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ABSTRACTS
Year : 2011  |  Volume : 10  |  Issue : 2  |  Page : 226-245

Abstracts of Poster Presentations (General Nuclear Medicine and Miscellaneous)


Date of Web Publication12-Nov-2011

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How to cite this article:
. Abstracts of Poster Presentations (General Nuclear Medicine and Miscellaneous). World J Nucl Med 2011;10:226-45

How to cite this URL:
. Abstracts of Poster Presentations (General Nuclear Medicine and Miscellaneous). World J Nucl Med [serial online] 2011 [cited 2019 Dec 13];10:226-45. Available from: http://www.wjnm.org/text.asp?2011/10/2/226/89790

P-072

Gamma Camera Based GFR Measurement as an Alternative to 24 Hours Urinary Creatinine Clearance in Healthy Kidney Donors

T. Ahmed


Department of Nuclear Medicine, INMAU, Dhaka, Bangladesh

Objective: GFR is the quantity of glomerular filtrate formed by all the nephrons of both kidneys per unit time, which cannot be measured directly. There are various techniques to measure GFR, of them the 24-hour creatinine clearance (CCr) is the standard clinical technique for measuring kidney function; however, this method is quite cumbersome and inconvenient. We hypothesized that a camera-based GFR measurement with 99mTc-diethylene triamine-penta-acetic acid (99mTc-DTPA) would compare and correlate well with the 24-hour creatinine clearance and could serve as a simple marker of kidney function. Furthermore, the aim of the study was to establish Camera based DTPA-GFR measurement as a valid alternative to CCr.

Materials and Methods: Data were obtained from a prospective analysis of 30 healthy donors with normal kidney function. The DTPA clearance was calculated using a camera-based technique without blood or urine sampling. The creatinine clearance was measured using the plasma creatinine and a 24-hour urine collection. The DTPA methods were corrected for body surface area. The 24 hours urinary Creatinine clearance and camera based DTPA GFR values were compared by paired t test and correlated by r test.

Results: Comparison between 24 hours urinary CCr and DTPA-GFR as diagnostic aids to evaluate kidney function shows that the two diagnostic modalities are fairly comparable (92.60 ± 10.60 vs. 90.45 ± 16.79 ml/min, P = 0.271) and both the methods show good correlation (r = 0.80 with P = <0.001).

Conclusion: The camera-based 99mTc-DTPA GFR measurement method is comparable and correlate with the 24-hour creatinine clearance and can provide a simple and convenient index of kidney function.

P-073

Differences in Decline in GFR with Age Between Males and Females-Reference Data on 24 Hours Urinary Creatinine Clearance and DTPA Clearance

T. Ahmed


Department of Nuclear Medicine, INMAU, Dhaka, Bangladesh

Background: To ensure that potential kidney donors have no renal impairment, it is extremely important to have accurate methods for evaluating the glomerular filtration rate (GFR). The standard 24- hours urinary creatinine clearance method and gamma camera based DTPA (Diethylene-triamine- penta-acetic acid) clearance method has been used in the present study to measure GFR. The aim was to evaluate the effects of age and gender on renal function and present reference data.

Materials and Methods: Data were obtained from a prospective analysis of 30 healthy adults with normal kidney function. 12 females and 18 males with age range 15-65 years were investigated. The DTPA clearance was calculated using a camera-based technique without blood or urine sampling. The creatinine clearance was measured using the plasma creatinine and a 24-hour urine collection. The DTPA methods were corrected for body surface area.

Results: The mean 24 hours urinary CCr and DTPA-GFR were (92.60 ± 10.60 vs. 90.45 ± 16.79 ml/min) respectively, and we found no difference between the males and females. When relating 24 hours urinary CCr and DTPA-GFR to age however, a significant decline was found in both methods in males, but not in females in the age range of 15-65 years. CCr fell by a mean of 10 ml/min/ and DTPA-GFR by 90 ml/min in male donors.

Conclusion: With adequate methods for determining GFR, a clear difference in the effect of age was seen between male and female. Males showed a significant decrease between 15 and 65 years of age, which was not seen in females. Females seem to be protected in the pre-menopausal period probably by estrogens.

P-074

Preparation and Bio Distribution of 99mTechnetium-annexin V for In vivo Detection of Apoptosis

S. Rajabifar, H. Zolata, F. Bolourinovin, A. Jalilian, F. Saddadi, M. Kazemisarchaghaee


Department of Nuclear Medicine, Agricultural, Medical and Industrial Research School, Karaj, Iran

Introduction: Annexin V a human protein belongs to a class of Ca2+ -dependent binding proteins and has a high affinity for phosphotydilserine and can be used in determination of apoptosis in cells. Annexin V and its conjugates may be used to detect apoptotic cells significantly earlier than DNA- based assays. Labeled Annexin V using 99mTechnetium may be useful in detection of apoptosis in vivo as well as effects of the drugs used for the therapy.

Materials and Methods: For radiolabelling of Annexin V with 99mtechnetium succinic dihydrazide, propylene diamine tetra acetic acid, tricine, nicotinic acid and stannous chloride at their best concentrations in 0.1 M hydro chloric acid were added to phosphate buffer at pH=8.5 and then 110 MBq 99mtechnetium eluted by normal saline and Annexin V were added to this mixture and heated at 90°c for 10 minutes using stirrer at 1400 rpm. The radiochemical purity of 99m-technetium was determined by ascending Instant Thin Layer Chromatography (ITLC) with silica gel fiberglass sheet. Two solvents such as physiologic saline and acidified 85% ethanol were used and compared. The radiopharmaceutical prepared was administered through tail vein to experimental animals (n=5) and under anesthesia sacrificed for bio distribution studies at 1 and 3 hrs in the Liver, kidney, heart, muscle, spleen, stomach and intestine.

Results: The radio chemical purity was found to be not less than 90% and the ethanol solvent showed better results as compare to the normal saline. The serum stability studies showed the product is stable at least up to 1 hr. The highest percentage of injected dose per gram of organ (%ID/g) with the mean value were observed in liver 2.56, kidney 1.36, heart 0.53, stomach 0.39, spleen 0.37 and muscle 0.12. Appreciable radio activity could be detected in the liver and kidneys until 3 hrs post injection of 99mtechnetium- Annexin V indicating radiopharmaceutical primarily excretion by hepatic and renal pathway. Stomach uptake is commonly assumed as a control of 99mtechnetium labeled compounds stability in vivo assays, this tissue actively uptakes free 99m technetium, which is a good indicator of radiochemical purity.

Conclusion: 99mtechnetium-Annexin V is successfully labeled and the highest uptakes were observed in liver and kidney. Stomach uptake of 99mTc labeled Annexin was negligible confirming no contamination of free 99mtechnetium in the preparation.

P-075

Ciprofloxacin Labeling by 99mTechnetium and its Bio Distribution in Normal and Infected Animals

S. Rajabifar, M. Ghafouri, S. Moradkhani, A. Jalilian, F. Saddadi


Department Nuclear Medicine Agricultural, Medical and Industrial Research School, Karaj, Iran

Introduction: Infectious diseases are among those diseases that have to be diagnosed and treated immediately. A different method such as infection imaging using 67 Galium is available for diagnosis, which is not specific, so cannot be helpful for infection diagnosis. Labeled ciprofloxacin is a suitable method for finding the site of infection and the kind of infection as well as effect of the treatment. This method can also evaluate the resistance to the treatment.

Materials and Methods: Labeling of ciprofloxacin by 99mTecnhetium at best concentration (2mg) and tin chloride at concentration of 50-600 micrograms at different temperatures as well as pH using thin layer chromatography and different solvents were evaluated. Infection in one thigh was induced by staphylococcus aureus, which was cultured for 24 hrs. and 100 ul of the solution containing 106 -108 bacteria which was approved by turbidometry injected to the rats and were kept for 48 hrs. for the reproduction of bacteria and inflammation to occur. Heart, lung, stomach, intestine, kidney, blood, spleen, infected thigh muscle and uninfected thigh muscle issues separated and counted by High Purity Germanium (HPGe).

Results: Radiochemical purity found to be not less than 90% and serum stability was the same at least for 1hr. Bio distribution studies showed the highest uptake in normal rats for 1 and 4 hrs. respectively in liver 1.93±0.06, 2.13±0.12, kidney 2.2±0.13, 1.2±0.13, spleen 1.06±0.1,0.5±0.03 and muscle 0.06±0.0,0.07±0.0 and infected rats in liver 1.85 ±0.07, 3.0 ±0.15, kidney 2.4 ±0.13, 1.22±0.13, spleen 1.06±0.15, 1.28±0.15 and infected thigh muscle 0.45±0.07, 0.6±0.07 and uninfected thigh muscle 0.06±0.0, 0.07±0.0.

Conclusion: Ciprofloxacin 99m technetium was successfully labeled. The highest uptakes were observed in liver, kidney, spleen and infected muscle. Ciprofloxacin labeling by direct method with high radiochemical purity may be used as a formulated compound for the site of infection diagnosis in experimental animals.

P-076

Production and Quality Control of 99mTechnetium-IgG-hynic for Infection Imaging in Experimental Rats

S. Rajabifar, A. Jalilian, S. Moradkhani, F. Saddadi


Department of Nuclear Medicine, Agricultural, Medical and Industrial Research School, Karaj, Iran

Introduction: Over the last decades several radiopharmaceuticals have been developed for the detection of infection and inflammation some have found their way into clinical practice and routinely used for evaluation of infectious and inflammatory diseases. Human gamma globulin can be labeled by direct or indirect method of radiotracer incorporated in protein molecule. In this indirect method hydrazine nicotinic acid or hynic is used which saves the structure and biological activity of the protein. Infection is induced by inoculation of Staphylococcus aureus Scientific Name Search  in one thigh and inflammation by turpentine in another.

Materials and Methods: Immuno globulin is mixed with s-hynic and IgG-hynic is developed using slide- A lyzer and stored at -20°C which can be used at least for six months and then sn-tricine kit is prepared which is used for 99mTc labelling. Efficiency of 99mTc-IgG-hynic labelling at pH 6.4 was very much dependent on ligand (hynic) and coligand (tricine) presence in the reaction mixture. Wistar rats (n=5) were used for bio distribution as well as imaging studies.

Result: Radiochemical purity was found to be more than 90% in the kits prepared. Serum stability study showed no decomposition of 99mTechnetium from the complex. The bio distribution studies showed the highest percentage ID/organ in Blood, Liver and Kidney respectively and the imaging studies revealed the site of infection in the thigh as compared to the inflamed thigh using turpentine.

Conclusion: A human gamma globulin was successfully labeled through hynic to 99mTechnetium by indirect method with high radiochemical purity and differentiation in infected and inflamed thigh by imaging studies, which is a good imaging property.

