Observations on the sequential use of Tc-99m phosphonate and Ga-67 imaging in untreated primary and secondary malignant tumors of the head and neck

Scintigraphy using both Tc-99m phosphonate and Ga-67 was performed in 55 cases of untreated primary and secondary tumors of the head and neck. In 21 patients with primary tumors of jaws, eye, tongue, or parotid gland, Ga-67 scintigraphy visualized the primary tumor in all cases and metastases in 12. Scintigraphy using Tc-99m phosphonate disclosed primary bone involvement in 12 cases and skeletal metastases in two. In eight of 13 patients with metastatic lesions of jaws and skull, bone scintigraphy showed skeletal metastases. In seven of these patients, Ga-67 scintigraphy detected the primary tumor and in 11 cases detected metastases. Bone scintigraphy disclosed skeletal metastases in six of 21 patients with malignant neck tumors. In 13 of these patients, Ga-67 scintigraphy visualized the primary tumor, whereas it showed metastases in seven. It is concluded that Ga-67 scintigraphy should be used in the investigation of untreated primary or secondary malignant tumors of the head and neck. Bone scintigraphy may be indicated as an additional study in selected cases only.     

Neuroblastoma: imaging evaluation by sequential Tc-99m MDP, I-131 MIBG, and Ga-67 citrate studies

Fourteen children with histopathologically confirmed neuroblastoma underwent sequential correlative imaging studies using I-131 MIBG, Tc-99m MDP, and Ga-67 citrate during various stages of the disease. Of the patients 86% showed I-131 MIBG accumulation in the primary tumoral site, whereas 71% showed Tc-99m MDP and 79% Ga-67 citrate uptake. In 86% at least one of the two latter radiopharmaceuticals concentrated in the primary tumor. The use of all three radiopharmaceuticals raised the detection rate to 93%. Of the osseous or extraosseous metastases 100% were detected by Tc-99m MDP studies. The I-131 MIBG studies were positive in 71% of the osseous metastases and in 70% of the extraosseous metastases. No Ga-67 citrate uptake was demonstrated in osseous metastases, although one extraosseous lung metastasis concentrated this radiopharmaceutical. Tc-99m MDP bone imaging was the best method for diagnosing metastatic spread of the disease and for monitoring the results of treatment. Primary tumor uptake was best indicated by I-131 MIBG. Both Ga-67 citrate and I-131 MIBG were superior to Tc-99m MDP with regard to accurately demonstrating the extent of primary tumors. Only Tc-99m MDP indicated the relationship of these tumors to the kidneys and neighboring osseous structures, providing early screening of kidney compression. Ga-67 citrate study was mainly indicated in tumors with catecholamine depletion, which failed to concentrate the other two radiopharmaceuticals. I-131 MIBG proved especially useful in detecting neuroblastoma with negative Tc-99m MDP and Ga-67 citrate studies and also proved to be helpful with those cases in which I-131 MIBG was planned for therapy. The following strategy is suggested for evaluating neuroblastoma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparative evaluation of technetium-99m glucoheptonate and gallium-67 citrate thoracic imaging in detection of mediastinal and hilar involvement in primary lung cancer

Fifty-two patients with proven primary lung cancer who were referred for mediastinoscopy were prospectively studied with Tc-99m glucoheptonate and Ga-67 citrate thoracic scintigraphy. Primary lung tumors concentrated Ga-67 in 92% of cases, compared to 88% for Tc-99m glucoheptonate. Mediastinoscopy confirmed the presence of mediastinal metastases in 23 patients. The sensitivity of Tc-99m glucoheptonate and Ga-67 scans for mediastinal involvement detection is respectively 52% and 83%, for a specificity of 100% (Tc-99m glucoheptonate) and 88% (Ga-67). Twenty-nine patients underwent thoracotomy after a negative mediastinoscopy. Hilar metastatic involvement was present in eight patients. The sensitivity and the specificity for detection of hilar involvement were respectively 63% and 95% for Tc-99m glucoheptonate and 88% and 78% for Ga-67. Although more specific than Ga-67 scan, Tc-99m glucoheptonate thoracic imaging cannot be recommended in the staging of lung cancer because of its low sensitivity in the detection of intrathoracic metastatic spread of primary lung carcinoma.     

