Quantitative thallium-201 scintigraphy after dipyridamole infusion combined with low level exercise in healthy volunteers

To establish test specific normal limits for quantitative analysis of uptake and washout of ²⁰¹Tl after dipyridamole infusion combined with low level exercise, 20 healthy volunteers were studied with low likelihood of coronary artery disease (CAD) assessed by a stepwise probability analysis based on age, sex, symptoms, resting electrocardiogram, and exercise electrocardiography. Likelihood of CAD in these volunteers was calculated as 1%. After dipyridamole infusion combined with low level exercise, one volunteer complained of headache; no other side effects were observed. There were no chest pain complaints. Maximal hemodynamic changes were achieved during the 6th and 7th min of the test. No ST segment depression was recorded. Visual analysis of the ²⁰¹Tl scintigrams was normal in all volunteers. Mean regional washout at 4 h was 44.37%±2.11%. The regional washout in the 70° LAO view (46.65%±1.10%) was significantly higher than in the anterior and 30° LAO views (43.44%±1.50% and 43.02%±1.45%, respectively). Profiles of uptake and washout of ²⁰¹Tl were different after dipyridamole infusion combined with low level exercise as compared to maximal exercise. Thus, in quantitative analysis of ²⁰¹Tl scintigraphy after dipyridamole infusion in conjunction with low level exercise as applied in the present study, it is mandatory to use normal limits of uptake and washout of ²⁰¹Tl derived from healthy volunteers who underwent the same combined protocol.     

Uptake of99mTc-tetrofosmin,99mTc-MIBI and201TI in malignant thymoma

99mTc-tetrofosmin, Thallium-201-chloride (201Tl) and 99mTc-MIBI imagings were performed in a patient with malignant thymoma. Tracer uptake in the primary tumor was demonstrated. The tumor-to-background ratios of planar and SPECT imagings were 1.60 and 1.98 for 99mTc-tetrofosmin, 1.12 and 2.09 for 201Tl, and 1.19 and 1.80 for 99mTc-MIBI, respectively. In another patient 99mTc-tetrofosmin and 201Tl imagings were performed. Not only the primary tumor but also the direct invasions and metastatic lesions (bone metastases) were clearly detected. The tumor-to-background ratios of planar and SPECT imagings were 2.31 and 2.78 for 99mTc-tetrofosmin and 2.45 and 3.58 for 201Tl, respectively. In 99mTc-tetrofosmin scintigraphy we acquired delayed images, and the tumor-to-background ratios of planar and SPECT delayed images were 1.20 and 1.86, the retention ratios were -1.11 and -0.92 and the retention indices were -48.1 and -33.1, respectively. Our preliminary results suggest that 99mTc-tetrofosmin is useful in detecting not only the primary tumor but also metastatic lesions from malignant thymoma.     

Fabrication of Lead Free Borate Glasses Modified by Bismuth Oxide for Gamma Ray Protection Applications

In the present work, bismuth borate glass samples with the composition of (99-x) B₂O₃ + 1Cr₂O₃ + (x) Bi₂O₃ (x = 0, 5, 10, 15, 20, and 25 wt %) were prepared using the melt quenching technique. The mass attenuation coefficient (MAC) of the prepared glass samples was measured through a narrow beam technique using a NaI(Tl) scintillation detector. Four point sources were used (²⁴¹Am, ¹³³Ba, ¹⁵²Eu, and ¹³⁷Cs) to measure the MAC for the prepared glasses. The experimental data were compared with the theoretical results obtained from the XCOM, and it was shown that for all samples at all tested energies, the relative deviation between the samples is less than 3%. This finding signifies that the experimental data can adequately be used to evaluate the shielding ability of the glasses. The MAC of the sample with x = 25 wt % was compared with different lead borate glasses and the results indicated that the present sample has high attenuation which is very close to commercial lead borate glasses. We determined the transmission factor (TF), and found that it is small at low energies and increases as the energy increases. The addition of Bi₂O₃ leads to reduction in the TF values, which improves the shielding performance of the glass system. The half value layer (HVL) of the BCrBi-10 sample was 0.400 cm at 0.595 MeV, 1.619 cm at 0.2447 MeV, and 4.946 cm at 1.4080 MeV. Meanwhile, the HVL of the BCrBi-20 sample is equal to 0.171 and 4.334 cm at 0.0595 and 1.4080 MeV, respectively. The HVL data emphasize that higher energy photons tend to penetrate through the glasses with greater ease than lower energy photons. Furthermore, the fast neutron removable cross section (FNRC) was determined for the present samples and compared with lead borate glass and concrete, and the results showed a remarkable superiority of the bismuth borate glass samples.     

Does supplementation of contrast MR imaging with thallium-201 brain SPECT improve differentiation between benign and malignant ring-like contrast-enhanced cerebral lesions?

