jIUn/ADJUNCTIVE MEDICAL KNOWLEDGE

The Complementary Use of B—Scan Ultrasound and Radlonuclide Imaging Techniques

AngelitaDingcongSandersandRogerC.Sanders

Johns Hopkins Medical Institutions, Baltimore, Maryland

Too often a single noninvasive imaging technique the kidneys will be enlarged and numerous cystic fails to provide enough information to permit a diag areas will be present. Differentiation between the nosis to be made, whereas a judicious combination two conditions is usually simple: the cysts in a poly of two or more techniques will frequently provide cystic kidney vary markedly in size and in the enough data to obviate the need for such invasive smoothness of the wall, whereas several character procedures as or exploratory laparot istic ultrasonic configurations may be seen in hydro omy. In this article we shall endeavor to correlate nephrosis when it is severe (2). Multiple cystic struc the use of techniques with sonogra tures of similar size radiating from the center of the phy in several organ systems. In most instances we kidney occur if the bulk of the pressure changes have believe that nuclear medicine and ultrasound should been borne by the calyces, or, if the pelvis is most play complementary roles, although one or the other affected, a large cystic “sac-like―area surrounded by may be uniquely suited to the diagnosis of some a small rim of renal parenchyma will be seen. A conditions. We will attempt to put these noninvasive third configuration occurs in hydronephrosis due to procedures in perspective and develop a guide to obstruction of the ureteropelvic junction : both the their most efficient utilization. Certain conditions are extrarenal and intrarenal pelves dilate, causing two best diagnosed by sonography, such as obstetric adjacent cystic areas with a “dumbbell―shape. problems and abdominal aneurysms. Since ultra Although ultrasound is sufficiently reliable for the sound cannot pass through gas or bone, pulmonary diagnosis of hydronephrosis (1 ), only anatomic and bone lesions must be investigated by nuclear changes are shown, and the degree of renal function medicine or radiologic techniques. Most organs in cannot be assessed. If some renal function persists, the abdomen, thyroid, and breast can be examined nuclear techniques are helpful in three ways: advantageously with both nuclear medicine and 1. A e9mTc-DTPA scan allows one to detect ultrasound. We will consider only those conditions the level of the obstruction. Only severely wherein both these techniques can be used with mu dilated ureters can be visualized with ultra tual benefit, and not those where one or the other sound. has little or no role. This communication will be 2. A 9OmTc..DMSAscan delineates the amount concerned with an assessment of how the two mo of functioning parenchyma in each kidney dalities should be used together for best patient man (3) and permits the surgeon to decide agement in these areas. whether a drainage procedure is indicated. KIDNEY 3. A sonographicdiagnosisof polycystickid ney can be supported if numerous areas of Genitourinary diagnosis involves several problems decreased uptake are seen within the renal in which ultrasound and nuclear medicine play im outline (3) (Fig. 1). portant complementary roles. Kidneys not visualized adequately on excretory urography (IVP) in the presence of renal failure should be studied next with Received Aug. 18, 1976; original accepted Sept. 21, 1976. ultrasound to exclude bilateral hydronephrosis or For reprintscontact: Roger C. Sanders, Dept. of Radiol ogy, Johns Hopkins Medical Institutions, 601 N. Broadway, polycystic kidneys (Fig. I ) (1 ). In both conditions Baltimore, MD 21205.

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FIG. 1. Polycystickidney.(Top)Transversepronesection,5 cm (S) is vertebral column. Arrows indicate septa. (Bottom) Right pos. abov iliac crest, showstypical sonographic changes of polycystic tenor oblique and left posterior oblique views of @Tc-DM$A kidneys. Both kidneysare markedly enlarged with multiple cysts(C) scan on same patient showstypical appearance of polycystickid. of varying sizes. Pelvicalyceal echoes (P), although disorganized, are neys: distortion of renal outline with multiple defects correspond. still recognizable. Sound.obsorbingstructure between two kidneys in9 to cystsseenon sonogram.

Renal failure due to vascular disorders (e.g., for an ectopic kidney in the pelvis. Should none be thrombosis) may be diagnosed if the kidneys are found, perhaps because of overlying bowel gas, a found to be small or normal in size by ultrasound ODmTc-DTPA scan with flow study, done in the an and if there is no perfusion to the renal bed by a tenor projection using a diverging collimator, will ø9mTcO4flow study. In acute renal failure, the degree show both renal beds and the pelvis, where an cc of ‘311-Hippuranconcentration in the kidneys may topic kidney might be. be of diagnostic significance regarding eventual renal In the absence of hematuria, demonstration or function (4) . In end-stage renal failure, where ultra suspicion of a renal mass on an 1W should lead to sound has shown small but otherwise normal kid an ultrasonic examination to determine whether the neys, there is as yet no means of distinguishing among mass is cystic or solid (7) . Cystic lesions show large the many causes, such as chronic , posterior-wall echoes, smooth walls, and no internal chronic glomerulonephritis, or renal artery stenosis, echoes. Solid lesions, although they usually contain since all will show diminished flow on the 9omTc@ numerous echoes, may also be more or less echo DTPA flow study. End-stage kidneys retain some free; however, their posterior-wall echo is small perfusion but show equally poor function. because sound has been absorbed. An attenuated In the absence of renal failure, a single kidney posterior-wall echo has been found to correlate with failing to visualize on excretory urography should solid avascular neoplasms (8) , and the accuracy in first be studied with ultrasound, since hydronephro distinguishing cysts from solid lesions has been re sis can be diagnosed easily and a number of the ported as 95% (9). Solid lesions are due to neo other possible causes have typical appearances (5). plasms and arteriography is required to establish the In addition, ultrasound provides information about neighboring organs which may not be available with a 99mTc-DTPA scan (Fig. 2). The sonographic ap pearance of multicystic kidney is that of a cystic mass with multiple cysts of varying sizes within it (6). Sincetherenalarteryisatretic,a 9DmTc@DTPA flow study will show no perfusion on the affected side. If a neoplastic mass occupies the whole kidney, the sonogram will show distortion of the renal out line and central pelvic echoes and, in general, extra echoes within the renal parenchyma. A recent uni lateral renal infarct causes little change in the sono graphic appearance of the kidney, but a oomTc@DTPA flow study will show absence of perfusion to the FIG.2. Bilateraladrenalhemorrhageandrightrenalinfarctin affected kidney (Fig. 2). A small end-stage kidney neonate with oliguria. (L.ft) “@Tc.DTPAflow study, 30.sec frame, shows left kidney (1k) but not right kidney. Visibly avascular is usually detectable by ultrasound if the kidney is areas, thought to be intrarenal, are present in superior aspect of not too small (below approximately 3 cm) . A 9omTc@ left kidney and in region of right kidney (arrows). (Right) Longi. tudinal sonogram through right kidney (rk) in prone position shows DTPA flow study will show a very little or absent cystic lesion (C) above grossly normal kidney and separated by perfusion to the affected side. If none of these mdi w.ll.deflned interface (arrows).(Sonogramof left side was similar.) Bilateral adrenal hemorrhages were found at surgery, with multiple cations is seen, a sonographic search should be made smallarterial emboli in right kidney.

