67 Gallium

1. 67 Gallium Looking at the Diagnosis

2. Lymphomas • Hodgkin’s and Non-Hodgkin’s are two classes of lymphomas. • Hodgkin’s Lymphomas have a specific cell called Reed-Sternburg. • All other lymphomas not having that cell are classified as Non-Hodgkin’s Lymphomas. • From that point, Hodgkin’s and Non-Hodgkin’s are classified into subcategories depending on symptoms and cell structure.

3. Lymphoma Normal Gallium Image 4 months prior Abnormal Thallium Image 4 months ago showing: Active non-Hodgkin's lymphoma in the axilla and the left neck Patient refused treatment at the time

4. Lymphoma • 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 initiated

5. Study 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.

6. Hodgkin’s Lymphoma

7. Lung - Infection • Gallium provides a means of sensitive detection of an active pulmonary infection. • The degree of gallium uptake correlates with the degree of activity of the inflammatory site. • Gallium uptake is seen in • Active TB • Opportunistic infections • Diffuse infiltrative lung disease • Sarcoidosis • A rare disease of unknown cause in which inflammation occurs in lymph nodes and other tissues throughout the body, usually the lungs, liver, skin and eyes. • Symptoms include fever and generalized aches. There may also be enlargement of lymph nodes in the neck or elsewhere, breathlessness, arthritis, or erythema nodosum (red purple swellings on the legs)

8. Sarcoidosis • Sarcoidosis • Symptoms for acute sarcoidosis include fever and generalized aches. There may also be enlargement of lymph nodes in the neck or elsewhere, breathlessness, arthritis, or erythema nodosum (red purple swellings on the legs) • Symptoms for chronic are fever, purple rash on the face, painful joints, painful blood shot eyes, and areas of numbness. • Sometimes there are no symptoms. • 90% of patients recover in two years. Corticosteroids are prescribed to treat the disease. • When performing a gallium scan for sarcoidosis, you are looking for the extent of involvement of the lymph nodes.

9. Sarcoidosis Panda sign Lambda sign - Λ

10. Lung Gallium • 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)

11. Quantitative Lung Index • Data is helpful in measuring the response to therapy. • The degree and extent of abnormal uptake in the lungs correlates with many lung inflammatory disorders.

12. Abdominal Imaging with Gallium • The abdomen is difficult to image with gallium because after the first 24 hours, there may be colon uptake due to excretion of the isotope. • Enemas can be administered to move the colon contents. • If questionable area does not move and stays in the same area post enema/laxative then this could be an indication of disease. • 111In or 99mTc-WBC may be the more appropriate study when evaluating the abdominal processes

13. Liver Imaging with Gallium • Gallium concentrates in hepatic abscesses and neoplasms, but not in cysts hematomas, or non infectious fluid collections. • In conjunction with 99mTc-sulfur colloid, a liver scan should be done prior to a 67Ga scan (more specifically the injection). • 111 Indium and 99mTc labeled WBCs also localize in hepatic abscesses, but not in cysts, hematomas, or non infectious fluid collections.

14. Gallium in Liver Imaging Anterior Posterior • Differentiating a hepatoma from surrounding tissue in a cirrhotic liver • Diagnosis • Gallium-67 is taken up by hepatomacells giving a "hot spot" or at least an area of equal uptake to surrounding liver Transverse Coronal

15. Renal Imaging with Gallium • 99mTc renal imaging agents will show focal abnormalities and usually diminished overall function in the kidney with pyelonephritis or abscess. • Gallium imaging adds specificity. • Gallium concentrates in active pyelonephritis, while normal kidneys imaged 48 hours after gallium injection show no uptake. Note – kidneys should only be seen at 24 hours. Why? • Gallium imaging can help in distinguishing lower urinary tract infection from upper tract disease, or by diagnosing both.

16. Subcapsular Hematoma of the Left Kidney 99mTc Renal 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 Scan

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

18. Pneumocystis carinii pneumonia (PCP) caused by single celled parasite; symptoms dry cough and SOB Candida esophagitis infection; oral lesions which adhere to oral mucosa Cytomegalovirus common herpes virus that usually has no symptoms Cryptococcus airborne, found in soil esp. contaminated with pigeon droppings--can cause meningitis Herpes simplex Kaposis Sarcoma blue/red malignant skin tumors that usually start at the feet then spread Lymphoma Hodgkin’s (malignant disorder of the lymphoid tissue, more sever than Non Hodgkin’s Toxoplasmosis Caused by bacteria in rare meat from infected animals Myciobacterium aviumintrcellulare (MAI) in family with tuberculosis organism Disorders in AIDS Patients

19. Imaging PCP Patients • If a patient is undergoing therapy for PCP the gallium uptake can be less intense than those patients not being treated. • Gallium is positive in the lungs in 100% of patients with AIDS and PCP, who are asymptomatic. • Shows the importance of a gallium scan in AIDS patients with negative chest x-ray studies. • It can be a baseline for future indications, severity and extent of the infection, which can be used as a guideline for further diagnostic interventions.

20. Gallium Scan in AIDS Patient 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.

21. Gallium 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).

22. Bone Imaging With Gallium • 99mTc bone agents are sensitive in detecting the increased bone blood flow and bone mineral turnover associated with osteomyelitis, localizing the disease process 1-2 weeks before discernible radiograph changes take place. • Three phase is useful in distinguishing between osteo and cellulitis. • But again, many bony abnormalities provoke a similar bone response, including benign or malignant neoplasms, infarct repair, trauma and post-surgical changes.

23. Bone/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