67 67 GalliumGallium

Looking at the DiagnosisLooking at the Diagnosis

LymphomasLymphomas

Hodgkin’s and Non-Hodgkin’s are two Hodgkin’s and Non-Hodgkin’s are two classes of lymphomas.classes of lymphomas.

Hodgkin’s Lymphomas have a specific cell Hodgkin’s Lymphomas have a specific cell called Reed-Sternburg.called Reed-Sternburg.

All other lymphomas not having that cell All other lymphomas not having that cell are classified as Non-Hodgkin’s are classified as Non-Hodgkin’s Lymphomas.Lymphomas.

From that point, Hodgkin’s and Non-From that point, Hodgkin’s and Non-Hodgkin’s are classified into subcategories Hodgkin’s are classified into subcategories depending on symptoms and cell depending on symptoms and cell structure.structure.

LymphomaLymphoma

Normal Gallium ImageNormal Gallium Image

4 months prior 4 months prior

Abnormal Thallium ImageAbnormal Thallium Image

4 months ago showing:4 months ago showing:

Active non-Hodgkin's lymphoma in the axilla and the left neck

Patient refused treatment at the time

LymphomaLymphoma Current 67Ga image showed

new findings of active non-Hodgkin's lymphoma in the left axilla and left neck.

Tl-201 imaging showed findings of active non-Hodgkin's lymphoma in the left neck and bilateral axilla. Compared to the prior 210Tl exam, current image indicates increase intensity and further extension of disease Chemotherapy was initiatedChemotherapy was initiated

Study EvaluatedStudy Evaluated

Experience suggests that 67Ga uptake in non-Hodgkin's lymphoma has a proportional relationship between intensity of uptake (and involvement) to disease grade. Furthermore non-Hodgkin's lymphomas tend to be more avid for 201Tl than 67Ga. Thus, the interpretation of the imaging studies was that there was a mixed population of non-Hodgkin's lymphoma cells, and that both the higher and lower grade non- Hodgkin's lymphoma cells were proliferating in the axilla and left neck.

Hodgkin’s LymphomaHodgkin’s Lymphoma

Lung - InfectionLung - Infection Gallium provides a means of sensitive Gallium provides a means of sensitive

detection of an active pulmonary infection.detection of an active pulmonary infection. The degree of gallium uptake correlates The degree of gallium uptake correlates

with the degree of activity of the with the degree of activity of the inflammatory site.inflammatory site. Gallium uptake is seen inGallium uptake is seen in

Active TBActive TB Opportunistic infectionsOpportunistic infections Diffuse infiltrative lung diseaseDiffuse infiltrative lung disease SarcoidosisSarcoidosis

A rare disease of unknown cause in which A rare disease of unknown cause in which inflammation occurs in lymph nodes and other tissues inflammation occurs in lymph nodes and other tissues throughout the body, usually the lungs, liver, skin and throughout the body, usually the lungs, liver, skin and eyes.eyes.

Symptoms include fever and generalized aches. There Symptoms include fever and generalized aches. There may also be enlargement of lymph nodes in the neck or may also be enlargement of lymph nodes in the neck or elsewhere, breathlessness, arthritis, or erythema elsewhere, breathlessness, arthritis, or erythema nodosum (red purple swellings on the legs)nodosum (red purple swellings on the legs)

SarcoidosisSarcoidosis

SarcoidosisSarcoidosis Symptoms for Symptoms for acuteacute sarcoidosis include fever and sarcoidosis include fever and

generalized aches. There may also be enlargement of generalized aches. There may also be enlargement of lymph nodes in the neck or elsewhere, lymph nodes in the neck or elsewhere, breathlessness, arthritis, or erythema nodosum (red breathlessness, arthritis, or erythema nodosum (red purple swellings on the legs)purple swellings on the legs)

Symptoms for Symptoms for chronicchronic are fever, purple rash on the are fever, purple rash on the face, painful joints, painful blood shot eyes, and areas face, painful joints, painful blood shot eyes, and areas of numbness.of numbness.

Sometimes there are no symptoms.Sometimes there are no symptoms. 90% of patients recover in two years. Corticosteroids 90% of patients recover in two years. Corticosteroids

are prescribed to treat the disease.are prescribed to treat the disease. When performing a gallium scan for sarcoidosis, you When performing a gallium scan for sarcoidosis, you

are looking for the extent of involvement of the lymph are looking for the extent of involvement of the lymph nodes.nodes.

