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Year : 2005  |  Volume : 15  |  Issue : 1  |  Page : 31-32
Radionuclide detection of accessory reticuloendothelial thoracic masses, coupled with congenital hepatic abnormality


Department of Nuclear, Medicine, Institute of Nuclear Medicine and Allied Sciences, Delhi, India

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   Abstract 

Congenital hepatic abnormality is quite rare while congenital thoracic reticulo-endothelial masses have been rarely reported. Further, an association between accessory reticulo-endothelial (RES) masses and congenital hepatic abnormality is extremely rare. We report a case with both these unusual features.

Keywords: Tc-99m Sulphur colloid, Accessory Reticuloendothelial masses

How to cite this article:
Bhatnagar P, Rawat H, Kishan S, Bhatnagar A, Kashyap R. Radionuclide detection of accessory reticuloendothelial thoracic masses, coupled with congenital hepatic abnormality. Indian J Radiol Imaging 2005;15:31-2

How to cite this URL:
Bhatnagar P, Rawat H, Kishan S, Bhatnagar A, Kashyap R. Radionuclide detection of accessory reticuloendothelial thoracic masses, coupled with congenital hepatic abnormality. Indian J Radiol Imaging [serial online] 2005 [cited 2019 May 26];15:31-2. Available from: http://www.ijri.org/text.asp?2005/15/1/31/28739

   Case report Top


A 65-year-old male, with a suspected liver pathology came to us for a Tc-99m Sulphur colloid liver-spleen scan. He had no prior history of any serious trauma or surgery. The preparation was injected (5mCi) and planar acquisition of different views was done after 20 min (600k each view). Most of the activity was localized in liver that looked normal in function and morphology, except a hump like projection at its superior border, almost pushing the heart laterally. Spleen appeared unremarkable. Two intense focal areas of uptake were noted in the thoracic region [Figure - 1]. SPECT examination along with CT coregistration using GE-Hawkeye confirmed intrapulmonary location of the RES masses [Figure - 2]. Hence a diagnosis of accessory reticuloendothelial thoracic masses along with congenital abnormality of the liver was made, which was later confirmed by X-Ray Chest.


   Discussion Top


Ectopic RES tissues in the thoracic cavity is quite rare and to the best of our knowledge a twin lesion has not been reported. Owing to the abnormal shape of the liver, we conclude that it was also a congential abnormality, as congenital conditions are known to occur in multiples. Such lesions are usually discovered incidentally. Rarely do they become symptomatic. Thus, there were 3 RES congenital abnormalities in this case which were diagnosed on liver-spleen scintigraphy.

Though CT is quite sensitive to located such thoracic masses, in this particular case, it was a missed diagnosis. Also, it is difficult to characterize thoracic masses as RES masses on CT, for which Liver-Spleen scintigraphy is considered as the gold standard. Particles between 0.3 and 1.0 microns are predominantly phagocytized by the Kupffer cells of the liver. Small particles (less than 0.1 micron) distribute primarily to the bone marrow. Particles larger than 1 micron distribute mostly to the spleen, while very large particles will deposited in the lungs. The sulfur colloid particles are phagocytized by the reticuloendothelial cells and are fixed intracellularly for an indefinite period of time. Particle size is an important determinant of their distribution. Single photon emission computed tomography (SPECT) imaging can provide cross sectional images and resolve more subtle areas of abnormal activity.

Pulmonary uptake of Tc-99m sulphur colloid is felt to involve activation of pulmonary macrophages, RE cell migration from other parts of the body to the lungs, or and alteration in pulmonary endothelium. There is a long list of causes for uptake by lungs, the most common being cirrhosis, hypercoagulable staes, malignancy-both primary and matastatic, malignant lymphomas, radiopharmaceutical preparation, normal finding in childhood. [1], disseminated intravascular coagulation [2], intrathoracic hemorrhage [3], posttraumatic [4], focal atelectasis [5], stimulation of reticuloendothelial elements in the lungs with pulmonary migration of additional macrophages from liver [6]. In our case, the diagnosis of accessory RES masses was reached as they were focal and not diffuse, as is expected in cirrhosis, hypercoagulable states, malignancy or faulty radiopharmaceutical preparation. Other causes of focal uptake include intrathoracic haemorrhage which was ruled out because the intensity of the tracer was increased unequivocally. Another possibility of such intense focal uptake could be ectopic lymph nodes, but the patient had no lung pathology. Hence our diagnosis of accessory RES masses was reached based on the current medical norms, precedent and logic.

There are several unusual features associated with the case. Firstly, we are not aware of any other case with thoracic location of multiple accessory RES masses; only abdominal locations have been described in literature. In the non-abdominal category, we could find only one case report that describes the placement of accessory thoracic spleen in a diaphragmatic hernial sac [1]. Secondly, its association with diaphragmatic hump on the right side has not been reported. This case also highlights the importance of fusion imaging by coregistration of SPECT with CT with the help of latest state of the art technology and provides important information related to anatomy as well as the physiology of the system being imaged.


   Conclusion Top


Hence, Liver-spleen scintigraphy should be done to characterize such mediastinal lesions which may be missed on CT.[7]

 
   References Top

1.Ohta H et al. A case of diaphragmatic hernia containing accessory spleen and great omentum detected by Tc-99m Phytate scintigraphy. Annals of Nucl Med 13:347-349, 1999.   Back to cited text no. 1    
2.Ehrich C. P. et al. Splenic scintigraphy using Tc-99m labeled heat denatured re blood cells in pediatric patients: Concise communication. J. Nucl Med 13:231- 9,1982.   Back to cited text no. 2    
3.Bidet A. C. et al. Diahgnosis of splenosis : The advantages of splenosis: The advantages of splenic scintiscanning with Tc-99m heat damaged red blood cells. Eur J Nucl Med 12:357-358,1986   Back to cited text no. 3    
4.Fredrick L. Datz. Gamuts in Nuclear Medicine. Third ed:265,1995   Back to cited text no. 4    
5.Jacobson A. F. et al. Increased lung uptake of Tc-99m Sulphur Colloid as an early indicator of the development of hepatic veno-occlusive disease in bone marrow transplant patients. Nuc Med Comm 14:706-711,1993   Back to cited text no. 5    
6.Mikhael M.A., et al. Migration and embolization of macrophages to the lungapossible mechanism for colloid uptake in the lung during liver scanning. J Nucl Med 16:22-27,1975   Back to cited text no. 6    
7.Parul Bhatnagar et al. Radionuclide detection of accessory thoracic spleen coupled with diaphragmatic herniation of hepatic tissue. IJNM, 16(1):40-42,2001.  Back to cited text no. 7    

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Correspondence Address:
P Bhatnagar
Department Of Nuclear Medicine, Institute Of Nuclear Medicine and Allied Sciences, Brig. S. K. Mazumdar Road, Delhi - 110054
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-3026.28739

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    Figures

[Figure - 1], [Figure - 2]



 

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