CASE REPORT 

Annals of Nuclear Medicine Vol. 10, No. 4, 425-428, 1996 

Ring appearance on Tc-99m MIBI thoracic SPECTS and increased uptake on Tc-99m HMDP thoracic SPECTS in a pulmonary mass of small cell carcinoma 

Wei-Jen SHIH, Francesco TURTURRO, Vickie STIPP and Philip DESIMONE 
Nuclear Medicine Service and Division of Hematology and Oncology, VAMC and University of Kentucky Medical Center, USA 

Tc-99m MIBI is taken up avidly by viable tumor tissue and does not accumulate in the necrotic carcinoma. We present a patient who underwent Tc-99m MIBI and Tc-99m HMDP thoracic SPECTS: a large area of increased MIBI uptake with central photopenia (ring appearance) in the right upper lung localizes bone imaging agent and does not localize multiple areas of intense uptake in the metastatic hilar mediastinum lymph nodes. Rapid growth of tumor cells in the lung leading to central necrosis/ischemia accounts for bone imaging agent localization in the tumor, as well as the ring-appearance of lung mass on Tc-99m MIBI imaging. These findings may reflect less viability of the lung tumor as compared with intense MIBI uptake in hilar/mediastinal lymph node uptake without bone agent localization. 

Key words: small cell carcinoma of the lung, Tc-99m MIBI SPECT, Tc-99m HMDP SPECT, photopenia, bone agent extraosseous localization 

CASE REPORT 

A 56-YR-OLD MAN (SW4997) complained of cough with hemoptysis for three weeks; he had three episodes of bronchitis and as a result lost 9.1 kgs of body weight over the previous year. He smoked three packs of cigarettes a day for 27 years. Physical exam revealed diffuse inspiratory and expiratory wheeze in both lungs. Chest radio-graph showed a mass lesion in the right lung. CTS of the chest showed a large mass lesion in the right upper lung with several enlarged mediastinal lymph node (Fig.1). Tc-99m HMDP planar bone images showed no focal area of increased uptake to suggest bone metastasis, but did display a suspicious area of increased uptake in the right upper lung, SPECTS of the thorax showed a large focal area of increased uptake in the right upper lung posteriorly (Fig. 2). Tc-99m MIBI thoracic SPECTS performed seven days later showed ring appearance of the tumor mass in the right upper lung and areas of intense uptake in the hilar/mediastinal lymph nodes (Fig. 3). A bronchial wash and biopsy confirmed small cell carcinoma of the lung. The patient was undergoing chemotherapy. 

DISCUSSION 

Tc-99m MIBI has been introduced to use myocardial perfusion imaging,1 and noncardiac applications of the agent have successfully localized primary and secondary malignant lesions of the lung, breasts, thyroid, parathyroid, brain, bone and liver.2-11 
 Tc-99m MIBI can be used as a sensitive indicator of myocardial cell viability11 because MIBI does not accumulate at all in the necrotic or irreverse in the ischemic myocardial tissue. 1,13-16 
 Likewise, absence of MIBI uptake in bronchogenic carcinoma may be due to tumor necrosis.2,16,17 Tumor necrosis of lung cancer on MIBI images showed focal uptake with a central hypoactive focus that paralleled tumor necrosis seen on CT.18 
 Tc-99m MIBI is avidly taken up by viable tumor tissue and effectively imaged in detection of hilar/mediastinal lymph node metastases.18 MIBI uptake reflects viable tumor tissue by differentiating viable residual/recurrent disease from post therapy necrosis.17 As a consequence, MIBI has been proposed to be a valuable clinical tool in the follow-up of patients with lung cancer. 
 Our patient's ring-appearance of the right upper lung tumor on MIBI images reflects tumor irreversible ischemia/ undergoing tumor necrosis. Tumor necrosis shown on concurrent CT of the thorax was mild, however, the necrosis may not have been severe enough to appear. Scintigraphies were more sensitive, however, in demon-strating earlier pathophysiologic processes of ischemia adjacent to necrosis, and depicted central photopenia of Tc-99m MIBI tumor uptake (ring appearance) (Fig. 3) and bone agent localization (Fig. 2). 
Bone scintigraphy using Tc-99m HMDP has been widely used for the detection of bone metastasis and extra-osseous localization of bone imaging agent has been observed18-27 in various malignant tumors. Bone imaging agent localization in our patient's lung tumor is similar to bone agent localization in massive/multiple metastases of the liver from colon cancer.28 It has been proposed that tissue necrosis/irreversible ischemia is related to bone agent localization, since massive hepatic necrosis has been reported diffuse uptake of bone agent.29 
 Intensity of uptake MIBI depends on blood perfusion and tumor viability. The intensity of our patient's mediastinal lymph node uptake has been shown to be much higher than that of the original tumor mass in the lung. These findings represent that lung tumor undergoing necrosis/necrotic change and that viability of mediastinal metastatic lymph nodes appear to be high. Intensity of MIBI uptake of tumor may indicate tumor viability. 
 In conclusion, ring-appearance of lung mass on MIBI imaging associated with bone imaging agent localization may reflect the tumor ischemia/undergoing necrosis. Whether the viability of tumor with ring-appearance on MIBI imaging and bone agent localization is less than the tumor without ring appearance and localization should be further investigated. 