SarcoidosisSarcoidosis

Panda signPanda sign

Lambda sign - Lambda sign - ΛΛ

Lung Lung GalliumGallium

A 49 year-old, diabetic male was admitted 10 days prior to the scan for debridement of his right foot ulcer. Following the procedure the patient had persistent fevers, leukocytosis and worsening respiratory function. A gallium scan was requested to localize a source of infection.

Diagnoisis-Acute Respiratory Distress Syndrome (ARDS)

Quantitative Lung IndexQuantitative Lung Index

Data is helpful in measuring the Data is helpful in measuring the response to therapy.response to therapy.

The degree and extent of abnormal The degree and extent of abnormal uptake in the lungs correlates with uptake in the lungs correlates with many lung inflammatory disorders.many lung inflammatory disorders.

Abdominal Imaging with Abdominal Imaging with GalliumGallium

The abdomen is difficult to image with The abdomen is difficult to image with gallium because after the first 24 hours, gallium because after the first 24 hours, there may be colon uptake due to excretion there may be colon uptake due to excretion of the isotope.of the isotope.

Enemas can be administered to move the Enemas can be administered to move the colon contents.colon contents.

If questionable area does not move and stays If questionable area does not move and stays in the same area post enema/laxative then in the same area post enema/laxative then this could be an indication of disease.this could be an indication of disease.

111111In or In or 99m99mTc-WBC may be the more Tc-WBC may be the more appropriate study when evaluating the appropriate study when evaluating the abdominal processesabdominal processes

Liver Imaging with Liver Imaging with GalliumGallium

Gallium concentrates in hepatic abscesses Gallium concentrates in hepatic abscesses and neoplasms, but not in cysts hematomas, and neoplasms, but not in cysts hematomas, or non infectious fluid collections. or non infectious fluid collections.

In conjunction with In conjunction with 99m99mTc-sulfur colloid, a Tc-sulfur colloid, a liver scan should be done prior to a liver scan should be done prior to a 6767Ga Ga scan (more specifically the injection).scan (more specifically the injection).

111 111 Indium and Indium and 99m99mTc labeled WBCs also Tc labeled WBCs also localize in hepatic abscesses, but not in localize in hepatic abscesses, but not in cysts, hematomas, or non infectious fluid cysts, hematomas, or non infectious fluid collections.collections.

Gallium in Liver Gallium in Liver ImagingImaging

Differentiating a hepatoma from surrounding tissue in a cirrhotic liver

Diagnosis Gallium-67 is taken

up by hepatoma cells giving a "hot spot" or at least an area of equal uptake to surrounding liver

Anterior PosteriorAnterior Posterior

Transverse CoronalTransverse Coronal

Renal Imaging with Renal Imaging with GalliumGallium

99m99mTc renal imaging agents will show focal Tc renal imaging agents will show focal abnormalities and usually diminished overall abnormalities and usually diminished overall function in the kidney with pyelonephritis or function in the kidney with pyelonephritis or abscess.abscess. Gallium imaging adds specificity.Gallium imaging adds specificity. Gallium concentrates in active pyelonephritis, Gallium concentrates in active pyelonephritis,

while normal kidneys imaged 48 hours after while normal kidneys imaged 48 hours after gallium injection show no uptake. Note – kidneys gallium injection show no uptake. Note – kidneys should only be seen at 24 hours. Why?should only be seen at 24 hours. Why?

Gallium imaging can help in distinguishing lower Gallium imaging can help in distinguishing lower urinary tract infection from upper tract disease, urinary tract infection from upper tract disease, or by diagnosing both.or by diagnosing both.

Subcapsular Hematoma of the Left Kidney99m99mTc RenalTc Renal

Gallium ScanGallium Scan

Patient diagnosed with subcapsular hematoma of the left kidney on CT. Because of recurrent episodes of unexplained fever a Gallium Scan was performed to rule out abscess formation in the left perinephric hematoma. There was no uptake in the left kidney region. The right kidney, however, showed intense homogeneous Gallium uptake post 24 hours.

Gallium in AIDS PatientsGallium in AIDS Patients

Gallium is useful in imaging patients Gallium is useful in imaging patients who have AIDS, because they can who have AIDS, because they can have a variety of infections that will have a variety of infections that will be detected on a whole body gallium be detected on a whole body gallium scan.scan.