P-077

Role of Tc-99m Ethambutol Scintigraphy in Diagnosing Tuberculosis in Children with Scoring Systems as Diagnostic Approach

A. D. Siswoyo, A. H. S. Kartamihardja, J. S. Masjhur


Department of Nuclear Medicine, School of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Background: Tuberculosis (TB) is world's endemic infection, especially in developing countries. In children, tuberculous infection can be seen as the great masquerader because it has non-specific symptoms. Diagnosis of tuberculous infection is more difficult in children because chest x-rays are less specific; standard sputum samples are often difficult to collect; lower bacterial loads made microscopic and culture more difficult. Based on these limitations, bacteriological examination as a gold standard is rarely used in children. Several diagnostic approaches are developed to overcome diagnostic problem of TB in children. 99mTc-Ethambutol SPECT/CT can be used to detect and to localize tuberculous infection. Various scoring systems and diagnostic classifications have been developed as screening test that may help clinical judgment in diagnosing tuberculosis in children. Among different scoring systems, the Keith-Edwards scale (WHO TB score) is the most widely used in clinical setting. Kenneth-Jones criteria (KJS) has been used in several centers as diagnostic approach in diagnosing TB. The aim of this study is to describe role of Tc-99m Ethambutol Scintigraphy in diagnosing tuberculosis in children based on KJS and WHO TB score as diagnostic approaches.

Materials and Methods: Our study population comprised of 84patients (42 boys and 42 girls with age range 3-168 months). SPECT/CT were done 1 and 3 hours after injection of 67-444 mCi MBq 99mTc-Ethambutol (based on body weight). Sedation was given before acquisition for uncooperative patients to avoid movement. KJS and WHO TB score as scoring system were used as diagnostic approach in diagnosing TB. KJS consists of variables such as: AFB smear, chest X-ray, BCG vaccination, glaucomatous lesions in histopathological result, physical findings, tuberculin test, history of contact with TB patient or sputum smear positive, age below 2 years, history of anti tuberculous drugs, and degree of malnutrition. According to KJS scoring system, score ≥ 7 indicates unquestionable TB. The variables in WHO TB score include: duration of illness, nutritional state, history of TB in the family, tuberculin test, malnutrition, symptom of fever and night sweats, local clinical findings of tuberculous lesions. WHO TB score ≥ 7 indicates a high likelihood of TB. When KJS and WHO TB score ≥ 7 diagnose of TB should be considered.

Results: From total 84 patients, positive 99mTc-Ethambutol scintigraphy were found in 51 of 52 patients with KJS ≥ 7 (98.1%) and 53 of 56 patients with WHO TB score ≥ 7(94.6%). Negative 99mTc-Ethambutol scintigraphy were found in 25 of 32 patients with KJS < 7 (78%), and 25 of 28 patients with WHO TB score < 7 (89.3%). False positive of scintigraphy results were found in 7 patients based on KJS and 5 patients based on WHO TB score. While false negative scintigraphy result was found in 1 patient based on both scoring systems.

Conclusion: 99mTc-Ethambutol can be used as one of the diagnostic approaches for TB in children.

P-078

A Comparative Study of Dobutamine Stress Myocardial Perfusion Imaging and Dobutamine Stress Echocardiography in the Detection of Coronary Artery Disease in Female Patients -initial Experience

N. Sultana, L. Nisa, S. Banerjee, A. M. Chowdhury, S. Quddus


Department of Cardiology, Institute of Nuclear Medicine and Ultrasound, Dhaka, Bangladesh

Introduction: Dobutamine stress echocardiography (DSE) and Dobutamine stress myocardial perfusion scan were evaluated in a female population with suspected coronary artery disease and scheduled for diagnostic coronary angiography within one month after imaging modalities.

Aim and Objectives: To compare the accuracy of these two techniques in the detection of CAD in female patients.

Materials and Methods: A total 22 subjects, age range from 40 to 60 years with mean age 49±0.81 yr. were studied. Patients underwent Dobutamine stress echocardiography according to standard Mayo Clinic protocol and Tc -99m tetrofosmin was administered at the peak of the Dobutamine effect. Stress and rest images were performed as per single day protocol.

Results: With this approach 36% (n=8) patients were correctly identified by DSE (sensitivity 61%, specificity 83%). On the other hand 54% (n=12) patients were correctly diagnosed by Dobutamine stress myocardial perfusion imaging, resulted in increased specificity (90%) and decreased sensitivity (64%)

Conclusion: Dobutamine stress myocardial perfusion imaging appeared to be slightly superior to DSE for the detection of CAD in this population but the difference is not statistically significant.

P-079

I-131 Meta-Iodobenzylguanidine and Tc99m Sestamibi Parathyroid SPECT Scintigraphy in Diagnosis of Multiple Endocrine Neoplasia 2A Syndrome

J. Gomez, I. Bandong, E. Barrenechea


Department of Nuclear Medicine, St. Luke's Medical Center, Quezon City, Philippines

Background and Aim: Multiple Endocrine Neoplasia (MEN) 2A syndrome consists of medullary thyroid carcinoma, pheochromocytoma and hyperparathyroidism. Pheochromocytoma occurs in 50% of MEN 2A syndrome. Establishment of bilaterality is fundamental for treatment and is confirmed by I-131 meta-iodobenzylguanidine (MIBG) scintigraphy. On the other hand, Tc99m Sestamibi parathyroid (PTH) SPECT scintigraphy is the primary imaging modality for localization of hyperfunctioning parathyroids. The aim of this paper is to present a case of MEN 2A syndrome and to discuss the integral role of nuclear medicine imaging in its diagnostic approach. This is a case of a 32-year-old female with 2-year history of sporadic palpitations, headaches and sweating. Patient was initially diagnosed with hypertension and diabetes mellitus. The following laboratory exams were requested: 24-hour urine creatinine and protein clearance, FBS, serum VMA, urine metanephrine and catecholamine, calcitonin and iCa. Likewise, ultrasound of the kidneys and thyroid, MIBG and parathyroid scans were also performed. Patient opted to be managed medically.

Results: The 24-hour urine protein was increased. Renal ultrasound was then requested and revealed suprarenal masses. MIBG scan was done and showed MIBG-avid foci in both suprarenal regions consistent with bilateral pheochromocytoma. VMA and urine metanephrine levels were also elevated. Thyroid ultrasound showed right lobe nodule with calcifications, left lobe and isthmus nodules. FNAB of the thyroid right lobe and isthmus disclosed atypical thyrocytes suspicious for malignancy. Serum calcitonin and iCa levels were elevated. PTH scan was negative for parathyroid adenoma/ hyperplasia. The following year, intact PTH level was elevated. A repeat parathyroid scan showed faint Sestamibi-avid focus inferior to the left thyroid lobe, suspicious for parathyroid hyperplasia versus adenoma. A repeat MIBG scan demonstrated MIBG-avid foci in both adrenal glands with an interval increase in the size of the left adrenal gland lesion with a necrotic center. VMA, metanephrine and catecholamine levels remained persistently elevated. She is scheduled for genetic testing.

Summary: The authors report a case of MEN 2A syndrome and the important diagnostic contributions of I-131 MIBG and PTH scans. Biochemical exams (metanephrines, calcitonin, iCa, PTH) were complimented by anatomic and functioning imaging.

P-080

Myocardial Perfusion Imaging and Calcium Scoring as Coronary Artery Disease Predictors

J. Gomez, I. Bandong, E. Barrenechea


Department of Nuclear Medicine, St. Luke's Medical Center, Quezon City, Philippines

Introduction: Coronary artery disease (CAD) diagnosis and risk stratification are enhanced by various non-invasive procedures, among these are calcium score CT scan (CAC) and myocardial perfusion imaging (MPI) for anatomic and functional assessment, respectively. Although the usefulness of each is proven, at present there are conflicting studies on their correlation, with some studies showing these two as independent predictors of CAD. This study aimed to determine the correlation of MPI and CAC as CAD predictors.

Materials and Methods: Among 370 suspected CAD patients who had MPI and CAC from 2005-2010, only 32 patients fulfilled the selection criteria and were included in this study. These patients had no known CAD and coronary intervention and underwent MPI and CAC within a six-month period interval. An MPI score of 0 was given to normal results, a score of 1 in the presence of ischemia, and a score of 2 in the presence of infarcts. The CAC result was positive if more than 400 and negative if less than or equal to 400. Their clinical profile was correlated with the results.

Results: Spearman's correlation of rank coefficient analysis showed a significant correlation of MPI and CAC scores (r = 0.4611, which is greater than the critical values 0.306 and 0.432 at α equal to 0.05 and 0.01, respectively). Chi squared testing (at α = 0.05) revealed a significant effect of the following risk factors present in the subjects on their MPI and CAC scores: hypertension (c2 c = 18.75 and 18.25), dyslipidemia (c2 c = 30.75 and 33.25), diabetes (c2 c = 25 and 17.75), obesity (c2 c = 25 and 18.25), cerebrovascular disease (c2 c = 43.75 and 43.125), smoking history (c2 c = 15.88 and 15.75) and alcohol intake (c2 c = 45 and 44.75). These were above the chi squared cut- off value of 7.82.

Conclusions: There is a significant correlation between MPI and CAC scores, such that as the CAC score value increases, the MPI score increases, corresponding to an abnormal MPI result. In addition, hypertension and dyslipidemia, diabetes, cerebrovascular disease, smoking and alcohol intake are the risk factors, which showed significant effect on both MPI and CAC scores.

P-081

Comparison of 99mTc-Ethambutol Scintigraphy and Scoring System in Diagnosing Pediatric Tuberculosis

I. D. Mulyanto, A. H. S. Kartamihardja


Department of Nuclear Medicine, Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Background: Tuberculosis, remains to cause morbidity and mortality in children from developing countries. The diagnosis is challenging because of the difficulty in obtaining appropriate specimens, paucibacillary disease, and nonspecific clinical presentation. A cross sectional study was designed to compare of 99mTc-Ethambutol scintigraphy and scoring system in diagnosing pediatric tuberculosis.

Materials and Methods: Whole body scintigraphy and SPECT-CT were done one hour after intravenous injection of 67-444 MBq 99mTc-Ethambutol (based on body weight) in pediatric patients with suspected of having tuberculous infection. A dose of 25-50 mg/kg chloral hydrate was given before the acquisition procedure whenever sedation needed. Scoring system of Indonesian Pediatrician Society 2005 was applied to all patients. This scoring system consist of several indicators such as history of close contact with person who were suspected or confirmed tuberculous infection, tuberculin skin test, nutritional state, two weeks or more of fever, cough, neck or axillary or inguinal lymphadenopathy, bone or joint disease, and chest X-ray. When the score was ≥ 6, then tuberculous infection could be considered.

Results: A total of 73 pediatric patients (33 males and 40 females; age range 3-156 mo) were recruited, of whom 43 (59%) had score ≥ 6. From these 43 patients, 42 (97%) had positive Tc-99m Ethambutol scintigraphy. Scintigraphy were negative in 25 (83%) of 30 patients who had score < 6 (P<0.0001). There were 5 patients who had score < 6 with positive scintigraphy. There was one patient who had score 8 with negative scintigraphy.

Conclusion: From our study, 99mTc-Ethambutol scintigraphy has good association with scoring system, which is widely used in clinical setting.

