B Cell Lymphoma: A Case With Localized Involvement of the Prostate on F-18-FDG Examination

An 80-year-old man had symptoms of urinary retention. Biopsy of the prostate revealed B cell lymphoma. To evaluate the extent of the disease, an F-18 FDG study was performed with positron emission tomography/computed tomography (CT). One hour after intravenous administration of 18.5 mCi F-18 FDG, imaging was carried out from the skull base to the upper thigh. An area of moderately increased activity was noted within the prostate bed. A noncontrast CT, for attenuation correction and anatomic localization, revealed maintenance of fat planes around the prostate, indicating disease localized to that organ. Hence, a B cell lymphoma had been localized to the prostate.

Asymmetric Tongue Muscle Uptake of F-18 FDG

A 58-year-old woman, with nonsmall cell carcinoma, had multiple metastasis on 2-F-18 FDG positron emission tomography imaging. The right hemitongue had increased activity as compared with the left. This was not the result of the presence of a metastasis to the tongue, as shown by a negative computed tomography scan of the region and failure to demonstrate a lesion over a period of weeks. Uptake was likely related to right hemiglossal muscle activity. This was made more apparent by decreased uptake on the opposite side of the tongue (up to the midline) as a result of left cranial nerve XII paralysis.

Preoperative lymphoscintigraphy during lymphatic mapping for breast cancer: improved sentinel node imaging using subareolar injection of technetium 99m sulfur colloid

BACKGROUND

Preoperative lymphoscintigraphy has been recommended to confirm the successful uptake and direction of migration of radiotracer into sentinel nodes during lymphatic mapping for breast cancer. In addition, preoperative lymphatic mapping may provide a visually useful aid to the relative location of sentinel nodes within a nodal basin. One common method of breast lymphoscintigraphy involves injections of unfiltered technetium 99m sulfur colloid (Tc-99m-SC) directly into parenchymal tissues surrounding a tumor or biopsy cavity (IP injection). Because of the many imaging failures and prolonged imaging times of IP lymphoscintigraphy, the procedure has fallen into disfavor by oncologic surgeons. The purpose of this study is to document the increased success rate of preoperative breast lymphoscintigraphy using a new anatomic site of injection, the subareolar lymphatic plexus (SA injection).

STUDY DESIGN

In the 12 months between December 1, 1998, and December 29, 1999, 42 women with stage I and II breast cancer underwent preoperative lymphoscintigraphy by either the IP (n = 12, December 1998 to May 1999) or SA (n = 30, May 1999 to December 1999) route of injection. Both groups were injected with 1 mCi (37 MBq) of unfiltered Tc-99m-SC followed immediately by external gamma-camera imaging. The success rate for preoperative sentinel node imaging and the total imaging time were recorded in both groups.

RESULTS

The success rate of identifying a sentinel node by SA lymphoscintigraphy was 90% (n = 27 of 30 patients), compared with 50% (n = 6 of 12 patients) for IP lymphoscintigraphy (p = 0.009). The imaging time in the SA injection group was 34 +/- 16 minutes, which was 59% shorter than the imaging time in the IP injection group of 82 +/- 48 minutes (p < 0.001). No uptake into internal mammary nodes was seen in either group.

CONCLUSIONS

Moving the site of injection ofunfiltered Tc-99m-SC to the subareolar lymphatic plexus (SA injection) increased the success rate of preoperative lymphoscintigraphy to 90%, compared with 50% using IP injections. Preoperative SA lymphoscintigraphy resulted in the rapid visualization of axillary sentinel nodes within 30 minutes of SA injection, enabling a visual determination of the approximate number of sentinel nodes and their relative locations within the axilla. We conclude SA injection of unfiltered Tc-99m-SC is superior to IP injections when performing preoperative breast lymphoscintigraphy and is a visually useful aid to lymphatic mapping for breast cancer.

Ureteral leak after renal transplantation

In the course of radionuclide dynamic studies in 187 consecutive patients who had renal transplants, leakage from a ureter was identified in five cases (an incidence of less than 3%). Demonstrated patterns fell into three classes: 1) perirenal collection (n = 2), 2) peribladder activity (n = 2), and 3) downward dissection (n = 1 case). The sensitivity and specificity of the radionuclide study for detecting ureteral escape of urine after renal transplantation is unknown. However, this study suggests that both indices may be high.

