Annals of Nuclear Medicine (v.23, #9)

Esophageal transit scintigraphy and structured questionnaire in patients with systemic sclerosis with endoscopically proven reflux esophagitis by Kenichi Nakajima; Anri Inaki; Takashi Hiramatsu; Minoru Hasegawa; Manabu Fujimoto; Kazuhiko Takehara; Seigo Kinuya (771-776).
Esophageal complications are common in patients with systemic sclerosis (SSc). The relationship between gastroesophageal reflux (GER) symptoms and dysmotility was examined in endoscopically confirmed patients suspected of having reflux esophagitis.A total of 32 patients with limited and diffuse type SSc (lSSc, dSSc) were examined based on a structured questionnaire score (QS) of GER symptoms, retention fraction of esophageal scintigraphy at 90 s (R 90) and gastric emptying time.The QS was significantly higher in the reflux esophagitis group than in the non-esophagitis group (5.4 ± 3.5, 1.4 ± 2.9, P = 0.003). When the non-esophagitis group was further divided into lSSc and dSSc groups, R 90 was higher in the reflux esophagitis group (31 ± 18%) and the non-esophagitis group with dSSc (34 ± 32%) than in the non-esophagitis group with lSSc (8 ± 3%, P = 0.02). Both high R 90 ≥ 15% and QS ≥ 4 indicated reflux esophagitis. Conversely, both normal R 90 and QS indicated no reflux esophagitis.A combination of esophageal scintigraphy and structured questionnaire demonstrated different aspects of esophageal dysfunction, namely dysmotility and GER. Patients with high QS and dysmotility may be indicated for further evaluation including endoscopic examination and medical treatment.
Keywords: Systemic sclerosis; Esophageal transit scintigraphy; Esophageal dysmotility; Gastroesophageal reflux; Structured questionnaire

Comparisons of I-123 diagnostic and I-131 post-treatment scans for detecting residual thyroid tissue and metastases of differentiated thyroid cancer by Shingo Iwano; Katsuhiko Kato; Takashi Nihashi; Shinji Ito; Yasushi Tachi; Shinji Naganawa (777-782).
We assessed the performance of 37 MBq I-123 as a diagnostic imaging agent in patients with differentiated thyroid cancer using comparisons with their corresponding high-dose post-treatment I-131 scans.We reviewed diagnostic I-123 whole-body scans and post-treatment I-131 scans of 69 patients who underwent I-131 therapy for differentiated thyroid carcinoma (47 papillary and 22 follicular). Diagnostic scans were performed 24 h following the oral administration of 37 MBq of I-123. I-131 doses were administered 3 days after the I-123 diagnostic scans using 2.22–7.4 GBq (median = 5.55 GBq). All images for diagnostic I-123 scans and the corresponding post-treatment I-131 scans were interpreted by consensus of at least 2 experienced radiologists. They evaluated the accumulations of radioiodine in the following 5 sites: thyroid bed, cervical and mediastinal lymph nodes, lung, bone and others. The concordance rates between I-123 scans and I-131 scans were calculated.A total of 108 sites were identified on the post-treatment I-131 scans. Seventy-seven sites (71%) were also identified on the I-123 diagnostic scans. The concordance rates between I-123 diagnostic scans and I-131 post-treatment scans were high for thyroid bed and bone metastases (89 and 86%, respectively), while they were low for lymph node and lung metastases on post-treatment scans (61 and 39%, respectively).Diagnostic scanning with relatively low dose I-123 is not always predictive of subsequent therapeutic I-131 uptake, especially for lymph node and lung metastases of differentiated thyroid cancer.
Keywords: Thyroid cancer; Radioiodine treatment; I-131; I-123; Whole body scan

