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• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Adrenal glands: □ hot □ cold
– Kidneys and female reproductive system: □ hot □ cold
– Vascular system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ goitrous right lobe
– Parathyroid glands: □ normal □ ectopic adenoma
– Breasts: □ normal □ prostheses
– Chest wall: □ normal □ metallic object
– Skeleton: □ normal □ multiple myeloma
– Pleura: □ normal □ effusion
– Lungs: □ normal □ hyperinfl ation/chronic obstructive pulmonary disease
(COPD)
– Mediastinum: □ normal □ hiatal hernia
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle: □ normal □ right auricular appendage
– Vascular system: □ normal □ injection site
– Lymphatic system: □ normal □ lymphoma
– Diaphragm: □ normal □ fl attening
• Abdomen
– Abdominal wall: □ normal □ metallic object
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ cysts
– Biliary system and gallbladder: □ normal □ chronic calculous cholecystitis
– Spleen: □ normal □ enlargement
– Stomach: □ normal □ duodenogastric refl ux
– Small intestine and large intestine: □ normal □ stasis in jejunum
– Adrenal glands: □ normal □ mass, left side
– Kidneys and female reproductive system: □ normal □ chronic/end-stage renal
disease
– Vascular system: □ normal □ extravasation
29.10 Case Challenge #34
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29.10.2 Solution
Additional Annotated Images
g
See Video 29.10c
c
e
d
f
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i
See Video 29.10d
h
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( c ) PA chest radiograph
( d ) Lateral chest radiograph
( e ) Ultrasound of gallbladder
( f ) Ultrasound of left kidney
( g ) Stress raw projection image (Video 29.10c, frame 56),
99m
Tc sestamibi, metallic
object ( pink circle ), left kidney ( yellow box )
( h ) Stress/rest processed SPECT images (SA, HLA, VLA)
( i ) Stress gated SPECT (Video 29.10d, frame 1) (SA, VLA, HLA)
The Pertinent Findings
• Chest
– Breasts: □ hot ■ cold
– Chest wall: □ hot ■ cold
– Pleura: □ hot ■ cold
– Lungs: □ hot ■ cold
– Right atrium and right ventricle: ■ hot □ cold
– Diaphragm: □ hot ■ cold
• Abdomen
– Abdominal wall: □ hot ■ cold
– Biliary system and gallbladder: ■ hot ■ cold
– Stomach: ■ hot □ cold
– Small intestine and large intestine: ■ hot □ cold
– Kidneys and female reproductive system: □ hot ■ cold
The Relevant Diagnosis(es)
• Chest
– Breasts: ■ prostheses
– Chest wall: ■ metallic object
– Skeleton: ■ normal
– Pleura: ■ effusion
– Lungs: ■ hyperinfl ation/hyperinfl ation/chronic obstructive pulmonary disease
(COPD)
– Right atrium and right ventricle: ■ right auricular appendage
– Diaphragm: ■ fl attening
• Abdomen
– Abdominal wall: ■ metallic object
– Biliary system and gallbladder: ■ chronic calculous cholecystitis
– Stomach: ■ duodenogastric refl ux
– Small intestine and large intestine: ■ stasis in jejunum
– Kidneys and female reproductive system: ■ chronic/end-stage renal disease
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Discussion
Chest
A “cold” defect is present in a superfi cial location on the left lateral chest wall/upper
abdominal wall; on some projections, it overlies the spleen and on others, the left
ventricular apex (b, g). There is a subtle photopenia at the right lung base (b), correlating with pleural effusion radiographically (c, d); right pleural effusions may be
diffi cult to appreciate due to the axis of rotation from the right anterior oblique
projection to the left posterior oblique. The radiographic left pleural effusion (in the
upright position) is too small to detect by MPI (in the supine position). The lungs
appear hyperinfl ated with fl attened diaphragms (a, b, c, d), characteristic of chronic
obstructive pulmonary disease.
The right auricular appendage is faintly seen (a, b). There is cardiomegaly and
the left ventricular cavity is enlarged (a, b, h, i). Processed SPECT (h) and gated
SPECT (i) show a medium-size, mild, fi xed inferolateral wall defect with associated
hypokinesis. LV end-diastolic volume is 189 mL and LVEF is 49 %.
Abdomen
There is duodenogastric refl ux accounting for the “hot” stomach (a, b). Note how
the jejunum appears quite “hot” and localized in the left upper quadrant on the rest
images, but the activity moves along with peristalsis by the time of the stress imaging. The stone-fi lled gallbladder (e) is not visualized on rest raw images (a) but
visualizes on later same-day stress raw images (b). There are gallstones (e). The
diagnosis is chronic calculous cholecystitis. The left kidney is small (a, b, f, g),
consistent with chronic renal disease.
Relevant Chapter(s)
Chapters 6 , 7 , 9 , 10 , 13 , 16 , 17 , 20 , 22 , 23 , and 25
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29.11 Case Challenge #35
29.11.1 Problem
Clinical Highlights
A 43-year-old female awaits organ transplant. She exercised 6 minutes on a treadmill achieving 7 METS, without chest pain nor ECG changes.
