Testicular involvement of sarcoidosis diagnosed by gallium-67 scintigraphy

Gallium-67 scintigraphy helped to determine the extent of systemic sarcoidosis and demonstrated testicular involvement in a 32-year-old black man who presented with ataxia, weight loss, and a left testicular mass. To our knowledge, this is the first case of testicular sarcoidosis demonstrated by gallium-67 scintigraphy in a patient with systemic sarcoidosis.     

Ga-67 positivity in sarcoidosis of the skin with coincident thyroid uptake of uncertain etiology

Gallium-67 citrate scintigraphy of a 26-year-old woman with systemic sarcoidosis demonstrated abnormal radiotracer uptake within multiple biopsy-proven sarcoidal cutaneous lesions and within both lobes of the thyroid gland. The etiology of the thyroidal uptake of the Ga-67 was uncertain but it may represent sarcoidal involvement of the gland.     

Muscular sarcoidosis: Ga-67 scintigraphy and magnetic resonance imaging

Ga-67 scintigraphy is helpful in the assessment of active extrapulmonary sarcoidosis. Muscular involvement of sarcoidosis is often asymptomatic or nonspecific, and laboratory examinations do not provide convincing evidence of muscular involvement. The authors report a case of muscular sarcoidosis detected by Ga-67 scintigraphy. In a patient who had fever and arthralgia of both knee joints, Ga-67 scintigraphy showed mediastinal and hilar involvement of sarcoidosis with unexpected extensive muscular uptake. Magnetic resonance imaging revealed in detail intramuscular infiltration of sarcoid granuloma. Ga-67 scintigraphy is useful in detecting inflammatory muscular involvement of sarcoidosis and other multiorgan involvement.     

The evolutional stage changes in sarcoidosis on gallium-67 scintigraphy

Gallium-67 scintigraphy has been proven as the imaging modality of choice in monitoring the presence of active disease in sarcoidosis. The purpose of this study is to analyze the patterns of evolutional stage changes of sarcoidosis while on steroid therapy by Ga-67 scintigraphy.Methods: Eighty-six consecutive patients with biopsy-proved sarcoidosis are evaluated by Ga-67 scintigraphy. Thirty-six of 86 patients have had a baseline and one to eight follow-up Ga-67 scintigraphs (total 136 studies). The initial follow-up scintigraphs are obtained on average about 4–12 months after the baseline study.Results: Seventeen of 36 patients (47.2%) are in stage IV at the time of the baseline study. Following their first course of corticosteroid therapy, 13 patients remained in the same stage and activity distribution pattern while 13 patients have shown reversion to other stages, eight patients showed complete remission while two patients became active from inactive stage.Conclusion: Evolutional stage changes are seen in 23 patients (63.9%), including eight patients (22.2%) who showed complete scintigraphic remission. The evolutionary stage changes remain quite variable and unpredictable. This, however, should not detract from the usefulness of Ga-67 scintigraphy in the diagnosis and prognostic evaluation of sarcoidosis, particularly when extrapulmonary involvement (Stage IV disease) is present.     

Usefulness of fasting 18F-FDG PET in identification of cardiac sarcoidosis.