Whole-body FDG-PET/CT on rheumatoid arthritis of large joints by Kazuo Kubota; Kimiteru Ito; Miyako Morooka; Takuya Mitsumoto; Kyoko Kurihara; Hiroyuki Yamashita; Yuko Takahashi; Akio Mimori (783-791).
Fluorodeoxyglucose (FDG) uptake in joint lesions in patients with rheumatoid arthritis (RA) reportedly represents the degree of synovial inflammation. Most previous studies have focused on small joints, and the application of whole-body positron emission tomography (PET) combined with computed tomography (CT) (PET/CT) for the evaluation of inflammatory activity in large joints has not been well studied.Eighteen patients with RA underwent FDG-PET/CT. FDG uptake in the knee, hip, carpal, wrist, elbow, shoulder, and atlanto-axial joint (total of 13 joints) and in the axillary lymph nodes was evaluated by calculating the maximum standardized uptake value (SUVmax) and the visual uptake scores as follows: 0, no uptake; 1, slight uptake; 2, moderate uptake (same as in liver); 3, higher than in liver; 4, highest uptake. The number of painful/swollen joints, the white blood cell (WBC) count, and the C-reactive protein (CRP) level were also evaluated.Whole-body FDG-PET/CT delineated large-joint lesions in patients with RA, and the metabolic activity of inflammation was accurately overlaid on the joint anatomy. The total FDG score for all 13 joints was significantly correlated with the CRP level (r = 0.653, p < 0.01, n = 18). The total SUVmax and the CRP level were weakly, but not significantly, correlated (r = 0.377, p > 0.05). The WBC count was not correlated with any other parameter. The mean number of joints per patient with an FDG uptake score of 2 or more was significantly larger than the mean number of painful/swollen joints (6.2 ± 3.3 vs. 3.1 ± 2.7, n = 18, p < 0.01) and both parameters were strongly correlated (r = 0.588, p < 0.01, n = 18). Also, FDG uptake score and SUV of painful/swollen joints were significantly higher than these of not painful/swollen joints. FDG uptake was significantly different from patients of remission and patients of active arthritis. Uptake in the atlanto-axial joint was observed in five (mostly asymptomatic) patients (5/18, 28%), and the uptake score was significantly correlated with the total FDG score (r = 0.669, p < 0.01, n = 18). The axillary lymph nodes score was correlated with the arm joints score.FDG-PET/CT represents the inflammatory activity in large joints in patients with RA accurately and sensitively and may be helpful for early evaluations of the extent of RA throughout the whole body including high risk lesion of atlanto-axial joint. Furthermore, the visual FDG uptake score may be useful for evaluating arthritis in large joints.
Keywords: Rheumatoid arthritis; FDG; PET/CT; Large joint; Atlanto-axial joint

Ability of 201Tl and 123I-BMIPP mismatch to diagnose myocardial ischemia in patients with suspected coronary artery disease by Ayako Nakamura; Mitsuru Momose; Chisato Kondo; Takatomo Nakajima; Kiyoko Kusakabe; Nobuhisa Hagiwara (793-798).
A mismatch defect between 201TL and 123I-BMIPP dual isotope SPECT (d-SPECT) is useful to detect myocardial ischemia in patients with acute coronary syndrome. However, whether mismatched d-SPECT findings reflect actual myocardial ischemia in stable patients with suspected, but unknown ischemic heart disease is unclear. The present study assesses the significance of a d-SPECT mismatch among such patients.Forty-nine patients with suspected stable coronary heart disease who had been referred for chest pain, ECG abnormalities or multiple risk factors (66 ± 11 years old, 34 males) with a d-SPECT mismatch participated in this study. All of them underwent coronary angiography (CAG) to assess coronary artery disease. The entire myocardial area on d-SPECT images was divided into 17 segments, each of which was scored from 0 (normal) to 4 (defect). The d-SPECT mismatch score (MS) was defined as the summed BMIPP defect score (BM-TDS) minus the summed defect score (TL-TDS). The inclusion criterion was MS ≥ 1, and the mismatch was defined as true positive if the mismatched area was concordant with the territories supplied by significant coronary stenotic arteries by CAG.Ischemic heart disease was judged by coronary angiography in 31 (63%) patients (IHD group), of which 24 (49.0%) were true positives. Of the remaining 18 (37%) patients without no significant coronary stenosis (non-IHD group), 12 (24%) had some types of organic heart disease. If MS ≥ 4 was defined as the threshold for an ischemic positive mismatch, then the sensitivity and specificity were 80% and 63%, respectively. However, mismatch scores did not significantly differ between the groups with true positive-IHD and organic heart disease in non-IHD group (6.6 ± 4.4 vs. 6.4 ± 3.7).A d-SPECT mismatch score of ≥4 was an appropriate cutoff at which diagnosis of myocardial ischemia in patients who were screened for ischemic heart disease. However, since patients with non-ischemic but organic heart disease can also present with abnormal mismatch findings, coronary angiography or CT might be warranted to differentiate IHD from non-IHD.
Keywords: Dual SPECT; Mismatch score; Fatty acid metabolism; Sarcoidosis; Dilated cardiomyopathy

