• CLINICAL RESEARCH •
Role of SPECT/CT in diagnosis of hepatic hemangiomas
Jian-Guo Zheng, Zhi-Ming Yao, Chong-Ye Shu, Ying Zhang, Xia Zhang
PO Box 2345, Beijing 100023, China World J Gastroenterol 2005;11(34):5336-5341
www.wjgnet.com World Journal of Gastroenterology ISSN 1007-9327
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Jian-Guo Zheng, Zhi-Ming Yao, Department of Nuclear Medicine,
Beijing Hospital, Beijing 100730, China
Chong-Ye Shu, Imaging Center, Central Hospital of Siping City,
Siping 136000, Jilin Province, China
Ying Zhang, Department of Nuclear Medicine, People’s Hospital
in Liaocheng City, Liaocheng 252000, Shandong Province, China
Xia Zhang, Department of Anesthesiology, West China Hospital,
Sichuan University, Chengdu 610041, Sichuan Province, China
Correspondence to: Xia Zhang, Department of Anesthesiology,
West China Hospital, Sichuan University, Chengdu 610041, Sichuan
Province, China. firstname.lastname@example.org
Telephone: +86-28-85422518 Fax: +86-28-85422518
Received: 2005-02-17 Accepted: 2005-04-02
AIM: To investigate the role of SPECT/CT in the diagnosis
of hepatic hemangiomas whose anatomical positions are
not ideal, situated adjacent to the heart, the inferior cava,
hepatic vessels or abdominal aorta, etc.
METHODS: The hepatic perfusion, blood pool, and fusion
imaging were carried out using SPECT/CT in 54 patients,
who were suspected for hepatic hemangiomas. When
the anatomical positions were not ideal, the diagnosis
was difficult by SPECT only. So the information of computed
tomography (CT) was applied to help in diagnosing. The
results were recorded as hemangiomas or not.
RESULTS: Of the 54 patients, 31 patients were diagnosed
as suffering from hepatic hemangiomas. The anatomical
positions of eight patients’ hepatic hemangiomas (25.81%)
were not ideal. Among these lesions of the eight patients,
three patients’ hepatic lesions were located near to the
abdominal aorta, one to the heart, and four to the inferior
cava. In addition, six abnormal radioactivity accumulation
regions, adjacent to the heart and inferior cava, with the
help of CT, were confirmed to be the imaging of inferior
cava other than hepatic hemangiomas.
CONCLUSION: When the anatomical positions of hepatic
hemangiomas are not good enough for diagnosis, the
fusion imaging of SPECT/CT is a simple and efficient method
for differential diagnosis.
© 2005 The WJG Press and Elsevier Inc. All rights reserved.
Key words: SPECT/CT; Hepatic hemangiomas; Scintigraphy
Zheng JG, Yao ZM, Shu CY, Zhang Y, Zhang X. Role of
SPECT/CT in diagnosis of hepatic hemangiomas. World J
Gastroenterol 2005; 11(34): 5336-5341
The diagnosis of a number of atypical hepatic hemangiomas
in cross-sectional images is also very difficult. Moreover,
when the tumor is present in staging or in the follow-up of
oncological patients, the differentiation of hepatic hemangioma
from hepatic metastatistic diseases is a common clinical question.
Contrast-enhanced magnetic resonance imaging (MRI) and
multiple helical computed tomography (CT) is also limited
to distinguish focal hepatic lesions in some ways. Contrast-
enhanced ultrasonography (US) is helpful to confirm the
characterization of the focal liver disease. However, the
diagnosis is associated with the experience of the surgeon.
As regards single-photon emission computed tomography
(SPECT), when the anatomical positions of hepatic
hemangiomas were not ideal, for example, close to the heart,
inferior cava or main hepatic vessels, etc., it may cause some
difficulty for diagnosis, because the radioactivity of the 99mTc-
labeled RBC is centralized in the heart, inferior cava, abdominal
aorta and main hepatic vessels, and the radioactivity of
blood pool is existing from the start. Thus, it is difficult to
detect hepatic hemangioma, which is close to the above-
mentioned structure, especially tiny ones.
