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Original Studies |
Departments of Endocrinology (G.K., M.K., E.Z., J.J.M., P.J.J., S.L.C., J.P.M., G.M.B., A.B.G.), Diagnostic Radiology (R.R.), and Nuclear Medicine (R.F., K.E.B.), St. Bartholomew’s Hospital, London, United Kingdom EC1A 7BE
Address all correspondence and requests for reprints to: Prof. A. B. Grossman, Department of Endocrinology, St. Bartholomew’s Hospital, London, United Kingdom ECIA 7BE. E-mail: a.b.grossman{at}mds.qmw.ac.uk
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Abstract |
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In conclusion, scintigraphy with [111In]pentetreotide detects more metastatic lesions than [123I]MIBG in patients with carcinoid and pancreatic islet cell tumors and medullary thyroid carcinomas; [123I]MIBG scintigraphy may be more sensitive for sympathoadrenomedullary tumors. The radionuclides may exert a complementary role in the detection and treatment of neuroendocrine tumors in occasional patients, as areas of different pattern of uptake were identified within the same patient. These data have implications not only for staging such tumors, but also for identifying patients who might benefit from treatment using either [131I]MIBG or radioactive somatostatin analogs.
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Introduction |
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TopAbstractIntroductionSubjects and MethodsMaterials and MethodsResultsDiscussionReferences |
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Meta-iodobenzylguanidine (MIBG) is a catecholamine analog that uses the amine precursor uptake mechanism and may thus be incorporated into vesicles or neurosecretory granules in the cytoplasm; it has been shown to be highly sensitive for detecting tumors arising from the adrenal medulla and may be also taken up by nonadrenomedullary neuroendocrine tumors (2, 3, 4, 5). Radiolabeled octreotide, an analog of somatostatin, is used in vivo to demonstrate tumors that have somatostatin receptors on their surface. It has been suggested that octreotide scanning may be more sensitive, although less specific, than MIBG in the detection of neuroendocrine tumors other than pheochromocytomas, although direct comparisons were performed in different patients (2, 3, 4, 5); however, these radionuclides may be complementary in the diagnosis of neuroendocrine tumors (2, 3, 4, 5, 6). In addition, considerable experience has been gained with the use of [131I]MIBG for the treatment of a variety of neuroendocrine tumors (4). Although the radionuclide profile of [111In]pentetreotide, the principal radiodiagnostic somatostatin analog, makes it a weak therapeutic agent, other labeled somatostatin analogs have recently been introduced into clinical trial (5). However, until now the relative utility of diagnostic radionuclides has been unclear, as the range of neuroendocrine and related tumors in which formal comparisons of [123I]MIBG and [111In]pentetreotide scintigraphy have been made remains limited. In addition, information on correlations with other indicators of disease activity, e.g. symptoms and hormonal markers, is even more sparse, particularly in patients with metastatic disease (3, 4, 6, 7, 8, 9).
This study analyses the experience using both radiopharmaceuticals in a total of 54 patients. In 46 patients with disseminated neuroendocrine tumors (carcinoid tumors, pheochromocytomas, medullary carcinomas of the thyroid, islet cell tumors, and a pituitary carcinoma), both radiopharmaceuticals were used in the diagnosis and detection of the extent of the disease and in helping identify patients who may benefit from treatment with either [131I]MIBG or, more recently, labeled long-acting somatostatin analogs. A further 8 patients with clinical and/or biochemical evidence of recurrent neuroendocrine tumors or unidentified primary lesions, not apparent on conventional radiology, were also included in the analysis. The results obtained from conventional radiology [computed tomography (CT)/magnetic resonance (MR) imaging] were compared with those from the radiopharmaceuticals and were correlated with the presence of symptoms and hormonal markers to identify possible clinical or biological predictors of a positive scan. Preliminary data on the first 7 patients of this cohort have previously been reported (9). Brief details of the octreotide (but not [123I]MIBG) scans on some of the metastatic carcinoids and islet cell tumors have also been presented (10).