Left ventricular (LV) dyssynchrony after reperfusion therapy has been closely examined as a cause of chronic remodeling, but the details have not been clarified. The present study measured LV dyssynchrony appearing immediately after reperfusion therapy using real-time three-dimensional echocardiography (RT-3DE), and assessed the significance of this phenomenon in relation to dual single photon emission computed tomography (SPECT) of 123iodine β methyliodophenyl pentadecanoic acid (123I-BMIPP) and 201thallium (201Tl).Subjects comprised 58 patients with first-time acute myocardial infarction who received reperfusion therapy and underwent RT-3DE and dual SPECT of 123I-BMIPP and 201Tl within two weeks of onset. Two dyssynchrony parameters were measured using RT-3DE in the acute phase and six months later. After evaluating the correlation of these dyssynchrony parameters to resting 201Tl uptake, 201Tl washout, 123I-BMIPP uptake, and 201Tl–123I-BMIPP discrepancy (Tl–BMIPP discrepancy), we compared scintigraphic parameters in the chronic phase between groups with improved dyssynchrony and those without.Acute dyssynchrony exhibited a significant positive correlation to Tl–BMIPP discrepancy and it was significantly increased in the group with improved dyssynchrony in the chronic phase, revealing close relationship between dyssynchrony and Tl–BMIPP discrepancy. Then the subjects were divided into positive Tl–BMIPP discrepancy and negative discrepancy groups, and the parameters of cardiac function were compared between them. In the chronic phase, improved cardiac function was observed in the group with positive Tl–BMIPP discrepancy compared to negative discrepancy.LV dyssynchrony after reperfusion therapy correlates positively with Tl–BMIPP discrepancy, reflecting acute myocardial stunning, in which ventricular contraction improves during the chronic phase.
Keywords: Dyssynchrony; RT-3DE; Dual SPECT; 201Tl–123I-BMIPP discrepancy

18F-FDG-PET findings of rare case of nonsecretory plasmablastic myeloma by Hiroko Kaibara; Hayato Kaida; Masatoshi Ishibashi; Seiji Kurata; Korenori Otsubo; Kiminori Fujimoto; Masafumi Uchida; Toshi Abe; Maiko Kobayashi; Ryousuke Doi; Yukiko Kunou; Takashi Okamura; Koichi Oshima; Naofumi Hayabuchi (807-811).
A 61-year-old woman presented with pancytopenia and underwent a bone marrow biopsy. The patient was diagnosed with nonsecretory myeloma (plasmablastic type) based on both the bone marrow biopsy findings and her laboratory data. Fluorine-18 fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) was performed prior to chemotherapy showing diffuse bone marrow uptake, splenic uptake, and focal uptake of the right anterior chest wall. The patient underwent an 18F-FDG-PET examination to evaluate the curative effects after three cycles of chemotherapy, and no abnormal uptake on 18F-FDG-PET was found. Bone marrow biopsy to evaluate the curative effect showed no viable tumor cells. We present a rare case of nonsecretory plasmablastic myeloma detected by 18F-FDG-PET.
Keywords: Fluorine-18 fluorodeoxyglucose-positron emission tomography; Nonsecretory myeloma; Plasmablastic type

