Ausl. Radiol. (1976). 20,296
Whole Body Scanning with 67Gain the Investigation of Patients with Lymphomas and Suspected Lymphomas J. T. ANDREWS, M.B., F.R.A.C.P., M.R.A.C.R. Director of Nuclear Medicine, R.M.H.
J. R. SULLIVAN, M.B., F.R.A.C.P. Physician, Special Haematology Clinic, R.M.H. P. A. GUIGNARD, Lic.Sc.Phys. Physicist, Department of Nuclear Medicine, R.M.H. T. H. HURLEY, M.D., F.R.A.C.P. Chairman, Special Haematology Clinic, R.M.H. From Department of Nuclear Medicine and Special Haematology Clinic Royal Melbourne Hospital Presented by 1. T . Andrews at the First Asia and Oceania Congress of Nuclear Medicine, Sydney, September, 1976 INTRODUCTION Gallium ( ' W a ) has a physical half life of 78 hours decaying by electron capture and giving 4 main y peaks of 93 KeV (40%), 185 KeV (24% ), 296 KeV (22% ) and 388 KeV (7% ) . Visualization of tumours using this agent can be obtained by different types of scanners or a scintillation camera (Winchell et al., 1970), although the mechanism by which it is concentrated in various lesions remains somewhat uncertain (Hurst et al., 1974). *'Ga Citrate does not produce untoward reactions and gives an acceptable radiation burden of the order of 0.3 rads/mCi. The compound is of value in the staging of Hodgkin's Disease ( T u r n e r et al., 1972, Johnston et al., 1974, Greenlaw et al.. 1974, Palumbo et al., 1974) and of other lymphoms (Richman et al., 1975) and an overall accuracy in localization of 83% of all lymphomas (Adler et al., 1975). The value of whole body scanning with *'Ga is recorded (Andrews and Edwards, 1975) and this paper attempts to evaluate *'Ga Citrate in lymphomas using a gamma camera and a whole body bed facility. MATERIALS AND METHODS All of the patients studied were scanned with a Nuclear Chicago Pho Gamma IV gamma camera and moving bed, generally 48 hours 296
after the intravenous injection of approximately 3 mCi of the radionuclide. A bowel preparation of Coloxyl was given for each patient prior to the scan. Scans were made from a posterior aspect with the patient supine and the camera head below the scanning bed. The camera scanning bed system is shown in Figure I . The 93 KeV peak (40%) of "'Ga was set with a window of 25% and a medium energy parallel holed collimator was used in every case. This collimator has an energy limit of 410 Key The time for each study was approximately 30 minutes scanning from head to thigh and the total number of counts accumulated were
FIGURE 1-The camera scanning bed system. Awtralasian Radiology, Vol. XX,N o , 3 , Seprember, 1976
WHOLEBODYSCANNING WITH “GA
TABLE 1 RESULTSOF GALLIUM SCANNING i~ LYMPHOMA ACCORDING TO DIAGNOSES ~~~
NonHodgkin’s Hodgkin’s Disease Lymphoma Initial Staging (Diagnosis known) Immediate Restaging (following treatment) Subsequent Reinvestigation (previous diagnosis of lymphoma) P.U.O.
Investigation of possible lymphoma (other than P.U.O.)
