G A M U T

Liver Uptake of 99mTe-Pyrophosphate

Steven Hansen and Rober t C. Stadaln ik

A 56-yr-old chronic schizophrenic with a prior history of anterior myocardial infarc-

tion was hospitalized with a 2-day history of progressive abdominal pain and shortness of breath. Physical examination revealed an agitated male with regular pulse of 100/min, blood pressure of 112/70, respiratory rate of 30/rain, and slightly elevated temperature of 100~ The jugular veins were distended to the level of the jaw and bibasilar rates were ausculted in the lungs. The liver was enlarged, firm, and mildly tender. The chest roentgeno- gram showed pulmonary interstitial edema and pulmonary venous congestion. On admission, creatine phosphokinase (CPK) was 2464, lactate dehydrogenase (LDH) 1110, glutamic oxalactic transaminase (SGOT) 1210, bilirubin 0.8, and alkaline phosphatase 177. The prothrombin time and partial thromboplastin time were elevated at 22.5 and 45.4 sec, respectively. Serum urea nitrogen (BUN) was 66 with creatinine level 1.9. The EKG showed right bundle branch block, old Q waves in the precordiaI leads, and new Q waves in leads I1, lI1, and AVF. Diagnosis on admission was recent inferior MI, right- and left-sided congestive heart failure, congestive hepatopathy, and acute renal failure. Subse- quent CPK isoenzyme fractionation failed to support the diagnosis of acute myocardial infarc- tion, and a 99mTc-pyrophosphate myocardial scintigram was performed on the third hospital day that showed intense labeling of the liver without demonstrable myocardial activity. (Fig. 1).

It was postulated that the patient's myocar- dial infarction had occurred 3-5 days prior to admission, and that the persistent elevation of CPK was due to rhabdomyolysis. Right heart catheterization performed after correction of coagulation parameters with fresh frozen plasma revealed markedly elevated right-sided pres- sures, with right atrial pressure 23 mm Hg, RV 47/20, and pulmonary artery wedge 28. The cardiac output was 2.8 liter/min. On nitroprus- side and dopamine, the hemodynamic param- eters improved somewhat with diuresis and concomitant improvement in hepatic function.

On the seventh hospital day, the patient devel- oped supraventricular tachycardia, which pro- gressed to ventricular fibrillation. Resuscitation was performed; however, a downhi|l course ensued and the patient expired 3 days later. Permission for autopsy was not granted.

This case demonstrates diffuse hepatic label- ing by 99mTc-pyrophosphate in a clinical setting with high likelihood of central hepatic necrosis secondary to severe congestive heart failure. Liver uptake of bone imaging agents is unusual; in a study of 250 consecutive bone scans, liver uptake occurred only in 5 cases, 2 of which were associated with metastases and the remaining 3 due to "poor radiopharmaceutical quality. ''~ Diffuse hepatic uptake of 99roTe-phosphate compounds has since been shown to occur in massive liver necrosis, 2 in the presence of high serum AI +§ levels, 3 and in amyloidosis. 4 Animal studies have shown elevated liver uptake with increased phosphate salt concentration: and with combination of tin and 99mTc-reagents prior to the addition of the phosphate-chelating agent during radiopharmaceutical preparation. 6 In liver necrosis and amyloidosis, labeling occurs presumably due to phosphate localization at sites of cellular damage by mechanisms to be discussed, while in the other cases, reticuloendo- thelial uptake of microcolloidal particles is the postulated mechanism: ~

Focal uptake of 99roTe-phosphate compounds by hepatic metastases from adenocarcinoma of the colon, breast carcinoma, oat cell carcinoma of the lung, malignant melanoma, and esopha- geal squamous cell carcinoma has been reported. 7-~~ A single case of uptake by cholan- giocarcinoma has also been described. 8 Tumor localization of phosphate compounds probably

From the Department of Radiology, Division of Diagnos- tic Radiology, Division of Nuclear Medicine, University of California, Davis, Medical Center, Sacramento, Calif.

