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The Significance of the Liver-Spleen Uptake Ratio in Liver Scanning

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The Significance of the Liver-Spleen Uptake Ratio in Liver Scanning THE SIGNIFICANCE OF THE LIVER-SPLEEN UPTAKE RATIO IN LIVER SCANNING George A. Wjlson and John W. Keyes, Jr. University of Michigan Medical Center, Ann Arbor, Michigan The use of a simple criterion for assessing the bid seen on liver images as measured by a simple, relative uptake of colloid in the liver and spleen easily applied criterion in an unselected group of was evaluated in a series of patients unselected patients. for type of diagnosis. Categorization of liver scans into groups showing equal, increased, or METHODS decreased relative splenic uptake provides use All nOmTc_sulfur colloid liver and spleen scans per ful differential diagnostic information. In. formed at the University of Michigan Medical Center creased splenic uptake was seen most commonly between January 1969 and September 1971 inclu in cirrhosis, carcinoma, and diabetes mellitus. sively were reviewed. Only studies performed with a Decreased uptake was seen in RES malignancies. rectilinear scanner were considered. To eliminate the No association with anemia alone was found. possibility of variations in technical factors affecting the apparent density, only those studies in which both the liver and spleen were visible in a single posterior Technetium-99m-sulfur colloid is most widely used view were included in the final evaluation. Colloid to image and evaluate hepatic and splenic anatomy. distribution was assessed by comparison of the area The final image obtained is a function of several fac of greatest density in the liver with the area of great tors including the physiological state and distribution est density in the spleen on the single posterior view. of the reticuloendothelial cells among the different A simple visual estimation of relative density was organs and the amount of blood flow to these organs. used and the scans were broken into three groups. Different disease states may alter one or more of Those patients whose scan demonstrated a greater these factors thus changing the relative colloid dis density in the spleen than in the liver (Fig. 1A ) were tribution resulting in an abnormal image. Numerous designated Group A. Patients who had greater density studies have noted a relative decrease in hepatic over the liver than the spleen (Fig. 1B) were desig uptake of colloid in diseases such as hepatitis (1,2) nated as Group B. Equal density in liver and spleen and cirrhosis (3—6)which is apparently a reflection (Fig. 1C) was arbitrarily designated as “normal― of the general impairment of hepatic function seen and the group of patients showing equal density in in these illnesses. However, only a single study to both organs was designated as Group C, to serve date has come to our attention in which the authors as controls. All scans were reviewed by both authors. have attempted to analyze the alterations in colloid In cases where there was disagreement about the distribution in a systematic fashion and to determine density, the scan was included in Group C. Thus, their clinical significance (7). all patients in Groups A and B had unequivocal dif The latter study was limited to patients with diag ferences in the apparent uptake of the liver and noses of cirrhosis, anemia, systemic proliferative dis spleen. eases, and hematopoietic tissue neoplasms. As this All scans were performed using 99mTc@sulfur col is not fully representative of the spectrum of diseases seen in most nuclear medicine laboratories, the re suits are difficult to generalize. The present study was Received Oct. 23, 1973; revision accepted Feb. 4, 1974. undertaken in an attempt to evaluate the meaning For reprints contact : George A. Wilson, Div. of Nuclear Medicine, Strong Memorial Hospital, 260 Crittenden Blvd., of alterations in the distribution of ftDmTc_sulfur col Rochester, N.Y. 14642. Volume 15, Number 7 593 WILSON AND KEYES significant secondary diagnosis, the primary diag nosis was considered to be malignancy if present. If the patient had no form of malignancy, liver disease if present was the primary diagnosis. Diabetes mel p litus was considered a primary diagnosis only in the absence of malignancy or liver disease. RESULTS A total of 1,300 rectilinear liver and spleen scans were reviewed. This included scans from I ,119 pa tients. Five hundred sixty-three patients had posterior S view scans in which there was sufficient liver and spleen demonstrated