Dynamic 99Tcm-HIDA SPET: non-invasive measuring of intrahepatic bile flow. Description of the method and a study in primary sclerosing cholangitis

Liver function assessment using 99mTc-GSA single-photon emission computed tomography (SPECT)/CT fusion imaging in hilar bile duct cancer: A retrospective study

BACKGROUND

The objective of this study was to determine the utility of Tc-99m-diethylenetriamine-penta-acetic acid-galactosyl human serum albumin ((99m)Tc-GSA) single-photon emission computed tomography (SPECT)/CT fusion imaging for posthepatectomy remnant liver function assessment in hilar bile duct cancer patients.

METHODS

Thirty hilar bile duct cancer patients who underwent major hepatectomy with extrahepatic bile duct resection were retrospectively analyzed. Indocyanine green plasma clearance rate (KICG) value and estimated KICG by (99m)Tc-GSA scintigraphy (KGSA) and volumetric and functional rates of future remnant liver by (99m)Tc-GSA SPECT/CT fusion imaging were used to evaluate preoperative whole liver function and posthepatectomy remnant liver function, respectively. Remnant (rem) KICG (= KICG × volumetric rate) and remKGSA (= KGSA × functional rate) were used to predict future remnant liver function; major hepatectomy was considered unsafe for values <0.05. The correlation of remKICG and remKGSA with posthepatectomy mortality and morbidity was determined.

RESULTS

Although remKICG and remKGSA were not significantly different (median value: 0.071 vs 0.075), functional rates of future remnant liver were significantly higher than volumetric rates (median: 0.54 vs 0.46; P < .001). Hepatectomy was considered unsafe in 17% and 0% of patients using remKICG and remKGSA, respectively. Postoperative liver failure and mortality did not occur in the patients for whom hepatectomy was considered unsafe based on remKICG. remKGSA showed a stronger correlation with postoperative prothrombin time activity than remKICG.

CONCLUSION

(99m)Tc-GSA SPECT/CT fusion imaging enables accurate assessment of future remnant liver function and suitability for hepatectomy in hilar bile duct cancer patients.

Assessment of liver function and liver fibrosis with dynamic Gd-EOB-DTPA-enhanced MRI

RATIONALE AND OBJECTIVES

To evaluate the ability of segmental linear fitting analysis of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid liver perfusion magnetic resonance imaging (MRI) to assess liver function and liver fibrosis.

MATERIALS AND METHODS

Gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid liver perfusion MRI was performed in 41 patients, and perfusion estimates were generated by segmental linear fitting analysis of the time-intensity curves. The relationships of Tin, Tout, Kup, and the ratio between the signal intensities of the peak and the last phase with liver fibrosis stage and laboratory measurements of liver function were evaluated.

RESULTS

Serum prealbumin concentration was significantly positively correlated with Kup and the signal intensity ratio and was significantly negatively correlated with Tin and Tout. Tin and Tout were significantly higher and Kup and the signal intensity ratio were significantly lower in patients with advanced fibrosis than those without. Tout was the best predictor of advanced fibrosis, with an area under the receiving operating characteristic curve of 0.843, a sensitivity of 100%, and a specificity of 80%.

CONCLUSIONS

A new procedure of quantifying the hepatocyte-specific uptake of a T1-enhancing contrast agent can be used to assess impaired hepatobiliary function. The parameters obtained from perfusion MRI have the potential to predict advanced fibrosis.

Functional discrepancy between two liver lobes after hemilobe biliary drainage in patients with jaundice and bile duct cancer: an appraisal using (99m)Tc-GSA SPECT/CT fusion imaging

PURPOSE

To determine the functional discrepancy between the two liver lobes using technetium 99m ((99m)Tc) diethylenetriamine-pentaacetic acid-galactosyl human serum albumin ( GSA diethylenetriamine-pentaacetic acid-galactosyl human serum albumin ) single photon emission computed tomography (SPECT)/computed tomography (CT) fusion imaging following preoperative biliary drainage and portal vein embolization ( PVE portal vein embolization ) in patients with jaundice who have bile duct cancer ( BDC bile duct cancer ).