206 JOURNAL OF NUCLEAR MEDICINE ADJUNCTIVE MEDICAL KNOWLEDGE pattern of vascular supply and the presence or ab sence of inferior vena caval involvement. The lower limits of consistent visualization of cysts using gray scale equipment is about 1.5 cm, although 1-cm cysts may sometimes be seen. Solid lesions less than 2 cm in diameter may not be shown by ultrasound but may be detected by a renal image taken with °9mTcDM5A(dimercaptosuccinicacid), especially if the lesion is peripherally located. The o9mTc@ DMSA accumulatesin the proximaland distalcon voluted tubular cells and thus normally outlines the extent of the renal cortex (10) ; consequently, mass FIG.3. Lymphoc.le.(Left) @Tc-DTPAscanshowslargeavas lesions in the cortex will be visualized. Small lesions cular area (arrows) above transplant (1). (Right) Transvsrse sono. deeper in the kidney and close to the pelvicalyceal graphic ssction through renal transplant shows irregularly shaped cysticlesion(C)with septumin its lower aspect(arrow). system may not be detected with a DMSA scan (3). Ultrasound is probably more sensitive in detecting deep lesions, particularly if they distort the pelvic line study for perfusion and function should be oh echoes. Occasionally a suspected intrarenal mass is tamed within 24 hr of renal transplantation to assess due to a hypertrophied column of Bertin. Sonogra acute tubular necrosis. This also provides a con phy and imaging will show the presence venient comparison with future studies so that acute of cortical tissue instead of the decreased activity rejection or other complications can be detected that would accompany a true mass (11). early (15). Acute tubular necrosis (ATh) is charac A lesion at the upperpole of the left kidneymay terized on the scan by good perfusion and dispro be difficult to detect by ultrasound because of over portionately poor function, with gradual improve lying ribs and lung. Should the NP indicate a mass ment of function over a period of time, depending on in this area and if the sonogram is negative, a @mTc@its severity. The prognosis appears to be related to DMSA scan is helpful.The upperpole of the right the duration of ischemia during transplantation (18). kidney does not pose the same problem for sonogra Any subsequentdecreaseof perfusionand concomi phy because it can be examined with the patient tant loss of function, compared with the initial study, supine, with the liver providing a transonic path. should indicate a high probability of acute rejection, Locating the kidney for percutaneous biopsy is but arterial stenosis or renal-vein thrombosis and best done with ultrasound (12). It gives an accurate obstruction must be excluded. The graft can be meas guide as to the depth and direction to which the ured sonographically to look for the increase in size needle should be introduced and can show the loca that occurs in acute rejection, but the problem of tion of the kidney even in the presence of severe obtaining ultrasonic scans at exactly the same level uremia. on serial examination makes it a difficult procedure Monitoring renal transplants is another area where to perform accurately (20). Another sonographic and ultrasound play complementary criterion for the diagnosis of rejection is a decrease roles. Radioactive fibrinogen and @mTc@sulfurcol in the amplitude of the pelvicalyceal echoes, but this bid have been reported to accumulate in a graft finding too is difficult to quantify on serial examina undergoing rejection (13,14), but both need further tions by the currently available methods, and it could evaluation. Also, a9mTc_sulfur colloid was seen to be produced artifactually by differences in time concentrate in acute tubular necrosis. Perfusion and compensated gain and output settings. Failure of function in the allograft have been assessed using the patient to improve with therapy for rejection 1311-Hippuran, with or without imaging (15—18). A should raise the possibility of arterial stenosis; angi more recent method, which provides an indication ography is then necessary to make the diagnosis. of the overall status of the transplant, is the 99mTc_ Both °°@‘Tc-DTPAimaging and ultrasound can DTPA flowstudy(15). Interpretationwiththis pro diagnose obstruction, but with at least fair function cedure, however, is made more difficult by the lack of the transplant the radionuclide study shows the of a normal side for comparison. Moreover, many level of obstruction more reliably. If transplant func of the problems that can arise produce very similar tion is poor, however, the ultrasonic study is better clinical pictures, so that at times only subtle differ since it depends on anatomic rather than functional ences in the 9@Tc-DTPA study are seen. Since only change. Delayed images, obtained 1—2hr after tracer one kidney is visualized, the degree of perfusion is injection, may be used to exclude obstruction if ac assessed by using the aorta for comparison. A base tivity is seen in the bladder but not in the ureter and

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FIG.4. (Left)sonogramshowscysticmass(U)betweenbladder or urinoma. (Right) @mTc-DTPAscansat 10 and 30 mm show tracer (B) and transplanted kidney (K). Cyst could be either lymphocel. concentration (arrow) by mass between kidney and bladder.

the renal pelvis (21 ) . If no obstruction is seen by any of these methods, and there is no clinical cvi dence of iliac vein thrombosis, treatment for acute rejection can be started. Fluid collections in the vicinity of the renal trans plant usually occur between the kidney and the blad der and may be seen as avascular areas on the v9mTc_ DTPA study (Fig. 3), but they arefrequentlybetter shown with sonography, although the various kinds of fluid are difficult to distinguish (22,23). Fresh or nonclotted hematomata are usually echo-free, but older hematomata develop internal echoes. By sonog L Post A Post raphy an abscess may have ill-defined margins and a more complex character due to areas that are not entirely cystic. On the other hand, lymphocele (the most common fluid collection around a renal p transplant) and a urinoma usually appear identical: typically cystic-looking, having smooth margins, good through transmission, and few or no internal echoes (Fig. 3). A 9°―Tc-DTPAscan is a useful sequel to a sonographic diagnosis of a cystic mass, since the scan can establish the diagnosis of a un noma (24) (Fig. 4). A fluid collection shown by ultrasound, together with a radionuclide study show ing activity outside the expected confines of the un nary tract, are pathognomonic of urinary extravasa tion. Occasional false negatives occur when the area of extravasation overlies the bladder, but such prob lems can be avoided by performing a delayed scan FIG.5. Perinephrichematomain [email protected]. immediately after the patient has voided. If the fluid grade fever and right flank pain and tenderness.(lop) mmTc.DMSA scan. Left kidney showsnormal pattern of accumulation,with rela. collection does not show activity on the renal scan, fively “cold―area in upper pole and, lessobviously,in lower pole a diagnosis of lymphocele, hematoma, or abscess representing calyceal and medullary structures. Outline of right kidney is somewhat unusual in that kidney is straight, but no focal should be entertained and the lesion aspirated percu defects are seen. Dark lines at both lower poles are artifacts. (Bot. taneously under ultrasonic control for definitive tom) Longitudinal section through right kidney (K), with patient in prone position, shows sonolucent area posterior to upper pole of diagnosis (25) . A will indicate the kidney. Arrow indicates normal pelvicalyceal echoes. Differential possible inflammatory nature of the lesion, but the diagnosiswas abscess,hematoma,or urinoma. Percutaneousneedle aspiration yielded nonclotting blood, cultures of which were nega delay required before imaging makes 6TGa scanning tive. Diagnosis was perirenal hematoma.