Disorders in AIDS Disorders in AIDS PatientsPatients

Pneumocystis carinii Pneumocystis carinii pneumonia (PCP)pneumonia (PCP)

caused by single celled caused by single celled parasite; symptoms dry parasite; symptoms dry cough and SOBcough and SOB

Candida esophagitisCandida esophagitis infection; oral lesions infection; oral lesions

which adhere to oral which adhere to oral mucosamucosa

CytomegalovirusCytomegalovirus common herpes virus that common herpes virus that

usually has no symptomsusually has no symptoms CryptococcusCryptococcus

airborne, found in soil esp. airborne, found in soil esp. contaminated with pigeon contaminated with pigeon droppings--can cause droppings--can cause meningitismeningitis

Herpes simplexHerpes simplex

Kaposis SarcomaKaposis Sarcoma blue/red malignant skin blue/red malignant skin

tumors that usually start at tumors that usually start at the feet then spreadthe feet then spread

LymphomaLymphoma Hodgkin’s (malignant Hodgkin’s (malignant

disorder of the lymphoid disorder of the lymphoid tissue, more sever than Non tissue, more sever than Non Hodgkin’s Hodgkin’s

ToxoplasmosisToxoplasmosis Caused by bacteria in rare Caused by bacteria in rare

meat from infected animalsmeat from infected animals Myciobacterium Myciobacterium

aviumintrcellulare aviumintrcellulare (MAI)(MAI)

in family with tuberculosis in family with tuberculosis organismorganism

Imaging PCP PatientsImaging PCP Patients

If a patient is undergoing therapy for PCP the If a patient is undergoing therapy for PCP the gallium uptake can be less intense than those gallium uptake can be less intense than those patients not being treated.patients not being treated.

Gallium is positive in the lungs in 100% of Gallium is positive in the lungs in 100% of patients with AIDS and PCP, who are patients with AIDS and PCP, who are asymptomatic.asymptomatic. Shows the importance of a gallium scan in AIDS Shows the importance of a gallium scan in AIDS

patients with negative chest x-ray studies.patients with negative chest x-ray studies. It can be a baseline for future indications, severity and It can be a baseline for future indications, severity and

extent of the infection, which can be used as a guideline extent of the infection, which can be used as a guideline for further diagnostic interventions.for further diagnostic interventions.

Gallium Scan in AIDS Gallium Scan in AIDS PatientPatient

42 year old male, 3 week history of fevers/sweats. No respiratory symptoms such as cough or sputum. Diagnosed as HIV positive 5 years earlier. CXR was normal. Gallium scan revealed diffuse lung uptake. Washings from fibreoptic bronchoscopy confirmed pneumocystis carinii (PCP) infection.

Gallium in AIDS ImagingGallium in AIDS Imaging 43 year old male with AIDS. SOB, non-productive

cough, & fever for 2 days. Chest x-ray showed bilateral interstitial and alveolar infiltrates. Gallium scan to rule out pneumocystis carinii pneumonia (PCP).

Diffuse bilateral increased lung uptake suggestive of Pneumocystis Carinii Pneumonia(PCP).

Bone Imaging With Bone Imaging With GalliumGallium

99m99mTc bone agents are sensitive in detecting Tc bone agents are sensitive in detecting the increased bone blood flow and bone the increased bone blood flow and bone mineral turnover associated with mineral turnover associated with osteomyelitis, localizing the disease process osteomyelitis, localizing the disease process 1-2 weeks before discernible radiograph 1-2 weeks before discernible radiograph changes take place. changes take place.

Three phase is useful in distinguishing Three phase is useful in distinguishing between osteo and cellulitis. between osteo and cellulitis. But again, many bony abnormalities provoke a But again, many bony abnormalities provoke a

similar bone response, including benign or similar bone response, including benign or malignant neoplasms, infarct repair, trauma and malignant neoplasms, infarct repair, trauma and post-surgical changes.post-surgical changes.

Bone/Gallium ScanBone/Gallium Scan 99mTc-MDP bone scan shows

increased activity in the left SI Joint.

Ga 67 scan was positive in the same region.

Follow-up x-rays of the left femur showed calcifications which appeared to be within the marrow and suspicious of infarction.

67Ga further identified an infection in the same area.

Blood cultures confirmed infection and the patient was put on Ab therapy