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsMaterials and MethodsResultsDiscussionReferences |
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Fifty-four patients who had undergone imaging with both [123I]MIBG and [111In]pentetreotide scintigraphy were retrospectively analyzed. Forty-six patients (22 men and 24 women; mean age, 50 yr; range, 9–80 yr) had histologically proven metastatic neuroendocrine tumors (including 1 patient with a metastatic prolactinoma); an additional 8 patients had either histologically proven evidence of a neuroendocrine tumor in a single unusual site (2 breast carcinoids), clinical and/or biochemical evidence of recurrence of a previously histologically proven neuroendocrine tumor (n = 5), or clinical and biochemical evidence of a neuroendocrine tumor not seen on conventional imaging (n = 1). The order of radionuclide imaging was varied according to logistic demands; in 32 patients the [123I]MIBG was given first, and in 22 the [111In]pentetreotide was the first imaging modality.
Metastatic neuroendocrine tumors
Carcinoid tumors (n = 24). Twenty-four patients (12 men and 12 women; mean age, 54 yr; range, 27–80 yr) with a histologically proven diagnosis of carcinoid tumor were included in this group. The primary origin of the carcinoid tumors was known in 18 patients [bowel (11), bronchus (5), and pancreas (2)] and unknown in 6; in patients with an unknown primary, the diagnosis was based on tissue biopsy from metastatic deposits. Fifteen patients had imaging studies before any treatment was applied, and 9 had previous treatment (6 surgery alone, 1 surgery and radiotherapy, and 2 surgery and cytotoxic chemotherapy).
Islet cell carcinomas (n = 12). Twelve patients (five men and seven women; mean age, 53 yr; range, 9–79 yr) had histologically proven islet cell tumors (six gastrinomas, four vipomas, and two insulinomas); four patients had islet cell tumors in the context of multiple endocrine neoplasia syndrome type 1. Six patients had undergone previous abdominal surgery, and one had also received chemotherapy.
Medullary carcinoma of the thyroid (n = 5). Five patients (two men and three women; mean age, 33 yr; range, 27–53 yr) had histologically proven medullary thyroid carcinomas; four patients had previously undergone thyroidectomy with neck dissection, and one had received a single treatment of [131I]MIBG treatment (200 mCi).
Malignant pheochromocytomas and paragangliomas (n = 4). Four patients (one man and three women; mean age, 37 yr; range, 25–53 yr) had histologically proven malignant sympatho-adrenomedullary tumors (three pheochromocytomas and one paraganglioma); all four patients had previously undergone surgery, whereas one patient had also received chemotherapy.
Malignant pituitary tumor (n = 1). There was one patient with a malignant prolactinoma (male; age, 33 yr) who had undergone transsphenoidal and transfrontal surgery, external beam radiotherapy, and chemotherapy. He has been previously presented in more detail (11).
Nonmetastatic neuroendocrine tumors (n = 8)
Eight patients were included in this group (three men and five women; mean age, 49 yr; range, 31–85 yr). Seven patients had a previously histologically proven neuroendocrine tumor (four carcinoids, one pheochromocytoma, and one medullary thyroid carcinoma), including one patient with a pleural fibroma secreting proinsulin-like growth factor II who has also been previously reported (12); they underwent imaging for either staging or detection of the site of the primary tumor (two patients had breast carcinoids) or when seeking a recurrence in the face of clinical and biochemical evidence of disease, but with negative conventional imaging (n = 5). One patient had biochemical evidence of a pheochromocytoma but negative conventional imaging studies.
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Materials and Methods |
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TopAbstractIntroductionSubjects and MethodsMaterials and MethodsResultsDiscussionReferences |
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-fetoprotein, carcinoembryonic antigen, hCGß, gastrointestinal
hormones (vasointestinal peptide, pancreatic polypeptide, gastrin,
glucagon, somatostatin, and neurotensin), calcitonin, and GHRH levels.
Where relevant, the patients also had a five-point serum GH profile on
a single day as an indicator of biochemical evidence of GH
hypersecretion, and/or a midnight cortisol determination as evidence of
autonomous cortisol secretion (13). In cases of ectopic
humoral syndromes the relevant hormones were measured. All hormonal
measurements were performed at the Department of Chemical
Endocrinology, St. Bartholomew’s Hospital (London, UK), as previously
published, except the gastrointestinal hormones, which were measured at
the Department of Chemical Endocrinology, Hammersmith Hospital (London,
UK) (13). The radiological assessment included
conventional plain chest radiograph, CT and/or MR imaging of the
abdomen in all patients, and, when indicated, CT and/or MR scanning of
the chest and/or bone and/or CT brain scanning. The positive findings
were compared with those obtained from the radionuclide scans. CT and MR scanning
All scans were interpreted at the time of their performance by two observers who were blinded to the results of other investigations. They were then reviewed in conference by a radiologist (R.R.) who has special expertise in cross-sectional imaging. CT scans were carried out on an IGE High Speed Advantage (Milwaukee, IL) spiral CT scanner with 3–5 mm organ-dependent collimation. The pitch was set at 1–1.5 and reconstructed on a high resolution algorithm depending on the organ. Nonionic contrast medium was given at a rate of 3 mL/s to a total volume of 100–150 mL. MR imaging was carried out on an IGE Signa 1.5T, the precise sequence depending on the specific organ, but generally with spin echo T1- and T2-weighted, fat-suppressed T1-weighted, and gradient echo (SPER 90) imaging, with and without gadolinium enhancement.