~~
POSITIVE CASES
TOTAL CASES Other
Hodgkin’s Disease
NonHodgkin’s Disease
Other
8
13
0
4
5
0
3
8
0
0
0
0
6
6
0
4
1
0
0
4
3
0
2
14
0
1
2 (chronic lymphatic leukemia. psittacosis) 3 (seminoma, amyloidosis, carcinoma of the breast)
0
3
between 160 and 560 K, with an average of 250 K per study. Each patient routinely had also a standard u!’mTcsulphur colloid liver and spleen scan using 1-2 mCi of the radionuclide. This study was made prior to the ‘;;Cia scan in each case. A total of 68 patients were studied from February 1975 to July 1976 (17 months). Scanning was performed in 24 patients because a lymphoma was suspected clinically or on x-ray or as part of a workup for pyrexia of unknown origin. 32 patients with proven Hodgkin’s disease or Non-Hodgkin’s lymphoma were scanned as part of initial staging investigations or as part of a restaging procedure after a course of treatment had been given with radiotherapy or chemotherapy. 12 scans were performed as part of subsequent re-investigation in patients who had been treated for lymphona some years previously. See Table 1. 17 patients had Hodgkin’s disease, 34 NonHodgkin’s lymphoma (lymphosarcoma, reticulum cell sarcoma) and 17 were subsequently shown to have a variety of disorders including chronic lymphatic leukaemia, carcinoma of the breast, amyloidosis ( 2 cases), seminoma, nonspecific lymphadenopathy (5 cases), P.U.O. not yet diagnosed ( 3 cases), cystic hygroma. psittacosis, myetoproliferative syndrome and cirrhosis of the liver with chylous ascites.
RESULTSAND CASES Twenty positive gallium scans were recorded in 68 patients (19.4% 1. Eight positives were recorded in 17 patients with Hodgkin’s disease (47% ). Seven positives were recorded in 34 patients with Non-Hodgkin’s lymphoma (20.5% ). Thirty-seven patients were male and 31 female. Twenty patients were initially staged with gallium scans. Four of eight patients with Hodgkin’s disease (50% ) were positive and 5 of 13 patients with Non-Hodgkin’s lymphoma (38% 1 were positive. See Table 1. Cases t -5 illustrate this group. Eleven scans were performed as part of immediate restaging to assess the effectiveness of treatment. All were negative. In one case the scan prior to treatment had been performed and was positive. The repeat scan was negative. See Case 6. Twelve scans were done on patients in whom recurrence was suspected some years after initial treatment. Five were positive. See Cases 7 and 8. Seven scans were performed because of P.U.O. and 4 were positive. Two patients had Non-Hodgkin’s lymphoma, one chronic lymphatic leukaemia and one psittacosis. Seventeen scans were performed in patients suspected of having a lymphoma on other clinical grounds. Four were positive although 3 of these were not due to lymphoma (seminoma, amyioid. carcinoma of the breast).
A~strrrlasiunRadiology. Vol. XX. No. 3, September, 1976
297
J. T. ANDREWS, J. R. SULLIVAN, P.A. GUIGNARD AND T. H. HURLEY
FIGURE ?-Case I . Hodgkin’s disease. Uptake in mediastinum and lumbar region.
FIGURE3 - C a ~ e2. Hodgkin’s disease. Uptake in thyroid region and contiguous areas also in apex of right lung.
Case I
Non-Hodgkin’s lymphoma. Gallium scan (Figure 5 ) showed uptake in the region of the laminectomy and in the abdomen.
A 34 year old man was found at laminectomy, performed because of back pain, to have Hodgkin’s disease of the lumbar spine. Gallium scanning showed uptake in that region and also in the mediastinum (see Figure 2). Case 2 A 23 year old woman was noted to have a thyroid enlargement. Biopsy showed lymph node masses of Hodgkin’s disease infiltrating the thyroid. A gallium scan (Figure 3) showed uptake in the thyroid region and in the right hilum of the lung. Case 3 A 68 year old woman presented with night sweating and weight loss. A large multinodular goitre had been present for many years. Enlarged lymph nodes were noted in the right supraclavicular triangle. Biopsy showed Hodgkin’s disease. A gallium scan (Figure 4) showed uptake in the region of the neck and the axilla. Case 4 A 46 year old woman was treated by laminectomy because of mid thoracic cord compression. Biopsy of the extradural mass showed a
298
Case 5
A 64 year old female with fever, night sweating, weight loss and enlarged lymph nodes above and below the diaphragm. Biopsy showed Hodgkin’s disease. Gallium scan (Figure 6 ) showed a marked uptake in the left cervical and axillary area, and to a lesser extent the right axilla and abdomen. Case 6
A 68 year old woman complained of vague lower abdominal pain for 6 months. Barium enema was normal. She then presented with a large bowel obstruction and at laparotomy was found to have a large mass obstructing the ascending and mid transverse colon. A right hemicolectomy was performed. Biopsy showed reticulum cell sarcoma involving the colon and pericolic lymph nodes. Gallium scan (Figure 7) showed uptake in the region of the lower abdomen. Treatment was given with Cyclophosphamide, Vincristine, Methotrexate and Adriamycin. Subsequent gallium scan (Figure Australasian Radiology, Vol. X X , N o . 3 , September. 1976
WHOLE
BODYS C A N N I N G
WITH
“’GA
FIGURE S--Case 4 . Non-Hodgkin’s lymphoma. Uptake in mid thoracic region and in all of mid line abdomen gland areas.
