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Liver Scintigrams Compared with Alkaline Phosphatase and Bsp Determinations in the Detection of Metastatic Carcinoma

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Liver Scintigrams Compared with Alkaline Phosphatase and Bsp Determinations in the Detection of Metastatic Carcinoma LIVER SCINTIGRAMS COMPARED WITH ALKALINE PHOSPHATASE AND BSP DETERMINATIONS IN THE DETECTION OF METASTATIC CARCINOMA Satish G. Jhingran, Leon Jordan, Monroe F. Jahns, and Thomas P. Haynie The University of Texas M. D. Anderson Hospital and Tumor Institute at Houston, Houston, Texas Liver scanning is a well-established technique in fling and color scanning devices with a 3 x 2-in. the detection of metastatic liver cancer (1—5), but NaI(Tl) crystal, a 19-hole focusing collimator with from time to time reports are published which ques dot factor and scanning speed adjusted according to tion the accuracy of the scintigram compared with the maximum counting rate (Picker Magnascanner). liver function tests for detecting hepatic metastases In general, only anterior views were obtained. (6) . However, liver function tests often indicate Technetium-99m liver scanning. With no prior abnormality in patients with cancer where no liver preparation, each patient received intravenously 3 metastases are present (2,7). mCi of O9mTc..sulphurcolloid. Scans were performed To assess our own experience in regard to liver 15 mm after injection using a commercially avail scintigrams and liver function tests, a retrospective able gamma camera with an 11 X ½-in.NaI(Tl) study was made comparing the diagnostic accuracy crystal, 4,000 channel straight-bore collimator, and of liver scintigrams with alkaline phosphatase (AP) oscilloscope display with Polaroid recording (Nu and bromsuiphalein (BSP) determinations in a clear-Chicago, Pho/Gamma III). Routinely, an seriesof cancer patients studied in our institution. tenor, right lateral, and posterior scans were per formed on each patient. METHODS Classification of patients. A subgrouping of the The study includes 284 patients with cancer who metastatic cases was devised on the basis of the esti were referred to the Radioisotope Laboratory of The mated extent of involvement at the time of laparot University of Texas M. D. Anderson Hospital and omy or postmortem examination of 104 patients. Tumor Institute at Houston for liver scintigrams Thus the presence of a single nodule or several nod from September 1966 through June 1968. All pri ules in the liver with less than ½of the liver in mary cancer diagnoses were proved pathologically, volved was designated as Group I, numerous nodules and the status of the liver for disease or normality involving ½—½of the liver as Group II, and ex also was substantiated by pathological examination, tensive involvement with more than 2/3 of the liver either by liver biopsy (85 cases), postmortem exami tissue replaced by tumor as Group III. nation (82 cases), laparotomy (74 cases), or lapa Interpretation of SCIntigramS. All scans were re rotomy and biopsy (43 cases) within 1 month of the viewed and assigned to a normal or abnormal cate study. Only positive evidence of metastatic disease gory. The scans were considered abnormal if they was accepted as proof of diagnosis by needle biopsy showed obvious uneven uptake or definite cold areas. because a normal needle biopsy of the liver does Abnormal scans were further reviewed to determine not rule out metastatic disease. the extent of liver involvement. Liver scintigrams were performed either with 198Au-colloidal gold and the rectilinear scanner or Liver function tests. Alkaline phosphatase (AP) with P9mTcsulfur colloid and the gamma camera. and bromsulphalein (BSP) analyses were performed The scans were about equally divided between the on each patient using standard methods (9,10) . AP two techniques. In a previous study we found no values of 2.3 Bessey-Lowry (BL) units or less significant difference in the true-positive rates be were considered normal; values above 2.3 were con tween ‘98Auand 99mTcscintigrams (8). sidered abnormal. Gold-198 liver scanning. With no prior prepara tion, each patient received intravenously 200 @Ciof Received July 1, 1970; revision accepted Dec. 11, 1970. 198Au-colloidal gold. Liver scans were begun 30 mm For reprints contact: S. 0. Jhingran, M. D. Anderson Hospital and Tumor Institute, Texas Medical Center, Hous after injection of the radionuclide using photoscan ton, Tex. 77025. Volume 12, Number 5 227 JHINGRAN, JORDAN, JAHNS, AND HAYNIE evidence of anatomical liver disease. Figure 1 shows TABLE 1. RESULTSOF SIMULTANEOUS LIVER the correlation of metastatic disease with the results SCANS AND FUNCTION TESTSIN 284 PATIENTS of all three tests. Results of all three tests were ab correctlydiagnosedLiverscansAPPcrcent normal in 54 patients, and in this group 48 (89%) had hepatic metastasis. Results of two of three tests were abnormal in 59 patients, and 36 (61 % ) had BSP hepatic metastasis. Results of one of three tests were Overall accuracy 81 67 72 abnormal in 45 patients, and 14 (3 1% ) had hepatic No