Colloid Scan Research Articles

Focal hepatic hot spot sign: Clinical image

A 51‐year‐old women was hospitalized to start chemotherapy for small cell lung cancer diagnosed one months earlier. She underwent Computed Tomography (CT) of the chest and abdomen to re‐evaluate the progression of the lung tumour. Contrast-enhanced CT of the chest indicated an invasive anterior left lung tumour that caused an obstruction of the Superior Vena Cava (SVC) (Figure 1). Contrast-enhanced CT of the abdomen revealed an intense focal wedge-shaped homogeneous enhancement area in the quadrate lobe of the liver, which is known as the hot spot sign (Figure 2). Focal hepatic hot spot sign was first described by Ishikawa in 1983. The sign can be observed on technetium 99m (99mTc) Sulphur colloid scans or on contrast, material enhanced CT scans [1]. Hot spot sign is caused by portosystemic venous shunting between the superior vena cava and the left portal vein via the internal mammary and paraumbilical veins along the ligamentum teres, secondary to superior vena cava obstruction. The hot spot is created by areas of focally increased blood flow that result from this shunting [2]. Stanford and colleagues classified SVC syndrome into four types - type I and type II referred as supra-azygous partial and near complete obstruction of SVC with antegrade flow in azygous vein. Type III is defined as complete obstruction of SVC with reversal of azygous blood flow and type IV as complete obstruction of SVC and azygous system with development of chest wall collaterals [3]. This sign has been reported in Budd-Chiari syndrome, the causes of SVC syndrome (neoplasms of the thorax as lung carcinoma and lymphoma, Vasculo‐Behcet’s disease, fibrosing mediastinitis, and luetic aneurysm), and masses of the liver (abscess, haemangioma, focal nodular hyperplasia, and hepatocellular carcinoma) [4].

Colloid gastric emptying with SPECT-CT after oesophagectomy.

Scintigraphic analysis of gastric motility uses the rate of gastric emptying by measuring radioactivity remaining in the stomach at pre-defined points in time. It helps to assess unresolved symptoms of functional gastrointestinal disorders such as gastroparesis. Delayed gastric emptying can occur in post-oesophagectomy patients. Squamous cell carcinoma of the esophagus is a common indication for oesophagectomy. In such patients presenting with post-prandial symptoms of bloating, nausea or vomiting, colloid scintigraphy can play a vital role in evaluation of their symptoms. We present an interesting image of a post-oesophagectomy patient with persistent gastric dilatation suspected of delayed gastric emptying.

509 Splenosis, an Important Differential for Peritoneal Metastases

Abstract Splenosis is defined as the auto-transplantation of splenic tissues in other sites of the body. It is a rare benign condition and can be an incidental finding. However, early diagnosis is essential as the differential diagnosis of splenosis includes peritoneal metastases. Early identification relies on recognising relevant past medical history including splenic injury and or splenectomy. Splenosis can be confirmed through the usage of a technetium-99m colloid scan. By using nuclear medicine scans, repeated invasive investigations such as biopsy and diagnostic laparoscopies can be avoided. We present here a case of a 51-year-old woman who was extensively investigated by the gynaecology department and general surgery department, even undergoing a diagnostic laparoscopy following repeated presentations to primary and secondary care with chronic abdominal and pelvic pain. She had a splenectomy 28 years earlier for traumatic splenic injury. CT scan of abdomen and pelvis showed features suspicious of multiple peritoneal metastases and hence she was urgently referred to a colorectal cancer multidisciplinary meeting. A subsequent technetium-99m colloid scan confirmed multiple splenic nodules in the peritoneal cavity. The patient was reassured and discharged. In conclusion, in a patient with a known history of splenic trauma, splenosis is an important differential diagnosis. A careful past medical history and appropriate investigations will avoid unnecessary referral and invasive investigations.

Recognizing the Role of the Reticuloendothelial System in the Late Phase of US Contrast Agents.

Recognizing the Role of the Reticuloendothelial System in the Late Phase of US Contrast Agents.