[123I]MIBG scintigraphy
Radioiodine-labeled MIBG was obtained from a commercial source (Amersham International, Gloucester, UK). Between 130 and 185 MBq [123I]MIBG were injected iv over 30 s. Imaging was obtained using a large field of view camera (Simmons, Erlangen, Germany) set with a 15% window around the photo peak of 159 Kev, and a parallel hole, low energy, general purpose collimator. Images for 500,000 counts were obtained at 10 min, 22 h, and 48 h postinjection covering the head, torso, and thighs, anteriorly and posteriorly. Images were stored on line in a Hermes Sun workstation (Nuclear Diagnostics, Hagersten, Sweden). The thyroid uptake was blocked by 100–200 mg potassium iodide administered orally for 2 days, starting the day before [123I]MIBG administration and for 24 h thereafter.
[111In]DTPA-labeled-pentetreotide scintigraphy
An octreotide analog, pentetreotide
(Octreoscan-111, Mallinckrodt, Inc., Petten, The
Netherlands), was supplied as a radioactive preparation in single dose
ampules. [111In]Pentetreotide was
given as a bolus iv injection at a dose up to 120 MBq. Whole body
planar images were obtained after 10 min and then after 4 and 21
h. Scanning was performed using a 
-camera with a large field of view
(Counterbalance 3700, Siemens Gammasonics, Erlangen, Germany)
interfaced to an on-line computer (DEC PDP11–44). Positive scans were
defined as those in which uptake of tracer occurred in areas not
normally associated with its accumulation. No patient was receiving
depot octreotide, and plain octreotide treatment was stopped at least
48 h before the time of imaging, as the pharmacokinetic half-life
of octreotide is of the order of 1–2 h.
All radionuclide studies were reported by the same physician without
knowledge of the results of previous investigations. The scintigraphic
results were classified as positive if it was possible to prove the
presence of a tumor radiologically (by means of CT and/or MR scanning)
or surgically at a site of uptake or as negative. The term false
positive was used when there was apparent uptake on the scan but
additional radiological examination did not reveal the presence of a
metastatic deposit at that time or on subsequent follow-up. A
relationship was sought between scintigraphic results using the two
radionuclides and the anatomical origin of the tumor, the site of
deposits, the previously applied local or systemic treatment, the
clinical symptomatology for carcinoid syndrome and pheochromocytoma,
the presence of ectopic humoral syndromes and hepatic metastases, and
the presence of hormonal markers. All comparisons were made using the
2 test, with statistical significance taken as
P < 0.05.
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Results |
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TopAbstractIntroductionSubjects and MethodsMaterials and MethodsResultsDiscussionReferences |
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Overall, scintigraphy with
[111In]pentetreotide was positive
in 36 patients (78%) compared with [123I]MIBG
in 20 patients (43%; P < 0.05). Twenty-seven patients
in total had hepatic metastases;
[111In]pentetreotide scintigraphy
was positive in 22 patients (81%), and
[123I]MIBG scintigraphy was positive in 15
patients (55%). However, in 3 patients in whom both scans were
positive there were complementary areas of uptake (Fig. 1
). The overall performance of
[111In]pentetreotide and
[123I]MIBG scintigraphy is shown in Table 1.