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board, with waiver of informed consent. Preoperative (99m)Tc- GSA diethylenetriamine-pentaacetic acid-galactosyl human serum albumin SPECT/CT fusion images from 32 patients with extrahepatic BDC bile duct cancer were retrospectively reviewed. Patients were classified into four groups according to the extent of biliary drainage and presence of a preoperative right PVE portal vein embolization : right lobe drainage group (right drainage), bilateral lobe drainage group (bilateral drainage), left lobe drainage group (left drainage), and left lobe drainage with right PVE portal vein embolization group (left drainage with right PVE portal vein embolization ). Percentage volume and percentage function were measured in each lobe using fusion imaging. The ratio between percentage function and percentage volume (the function-to-volume ratio) was calculated for each lobe, and the results were compared among the four groups. Statistical analysis was performed with Wilcoxon signed-rank tests and Mann-Whitney U tests.

RESULTS

The median values for the function-to-volume ratio in the right drainage, bilateral drainage, left drainage, and left drainage with right PVE portal vein embolization group were 1.12, 1.05, 1.02, and 0.81 in the right lobe; and 0.51, 0.88, 0.96, and 1.17 in the left lobe. Significant differences in the function-to-volume ratio were observed among the four groups (right drainage vs bilateral drainage vs left drainage vs left drainage with right PVE portal vein embolization ; with P < .002, P = .023, and P < .002 for the right lobe and P < .001, P = .023, and P < .002 for the left lobe).

CONCLUSION

Hepatic lobar function significantly differs between the two lobes, depending on the extent of biliary drainage and the presence of portal vein embolization.

CT/99mTc-GSA SPECT fusion images demonstrate functional differences between the liver lobes

AIM: To evaluate the functional differences between the 2 liver lobes in non-cirrhotic patients by using computed tomography/^99mTc-galactosyl human serum albumin (CT/^99mTc-GSA) single-photon emission computed tomography (SPECT) fusion images.

METHODS: Between December 2008 and March 2012, 264 non-cirrhotic patients underwent preoperative liver function assessment using CT/^99mTc-GSA SPECT fusion images. Of these, 30 patients, in whom the influence of a tumor on the liver parenchyma was estimated to be negligible, were selected. Specifically, the selected patients were required to meet either of the following criteria: (1) the presence of an extrahepatic tumor; or (2) presence of a single small intrahepatic tumor. These 30 patients were retrospectively analyzed to calculate the percentage volume (%Volume) and the percentage function (%Function) of each lobe. The ratio between the %Function and %Volume (function-to-volume ratio) of each lobe was also calculated, and the ratios were compared between the 2 lobes. Furthermore, the correlations between the function-to-volume ratio and each of 2 liver parameters [lobe volume and diameter ratio of the left portal vein to the right portal vein (LPV-to-RPV diameter ratio)] were investigated.

RESULTS: The median values of %Volume and %Function were 62.6% and 67.1% in the right lobe, with %Function being significantly higher than %Volume (P < 0.01). The median values of %Volume and %Function were 31.0% and 28.7% in the left lobe, with %Function being significantly lower than %Volume (P < 0.01). The function-to-volume ratios of the right lobe (1.04-1.14) were significantly higher than those of the left lobe (0.74-0.99) (P < 0.01). The function-to-volume ratio showed no significant correlation between the lobe volume in either lobe. In contrast, the function-to-volume ratio showed significant correlations with the LPV-to-RPV diameter ratio in both lobes (right lobe: negative correlation, r_s = -0.37, P = 0.048; left lobe: positive correlation, r_s = 0.71, P < 0.001). The function-to-volume ratio in the left lobe tended to be higher, and that in the right lobe tended to be lower, in accordance with the increase in the LPV-to-RPV diameter ratio.

CONCLUSION: CT/^99mTc-GSA SPECT fusion images demonstrated that the function of the left lobe was significantly decreased compared with that of the right lobe in non-cirrhotic livers.

Liver analysis using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging: Correlation with histological grading and quantitative liver evaluation prior to hepatectomy

AIM

  To examine the effectiveness of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in the assessment of parenchymal liver fibrosis and quantitative liver function prior to hepatectomy.

METHODS

  Between July 2008 and September 2011, the data of 93 consecutive patients undergoing preoperative Gd-EOB-DTPA-enhanced MRI were analyzed, including serum fibrosis marker levels (hyaluronic acid, type IV collagen), 15-min retention rates of indocyanine green (ICG-R15) in the ICG clearance test, and technetium-99m galactosyl serum albumin scintigraphy results. Liver intensity values were obtained by calculating the differences between the intensity of the liver and that of other organs in the hepatobiliary phase. Degrees of liver fibrosis were quantitatively assessed (F0-4). MRI data were correlated with the prospectively acquired clinical data.