FIGURF4-Case 3. Hodgkin’s disease. Uptake in right cervical and axillary nodes.
8 ) showed resolution of the mass on this treatment. Case 7 A 47 year old executive was treated for stage 1Vb Hodgkin’s disease with Procarbazine in 1967. Subsequently he was well and on no treatment. H e then developed a normochromic. normocytic anaemia and vague dyspeptic symptoms. A Barium swallow, gastroscopy and liver/spleen scan were normal. Bone marrow aspirate was normal. Gallium scan (Figure 9 ) showed uptake in the region of the epigastrium. Subsequently a laparotomy showed tumour encasing the region of the pancreas which, on biopsy. was recurrent Hodgkin’s disease. Case 8 A 47 year old man presented with fever of unknown origin. Lymph node biopsy and liver biopsy showed stage 1Vb Hodgkin’s disease. Treatment with modified M.O.P.P. (Nicholson el al.) resulted in resolution of fever and clinical Improvement. No further treatment was then given for a period of 18 months following which the patient became generally unwell again Australasian Radiologv, Vol. X X . N o . 3 , September. I976
FIGURE 6-Case 5. Hodgkin’s disease. Uptake in left cervical and axillary regions. Less uptake in right axilla and mid line abdomen.
with occasional night sweating. E.S.R. was 40 mm in 1 hour. Gallium scanning (Figure 10) showed an uptake in the epigastric region. A repeat lymph node biopsy showed recurrent Hodgkin’s disease. 299
J. T. ANDREWS, J. R. SULLIVAN, P. A. GUICNARD AND T. H. HURLEY
FIGURE 7-Case 6. Non-Hodgkin’s lymphoma. Uptake in abdomen. FIGURE 8-Case
DISCUSSION It is evident from the study that gallium scanning is most effective in the investigation of patients with possible recurrence of lymphoma after some years. In this series 4 of 6 patients with recurrent Hodgkin’s disease had positive gallium scans. See Table 1. It was particularly useful in patients with recurrent disease in the upper abdomen (Andrews et al., 1976) as illustrated by Cases 7 and 8. Positive scans were obtained during initial staging investigations in a slightly smaller percentage of cases. In one case uptake in the mediastinum made subsequent interpretation of this area on chest x-ray easier. In both of the above groups of patients a higher rate of positive scans was obtained in Hodgkin’s disease compared to Non-Hodgkin’s lymphoma. In the investigation of P.U.O. positive gallium scans were obtained in 5 of 8 cases. However in two of these cases, the final diagnosis was not lymphoma. P.U.0.k are difficult to investigate and the gallium scan in this situation was often helpful in directing the subsequent investigations although not diagnostic of a lymphoma. Where lymphomas are suspected on other clinical grounds a gallium scan was less commonly positive and in our series a positive test was more likely due to a diagnosis other than lymphoma. See Table 1.
300
6 . Following treatment scan became normal.
