An Unexpected and Less Recognized Altered Distribution on Bone Scintigraphy; Possibility of 99mTc-Dextrose Complex as a Cause

Abstract

Optimal performance of diagnostic tests and correct interpretation depend on multiple factors, one of which is proper radiopharmaceutical preparation. Unwanted impurities result in altered distribution of radiopharmaceuticals and then poor-quality or uninterpretable studies. Therefore, following the reconstitution steps according to standard and validated protocols by the technologist is mandatory. Here, we present 2 cases with unexpected and less recognized distribution of Tc-methylene diphosphonate on bone scintigraphy.

Altered Distribution of 99mTc-MDP Bone Scintigraphy

“…Errors in reconstitution of vial, for example, using dextrose instead of saline solution were sought to realize the potential mistake, but nothing was found. Contrary to the pattern in the previous report, 2 blood pool activity is less pronounced, but instead, early intestinal excretion is evident. Owing to these findings, we checked blood sugar, and it was higher than 300 mg/dL, possibly due to steroid therapy.…”

“…Meticulous efforts must be made in reconstitution phase of radiopharmaceutical preparation. One of the rare causes of such technical problems is presence of technetium-labeled complexes of glucose or dextrose, whether produced in the vial or in vivo after intravenous injection, which is yet to be clarified 1–3 . Regarding our 2 reports previously published related to this issue in 99m Tc-MDP 2 and 99m Tc-octreotide 3 scans, we intend to present another one with some dissimilarity to previous patterns.…”

“…One of the rare causes of such technical problems is presence of technetium-labeled complexes of glucose or dextrose, whether produced in the vial or in vivo after intravenous injection, which is yet to be clarified 1–3 . Regarding our 2 reports previously published related to this issue in 99m Tc-MDP 2 and 99m Tc-octreotide 3 scans, we intend to present another one with some dissimilarity to previous patterns. In the present patient, a 47-year-old woman diagnosed as having acute lymphocytic leukemia who underwent bone marrow transplantation now presents with thrombocytopenia and elevated serum calcium.…”

Intravial or In Vivo Production of 99mTc-Dextrose Complexes May Play a Role in Altering Biodistribution of 99mTc-HYNIC-Octreotide Scan

“…Specifically, in somatostatin receptor-based imaging agents, that is, radiolabeled octreotide, meticulous consideration should be taken into account. 1,2 An unprecedentedly reported cause in labeled somatostatin analogs, but reported in scans with other agents, for example, methylene diphosphonate, 3,4 is emerging of 99m Tcdextrose complexes in the reconstitution vial of 99m Tc-octreotide or inside the body, as we observed in a 42-year-old man with a prior pathologically proven diagnosis of neuroendocrine carcinoma and liver metastasis who was referred to our department for 99m Tc-HYNIC-octreotide scan for whole-body survey before the institution of chemotherapy. On abdominal CT scan, a pancreatic head mass with hypodense liver lesions is documented (Fig.…”

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2 cases, pulmonary scintigraphy was used, in 3 cases PET/CT, and in 1 leukocyte scintigraphy; in the latter case, the test did not provide useful information. 4 This makes the authors' contribution all the more clinically relevant, as it reopens the issue of the position of nuclear medicine techniques in the clinical management of this condition. This seems particularly the case as the embolic complications of Lemierre syndrome can even occur days after initial diagnosis and hospital admission.Lemierre syndrome is still associated with considerable mortality.

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