I-123 MIBG scintigraphy in adults. A report of clinical experience

Thirty-one adult patients with clinical findings suggestive of pheochromocytoma were studied with I-123 MIBG. All patients had images obtained at 24 and 48 hours. Five patients had abnormal uptake proved to be because of I-123 MIBG avid tumors. The remaining 26 patients had no proven tumors and showed physiologic uptake in various organs. The 24-hour images were of high quality. In all cases, the 48-hour images contributed no significant additional information. Only in 1 patient did the 48-hour image add some certainty. Physiologic uptake was seen in the salivary glands, liver, G.I. tract, and urinary bladder in all patients (100%). Uptake was also observed in the lung and heart (90%), normal adrenal glands (32%), thyroid (29%), spleen (23%) uterus (13%), and neck muscles (6%). The authors' experience indicates that I-123 MIBG gives superior images compared to the previously used I-131 MIBG, that the optimum imaging time for adults is 18-24 hours, and that normal distribution patterns including uterine and neck muscle uptake should be familiar to physicians interpreting the studies.     

Comparison of inferior myocardial defect between planar and SPECT image of 123I-metaiodobenzylguanidine cardiac scintigraphy

Discordant findings of inferior MIBG defect between SPECT and planar images were sometimes observed in the clinical studies. In this study, we compared inferior myocardial findings between planar and SPECT image of 123I-metaiodobenzyl-guanidine (MIBG) cardiac scintigraphy in 29 patients. All patients were estimated as normal in anterior accumulation of MIBG. The patients were divided into 3 groups according to the visual finding of inferior defect in the planar and SPECT image; normal group (normal inferior accumulation of MIBG both in the planar and SPECT image, N = 10), discordance group (inferior MIBG defect was only observed in the SPECT image, but was not observed in the planar image, N = 7), inferior defect group (inferior MIBG defect was observed both in the planar and SPECT image, N = 12). Inferior/anterior count ratio of SPECT and planar image were 0.96 +/- 0.11 vs. 0.97 +/- 0.05 in normal group, 0.59 +/- 0.21 vs. 0.99 +/- 0.13 in discordance group, 0.46 +/- 0.13 vs. 0.82 +/- 0.04 in inferior defect group. Liver/heart count ratio was significantly higher in the discordance group (2.07 +/- 0.49) than that in the normal (1.14 +/- 0.15) and inferior defect group (1.45 +/- 0.39). In phantom study, it has been reported that increased liver accumulation of MIBG causes artifactual inferior defect adjacent to the liver. These data indicate that increased liver/heart count ratio may cause artifactual inferior defect on MIBG SPECT image in the clinical studies. Planar image evaluation may be helpful to distinct the artifactual inferior defect on SPECT image.     

The results of questionnaire on quantitative assessment of 123I-metaiodobenzylguanidine myocardial scintigraphy in heart failure

This study was done by working group under the cooperation between Japanese Society of Nuclear Medicine and Japanese Circulation Society. We evaluated the usefulness of quantitative assessment of 123I-metaiodobenzylguanidine (MIBG) myocardial scintigraphy in heart failure by the results of questionnaire. Forty-nine (72.1%) of 68 selected institutions participated in this study. The incidence of MIBG myocardial scintigraphy used in heart failure was 41.1%. The imaging protocol was mostly done by both planar and SPECT at 15 min and 3.6 hr after intravenous injection of 111 MBq of MIBG. The quantitative assessment was mostly done by heart/mediastinum (H/M) ratio and washout rate analysis based on planar imaging. The mean normal value of H/M ratio were 2.34 +/- 0.36, and 2.49 +/- 0.40, at early and delayed images, respectively. The normal value of washout rate was 27.74 +/- 5.34%. On the other hand, those of H/M ratio in heart failure were 1.87 +/- 0.27, and 1.75 +/- 0.24, at early and delayed images, respectively. That of washout rate was 42.30 +/- 6.75%. These parameters were very useful for the evaluation of heart failure. In conclusion, MIBG myocardial scintigraphy was widely used for not only early detection and severity assessment, but also indication for therapy and prognosis evaluation in heart failure patients.     

