Your SlideShare is downloading. ×
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Nuclear Medicine Procedures
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Nuclear Medicine Procedures

6,254

Published on

Published in: Health & Medicine, Technology
3 Comments
3 Likes
Statistics
Notes
No Downloads
Views
Total Views
6,254
On Slideshare
0
From Embeds
0
Number of Embeds
4
Actions
Shares
0
Downloads
614
Comments
3
Likes
3
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 1. 489 NUCLEAR MEDICINE Nuclear Medicine Procedures Clinical Practices Contents Radiopharmaceutical Dose Considerations 495 Bone 496 Central Nervous System (CNS) 498 Gastrointestinal 502 Three Phase Bone Scan 496 Bone Scan Spot Views 496 Whole Body Format Bone Scan (Single Pass Imaging) 497 Brain Imaging - Blood Brain Barrier Agents 498 Brain Imaging - SPECT Perfusion Imaging 499 Brain Death Evaluation 500 Cerebral Spinal Flow (CSF) 500 CSF Leak Determination 501 Cholescintigraphy 502 Gastric Emptying Solid Phase 503 Gastric Emptying and GE Reflux (Milk Study) - Liquid Phase 503 Labeled Red Blood Cell Scan (GI Bleeding) 504 Meckel’s Diverticulum 505 Liver Fat Determination 505 Liver/Spleen Imaging - 99mTc Sulfur Colloid 506 Hepatic Hemangioma Imaging 507 Hepatic Pump 508 LaVeen Shunt Patency 508 Parotid Gland Imaging 509
  • 2. 490 CLINICAL PRACTICES Nuclear Medicine Procedures Clinical Practices Contents Genitourinary 510 Renal Function 510 DMSA Renal Imaging 511 Diuretic (Lasix) Renogram 511 Captopril Renal Scan for Evaluation of Renovascular Hypertension 512 Testicular Imaging 513 Radionuclide Cystogram 514 Lung 519 Lung Perfusion 519 Lung Ventilation 520 Pulmonary Aspiration 521 111In White Blood Cell Scan for Infection 518 Inflammation 517 67Ga Inflammation 517 99mTc White Blood Cell Scan for Infection 518 99mTc labeled RBC Volume Determination 515 Hematology 515 Bone Marrow 515
  • 3. 491 NUCLEAR MEDICINE Nuclear Medicine Procedures Clinical Practices Contents Endocrine 521 Thyroid Imaging and Uptake (99mTc) 521 Thyroid Uptake and Imaging (123I) 522 123I Potassium Perchlorate Washout Test 523 Parathyroid Imaging 524 67Ga Tumor 525 111In Pentetreotide Imaging Tumor 524 IIodine - 131 MIBG Imaging of Adrenergic Tumors 524 Strontium - 89 Radiotherapy 527 Miscellaneous 527 Right to Left Shunt (MAA Technique) 530 Lymphoscintigraphy: Melanoma 531 Shilling Test Part I 532 Shilling Test Part II 534 Distribution of Schilling Test Results 1981-1984 535 Oldendorf Technique for Bolus Infection 537 Modified Method for the In Vivo Labeling of Red Blood Cells with Technitium 538 Single Photon Emission Computed Tomography 538 Quality Control Procedures for Scintillation Cameras 540 Quality Control Report Form 543 Daily Quality Control Log for Scintillation Cameras 544 111In Pentetreotide Imaging 529 131I Whole Body or Neck with Quantitation 526
  • 4. 492 CLINICAL PRACTICES Nuclear Cardiovascular Procedures Clinical Practices Contents Tc-99m-MIBI Adenosine Stress 557 Tc-99m-MIBI Dipyridamole Stress 557 Tc-99-MIBI Dobutamine Stress 557 Myocardial Perfusion Imaging 550 Thallium - 201 Rest and Redistribution 550 Thallium - 201 Exercise Stress with Reinjection 552 Dipyridimole Thallium Stress Study with Reinjection 553 Thallium Adenosine/Dobutamine Stress with Reinjection 555 Tc-99m-MIBI Exercise Stress Study 555 Imaging of Ventricular Function 545 Gated Cardiac Blood Pool - Gated First Pass and Equilibrium 545 Ungated First Pass Ventriculogram 547 Exercise Radionuclide Ventriculogram 548 Gated SPECT - Myocardium 549 Gated SPECT - Cardiac Blood Pool 550 Imaging of Cellular Injury 545 Antimyosin Imaging of Infarct, Myocarditis, and Transplant Rejection 545
