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Applications of SPECT/CT in Nuclear Radiology

¹ Department of Radiology, Mayo Clinic Scottsdale, 13400 E Shea Blvd., Scottsdale, AZ 85259.
² Department of Surgery, Mayo Clinic Scottsdale, Scottsdale, AZ.

Received December 18, 2007; accepted after revision March 28, 2008.

 
Address correspondence to M. C. Roarke (roarke.michael{at}mayo.edu).

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Abstract

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

 
OBJECTIVE. The purpose of this pictorial essay is to illustrate several clinical situations in which SPECT/CT can be effectively applied in nuclear radiology practice.

CONCLUSION. SPECT/CT has recently emerged as a valuable adjunct to standard techniques in clinical nuclear radiology. This technique provides significantly improved scintigraphic localization and characterization of disease, increasingly important in this era of minimally invasive surgery and targeted radiotherapy.

Keywords: intensity-modulated radiation therapy (IMRT) • minimally invasive surgery • nuclear radiology • scintigraphy • SPECT • SPECT/CT

Introduction

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

 
In-line hybrid SPECT/CT is a recent addition to the nuclear radiology armamentarium which generates coregistered SPECT and CT images acquired with a single device during a single imaging session. SPECT/CT is similar conceptually to PET/CT. The SPECT and CT images are acquired during a single, approximately 35-minute-long imaging session.

The CT information is used for attenuation correction and anatomic localization. Although the CT image quality from earlier generation SPECT/CT hybrid scanners is not adequate for stand-alone diagnostic CT interpretation, newer generation devices provide higher quality anatomic MDCT imaging.

In a manner analogous to PET/CT, SPECT/CT provides complementary, not redundant, information because sites of abnormal radiopharmaceutical uptake on the SPECT images can be anatomically localized on CT, anatomic abnormalities on the CT images can draw attention to subtle abnormalities of tracer uptake on SPECT, a lesion discovered on a preceding diagnostic imaging study can be shown to precisely match the area of abnormal radiopharmaceutical uptake on SPECT, and combined SPECT/CT can improve test specificity by reducing the uncertainties associated with low-resolution SPECT alone.

In this article, we illustrate several useful clinical applications of SPECT/CT, including localization of parathyroid adenomata, prostate cancer localization and staging, sentinel lymph node mapping, neuroendocrine tumor staging and localization, and as an adjunct to routine bone scintigraphy.

There are several additional SPECT/CT applications that could not be included in this pictorial essay because of space limitations. These include gallium and ¹¹¹In-labeled leukocyte imaging of inflammation and infection, radioiodine imaging of thyroid cancer, and, potentially, any other application for which stand-alone SPECT would be indicated.

Image Acquisition

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

 
Although SPECT/CT technology is evolving and imaging parameters will vary by manufacturer, the images presented in this article were acquired with the following technical parameters. SPECT acquisitions were performed using energy-appropriate parallel-hole collimators, large field-of-view gamma detectors (range, 40 cm), 360° arc, 3° view angle, zoom of 1.0, and 35 seconds per stop. Images were acquired with a 128 x 128 matrix and then reconstructed using a 2D ordered-subset expectation maximization iterative technique (10 subsets and two iterations). CT images were acquired using single-detector step-and-shoot technique, 10-mm slice interval, current of 2.5 mA, voltage of 140 kV, 256 x 256 matrix, and a Hann filter. Total imaging time for most studies was approximately 35 minutes, with the SPECT acquisition requiring approximately 25 minutes and the CT acquisition, approximately 10 minutes.

Hyperparathyroidism

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

 
The literature regarding SPECT versus SPECT/CT in evaluation of hyperparathyroidism has been somewhat conflicting, with studies reporting increased value of SPECT/CT [1–3], whereas others claim little incremental benefit [4]. However, the consensus seems to be that SPECT/CT has the most utility in patients with ectopic parathyroid adenoma, those with distorted neck anatomy due to prior surgery, and those with prior failed parathyroid surgery. Whereas planar techniques can depict the relative position of the abnormality, cross-sectional multiplanar imaging will precisely specify the depth of the focus and its position with respect to the surrounding and adjacent structures (Fig. 1A, 1B, 1C). For example, the surgical approach to an adenoma adjacent to a thyroid gland lobe will require a less-involved procedure than one that is located deeper in the prevertebral or retroesophageal space (Figs. 2A, 2B, 3A, 3B, 4). The addition of the CT component in hybrid SPECT/CT therefore would be expected to improve mediastinal focus localization even further because both the scintigraphic and corresponding CT abnormality can be pinpointed simultaneously. This information should serve to clarify presurgical planning and can potentially decrease intraoperative search time.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —64-year-old man with primary hyperparathyroidism referred for parathyroid imaging before anticipated minimally invasive gamma probe–guided parathyroidectomy. Left anterior oblique planar 99mTc sestamibi (740 MBq [20 mCi] IV) image shows focus of tracer retention inferior in relation to normal left thyroid lobe (arrow).