A Diagnostic Dilemma of Hepatocellular Carcinoma on a Background of Thalassemia

Purpose: Thalassemia (HbH) is a chronic condition that may have potential complications of liver cirrhosis secondary to iron overload or hepatitis. Iron deposition in the liver can mask the classic imaging findings of hepatocellular carcinoma. We report an interesting case with similar nature with diagnostic dilemma, where multiple imaging modalities were unable to delineate the nature of the liver nature, and the patient was eventually diagnosed with hepatocellular carcinoma, after percutaneous biopsy was performed. Method: A 61-year-old male, with background history of HbH disease and transfusion dependent, presented with an incidental finding of 2 liver nodules on an ultrasound scan after complaints of right hypochondrium pain. A computed tomography (CT) scan diagnosed one nodule as a flash-filling haemangioma but was inconclusive about the other larger nodule. A magnetic resonance imaging (MRI) scan was also inconclusive but gave the differentials of extramedullary haematopoiesis. A sulphur colloid scan did not show uptake, making extramedullary haematopoiesis less likely. Results: A percutaneous biopsy of the indeterminate liver nodule was performed, and the histology showed hepatocellular carcinoma. The patient underwent wedge resection of the hepatocellular carcinoma and recovered well post-operatively. Conclusion: In the event of inconclusive imaging in patients with significant risk factors for hepatocellular carcinoma, a percutaneous biopsy should be performed for definitive diagnosis.

Radionuclide Liver-Spleen Scan to Detect Splenosis

Splenosis is defined as heterotopic auto-transplantation of splenic tissue at ectopic location following splenic injury or surgery. It can be seen in any location in the abdomen and thorax as well as rare sites such as the brain and subcutaneous tissue and derives its blood supply from adjoining structures. Accessory spleen is a congenital condition and draws its blood supply from accessory splenic artery. It is located in gastrosplenic or lienorenal ligament. They are fewer in number and without preceding trauma. Colloid liver-spleen scan objectively localizes splenosis. Presented here is a case of hemolytic anemia who underwent splenectomy in 2007 for hereditary spherocytosis. Patient had vague abdominal pain 12 years post-surgery. Sonography and CT scan showed soft tissue lesions in abdomen. Colloid liver-spleen scan showed evidence of reticuloendothelial cells confirming the diagnosis of splenosis.

Renal Pseudo-tumor Related to Renal Splenosis: Imaging Features

To report the case of a 29-year-old patient presenting with renal splenosis along with a complete review of literature on this condition. Splenosis is a frequent condition following abdominal trauma or splenectomy, described as splenic tissue that autotransplants into a heterotopic location. However, renal splenosis is rare and often mistaken with renal carcinoma. The patient was initially referred to our department for a renal mass incidentally discovered on ultrasound. Further investigation included with computed tomography and magnetic resonance imaging. Imaging features revealed a well circumscribed solid renal mass, exhibiting an isosignal on T1- and T2-weighted sequences in comparison with the renal cortex. The mass exhibited a heterogeneous enhancement on the arterial and portal phases, homogeneous patterns during the delayed phases, and high signal intensity on diffusion-weighted images. A partial nephrectomy was performed and pathological examination revealed the final diagnosis of renal splenosis. Imaging features alone do not provide a definitive diagnosis of splenosis but suggestive past history associated with imaging findings consistent with splenic tissue should lead to 99m technetium-sulfur colloid scanning or ferumoxid-enhanced MRI to avoid useless surgery.

Assessment of Spleen Filtrate Function in Renal Transplant Recipients Using Technetium-99m Stannous Colloid Liver-Spleen Scan

BackgroundFunctional hyposplenism (FH) is indicated by an anatomically present spleen that fails to take up radiolabeled colloid. The occurrence of FH has been reported in a small group of renal transplant recipients based on hematologic parameters. The aim of this study was to replicate this association in a larger group of renal transplant recipients with the use of technetium-99m–stannous colloid liver-spleen scan to assess the spleen function. MethodsThis survey based on single samples enrolled 101 unselected adult patients with functional kidney grafts >180 days after transplantation. All patients underwent 99mTc-stannous colloid scan to assess spleen function as well as bone marrow uptake of radiocolloid along with an anatomic and blood flow study of the spleen and kidney with the use of Doppler sonography. ResultsThe prevalence of hyposplenism was 32.7% (33/101) for the cohort, and increased uptake of radiocolloid by the bone marrow was seen in 9.9% (10/101). According to the multivariate analysis, the frequency of hyposplenism was significantly influenced by indirect bilirubin and hemoglobin, and direct bilirubin and neutrophil count remained as independent predictors of bone marrow uptake. ConclusionsThis study demonstrated that a group of renal transplant recipients has FH. In addition, bone marrow uptake might be interpreted as liver dysfunction. In this situation, the small amount of contrast (spleen compared with liver) would leave hyposplenism undiagnosed. Further prospective and longitudinal clinical studies are needed to determine the clinical impact of this condition on the management of renal transplant recipients.

