Life-endangering effects of deep abscesses make early and precise identification and localization important to permit adequate surgical drainage. An experiment was undertaken to study the feasibility of detecting abscesses by using leucocytes tagged with radioactive isotopes. For the labeling, 51chromium appeared preferable to 131iodine or 99technetium. Leucocytes so labelled will concentrate sufficiently in abscesses to permit identification of abscesses by scintillation scanning. For clinical application, techniques require further simplification and refinement to eliminate interference by collection of radioactive isotopes in the liver and spleen

Allen, H. M.

Berguer, R.

Block, M. A.

DuSault, L. A.

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical JournalVolume 21 | Number 3 Article 29-1973Localization of Deep Abscesses with RadioactiveIsotopes: An Experimental StudyH. M. AllenR. BerguerL. A. DuSaultM. A. BlockFollow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public HealthCommonsThis Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.Recommended CitationAllen, H. M.; Berguer, R.; DuSault, L. A.; and Block, M. A. (1973) "Localization of Deep Abscesses with Radioactive Isotopes: AnExperimental Study," Henry Ford Hospital Medical Journal : Vol. 21 : No. 3 , 111-116.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol21/iss3/2H e n r y Ford H o s p . M e d . j o u r n a l V o l . 2 1 , N o . 3, 1973 Localization of Deep Abscesses with Radioactive Isotopes An Experimental Study H. M. A l len , M D , * R. Berguer , M D , * L. A . DuSaul t , A B * and M. A . B lock , M D * Life-endangering effects of deep abscesses make early and precise identification and localization important to permit adequate sur-gical drainage. An expenment was undertaken to study the feasibility of detecting abscesses by using leucocytes tagged with radioactive isotopes. For the labeling, ''Chromium appeared preferable to "Vod/ne or ''''tech-netium. Leucocytes so labelled will con-centrate sufficiently in abscesses to permit identification of abscesses by scintillation scanning. For clinical application, techniques require further simplification and refinement to eliminate interference by collection of radioactive isotopes in the liver and spleen. •Department of General Surgery •'Formerly Department of Radiology (retired) This study was supported by research funds of the Henry Ford Hospital. Address reprint requests to Dr. Allen at Henry Ford Hospital, 2799 West Grand Blvd, Detroit Ml 48202 I HE precise identi f icat ion and local-ization of abscesses in deep-seated loca-t ions, particularly in the peritoneal cavity and retroperitoneal regions, is critical for ea r l y , d i r e c t and a d e q u a t e su rg i ca l d ra inage. Patients w i t ha abscesses in these l oca t i ons are se r i ous l y III and require surgical drainage w i th minimal ope ra t i ve t r auma to save the i r l ives. Sawyer and associates' report a 43% mor-tality for retroperitoneal abscesses. We undertook a study to localize deep abscesses experimentally by using leuco-cytes tagged w i th radioactive materials which wou ld be identi f ied by scinti l lation scanning. Efforts consisted of the devel-opment of a reliable technique for the experimental product ion of abscesses, in v i t r o m a n i p u l a t i o n s to i n c o r p o r a t e radioactive isotopes in viable leucocytes, a n d f i n a l l y d e t e r m i n i n g p r a c t i c a l techniques to identify the abscesses by means of tagged leucocytes. We found it possible to detect abscesses by these techniques, but their localization is not suff iciently precise, and the procedures are too cumbersome to permit their cl ini-cal use at this t ime. Experimental Production of Standard Abscesses We used three materials to produce abscesses in dogs: 5% phenol solut ion. 111 Allen, Berguer, DuSault and Block s u s p e n s i o n s of c o a g u l a s e p o s i t i v e staphylococcus organisms, and suspen-sions of feces. The concentrat ion of the staphylococcus aureus organisms was 1 x 10* per cubic mil l imeter. The phenol solution and staphylococcus suspension were injected into the animals sub-cutaneously in 1 cc volumes. Success was inconsistent . Qui te frequent ly the injec-t ion of phenol wi l l produce a local burn wh i ch is resolved w i t h scar f o rma t i on unless it became secondari ly in fec ted. There was also an inconsistent response to the p r o d u c t i o n of abscesses w i t h s taphy lococcus o rgan i sms . This was probably related to the fact that some of the animals, when initially brought to the hospital