Images for Review
Fig. 29.11
ab
c
See Video 29.11a See Video 29.11b
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( a ) Stress “black-on-white” raw projection images (Video 29.11a, frame 1),
99m
Tc
sestamibi
( b ) Stress “white-on-black” raw projection images (Video 29.11b, frame 1),
99m
Tc
sestamibi
( c ) Stress processed SPECT images (SA, VLA, HLA) without and with AC [ top
row : non-AC; bottom row : AC]
( d ) Stress gated SPECT (Video 29.11c, frame 1) (SA, VLA, HLA)
Characterize the Pertinent Finding(s)
• Chest
– Thyroid gland: □ hot □ cold
– Parathyroid glands: □ hot □ cold
– Breasts: □ hot □ cold
– Chest wall: □ hot □ cold
– Skeleton: □ hot □ cold
– Pleura: □ hot □ cold
– Lungs: □ hot □ cold
– Mediastinum: □ hot □ cold
– Myocardium and pericardium: □ hot □ cold
– Right atrium and right ventricle: □ hot □ cold
– Vascular system: □ hot □ cold
– Lymphatic system: □ hot □ cold
– Diaphragm: □ hot □ cold
d
See Video 29.11c
Fig. 29.11 (continued)
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• Abdomen
– Abdominal wall: □ hot □ cold
– Peritoneum: □ hot □ cold
– Liver: □ hot □ cold
– Biliary system and gallbladder: □ hot □ cold
– Spleen: □ hot □ cold
– Stomach: □ hot □ cold
– Small intestine and large intestine: □ hot □ cold
– Adrenal glands: □ hot □ cold
– Kidneys and female reproductive system: □ hot □ cold
– Vascular system: □ hot □ cold
State Your Relevant Diagnosis(es)
• Chest
– Thyroid gland: □ normal □ primary malignancy
– Parathyroid glands: □ normal □ multigland hyperplasia
– Breasts: □ normal □ large, with periareolar uptake
– Chest wall: □ normal □ multifocal melanoma
– Skeleton: □ normal □ sternotomy
– Pleura: □ normal □ effusion
– Lungs: □ normal □ pneumothorax
– Mediastinum: □ normal □ esophageal tumor
– Myocardium and pericardium: □ normal □ effusion
– Right atrium and right ventricle: □ normal □ dilatation
– Vascular system: □ normal □ injection site
– Lymphatic system: □ normal □ lymphoma
– Diaphragm: □ normal □ paralysis
• Abdomen
– Abdominal wall: □ normal □ multifocal melanoma
– Peritoneum: □ normal □ ascites
– Liver: □ normal □ metastases, colon carcinoma
– Biliary system and gallbladder: □ normal □ cholecystectomy
– Spleen: □ normal □ splenomegaly
– Stomach: □ normal □ gastropathy
– Small intestine and large intestine: □ normal □ stasis
– Adrenal glands: □ normal □ cystic mass
– Kidneys and female reproductive system: □ normal □ polycystic disease
– Vascular system: □ normal □ extravasation
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29.11.2 Solution
Additional Annotated Images
ef
g
See Video 29.11d See Video 29.11d
( e ) Stress “white-on-black” raw projection image (Video 29.11d, frame 1),
99m
Tc
sestamibi, right kidney ( yellow box )
( f ) Stress “white-on-black” raw projection image (Video 29.11d, frame 46),
99m
Tc
sestamibi, left kidney ( yellow box )
( g ) Coronal CT of posterior abdomen at level of kidneys ( yellow boxes )
The Pertinent Findings
• Chest
– Breasts: ■ hot ■ cold
• Abdomen
– Kidneys and female reproductive system: □ hot ■ cold
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The Relevant Diagnosis(es)
• Chest
– Breasts: ■ large, with periareolar uptake
• Abdomen
– Kidneys and female reproductive system: ■ polycystic disease
Discussion
Chest
There are prominent “cold” breasts with symmetric slight increased (“hot”) periareolar uptake. This is a normal appearance. Note that the breasts are large and create “photopenia” that extends to the lateral chest wall. There is also curvilinear
increased uptake along the underside of the lower breasts where they overlie the
chest wall; this is due to low-angle scatter artifact at the skinfold interface .
The stress-only processed images (c) are normal, with a very small left ventricular cavity (end-diastolic volume of 45 mL) and a calculated LVEF of 87 % (d)
(note: high LVEFs are often seen in such patients with low EDVs).
Abdomen
There are striking large “cold” regions in the abdomen (a), better appreciated on
“white-on-black” (b, e, f) rendering of the images. The left-sided abnormality is
better seen due to the axis of rotation for imaging. These “cold” regions are located
within markedly enlarged “lumpy-bumpy” kidneys as shown on the CT image (g).
Note that the “hot” gallbladder is slightly more medially positioned than usual; this
may be related to some mass effect on the liver from the enlarged right kidney. A
normal-size spleen is anatomically present but diffi cult to appreciate due to the large
“cold” left kidney occupying the left upper quadrant (a, b). The fi nal diagnosis is
adult polycystic kidney disease.
Relevant Chapter(s)
Chapters 6 and 25
29 Self-Assessment Cases: Advanced
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