Cardiac PET using (18)F-FDG under fasting conditions (fasting (18)F-FDG PET) is a promising technique for identification of cardiac sarcoidosis and assessment of disease activity. The aim of this study was to investigate the usefulness of fasting (18)F-FDG PET in detecting inflammatory lesions of cardiac sarcoidosis from a pathophysiologic standpoint. METHODS: Twenty-two patients with systemic sarcoidosis were classified into 2 groups of 11 each according to the presence or absence of sarcoid heart disease. Cardiac sarcoidosis was diagnosed according to the Japanese Ministry of Health and Welfare guidelines for diagnosing cardiac sarcoidosis with the exception of scintigraphic criteria. Nuclear cardiac imaging with fasting (18)F-FDG PET, (99m)Tc-methoxyisobutylisonitrile ((99m)Tc-MIBI) SPECT, and (67)Ga scintigraphy were performed in all patients. PET and SPECT images were divided into 13 myocardial segments and the standardized uptake value (SUV) of (18)F-FDG was calculated and defect scores (DS) for (99m)Tc-MIBI uptake were assessed for each segment. The total SUV (T-SUV) and total DS (TDS) were calculated as the sum of measurements for all 13 segments, and the diagnostic accuracy of fasting (18)F-FDG PET was compared with that of the other nuclear imaging modalities. In addition, pathophysiologic relationships between inflammatory activity and myocardial damage were examined by segmental comparative study using the SUV and DS. RESULTS: In patients with cardiac sarcoidosis, fasting (18)F-FDG PET revealed a higher frequency of abnormal myocardial segments than (99m)Tc-MIBI SPECT (mean number of abnormal segments per patient: 6.6 +/- 3.0 vs. 3.0 +/- 3.2 [mean +/- SD], P < 0.05). The sensitivity of fasting (18)F-FDG PET in detecting cardiac sarcoidosis was 100%, significantly higher than that of (99m)Tc-MIBI SPECT (63.6%) or (67)Ga scintigraphy (36.3%). The accuracy of fasting (18)F-FDG PET was significantly higher than (67)Ga scintigraphy. The T-SUV demonstrated a good linear correlation with serum angiotensin-converting enzyme levels (r = 0.83, P < 0.01), and the TDS showed a significant negative correlation with the left ventricular ejection fraction (r = -0.82, P < 0.01). In abnormal myocardial segments on the nuclear scan, the SUV showed a significant negative correlation with the DS (r = -0.63, P < 0.0001). CONCLUSION: This study suggests that fasting (18)F-FDG PET can detect the early stage of cardiac sarcoidosis, in which fewer perfusion abnormalities and high inflammatory activity are noted, before advanced myocardial impairment.     

Scintigraphic demonstration of myocardial sarcoidosis: The added value of single-photon emission computed tomography

Conclusions  Myocardial involvement in sarcoidosis can be diagnosed noninvasively by a combination of radionuclide studies. Myocardial ⁶⁷Ga uptake in this case study was demonstrable only with SPECT. This emphasizes the fact that SPECT enhances the diagnostic value of most scintigraphic procedures as a result of better contrast and three-dimensional orientation. It is inferred from this case that negative planar ⁶⁷Ga scintigraphy is inconclusive with regard to myocardial involvement of sarcoidosis.     

67Ga scintigraphy as an index of disease activity in pulmonary sarcoidosis

Gallium-67 scintigraphy was performed in 38 patients with pulmonary sarcoidosis to assess its value as a supplement to the clinical, radiographical and functional investigations. In 32 (84%) of the 38 patients the scan was abnormal and showed ⁶⁷Ga uptake in the pulmonary parenchyma and/or hilum. The incidence and severity of pulmonary symptoms correlated poorly with the localization and degree of ⁶⁷Ga accumulation. During the clinical follow-up of untreated patients ⁶⁷Ga scintigraphy showed regression earlier than chest radiography. Large doses of corticosteroids decreased the accumulation of ⁶⁷Ga in the pulmonary parenchyma and hilum. The chest radiographical improvement was more gradual.The ⁶⁷Ga scan can be used as an index of disease activity in the follow-up of patients with pulmonary sarcoidosis, whether or not they are treated with corticosteroids. Nevertheless, the results have to be considered together with other clinical data.     

Positivity of extrapulmonary Ga-67 uptake in sarcoidosis: Thyroid uptake due to chronic thyroiditis and bone uptake due to fibrous dysplasia

Ga-67 citrate scintigraphy was performed on a 29-year-old man who had been diagnosed as having pulmonary sarcoidosis by a transbronchial lung biopsy. A Ga-67 citrate scintigram showed increased uptake not only in the pulmonary hilum and mediastinum, but also in the thyroid gland and the right ilium. Chronic thyroiditis was confirmed by aspiration biopsy of the thyroid gland, and fibrous dysplasia was confirmed by CT guided biopsy of the right ilium. Extrapulmonary Ga-67 uptake in patients with sarcoidosis does not necessarily indicate the involvement of other tissues and organs.     

Comparative evaluation of 18F-FDG PET and 67Ga scintigraphy in patients with sarcoidosis.

