Abnormalities of the Breast

Thaffium Scintigraphy in the Evaluation of Mass Abnormalities of the Breast

Alan D. Waxman, Lalitha Ramanna, Leslie D. Memsic, Clarence E. Foster, Allan W. Silberman, Stewart H. Gleischman, R. James Brenner, Michael B. Brachman, Christopher J. Kuhar, and Joseph Yadegar

Department ofNuclear Medicine, Surgery, and Radiology, Cedars-Sinai Medical Center, Los Angeles, California

tecting lesions in the dense or dysplastic breast (3,4). It Palpable mass abnormalities of the breast are often difficult has also been demonstrated that treatment of palpable to evaluate mammographically,especiallyin patients with breast masses may be adversely affected when the clinician fibrocystic change and dense breasts. The current study delays biopsy (5,6). Mann et al. demonstrated that a false evaluates 201T1scintigraphy as a potential test in detecting negative mammogram may cause a considerable delay in malignancyand in differentiatingmalignant from benign the decision to biopsy a patient subsequently shown to masses. Eighty-one female patients underwent thallium san have carcinoma of the breast (1). tigraphy of the breast because of palpable breast masses. An Patients who are in a high risk category for the devel additional 30 females with no palpable breast abnormalities opment ofbreast cancer (i.e., patients with a strong family were also studied using201TI.Of 44 patientswith palpable breastcarcinomas,42 carcinomas(96%) weredetectedusing history of breast cancer, patients with prior histologic 20111scintigraphy. Three of three patients had other primary evidence of cellular atypia, patients with a prior history of breastmalignanciesthat were also detected. In contrast,19 breast cancer who have undergone lumpectomy and radia patients with palpable breast abnormalities shown on biopsy tion therapy) may be difficult to evaluate and follow to be benignfibrocysticdiseaseprocesseswere not detect mammographically because of a dense fibroglandular pat able on thalliumstudies.Of two patientswith fat necrosis, tern of physical changes caused by radiation. Currently, nonewere detectable.Three of 13 patientshadadenomasof the only established method to resolve such a dilemma is the breast (23%) that were detected. The three detectable random tissue sampling which is usually attended by high adenomas were all highly cellular. The smallest detectable nonmalignant-to-malignant biopsy ratios. carcinomawas an adenocarcinomameasuring1.3 x 1.1 x Thallium-201 has been shown to be an effective radio 0.9cm.Thallium-201scintigraphyofpalpablebreastlesionspharmaceutical in the detection of many types of malig is an effective test for evaluation of palpable masses. Sensi tivity for detection of malignant masses greater than 1.5 cm nancies (7â€”29).In a series of malignancies evaluated by is high.Highlycellularadenomas,however,maydemonstrate Hisada et aL, two patients were shown to have primary significant @Â°1TIuptake. Benign fibrocystic disease is not carcinoma of the breast detected with 201Tlimaging (10). detectable with thallium scintigraphy. Thallium scintigraphy of Sehweil et al. demonstrated that 201T1accumulated in 20 breastlesionsis an effectivemeansof differentiatingbenign of 20 patients with primary carcinoma of the breast (20). frommalignantlesions. The purpose of the current study was to evaluate 201Tl J NuclMed 1993;34:18-23 as a tumor-seeking agent in patients with palpable mass abnormalities of the breast. In addition, we attempted to determine sensitivity and specificity for tumor detection in a large number of patients with palpable breast abnor malities in order to determine whether thallium could be omen with significant clinical fibrocystic changes used to differentiate masses caused by malignancy from are typically difficult to evaluate clinically using physical benign breast masses. The main purpose was to determine palpation of the breast alone. This patient group also may sensitivity and specificity for tumor detection and to de be difficultto evaluate mammographicallybecause of termine whether thallium could be used to differentiate dense fibroglandular patterns. Even palpable cancers may tumor benign breast masses from masses demonstrated to not be evident mammographically in many patients (1,2). be malignant. Mammography is known to be very accurate in examina tions of fatty breasts of older women. It has been reported that the mammographic technique is less reliable for de MATERIALSANDMETHODS Eighty-onefemalepatients were referredfor thallium testing because of palpable breast masses. There were no patients in ReceivedSept. 13, 1991; revision accepted Jul. 17, 1992. cluded in this seriesin which mammographydemonstratedab Forcorrespondenceor reprintscontact:AlanD. Waxman,MD,Cedars Sinai Med@aICenter, Nuclear Medicine Department, 8700 Beve,ly Blvd., Los normalities such as calcifications or suspicious masses if a mass Angeles,CA 90048. could not be palpated by the referring physician or a second