A method, SPECT/CT, which can localize the hepatic
lesions accurately will be helpful to diagnose this kind of
hepatic hemangioma. The imaging of 99mTc-labeled red blood
cell scintigraphy through SPECT is non-invasive and highly
specific, able to avoid invasive method or biopsy. Meanwhile,
when the anatomical position is not ideal, close to heart,
inferior cava, main hepatic vessels, abdominal aorta, upside
of right kidney, the diagnosis accuracy is improved owing
to the locating function of the CT.
MATERIALS AND METHODS
TERIALS AND METHODS
TERIALS AND METHODSTERIALS AND METHODS
TERIALS AND METHODS
Fifty-four patients who were suspected for hepatic hemangiomas
found by US, CT, and or MRI, and were examined by
SPECT/CT from April 26, 2001 to July 15, 2004 in Beijing
Hospital. Their average age was 49.15±13.78 years. Among
them, 31 were men with an average age of 50.38±15.36 years;
23 were women with an average age of 47.36±11.22 years.
The oldest was 91 years old and the youngest was 27 years old.
First, the patients were required to take 400 mg of perchlorate
potassium. Thirty minutes later, 10 mg of pyrophosphate
dissolved in 2 mL of water for injection was administered
into one patient. Thirty minutes later again, 740 MBq of
Na99mTcO4 was also administered intravenously by bolus
injection. The imaging was obtained using the SPECT/CT
(Hawkeye, General Electronic Medical System).
Hepatic blood perfusion imaging
The patients were laid on the table and the detector was
placed at front-back imaging position or back-front one.
The field of vision included parts of heart, abdominal aorta,
liver, spleen, and kidney. The SPECT was equipped with
low-energy parallel hole general collimator or high-resolution
collimator. The energy peak was 140 keV, the width of the
energy window was from 15% to 20%, and the matrix
128×128. When Na99mTcO4 was injected through elbow vein
by bolus, the acquisition was carried out immediately at the
speed of 2 s/frame, totally 30 frames.
Planar hepatic blood pool imaging
The static imaging was obtained at 5, 10, 15, and 20 min after
intravenous injection. The delayed imaging was obtained
from 1.5 to 2 h after injection, and 4-6 h if necessary.
Planar imaging: The patients were laid on the table. The
detector was placed at the front-back and back-front
position, or in the position where hepatic lesions were able
to be shown clearly. The detectors were equipped with low-
energy parallel hole general collimator or high-resolution
collimator. The energy peak was 140 keV, the width of the
window 20%, and the matrix 256×256. The count was set
up 500 K/frame in advance.
The hepatic blood pool cross-sectional imaging was acquired
and together with CT scanning after 40 min of bolus intravenous
injection. The X-ray transmission scanning, which needed
0.8 min, was obtained firstly with the matrix of 384×800
to identify the liver position. Then X-CT acquisition, which
needed 10.8 min, was followed with matrix of 256×256,
zoom of 1.105, 10 mm per layer, totally 40 cross-sections.
After transmission process, the detector automatically came
back to the start position. Then SPECT acquisition over
360° was performed with the matrix of 128×128, zoom of
1.28, 20 s/frame, and 6°/frame. The technique of automatic
human body contour was applied to making detector get
closer to the patient’s body.
The SPECT images were reconstructed from the raw data by
filtered back projection using a HANN filter (filter parameter:
0.85). The CT data were reconstructed using nuclear medicine
workstation (eNTEGRA, General Electronic Medical
System). Then the matching emission and transmission were
fused to form the fusion images.