The gallium scan, although having a relatively low yield of positive results in the lymphomas particularly the Non-Hodgkin’s lymphomas is still a useful procedure. It has a low morbidity compared to procedures with similar yields such as lymphangiography. The whole body technique has the advantage of scanning all lymph node areas simultaneously with the same low morbidity. A positive test, though relatively infrequent, has the advantage of immediately pointing the direction for further investigation. An added advantage compared to a lymphogram is that the histology is not altered by the imaging agent. CONCLUSION The gallium scan is a useful procedure even though the yield in lymphoma, particularly Non-Hodgkin’s lymphoma, is relatively low. It virtually has no morbidity compared to procedures with a similar yield such as lymphangiography and in addition the histology is not altered by the imaging agent. The whole body technique has the advantage of scanning all areas of interest at the one investigation. A positive test immediately indicates the direction for further investigation. The greatest returns may be in the subsequent re-investigation of a patient previously treated.
Australasian Radiology, Vol. XX.N o . 3 , September, 1976
WHOLE
FIGURE 9-Case
BODYSCANNING
WITH
“’GA
7 . Recurrent Hodgkin’s disease. Uptake in epigastric region.
REFERENCES Adler, S., Parthasarathy, K. L., Bakshi, S. P., Stutzman. L. (1975): “Gallium“ Citrate Scanning for Localization and Staging of Lymphomas.” J . Nuc. Med., 16.255-260. Andrews, J. T., Sullivan, J. R., McKay, W. J., Hurley, T. H. (1976): “The Value of Gallium“ Scanning In Upper Abdominal Lymphomas.” Med. I. Ausf., 2, 170-172.
Andrews, G. A.. Edwards, C. L. (1975): “Tumor Scanning with Galliume7.”J A M A , 233, 1100-1103. Greenlaw, R. H., Weinstein, M. D., Brill, A. B.. McBain, J. K., Murphy, L., Kniseley, R. M. (1974) : “%a-Citrate Imaging in Untreated Malignant Lymphoma. Preliminary Report of Co-operative Group.” J. Nuc. Med.. 15. 404-407. Hurst, W. B., Andrews, J. T., Chmiel, R. L., Martin, J. J., Sephton, R. G., and Budd, R. S. (1974): “The Use of “Gallium Citrate Scanning to Stage Malignancies of the Head and Neck.” Ausfralasian Radiol., 18. 19-26. Johnston, G., Benua, R. S., Teates, C. D., Edwards, C. L., e i s e l e y , R. M. (1974): ‘Wa-Citrate Imaging in Untreated Hodgkin’s DiseasePreliminary Report of Co-operative Group.” 1. Nuc. Med.. 15. 399-403.
FIGURE10-Case 8. Recurrent Hodgkin’s disease. Uptake in epigastric region.
Nicholson, W. M., Beard, M. E. J., Crowther, D., Stansfield, A. G., Vartan, C. P., Malpas, J. S., Fairley, G. H., and Scott, R. B. (1970): “Combination Chemotherapy in Generalised Hodgkin’s Disease.” Brif.Med. I., 3.7-10. Palumbo, R., Tonato, M., Martelli, M. F., Corso, S., Allegra, A., Crini, L., Orignani, F. 11974): Scanning in the Staging of Hodgkin’s Disease.” A c f a haemat., 52,280-288. Richman, S. D., Levenson, S. M., Jones, A. E., and Johnston, G. S. (1975): “Radionuclide Studies in Hodgkin’s Disease and Lymphomas.” Seminars in Nuclear Medicine, 5. 103-118. Turner, D. A., Pinsky, S. M., Gottschalk, A., Hoffer. P. B., Ultmann, J. E., and Harper, P. V. (1972): “The Use of “Ga Scanning in the Staging of Hodgkin’s Disease.” Radiology, 104, 97-101. Winchell, H. S., Sanchez, P. D.. Watanabe, C. K., Hollander, L., Anger, H. O., McRae, J., Hayes, R. L., and Edwards, C. L. (1970) : “Visualization of Tumors in Humans Using ”Ga-Citrate and the Anger Whole B o d y Scanner, Scintillation Camera and Tomographic Scanner.” I . Nuc. Med.. 11.
Australasian Radiology, Vol. X X , N o . 3. September, 1976
459-466.