View larger version (52K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —64-year-old man with primary hyperparathyroidism referred for parathyroid imaging before anticipated minimally invasive gamma probe–guided parathyroidectomy. Multiplanar SPECT/CT (B) pinpoints this uptake to 11-mm left paratracheal nodule (arrow) that was overlooked on earlier chest CT (arrow, C). This uptake is just inferior in relation to left thyroid lobe in left tracheal–esophageal groove, 2–3 cm above axial level of sternal notch. At surgery, 1,400 mg left inferior parathyroid adenoma was resected from this location.

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C —64-year-old man with primary hyperparathyroidism referred for parathyroid imaging before anticipated minimally invasive gamma probe–guided parathyroidectomy. Multiplanar SPECT/CT (B) pinpoints this uptake to 11-mm left paratracheal nodule (arrow) that was overlooked on earlier chest CT (arrow, C). This uptake is just inferior in relation to left thyroid lobe in left tracheal–esophageal groove, 2–3 cm above axial level of sternal notch. At surgery, 1,400 mg left inferior parathyroid adenoma was resected from this location.

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —87-year-old woman who presented with hypercalcemia and inappropriate parathyroid hormone (PTH) levels. Parathyroid scintigraphy with SPECT/CT was requested. Planar scintigraphy after IV injection of 740 MBq (20 mCi) 99mTc sestamibi revealed midline focus of radiopharmaceutical uptake in lower neck. SPECT/CT images localize this radiopharmaceutical uptake to retroesophageal region (arrows).

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —87-year-old woman who presented with hypercalcemia and inappropriate parathyroid hormone (PTH) levels. Parathyroid scintigraphy with SPECT/CT was requested. Planar scintigraphy after IV injection of 740 MBq (20 mCi) 99mTc sestamibi revealed midline focus of radiopharmaceutical uptake in lower neck. Unfused low-dose localizer–attenuation correction CT image shows soft-tissue nodule (arrow), confirmed as ectopic parathyroid adenoma at surgery.

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A —63-year-old woman with hypercalcemia and inappropriate parathyroid hormone (PTH) levels who underwent parathyroid scintigraphy with SPECT/CT after IV injection of 740 MBq (20 mCi) 99mTc sestamibi. SPECT/CT (A) shows focus of tracer uptake in anterior mediastinum (arrow, A) that matched a soft-tissue nodule (arrow, B) on the CT (B) consistent with ectopic parathyroid adenoma. Parathyroid adenoma was subsequently resected from the mediastinum, with resolution of hypercalcemia.

View larger version (83K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B —63-year-old woman with hypercalcemia and inappropriate parathyroid hormone (PTH) levels who underwent parathyroid scintigraphy with SPECT/CT after IV injection of 740 MBq (20 mCi) 99mTc sestamibi. SPECT/CT (A) shows focus of tracer uptake in anterior mediastinum (arrow, A) that matched a soft-tissue nodule (arrow, B) on the CT (B) consistent with ectopic parathyroid adenoma. Parathyroid adenoma was subsequently resected from the mediastinum, with resolution of hypercalcemia.

View larger version (32K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4 —52-year-old man who presented with hyperparathyroidism and was referred for 99mTc sestamibi (740 MBq [20 mCi] IV) parathyroid scintigraphy with SPECT/CT before anticipated minimally invasive radioguided parathyroidectomy with intraoperative parathyroid hormone (PTH) monitoring. SPECT/CT multiplanar and SPECT maximum-intensity-projection (MIP) (far right) images reveal focus of uptake in unusual location adjacent to proximal left common carotid artery (arrows). During curative surgery, 22-mg ectopic left parathyroid gland was found within left carotid sheath. Surgeon remarked that SPECT/CT information significantly enhanced preoperative planning of surgical approach.