laboratory, were rout inely treated wi th high doses of penic i l l in, and no abscess wou ld be produced. On the o t h e r h a n d , ce r t a i n an ima ls — in a debil i tated state w i th respiratory infec-t ion — wou ld develop an overwhelming sepsis wi th the injection of staphyloccus. They w o u l d succumb w i t h i n 48 hours before a well demarcated abscess could develop. Our greatest success was w i th the suspension of dog feces. This was placed in a gelatin capsule w i th a small amount of USP barium sulfate in order to serve as a radio-opaque marker for the i m p l a n t a t i o n s i t e . T h e d o g was anesthetized and the left lower quadrant was shaved and prepared w i th merth i -olate. A 15 mm transverse skin incision was made over the left lower quadrant. The external ob l ique muscle was opened and the capsule implanted between the external and internal ob l ique muscles of the abdomina l wa l l . The defect in the musc les was c losed w i t h f i ne ca tgu t suture, as was the skin. Invariably, w i th in 48 hours, an area of abscess and sur-r o u n d i n g ce l lu l i t i s d e v e l o p e d . If t he abscess was left undrained or untreated, it f r e q u e n t l y p roved fatal w i t h i n one week's t ime. Labeling of Leucocytes with Radioactive Isotopes One of our objectives was to achieve a pure col lect ion of autogenous leuco-cytes which could be labeled by uptake of a radioactive isotope and yet retain a high degree of viabil i ty. Previous work in this area had obtained leucocyte prep-aration rich in viable leucocytes by the techn iqueof a peritoneal lavage^ We felt this method did not have application to human medical practice, and it was dis-carded. Otherworkers made whi te b lood cell enr iched preparations wi th sedimen-tation of anticoagulated whole b lood and progressive cent r i fugat ion to separate the buffy coat^ Whi le this method pro-duces a high whi te b lood cell count , its main drawback is again the many residual red cells in the preparat ion. Wi th the aid of Dr. Hajime Hayashi o f t h e Department of Pathology, we employed a technique similar to the last described. In addi t ion, an effort was made to remove the high number of red b lood cells remaining in the preparat ion. The procedure ul t imately deve loped for product ion of leucocytes requires the removal of 120 cc of whole b lood f rom the dog wi th the abscess. The b lood is divided into 20 cc al iquots, each contain-ing 1.5 cc of heparin (10,000 units per cc) and 2 cc of dextran solut ion (molec-ular weight approx imate ly 200,000) for sedimentat ion of red b lood cel ls. This sedimentation is permit ted to occur for 30 minutes, after which the supernate, rich in whi te b lood cells, is removed f rom each al iquot, and all are combined for cen t r i f uga t i on at 800 revo lu t i ons per minute for 5 minutes. This provides a but-ton consisting of equal volumes of leuco-cytes and erythrocytes. This " red b u t t o n " measures about 1.5 cc, and is resus-pended in 2 cc of 9.5% saline at 4° C. Adding 5 cc of disti l led water at 4° and a g i t a t i n g f o r 30 s e c o n d s l ysed t h e erythrocytes in this col lect ion. After add-ing 1.5 cc of 5% sodium chlor ide solut ion, the resulting suspension was centrifused for two minutes at 800 revolutions per minute. The supernatant f lu id containing the hemolyzed red corpuscles is dis-112 Localization of Deep Abscesses with Isotopes c a r d e d , leav ing a " w h i t e b u t t o n " of leucocytes. These leucocytes are then resuspended in 20 cc of Hartman's solu-t ion and incubated in an agitator bath wi th the radioactive isotope at 37° C for 45 minutes. Following this, the leuco-cytes were washed in 9.5% saline usually for three t imes. The cells are resus-pended in 20 cc of buf fered Ringer's solu-t ion con ta in ing g lucose , hepar in and high molecular weight dextran. The level of radioactivity in the cell suspension is checked and the material is then injected i n t r a v e n o u s l y f o r l o c a l i z a t i o n of an abscess in the dog. We found that a number of radioactive isotopes wi l l concentrate in leucocytes. The p e r c e n t u p t a k e by l e u c o c y t e s depended in part upon the washings car-r i ed o u t a f t e r i n c u b a t i o n s . Up takes obtained were 4-12% for ""Te, 2-21% for '^M and 2-6% for ^ '^Cr. The technique for preparing leuco-cytes has yielded approximately 60% via-ble cells in final suspension. Viabil ity was judged by cell moti l i ty and pseudopod format ion and moist slide preparations, appearance of morpho logy on Wr igh t sta ined smears, and