Evaluation ofa Liver Transplant by Tc-99mDimethyl-IDA Scintigraphy

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CASE            REPORTS

          Evaluationof a Liver Transplantby Tc-99m Dimethyl-IDA Scintigraphy
                                    J. V. Herry, P. Brissot, J. J. Le Jeune, B. Launois, and M. Bourel

                                                    Hópita!do Pontchaiiou, Rennos, France

                    In lIver-transplantpatients,It is always difficultto differentIatebetween rejec
                 tion crisesand extrahepaticblliaryobstruction the basisof standardbiocheml
                 cal tests alone.A case is reportedof a patientwho receIveda transplantfollowing
                 total hepatectomyperformedbecause of a hepatoma. Scintigraphywith Tc-99m
                 N-(dimethylphenylcarbamoylmethyl)imlnodiacetic poIntedconclusivelyto an
                 obstructiveprocess,whichwas confirmedat re-operation.

                 J NucI Med 21: 657-659,                1980

   Restoration of normal bile flow from liver to intestine is one of            liver. Selective hepatic arteriography showed pronounced changes
the major problems of liver transplantation. In a large proportion              consistent with an invasive tumor. Catheterization of the splenic
of cases, transplant failure is due to complications, mechanical                and superior mesenteric arteries showed partial invasion of the
and/or infective, involving the bile-duct-to-bowel anastomosis (1).             portal vein and its branches. Exploratory Iaparotomy confirmed
Personal experience of the effectiveness of Tc-99m N-(dimeth                    the impracticability of attempting tumor removal by subtotal
ylphenylcarbamoylmethyl) iminodiacetic acid (Tc-99m di                          hepatectomy.    Since no evidence of extrahepatic       spread was seen,
methyl-IDA)     in imaging bile-duct-to-bowel    anastomoses        prompted    the decision was made to perform a liver transplant@ttion.Following
its use in the monitoring of a liver transplant. Scintigraphic studies total hepatectomy,   the liver of a 20-year-old male road-accident
were performed on five occasions. Results of a scintigraphic study     victim was grafted into the patient. Normal bile flow was re-es
of I6 healthy individuals were used as reference. Analysis of the      tablishedby anastomosis    ofthe gallbladderand thejejunum. Three
scans  focused  onthequalityof liveruptake,time-activitypatterns days after transplantation a Tc-99m dimethyl-IDA scintigram
over the liver and bile ducts, degree of renal clearance,   and onset  (Fig. I) showed almost normal patterns. Liver uptake was intense.
and intensity of intestinal radioactivity. In the normal scintiscan     Imaging of renal excretion ceased at around I 5 mm. At I 2 mm
sequence, early hepatic activity is intense and homogeneous,           onset of activityover the anastomosisoccurred.Thereafter activity
reaching maximumat around20 mm. Renalactivitydisappears over the anastomosis and intestinal tract increased regularly. A
at around I0 mm. As a rule the biliary tree begins to appear at I 2    second scan, performed 3 days later because of elevated serum
mm. Onset of intestinal excretion is variable but on average occurs    alkaline phosphatase (92 U/I), showed little change in liver uptake
at around 23 mm.                                                        but much weaker and considerably delayed activity of the tracer
                                                                       over the anastomosis. At the same time, intestinal accumulation
                                                                        was diminished. Five days later another scintigram revealed total
                           CASE REPORT
                                                                        biliary excretory failure. Liver uptake remained pronounced but
                                                                                at I hr bowel   activity    was not seen.   An area   of clearly     reduced
                                     ofabdominal pain and
  A 46-year-oldman wasadmitted because
              disorders. historyfeatureda moderate
                       The                        degree                        activity suggestive of biliary distension was noted over the left lobe.
of alcoholism   and chemical   diabetes.   Laboratory    findings     pointed
                                                                                At this time total bilirubinemia was 84 @zmol/l alkaline
to hepatic cytolysis: SGPT 77 U/I (normal @I5),   SGOT 63 U/I   phosphatase 171 U/I. Two days after the last scintigraphic ex
(normal @20); cholestasis:otal bilirubinemia 34 zmol/l
                 and              t                             amination, an i.v. cholangiogram confirmed bile-duct distension.
(normal @l7),  serum alkaline phosphatase 124 U/I (normal @30). At re-operation the gallbladder appeared fibrotic and atrophied
HB,Ag waspresent in the serum.Scintigraphyshoweda largearea                     and the biliary tree was markedly dilated (Fig. 2). After removal
of diminished activity over the junction between the right and left             of the gallbladder,    bile flow was established      through      a choledo
lobes. Laparoscopy and histologic examination of biopsy specimens               chojejunal anastomosis. Patency of this newconduit was demon
pointed conclusivelyto a hepatoma complicating cirrhosis of the                 strated on a scintigram performed 2 days later, whichalso showed
                                                                                persistent changes, such as weak hepatic uptake, pronounced
                                                                                background activity, marked renal excretion, and slowduodenal
  Received May 21, 1979; revision accepted Jan. 15, 1980.                       flow. These abnormalities     were undoubtedly     related to the fact that
  For reprints contact: J. Y. Herry, MD, Laboratoire de Medecine                the liverhad not yet recoveredfrom the 20-dayperiodof bilestasis,
Nucleaire, Centre Eugene Marquis, I-Iôpital Pontchaillou, 3501 1
                                           de                                   which wasseen,on laboratoryevidence,to persist.The subsequent
Rennes Cedex, France.                                                           outcome was favorable. Two Tc-99m dimethyl-IDA scintigrams,