208 JOURNAL OF NUCLEAR MEDICINE ADJUNCTIVE MEDICAL KNOWLEDGE

nation is to Sort out the anatomic relationships of the mass and show that it is separate from the kidney (Fig. 6) . At times it is impossible to decide whether a large mass is primarily intrarenal on is extrarenal and invading the kidney, but once a renal origin has been excluded, the extent of the mass is determined. The ultrasonic scanning must be performed with the !@•, patient both prone and supine: the prone scan should define the relationship of the mass to the kidneys r @ @i.;*@ while the supine scan explores its relationship to the great vessels and searches for a possible extension 20 sec across the midline. Absorption by the vertebrae makes the supine position the one of choice for the evaluation of retroperitoneal nodes or retroperitoneal fibrosis. Under sonographic examination, retroperi

FIG.6. Poorlyfunctioningdisplacedleftkidneyin42.year.old woman with chronic myelog.nous leukemia and known urate ne phropathy (nonvisualizing left kidney on intravenous ). (Top)PosteriormmTc.DTPAflow studiesat 20 secand 15 mm. Left C D kidney is poorly seen and is displaced inferiorly and medially. Ob. structioncould not be excluded.Diamondsmark midline. (Bottom) Transversesection3 cm above iliac crest,with patient prone, shows normal right kidney and structurally normal l.ft kidney (arrows) being displaced towards spine (V) by very large spleen (S). Liver in. dicated by L. No hydronephrosis was found.

E F less valuable than ultrasonography and percutaneous puncture. A fluid collection in the vicinity of a kidney in its usual location is either a urinoma, a hematoma, or an abscess, and the same considerations apply as in fluid collections around a renal transplant (Fig. 5).

RETROPERITONEUM FIG.7. Varioussonographicconfigurationstakenbylymph The retropenitoneal region is one of the more dif nodes (N): (L) liver; (v) inferior vena cava; (a) abdominal aorta. (A) Transverse section of upper abdomen shows enlarged nodes sur ficult areas to evaluate by the usual radiographic roundingaorta, extendingto region of porta hepatis.(B)Enlarged methods. Ultrasound can detect retropenitoneal nodesare seento silhouetteaorta and inferior venacavaat normal gain. Interface between nodes and great vesselscan be brought masses and characterize them as being solid or cys out by increasing gain. (C) Purely mesenteric pattern, showing no tic (26). Besides the usually encountered solid le evidence of enlarged nodes around great vessels, but predominantly sonolucentmassesare seen within peritoneal cavity. (D) Combination sions in the retropenitoneal space outside the kidneys, of mesentericand retroperitoneal nodes extend into region of left occasional neoplasms arise from the posterior walls kidney, displacing it laterally. Enlarged nodes may displace other organs as well. (E) Longitudinal section, supine, showing retro of the stomach, the second portion of the duodenum, peritoneal nodes anterior and posterior to aorta. Sometimes sepa. or the ascending or descending colon. These masses ration between aorta and spine may be only sign of retroperitoneal nodes. (F) Focal collection of nodes just anterior to aorta. If lo may produce urologic symptoms and signs referable cated near pancreas,this may be mistakenfor pancreatic mass.(0) to either kidney and can induce abnormalities in the Mesenteric nodes, longitudinal section. (H) Retroperitoneal nodes showing focal separation of aorta from spine. Arrowheads mark excretory pyelogram. The thrust of ultrasonic exami level of umbilicus.

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.,-@ FIG.8. Subcapsularliverhematoma in 36-year.old woman with history of cho. lecystectomy1 year previously, with pro fuse bleeding at surgery. (lop) Liver scan with @Tc.sulfurcolloid shows large cold area (arrows) in superior posterior aspect of right hepatic lobe. (Bottom, left) Flow study using mmlc.sulfurcolloid showscold defect (arrows) seen on static scans to be avascular. (Boftom, right) Transverse sec. tion 1 cm blow ziphisternum showslarge cystic area (C) with irregular margins (ar rows) in posterior superior aspect of right R.Ant hepaticlobe, correspondingto focal defect on radionuclide scan. Large subcapsular hematomawas evacuated at surgery.

toneal fibrosis presents a symmetric mantle-like rela and Hodgkin's; lymphocytic lymphonia is less avid tively echo-free mass enguffing the great vessels, with (30). Radionuclide lymphography with 198Au(31,32) smooth margins and without lobulations (27) . Ret has been reported to correlate well with biopsy find ropenitoneal nodes may appear similar but are more ings in lymphomas and some metastases, but the likely to be asymmetric, lobulated, and to have technique needs further evaluation. mesenteric and intraperitoneal components. Enlarged abdominal nodes present several ultrasonic patterns; LWER one simulates retroperitoneal fibrosis, and others are Radionuclide imaging with a labeled colloidal schematically shown in Fig. 7. When nodes “silhou agent such as 9OmTc..sulfurcolloid should be the first ette―the aorta and the margins of the aorta cannot diagnostic step in the evaluation of possible liver be delineated, the nodes may be confused with an disease, since information is obtained about both the abdominal aortic aneurysm; however, increasing the structure and the function of this organ. Since the gain will cause low-level echoes to become visible spleen can always be imaged concurrently, the cor in the nodes and the aortic interface to become dis relation of the two organs usually makes the scan cernible (28). Ultrasound is less sensitive than lym more specific than otherwise. phography in detecting lymph-node enlargement cx Diffuse disease of the liver, the condition most tending less than 3 cm along the external iliac or frequently encountered, often appears in the early periaortic lymph-node chains. Since nodes along the stages as hepatomegaly, with or without inhomo internal iliac chain, within the mesentery, or around geneity of tracer uptake in the various parts of the the pancreas are in “blind―areas for conventional liver. Gross hepatomegaly is easily detected but the lymphography, ultrasound may be helpful. milder degrees of liver enlargement are more difficult In the evaluation of retroperitoneal masses, nu to judge. A subjective impression of hepatomegaly clear medicine is best used to assess possible renal, can be obtained when the usual sharp points in the hepatic, or splenic involvement and to evaluate pa liver outline assume a rounded contour, e.g., along tients with known or suspected lymphoma (or metas the inferior margin, especially on the night side. The tasis) who might be saved a staging laparotomy if liver volume can be estimated by constructing the liver and spleen involvement can be proven by a best elliptical shape around the liver in the anterior 9OmTc..sulfuncolloid study. Moreover, in a patient and lateral projections, but this method requires who is technically difficult to examine ultrasonically experience because of the variability of liver shapes due to excessive obesity or the presence çfbowel and contours (33—35). Sonographic determination gas, a gallium study may detect abnormal concentra of liver volume has been proposed by Rasmussen tions of activity in lymph nodes and organs (29). (36), but his method does not appear to be any more Some metastases from lymphomas accumulate gal accurate than the scintigraphic method. The spleen hum quite avidly, predominantly the histiocytic type may appear normal in early diffuse liver disease, but