111In-pentetreotide scintigraphy is superior to 123I-MIBG scintigraphy in the diagnosis and location of chemodectoma

Chemodectomas, or glomus tumours, are unusual head and neck paragangliomas. A non-invasive imaging technique, 123I-metaiodobenzylguanidine (123I-MIBG) scintigraphy, has long been used for the diagnosis of all types of paraganglioma. The aim of this study was to evaluate and compare classic 123I-MIBG scintigraphy with the more recent 111In-pentetreotide scintigraphy in the diagnosis and location of chemodectomas. We performed 123I-MIBG and 111In-pentetreotide scintigraphy in eight patients (7 females, 1 male) with histologically or radiologically confirmed chemodectomas (five carotid body and three jugulotympanic chemodectomas). 123I-MIBG uptake was visualized in four patients on planar views and SPET images (sensitivity 50%); uptake was low in three patients. Using 111In-pentetreotide scintigraphy, all chemodectomas in eight patients were visualized (sensitivity 100%) and 111In-pentetreotide uptake was high in all cases. In conclusion, our results indicate that 111In-pentetreotide scintigraphy is superior to 123I-MIBG scintigraphy in the diagnosis and location of chemodectomas. In-pentetreotide or 123I-MIBG uptake suggests a neuroendocrine origin, providing important functional information in the diagnosis of chemodectomas. Moreover, 111In-pentetreotide scintigraphy permits a good classification of patients with or without somatostatin receptors in the chemodectoma in the application of pharmacological therapy with somatostatin analogues to inoperable tumours. The main therapeutic action of cold somatostatin analogues is to inhibit hormonal hypersecretion in different neuroendocrine tumours. In chemodectomas, however, the most important effect of somatostatin analogues is to reduce tumour volume or inhibit growth progression.     

Evaluation of myocardial uptake of beta-methyl-(123I)-iodophenylpentadecanoic acid (123I-BMIPP)

To evaluate the myocardial uptake of beta-methyl-(123I)-iodophenylpentadecanoic acid (123I-BMIPP), nineteen patients with ischemic heart disease including left ventricular hypertrophy (mean age 63 +/- 7.8, 14 males and 5 females) underwent BMIPP myocardial scintigraphy. Myocardial uptake (MU) of BMIPP to the total injected dose was calculated from anterior view of the planar image in all subjects, and was compared with plasma glucose (BS), triglyceride (TG), and free fatty acid (FFA). It was also compared with left ventricular mass (LVM) calculated with echocardiography. MU was not related to BS, TG, and FFA, however had the positive correlation with LVM (r = 0.676, p < 0.01). Myocardial uptake per left ventricular mass (MU/LVM) had the negative correlation with LVM (r = -0.671, p < 0.01). Further studies for the significance of MU/LVM will be required.     

MIBG detection of hepatic neuroblastoma: correlation with CT, US and surgical findings

The combination of ultrasound contrast media (US-CM) and color-coded duplex sonography (CCDS) is a very promising new diagnostic method. The principles of CCDS and US-CM are therefore briefly discussed. Different US-CM are described regarding their application and possible indications. This is followed by a summary of the first clinical experience with this new method.     

Location of a VIPoma by iodine-123-vasoactive intestinal peptide scintigraphy

A major problem in patients with small endocrine tumors is the difficulty in localizing the primary tumor site. Many endocrine tumors possess larger amounts of high affinity vasoactive intestinal peptide (VIP) binding sites compared with normal tissue or blood cells. We used radiolabeled VIP to localize the tumor site in a patient with Verner-Morrison syndrome (VMS). Under octreotide therapy, the VIP levels had declined in this patient, but a tumor site could not be detected by conventional techniques or by radiolabeled octreotide. However, using 123I-VIP, the tumor was detectable in the pancreatic tail. Surgical resection of the tumor was followed by complete remission of the VMS. Expression of VIP binding sites in the tumor was confirmed by a radioreceptor assay and showed cross-competition between VIP and octreotide. The identity of the VIP binding site in the tumor was analyzed by Northern blotting and revealed the expression of somatostatin receptor subtype 3, which binds both somatostatin-14 and VIP with higher affinity than octreotide. Iodine-123-VIP scintigraphy would be an effective tracer to identity the tumor site in VMS patients.     