Tc-99m PMT hepatobiliary scintigraphy in the differential diagnosis of extrahepatic metastases and hepatocellular carcinoma

PURPOSE: The authors evaluated the utility of hepatobiliary scintigraphy for tissue characterization of extrahepatic metastases from hepatocellular carcinoma (HCC) using Tc-99m N-pyrydoxyl-5-methyltriptophane (Tc-99m PMT). METHODS: We examined 13 patients with HCC (29 extrahepatic metastases and 3 benign bone lesions) and 5 patients with other cancers (15 extrahepatic metastases). Thirty minutes to 6 hours after intravenous administration of Tc-99m PMT, planar (all 47 lesions) and SPECT (42 lesions) images were obtained. Accumulation of Tc-99m PMT in the lesion was evaluated visually by comparing bone scintigraphy, computed tomography, magnetic resonance imaging, or all of these. RESULTS: Findings were positive in 12 of 13 patients with HCC and extrahepatic metastases (16 of 29 on planar imaging and 21 of 26 on SPECT). Findings in all three benign bone lesions and 15 metastatic lesions from non-HCC primary lesions were negative (0 of 18 on planar imaging, 0 of 16 on SPECT). There were no false-positive findings in these lesions. Lesion-by-lesion sensitivity, specificity, accuracy, and positive and negative predictive values were 55%, 100%, 72%, 100%, and 58% by planar imaging and 81%, 100%, 88%, 100%, and 76% by SPECT, respectively. CONCLUSIONS: Because of the high specificity and reasonable sensitivity, Tc-99m PMT appears to be useful for the differential diagnosis of extrahepatic metastases from HCC. SPECT improves the detectability of small or faint accumulation in metastases from HCC.     

Multifocal Pott's disease (tuberculous spondylitis) incidentally detected on Tc-99m MDP bone and Ga-67 citrate scintigraphy in a patient with diabetes

Pott's disease is an uncommon extrapulmonary form of tuberculosis. Delay in diagnosis and management may cause serious complications. The authors describe Pott's disease incidentally detected on Tc-99m MDP bone and Ga-67 imaging in a patient with diabetes. Tc-99m MDP bone scintigraphy showed intensely increased uptake in the lower cervical spine and lumbosacral regions. Ga-67 scintigraphy revealed intensely increased uptake corresponding to the areas noted on Tc-99m MDP bone scintigraphy. Magnetic resonance imaging showed destructive lesions in the C5-C6 and L5-S1 intervertebral discs with destruction of adjacent end plates. Biopsy of the lumbosacral area was guided by computed tomography, and histologic examination of the bone specimen showed caseation, giant cells, and acid-fast bacilli. Posterior decompression and posterolateral spinal fusion with bone grafts were performed. Antituberculous chemotherapy with isoniazid, rifampicin, pyrazinamide, and ethambutol was started. The patient showed remarkable relief of symptoms during a period of 9 months of therapy. Both Tc-99m MDP bone and Ga-67 imaging can offer the convenience of screening the entire body to detect multiple sites of Pott's disease.     

Tc-99m hexamethylpropylene-amine oxine (HM-PAO) uptake in a bone metastasis

Uptake of Tc-99m Hexamethylpropylene-amine Oxine (HM-PAO) was seen in bone metastases from carcinoma of the lung. The uptake was prominent when compared to Tc-99m MDP, I-123 IMP, and Ga-67 citrate. Brain imaging with Tc-99m HM-PAO and N-isopropyl-p-[I-123] iodoamphetamine (IMP) is now frequently performed. Uptake of these agents has been reported in brain tumors and melanomas. In this report, uptake of Tc-99m HM-PAO in a metastatic lesion in bone is discussed.     