Analysis of growth rate of pediatric kidneys transplanted into juveniles or adults

Estimation of renal length was carried out during radionuclide function studies, in cases of pediatric kidneys transplanted into adolescents or adults. In all 24 cases of single kidney transplants, the kidneys eventually increased in size, but at varying rates. From 5 cases with repeat studies close in time, and shortly after transplantation, an apparent maximal growth rate was estimated. In 3 pairs of dual renal transplants, with both kidneys surviving, marked differences in growth of each member of the pair was noted. The present initial description, of rates of change in size of the transplanted pediatric kidneys, may serve as a baseline from which to sort out the contributions of pre- and post-transplant factors.

Coexistent parathyroid adenomas and Hurthle cell tumors: failure of full detection by subtraction method

Tc-99m sestamibi and I-123 sodium iodide studies were performed on two patients, one with a neck mass and another with suspected hyperparathyroidism. Subtraction images, detected what proved to be Hurthle cell tumors in each case, but coexisting parathyroid adenomas, which were found at surgery, were not visualized. The findings indicate that both types of lesions can occur simultaneously, and that studies are needed to determine whether detailed assays of rate of washout could distinguish between the lesions.

Splenic and partial hepatic necrosis after vascular occlusion

A 74-year-old woman underwent two operations to correct an aortoduodenal fistula and to have an axillofemoral bypass graft inserted; these required temporary vascular occlusion. Her hepatic function test results began deteriorating. Initial and follow-up Tc-99m sulfur colloid studies revealed activity in the kidneys, consistent with disseminated intravascular coagulation. There was significant radiocolloid in the bone marrow and lungs, suggesting severe hepatic dysfunction. The spleen was not demonstrable on dynamic images or static views. In addition, there was a significant lateral hepatic defect, with a "lung overlap." The splenic lack of function and the hepatic lesion were due to necrosis (demonstrable on CT imaging), likely related to the prior vascular clamping.

Endodontic case selection: to treat or to refer

Endodontic treatment in the United States is delivered primarily by general dentists. A dilemma often arises as to which cases should be treated and which should be referred for specialty care. The case selection system described here rates endodontic cases so that practitioners can assess those cases they are best qualified to treat.

Value of 111indium leukocyte scanning in febrile organ transplant patients

Immunosuppressed febrile organ transplant patients present a diagnostic and therapeutic dilemma since symptomatology is often altered by immunosuppression, which also masks the location of infection. Fifty 111indium leukocyte ( 111In WBC) scans were performed to determine their usefulness in the organ transplant patient. The results were compared with computerized tomography (CT) and gallium 67-citrate (Ga) scanning. Eleven patients received both 111In WBC and Ga scans; 22 received both 111In WBC and CT scans. Ten 111In WBC scans had subtraction of 99m Tc sulfur or albumin colloid for liver evaluation and four 111In WBC scans had subtraction of 99m Tc DMSA for kidney evaluation. The overall sensitivity and specificity for 111In WBC scans was 90% and 90%, respectively. Lung uptake was sensitive (89%) and specific (97%) for pulmonary infections, including bacterial, fungal and cytomegalovirus pneumonias. Renal graft uptake occurred in 15 cases (41%), all except 2 being due to rejection, pyelonephritis, urinary tract infections, or cytomegalovirus infections. Pyelonephritis and renal abscesses were diagnosed in 3 cases with 99m Tc DMSA subtraction. Perihepatic abscesses (2), and infected liver cysts (4) were diagnosed with 99m Tc sulfur or albumin colloid subtraction. There were five false-negative CT scans and three false-negative Ga scans. Therefore, when compared with 111In: sensitivity = 88% vs 64% (CT), specificity = 80% vs 86% (CT); and sensitivity = 111In 90% vs 67% (Ga), specificity = 100% for both 111In WBC and Ga scans.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosing osteomyelitis in Gaucher's disease. Observations on two cases

Bone scans in two patients with Gaucher's disease were reported as consistent with Gaucher's-associated osseous crises. A bone-radiogallium subtraction study was also initially negative in each individual (although it later became positive in one). At surgery both patients were seen to have osteomyelitis. These two cases point out the difficulty in attempting to diagnose osteomyelitis in the presence of Gaucher's bone disease. A possible role for MRI in such instances was mentioned. Also noted was clinical reluctance to accept a diagnosis of osteomyelitis (positive bone-radiogallium subtraction study) in an afebrile Gaucher's patient.

