Comparison of simultaneous 99mTc-HMPAO and 111In oxine labelled white cell scans in the assessment of inflammatory bowel disease

Forty-seven patients, 29 with chronic inflammatory bowel disease (1131) and 18 with presumed irritable bowel syndrome, including one with uncomplicated diverticular disease, were studied with simultaneous technetium-99m hexamethylpropylene amine oxime and indium-111 oxine labelled leucocyte scans performed at 1, 3 and 24 h. Twenty-seven patients with IBD had active disease as judged by clinical and laboratory criteria and all of these had positive scans with both agents. No false positive studies were obtained. The 1-h ^99mTc-HMPAO WBC scans showed the same distribution to disease as the 3-h ¹¹¹-In WBC scans, with no difference in intensity (P < 0.92); they showed more extensive disease (P < 0.02) and more intense uptake (P < 0.001) than did the 1-h ¹¹¹-In scans. The 3-h ^99mTc-HMPAO WBC scans showed more extensive disease (P < 0.002), with greater intensity (P < 0.0005), than did the 3-h ¹¹¹In WBC scans. Physiological bowel activity on 3-h ^99mTc-HMPAO WBC scans was present in 12 patients but was faint and did not interfere with assessment of disease extent and activity. It is concluded that in terms of isotope availability, radiation dosimetry and image quality, ^99mTc-HMPAO is the agent of choice in detecting active IBD, with localization of disease possible at 1-h after re-injection and optimal resolution and definition of disease extent at 3 h. A negative scan reliably excludes active disease. Correspondence to: R.A. Allan     

99mTc-human immunoglobulin (HIG) — first results of a new agent for the localization of infection and inflammation

Technetium (^99mTc) labelled, polyclonal human immunoglobulin (HIG) is a new agent that detects focal infection and inflammation. This new agent was compared in 40 patients with the accepted standard, namely¹¹¹In-oxine-labelled leucocytes. This comparison resulted in a sensitivity of 94% and a specificity of 96% for^99mTc-HIG when¹¹¹In-oxine leucocytes were defined as giving the true result. The new agent was shown to localize both sepsis and active inflammatory bowel disease (IBD). There was 100% concordance in the 16 patients with IBD who were imaged with both^99mTc-HIG and¹¹¹In-oxine leucocytes. Discordant results were obtained in one case of suspected osteomyelitis, which was false-positive on the^99mTc-HIG scan, and one case of pyrexia of unkown origin when the^99mTc-HIG was false-negative and the¹¹¹In-oxine leucocyte scan demonstrated accumulation of tracer in the caecum at 24 h post-injection. Normal distribution for^99mTc-HIG demonstrated activity in the kidneys and bladder and that 50% of the tracer is cleared through the kidneys during the first 24 h post-injection. There were no major or minor side-effects.     

Technetium-99m scintigraphy: more accurate assessment of ulcerative colitis with exametazime-labelled leucocytes than with antigranulocyte antibodies

To compare two technetium-99m scintigraphic techniques —^99mTc-labelled antibodies against granulocyte non-specific cross-reacting antigen-95 and^99mTc-exametazime labelled leucocytes in ulcerative colitis —23 consecutive patients undergoing colonoscopy were investigated in a prospective and randomized study. In each patient the two scans and colonoscopy and biopsy were performed within 10 days. Scans, endoscopy and histology were independently graded for degree of inflammation in eight different colorectal segments for each patient. Active inflammation in one or more segments was present on endoscopy in 22 patients and on histology in 17 patients. Twenty-two patients had increased uptake on the antibody scan and 21 patients on the exametazime scan. Twelve patients showed the same disease extent with both scan methods (total colitis,n=10; distal colitis,n=2). Compared with endoscopy, sensitivity for inflammation in individual segments was 0.51 for antibody scan and 0.87 for exametazime scan; specificity was 0.67 and 0.55, respectively. The predictive value for presence of inflammation was 0.66 for antibody scan and 0.72 for exametazime; the predictive value for absence of inflammation was 0.52 and 0.77, respectively. Segmental scan uptake of endoscopically or histologically visualized inflammation was consistently lower for antigranulocyte antibodies than for exametazime. It is concluded that in patients with active ulcerative colitis, inflammation is better visualized with^99mTc-exametazime labelled leucocytes than with^99mTc-labelled antigranulocyte antibodies. The antibody technique offers the advantage of in vivo labelling, but is less reliable than the exametazime method for imaging of colonic inflammation.     

