99mTc bone scanning agents--III. Preparation and gel chromatography of 99mTc(Sn)MDP complexes

The preparation of 99mTc(Sn)MDP was investigated as a function of pH, MDP concentration and Sn(II) concentration. The labeling efficiency was over 90% in the majority of the experiments and remained constant over the range pH 2-9. The MDP concentration had little effect, while the Sn(II) concentration had a significant positive influence. The complex formation appeared to be partly reversible. The formation of different complexes was investigated by means of gel chromatography under various experimental conditions. Altogether six complexes were found. At acid conditions two major complexes were found and at neutral pH one major complex. The presence or absence of a particular complex was mainly determined by the pH and by the MDP concentration. The Sn(II) concentration had very little effect. The results are compared with previous results of similar experiments with 99mTc(Sn)pyrophosphate.     

In vitro comparison of HMPAO and gentisic acid for labelling leukocytes with 99mTc

Leukocytes can be labelled with 99mTc using HMPAO and gentisic acid methods. We compared the two methods with respect to labelling efficiency on mixed leukocytes and isolated polymorphonuclear (PMN) and mononuclear (MN) cells, and the in vitro stability of the label. HMPAO produced approximately 70% labelling efficiency on mixed or PMN cells and the label was stable in saline or plasma. Labelling efficiency on MN was only 14% and was less stable. Gentisic acid produced a labelling efficiency of 52% on PMN and 35% on MN; both were stable in saline but less stable in plasma. In conclusion, HMPAO produces higher labelling efficiency and the label shows greater in vitro stability in plasma. However, gentisic acid is much less expensive to use, allows labelling of MN cells, and should result in more favourable microdosimetry. Preliminary clinical results suggest that gentisic acid is equivalent to HMPAO but has the advantage of being much cheaper.     

In vitro comparison of HMPAO and gentisic acid for labelling leukocytes with99mTc

Leukocytes can be labelled with^99mTc using HMPAO and gentisic acid methods. We compared the two methods with respect to labelling efficiency on mixed leukocytes and isolated polymorphonuclear (PMN) and mononuclear (MN) cells, and the in vitro stability of the label. HMPAO produced approximately 70% labelling efficiency on mixed or PMN cells and the label was stable in saline or plasma. Labelling efficiency on MN was only 14% and was less stable. Gentisic acid produced a labelling efficiency of 52% on PMN and 35% on MN, both were stable in saline but less stable in plasma. In conclusion, HMPAO produces higher labelling efficiency and the label shows greater in vitro stability in plasma. However, gentisic acid is much less expensive to use, allows labelling of MN cells, and should result in more favourable microdosimetry. Preliminary clinical results suggest that gentisic acid is equivalent to HMPAO but has the advantage of being much cheaper.     

Technetium-99m (99mTc) mercaptoacetyltriglycine: update on the new 99mTc renal tubular function agent.

Technetium-99m (99mTc) mercaptoacetyltriglycine (MAG3) is a new renal radiopharmaceutical that was recently introduced as a 99mTc-labeled replacement for iodine-131 (131I) o-iodohippurate (OIH). Since its introduction, a wide variety of in vitro and in vivo studies have been performed to characterize the high-performance liquid chromatography (HPLC)-purified complex and kit formulations. [99mTc]MAG3 has a slower plasma clearance, a higher plasma protein binding, less red blood cell (RBC) penetration, a lower extraction ratio, and a smaller volume of distribution than OIH. Because of the slower plasma clearance, [99mTc] MAG3 cannot be used as a direct measurement of effective renal plasma flow. Simplified methods have been developed to calculate [99mTc]MAG3 clearances, as well as regression equations to convert these clearances to an equivalent OIH value. The image quality of [99mTc]MAG3 is superior to [131I]OIH; the renogram curves and the fraction of the dose of the two agents that appears in the urine are almost identical, even though the plasma clearance of [99mTc]MAG3 is only 50% to 65% that of OIH. [99mTc]MAG3 compares favorably with OIH in patients with a wide range of clinical problems. The radiation dose to a patient with normal renal function using standard imaging doses is higher for [99mTc]MAG3 than for [131I]OIH, but in patients with impaired renal function, the radiation dose from [131I]OIH is much higher than [99mTc]MAG3. [99mTc]MAG3 also provides superior image quality compared with [99mTc]diethylenetriaminepentaacetic acid (DTPA) in patients with impaired renal function, but it is important to note that [99mTc]MAG3 cannot be used to measure the glomerular filtration rate (GFR). [99mTc]MAG3 is the most promising 99mTc tubular function agent to date, and it has replaced OIH and [99mTc]DPTA in a number of institutions. However, there are physiologic differences between these three agents and, therefore, they should not be expected to behave identically in all clinical conditions.     