210 JOURNAL OF NUCLEAR MEDICINE ADJUNCTIVE MEDICAL KNOWLEDGE as this progresses, the spleen will show increasing uptake of colloidal radiopharmaceuticals (37) as well as a progressive increase in size. With still greater severity of the liven disease, the tracer will accumulate in the bone marrow and eventually in the lungs (38). The combination of hepatomegaly, R inhomogeneous hepatic uptake of tracer, decreased liver-to-spleen uptake ratio with or without spleno megaly, and bone-marrow activity is highly sugges tive of cirrhosis, but it may also be seen in severe fatty metamorphosis (39). One may also diagnose the more florid examples of diffuse liver disease with sonography, but the modality is less sensitive than the 99mTc@sulfur colloid scan. Fatty infiltration and cirrhosis both give diffuse strong echoes throughout the liver (40). With cirrhosis and portal hyperten sion, however, the extrahepatic veins in the portal system are dilated, venous collaterals may be seen, and the spleen is usually enlarged (41). Focal disease in the liver, such as primary or meta static tumor, abscess, cyst, or hematoma, usually ant r lat appears as a “cold―area on the colloid scan. “Hot― spots have been reported with superior vena cava obstruction (42), portocaval shunts (43), heman FIG.9. Livermetastasisin65-year-oldwomanwithrightupper gioma (44), hepatic-vein occlusive disease (45), quadrant pain for previous 10 months and gastric mass seen on up. per 01 series. (Top) Transverse sonogram taken at level of xiphister and following misdirected central venous pressure num shows relatively large anechoic area (arrows). (L) Normal liver catheters (46). Dynamic imaging (flow study) will parenchyma.Thislarge lesionhas completelysonolucentcenter(N) representingnecrotictumor; two smaller metastaticareas (M) of de. assist in differentiating lesions without Kupifer cells creasedechoescan be seen.(Bottom)Scantaken with “@Tc.sulfur but with normal or even greater than normal vas colloid of sameliver showslarge “cold―area (arrows)correspond ing to large lesion in right hepatic lobe seen on sonogram.Smaller cularity (hepatoma, hemangioma, and a few metas lesion in left lobe (arrowhead) was recognized only in retrospect. tases) from lesions that have no phagocytic cells and Lesion in caudate lobe seen on sonogram is not seen at all on radionuclidescan.At surgery,patient had leiomyosarcomaof stom little or no vascularity (hematoma, cirrhotic pseudo ach with metastases to liver. tumor, most metastases, cyst, and abscess) (47) (Fig. 8). Further information can be obtained by diagnosis of liver disease, the major role of ultra imaging with 67Ga citrate, which accumulates in most sound should be that of determining whether a lesion hepatomas, inflammatory lesions, and lymphomas found by radionuclide imaging is solid or cystic (57), and in some metastatic neoplasms (48,49). whether it is intrahepatic or perihepatic, and whether Although ultrasound can detect focal intrahepatic there is superimposed focal disease in those livers lesions down to 2 cm in size if done very systemati with inhomogeneous patterns of activity. cally and thoroughly by a skilled operator (50), the Sonographically, the normal liver shows diffuse inherent tediousness, the great variability of the tech low-level echoes throughout, with occasional tubular nique, and the lower sensitivity in detecting diffuse structures (branches of the portal or hepatic venous disease (51 ) make it a much less satisfactory systems) that can be traced to the inferior vena cava screening procedure than nadionuclide or to the porta hepatis (40) . Focal lesions that have (52) . However, in patients with a strong clinical characteristics of a cyst (no internal echoes, strong suspicion of focal liver disease, complementary stud posterior-wall echoes) are usually due to benign dis ies will be beneficial (53,54). Nuclear medicine tech ease, either simple cyst, abscess, or hematoma. These niques are more sensitive in detecting lesions close cyst-like lesions may appear similar, with smooth man to the surface but may miss those deeper in the gins, but abscesses usually have some internal echoes parenchyma (55), which ultrasound can demonstrate due to debris within the cavity and may be surrounded (Fig. 9). Gamma imaging may be less helpful in by a zone of decreased echoes, compared with the rest detecting lesions of the left lobe, which normally has of the liver, due to inflammation (Fig. I 1). Abscesses much less activity than the right lobe because of its can be differentiated from cysts and hematomas by thinness (56) and which cannot be imaged satisfac gallium imaging, which usually shows increased activ torily from the posterior projection (Fig. 10). In the ity in the case of a pyogenic abscess but decreased

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FIG. 10. Normalvariantliver.(Left)‘°mlc-sulfurcolloidscanof xiphisternumshowssizable gap (arrow) between right (R) and left liver showing suspiciouslesion at junction between right and left lobes (L) of liver. No abnormality could be found. Inferior vena lobes of liver (arrows). (Right) Transverse sonogram 3 cm below cava (V) and aorta (A) are seen.

activity in an amebic abscess (58,59). Frequently, dis some internal echoes if clots are present; they may crepancies are observed in abscess size as measured also differ in appearance depending on how recently by sonography and by imaging with either DamTc@ the bleeding occurred. A recent hematoma may show sulfur colloid or 67Ga (Fig. 11) . The discrepancy is a flat fluid interface that always stays parallel with probably due to the demonstration by ultrasound of the table regardless of the patient's positioning. This only the fluid-filled cavity without the surrounding effect is probably due to the setthng of the solid zone of inflammation, whereas this zone is usually elements in the blood to the lowest portion of the part of the focal defect seen on o9mTc scan or the cavity. Unfortunately, this finding is not specific area of abnormal accumulation of gallium. For this since it has also been seen in abscesses. Chronic reason, it is better to evaluate the adequacy of drain hematomas may be entirely cystic, but they often age from an intrahepatic abscess by sonography, develop a number of echoes within their substance. since it is less likely to give a false-positive result of The sonographic appearance of solid lesions in the residual pus collection (60). The continuing de liver can range from (A) echo-free areas that can creased or absent activity of the reticuloendothelial be mistaken for cysts (but which have poor trans cells and the increased uptake of gallium due to ne mission and fill with echoes as the transducer's out solving inflammation may be misinterpreted on the put is increased), to (B) areas with fewer echoes sulfur colloid and gallium scans (61 ) . Hematomas than surrounding parenchyma, and (C) highly echo may have irregular margins (Fig. 8) and may have genic areas (62). Metastases most commonly show

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FIG. 11. lntrahepaticabscessesin21-year-oldmanwithfever, lesion is an area of decreased acousticdensity (arrowheads).Scan leukocytosis,and right upper quadrant pain and tenderness. was interpreted as showing intrahepatic abscesswith surrounding (Left) Anterior mmTcsulfur colloid scan of liver shows cold―area area of decreased echoes representing inflammation. (Right) Gal (arrows) in region of gallbladder fossa. Black line representscostal Iium.67 scan of liver showsdiseased area seen on the @mTcscan margin. Whether this lesion was intrahepatic or not was uncertain. and on sonographyto concentrategallium (A). Black line represents Smaller areas of decreased activity in left lobe (arrowheads)were costal margin. Other less well-defined areas of abnormal gallium not originally appreciated. (Middle) Transversesectionshowsirregu. accumulation are seen. Large hepotic abscess in right lobe near larly shaped cystic area (arrows) with multiple internal septations normal gallbladder was drained at surgery. Inflamed liver tissue in anterior aspect of right lobe of liver. Surrounding this cystic correspondingto other gallium-avid areas could not be drained.