A case of hypertensive hypertrophy in which both regression of hypertrophy and improvement of the abnormalities in iodine-123-metaiodobenzylguanidine (MIBG) myocardial imagings were observed after antihypertensive therapy

A case of hypertensive hypertrophy is described in which both regression of hypertrophy and improvement of the abnormalities in iodine-123-metaiodobenzylguanidine (MIBG) myocardial imagings were seen after 7 months of antihypertensive therapy. A 58-year-old man was diagnosed as having essential hypertension and hypertensive hypertrophy. The patient was treated with antihypertensive drugs and showed regression of left ventricular hypertrophy on electrocardiograms and echocardiograms. MIBG observations made before and after antihypertensive therapy showed increased heart-to-mediastinum activity ratio and decreased cardiac washout ratio. Despite the many theories addressing the mechanisms of regression of left ventricular hypertrophy, the process is still unclear. In the present case, the improvement of cardiac sympathetic nervous dysfunction might have been related to the regression of left ventricular hypertrophy because the abnormality in MIBG images improved. MIBG, therefore, may be helpful in clarifying the mechanisms of the regression of hypertensive hypertrophy.     

Assessment of 123I-beta-methyl iodophenyl pentadecanoic acid (BMIPP) myocardial scintigraphy in patients of chronic right ventricular overload--fatty acid metabolism in right ventricular myocardium

An investigation on the right ventricular pressure level and the abnormalities in the fatty acid metabolism of myocardium was made using 123I-beta-methyl-iodophenyl pentadecanoic acid (BMIPP) myocardial SPECT in patients with chronic right ventricular overloading. Twenty patients who presented with right ventricular systolic pressure (RVSP) of 35 mmHg or more were used as the subjects. Dual myocardial SPECT with 201TlCl (Tl) and BMIPP was carried out for the subjects and RVc/LVc, a ratio of radioactivity count incorporated in the right ventricular free wall to the left one was determined for Tl and BMIPP. And the correlations between RVc/LVc and RVSP, and RVc/LVc and RVSP/LVSP were examined. The subjects were classified into 3 groups based on the RVSP levels and the count ratio, BMIPP/Tl was compared among the three groups. With respect of Tl uptake, there were significant, positive correlations between RVc/LVc and RVSP (correlation coefficient r = 0.51, p < 0.05) and between RVc/LVc and RVSP/LVSP (correlation coefficient r = 0.59, p < 0.01). On the other hand, no significant correlation was found between them with respect of the uptake of BMIPP. The BMIPP/Tl ratio in the group with higher than 80 mmHg of RVSP was 0.82 +/- 0.06, which was significantly lower than the ratio's for two groups of less than 80 mmHg; 0.91 +/- 0.07 and 0.98 +/- 0.04 in the group with 35-49 and 50-79 mmHg of RVSP, respectively. These results show that when compared with BMIPP, Tl is superior for the estimation of right ventricular pressure. For the patients with right ventricular overloading, it was suggested that when RVSP reaches 80 mmHg or more, there appear some disorders in the fatty acid metabolism in the right ventricular myocardium.     

