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Society of Nuclear Medicine

Procedure Guideline for
Hepatic and Splenic Imaging 3.0
version 3.0, approved July 20, 2003

Authors: Henry D. Royal, MD (Mallinckrodt Institute of Radiology, St. Louis, MO); Manuel L. Brown, MD (Henry Ford
Hospital, Detroit, MI); David E. Drum, MD (West Roxbury Veterans Administration, Boston, MA); Conrad E. Nagle, MD
(William Beaumont Hospital, Troy, MI); James M. Sylvester, MD (Our Lady of the Lake Medical Center, Baton Rouge,
LA); and Harvey A. Ziessman, MD (Georgetown University Hospital, Washington, DC).

I. Purpose ease. The decision to perform a liver biopsy or
to continue treatment with a hepatotoxic agent
The purpose of this guideline is to assist nuclear
may be influenced by the severity of liver dis-
medicine practitioners in recommending, perform-
ease that is seen on liver–spleen imaging.
ing, interpreting, and reporting hepatic and splenic B. Liver Blood Pool Imaging
imaging studies. This test is highly specific for cavernous heman-
giomas of the liver. The sensitivity for detecting
II. Background Information and Definitions lesions of the liver (>2–3 cm) is also high. He-
mangiomas as small as 0.5 cm may be detected
A. Liver–spleen imaging is performed after the in- with single-positron emission computed tomog-
jection of a 99mTc-labeled colloid that has been raphy (SPECT) using a multihead camera.
rapidly phagocytized by the reticuloendothelial C. Hepatic Perfusion Imaging
cells of the liver, spleen, and bone marrow. This study is useful for demonstrating that hep-
B. Liver blood pool imaging is performed after the atic artery catheters used to infuse chemothera-
injection of 99mTc-labeled red blood cells for the peutic or therapeutic radiolabeled microsphere
detection of cavernous hemangiomas of the liver. agents are positioned optimally to perfuse liver
C. Hepatic perfusion studies are performed after tumors and to avoid perfusion of normal extra-
the injection of 99mTc-macroaggregated albumin hepatic tissues (e.g., stomach).
(MAA) through a hepatic artery catheter to de- D. Splenic Imaging
termine that intra-arterially administered agents This study is used for detecting functional
are delivered optimally. splenic tissue. This study is often performed:
D. Splenic imaging is performed after the injection 1. In children to rule out congenital asplenia or
of 99mTc-labeled heat-damaged red blood cells. polysplenia
2. In adults whose thrombocytopenia has been
Damaged red blood cells are taken up selectively
treated previously with splenectomy
by functioning splenic tissue.
3. For characterizing an incidentally noted mass
as functional splenic tissue
III. Common Indications
A. Liver–Spleen Imaging IV. Procedure
This study can be used for determining the size A. Patient Preparation
and shape of the liver and spleen as well as for No patient preparation is required.
detecting functional abnormalities of the reticu- B. Information Pertinent to Performing the Procedure
loendothelial cells of these organs. Specifically, 1. Relevant history and results of physical exam
these studies are occasionally performed: 2. The results of other anatomic imaging studies
1. For suspected focal nodular hyperplasia of 3. The results of liver function tests
the liver. These lesions often have normal or 4. For splenic imaging, the results of a complete
increased uptake on sulfur colloid imaging. blood count and platelet count
2. To assess the function of the reticuloendothe- 5. For hepatic perfusion studies, the position of
lial system in patients with suspected liver dis- the hepatic artery catheter
54 • HEPATIC AND SPLENIC IMAGING