Simultaneous administration of111In-human immunoglobulin and99mTc-HMPAO labelled leucocytes in inflammatory bowel disease

Technetium-99m hexamethylpropylene amine oxime (HMPAO) labelled leucocytes and indium-111 polyclonal immunoglobulin (IgG) were simultaneously injected into a group of 27 patients routinely referred for the investigation of inflammatory bowel disease (IBD). Ten-minute anterior abdomen and tail on detector views were obtained at 30 min, 4 h and 24 h p.i. of both tracers. The diagnosis of IBD was obtained in all cases by endoscopy with biopsy and/or surgery. Images were blindly evaluated by two experienced observers who only knew of the clinical suspicion of IBD. IBD was confirmed in 20 patients (12 with Crohn's disease and eight with ulcerative colitis). Sensitivity, specificity and accuracy were 100%, 85% and 96% respectively for labelled leucocytes and 70%, 85% and 74% for IgG. Both IgG and leucocyte scans were normal in six out of seven patients in whom a diagnosis of IBD was excluded; the remaining patient, with ischaemic colitis, was falsely positive with both agents. As far as disease extension is concerned, the IgG study localized 27 diseased segments, whereas 49 were seen with the leucocyte study. Eighty-four segments were normal and 25 showed tracer uptake with both agents. Twenty-four were positive only with the leucocyte study and two were positive only with the IgG study. Agreement between the agents was 80.7%. These results confirm that¹¹¹In-human polyclonal scintigraphy is less sensitive than^99mTc-HMPAO scintigraphy both for the diagnosis of IBD and in the evaluation of disease extension. Nevertheless, if leucocyte labelling is not available, labelled IgG can be used only for diagnostic purposes.     

Leucocyte scanning: Preparation and labelling of leucocytes with 111-Indium oxine and its clinical application

A method for the concentration of leucocytes from blood and labelling of the separated cells with ¹¹¹-Indium oxine is described. This method guaranteed a good preparation. On average there were 64.8% of leucocytes from the blood in the concentrate. The yield of the labelling averaged 93%. Seventy-two patients from various departments were examined to test the clinical application of the labelled leucocytes in the diagnosis of inflammatory diseases. The results obtained led to the formulation of six indications for the appropriate application of leucocyte scanning in everyday clinical routine.     

Radiochemistry and biostability of autologous leucocytes labelled with 99mTc-stannous colloid in whole blood

Autologous leucocytes were labelled in whole blood by phagocytic uptake of ^99mTc-stannous colloid. This colloid has a mean particle size of 1.5 m and labels leucocytes with 81% efficiency. Individual cell uptakes were: granulocytes 42%, monocytes 39%. Isotonic sodium citrate added after the labelling procedure did solubilise excess colloid but was not necessary for adequate removal of excess colloid. Labelled leucocytes were shown in vitro to be viable and maintain normal bactericidal and chemotactic capacity. Biodistribution, clearance rates and dosimetry are presented. These results indicate that autologous leucocytes can be efficiently labelled with ^99mTc-stannous colloid with good residual cell function.     

The use of technetium-99m hexamethylpropylene amine oxime labelled white blood cells to detect subclinical inflammation of the heart after cardiopulmonary bypass in children with congenital heart disease

Ten children (6 boys and 4 girls, aged 1–9 years old) underwent operations with a cardiopulmonary bypass, and the technetium-99m hexamethylpropylene amine oxine (^99mTc-HMPAO) labelled white blood cell (WBC) heart scans were used to detect postoperative leukocyte infiltration in the hearts. The results showed that 80% (/810) of the cases had subclinical inflammation in the hearts (grading of WBC scans score 2), and a positive correlation (R = 0.77) was noted between the severity of the inflammation (grading of the WBC scans) and the duration of the cardiopulmonary bypass in the operations. Another control group (9 boys and 2 girls, aged 2–13 years old) underwent operations without a cardiopulmonary bypass, and subclinical inflammation of hearts was demonstrated in only 1 case (9%) by the ^99mTc-HMPAO labelled WBC scans (grading of WBC scans < score 2) after the operations. There was a significant difference (P < 0.001, by a Wilcoxon rank sum test) based upon the severity of the ischaemic heart damage in the two groups. In our preliminary conclusions, the ^99mTc-HMPAO labelled WBC heart scans may provide non-invasive and directly discernible evidence of subclinical inflammation in the heart due to a transient ischaemic state during a cardiopulmonary bypass, even if the clinical symptoms and signs of carditis are not apparent. Correspondence to: Chia-Hung Kao     

Cell labelling with colloidal substances in whole blood

A method for the labelling of leucocytes with ^99mTc-colloid is described. The labelling can be done in samples of whole blood, because the colloid is only taken up by the phagocytosing cells, the monocytes and the granulocytes. The part of the colloid that is not phagocytosed is brought to a soluble state with Na-citrate, so that only the phagocytosed colloid is reinjected. The labelling efficiency with this method is between 80% and 90%. Measurements of the activity in the leucocytes 3 h after reinjection, have shown that at least 50% of the labelled cells are at this time still available in the blood pool.The clinical results on 32 patients with the tentative diagnosis of an abdominal abscess and on 42 patients with the tentative diagnosis of septic loosening of an endoprosthesis have shown that the labelled leucocytes are very well suited to show up local foci of inflammation.     

