Saudi Journal of Gastroenterology
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Year : 1999  |  Volume : 5  |  Issue : 1  |  Page : 27-31
TC-99m-labeled red blood cell scintigraphy in the investigation of patients with hepatic cavernous hemangioma


1 Department of Nuclear Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Gastroenterology, King Khalid University Hospital, Riyadh, Saudi Arabia
3 Department of Radiology, King Khalid University Hospital, Riyadh, Saudi Arabia

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Date of Submission21-Dec-1997
Date of Acceptance26-Aug-1998
 

   Abstract 

Objective: To evaluate the diagnostic accuracy of 99m Tc-red blood cell scintigraphy in the diagnosis of hepatic cavernous hemangiomas. Patients and Methods: Sixty three patients, 56 females (89%) and 7 males (1 I%), with ages between 22 and 54 years (median 33 years) were investigated for liver masses found on ultrasonography of the abdomen. All the patients had undergone 99m Tc-liver-spleen scan followed by 99m Tc-red blood cells scintigraphy. The size of the lesions ranged between 3 and 9 cm. The final diagnosis was reached through cytology, and/or histopathology or follow up for more than 3 years. Results: A total of 70 lesions were found as a single lesion in 60 patients and multiple (i.e. total of 10 lesions) in the other 3 patients. The results of 99m Tc-red blood cells scintigraphy, compared to the results of the final diagnosis, showed sensitivity and specificity rates of 100% and 89% respectively, positive and negative predictive values of 98% and 100% repectively, and accuracy rate of 98.6%. A single false positive case was a hepatocellular carcinoma. Conclusion: 99m Tc- red blood cell scintigraphy is highly accurate in the diagnosis of liver cavernous hemangioma and should characterize liver mass found on ultrasonography and suspected for hemangioma.

How to cite this article:
El-Desouki M, Mohamadiyeh M, Al-Rashed R, Othman S, Malabary T, Al-Mofleh I. TC-99m-labeled red blood cell scintigraphy in the investigation of patients with hepatic cavernous hemangioma. Saudi J Gastroenterol 1999;5:27-31

How to cite this URL:
El-Desouki M, Mohamadiyeh M, Al-Rashed R, Othman S, Malabary T, Al-Mofleh I. TC-99m-labeled red blood cell scintigraphy in the investigation of patients with hepatic cavernous hemangioma. Saudi J Gastroenterol [serial online] 1999 [cited 2019 Nov 20];5:27-31. Available from: http://www.saudijgastro.com/text.asp?1999/5/1/27/33523


Hepatic cavernous hemangioma (HCH) is the most frequent benign liver lesions with an incidence rate that can be upto 7% [1] . It may affect people of all ages predominantely females in 60% to 80% of the cases [2] . Morbidity can be attributed to rupture (although rare), bleeding, infarction, or necrosis depending on the size of the lesion (i.e. the larger the size, the higher the morbidity). Most HCH are found incidently on ultrasound examination of the abdomen or other imaging modalities. lesions of HCH are typically solitary, but rarely can be multiple [3] . On ultrasound, upto 60% of HCH lesions appear hyperechoic and the rest can be isoechoic, hypoechoic or mixed echogenicity [4] . Therefore, the ultrasonographic appearance of HCH is not specific and can not be distinguished from other liver masses such as hepatocellular carcinoma, metastases, etc. Because of the risk of hemorrhage inherent in percutaneous biopsy of HCH, non-invasive diagnostic modalities have been sought and, indeed, utilized to make the distinction of HCH from other liver lesions. 99mm Tc- red blood cell scintigraphy has been reported to be useful in the diagnosis of HCH [5],[6],[7],[8],[9],[10],[11] . In this study we report on diagnostic accuracy of 99mm Tc­red blood cell scintigraphy in the diagnosis of hepatic cavernous hemangioma as a liver mass seen first on ultrasound.