18 The Journalof NuclearMedicineâ€¢Vol. 34 â€¢No. 1 â€¢January 1993 physician performing the thallium examination. Biopsies were All three positive adenoma patients had highly cellular performed in all patients within 14 days of thallium imaging. adenomas. Of the 34 patients with benign masses of the Three millicuries of 201Tlwere administered intravenously in breast, only three had a positive test (specificity = 91 %). the arm on the opposite side of the known breast lesion. Imaging was performed using a large field of view Anger camera. Imaging Normal Thallium-201 Breast Scintigraphy was begun 2 mm postinjection and consisted of two sequential The distribution of 201Tl appeared homogenous 10-mm anterior chest images with the arms raised and the hands throughout the breast tissue in normal patients. A normal placed behind the patient's head when possible. The breasts were pattern was also associated with patients who had evidence centered in the field of view, with the field of view extending of fibrocystic change and fatty necrosis. from the mid-facial region to an area just below the dome of the Figure 1 is an example of a normal patient with no liver. The initial two anterior images were followed when possible known breast masses. The patient was studied because of by both a right and left anterior oblique 10-mm view of the a suspected mediastinal mass, later demonstrated to be a affected breast with the field of view angled so as to include the axilla. Five minute marker views were done in similar positions nonmalignant vascular structure. Note the uniform tissue and include markers over the nipples as well as the breast abnor background within the breast and axillary regions. The mality. A final 10-mm anterior chest image was obtained approx thyroid and pulmonary activity appears greatest in the imately 1 hr postinjection. initial image and fades rapidly, with almost complete In special circumstances where the right breast overlies the clearance of the structures approximately 1 hr postinjec liver, the breast is taped in an elevated position and the camera tion. angled to optimize the viewing ofthe suspected breast abnormal ity. In addition, the left breast may be moved and/or taped, BreastMalignancy especially on suspected breast abnormalities overlying the heart The intensity of thallium uptake within breast malig and the camera angled to optimize the view. nancies presented in a narrow range, with no abnormalities All studies were interpreted independently by two nuclear noted to have activity greater than the heart. Activity medicine physicians (AW and LR). A third observer (MB) was greater than surrounding background activity within the used as an arbitrator if differences existed. The only clinical breast was considered as positive. Thus, there was no history available at the time of reading was the knowledge that attempt made to subjectively grade or quantitate an ab patients had breast masses as the basis for the study. The excep normal focus within the breast. tion to this wasthe control populationwho underwentthallium Figure 2 shows a patient with a surgically proven ade imaging of the neck and chest for evaluation of suspected chest nocarcinoma of the right breast. The activity in the breast tumors such as thyroid cancer, lymphoma or lung cancer. The protocol in evaluating these patients was similar to the protocol abnormality is above background, but considerably less for evaluating patients with breast cancer in that studies were than the activity within the myocardium. Physical exami done sequentially for I hr with multiple oblique views being taken. Marker views were used in the interpretation of all cases.

RESULTS The results for 201T1sensitivity in detecting mass lesions ofthe breast are summarized in Table 1. Ofthe 47 patients with proven breast malignancy, 45 demonstrated a positive thallium study for a sensitivity of 96%. In contrast, none of the 19 patients with fibrocystic breast abnormalities demonstrate positive thallium uptake. Three of 13patients with adenoma demonstrated increased thallium activity. The intensity of thallium uptake in these patients was similar to patients with malignancy and could not be separated scintigraphically from patients with malignancy.