P-082

Clinical Utility of 18F FDG PET/CT and TC-99M MDP Bone Scintigraphy with Ewing's Sarcoma and Other Sarcomas

J. Nguyen, K. Davis, E. Mittra, A. Quon, S. Gambhir, N. Marina, A. Iagaru


Department of Nuclear Medicine, Stanford University Medical Center, USA

Purpose: 99mTc-MDP has been the standard method for bone scintigraphy for more than 3 decades. The role of 18F FDG PET/CT is proven in a variety of cancers for which it has changed the practice of oncology. There are few prospective studies comparing these 2 methods of detection of skeletal metastases in sarcoma patients. The purpose of this study was to compare 18F FDG PET/CT and 99mTc MDP bone scintigraphy in the detection of primary and/or metastatic osseous lesions. Materials and Methods: Forty-eight consecutive patients with histopathological confirmation for either Ewing's sarcoma (EWS, n = 24) or other childhood sarcomas (rhabdomyosarcoma (n = 14), osteosarcoma (n = 5), synovial sarcoma (n = 3), spindle cell sarcoma (n = 1), high grade undifferentiated sarcoma (n = 1)) who had 18F FDG PET/CT and 99mTc MDP bone scintigraphy performed at our institution between 2003-2010 were included in this retrospective analysis. Only those patients who had these studies done within 3 months of each other were included. There were 24 males and 24 females, with an average age at time of diagnosis of 15.18 ± 8.1 years. Sensitivities and specificities were calculated for detection of osseous malignant lesions.

Results: No differences in sensitivity or specificity between the PET/CT and BS were observed in these cohorts, except for detection of bone metastases from non-EWS where PET performed better than BS. PET/CT also detected disease outside the skeleton in 29.2% of EWS patients and 62.5% of non-EWS patients. In EWS, BS was 85.7% sensitive and 94.4% specific for detection of the primary lesions (n=22), while PET was 85.7% sensitive and 88.9% specific. For detection of osseous metastases (n=24), BS was 60% sensitive and 93.1% specific, while PET was 66.7% sensitive and 96.4% specific. In non-EWS, BS was 78.6% sensitive and 100% specific for detection of the primary osseous lesions (n=11), while PET was 76.9% sensitive and 100% specific. For detection of osseous metastases (n=25), BS was 33.3% sensitive and 97.4% specific, while PET was 66.7% sensitive and 100% specific.

Conclusion: While this is a small cohort and the results will have to be confirmed in larger studies, it appears that 18F FDG PET/CT may successfully provide similar information regarding skeletal lesions as bone scintigraphy in subjects with sarcomas. In addition, 18F FDG PET/CT detected disease outside of the skeleton in a significant number of Ewing's and non-Ewing's sarcomas.

P-083

Castleman's Disease on18FDG PET-CT

J. Gomez, J. Santiago


Department of Nuclear Medicine and PET, St. Luke's Medical Center, Quezon City, Philippines

Background and Aim: The aim of this study is to present a case of Castleman's disease (CD) and to discuss the role of F-18 Fluorodeoxyglucose positron emission tomography (FDG-PET-CT) as part of its diagnostic approach. A 49-year-old female presented with malar rash and polyarthralgia and later on developed proteinuria, serositis, edema and hypertension. CT scan of the abdomen revealed multiple nodularities in the paraaortic, paracaval, gastrohepatic and gastrosplenic regions. Left cervical and right ileal lymph node biopsies showed histological features consistent with CD, of the hyaline vascular type. FDG PET/CT was done to monitor status of her disease.

Results: PET/CT demonstrated multiple enlarged lymph nodes on the left side of the neck, mediastinum, right hilum, and abdomen with low-grade FDG-uptake. Low-grade sub-centimeter inguinal lymph nodes were also seen.

Summary: The authors report a case of CD and its presentation on FDG-18 PET/CT. CD is a rare benign lymphoid disorder. Imaging modalities for CD are non-specific and may also present as granulomatous disorders, inflammatory lymphadenopathy and malignancy (lymphomas, metastases). This has been the first reported case of Multi-centric Castleman's disease with early-undifferentiated connective tissue disease.

P-084

Correlation Between Bone Scintigraphy and Tumor Markers in Patients with Breast Cancer

M. U. Mokaddema, S. Yasmeen, Md. Shakhawatt Hossain Khan, Tapati Mandal


Department of Nuclear Medicine, Institute of Nuclear Medicine and Ultrasound, Dhaka, Bangladesh

Purpose: The purpose of the study is to evaluate the appropriate role of bone scintigraphy, serum CEA and CA15.3 assays in monitoring of breast cancer and also to assess the diagnostic performance of these Tumor markers in detecting bone metastasis for determining whether these can guide the prescription of bone scan during follow up of the disease.

Materials and Methods: For this purpose, from July 2009 to June 2010, 110 histopathologically proven and treated female breast cancer patients (mean age 43 years; range 23-85years) underwent bone scintigraphy during follow-up. In these patients serum tumor markers levels were measured using the MEIA method and the values of tumor markers were correlated with bone scan findings. Some of the patients were checked repeatedly at interval of 6 months, resulting 39 patients with bone metastases and 81 patients without bone metastasis.

Results: Among the patients with bone metastasis serum CEA levels were abnormal (greater than 5 ng/ml) in 18/39 (46.2%) cases and CA 15.3 serum concentration were elevated above the cut-off (greater than 30 U/ml) in 25/39 (64.1%) cases. In patients without bone metastasis, CEA and CA 15.3 serum concentrations were normal in 76/81 (93.8%) and 77/81 (95.1%) cases respectively. The combination of two markers brings about a certain improvement in the diagnostic sensitivity (31/39=79.5%).

Conclusion: The study shows CA 15.3 is more sensitive marker than CEA in detecting bone metastasis and combination of these two markers improves diagnostic sensitivity. Still the combined use of these two markers cannot predict bone scan results accurately. So it is not justified to omit bone scan on the basis of these markers but these can be used as adjuncts to bone scan in the monitoring of breast cancer patients.

P-085

Impact of F-18 FDG PET/CT in Staging of Carcinoma Cervix

Z. Chirag, B. Magsombol, W. Lam, W. Wong, C. Pang, A.Tan, A. Padhy


Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore

Background: Carcinoma cervix is the second most common cancer among women worldwide.

Objective: To identify the incremental value of F-18 FDG PET/CT over conventional imaging (CI) in pre-treatment staging of cervical carcinoma and in the detection of recurrent disease.

Materials and Methods: A retrospective analysis of F-18 FDG PET/CT studies of patients with histologically confirmed carcinoma cervix referred for staging or re-staging of disease status. All patients had thorough clinical work-up with staging using FIGO classification. Conventional imaging (CT/MRI) was done within ±10 days of the PET/CT scan. The results were analyzed as being concordant or discordant on the basis of agreement or disagreement between conventional imaging findings and the PET/CT findings.

Results: In the majority of patients, the findings of PET/CT and CI were in agreement. In 15 cases, PET identified additional metastatic sites either nodal or in distant organs eg. bone and pancreas.

Conclusion: F-18 FDG PET/CT is a helpful imaging modality in staging and re-staging cervical carcinoma. The addition of F-18 FDG PET/CT to conventional imaging results in improved detection of extra-pelvic metastases.

P-086

Clinical Implications of PSA Level and Gleason Score in Predicting Possible Metastatic Bone Disease in Patients of Carcinoma of the Prostate

Z. Chirag, S. Fatmi, I. Alam, K. Jabeen, K. Akhtar


Department of Nuclear Medicine, BINO, Bahawalpur, Pakistan

Objective: Prostate cancer worldwide is one of the leading causes of both morbidity and mortality among men. Treatment options available include surgery, chemotherapy, radiation therapy and hormonal therapy. Carcinoma of the prostate is notorious for its effect on treatment options in the presence of bone metastasis. The main objective of this work was to investigate what the possible association is of the PSA levels, Gleason Score and Bone scintigrams during initial diagnosis. Also, to determine the cut-off value helpful in predicting the positivity of bone scintigrams for skeletal metastatic disease.

Materials and Methods: 52 patients diagnosed as suffering from prostate cancer, who registered at BINO-Bahawalpur during Oct 2008 - March 2009 for treatment, were enrolled in the study. All the patients were evaluated during staging work up and their baseline PSA levels along with bone scintigrams were done. Average age of the total population was 65.98 ± 6.67 years (45-90). The average ages of patients with PSA levels of less than 10 ng/ml, 10.1-25 ng/ml and more than 25 ng/ml were 64.38 ± 6.25, 65.62 ± 6.87 and 67.48 ± 7.21 years respectively. The review of Gleason score (GS) depicted that one patient (2%) each had GS of 2 and 4; eight (15%) had 5; two (5%) had 6; thirteen (25%) each had a score of 7 and 8, respectively; twelve (23%) had 9 and two patients had a GS of 10.

Results: Patients with positive scintigrams for metastatic disease were 71% (age 64.24 ± 6.02 years) and those with no bone metastasis were 29% (age 70.26 ± 7.42 years). Our data showed that majority of the patients registered for treatment had a GS of either 7 or above. The positivity of bone scintigrams for skeletal metastatic disease was on the rise with the increasing PSA levels.

Conclusion: The baseline PSA levels combined with the GS can be a helpful tool in not only the early staging of prostate cancer but can also enable the treating physician to predict the possible skeletal involvement with the disease

P-087

Role of FDG PET/CT in Diagnostic Evaluation of Carcinoma Urinary Bladder: Comparison with CT

D. Chakraborty, B. R. Mittal, A. Bhattacharaya, R. Kashyap, V. Narang, A. Das, A. K. Mondal, S. K. Singh


Department of Nuclear and Experimental Medicine and Department of Nuclear Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, India

Background and Aim: Bladder carcinoma is the most frequent tumor of the urinary tract and accounts 7% of all malignancies in men and 2% of all malignancies in women. This retrospective study was designed to assess the diagnostic utility of 18F-FDG PET/CT in the imaging evaluation of bladder carcinoma.

Materials and Methods: Seventy-seven consecutive patients (male 72; female 5) with a known history of carcinoma urinary bladder who were referred for 18F-FDG PET/CT from April 2009 to June 2011 were included in this retrospective study. Patients were divided into 2 groups: those for initial staging after transurethral biopsy (34 patients) and another group of 43 patients for restaging. Apart from conventional staging procedure all patients underwent CT scan of abdomen and pelvis. PET/CT findings were correlated with diagnostic CT scan and histopathological findings. Average age of the patients was 60 yrs (Age range 30-88 years). 18F-FDG PET/CT was acquired from head to the upper thighs 60 min after the intravenous injection of 370-555 MBq of 18F-FDG. Additional pelvic images were acquired 1 h after the intravenous injection of furosemide, oral hydration and repeated bladder evacuation in 66 patients.