212 JOURNAL OF NUCLEAR MEDICINE ADJUNCTIVE MEDICAL KNOWLEDGE areas of decreased echoes (Fig. 9) ; metastases from PANCREAS adenocarcinoma are reported to form a bull's eye Lesions of the pancreas are more accurately de appearance: an echogenic area surrounded by echo tected and characterized by sonography (63,64) than free rim (62). With a nadionuclide flow study, by scintigraphy with T5Se-methionine. In one report those metastases having greater vascularity than the radionuclide imaging was 67% accurate in the de surrounding parenchyma may be confirmed. Most tection of pancreatic neoplasms greater than 2 cm metastases, however, seem to be avascular (47). in size, compared with an accuracy of 84% with Ultrasonic examination is very helpful in differ ultrasound (65). Radionuclide pancreatography is entiating scan defects due to intrahepatic lesions hampered by the difficulties of separating the pan from those produced by disease in adjacent structures creas from the left lobe of the liver, the variability and from defects due to unusual variations in the of pancreatic shape, the high percentage of falsely liver shape (Fig. 10) . The radionuclide defects most positive or negative scans (66,67), and the nonspeci difficult to interpret are usually located (A) in the ficity of an abnormal finding (68,69). Sonographi region of the gallbladder fossa; (B) posteriorly in the cally, the contour of the pancreas is irregularly vicinity of the kidney; (C) laterally where the ribs expanded, and reduced echoes are seen in areas in may produce indentations; (D) superiorly where the volved with neoplasm. Similar findings may also be hepatic veins emerge from the liver and where an seen, however, with focal chronic pancreatitis. Al enlarged heart may exert extrinsic pressure; (E) in though the accuracy of sonography in diagnosing the region of the porta hepatis; (F) in the fossa of pancreatic carcinoma is no greater than that of pan the inferior vena cava; or (G) in the areas where the creatic duct cannulation or angiography (65), the liver is normally thin such as in the left lobe or dome greater patient acceptability of ultrasound and its (Fig. 10). Sonography can demonstrate (A) normal, lack of morbidity give it a distinct advantage as a but thin liver parenchyma; (B) a normal structure screening procedure. While some neoplasms in the occupying the supposed defect (such as a gallbladder pancreas may be seen, many of those responsible for or hepatic veins) ; (C) an intrahepatic lesion; (D) jaundice are unfortunately less than 2 cm in diam extrinsic pressure from abnormal adjacent structures eter and are therefore unlikely to be visualized. Once such as polycystic or hydronephrotic kidneys or gall a pancreatic mass is detected by ultrasound, a defini bladder empyema; and (E) extrinsic masses. Occa tive diagnosis may be obtained by percutaneous sionally, the liver has unexpected dips and elonga needle biopsy of the mass under ultrasonic control tions along the periphery, particularly in patients (70) . Pancreatitis,if generalized,is readily diag with cirrhosis or asymmetric hypertrophy of the liver. nosable (Fig. 12), but, if focal, it may be confused The sonogram is helpful in verifying that there are no with neoplasm. Since ultrasonic scanning may not be masses along the periphery and that the variations able to distinguish a mass near the pancreas from a are merely due to an irregular borden. In cirrhotic pa true pancreatic lesion, a normal radionuclide pan tients who may be suspected of superimposed hepa creatognam can be helpful in confirming the extra toma, sonography will frequently show the presence pancreatic lesion. or absence of a neoplasm within the liver. Gallium Sonography is the procedure of choice for detect imaging can also be very helpful in these patients ing and following pancreatic pseudocysts (71 ), and since the vast majority of hepatomas concentrate that its diagnostic reliability is virtually 100% . Other radionuclide (49) . Similarly, patients with a focal techniques, such as radionuclide pancreatic scans hepatic defect due to previous irradiation can be and upper GI series, can indicate that a mass is pres investigated by ultrasound for possible recurrent tu ent, but the advantage of sonography is that it can mon. An alternative approach is to use a radiophar characterize the lesion as cystic. Pancreatic pseudo maceutical excreted by hepatocytes, such as 1311-rose cysts may change size abruptly if they discharge bengal, since hepatocytes are less sensitive to irradi spontaneously into neighboring viscera. Such changes ation than the neticuloendothelial cells. This method can be followed with sonography. is not foolproof, however, as hepatocytes can also be damaged by sufficient radiation. Comparing the SPLEEN shapes of the lesion as shown by the uamTc@sulfur Both radionuclide images and sonography define colloid scan and by the 131I-rosebengal scan can be spleen size well (Fig. 12), but a small spleen may helpful. If they have the same geometric shape, con be difficult to find with sonography. Detection of forming to the radiation port, the lesion is much possible accessory spleen is best resolved with a more likely due to irradiation rather than to neo spleen scan. As with the liver, the focal defects oh plasm. served on radionuclide images can be characterized

Volume 18, Number 3 213 SANDERSANDSANDERS

newer agents as OamTc..HIDA, but a partially ob structed bile duct cannot be distinguished from a patent duct (77). Sonography is the procedure of choice to differentiate between jaundice due to hepa

@ .. S ‘;@r—.i I@'@ ,@. tocellular disease or cholestasis and jaundice due to A extrahepatic biliary obstruction. Abnormally large intrahepatic biliary radicles can be seen if the ducts are sufficiently dilated (78) ; in practice, this implies a bilirubin value of 6—8.A dilated common bile duct can sometimes be traced, which provides a crude idea of the level of obstruction (79). The undistended corn ANT mon bile duct is not normally seen, but an enlarged one may be seen as a tubular structure coursing @ ,. ,4_ somewhat obliquely anterior to the portal vein throughout most of its course. Even with experience, the common bile duct may not be demonstrable for technical reasons such as obesity or overlying bowel gas. Ducts once dilated can remain chronically en 4 larged after the obstructive lesion is no longer pres @ - ent (77). Several possible causes of obstruction may be iden tilled. In general, gallstones are readily seen with ultrasound even when they are as small as 2 mm in diameter (80). Stones within the gallbladder pro FIG. 12. Splenic-veinthrombosissecondaryto pancreatitisin 33-year-old alcoholic man admitted with left upper quadrant pain duce discrete strong echoes in the dependent portion and tendernessand palpable left upper quadrant mass.Liver func of the gallbladder, and they are frequently so sound tion testswere abnormal. Serumamylase was normal. (Top) Anterior “@“Tc-sulfurcolloid scan showsnormal-sized liver with inhomogene. attenuating that an acoustic “shadow―is cast behind ous tracer uptake and markedly enlarged spleen without evidence them (81 ). In contrast to calcification within the of increasedactivity. (Bottom)Transversesection4 cm below xiphi. sternum again shows markedly enlarged spleen (5) and diffusely wall of the gallbladder, they fall to the most depend enlarged pancreas (p) containing fewer echoes than normal; this ent portion of the gallbladder when the ultrasonic pattern is typical of pancreatitis. (a) Aorta; (V) inferior vena cava. Angiography showedsplenic-veinthrombosis. examination is performed in the upright position. Small stones are difficult to differentiate from bile sludge. by sonography as cystic or solid. Solid lesions are due either to infarction or to metastatic disease, Choledochal cyst, usually diagnosed in childhood whereas cystic lesions are due to splenic cyst, ab (82), is a rare cause of jaundice and can be easily scesses, or hematomas. In subcapsular hematoma detected with ultrasound (83). Pancreatic pseudo the spleen scan usually shows a filling defect or cysts may also cause obstructive jaundice when they splaying of the spleen outline, the so-called “double are located in the head of the pancreas. Differentia density―sign ( 72 ) or “spleniccrowding―Sign (73). tion between choledochal cysts and pancreatic pseu Combined liver—spleenand lung scanning may show docysts is best made using such hepatocyte-excreted separation between the spleen and the lower lobe radiopharmaceuticals as 1811-rose bengal (82). Over of the left lung, particularly if the injury is to the a period of hours this agent will concentrate in a upper pole of the spleen. Experience with sonog choledochal cyst and not in a pancreatic pseudocyst. raphy for splenic trauma is less extensive, but if the If intrahepatic bile duct dilatation is not detected findings on a spleen scan are questionable, sonogra by ultrasound and the bilirubin is markedly elevated, phy may help in that it may show a cystic lesion significant extrahepatic obstruction is unlikely. In (74,75). Both modalities may occasionally show the vestigation should then be pursued for diffuse liver actual rent in the splenic tissue along its margin. disease or multiple focal lesions that can cause intra hepatic obstruction and cholestasis. As mentioned in BILIARY SYSTEM the section on the liver, radionuclide procedures are In clinical jaundice a9mTc_sulfurcolloid scans can to be preferred for this type of study. show dilated bile ducts, but only the grossest changes Sonography is still valuable if the bilirubin is low are detectable (76) . Dilated ducts can at times be but obstruction is suspected, because the outline of mistaken for focal defects. Complete biliary obstruc a large gallbladder may suggest distention. Chole tion can be diagnosed with 1311-rose bengal and such lithiasis or pancreatic neoplasm may be present, even