67Ga scintigraphy has been used for years in sarcoidosis for diagnosis and the extent of the disease. However, little information is available on the comparison of 18F-FDG PET and 67Ga scintigraphy in the assessment of sarcoidosis. The purpose of this study was to compare the uptake of 18F-FDG and 67Ga in the evaluation of pulmonary and extrapulmonary involvement in patients with sarcoidosis. METHODS: Eighteen patients with sarcoidosis were examined. 18F-FDG PET was performed at 1 h after injection of 185-200 MBq 18F-FDG. 67Ga whole-body planar and thoracic SPECT images were acquired 72 h after injection of 111 MBq 67Ga. We evaluated 18F-FDG and 67Ga uptake visually and semiquantitatively using standardized uptake values (SUVs) and the ratio of lesion to normal lumbar spine (L/N ratio), respectively. The presence of pulmonary and extrapulmonary lesions was evaluated histopathologically or by the radiologic findings. RESULTS: Five patients had only pulmonary lesions, 12 patients had both pulmonary and extrapulmonary lesions, and 1 patient had only an extrapulmonary lesion. Both 67Ga planar and SPECT images detected 17 of 21 (81%) clinically observed pulmonary sites. The mean +/- SD of the L/N ratio was 1.97 +/- 1.09. 67Ga planar images detected 15 of 31 (48%) clinically observed extrapulmonary sites. The mean +/- SD of the L/N ratio was 1.17 +/- 0.33. 18F-FDG PET detected all 21 (100%) clinically observed pulmonary sites. The mean +/- SD of the SUV was 7.40 +/- 2.48. 18F-FDG PET detected 28 of 31 (90%) clinically observed extrapulmonary sites. The mean +/- SD of the SUV was 5.90 +/- 2.75. CONCLUSION: The results of this clinical study suggest that 18F-FDG PET can detect pulmonary lesions to a similar degree as 67Ga scintigraphy. However, 18F-FDG PET appears to be more accurate and contributes to a better evaluation of extrapulmonary involvement in sarcoidosis patients.     

The appearance of "lambda" and "panda" sign on Ga-67 scintigraphy in sarcoidosis]

The lesions of sarcoidosis generally show relatively high Ga-67 uptake and the usefulness of scintigraphy using this agent in the evaluation of lesion activity is well known. In this report, we assessed characteristic uptake of Ga-67 in intrathoracic lymphnodes, the shape of which resembled the Greek letter Lambda (Lambda sign) and a symmetrical accumulation in bilateral lacrimal and salivary glands which resembled a Panda face (Panda sign) in patients with sarcoidosis. Our review of Ga-67 scans obtained from 15 patients with sarcoidosis and 1,779 patients with other disorders during the past 3 years revealed that the simultaneous presence of both Lambda and Panda signs was specific to patients with sarcoidosis and was not found in patients with various other disorders, although one of these signs might be observed in patients without sarcoidosis. When Lambda-like sign was observed, chest radiogram or CT was necessary for the differential diagnosis of sarcoidosis. Panda sign was observed frequently among patients who had previously received irradiation of the neck. Our results confirmed that sarcoidosis must be suspected when both Lambda and Panda signs were observed.     

Solitary muscular sarcoidosis: CT,MRI, and scintigraphic characteristics

Scintigraphy using gallium-67 (⁶⁷Ga) citrate and penvaralent technetium-99m dimercaptosuccinic acid {[^99mTc(V)]DMSA} and other radiological examinations were performed in three patients with solitary muscular sarcoidosis who had tumor-like muscular lesions. Although distinction from other invasive soft tissue tumors was difficult using plain and enhanced computed tomography and magnetic resonance imaging, marked uptake of⁶⁷Ga and moderate uptake of [^99mTc(V)]DMSA were shown at the sites of granulomatous inflammatory lesions of sarcoidosis. Both⁶⁷Ga and [^99mTc(V)]DMSA scintigraphy could be of value in the diagnosis and detection of distribution of granulomas of sarcoidosis in the soft tissue and in determining the appropriate region for biopsy.     

Somatostatin receptor scintigraphy and gallium scintigraphy in patients with sarcoidosis.

