Chronic berylliosis. Demonstration by gallium-67 imaging and magnetic resonance imaging

Ga-67 is known to localize in the lungs in a wide spectrum of pulmonary pathology. The nonspecific affinity of Ga-67 uptake in both inflammatory and neoplastic entities limits its utility in terms of pulmonary disease differential diagnosis. However, Ga-67 lung imaging has proven to be helpful in evaluating the extent of inflammatory activity, as well as in assessing responses to therapy. A case of active chronic berylliosis, a disorder in which Ga-67 uptake has not been previously reported is presented. There is diffuse bilateral Ga-67 pulmonary activity before therapy. Subsequent to steroid therapy, a marked decrease in pulmonary gallium uptake activity was noted with only residual hilar and mediastinal adenopathy noted.     

The role of Ga-67 citrate imaging in pancreatitis

Two patients with pancreatitis in whom an area of predominant uptake of Ga-67 citrate was demonstrated involving the entire pancreas are presented. Ultrasound and x-ray CT did not reveal any morphologic abnormalities in the pancreas, whereas Ga-67 citrate imaging indicated the presence of active inflammatory change. Ga-67 citrate imaging may be useful in confirming the diagnosis of acute pancreatitis or acute exacerbation of chronic pancreatitis based on clinical and laboratory data, especially when ultrasound and/or x-ray CT cannot reveal any morphologic abnormalities in the pancreas.     

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.     

Ga-67 scan to detect intra-abdominal infection in patients after colorectal surgery

PURPOSE: Intra-abdominal infection is still an important issue in colorectal surgery. The Ga-67 scan is relatively inexpensive, but the delay in diagnosis and the intense physiologic bowel activity are considerable drawbacks to its use in abdominal investigations. In this study, the authors performed 24-hour Ga-67 scans and read the images with the surgeon to detect abdominal infection in patients who underwent colorectal surgery. METHODS: Sixty-one patients who underwent colorectal surgery were enrolled in this study. Ga-67 scintigraphy was performed 24 hours, and later as needed, after the injection of 111 MBq (3 mCi) Ga-67 citrate. All scans were interpreted together by a nuclear medicine specialist and the surgeon. The intensity of Ga-67 uptake was recorded as grade 0: no uptake; grade 1: less than liver uptake; grade 2: equal to liver uptake; or grade 3: greater than liver uptake. When the intensity of Ga-67 uptake was equal to or greater than grade 2, the pattern of Ga-67 uptake was classified as changing or unchanging. A positive Ga-67 scan was defined as having an intensity of grade 2 or 3 with an unchanging pattern. RESULTS: Nineteen abdominal infections were diagnosed, all by Ga-67 scans, for a diagnostic sensitivity rate of 100%. Of the 42 patients with no intra-abdominal infection, only 2 had positive Ga-67 scans. This resulted in a specificity rate of 95.2%. The overall accuracy of the Ga-67 scan in the detection of intra-abdominal infection after colorectal surgery was 96.7%. CONCLUSIONS: The Ga-67 scan is useful for detecting intra-abdominal infection after colorectal surgery. Reading the images with the surgeon and using a lateral view can decrease the false-positive rate. A negative Ga-67 scan can rule out intra-abdominal infection, whereas a positive Ga-67 scan indicates the need for further patient evaluation after colorectal surgery.     

The role of Tc-99m MDP and Ga-67 citrate in predicting the cure of osteomyelitis

Twenty rabbits with chronic osteomyelitis of the tibia were treated for eight weeks and then scanned with Tc-99m MDP and Ga-67 citrate. All were sacrificed and bacteriologic cultures of the tibia were obtained. All rabbits had positive Tc-99m MDP scans at the end of treatment despite thirteen cures of osteomyelitis. Eight had negative gallium scans and negative cultures. Five of the twelve positive gallium scans had negative cultures, while seven had positive cultures. Tc-99m MDP alone is not sensitive enough to be useful in predicting the cure of osteomyelitis, and combining Tc-99m MDP and Ga-67 citrate scintigrams offers no additional information over the Ga-67 citrate scintigram alone in follow-up of osteomyelitis.     

