Sequential technetium-99m sulfur colloid/indium-111 white blood cell imaging in macroglobulinemia of Waldenstrom

Technetium-99m sulfur colloid (SC) and indium-111 labeled leukocyte (In-111 WBC) scintigraphy was performed on a 77-year-old female patient to rule out a left periprosthetic infection. Anterior Tc-99m SC and In-111 WBC images of the pelvis and femurs revealed no abnormal deposition of radiotracer about the Austin-Moore prosthesis. Absent radiotracer uptake, however, was demonstrated within the left hemipelvis. A left iliac bone marrow aspirate and biopsy revealed a lymphoplasmacytic infiltrate consistent with Waldenstrom's macroglobulinemia.     

In-111 leukocyte scanning and partial functional asplenia in a patient with Sézary syndrome

Functional asplenia is described in the case report of an 80-year-old woman who was admitted with Sézary syndrome. The spleen could not be visualized by a Tc-99m tin colloid (SnC) liver and spleen scan, but was visualized by a Tc-99m sulfur colloid (SC) scan, suggesting a different mechanism in accumulation of SnC and SC in the spleen. In-111 oxine labeled Sézary cells could be found in the spleen, bone marrow, and lymph nodes.     

A new formulation of Tc-99m minimicroaggregated albumin for marrow imaging: comparison with other colloids, In-111 and Fe-59

The biodistributions of five Tc-99m colloids were compared with the 24-hr distributions of Fe-59 and In-111 in dogs by direct radioassay 1 hr after intravenous injection. One formulation of Tc-99m minmicroaggregated albumin (particle size 30-100 mn), produced the highest marrow concentration, approximately six times that of Tc-99m sulfur colloid, with similar blood, and liver concentrations and a lower splenic uptake. Nevertheless, the best colloid marrow uptake was lower than the 24-hr value for In-11 and much lower than that for Fe-59. The marrow concentration of minimicroaggregated albumin was also higher than that of sulfur colloid in rats at 30 min after injection. The principal disadvantage of Tc-99m antimony sulfide colloid was its slow blood clearance. Clinical evaluation of Tc-99m minimicroaggregated albumin for marrow imaging appears warranted, although its hepatic activity will obscure overlying and immediately adjacent marrow.     

Tc-99m HMPAO-labeled leukocytes for hematopoietic marrow imaging. Comparison with In-111 chloride.

The current study was initiated to define whether Tc-99m leukocyte imaging, compared to In-111 chloride imaging, could provide additional information on the hematopoietic activity of the bone marrow in diffuse hematologic disorders. A total of 11 patients with hematologic disorders were studied both with Tc-99m leukocytes and In-111 chloride. One patient with myelofibrosis showed disparate tracer distribution in the bone marrow between the two; Tc-99m leukocyte uptake in the central marrow was highly decreased, whereas In-111 chloride showed expanded marrow. The disparate results of granuloid hypoplasia and erythroid hyperplasia obtained by bone marrow biopsy and aspiration in this patient were thought to give an explanation for the radionuclide findings. The remaining 10 patients showed similar tracer distribution in the marrow, and the observation of hematopoietic cellularity confirmed by bone marrow biopsy and aspiration correlated well with the radionuclide findings. These results demonstrate that Tc-99m leukocytes may be a potential imaging agent for evaluating hematopoietic activity in the bone marrow, in particular granulopoietic activity.     

Infected knee prosthesis: diagnosis with In-111 leukocyte, Tc-99m sulfur colloid, and Tc-99m MDP imaging

Forty-one possible cases of infected total knee prostheses studied with indium-111-labeled leukocyte scintigraphy were retrospectively reviewed. Twenty-four of the prostheses were studied with technetium-99m methylene diphosphonate bone scintigraphy and 19 with Tc-99m sulfur colloid marrow scintigraphy. Nine prostheses were infected, and 32 were uninfected. The accuracy of combined labeled leukocyte and sulfur colloid marrow imaging (95%) was higher than that of labeled leukocyte scintigraphy alone (78%), bone scintigraphy alone (74%), or combined labeled leukocyte and bone scintigraphy (75%). The authors conclude that combined labeled leukocyte and sulfur colloid imaging is an accurate method for diagnosis of infected knee prostheses. In this series, this technique was superior to labeled leukocyte and bone imaging, alone or in combination.     