Standard of diagnosis
The standard of diagnosis is that an increase of blood pool
activity within a liver lesion is typical of hemangioma. And
in the CT scanning, the density of the lesion is low and
even. The images were read by experienced physicians, who
have worked in the department of nuclear medicine for at
least 5 years. The results were recorded as hepatic hemangioma
Of the 54 patients, 31 (57.41%) were diagnosed as hepatic
hemangioma patients by SPECT/CT and were not taken
for further examination. The diameter of hepatic lesions
was from 1 to 9 cm. Twenty-three patients (42.59%) were
excluded from the hepatic hemangioma, because their
hepatic lesions did not meet the characterization of the
hepatic hemangioma. Among them, 9 patients lost contact
with us, the 13 patients’ were diagnosed as hepatic cancer,
and one as hepatic cyst.
Of the 31 patients, the anatomical positions of the hepatic
hemangiomas in 8 patients (25.81%) were not ideal. Among
them, the hepatic lesions of three patients’ were close to
abdominal aorta (Figures 1A and B and 2A), that of four patients
to inferior cava, that of one patient to heart (Figure 2B). Under
these conditions, it was difficult to diagnose by only using
SPECT. In SPECT/CT fusion imaging, CT was able to
locate the position of focal radioactivity accumulation region,
and at last diagnosed it as hepatic hemangioma.
In the research, there are six round-like regions with
high radioactivity, close to the heart and inferior cava in six
patients on the brim of the liver. The CT showed that they
were in the inferior cava. Finally, hepatic hemangioma was
excluded (Figure 2C).
As a benign tumor, the hepatic hemangioma most frequently
appeared in the liver. The incidence of the disease is about
from 2% to 7% of the liver lesions. The hepatic hemangioma
is classified as capillary and cavernous hepatic hemangioma.
The former is not common, and able to change to the other.
Thus, the majority is cavernous hepatic hemangioma.
As a non-invasive and highly specific method for diagnosing
hepatic hemangioma, the 99mTc-labeled RBC scintigraphy
can avoid invasive imaging or biopsy. And thanks to the
application of SPECT, the sensitivity of the method is improved
obviously. However, when the diameter of hepatic lesion is
less than 1.3 cm, the sensitivity of SPECT is quite low. When
the diameter is less than 1 cm, false negative appeared. And
when the larger hepatic lesions (diameter more than 2.5 cm)
with the bad anatomical positions, close to the heart, inferior
cava or main hepatic vessels, etc., the diagnosis is difficult in
a way, especially tiny hepatic hemangiomas. As reported by
Birnbaum et al., the hepatic lesions of 18 patients, whose
hepatic hemangiomas were adjacent to the above-mentioned
positions, 6 of the patients were not able to find them out.
As reported by Schillaci et al., 24 patients were sceptical
of suffering from hepatic hemangiomas. Of them, six patients’
anatomical position were not ideal; three patients’ were close
to main hepatic vessel, and two close to inferior cava, one
close to heart. When SPECT/CT was carried out, with the
help of CT, four were diagnosed as hepatic hemangioma,
two were excluded from the hepatic hemangioma. In this
research, about 25.81% patients’ anatomical position was
not ideal. When SPECT/CT was applied, with the help of
CT, finally hepatic hemangioma was diagnosed.
The functional information from the SPECT combining
with the anatomical information from the CT is able to
solve the problem that anatomical position of hepatic
hemangioma is not ideal. CT can accurately locate the lesion
of radioactivity concentration region. Several years ago, a
new apparatus was discovered. It combined the rotatable
double-detectors camera γ with low-dose X-rays tube. The
Zheng JG et al. Applying SPECT/CT in the hepatic haemangiomas 5337
Figure 1 Female, 46 years old. US showed that there was a lesion in the left
liver with the size 3.6×2.3 cm2. The function of liver was normal. SPECT/CT
test was carried out to exclude hepatic hemangioma. A: The hepatic blood
perfusion im aging. The abnorm al focal accum ulation of the radioactivity was not
shown obviously; B: The radioactivity accumulation of the focus (pointed by
the red arrows) in the left liver was a little higher than the normal liver tissue.