  • 5. 493 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Clinical Practices Contents Vascular Shunt Imaging 558 Stress Testing and Cardiac Emergencies 560 Right to Left Shunt: Angiographic Method 558 Right to Left Shunt: MAA Technique 558 Left to Right Shunt 559 General Considerations 560 Patient Preparation 560 Indications for Stress Testing 561 Contraindications to Stress Testing 561 Bruce Protocol 561 Modified Bruce Protocol 562 MGH Modified Bruce 562 Dipyridamole-Thallium/Tc-99m-MIBI Test Protocol 562 Dobutamine-Test Protocol 562 Adenosine Stress Test 563 General Statement 564 Non Arrhythmia Ischemia, LV Failure, or Other Medical Problems 564 Arrhythmia and AV Conduction Abnormality 564 Management of Complications During Stress Testing 564
  • 6. 494 CLINICAL PRACTICES
  • 7. 495 NUCLEAR MEDICINE Nuclear Medicine Procedures Radiopharmaceutical Dose Considerations Standardadultdosesforspecificproceduresarelisted intherelevantsections. Somedoses (e.g.201TL) are normallyscaledwithinaspecificrangebybodyweight. Othersmayrequiremodificationasdeterminedby specificpatientfactors. Pediatric Pediatricdosagecanbedeterminedinoneofseveral ways. TheeasiestoftheseisWebster’sRule: Pediatric dose = age + 1 age + 7 Thisformulamaybeinaccurateininfants. Themost precisecorrectionusesrelativebodysurfacearea,esti- matedbyenteringheightandweightintoanomogram.A closeapproximationofthiscanbemadebyusingbody weight,sothat Pediatricdose = patientweight 70 kg Insomeoccasions,thecalculateddosemaybeinadequate forimagerequirements. Agoodexampleofthisis hepatobiliaryscanninginthenewborn,whichmayre- quire images at 24 hours after injection. The staff physicianshouldchecktheadequacyofcalculateddoses inchildrenlessthanoneyearold. Measuring Activity and Radiation Dose The FDA has mandated that all labeling of radiopharmaceuticalsmustbeprintedwith“LeSysteme Internationald’Units(SIunits)assoonaspossibleorat thenextlabelprinting. Thecurrentunitofmeasure (Curie)isstillincommonuse,butSIunitswillbethe primarysystemformeasuringactivityandradiationdose inthefuture. Adults iThenewsystemwasdevelopedbytheInternationalCom- mitteeofWeightsandMeasuresandwaspublishedin ts entirety in 1979. It has been adopted for radiopharmaceuticalsbymajornationsandiscurrently beingusedbymostofthem. Becquerel(Bq) IntheSISystem,theunitofactivityistheBecquerel (Bq),whichisequivalenttoonenucleartransitionper second. NotethattheBecquerelisaverysmallunitand thecuriesisaverylargeone. TheMegabecquerel(MBq) whichisonebillionBecquerels,orGigabecquerels(GBq) whichisonebillionBecquerels. Curies Thecuriesisequivalentto37billiontransitionsper second. Because the curies is so large, we would commonly use sub-units such as millicuries and microcuries. Arithmetically,thefollowingequalitiesexist: 1mCi = 37 MBq 1Rad = 0.01 GY or 1GY 100 Rad Possible Pregnancy Allwomenofchildbearingagemustbeaskedabout possible pregnancy before they are injected with a radiopharmaceutical. Ifthelastmenstrualperiodwaslessthanoneweekprior toinjection,itcanbesafelyassumedthatthepatientis notpregnant. Ifanyquestionarisescheckwiththe NuclearMedicinestaffphysician. X Adultdose X Adultdose =
  • 8. 496 CLINICAL PRACTICES Three Phase Bone Scan Thisstudyisperformedtoevaluatebloodflowandsoft tissueabnormalitiestoaugmentstandardboneimages. InstrumentsandEquipment Largeorregularfieldofviewgammacamerawithlow energyhighresolutioncollimatorandcomputersystem. Radiopharmaceutical 99mTcMethyleneDiphosphonate(MDP). TimeofImaging Immediatelyuponinjectionofradiopharmaceutical. Dose Age+1 Age+7 PatientPreparation None Administration Intravenousinjectionofasmallvolumeof99mTcMDP usingthemodifiedOldendorftechnique. Use4-waystop- cock,appropriatebutterflyneedleandtubing,and saline flush. If area of interest is in upper limbs injectwithtourniquetonlytoavoidischemic-hyperemic response. Donotinjectinarmofinterest. All