Granulocyte-specific monoclonal antibody technetium-99m-BW 250/183 and indium-111 oxine-labelled leucocyte scintigraphy in inflammatory bowel disease

Thirty-three patients suspected of suffering from inflammatory bowel disease were studied. Autologous leucocytes were labelled with indium 111 oxine and re-injected simultaneously with 0.3–0.5 mg of technetium 99m granulocyte-specific monoclonal antibody BW 250/183. Two scans were obtained, the early scan 3–4 h postinjection (p.i.) and the late scan 18–24 h p.i. Using the endoscopy study as standard, the diagnostic accuracy of both agents was determined. Sensitivity, specificity and accuracy of ¹¹¹In scans was 88.8%, 100.0% and 93.7% at 4 h and 94.7%, 100.0% and 96.9% at 24 h, respectively. Concerning the results using antibodies, the values were 61.1%, 100.0% and 78.1% at 4 h and 78.9%, 92.8% and 84.8% at 24 h, respectively. Segmental analysis showed concordance in 89.3% and 93.3% of the cases at 4 and 24 h, respectively. Though less sensitive and less accurate than scanning employing indium 111 leucocytes, BW 250/183 granulocyte-specific scintigraphy can be used for inflammatory bowel disease diagnosis and localization. Offprint requests to: J. Martin-Comin     

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.     

Technetium-99m and indium-111 double labelling of granulocytes for kinetic and clinical studies

A new technique of labelling granulocytes with both technetium-99m hexamethylpropylene amine oxime (HMPAO) and indium-111 in a single protocol was developed in order to exploit the advantages of each radiolabel in clinical and investigative studies. Fourteen patients were included in this prospective study. Granulocytes were labelled with both¹¹¹In-tropolonate and^99mTc-HMPAO. In vitro shape change assay and in vivo distribution and recovery studies were performed to assess the activation of and damage to these cells due to the labelling procedure. The comparative kinetics of¹¹¹In and^99mTc in the blood, liver, spleen, and bone marrow were studied by blood sampling and dual radionuclide imaging early (1 h) and late (24 h) after injection. The functional integrity of the double-labelled granulocytes and the feasibility of the technique were investigated in 14 patients with a painful prosthetic hip due to causes other than infection. The efficiency of double labelling was 63% (SD 14%) for¹¹¹In and 39% (SD 12%) for^99mTc-HMPAO. In vitro granulocyte activation and ex vivo recovery values were comparable to those from single radionuclide labelling. No artefactual granulocyte sequestration was seen in the lungs or liver. The radioactivity was distributed between the liver, spleen and bone marrow and, to a lesser extent, the lung. Early^99mTc counts in the liver, spleen and bone marrow, in relation to background, were significantly higher than¹¹¹In counts while the reverse was seen in late images. Furthermore, circulating free^99mTc was significantly higher than free¹¹¹In at 24 h. Organ^99mTc counts, expressed in relation to the activity in early images, decreased in the spleen, increased in the liver and remained unchanged in bone marrow, whereas¹¹¹In counts increased in the bone marrow and liver, and decreased in the spleen. Granulocytes can be labelled with both¹¹¹In and^99mTc-HMPAO in a single protocol without crosschelation, cellular activation or damage. By favourably exploiting their kinetics for early and late imaging, double-labelled granulocytes may be useful in several clinical and investigative situations.     

Tc Nanocoll: A radiopharmaceutical for sentinel node localisation in breast cancer—In vitro and in vivo results

This study evaluated labelling efficiency and radiochemical purity of ^99mTc colloid albumin to identify an optimal labelling protocol for sentinel node detection. Results indicate that a 72 h eluate is not recommended for high specific labelling of ^99mTc colloid albumin. Ex vivo, significantly higher count rates were reached using a 2 h eluate in vacuum or nitrogen. Labelling 26 MBq/μg ^99mTc colloid albumin with a 2 h eluate under nitrogen is recommended because of the ease of labelling.     