TABLE I Thallium-201 Sensitivity in Mass Abnormalities of the Breast True-Positive totalwithdisease Sensitivity FIGURE 1. Patientwithno knownbreastabnormalitieson mammographyandno massabnormalitiesdetectedon palpation. Malignancy45/4796%Primary The arms are raised to expose the axillary areas. (A and B) Carcinoma41/4395%Other3/3100%Fibrocystic Anterior projectionswith A beginning2 mm postinjectionand B beginning 12 mm postinjection.(C) LAO projection of the left disease0/190%Fat chest and (0) RAO projection. Note the gradual fading of the necrosis0/20%Adenoma3/1 pulmonaryand thyroid regions as well as the small left lobe of 323% the thyroid.

Evaluating Breast Abnormalities with Thallium Scintigraphy â€¢Waxman et al. 19 sion to be 1.3 x 1.1 x .9 cm. Note the optimum tumor visualization on the 2â€”14mm image and rapid clearance from the tumor with poor visualization on the 14â€”26mm film.

Detection of Axillary Metastasis Twenty-one patients in this series were demonstrated to have axillary metastasis at the time of surgery. Of these, 12 were detected using 201Tl(sensitivity 57%). Of the 12 positive patient studies for axillary metastasis, only five had palpable axillary lymph nodes. Figure 4 shows a patient with a primary carcinoma of the left breast with three of three axillary nodes found to be positive at the time of surgery. The utility of oblique projections is shown in this patient with superior tumor localization within the breast and axilla noted on the right FIGURE 2. Patientwith an adenocarcinomaof the rightbreast anterior oblique view of the left breast and axilla. with no pathology found in the right axilla at the time of surgery. (A and B) Ten minute anterior projections.(C) An RAO 10-mm FibrocysticChange projectionwiththerightbreastplacedfirmlyagainstthecollima tor. Notethe especiallyclearviewof the right axilla.(D)A marker Nineteen patients were demonstrated to have fibrocystic view with a thallium marker placed over the palpable lesion of the change of the breast on biopsy. All of these patients rightbreast. presented with multiple palpable breast abnormalities, with at least one prominent area in excess of 1.0 cm. All patients within this group failed to demonstrate any 201T1 nation demonstrated a palpable mass with no axillary accumulation. These studies were all read as normal. adenopathy. At surgery, an adenocarcinoma of the breast Figure 5 shows a patient with a 5.0 cm firm irregular was found measuring 2.3 x 1.9 x 1.7 cm. mass of the right breast with additional smaller masses in Tumor Detectibility excess of 1.0 cm which were palpated bilaterally. At sur The malignant breast lesions ranged in size from a gery, the large mass was found to have extensive scarring tumor which measured 1.3 x 1. 1 x 0.9 cm to a tumor following a prior breast biopsy done 1 yr before the current which measured 3.2 x 3.0 x 2.4 cm. Forty patients dem study. In addition, extensive fibrocystic change was pres onstrated the tumor to be greater than 1.6 cm in maximum ent. No thallium activity was noted within this large mass dimensions. Five patients had a measured maximum di or remaining breast tissue. mension of 1.3â€”1.5cm. A region of increased uptake to the right of the heart Figure 3 is a patient with an adenocarcinoma of the near the midline in this patient is similar to uptake noted right breast. The lesion was palpated with some degree of in 30%â€”40%of all patients studied with 201Tl. It is felt to difficulty, but visualized well mammographically. This tumor is the smallest malignancy detected with 201Tl in this series. The pathology specimen demonstrated the le

A B A B FIGURE4. Patientwithanadenocarcinomaoftheleftbreast. Thethalliumstudydemonstratesincreasedactivityinat leasttwo FIGURE 3. Patientwithanadenocarcinomaoftherightbreast foci within the left breast as well as axillaryadenopathyboth on which was palpated with some difficulty. The lesion measured the anterioras well as RAOprojectionof the left breastandaxilla 1.3 x 1.1 x 0.9 cm on pathologicsection.Theaxillawas negative (B).Theaxillarynodes(whitearrows)areoutlinedbytherelatively at surgery.(A)A 10-mmimagebeginning2 mmpostinjection.(B) lowactivitywithinthe axilla.The nipplemarkeris demonstrated Image 12 mm postinjection and data accumulatedfor 10 mm. bytheblackarrowwhiletheleftbreastdemonstratestwodiscrete Notethe fadingof the lesionby the secondimage(B). areasof tumor.