dynamicstudiesoftheextremitiesshouldincludeboth extremitiestoprovideanormalreference. Includea markeroftherightsideintheimagefield. PatientPositioning Flow study is performed over the area of interest designatedbyastaffphysician. DataAcquisition Analog-SiemensOrbiterandBodyScanCameras: Usinga9formatacquireimagesevery 5secondsfor9frames. Acquireanimmediatestaticimagefor1000K inthe9format. Digital-Allcameras Immediatelyuponinjectionacquireimagesina 128x128matrixevery2secondsfor32 Acquireimmediatestaticimageina256x matrixfor1000K. ImageProcessing Prepareasavescreenoftheflowimages-32 imagesononesheetoffilm. Labelthetimeofevery5thimage. Prepareasavescreenoftheimmediateimage -label:“immediate.” Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimages forinterpretation. SpecialViews Asrequestedbystaffphysician. DelayedImages Asperprotocolfor“BoneScanSpotViews.” Bone Scan Spot Views Toaidinthediagnosisandmanagementofprimaryand secondarybonedisease,andtoobtainhigherresolution imagesthanmaybepossiblewithwholebodyimaging. InstrumentsandEquipment Largefieldofviewgammacamerawithhighresolution parallelholecollimator. Ultrahighresolutioncollimator withMS-2. Radiopharmaceutical 99mTcMethyleneDiphosphonate(MDP). TimeofImaging Notlessthan21/2hourspostinjection. Dose Age+1 Age+7 Bone frames. 256 x740MBq x740MBq
  • 9. 497 NUCLEAR MEDICINE DataAcquisition Analog-SiemensOrbiterandBodyCameras: Acquireallspotimagesinthe9format. Acquireanteriorchestimageforeither750K (Orbiters),or1100Konallothercameras. Recordthetimeandacquiretheremainderof imagesforthesametime. Digital-AllCameras Acquireimagesasdescribedabove-256x 256 matrix. ImageProcessing Prepareasavescreenoftheimagesusingthe generaldisplayifdigitalimagesareneeded. Labeleveryimage. Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimages forinterpretation. PatientPreparation Hydratethepatientwith2glasses ofwaterfollowing administrationofradiopharmaceutical.Patientisto urinatejustpriortostartingtheimagingprocedure.Have patientremoveallmetalobjects(jewelry,beltbuckle,etc.) andanyprosthesis. Administration Intravenousinjection. PatientPositioning Placepatientinthesupineposition. Projections: (Inthefollowingorder.) 1. Anteriorchest 2. Skull-bothlaterals 3. Rightandleftanteriorchesttoinclude shoulderand arms. 4. Anteriorpelvistoincludeiliaccrestsand hips. 5. Anteriortibiaetoincludeknees 6. Posteriorcervicalspine 7. Posteriorchest,thoracicandlumbarspine 8. Posteriorpelvisandproximalfemurs Includeamarkeroftherightsideineachimage. Comments Additionalviewsmaybenecessary.Theseshouldbehigh resolutionimages. Theimagesofspine,chestorpelvis, extremitiesandskullshouldbeacquiredfor1000K or15minutesmaximum. Havethepatienturinate againpriortoadditionalpelvicview. Whole Body Format Bone Scan (Single Pass Imaging) Toaidinthediagnosisandmanagementofprimaryand secondarybonedisease. Theradiolabel99mTcMDPis absorbedontohydroxyapatitecrystal,andconcentration onboneisdirectlyrelatedtoregionalbloodflowandnew boneformation. InstrumentsandEquipment SiemensDualHeadedBodyScannerwithhighresolution parallelholecollimatororSiemensMS-2withultra-high resolutionparallelholecollimator. Radiopharmaceutical 99mTcMethyleneDiphosphonate(MDP). TimeofImaging Atleast21/2hourspostinjection. Dose 740MBq-Adult-70kg Webster’sRule -Pediatric PatientPreparation Hydratethepatientwith2glassesofwaterfollowing administrationofradiopharmaceutical.Patientisto urinatejustpriortostartingimagingprocedure. Have patientremoveallmetalobjects(jewelry,beltbuckle,etc) andanyprosthesis. Administration Intravenousinjection. PatientPositioning Placepatientinsupinepositionontablewitharmsclose to sides and feet together and touching. Tape feet togetherlightlyinorderto assistpatientinholdingthis positionthroughoutthestudy. SpecialViews Asrequestedbystaffphysician.