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Sixteen patients with metastatic carcinoid tumors had positive
[111In]pentetreotide scintigraphy
(67%), and 12 positive [123I]MIBG scintigraphy
(50%). The presence of a positive scan was not affected by the primary
origin of the tumor, previous localized treatment (surgical resection
and/or focal radiotherapy), or chemotherapy (Table 2). The presence of
nonlocal clinical symptoms also did not predict a positive scan,
although patients with the carcinoid syndrome more often had a positive
than a negative scan (12 of 18 vs. 2 of 8; P
= 0.09). No association was found with individual components of the
carcinoid syndrome and a positive scan. Eighteen patients had liver
metastases (75%):
[111In]pentetreotide scintigraphy
was positive in showing hepatic metastases in 14 of 18 (78%), whereas
[123I]MIBG scintigraphy was positive in 12 of
18 (67%); scintigraphy with both nuclides was negative in 2 patients.
However, in 2 patients
[111In]pentetreotide scintigraphy
was negative, and [123I]MIBG was positive,
whereas in 4 patients [123I]MIBG scintigraphy
was negative, and
[111In]pentetreotide was positive.
The presence of increased levels of all hormones measured was not
related to a positive scan; 12 of the 16 patients with positive
scintigraphy with either radiopharmaceutical had at least 1 elevated
hormonal marker. Of the 24 patients with carcinoid tumors, 8 had
negative [111In]pentetreotide
scintigraphy, and 6 of these had a raised tumor marker (Table 2).
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Two false positive results with each of [111In]pentetreotide and [123I]MIBG scintigraphy were noted.
Islet cell carcinomas (n = 12)
Eleven patients had positive
[111In]pentetreotide scintigraphy
(91%), whereas only one patient with a gastrinoma associated with the
multiple endocrine neoplasia syndrome type 1 syndrome had positive
[123I]MIBG scintigraphy (9%); in this patient
scintigraphy with both radiopharmaceuticals revealed a previously
unsuspected lesion in the mediastinum. Scintigraphy with
[111In]pentetreotide
also revealed clinically nonsuspected lesions in the orbit and abdomen;
both scans were negative in one patient with an insulinoma. In a
patient with elevated serum somatostatin levels, scintigraphy with
[111In]pentetreotide
was positive (Table 2
). With the exception of one patient with an
insulinoma who also had negative scintigraphy with
[111In]pentetreotide, all patients
responded clinically and biochemically to systemic octreotide
treatment.
Medullary thyroid carcinoma (n = 5)
All five patients had positive scintigraphy with [111In]pentetreotide and three with [123I]MIBG; scintigraphy with both radiopharmaceuticals detected a previously unsuspected deposit in one patient, whereas in one patient with neck metastases the two radionuclides exhibited a different pattern of uptake. Previous surgical treatment or treatment with [131I]MIBG did not affect the uptake of the radiopharmaceuticals. Subsequent treatment with octreotide did not affect the elevated hormonal levels. Scintigraphy with [123I]MIBG was falsely positive in one case where apparent adrenal uptake was not confirmed on CT imaging.
Pheochromocytomas and paragangliomas (n = 4)
All patients had elevated plasma and urinary catecholamine levels; all four patients with pheochromocytomas had positive [123I]MIBG, and three showed positive [111In]pentetreotide scintigraphy; [123I]MIBG scintigraphy detected two previously unsuspected lesions, whereas scintigraphy with both radiopharmaceuticals was false positive on two different occasions, both showing apparent hepatic metastases not seen on CT or MR scanning. Patients with false positive scans did not develop obvious lesions on CT and/or MR scanning on subsequent follow-up.
Hepatic metastases
In total, 27 patients had hepatic metastases (18 carcinoids, 6 pancreatic tumors, 2 pheochromocytomas, and 1 medullary thyroid carcinoma); [111In]pentetreotide scintigraphy was positive in 22 (81%), compared with 15 (55%) for [123I]MIBG (P < 0.05). Scintigraphy with [111In]pentetreotide and [123I]MIBG exhibited a 76% vs. 71% sensitivity in detecting radiologically demonstrable hepatic metastases in patients with carcinoid tumors, medullary thyroid carcinomas, and pheochromocytomas combined (P > 0.05). In the patient with malignant prolactinoma, scintigraphy with [123I]MIBG was negative, but scintigraphy with [111In]pentetreotide revealed uptake in the pituitary carcinoma, but not in the metastases.