Objective To determine whether thallium-201 (²⁰¹Tl) brain single photon emission computed tomography (SPECT) could supplement magnetic resonance (MR) imaging diagnostic information by visual comparison of two separate data sets from patients with ring-like contrast-enhanced cerebral lesions. Methods A combination of MR imaging and ²⁰¹Tl brain SPECT sets obtained from 13 patients (10 men, 3 women) ranging in age from 26 years to 86 years (mean 61.0 years) were retrospectively reviewed. A total of 12 patients had a solitary lesion, and the others had multiple lesions. All but two intracranial foci were pathologically confirmed. The final diagnoses were six glioblastomas, two cerebral metastases from lung cancer, and one each of abscess, resolving hematoma, primary central nervous system lymphoma, toxoplasmosis, and radiation necrosis. The two separate image formats (MR images and SPECT) were shown to ten readers with practical experience. All of the MR images for each patient were shown to each reader first. After interpreting them, the readers were shown the SPECT images. Images were scored in terms of how benign or malignant the foci were on a 5-point scale from “definitely benign” to “definitely malignant.” Results The improvement in the performance of all ten readers was from 67.7% to 93.8% in mean accuracy (P = 0.0028) and from 0.730 to 0.971 in mean Az value (P = 0.0069) after they were shown the ²⁰¹Tl brain SPECT images. Conclusions ²⁰¹Tl brain SPECT should substantially increase confidence in the diagnosis of intracranial lesions with ring-like contrast enhancement when MR imaging does not permit differentiation between benign and malignant disease.     

Use of 201Tl SPECT Imaging to Assess the Response to Therapy in Patients with High Grade Gliomas

Purpose. To assess the potential role of ²⁰¹Tl single photon emission tomography (201-Thallium SPECT) when compared to other imaging modalities in the evaluation of the response to therapy in high grade gliomas. Materials and methods. Twenty patients with histologically proved high grade glioma have been included: 15 with glioblastoma (GBM), 3 with anaplastic astrocytoma (AA) and 2 with anaplastic oligoastrocytoma (AOA). Patients were assessed by ²⁰¹Tl SPECT, computed tomography (CT) and magnetic resonance imaging (MRI) at (a) either at the moment of maximum response to first line chemotherapy, or after the completion of radiotherapy and chemotherapy if post-surgical residual disease was present, and (b) after the completion of second line chemotherapy if disease persisted, or either a relapse or disease progression was confirmed. Final response was evaluated according to the McDonald criteria, and by comparing SPECT, CT and MRI results. Results. According to the McDonald criteria, clinical response after first line chemotherapy was 5 partial response, 7 stable disease and 8 progressive disease. Evaluation by ²⁰¹Tl SPECT was in agreement with such criteria in nearly all patients (90%). MRI findings closely agreed with the clinical follow-up. CT findings clearly differed from those observed by SPECT and MRI. After second line therapy, 10 patients progressed, 3 had stable disease and 7 had partial response. ²⁰¹Tl SPECT agreed with the clinical status in 89% cases, whereas MRI and, specially CT, fared significantly lower. Conclusion. Compared to conventional neuroimaging, ²⁰¹Tl SPECT added valuable information in the assessment of the response to therapy in our patient population; whenever findings were not conclusive and in the case of disagreement between CT and MRI findings.     

The predictive value of<Superscript>201</Superscript>Tl rest-redistribution and<Superscript>18</Superscript>F-fluorodeoxyglucose SPECT for wall motion recovery after recent reperfused myocardial infarction

201Tl and 18F-FDG are useful for acute myocardial infarction (MI) assessment. The goal of this study was to compare their predictive value for wall motion recovery in the culprit area after a recent reperfused MI using SPECT technique. METHODS: Forty-one patients (mean age: 56 +/- 12 years) were included, 81% of them male; all were studied within 1-24 days post MI. They underwent angioplasty in 27 cases (12 primary); bypass grafting in 10 cases and successful thrombolysis in 4. SPECT 201Tl injected at rest and redistribution (R-R) and also 18F-FDG, were performed on different days. Processed tomograms were interpreted blinded to clinical or angiographic data. Segmental wall motion assessed with echocardiography at baseline was compared with the 3 month follow up. RESULTS: Sensitivity [Confidence Interval] for 201Tl R-R was 74.6% [60.5-84.5], for FDG it was 82.1% [70.8-90.4]; specificities were 73% [64.3-80.5] and 54.8% [45.6-63.7], respectively. 18F-FDG tended to be more sensitive than 201Tl R-R, but the latter was more specific (p < 0.0004). Both 201Tl RR and 18F-FDG presented high negative predictive value (p: ns). CONCLUSION: In recent MI, SPECT 201Tl R-R is a valuable and widely available technique for viability detection, with similar sensitivity and significant better specificity than SPECT 18F-FDG.     