Ga-67 and Fe-59 distributions in mice

Tissue distributions of i.v.-injected Ga-67 citrate and [59Fe] ferric citrate were measured in normal mice and in lymphoid-tumor hosts. The study arose out of previously reported tissue-culture work showing marked transferrin stimulation of Ga-67 and Fe-59 uptakes by cultured cells from mouse lymphoid tumors. In vivo, however, no obvious correlation was found between Ga-67 and Fe-59 tissue distributions; indeed, Ga-67 showed high affinity for tumor tissue and low affinity for hemopoietic tissues, while for Fe-59 the reverse applied. Taken together, these comparisons of kinetics and distributions for Ga-67 and Fe-59 suggest that a tissue's avidity for Ga-67 is strongly influenced by other factors besides the cell population's capacity for transferrin interactions.     

Tl-201 and Ga-67 scintigraphy in non-Hodgkin's lymphoma.

Ga-67 scintigraphy is routinely used to stage and monitor non-Hodgkin's lymphoma (NHL). It is highly sensitive in high-grade NHL but less so in intermediate- and low-grade NHL. Several studies have reported the use of Tl-201 in the low and intermediate grades of NHL and found it superior in low-grade NHL. In this study, the authors evaluated the utility of combined Ga-67 and Tl-201 scintigraphy in low, intermediate, and unusual types of NHL. Combined Tl-201 and Ga-67 scintigraphy were done in 33 patients (18 women, 15 men; age range, 21-91 years; mean age, 56 years). Tl-201 and Ga-67 had similar overall patient sensitivity in the 33 patients studied. However, the use of both agents increased the overall patient sensitivity from 67% (for Ga-67 only) to 82% and improved the overall site detection from 59 positive sites with Ga-67 to 81 abnormal sites with both Tl-201 and Ga-67. The combined use of Tl-201 and Ga-67 scintigraphy in low- and intermediate-grade NHL resulted in increased disease and site detection and is beneficial for clinical follow-up.     

Ga-67 lung uptake in patients with adult respiratory distress syndrome. Association with lung infection and patients' prognosis.

Nine patients with adult respiratory distress syndrome (ARDS) were studied with Ga-67 imaging in search for a site of infection. Different degrees and two patterns of Ga-67 lung uptake scoring in comparison with liver uptake were demonstrated. All patients had diffuse lung uptake, whereas five of them also showed additional focal lung activity. In only one patient was an abdominal focal uptake detected. Chest radiographs of all patients revealed diffuse and focal lung infiltrates that correlated with the Ga-67 uptake patterns. Therefore, Ga-67 imaging was unhelpful in differentiating patients with ARDS with lung infection from patients without lung infection. The intensity of Ga-67 uptake, as expressed by Ga-67 scoring, correlated with the course and outcome of ARDS. Patients exhibiting a high Ga-67 score had long periods of hospitalization and eventually died (four patients), whereas those who had low Ga-67 scores had a short disease course and survived (five patients). It is concluded that Ga-67 imaging in ARDS patients is unable to detect lung infection; however, it may be useful in the assessment of patients' prognosis.     

Nonvisualization of an enlarged spleen on Ga-67 scintigraphy but demonstrated by CT after splenic irradiation

Presence of enlarged spleen using CT with absence of splenic visualization in Ga-67 citrate images in a patient with chronic myelogenous leukemia and splenomegaly after splenic irradiation was observed. Since Howell-Jolly bodies had not been identified in the peripheral circulation, the finding of splenic nonvisualization was explained by disassociated splenic functions, which are not tightly coupled, and some activities that can be suppressed by irradiation without impairing others. The Ga-67 splenic localization mechanism is probably more sensitive and liable to disruption by irradiation, and was independent of spleen size. Ga-67 scintigraphy and Tc-99m sulfur colloid liver-spleen scintigraphy are two organ function-dependent imaging procedures, while CT provides anatomic information.     