Diagnosis of hepatic hemangioma with simplified double 99mTc labelling

The authors report on their experience with liver hemangioma (LH) diagnosis by means of a simplified method--that is, the simultaneous, in vivo, double labelling of liver reticuloendothelial system (RES) and of red blood cells (RBC) by 99mTc. Twenty-eight patients with US diagnosis of suspected LH and 15 controls were examined after sequential iv injection of SnCl2, of 99mTc-mucolloid albumin and, after liver scintigraphy, of 99mTc-pertechnetate to conclude in vivo RBC labelling. All patients underwent CT and, if necessary, CT-guided biopsy. Focal colloid defects filled after RBC labelling were shown in 20/22 patients with unquestionable LH. No colloid defects were shown in 6/28 cases (expansive process). 15/15 controls showed unchanged non-filling defects after double labelling. Finally, the authors point out that, in the diagnosis of LH, sequential double labelling of liver RES and RBC appears to be a quicker scintigraphic technique than conventional ones. Moreover, this technique has the same high specificity and sensitivity as more time-consuming ones.     

A convenient method for the preparation of 99mTc(V)dimercaptosuccinic acid (99mTc(V)-DMSA)

Tc(IV)-DMSA for kidney scintigraphy has been prepared in acidic solution. Once the labeling is done in basic solution, upon addition of a small amount of NaHCO3, a mixture of 3-4 other DMSA-complexes is formed, presumably containing Tc(V). Kidney uptake in male adult rats of the 99mTc(V)-DMSA is 1.6% injected dose/g (4.9%/total organ) compared to 16.4% injected dose/g (resp. 50.3%/total organ) for 99mTc(IV)-DMSA.     

Improved brain scan specificity utilizing 99mTc-pertechnetate and 99mTc(Sn)-diphosphonate.

Each of 36 patients was studied with two separate brain scans performed sequentially after the injection of 20 mCi of 99mTc-pertechnetate or 20 mCi of 99mTc(Sn)-diphosphonate. The resulting scans were qualitatively compared, and lesion-to-nonlesion ratios of activity determined. Diagnoses were established by clinical criteria and were supported in the majority of cases by computerized axial tomography or roentgen angiography or both. Histologic confirmation was available in five cases of tumor and in the single cases of subdural hematoma and cerebral abscess. Of 22 cerebral infarctions, 15 were better demonstrated with 99mTc-(Sn)-diphosphonate than with 99mTc-pertechnetate. Of the seven remaining cases, three were visualized equally well with each agent, and three were better demonstrated with 99mTc-pertechnetate. One was not seen with either agent. Of the 12 tumors, 11 were visualized better with 99mTc-pertechnetate than with 99mTc-(Sn)-diphosphonate while in one case the lesion was seen equally as well with both agents. In no case was a lesion definitely seen with one radiopharmaceutical and not with the other. These results indicate that this dual method is helpful in differentiating gliomas and metastases from cerebral infarctions.     

The Clinical Usefulness of 99mTc HMPAO Leukocyte/99mTc Phytate Bone Marrow Scintigraphy for Diagnosis of Prosthetic Knee Infection: A Preliminary Study

Purpose

The preferred radionuclide imaging procedure for diagnosing prosthetic joint infection is combined radiolabeled leukocyte/^99mTc sulfur colloid bone marrow scintigraphy, which has an accuracy of over 90 %. Unfortunately, sulfur colloid is no longer available in South Korea. In this study, we evaluated the usefulness of ^99mTc phytate, a substitute for ^99mTc sulfur colloid, when combined with radiolabeled leukocyte scintigraphy in suspected prosthetic knee infections.

