Journal Club On

SPECT/CT
Presented by: CNMU, Mymensingh Speaker: Dr. M Nasim Khan Assoc. Prof. CNMU, Mymensingh Chairperson of the Session: Dr S M Moinul Islam Prof. & Director of CNMU, Mymensingh.

SPECT/CT

Andreas K. Buck1, Stephan Nekolla1, Sibylle Ziegler1, Ambros Beer1, Bernd J. Krause1, Ken Herrmann1, Klemens Scheidhauer1, Hans-Juergen Wester1, Ernst J. Rummeny2, Markus Schwaiger1 and Alexander Drzezga1
1

Department of Nuclear Medicine, Technische Universitt Mnchen, Mnchen, Germany; and 2 Department of Radiology, Technische Universitt Mnchen, Mnchen, Germany Journal of Nuclear Medicine Vol. 49 No. 8 1305-1319 2008

Introduction
Hybrid imaging techniques allow the direct fusion of
morpholgic information and functional information together. Since its introduction to clinical medicine in 2001, PET/CT has become the fastest growing imaging modality. CT coregistration has led to definite diagnoses by PET and more acceptance of functional imaging. Recently, integrated SPECT/CT scanners have been made available. With SPECT/CT, lesions visualized by functional imaging can be correlated with anatomic structures. The addition of anatomic information increases the sensitivity as well as the specificity of scintigraphic findings.

SPECT/CT FOR SLN MAPPING

For patients with cancer, accurate lymph node

staging is mandatory for appropriate treatment planning. A combination of lymphoscintigraphy before surgery and mapping with blue dye during surgery has been demonstrated to be a practicable approach for accurately localizing the SLN. Although most sentinel nodes can be identified during surgery with a hand-held probe, SLN identification may be impossible in certain cases.

 Anatomic coregistration represents a valuable tool for

SLN detection in the pelvis, the mediastinum, or the head and neck region. For a series of 34 patients, SPECT/CT identified sentinel nodes in 94% of patients (32/34) and identified additional nodes in 15 (47%) of those 32 patients.

Husarik and Steinert examined the added value of

SPECT/CT in breast cancer. For 41 consecutive patients, findings from planar scintigrams and SPECT/CT were identical in only 7 patients (17%); SPECT/CT indicated the correct anatomic localization in 29 patients (70%).

Accurate anatomic localization of sentinel node in patient with breast cancer

FIGURE 2. Accurate anatomic localization of sentinel node in patient with breast cancer by sentinel node scintigraphy (99mTc-Nanocoll; Amersham) and CT coregistration. Correct anatomic localization of sentinel node in left axilla is llustrated by 3-dimensional projections of fused images.

SPECT/CT IN SKELETAL DISEASES

For more than 30 yrs, planar bone scintigraphy

has been used as a valuable method for sensitively detecting or characterizing bone pathology. Although functional bone imaging is a highly sensitive method, it lacks specificity . Therefore, radiography, CT, or MRI is frequently performed after bone scintigraphy to further characterize lesions evident on bone scans. Integrated SPECT/CT offers a direct correlation of focal bone pathology with anatomic structures and therefore minimizes the number of equivocal findings.

SPECT/CT IN MALIGNANT SKELETAL DISEASES

Screening for bone metastases and evaluation

of the treatment response are the most frequent indications for bone scanning. Although the majority of bone metastases appear as hot spots, some appear as cold lesions. Benign lesions, such as hemangioma, may also appear as cold, making the differential diagnosis problematic. The differentiation of benign and malignant lesions can usually be achieved with CT coregistration and is a major advantage of SPECT/CT . In addition, fused images can be used to further guide biopsies of bone lesions.