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

Intensity-modulated radiation therapy (IMRT) is a method of treating localized prostate cancer by providing graded dose boosting to involved areas of the prostate. By importing the SPECT/CT images to the treatment planning computer, the radiation oncologist can tailor the clinical treatment dose profile to maximize radiation dose to the tumor and minimize the dose to surrounding normal tissues (Figs. 5A, 5B, 6A, 6B, 6C, 7A, 7B, 7C, 8A, 8B). Indeed, SPECT/CT has been reported to effectively contribute to modifications of clinical target volume (CTV) in ways that spare more surrounding normal tissue [7, 8].

View larger version (142K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —60-year-old man 2 years after radical prostatectomy for Gleason 6 prostate cancer. Pathology showed tumor focally at inked surface of left bladder base. Lymph nodes were negative for metastases. Postoperative prostate-specific antigen (PSA) was 0.1 until 1 year later, when it rose to 0.38. His most recent PSA was 0.55. To help minimize radiation dose to bladder and rectum, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested for intensity-modulated radiation therapy planning. Planar whole-torso scintigraphy findings were negative.

View larger version (117K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —60-year-old man 2 years after radical prostatectomy for Gleason 6 prostate cancer. Pathology showed tumor focally at inked surface of left bladder base. Lymph nodes were negative for metastases. Postoperative prostate-specific antigen (PSA) was 0.1 until 1 year later, when it rose to 0.38. His most recent PSA was 0.55. To help minimize radiation dose to bladder and rectum, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested for intensity-modulated radiation therapy planning. Multiplanar SPECT/CT clearly shows site of recurrence (thick arrow) from rectum (thin arrow).

View larger version (64K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —72-year-old man with history of Gleason 7 aneuploid prostatic adenocarcinoma with prostate-specific antigen (PSA) recurrence 7 months after radical prostatectomy. For this patient, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested before salvage external-beam radiation therapy. Planar whole-torso image shows negative findings.

View larger version (29K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —72-year-old man with history of Gleason 7 aneuploid prostatic adenocarcinoma with prostate-specific antigen (PSA) recurrence 7 months after radical prostatectomy. For this patient, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested before salvage external-beam radiation therapy. SPECT/CT images at 96 hours after injection (B) show recurrent disease in left seminal vesicle fossa (arrows), visible only as wispy increased density on CT (C).

View larger version (62K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6C —72-year-old man with history of Gleason 7 aneuploid prostatic adenocarcinoma with prostate-specific antigen (PSA) recurrence 7 months after radical prostatectomy. For this patient, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested before salvage external-beam radiation therapy. SPECT/CT images at 96 hours after injection (B) show recurrent disease in left seminal vesicle fossa (arrows), visible only as wispy increased density on CT (C).

View larger version (94K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —78-year-old man who underwent radical retropubic prostatectomy in 1999 for adenocarcinoma of prostate. He developed prostate-specific antigen (PSA) recurrence in 2001, originally treated with single Lupron injection (leuprolide acetate, TAP Pharmaceuticals), and PSA normalized. In 2003, PSA again began rising, and he was placed on Zoladex (goserelin acetate, AstraZeneca). In 2005, he again developed rising PSA and was placed on Casodex (bicalutamide, AstraZeneca). Restaging CT and bone scans were always negative. At this point, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested for localization of occult recurrent disease. Planar whole-torso images (not shown) showed negative findings. SPECT/CT images obtained at 96 hours after injection detect recurrence in CT-negative, normal-sized retroperitoneal interaortocaval lymph node (arrows). This case shows synergism of combined SPECT/CT.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —78-year-old man who underwent radical retropubic prostatectomy in 1999 for adenocarcinoma of prostate. He developed prostate-specific antigen (PSA) recurrence in 2001, originally treated with single Lupron injection (leuprolide acetate, TAP Pharmaceuticals), and PSA normalized. In 2003, PSA again began rising, and he was placed on Zoladex (goserelin acetate, AstraZeneca). In 2005, he again developed rising PSA and was placed on Casodex (bicalutamide, AstraZeneca). Restaging CT and bone scans were always negative. At this point, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested for localization of occult recurrent disease. Planar whole-torso images (not shown) showed negative findings. SPECT/CT images obtained at 96 hours after injection detect recurrence in CT-negative, normal-sized retroperitoneal interaortocaval lymph node (arrows). This case shows synergism of combined SPECT/CT.