301
Whole Body Scanning with 67Gain the Investigation of Patients with Lymphomas and Suspected Lymphomas J. T. ANDREWS, M.B., F.R.A.C.P., M.R.A.C.R. Director of Nuclear Medicine, R.M.H.
J. R. SULLIVAN, M.B., F.R.A.C.P. Physician, Special Haematology Clinic, R.M.H. P. A. GUIGNARD, Lic.Sc.Phys. Physicist, Department of Nuclear Medicine, R.M.H. T. H. HURLEY, M.D., F.R.A.C.P. Chairman, Special Haematology Clinic, R.M.H. From Department of Nuclear Medicine and Special Haematology Clinic Royal Melbourne Hospital Presented by 1. T . Andrews at the First Asia and Oceania Congress of Nuclear Medicine, Sydney, September, 1976 INTRODUCTION Gallium ( ' W a ) has a physical half life of 78 hours decaying by electron capture and giving 4 main y peaks of 93 KeV (40%), 185 KeV (24% ), 296 KeV (22% ) and 388 KeV (7% ) . Visualization of tumours using this agent can be obtained by different types of scanners or a scintillation camera (Winchell et al., 1970), although the mechanism by which it is concentrated in various lesions remains somewhat uncertain (Hurst et al., 1974). *'Ga Citrate does not produce untoward reactions and gives an acceptable radiation burden of the order of 0.3 rads/mCi. The compound is of value in the staging of Hodgkin's Disease ( T u r n e r et al., 1972, Johnston et al., 1974, Greenlaw et al.. 1974, Palumbo et al., 1974) and of other lymphoms (Richman et al., 1975) and an overall accuracy in localization of 83% of all lymphomas (Adler et al., 1975). The value of whole body scanning with *'Ga is recorded (Andrews and Edwards, 1975) and this paper attempts to evaluate *'Ga Citrate in lymphomas using a gamma camera and a whole body bed facility. MATERIALS AND METHODS All of the patients studied were scanned with a Nuclear Chicago Pho Gamma IV gamma camera and moving bed, generally 48 hours 296
after the intravenous injection of approximately 3 mCi of the radionuclide. A bowel preparation of Coloxyl was given for each patient prior to the scan. Scans were made from a posterior aspect with the patient supine and the camera head below the scanning bed. The camera scanning bed system is shown in Figure I . The 93 KeV peak (40%) of "'Ga was set with a window of 25% and a medium energy parallel holed collimator was used in every case. This collimator has an energy limit of 410 Key The time for each study was approximately 30 minutes scanning from head to thigh and the total number of counts accumulated were
FIGURE 1-The camera scanning bed system. Awtralasian Radiology, Vol. XX,N o , 3 , Seprember, 1976
WHOLEBODYSCANNING WITH “GA
TABLE 1 RESULTSOF GALLIUM SCANNING i~ LYMPHOMA ACCORDING TO DIAGNOSES ~~~
NonHodgkin’s Hodgkin’s Disease Lymphoma Initial Staging (Diagnosis known) Immediate Restaging (following treatment) Subsequent Reinvestigation (previous diagnosis of lymphoma) P.U.O.
Investigation of possible lymphoma (other than P.U.O.)