Results: Initial staging group: (total population 34) Both PET/CT and CT detected primary lesion (SUVmax 5.7 to 30.4) in the bladder in 30 patients, which was proved histopathologically. For lymph nodal metastases PET/CT was true positive (TP) in 7 patients (31%), false positive (FP) in 3(13%), true negative in 12 patients (52%) and false negative (FN) in 1 patient (4%). CT detected metastatic lymph nodes correctly in 6 patients (26%) (TP). 6 patients (26%) were found to be FP. Eight patients (35%) were true negative and 3 (13%) were false negative. PET/CT detected metastatic disease in 8 patients where as CT detected in 4 patients. (11 patients HPR report was not found). Restaging group: (total population 43) Both PET/CT and CT detected local recurrence (SUVmax 5.2 to 30.8) in 24 patients. For detection of lymph node metastases PET/CT was TP in 6 patients (35%), FP in 4(24%), TN in 6(35%) and FN (6%) in 1 patient respectively. Whereas CT was TP in 4(24%), FP in 6(35%), TN in (35%) and FN in 1(6%) patient's respectively. 19 patients were detected to have metastatic disease by PET/CT, whereas CT detected metastases in 11 patients. (26 patients HPR report was not found) Forced diuresis coupled with oral hydration showed marked reduction of urinary tract activity to near-background level in 49 patients (77%) of 63 bladder-preserved patients. Bone metastases were detected in 12 patients by 18F-FDG PET/CT. Bone scan was done in 25 patients and it was found to be positive in 8 patients.

Conclusion: 18F-FDG PET/CT with delayed imaging after forced diuresis may improve imaging evaluation and could replace CT and bone scintigraphy in preoperative staging and monitoring after surgery, chemotherapy or radiotherapy of patients with carcinoma urinary bladder.

P-088

Role of Tc99m MIBI Lower Limb Muscle Perfusion SPECT: In Diagnosis and Follow Up of Peripheral Arterial Diseases

R. Rashid, D. Sabih, M. Kashif Raheem


Department of Nuclear Medicine, Gujranwala Institute of Nuclear Medicine, Gujranwala, Pakistan

Background: Peripheral arterial disease (PAD) is an important healthcare problem and is associated with considerable morbidity and mortality. Early diagnosis and proper treatment can save the limb from long-term complications and disability. The study was conducted to evaluate the clinical utility of Tc99m MIBI lower limb muscle perfusion single photon emission tomography (SPECT) for diagnosis and follow up of PAD.

Materials and Methods: The study was performed to develop normal values of lower limb muscle perfusion for normal local population (N=36) by using SPECT and planar scintigraphic techniques. Patients (N=44) with established PAD were compared with age-matched data of normal population. Normal range developed for planar study (0.90-0.10±2S.D) was used as reference for planar study in patient population.

Results: In SPECT study visual analysis correlated extremely well with clinical features. Comparison of patient SPECT data with normal population showed significant hypoperfusion of lower limbs in terms of counts (P-value <0.001). Follow- up of patients (N=12) showed significant improvement of muscle perfusion in nine patients while three patients showed no improvement. Comparison of follow- up planar study values with baseline was not conclusive for any improvement in limb perfusion ( p0 -value ~ 0.98). Comparison of SPECT study with other modalities showed higher sensitivity than Doppler ultrasound (P-value <0.05), ABI (P-value <0.001) and planar scan (P-value <0.001) The sensitivity, specificity, positive predictive values and negative predictive values are 93%, 100%, 100%, 92% for Tc99m MIBI; 64%, 100%, 100%, 69% for ABI; 77%, 100%, 100%, 78.3% for Doppler ultrasound and 75%, 100%, 100%, 76.6% for planar scan respectively.

Conclusion: Tc99m MIBI lower limb muscle perfusion scan is an excellent tool for diagnosis and follow- up in peripheral arterial diseases and it is suggested that this investigation should be performed in patients with peripheral arterial diseases and should be a baseline tool for assessment of patient response to treatment.

P-089

Carotid Intima-media Thickness as a Predictor of Hemodynamically Significant Coronary Artery Disease Detected by Myocardial Perfusion Imaging

T. Mandal, L. Nisa, S. Nasreen, M. Moshi


Department of Nuclear Medicine, Institute of Nuclear Medicine and Ultrasound, Dhaka, Bangladesh

Introduction: Coronary Artery Disease (CAD) is the leading cause of myocardial ischaemia and/or infarction and is often the sequel of a generalized vascular disorder called atherosclerosis. Changes in the coronary arteries due to atherosclerosis are known to have variable hemodynamic effect on myocardial perfusion, which can be assessed by SPECT Myocardial Perfusion Imaging (MPI). Increased Carotid Intima Media Thickness (CIMT) is recognized as a marker of atherosclerosis that can predict cardiovascular risk.

Objective: The purpose of this study is to assess the diagnostic performance of Carotid Intima-Media Thickness (CIMT) for prediction of haemodynamically significant CAD detected by MPI and thus to apply the measurement of CIMT as a pre-screening tool to select the patients according to their urgency for doing the SPECT MPI.

Materials and Methods: This cross sectional study was carried out in the Institute of Nuclear Medicine and Ultrasound, BSMMU campus, Dhaka from January 2010 to December 2010. The study subjects consisted of 40 patients with mean age of 52.65± 6.15 years with known or suspected CAD. SPECT myocardial perfusion imaging was done with Tc99m Sestamibi using a one-day stress/rest protocol and the carotid intima media thickness (CIMT) was measured with B-mode ultrasound. The SPECT myocardial perfusion images were semi quantitatively analyzed to obtain the summed stress score (SSS), which was used for optimum correlation with the CIMT measurement in each patient.

Result: The correlation of mean maximum values of CIMT with SSS showed that in patients with normal MPI the CIMT was normal or mildly increased. In patients with abnormal MPI, the CIMT remained constantly high in relation to the extent and severity of CAD in a large majority of the study population. This relationship was analyzed by the Pearson's correlation coefficient showing a positive correlation of r=0.550 which was statistically highly significant (P<0.001). The accuracy of mean maximum CIMT to predict haemodynamically significant CAD, measured from the area under the receiver-operating (ROC) curve was 0.0824, which was quite good. Thus a CIMT value of ≥1.25 mm was found to be a predictor of abnormal perfusion detected by MPI. This CIMT cut off value showed a sensitivity of 70.6%, specificity of 87.0%, positive predictive value of 80.0%, negative predictive value of 80.0% and accuracy of 80.0% for prediction of the haemodynamically significant CAD that could be detected by myocardial perfusion imaging.

Conclusion: The findings from this small sample of patients, though insufficient, suggest that CIMT can be independently used in the selection strategy of patients for SPECT MPI and thus improve patient outcome while maintaining cost effectiveness.

P-090

Hepatobiliary Scintigraphy in the Non-invasive Assessment of Early Hepatic Dysfunction in Patients with Risk Factors for Metabolic Syndrome

A. Shinto, J. Selvakumar


NM and PET KMCH, CBE, India

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the commonest cause of abnormal liver function in Western Europe (Targher 616) with estimated prevalence of 70-75% in patients with type 2 diabetes (T2DM) and associated with increased risk of cardiovascular disease and hepatic fibrosis (Targher). Conventional imaging with ultrasonography, although widely used, has low sensitivity in mild to moderate disease and is not well correlated with hepatic histopathology. Mebrofenin scintigraphy (TMS) estimates Hepatocellular function because of its high hepatic specificity and is correlated with histopathological severity.

Objective: The aim of this case control pilot study was to evaluate hepatobiliary function by 99mTc-mebrofenin scintigraphy in Type II diabetes and further evaluation was done within the diabetic group based on the presence of additional risk factors like increasing age, BMI, dyslipidemia and obesity.

Materials and Methods: 40 T2DM patients (BMI 25.2± 4.15, 25 males, minimum 2 years duration of DM) were injected with 185 MBq 99mTc-mebrofenin intravenously in the left antecubital vein after a standardized breakfast. Dynamic images were obtained for 60 min with 10 min (1 sec/frame) liver uptake sequence and 50 min bile excretion sequence (60 sec/frame) and liver uptake calculated. Hepatic radiotracer activity accumulation rate was estimated as percentage of total activity (FOV curve) and the T ½ of its ascending portion.

Results: There was a significant difference in ascending curve T ½ and hepatic uptake as percentage of injected dose, between the diabetics with additional risk factors and the group with only TDM. The T1/2 ascend was prolonged in obese T2DM in the older age group with dyslipidemia and BMI > 25 (76.4 ± 17.8 vs. 64.1 ± 12.3 seconds, P <0.005) suggesting slower rate of uptake and the hepatic uptake was also decreased (73.4± 5.5 % vs. 79.5± 2.6 %, P < 0.005). There is also significant difference among T2DM subgroups with BMI < 25 (n=11) and > 25 (n=18) in T ½ (64.6 vs 74.7 P =0.04) and uptake (79.1vs 75.6 P=0.04). Similar derangements were also noted in T2DM subgroups with and without dyslipidemia, obesity and duration of diabetes.

Conclusions: Although liver biopsy remains the gold standard for diagnosis, our pilot results suggest nuclear medicine imaging with 99mTc-mebrofenin is a useful tool in the investigation of NAFLD in T2DM with added risk factors.

P-091

Tc 99m HIDA Diagnoses Early Hepatic Dysfunction in Type II Diabetics

A. Shinto, J. Selvakumar


NM and PET KMCH, CBE, India

Introduction: Non-alcoholic fatty liver disease (NAFLD) is the commonest cause of abnormal liver function in Western Europe (Targher 616) with estimated prevalence of 70-75% in patients with type 2 diabetes (T2DM) and associated with increased risk of cardiovascular disease and hepatic fibrosis (Targher). Conventional imaging with ultrasonography, although widely used, has low sensitivity in mild to moderate disease and is not well correlated with hepatic histopathology. Mebrofenin scintigraphy (TMS) estimates Hepatocellular function because of its high hepatic specificity and is correlated with histopathological severity.

Objective: The aim of this case control pilot study was to evaluate hepatobiliary function by 99mTc-mebrofenin scintigraphy in Type II diabetes.

Materials and Methods: 29 T2DM patients (BMI 25.2± 4.15, 25 males, with a minimum of 2 years duration of DM) and 20 BMI matched volunteers were injected with 185 MBq 99mTc-mebrofenin intravenously in the left antecubital vein after a standardized breakfast. The liver function tests and viral serology of all patients and volunteers were within normal limits. Dynamic images were obtained for 60 min with 10 min (1 sec/frame) liver uptake sequence and 50 min bile excretion sequence (60 sec/frame) and liver uptake calculated. Hepatic radiotracer activity accumulation rate was estimated as the T ½ of its ascending portion of the Time activity curve and maximal accumulation as percentage of total activity (FOV curve).

Results: There was a significant difference in ascending T ½ and maximal hepatic uptake between the diabetic and control population groups. The T1/2 ascend was prolonged in T2DM (70.9± 13.8 Vs. 54.2± 14.3 seconds, P<0.0001) suggesting slower rate of uptake and the hepatic uptake was also decreased (76.9± 5.5% Vs. 85.5± 2.6% P<0.0001). There is also significant difference among T2DM subgroups with BMI < 25 (n=11) and > 25 (n=18) in T ½ (64.6 vs 74.7 P =0.04) and uptake percentage (79.1%vs 75.6% p=0.04).

