67Ga

scintigraphy in the sarcoidosis diagnosis. Should we forget this technique?

L.M. Quintero, MD. C. Moreno, MD Hospital Universitario Joan XXIII, Spain.
INTRODUCTION

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology that affects about of 16.5/100,000 in men and 19/100,000 in women, throughout the world; and is characterized by the presence of noncaseating granulomas in involved organism. The role of 67Ga scintigraphy has also been established in several studies, for assessing pulmonary and extrapulmonary lesions in Sarcoidosis. However, the images are difficult to interpret and the findings can be nonspecific, limiting the role of this test in evaluation of this pathology, besides other techniques win importance, like FDG-PET, 99m Tc-depreotide (DP) and Somatostatin receptor imaging (SRS) with 111In, make the use of 67 Ga in this moment be controversial.

CLINICAL CASE A 47 year-old woman, who had two months of progressive respiratory distress, associated with cardiac insufficiency, and red eyes. Her blood test showed: All laboratory testing was normal.

X-ray Chest: Cardiomegaly with prominent right filum and mediastinal widening.

CT Chest scan demonstrated multiples adenopathies in mediastinum, mainly in left anterior traqueobronchial, right bronchopulmonary and hiliar regions.

67Ga scintigraphy planar study showed increased uptake in hiliar regions, mainly Left hiliar and mediastinum.

The 67Ga-SPECT confirmed the anatomic localizations of increased tracer uptake found in the planar study.

Mediastinum lymphatic node's biopsy: was positive for noncaseating granulomas chronic inflammation. Diagnosis: Sarcoidosis stage I. Patient whit a good clinic evolutiuon, after treatment with oral steroid and furosemide.

CONCLUSION
67Ga

scintigrahy is one of the most widely used techniques in nuclear medicine for the diagnosis and monitoring of patients with Sarcoidosis. In a case's revision in our department in the last year, demonstrated that 25 people with clinic suspect of sarcoidosis come for a 67Ga-citrate scintigraphy performance evaluation, were high suspect positive for imaging 10 patients (33%), with a confirmation for biopsy of eight of them; (other two were positive for TBC and metastases diseases respectively). For that reason in our department the sensibility for this technique in the last year, was 100%, specificity 88%, with a positive predictive value (PPV) of 80% and negative predictive value (NPV) of 100%. Recent studies show that 67Ga is being displaced by other techniques like 18FDGPET/CT imaging allows to complete morphology and functional cartography of active inflammatory sites and detection of treatment response in patients with Sarcoidosis, particularly in atypical, complex and multisystem forms of the disease. Tracers as 111 In-Penteotride (SRS) appears to be more accurate and contributes to a better evaluation of organ involvement in Sarcoidosis patients, especially in those treated with corticosteroids than 67Ga-citrate scintigraphy (sensitivity 100% vs 89% respectively) and finally the 99mTc-Depreotide (DP) scintigraphy who allows abnormalities in patients with normal chest radiographs. However, these advances are not yet available to all institutions, this is mainly due to the high costs that have technologies such as PET and their tracers. On the other hand, the crisis of the isotope of technetium that exists worldwide, limiting the use of tracers such as 99mTc-DP and the SRS is costly compared to gallium, and in economies in crisis that is can be important . Therefore, we believe that until the above techniques fail to be available to all, tests such as gallium, are still relevant at the time of diagnosis, staging and monitoring, patients with suspected or established diagnosis of Sarcoidosis since its sensitivity is high and available to all; specially in patients with abnormal X-ray Chest and without steroid treatment.

REFERENCES

1. Basu S. et al: Funcional imaging of inflammatory diseasses using nuclear medicine techniques. Semin Nucl Med 39: 124-145, 2009. 2. Prager E et al: Comparison of 18F-FDG and 67Ga-citrate in sarcoidosis imaging. Nuklearmedizin 47: 18-23, 2008. 3. Shorr AF et al: Depreotide scanning in sarcoidosis: A pilot study. Chest 126: 1337-1343, 2004. 4. Lebtahi R et al: Somatostanin receptor scintigraphy and gallium scintigraphy in patients with sarcoidosis. J Nucl Med 42: 21-26, 2001.

5. Baughman RP et al: Predictive value of gallium scan, angiotensine converting enzyme level, and bronchoalveolar lavage in two year follow-up of pulmonary sarcoidosis. Lun 165: 371, 1987.

SARCOIDOSIS

CHEST RADIOGRAPH Stage I: Presence of bilateral hilar adenopathy. (50%). Stage II: Bilateral hilar adenopathy and reticular opacities. (25%). Stage III: Consists of reticular opacities with shrinking hilar nodes. Stage IV: Reticular opacities with evidence of volume loss, predominantly distributed in the upper lung zones. Nodular sarcoid: The chest radiograph may show multiple, bilateral lung nodules and minimal hilar adenopathy. (May simulate metastasic disease). CT Scan Hilar and mediastinal lymphadenopathy. Beaded or irregular thichening of the bronchovascular bundles. Nodules along bronchi, vessels, and subpleural regions. Bronchial wall thickening. Ground glass opacification. Parenchymal masses or consolidation. Parenchymal bands. Cyst Traction bronchiectasis. Fibrosis with distortion of lung architecture. PET Scan A 18F-FDG: this test does not differentiate sarcoidosis from malignancy.(+) 18F-FDG: accurate for initianing an optimal of disease activity in Sarcoidosis 18F-FMT (methyltyrosine): was able to differentiate sarcoidosis from malignancy.(-) Radiotracer scannig

Controversial. It has been suggested that there is a direct relationship between a visual index of gallium-67 uptake in the lung and the number of inflammatory cells (macrophages) recovered by bronchoalveolar lavage in patients with Sarcoidosis (and idiopathic pulmonary fibrosis). SRS (somatostatin receptor imaging) Vs 67Ga: appears to be more accurate and contributes to better evaluation of organ involvement in sarcoidosis patients,especially in those treated with corticosteroids. 99mTc-DP (depreotide) scintigraphy: more sensitivity in patients with normal xchest.