Primary Ewing sarcoma: follow-up with Ga-67 scintigraphy

While avid accumulation of gallium-67 citrate and technetium-99m methylene diphosphonate (MDP) occurs initially in most cases of primary Ewing sarcoma, uptake after therapy is less well defined. Thirty patients with Ewing sarcoma who underwent Ga-67 and bone scintigraphy at diagnosis, at completion of therapy, and at relapse from 1978 to 1988 were evaluated. All 30 patients showed less primary site Ga-67 activity following therapy. Twenty-three of 28 patients who underwent corresponding bone scintigraphy showed less uptake, but residual activity was usually more intense than with Ga-67. Avid reaccumulation of Ga-67 occurred in four of five patients with primary site relapse, while patients who underwent bone scintigraphy showed less change. It was concluded that a greater decrease in Ga-67 than in Tc-99m MDP uptake often occurs in patients successfully treated for primary Ewing sarcoma. Information obtained at Ga-67 scintigraphy is most likely to be helpful if results of bone scintigraphy remain abnormal or if occult relapse is suspected.     

Tc-99m DTPA used as reference imaging to evaluate the distribution of other tumor-seeking tracers in tumors associated with neurofibromatosis.

Two patients with multiple benign and malignant tumors associated with neurofibromatosis underwent radionuclide imaging with Tc-99m DTPA, Tl-201, and Ga-67. In these patients, Tc-99m DTPA accumulated intensively in both the benign and malignant tumors and localized and defined the extent of every tumor. In contrast, Ga-67 and Tl-201 uptake was seen only in focal areas of tumor where there was malignant transformation or at sites that showed progressive tumor growth. Tc-99m DTPA imaging accurately demonstrated areas of neoplastic involvement and identified the areas that would be seen with the other two tracers in individual tumors. Tc-99m DTPA may not always be used for the differential diagnosis of malignant and benign tumors of neurofibromatosis, but it can provide a reference pattern for imaging to evaluate accurately the distribution of Tl-201 and Ga-67 by mapping out the anatomic extent of these tumors.     

Subacute and chronic bone infections: diagnosis using In-111, Ga-67 and Tc-99m MDP bone scintigraphy, and radiography

The usefulness of indium-111 white blood cell scintigraphy in the diagnosis of subacute or chronic bone infection was examined in 21 orthopedic patients. In-111 WBC imaging was compared with gallium-67 and technetium-99m methylene diphosphonate skeletal scintigraphy and bone radiography, all studies being performed within 1 week. In-111 WBC scintigraphy showed no definite advantage over Ga-67 scintigraphy in the identification of chronic bone infection. The two tests had the same sensitivity (80%) and similar specificity (In-111 WBC 75%, Ga-67 83%; difference not significant). Bone radiography had a sensitivity of 60% and a specificity of 67%. A negative Tc-99m MDP bone scintigram ruled out infection (sensitivity 100%), but because of low specificity (25%), final evaluation required performance of Ga-67 or In-111 WBC scintigraphy.     

Tl-201 uptake in brown tumors of hyperparathyroidism.

Tl-201 chloride bone scans were performed on nine patients with primary hyperparathyroidism just after Tl-201 and Tc-99m parathyroid subtraction scintigraphy. Bone lesions accumulate Tl-201, especially in sites of brown tumor formation. This was proven by the histopathologic examination of two patients. Eight patients had bone scans with Tc-99m MDP. The lesion-to-background ratio was quantified in seven patients for Tl-201 and in four patients for Tc-99m MDP. Tl-201 uptake of the lesions were quantified in two patients. The lesion-to-background ratio was 1.63 +/- 0.21 and 2.51 +/- 0.88 for Tl-201 and Tc-99m MDP, respectively. A Ga-67 citrate scan was performed on one patient, and the lesion-to-background ratio was 1.49 +/- 0.06. The accumulation of Tl-201 in brown tumors of bone might be due to increased blood flow and local metabolic activity. Tl-201 chloride was inferior to Tc-99m MDP in lesion detection. It is concluded that bone imaging with Tl-201 can easily be performed following parathyroid subtraction scintigraphy to delineate the sites of brown tumor formation.     

