Ga-67 scintigraphy in patients with breast lymphoma.

PURPOSE: The authors studied the utility of Ga-67 citrate scintigraphy in patients with breast lymphoma. METHODS: Seven patients with histologically proved breast lymphoma were examined. In three patients, both breasts were involved, and all patients had rapidly growing breast masses. Planar and SPECT images were obtained 72 hours after injection of Ga-67. RESULTS: Ga-67 scintigraphy showed intense accumulation in all lymphomas. SPECT images provided better contrast than did planar images. In one of the seven patients, the axilla and mediastinum were also involved. In six of the seven patients, Ga-67 scintigraphy was also performed after treatment and showed the disappearance of Ga-67 accumulation. In one patient with local recurrence and lung involvement, abnormal accumulation was depicted on follow-up Ga-67 scintigraphy. CONCLUSIONS: Ga-67 scintigraphy was helpful to confirm the diagnosis and the systemic extent of lymphoma and to evaluate the therapeutic effect during follow-up in patients with breast lymphoma.     

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.     

Mechanism of gallium-67 accumulation in inflammatory lesions

Multiple factors contribute to the accumulation and retention of gallium-67 in inflammatory lesions. Adequate blood supply is essential. Gallium-67, mainly in the form of transferrin-Ga-67 complex, is delivered to the inflammatory lesions through capillaries with increased permeability. At the site of inflammation, some Ga-67 is taken up by leukocytes and bacteria when they are present. In addition, Ga-67 may also bind to lactoferrin and bacterial siderophores. Multiple contributing factors often coexist at any given inflammatory lesion. The nature and intensity of the inflammation affects the relative contribution of these factors. Thus, there may be situations in which all the contributing factors are present, but in such a low intensity that they escape clinical detection by Ga-67 scans. On the other hand, there may be situations in which one or more contributing factors are missing, such as in patients with agranulocytosis, while they are readily detected by Ga-67 scans.     

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.     

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.     

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.     

Gallium-67 citrate scintigraphy in pulmonary embolism

Eight cases of pulmonary embolism were evaluated with Ga-67 citrate scintigraphy. Of the eight patients, all but one showed evidence of abnormal Ga-67 citrate localization within involved regions of the lung as demonstrated by ventilation-perfusion lung scintigraphy. The sole patient who did not demonstrate Ga-67 localization within the lung had marked breast accumulation of the radiotracer which may have obscured lung parenchymal uptake. Since Ga-67 citrate is known to accumulate within inflammatory lung processes, this radiotracer would not have a specific role in differentiating pulmonary embolism from these conditions. This study disagrees with the results of other studies in the medical literature that describe such a role.     

A case of tuberculous peritonitis monitored by gallium-67 scintigraphy

An 18-year-old man was admitted to our hospital for further examination of fever of unknown origin and ascites. Ga-67 scintigraphy revealed diffuse increased uptake throughout the abdomen. He was diagnosed with tuberculous peritonitis and began the treatment for tuberculosis (rifampicin, 450 mg/day orally and isoniazid, 300 mg/day orally, and 0.75 g of streptomycin by intramuscular injection 2 times a week). One year after starting the treatment, Ga-67 scintigraphy revealed accumulation of radioactivity in the upper abdomen, but the diffuse accumulation in the abdomen decreased. A specimen obtained by tumor biopsy under ultrasonic guidance revealed a tuberculous granuloma. Percutaneous injection was performed in the tumor with 1.0 g of streptomycin. On Ga-67 scintigraphy performed 2 weeks after the injection of streptomycin, the accumulation of radioactivity in the upper abdomen had disappeared. These findings suggest that Ga-67 scintigraphy is useful for diagnosis and observation during treatment of tuberculous peritonitis.     

Ga-67 uptake in diethylstilbestrol-induced gynecomastia. Experience with six patients

Six patients who had been treated with diethylstibestrol (DES) for prostatic cancer had symmetrical breast uptake of Ga-67. Of these patients, five proved to have DES-induced gynecomastia. The minimum dose and administration period of DES required for Ga-67 uptake in gynecomastia is discussed.     

Ga-67 citrate scan in vascular graft infection

The clinical utility of the Ga-67 scan has been studied in 9 patients with clinical suspicion of vascular graft infection. Eleven grafts were analyzed: 4 aortobifemoral, 2 iliofemoral, 3 femoropopliteal, 1 axillofemoral, and 1 axillobifemoral. The Ga-67 scan was positive in 8 grafts with bacteriological proof of infection and negative in 3 grafts in which infection was ruled out by clinical follow-up. A Ga-67 scan also demonstrated the spread of infection to the thigh in two patients and to the pelvis in another two patients. In 4 patients CT was performed. The CT findings included graft thrombosis, perigraft fluid collection and thickened graft wall. No discrepancies were found between the CT scan and Ga-67 scan. In three patients a control Ga-67 scan was carried out after specific antibiotic and surgical treatment. Two of these showed increased Ga-67 uptake and spreading of infection along the graft; in the other patient, a Ga-67 scan revealed normalization after resolution of an abdominal abscess. In conclusion, the Ga-67 scan proved useful in the diagnosis of vascular graft infection, the definition of location of the extent of the disease and in the evaluation of the efficiency of treatment.     

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.     

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.     