to determine the relative col bid uptake. Two-hundred-ninety patients were clas @r sified as Group A. There were I 22 males and 168 females. The average age was 50.5 years. Fifty-eight V patients were placed in Group B. This group in cluded 24 males and 34 females with an average age C of 5 1.7 years. Group C consisted of 215 patients; 130 males and 85 females with an average age of FIG. 1. Posteriorscanof GroupA patientwithincreasedsple 53 years. Overall ages ranged from 1 to 88 years. nic uptake (A), of Group B patient with decreased splenic uptake (B), and on Group C patient with equal liver-spleen uptake (C). The primary diagnoses by major systems are given in Table I . The types of malignancy are further bid prepared in-house by a technique which has broken down in Table 2. In both tables the presence been previously published (8). Two millicuries of of a figure in the column P signifies that there is a this preparation were administered to adult patients statistically significant difference for that category with proportionate lesser amounts to younger pa between the adjacent groups as determined by the tients included in the series. Clinical and pathological Chi-square test. If no figure is given, the difference findings were evaluated and correlated for the differ was not significant at the 0.05 level or greater. ent groups and evaluated for statistical significance. Included under miscellaneous liver disease in Ta Patients were evaluated for primary diagnosis, hemo ble 1 in Group A was one patient each with status globin levels, and liver function. Only one diagnosis post-right hepatectomy for trauma, hepatic abscess, was recorded for each patient. In patients with a hematoma of the liver after trauma, fasciola hepatica TABLE 1. PATiENT PRIMARY DIAGNOSIS BY CATEGORY Group A B Group C Group A Diagnosis (No.) (%)Group P (No.)(%) P (No.) (%) P (No.) (%) Malignancy(see Table 2) 139—48 34-59 110—51.2 139—48 Liver disease cirrhosis 39—13.4 <0.025 1—13 7—3.3 <0.005 39—13.4 hepatitis 22—7.6 <0.25 1—17 9—4.2 22—7.6 fatty infiltration of the liver 3—1.0 1—0.5 3—1.0 miscellaneous 7—2.4 1-17 5—2.3 7—2.4 Diabetes mellitus 30-103 4—7.0 7—3.3 <0.005 30—10.7 Alcoholism 6—2.1 <0.05 6—2.1 Pulmonary disease 6—2.1 2—3.5 9—4.2 6—2.1 Gasfrointestinal disease other than liver 11—3.8 5—8.6 8—33 11—3.8 Infection 5—13 3—5.2 18—8.4 <0.005 5—1.7 Genitourinary 3—1.0 2—3.5 1-0.5 3—1.0 Endocrine disease 1—0.3 1-17 5—2.3 <0.05 1-0.3 Cardiovascular disease 5-17 8-37 5—13 Nervous system disease 3—1.0 1—1j 4—1.8 3—1.0 Collagen disease and arthritis 4—1.4 2-3.5 13-6.1 <0.005 4—1.4 Miscellaneous 6—2.1 1—13 10—4.6 6—2.1 Total patients 290 58 215 290 594 JOURNAL OF NUCLEAR MEDICINE LIVER—SPLEENUPTAKE RATIO IN LIVER SCANNING TABLE 2. TYPES OF MALIGNANCY Grou A Group B C Group A Malignancy type (No.)p (01°) P (No.) (0/•)Group P (No.) (0/•) P (No.) Carcinoma total 100—72 <0.001 16-47 <0.0005 85—77 100 adenocarcinoma GI tract 44 <0.01 6 22 <0.05 44 Other 23 2 19 23 squamouscell carcinoma 20 5 28 <0.05 20 other carcinoma 13 3 16 13 Sarcoma 7—5 2—6 11—10 7 Melanoma 14—10 2—6 10—9 14 Hodgkin's disease 11-8 <0.005 9—26 <0.0005 2—2 <0.05 11 Leukemia 5-4 2—6 1—1 5 Multiple myeloma <0.0005 3—9 <0.005 Miscellaneous 2—1 1—1 2 60% average hemoglobin level was 12.8 gm; males 13.1 gm and females 12.3 gm. 50%• Abnormally elevated alkaline phosphatase levels (Fig. 2) were present in 50% of Group A patients, 40%@ in 43% of Group B patients, and in 41 % of Group C patients. Serum glutamic oxaloacetic transaminase levels were elevated in 61 % of Group A patients, in 30%• 60% of Group B patients, and in 43 % of Group C patients. Serum bilirubin levels greater than I mg% 20% were present in 35% of Group A patients, 21 % of Group B patients, and in 16% of Group C patients. 10% DISCUSSION GROUPA B C GROUPA Malignancy was the most frequent primary disease ALKALINE SGOT TOTAL in all three groups and is probably a reflection of PHOSPHATASE BURU@N the frequent use of the liver scan to detect possible FIG. 2. Percentof each group with elevated alkaline phos metastases in patients with known malignancy. The phatase, SGOT, and total bilirubin level. incidence of the different types of malignancy, how ever, varied between the groups. Some form of car infestation, alcoholic liver disease, glycogen storage cinoma was present in about three-quarters of all disease, multicystic renal and liver disease, and one types of malignancy in Groups A and C whereas with undiagnosed hepatomegaly and elevated liver carcinoma accounted for less than half the malig enzymes.
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