Conclusions: Although liver biopsy remains the gold standard for diagnosis, our pilot results suggest nuclear medicine imaging with 99mTc-mebrofenin is a useful tool in the investigation of NAFLD in T2DM.

P-092

Early and Delayed F18 FDG PET in Assessment of Disease Activity in Tuberculosis

A. Shinto, N. Baghel


NM and PET, KMCH, CBE, India

Introduction: F18 FDG PET has widespread application in the diagnosis of various infections and malignancies. This study evaluates the possibility of using dual time point FDG PET imaging to diagnose, stage and assess the treatment response in patients with proven tuberculosis.

Materials and Methods: 42 patients (22 males, 20 females, age range 5 -75 years) with histo pathologically proven active Koch's infection were examined using early (1 hour) and delayed (3 hours) F 18 FDG PET scans. The results were evaluated. Comparisons were drawn between the SUV values at different times in the same patient and the general trends of SUV change in various presentations of Koch's infection.

Results: All the lesions of proven active Koch's lesions showed rising trend of SUV values at 3 hours compared to 1-hour values (aver 42% in pre treatment cases, 17% in mid treatment cases and no uptake or increase in healed cases). Statistically significant (P<0.05) difference between the Retention Index (RI) of F18 FDG - SUV was seen between the non -treated, mid- treatment and post- treatment cases and lesions.

Conclusions: Dual time point PET imaging with semi -quantitative SUV evaluation could be a reliable method for the differentiation between active and healed or healing Koch's infectious foci. Moreover, it could direct the site for biopsy and establish a more accurate pre treatment staging.

P-093

Vision of Nuclear Medicine in Bangladesh - A Road Map

M. Hasan, N. Nahar, F. Alam, R. Hussain


Nuclear Medicine, Institute of Nuclear Medicine and Ultrasound, BSMMU, Dhaka, Bangladesh

One of the peaceful uses of nuclear energy in Bangladesh is Nuclear Medicine. Bangladesh Atomic Energy Commission (BAEC) is contributing in the health sector of the country for last few decades through its nuclear medicine service. The first nuclear medicine centre of the country was established back in 1962. Bangladesh is an endemic zone for iodine deficiency. Thyroid disorders including goiter is quite common in this land from ancient time. Nuclear Medicine started its journey with investigation of thyroid disorder by using a small amount of radioactive iodine. Today it is keeping its role in almost all the body systems by application of a wide range of radionuclides. BAEC is committed to peaceful use of nuclear energy. With that motto BAEC has expanded its nuclear medicine service throughout the country in last few years. At present 14 nuclear medicine centres including one institute in different parts of the country are functioning under BAEC to contribute in our health sector. Besides 4 more centres are contributing in private hospitals. One of them named United Hospital has already established the first PET-CT centre of the country with cyclotron recently and giving services to the patients. Bangladesh Atomic Energy Commission is presently serving more than 200.000 patients per year through its 14 nuclear medicine establishments. The main objectives of nuclear medicine service rendered by Bangladesh Atomic Energy Commission are as follows:

  1. To render specialized medical services to the people using nuclear technology.
  2. To improve and upgrade nuclear medicine facilities in Bangladesh.
  3. To conduct training of physicians, physicist, radiopharmacist and technologists in the field of nuclear medicine.
  4. To conduct academic and research activities.


Clinical Services: The clinical services are run by a group of well-trained physicians, physicists, radiopharmacists and technologists. The main equipment used in scintigraphy and thyroid division is gamma camera. Most of the cameras have got SPECT facilities. Thyroid uptake system is used in selected number of cases for diagnosis and therapeutic consideration of thyroid disorders. Apart from routine services like bone scan, kidney and thyroid function studies specialized nuclear medicine imaging procedures are being done in different areas including in the field of cardiology, neurology and oncology. Currently nuclear cardiology is keeping a tremendous role in the management of myocardial ischemic disease. With introduction of some newer radiopharmaceuticals services of nuclear medicine has recently been expanded in the field of oncology. Besides imaging various thyroid related hormones and other hormones like pituitary hormones, estrogen, progesterone, follicular and leutinizing hormones are assayed routinely at a very low cost.

Nuclear Medicine services are not limited to diagnosis only. It treats also a number of diseases. Thyrotoxicosis and thyroid cancer are most important of them. By using radioactive iodine these two conditions are successfully treated. In addition P-32 therapy for myeloproliferative disease, Strontium 90 for pterygium, corneal neo vascularization and squamous cell carcinoma of the conjunctiva are routine procedures. Application of other radionuclides for targeted therapy such as I-131 labeled MIBG for diagnosis and therapy of neuroendocrine tumors, Sr 89, Re 186 and Samarium 153 for palliative therapy for metastatic bone are the future consideration.

Academic Activities: The Institute of Nuclear Medicine and Ultrasound is an affiliated institute of Dhaka University. This institute offers post graduation degree in nuclear medicine. Besides training program in nuclear medicine and ultrasound, the institute has also got facilities for thesis work for M.Phil and Ph.D students. The other nuclear medicine centres are also engaged in training programme of under and post graduate medical students.

Research and Development Activities: Research and development are part of activities of nuclear medicine services in Bangladesh. A number of research projects are going on in the institute and different centres either in national level or as a part of a regional project in collaboration with IAEA, RCA etc.

Future Direction: The present population of the country is about 142 million. With the present 14 nuclear medicine centres, the service could be rendered only to 10-15% of the total population. To extend the service to the rest of the population number of nuclear medicine centres must be increased. We have a goal to establish at least one nuclear medicine centre in each district hospital. Nuclear Medicine is a rapidly developing subject. New equipments and new radiopharmaceuticals are coming up for giving better service. We like to introduce those new techniques. SPECT gamma camera and SPECT-CT are the choice of equipments for the nuclear medicine centres. Newer radiopharmaceuticals like Rhenium, Sammarium, Strontium, MIBG, Octreotide etc. should be introduced in near future.

Positron Emission Technology is currently keeping a great role in the management of cancer related patients in the developed as well as some of the developing countries. With that vision a project on Positron Emission Technology-Computed Tomography (PET-CT) has already been submitted to the ministry for INMU which is now under active consideration of the government.

BAEC has taken a new project using its nuclear medicine facilities for identification of babies who are born with thyroid hormone deficiency. This condition known as congenital hypothyroidism (CH) is a grave situation where a baby is grown with permanent mental and physical retardation if not identified and treated within 4 weeks of life. BAEC has a vision to introduce this newborn screening system in our country to save our future generation not only from CH but also from other inborn error of metabolism.

Human Resource Development is probably most important task ahead. Nuclear Medicine service is a different entity where a group of people like physicist, radiochemists, technologists, electronic engineers and physicians are involved to run the service properly. Our country has got a tremendous deficiency of manpower in this field. So before expansion of the service, this aspect should be duly considered.

Conclusion: The Govt. of Bangladesh has a commitment for "health for all" by the year 2020. Bangladesh Atomic Energy Commission also likes to keep a role in the health sector of the country by providing a better service of nuclear medicine to reach that target.

P-094

Technetium -99m-Sestamibi Scintigraphy on Patient with Nasopharyngeal Carcinoma and Tubercular Lymphadenopathy: A Case Report

Y. Kurniawati, H. Basuki, B. Darmawan


Department of Nuclear Medicine, Universitas Padjadjaran, School of medicine, Bandung, Indonesia

99m Tc-Sestamibi has been known as tumor seeking agent. However inflammatory process can caused false positive result in 99m Tc-Sestamibi scintigraphy. We present a case report highlighting the role of 99m Tc-Sestamibi scintigraphy in a patient of Nasopharyngeal Carcinoma with cervical lymphadenopathy, which turned out to be granulomatous in nature.

Tc-99m Sestamibi SPECT may play a role in detecting primary NPC. It also may hold potential advantages for follow-up evaluation post radio therapy and differentiating between lymphadenopathy caused by inflammation and malignancy, especially in developing country setting.

P-095

Evaluation of Low Grade Gliomas Using F-18 FDOPA and F-18 FDG PET/CT

A. Jaimini, M. Tripathy, R. Sharma, M. D'Souza, A. Mishra, A. Mondal


Molecular Imaging and Research Centre, Institute of Nuclear Medicine and Allied Sciences, New Delhi, India

Introduction: A prospective study was done to compare amino acid metabolism and glucose metabolism in low grade gliomas using positron emission tomography (PET)/computed tomography with F-18 FDOPA and F-18 FDG.

Materials and Methods: Twenty four patients with newly diagnosed or previously treated low grade gliomas (WHO grade I or II) were subjected to F-18-FDOPA and F-18 FDG PET/computed tomography studies on consecutive days. This included 2 patients in remission as control subjects. Uptakes of both tracers were analyzed visually and quantified using standardized uptake values and tumor to normal (T/N) ratios. The accuracy of both PET tracers in the detection of newly diagnosed and recurrent low grade gliomas was compared.

Results: F-18 FDOPA was positive in all cases of primary and recurrent low grade gliomas and negative in the patients in remission. Tumor was visualized on F-18 FDG in 9 of 22 cases. Though the average tumor standardized uptake values max for F-18 FDG was found to be 3.16 ± 1.95 times that of F-18 FDOPA, the T/N ratio for F-18-FDOPA was 2.94 ± 1.24 times higher than F-18 FDG providing good image contrast for tumor detection in positive cases.

Conclusion: F-18 FDOPA scan is superior to F-18 FDG for visualization of primary and recurrent low grade gliomas.

P-096

Tc-99m-Ethambuthol Uptake in Case of Leprosy: Case Report

A. H. Gunawan, B. Hidayat, A. S. H. Kartamihardja


Department of Nuclear Medicine, Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Introduction: Ethambutol scan has recently been used for imaging active tuberculosis, both pulmonary and extrapulmonary infection. Its sensitivity helps clinician to distinguish tuberculosis from other bacterial infections. The mechanism of Ethambutol uptake is based on the drug inhibitory ability on arabinosyl transferase, an essential enzyme which is involved in polymerization reaction of arabinoglycan, an important component of mycobacterial cell wall.

Case Presentation: A 53 year-old female complained of low back pain and lower limb paralysis, was referred to our department for Ethambutol scintigraphy. The patient was under multidrug antileprosy treatment. No trauma history was recorded, neither was tuberculosis. X-ray examination had showed destructive lesions on the lumbar vertebrae, as well as lytic lesion on the head of the left hipbone and acetabulum. Ethambutol scan result showed uptake on multiple lumbar vertebrae, consistent with the X-ray result.

Conclusion: This case revealed the possibility of Ethambutol uptake by Mycobacterium leprae or other Mycobacterium species.