Impairment of cardiac neuronal function in acute myocarditis: iodine-123-MIBG scintigraphy study

Gene mapping techniques to identify gene mutations in humans and animals with phenotypic abnormalities in iron metabolism are providing important insights into the probable molecular mediators of intestinal iron absorption. Positional gene cloning in humans with hereditary hemochromatosis has identified a mutation in a novel major histocompatibility complex (MHC) gene called HFE that is likely to be involved in regulating intestinal iron absorption. In addition, recent observations based on positional cloning strategies in the mk/mk mouse and the Belgrade (b/b) rat rodent models of hypochromic, microcytic anemia have shown that the phenotypic abnormality in iron metabolism is associated with a mutation in the Nramp2 gene. Functional cloning studies in Xenopus oocytes have characterized DCT1 (Nramp2) as an iron-regulated proton-coupled divalent cation transporter. Nramp2 is likely to be the membrane transporter that functions in controlling iron entry across the apical membrane and in the export of iron out of endosomal vesicles. The observation that the expression of both HFE and Nramp2 mRNAs are reciprocally regulated by cellular iron status in Caco-2 cells, a human intestinal cell line, lends additional credence to the notion that these proteins may work in concert to regulate intestinal iron absorption.     

Clinical relevance of I-123/I-131-MIBG scintigraphy in intestinal carcinoid tumors

AIM: Of this retrospective study was to determine the value of MIBG-scintigraphy in patients with intestinal carcinoids dependent on histological, clinical, and biochemical parameters. METHODS: In 15 patients uptake in carcinoid tumors and metastasis was correlated with location of the primary tumor, intra- and extrahepatic tumor masses, histology, immunhistochemistry, neuroendocrinological markers, and clinical symptoms. RESULTS: High uptake was to be seen almost only in tumor masses of primary tumors located in the terminal ileum. There also was a positive correlation with clinical symptoms for carcinoids and urinary 5-HIAA level. No correlation between MIBG uptake and tumor masses, histology, and most of the immunhistochemical and neuroendocrinological markers could be found. CONCLUSION: There is a limited indication for MIBG-scintigraphy in follow up of intestinal carcinoids. In patient with proven uptake MIBG scintigraphy is suitable for long-term follow up and therapy monitoring.     

Significance of inhalation and perfusion scintigraphy for the diagnosis of pulmonary embolism (author's transl)

Inhalation and perfusion scintigrams, general radiological examination of the thorax and an EKG were done on 43 patients with clinically suspected pulmonary embolism. In 11 cases, the clinical diagnosis could be confirmed on the basis of the scintigraphic examination. In the remaining 32 patients, an embolich event could be excluded by pulmonary scintigram, radiological examination and later the clinical course. A synopsis of clinical observations, X-ray and scintigraphy, therefore, permitted a basically reliable diagnosis of pulmonary embolism; selective pulmonary angiography should be used only in exceptional cases.     

Kit method of preparation of 4-lodoantipyrine (I-123) from Na123I: concise communication

4-Iodoantipyrine (4-IAP), containing 123I, has been suggested as a radio-pharmaceutical for direct imaging of regional cerebral perfusion. In routine clinical use, a reliable source of the labeled compound is required. The 4-IAP (I-123) can be prepared by exchange between Na123I and 4-bromoantipyrine (4-BrAP) or 4-IAP with heating in aqueous acidic solution. Using an H3PO4 buffer system at pH 2.5 during labeling, with addition of NaOH for subsequent buffering at pH 7.0, a convenient reliable kit for routine preparation of 4-IAP (I-123) from commercially available Na123I has been developed.     

Bone scintigraphy in osteodystrophia deformans (Paget's disease)

The value of combined investigations using both scintiscanning and radiological procedures has been proved for the disease's extension and activity in 28 patients suffering from osteodystrophia deformans (Pagets disease). It was seen that such a method leads to more precise results concerning the patient's condition. Special therapy indications were set up, based on these summarized findings. A further advantage of bones scanning alone is the lower radiation dose, which is mainly indicated for control tests in Paget's course. At present, we have no experience of malignant forms of this disease among our group of patients.     