Chronic osteomyelitis: diagnosis with tech netium-99m-d,l-hexamethylpropylene amine oxime labelled leucocytes

To evaluate the diagnostic value of technetium-99md,l-hexamethylpropylene amine oxime (HMPAO) labelled leucocytes in combination with a^99mTc-methylene diphosphonate (MDP) bone scan in the detection of chronic osteomyelitis, we retrospectively reviewed 55 patients. Prior to the^99mTc-d,I-HMPAO labelled leucocyte scan, all patients underwent a^99mTc-MDP bone scan. The correct diagnosis was confirmed by long-term clinical follow-up (n=29) or by bacteriological cultures (n=26). We found an overall sensitivity of 94%, a specificity of 91% and an accuracy of 92% for^99mTc-d,l-HMPAO labelled leucocyte scintigraphy in the diagnosis of chronic osteomyelitis. When the patients were divided into three groups according to the location of the infection, our study results showed a sensitivity and specificity for the central location (containing active bone marrow) of 94% and 100% respectively; for the peripheral location (hands and feet) both parameters were 100%, and for the middle location (all sites between the central and the peripheral location) the values were 92% and 81% respectively. Specificity and accuracy were significantly lower in the middle location than in the central and peripheral locations. The results of our study confirm that a^99mTc-d,l-HMPAO labelled leucocyte scan in combination with an^99mTc-MDP bone scan is a reliable way to diagnose chronic osteomyelitis, except for vertebral osteomyelitis.     

Biological consequences of the heterogeneous irradiation of lymphocytes during technetium-99m hexamethylpropylene amine oxime white blood cell labelling

Technetium-99m hexamethylpropylene amine oxime (^99mTc-HMPAO) labelling of white blood cells, routinely used for the detection of infection, results in the incorporation of radioactivity by polymorphonuclear leucocytes and also lymphocytes and can induce cell lesions in the latter case. The aim of this study was therefore to acquire data on the morphological and functional status of labelled lymphocytes present in the ^99mTc-HMPAO leucocyte mixture and to determine the cellular consequences of labelling. The mean radioactivity associated with lymphocytes was 325±10.8 kBq/10⁶ lymphocytes under standard labelling conditions. Microautoradiographic studies showed that labelling was heterogeneous (4% intensely labelled cells), which prevented calculation of the mean absorbed dose. The frequency of chromosomal aberrations (dicentrics and rings) in the labelled lymphocytes for 380 kBq/10⁶ cells was 1.08±0.09 but no abnormality was observed in the unlabelled control lymphocytes. The plating efficiency of labelled lymphocytes was reduced, as compared with that for control cells, but some lymphocytes were still able to form clones and were still ”alive” by radiobiological definition. It is therefore suggested that lymphocytes should be removed from ^99mTc-HMPAO cell preparations before administration to patients. Received 9 March and in revised form 1 June 1998     

Oxygen bubbling can improve the labelling of pentavalent technetium-99m dimercaptosuccinic acid

It has previously been reported that almost all of the trivalent technetium-99m dimercaptosuccinic acid (^99mTc (III) DMSA) present in the labelling product of pentavalent technetium-99m DMSA (^99mTc (V) DMSA) can be changed into^99mTc (V) DMSA by bubbling with pure oxygen. We therefore performed studies in animals (mice) and humans to investigate the effect of such oxygen bubbling on the labelling efficiency of and on the renal uptake of^99mTc. The method of labelling of^99mTc (V) DMSA was that of Hirano. It was found that oxygen bubbling oxidized the contaminated^99mTc (III) DMSA into^99mTc (V) DMSA in vitro and decreased the uptake of radioactivity in the kidney in both animals and humans.     

The use of technetium-99m labelled heat-damaged red cells for the quantitative measurement of splenic function

A comparison of the rates of clearance of ⁵¹Cr labelled and ^99mTc labelled heat-damaged red cells in 25 patients and 4 control subjects is reported. Very little correlation was found between the clearance half-times of the two types of labelled cells when the cells were labelled with ^99mTc prior to heat damaging. The correlation was improved when the labelling step occurred after the cells had been damaged. Urinary excretion measurements revealed that the rate of excretion of ^99mTc could be as much as nine times that of the ⁵¹Cr label. ^99mTc labelled heat-damaged red cells were found not to be sufficiently stable a preparation for use in quantitative clearance studies.     