Volume 21, Number 7                                                                                                                                       657
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        ---.@                                                                                                         FIG. 1. Tc-99m dimethyl-IDAscintigraphy
                                                                                                                      of the hepatobiliary system. Scintiphotos
                                                                                                                      taken 10, 30, and 60 mm after injection of
                                                                                                                      theradiopharmaceutical(A)at fter
                                                                                                                      transplant, (B) at 11 days, and (C) at 60

    performed at 2 and 3 mo, respectively, showed satisfactory                               Tc-99m dimethyl-IDA. In viewofthe need for repeated radionu
    transplant function.                                                                     elide and radiologic procedures in liver-transplant evaluations, as
                                                                                             well as the increased survival expectations for transplant recipients,
                                                                                             such dosimetry considerations are of no little importance.
                                                                                               In conclusion, the case described points to the effectivenessof
      Several studies of hepatobiliary diseases have been conducted                          Tc-99m dimethyl-IDA scintigraphy in the monitoring of liver
    with the aid of iminodiacetic acid derivatives (2—4). ur case iI
                                                          O                                  transplants. The results obtained reflect both the functional status
    lustrates the usefulness ofTc-99m dimethyl-IDA scintiscanning                            of the liver cell and the patency of the bile-duct-to-bowel anasto
    in liver-transplant        studies.   Sequential     scintigrams     performed    very
                                                                                             mosis. Unlike liver biopsy or transhepatic cholangiography, the
    soon after operation pointed to satisfactory liver function: hepatic                     method is safe, painless, and easy to perform and, by the same
    uptake was intense and homogeneous, renal activity ceased almost                         token, highly suitable for repeated examinations.
    within normal time limits, and early accumulation of the tracer
    was seen at the anastomosis. Maintenance of excellent transplant
    function was probably because the hepatectomy operations in both
    donor and recipient were performed simultaneously, so that there
    was no need for artificial preservation of the liver graft. Scans
    performed on the sixth and eleventhdays becauseof deteriorating
    liver tests, made it possible to pinpoint its cause and resolve the
    diagnostic dilemma: graft-rejection crisis or biliary complication.
    In view of the comparatively strong liver uptake and a marked
    slowing of intestinal excretion, little doubt remained that the
    problem was a biliary obstruction. The area of reduced activity
    seen over the left lobe was interpreted as evidence ofdilatation of
    the intrahepatic bile ducts. On the strength of these findings the
    decision was made to re-operate. A striking feature of the exami
    nation was the fact that the scintigraphic changes appeared very
    early in the obstructive process, at about the same time as the
    serum alkaline phosphatase began to rise, whereas the elevation
    in bilirubin    occurred      at a much     later   stage.   Follow-up   scintigrams
    confirmed patency of the new anastomosis and restoration of
    normal function of the hepatobiliary system. In the present case
    it is likely that similar findings could have been obtained with I- 131
    rose bengal scans. However, despite previous positive experience
    with rose bengal in liver-transplant monitoring (5), Tc-99m di
    methyl-IDA is to be preferred not only because ofimproved scan
    quality—an advantage documented by several investigators (6,
    7)—but also because ofdosimetry considerations. For an iv. dose
    of I mCi, total-body radiation with I- 13 1 rose bengal is approxi                                                            s
                                                                                             FIG.2. Intra-operativecholangiography, howingmarkeddistension
    mately 0.4 rad (8), compared with an estimated 0.02 rad with                             of common bile duct.