Reprint requests should be addressed to Robert C. Stadalnik, M.D., Division of Nuclear Medicine, University of California, Davis, Medical Center, 2315 Stockton Boule- vard, Sacramento, Calif. 95817.

�9 1982 by Grune & Stratton, Inc. 0001-2998/82/1202-0009501.00/0

Seminars in Nuclear Medicine, VoL XII, No. 1 (January), 1982 89

90 HANSEN AND STADALNIK

on the mi t rochondr ia . 2'H In the same pat ient , phosphate binding m a y occur at one site of metastasis and be absent a t another , ~6 emphas iz - ing the impor tance and var iabi l i ty of local factors required for bone agent uptake.

Fig. 1. An anterior image of the liver taken 2 hr post intravenous administration of 15 mCi of m"Tc-pyrophos- phate demonstrates intense diffuse hepatic uptake of redionuclide.

involves several different mechanisms, depend- ing on the charac ter i s t ics of the neoplast ic t issue and local factors such as ca lc ium deposit ion in me tas t a t i c deposits of mucinous adenocarc inoma of the colon, or dys t rophic calcif ication in anoxic areas of tumor. 7 Ca lc ium deposi ts are not invari- ab ly present in phosphate-av id tumors, ~3'~4 and phosphate binding has also been postula ted to occur in areas of high phosphatase enzyme

concentrat ion, ~4'~s or in d a m a g e d cells with a l te red calc ium metabol i sm, in which case the bone agent is deposi ted with or bound to ca lc ium

LIVER UPTAKE OF 99mTc-PHOSPHATE COMPOUNDS

Common

1. A r t i f a c t u a l - - p r i o r 99mTc-sulfur co l lo id s tudy (diffuse) 8

2. A p p a r e n t - ~ l u e to abdomina l wall or r ib uptake ( focal ) '

3. Metas t a t i c ca rc inoma (focal) (A) Colon s'12'13

(B) Breast II (C) Squamous cell carc inoma of esopha-

gus 7

(D) Oa t cell ca rc inoma of lung 9 (E) Ma l ignan t me lanoma ~~

Uncommon

1. Diffuse hepa t ic necrosis (diffuse) 2 2. Elevated se rum AI §247 (diffuse) 3 3. E leva ted AI §247247 in genera tor e lua te (dif-

fuse) 3

Rare

1. Cholang iocarc inoma (focal) 8 2. Improper p repara t ion of r ad iopha rmaceu -

t ical causing microcol loid format ion (dif- fuse) 1,5

3. Amyloidosis (diffuse) 4

REFERENCES

1. Poulose KP, Reba RC, Eckelman WC, et al: Extraos- seous localization of Tc-99m-Sn pyrophosphate. Br J Radiol 48:724--726, 1975

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3. Chaudhuri TK: Liver uptake of Tc-99m diphosphon- ate. Radiology 119:485-486, 1976

4. Vanek JA, Bukowski RM: Hepatic uptake of Tc- 99m-labeled diphosphonate in amyloidosis: Case report. J Nucl Med 18:1086-1088, 1977

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10. De Long JF, Leonard JC, Allen EW, et al: Case report: Tc-99m diphosphonate concentration in malignant melanoma metastatic to liver. Trans Equilib 6:1, 1977

I 1. Baumert JE, Lantieri RL, Horning S, et al: Liver metastases of breast carcinoma detected on Tc-99m methy- lene-diphosphonate bone scan. A JR 134:389-391, 1980

12. Papavasiliou C: Cancer of the colon visualized by strontium scintigraphy. J Nucl Med 15:824, 1974

ggmTC-PYROPHOSPHATE LIVER UPTAKE 91

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14. Chaudhuri TK, Chaudhuri TK, Gulessarian HP, et al: Extraosseous noncalcified soft-tissue uptake of Tc-99m polyphosphate. J Nucl Med 15:1054-1056, 1974

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