A comparison of radiopharmaceutical labelling efficiency of chromatographic generator vs MEK extraction [99mTc]pertechnetate

Technetium-99m radiopharmaceuticals prepared for routine clinical use, were labelled with [^99mTc]pertechnetate obtained from either a commercial chromatographic generator or from a Winnipeg Health Sciences Centre semi-automated self-shielded methyl ethyl ketone extraction system. The [^99mTc]pertechnetate source for each ^99mTc radiopharmaceutical was selected at random over a 16 month period of time. The routine quality control data (silica-gel thin layer chromatography) was reviewed retrospectively, as an in vitro assessment of the quality of the [^99mTc]radiopharmaceutical prepared from each [^99mTc]pertechnetate source. Bone scans ([^99mTc]pyrophosphate) and wall motion studies ([^99mTc]red blood cells) were evaluated as an in vivo assessment of the [^99mTc]pertechnetate used to label the pyrophosphate or red blood cells. The in vitro studies indicated no difference in the labelling efficiency and radiochemical purity of the ^99mTc radiopharmaceuticals prepared from either source of [^99mTc]pertechnetate and there was also no difference observed in the image quality of either bone scans or wall motion studies obtained with either source of [^99mTc]pertechnetate.     

Autoradiography and density gradient separation of technetium-99m-Exametazime (HMPAO) labelled leucocytes reveals selectivity for eosinophils

Technetium-99m-Exametazime (HMPAO) is widely used for radiolabelling leucocytes for localization of infection. The subcellular distribution of radionuclide in the labelled cells and the distribution of radioactivity among the leucocyte population are incompletely understood. Frozen section autoradiography was used to determine quantitatively the distribution of ^99mTc in leucocytes labelled with ^99mTc-Exametazime. Sections of rapidly frozen suspensions of labelled leucocytes in plasma were autoradiographed on Ilford K2 emulsion and stained with haematoxylin and eosin. Neutrophils, eosinophils and mononuclear cells were separated by Percoll density gradient centrifugation. Cell nuclei were isolated by a rapid cell-breakage and fractionation method. In a typical experiment mean grain densities [grains/100 m² (ESD)] over cells were: eosinophils 31.2 (18.4), neutrophils 3.5 (3.5), mononuclear cells 4.2 (5.1). Mean grain numbers per cell (ESD) were: eosinophils 13 (6.8), neutrophils 1.3 (1.3), mononuclear cells 1.1 (1.3). These findings were confirmed by separation of labelled leucocytes on discontinuous density gradients. In four separation experiments, the mean activityper-cell ratio for eosinophils to neutrophils was 10.1 (4.8):1, and for eosinophils to mononuclear cells, 14.1 (6.7):1. The subcellular distribution of the label was investigated using image analysis of autoradiographs and cell fractionation. This revealed no selectivity for nuclear or extranuclear compartments. It may be concluded that ^99mTc-Exametazime. has strong selectivity for eosinophils over other leucocytes but no selectivity for nuclear/cytoplasmic compartments. Correspondence to: P.J. Blower     

Donor leucocyte imaging in patients with AIDS: a preliminary report

Four patients with the acquired immunodeficiency syndrome (AIDS) and fever were investigated using donor leucocyte scans. The lung/liver and lung/spleen uptake ratios in these patients were compared with the uptake ratios in donor leucocyte scans in seven neutropenic (non-AIDS) patients and five patients who had autologous leucocyte scans performed over the same time period. For all scans indium-111-oxime-labelled leucocytes were used, except for one AIDS patient in whom technetium-99m hexamethyl-propylene amine oxide (HMPAD)-labelled donor leucocytes were used. There were no adverse reactions to the donor cell infusions. Two patients had repeat studies 8 weeks apart (from different donors) without ill effect. There were no differences in the¹¹¹In uptake ratios between the three groups. There were three positive studies in the patients with AIDS, and these elucidated the cause of the pyrexia in all three. The negative case is more difficult to confirm, but the clinical course and the absence of focal disease on post-mortem have been taken to support the scan findings. There was no difference in the acceptability of the technique or the distribution of the labelled leucocytes between the AIDS and non-AIDS patients. Donor leucocyte imaging of patients with AIDS is probably more effective and considerably less hazardous for technical staff than autologous leucocyte methods. This study demonstrates that the technique can be applied successfully to patients with AIDS.     

Scintigraphic localization of occult gastrointestinal bleeding using a combination of 111In-labelled platelets and 99mTc sulphur colloid

Repeated scintigraphy was performed for 6 days after the injection of autologous ¹¹¹In-labelled platelets in a patient showing signs of recurrent occult gastrointestinal bleeding. Colonic activity was observed 142 h post injection, at which time a superimposed study using ^99mTc sulphur colloid pinpointed the source of bleeding in the transverse colon.