P-097

Role of Tc-99m Ethambutol Scintigraphy in Diagnosing Tuberculosis in Children with Scoring Systems as Diagnostic Approach

A. D. Siswoyo, A. H. S. Kartamihardja, J. S. Masjhur


Department of Nuclear Medicine, School of Medicine Universitas Padjadjaran, Dr. Hasan Sadikin Hospital, Bandung, Indonesia

Background: Tuberculosis (TB) is world's endemic infection, especially in developing countries. In children, tuberculous infection can be seen as the great masquerader because it has non-specific symptoms. Diagnosis of tuberculous infection is more difficult in children because chest X-rays are less specific; standard sputum samples are often difficult to collect; lower bacterial loads made microscopic and culture more difficult. Based on these limitations, bacteriological examination as a gold standard is rarely used in children. Several diagnostic approaches are developed to overcome diagnostic problem of TB in children. 99mTc-Ethambutol SPECT/CT can be used to detect and to localize tuberculous infection. Various scoring systems and diagnostic classifications have been developed as screening test that may help clinical judgment in diagnosing tuberculosis in children. Among different scoring systems, the Keith-Edwards scale (WHO TB score) is the most widely used in clinical setting. Kenneth-Jones criteria (KJS) has been used in several centres as diagnostic approach in diagnosing TB. The aim of this study is to describe role of Tc-99m Ethambutol Scintigraphy in diagnosing tuberculosis in children based on KJS and WHO TB score as diagnostic approaches.

Material and Methods: Our study population comprised of 84patients (42 boys and 42 girls with age range 3-168 months). SPECT/CT was done 1 and 3 hours after injection of 67-444 mCi MBq 99mTc-Ethambutol (based on body weight). Sedation was given before acquisition for uncooperative patients to avoid movement. KJS and WHO TB score as scoring system were used as diagnostic approach in diagnosing TB. KJS consists of variables such as: AFB smear, chest X-ray, BCG vaccination, glaucomatous lesions in histopathological result, physical findings, tuberculin test, history of contact with TB patient or sputum smear positive, age below 2 years, history of anti tuberculous drugs, and degree of malnutrition. According to KJS scoring system, score ≥ 7 indicates unquestionable TB. The variables in WHO TB score include : duration of illness, nutritional state, history of TB in the family, tuberculin test, malnutrition, symptom of fever and night sweats, local clinical findings of tuberculous lesions. WHO TB score ≥ 7 indicates a high likelihood of TB. When KJS and WHO TB score ≥ 7 diagnose of TB should be considered.

Results: From total 84 patients, positive 99mTc-Ethambutol scintigraphy were found in 51 of 52 patients with KJS ≥ 7 (98.1%) and 53 of 56 patients with WHO TB score ≥ 7(94.6%). Negative 99mTc-Ethambutol scintigraphy were found in 25 of 32 patients with KJS < 7 (78%), and 25 of 28 patients with WHO TB score < 7 (89.3%). False positive of scintigraphy results were found in 7 patients based on KJS and 5 patients based on WHO TB score. While false negative scintigraphy was found in 1 patient based on both scoring systems.

Conclusion: 99mTc-Ethambutol can be used as one of the diagnostic approaches for TB in children.

P-098

Role of Dobutamine Stress Myocardial Perfusion Imaging for the Detection of Myocardial Viability in Significantly Stenosed Coronary Artery Disease

S. A. S. Khandaker


Department of Nuclear Medicine, Institute of Nuclear Medicine and Ultrasound, Dhaka, Bangladesh

Objective: The aim of the study was to evaluate myocardial viability by SPECT MPI in the patients with significantly stenosed coronary arteries to predict the future surgical outcome.

Materials and Methods: This is a cross sectional study. Total number of the patients was 50 (86% male and 14% female). Age ranging from 36 to 75 years. All had (CAD) as diagnosed by coronary angiogram. All the patients underwent Dobutamine stress echocardiography (DSE). After DSE, MPI study was performed with Tc-99m Sestamibi following MAYO Clinic protocol.

Result: In DSE, 40 (80%) of the patients had Echo Ejection Fraction (EEF) 35% or >35% and rest 10 (20%) had <35%. In resting gated SPECT MPI, EF was >35% in 35 (70%) patients and <35% in 15 (30%) patients, which were comparable ( p0 =0.104). Apart from lateral wall, wall motions abnormalities detected on anterior, inferior and septal walls were fairly comparable by two diagnostic modalities. In lateral wall SPECT MPI was found significantly more sensitive than DSE (P=0.042). By coronary angiogram, out of 50 patients 44 (88%) of the patients had significant stenosis and rest 6 (12%) had insignificant stenosis in their coronary arteries. Detection rate of viable myocardium by SPECT MPI among the patients of significant stenosis was significantly higher (72.7%) than by DSE suggesting that decision for revascularization should be taken after MPI.

Conclusion: SPECT MPI provided valuable information in decision-making for patients with significantly stenosed CAD. It has a better role in predicting the potential value of revascularization, thus improving myocardial functional status and survival.

P-099

Optimization of SPECT MPI Using a Prototype Dynamic Heart Phantom

O. Demetriadou, C. Yiannakkaras, D. Kaolis, I. Chrysanthou, S. Christofides, Y. Parpottas, M. Wasilewska-Radwanska, T. Fiutowski, A. Rosiek


Department of Nuclear Medicine, Limassol General Hospital, Limassol, Cyprus

Introduction: Myocardial perfusion scintigraphy with single-photon emission computed tomography (SPECT) is an established, non-invasive imaging technique with diagnostic and prognostic efficacy in the investigation of Coronary Artery Disease. Is a method that is widely used to assess myocardial perfusion directly but there are differences in the way it is performed in various national and international centers. Defect location, image acquisition parameters, image reconstruction parameters, radiopharmaceutical used, dose used and commercially available cardiac quantification programs affect the quantitative results of the extend and of the severity of ischemic heart disease. The European Union requires member states to promote the establishment and use of diagnostic reference levels (DRLs), (Radiation Protection 109, 1999), which limit the administered activity for nuclear and radiological examinations. On the other hand in obese patients, a significant amount of the emitted photons is attenuated, and a relatively high dose must be administered in order to obtain an image of sufficient quality.

Aim: The aim of this project is to optimize the diagnostic value of SPECT myocardial perfusion studies (MPI) using a constructed dynamic heart phantom embedded in an anthropomorphic phantom, in order to understand how the above mentioned parameters influence the results and the diagnostic accuracy of myocardial perfusion studies.

Materials and Methods: This dynamic heart phantom is based on a twin membrane that allows the insertion of known defects at known locations. The inner membrane outlines the left ventricular cavity while the outer membrane determines the thickness of myocardial wall, which is actually the space between the two membranes. The membranes expand during the diastole and retract during the systole into their initial shape. Defects are introduced in-between the two membranes to mimic the human situation of mild, moderate and severe ischaemic heart disease in all possible vascular territories. The defects vary in number, location, extent and severity. The location of the defects is given by the anatomy of the branches of the main coronary arteries, which might be affected. This methodology allows the study of defects (small and medium size) with specific parameters in a way that is not possible with repeated patient studies. It allows direct comparison between the calculated and diagnosed results of the severity, extent and location of a defect, the initial values known a priori. Images are acquired on two different gamma camera systems, Millenium GE with Hawkeye and Phillips Forte with Gadolinium sources. Three different commercially available programs are used to evaluate the simulated clinical problems in order to assess the different images in an automated and objective way. The Philips AutoQUANTTM and GE EC Toolbox and QGS are used.

Conclusions: There are differences in the quantitative assessment of perfusion defects depending on the type of protocol used, 1-day, 2-day protocol, Gated SPECT, SPECT, applying attenuation correction or not, using technetium or thallium of a magnitude that warrants clinical awareness. This work aims to evaluate the image quality, the interpretive certainty and diagnostic accuracy of myocardial perfusion, considering the radiation dose as a major constraint, using the prototype dynamic heart phantom discussed above and custom built software. Defects in the context of examining precisely controllable variations are applied, in order to understand trends that would be expected also in patients. In the current work, the existence of defects, their size and location is known a priori by construction. The preliminary results of the evaluation of the first images will be presented.

P-100

Outcome of Patients with Positive Exercise Test and Normal Exercise Myocardial Perfusion SPECT

F. Nasreen, L. Nisa, A. Kabir


Department of Nuclear Medicine, Institute of Nuclear Medicine and Ultrasound, Dhaka, Bangladesh

Objective: In our clinical practice, we often face the difficulty when there is a discordant finding between exercise ECG and myocardial perfusion SPECT (MPS). Our objective was to find the outcome of such patients having a positive exercise test and normal exercise myocardial perfusion SPECT in a 24 months follow- up.

Materials and Methods: A total of 392 MPS were reviewed in our Institute. Subjects (30 patients) who met our study category had follow up at six months interval for the next 24 months. The final outcome was established according to clinical evolution, hard and soft cardiac events. We evaluated age, sex, clinical symptoms, various risk factors, relevant biochemical parameters, rest ECG abnormalities, rest left ventricular ejection fraction to establish the final diagnosis.

Results: We studied 30 patients (21 males and nine females) having a mean age of 53±7 years. All of the patients had a positive exercise test and a normal MPS. During the follow up period, there was no hard cardiac event. One patient died from renal cause. One patient had soft cardiac event and required CABG. In the remaining 28 patients, follow up was quite uneventful. There was some change in medications in 15 patients and no change in rest of the 13 patients.

Conclusion: Patients having positive exercise test and normal MPS have an excellent prognosis in an intermediate follow-up period.

P-101

Usefulness of Dacroscintigraphy in the Management of Patients with Epiphora

M. K. Srivastava, S. Simon, M. Indirani, A. Pawaskar


Department of Nuclear Medicine, Apollo Hospitals, Chennai, India

Purpose: Epiphora is a common ophthalmic problem. Lacrimal drainage disorder is one of main cause of epiphora, be it functional or anatomical obstruction. Since the introduction of dacryoscintigraphy by Rossomondo et al in 1972, this investigation is one of the most simple, noninvasive and underutilized nuclear medicine investigations.

Materials and Methods: Since the start of this study, till now, dacryoscintigraphy had been performed in 4 patients with 7 eye problems. The procedure was performed before surgery for evaluation of the level of obstruction and surgery was planned accordingly. Post surgery, the procedure was repeated after 3 weeks to know the status of the obstruction and correlated to patient's symptoms. We intend to study 40 eye problems.

Results: Patients were classified into Grade I, II, and III according to the classification proposed by Chung et al, Ann Nucl Med. 2005. Relief of symptoms was seen in all the 7 eyes at 3 weeks with free flow of tracer in 6/7 eyes. 1 eye was symptom free but delayed imaging till 2hours showed no tracer flow into the nasal cavity.

Conclusion: Preliminary results of the study are encouraging with dacryoscintigraphy being a useful noninvasive procedure in the follow-up of epiphora cases.