Osteoblastic osteosarcoma of the mandible: findings on Tc-99m HMDP bone and Ga-67 citrate scintigraphy

A 25-year-old woman presented with a disturbance in the opening of her mouth 5 months before admission. On admission, painful swelling of the right preauricular region was revealed. Computed tomography (CT) demonstrated a soft tissue density mass around the right condylar process of the mandible. Tc-99m hydroxymethylene diphosphonate (HMDP) bone scintigraphy and Ga-67 citrate scintigraphy showed avid uptake in the mass. The tumor was histologically identified as an osteoblastic osteosarcoma of the right mandible. There are few reports of Ga-67 citrate scintigraphy findings of osteoblastic osteosarcoma of the mandible. The accumulation patterns on Tc-99m HMDP bone scintigraphy and Ga-67 citrate scintigraphy are possibly characteristic of osteoblastic osteosarcoma of the mandible.     

Lung,gastric, and soft tissue uptake of Tc-99m MDP and Ga-67 citrate associated with hypercalcemia

Metastatic calcifications are associated with chronic renal failure, hyperparathyroidism, metastatic neoplasms, hypervitaminosis D, and hypercalcemia of other origins. Bone scanning agents accumulate within these extraskeletal metastatic calcifications. The authors describe two patients with hypercalcemia associated with Tc-99m MDP uptake in the lungs, stomach, and soft tissues. Ga-67 scintigraphy was also performed and showed increased uptake in the same locations as those of Tc-99m MDP, suggesting the existence of an inflammatory process. Despite adequate treatment, only partial resolution of extraskeletal uptake was observed.     

Combined bone marrow and gallium imaging. Differentiation of osteomyelitis and infarction in sickle hemoglobinopathy

The clinical records and scintigrams of patients with sickle hemoglobinopathy who underwent combined Tc-99m bone marrow imaging and Ga-67 imaging to differentiate osteomyelitis from bony infarction were reviewed. Of 18 paired examinations in 15 patients, osteomyelitis was diagnosed correctly in six cases; in all six, gallium uptake at the symptomatic site was incongruently increased relative to the bone marrow activity. Of the 12 episodes of infarction, 11 showed congruent activity on both Tc-99m and Ga-67 images. The remaining study was interpreted incorrectly as osteomyelitis due to incongruent Tc-99m and Ga-67 uptake. The use of sequential Tc-99m bone marrow and Ga-67 imaging is an effective means of distinguishing osteomyelitis from bony infarction in patients with sickle hemoglobinopathy.     

Accumulation of Tc-99m MIBI in breast lymphoma: Comparison with Ga-67 citrate

We report 2 cases of malignant lymphoma of the breast which were clearly shown on total body imaging as well as on SPECT with Ga-67 and Tc-99m MIBI. Tumor accumulation of Ga-67 was seen in all cases including a recurrent tumor. Ga-67 scintigraphy is useful for follow up in detecting relapse, as well as in predicting responses to therapy. Tc-99m MIBI was found to accumulate in the malignant lymphoma of the breast, and especially SPECT images of breast lesions provided better contrast than planar images, and Tc-99m MIBI SPECT could diagnose localization of the tumor because there was no uptake by the breast. But the Tc-99m MIBI accumulation of the tumor was lower than Ga-67.     

