Liver scintigraphy

Introduction
Nuclear medicine: played an important role in liver imaging for decades

Today: CT and u/s almost replaced radionuclide imaging

Indications
RADIOPHARM Tc-99m sulfur colloid Tc-99m RBCs Tc-99m MAA MECH OF UPTAKE Kupffer cell uptake RBC labelling/ bloodpool distribution Blood flow, capillary blokage INDICATION Follicular nodular hyperplasia Carvenous hemangioma Hepatic arterial perfusion

Xenon-133
Gallium-67 citrate F-18 FDG

Lipid soluble
Lactoferrin transport and iron binding Glucose metabolism

Focal fatty tumor uptake

Tumor/ abscess imaging Tumor imaging

Tc-99m sulfur colloid

Capitalizes on phagocytic function of liver Uptake reflects distribution of both functioning reticulo-endothelial cells and hepatic perfusion. Rapid uptake by phagocytes of the reticuloendothelial system = simultaneous imaging of liver and spleen

 Tc-colloid agents: half time in blood stream= 2-3min 80-90% sequestered by the liver 5-10% localised in the spleen Small amounts may appear in bone marrow but insufficient for marrow imaging

procedure
Imaging time: 20 min Method of admin; IV bolus Activity; 4-6 mCi (148-222 MBq0 Patient prep; non Patient positioning; supine Collimator; LEAP, parallel-hole

 Counts; 1000k counts- ant. supine, 500k counts all other views Routine views; ant. supine, ant. supine with lead marker, ant. erect (if possible),right ant. oblique, rt lat., rt post. oblique, post, lt lat. Photopeak selection; 140kev (20% window) Effectivedose;0.034rads/mCi (0.009mGy/MBq) Target organ; spleen -0.27rads/mCi (0.07)

SPECT
Collimator; LEHR Counts & time; 60-64 stops for 30s each Routine views; 360 degree arc of rotation Patient position; supine with both arms overhead

Conflicting exams & medications

Recent upper gastrointestinal series or barium enema with retained barium Increased bone marrow uptake: nitrosoureas or if the colloid size is too small Increased spleen uptake: nitrosoureas, recent halothane or methylcel- lulose. Lung uptake: aluminum antacids, iron preparations, virilizing androgens, Mg2preparations, niacin, colloid size too large, Al3 in preparation, and particle clumping.

Important to note that

Adequate accumulation of colloid in liver requires 5-10min in normal pts; allowing for optimal liver/spleen to background ratio Patients with compromised hepatic function or portal HPT may require longer inj to imaging time. Anterior view with lead marker identify right inferior costal margin helps and with liver measurement.

 SPECT of the liver occasionally add additional information, although focal areas of decreased activity due to normal biliary and vascular structures often make interpretation difficult. Defects thought of as pathology should at least be seen in 2 planes before describing.

Evaluation of liver scan

Should include;
Size, shape & position of liver Homogeneity of activity within the liver Relative distribution of colloid between liver, spleen and bone marrow.

Interpretation of Tc-99m sulfur colloid scan requires appreciation of normal variability of liver anatomy, effect of extrinsic liver compression by normal & abnormal structures, and common artifacts.

Norman scan
Length on anterior view of right lobe generally 17-18cm from highest point to the inferior tip of right lobe Liver is pliable to changes in shape from deep inspiration to expiration as well as from upright to supine Homogeneous distribution of colloid throughout organ

 Various liver shape variants may be seen with the most common being long, thin right lobe (Riedel,s lobe) and prominent quadrate lobe. Porta-hepatis: frequently seen as an area of decreased activity in the inferiomedial aspect of right lobe. This should not be mistaken for a lession

 Peripheral marginal indentations in liver may normally be produced by the lateral rib margins, xiphoid, gall bladder, right kidney, suprahepatic veins, heart and intrathoracic abnormalities that affect the diaphragmatic configuration. Breast-shadow artifact is often seen in women. Eliminate artifact by moving right breast away from liver in anterior and right anterior oblique views.

Tc-99m RBCs
Primarily indicated for hepatic blood pool imaging. Used in diagnosis of Cavernous Hemangioma After injection, the Tc-99m-labeled RBCs are distributed within the blood pool of the liver. Need for time to exchange and equilibrate within the large, relatively stagnant, nonlabeled bloodpool of the hemangioma (30120 minutes).

Procedure
3 phase planar + SPECT Iv bolus of 25mCi Tc-99m RBCs Large field of view gamma camera with SPECT Energy peak 140kev (15% window) Collimator; LEHR, parallel-hole

 Planar Imaging
Blood flow:1-sec frames for 60 sec on computer and 2-sec film images. Immediate images: acquire 750k1000k count planar image in same projection and other views as necessary to best visualize lesion(s). Delayed images: acquire 750k1000k count planar static images 12 hr after injection in multiple projections (anterior, posterior, lateral, and oblique views).

SPECT; similar procedure to Tc colloid

 Image interpretation usually done with CT/ US for direct anatomical correlation to ensure proper identification of abnormality in question. Organs with highest counts usually heart, spleen followed by kidney. Normal liver has much less bloodpool activity. Much of this normal vascular anatomy of the liver is seen with Tc-99m labeled RBCs. The aorta, inferior vena cava, and occasionally the portal vein can be seen with planar imaging whilst portal branching vessels and hepatic veins can be seen on SPECT

Tc-99m MAA
For hepatic arterial perfusion studies. Performed after initial catheter placement and before subsequent courses of chemotherapy Reliably estimates the adequacy of blood flow to intra-hepatic tumor and determines the presence or absence of extra-hepatic perfusion, a frequent cause of gastrointestinal and systemic toxicity. also used to quantify lung shunting (prior to using therapeutic Y-90 radiolabeled microspheres) to ensure minimal radiation to the lungs.

 Liver tumor cells derive most of blood supply from hepatic artery Vs normal liver cells supplied by portal circulation. Tumor/non-tumor uptake ratio of 3:1 particle size range b/n 10 to 90 m. Given intra-arterially via a hepatic artery catheter, the MAA particles will localize within the liver in a distribution similar to that of the chemotherapeutic agent or therapeutic radiolabeled microspheres being introduced through the catheter.

 Administered dose; 14 mCi (37148 MBq) for planar imaging and 56 mCi (185222 MBq) for SPECT Hepatic uptake is typically inhomogeneous. Tumor nodules have increased uptake compared with surrounding normal liver. Multiple planar views (right lateral, anterior, posterior, left lateral) or SPECT can determine the perfusion distribution.

 Arteriovenous shunting is noted as lung uptake Tc-99m-MAA particles shunted through the tumor bypass the liver capillary bed and are trapped in the lung. Lung shunting gives an estimate of the percentage of drug not delivered to the tumor that may result in systemic exposure and toxicity