214 JOURNAL OF NUCLEAR MEDICINE ADJUNCTIVE MEDICAL KNOWLEDGE though the ducts are too small to be visualized by cholecystitis. When the wall of the gallbladder is ultrasound. inflamed and edematous, irregularity and a double Several complementary imaging techniques are contour to the gallbladder may be seen; it is unclear available for the diagnosis of acute cholecystitis. In how often this finding occurs in acute cholecystitis. fusion cholangiogram (a procedure that usually re Inflammation-causing disease within the gallbladder, quires ) will visualize the biliary tree but such as gallstones, will be detected. not the gallbladder and cystic duct, a combination Masses that arise from the gallbladder, such as that nearly always indicates acute or chronic disease polyps and carcinoma, distort the wall and have the of the gallbladder. However, infusion cholangiogra different acoustic texture of neoplasia to distinguish phy is time-consuming and carries a relatively high them from the liver parenchyma. Inability to visual risk of an allergic reaction to the contrast medium. ize the gallbladder sonographically, in a patient with Ultrasound may be helpful in the diagnosis of acute a nonvisualizing gallbladder on reinforced oral cho lecystogram, is strong evidence of a chronically dis eased gallbladder. Radionuclide techniques are useful in acute chole cystitis. Cystic duct obstruction can be excluded if the tracer accumulates in the gallbladder. Radio labeled rose bengal has been the most used radio pharmaeutical for this purpose, but 9°―Tc-labeled hepatobiliary agents with much better imaging char acteristics are now in development (84) . One of P R these, HIDA, has been reported useful even when the bilirubin is significantly elevated (77). Empyema of the gallbladder is difficult to distin guish from acute cholecystitis by radiologic or radio nuclide procedures, since neither the contrast media nor the radioactive agents will enter the gallbladder. Gallium-67 imaging, however, will show uptake in the gallbladder area. Ultrasonic findings may be suggestive. When the common bile duct or cystic duct is obstructed and the gallbladder wall is producing pus, a “tense―configuration is adopted: the gall bladder is enlarged and the wall is rounded. To date we have no good standards to tell us when a gall bladder, under ultrasonic examination, is too large to be considered normal. If the gallbladder is fibrosed before the attack of acute cholecystitis or empyema, a smaller size may be abnormal. In empyema the surrounding liver may well be affected by an inflam matory response and show an altered ultrasonic tex ture with decreased echoes.

ABSCESS DETECTION A possible cause of fever is an intra-abdominal abscess, and there may be no signs pointing to a FIG.13. Pyelonephritisin18-year.oldmanwithfeverandright specific region. Gallium-67 has a great affinity for upper quadrant pain and tenderness. Subphrenic, intrahepatic, or perinephric abscesswas clinically suspected.(Top) Gallium.67 ci. inflammatory lesions and is the screening agent of trate scan shows abnormal gallium accumulation in right upper choice (85,86). The major disadvantage of gallium quadrant, seen best on posterior view. Without moving patient, repeat scanwas taken of same area with “ETc-sulfurcolloid. Abnor imaging is the substantial delay following injection mal gallium accumulation is below liver and in region of right before the study can be performed (87) ; occasionally kidney. (Middle) @Tc-DMSAscan of kidneys done next day shows focal defect in upper pole of right kidney. Together with findings repeat studies are necessary at 24, 48, and even 72 in gallium scan, this defect was interpreted as renal abscess. (Right) hr. In cases where bowel cleansing cannot be used Longitudinal sonogram 6 cm to right of midline showsslight dis tortion of upper-pole calyces of right kidney (arrows) but no (e.g., in a patient who has inflammatory bowel dis evidence of cystic area. Because of absence of fluid collection, ease or immediately following bowel surgery) , areas pyelonephrltis was diagnosed. Patient subsequently improved on conservativetherapy with antibiotics. of gallium accumulation may be difficult to interpret,

Volume 18, Number 3 215 SANDERS AND SANDERS

FIG. 14. Thyroidcystpresentingas A palpable nodule in left lobe of thyroid in 33-year-old woman. (Left) ‘@TcO@thyroid I scan shows nodule to be “cold―(arrows). (Right) Transversesonogram 2 cm above sternal notch showsoutline of normal thy roid tissue (arrow). Nodule in left lobe of thyroid (C) shows sonographic character ant isticstypical of cyst.(I) Trachea. especially in the subhepatic, left subphrenic, and trates in both inflamed tissue and frank abscesses is pelvic areas. not a disadvantage since the ultrasonic examination Although impressive results have been reported, can be directed to that area. If a fluid collection can generally ultrasonic examination is not as good a be seen sonographically, then the abscess can be screening technique as the gallium study (88) . Small drained, but if an area of definitely abnormal gallium or incipient abscesses may be overlooked, and it is accumulation is shown by ultrasound not to be cystic, difficult to make out areas in which inflammation is then a walled-off abscess is not present and treatment present but frank pus formation has not yet occurred. should be medical (Fig. 13). If conservative man Intestinal gas may well prevent visualization of in agement is adopted, careful sonographic followup fected areas. Frequently the sonogram may be used studies can be done to ensure that no drainable col in conjunction with nuclear medicine studies, par lection of fluid develops. ticularly while waiting for a gallium study, but surgi When the diagnostic problem involves possible cal drains and dressings may prevent the transducer's subphrenic abscess, a gallium image may show an access to the surgical area. The left subphrenic re area with greater activity than that of the liver or gion is a difficult one to assess sonographically be spleen (91 ) . Frequently, however, a subphrenic ab cause of the usual presence of gas in the fundus of scess cannot be distinguished from the normal liver the stomach or in the splenic flexure, but a lateral or spleen accumulation (also true of intrahepatic or posterior approach may be fruitful. In cases in which subhepatic abscesses) . A radionuclide colloid scan suspicious gallium accumulations have been found, should show a focal defect in the involved area if but where these accumulations might be due to gal it is located within the liver, using subtraction tech hum in the gut on the liver, the sonogram may estab niques for small perihepatic abscesses that would lish the presence or absence of fluid accumulation at otherwise be missed (92). A combined lung—liver the site of suspicion. The sonographic examination scan may occasionally be of help, but the accuracy of an abscess may show that one or more septa sepa is low (93). Ideally, a gap in the activity should be rate different loculi of pus. This finding is important seen between the lung and liver if a subphrenic ab since it will indicate whether a simple incision would scess is present, but subphrenic abscesses usually allow drainage of the whole abscess (89). incite an ipsilateral sympathetic pleural effusion, If an area of abnormal gallium accumulation cor which can itself cause a gap between the lung and responds to a region of previous surgery, interpretive liver images (94). Evidence suggestive of a sub problems are encountered, but a subsequent sono phrenic abscess is an irregularity of the upper border graphic examination is helpful. Many individuals of the liver. Once again, the addition of an ultra show an echo-free area immediately beneath the sonic study is helpful. If the patient is not exception incision, apparently representing an understandable ally large, the right subphrenic area is readily ac ultrasonic variant. If this area is excessively large or cessible provided that a single-pass scan in the is not limited to the skin and subfascial tissues, it is longitudinal axis, with breath-holding, is performed. likely to be an abscess. Once a lesion has been de The diaphragm stands out as a black line, above tected, the differential diagnosis lies between hema which a loculated subpulmonic pleural effusion is toma and abscess (90). easily visible and below which the irregular margins A disadvantage of ultrasonic imaging is that it will of a subphrenic abscess can be made out. be unequivocally positive only if a walled-off abscess has been formed; there will be difficulty in detecting THYROID an inflammatory focus in which there is no fluid col The thyroid is an organ whose physiology is ideally lection (Fig. 13 ) . The fact that gallium-67 concen suited for evaluation by radionuclide tracer tech