Increased bone marrow uptake on Tc-99m DMSA scintigraphy in a patient with renal osteodystrophy

A 16-year-old male patient was evaluated with Tc-99m Diethylenetriamine-pentaacetic acid (DTPA) and Tc-99m 2–3 Dimercaptosuccinic acid (DMSA) scintigraphy for renal failure secondary to renal calculi. The uptake in the renal cortex was significantly decreased both on DMSA and DTPA studies. Uptake calculation on DMSA scintigraphy in the kidneys disclosed values of less than 5 %. The activity in the liver and bone was significantly increased. A bone scan performed with Tc-99m methylene diphosphonate (MDP) revealed increased bone uptake with decreased soft tissue activity. Findings on bone scan were compatible with super scan, most likely due to renal osteodystrophy. This case illustrates the altered biodistribution of Tc-99m DMSA and a shift of the radiopharmaceutical to the bone marrow which is mot likely related to colloid formation due to changes in mineral balance in patients with renal failure.     

Indium-111 labeled leukocyte imaging following hepatic artery embolization

The use of In-111 labeled leukocytes for abscess localization is becoming well established. The first report of In-111 imaging following hepatic embolization is presented. A 45-year-old man with adenocarcinoma of the colon and metastatic liver disease was treated for intractable pain using particulate embolization of the hepatic artery. In-111 leukocyte imaging was performed to rule out abscess formation. The distribution of the labeled leukocytes demonstrated hepatic uptake commensurate with Tc-99m sulfur colloid (SC) images. Areas of embolization did not accumulate tracer. Pathologic examination at autopsy correlated with the distribution of the labeled leukocytes. Thus, therapeutic embolization did not alter the normal distribution of this tracer in functional hepatic tissue.     

Evaluation of a 3-hour indium-111 leukocyte image as a surrogate for a technetium-99m nanocolloid marrow scan in the diagnosis of orthopedic infection

OBJECTIVES: This is a retrospective study to evaluate a 3-hour In-111-labeled leukocyte image as a surrogate for a Tc-99m nanocolloid marrow scan in the investigation of suspected orthopedic infection using In-111 leukocyte scintigraphy. METHODS: Images from 51 patients who had received contemporaneous In-111-labeled leukocyte scintigraphy and Tc-99m nanocolloid marrow scintigraphy were reviewed. Initially, the 3-hour and 22-hour In-111-labeled leukocyte images were compared. Sites of abnormal uptake on the 22-hour image were correlated with the 3-hour image and were graded according to the level of concordance or discordance. One week later, the Tc-99m nanocolloid images and 22-hour In-111-labeled leukocyte images of the same patients were compared and graded for concordance or discordance. When discrepancies in grading arose between the observers, a consensus opinion was achieved after additional review of the images a week later. RESULTS: On inspection of the 22-hour In-111 leukocyte images, 93 sites of focal, potentially abnormal leukocyte accumulation were identified. When the grading system was reduced to simply "concordant" or "discordant," there was good agreement between the observers in the majority of cases, with kappa statistics 0.77 for Tc-99m nanocolloid versus 22-hour In-111-labeled leukocyte images and 0.78 for 3-hour versus 22-hour In-111-labeled leukocyte images. Using the comparison of the Tc-99m nanocolloid marrow scan and the 22-hour In-111-labeled leukocyte images to identify concordance or discordance as the "gold standard" for scintigraphic evaluation of suspected orthopedic infection, comparison of the 3-hour In-111-labeled leukocyte images with the 3-hour In-111-labeled leukocyte images gave a sensitivity of 77%, a specificity of 77%, and an accuracy of 77%. CONCLUSIONS: A 3-hour image is helpful using In-111-labeled leukocyte scintigraphy.     

Postoperative bone marrow alterations: potential pitfalls in the diagnosis of osteomyelitis with In-111-labeled leukocyte scintigraphy.