Methods

Eleven patients (nine women, two men; mean age 72 ± 6 years) with painful knee prostheses and a suspicion of infection underwent both ^99mTc HMPAO leukocyte scintigraphy (LS) and ^99mTc phytate bone marrow scintigraphy (BMS). The combined images were interpreted as positive for infection when radioactivity in the LS at the site of clinical interest clearly exceeded that of the BMS (discordant); they were interpreted as negative when the increased activity in the LS was consistent with an increased activity in the BMS (concordant). The final diagnosis was made with microbiological or intraoperative findings and a clinical follow-up of at least 12 months.

Results

Five of eleven patients were diagnosed as having an infected prosthesis. The overall sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of the combined LS/BMS were 100 %, 83 %, 83 %, 100 % and 91 %, respectively.

Conclusion

We find that combined ^99mTc HMPAO LS/^99mTc phytate BMS shows comparable diagnostic performance to other studies utilizing sulfur colloid. Combined ^99mTc HMPAO LS/^99mTc phytate BMS is therefore expected to be an acceptable alternative to combined radiolabeled LS/^99mTc sulfur colloid BMS for diagnosing prosthetic knee infections.     

99mTc bone scanning agents--II. Adsorption of 99mTc(Sn)pyrophosphate complexes on the mineral phase of bone

The adsorption of pyrophosphate, tin-pyrophosphate and 99mTc(Sn)pyrophosphate on Ca3(PO4)2 was investigated at pH 4.0 and pH 7.4. All components were radioactively labeled. Tin and reduced technetium were in most cases almost completely bound. The adsorption of pyrophosphate, tin(II) and technetium-99m at pH 4.0 was higher than at pH 7.4. The presence of tin gave rise to an increase of the pyrophosphate adsorption that was much larger than can be accounted for by a stoichiometric adsorption of tin-pyrophosphate. It is concluded that tin and technetium are bound as negatively charged complexes with pyrophosphate. Finally it is argued that the fraction of the bone scanning agent that reaches the bone surface is adsorbed completely by the mineral phase.     

Seven-hour stabilization of 99Tcm-exametazime (HMPAO) for cerebral perfusion

The objective of this study was to increase the stability of 99Tcm-exametazime and to investigate the effects of relaxing the eluate restrictions imposed by the manufacturer. We added 1800 MBq freshly eluted pertechnetate to 0.5 ml aliquots of stannous-enhanced exametazime followed by the addition of 0.7 mg gentisic acid and 0.5 ml sterile absolute alcohol BP. The radiochemical purity as measured by thin-layer chromatography was maintained at over 80% (range 88-99%, n = 40) for up to 7 h after preparation. High-performance liquid chromatography confirmed that the primary complex was maintained at over 80% (ranges 89-92%) for up to 7 h. In a second series of studies using the first eluate from a newly delivered generator to prepare 99Tcm-exametazime, a radiochemical purity of more than 80% was achieved for up to 7 h (range 88-95%, n = 24). In a third series using a 3-hour-old generator eluate, a radiochemical purity of more than 80% (range 88-93%, n = 18) was achieved for up to 5 h (for logistic reasons, we were unable to continue readings beyond 5 h). These results suggest that the manufacturer's restrictions on the eluate may be relaxed. Clinical validation was performed in a blinded study of 21 patients using single photon emission tomography. Image quality was assessed on the basis of salivary activity, nasal activity and the overall (global) image quality. There was no significant difference between the images obtained using the stabilized exametazime and exametazime prepared without gentisic acid and ethanol (chi 2 = 2.85, P = 0.05). We conclude that stabilization of 99Tcm-exametazime can be achieved for up to 7 h by using gentisic acid and alcohol and that the eluate restrictions may be disregarded.     