C. Precautions prove the results of imaging. Some experts
When red blood cells are labeled, strict adher- recommend using only in vitro labeling.
ence to a procedure designed to prevent the ad- 3. Hepatic artery perfusion imaging
99m
ministration of one patient’s labeled red blood Tc-MAA is injected slowly via the hepatic
cells into another patient is mandatory. Proce- arterial catheter or infusion pump.
dures and quality assurance for correct identifi- 4. Splenic imaging
99m
cation of patients and handling blood products Tc-labeled red blood cells typically are
are essential. See the Society of Nuclear Medicine damaged by heating for 20 min in a waterbath
Procedure Guideline for Use of Radiopharmaceuticals. at 49°–50°C.
D. Radiopharmaceutical E. Image Acquisition
1. Liver–spleen imaging 1. Liver–spleen imaging
99m
Tc-sulfur colloid (SC) is preferred for Imaging is begun 10–15 min or longer after
liver–spleen imaging because the biodistribu- the intravenous administration of 99mTc-col-
tion and biokinetics of this agent are more re- loid. Anterior, posterior, right lateral, right
producible than those of 99mTc-albumin col- anterior oblique, and right posterior oblique
loid (AC). At the time of this revision, images of the liver are commonly obtained.
99m
Tc-AC was no longer available in the Left posterior oblique and left lateral views
United States. are added for evaluating the spleen. For
2. Liver blood pool imaging small-field-of-view gamma cameras and
99m
Tc-labeled red blood cells can be labeled standard amounts of administered activity,
using in vitro, in vitro/in vivo, or in vivo images are usually collected for a minimum
methods. Methods with higher labeling effi- of 300,000–500,000 counts. For large-field-of-
ciency (in vitro/in vivo or in vitro) may im- view gamma cameras, an anterior image is

Radiation Dosimetry in Normal Adults

Radiopharmaceutical Administered Organ Receiving the Effective
Activity Largest Radiation Dose Dose
MBq mGy/MBq mSv /MBq
(mCi) (rad /mCi) (rem/mCi)

99m
Tc-colloid* 150–220 Spleen 0.014
(4–6) 0.074 (0.052)
(0.27)

99m
Tc-labeled red 750–925 Heart 0.0085
blood cells† (20–25) 0.023 (0.031)
(0.085)

99m
Tc-macroaggregated 40–110 Liver Variable
albumin (1–3) Variable (Variable)
(Variable)

99m
Tc–heat-damaged 40–110 Spleen 0.041
red blood cells‡ (1–3) 0.56 (0.15)
(2.1)
*
International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
ICRP report 53. London, UK: ICRP; 1988:180.

International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
ICRP report 53. London, UK: ICRP; 1988:210.

International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
ICRP report 53. London, UK: ICRP; 1988:212.
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL AUGUST 2003 • 55

Radiation Dosimetry in Children
(5 Years Old)

Radiopharmaceutical Administered Organ Receiving the Effective
Activity Largest Radiation Dose Dose
MBq/kg mGy/MBq mSv/MBq
(mCi) (rad/mCi) (rem/mCi)
99m
Tc-colloid* 1.5–2.2 Spleen 0.041
(0.04–0.06) 0.25 (0.15)
(0.93)
99m
Tc-labeled red 7.0–11.0 Heart 0.025
blood cells† (0.2–0.3) 0.062 (0.093)
(0.23)
99m
Tc-macroaggregated 1.5–2.2 Liver Variable
albumin (0.04–0.06) Variable (Variable)
(Variable)
99m
Tc–heat- 0.7–1.5 Spleen 0.13
damaged red blood (0.02–0.04) 1.8 (0.48)
cells‡ (6.7)
*
International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
ICRP report 53. London, UK: ICRP; 1988:180.

International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
ICRP report 53. London, UK: ICRP; 1988:210.

International Commission on Radiological Protection. Radiation Dose to Patients from Radiopharmaceuticals.
ICRP report 53. London, UK: ICRP; 1988:212.