Differentiating Osteomylelitis from Charcot Joint by Using Sulphur Colloid and Besilosomab (Scintimun®) Scan at Sarawak General Hospital

Introduction: Differentiating osteomyelitis (OM) from charcot joint is a vital necessity. Despite having almost similar presentation, both OM and charcot joint are managed vastly different. This study proposes the use of combined Sulphur Colloid and Besilosomab (Scintumun) scan to differentiate OM from Charcot Joint based on the understanding of their dissimilar pathophysiology. Method: Image acquisitions of two patients using the 99mTc-Scintimun and 99mTc-Sulphur colloid were obtained accordingly at the affected sites. Result: Both patients produced similar images on the combined Sulphur Colloid and Scintimun scans. There were increased activity on both Sulphur Colloid and Scintimun scans which suggested the exclusion of OM in both cases. Both patients were treated conservatively by the primary team. Conclusion: The combined study of Scintimun and Sulphur Colloid imaging is a useful tool in assisting the primary team to exclude OM although a wider data sample is needed to further support this study.

Pelvic splenosis presented as pelvis mass and gross hematuria

Pevlic splenosis is a very rare condition, particularly when the condition is diagnosed during a hematuria workup. Hematuria can be caused by genitourinary system infection, urolithiasis, neoplasm, or trauma. Hematuria can be seen in patients with symptoms or without symptoms. The standard work-up for hematuria includes a computed tomography (CT) scan which can sometimes have incident findings that can make diagnosis difficult. We report a rare case of a 44-year-old patient with painless gross hematuria and the CT scan revealed a pelvic mass that was eventually confirmed to be a pelvic splenosis by a nuclear liver–spleen sulfur colloid scan.

Non-cirrhotic portal fibrosis at a tertiary care centre in South India.

Non-cirrhotic portal fibrosis (NCPF) is one of the important causes of upper gastrointestinal haemorrhage in patients in tropical countries. The aim of this study was to describe the clinical and laboratory profile of 68 patients with NCPF. NCPF is defined as liver disease with: (1) evidence of portal hypertension; (2) a liver biopsy showing no cirrhosis or a Tc-labelled sulphur colloid scan showing a pattern suggestive of NCPF; and (3) a patent splenoportal axis. The clinical, laboratory and demographic features of 68 patients with such criteria were studied and analysed. NCPF was common in women (73.5%) in the fourth decade of life. The median duration of illness was 24 months (range, 1 month-28 years). Patients presented to hospital with the sensation of a mass in the abdomen (50%) or with haematemesis (26.5%). They had splenomegaly (95.6%) and thrombocytopenia (88.2%). The majority of patients had normal liver function tests. Abdominal ultrasonography showed increased periportal and peri gallbladder echoes (72%), spontaneous collaterals (41.2%) and ascites (19.1%). Liver biopsy revealed portal venous sclerosis (76.3%) and periportal fibrosis (55.3%). Tc-labelled sulphur colloid scan was suggestive of NCPF in the remaining 30 cases. NCPF is common in South India. Transient ascites occurs due to decompensation of liver function after variceal bleeding and in long standing cases of NCPF. Our study used Tc-sulphur scan for diagnosing NCPF in patients where liver biopsy was contraindicated in view of severe thrombocytopenia; however, the diagnostic utility of Tc-sulphur nuclear scan to diagnose NCPF in patients with severe hypersplenism needs to be further evaluated in future studies.

Displacement of the Spleen Mimicking Renal Cell Cancer Recurrence Post-Nephrectomy: A Case Report.

Local regional recurrence of renal cell cancer post-nephrectomy most often occurs within three years after surgery. Post-nephrectomy, many processes may mimic RCC recurrence. We present the case of a 75 year-old Caucasian male patient with a mass in his renal fossa post-nephrectomy for renal cell cancer, suggesting local recurrence. Use of the technetium-99m sulfur colloid scan showed that the mass was his spleen which had been displaced into the renal fossa. With high index of suspicion, characterization of these processes as splenic in origin would prevent subjecting patients to risks of biopsy or even surgery.