Somatostatin receptor scintigraphy (SRS) has been shown to reveal sarcoidosis sites. The aim of this study was to prospectively compare SRS and gallium scintigraphy in the evaluation of pulmonary and extrapulmonary involvement in patients with proven sarcoidosis. METHODS: Eighteen patients with biopsy-proven sarcoidosis were included. Nine were or recently had been receiving steroid therapy at the time of the examination. Planar gallium scintigraphy (head, chest, abdomen, and pelvis) and thoracic SPECT were performed at 48-72 h after injection of a mean dose of 138 +/- 21 MBq 67Ga. Planar SRS and thoracic SPECT were performed at 4 and 24 h after injection of a mean dose of 148 +/- 17 MBq 111n-pentetreotide. RESULTS: Gallium scintigraphy found abnormalities in 16 of 18 patients (89%) and detected 64 of 99 clinically involved sites (65%). SRS found abnormalities in 18 of 18 patients and detected 82 of 99 clinically involved sites (83%). Of the 9 treated patients, gallium scintigraphy found abnormalities in 7 (78%), detecting 23 of 39 clinically involved sites (59%), whereas SRS found abnormalities in 9, detecting 32 of 39 clinically involved sites (82%). CONCLUSION: This study suggests that, compared with gallium scintigraphy, SRS appears to be accurate and contributes to a better evaluation of organ involvement in sarcoidosis patients, especially those treated with corticosteroids.     

Effectiveness of prolonged fasting 18f-FDG PET-CT in the detection of cardiac sarcoidosis

Background  

The Japanese Ministry of Health and Welfare guidelines (JMHWG) are currently the standard used to diagnose cardiac sarcoidosis. JMHWG incorporate ⁶⁷Gallium scintigraphy as a minor criterion, while fasting ¹⁸fluorine-2-fluro-2-deoxy-d-glucose (FDG) PET is not included. As there is no published data comparing the accuracy of prolonged fasting FDG PET-CT (PF-PET) and Gallium scintigraphy for detecting active cardiac sarcoidosis, we sought to compare these two modalities.     

Clinical relevance of gallium-67 scintigraphy in lymphoma before and after therapy

The clinical impact of gallium-67 scintigraphy before and after therapy for lymphoma remains controversial. The aims of this study were: (1) to compare the staging of lymphoma by ⁶⁷Ga scintigraphy only with staging by clinical examination and conventional imaging (CI), and (2) to analyse the clinical relevance of both ⁶⁷Ga imaging and CI after treatment. From March 1995 to November 1998, 86 ⁶⁷Ga scintigraphy studies were performed in 62 patients with Hodgkin’s disease (n=52) or non-Hodgkin’s lymphoma (n=10). ⁶⁷Ga scintigraphy was performed at diagnosis (n=44) or after therapy (n=42) using 185–220 MBq ⁶⁷Ga citrate and planar and single-photon emission tomography (SPET) studies. Treatment comprised radiotherapy, chemotherapy or combined modalities. CI included plain chest radiography, computed tomography (CT) of the chest and abdomen/pelvis, ultrasound of the abdomen, lymphography, bone marrow biopsy and, when necessary, magnetic resonance imaging (MRI) and bone scintigraphy. For individual suspected sites of disease before treatment, complete agreement between clinical examination and CI on the one hand and ⁶⁷Ga scintigraphy on the other hand was observed in 25/44 patients (57%; 95% confidence interval 41%–72%). Clinical examination and CI showed more sites than did ⁶⁷Ga scintigraphy in 12/44 patients (27%) and ⁶⁷Ga imaging demonstrated more sites than CI in 6/44 patients (11%). The clinical stage of the disease as assessed using ⁶⁷Ga scintigraphy only was in agreement with that using all diagnostic procedures in 34/44 patients (77%; 95% confidence interval 62%–89%). Compared with CI staging, ⁶⁷Ga scintigraphy downstaged seven patients (16%) and upstaged three (7%). ⁶⁷Ga scintigraphy downstaged mainly because of the limited value of the technique below the diaphragm and upstaged owing to the good sensitivity in the lung. After therapy, both CI and ⁶⁷Ga scintigraphy were normal in 11 patients. All but one of these patients were in complete remission after a median follow-up of 31 months. In contrast, radiological residual mass was observed in 31/42 patients. ⁶⁷Ga imaging was normal in 22/31 (71%); 17 of these 22 patients, including nine with a large residual mass (≥2 cm), were in complete remission after a median follow-up of 32 months, while four suffered relapses 8–45 months later. The cause of death remained unknown in one patient. ⁶⁷Ga scintigraphy showed abnormal uptake in 9 of the 31 patients with a large residual mass. Active disease was demonstrated in eight patients and one patient was in complete remission 30 months thereafter. Our data show that ⁶⁷Ga imaging cannot replace CI in initial staging but can demonstrate additional individual sites of disease in more than 10% of patients and can lead to clinical upstaging with potential prognostic and therapeutic consequences. After therapy, ⁶⁷Ga scintigraphy has a clinical impact when radiological abnormalities persist because it can either avoid unnecessary complementary treatment or confirm the need to change treatment modalities. Received 5 July and in revised form 9 September 1999     

Gallium-67-citrate scanning in patients with sarcoid uveitis.