usually acquired for 500,000–1 million Immediate blood pool images may be ob-
counts. Subsequent images are then obtained tained in the view most likely to show the le-
for the same length of time as the anterior im- sion, as well as anterior, posterior, and right
age. SPECT imaging may be helpful, particu- lateral views. Generally these views are ac-
larly if focal disease is suspected. quired for 1,000,000–2,000,000 counts. These
Breath holding views may sometimes help immediate images are optional.
clarify ambiguous findings by eliminating im- Delayed (45–180 min after injection) blood
age degradation by respiratory motion. A size pool images are obtained in the view most likely
marker and a costal margin marker are to show the lesion, as well as anterior, posterior,
needed for measuring liver and spleen size and right lateral views. Generally these views
and for identifying anatomical landmarks. are acquired for 1,000,000–2,000,000 counts.
2. Hepatic blood pool imaging When the lesion is small (<2–3 cm) or if there
A rapid sequence of images (1 frame/s for are multiple lesions, SPECT imaging is rec-
60 s) immediately after the injections may re- ommended. If a high-quality delayed SPECT
veal useful information about regional vari- study is obtained, planar images are op-
ations in blood flow. This dynamic study tional. SPECT facilitates comparison with CT
should be performed in the view that is most and MR imaging.
likely to show the lesion. This view should 3. Hepatic perfusion imaging
be selected based on the location of the le- The radiopharmaceutical (99m Tc-MAA)
sion of interest that usually has been docu- should be infused very slowly (<1 mL/min)
mented on an earlier imaging study (i.e., at a measured rate through the hepatic perfu-
computed tomography [CT], ultrasound, or sion catheter to avoid perturbing perfusion
magnetic resonance [MR] imaging). The ini- patterns that could result from streaming of
tial flow study is optional. the injectate. Imaging is performed immedi-
56 • HEPATIC AND SPLENIC IMAGING

ately after the infusion of the agent. Anterior, sions <3 cm is improved by the use of SPECT
posterior, and right lateral images of the liver imaging, particularly when multihead cam-
containing 500,000–1,000,000 counts are typi- eras are used. SPECT imaging is also helpful
cally acquired. Images of the lung are re- when there are multiple lesions in the liver
quired to identify intrahepatic arteriovenous and facilitates comparison with CT and MR
fistulas. imaging.
4. Splenic imaging 3. Hepatic perfusion imaging
Imaging may begin 30–120 min after the injec- The images should be assessed for the pres-
tion of the radiopharmaceutical. Anterior, ence of extrahepatic accumulation of activity
posterior, and posterior oblique images of the (e.g. stomach, pancreas). Some lung activity
expected location of the spleen should be ac- may be seen with a properly positioned
quired for 300,000–750,000 counts. If ectopic catheter as a result of arteriovenous fistulas in
splenic tissue is a concern, the entire abdomen the liver. Significant lung uptake may pre-
should be imaged. If the patient has had prior clude the administration of therapeutic radio-
trauma that may have resulted in a diaphrag- labeled microspheres. The presence of stom-
matic rupture, the chest also should be im- ach or splenic activity indicates that the
aged. SPECT imaging facilitates comparison catheter is not optimally positioned.
with CT and MR imaging. 4. Splenic imaging
F. Interventions Functional splenic tissue is preferentially vi-
None sualized when heat damaged blood cells are
G. Processing used.
None I. Reporting
H. Interpretation Criteria 1. Liver–spleen imaging
1. Liver–spleen imaging The size and shape of the liver and spleen and
Most focal lesions in the liver will have less ac- the relative amount of activity in the liver,
tivity than the liver. Focal nodular hyperpla- spleen, and bone marrow should be noted. It
sia may have activity equal to or greater than is not always necessary to include measure-
the surrounding liver in about 50% of pa- ments of liver or spleen size.
tients. Finding normal activity or increased 2. Hepatic blood pool imaging
activity in a lesion is very suggestive of focal The report should include the results of other
nodular hyperplasia. imaging studies when they are available.
A relative radiocolloid “shift” (increased When multiple lesions have been noted on
radionuclide deposition in the spleen and other imaging studies, the presence or absence
bone marrow relative to liver) may occur in of increased blood pool should be reported on
hepatic dysfunction but also may be seen with a lesion-by-lesion basis when possible.
portal hypertension, hypersplenism, marrow- 3. Hepatic perfusion imaging
active anemia as response to chemotherapy, The approximate rate (mL/min) of the injec-
and in some patients with malignant tion of the radiopharmaceutical should be in-
melanoma. Because of the variable particle cluded in the report. The presence of any ex-
size, colloid shift is more difficult to assess trahepatic activity should be noted. When
with 99mTc-AC than with 99mTc-SC. indicated, the percentage of the activity in the
2. Hepatic blood pool imaging lung should be reported.
The finding of markedly increased blood pool 4. Splenic imaging
activity within a lesion is pathognomonic of a The time between injection and imaging
cavernous hemangioma of the liver. Heman- should be reported, as well as the number, ap-
giomas typically have decreased or normal proximate size, and location of any function-
blood flow. Rarely, other tumors of the liver ing splenic tissue.
(e.g., angiosarcomas) have been reported to J. Quality Control
have increased blood pool on delayed images. None
However, they can usually be differentiated K. Sources of Error
from cavernous hemangiomas by the fact that 1. Liver–spleen imaging
they also have increased blood flow. a. Anatomic variations
Cavernous hemangiomas that are 3 cm or b. Respiratory motion
greater in size almost always demonstrate c. Colloid size: Small particles preferentially
markedly increased blood pool even on pla- go to the bone marrow and large particles
nar images. The sensitivity for detecting le- preferentially go to the spleen.
SOCIETY OF NUCLEAR MEDICINE PROCEDURE GUIDELINES MANUAL AUGUST 2003 • 57