by t f ie ab i l i t y to incorporate vital stains. This percentage of v i a b i l i t y is s o m e w h a t l o w e r t han reported by other authors, and probably is ind icat ive of the cel l t rauma of the many manipulations per formed. Serious disadvantages are inheren t wi th all of the radioactive isotopes used to label leucocytes. The associated label-ing of p ro te in by ' ^ ' iod ine resul ted in i n te r fe rence due to co l l ec t i on of the isotope in the spleen and liver. The short ha l f - l i f e ( a p p r o x i m a t e l y 6 hours ) of ' '•'technetium, given as technet ium 99m pertechnetate, is clinically advantageous by permit t ing higher concentrations and safety. However, this t ime interval is too short fo r the p rocedures used in th is study. Also, since these isotopes appar-ently funct ion as intracellular rather than membrane tags, labeled cellular debris as wel l as free isotopes are caught by the re t icu loendothe l ia l system, p roduc ing unwanted visualization o f t h e spleen and l iver. The use of " " technet ium- labeled diethylamine pentici l l ic acid, a chelating agent e x c r e t e d o n l y by t h e k i d n e y , appeared promising. But, its rapid excre-t ion prevented adequate concentrat ions in abscesses. The '^'chromium concen-trates wel l in leucocytes but has the dis-advantageous characteristic of also con-centrating in erythrocytes. It is essential to r e m o v e t h e s u p e r n a t a n t p r o t e i n mater ia l , as we l l as contaminat ing red b l o o d c o r p u s c l e s , f r o m the l abe led leucocytes. Early in the study we found that the y ie ld o f w h i t e b l o o d cel ls f r o m the infected animals varied greatly. The aver-age whi te cell count in the infected ani-mals was 19,400 per cub ic m m w i th a range of 7,200 to 31,000 per cubic m m . The whi te blood cell count in the cell suspensions that were reinjected into the animals averaged 3,300 per cubic mm wi th a range of 300 to 6,300 per cubic m m , in a total volume of 20 cc. This gives a p r o j e c t e d t o t a l n u m b e r of v i a b l e autogenous whi te corpuscles at approx-imately 6.3 x 10^ Concentration of Labeled Leucocytes in Abscesses Initial exercises were per formed using 300 microcur ies of ^'Cr for label ing of a u t o g e n o u s l e u c o c y t e s . These w e r e in jected in t ravenous ly in to dogs w i t h abscesses. Single crystal sc in t i l l a t ion counter probes were placed over each of three sites: In the left lower extremity containing an experimental abscess, in the right lower extremity as a cont ro l , and in the heart as a measure of circulat-ing isotope. The tracing of this informa-t ion gave a qual i ta t ive est imate of the radioactivity in the three locations. The radioact ive isotope d id concentrate in 113 Al len, Berguer, DuSault and Block INJECTION 45 min TIME 75 min Figure 1 Tracing demonstrating increasing activity in abscess (A) and bacltground activity (B). the experimental abscesses. Activity pre-sent at 45 minutes fo l lowing the inject ion was considerably di f ferent as compared wi th the peak of activity of the isotope in the abscess which occurred at approx-imately 75 minutes (Figure 1). The contro l probe remained at background levels of radioactivity. A total of 57 animals was prepared sub-sequently and studied in greater detail using varying techniques. The scans of abscesses were made at intervals using a 5-inch Picker color scan or a Dynapix scinti l lation scanner. Table 1 shows the various isotopes and number of animals used in each g r o u p . The last c o l u m n depicts the percentage of success wi th each i s o t o p e . W e had t h e g rea tes t number of runs using " ' I , and here our success rate was the poorest . Because this was the initial isotope used, many failures were related to our gaining skill Table I ISOTOPE NUMBER OF DOGS ABSCESS IDENTIFIED PERCENTAGE SUCCESS RATE s'Cr 19 15 78% 131 1 27 5 18% 99Te 6 2 33% DPTA 3 1 33% 114 Localization of Deep Abscesses with Isotopes Figure 2 Abdominal scan of dog with concentration of isotope in left lower quadrant abscess, and activity in fiver area. in the manipulat ion of the cells. Other fa i lures were also related to the poo r abscess development in the animal, and to equipment breakdown. Thus, percent-ages shown in the table do not quantitate the des i r ab i l i t y of c h o i c e of a g i ven isotope. Al though our criteria for success was the demonstration of the abscess on a scan, this is a subjective matter. We were able to produce a positive scan wi th each isotope at least one t ime. However, our