~~
POSITIVE CASES
TOTAL CASES Other
Hodgkin’s Disease
NonHodgkin’s Disease
Other
8
13
0
4
5
0
3
8
0
0
0
0
6
6
0
4
1
0
0
4
3
0
2
14
0
1
2 (chronic lymphatic leukemia. psittacosis) 3 (seminoma, amyloidosis, carcinoma of the breast)
0
3
between 160 and 560 K, with an average of 250 K per study. Each patient routinely had also a standard u!’mTcsulphur colloid liver and spleen scan using 1-2 mCi of the radionuclide. This study was made prior to the ‘;;Cia scan in each case. A total of 68 patients were studied from February 1975 to July 1976 (17 months). Scanning was performed in 24 patients because a lymphoma was suspected clinically or on x-ray or as part of a workup for pyrexia of unknown origin. 32 patients with proven Hodgkin’s disease or Non-Hodgkin’s lymphoma were scanned as part of initial staging investigations or as part of a restaging procedure after a course of treatment had been given with radiotherapy or chemotherapy. 12 scans were performed as part of subsequent re-investigation in patients who had been treated for lymphona some years previously. See Table 1. 17 patients had Hodgkin’s disease, 34 NonHodgkin’s lymphoma (lymphosarcoma, reticulum cell sarcoma) and 17 were subsequently shown to have a variety of disorders including chronic lymphatic leukaemia, carcinoma of the breast, amyloidosis ( 2 cases), seminoma, nonspecific lymphadenopathy (5 cases), P.U.O. not yet diagnosed ( 3 cases), cystic hygroma. psittacosis, myetoproliferative syndrome and cirrhosis of the liver with chylous ascites.
RESULTSAND CASES Twenty positive gallium scans were recorded in 68 patients (19.4% 1. Eight positives were recorded in 17 patients with Hodgkin’s disease (47% ). Seven positives were recorded in 34 patients with Non-Hodgkin’s lymphoma (20.5% ). Thirty-seven patients were male and 31 female. Twenty patients were initially staged with gallium scans. Four of eight patients with Hodgkin’s disease (50% ) were positive and 5 of 13 patients with Non-Hodgkin’s lymphoma (38% 1 were positive. See Table 1. Cases t -5 illustrate this group. Eleven scans were performed as part of immediate restaging to assess the effectiveness of treatment. All were negative. In one case the scan prior to treatment had been performed and was positive. The repeat scan was negative. See Case 6. Twelve scans were done on patients in whom recurrence was suspected some years after initial treatment. Five were positive. See Cases 7 and 8. Seven scans were performed because of P.U.O. and 4 were positive. Two patients had Non-Hodgkin’s lymphoma, one chronic lymphatic leukaemia and one psittacosis. Seventeen scans were performed in patients suspected of having a lymphoma on other clinical grounds. Four were positive although 3 of these were not due to lymphoma (seminoma, amyioid. carcinoma of the breast).
A~strrrlasiunRadiology. Vol. XX. No. 3, September, 1976
297
J. T. ANDREWS, J. R. SULLIVAN, P.A. GUIGNARD AND T. H. HURLEY
FIGURE ?-Case I . Hodgkin’s disease. Uptake in mediastinum and lumbar region.
FIGURE3 - C a ~ e2. Hodgkin’s disease. Uptake in thyroid region and contiguous areas also in apex of right lung.
Case I
Non-Hodgkin’s lymphoma. Gallium scan (Figure 5 ) showed uptake in the region of the laminectomy and in the abdomen.
A 34 year old man was found at laminectomy, performed because of back pain, to have Hodgkin’s disease of the lumbar spine. Gallium scanning showed uptake in that region and also in the mediastinum (see Figure 2). Case 2 A 23 year old woman was noted to have a thyroid enlargement. Biopsy showed lymph node masses of Hodgkin’s disease infiltrating the thyroid. A gallium scan (Figure 3) showed uptake in the thyroid region and in the right hilum of the lung. Case 3 A 68 year old woman presented with night sweating and weight loss. A large multinodular goitre had been present for many years. Enlarged lymph nodes were noted in the right supraclavicular triangle. Biopsy showed Hodgkin’s disease. A gallium scan (Figure 4) showed uptake in the region of the neck and the axilla. Case 4 A 46 year old woman was treated by laminectomy because of mid thoracic cord compression. Biopsy of the extradural mass showed a
298
Case 5
A 64 year old female with fever, night sweating, weight loss and enlarged lymph nodes above and below the diaphragm. Biopsy showed Hodgkin’s disease. Gallium scan (Figure 6 ) showed a marked uptake in the left cervical and axillary area, and to a lesser extent the right axilla and abdomen. Case 6
A 68 year old woman complained of vague lower abdominal pain for 6 months. Barium enema was normal. She then presented with a large bowel obstruction and at laparotomy was found to have a large mass obstructing the ascending and mid transverse colon. A right hemicolectomy was performed. Biopsy showed reticulum cell sarcoma involving the colon and pericolic lymph nodes. Gallium scan (Figure 7) showed uptake in the region of the lower abdomen. Treatment was given with Cyclophosphamide, Vincristine, Methotrexate and Adriamycin. Subsequent gallium scan (Figure Australasian Radiology, Vol. X X , N o . 3 , September. 1976
WHOLE
BODYS C A N N I N G
WITH
“’GA
FIGURE S--Case 4 . Non-Hodgkin’s lymphoma. Uptake in mid thoracic region and in all of mid line abdomen gland areas.