The Pediatric Oncology Group experience with the international staging system criteria for neuroblastoma. Member Institutions of the Pediatric Oncology Group

PURPOSE: An international consensus on the criteria for surgicopathologic staging (INSS) of patients with neuroblastoma has been published, but has not been validated. A retrospective study was conducted to assess if the INSS definitions identified prognostic subsets of patients with neuroblastoma. PATIENTS AND METHODS: The initial operative and pathology reports were reviewed from 675 patients on Pediatric Oncology Group (POG) #8104, a stage- and age-related treatment study that used the POG surgicopathologic staging system. RESULTS: Of 596 eligible cases, there was concordance between the POG and INSS stages for the 193 patients with localized, resected disease (POG stage A), the 202 with distant metastases, the 51 with POG stage Ds (IVs) tumors, and 40 of the cases with grossly unresected, localized tumor without lymph node involvement (POG stage B). Of the remaining 19 patients with POG stage B tumors, five were INSS stage 2B and 14 INSS stage 3. All of the 91 cases with nonadherent, regional lymph node metastases (POG stage C) conformed to the definitions for INSS stage 2B (n = 42) or 3 (n = 49). In infants, there was no difference in event-free survival (EFS) among INSS stages 2A, 2B, or 3. In contrast, older children with INSS stage 3 disease had inferior EFS compared with INSS stage 2A or 2B tumors. CONCLUSION: We conclude the following: (1) the INSS identifies distinct patient subsets, particularly in children; (2) infants remain a favorable group, regardless of INSS/POG stage; and (3) the INSS deserves further prospective study especially in the light of recent biologic prognostic variables.     

Gamma scintigraphy of a 123I-labelled N-(2-hydroxypropyl)methacrylamide copolymer-doxorubicin conjugate containing galactosamine following intravenous administration to nude mice bearing hepatic human colon carcinoma

A surgical method for treatment of the extremely hypoplastic tuberous breast is described. It is based on turning differently shaped glandular flaps to correct the deformity, followed by insertion of a prosthesis, and, where necessary, correction of areola size and position and adjustment of the skin of the inferior pole. The results so far have afforded total and recurrence-free aesthetic correction of the usual deformities. The underlying aim of the operation is to transform a hypoplastic tuberous breast into a simple hypoplasia without discarding gland tissue which can be used to thicken the most deficient mammary area.     

Iodine-131 metaiodobenzylguanidine scintigraphy for localization of lesions in children with neuroblastoma: comparison with computed tomography and ultrasonography

Iodine-131 metaiodobenzylguanidine (MIBG) scintigraphy, computed tomography (CT) and ultrasonography (US) were used to localize tumour lesions in 28 children with histologically proven neuroblastoma. Overall, a total of 73 lesions were detected on imaging studies. MIBG scintigraphy, CT and US localized 63 (86%), 49 (67%) and 36 (49%) of these lesions, respectively. The findings of the three imaging techniques were concordant in respect of only 31 (42%) of the lesions. The best agreement among MIBG scintigraphy, CT and US was observed for abdominal lesions (the techniques were concordant for 22 of 23 lesions, i.e. 96%). MIBG scintigraphy detected nine out of ten (90%) liver metastases, but agreement with CT and US was observed in only six instances (60%). The imaging findings were concordant in respect of only two (33%) out of six lymph node metastases; the MIBG scan was normal in the other four cases. Imaging agreement was observed for a lesion located in the pelvis. MIBG and CT findings were concordant in four lesions located in the chest, but US was not performed. MIBG scintigraphy depicted the majority (96%) of the skeletal lesions (23/24); CT showed five of these, but, again, US was not performed. The imaging findings were not concordant as regards the remaining five lesions located in different anatomical sites. The results indicated that MIBG imaging is more sensitive that CT and US in localizing the majority of neuroblastoma lesions. Since the metastatic spread of neuroblastoma is unpredictable, we recommend MIBG scintigraphy as the initial imaging modality for staging of these patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

The bone scintigraphy in eosinophilic granuloma (author's transl)