RESULTS

  Varying degrees of liver fibrosis were detected in 31 of the 93 patients. The intensity ratio of the liver to spinal cord on MRI negatively correlated with hepatic fibrosis (R = -0.479, P < 0.001) and ICG-R15 (R = -0.492, P < 0.001). When patients with F0-2 (normal/moderate) and F3-4 (severe) liver fibrosis were compared, the intensity ratio of the enhanced liver to spinal cord (IRLS) on MRI was significantly lower in the F3-4 group than in the F0-2 group. IRLS was correlated with liver fibrosis, and, when an IRLS criterion of less than 1.702 was used, severe liver fibrosis could be predicted with 68.8% sensitivity and 93.5% specificity.

CONCLUSION

  Preoperative Gd-EOB-DTPA-enhanced MRI analysis can detect quantitative indicators of liver fibrosis and function, thus aiding the assessment of hepatic remnants prior to hepatectomy.

Consensus report of the 4th International Forum for Gadolinium-Ethoxybenzyl-Diethylenetriamine Pentaacetic Acid Magnetic Resonance Imaging

This paper reports on issues relating to the optimal use of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid magnetic resonance imaging (Gd-EOB-DTPA MR imaging) together with the generation of consensus statements from a working group meeting, which was held in Seoul, Korea (2010). Gd-EOB-DTPA has been shown to improve the detection and characterization of liver lesions, and the information provided by the hepatobiliary phase is proving particularly useful in differential diagnoses and in the characterization of small lesions (around 1-1.5 cm). Discussion also focused on advances in the role of organic anion-transporting polypeptide 8 (OATP8) transporters. Gd-EOB-DTPA is also emerging as a promising tool for functional analysis, enabling the calculation of post-surgical liver function in the remaining segments. Updates to current algorithms were also discussed.

Imaging of normal lung, liver and parotid gland function for radiotherapy

There is growing clinical evidence that functional imaging is useful for target volume definition and early assessment of tumour response to external beam radiotherapy. A subject that has perhaps received less attention, but is no less promising, is the application of functional imaging to the prediction or measurement of radiation adverse effects in normal tissues. In this manuscript, we review the current published literature describing the use of positron emission tomography (PET), four-dimensional computed tomography (4D-CT), single photon emission computed tomography (SPECT) and magnetic resonance imaging (MRI) to study normal tissue function in the context of radiotherapy to the lung, liver and head & neck. Published results to date demonstrate that functional imaging can be used to preferentially avoid normal tissues not easily identifiable on solely anatomical images. It is also a potentially very powerful tool for the early detection of radiotherapy-induced normal tissue adverse effects and could provide valuable data for building predictive models of outcome. However, one of the major challenges to building useful predictive models is that, to date, there are very little data available with combined images of normal function, 3D delivered radiation dose and clinical outcomes. Prospective data collection through well-constructed studies which use established morbidity scores is clearly a priority if significant progress is to be made in this area.

Measurement of parenchymal function and bile duct flow in primary sclerosing cholangitis using dynamic 99mTc-HIDA SPECT

BACKGROUND AND AIM

Primary sclerosing cholangitis is a chronic cholestatic disease characterized by obliterative fibrosis of intrahepatic and/or extrahepatic bile ducts. The unpredictable clinical course of the disease can be relentless, leading to premature death in a large percentage of patients. Prognostic index formulas, the revised Mayo model being the most frequently used, have been developed to predict clinical course and prognosis. The aim of this study was to investigate the potential value of dynamic (99m)Tc-HIDA SPECT in patients with primary sclerosing cholangitis by correlating scintigraphic results with cholangiographic and biochemical findings and prognostic scoring systems used in clinical practice.

METHODS

In 18 patients with primary sclerosing cholangitis, segmental parenchymal and bile duct functions were measured using dynamic (99m)Tc-HIDA SPECT. Quantitative scintigraphic results were compared to cholangiographic findings, as graded by a biliary classification system, the Child-Pugh score and revised Mayo prognostic score, as well as the individual biochemical parameters included in the scoring systems.