FIGURF4-Case 3. Hodgkin’s disease. Uptake in right cervical and axillary nodes.
8 ) showed resolution of the mass on this treatment. Case 7 A 47 year old executive was treated for stage 1Vb Hodgkin’s disease with Procarbazine in 1967. Subsequently he was well and on no treatment. H e then developed a normochromic. normocytic anaemia and vague dyspeptic symptoms. A Barium swallow, gastroscopy and liver/spleen scan were normal. Bone marrow aspirate was normal. Gallium scan (Figure 9 ) showed uptake in the region of the epigastrium. Subsequently a laparotomy showed tumour encasing the region of the pancreas which, on biopsy. was recurrent Hodgkin’s disease. Case 8 A 47 year old man presented with fever of unknown origin. Lymph node biopsy and liver biopsy showed stage 1Vb Hodgkin’s disease. Treatment with modified M.O.P.P. (Nicholson el al.) resulted in resolution of fever and clinical Improvement. No further treatment was then given for a period of 18 months following which the patient became generally unwell again Australasian Radiologv, Vol. X X . N o . 3 , September. I976
FIGURE 6-Case 5. Hodgkin’s disease. Uptake in left cervical and axillary regions. Less uptake in right axilla and mid line abdomen.
with occasional night sweating. E.S.R. was 40 mm in 1 hour. Gallium scanning (Figure 10) showed an uptake in the epigastric region. A repeat lymph node biopsy showed recurrent Hodgkin’s disease. 299
J. T. ANDREWS, J. R. SULLIVAN, P. A. GUICNARD AND T. H. HURLEY
FIGURE 7-Case 6. Non-Hodgkin’s lymphoma. Uptake in abdomen. FIGURE 8-Case
DISCUSSION It is evident from the study that gallium scanning is most effective in the investigation of patients with possible recurrence of lymphoma after some years. In this series 4 of 6 patients with recurrent Hodgkin’s disease had positive gallium scans. See Table 1. It was particularly useful in patients with recurrent disease in the upper abdomen (Andrews et al., 1976) as illustrated by Cases 7 and 8. Positive scans were obtained during initial staging investigations in a slightly smaller percentage of cases. In one case uptake in the mediastinum made subsequent interpretation of this area on chest x-ray easier. In both of the above groups of patients a higher rate of positive scans was obtained in Hodgkin’s disease compared to Non-Hodgkin’s lymphoma. In the investigation of P.U.O. positive gallium scans were obtained in 5 of 8 cases. However in two of these cases, the final diagnosis was not lymphoma. P.U.0.k are difficult to investigate and the gallium scan in this situation was often helpful in directing the subsequent investigations although not diagnostic of a lymphoma. Where lymphomas are suspected on other clinical grounds a gallium scan was less commonly positive and in our series a positive test was more likely due to a diagnosis other than lymphoma. See Table 1.
300
6 . Following treatment scan became normal.