5338 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol September 14, 2005 Volume 11 Number 34
Max intensity projection
Sagittal Sagittal Sagittal
Max intensity projection
Zheng JG et al. Applying SPECT/CT in the hepatic haemangiomas 5339
camera γ/CT machine would obtain SPECT and CT images
respectively. The projection of X-ray was helpful to find
the location of the radioactivity concentration focus. This
was SPECT/CT fusion imaging. The SPECT/CT was used
to diagnose hepatic hemangioma with the following
A. CT can accurately locate the position of radioactivity
accumulating focus theoretically. However, the quality of
the present CT in SPECT/CT is not very good. Under
some conditions, it is very difficult to indicate the position
accurately. But it is believed when multiple helical CT is
used in fusion imaging in the future, the position of the
hepatic lesions will be located accurately. Moreover, it may
reach the function of diagnosis CT but not only in locating
the position of the disease.
B. When hepatic lesions are detected by CT scanning,
the hepatic colloid imaging may not be necessary. The colloid
imaging is mainly used to find out the lesion of the liver.
But CT is more superior to the hepatic colloid imaging in
this respect. Its sensitivity is much higher than the hepatic
colloid imaging. Therefore, when hepatic lesions are detected
by CT scanning, the hepatic colloid imaging is not necessary.
C. Fusion imaging can be attenuation-corrected by X-
ray. Therefore, the quality of the images would be improved.
Because of the high quantity of information of X-ray,
especially when the injected dose of 99mTc-labeled RBC is
comparatively low and the patient is fat, the quality of the
images will be improved obviously.
D. Improving the accuracy of diagnosis. Typical
characterization of hepatic hemangioma is that its density
is even and low by general CT scanning. The worth of
common CT is limited. Usually it indicates the position of
hepatic lesions, which is radioactive accumulation region. It
provides anatomical information for hepatic hemangioma.
SPECT can provide the functional information for pathological
changes. Functional information coordinates with anatomical
information, in this way the accuracy of diagnosis is improved.
Furthermore, it is worth paying attention to that, when
Figure 2 The round-like radioactive accumulation region (pointed by the red
arrow) was just on the abdom inal aorta. If fusion im aging was not obtained, then
to decide whether it was abdominal aorta or hepatic hemangioma would have
been difficult. As shown in the CT of fusion im aging, the focus (the red cross) was
located in the left liver, but not in abdominal aorta, thus diagnosed as hepatic
hem angiom a. Fem ale, 39 years old. A lesion in the liver with the diam eter of 4 cm
was found in the physical exam ination by US. It m ight be a hepatic hem angiom a.
SPECT/CT was perform ed for differentiation (A). The hepatic lesion (pointed by
the red arrow) situated adjacent to the heart, whose abnormal radioactive
concentration was a bit lower than the heart. The CT showed that the lesion (the
red cross) was located in the left liver. The diagnosis was a left hepatic hem angiom a.
Male, 43 years old. The US showed a few lesions in the liver. They were
sceptical of hepatic hem angiom as to go through SPECT/CT exam ination (B). The
abnormal focal radioactive concentration region of left liver (pointed by the red
arrow) was not only close to the heart, but also close to the inferior cava. The CT
indicated that it was a part of the inferior cava (the red cross), and exclude the
possibility of hepatic hem angiom a. But other three round-like radioactive accum ulation
regions in the right liver were diagnosed as hepatic hem angiom as (C).
Max intensity projection
5340 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol September 14, 2005 Volume 11 Number 34
inferior cava passes by the liver, and enters right heart, a
great majority can form a round-like radioactive accumulation
region on the brim of the liver (Figure 2C). Under the
condition, with the help of CT, the radioactive concentration
region may be seen under the heart, link with the inferior
cava and out of the liver. If it is, then hepatic hemangioma
can be excluded. If it is not and the, the focus is in the liver,
the diagnosis of hepatic hemangioma could be made.
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Science Editor Guo SY Language Editor Elsevier HK
Zheng JG et al. Applying SPECT/CT in the hepatic haemangiomas 5341