Nonmetastatic neuroendocrine tumors
Scintigraphy with [111In]pentetreotide was positive in three patients (37.5%), whereas [123I]MIBG was positive in only a single patient (12.5%); this patient also had positive [111In]pentetreotide scintigraphy. Scintigraphy with [111In]pentetreotide was positive in two patients with breast carcinoid tumors, but did not reveal evidence of another primary tumor or metastases; it also failed to locate a lesion in two patients with clinical suspicion of recurrence of a previously histologically proven carcinoid tumor of the bronchus and abdomen. Scintigraphy with both [111In]pentetreotide and [123I]MIBG was negative in two patients with biochemical evidence of primary or recurrent pheochromocytomas. However, scintigraphy with [111In]pentetreotide was positive in one patient who presented with recurrent hypoglycemia and was found to have pleural fibroma with neuroendocrine features secreting pro-IGF-II. Octreotide treatment in this patient failed to relieve the hypoglycemia.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsMaterials and MethodsResultsDiscussionReferences |
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The results of this study in patients with a variety of neuroendocrine tumors clearly suggest that [111In]pentetreotide scintigraphy is in general more sensitive in detecting neuroendocrine tumors than radiolabeled MIBG (2, 3, 4, 6). However, occasionally scintigraphy with [123I]MIBG may appear to play a complementary role by demonstrating uptake in nonoctreotide avid lesions, mainly in the context of hepatic metastases.
The few comparative studies between [123I]MIBG and [111In]pentetreotide scintigraphy in carcinoid tumors have shown a higher overall [111In]pentetreotide sensitivity for the detection of either one or all metastatic sites (7, 16); however, a complementary role of [123I]MIBG scintigraphy was noted as either different intensity of uptake or uptake in nonoctreotide-avid regions (6, 7, 8). In our patients, although scintigraphy with [111In]pentetreotide was the more sensitive technique overall, the sensitivities of the two techniques in detecting liver metastases were comparable, e.g. 78% for [111In]pentetreotide vs. 67% for [123I]MIBG scintigraphy. Scintigraphy with [111In]pentetreotide was more sensitive in detecting extraabdominal (9) and previously unsuspected lesions (2, 7, 8), whereas a particular predilection of this radiopharmaceutical was noted in identifying orbital lesions; unlike [111In]pentetreotide, no previously unsuspected lesion was detected solely with [123I]MIBG scintigraphy (7). No correlation of a positive scan was found with the anatomical site of origin of the carcinoid tumor (7), the presence of flushing (7), or the presence of the carcinoid syndrome (6). Previous surgical or systemic therapy did not alter the uptake of these radiopharmaceuticals and should not therefore be a reason for excluding [111In]pentetreotide or [123I]MIBG scintigraphy. Although a variety of hormonal markers were investigated, no specific hormonal predictors of a positive scan were identified.
The majority of endocrine pancreatic tumors can be visualized using [111In]pentetreotide scintigraphy (3, 24, 25); [123I]MIBG has been reported as having an overall low sensitivity of 25% (3, 24). Only 1 of the 12 patients with malignant pancreatic tumors demonstrated an uptake in scintigraphy with [123I]MIBG, whereas scintigraphy with [111In]pentetreotide was almost always positive, even in patients with high circulating somatostatin levels.
Studies in different patients with comparable tumors have shown scintigraphy with [111In]pentetreotide to be twice as likely to demonstrate lesions as [123I]MIBG in patients with medullary thyroid carcinomas (2, 3). Our observations combined with the few existing formal comparative studies have shown that [111In]pentetreotide scintigraphy is more likely to visualize primary tumors and lymph node and bone metastases, but less successful in detecting liver metastases, whereas [123I]MIBG has limited diagnostic effectiveness (20, 26). These findings confirm the superior sensitivity of radiolabeled octreotide, but indicate that both scans may still be usefully applied on occasions in individual patients, as hepatic metastases with a different pattern of uptake may be identified by the two radionuclides.
In the small number of reports including comparisons between [123I]MIBG and [111In]pentetreotide scintigraphy in patients with malignant pheochromocytomas, [123I]MIBG was noted to have an overall higher detection rate, whereas scintigraphy with [111In]pentetreotide may occasionally reveal [123I]MIBG-negative lesions (18, 21); a higher rate of false positive [111In]pentetreotide scintigraphy has also been described (18). Similarly, in this relatively small group of patients scintigraphy with [123I]MIBG was more sensitive, but the complementary role of [111In]pentetreotide was established as differential location of uptake in hepatic metastases was seen. These findings may have clinical implications, in that [111In]pentetreotide scintigraphy could be adjunctive to the other diagnostic methods used for staging malignant pheochromocytomas.