ACKNOWLEDGMENT 

We thank Ms. Lillian Owens and Mrs. Edie Hom for their help during the preparation of this manuscript. 

REFERENCES 

1. Sinusas AJ. Watson DD, Cannon JM, Beller GA. Effect of ischemia and postischemic dysfunction on myocardial up-take of technetium-99m labelled methoxyisobutyl isonitrile and thallium-201 . J Am Cardiol 14: 1785-1793, 1989. 
2. Aktolun C, Bayhan H, Kir M, et al. Clinical experience with Tc-99m MIBI imaging in patients with malignant tumors: preliminary results and comparison with Tl-201 . Clin Nucl Med 17: 171-176, 1992. 
3. Hassan IM. Sahweil A, Constantinides C, et al. Uptake and kinetics of Tc-99m hexakis 2-methoxy isobutyl isonitrile in benign and malignant lesions in the lungs. Clin Nucl Med 14: 333-340, 1989. 
4. Lu G, Shih WJ, Xiu JY. Tc-99m MIBI uptake in a parathyroid carcinoma and Brown tumor. J Nucl Med 36: 811-813, 1995 . 
5. O'Tuama LA, Packard AB, Treves ST. SPECT imaging of pediatric brain tumor with hexakis (methoxy isobutyl isonitrile) technetium (1). J Nucl Med 31 : 2040-2041 , 1990. 
6. Caner B, Kitapci M. Aras T, Erbengi G, Ugur O, Bekdik C. Increased accumulation of hexakis (2-methoxyiso-butylisonitrile) technetium (1) in osteosarcoma and its metastatic lymph nodes. J Nucl Med 32: 1977-1978, 1991 . 
7. Caner B, Kitapci M, Unlu M, et al. Technetium-99m MIBI uptake in benign and malignant bone lesions: a comparative study with technetium-99m MDP. J Nucl Med 33 : 319-324, 1992. 
8. Waxman AD, Ramanna L, Memsic LD, et al. Thallium scintigraphy in evaluation of mass abdominal abnormalities of the breast. J Nucl Med 34: 19-23, 1993. 
9. Mueller SP, Piotrowski B. Guth-Tougelides B, Reiners C. 
Tc-99m MIBI and Tl-201 uptake in thyroid carcinoma (abstract). J Nucl Med 29: 854, 1988. 
10. O'Driscoll CM, Baker F. Casey MJ, Duffy GJ. Localization of recurrent medullary thyroid carcinoma with technetium-99m-methoxyisobutylnitrile scintigraphy: a case report. J Nucl Med 32: 2281-2283, 1991. 
11. Al-Sebaie S, Rush C. Liver metastases detected by Tc-99m sestamibi during routine cardiac imaging. Clin Nucl Med 20: 84-85, 1995. 
12. Crane P, Laliberte R, Heminway S, Thoolen M, Orlandi C. Effect of mitochondrial viability and metabolism on technetium-99m sestamibi myocardial retention. Eur J Nucl Med 20: 20-25, 1993. 
13. Sinusas AJ, Truatman KA, Bergin JD, Watson DD. Smith WH, Beller G. Quantification of area of risk during coronary occlusion and degree of myocardial salvage after reperfusion with technetium-99m 2-methoxyisobutyl isonitrile. Circulation 82: 1424-1437, 1990. 