   Patients And Methods Top


Sixty three patients, 56 females (89%) and 7 males (11%), with ages between 22 and 54 years (mean 33 years) were investigated for liver masses found on abdominal ultrasonography (US). The patients were referred to nuclear medicine in for further evaluation. All the patients had undergone 99mm Tc­liver-spleen (LS) scan followed by 99mm Tc-Red Blood Cells (RBCs) study. The results were analyzed retrospectively and compared to the final diagnosis reached by biopsy, computerized tomography CT results, surgery or followup for more than 3 years.

99m Tc-liver-spleen scan was performed using sulfur colloid or nanocolloid in a dose of 222 MBq (6 mCi) injected intravenously (iv). Imaging field was the anterior upper abdomen including liver and spleen using a gamma camera with low energy, high resolution, parallel hole collimator. Simultaneously with the injection, acquisition started with 16 frames (2 sec/ frame) of dynamic flow and a blood pool image of 120 sec followed by a set of static images of 3 minutes each in different projections.

99mm Tc-red blood cells scintigraphy was performed by in-vivo labeling the red blood cells first through injecting cold pyrophosphate iv. 20 minutes before injecting 925 MBq (25 mCi) of 99mm Tc-pertechnetate. Equipment and acquisition parameters were as described above.

Ultrasound examination of the abdomen was performed as per the standard.


   Diagnostic Criteria of Hemangioma Top


The diagnosis of HCH on US [Figure l]a was suggested when the lesion appeared with typical features of liver hemangioma that is hyperechoic, surrounded by a halo with posterior enhancement and a hypoechoic center (12) However, HCH may have other spectrum of echogenicity (i.e. mixed or hypoechoic).

The scintigraphic appearance of HCH was considered diagnostic when the lesion appeared cold on LS [Figure l]c, cold on RBCs-blood flow as well as immediate blood pool images, cold or starts filling­in on RBCs-blood pool image and finally and filled­in with activity (i.e. hot) on later RBCs-images [Figure l]d and e. CT scan results were non-specific.


   Results Top


A total of 70 lesions were found as a single lesion in 60 patients and multiple (i.e. total of 10 lesions) in the other 3 patients. The final diagnosis was reached through cytology, biopsy and / or histopathology tests in addition to a follow up for 36 months thereafter clinically and with US. Sixty one lesions proved to be cavernous hemangiomas and the other 9 lesions had other pathologies;5 hepatocellular carcinoma, 3 secondaries and adenoma.


    99m Tc-Red Blood Cell Scintigraphy Top


Diagnostic accuracy of 99m Tc-red blood cell scintigraphy is summerized in [Table - 1]. The sensitivity and specificity rates were 100% and 89% respectively. The positive and negative predictive values were 98% and 100% respectively. The accuracy rate resulted 98.6%. Only a single resulted false positive and it was a hepatocellular carcinoma.


   Ultrasonography Top


The ultrasonographic characteristics of the lesions are sununerized in [Table - 2] in terms of echogenicity, outline and location. Fourty one (59%) lesions were hyperechoic, 8 (11%) were hypoechoic and 21 (30%) had mixed echogenicity. The lesions' were well-defined in 68 (97%) and ill-defined in 2 (3%). Sixty two (89%) lesions were located in the right lobe, 8 (11%) in the left lobe. Fifty eight (83%) subdiaphragmatic, 51 (73%) superficial, 19(27%) deep, 45 (63%) posterior and 25 (36%) were anterior. Posterior enhancement was seen in all the lesions. The size of the lesions was between 3 and 9 cm (median 4.8 cm).