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7C —78-year-old man who underwent radical retropubic prostatectomy in 1999 for adenocarcinoma of prostate. He developed prostate-specific antigen (PSA) recurrence in 2001, originally treated with single Lupron injection (leuprolide acetate, TAP Pharmaceuticals), and PSA normalized. In 2003, PSA again began rising, and he was placed on Zoladex (goserelin acetate, AstraZeneca). In 2005, he again developed rising PSA and was placed on Casodex (bicalutamide, AstraZeneca). Restaging CT and bone scans were always negative. At this point, 111In capromab pendetide (222 MBq [6 mCi] IV) scintigraphy was requested for localization of occult recurrent disease. Planar whole-torso images (not shown) showed negative findings. SPECT/CT images obtained at 96 hours after injection detect recurrence in CT-negative, normal-sized retroperitoneal interaortocaval lymph node (arrows). This case shows synergism of combined SPECT/CT.

View larger version (63K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —61-year-old man with newly diagnosed localized prostate adenocarcinoma. Obtained at 120 hours after injection, 111In capromab pendetide (222 MBq [6 mCi] IV) SPECT/CT image localizes focal right-sided prostate carcinoma (arrow).

View larger version (65K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —61-year-old man with newly diagnosed localized prostate adenocarcinoma. Separately acquired intensity-modulated radiation therapy (IMRT) treatment planning CT image based on incorporation of SPECT/CT data shows tumor location (thick arrow) with respect to 82-, 75.6-, 70-, and 60-Gy isodose lines (thin arrows). By contouring dose profile, site of highest tumor concentration can receive boosted dose, while dose is reduced to surrounding normal tissues.

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9A —68-year-old man with locally recurrent left forehead melanoma who underwent preoperative lymphoscintigraphy after circumferential perilesional intradermal injections of 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi]). Left lateral planar lymphoscintigram, with head outline for preoperative landmark identification, shows forehead injection site (small arrow) and intraparotid (large arrow) and jugulodigastric (arrowhead) sentinel lymph nodes.

View larger version (24K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9B —68-year-old man with locally recurrent left forehead melanoma who underwent preoperative lymphoscintigraphy after circumferential perilesional intradermal injections of 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi]). Multiplanar SPECT/CT of the intraparotid node (arrows) shows that SPECT/CT is particularly useful when localizing nodes in difficult anatomic locations, such as within parotid, and helps to decrease risk to structures such as facial nerve.

View larger version (69K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —75-year-old man who noticed raised pimple on right midback. Shave biopsy revealed malignant melanoma involving dermis with no epidermal involvement. For this patient, 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi]) lymphoscintigraphy was requested. Planar scintigraphic images show intense activity at right-back injection site, with closely adjacent in-transit node (thin arrows) and lymphatic channels coursing to right axillary sentinel nodes (thick arrows).

View larger version (28K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —75-year-old man who noticed raised pimple on right midback. Shave biopsy revealed malignant melanoma involving dermis with no epidermal involvement. For this patient, 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi]) lymphoscintigraphy was requested. SPECT/CT images reveal precise location of in-transit node (arrows). SPECT/CT images provide radiologist with precise location and depth for placing ink marks on skin. At surgery, all sentinel nodes were negative.

View larger version (55K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11A —75-year-old man with history of wide local excision and negative sentinel lymph node biopsy for desmoplastic melanoma on back 3 years earlier who presented with local recurrence. Planar dynamic posterior postinjection 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi] intradermally) lymphoscintigraphy image shows rapid drainage from injection site (arrowhead) toward left axilla (thin arrows) and to right axilla (large arrow).

View larger version (81K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11B —75-year-old man with history of wide local excision and negative sentinel lymph node biopsy for desmoplastic melanoma on back 3 years earlier who presented with local recurrence. Coronal SPECT/CT images show location of bilateral axillary nodes (arrows).

View larger version (95K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11C —75-year-old man with history of wide local excision and negative sentinel lymph node biopsy for desmoplastic melanoma on back 3 years earlier who presented with local recurrence. Coronal SPECT/CT images show location of bilateral axillary nodes (arrows).

View larger version (28K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11D —75-year-old man with history of wide local excision and negative sentinel lymph node biopsy for desmoplastic melanoma on back 3 years earlier who presented with local recurrence. Multiplanar SPECT/CT images show precise location and depth of periscapular in-transit sentinel node (arrows).

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12A —69-year-old woman with invasive ductal carcinoma of right breast who was referred for 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi] intradermally) lymphoscintigraphic mapping before right mastectomy and sentinel lymph node biopsy. Anterior and lateral planar lymphoscintigrams show injection site (arrowheads) and right axillary (thin arrows) and internal mammary (thick arrow) sentinel lymph nodes.

