with dual energy windows for a Tl-201 line source and an I-123 line source were obtained to measure line spread functions (LSFs) and crosstalk ratios for each image. The line source experiments showed that the LSFs for the Tl-201 imaging window from the single Tl-201 source were very similar to those for the I-123 imaging window from the single Tl-201 source, but the LSFs for the Tl-201 imaging window from the single I-123 source had broad shapes which differed from those for the I-123 imaging window from the single I-123. To obtain accurate I-123 crosstalk images in the Tl-201 imaging window from the I-123 images in the I-123 imaging window, we designed a low-pass blurring filter. In 7 clinical I-123 MIBG studies, I-123 window images processed with this filter became very similar to the Tl-201 window image from the single I-123 source. The method proposed in this study can accurately correct the crosstalk in dual isotope studies with Tl-201 and I-123 and is easily applicable to conventional gamma camera systems with any dual energy window acquisition mode.

Diagnostic accuracy of simultaneous acquisition of transmission and emission data with technetium-99m transmission source on thallium-201 myocardial SPECT.

PURPOSE: This study evaluates not only the clinical usefulness but also the problems in attenuation correction for thallium-201 (Tl-201) myocardial SPECT by means of simultaneous transmission and emission data acquisition in the detection of coronary artery disease (CAD). METHODS: A three-detector SPECT system equipped with a Tc-99m line source and fan-beam collimators was used for simultaneous transmission and emission data acquisition for Tl-201 myocardial SPECT in 73 patients (18 patients for normal database and 55 patients for the evaluation of diagnostic accuracy). Attenuation-corrected (AC) images and non-attenuation-corrected (NC) images were reconstructed with an iterative maximum-likelihood estimation-corrected (ML-EM) algorithm. Both sets of images were reoriented into the short axis. Normal database polar maps were constructed from the AC and NC images for quantitative analysis. RESULTS: There was a significant difference in specificity between NC and AC images in the RCA territory and those in specificity and accuracy in the LCX territory. There was no significant difference in sensitivity found between NC and AC images in either territory, but sensitivity in both territories tended to decrease with attenuation correction. In the LAD territory, there were various changes in sensitivity and specificity observed with attenuation correction in cases with each quantitative criterion. CONCLUSIONS: Diagnostic performance of significant stenosis in the RCA and LCX territories quantitatively improved with attenuation correction because of an increase in specificity, but no significant improvement in diagnostic performance was obtained in the LAD territory with attenuation correction. We recommend combined interpretation of AC and NC images and careful evaluation of any SPECT image by means of transmission computed tomography.

Quantitative renography with the organ volume method and interporative background subtraction technique.

When quantification of renal activity is performed by planar imaging, many correction factors must be considered. To obtain quantitative renal images and renogram, we have examined our proposed method by using the organ volume for scatter, attenuation, and background activity, and the interporative background subtraction (IBS) technique in phantom and clinical studies. A renal phantom study was performed by varying the renal depth from 3 to 11 cm and the kidney-to-background activity concentration ratio from 5 to 80. Planar images were properly corrected for scatter, attenuation and background activity by our method and the corrected images were compared with the images obtained by the conventional method for the estimation of true renal activity. Clinical Tc-99m DTPA dynamic data for both a good and a poor renal function were also corrected by our method and volume-corrected renograms were obtained. For the phantom study, depth-independent images were obtained and these images gave a good estimation of the true count rate. In the clinical study, the conventional renogram was especially modified to allow for oversubtraction of background counts in the early phase (0-4 min). In conclusion, our proposed correction method can assess renal function qualitatively and quantitatively in both static and dynamic planar renal imaging.

Value of ultrasound-guided core-needle biopsy for peripheral intrathoracic and mediastinal lesions.

To evaluate the value of ultrasound (US)-guided core-needle biopsy (CNB) for peripheral intrathoracic and mediastinal lesions. Fourteen patients who had intrathoracic or mediastinal lesions underwent US-guided CNB with 17- or 18-gauge needles. The lesions in this study were seven cases of lung carcinomas including four cases of adenocarcinomas and three cases of squamous cell carcinomas, two cases of thymomas, and one case each of aspergillosis, sarcoidosis, MFH, lung abscess, and lung fibrosis. Diagnosis was possible in 13 of 14 (92.8%) cases histologically. There were three cases of complication (21.4%); one case each of pneumothorax, pleuritis, and hemosputum. They were all cured with medication. We concluded that real-time US-guided CNB is a useful and safe method for the examination of peripheral intrathoracic and mediastinal lesions.

Functional evaluation of transplanted kidneys by Gd-DTPA enhanced turbo FLASH MR imaging.

We evaluated the usefulness of dynamic turbo FLASH MR imaging in the differential diagnosis of complications after renal transplantation in 17 patients (10 from living relatives and 7 from cadavers). Coronal turbo FLASH dynamic images were obtained every 5 sec for 5 min after an intravenous bolus injection of Gd-DTPA. Corticomedullary differentiation (CMD) on spin echo coronal T1-weighted images and MR renogram patterns of the renal cortex and medulla were obtained for quantitative analysis of the Gd-DTPA-enhanced dynamic turbo-FLASH images. The signal intensity ratio of the medulla to cortex after Gd-DTPA enhancement was compared among four groups: normal (n = 9), acute tubular necrosis (ATN) or cyclosporine A (CyA) tubulopathy (n = 6), acute rejection (AR) in the living related donor kidney (n = 4), and AR in the cadaveric kidney (n = 5). Although loss of CMD was seen in severe renal dysfunction in the transplanted kidneys, there was considerable overlap among the four groups. On dynamic study, there was significant differences in the signal intensity ratio of the medulla to cortex between normally functioning kidneys or ATN/CyA tubulopathy and AR (p < 0.01). In patients with severe renal dysfunction, the arterial cortical peak was indistinct. In conclusion, MR renograms obtained from dynamic turbo FLASH MR imaging played a significant role in evaluating dysfunction of the renal transplant.