Evaluation of metastatic bone disease with pentavalent 99Tc(m)-dimercaptosuccinic acid: a comparison with whole-body scanning and 4/24 hour quantitation of vertebral lesions

The aim of this study was to establish the value of 99Tcm(V)-DMSA scintigraphy in the detection of metastatic bone lesions and compare the results to 99Tcm-MDP bone scintigraphy. Thirty-four patients presenting with metastatic bone disease (Group 1) and 12 controls with degenerative skeletal lesions (Group 2) were studied. Conventional bone scanning and 99Tcm(V)-DMSA whole-body scanning were performed on all patients. All scans were interpreted visually. Furthermore, lesion-to-normal bone ratios (L/N) in vertebral metastases on the 4 and 24 h bone scans were obtained in 58 lesions of cancer patients and in 23 benign (degenerative) vertebral lesions of the control group. 99Tcm-MDP L/N ratios at 24 h (3.08 +/- 0.32) were significantly higher than those at 4 h (2.48 +/- 0.24) in the malignant foci (P < 0.001). No significant difference was observed in benign lesions (P > 0.05). In 167 (164 metastatic, 3 traumatic) of 186 99Tcm-MDP positive lesions (90%) of Group 1, 99Tcm(V)-DMSA uptake was observed. The remaining 19 lesions (10%) were 99Tcm(V)-DMSA negative. Fourteen of these 19 sites were diagnosed as benign. The remaining five foci were malignant. In four lung cancer metastases showing no 99Tcm-MDP uptake, 99Tcm(V)-DMSA uptake was observed. There was no 99Tcm(V)-DMSA accumulation in any of the 99Tcm-MDP positive degenerative lesions of Group 2. All quantitatively evaluated (n = 42) vertebral metastatic foci and two compression fractures in Group 1 showed 99Tcm(V)-DMSA accumulation and an increased 99Tcm-MDP L/N ratio at 24 h. A total of 36 degenerative lesions (Groups 1 and 2) and one compression fracture (Group 1) showed neither 99Tcm(V)-DMSA uptake nor an increased 99Tcm-MDP L/N ratio at 24 h. Our results indicate that quantitative 4/24 h analysis of vertebral lesions on 99Tcm-MDP scans has a similar diagnostic value to 99Tcm(V)-DMSA imaging in the detection of bone metastases. However, the accumulation of 99Tcm(V)-DMSA in four lung cancer metastases showing no 99Tcm-MDP uptake is encouraging and justifies further research in patients with proven bone metastases and negative bone scans.     

The usefulnes of99mTc-HMPAO-labeled leukocyte scintigraphy in the diagnosis of skeletal metastases of cancers

The usefulness of bone marrow scintigraphy with 99mTc-HMPAO-labeled leukocytes (leukocyte bone marrow scintigraphy) in the diagnosis of skeletal metastases of cancers was investigated in 70 lesions in 27 patients with various types of cancer. The final diagnosis of skeletal metastases was based on one or more criteria consisting of histological confirmation, typical findings of metastases by bone radiograph, CT and MRI, or progressive swellings of the lesions with severe pain due to nerve compression. Of the 70 lesions, 55 were finally diagnosed as metastases, and 15 as benign lesions. Leukocyte bone marrow scintigraphy showed photopenic defects in 52 of the 55 metastatic lesions (sensitivity 95%), and the remaining 3 negative lesions were found positive for metastases by MRI. In contrast, MRI could evaluate only 39 of the 55 lesions because 16 lesions in the ribs, scapula and sternum were not visualized. Of these 39 lesions, MRI showed positive findings for metastases in 33 (sensitivity 85%), and negative findings in 6 with photopenic defects found by leukocyte bone marrow scintigraphy. Of the 15 benign lesions, 3 were false positive for metastases on leukocyte bone marrow scintigraphy (specificity 80%). We conclude that 99mTc-HMPAO-labeled leukocyte bone marrow scintigraphy may be useful in the diagnosis of skeletal metastases of cancers, particularly when MRI fails to evaluate the lesions.     