d. Artifacts resulting from radiation therapy carcinoma: value of labeled RBC-SPECT scanning.
e. Breast attenuation artifact Am J Radiol. 1989;152:977–983.
2. Splenic imaging Oates E, Austin JM, Becker JL. Technetium-99m-sulfur
Degree of damage to the red blood cells colloid SPECT imaging in infants with suspected
heterotaxy syndrome. J Nucl Med.
1995;36:1368–1371.
V. Issues Requiring Further Clarification
Pohlson EC, Wilkinson RW, Witzum KF, et al. Heat-
None damaged red cell scan for intraoperative localiza-
tion of the accessory spleen. J Pediatr Surg.
1994;29:604–608.
VI. Concise Bibliography
Ziessman HA, Silverman PM, Patterson J, et al. Im-
American College of Radiology. ACR Standard for the proved detection of small cavernous hemangiomas
Performance of Liver/Spleen Scintigraphy. In: ACR of the liver with high-resolution three-headed
Standards 2001–2002. Reston, VA: American College SPECT. J Nucl Med. 1991;32:2086–2091.
of Radiology; 2002:471–479.
Bakir M, Bilgic A, Ozmen M, et al. The value of ra-
VII. Disclaimer
dionuclide splenic scanning in the evaluation of as-
plenia in patients with heterotaxy. Pediatr Radiol. The Society of Nuclear Medicine has written and ap-
1994;24:25–28. proved guidelines to promote the cost-effective use of
Groshar D, Slobodin G, Zuckerman E. Quantitation of high-quality nuclear medicine procedures. These
liver and spleen uptake of (99m)Tc-phytate colloid generic recommendations cannot be applied to all pa-
using SPECT: detection of liver cirrhosis. J Nucl tients in all practice settings. The guidelines should not
Med. 2002;43:312–317. be deemed inclusive of all proper procedures or exclu-
Habbe TG, McCowan TC, Goertzen TC, et al. Compli- sive of other procedures reasonably directed to obtain-
cations and technical limitations of hepatic arterial ing the same results. The spectrum of patients seen in a
infusion catheter placement for chemotherapy. J specialized practice setting may be quite different from
Vasc Intervent Radiol. 1998;9:233–239. the spectrum of patients seen in a more general practice
Kehagias D, Moulopoulos L, Antoniou A, et al. Focal setting. The appropriateness of a procedure will de-
nodular hyperplasia: imaging findings. Eur Radiol. pend in part on the prevalence of disease in the patient
2001;11:202–212. population. In addition, the resources available to care
Krause T, Hauenstein K, Studier-Fischer B, et al. Im- for patients may vary greatly from one medical facility
proved evaluation of technetium-99m-red blood to another. For these reasons, guidelines cannot be
cell SPECT in hemangioma of the liver. J Nucl Med. rigidly applied.
1993;34:375–380. Advances in medicine occur at a rapid rate. The date
Kudo M, Ikekubo K, Yamamoto K, et al. Distinction be- of a guideline should always be considered in deter-
tween hemangioma of the liver and hepatocellular mining its current applicability.