View larger version (34K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12B —69-year-old woman with invasive ductal carcinoma of right breast who was referred for 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi] intradermally) lymphoscintigraphic mapping before right mastectomy and sentinel lymph node biopsy. SPECT/CT fusion images show internal mammary sentinel lymph node location (arrows). Unfused CT axial comparison view is at far right.

View larger version (108K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —77-year-old man with melanoma arising in large congenital nevus on lower back who presented for 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi] intradermally) sentinel lymph node mapping before wide local excision and sentinel lymph node biopsy. Anterior and posterior planar lymphoscintigraphy image of the torso shows drainage from radiopharmaceutical injection site to right axillary (arrowheads), right groin (thick arrow), and right paraspinal (thin arrows) nodal basins.

View larger version (74K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —77-year-old man with melanoma arising in large congenital nevus on lower back who presented for 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi] intradermally) sentinel lymph node mapping before wide local excision and sentinel lymph node biopsy. Axial SPECT/CT pinpoints location of right paraspinal–retroperitoneal sentinel lymph nodes on fused SPECT/CT (B) (straight arrow, B) and unfused CT (C) (arrow, C) images with respect to skin injection site (curved arrow, B), providing vital preoperative anatomic localization information.

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13C —77-year-old man with melanoma arising in large congenital nevus on lower back who presented for 99mTc filtered sulfur colloid (5.55 MBq [0.150 mCi] intradermally) sentinel lymph node mapping before wide local excision and sentinel lymph node biopsy. Axial SPECT/CT pinpoints location of right paraspinal–retroperitoneal sentinel lymph nodes on fused SPECT/CT (B) (straight arrow, B) and unfused CT (C) (arrow, C) images with respect to skin injection site (curved arrow, B), providing vital preoperative anatomic localization information.

Neuroendocrine Tumors

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

 
SPECT/CT can provide enhanced localization and staging of neuroendocrine neoplasms with ¹¹¹In octreotide and ¹²³I MIBG, especially for lesions within the peritoneal cavity, mesentery, and pancreas (Figs. 14A, 14B, 15A, 15B, 16A, 16B, 16C, 17A, 17B). Differentiation from physiologic activity in the bowel can be readily distinguished from foci just outside the bowel. For such neuroendocrine neoplasms, studies have reported that SPECT/CT is more accurate than SPECT or CT alone and changes or guides management in patients with neuroendocrine tumors, particularly when other imaging studies are equivocal [11–17].

View larger version (184K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —42-year-old man with partially calcified pancreatic neck mass. CT image shows partially calcified 3-cm exophytic hypervascular pancreatic neck mass (arrow).

View larger version (51K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —42-year-old man with partially calcified pancreatic neck mass. Obtained at 24 hours, 111In pentetreotide (222 MBq [6.0 mCi] IV) SPECT/CT confirms that lesion on CT is somatostatin-receptor positive, consistent with suspected neuroendocrine origin, by showing intense focal uptake within lesion (arrows). Patient underwent exploratory laparotomy with essential pancreatectomy, Roux-en-Y pancreaticojejunostomy, cholecystectomy, and common bile duct exploration. Pathology confirmed islet cell tumor.

View larger version (161K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —69-year-old woman with new cecal carcinoid found incidentally at routine surveillance colonoscopy. CT coronal image from 111In pentetreotide scintigraphy (222 MBq [6.0 mCi] IV) at 6 hours after injection shows hypervascular cecal mass (arrow).

View larger version (28K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —69-year-old woman with new cecal carcinoid found incidentally at routine surveillance colonoscopy. Multiplanar SPECT /CT and maximum-intensity-projection (far right) images show intense 111In pentetreotide uptake precisely at site of cecal mass (arrows), confirming probable carcinoid. Patient underwent laparoscopy-assisted right hemicolectomy. Pathology confirmed carcinoid tumor.

View larger version (154K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16A —65-year-old man who presented with abdominal bloating and gas pains. Abdominal CT reveals 2.2-cm partially calcified irregular mass (arrow) in right lower quadrant mesentery, with principal CT differential diagnosis of sclerosing mesenteritis versus carcinoid. No other abnormal intraabdominal findings are seen on CT.

View larger version (30K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16B —65-year-old man who presented with abdominal bloating and gas pains. Multiplanar 111In pentetreotide scintigraphy (222 MBq [6.0 mCi] IV) SPECT/CT at 6 hours after injection (B) reveals unsuspected focal uptake in pancreas (arrows, B), which was present in retrospect but overlooked on arterial phase of biphasic CT (arrow, C). Tracer uptake in the mesenteric mass was unimpressive. At mesenteric mass resection, an invasive 2-cm ileal carcinoid was removed, with tiny mesenteric implants in vicinity. Pancreatic deposit was not removed but has remained stable on serial follow-up CT since patient began octreotide acetate treatment.

