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Nuclear Medicine in the Assessment of Adverse Effects of Cancer Therapy in the Lung, Kidney, and Gastrointestinal Tract

Nuclear Oncology

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Abstract

Radiotherapy or chemotherapy and new drugs and strategies in oncology can produce damage in normal organs and tissues affecting the quality of life of the patient. Pulmonary toxicity is frequently seen in patients treated with bleomycin or other chemotherapeutic agents. The most common clinical form of bleomycin pulmonary toxicity is the subacute condition, which may progress to lung fibrosis and death, if not recognized and appropriately managed. The diagnosis is usually established by a combination of clinical, radiographic, and pulmonary function test abnormalities. X-ray and high-resolution CT scan findings are used to identify pulmonary fibrosis. 67Ga-citrate scintigraphy has been used to detect and assess the extent of pulmonary toxicity related to bleomycin in patients who otherwise have normal chest radiographs.

Since conventional CT scanning is not able to distinguish fibrosis and active inflammation, [18F]FDG-PET has been suggested as a tool to indicate the resolution of disease activity. Moreover, [18F]FDG-PET could be useful to detect early preclinical pneumonitis induced by bleomycin. As pulmonary permeability can be altered by chemotherapy, 99mTc-DTPA aerosols can be used to assess a reduced epithelial permeability.

Acute radiation lung injury can occur within 1–3 months after radiation therapy of the thorax, whereas lung fibrosis can develop 6–24 months later, leading to progressive impairment of pulmonary function. Clinical manifestations, chest radiographs, and pulmonary function tests may help to establish an early diagnosis. Scintigraphic abnormalities can be demonstrated in the acute phase often before radiologic changes become apparent by 67Ga-citrate scintigraphy. Moreover, 111In-pentetreotide may have a role in the differential diagnosis of patients with complaints after radiotherapy and in the monitoring of the response to corticosteroid therapy. [18F]FDG uptake in the irradiated region can be observed up to about 2 months following therapy. The persistence of activity beyond 8 weeks raises the likelihood of persistence of disease within the irradiated region.

Lung scintigraphy with 99mTc-DTPA aerosol or 99mTc-MAA (macroaggregates of albumin) has been performed to assess radiation-induced ventilation/perfusion changes.

Drugs for the treatment of abdominal malignancies, such as cisplatin and ifosfamide, and abdominal radiation can cause renal damage.

Chemotherapy-induced nephropathy can be identified with quantitative measurement of glomerular filtration rate. 99mTc-DTPA has become the preferred radiopharmaceutical because of availability and cost. 99mTc-DMSA scintigraphy can be used to establish tubular dysfunction induced by nephrotoxic drugs. Nuclear medicine techniques also offer the possibility to follow the clinical evolution of radiation nephropathy. Bone scans using 99mTc-MDP can show increased kidney uptake early after radiation in patients with radiation fields including kidneys. Over the subsequent 6–12 months the uptake decreases to normal or below normal levels, associated with the loss of function. Renography with 99mTc-DTPA can be performed to assess radiation nephropathy. 99mTc-DTPA Captopril renography test has been used to investigate the relation between small vessel injury due to radiation and hypertension.

Nuclear medicine examinations can play a role in the detection of radiation-induced digestive tract damage.

In cancers of the cervix, endometrium, ovary, prostate, bladder, or rectum, radiation therapy is often required. Radiation proctitis is usually self-limiting and resolves within a month after the conclusion of therapy. Damage of the small bowel is seen in 0.5–15% of the patients. Chronic injuries to the small bowel are manifest 6 and 24 months after radiation. Ileal dysfunction is due to bile acid malabsortion, to bacterial overgrowth in the small bowel, or to the combination of both. 75Se-homocholic acid conjugated with taurine (75Se-HCAT) and 14C-glycochol breath test can be used to differentiate between normal functioning ileum (both tests negative) and ileal dysfunction (one or both tests positive). The combination of both tests may allow the differentiation between bile acid malabsorption (75Se-HCAT positive) and bacterial overgrowth (75Se-HCAT negative).

These techniques may also help to document the benefit of innovative therapeutic approaches such as the use of somatostatin analogs (SOM230). In cases of radiotherapy and chemotherapy-associated liver injury, radionuclide studies can be performed using 99mTc-iminodiacetic acid or 99mTc-colloid. In patients receiving radiotherapy, the most common finding is the loss of function of the part of the liver involved in the radiation field, with a reduced uptake in irradiated areas. Recently, acute radiation-induced hepatitis has been reported as a potential cause of false-positive findings of malignancy on [18F]FDG-PET scans. Moreover, esophagitis postradiotherapy can be observed on [18F]FDG-PET scans.

Leucocytes labeled with 111In or with 99mTc-HMPAO or [18F]FDG can be used in patients with suspected radiation enterocolitis.

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Abbreviations

[18F]FDG:

2-deoxy-2-[18F]fluoro-D-glucose

75Se-HCAT:

75Se-Homocholic acid conjugated with taurine

99mTc-DMSA:

99mTc-dimercaptosuccinic acid

99mTc-DTPA:

99mTc-diethylenetriaminepentaacetic acid

99mTc-HMPAO:

99mTc-hexamethylpropyleneamine oxime

99mTc-IDA:

99mTc-iminodiacetic acid

99mTc-MAA:

99mTc-macroaggregated albumin

99mTc-MDP:

99mTc-methylene diphosphonate

AVBD:

chemotherapy regimen based on adriamycin, vinblastine, bleomycin and dacarbazine

CT:

X-ray computed tomography

DLCO:

Diffusing capacity of the lung for carbon monoxide

EDTA:

Ethylenediaminetetraacetic acid

GFR:

Glomerular Filtration Rate

GI:

Gastrointestinal

Gy:

Gray unit (ionizing radiation dose in the International System of Units, corresponding to the absorption of one joule of radiation energy per kilogram of matter)

MIP:

Maximum Intensity Projection

NSCLC:

Non-small cell lung cancer

PET:

Positron emission tomography

PET/CT:

Positron emission tomography/Computed tomography

ROS:

Reactive oxygen species

SPECT:

Single-photon emission computed tomography

SPECT/CT:

Single-photon emission computed tomography/Computed tomography

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Authors and Affiliations

  1. Department of Nuclear Medicine, Hospital Sant Pau, Autonomous University of Barcelona, Pare Claret 167, 08025, Barcelona, Spain

    Diego Alfonso López Mora & Ignasi Carrió

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  1. Diego Alfonso López Mora
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  2. Ignasi Carrió
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Correspondence to Ignasi Carrió .

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Editors and Affiliations

  1. Attending Emeritus, Memorial Sloan-Kettering Cancer Center Dept. Radiology, New York, New York, USA

    H. William Strauss

  2. Professor Emeritus, University of Pisa, Pisa, Italy

    Giuliano Mariani

  3. Associate Professor and Director of Nuclear Medicine, University of Pisa, Pisa, Italy

    Duccio Volterrani

  4. Attending Physician, Memorial Sloan-Kettering Cancer Center, New York, New York, USA

    Steven M. Larson

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López Mora, D.A., Carrió, I. (2016). Nuclear Medicine in the Assessment of Adverse Effects of Cancer Therapy in the Lung, Kidney, and Gastrointestinal Tract. In: Strauss, H., Mariani, G., Volterrani, D., Larson, S. (eds) Nuclear Oncology. Springer, Cham. https://doi.org/10.1007/978-3-319-26067-9_30-1

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