    658                                                                                                  THE JOURNAL            OF NUCLEAR          MEDICINE
                                                                                                                      CLINICAL SCIENCES
                                                                                                                               CASE REPORTS

                               REFERENCES                                       of Tc-99m-diethyl-IDA in hepatobiliary disorders. J Nuci Med
                                                                                19:783—788, 978
1. CALNE RY, WILLIAMS R: Liver transplantation.Current                       5. LAUNOIS B, CORMAN JL, PORTER KA, et al: Radioiodinated
   Problems in Surgery I6:000-000, 1979                                         rose bengal kinetics in extrahepatic biliary obstruction and
2. RYAN i, COOPERM, LOBERGM, et al: Technetium-99m-                             hepatic homograft rejection in the dog. Surg Forum 23:
   labeled N-(2,6-dimethylphenylcarbamoylmethyl) iminodi                        338-339,  1972
   acetic   acid   (Tc-99m     HIDA):    A new radiopharmaceutical     for   6. EIKMAN EA: Radionuclide hepatobiliary procedures: when
   hepatobiliary      imaging       studies. J NucI   Med    18:997-1004,                         J
                                                                                canHIDA help? NuciMed 20:358-361,           1979
   I977                                                                      7. KLINGENSMITH WC, FRITZBERGAR, KOEP Li: Compar
3. NIELSEN SP, TRAP-JENSEN J, LINDENBERG J, et al: Hep                          ison of Tc-99m-diethyl-iminodiacetic    acid and I- I 3 1 rose
   ato-biliary scintigraphy and hepatography with Tc-99m di                     bengal for hepatobiliary studies in liver-transplant patients:
   ethyl-acetanilido-iminodiacetate in obstructive jaundice. J Nuci             concise communication. J Nuci Med 20:314-31 8, 1979
   Med 19:452-457,           1978                                            8. HALL EJ: Radiobiology for the Radiologist. 2nd ed. New
4. PAUWELS5, STEELSM, PIRET L, et al: Clinical evaluation                       York, Harper and Row, I978, p 432

                                        EmboliLodgePreferentially PriorFoci?
                    Do RecurrentPulmonary                       in
                                                                        Bruno Schober

                     Lions Gate Hospital, North Vancouver,and Vancouver General Hospital, Vancouver, B.C., Canada

                      Two cases of recurrentpulmonaryembolismare presented:the perfusionlung
                                 h                              l
                    scintigrams, avingbeenpositiveonadmissIon, ater showednearlycompleteres
                    torationof perfusion.However,duringthe secondepIsodeof pulmonary  embolism,
                    whichoccurredseveralyearslater, the perfusIon defectswere locatedinthe same
                    foci as previously.

                   J NucI Med 21: 659—661,

   It is known that recurrent pulmonary embolism occurs not                                           CASE REPORTS
only in the elderly bedridden patient—especially if he suffers from
serious cardiopulmonary or malignant disease—but also in the                 Case I. In April 1975 a fifteen-year-old student presented herself
apparently healthy, physically active, and, often, young individual          with progressing neurological problems that were due to an epi
(I ).Guter nd
         a Serafini
                                             must                            dermoid cystic tumor of the third ventricle. After surgical removal
occur in previously obstructed portions of the lung, but they cite           of the tumor, she had a complicatedrecovery,includingdeep-vein
no examples and suggest no estimate of their frequency. Similarly            thrombosis and pulmonary embolism. The chest radiograph was
Johnson (3) stated that serial lung scanning guards against future           normal, but on May 22 a perfusionlung scanconfirmed pulmonary
misdiagnosis: “Should  these deficits involve new regions of the           embolism.The right middlelobe,the anterior and lateral segments
lungs, it is highly probable that they represent new emboli, but             of the right lower lobe, the lingulae, and the anterior segmentof
should they coincide with previous areas ofischemia it is possible           the left lower lobe were without perfusion. (For the defects seen
that they represent nothing more than residual ischemia from                 on the lateral views see Fig. IA.) After appropriate medication she
earlier emboli that failed to resolve completely.―                         gradually improved and was discharged in June 1975.
   The following two case reports show that this may not always                In November 1976a regrowth ofthe tumor was surgically re
be so and that the lodging of recurrent pulmonary emboli into                moved.The postoperativerecoverywassimilar to the previousone,
previously compromised areas could be more frequent than is                  including a clinically diagnosed pulmonary embolism. At that time,
suspected.                                                                   no perfusion lung scan was done.
                                                                               In January 1977the patient was readmitted because recurrent
                                                                             pulmonary embolism was suspected. A perfusion lung scan was
  Received                      accepted
            Oct. 8, 1979:revision        Jan. 15, 1980.                      not remarkable except for perfusion defects in the left hilar region
  For reprints contact: Bruno Schober, Div. of Nuclear Medicine,             and the left lower lobe; these were ascribed to residual ischemia
LionsGate Hospital,230E. 13th St., North Vancouver,B.C.Canada                from the previous insult (Fig. I B).
V7L 2L7.                                                                       On March I I, I979 she came to the emergency ward because

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