Tc-99m PMT whole-body scintigraphy for evaluated of therapeutic effect and for monitoring bone metastasis in a patient with hepatocellular carcinoma

Detection of metastatic lesions by bone scintigraphy is highly sensitive but has a low rate of specificity. Often bone metastases from hepatocellular carcinoma are not detected by bone scintigraphy because of low uptake or a photopenic area in the tumor. In contrast, Tc-99m Sn-N-pyridoxy-5-methyltryptophan (Tc-99m PMT) whole-body scintigraphy reflects tumor viability, and the specificity of detection is so high that tumor structure can be shown well. Tc-99m PMT whole-body scintigraphy was helpful for evaluating the response to therapy and monitoring the course of the patient described here with bone metastasis from hepatocellular carcinoma.     

The role of Tc-99m (V) DMSA scintigraphy in the evaluation of superscan on bone scintigraphy

PURPOSE: This study evaluated the biodistribution of Tc-99m (V) DMSA in patients with superscans on bone imaging and defined its role in differentiating the underlying cause. METHODS: Nine patients (five with metastatic and four with metabolic bone disease) with classical superscans were entered into the study. All patients had the necessary radiologic and biochemical studies and a final diagnosis was reached accordingly. Tc-99m (V) DMSA scintigraphy was performed 1 week after Tc-99m MDP whole-body bone imaging. RESULTS: In four of five patients with widespread skeletal metastases, Tc-99m (V) DMSA scan showed diffusely increased bone uptake. In the remaining patient, the Tc-99m (V) DMSA scan showed a normal distribution pattern. All patients with metabolic bone disease had increased bone uptake on Tc-99m (V) DMSA scans. CONCLUSION: Tc-99m (V) DMSA shows increased bone uptake in patients having a superscan appearance in metastatic or metabolic bone disease. Tc-99m (V) DMSA imaging may play a role in the evaluation of patients with equivocal bone scan findings for a superscan.     

99mTc-MIBI scintigraphy in musculoskeletal tumors.

The aim of this study was to assess the value of 99mTc-hexakis2-methoxyisobutylisonitrile (MIBI) scintigraphy in patients with clinical and radiologic features of primary or metastatic musculoskeletal tumors. METHODS: The scintigraphic findings for 84 patients were compared with the surgical and histologic findings. Each patient underwent three-phase bone scanning with 99mTc-methylene diphosphonate (MDP) and dynamic and static MIBI scintigraphy. The MIBI scans were evaluated by visual and quantitative analysis. The count ratio of the lesion to the adjacent or contralateral normal area (L/N) was calculated from the region of interest drawn on the MIBI scan. The Mann-Whitney test was used to determine the differences between the uptake ratios of malignant and benign lesions. RESULTS: Although increased MDP uptake was not specific for bone malignancy, a significant difference was found between benign tumors (L/N = 1.22 +/- 0.43) and malignant tumors (L/N = 2.25 +/- 1.03) on MIBI scans. Sensitivity and specificity were 81% and 87%, respectively. Forty-six of 53 proven benign lesions did not show significant MIBI uptake. The negative predictive value was 88%. In all seven sites of pathologic fracture, significant uptake was seen. However, three malignant lesions were not detected by MIBI scintigraphy, whereas seven benign lesions showed false-positive results. CONCLUSION: The major diagnostic worth of MIBI scintigraphy is its high negative predictive value. Although not capable of replacing tissue biopsy as a definitive diagnostic modality for musculoskeletal neoplasms, MIBI scintigraphy does appear to have a role in better preoperative assessment and in distinguishing between pathologic and simple fractures.     

Uptake of 99Tcm-MDP in lung metastasis from osteosarcoma: clinical and animal studies

Bone scintigraphy was performed in 17 patients with previously known lung metastases of osteosarcoma. 99Tcm-MDP uptake was observed in all primary bone lesions but lung metastatic lesions were positive in only six patients (35%). 99Tcm-MDP uptake by lung metastases was significantly correlated with bone and osteoid formation in the metastatic lesions and preoperative serum ALPase values. These clinical observations were confirmed by using nude mice transplanted with human lung metastatic osteosarcoma. 99Tcm-MDP scintigraphy appears to be useful for detecting lung metastases of osteosarcoma only in a selected group of patients.