CLINICALSCIENCES

CASE REPORTS

Local ColloidTrapping in the Liverin the InferiorVena Cava Syndrome

Max S. Lin, James W. Fletcher, and Robert M. Donati

Veterans Administration Medical Center and St. Louis University, St. Louis, Missouri

Local radioactiveareas In the liver were observedas a resultof superficialca voportal shunting of radiocolloids in two patients with the inferIor vena cava syn drome.in one patienta paraumbllicaland/or a recanalizedumbilicalveinwas ap parently involvedin the hepatopetalshunting.In the other patient a superficial anastomosisother than the paraumbilicalvein shuntedcolloidto the liver. Rela tivelydiscreteareasof IncreasedradioactivIty,singleor multiple,were seeninthe left lobe. Virtuallyall reportedinstancesof hepatopetalshuntingof radloparticles in a superioror an inferiorvena cava syndromehave demonstratedsimilarfind ings.Varioushepatopetalcollateral pathwaysIn Infrarenalcaval obstructionare considered,and factorsthat couldaffect liver scan findingsIn the infrarenalob structionare discussed.

J NucI Med 22: 344—346,1981

In the superior vena cava (SVC) syndrome, radiocolloid liver showed extensive pelvic collaterals with nonfilling of the right scansmay showan areaof increasedactivity in the left lobeof the common ilica vein and retrograde filling of the left external iliac organ. At least 26 casesof focal colloid liver concentration have vein. He was treated conservatively with anticoagulants. been reported in the literature through 1979 (1—14).The accu One month later, he wasreadmitted becauseof a grosshema mulated data suggestthat the area is produced by collaterally tuna. Cystoscopy showed blood coming from the right ureter. An shuntedcolloids. A paraumbilical vein or a dilated umbilical vein intravenouspyelogramand an abdominal sonogramwerenormal, has been mentioned as a last leg in the hepatopetal collateral although the latter failed to visualize the IVC. A Tc-99m sulfur journey following administration of radioparticles to an upper colloid study was obtained following a deliberate administration extremity. Analogous areasof increaseduptake should occur in in the right leg. The colloid arrived in the left lobe through what an inferior vena cava (IVC) syndrome if the colloid is given appeared to be a paraumbilical vein and produced multiple focal through a legvein. In this communication,wereport two suchcases increased concentrations in the lobe (Fig. 1). The hematuria was and review related observationsin the literature. ascribed to the anticoagulant and did not recur after the drug was discontinued. Case 2. A 58-year-old man was admitted for evaluation of lower CASE REPORTS abdominal pain. Pasthistory included resectionofa colonic ade CaseI. A 47-year-old man presentedwith edemaofboth lower nocarcinoma 2 yr before admission, and a briefepisode of severe extremities and a long history of right-leg swelling and right-groin edemaof both lowerextremitiesandgroins I .5yr beforeadmission. varicosity. Two weeksbefore admission,he noted aggravation of Physical examination on admission showed a scaphoid abdomen the legswelling and for the first time developedswelling in the left with prominent veins and surgical scars, but with no palpable mass. leg. Inspection of the abdomenshowedprominent veinsover the Edemawasabsentin all extremities.Urinalysis wasnormal. Figure 2 shows a Tc-99m SC study obtained after admission. With no epigastrium and both lower quadrants, with a midline scar from suitable veins in the arms, the colloid was administered through a prior umbilical herniorrhaphy. Urinalysis, SMA-12, and chest a leg vein. A hepatopetal shunting occurred, producing an area of radiographs were all normal. A right-leg contrast venogram increased uptake in the quadrate area of the left lobe. The obser vation indicated an IVC syndrome, which had escaped recognition Received Sept. I 8, 1980; revision accepted Dec. 5, 1980. until then. Subsequentlywe learned that he had had a sulfur-col For reprints contact: Max S. Lin, MD, PhD, Nuclear Medicine bid scintigram I I mo before the admission; difficulty was en Service( I ISiC), VA Medical Center,St. Louis, MO 63I25. countered with intravenous administration, and the colloid had

344 THE JOURNAL OF NUCLEAR MEDICINE CLINICALSCIENCES CASEREPORTS

FIG.1. Superficialhepatopetalcollaterals andfocal areasof activfty in liver(Case 1). Tc-99m sulfur colloid (3 mCi) was admin Isteredthrougha right leg vein. Shownare @ eight consecutive dynamic frames (8 A t: +@#1/)@)e sec/frame, beginning 17th second after injection) and anterior and right lateral static images.Notecephaladflow in visu alized right inferior epigastric vein, sub I I sequentvisualizationof paaumbllical vein, nonuniform uptake in left lobe, and non visualizationof Inferior vena cava.