Standardization of 99mTc.

The radioactivity of 99mTc was standardized by the 4piPC-gamma coincidence method with two different modes. One is using coincidences between (119.5-142.6)keV conversion electrons and K X-rays, and the other is coincidences between the 2.13 keV conversion electrons and 140.5 keVgamma-rays. The background of the K X-ray peak and the sensitivity of the proportional counter (PC) to 140 keV gamma-rays were the main sources of uncertainties in the first case and low detection efficiency for conversion electrons in the second case. General coincidence equations were written, with specific forms, for the three measurement variants, including literature variant. Comparison with the ionization chamber calibration is reported.     

Protein-binding and urinary excretion of 99mTc(Sn)-MDP and 99mTc-MDP

In an incubation experiment the Human Serum Albumin (HSA) binding of 99mTc-MDP (electrolytically labeled) and 99mTc(Sn)-MDP is established. During the incubation some pertechnetate is formed and in the case of 99mTc(Sn)-MDP also some hydrolyzed 99mTc. The HSA binding of 99mTc-MDP is less than the HSA binding of 99mTc(Sn)-MDP as established with gel chromatography, TCA-precipitation, ammonium sulfate precipitation and ultrafiltration. TCA-precipitation seems to be an insufficient method for determining the protein binding of 99mTc(Sn)-MDP. The urinary excretion in rats shows only one 99mTc-compound in both cases. The bone seeking properties of the urine-excreted 99mTc-compound were confirmed in another rat.     

99mTc bone scanning agents--I. Influence of experimental conditions on the formation and gel chromatography of 99mTc(Sn)pyrophosphate complexes

The conversion of 99mTcO4- to 99mTc(Sn)pyrophosphate complexes was investigated under various experimental conditions. An increase of the Sn(II) concentration had a beneficial effect, whereas the ligand concentration had little effect. The pH had only a small influence over the range 2-8. Raising the pH to 10 resulted in the partial decomposition of the complexes, which could be reversed by lowering the pH. Furthermore, the occurrence of various complexes was investigated by means of gel chromatography on Biogel P-4 as a function of pH and of the Sn(II) and pyrophosphate concentrations. Four major fractions were found. A single preparation contained, however, no more than two major fractions. The formation of the different complexes was mainly governed by the pH and the ligand concentration. The influence of the eluent on the decomposition and interconversion of the complexes during chromatography was also studied. It appeared to be necessary that the eluent should have the same composition (except for 99mTcO4-) as the reaction mixture.     

A comparative study of 99mTc and 131I in thyroid scanning

Thyroid scans performed with both 99mTc pertechnetate (99mTcO4) and (131I) were compared in 46 patients with palpable thyroid nodules to determine whether 131I scanning is any longer a necessary procedure. A discrepancy between the two types of scan existed in only three cases, in one of which the thyroid nodule showed uptake of 99mTcO4 but not of 131I. Subsequent surgery revealed a thyroid malignancy in this patient. In each of the other two discrepancies a nodule "cold" on 99mTcO4 scanning was apparently functioning on 131I scanning, and was found to be benign at surgery. As the convenience and lower radiation absorbed dose of 99mTcO4 patients compared with 131I make it a better scanning agent, it is recommended that 99mTcO4 scans of the thyroid be first nodules. If these nodules prove to be functioning equally with paranodular tissue, a 131I scan should also be performed to help exclude a possible thyroid malignancy.     

A comparative study of 99mTc and 131I in thyroid scanning

Thyroid scans performed with both ^99mTc pertechnetate (^99mTcO₄) and (¹³¹I) were compared in 46 patients with palpable thyroid nodules to determine whether ¹³¹I scanning is any longer a necessary procedure. A discrepancy between the two types of scan existed in only three cases, in one of which the thyroid nodule showed uptake of ^99mTcO₄ but not of ¹³¹I. Subsequent surgery revealed a thyroid malignancy in this patient. In each of the other two discrepancies a nodule cold on ^99mTcO₄ scanning was apparently functioning on ¹³¹I scanning, and was found to be benign at surgery. As the convenience and lower radiation absorbed dose of ^99mTcO₄ compared with ¹³¹I make it a better scanning agent, it is recommended that ^99mTcO₄ scans of the thyroid be first performed in the assessment of patients with thyroid nodules. If these nodules prove to be functioning equally with paranodular tissue, a ¹³¹I scan should also be performed to help exclude a possible thyroid malignancy.     