livermetastasis,79 patients 91 59 39 metastasis. Of the three tests, none gave abnormal Metastatic cancer, 146 patients 83 71 91 Nonmalignant liver disease, results in 25 patients, and six (24% ) had hepatic 59 patients 70 77 96 metastasis. Comparison of scintigrams with combined tests. In an attempt to better separate metastatic liver dis ease from normal liver, the following criteria for In BSP tests, 6% retention or less in 45 mm was classification were considered. considered normal. Criterion 1. Classify the individual as normal if two or more of the tests are normal; otherwise RESULTS classify as diseased. Comparison of tests. Of the 284 patients studied, Criterion 2. Classify the individual as abnormal 139 were diagnosed as having hepatic metastases, 53 if the scan test indicates an abnormality and if had diffuse benign disease (most commonly hepatitis one of the two other tests is also abnormal; other or cirrhosis) , six had posthepatic obstructive jaun wise classify as normal. dice, and seven had primary liver cancer. Seventy nine had no pathologic evidence of liver disease, Table 2 shows the percentages of correct diagnoses but it should be stressed that all of these patients had when diagnosis is based on scan results alone, on cancer elsewhere in the body, even though the liver was not involved. The results of the three tests were correlated with the presence of or absence of disease, and Table 1 gives the percentages of cases within each of these categories which were diagnosed cor rectly. In this series, the highest percentage of cor PERCENT WITH HEPATIC rect diagnosis was by scintiscan, with the BSP sec METASTASES ond, and the AP third. This higher percentage of accuracy for the scan was related primarily to a lesser number of false positives. The incidence of abnormality was comparable for all three tests in patients with metastatic disease. Chi-square test p ABNORMAL A113 2of3 1of3 Oof3 values (11 ) obtained from comparisons of scan results with AP results and with BSP results yielded FIG. 1. When liver scintigrams,AP, and BSPdeterminations were made simultaneously in group of patients where 57% had p < 0.01 , and p = 0.02, respectively, for the over metastatic disease and 43% did not, percent of patients with all accuracies. hepatic metastasis was correlated with number of tests which were abnormal. In metastatic liver disease, the scan, AP, and BSP gave the correct diagnosis in 83 % , 7 1% , and 81% of all metastatic cases, respectively. Statistically, there is no significant difference between these per TABLE 2. APPLICATION OF SELECTED centages since p values for scan versus BSP, and CRITERIA TO DIAGNOSIS scan versus AP are > 0. 10 and 0.09, respectively. Percentwith For cases which do not have liver disease, the scan correctdiagnosis had a significantly higher proportion of correct diag (284 patients) noses than either AP or BSP. The p values for these Scintigram alone 87 tests are < 0.01. Classify abnormal only when two or three tests abnormal 75 Combined testing. All three tests were performed Classifyabnormal only when scanand one simultaneously in 183 patients, of whom 104 (57%) or two liver functiontestsabnormal 83 had metastatic liver disease and 79 (43 % ) had no 228 JOURNAL OF NUCLEAR MEDICINE LIVER SCINTIGRAMS TO DETECT METASTATIC CARCINOMA ALKALINE B.S.P. SCINTuRAN to be in the range from 0 to 40% . These false PHOSPHATASE ,. + 81 positive results may be attributable to subclinical ,: @37 ,. + 37 3 Y 1.17+ 1.311 I. 5.90+3.995 421 @.-2I4O.I9.84J hepatic abnormality or to disease elsewhere in the body. Abnormal AP test results have been reported II I 36@ (13,14) in benign and malignant gastrointestinal dis @ j a 301 orders in the absence of direct liver involvement. The present study revealed 8 1% accuracy in diag S 241 71 nosis of metastatic cancer in liver by BSP, which @ I8@ 1@ agrees with other studies (2,13,14,16,17,19,20) . The a, 121 incidence of false positives from BSP in the present 5] study was 61%; other studies (2,6,13,14,17,19) 61 II I report a range from 25 % to 58%. N I II III N I II LII The results of this evaluation show the accuracy of scanning in metastatic liver cancer to be 83%. EXTENT OF INVOLVEMENT False-positive liver scans in this series occurred in 9 % of all cases with normal liver. These values are FIG. 2. In 104 patientswith provedmetastaticdiseasegraded I, II, and Ill, and also with group of patients with no liver disease in agreement with those reported by others (1—3, (N), degree of abnormality of AP, BSP, and liver scintigram was 21,22). correlated with degree of involvement. Correlation coefficient (r) for liver scintigrams was significantly higher than for either AP For cases having metastatic liver disease, chi or BSP. square tests showed no significant difference between diagnosis by BSP retention, by AP elevation, and Criterion 1, and on Criterion 2. These alternate cri by scanning. In cancer patients without liver metas teria offer no overall improvement over diagnosis tases, the scan was definitely superior to BSP and based on scan results alone.
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