1. Interesting images
Tawika, M.D.

2. Eur J Nucl Med Mol Imaging (2011) 38:412
DOI 10.1007/s00259-010-1656-1
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99m
Intrathoracic splenosis: evaluation by Tc-labelled
heat-denatured erythrocyte SPECT/CT
Cinzia Crivellaro & Grazia Cabrini & Emma Gay &
Roberto Sara & Claudio Rossetti
Received: 12 August 2010 / Accepted: 19 October 2010 / Published online: 11 November 2010
# Springer-Verlag 2010
In a 39-year-old man, 14 years after splenectomy for injury 38:412
Eur J Nucl Med Mol Imaging (2011)
DOI 10.1007/s00259-010-1656-1
sustained in a road accident, a chest radiograph performed
for dyspnoea showed an abnormal opacity. Computed
IMAGE OF THE MONTH
tomography (CT) confirmed a mediastinal left para-aortic
mass suggestive either of confluent enlarged lymph nodes or
ectopic splenic tissue. Thus, 99mTc-labelled heat-denatured
red blood cell (DRBC) scintigraphy was performed. Planar 99m
Intrathoracic splenosis: evaluation by
images showed left paravertebral uptake in the chest and Tc-la
heat-denatured erythrocyte SPECT/CT
multiple little uptakes in the left upper abdomen. Single
photon emission computed tomography (SPECT)/CT
(Siemens Symbia) images confirmed 99mTc-DRBC left

3. • A 39-year-old man, 14 years after splenectomy for injury
sustained in a road accident, a chest radiograph performed for
dyspnoea showed an abnormal opacity. Computed tomography
(CT) confirmed a mediastinal left para-aortic mass
• DDx confluent LN or splenic tissue

4. 99m
Tc-labelled heat-denatured
graphy was performed. Planar
bral uptake in the chest and
left upper abdomen. Single
tomography (SPECT)/CT
line: 11 November 2010
confirmed 99mTc-DRBC left
ing to a solid mass from the
aorta (a, b), consistent with
lets of splenic tissue were also
e left subdiaphragmatic region
is defined as heterotopic
tissue, usually occurring after
en or splenectomy. Although
ing, a high index of suspicion
nts with previous splenectomy
being followed up, as no more
d unless symptoms worsen
hy remains the method of Conflicts of interest None.
onal evaluation of splenosis,
PECT/CT has been demon-
References
for correctly identifying and

5. Tc-99m Heat-damaged RBC
• Method of choice of non-intervention
evaluation of the accessory spleen/splenosis
• In vitro labeling of patient’s RBCs with
Tc-99m pertecnitate

6. waterbath 49-50 degree celcius for 15-20 min

7. • Maintaining specified temperature throughout the heating
process is critical
• Overheating will lead to excessive damage of the RBCs,
resulting in increased uptake by the liver and decreased
uptake by the splenic tissue
• Underheating will lead to insufficient damage of RBCs,
resulting in decreased splenic uptake, along with increased
activity in the circulating blood pool.

8. Clinical application
• To identify splenules
• To assess splenic number; asplenia, polysplenia
• To assess mass which is suspicious of wandering spleen
or splenosis
• DDx LN vs splenules or hypervascular (pancreatic tail)
tumor vs implanted splenule

9. • searching for accessory splenic tissue, the
entire abdomen must be imaged
• seeking for splenosis, thorax must be
imaged
• Diaphragm may have been violated
during trauma

10. • The image acquisition can begin 30 min
after injection because of the rapid splenic
sequestration of damaged RBCs
• More than 50% of HDRBCs localize in the
spleen about 1 hour after injection

11. Other radiopharmaceuticals
• radiocolloids
• about 30% of administered activity
accumulates in the spleen about 1 hour
• splenule activity can be obscured by
hepatic uptake
• SPECT is helpful

12. • Other labeled formed elements
• Labeled leukocytes and platelets

13. Splenosis vs Splenules
• Splenules: Congenital accessory splenic
tissue
• Splenosis: Autotransplanted splenic tissue
from secondary cause

14. is specific for splenic tissue and quite sensitive given the high
contrast between splenules and surrounding tissues. A 99mTc-
sulfur colloid study is another nuclear medicine study that
may be used to assess splenic tissue. However, the colloid
is also taken up by the liver and bone marrow, and conse-
quently this test is less sensitive and specific. The normal
FIGURE 16. CT scan (A
pancreas (arrowheads) and
responding transaxial slic
FIGURE 14. Heat-damaged RBC study assessing for pres- study demonstrates intens
ence of splenules in patient with ITP. Anterior MIP image (A) and it is simply an accessory s
transaxial image (B) from SPECT acquisition demonstrate small depicts uptake in mass (ar
but intense focus of uptake in splenic bed (arrow), consistent intense normal uptake in sp
with splenule. MIP 5 maximum intensity projection. maximum intensity project
142 JOURNAL OF NUCLEAR MEDICINE TECHNOLOGY • Vol. 36 • No. 3 • Septem