P-102

Noninvasive Rest and Acetazolamide 99mTc-HMPAO Brain Perfusion SPECT Imaging with One-day Protocol Using SPECT/CT System

B. Dang An, H. Toyama, M. Ishiguro, V. Tran Vu Quynh, T. Pham Van, T. Tran Song, T. Pham Ngoc, N. X. Canh, B. D. Hang


Department of Nuclear Medicine, Cho Ray Hospital, HCMC, Vietnam

99mTc-HM-PAO brain perfusion SPECT imaging was performed for evaluating cerebral perfusion reserve by acetazolamide (Diamox) test with one-day protocol using SPECT/CT system.

Materials and Methods: We used a dual -head rotating SPECT with CT system (SPECT/CT) (Symbia, Siemens). Attenuation correction was performed with CT. To measure regional cerebral blood flow (rCBF) non-invasively, the Patlak plot analysis developed by Matsuda was applied to time-activity data for the aortic arch and brain hemispheres on radionuclide (RN) angiography after intravenous injection of 99mTc-HM-PAO. Then, the 1 st rest SPECT imaging was carried out for 30 min after 3 min post injection of 370 MBq (10 mCi) of 99mTc-HM-PAO. Immediately after the 1 st SPECT study, 1 g of acetazolamide was intravenously injected. Ten minutes later, 740 MBq (20 mCi) of 99mTc-HM-PAO from the same vial as the 1 st study was additionally injected. Three minutes later the 2 nd SPECT study was carried out for 30 min. Hemispherical brain perfusion indices (BPI) on RN angiography for 99mTc-HM-PAO were converted to rCBF values, then raw 1 st rest SPECT images were converted to 1 st rCBF maps using Lassen's correction algorithm. Based on the increased count ratio in cerebellum between decay corrected 1 st and 2 nd SPECT images, acetazolamide increasing ratio was calculated, and then 2 nd acetazolamide rCBF SPECT images were generated. Regions of interest (ROI) in 1 st and 2 nd SPECT images were set, then %increase: (2 nd SPECT ROI values - 1 st SPECT ROI values)/1 st SPECT ROI values were calculated.

Results: Four cases of cerebro-vascular disease were performed. The rest cortices showed rCBF value by 36.9±1.8 ml/100g/min, acetazolamide enhanced cortices showed rCBF value by 43.5±1.5 ml/100g/min, and %increase value by 23.0±2.0 on average.

Conclusion: These results suggest that this noninvasive method would be significant for evaluating cerebral perfusion reserve in the routine cerebro-vascular disease.

P-103

Differentiating Benign and Malignant Lesions of the Uterus by FDG and FES PET Imaging

R. Hussain


Institute of Nuclear Medicine and Ultrasound, BAEC, Dhaka, Bangladesh

Among the uterine neoplasias, leiomyoma is very common benign tumor that occurs in 20%-25% of women. The management of these neoplasias is dependent on patient age, symptoms, and clinician skill. However, approximately 80% of hysterectomies performed for uterine leiomyoma are judged as inappropriately recommended because of a suspected non-benign tumor based on tumor size and ultrasonographic characteristics. Thus, differentiating benign from non-benign tumor is one of the most important clinical dilemmas. As preoperative histologic examination of myometrial lesions is not possible, imaging plays an important role in evaluation of myometrial lesions. Positron emission tomography (PET) is a biologic imaging modality that can present an image of physiologic function. PET with 2-[18F] fluoro-2-deoxy-D-glucose (FDG) can reflect glucose metabolism and activity of lesions including malignant tumors. FDG-PET is used for the evaluation of gynecologic malignancies in preoperative staging, post-surgical monitoring, and surveillance for recurrence. This is considered to be superior to conventional imaging methods in diagnostic accuracy for detection of metastatic lesions and local recurrence. However, the diagnostic accuracy for primary tumors is inferior to that of magnetic resonance (MR) imaging. This is because the size of the tumor and inflammatory changes of the lesion may affect PET imaging and FDG accumulation. On the other hand, 16 -[18F] fluoro-17-estradiol (FES) is an 18F-labeled compound of estradiol, which is the most bioactive type of estrogens. FES-PET enables us to evaluate the estrogen receptor (ER) density of a lesion and is usually used for the detection and management of ER-positive malignant tumors such as breast cancer. ER exists in two main forms, ERa and Erß and the binding affinity of FES is 6.3-fold higher for ERa than Erß.

PET show opposite patterns between benign and malignant lesions. Patients with endometrial carcinoma show a significantly higher accumulation of FDG than of FES in the primary tumors. In contrast, patients with endometrial hyperplasia show a significantly higher uptake for FES than for FDG. In patients with smooth-muscle tumors, those with leiomyomas show a significantly higher uptake for FES than for FDG, whereas leiomyosarcomas and carcinosarcomas show a higher concentration for FDG and a lower accumulation for FES. The tracer accumulation pattern is different between benign and malignant tumors for both endometrial and myometrial diseases. PET studies with both FES and FDG can provide pathophysiologic information for the differential diagnosis of uterine endometrial neoplasias (endometrial carcinoma and hyperplasia) and myometrial tumors (sarcoma and leiomyoma).

P-104

Illustration of a Single Anomalous Coronary Artery with Myocardial Ischemia by Fusion of N-13 Ammonia PET/CT with CT Coronary Angiography - Case Report

H. S. Bom, S. P. Hong, J. H. Kim, S. G. Cho, J. J. Min


Department of Nuclear Medicine and Cardiology, CNU Medical School Huasun, South Korea

Computed tomographic coronary angiography (CTCA) is a useful tool to evaluate anatomy of coronary artery. Diagnosis of myocardial ischemia by CTCA is a challenge. While nitrogen-13 (N-13) ammonia PET/CT is a well-established technology for quantitative and qualitative evaluation of myocardial perfusion. A fusion technology of CTCA and PET/CT was reported to show better diagnostic performance as compared to CTCA or PET/CT alone. Authors illustrate a rare coronary artery anomaly showing myocardial ischemia using a fusion technology of CTCA and N-13 ammonia PET/CT. A 49-year-old male patient was referred to the department of nuclear medicine for evaluation of myocardial ischemia using N-13 ammonia PET/CT. He complained of a typical chest pain which lasted for 10 minutes, and which was subsided by sublingual nitroglycerin. He underwent CTCA, which showed a single origin of right coronary artery (RCA) from right coronary sinus of Valsalva. Left anterior descending artery (LAD) was originated from proximal RCA. Left circumflex artery was originated from the distal RCA. A moderate degree of luminal narrowing with mixed plaque was noted in mid LAD, and a mild degree of luminal narrowing with mixed plaque in proximal LAD, and multifocal luminal narrowing on RCA. Percutaneous intervention was performed to the proximal RCA lesion. Following rest and adenosine stress ammonia PET showed multiple ischemic lesions at basal inferoseptal, mid to basal inferolateral, apical inferior and apical walls. We used a fusion imaging of CTCA and N-13 ammonia PET/CT which led a diagnosis of severe myocardial ischemia.

P-105

Comparative Study of Exercise Tolerance Test and SPECT-Myocardial Perfusion Imaging in the Diagnosis of Coronary Artery Disease in Bangladeshi Women

N. Akhter


Department of Nuclear Medicine, Centre for Nuclear Medicine and Ultrasound, Dinajpur, Dhaka, Bangladesh

Purpose: There are some specifics in the presentation of coronary artery disease in women. The early diagnosis of coronary artery disease continues to be a challenge in women because non-invasive diagnostic tests to evaluate ischemia, such as ETT are less accurate in this group of patients. So far, there are no prospective studies with non-invasive test like SPECT-MPI in Bangladeshi women. The aim of the study is to determine the accuracy of MPI with SPECT for the detection of ischemia.

Materials and Methods: The study included 75 women who were assessed by myocardial perfusion imaging with SPECT, exercise tolerance test and coronary angiography.

Results: The prevalence of angiographically significant coronary artery disease was 69%. The sensitivity and specificity of myocardial perfusion imaging for the detection of ischemia was 85% and 79% respectively. The sensitivity and specificity of exercise tolerance test was 39% and 87%. Accuracy of myocardial perfusion imaging was higher in the postmenopausal patients.

Conclusion: The result of this study suggests that diagnostic accuracy of SPECT-MPI is efficient enough in detecting coronary artery disease among women. It is a very useful tool for detection of ischemia in women with coronary artery disease, being superior to other non- invasive test as exercise tolerance test.

P-106

Radiation Exposure of Patients Undergoing Whole-body Dual-modality 18F-FDG PET/CT Examinations at Cho Ray Hospital - Vietnam

K. Le Tran Tuan, H. Nguyen Van, N. X. Canh


Nuclear Medicine and PET, Cho Ray Hospital, HCMC, Vietnam

Background: PET/CT is a technology that merges PET (Positron Emission Tomography) and CT (Computed Tomography) into one combined scanning system that can provide metabolic and anatomic information in the human body in a single scan and allows examining the entire body at once. However, patient exposure in PET/CT examinations arises from both internal (PET) and external (CT) sources. In this study, we investigate effective dose of patient in PET/CT whole body scan by 18F-FDG.

Materials and Methods: Patient doses were estimated by using established dose co-efficients for 18F-FDG and DLP, CTDIvol value taken from CT data.

Results: Patients undergoing contrast-enhanced PET/CT with 18F-FDG received the mean effective dose of 18 mSv.

Conclusion: The diagnostic protocol of PET/CT with 18F-FDG showed the acceptable effective dose.

P-107

The Role of 99mTc-MIBI Pinhole Scintigraphy in Preoperative Parathyroid Localization in Era of SPECT/CT

L. Kaliska, M. 1 Vereb, L. 2 Sinkovic


Institute Nuclear and Molecular Medicine, Banska Bystrica, Slovakia, 1 Department of Nuclear Medicine, Outpatient Health Centre Sekcov, Presov, Slovakia, 2 2 nd Surgery Clinique, Roosevelt University Hospital, Banska Bystrica, Slovakia

Aim of the present study was to investigate reliability of parathyroid imaging in patients with primary hyperparathyroidism (pHPT) using pinhole imaging in setting of pre-operative localization studies. The integrated diagnostic approach based on pinhole 99m-TcO4 thyroid scintigraphy, followed by KClO4 oral administration and consecutive early 99m-Tc-MIBI pinhole anterior views with additional early LAO and RAO views, finished by 2 hours delayed 99m-Tc-MIBI pinhole anterior views was used in our study. One early image of mediastinum was also recorded in order to exclude ectopic parathyroid adenoma (ePA). The data of radionuclide pinhole imaging obtained in a group of patients with high probability of pHPT were studied. Patients that accomplished strict inclusion criteria for minimally invasive radio-guided parathyroidectomy (MIRP) underwent minimally invasive surgery with intra-operative iPTH assay. The rest of patients underwent traditional bilateral neck exploration surgery, however the gamma-probe navigation was also employed. Parathyroid adenomas were excised and confirmed by histopathological exam. Post-surgical follow-up of patients ranged in 6-60 months. According to our experience we can state that parathyroid imaging based on pinhole scintigraphy is extremely accurate in identifying of correct localization of parathyroid adenomas in patients with pHPH (so in single as in multiglandular parathyroid lesions) and allows correct choice of consecutive surgery, particularly the selection of patients suitable for MIRP surgery. Moreover, allows for the contemporary evaluation of thyroid gland and determination of possible thyroid disease that has second impact in consecutive surgery. SPECT imaging may be still useful in patient with ectopic parathyroid adenomas in order to gain more precise identification of lesion localization for further surgical planning.

