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Importance of SPECT/CT in Detecting Multiple Hemangiomas on 99m Tc-Labeled RBC Blood Pool Scintigraphy Shambo Guha Roy, MBBS, Sellam Karunanithi, MD, Krishan Kant Agarwal, MD, Chandrasekhar Bal, MD, DSc (HC), and Rakesh Kumar, MD, PhD Abstract: Vascular malformations and hemangiomas are common in children, but gastric hemangioma is extremely rare with less than 15 reported cases in the pediatric age group. Gastric hemangioma accounts for only 0.05% of all gastrointestinal neoplasms, and intra-abdominal hemangiomas are rarely found outside of the liver. We present a unique case of gastric hemangioma, and multiple hemangiomas were detected in a single scan by 99mTc-labeled RBC blood pool imaging. This case also depicts the incremental role of SPECT/CT over planar acquisition for detecting multiple hemangiomas, especially for those lesions located adjacent to physiological blood pool activity. Key Words: gastric hemangiomas, blood pool scintigraphy, 99mTc-RBC, SPECT/CT (Clin Nucl Med 2015;40: 345–346)

Received for publication July 16, 2014; revision accepted October 29, 2014. From the Department of Nuclear Medicine and PET, All India Institute of Medical Sciences, New Delhi, India. Conflicts of interest and sources of funding: none declared. Reprints: Rakesh Kumar, MD, PhD, Department of Nuclear Medicine and PET, All India Institute of Medical Sciences, Room No. 57A, Ansari Nagar, New Delhi, India. E-mail: [email protected]. Copyright © 2014 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0363-9762/15/4004–0345

REFERENCES 1. Fevurly RD, Fishman SJ. Vascular anomalies in pediatrics. Surg Clin North Am. 2012;92:769–800. 2. García-Hernández C, Landa-Juárez S, Carvajal-Figueroa L, et al. Laparoscopic resection of a gastric giant cavernous hemangioma in a child. Cir Cir. 2012;80: 368–370. 3. Wan YL, Eng HL, Lee TY, et al. Computed tomography of an exophytic gastric hemangioma with torsion and intratumoral hemorrhage. Clin Imaging. 1993;17: 210–212. 4. Medina V, Alarco A, Martin A, et al. Gastric cavernous hemangioma as a cause of upper digestive hemorrhage. Rev Esp Enferm Dig. 1995;87:323–326. 5. Nagaya M, Kato J, Niimi N, et al. Isolated cavernous hemangioma of the stomach in a neonate. J Pediatr Surg. 1998;33:653–654. 6. Murata Y, Yamada I, Umehara I, et al. Perfusion and blood-pool scintigraphy in the evaluation of head and neck hemangiomas. J Nucl Med. 1997;38:882–885. 7. Fukuda Y, Murata Y, Umehara I, et al. Perfusion and blood pool scintigraphy for diagnosing soft-tissue arteriovenous malformations. Clin Nucl Med. 1999;24: 232–234. 8. Krause T, Hauenstein K, Studier-Fischer B, et al. Improved evaluation of technetium-99m–red blood cell SPECT in hemangioma of the liver. J Nucl Med. 1993;34:375–380.

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Clinical Nuclear Medicine • Volume 40, Number 4, April 2015

FIGURE 1. A 4-year-old boy presented in the emergency department with 8 episodes of hematemesis for the last 5 days. The child was conscious, alert, and hemodynamically stable. His hemoglobin level was 5.4 g% with normal platelet count and coagulation profile. After initial stabilization and transfusion of 4 units of packed RBC, he was taken for upper gastrointestinal endoscopy, which revealed a large vascular mass along the greater curvature of the stomach. Considering the vascularity of the lesion, biopsy was not taken. He was referred to our department to see the extent of the disease and characterization of the lesion. 99mTc-labeled RBC scintigraphy was performed in this boy, and images were acquired till 24 hours. Serial anterior and posterior views of whole-body planar images revealed 2 foci of radiotracer concentration, one in the gastric region and another in the posterior upper thigh region (A and B). Hybrid SPECT/CT (C-H) was performed for anatomical delineation of the gastric (E and F, arrows) and the thigh lesion (G and H, arrows). Interestingly, SPECT/CT revealed an additional intramuscular lesion in the paravertebral region at the level of D8 vertebra (C and D, arrows), which was masked by mediastinal blood pool activity in planar images. All these 3 lesions were suggestive of multiple hemangiomas. Later, these multiple lesions were confirmed to be hemangiomas on CT angiography. In addition, the patient underwent surgical resection of the gastric lesion, which on histopathological examination revealed cavernous hemangioma. Vascular malformations and hemangiomas are common in children, but gastric hemangioma is extremely rare with less than 15 reported cases in the pediatric age group.1,2 Gastric hemangioma accounts for only 0.05% of all gastrointestinal neoplasms,3 and intra-abdominal hemangiomas are rarely found outside of the liver. The submucosal localization and dense vascular nature of gastric hemangioma limit the role of endoscopic biopsy in the preoperative histopathological diagnosis.4 The curative treatment is surgery. Wedge resection and partial or total gastrectomy constitute the standard treatment modalities for gastric hemangiomas.5 99mTc-labeled RBC scintigraphy is an age-old technique for detection of vascular malformation and hemangiomas.6,7 Incremental role of SPECT has been documented for detecting hepatic hemangiomas less than 3 cm.8 Our case is a unique case to detect gastric hemangioma and multiple hemangiomas in a single scan by 99mTc-labeled RBC blood pool imaging. This case also depicts the incremental role of SPECT/CT over planar acquisition for detecting multiple hemangiomas, especially for those lesions located adjacent to physiological blood pool activity.

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CT in detecting multiple hemangiomas on 99mTc-labeled RBC blood pool scintigraphy.

Vascular malformations and hemangiomas are common in children, but gastric hemangioma is extremely rare with less than 15 reported cases in the pediat...
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