Utility of SPECT/CT with Meckel’s scintigraphy by Jonathan R. Dillman; Ka Kit Wong; Richard K. J. Brown; Kirk A. Frey; Peter J. Strouse (813-815).
Meckel’s diverticulum is a relatively common source of gastrointestinal tract morbidity in children. Individuals may present with symptoms of lower gastrointestinal tract bleeding, bowel obstruction or diverticulitis. Technetium-99 m pertechnetate scintigraphy is used to demonstrate those Meckel’s diverticula that contain heterotopic gastric mucosa. We present a case of an adolescent male patient with rectal bleeding and suspected Meckel’s diverticulum where the use of SPECT/CT fusion imaging provided valuable diagnostic information and prevented a false-negative study.
Keywords: Meckel’s diverticulum; Tc-99 m pertechnetate scintigraphy; SPECT/CT

Normal uptake of F-18 FDG in the testis as assessed by PET/CT in a pediatric study population by Ingeborg Goethals; Ciel De Vriendt; Pieter Hoste; Peter Smeets; Hamphrey Ham (817-820).
To investigate the correlation between the F-18 FDG uptake in the normal testis as assessed by PET–CT and patient age in a pediatric study population.The study population consisted of 22 subjects aged between 9 and 17 years. For these subjects 42 PET–CT scans were available for analysis. The testis was identified on the CT images. Mean standard uptake values and testicular volume were calculated based on manually drawn regions-of-interest over the organ. The correlation between mean SUV and age as well as between testicular volume and age was calculated using Pearson’s correlation coefficient.A strong and statistically significant positive correlation between F-18 FDG uptake in the testis and age was documented. The correlation coefficient was 0.406 in the analysis based on 42 PET–CT studies (p = 0.005). The correlation between tracer uptake and age was reassessed based on 22 PET–CT studies including the last recorded PET–CT scan per patient. The correlation coefficient was 0.409 (p = 0.05). In addition, based on 22 PET–CT scans, a strong and statistically significant positive correlation between testicular volume and age was documented (r = 0.67, p < 0.001).Whereas it was previously shown that in adult men there was a weak but statistically significant negative correlation between F-18 FDG uptake in the normal testis and age, we found a strong and statistically significant positive correlation in children and teenage boys.
Keywords: FDG PET; Testis; Pediatric

Comparison between rebinning methods and geometric re-projection for the estimation of missing oblique data in 3D-PET by Fayçal Ben Bouallègue; Jean-François Crouzet; Denis Mariano-Goulart (821-827).
Classically, the missing portions in the oblique projection data acquired from cylindrical scanners are synthesized by forward projecting an estimation of the activity computed from non-oblique data. Another quick and powerful way to perform the estimation of the truncated portions consists in applying Fourier rebinning methods. This paper intends to compare the performances of 3D geometric re-projection versus two Fourier rebinning techniques (iterative FOREPROJ and extended FORE) designed for re-projection.Both analytical and noisy 3D projection data corresponding to a phantom constituted of warm and cold ellipsoids over a uniform background are simulated numerically for the SIEMENS Hi-Rez scanner. The object is reconstructed using 3D filtered back-projection. A prior estimation of the missing oblique data is performed using the three algorithms.The resolution properties and noise behavior of the three methods are compared and demonstrate a significant signal to noise ratio improvement using rebinning-based algorithms.We show that iterative FOREPROJ provides projection data with high accuracy 60% less time than geometric re-projection.
Keywords: Image reconstruction; Positron emission tomography; Fourier rebinning; Re-projection