P-108

Langerhans Cell Histiocytosis: Imaging Findings and Utility of FDG PET/CT in an Adult Patient with Multi-organ Involvement

W. Xie, A. Tan, W. Lam


Department of Nuclear Medicine and PET, Singapore General Hospital, Singapore

Langerhans cell histiocytosis is a rare disease characterized by the abnormal proliferation of histiocytes and the diversity of clinical presentations. Such histiocytic proliferations have been shown to demonstrate significant FDG uptake in positron imaging, and FDG PET/CT potentially addresses several limitations in current pre and post therapy evaluation strategies. We present a case of adult onset multiorgan involvement LCH for whom FDG PET/CT was performed to evaluate the extent of disease involvement.

P-109

Juxtapapillary Dieulafoy Lesion: An Obscure Case of G.I. Bleeding Localized Using Tc-99m RBC Scintigraphy

M. G. de Guzman, N. Lopez, R. de Guzman, C. L. Lazaro


Department of Nuclear Medicine, University of Santo Tomas, Manila, Philippines

Dieulafoy lesion is an uncommon etiology of upper gastrointestinal bleeding, responsible for 0.5-7% of significant upper gastrointestinal hemorrhage. Diagnosis is difficult because bleeding is often massive and obscures the small lesion. Dieulafoy lesion in the small intestine, more so located in a diverticulum, is rare. Tc-99m RBC scan aided to accurately localize the site of bleeding. A 72-year old male was admitted due to one-month history of intermittent melena requiring repeated transfusions. The patient was pale with baseline hemoglobin of 62g/dL. Initial gastroscopy showed that the descending duodenal area was coated with fresh blood without a definite identifiable source of bleeding. Tc-99m RBC tagging scan revealed focal activity that increased over time with antegrade flow of tracer agent in the proximal small intestines most likely originating at the second portion of the duodenum. Repeat gastroscopy using a side viewing endoscope revealed fresh blood clot in the 2 nd portion of the duodenum. Upon clearing the clot with aggressive water flushing, a 0.1cm round mucosal break with pale red borders consistent to a Dieulafoy lesion was seen near the center of a large juxtapapillary divericulum. The rest of the hospital stay was unremarkable with no recurrence of melena. Repeat hemoglobin two weeks post discharge was 118g/dL.

P-110

Utility of Delayed Imaging in Evaluating Common Bile Duct Obstruction with Tc-99m Mebrofenin Hepatobiliary Scanning

N. Relan, R. Matthews, M. Goodman, E. Safaie, D. Franceschi


Radiology, Stony Brook University Medical Center, Stony Brook, USA

Hepatobiliary imaging is typically performed to assess cholecystitis. However, it occasionally yields an obstructive picture. Delayed hepatobiliary imaging is commonly used in the assessment of biliary atresia in the pediatric population; yet there is room to clarify the use of delayed imaging in the adult population. We studied the pathological findings associated with an obstructive pattern on delayed hepatobiliary imaging within the adult population. We performed a retrospective review of medical records for patients demonstrating an obstructive pattern with delayed Tc-99m mebrofenin hepatobiliary imaging at university hospital from 2004-2009. Two radiologists blindly qualified the presence of radio-tracer in delayed images of the gall-bladder (positive, negative) and intestines (negative, moderate to high) for patients without intestinal activity on delayed imaging. Determination of extrahepatic or intrahepatic causes were obtained from the chart reviews. 24 patients demonstrated an obstructive pattern using delayed Tc-99m mebrofenin hepatobiliary imaging, with a delay period ranging from 4-24 hours. Extrahepatic pathologies (choledocholithiasis, stricture, other) represented 67% of cases (n=16) and intrahepatic pathologies (cirrhosis, medication effect, other) represented 33% cases (n=8). 59% of the extrahepatic patients showed moderate to high radiotracer presence in intestine as compared to 62% in intrahepatic patients. GB activity was in 30% of extrahepatic and 57% in intrahepatic cases. Majority of cases demonstrating an obstructive pattern on delayed hepatobiliary scanning was due to extrahepatic obstruction. Radiotracer activity in intestine was evenly distributed in both the groups, whereas GB activity was more in intrahepatic than the extrahepatic patient. There is likely a role for delayed scintigraphy in clarifying obstructive pathology.

P-111

Role of 18F-Fluoro-deoxyglucose Positron Emission Tomography/Computed Tomography Fusion Imaging (18F-FDG PET/CT) for Preoperative Axillary Staging in Primary Breast Cancer: A Prospective Analysis

A. Pruthi, V. Chauhan, A. Gupta, R. Sharma, S. Tayal, R. Sengupta, P. S. Choudhary


Department of Nuclear Medicine, Rajiv Gandhi Cancer Institute and Research Centre, New Delhi, India

Background: Axillary lymph node (ALN) status is an important predictor of recurrence and overall survival in breast cancer. Accurate staging of axilla is desirable before treatment of primary breast cancer as lymph nodal staging is related to patient prognosis and influences the decision of adjuvant chemotherapy. 18F-Fluorodeoxyglucose positron emission tomography (18F-FDG PET) is considered to be a non-invasive approach to evaluate patients having axillary lymph nodal involvement.

Objective: To evaluate the accuracy of 18F Fluorodeoxyglucose positron emission tomography (18F-FDG PET) in axillary lymph nodal staging in breast cancer.

Materials and Methods: A total of thirty-six females (n=36) with primary operable breast cancer who underwent whole body 18F-FDG PET-CT as a part of staging work up from Jan'10 to July'11 at our institute were evaluated prospectively. Standard procedures for patient preparation and acquisition protocol were followed. All of them underwent modified radical mastectomy and complete axillary lymph node dissection. PET-CT scans were interpreted with respect to the FDG avidity and size of the primary tumour and the axillary lymph nodes. The results were compared to histopathological analysis of the axillary lymph nodes. SUVmax ≥= 1.5 was considered as the cut-off point for determining positivity on 18F-FDG PET scan.

Results: The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 18F-FDG PET (cut-off SUVmax was taken as 1.5) for the detection of axillary lymph nodal metastasis were 80.95%, 100%, 100%, 78.94% and 88.88% respectively. There was no significant correlation between the nuclear grade of the primary breast Tumor or the number of histologically confirmed lymph nodes with the FDG avidity ( p0 = 0.16, p0 =0.96). The number of positive lymph nodes visible on PET-CT was less than those found positive during histological analysis.

Conclusion: PET imaging improves the preoperative staging of the disease in breast cancer patients and, therefore, might alter therapeutic regimen. The sensitivity of 18F-FDG PET to detect axillary metastases in operable breast cancer was satisfactory. In view of excellent specificity and positive predictive value of 18F-FDG PET, it can be safely proposed that FDG positivity in the axilla obviates the need for histological confirmation and is an indication for axillary lymph node dissection (ALND) without performing sentinel lymph node biopsy. There was no significant correlation between the FDG avidity of axillary lymphnodes and histological grade of the primary Tumor and number of histologically confirmed lymphnodes. Due to limitations in the resolution of PET, a number of histologically positive lymphnodes were underestimated in the PET images. However the information was adequate to avoid sentinel lymph node biopsy. The evaluated patients are on follow- up to determine the prognostic value of the findings.

P-112

Role of FDG in Primary Lesion Identification (A Preliminary Result)

H. Budiawan


Department of Nuclear Medicine, MRCCC, Jakarta, Indonesia

Background: Detecting primary lesion is very challenging. In many cases, metastatic diseases are very obvious, but the primary lesion cannot be found. Determination of primary lesion is very important, because treatment may vary among diseases. In this study, we tried to use (18F] Fluorodeoxyglucose (FDG) as the most commonly used PET tracer to explore the high glycolytic rate of malignant cells in finding the primary lesion.

Materials and Methods: The study population consisted of 13 cases suspicious of malignancy sent for primary lesion identification. Some of them were sent with known metastatic lesions proven by biopsy or conventional diagnostic imaging with or without tumor markers evaluation. Each patient underwent PET/CT imaging. FDG uptake in each lesion was measured by standardized uptake value (SUV).

Results: Of 13 patients, metastatic lesions were found in the brain (3), bone/vertebra (5), liver (2), soft tissue (1); while 3 other cases with symptoms of memory disturbance, ascites, and weight loss which were suspected related to malignancy. PET-CT determined the primary lesions or confirmed diagnosis in 10 cases (77%): lung in 6 cases, gall bladder in 1 case, seminal vesicle in 1 case, soft tissue in 1 case, and 1 case with malignant lymphoma. All the lesions had SUV maximum greater than 3.0. Primary lesion could not be identified in 3 cases (brain/cerebellar, bone, and liver metastases).

Conclusion: Along with other studies, this finding also proves that FDG PET/CT provides higher rate of detection of primary lesions, although some cases in this study cannot be classified as cancer of unknown primary.

P-113

PET/CT and Contrast Enhanced CT in the Detection of Malignant Lesions: A Prospective Study

S. Gironella-Camomot


Department of Nuclear Medicine St. Luke's Medical Center, Quezon City, Philippines

Objective: The study aimed to prospectively evaluate the accuracy, sensitivity and specificity of integrated 18F 2-2- Fluorodeoxyglucose positron emission tomography and low dose computed tomography (FDG-PET/CT) and contrast-enhanced computed tomography (CECT) in the detection of malignant lesions.

Materials and Methods: 56 patients from April 2008 to April 2009 who fit the inclusion criteria with mean age 59.07 years [SD + 12.25], underwent PET/CT and CECT. Both PET/CT and CECT were done prior to the tissue biopsy, colonoscopy, endoscopy or bronchoscopy and were interpreted separately to determine the performance of each imaging modality. Histopathology served as reference in all patients, where the mean days of follow-up is 63 (±25).

Results: A total of 81 histology findings revealed 34 (42%) malignant and 47 (58%) benign findings. The overall accuracy, sensitivity and specificity for PET/CT and CECT were: 86% and 76%, 85% and 85%, 81% and 70%, respectively. PET/CT has a positive predictive value (PPV) of 76% and a negative predictive value (NPV) of 88% while CECT has 67% and 87%, respectively. The results showed that PET/CT improved the detection of various oncologic lesions, which may lead to more accurate staging, prognostication, assessment of response to therapy, evaluation of recurrent disease and overall improved management of cases.

Conclusion: For differentiation of benign from malignant lesions in diagnosed malignant cases, integrated FDG-PET/CT imaging was more accurate than CECT. The addition of metabolic imaging (FDG-PET) to morphological imaging (CT) leads to an increase in specificity but comparable sensitivity of both modalities in already histologically diagnosed cases.




 

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