The gallium scan, although having a relatively low yield of positive results in the lymphomas particularly the Non-Hodgkin’s lymphomas is still a useful procedure. It has a low morbidity compared to procedures with similar yields such as lymphangiography. The whole body technique has the advantage of scanning all lymph node areas simultaneously with the same low morbidity. A positive test, though relatively infrequent, has the advantage of immediately pointing the direction for further investigation. An added advantage compared to a lymphogram is that the histology is not altered by the imaging agent. CONCLUSION The gallium scan is a useful procedure even though the yield in lymphoma, particularly Non-Hodgkin’s lymphoma, is relatively low. It virtually has no morbidity compared to procedures with a similar yield such as lymphangiography and in addition the histology is not altered by the imaging agent. The whole body technique has the advantage of scanning all areas of interest at the one investigation. A positive test immediately indicates the direction for further investigation. The greatest returns may be in the subsequent re-investigation of a patient previously treated.
Australasian Radiology, Vol. XX.N o . 3 , September, 1976
WHOLE
FIGURE 9-Case
BODYSCANNING
WITH
“’GA
7 . Recurrent Hodgkin’s disease. Uptake in epigastric region.
REFERENCES Adler, S., Parthasarathy, K. L., Bakshi, S. P., Stutzman. L. (1975): “Gallium“ Citrate Scanning for Localization and Staging of Lymphomas.” J . Nuc. Med., 16.255-260. Andrews, J. T., Sullivan, J. R., McKay, W. J., Hurley, T. H. (1976): “The Value of Gallium“ Scanning In Upper Abdominal Lymphomas.” Med. I. Ausf., 2, 170-172.
Andrews, G. A.. Edwards, C. L. (1975): “Tumor Scanning with Galliume7.”J A M A , 233, 1100-1103. Greenlaw, R. H., Weinstein, M. D., Brill, A. B.. McBain, J. K., Murphy, L., Kniseley, R. M. (1974) : “%a-Citrate Imaging in Untreated Malignant Lymphoma. Preliminary Report of Co-operative Group.” J. Nuc. Med.. 15. 404-407. Hurst, W. B., Andrews, J. T., Chmiel, R. L., Martin, J. J., Sephton, R. G., and Budd, R. S. (1974): “The Use of “Gallium Citrate Scanning to Stage Malignancies of the Head and Neck.” Ausfralasian Radiol., 18. 19-26. Johnston, G., Benua, R. S., Teates, C. D., Edwards, C. L., e i s e l e y , R. M. (1974): ‘Wa-Citrate Imaging in Untreated Hodgkin’s DiseasePreliminary Report of Co-operative Group.” 1. Nuc. Med.. 15. 399-403.
FIGURE10-Case 8. Recurrent Hodgkin’s disease. Uptake in epigastric region.
Nicholson, W. M., Beard, M. E. J., Crowther, D., Stansfield, A. G., Vartan, C. P., Malpas, J. S., Fairley, G. H., and Scott, R. B. (1970): “Combination Chemotherapy in Generalised Hodgkin’s Disease.” Brif.Med. I., 3.7-10. Palumbo, R., Tonato, M., Martelli, M. F., Corso, S., Allegra, A., Crini, L., Orignani, F. 11974): Scanning in the Staging of Hodgkin’s Disease.” A c f a haemat., 52,280-288. Richman, S. D., Levenson, S. M., Jones, A. E., and Johnston, G. S. (1975): “Radionuclide Studies in Hodgkin’s Disease and Lymphomas.” Seminars in Nuclear Medicine, 5. 103-118. Turner, D. A., Pinsky, S. M., Gottschalk, A., Hoffer. P. B., Ultmann, J. E., and Harper, P. V. (1972): “The Use of “Ga Scanning in the Staging of Hodgkin’s Disease.” Radiology, 104, 97-101. Winchell, H. S., Sanchez, P. D.. Watanabe, C. K., Hollander, L., Anger, H. O., McRae, J., Hayes, R. L., and Edwards, C. L. (1970) : “Visualization of Tumors in Humans Using ”Ga-Citrate and the Anger Whole B o d y Scanner, Scintillation Camera and Tomographic Scanner.” I . Nuc. Med.. 11.
Australasian Radiology, Vol. X X , N o . 3. September, 1976
459-466.
301