The influence of ferric metabolism on Ga-67 distribution in the human body

This investigation was undertaken to make clear the influence of ferric metabolism on Ga-67 distribution in human body. Count ratios for each organ to femoral soft tissue (i.e. relative Ga-67 uptake) were calculated in 125 scintigrams obtained 48 hours following injection, and the relation between the relative Ga-67 uptake in each organ and serum Fe, or UIBC were investigated. The relative Ga-67 uptake in the liver and the lumbar vertebra had negative correlation to serum Fe, and had positive correlation to UIBC. However, there was no significant difference in the relative Ga-67 uptake in the lumbar vertebra between normal and high serum Fe group. Only in group with exceedingly low serum Fe, each vertebral body was visualized separately in posterior view of the abdomen. These findings indicated that in group with exceedingly low serum Fe, Ga-67 accumulated mainly in the bone marrow, and in group with high serum Fe, Ga-67 accumulated mainly in the bone. The urinary bladder was visualized only in group with high serum Fe, which suggested that the excretion of Ga-67 to the urine was continued yet at 48 hours after injection. Ferric metabolism affected remarkably on the relative Ga-67 uptake in the liver, the bone marrow and the bone, and also the excretion of Ga-67 to the urine.     

The effects of inadvertent administration of antineoplastic agents prior to Ga-67 injection: concise communication

Alteration of the gallium-67 (Ga-67) distribution after administration of chemotherapeutic agents has been demonstrated in experiments on both normal and tumor-bearing animals. We have encountered eight patients who had Ga-67 scintigrams in which the findings were similar to those in the animals experiments: markedly increased uptake in bone, with suppressed uptake in liver, muscle, and tumor. Five of the patients had hematologic neoplasms, and three had solid tumors, and each had received one or more chemotherapeutic agents during the 24 hr preceding Ga-67 administration. In three patients while not on antineoplastic medication subsequent Ga-67 images showed a return to the usual Ga-67 distribution pattern. The altered Ga-67 distribution may result from inhibition of protein synthesis or of a serum-binding agent for Ga-67, or from competitive blockage of specific Ga-67 organ receptors by the antineoplastic agents.     

SPECT imaging with Tl-201 and Ga-67 in myocardial sarcoidosis

Two patients with myocardial sarcoidosis are presented, both of whom underwent SPECT imaging with Tl-201 and Ga-67. The first had Ga-67 myocardial uptake with a Tl-201 defect, which disappeared with corticosteroid therapy. The second had multiple Tl-201 defects without Ga-67 uptake, which persisted despite corticosteroid therapy. Therefore, the combination of Tl-201 and Ga-67 imaging may be useful for recognizing myocardial sarcoidosis and for predicting the response to corticosteroid therapy.     

Diffuse gallium-67 uptake in radiation pneumonitis

To evaluate the clinical usefulness of Ga-67 imaging for the assessment of radiation pneumonitis, 12 patients who had developed radiation pneumonitis after receiving radiotherapy alone for non-small-cell lung cancer from 1979 through 1988 were reviewed. Diffuse bilateral Ga-67 uptake occurred in 5 out of the 12 cases; in the other 7 cases, Ga-67 uptake was confined to the irradiation lung. Conversely, chest radiography showed infiltrates only in the irradiated lung. Histopathology of the lung in four out of the five cases that showed diffuse Ga-67 uptake in the lung, however, revealed that the lung outside the radiation field with Ga-67 uptake was consistent with interstitial pneumonitis induced by radiation. These results suggest that radiation pneumonitis could extend beyond the irradiated lung and that Ga-67 imaging is more useful than chest radiography for the assessment of the spatial extent of radiography pneumonitis.     

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.     

A transferrin-mediated uptake of gallium-67 by EMT-6 sarcoma. II. Studies in vivo (BALB/c mice): concise communication

The EMT-6 sarcoma-like tumor of BALB/c mice can be grown as a solid subcutaneous transplantable tumor in vivo or as a monolayer culture in vitro. We have studied the uptake of gallium-67 by this tumor growing subcutaneously on the backs of 6-week-old BALB/c mice. After i.v. administration of Ga-67 citrate, tumor uptakes were as high as any others reported for mouse tumors. Also, for unknown reasons, there was appreciable reduction in tumor uptake with increasing amounts of Ga-67 citrate, even in the microcurie range. Furthermore, when mouse serum is prelabeled with Ga-67 and then injected, the EMT-6 uptake is greater than with Ga-67 administered as citrate (p less than 0.02). We believe that the finding of avid Ga-67 uptake in vivo helps to establish this unique in vivo/in vitro tumor system as a valid experimental model for studies regarding the mechanism of Ga-67 accumulation by neoplastic tissue.     

