Gastrointestinal System

Nuclear medicine part 2

Liver Blood Flow and

Blood Pool Imaging
Principle:
◆ The liver scan may be profitably extended in
certain situations by studying the initial blood
flow of the radionuclide to it or by a subsequent
scan with a blood-pool marker.
◆ The combination of reticuloendothelial(colliod
liver scan) and blood-flow scanning is helpful
in some cases in differentiating a malignant
tumor from an abscess or a cyst .
◆ The reason for this is that the malignant
tumors are often vascular at least in part but
abscess or a cyst are avascular.And depend
on the reason that malignant tumors contain
a lot of arterial tube and hemangiomas
contain a vast venous blood,we can use liver
Blood Flow and Blood Pool Imaging to
differentiating them.
Indications:
◆ 1.To differentiate the space-occupying
lesion on the colloid liver scan ;
◆ 2.Diagnosing the hemangiomas;
◆ 3.To detect the blood supplying and it's
capacity of malignant tumors in order to
provide a better chemical treatment
scheme and to predict the relapse of the
malignant tumor.
Radiopharmaceuticals and Dosage:

◆ 99m
Tc labeled red blood cell(99m Tc-RBC)
◆ The labeling methods include two kind technic
; in vitro and in vivo.The in vitro method is
rarely used today for it's complicated
procedure and the latter is often used in clinics
now.
◆ The in vivo method involes the injection of
approximately 1mg stannous ion (usually in the
form of stannous pyrophosphate,PYP)
◆ Intravenously to prime the red blood
cells,follows at about 30min by 15-20mCi
99m
Tc-pertechnetate to label the erythrocytes.
◆ The modified in vivo approach provides a
higher labeling efficiency than the in vitro
method without the usual requirement for
centrifugation of the cells .
Imaging Acquisition:

◆ There is no patient preparation for

data acquisition.The patient is placed
supine on the γ camera or SPECT and
take the anterior images of the liver at
a frame/s speed for 32-64s after the
injection of 99mTc-pertechnetate for the
liver blood flow images.
◆ The equilibrium imaging is taken after
20min and this indicates the liver blood
pool.We can get the planar or tomogram
of the liver blood pool images using
γcamera or SPECT.The delayed imaging
always can be taken during 2hrs.
Analysis:
◆ Liver hemangiomas are the most common benign
tumour of the liver .The cavernous hemangioma is
a benign tumor of the liver with an
uncomplicated course,that is ,it does not usually
cause the patient any problems .They can
appear as either single or multiple lesions .They are
often discovered on Ultrasound or CT,but these
tests are unable to confirm whether they are a
hemangioma or a malignant tumor .
◆ When the nuclear medicine 99mTc labeled
RBC study is performed well it can be almost
100% accurate in confirming the diagnosis.
MRI is a very good imaging modality for
hemangioma but is far more expensive and not
reliably available . It is essential to give an
accurate diagnosis for hemangioma because if
the patient is sent for a biopsy there is a great
risk of haemorrhage.
◆ A 99m
Tc labeled RBC study using planar imaging
can reliably detect lesion as small as 2-3cm,
SPECT imaging can detect lesions as small
as 1-2cm. SPECT therefore is the ideal
imaging procedure for locating hemangiomas.
◆ The blood supply to a malignant tumour and
the hemangioma are different .These means
that the blood flow and blood pools are
important when comparing them to the
dynamic and delayed images.This difference in
blood supply also means that adequate time
must be allowed to differentiate the
hemangioma from the malignant tumour .
◆ Malignant lesions get their blood
supply primarily from the hepatic
artery . This means that the blood flow to
these lesions is seen earlier than normal
hepatic tissue. For example : on the
dynamic imaging there will appear an
area of increased uptake before the liver
is seen .
◆ Hemangiomas are benign tumours,will show no
difference on the flow but may show increased
activity on the blood pool images but this is not
always the case .
◆ On the delayed images:malignant lesion such as
hepatomas will have decreased uptake in the lesion
at 2hrs. The characteristic uptake of a hemangioma
will show increased uptake in the blood pool and an
increased uptake in the delayed images .
◆ The characteristic uptake of a malignant lesion
will have increased uptake on the flow and
blood pool image but decreased uptake on the
2hr delay. Only hemangiomas can retain the
99m
Tclabelled RBC for the 2hrs. Therefore
adequate time must be allowed to for the
hemangioma to accumulate sufficient quantities
◆ of Tc labeled Red Blood Cells.
99m
Cavernous Hemangioma:
◆ Cavernous hemangioma is the most common
benign liver tumor with a 3 to 7% incidence
from autopsy data . They are typically
asymptomatic (only about 10% of patients have
symptoms). Rupture with hemoperitoneum is a
rare, but potentially serious complication. The
lesions are most frequently subcapsular
(peripheral) in the right lobe.
◆ Hemangiomas are typically solitary,but may be
multiple (10-20% of cases). Treatment is not
usually necessary.
◆ On pathologic analysis the internal
architecture of the lesion changes with
growth, and there may be hemorrhage,
myxomatous change, fibrosis, or
calcification. Hemangiomas lack a capsule,
but are well marginated.
◆ Hemangiomas appear as radioactive deficient or
defect(cold spot ) lesions on colloid scans.
99m
◆ Tc-RBC imaging is the most specific test
available for the diagnosis of cavernous
hemangioma. (Sensitivity 90% for lesions larger
than 1.5 to 2cm; Specificity approaches 100%;
Accuracy 90-95%) With SPECT lesions down to
about 1cm in size can be detected.
◆ [SPECT sensitivity by size: 1.5 cm (100%), 1 cm
(65%), 0.5 cm (20%)] False negatives may occur
due to small size of the lesion, lesion adjacent to a
vascular structure ( vein, liver hilum, or
heart),or thrombosed/fibrosed lesion. Lesions
located deep within the liver may not be
detected by planar imaging, but are often
readily demonstrated with SPECT.
◆ The classic findings of hemangioma on 99mTc-
RBC imaging are decreased activity within the
lesions on flow and early blood pool images,
with increased activity on delayed scans at 1 to
2 hours post injection ( Hot spot on delayed
imaging). Hepatomas will show increased
perfusion due to their predominant arterial
blood supply, and decreased uptake on delayed
images.
◆ However, 80% or more of malignant
lesions are hypovascular throughout the
first phase of the exam and remain
poor radioactive uptake on delayed
images.
◆ Hepatomas occasionally have uptake
equal to the liver on delayed images.
Hepatoblastoma:

◆ Hepatoblastoma is the most common

primary malignant tumor in young
children (up to age 5y). About 50% of
cases present before 1 year of age. On
Liver Blood Flow and Blood Pool
Imaging , the lesion is noted to have
hypervascular flow, but will appear as a
cold defect on delayed images.
◆ Very necrotic lesions may appear cold
on both flow and static images. Very
rarely, increased Liver Blood Flow and
Blood Pool Imaging uptake has been
reported.
Abscess or a cyst and other avascular
liver lesion:
◆ Abscess or a cyst and other avascular liver lesion

◆ Always appears cold spots on liver colloid

scans and Liver Blood Flow and Blood Pool
Images (early phase and delayed images) ,
because they lack not only reticuloendothelial
cells but also blood flow and blood pool.
Summarizing:

◆ blood flow and blood pool matching:

◆ 1.blood flow(+);blood pool(+)
Hemangioma;
◆ 2.blood flow(-);blood pool(-) abscess,
fibrosed lesionor a cyst and other
avascular liver lesions.
◆ blood flow and blood pool not
matching:
◆ 1.blood flow(+);blood pool(-) likely
malignant tumor;
◆ 2.blood flow(-);blood pool(+)
Hemangioma.
Colloid and blood pool matching:

◆ 1.colloid(cold spots) blood pool

◆ (no rdioactivity filled) abscess,fibrosed
lesion or a cyst and other avascular liver
lesions;
◆ 2.colloid(cold spots) blood pool (average
rdioactivity filled) likely malignant
tumor;
◆ 3.colloid (cold spots ) blood pool
(rdioactivity over filled ) Hemangioma.
Planar liver colloid imaging 3