beeninjected into a femoral artery. Although initially interpreted syndrome (1—14).Only in a few colloid studies (4) doesthe left as normal, upon review the scintigram indicated an interruption lobe,asidefrom focal areasof uptake, look generally more active of the IVC at a high infrarenal level without visible collateral or than the right one.The presentCase2 is an example of such cx localized liver uptake. ceptions (Fig. 2). Hepatopetal shunting of Ic-99m albumin mi crospheres has been observed by others in two cases of IVC syn DISCUSSION drome (10,20). In both cases,a singleareaof mi@resphereuptake wasseenwithin but not over the entire region of the left lobe. In both cases,the IVC syndromeappearedto be due to an in Even if shuntedcolloid enters through the paraumbilical vein frarenal IVC obstruction. There was no nephrotic syndrome or into the left main branch of the portal vein in an SVC or IVC other renalfunctional impairment to suggestinvolvementof a renal syndrome,the left lobe would not becomeuniformly radioactive, vein. In Case 1, the chronicity of the course and the history of if it contains lesions such as metastases. However, disease in the asymmetric involvement of lower extremities indicated a benign left lobeasa possiblebasisfor the nonuniformityappearsto be thrombosis rather than malignant obstruction of the infrarenal exceptional(10,11). In virtually everyinstanceof SVC syndrome, IVC (15). Contrastvenographyin thiscaseshowedapparentbi the liver scanis normal except for visualized collaterals and the lateral iliac venousocclusion. Obstruction of the IVC itself was area of localized activity (1—14).In most instances,there is just not directly demonstrated, but could havebeenpresentsince no a singlewell-definedareaofactivity, which is mostcommonlyseen segmentof the IVC wasvisualized in the dynamic colloid study in the inferior (quadrate) area of the medial segment of the left (Fig. 1). Bilateral occlusionof the commoniliac veins,without an lobe (18). Many other patterns, however, such as that of the obstruction of the IVC, produces almost the same syndrome as that presentCaseI, havebeenobserved.The nonuniformity and varied of an infrarenal IVC obstruction (16). patterns of the abnormal left-lobe uptake in an SVC or IVC syn In Case2, the obstructive level appearedto behigh infrarenal. drome suggesta few possibilities. First, paraumbilically shunted Patencyof the IVC belowthis level,andofthe commoniliac veins, colloid that entersthe left main branch of the portal vein could be was left uncertain. The most common causeof infrarenal and subjectto a streamingeffect within the left main branch. Second, midcaval IVC obstructionsis an ascendingthrombophlebitis from there might be places other than the left main branch where one or both iliofemoral veins (16). Thrombosis can alsOoccur paraumbilically shuntedcolloid could enterthe left-branch system, primarily in the IVC, but may subsequently propagate distally. and theseentry sitescould vary from one patient to another. Thrombotic occlusion of one or both common iliac veins in addition Cavoportal pathways in infrarenal IVC obstruction also include to the IVC would encouragethe developmentof superficial ab visceral routesthrough the inferior and superior mesentericveins dominal collaterals and thus possibly the development of (2!). A liver-scan pattern resulting from shunting through these paraumbilical shunting to the liver aswell (17). mesentericpathways would dependin part on the extent of any A paraumbilical vein, and occasionallya persistent umbilical streaming in the portal vein (vide infra) and on the formation of vein, it is said,join the left main branchofthe portal vein (18,19). the portal vein from its major tributaries, namely,the splenicvein After entering the left main branch, shunted colloid would dis and the mesentericveins(18). Whether the venousbloodfrom the tribute itselfevenly in the left hepaticlobe,ifthere is nostreaming major tributaries completely mixes in the portal vein before of the colloid in the left main branch (18). Activity in the whole reaching the main branches is not clearly known (18). At the 1973 lobe, rather than in a focal area, would result. However,uniform annual meeting of the Radiological Society of North America, trapping in the entire left lobedid not occur in either of thesetwo Henkin and otherspresentedstudiesin a young woman with both cases of IVC syndrome or in any of 26 reported cases of SVC IVC andSVCocclusion.Technetium-99malbuminmicrospheres,

FIG.2. SuperfIcialhepatopetalshunting producing increased concentration in quadrate area In Case 2. Tc-99m sulfur ‘4 @. collold (3 mCi)was given Intoleft legvein. Shown are eight consecutivedynamic frames (8 sec/frame, beginning 9th second I j •1•I after Injection) and anterior and ri@'it lateral static Images.Note spiraling midline col lateralswith faint offshootto right, pro ducing uptake in quadratearea and non visualization of Inferior vena cave. Offshoot doesnot follow coirse of paraumbilicalor umbilical vein.