20 The Journalof NuclearMedicineâ€¢Vol. 34 â€¢No. 1 â€¢January 1993 fades gradually over a 1 hr period. Pulmonary background activity is also higher on the initial images, as is the general soft-tissue uptake. All of the breast tumors were observed on the initial 10 mm image which was started 2 mm post injection. In addition, the tumors were visible throughout the study including the final image which was completed approximately 1 hr postinjection. Subjectively, the opti mum time for observation appeared to be 15â€”45mm post injection, and corresponded to reduction in soft-tissue and A B pulmonary activity. In one instance, the tumor was best seen on the initial 10-mm image and appeared to fade FIGURE5. Patientwithknownfibrocysticdiseasewhounder rapidly with the delayed views(Fig. 3). This was an unusual went breast biopsyone year priorto this study.Ten-minute imagesbegun2 mmpostinjectionof the anteriorchest (A and B) circumstance and not generally observed in the study. demonstrateno abnormalaccumulationdespite a 5.0 cm right The use of multiple views gave a greater degree of breastmasswhichwas firmandirregularto palpation.At surgery, confidence in the reading of breast abnormalities. The the patient was found to have a large connectivetissue scar as oblique views seem to give more information with respect a reactionto a priorbiopsy.Extensivefibrocysticdiseasewas also presentand there was no evidenceof carcinoma. to the axillary areas. The current study demonstrates a high sensitivity for thallium in palpable breast malignancies. In 47 palpable be normal uptake in the region of the superior venacava breast malignancies, only two were not detected with 201'fl. and right atrium. Both were adenocarcinomas of the breast. One tumor Controlled Population was a 2.0 x 1.8 x 1.8 cm tumor deep within the breast in Thirty patients with no palpable breast abnormalities a patient with a large pendulous breast. The other tumor were included in the series. These patients were referred not detected was a 1.6 x 1.5 x 1.5 cm tumor located in for evaluation of other potential tumors, and were studied the high posterior superior tail of the breast tissue with imaging protocols similar to those studied for breast adjacent to the axilla. The smallest lesion detected was a cancer, with the exception ofno marker views and oblique 1.3 x 1.1 x 0.9 cm tumor (Fig. 3). Our findings are in views limited to the right anterior oblique view ofthe right agreement with Sehweil et al. demonstrating an extremely breast and left anterior oblique view of the left breast. high sensitivity for detecting palpable carcinoma of the There were no false-positive readings within this patient breast (25). group (specificity = 100%). Patients referred to the study because of palpable breast masses and found to have fibrocystic changes pathologi DISCUSSION cally with no evidence for tumor or adenoma failed to Thallium-201 is thought to behave similarly to potas demonstrate abnormal thallium activity. The results in sium biologically (30-33). Possible mechanisms for uptake this population were similar to the control group in which into tumor cells include the action ofthe ATPase sodium no palpable breast abnormalities were evident. Of the 19 potassium transport system in the cell membrane which patients with adenomas of the breast, 16 were considered creates an intracellular concentration of potassium greater entirely normal. Three patients showed significant activity than the concentration in the extracellular space (34). within the adenoma and all three demonstrated highly Thallium is thought to be influenced significantly by this cellular adenomas. The intensity of uptake in the three system in tumors (35,36). In addition, a co-transport adenomas was in the same narrow range as the carcinomas system has been identified which also is felt to be important and could not be differentiated from a malignant lesion. in uptake ofthallium by tumor cells (36). In two patients demonstrated to have fat necrosis as the Ando et al. determined that the biodistribution of thai basis for the mass abnormality of the breast, no abnormal hum in animal tumor models was strongly influenced by thallium activity could be demonstrated. tumor viability (37). Tumor uptake in humans has also Mammography has been shown to be an imperfect test been shown to be related to viability (14,25). Blood flow for detecting breast carcinoma. Mann et al. examined 165 to the tumor tissue appears important for purposes of patients with palpable breast masses that were determined delivery (8,14,33,35). Cell characteristics such as tumor to be malignant. Of the 165 patients, 105 had mammog type or tumor grade may also influence thallium uptake raphy during their initial examination. Thirty-six patients in several tumors (14,17,22,23,27). were found to have false-normal mammograms (34.2%). The rationale for multiple sequential images of the When biopsies were performed within 2 mo ofthe false breast was based upon the observation that thallium dis negative mammograms, 17.6% ofthe patients had axillary tribution changes over time in many organs. node involvement. When the biopsies were delayed from Initially, there is a high degree of concentration in the 3â€”24mo, there was a threefold increase in the number of thyroid occurring within a few seconds postinjection. This patients with abnormal nodes. Mann as well as other