Although somatostatin receptors have been described in the pituitary, mainly in GH-secreting tumors, prolactinomas in general have a relative poor [111In]pentetreotide uptake (27). Although experience with scintigraphy in malignant pituitary tumors is limited, [111In]pentetreotide scintigraphy has revealed previously undetected lesions, established the site of metastases, and revealed tumor recurrence at follow-up (28). However, in our patient, despite the fact that [111In]pentetreotide revealed uptake in the pituitary region, no response to systemic octreotide administration was noted.
In patients with a strong suspicion of a neuroendocrine tumor but in whom all imaging modalities were negative, scintigraphy with [111In]pentetreotide identified more lesions than [123I]MIBG, although the detection rate was still low. In such patients, hormonal measurements are more predictive, and other imaging modalities, e.g. venous sampling, may be necessary to reveal these indolent tumors (25). Both radiopharmaceuticals showed occasional positive uptake despite negative imaging on conventional radiology, defined as false positives. However, it is possible that scintigraphy is actually correctly detecting lesions that are functioning but too small to be seen on MR/CT scanning. It is possible that positron emission tomography scanning may also be useful in such situations (29).
Targeted radiotherapy with radionuclides has been effective in treating tumors because of the localization of the ß-emitting radionuclide, either within the tumor cell or in its proximity, compared with nontarget cells. [131I]MIBG, based on a positive [123I]MIBG uptake, has been used in the treatment of malignant pheochromocytomas, neuroblastomas, carcinoid tumors, and medullary thyroid carcinomas; the overall consensus is that although complete responses have been observed in only a minority of cases, partial responses are common, whereas in most cases clinically useful hormonal and symptomatic responses may be obtained (3, 5). Radiolabeled somatostatin analogs represent a separate novel therapeutic modality of neuroendocrine tumors. The current data suggest that therapy with somatostatin analogs radiolabeled with ß-emitters will be applicable to a larger population of patients with neuroendocrine tumors, and will generally locate the same lesions identified by [123I]MIBG (30). This study suggests that lesions not shown by scintigraphy with [111In]pentetreotide will only rarely be picked up by scintigraphy with [123I]MIBG, although occasional patients, mainly with hepatic metastases, may show complementary uptake with [123I]MIBG and [111In]pentetreotide scintigraphy: in such patients therapy with both labeled radionuclides might be feasible.
In conclusion, scintigraphy with [111In]pentetreotide in general detects more metastatic lesions than [123I]MIBG in patients with neuroendocrine tumors. In occasional patients scintigraphy with [123I]MIBG demonstrated lesions not evident with [111In]pentetreotide. No reliable clinical and/or biological predictors other than the presence of hepatic metastases exist. Although both were effective in identifying hepatic metastases, there were qualitative differences in the pattern of uptake. It is concluded that scintigraphy with [123I]MIBG may indicate areas of uptake in a significant proportion of patients with neuroendocrine tumors, which would suggest the feasibility of [131I]MIBG therapy. When this is negative, [111In]pentetreotide is more likely to demonstrate lesions in all types of neuroendocrine tumors, other than those originating from sympatho-adrenomedullary tissue, and may indicate those in whom treatment with ß-emitting somatostatin analog radiopharmaceuticals might be indicated.
Received April 11, 2000.
Revised September 11, 2000.
Accepted October 18, 2000.
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 A.-M. O'Carroll Localization of Messenger Ribonucleic Acids for Somatostatin Receptor Subtypes (sstr1-5) in the Rat Adrenal Gland J. Histochem. Cytochem., January 1, 2003; 51(1): 55 - 60. [Abstract] [Full Text] [PDF]
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A. M. Isidori, G. Kaltsas, V. Frajese, B. Kola, R. A. F. Whitelocke, P. N. Plowman, K. E. Britton, J. P. Monson, A. B. Grossman, and G. M. Besser Ocular Metastases Secondary to Carcinoid Tumors: The Utility of Imaging with [123I]Meta-Iodobenzylguanidine and [111In]DTPA Pentetreotide J. Clin. Endocrinol. Metab., April 1, 2002; 87(4): 1627 - 1633. [Abstract] [Full Text] [PDF]
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, Positive
pentetriotide uptake; 
, positive [123I]MIBG uptake.