Scintigraphy was used after injection of technetium-99m methylene diphosphonate (MDP) and indium-111-labeled white blood cells (WBCs) to assess for the presence of osteomyelitis in 97 patients who had undergone prior surgical procedures. Thirty-four patients with abnormal In-111-labeled WBC patterns underwent restudy with Tc-99m albumin colloid (AC). Scintigraphic findings were considered positive for osteomyelitis whenever localization of In-111-labeled WBCs exceeded Tc-99m AC activity in extent or focal intensity (discordant pattern). Ten of 12 patients with culture-proved osteomyelitis had discordant patterns; two had false-negative (concordant) patterns. The cases of 20 of 22 patients without infection who were considered to have osteomyelitis on the basis of patterns of In-111-labeled WBCs and Tc-99m MDP were reclassified correctly on the basis of concordant patterns of In-111-labeled WBCs and Tc-99m AC. Radiocolloid images improved the overall scintigraphic specificity for osteomyelitis from 59% without bone marrow imaging to 92%; sensitivity decreased from 94% to 88%.     

Tc-99m white cell scintigraphy in suspected acute infection

The usefulness of In-111 labeled white cells in acute infection is well documented but the role of Tc-99m labeled white cell scintigraphy (WCS) has not been as clearly established. Using stannous fluoride colloid and a simple labelling procedure with 20 ml of autologous whole blood, three cases are presented in which Tc-99m WCS established unexpected diagnoses in patients who had remained undiagnosed despite extensive investigation.     

Importance of Tc-99m sulfur colloid liver-spleen scans performed before indium-111 labeled leukocyte imaging for localization of abdominal infection

INTRODUCTION: The localization of intraabdominal abscesses is a difficult imaging problem in nuclear medicine, especially when the location of the abscess is in the area of the liver and spleen. The need for performing Tc-99m sulfur colloid liver-spleen scans before injecting indium-111 leukocytes for improved lesion detection and characterization versus performing In-111 leukocyte scans alone has been questioned in the literature MATERIALS AND METHODS: We present 3 patients with intraabdominal abscesses in the liver-spleen area, in which liver-spleen scans were performed before In-111 leukocyte scans. The findings of all were correlated with computed tomography and interventional procedures. RESULTS: In all patients, the Tc-99m liver-spleen scan helped for accurate recognition of the location of the abscess, correlated with computed tomography findings, and were helpful for intervention and exclusion of the other sources of infection. CONCLUSION: Data from these 3 patients reinforces the need for Tc-99m sulfur colloid liver-spleen scans before performing In-111 WBC scans for better localization and interventional treatment of intraabdominal abscesses.     

Indium-111 WBC scan in acute toxic centrilobular hepatic necrosis

In this case of prolonged fever and abnormal liver functions, dual tracer scintigraphy with In-111 WBCs and Tc-99m SC led to a biopsy-proven diagnosis of severe acute toxic hepatitis (hepatocellular necrosis). Correlation of the Tc-99m SC scan findings with those previously reported for "pseudotumors" of the liver is discussed. A "pseudonormal" scan pattern is described for the In-111 WBC scintigraphy. Discordance between In-111 WBC and Tc-99m SC scintigraphy in this clinical setting should raise the possibility of hepatic necrosis as a diagnostic alternative to hepatic abscess.     

Subacute splenic abscess. Appearance on indium-111 leukocyte, gallium-67, and technetium-99m sulfur colloid imaging

A case of a 23-year-old man with an encapsulated, anaerobic splenic abscess is reported. Both the In-111 leukocyte and Tc-99m sulfur colloid scans demonstrated an intrasplenic defect. The Ga-67 citrate scan revealed uptake in the rim of the abscess only where the abscess cavity was relatively photon-deficient. The combined Tc-99m sulfur colloid/In-111 leukocyte/Ga-67 scan appearance of a subacute splenic abscess has not been described previously. In cases suspected to be splenic abscesses the combined In-111 leukocyte/Tc-99m sulfur colloid imaging is the most useful.     

Scintigraphic findings in infantile hemangioendothelioma

The scintigraphic findings on sulfur colloid liver-spleen imaging, Tc-99m labeled RBC blood pool imaging, and Tc-99m MDP bone imaging in four patients with infantile hemangioendothelioma are described. Thirteen radionuclide studies were performed, with serial sulfur colloid images obtained in three patients, allowing interval assessment of liver size and tumor involvement. Findings of Tc-99m MDP uptake in the livers of two patients with hemangioendothelioma and diffuse increase in hepatic RBC labeled blood pool activity in one patient also are reported.     