Gallium-67 myocardial imaging for the detection of adriamycin cardiomyopathy

To detect Adriamycin cardiomyopathy, radionuclide myocardial imagings with Tl-201, Tc-99m pyrophosphate, I-123 metaiodobenzylguanidine and Ga-67 were performed in a 49 year-old-woman receiving Adriamycin (a total dose of 230 mg/m2) for the treatment of breast cancer. This patient demonstrated symptoms of congestive heart failure 2 months after the last intravenous administration. At the period of performing the radionuclide studies, echocardiographic LV ejection fraction (EF) was 22%. Despite severe deterioration of cardiac function, Tl-201 SPECT demonstrated no defect and Tc-99m pyrophosphate (PYP) SPECT demonstrated no positive finding. I-123 metaiodobenzylguanidine (MIBG) scintigraphy demonstrated no regional defect. However, I-123 MIBG washout rate during 4 hours was markedly enhanced, probably reflecting abnormalities of norepinephrine kinetics due to the progression of heart failure. Compared to these pharmaceuticals, Ga-67 was diffusely accumulated in the heart. Then, 5 months after the first study, when LV EF improved to 30% and congestive symptoms disappeared probably owing to beta-blockade therapy, myocardial accumulation of Ga-67 markedly reduced. It has been reported that Ga-67 accumulates in malignant tumor cells and leukocytes. Since, in Adriamycin cardiomyopathy, myocardial accumulation of leukocytes with myocardial fibrotic changes have been histologically demonstrated, the results of Ga-67 scintigraphy may reflect the accumulation of leukocytes. Thus, this case indicates that Ga-67 scintigraphy is advantageous for detecting Adriamycin cardiomyopathy and may be more useful than Tl-201 and Tc-99m PYP scintigraphies.     

Intense accumulation of gallium-67 citrate in pancreatic endocrine tumor

We report intense accumulation of gallium-67 (Ga-67) citrate in a pancreatic endocrine tumor. A 69-year-old woman was admitted because of cough, fever, and weight loss. An abdominal enhanced computed tomography (CT) scan revealed a large tumor located between the liver and pancreas as well as swollen paraaortic lymph nodes. Whole-body scintigraphy with Ga-67 revealed intense accumulation in the upper abdomen corresponding to the mass, as well as in the midabdomen and the mediastinal lesion. Percutaneous needle biopsy was performed, and the diagnosis was adenocarcinoma of the pancreas. The patient's condition deteriorated, and she died 2 months after admission. The pathological examination at autopsy revealed a pancreatic endocrine tumor. No report has described findings of Ga-67 citrate scintigraphy of pancreatic endocrine tumors. Pancreatic endocrine tumor should be included in a differential diagnosis when such scintigraphic findings are encountered.     

Hepatic carcinosarcoma demonstrated by Ga-67 scintigraphy

A case of a primary hepatic carcinosarcoma, a very uncommon liver tumor in adults, demonstrated by Ga-67 scintigraphy, was reported. The liver image showed a lesion of low activity in the left lobe of the liver, whereas the Ga-67 image showed a moderate accumulation in the lesion detected by the liver scan and further indicated a high accumulation extending downwards from the hepatic lesion. An autopsy revealed that the huge abdominal tumor was composed of hepatocellular carcinoma and malignant mesenchymoma in the left hepatic lobe and in the lower part of the tumor, respectively. The Ga-67 image demonstrated these two different histological components of the tumor.     

Scintigraphic visualization of extraosseous xanthomatosis

A histologically proven case of extraosseous xanthomatosis is presented. Both Ga-67 citrate and Tc-99m-MDP imagings demonstrated tumor uptake of radiotracers. A second Ga-67 imaging taken after excisional biopsy of the left knee lesion revealed disappearance of the lesional uptake of the tracer seen on the preoperative Ga-67 scan. Radiotracer accumulation in extraosseous xanthomatosis has not been reported previously.     

Mesenteric desmoid with uptake on gallium-67 citrate scintigraphy

A 72-year-old man was hospitalized for further evaluation of a space-occupying lesion in the abdomen. Magnetic resonance imaging revealed a tumor 40 mm in diameter in the abdomen. Anterior Ga-67 citrate scintigraphy revealed a region of accumulation of radioactivity in the abdomen corresponding to the tumor. Mesenteric desmoid was diagnosed on the basis of histological findings for the excised tumor. These finding suggested that mesenteric desmoid may be one of the tumors which show high uptake of Ga-67.     

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.     

Detectability of metastatic bone tumor by Ga-67 scintigraphy

Ga-67 scintigrams in patients with malignant diseases sometimes reveal uptake of the tracer in the bone metastases. Detectability of Ga-67 scintigraphy for metastatic bone tumors and benign bone lesions was compared with that of Tc-99m bone scintigraphy. Countable bone metastases detected by bone scintigraphy were evaluated whether the lesion showed apparent, faint, or negative Ga-67 uptake. Of 47 lesions 23 (49%) showed apparent uptake and 17 (36%) showed negative uptake. On the other hand, of 71 benign bone lesions, only 7 (10%), mostly fracture/osteotomy, showed apparent uptake of the tracer. Uptake in the other benign lesions such as trauma of the ribs, spondylosis deformans, and arthrosis deformans was rather faint. In patients with multiple bone metastases, 9 patients (82%) out of 11 showed more prominent abnormal findings in Tc-99m MDP bone scintigraphy than in Ga-67 scintigraphy; that is, Ga-67 scintigraphy was not able to reveal all metastatic bone lesions. In patients with untreated or recurrent tumors, relation between Ga-67 uptake in the tumors and that in the bone metastases was evaluated. Of 7 patients with negative Ga-67 uptake in the primary tumors, 5 showed positive Ga-67 uptake in the bone metastases; that is, there seemed to be little relation between Ga-67 affinity to the primary tumors and that to the bone metastases. Mechanisms of the Ga-67 uptake in the bone metastases were discussed. Not only the tumor cells or tissues in the bone metastases but also bone mineral or osteoclasts might be the deposition sites of Ga-67.     

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.