Pyometra as a lower abdominal doughnut sign on a Ga-67 scan

A 77-year-old woman was referred for Ga-67 scan to evaluate intermittent fever and chills that had lasted more than 20 days. The Ga-67 whole-body scan revealed a doughnut-shaped Ga-67 accumulation in the lower abdominal region. Combined Ga-67 and Tc-99m MDP bone scan confirmed that this activity was in the uterus, because the shape of the urinary bladder on bone scan was different from that of the Ga-67-avid lesion. Pyometra was proved during operation, and pus culture was performed.     

Ga-67 scintigraphy in chromomycosis

We examined an interesting case of chromomycosis that had a characteristic Ga-67 accumulation. This patient had had widespread chromomycosis skin lesions for 8 years. We performed Ga-67 scintigraphy in an attempt to obtain additional information on the site and extent of the lesion. Ga-67 scintigraphy revealed not only all subcutaneous nodules but also an unsuspected enlarged lymphnode and a visceral lesion. This case indicates that Ga-67 scintigraphy is a very useful method to use in detecting the site and extension of chromomycosis, especially in the nodal and the visceral lesions, and sometimes might help in differential diagnosis.     

Studies on gallium accumulation in inflammatory lesions: I. Gallium uptake by human polymorphonuclear leukocytes.

The mechanism of ionic gallium-67 localization in inflammatory lesions was studied. Human polymorphonuclear leukocytes (PMN) had higher Ga-67 uptake than lymphocytes, whereas red blood cells had no affinity for Ga-67. Uptake by PMN showed temperature dependence, was independent of Ga-67 concentrations, and was not inhibited by metabolic inhibitors. However, its binding to PMN could be removed by trypsin but not by neuraminidase. These results are consistent with the hypothesis that the plasma membrane serves as a diffusion barrier and Ga-67 only binds to the surface of the PMN plasma membrane. When this membrane's permeability barrier was disrupted, as in heat-killed PMN, Ga-67 uptake increased markedly. Experimental abscesses were induced with E. coli or turpentine in rabbits. Twenty-four hours after i.v. injection, only 20% of Ga-67 in abscesses was in fractions containing intact PMN, cell debris or bacteria; the remainder was in a soluble, non-cellular fraction (2,500-g supernatant).     

Gallium-67 uptake in Bellini duct carcinoma of the kidney

Bellini duct carcinoma is a rare variant of renal cell carcinoma and usually has a poor prognosis. In this article, we report the Gallium-67 citrate (Ga-67) uptake in Bellini duct carcinoma. To our knowledge, this is the second reported case of Bellini duct carcinoma in which Ga-67 uptake was positive. We suggest that Ga-67 scintigraphy has potential utility in detecting Bellini duct carcinoma of the kidney. And if a hypovascular tumor of the kidney shows Ga-67 uptake, Bellini duct carcinoma should be included in the differential diagnosis.     

Intense Ga-67 uptake in adenosquamous carcinoma of the pancreas

Gallium-67 citrate (Ga-67) scintigraphy was performed in a patient with adenosquamous carcinoma of the pancreas. Intense and homogeneous uptake was observed in the tumor. Few reports have dealt with Ga-67 findings in pancreatic cancers. Ga-67 uptake in the tumor was assumed to be due to accumulation in the component of squamous cell carcinoma. This case suggested that Ga-67 citrate scintigraphy may be useful in detecting adenosquamous carcinoma of the pancreas. To our knowledge, no report has described findings of Ga-67 citrate scintigraphy of adenosquamous carcinoma of the pancreas. Radiologists should remember adenosquamous carcinoma of the pancreas when encountering such scintigraphic findings.