Clinical Significance of Hepatobiliary Localization of Tc-99m EC in Diuretic Renography

Abstract

Objective Technetium-99m ethylene dicysteine (Tc-99m EC) is a well-established, tubular tracer for diuretic renography. Few occasional cases have been reported in literature regarding visualization of liver, gallbladder (GB), or bowel due to increased hepatobiliary route of excretion of Tc-99m EC on diuretic renography. This study aimed to retrospectively review the incidence of visualization of liver, GB, or bowel and its clinical significance in Tc-99m EC diuretic renography.

Materials and Methods Data of all patients who underwent diuretic renography in the department from January 24, 2022 to March 31, 2023 was included in the study. The data was analyzed to assess the incidence of visualization of GB or bowel loops, correlation of the hepatobiliary localization with factors like age of the patient, concentration of 99m TcO4 solution, quality control parameters, presence of renal stone disease, serum creatinine, relative renal function, and effective renal plasma flow. Effect of hepatobiliary localization on scan interpretation and reporting was assessed.

Results The retrospective analysis of 437 diuretic renograms revealed the hepatobiliary localization of tracer in 34 patients. Out of these 34 patients, 14 patients had only faint visualization of tracer at 4 hours delayed image. Twenty scans had visualization of both GB and bowel. Out of these 20 scans, GB and bowel were visualized during dynamic imaging in one scan, after initial 20 minutes in two scans and in 2 to 4 hours delayed images in rest of the 17 scans. Two out of 20 patients had increased serum creatinine, 16 patients had either single kidney or relative renal function less than 26%, and 12 patients had renal stone disease. Out of the four patients in whom relative renal function was more than 25%, one patient had raised serum creatinine and three patients had renal stone disease. Interpretation of images was affected only in three patients, in which reporting of the scans required single-photon emission computed tomography imaging and correlation with other imaging modalities.

Conclusion Hepatobiliary excretion of Tc-99m EC usually does not usually affect the scan interpretation and quantitative renogram analysis, but reader should be cognizant of the potential pitfalls during scan interpretation. In this study, we reviewed the possible causes of this hepatobiliary clearance and importance of additional views and correlation with other imaging modalities to clarify the suspicion arises for accurate reporting.

Keywords

renal dynamic scintigraphy - hepatobiliary excretion of Tc-99m EC - bowel - gallbladder and/or liver visualization on Tc-99m EC scan - SPECT/CT

Ethics Approval

This study was performed in accordance with the ethical standards as laid down in the 2013 Declaration of Helsinki and its later amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from the participant for the study mentioned as a part of the institutional protocol.

Authors' Contributions

Suruchi Jain and Deepa Singh were involved in conceptualization, methodology, and writing—original draft preparation. Suruchi Jain, Deepa Singh, Anuj Jain, and Sanchay Jain helped in writing—review and editing. Suruchi Jain and Deepa Singh supervised the study. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Publication History