Evaluating Breast Abnormalities with Thallium Scintigraphy â€¢Waxman et al. 21 investigators have determined that delays in diagnosis and diagnosisof breastcancer.N EnglJ Med 1978:299:201â€”202. 6. BurnsPE,GraceMG,LeesAW,etal. False-negativemammogramscausing treatment may be associated with an increase in advanced delayin breastcancerdiagnosis.J CanAssocRadio! 1979;30:74â€”77. disease (36â€”38).This group concluded that mammogra 7. Salvatore M, Carratii L, Ports E. Thallium-20l as a positive indicator for phy had certain limitations particularly in young women lung neoplasms:preliminary experiments.Radiology 1976;12l:487â€”488. 8. Tonami N, Hisda K. Clinicalexperienceoftumor imagingwiththallium with dense breasts. 201 chloride. Clin Nuci Med l977;2:75â€”8l. Holland et al. evaluated patients with mammographi 9. AncriD,BassetJY,LonchamptMF,etal.Diagnosisofcerebrallesionsby cally occult breast cancers (2). In this series, five patients thallium-201.Radiologyl978;l28:4I7â€”422. 10. Hisada K, Tonami H, Miyamae T, et al. Clinical evaluationof tumor had invasive ductal carcinoma and five patients had in imagingwith thallium-20l chloride.Radiology1978;l29:497â€”500. vasivelobular carcinoma. The mean diameter of the five 11. Tonami N, HisadaK. Thallium-201scintigraphyin postoperativedetection mammographically occult invasive ductal carcinomas was of thyroid cancer, a comparative study with 1-131. Radiology 1980;l36:461â€”464. 2.0 cm, while the mean size for the mammographically 12. Winzelberg GG, Melada GA, Hydrovitz JD. False-positive thallium-20l occult invasive lobular carcinomas was 5.0 cm. This group parathyroidscan of the mediastinumin Hodgkin's lymphoma. AJR felt that invasive ductal carcinomas are mostly associated 1986;147:819â€”821. 13. Stoller DW, Waxman AD, Rosen G, et al. Comparison of thallium-20l, with a strong desmoplastic reaction, but if the tumor is gallium-67, technetium-99m MDP and magnetic resonanceimaging of imbedded in dense fibroglandular tissue the difference in musculoskeletalsarcomalAbstract]. Clin Nuci Med 1986;12(suppl):P15. density may not be enough to be appreciated mammo 14. Kaplan WD, Takvorian T, Morris JH, et al. Thallium-20l brain tumor imaging: a comparative study with pathological correlation. J NucI Med graphically as a focal mass. This group also found that 1987:28:47â€”52. invasive lobular carcinoma in dense breasts can obtain a 15. Waxman AD, Goldsmith MS, Greif PM, et al. Differentiation of tumor size of several centimeters and may still lack mammo versussarcoidosisusingthallium-20l in patientswith hilar mediastinal adenopathy[Abstracti.J NuclMed 1987;28:561. graphic signs. 16. Ramanna L, Waxman AD, Binney G, et al. Increasing specificity of brain In patients with a high risk for the development of breast scintigraphy using thallium-201 [Abstract]. J NucI Med 1987;28:658. cancer and who have mammograms considered difficult 17. Mounts JM, Stafford-Schuck,McLeever P, et al. The tumor/cardiac ratio: a newmethodto estimateresidualhighgradeastrocytomausingthallium to interpret, a thallium study may help to determine which 201 [Abstract]. J NuclMed 1987;28:706. patient population should be evaluated surgically. 18. Hofnagel CA, Delprat CC, Marcus HR, et al. Role of thallium-201 total The data indicate that the use ofthallium can potentially body scintigraphy in follow-up of thyroid carcinoma. I Nucl Med 1988;27:1854â€”1857. define a population of patients in whom the presence of a 19. LeeVW, RosenMP, BaumA, CohenSE,CooleyT, LiebmanHA. AIDS positive test would justify an immediate biopsy due to the related Kaposi sarcoma:findings on thallium-201 scintigraphy.AiR high specificity for carcinoma. The presence of a negative 1988:151:1233â€”1235. 