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 16C —65-year-old man who presented with abdominal bloating and gas pains. Multiplanar 111In pentetreotide scintigraphy (222 MBq [6.0 mCi] IV) SPECT/CT at 6 hours after injection (B) reveals unsuspected focal uptake in pancreas (arrows, B), which was present in retrospect but overlooked on arterial phase of biphasic CT (arrow, C). Tracer uptake in the mesenteric mass was unimpressive. At mesenteric mass resection, an invasive 2-cm ileal carcinoid was removed, with tiny mesenteric implants in vicinity. Pancreatic deposit was not removed but has remained stable on serial follow-up CT since patient began octreotide acetate treatment.

View larger version (159K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17A —49-year-old woman with history of left adrenalectomy 4 years earlier who presented with symptoms and laboratory findings consistent with recurrent pheochromocytoma. Gadolinium-enhanced T1-weighted adrenal MR image shows nodular, mildly enhancing soft-tissue mass in left adrenalectomy bed (arrow).

View larger version (40K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 17B —49-year-old woman with history of left adrenalectomy 4 years earlier who presented with symptoms and laboratory findings consistent with recurrent pheochromocytoma. Multiplanar 131I MIBG (18.5 MBq [0.500 mCi]) IV, unfused (top row, black arrows) and fused (bottom row, white arrows), SPECT/CT images of abdomen at 48 hours after injection confirm presence and location of recurrent pheochromocytoma. This recurrence was then successfully surgically resected.

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

View larger version (71K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18A —70-year-old man with newly diagnosed Gleason 8 prostate cancer; prostate-specific antigen (PSA) 7.1 ng/mL. At 2.5 hours after injection, 99mTc MDP (740 MBq [20 mCi] IV) planar bone scintigram shows indeterminate focus of uptake (arrow) in right mid lumbar spine. Metastasis cannot be excluded.

View larger version (74K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 18B —70-year-old man with newly diagnosed Gleason 8 prostate cancer; prostate-specific antigen (PSA) 7.1 ng/mL. Multiplanar unfused (top row) and fused (bottom row) SPECT/CT images show degenerative disk-related osteophyte at L3–L4 (arrows), which explains uptake on bone scan. No radiographs or additional imaging was required, and the patient proceeded directly to robotic retropubic prostatectomy.

View larger version (147K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19A —56-year-old previously healthy man with 5-month history of left upper back pain who was referred by physical medicine to assess for suspected costovertebral arthritis. At 2.5 hours after injection, 99mTc MDP (740 MBq [20 mCi] IV) planar bone scintigraphy image of posterior ribs shows very mild focal uptake involving left seventh through tenth posterior ribs, most notably in posteromedial ninth rib (arrow).

View larger version (124K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19B —56-year-old previously healthy man with 5-month history of left upper back pain who was referred by physical medicine to assess for suspected costovertebral arthritis. Coronal SPECT/CT images show left paraspinal soft-tissue mass (arrow, B) adjacent to medial margin of ninth rib tracer uptake (arrow, C).

View larger version (129K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19C —56-year-old previously healthy man with 5-month history of left upper back pain who was referred by physical medicine to assess for suspected costovertebral arthritis. Coronal SPECT/CT images show left paraspinal soft-tissue mass (arrow, B) adjacent to medial margin of ninth rib tracer uptake (arrow, C).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 19D —56-year-old previously healthy man with 5-month history of left upper back pain who was referred by physical medicine to assess for suspected costovertebral arthritis. Axial unfused CT image shows lytic mass invading left ninth rib and vertebra (arrows). Biopsy revealed plasmacytoma. In this case, SPECT/CT was pivotal in identifying source of patient's pain and provided localization information for CT-guided biopsy. Note unsharp CT image component in this case, which is result of single-detector, step-and-shoot capability of SPECT/CT unit used in acquiring these images. Newer-generation scanners provide MDCT capability, with correspondingly improved CT image resolution.

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

Acknowledgments
 
We thank Chris Tollefson and Steven Schild for their assistance in gathering images used in this pictorial essay.

References

Top Abstract Introduction Image Acquisition Hyperparathyroidism Prostate Cancer Sentinel Lymphoscintigraphy Neuroendocrine Tumors Bone Scintigraphy Conclusion References

 

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