15. . However, small accessory
population, being present in
ortem studies. Consequently,
w platelets even though their
option for therapy in this case
accessory splenic tissue. The
he most effective method of
Figure 14 is such a study in a
e platelet levels were falling
splenectomy. A solitary in-
onstrated in the splenic bed.
e is overestimated on these
olution) it could not be iden-
trospect. The patient went on
used intraoperatively to locate
emoved.
d female patient also under-
sing platelet counts in the FIGURE 15. Anterior MIP image demonstrates no concentra-
no accessory splenic tissue tion of heat-damaged RBCs within accessory splenic tissue. This
onstrates that in the absence negative study depicts distribution of damaged RBCs through-
nic tissue, the distribution of out blood pool when there is no significant functioning splenic
tissue to sequester them. MIP 5 maximum intensity projection.
e circulating blood pool.
other indication for the heat-
65-y-old male patient, a CT spleen takes up only about 10% of injected 99mTc-sulfur
ed reason identified a 3.1-cm colloid, versus 90% of heat damaged RBCs (28).
as. The concern was that this

16. e, and no further work- nuclear medicine procedures and may serve as a reference
e identified on anatomic
MRI. However, as indi-
ties are neither sensitive
at-damaged RBC study
sensitive given the high
nding tissues. A 99mTc-
ar medicine study that
. However, the colloid
ne marrow, and conse-
d specific. The normal
FIGURE 16. CT scan (A) revealed mass (arrow) near tail of
pancreas (arrowheads) and spleen (double arrowhead). (B) Cor-
responding transaxial slice from heat-damaged RBC SPECT
udy assessing for pres- study demonstrates intense uptake in mass (arrow), confirming
nterior MIP image (A) and it is simply an accessory spleen. (C) Anterior MIP image further
sition demonstrate small depicts uptake in mass (arrow) near splenic hilum. There is also
bed (arrow), consistent intense normal uptake in spleen and faint uptake in liver. MIP 5
ty projection. maximum intensity projection.

17. Eur J Nucl Med Mol Imaging (2011) 38:1586
DOI 10.1007/s00259-011-1791-3
IMAGE OF THE MONTH
123
I-Metaiodobenzylguanidine ‘superscan’ in an adult
patient with neuroblastoma
Víctor Andrés Marín Oyaga & Juan Ignacio Cuenca Cuenca &
Juan Luis Tirado Hospital & Rosa Fernández López & Isabel Borrego Dorado &
Ricardo Vázquez Albertino
Received: 24 November 2010 / Accepted: 7 March 2011 / Published online: 29 March 2011
# Springer-Verlag 2011
Eur J Nucl Med Mol Imaging (2011) 38:1586
Neuroblastoma is extremely rare in patients over 10 years
old [1]. 123I-MIBG has 10.1007/s00259-011-1791-3
DOI a high sensitivity for the diagnosis
of primary and metastatic neuroblastoma [2].
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A 29-year-old man with a neuroblastoma IIB was
referred to us for an extension study after adrenalectomy.
Bone scan with 99mTc-HDP (a) showed several patholog-
ical lesions suggestive of metastatic spread.123I-MIBG
whole-body scintigraphy (b) and SPECT/CT showed
123
marked uptake of the radiopharmaceutical in the bone
I-Metaiodobenzylguanidine ‘supe
marrow throughout the axial skeleton and in the proximal
humeri and femora compatible with metastatic spread in
the bone marrow and an abnormal distribution of tracer

18. shed online: 29 March 2011
years
gnosis
was • A 29-year-old man with a
neuroblastoma IIB was
tomy. referred to us for an
holog- extension study after
MIBG adrenalectomy. Bone scan
owed with 99mTc-HDP showed
bone several pathological lesions
ximal suggestive of metastatic
ead in spread
tracer
r and
wed a
merate
These superscan’ study due to the extensive involvement of the

19. • 123I-MIBG whole-body scintigraphy (b) and
SPECT/CT showed marked uptake of the
radiopharmaceutical in the bone marrow
throughout the axial skeleton and in the
proximal humeri and femora
• 18F-FDG PET/CT (c) showed a
hypermetabolic retroperitoneal adenopathic
conglomerate with involvement of the bone
and bone marrow
ue to the extensive involvement of the