Focal Fat Sparing of the Liver

Fat spared area of liver can appear as focal areas of elevated FDG uptake on a PET scan. This may mimic metastases. PET scan performed for metastatic workup in a 35-year-old female patient, a case of exocrine tumor of the pancreas, showed focal areas of increased FDG uptake. Contrast-enhanced CT performed as a part of the PET/CT study showed enlarged fatty liver with focal hyperdense areas suggesting fat sparing. Sulfur colloid scan showed physiological colloid uptake in the suspicious areas indicating preserved Kupffer cell function. The patient is on close follow-up without any evidence of metastatic disease.

Noncirrhotic intrahepatic portal hypertension.

Noncirrhotic intrahepatic portal hypertension.

A case series study of therapeutic implications of Type IIIb4: A rare variant of esophageal atresia and distal tracheoesophageal fistula

BackgroundA wide spectrum of variations can occur in type IIIb esophageal atresia and distal tracheoesophageal fistula [EA-TEF] (Kluth D. Atlas of esophageal atresia. J Pediatr Surg 1976; 11 (6):901–19). The aim of this study was to evaluate the variant anatomy of subtype IIIb4 EA-TEF and its therapeutic implications. MethodsWe performed a retrospective review of 4 patients of this variant subtype within a series of 259 esophageal atresias, managed over a study period of three years, at our institution. The diagnosis was made at thoracotomy. The overlapping upper and lower esophageal pouches, initially, gave a false impression of esophageal continuity. The long TEF coursed parallel in proximity to the upper pouch (UP) and the trachea needing meticulous dissection. The TEF measured 8–10mm in diameter and was ligated and divided high on the trachea near the thoracic inlet. The patients were followed up by a contrast swallow, radioactive technetium-99m- sulfur colloid scan, echocardiography and bronchoscopy (if indicated). ResultsThe mean birth weight and gestational age was 2250g and 38weeks respectively. The mean follow up was eighteen months (range 5–42months). An associated anorectal malformation was present in two patients while none had associated congenital heart disease. The Waterston grading was A and B in one patient each and C in two patients. All the patients had muscular UP extending up-to the level of arch of azygous vein (T 3–4). The lower esophageal pouch (LP) and the fistula extended high, near the thoracic inlet. Tracheal injury occurred in one patient, with thin LP, warranting postoperative elective ventilation. A postoperative barium swallow did not reveal anastomotic leak or stricture in any patient. Follow-up barium swallow showed long LP extending high up in the chest, up to clavicles in all four patients and redundancy of UP in case 1. Severe gastroesophageal reflux was present in two patients. Bronchoscopy revealed tracheomalacia in case 1. Three patients were thriving well at the last follow-up. One patient died at five months of age due to aspiration pneumonia. ConclusionsThe knowledge of diagnostic and therapeutic implications of the variant subtype IIIb4 EA-TEF should be in the armamentarium of the treating surgeon to reduce pitfalls in its management.

Intracranial Extramedullary Hematopoiesis: A Rare Cause of Headaches

Ectopic bone marrow production, known as extramedullary hematopoiesis, may result in symptoms due to compression on normal structures. We present the multimodality imaging findings and subsequent management of a rare case of symptomatic extramedullary hematopoiesis within the calvarium. Case report. A 54-year-old male with a history of myelofibrosis and no previous diagnosis of a headache disorder presented to the emergency department with worsening severe bilateral headaches. A nonenhanced CT of the brain was performed and diffuse extra-axial nodular hyperdensities were visualized. MRI of the brain demonstrated diffuse extra-axial avidly enhancing nodular masses, dural thickening and marked susceptibility. No paravertebral masses, typical for extramedullary hematopoiesis, were present in the chest or abdomen. Although the clinical team considered a biopsy to confirm the diagnosis, we suggested a noninvasive confirmatory test. The subsequent Tc99m sulfur colloid scan corroborated the diagnosis. The patient was then referred to radiation oncology for treatment. In summary, extramedullary hematopoiesis is a hematologic compensatory disorder that rarely occurs within the CNS and may cause neurological compromise due to compression on underlying structures. The diagnosis can be made with noninvasive imaging and treated with low dose radiation therapy.