Article published online:
22 April 2024

• References

• 1 Moran JK. Technetium-99m-EC and other potential new agents in renal nuclear medicine. Semin Nucl Med 1999; 29 (02) 91-101
• 2 Gupta NK, Bomanji JB, Waddington W. et al. Technetium-99m-L,L-ethylenedicysteine scintigraphy in patients with renal disorders. Eur J Nucl Med 1995; 22 (07) 617-624
• 3 Kabasakal L, Turoğlu HT, Onsel C. et al. Clinical comparison of technetium-99m-EC, technetium-99m-MAG3 and iodine-131-OIH in renal disorders. J Nucl Med 1995; 36 (02) 224-228
• 4 Van Nerom CG, Bormans GM, De Roo MJ, Verbruggen AM. First experience in healthy volunteers with technetium-99m L,L-ethylenedicysteine, a new renal imaging agent. Eur J Nucl Med 1993; 20 (09) 738-746
• 5 Keramida G, James JM, Prescott MC, Peters AM. Pitfalls and limitations of radionuclide renal imaging in adults. Semin Nucl Med 2015; 45 (05) 428-439
• 6 Arroyo AJ, Semaan HB, Minkus KD, Patel YP. Factors affecting the hepatobiliary excretion of 99mTc-MAG3: its clinical significance in routine renography. J Nucl Med Technol 2003; 31 (01) 18-20
• 7 Eshima D, Eshima L, Hansen L, Lipowska M, Marzilli LG, Taylor Jr A. Effect of protein binding on renal extraction of 131I-OIH and 99mTc-labeled tubular agents. J Nucl Med 2000; 41 (12) 2077-2082
• 8 Prvulovich EM, Bomanji JB, Waddington WA, Rudrasingham P, Verbruggen AM, Ell PJ. Clinical evaluation of technetium-99m-L,L-ethylenedicysteine in patients with chronic renal failure. J Nucl Med 1997; 38 (05) 809-814
• 9 Kibar M, Noyan A, Anarat A. 99Tcm-N,N-ethylenedicysteine scintigraphy in children with various renal disorders: a comparative study with 99Tcm-MAG3. Nucl Med Commun 1997; 18 (01) 44-52
• 10 Danilczuk A, Nocun A, Chrapko B. Normal ranges of renal function parameters for 99mTc-EC renal scintigraphy. Nucl Med Rev Cent East Eur 2020; 23 (02) 53-57
• 11 Kabasakal L, Atay S, Vural VA. et al. Evaluation of technetium-99m-ethylenedicysteine in renal disorders and determination of extraction ratio. J Nucl Med 1995; 36 (08) 1398-1403
• 12 Bar-Sever Z, Shammas A, Gheisari F, Vali R. Pediatric nephro-urology: overview and updates in diuretic renal scans and renal cortical scintigraphy. Semin Nucl Med 2022; 52 (04) 419-431
• 13 Verbruggen AM, Nosco DL, Van Nerom CG, Bormans GM, Adriaens PJ, De Roo MJ. Technetium-99m-L,L-ethylenedicysteine: a renal imaging agent. I. Labeling and evaluation in animals. J Nucl Med 1992; 33 (04) 551-557
• 14 Buyukdereli G, Guney IB. Role of technetium-99m N,N-ethylenedicysteine renal scintigraphy in the evaluation of differential renal function and cortical defects. Clin Nucl Med 2006; 31 (03) 134-138
• 15 Arora G, Damle NA, Tripathi M, Bal C, Kumar P. Vicarious visualization of gall bladder on Tc-99m ethylene dicysteine renal dynamic study. Indian J Nucl Med 2012; 27 (04) 257-258
• 16 Jain TK, Phulsunga RK, Gupta N, Sood A, Bhattacharya A, Mittal BR. Vicarious liver visualization in solitary functioning kidney with technetium-99m ethylenedicysteine renal scintigraphy. Indian J Nucl Med 2015; 30 (03) 272-274
• 17 Zakko S, Mrhac L, Al-Bahri J, Al-Shamsi H, Lootah S, Benjamin RJ. Biliary excretion of Tc-99m EC in renal studies. Clin Nucl Med 1998; 23 (07) 417-419
• 18 Goel P, Bajpai M, Damle NA, Naranje P, Tripathi M. Bowel excretion of technetium-(99m)L, L-ethylene dicysteine masquerading as a dilated ureter in a case of pelvi-ureteric junction obstruction. J Indian Assoc Pediatr Surg 2019; 24 (03) 222-224
• 19 Aka S, Moulika JS, Mohan VK, Priya RR, Manthri R, Kalawat TC. Gall bladder activity on technetium99m-ethylenedicysteine renogram masquerading as ectopic kidney. Indian J Nucl Med 2019; 34 (01) 57-59
• 20 Jain V, Arora S, Passah A. et al. Comparison of the renal dynamic scan performed with 99mTc-L,L-EC and 99mTc-MAG3 in children with pelviureteric junction obstruction. Nucl Med Commun 2018; 39 (11) 1053-1058
• 21 Barone S, Xu J, Zahedi K, Brooks M, Soleimani M. Probenecid pre-treatment downregulates the kidney Cl^-/HCO₃ ^- exchanger (Pendrin) and potentiates hydrochlorothiazide-induced diuresis. Front Physiol 2018; 9: 849