Histologic evaluation of the pulpal response to temperature probe placement in the Macaca fascicularis monkey

A method to measure intrapulpal temperatures during cavity preparation and restorative procedures has been developed. It involves placement of temperature probes to the dentinoenamel and dentinopulpal junctions. After placement of the probes, the pulps of the test teeth were examined histologically to determine whether their placement caused a pulpal response. The test teeth displayed no adverse response in the areas of the pulp opposite or adjacent to the position of the probes. Therefore the developed method of temperature probe placement to measure intrapulpal temperatures does not interfere with those measurements by adversely affecting the pulp tissues.

Gastric pertechnetate contribution to blood pool images

During a cardiac blood pool study (Tc-99m erythrocytes), there was an apparent "cold" area in the left lobe of the liver. At one hour, the prior void appeared to have filled in, suggesting an intrahepatic hemangioma. However, the changing pattern of radioactivity, and its shape, indicated that this actually represented Tc-99m pertechnetate in the gastric wall and stomach cavity. In a second case, the interval between intravenous injection of stannous pyrophosphate and Tc-99m pertechnetate was prolonged. Changing activity, again in the gastric wall and cavity, obscured part of the liver. This cleared with time, allowing hepatic evaluation. Thus, gastric pertechnetate can contribute to blood pool images of the heart or liver and multiple images may be needed to separate this component from nearby tissues.

Nuclear medicine studies of aging--IX. Resting left ventricular ejection fraction-diastolic area relationship in the "oldest old"

We retrospectively investigated the relationship between left ventricular ejection fraction (EF) and end diastolic cross sectional area (DCS), by means of gated cardiac blood pool studies, in 62 individuals (68 studies) who were of age 85 y or older. In these "oldest old", a plot of log ejection fraction as a function of log cross sectional area revealed good correlation (r = 0.66). The graph demonstrated the increase in heart size with a falling ejection fraction. Of the "oldest old", 38% had EF values at or above 55%. By comparison, in a group of 100 patients of ages 55-75 y, 32% had EF values of or above 55%. In the "oldest old" 13/68 (19%) had "hyperdynamic" EF values over 65%; in the 55-75 y old group, this value was 16%. The log-log plot was divided into four quadrants by two lines (one at a DCS of 26 cm2 and the other at EF of 55%). Possible prognostic significance of each of these four categories will have to be determined by following the patients and sorting out the contributions of such factors as hypertension, coronary artery disease and medications.

Nuclear medicine studies of aging--I. Procedure utilization in the oldest old

Analyses of procedure utilization are of importance if accurate projections are to be made of local and national needs as the population ages. Nuclear Medicine records of a general hospital were analyzed for 1986, to determine utilization patterns in the oldest old (age 85 years and greater) as compared with younger patients. The most elderly comprised 1.3% of the population of this state, but "consumed" 3.9% of the studies carried out in Nuclear Medicine (or a rate 3 times greater than expected). The average number of procedures/patient during the year was 1.56 in the oldest old vs 1.57 in younger individuals. The sex ratio of procedure utilization was 65% female (slightly lower than state wide national estimates of the female portion of the population). A far lower percentage of studies were performed as outpatients in the oldest old (12.2%) than in the younger population (44.9%); contributing factors were discussed. Of the procedures, several had the same percentage utilization in the oldest old and younger groups (gated cardiac blood pool, liver plus hepatobiliary, and radiogallium imaging). Bone scans were slightly less common in the very elderly. However, thyroid studies and radiothallium cardiac imaging were performed significantly less frequently in the more elderly. Procedures carried out more frequently in the very elderly were gastrointestinal bleeding examinations and lung imaging. Possible reasons for this were pointed out.

Recovery of femoral head perfusion after drainage of septic joint

A 64-year-old woman was febrile and had pain near the right hip. Blood cultures grew beta hemolytic streptococci. A bone scan showed reduced activity in the right femoral head and neck compared with the left femoral head and neck. She was treated with intravenous antibiotics and surgical decompression of a tense and bulging right hip joint. Five days later, a repeat bone scan revealed much of the femoral head activity to have returned. By day 20 after the initial bone image, there was intense activity throughout the femoral head and neck. Prompt relief of a distended hip joint can result in reperfusion of the femoral head and neck.

Varied appearance of cardiac pseudoaneurysms on blood pool images

Three cases of cardiac pseudoaneurysms were presented, with findings at the time of gated blood pool imaging. In only one of three was there the finding of a small neck connecting the ventricular cavity with the pseudoaneurysm. In the other two patients, there was a considerably larger communication. The size of the pseudoaneurysm itself was also of little diagnostic assistance. In one case it was small, while in a second patient it was larger in size. The third case revealed a pseudoaneurysm of enormous size (larger than the ventricular cavity). Gated blood pool imaging apparently can be called upon to demonstrate the presence of an abnormality. It may not be able to definitely establish the diagnosis of pseudoaneurysm, but should suggest the use of cardiac angiography to distinguish these life threatening lesions from true aneurysms.