20. ears
nosis
was
omy.
log-
IBG
wed
bone
imal
d in
acer
and
d a

21. Superscan on Bone scintigraphy
• Diffusely increased tracer uptake in axial skeleton
• Homogeneous uptake
• Heterogeneous uptake
• Total absence of soft-tissue activity
• Lack of or faint kidney activity

22. Superscan
• Renal osteodystrophy • CA prostate : most
common cause
• Hyperparathyroidism
• CA breast : 2nd most
• Osteomalacia common
• Fibrous dysplasia • CA lung
• Paget’s disease • CA bladder
• Lymphoma

23. • MIBG: Meta-iodobenzylguanidine
• NE and guanitidine analoque
• MIBG is taken up into the storage
granules of both normal and abnormal
neural crest cells

24. • Normal distribution of MIBG
• salivary glands
• myocardium
• liver
• GI tracts
• urine

25. • Small percentage of patients show some
activity in...
• Blocked thyroid gland
• normal adrenal gland
• lung
• skeletal muscle

26. • NO activity in........in normal populations
• bone
• bone marrow
• spleen

27. Figure 10
Figure 10: Anterior (left) and
posterior (right) planar MIBG
scans of 5-year-old girl with left
retroperitoneal neuroblastoma.
MIBG uptake in primary tumor
(arrow), as well as diffuse
osteomedullary metastases in
cranial vault, skull base, sternum,
spine, humerus, ribs, pelvis,
femurs, and tibias, is visible.

28. • Distant metastases of neuroblastomas are
located primarily in bone marrow (70%) or
bone (55%)
• MIBG scanning is an accurate method for
detecting osteomedullary metastases with
sensitivity and specificity estimated at 90% and
100%, respectively
• Bone scan has a reported sensitivity of 70%–
78% and a specificity of 51% for the detection
of bone metastases

29. Case 3
co
the
lat
FIGURE 15. Anterior im- sin
age from lymphoscintigra-
phy study in same patient inc
as in Figure 14, extending ph
from neck to upper pelvis. dy
Abnormal accumulation of jui
radiopharmaceutical is seen dy
throughout right side of tho-
rax (arrowheads), confirming un
lymphatic leak. Appropriate ad
uptake is seen in abdominal gla
and superior mediastinal cre
lymphatics and within liver ula
(L) and spleen (S).
ca
(2). The patient is asked to lie supine in the Water’s position be
(chin and nose touching collimator face), and approxi- ac

30. • a patient who had recently
undergone right lung surgery for
excision of metastases. A pleural
effusion developed after the
operation, and it was suspected that
this may have arisen from damage to
the thoracic duct, resulting in leakage
lymphatic fluid into the pleural space
(chylothorax)
•

31. continue to hold as still as possible for the
the acquisition. Static images in the right la
lateral positions are acquired as needed. Al
FIGURE 15. Anterior im- single longer dynamic acquisition may a
•
age from lymphoscintigra-
Anterior image from lymphoscintigra-
phy study in same patient incorporating both the prestimulus and
as in Figure phy extending phase. For example, one may choose to
14, study, extending from neck to upper
from neck topelvis. Abnormal accumulation of 40 min and adminis
upper pelvis. dynamic acquisition for
Abnormal accumulation of juice via a straw to the supine patient 20
radiopharmaceutical is seen dynamicisacquisition. It is important to kee
radiopharmaceutical seen throughout
throughout right side of tho- thorax (arrowheads),
right side of unaware of the lemon juice stimulation unt
rax (arrowheads), confirming
confirming lymphatic leak. Appropriate
lymphatic leak. Appropriate administration, to prohibit psychologic stim
uptake is seen in abdominal glands. Normal and superior exhibit a s
uptake is seen in abdominal glands should
and superior mediastinal lymphatics activity almost immediately after
mediastinal crease in and within liver
lymphatics and within liver ulation, with a resultant increase in activit
(L) and spleen (S).and spleen (S).
(L)
cavity (Fig. 16).
During the prestimulus phase, an increase i
(2). The patient is asked to lie supine in the Water’s position be due to local inflammation or infection.
(chin and nose touching collimator face), and approxi- acute sialadenitis on scintigraphy displays a
mately 555 MBq (15 mCi) of pertechnetate are adminis- blood flow, resulting in marked uptake and
tered intravenously. A dynamic blood flow study is pertechnetate within the entire gland. On the

32. ne: 6 April 2011
Eur J Nucl Med Mol Imaging (2011) 38:1746
DOI 10.1007/s00259-011-1793-1
IMAGE OF THE MONTH

34. The End