14. Beenlands RSB, Dawood F, Wen WH. Are the kinets of technetium 99m methoxyisobutyl isonitrile affected by cell metabolism and viability? Circulation 82: 1802-1814, 1990. 
15. Freeman I, Gruwald AM, Hoory S, Bodenheimer MM. Effect of coronary occlusion and myocardial viability on myocardial activity of Tc-99m sestamibi. J Nucl Med 32: 292-298, 1991. 
16. Bayhan H, Aktolun C, Kir KM, et al. Tc-99m MIBI imaging in patients with intrathoracic malignant tumors (abstract). Eur J Nucl Med 18: 675, 1991 . 
17. Aktolun C, Bayhan H, Kir MK, Bilgic H. Evaluation of Tc-99m MIBI for localizing untreated primary lung carcinoma: A clinical study (abstract). Nucl Med Commun 13: 249, 1992. 
18. Aktolun C, Bayhan H, Pabuccu Y, Bilgic H, Acar H, Kaylu R. Assessment of tumor necrosis and detection of mediastinal lymph node metastasis in bronchial carcinoma with Tc-99m sestamibi imaging: comparison with CT scan. Eur J Nucl Med 21 : 973-979, 1994. 
19. Shih WJ. Domstad PA, Lieber A, DeLand FH, Coupal JJ. Localization of Tc-99m HMDP in hepatic metastases from chorionic carcinoma. AJR 146: 333-336, 1986. 
20. Que L. Wiseman J, Hales B. Small cell carcinoma of the lung: primary site and hepatic metastases both detected on Tc-99m pyrophosphate bone scan. Clin Nucl Med 6: 260-262, 1980. 
21. Lowenthal IS, Tow DE, Chang YC. Accumulation of Tc-99m polyphosphate in two squamous cell carcinomas of the lung. J Nucl Med 16: 1021-l032, 1975. 
22. Poulose KD, Reba RC, Eckelman WC, Goodyear M. Extraosseous localization of Tc-99m Sn pyrophosphate, Br J Radiol 48: 724-726, 1975. 
23. Heisel AM, Miller JH, Reid BS, Siegel SE. Radionuclide bone scan in neuroblastoma. Pediatrics 71 : 206-209, 1983. 
24. Stone CK, Sisson JC. What causes uptake of Tc-99m methylene diphosphonate by tumors? A case where tumor appeared to secrete a hypercalcemia-causing substance. J Nucl Med 26: 250-253, 1985. 
25. Baumert JE, Lanteri RL. Horning S, et al. Liver metastases of breast carcinoma detected on 99mTc-methylene diphosphonate. AJR 134: 389-391 , 1980. 
26. Balachandran S. Localization of Tc-99m-Sn-pyrophosphate in liver metastasis from carcinoma of colon. Clin Nucl Med 1: 165-166, 1976. 
27. Garcia AC, Yeh SDJ, Benau RS. Accumulation of bone seeking radionuclides in the liver metastasis from colon carcinoma. Clin Nucl Med 2: 265-269, 1977. 
28 Stevens JS, Clark EE. Liver metastasis of colon adenocarcinoma demonstrated on Tc-99m pyrophosphate bone scan. Clin Nucl Med 2: 270-271 , 1977. 
29. Shih WJ. Coupal J. Diffuse and intense Tc-99m HMDP localization in the liver due to hypoxia secondary to respiratory failure. Clin Nucl Med 19: 116-120, 1994.