Patient with lung cancer and 2 hot spots

FIGURE 3. Patient with lung cancer and 2 hot spots, in lower lumbar spine and pelvis (os sacrum). (A and B) Planar scintigrams from skeletal scintigraphy (99mTc-hydroxymethylene diphosphonate). (C) Detailed view of pelvis with 2 hot spots (arrows). (D) Transverse section of upper lesion in lumbar vertebra 5. (E) Small osteolytic lesion with intense tracer uptake indicating bone metastasis in lower pelvis. (F) Fused image. (G and H) Spondylarthrosis of right facet joint with intense tracer uptake indicating degenerative lesion.

Applications in Benign Skeletal and Infectious Diseases

Recently, it has been reported that SPECT/CT allowed a

definite diagnosis for the majority of indeterminate scintigraphic findings in nononcologic situations. Infectious bone lesions, such as osteomyelitis, may be diagnosed by 3-phase bone scintigraphy with 99mTclabeled diphosphonates. This approach has high sensitivity but lacks specificity. Another option is the use of radiolabeled autologous leukocytes (WBC), still considered the gold standard for localizing an area of infection by scintigraphic procedures. A more practicable approach is the use of 99mTc-labeled monoclonal antigranulocyte antibodies directed against the CD66 antigen, which is expressed on granulocytes and macrophages.

Applications in Benign Skeletal and Infectious Diseases

99mTc-labeled ciprofloxacin was recently suggested to

specifically detect infection through the accumulation of the radiotracer in living bacteria. CT coregistration may improve the specificity as well as the sensitivity of these scintigraphic techniques. CT is able to detect small areas of cortical destruction and to identify soft-tissue abscesses or empyema located in neighboring soft-tissue structures. CT data can be correlated with the accumulation of granulocytes or increased bone turnover, as indicated by scintigraphy, thus confirming or excluding infectious bone lesions. It is obvious that combined imaging makes the interpretation of SPECT and CT easier and more reliable.

SPECT/CT for suspected bone infection on GS

A 56-y-old woman presented with fever, low back pain, and infected scar 1 mo after spinal surgery and was referred for GS for suspected vertebral osteomyelitis. (A) Planar posterior whole-body GS image (left) shows prominent abnormal uptake in left lower back, corresponding in part to regions of increased irregular uptake seen on planar posterior whole-body 99mTcMDP image (right) along operated vertebrae. (B) Transaxial GS SPECT/CT image (left) localizes abnormal uptake on GS (center) to paravertebral soft-tissue abscess seen on corresponding CT image (right), thus defining soft-tissue infection without osteomyelitis. There was no evidence of vertebral osteomyelitis on follow-up CT 4 wk later.

SPECT/CT IN DIFFERENTIATED THYROID CANCER

In patients with differentiated thyroid carcinoma, whole-

body imaging after oral administration of I-131 or 123I is commonly performed to identify residual or metastatic disease. Radioiodine scintigraphy has a higher sensitivity than morphologically based imaging modalities. However, the interpretation of I-131 images may be difficult because of the absence of anatomic landmarks. Therefore, precise localization of hot spots is frequently not possible. In addition, physiologic uptake of 131I may cause false-positive findings.

Exact delineation of focal pelvic 131I uptake in patient with differentiated thyroid cancer

FIGURE 4. Exact delineation of focal pelvic 131I uptake in patient with differentiated thyroid cancer. (A and B) Planar 131I scintigrams (anterior view [A] and posterior view [B]) showing focal tracer uptake in left pelvic region (arrow). Lesion cannot be definitely assigned as benign or solitary bone metastasis. (C and D) Corresponding CT section (C) and fused SPECT/CT image (D) demonstrating nonspecific tracer uptake in diverticulum of colon (arrow)

SPECT/CT IN PARATHYROID TUMORS

In primary hyperparathyroidism, 99mTc-MIBI scintigraphy plays a
minor role, because bilateral neck exploration has a success rate of up to 95%. However, with the increasing use of minimal invasive parathyroidectomy, presurgical imaging and precise localization of a parathyroid adenoma are critical for successful surgery. For a series of 110 patients, Lavely et al. compared the diagnostic performance of planar imaging, SPECT, SPECT/CT, and single- and dual-phase 99mTc-MIBI parathyroid scintigraphy In this prospective study, dual-phase planar imaging, SPECT, and SPECT/CT were significantly more accurate than single-phase early or delayed planar imaging. Early-phase SPECT/CT in combination with any delayed imaging method (planar or SPECT) was superior to dual-phase planar imaging or dual-phase SPECT with regard to sensitivity, area under the curve, and positive predictive value (PPV). The authors therefore concluded that CT coregistration is a valuable tool for the precise delineation of parathyroid adenomas.