216 JOURNAL OF NUCLEAR MEDICINE ADJUNCTIVEMEDICALKNOWLEDGE

niques, by both imaging and in vitro studies. Func tion in terms of T4 and T3 output and its complex relationship with various factors are easily assessed, as also are organ size, shape, and the presence of hot or cold nodules. Although ultrasound can be used to measure the thyroid volume by means of serial scans and the formula proposed by Rasmussen (95), assessing the thyroid size by radionuclide imaging

FIG. 16. Malignantascites.Transversesonographicsection4 cm below umbilicus shows multiple fluid collections (a). Intestines (b) lie mostly in dependent portion, but bowel loop is adherent to R anterior abdominal wall (arrowheads),a commonfinding in malig nant ascites.Patient had disseminatedcarcinomaof ovary.

is so much easier that this aspect of thyroid evalua tion is best left to nuclear medicine except when the uptake of tracer by the gland is so poor that the borders are not defined. The role of ultrasound in the evaluation of thyroid disease is confined to situations where a solitary cold nodule is revealed by radionuclide techniques (Figs. 14 and 15). The nodulecan then be classifiedas V a f •.@ solid or cystic by ultrasound and, if cystic, it can be @ R N T V aspirated under ultrasonic control and the cell con L tents of the fluid examined.

MISCELLANEOUS Large amounts of free intrapenitoneal fluid can be diagnosed by plain radiographs of the abdomen, liver—spleen scintigraphy, and sonography. An avas cular area is observed around the liver and spleen on the radionuclide images, and they frequently re . @p - @ V d ‘@‘@ veal poor definition of the margins. On sonography a fluid collection is seen first along the inferior mar gin of the liver and then surrounding the bowel in @ R L increasing amounts. Quantities of free fluid as small as 100 cc can be accurately detected by using A mode @ ‘4 and placing the transducer near the umbilicus with the patient in a knee—handposition (96). Small amounts of loculated intraperitoneal fluid and locu FIG. 15. Thyroidadenomain42-year-oldwomanwithpalpa. lation within a large free effusion can only be diag ble thyroid nodule. (lop) mmTcO4thyroid scan showsarea of de. creased activity (arrow) in lower pole of right lobe of thyroid car nosed by ultrasound. This information indicates that responding to palpable nodule. (Middle) Transversesonogram 3.5 the ascites is either of an inflammatory or malignant cm above sternal notch shows normal thyroid tissue (arrows), cx tending across trachea (T) anteriorly: (V) jugular vein; (a) carotid nature and allows accurate localization@for paracen artery. Posterior aspect of right lobe has sonolucent area (N). tesis (Fig. 16). Unlike typical cysts, however, sonolucentstructuresdid not have good through transmissionand posterior-wall echoes are not Ultrasound has been found useful in classifying prominent. (Bottom)Transversesection 3.5 cm above sternumwith masses within the breast into three types: cysts, be increased gain shows similar normal structures as scan through same level (Fig. 15B). However, previously noted sonolucentarea nign masses, and malignant masses. The accuracy (N) has developed internal echoesas expected for solid homogene rate is said to be as high as that obtained with mam ous lesion, whereas really cystic structures(e.g., vessels)have re mained echo-free. Diagnosiswas thyroid adenoma. mography (97). Bone-seeking radiopharmaceuticals

Volume 18, Number 3 217 SANDERS AND SANDERS

(e.g., oomTc@labeled phosphates) have been reported imaging in post-renal transplant complications. to accumulate in breast tumors (98,99), but they lii:347—358,1974 may also accumulate in normal breast tissue and in ;18. HOLLENBERG NK, B1RTcH A, RAsHiD A, et al. : Rela tionships between intrarenal perfusion and function : Serial breasts with benign disease. Indium-i 11-bleomycin hemodynamic studies in the transplanted human kidney. was found 74% accurate in predicting malignancy Medicine5l:95—106,1972 of palpable breast masses in 3 1 patients. Techne 19. HöR0, PABSTHW, PFEIFERKJ, et al. : Radionuclides tium-99m has been reported to be fairly reliable in in renal transplantation. I Nuci Med 13: 795—800,1972 predicting malignancy ( 88 % accurate in 16 cancers) 20. BARTRUMRJ, SMITH EH, D'On.si CJ, Ct al.: The ultra sonic determination of renal transplant volume. I Clin Ultra but its use is limited by the righ rate of false positives sound2:281—285,1975 (29 % ) in benign breast disease. Gallium-67 is much 21. PAVELDG, JoNAssoNOM, ANDERSON0, et al.: Im less sensitive as an indicator of breast malignancy, proved diagnosis of post renal transplant collecting system being positive in only 5 out of 10 breast carcinomas abnormalities by radionuclide studies. I NucI Med 16: 557, (100). 1975 22. NESBITR, BLAKEDD, EKSTRANDK, et al. : Lympho cele following renal transplantation: Value of ultrasonogra REFERENCES phy in diagnosis and follow-up studies. South Med I 69: 303-304, 1976 1. SANDERSRC, JECKDL: B-scan ultrasound in the evalu 23. SANDERSRC,HILLMC: “Cystic―massdifferentiation ation of renal failure. Radiology 119: i99—202, 1976 by grey scale B-scan ultrasonic pattern. Presented at 2. SANDERSRC, BEARMANS: B-scan ultrasound in the World Federation of Ultrasound in Medicine and Biology, diagnosis of hydronephrosis. Radiology 108 : 375—382, 1973 San Francisco, August, 1976 3. HANDMAKERH, YOUNGBW, LOWENSTEINJM: Clini 24. 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218 JOURNAL OF NUCLEARMEDICINE ADJUNCTIVE MEDICAL KNOWLEDGE