Splenic-Gonadal Fusion in a 6-Year-Old Boy, Confirmed by Tc-99m Sulfur Colloid Scanning

Splenic-gonadal fusion is a rare congenital anomaly, in which splenic tissue is connected to the gonad. It is almost always on the left side, is difficult to be recognized, and unfortunately the final diagnosis is confirmed after an unnecessary orchiectomy in one-third of the cases. We report a case of splenic-gonadal fusion in a 6-year-old boy, referred for a palpable mass at the left testicle. Ultrasound and MRI were performed; and the final diagnosis was confirmed by Tc-99m colloid scanning. The child was operated, orchiectomy was avoided, the mass was removed, and pathology confirmed normal splenic tissue.

Diagnosis of Acute Osteomyelitis in Previously Irradiated Bone

Abstract: We are reporting a case of acute osteomyelitis in previously irradiated bone. In nonirradiated bone the diagnosis of acute osteomyelitis is established by the mismatch between focal indium-111 whole body scintigraphy (WBC) bone uptake and bone marrow replacement as seen on the Tc-99m sulfur colloid scans in areas of acute osteomyelitis. In previously irradiated bone, the bone marrow is absent due to radiation effects. Accordingly, the combination of indium-111 WBC and Tc-99m sulfur colloid mismatch cannot be implemented. In this case, we found that in spite of previous irradiation of the bone there is uptake in the bone matrix due to cortical and osteoblastic activity as seen on the Tc-99m MDP bone scan. For this reason we are recommending that for the diagnosis of acute osteomyelitis in previously irradiated bone, dual isotope imaging using indium-111 WBCs and Tc-99m MDP is more accurate than indium-111 WBCs and Tc-99m sulfur colloid.

Esplenosis simulando una masa renal izquierda

To report a case of splenosis and to review its diagnosis and treatment in the related literature. We report the case of an asymptomatic 49-year-old man with splenectomy performed when he was 22. Lumbo-sacral MRI showed a left perirenal mass probably with renal origin. CT scan ruled out the renal origin. Due to previous splenectomy, splenosis was suspected. 99mTc-labeled heat-damaged erythrocytes scan confirmed the diagnosis. No treatment was applied. Clinicians should be aware that unknown origin masses, mainly in the peritoneal cavity, with a history of previous splenic trauma or splenectomy, might represent splenosis. A non-invasive diagnosis can be achieved with 99mTc-sulphur colloid scan, 99mTc-labeled heat-damaged erythrocytes or ferrumoxide-enhanced MRI, thus avoiding unnecessary surgical explorations.

Hepatic Splenosis Mimicking Hepatocellular Carcinoma

Purpose: Splenosis is heterotropic implantation of splenic tissue after splenectomy or traumatic rupture of spleen. We report patient with alcoholic liver disease, who was found to have enhancing hepatic lesion during surveillance for HCC but was diagnosed as splenosis based on characteristic imaging, nuclear scintigraphic findings and associated multiple splenules. A 39-year-old man with alcoholic cirrhosis on routine surveillance for HCC was found to have small hypoechoic lesion on ultrasound, follow up MRI revealed a mass in right lobe of liver measuring 4.5 × 5.3 cm with enhancement in early phase and an isodense lesion on late phase (white arrow in Fig. 1). These findings suggested a diagnosis of hepatocellular carcinoma. There were also multiple enhancing lesions in mesentery and splenic bud suggestive of splenules (black arrow in Fig. 1). A Tc-99m sulfur colloid scan showed uptake in the area of hepatic mass and splenules (marked with black and white arrow respectively in Fig. 2). Patient had splenectomy in past after abdominal trauma. Laboratory data revealed Alpha-fetoprotein 3.5, AST 58, and ALT 45. Six months later repeat imaging showed no increase in size of mass. In our case, the presence of concurrent mesenteric splenosis, normal alpha-fetoprotein, no growth on subsequent imaging and radio isotope uptake in liver and splenic bed on Tc-99m scan established the correct diagnosis of splenosis and averted the need for biopsy. Majority of the time splenosis is an incidental finding at surgery or autopsy, and at times discovered during computed tomography (CT) or magnetic resonance imaging (MRI). Splenosis being highly vascular mimics other vascular hepatic neoplasia and presents a dilemma in diagnosis of Hepatocellular carcinoma (HCC).[figure1][figure2]FigureFigure