greatest success and reproducibi l i ty came w i t h the use o f ' ' C r (Figure 2). Advantages of this isotope are the ease of t agg ing the leucocy tes and ready removal o f t h e free " C r in solut ion wi th ascorbic acid, el iminat ing the need for repeated washing o f t h e leucocytes. The major disadvantages wi th the ='Cr is that the preparation must be totally free of red b lood cells. A l though lysis of red cells by dist i l led water was effective, it killed off some whi te b lood cells. We postu-lated that these in jured whi te cells and red cell envelopes secondar i ly tagged were removed by the ret iculoendothel ial system. Therefore, interference by a col-lec t ion of the isotope in the l iver and spleen was never entirely el iminated. Our study demonstrated the feasibility of i d e n t i f i c a t i o n and l o c a l i z a t i o n of abscesses which are labeled by autogen-ous leucocytes, tagged wi th radioactive isotopes, and detected by scint i l la t ion scanning. However, the procedure lacks 115 Allen, Berguer, DuSault and Block facility for clinical use since interference by co l lec t ion of the isotopes in major organs remains a p rob lem, the proce-dure is cumbersome, and safety of the technique has not yet been established. O t h e r s have u t i l i z e d v a r i o u s techn iques in exper imenta l studies to achieve de tec t i on of deep abscesses. L a b e l i n g of p r o t e i n by r a d i o a c t i v e i s o t o p e s has n o t b e e n s u f f i c i e n t l y spec i f ic " . W i n k e l m a n and associates^ have demonstrated the efficacy of ^'Cr labeled leucocytes in del ineating experi-m e n t a l a b s c e s s e s l o c a t e d in t h e extremities. Deysine and associates^ have harvested ery th rocy te- f ree leucocytes f rom the peritoneal cavity experimental ly in order to el iminate the problem of con-tamination by erythrocytes labeled w i th ^'Cr. However, this technique does not appear to be applicable clinically. Available radiologic techniques pro-v i d e s o m e a id in t h e d e t e c t i o n o f abscesses. These inc lude l iver scans, l iver-lung scans, the use of subtraction scans, and the use of a variety of other mult iple organ scans. Combinat ions of organ scans, arteriography, intravenous pye log rams , and s tandard rad io log ic studies of the gastrointestinal tract wi th radio-opaque media can provide diag-nostic aid but are t ime-consuming and are f requent ly excessively r igorous for critically ill patients. Al though echograms are repo r ted l y capable of i den t i f y i ng deep abscesses, we have found accuracy affected by the gas and f lu id-containing gastrointestinal tract and confusion due to the s imi lar i ty of interfaces of some tumors wi th those of abscesses. Further-m o r e , n o n e of these t e c h n i q u e s are specific for abscesses or in f lammat ion. A technique is needed which positively iden t i f i es abscesses, rather than one which provides evidence for exclusion. The abscesses produced exper imen-ta l ly w e r e acute in na tu re . W h e t h e r l e u c o c y t e s t agged w i t h r a d i o a c t i v e isotopes collect satisfactorily in chronic abscesses was not determined. Also, a comparison was not made between cel-lulitis and abscesses relative to the collec-t ion of labeled leucocytes. Other vari-a b l e s r e q u i r i n g s t u d y i n c l u d e t h e min imum size of an abscess to be detect-a b l e , n u m b e r of l abe led l eucocy tes n e e d e d fo r d e t e c t i o n , and rad ia t i on safety factors. Acknowledgments The authors gratefu l ly acknowledge efforts by numerous individuals in assist-ing the project, in particular Dr. Hajime Hayashi o f t h e Department of Pathology for valuable advice and help in achieving isolation of leucocytes. References 1. Sawyer RB, Sawyer KG, Mikolaschek K and Manke WF: Retroperitonitis. Arch Surg 98:534-38, April 1969 2. Deysine M, Robinson RG and Wilder IR: Abscess de tec t i on by rad ioac t ive chromium labeled autologous white blood cells. Surg Gynec and Obstet 131:216-20, Aug 1971 Winkelman J, Collica CJ and Sandler SC: The delineation of abscesses by scin-tiphotography using Cr'' labeled leuco-cytes. Amer ] Roentgen 103:881-5, Aug 1, 1968 Ariel M: Pickup of radioactive iodinated albumin by abscesses. Arc6 Surg 84:432-3, April 1962 116 

Localization of Deep Abscesses with Radioactive Isotopes: An Experimental Study

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Localization of Deep Abscesses with Radioactive Isotopes: An Experimental Study

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