Dual radionuclide subtraction imaging of the spleen

Dual radionuclide subtraction imaging of the spleen using 67Ga citrate and 99mTc is useful in further delineating lesions that are identified on either a routine radiogallium survey or on a conventional sulfur colloid liver-spleen image. Better anatomic localization of left subphrenic abscesses may be obtained. Differentiation of tumors and abscesses from less serious lesions such as cysts, infarcts, and hematomas is possible. We have found this technique to be generally applicable to any organ that can be selectively imaged using a technetium radiopharmaceutical, including the liver, bones, and kidneys. In addition, we are currently evaluating thallium-pertechnetate subtraction imaging in the evaluation of parathyroid adenomata.

Delayed splenic rupture: a suggestion for "predictive monitoring"

Two cases of delayed splenic rupture are presented. In one, splenic damage was demonstrated on Day 29 following trauma, and rupture of the organ occurred 2 days later. In the second patient, splenic trauma was documented 1 day after an accident, and rupture occurred on Day 26. Each case was marked by the fact that only one spleen scan had been performed (in the first case because of discovery only long after the trauma, and in the second case because of the patient's failure to return). That is, while damage to the spleen was evident, there was no follow-up to document healing. Based on this, it is suggested that spleen imaging be carried out soon after trauma. If a trauma-related defect is shown, then a repeat study may be mandatory to document healing. Lack of such healing, or failure to progress at a normal rate, may be an altering sign to impending splenic rupture. Hence, "predictive monitoring" by early and then repeat imaging at a later date, is proposed.

"Reactivation" of Tc-99m MDP uptake in heterotopic bone

Heterotopic bone in the left femoral head area showed progressive decrease in Tc-99m MDP uptake, only to reveal increased uptake at a later date.

Rapid response of intrasplenic lesions to steroids in non-Hodgkin's lymphoma

A 70 year old woman had a [99mTc]sulfur colloid liver/spleen scan that showed splenomegaly and multiple intrasplenic defects. The lesions failed to concentrate radiogallium. Thirteen days later, after being on steroid therapy, the spleen had decreased in size and the lesions were only barely apparent. The intrasplenic process, due to non-Hodgkin's lymphoma, was thus markedly sensitive to steroids. It is uncertain if such rapid regression can be employed as a prognostic indicator in non-Hodgkin's lymphoma and suggests the need for further monitoring. The differential diagnosis of the rapid response of intrasplenic lesions to steroids is a limited one, and likely includes sarcoidosis.

Scintigraphic appearance of axillofemoral and femorofemoral bypass grafts

The scintigraphic appearance of axillofemoral and femorofemoral bypass grafts was reviewed in three cases in which the grafts were patent and intravascular radiotracers defined their course. In a fourth case, the axillofemoral graft was occluded and an aberrant vessel was identified (probably acting as a physiological shunt).

The basement membrane of the enamel organ in human odontogenesis

This study was designed to record findings of a basement membrane in human fetal jaws relative to the oral epithelium, dental lamina, and developing teeth. With the use of Lillie's allochrome stain, this could be followed from the oral epithelium and dental lamina to the tooth jaws. The basement membrane was easily traced along the inner enamel epithelium, but only after elimination of the counterstaining phases was it visible adjacent to the outer enamel epithelium.

Hyperthyroidism with metastatic follicular thyroid carcinoma

A 70-yr-old woman presented with hyperthyroidism and metastatic follicular carcinoma of the thyroid. The blood level of thyroid stimulating immunoglobulin (TSIg) was elevated. A total thyroidectomy was performed. One month later she remained hyperthyroid. Three weeks after therapy with 218 mCi of I-131 sodium iodide, the patient was euthyroid. Six months after the initial radioiodide therapy, she was again hyperthyroid and was given a second oral treatment dose of I-131 (220 mCi). Five months later, the patient had again become euthyroid. It is likely that initially the woman's metastases were producing sufficient hormone to render her hyperthyroid. After thyroidectomy and two large doses of radioiodide, she has remained euthyroid without having to take exogenous hormone. The blood level of TSIg had become undetectable. Based on this finding, we offer a tentative classification of the causes of hyperthyroidism in patients with thyroid carcinoma.