The significance of bone scintigraphy using 99mTc-polyphosphate or 99mTc-diphosphate in the diagnosis of eosinophilic granuloma was discussed on the basis of our experience with four cases. The summary is following: 1. On diagnostic procedure of eosinophilic granuloma, it was found that abnormal RI accumulation in the bone scintigram was more marked than that in the ordinary brain scintigram. 2. The bone scintigram of eosinophilic granuloma showed more accurately the extent of skull involvement of cellular infiltration than the plain skull X-rays or brain scintigram. Accordingly, the bone scintigram was helpful for neurosurgeon in planning the operative procedure and determining the extent of removal of the involved skull. 3. The plain skull X-rays show the size of skull defect, and the brain scintigram reveals the size of the size of granuloma per se, as well as soft tissue involvements. We can conjecture the stage of the diseases by comparison between the findings of bone scintigram and those of above procedures: plain skull X-rays and brain scintigram. Viz, the bone scintigram showed more extensive areas of RI accumulation including the surrounding cellular infiltration in the acute stage, but the same size of the lesions shown by the ordinary brain scintigram and plain skull X-rays is chronic stage. Furthermore, we discussed the possibility of the differential diagnosis between eosinophilic granuloma and other neoplastic bone diseases, such as intracranial metastatic tumors and multiple myelomas etc., by further experience with the bone scintigram.     

Surgical management and outcome of locoregional neuroblastoma: comparison of the Childrens Cancer Group and the international staging systems

Although precise anatomic staging is prognostically important in neuroblastoma, most widely employed staging systems remain incompatible. The International Neuroblastoma Staging System (INSS) was formulated to incorporate the basic elements of several systems to and define the significance of tumor resectability, anatomic "midline," and lymph node involvement. The authors sought to determine the applicability and value of the INSS compared with the classic Evans system. Between 1980 and 1992, 424 children with the diagnosis of local or regional neuroblastoma were entered in Childrens Cancer Group (CCG) clinical trials. The patients were assigned to Evans stage I, II, or III, by clinical and surgicopathologic assessment, and were treated uniformly by Group-wide therapy protocols. INSS stage 1, 2A, 2B, or 3, was applied, by retrospective analysis, to the children in the earlier studies, and by prospective evaluation of recent patients in the current studies. Survival and relapse-free survival (RFS) rates were determined and compared, based on age at diagnosis, extent of resection, and staging reassignment. All 87 Evans stage I patients were classified as INSS stage 1 and had a 92% 3-year RFS rate. Of the 144 Evans stage II patients, 65 also qualified as INSS stage 1 patients, with an 82% RFS rate. The other 79 stage II children remained in INSS stage 2A or 2B and had a 70% RFS rate (P = .10). Of the 193 Evans stage III patients, 24 were reassigned to INSS stage 1 (85% RFS rate) and 33 to stage 2A or 2B (65% survival rate; 61% RFS rate).(ABSTRACT TRUNCATED AT 250 WORDS)     

Assessment of regional sympathetic nerve activity in vasospastic angina: analysis of iodine 123-labeled metaiodobenzylguanidine scintigraphy

Injury of the normal central nervous system is a major concern in the radiotherapy of brain tumors, but the pathogenesis of injury remains poorly understood. Modulation of the production of growth factors is associated with ischemia and traumatic injury in the central nervous system. Ionizing radiation has been shown to induce basic fibroblast growth factor in endothelial cells and in cells of a human breast carcinoma cell line. The inducibility of basic fibroblast growth factor after irradiation and its potential role in the recovery response of the central nervous system led us to investigate the effects of radiation on the expression of this growth factor in primary cultures of normal rat type 1 astrocytes. Astrocyte monolayers were exposed to ionizing radiation (1 to 10 Gy). Northern blot analysis revealed that doses of 2 to 10 Gy markedly reduced the expression of basic fibroblast growth factor as early as 1 h after irradiation, and that it remained below levels in unirradiated cells for at least 24 h. The effect was not associated with astrocyte cytotoxicity, and it appears to have some specificity for basic fibroblast growth factor since the levels of mRNA coding for ciliary neurotrophic factor and glial fibrillary acidic protein were not affected.