In-111 octreotide scan in a case of a neuroendocrine tumor of unknown origin

Major neuroendocrine tumors contain many somatostatin receptors. This feature allows for the localization of primary tumors and tumor metastases by scintigraphy with the radiolabeled somatostatin analog octreotide. We describe a patient with nonspecific clinical data and ultrasonography and CT that showed an isolated focal lesion in the liver. In-111 octreotide scintigraphy was essential in establishing the diagnosis of liver metastasis from a neuroendocrine tumor confirmed by pathologic findings. Because clinical symptoms recurred, ultrasonography and CT were performed a few months after surgery. Both were negative. However, In-111 octreotide scintigraphy suggested multiple bone metastases and established the diagnosis of bone metastases from a neuroendocrine tumor, which was confirmed by Tc-99m MDP bone scans and MRI.     

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.     

Clinical usefulness of In-111 chloride and Tc-99m Sn colloid scintigraphy in the diagnosis of intrathoracic extramedullary hematopoiesis

We report a case of intrathoracic extramedullary hematopoiesis associated with hemolytic anemia. While the paravertebral localization of the lesions demonstrated on CT and MRI was suspicious of intrathoracic extramedullary hematopoiesis, In-111 chloride and Tc-99m Sn colloid bone marrow scintigraphies showing a bone marrow element of the lesion were useful to confirm the diagnosis.     

Simultaneous demonstration of pleural effusion and ascites by technetium-99m sulfur colloid liver-spleen scintigraphy

Scintigraphic evidence of ascites has been observed in Tc-99m sulfur colloid studies of the liver and spleen, in Tc-99m HIDA hepatobiliary scans, in Ga-67 citrate scans, and in Tc-99m phosphonate bone images. Pleural effusion has been demonstrated in Tc-99m phosphonate bone scintigraphy. The case of a 48-year-old man whose Tc-99m sulfur colloid liver-spleen scintigram simultaneously demonstrated a right pleural effusion and ascites is presented.     

Abnormal pulmonary accumulation of indium-111 chloride in pneumocystis carinii pneumonia as detected by bone marrow scintigraphy

PURPOSE: Unusual pulmonary uptake of In-111 chloride in a patient with Pneumocystis carinii pneumonia and autoimmune hepatitis is described. METHOD: In-111 chloride bone marrow scintigraphy was performed to evaluate the bone marrow activity associated with pancytopenia in a 56-year-old woman with autoimmune hepatitis. RESULTS: An In-111 chloride bone marrow scan showed increased pulmonary uptake predominantly in both upper lung fields. P. carinii pneumonia was seen to be developing as an immunocompromised complication after treatment for autoimmune hepatitis. CONCLUSION: When In-111 chloride bone marrow scintigraphy shows increased uptake in the lungs of immunocompromised patients, a combined opportunistic inflammatory disease such as P. carinii pneumonia should be considered in the diagnosis.     

Demonstrating alcoholic cirrhosis of the liver by Tc-99m BIDA scintigram

Six patients with decompensated cirrhosis of the liver underwent Tc-99m BIDA studies. All demonstrated 1) persistently high blood pool activity in the heart, lung, and soft tissue, 2) slow hepatic tracer uptake, 3) prolonged liver-to-bowel transit time, and 4) visualization of an enlarged spleen. Four of the six patients demonstrated evidence of ascites and in one patient there were visible collateral veins of the abdomen. These findings are due primarily to hepatic dysfunction and retaining Tc-99m BIDA in blood pool because of Tc-99m BIDA exclusively hepatic excretion and little or no alternative renal excretion. All six Tc-99m sulfur colloid studies were performed concomitantly. Except for bone marrow uptake and reversal of the normal liver-spleen ratio of radioactivity, the imaging abnormalities observed with Tc-99m BIDA were similar to those seen by Tc-99m SC. It is concluded that with Tc-99m BIDA studies, three of six abnormal findings, as described, suggest a decompensated stage of cirrhosis of the liver.