   Discussion Top


Imaging modalities of (HCH), larger than 3 cm, include US, CT, and magnetic resonance imaging (MRI) in addition to nuclear medicine techniques of 99mm Tc- RBCs scan. The appearance of HCH on US can be defined in three main parameters (i.e. echogenecity, outline, and location in the liver) as it is shown and summarized in [Table - 2]. However, these parameters are not specific for HCH. Sequential dynamic CT of the liver can be used in cases of HCH but only 55% to 86% of the cases fullfil the diagnostic criteria of this technique [13],[14] . On T2­weighted MRI, typical HCH may show a smooth outlines and homogenous high signal intensity [15] . Giant HCH may show a different appearance with irregular outlines and inhomogenous structure [16] . Appearance of HCH on all the above described imaging modalities may be nonspecific and, thus, confused with other masses of the liver such as metastases, sarcomas, and various adenocarcinomas [17],[18] . In most cases, HCH is an incidental finding on US and then the patients are referred to nuclear medicine for a further characterization. On 99mm Tc-LS scan, HCH appears as a cold area surrounded by a normal liver tissue [19] . This appearance is non specific but it can bespecific on serial images of 99mm Tc-RBC scan with the classic appearance [Figure - 2] of initial hypoperfusion followed by a gradual accumulation of activity giving the so called "perfusion-blood pool mismatch" pattern [20],[21] . In the literature, 99m Tc-RBC scan sensitivity rate ranged between 70% and 85% and specificity rate of 100% (17,22). In our series sensitivity and specificity rates were 100% and 89% respectively. The reason for the lower specificity was done to the single false positive case of HCC mimicking HCH. Although it is a rare occurrence that a perfusion-blood pool mismatch pattern can be seen in HCC exactly as in HCH, but it has been reported in the literature [7],[23] . However, when HCC is suspected, Gallium-67 scan can be performed to help to distinguish HCH, which does not concentrate Gallium-67, from HCC which concentrates Gallium in more than 88% of the cases [24] .

Improvements in nuclear medicine techniques have not added much to the already high diagnostic accuracy of 99m Tc-RBC scan in detecting HCH with sizes larger than 3 cm, but it ceratinly improved ability of the technique to detect lesions of a smaller size. The introduction of single photon emission tomography (SPECT) has been the most prominent improvement of the technique which enabled the detection of small size lesions [7],[21],[22] . The impact of use of SPECT in patients with HCH in our institution has been evaluated and is going to be published.

In conclusion, HCH is the most common benign hepatic tumor with a clinical diagnosis of a significant importance. 99m Tc- red blood cell scintigraphy is highly accurate in the diagnosis of liver HCH and should characterize liver mass found and suspected for hemangioma on ultrasonography and is recommended before the biopsy.