Gallium-67-citrate is useful for characterizing activity in patients with sarcoidosis. Gallium-67 uptake in bilateral symmetrical hilar lymphadenopathy and/or symmetrical salivary glands is typical of this clinical entity. Sarcoidosis is a systemic disease, and uveitis is considered the hallmark of ophthalmic sarcoidosis. We present two cases of ophthalmic sarcoidosis that shows uveal accumulation of 67Ga-citrate associated with clinical symptoms.     

Sarcoidosis: A truly protean disease

Sarcoidosis is a multisystem disease, the activity of the disease process can be ascertained by determining the angiotension levels in blood. This also can be achieved by ⁶⁷Ga scintigraphy that will inform about different areas of localisation of the disease process. ⁶⁷Ga-scintigraphy is also useful in the follow-up of patients with sarcoidosis and to evaluate the response to therapy.     

Detection of denervated but viable myocardium in cardiac sarcoidosis with I-123 MIBG and Tl-201 SPECT imaging

A 58-year-old man, who had biopsy-proven cardiac sarcoidosis, underwent TI-201 and I-123 MIBG cardiac scintigraphy. Although no perfusion defect was identified by Tl-201, mild heterogeneity of I-123 MIBG uptake was present in the myocardium. The denervated but viable myocardium was demonstrated in the heart with sarcoidosis. Cardiac sympathetic nerve function was impaired in cardiac sarcoidosis, slightly improved with steroid therapy. I-123 MIBG scintigraphy may be useful to assess extent of myocardial involvement and response to therapy.     

Sarcoidosis: a truly protean disease

Sarcoidosis is a multisystem disease, the activity of the disease process can be ascertained by determining the angiotension levels in blood. This also can be achieved by 67Ga scintigraphy that will inform about different areas of localisation of the disease process. 67Ga-scintigraphy is also useful in the follow-up of patients with sarcoidosis and to evaluate the response to therapy.     

A <Superscript>18</Superscript>F-FDG-positive, <Superscript>67</Superscript>Ga-negative,and transferrin receptor expression-negative patient with diffuse large B-cell lymphoma

We recently experienced a case with uveitis suffering from fever of unknown origin suspected of being caused by sarcoidosis. Chest computed tomography showed right supraclavicular, bilateral mediastinal, and right hilar lymphadenopathy, and intensive abnormal uptake of 2-[¹⁸F]fluoro-2-deoxy-d-glucose (¹⁸F-FDG) was observed on positron emission tomography with ¹⁸F-FDG (FDG-PET). On the other hand, ⁶⁷Ga scintigraphy showed almost no abnormal findings. Histopathological examination revealed the lesion to be a diffuse large B-cell lymphoma (DLBCL), namely, an aggressive non-Hodgkin lymphoma from a right supraclavicular lymph node biopsy specimen. Additional immunohistochemical analysis showed the negative expression of transferrin receptor (TfR) on the formalin-fixed paraffin-embedded specimen. Although DLBCL is generally considered to be a ⁶⁷Ga-avid tumor, it does not always have a large number of TfRs and that leads to a discrepancy between the ⁶⁷Ga scintigraphy and FDG-PET findings. FDG-PET should be more appropriate for the initial staging of DLBCL than ⁶⁷Ga scintigraphy, whereas ⁶⁷Ga scintigraphy might be able to provide additional information including prognostic factors and to support strategies that target TfR for cancer therapy.     

Sarcoidosis of the parotid gland

The clinical and radiological features of parotid-gland sarcoidosis in 22 patients are presented. This occurred in association with systemic disease as painless, diffuse and nonnodular parotid swelling. Conventional sialography usually demonstrated normal proximal ducts, a few fragile distal ducts and non-specific parenchymal nodules. Computed tomography, with or without simultaneous sialography, defined and characterised such nodules and demonstrated normal periparotid anatomy. Sialography contributes little additional information to thorough clinical examination in non-nodular or multinodular glands. However, solitary nodules appear to be better investigated by sialography, CT and CT-guided aspiration, thereby allowing diagnosis and direct medical therapy and avoiding surgery. Ultrasonography and nuclear scintigraphy were of little value in this study.