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Baltimore, Williams & Wilkins, 1976, pp 550— ease of liver and biliarytract. SeminNuc! Med 5: 307—324,563 1975 73. O'MARARE, HALLRC, DOMBOWSKIDL: Scintiscan fling in the diagnosis of rupture of the spleen. Surg Gynecol 52. LEYTON B, HALPERN5, LEOPOLD0, et al. : Come Obstet131.:1077—1084,1970 lation of ultrasound and colloid scintiscan studies of the 74. ASHERWM, PARVINS. VIRGIu0 RW, et al.: Echo normal and diseased liver. I NucI Med 14: 27—33,1973 graphic evaluation of splenic injury after blunt trauma. 53. GARRETT WJ, KOSSOFF 0, UREN RF, Ct al. : Gray Radio!ogy118:411—415,1976 scale ultrasonic investigation of focal defects on mmTc sul 75. KRISTENSENJK, BUEMANNB, KUHL E: Ultrasonic phur colloid liver scanning. Radiology I 19: 425—428,1976 scanning in the diagnosis of splenic haematomas. Ada Chir 54. LEE GC, WILsoN RL, WAXMAN AD, et al. : Comrela Scand 137:653—657,1971 tion of scintigraphic and sonographic findings in focal liver 76. HECKLL, GOTFSCHALKA: The appearanceof intra disease.JNuclMed15:511,1974 hepatic biliary duct dilatation on the liver scan. Radiology 55. VIDRIH VE, HIGGINS HP: Accuracy of liver scinti 99: 135—140,1971 photography using a plastic and water phantom. Can J Surg 77. RYAN J, ISIKOFF M, NAGLE C, et al. : The combined 14:273—279,1971 use of Tc-99m HIDA and ultrasound in differential diag @ 56. COVINGTON EE: Pitfalls in liver photoscans. A m I nosis of jaundice. I Nuc! Med 17: 545, 1976 Roentgenol Radium Ther Nuci Med 109 : 745—748,1970 78. TAYLORKJ, CARPENTERDA, MCCREADYVR : Ultra 57. THIJS LG, SNELLP: Diagnosisof cystic lesions of the sound and scintigraphy in the differential diagnosis of ob liver with special reference to the value o1@iagnostic ultra structive jaundice. I Clin Ultrasound 2: 105—116, 1974 sound. Neth I Med 18: 234—244,1975 79. PERLMUTrEROS, GOLDBERGBB: Ultrasonicevalua 58. KUMARB, COLEMANRE, ALDERSONP0: Gallium tion of the common bile duct. I Cli,; Ultrasound 4: 107— citrate Ga 67 imaging in patients with suspected inflamma Ill,1976 @ tory processes. Arch Surg I 10: 1237—1242,1975 80. DOUST BD, MAKLAD NF: Ultrasonic B-mode exami 59. GESLIENGE, THRALLJH, JOHNSONMC: Gallium nation of the gallbladder. Technique and criteria for the

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diagnosis of gallstones. Radiology I 10: 643—647,1974 91. BLAIR DC, CARROLLM, SILVAJ, et al. : Localization 81. HUBLITZ UF, KAHN PC, SELL LA: Cholecystosonog of infectious processes with gallium citrate Ga 67. JAMA raphy: An approach to the nonvisualized gallbladder. Ra 230:82—85,1974 diology 103: 645—649,1972 92. DAMRON JR, BEmN RM, SELBY JB, et al.: Gallium 82. ROSENFIELD N, GluscoM NT: Choledochal cysts: technetium subtraction for the localization of subphrenic Roentgenographic techniques. Radiology 114: 113—119, 1975 abscess. Radiology 113: 117—122,1974 83. FILLY RA, CARLSENEN: Choledochal cyst: Report 93. GOLD RP, JOHNSON PM: Efficacy of combined liver of a case with specificultrasonographicfindings.I Clin U!- lung scintillation imaging. Radiology 117: 105—111, 1975 trasound4: 7—10,1976 94. SANDERSRC : Post-operative pleural effusion and sub 84. HANDMAKER H: Nuclear medicine in the evaluation phrenic abscess. Clin Radio! 21 : 308—312, 1970 of the patient with jaundice. JAMA 231: 1172—1176, 1975 95. RASMUSSEN SN, HJORTH L: Determination of thy 85. ThATES CD, HUNTER JO : Gallium scanning as a roid volume by ultrasonic scanning. I Clin Ultrasound 2: screening test for inflammatory lesions. Radiology 1 16: 383— 143—147,1974 387, 1975 96. GOLDBERGBB, GOODMAN GA, CLEARFIELD HR: 86. LIi-FENBERGRL, TAKETA RM, ALAZRAKI NP, et al.: Gallium-67 for localization of septic lesions. Ann intern Evaluation of ascites by ultrasound. Radiology 96: 15—22, Med79: 403—406,1973 1970 87. HoPKINS GB, KAN M, MENDE CW: Early @Gascm 97. COLE-BEUGLET C, BEIQUE RA: Continuous ultra tigraphy for the localization of abdominal abscesses. I NucI sound B-scanning of palpable breast masses. Radiology 117: Med 17:990—992,1975 123—128,1975 88. MAKLADNF, DOUST BD, BAUM JK : Ultrasonic diag 98. WEINRAUB JM, ROSENBERG R, IRWIN GAL: Tech nosis of postoperative intra-abdominal abscess. Radiology netium-99mpolyphosphatein differentialdiagnosisof breast 113:417—422,1974 masses. I NuclMed 16: 581, 1975 89. UHRICHPC, SANDERSRC: Ultrasoniccharacteristics 99. HOLMES RA, MANOLI RS, ISITMAN AT: Tc-99m of pelvic inflammatory masses.I Clin Ultrasound 4: 199— labeled phosphates as an indicator of breast pathology. 204, 1976 I Nucl Med 16: 536, 1975 90. SMITH EH, BARTRUM RJ : Ultrasonically guided per 100. RICHMAN SD, BRODEY PA, FRANKEL RS, et al.: cutaneous aspiration of abscesses. Am I Roentgeno! Radium Breastscintigraphywith‘5―Tc-pertechnetateand “Ga-citrate. TherNuclMed 122:308—312,1974 I Nuc!Med 16:293—299,1975 (@ SNMTECHNOLOGISTSECTION 24th Annual Meeting June20—23,1977 McCormick Place Chicago,Illinois SIXTHCALLFORTECHNOLOGISTSCIENTIFICEXHIBITS TheTechnologistProgramCommitteejnvjtesthesubmissionof abstractsof exhibitsfor the24thAnnual Meeting. Applications are welcomed from all technologists. The Committee also welcomes exhibits that compliment presented papers on the program. All exhibits will be illuminated by availableroom light. Therewill be no provisionsfor transillumination, e.g., viewboxes.The exhibit should be mounted on poster board not exceeding 30x 30in. No morethan two boards maybeenteredforasubject.Exhibitsshouldbeclearlytitled.Submitthefollowinginformationwithyourappli cation:exhibitor'snameandaffiliation,title of exhibit(10wordsmaximum),abstract(100words),dimensions (maximum of 2 boards not exceeding 30 x 30 in.). First, Second, and Third place awards will be presented to the three most outstanding exhibits. These will be judgedon the basisof scientificmerit,originality,displayformat,andappearance. For additional information contact Joan A. McKeown,MercyCatholic MedicalCenter,PhiladelphiaSchool of Nuclear Medicine Technology, Lausdown & Bailey Road, Darby, PA 19023. DEADLINE: April 10, 1977

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