20. SehweilAM,McKillopJH, MilroyR,et at.Thallium-20lscintigraphyin thallium breast study is highly suggestive of benign etiol thestagingoflung cancer,breastcancerand lymphoma.Nuc!Med Comm ogies for palpable breast masses since the sensitivity for 1990;l 1:263â€”269. carcinoma in this group is high (96%). 21. Waxman AD, Ramanna L, Brachman MB, et al. Thallium scintigraphy in primary carcinoma of the breast:evaluation of primary and axillary me Thalhium-20l appears to be highly sensitive for the tastasis[Abstract]. J NuciMed l989;30:844. detection of breast malignancy in palpable breast masses 22. Waxman AD, Ramanna L, Said J. Thallium scintigraphy in lymphoma: and insensitive for the detection of benign abnormalities relationshipto gallium-67[Abstract].J NuclMed 1989;30:9l5. 23. Black KL, Hawkins R, Kim KT, et al. Use of thallium-201 SPECT to with the exception of highly cellular adenomas. These quantitate malignancy gradeofgliomas. J Neurosurg 1989:71:342â€”346. characteristics may be useful clinically when there is a 24. Tonami N, Shuke N, Kunihiko Y, et al. Thallium-20l single photon need to differentiate a benign from a malignant process in emissioncomputed tomography in the evaluation ofsuspectedlung cancer. J NuciMed 1989;30:997â€”l004. patients with palpable breast lesions and suggest a rationale 25. Ramanna L, Waxman AD, Binney G, et al. Thallium-201 scintigraphy in in selecting patients for biopsy. bone sarcoma:comparison with gallium-67 and technetium-MDP in eval uation ofchemotherapy response.J NuclMed 1990;31:567â€”572. 26. Kim KT, Black KL, Marciano D, et al. Thallium-20l SPECT imaging of ACKNOWLEDGMENTS brain tumors: methodsand results.J NuclMed 1990;31:965â€”969. 27. Kaplan WD, Wouthee ML, Annese MS. et al. Evaluating low and inter The authors thank the Du Pontâ€”Merck& Co., Inc. for grant mediategradenon-Hodgkin'slymphoma(NHL) with gallium-67(Ga) and support ofthis project. We would also like to thank Kathy Wenzel thallium-20l (Tl) imaging [Abstract]. J Nuc/Med 1990:31:793. 28. Waxman AD, Ramanna L, Memsic A, et al. Thallium scintigraphy in the and Robin Backer for their help in the preparation of this differentiation of malignant from benign massabnormalities of the breast manuscript. lAbstract]. J NudMed 1990:31:747. 29. Ramanna L, Waxman AD, Braunstein G. Thallium-20l scintigraphy in differentiatedthyroid cancer@comparisonwith radioiodinescintigraphy REFERENCES and serumthyroglobulindetermination.J NuclMed 199l;32:441â€”446. 30. Gehring PJ, Hammand PB. The interrelationshipbetweenthallium and 1. Mann BD, Giuliano AE, BassettLW, et al. Delayeddiagnosisof breast potassiuminanimals.J PharmacolExp Ther1967;155:187â€”201. cancerasa result ofnormal mammograms.Arch Surgery l983;118:23â€”25. 31. Lebowitz E, Greene MW, Greene R, et al. Thallium-201 for medical use. 2. Holland R, Jan HC, Hendricks L, Mravunac M. Mammographically occult I.JNuclMed 1975;l6:l5lâ€”l55. breast cancer: a pathologic and radiologic study. Cancer 1983;52:1810â€” 32. Bradley-Moore PR, Lebowitz E, Greene MW, Atkins HL, Ansari AN. 1819. Thallium-201 for medical use. II. Biologic behavior. J Nucl Med 3. Feig SA, Shaber GA, PatchefsklyA. Analysisof clinicallyoccult and 1975;16:156â€”160. mammographically occult breasttumors. AiR 1977;l28:403â€”408. 33. AtkinsHL, BudingerTF, LebowitzE,et al. Thallium-20l for medicaluse. 4. KalisherL. Factorsinfluencingfalsenegativeratesin xeromammography. III: humandistributionandphysicalimagingproperties.J NucIMed Radiology 1979;l33:297â€”301. 1977;18:133â€”140. 5. Burns PE,Grace MG, LeesAW, et al. False-negativemammogramsdelay 34. Britten iS, Blank M, Thallium activation of the (Na+, K+) activated