Volume 22, Number 4 345 LIN, FLETCHER, AND DONATI

admistered through a pedal vein, localized almost exclusively in of a liver scan“hotspot―in superior venacaval obstruction. her liver, producing a normally appearing liver scan.A contrast AmfRoentgenol 127:637-639,1976 inferior cavogramand the dynamic phaseof the microspherestudy 9. CHHABRIA PB,CHANDNANI PC:“Hot―spoton radiocolloid both showedthe inferior mesentericvein to bethe dominant col scanof the liver. Clin NucI Med 1: 258—259,1976 lateral (2! ). In this woman, the hepatic microspheredistribution 10. GOONERATNENS, BUSEMG, QUINN JL III, et al: “Hot was consistent with an absence of portal venous streaming and any spot―on hepatic scintigraphy and radionuclide venocavo portal vein formation (18). graphy. Am I Roentgenol I 29:447-450, 1977 A focal areaof increasedactivityin the liver,strikingas it is, 11. TETALMAN MR. KUSUMI R, GAUGHRAN G, et al: Ra may not necessarilybe a finding in an infrarenal IVC syndrome dionuclideliver spots:Indicator ofliver diseaseor a bloodflow as in the case of an SVC syndrome (11). Potential collateral phenomenon.Am I Roentgenol130:291-296,1978 pathways may not have developedfully at an early stageof the 12. VALDEZ VA, HERRERANE: Demonstrationofsuperior vena obstruction. A collateral venousreturn through mesentericveins, caval obstruction and “hotspot―on liver scan in a caseof though detectable on dynamic images, may not be apparent on non-Hodgkin's lymphoma. Clin Nucl Med 3:139-141, static imagesin the absenceof portal venousstreaming. Finally, I 978 nonhepatopetal pathways may dominate the return (2!). 13. HENKE CE, WOLFF JM, SHAFERRB: Vascular dynamics in liver scan “hotspot.―Clin Nucl Med 3:267—270,1978 REFERENCES 14. IMAJO Y, TAKASHIMA H, OGAWA Y, et al: “Hotspot―on thecolloidliverscanobservedin acaseof bronchogeniccancer I. COEL M, HALPERN 5, ALAZRAKI N, et al: Intrahepatic with superior vena caval obstruction. Radioisotopes 28: lesion presentingasan areaof increasedradiocolloid uptake 450—452,1979 ona liverscan.JNuclMed 13:221-222,1972 15. BEARDRG: Abdominal varicosevein. In French's Index of 2. JOYNER iT: Abnormal liver scan (radiocolloid “hotspot―) Differential Diagnosis. 9th ed., Douthwaite AH, Ed. Balti associated with superior vena cava obstruction. J Nucl Med more, Williams & Wilkins Company, 1967,pp 837-839 13:849—851,1972 16. SHACKELFORDRI: Peripheralvasculardisease.In Diagnosis 3. MIKOLAJKOW A, JASINSKI WK: Increasedfocal uptake of ofSurgicalDisease. Vol. 3,ShackelfordRI, Ed. Philadelphia, radiocolloid by the liver. I Nucl Med 14:175, 1973 WB SaundersCompany,1968,pp 1631-1633 4. HOLMQUESTDL,BURDINEJA:Caval-portalshuntingas 17. NETTER FH: Anatomy of the abdomen. In The Ciba Col a causeof a focal increasein radiocolloid uptake in normal lection ofMedical Illustrations. Vol. 3, part 2, Oppenheimer livers.JNuclMed 14:348—351,1973 E,Ed.CIBA, 1962,pp 37-38 5. MORITA El, MCCORMACK KR, WEISBERGRL: Further 18. NETTER FH: Normal anatomy ofthe liver, biliary tract and information on a “hotspot―in the liver. I NucI Med 14: pancreas.In the Ciba CollectionofMedicallllustrations. Vol. 606-6O8,1973 3, part 3, Oppenheimer E, Ed. CIBA, 1964,pp 13-19 6. HOPKINSG: Superior venacaval obstruction and increased 19. Goss CM: Gray's Anatomy. 27th ed., Philadelphia, Lea & radiocolloid activity on liver scintiphotos.I NucI Med 14:883, Febiger,1959,pp 762-765 I 973 (Letter to the Editor) 20. WRAIGHT EP: Ilio-portal shunt demonstrated during lung 7. KUMAR B, COLEMAN RE, MCKNIGHT R: Asymptomatic scanning.Br Med I 1:507, 1978 (Letter to the Editor) superior vena cava obstruction. I Nucl Med I 7:853—854, 21. FERRISEJ: Intrinsic obstruction. In Venographyofthe In 1976 feriorVenaCavaanditsBranches.FerrisEJ,HiponaFA, 8. LEE KR, PRESTON DF, MARTIN NL, et al: Angiographic Kahn PC, et al, Eds. Huntington, New York, Robert E. documentation of systemic-portalvenousshunting asa cause Krieger Publishing Company, 1973,pp 53-109

THE HAWAIICHAPTER SOCIETYOF NUCLEARMEDICINE 4TH ANNUAL MEETING

May 23-24, 1981 Hyatt Kuilima Resort Hotel Oahu, Hawaii

The Hawaii Chapter of the Society of Nuclear Medicine will hold its Fourth Annual Memorial Day Weekend Meeting Saturday, May 23 and Sunday, May 24, 1981. The location for the meeting will be the Hyatt Kuilima Resort Hotel on Oahu's beautiful north shore. The program will be divided into two segments with noted speakers from the Mainland presenting talks on Gastrointestinal Imaging and Nuclear Cardiology.

Due to the success of its previous annual meetings the Hawaii Chapter SNM is extending an invitation to all other chapters to join in an enjoyable and interesting weekend.For further information and registration pleasewrite: Patrick McGuigan Department of Nuclear Medicine HonoluluMedicalGroup 550 S. Beretania St. Honolulu, HI 96813

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