Biokinetics of bone tracers by means of deconvolution analysis--comparison of 99mTc MDP, 99mTc DPD and 99mTc EHDP

Transfer functions of 99mTc methylene diphosphonate (MDP), 99mTc 2,3-dicarboxypropane-1,1-diphosphonate (DPD) and 99mTc ethane-1-hydroxy-1,1-diphosphonate (EHDP) into bone and extravascular fluid of soft tissues were determined in 5 dogs by deconvolution analysis of the time-course of plasma, soft tissue and bone radioactivity. The transfer rates 5 min after injection--indicating the rapid exchange of the tracer between plasma and the extravascular fluid--decrease in the order MDP greater than EHDP greater than DPD (P less than 0.05). The transfer rates into bone--determined from transfer rates between 30 and 60 min--decreased in a different order, i.e. MDP greater than DPD greater than EHDP (P less than 0.05). The fractional bone uptake of diphosphonates estimated from the ratio of early to late transfer rates was slightly greater for DPD than for MDP and EHDP respectively. The difference between DPD and MDP was not significant (P greater than 0.05). The average bone and soft tissue concentrations of DPD 60 min after injection were greater than that of MDP and EHDP due to different plasma concentrations (DPD greater than EHDP greater than MDP), whereas the bone-to-soft tissue ratios decreased in the sequence MDP greater than DPD greater than EHDP (P less than 0.05).--Our results reveal different biokinetics of MDP, DPD and EHDP explaining variations in osseous and soft tissue uptake suggesting that deconvolution analysis could play an important role in bone scan interpretation.     

Determination of the oxidation state of Tc in 99Tc(Sn)EHDP, 99mTc(Sn)EHDP, 99Tc(Sn)MDP and 99mTc(Sn)MDP complexes. Characterization of Tc(III)-, Tc(IV)- and Tc(V)EHDP complexes

The oxidation state of complexed Tc was determined, by performing paper and thin-layer chromatography during potentiometric titrations. Both titrations of Sn(II) with TcO₄⁻ and of TcO₄⁻ with Sn(II) were performed at pH 2.5, 7.0 and 12.0. Differences were found in the number of electrons transferred to 1 mol of TcO₄⁻, n, in the titration solutions at the end point of a direct and a reversed titration. The oxidation state of Tc changes during a titration with the titration degree. It was possible to obtain almost pure Tc(III)-, Tc(IV)- and Tc(V)EHDP complexes, depending on the pH, titration mode and titration degree. These TcEHDP complexes were analyzed by u.v./vis spectrometry, anion-exchange HPLC on Aminex A-28, gel chromatography on Biogel P₄ and extraction with oxine in chloroform. The spectra of the pure Tc(III), Tc(IV) and Tc(V) species were calculated. Adsorption of these complexes on calcium phosphate increased in the order Tc(V) < Tc(IV) < Tc(III). From the chromatographic characterizations it was concluded that in the ^99mTc(Sn)EHDP bone scanning agent Tc is tetravalent. An analogous (though less elaborate) investigation was performed on the Tc(Sn)MDP complex.     

Positive imaging of cardiomyopathy with99mTc(V)-DMSA

A case of histologically proven dilated cardiomyopathy and a case of clinically diagnosed cardiomyopathy (cardiac amyloidosis was strongly suspected but was not confirmed) were examined with 99mTc(V)-dimercaptosuccinic acid (DMSA). 99mTc(V)-DMSA accumulation in the damaged myocardium was clearly demonstrated. These results suggested the possibility that 99mTc(V)-DMSA could be used as a positive agent for cardiomyopathy.