Parathyroid scintigraphy with SPECT/CT.

FIGURE 5. Parathyroid scintigraphy with SPECT/CT. (A and B) Planar views of 99mTc-MIBI scintigraphy 60 min (A) and 15 min (B) after 99mTc-MIBI injection. Arrows indicate lesions. (C) Transverse section of 99mTc-MIBI SPECT showing mildly intense focal lesion in right lower neck region (arrow). (D and E) Corresponding CT section (D) and fused image (E) indicating parathyroid adenoma below right thyroid gland (arrows). (F and G) Demonstration of parathyroid adenoma (arrows) in corresponding coronal CT (F) and SPECT/CT (G) image

SPECT/CT IN TUMORS OF SYMPATHETIC NERVOUS SYSTEM AND ADRENOCORTICAL TUMORS

Morphologic imaging modalities, such as CT or MRI, offer high

sensitivity for the detection of tumors of the sympathetic nervous system. The major advantages of radionuclide imaging, such as I-123-MIBG SPECT, 18F-HPL- PET, or 11-C-mHED- PET, have high specificity, which can be used to better characterize lesions, and superior differentiation of scar tissue and residual tumor after surgery. In a prospective study, Franzius et al. evaluated the clinical use of I123-MIBG SPECT/CT in 19 patients with a variety of tumors of the sympathetic nervous system, including neuroblastoma and pheochromocytoma. I-123-MIBG SPECT/CT had a sensitivity (93%) similar to that (99%) achieved by PET/CT with 11C-HED as a tracer.

Diagnosis of pheochromocytoma with 99mTc-MIBG SPECT/CT.

FIGURE 6. Diagnosis of pheochromocytoma with 99mTc-MIBG SPECT/CT. (A) Planar image showing mildly intense focal lesion extending to left suprarenal area. (BD) Corresponding sections of SPECT (B), CT (C), and fused SPECT/CT (D) images showing focal uptake extending to enlarged left adrenal gland, indicating pheochromocytoma. (EG) Corresponding transverse sections of right adrenal gland showing additional hot spot and enlargement of gland, indicating second pheochromocytoma, which was proven histologically. Lesion may be missed on planar image (A) or overexposed transaxial SPECT image (B).

SPECT/CT IN CARDIAC IMAGING

The prospects for hybrid cardiac imaging are promising,
and new clinical applications are being proposed. Combining function and morphology is highly attractive for several reasons: improved diagnosis and logistics as well as illustrative visualization. Hybrid SPECT/CTCA imaging results in improved specificity and PPV to detect hemodynamically significant coronary lesions in patients with chest pain. As an example of the increased interest in hybrid cardiac imaging, the Society of Nuclear Medicine awarded its 2006 image of the year award to a cardiac SPECT/CT study. This study demonstrated a defect in the inferior myocardium together with corresponding stenosis on CT angiography.

Complementary Nature of SPECT/CT IN CAD

CONCLUSION

The role of integrated SPECT/CT is growing, especially in

oncologic applications. CT coregistration results in higher specificity as well as sensitivity of scintigraphic findings and markedly reduces the number of indeterminate findings. The superiority of SPECT/CT over planar scintigraphy or SPECT has been clearly demonstrated for the imaging of benign and malignant skeletal diseases, thyroid cancer, neuroendocrine cancer, parathyroid adenoma, and mapping of SLNs. Studies demonstrating superiority in other clinical applications are lacking; however, pilot studies have encouraged the use of SPECT/CT in cardiac and neurologic imaging.