Correlation between angiogenesis and reduction ratio measured using<Superscript>201</Superscript>Tl chloride single photon emission computed tomography in patients with oral cavity squamous cell carcinoma

OBJECTIVE: The aim of this study is to examine the correlation between tumor angiogenesis and response to preoperative radiotherapy evaluated using 201Tl single photon emission computed tomography (Tl SPECT) in oral cavity squamous cell carcinoma (SCC). METHODS: Tl SPECTs before and after preoperative radiotherapy were obtained from 11 patients diagnosed with SCC in oral cavity. Regions of interest were set around the tumor and scalp respectively, and the ratio of mean counts in the tumor to those in the scalp was calculated (T/N). Immunohistochemical staining for investigating microvessel density of pre-treatment biopsy specimen was performed using CD31 monoclonal antibody. We compared microvessel density with semi-quantitative parameters obtained using Tl SPECT (T/N at pre- an post-treatment, reduction ratio) and prognosis. RESULTS: The subgroup with higher microvessel density showed a significantly higher reduction ratio than the one with lower microvessel density. Regarding prognosis, the subgroup with locoregional recurrent disease exhibited a significantly higher microvessel density than the one without recurrence. CONCLUSIONS: In SCC of the oral cavity, there was a significant correlation between microvessel density and response to preoperative radiotherapy. Namely, it was revealed that change of 201Tl uptake after preoperative radiotherapy correlated with tumor angiogenesis of oral cavity SCC.     

Paradoxical regional myocardial uptake between 201Thallium and 123I-BMIPP SPECT in patients with cardiomyopathy

 The clinical significance of the paradoxical mismatched phenomenon between ²⁰¹Tl and ¹²³I-BMIPP is still unknown. We report two cases that revealed paradoxical regional myocardial uptake between two tracers in patients with cardiomyopathy. There may be abnormal myocardium in these patients where active transportation of ²⁰¹Tl is disturbed and passive transportation of ¹²³I-BMIPP is not disordered. Received: July 31, 2002 / Accepted: September 21, 2002 Correspondence to K. Ueshima     

Effect of nicorandil on abnormal coronary flow reserve assessed by exercise201Tl scintigraphy in patients with angina pectoris and nearly normal coronary arteriograms

Summary The purpose of the present study is to assess the effect of nicorandil, a coronary vasodilator with a mechanism of potassium channel opening, on the abnormal myocardial²⁰¹Tl perfusion evoked by exercise. Eleven patients who had a history of typical angina, positive exercise electrocardiograms, positive²⁰¹Tl scintigraphy, nearly normal coronary arteriograms, and negative coronary vasospasm underwent exercise²⁰¹Tl scintigraphies under no medication (baseline test) and administration of nicorandil (nicorandil test).²⁰¹Tl was injected at a matched workload in both tests. Nicorandil did not alter heart rate, blood pressure, or the rate-pressure product at the end of the exercise, but it significantly improved the extent score from 0.37±0.22 to 0.20±0.15 (p<0.05) and the severity score from 33.9±32.2 to 13.5±16.4 (p<0.05), and also significantly hastened the²⁰¹Tl mean washout rate from 30.5±14.8% to 37.4±13.1% (p<0.05). Anginal symptoms disappeared in 3 of 5 cases and ST depression improved in 5 of 7 cases after nicorandil. We conclude that nicorandil augments coronary flow reserve, possibly due to a reduction of vasotone in the small coronary arteries.     

Novel insights into the pathophysiology of different forms of stress testing

Background

The impact of different forms of cardiac stress testing (exercise versus pharmacological stress testing) on cardiac wall stress and myocardial ischemia is incompletely understood.

Methods

In a prospective study, 331 consecutive patients with suspected myocardial ischemia referred for nuclear perfusion imaging were enrolled: 266 underwent exercise (bicycle) stress testing and 65 adenosine stress testing. Levels of B-type natriuretic peptide (BNP) measured before and 1 min after stress testing, ischemic ECG changes, and typical angina symptoms were used to compare the 2 testing modalities.

Results

Cardiac wall stress as quantified by changes in BNP levels significantly increased in the exercise stress group, but not in the adenosine group (increase in BNP levels 22 pg/ml (IQR 6–46) versus − 3 pg/ml (IQR − 3 to 28); p < 0.001). In the bicycle exercise stress group, patients with reversible defects on nuclear perfusion imaging more often had angina symptoms (25% vs. 9%, p = 0.0001) and ischemic ECG changes (33% vs. 12%, p = 0.0001) during the stress test, and a greater increase in BNP levels (28 (IQR 11–58) versus 16 (IQR 3–34) pg/ml, p = 0.001) compared to those without reversible defects. Those differences between patients with and without reversible defects were not observed with the adenosine protocol (p-values all > 0.05).

Conclusion

Exercise stress testing but not adenosine stress results in an increase of cardiac wall stress, angina symptoms and ECG changes. The absence of these surrogates of myocardial ischemia suggests that adenosine stress does not induce acute myocardial ischemia, but rather displays relative perfusion differences.