RESULTS

In individual segments, scintigraphic quantitative parameters indicative of bile flow showed a statistically significant correlation with the state of the bile-flow path for the respective segments as assessed by the biliary classification system. The revised Mayo score correlated with the scintigraphic quantitative parameters indicative of parenchymal function and bile flow as calculated for the whole liver.

CONCLUSIONS

Dynamic (99m)Tc-HIDA SPECT, capable of assessing different aspects of liver function for the total liver, as well as for individual segments, has potential value in the management of patients with primary sclerosing cholangitis.

Different concentrations of various radiopharmaceuticals in the two main liver lobes: a preliminary study in clinical patients

BACKGROUND

At clinical scintigraphic examinations of the abdomen using single photon emission computed tomography (SPECT), we have observed a different distribution between the left and right main liver lobes of various radiopharmaceuticals. This was studied retrospectively in clinical patients.

METHODS

Examinations with [123I]-metaiodobenzylguanidine MIBG; (n=19), a 99mTc-labelled monoclonal antibody against granulocytes (n=18), and 111In-pentetreotide (n=26) were assessed. There was no known history of, or risk factor for liver disease, and all lobes showed a uniform activity distribution. Twenty healthy volunteers underwent consecutive examinations with 99mTc-dimethyliminodiacetic acid (HIDA). The activity ratios between the left and right main liver lobes were calculated from the transverse tomographic (SPECT) sections.

RESULTS

The left: right lobar activity ratio for [123I]-MIBG was (mean+/-SD) 1.25+/-0.21 (null hypothesis=1.00; P<0.001); for the antibody, acquisition after 3-5 h was 0.98+/-0.06 (NS) and after 20-24 h, 0.99+/-0.11 (NS); for 111In-pentetreotide, 0.90+/-0.09 (P<0.001); for 99mTc-HIDA, immediate acquisition, 0.68+/-0.12 (P<0.001) and acquisition at 7 min, 0.66+/-0.12 (P<0.001).

CONCLUSIONS

The differences in tracer uptake between the liver lobes cannot be caused only by differences in blood flow. One explanation of the higher uptake of [123I]-MIBG by the left lobe may be a greater presence of catecholamines and a higher sympathetic nerve density in this liver portion. Consequently, there may be a functional difference between the two main liver lobes.

Preparation and in-vivo evaluation of 99mTc-IOTIDA for cholescintigraphy

The synthesis, radiolabeling and in vivo evaluation of 99mTc-IOIDA(3-iodo 2,4,6-trimethylpheyl carbamoylmethyl iminodiacetic acid) for the assessment of hepatocytic function and the functional status of the cystic duct and the gallbladder are described. For a scintigraphic imaging comparison, three different 99mTc-IDA derivatives, 99mTc-DISIDA, 99mTc-mebrofenin and 99mTc-IOTIDA, were prepared and evaluated for their in vivo pharmacokinetic behavior through animal studies. Serial static image scans of rabbits injected with 99mTc-IOTIDA revealed that none of the tissues except the hepatobiliary system showed radioactivity concentrations. A scintigraphic study in a healthy volunteer showed that most of the administrated radioactivity accumulated in the liver and was rapidly excreted through the hepatobiliary system, visualizing the gallbladder within 15 min. In conclusion, 99mTc-IOTIDA is a potential hepatobiliary imaging agent for the evaluation of the functional status of hepatocytes and the patency of the biliary duct.

Sclerosing cholangitis

Primary sclerosing cholangitis in children can mimic autoimmune hepatitis in the absence of inflammatory bowel disease. Most adult patients have been identified with human leukocyte antigens that either predispose or protect against disease. Novel class I alleles and cytokine polymorphisms may also contribute to disease susceptibility. Primary alpha-hemolytic streptococci infection does not appear to directly cause primary sclerosing cholangitis. Promising diagnostic modalities such as single photon emission tomography require further study in comparison with cholangiographic techniques. Positron-emission tomography and DNA cytometry appear promising for confirming occult cholangiocarcinoma when present. The chemoprevention effects of ursodeoxycholic acid on colorectal dysplasia await further investigation. Initial results from high-dose ursodeoxycholic acid in halting disease progression, however, suggest a beneficial effect. In contrast, the impact of endoscopic therapy on natural history remains unresolved. Although liver transplantation continues to be effective for end-stage liver disease, disease recurrence in the allograft is a controversial topic.