 
   References Top

1.Ishak KG, Robin L. Benign tumors of the liver. Med Clin North Am 1975;59:995-1013.  Back to cited text no. 1    
2.Tahagi H. Diagnosis and management of cavernous hemangioma of the liver. Semin Surg Oncol 1985;1:12-22.  Back to cited text no. 2    
3.EI-Desouki M, Joharjy IA, Al-Muzrakchi AM, Bashi SA. Uncommon scintigraphic findings of multiple hepatic hemangiomas. Clin Nucl Med 1991;16:178-81.  Back to cited text no. 3    
4.Jacobson AF, Teefey SA. Cavemous hemangiomas of the liver: Association of sonographic appearance and results of Tc-99m labeled red blood cell SPECT. Clin Nucl Med 1994;19:96-9.  Back to cited text no. 4  [PUBMED]  
5.Tamm EP, Rabushka LS, Fishman EK, et al. Intrahepatic, extramedullary hematopoiesis mimicking hemangioma on technetium-99m red blood cell SPECT examination. Clin Imaging 1995;19:88-91.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Tumeh SS, Benson C, Nagel JS, et al. Cavernous hemangioma: detection with single photon emission computed tomography. Radiology 1987; 164:353-6.  Back to cited text no. 6  [PUBMED]  
7.Kudo M, Ikekub K, Yamamoto K, et al. Distinction between hemangioma of the liver and hepatocellular carcinoma: value of labeled RBC-SPECT scanning Am J Roentgenol 1989;152:977-83.  Back to cited text no. 7    
8.Moinuddin M, Allison JR, Montgomery JH, et al. Scintigraphic diagnosis of hepatic hemangioma: its role in the management of hepatic mass lesions. Am J Roentgenol 1985;145:223-8.  Back to cited text no. 8    
9.Brodsky RJ, Friedman AC, Maurer AH, et al. Hepatic cavernous hemangiomas: diagnosis with 99m Tc-labeled red cells and single-photon emission CT. Am J Roentgenol 1987;148:125-9.  Back to cited text no. 9    
10.Rabinowitch SA, McKusick KA, Strauss HW. 99m Tc-red blood cell scintigraphy in evaluating focal liver lesions. Am .I RoentgenolI984;143:63-8.  Back to cited text no. 10    
11.Engel MA, Marks DS, Sandler MA, Shetty P. Differentiation of focal intrahepatic lesions with 99m Tc-red blood cell imaging. Radiology 1983;146:777-82.  Back to cited text no. 11  [PUBMED]  
12.Patel PJ, El-Desouki M, Al-Mofeh 1. Sonographic and scintigraphic diagnosis of large-size hepatic cavernous hemangiomas. IJRI 1990;44:19-22.  Back to cited text no. 12    
13.Freeny PC, Marks WM. Hepatic hemangioma: Dynamic bolus TC. AJR 1986;147:711-9.  Back to cited text no. 13  [PUBMED]  
14.Ashida C, Fishman EK. Zerhouni EA, et. al. Computed tomography of hepatic cavernous hemangioma. J Comput Assist Tomogr. 1987;11:455-60.  Back to cited text no. 14    
15.Sigal R, Lanier A, Atlan H, et al. Nuclear magnetic resonance imaging of liver hemangiomas. J Nucl Med 1985;26:1117-22.  Back to cited text no. 15    
16.Li KC, Glazer GM, Quint LE, et. al. Distinction of hepatic cavernous hemangioma from hepatic metastases with MR imaging. Radiol 1988;169:409-15.  Back to cited text no. 16    
17.Bimbaum BA, Weinreb JC, Megibow AJ, et.al. Definitive diagnosis of hepatic hemangiomas: MR imaging versus Tc-99m­labeled red blood cell SPECT. Radio! 1990;176:95-101.  Back to cited text no. 17    
18.Brant WE, Floyd JL, Jackson DE, et.al. the radiological evalyation of hepatic cavernous hemangioma. JAMA 1987;257:2471-4.  Back to cited text no. 18    
19.Moinuddin M, Allison JR, Montgomery JH, et al. Scintigrafic diagnosis of hepatic hemangioma: Its role in the management of hepatic mass lesions. AJR 1985;145:223-8.  Back to cited text no. 19  [PUBMED]  
20.Prakash R, Jena A, Behari V, et al. Technetium-99m red blood celiscintigraphy in the diagnosis of hepatic hemangioma. Clin Nucl Med 1987;12:235-7.  Back to cited text no. 20  [PUBMED]  
21.Drane WE. Nuclear medicine techniques for the liver and biliary system. Radiol Clin North Am 1991;29:1129-51.  Back to cited text no. 21  [PUBMED]  
22.Kraus T, Hauenstein K, Studier-Fisher B, et al. Improved evaluation technetium-99m-red blood cell SPECT in hemangioma of the liver..1 Nucl Med 1993;34:375-80.  Back to cited text no. 22    
23.Ali A, Berg R, Fordham EW. False-positive hepatic blood pool SPECT study for hepatic hemangioma. Clin Nucl Med 1994;19:687-8.  Back to cited text no. 23  [PUBMED]  
24.Cornelius LA, Atterbury CE. Problems in the imaging diagnosis of hepatoma. Clin Nucl Med 1984;9:31-8.  Back to cited text no. 24    

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Correspondence Address:
Mahmoud El-Desouki
Department of Nuclear Medicine, King Khalid University, P.O. Box 7805 (46), Riyadh 11472
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


PMID: 19864757

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