22 The Journalof NuclearMedicineâ€¢Vol. 34 â€¢No. 1 â€¢January 1993 ATPaseof rabbit kidney. Bioehi,n Biop/ivs Ada 1968:15:160â€”166. T+NA+â€”2Clâ€”cotransportis the central mechanism of ion uptake. Noel 35. Muranake A. Accumulation of radioisotopeswith tumor affinity. II. Com Med 1986;25:24â€”27. parison of the tumor accumulation of Ga-67 citrate and thallium-201 37. Ando A, Ando I, Katayama M, et al. Biodistribution ofTl-201 in tumor chloride in vitro. .4cia Med Okara@na1981:35:85â€”101. bearing animals and inflammatory lesion induced animals. Eur J Noel 36. SesslerMi, Geck P. Maul FD, et al. New aspectsofcellular Tl-201 uptake: Med 1987:12:567â€”572.

SELF-STUDY TEST Pulmonary Nuclear Medicine Questions are taken from the Nuclear Medicine Self-Study Program I, published by The Society of Nuclear Medicine DIRECTIONS The following items consist of a heading followed by numbered options related to that heading. Select those options you think are true and those that you think are false. Answers may be found on page 70.

I Â¶

FIGURE 1.

The 99mTcDTPA aerosol and 99mTcMAA perfusion images Truestatementsregardingsarcoidosisinclude: shown in Figure 1were obtained from a 65-yr-oldwoman who had increasing shortness of breath. The aerosol images (each 4. It is a systemic disorder associated with abnormalities of 100,000counts requiring about 150sec of imaging time) were the immune system's response to an infectious agent. obtained immediately before the perfusion images (each 5. Mostpatientswithsarcoidosisdevelopprogressive 400,000counts requiring about 60 sec). Truestatements con deterioration in pulmonary function as a result of exten sive pulmonary fibrosis. cerning these images include: 6. The pathologicfindinginthe lungsof patientswithearly 1. The centralairwaysdepositionindicatesthattheaerosol sarcoidosisthat ismostdirectlyrelatedto pulmonary67Ga droplets weretoo large to penetrateinto the periphery of uptake is alveolitiswith granuloma formation. the right lung. 7. Pulmonary function tests generally show progressive 2. The medialrightlowerlobe activityseen on the perfusion deteriorationof lung reservein patientswith normal 67Ga @ image probably is shine-through' from right lowerlobe pulmonary scintigrams. aerosol deposition. 8. Themagnitudeof 67Gauptakeinthe lungsof patientswith 3. The scintigraphic findings aretypical of those seen in pa sarcoidosis has been shown to correlate with both the tients who have undergone irradiation of the right severity of pulmonary function abnormality and the hemithorax for lung cancer. radiographic severity of pulmonary fibrosis. (continuedon page 70)

Evaluating Breast Abnormalities with Thallium Scintigraphy â€¢Waxman et al. 23