  • 10. 498 CLINICAL PRACTICES Analog-SiemensDualHeadedBodyScanner: Acquireanalogimagesinthewholebodymode. ScanSpeedDetermination(SiemensBodyScan): Scanpatientat224cm/min. Calculatetotalcountsinanteriorimage. Multiplyresultsby224,dividebydesiredtotal I.D.(300,000toobtaincorrectscanspeedin cms/minwhichisaround14cm/min. Carefullyscan,contouringanteriordetector. Note:DoNOTexceed18cm/min. Digital-SiemensDualHeadedBodyScannerorMS-2: Acquireanalogimagesinthewholebodymode. ScanSpeedDetermination-Asabovewithbody scanner. WhenusingMS-2withultra-highresolution collimator:mutiplyscanspeedby0.6. Alwaysuseauto-contourwithMS-2.(Seebelow.) SpecialViews (Totalbodybonescansmayrequireextraviews) Analog-SiemensOrbitersandBodyCameras: Acquireanalogextraviewsin9 formatfor750K ontheSiemensorbitercameraor1100Konall othercameras. Digital-AllCameras: Acquireimagesasdescribedabove-256x256 matrix. ImageProcessing Prepareasavescreenofthewholebodyusing thedualintensitydisplay. Prepareasavescreenofthespotimagesusing thegeneraldisplay. Labeleveryimage. Writescanspeedonfilms. Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimagesfor interpretation. Projections AnteriorandPosterior DataAcquisition Brain Imaging Blood Brain Barrier Agents Normally99mTcDTPAandglucoheptonate(GHA)donot crossthebloodbrainbarrier(braincapillaryendothelium). The BBB is disrupted in most inflammatory, ischemic,neoplasticortraumaticcerebraldisorders, resulting in focal accumulation of the radiolabel. 99mTcDTPAandGHAhavebeenusedinthepastas brainimaging agentsbecauseofrapidrenal(andblood) clearance which results in a potentially high target/non-targetratio. InstrumentsandEquipment Regularfieldorlargefieldofviewgammacamerawith lowenergyallpurposecollimatorandcomputersystem. Aconvergingcollimatormaybeneededforspecialviews. Radiopharmaceutical 99mTcDTPAorGlucoheptonate. TimeofImaging Dynamicimagesrecordedimmediatelyupon injection. Delayedimagesarerecordedatleast3hourslater. Dose 740MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Intravenousinjectionofasmallbolususingmodified Oldendorftechnique. Setup4-waystopcock,appropri- atebutterflyneedleandtubing,andsalineflush. PatientPositioning Patientshouldbepositionedsothataminimalamount offacialactivityispresentinthefieldofview. Central Nervous System (CNS)
  • 11. 499 NUCLEAR MEDICINE Projections Flowstudyisusuallyrecordedintheanteriorprojection. StaticImages: Anterior Posterior Rightlateral Leftlateral Vertex DataAcquisition Digital FlowImages: Acquireimagesata3secondframeratefor oneminutein128x128matrix. StaticImages: Acquireanimmediate500Kstaticin256x256 matrix. Usuallyanteriorview. DelayedImages: (Minimumof3hrspostinjection). Acquirestaticimagesin256x256matrix. ImageProcessing Prepareasavescreenoftheimagesusingthe generaldisplay. Labeleveryimage. Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimages forinterpretation. Comments Patientconditionorthenatureofthesuspecteddisease mayrequiremodificationoftechnique. Delayedimages beyond3hourspostinjectionmaybeindicated. Brain Imaging SPECT Perfusion Imaging Followingintravenousinjection,99mTc-HMPAO (exemetazime)and99mTc-ECD(bicisate)crosstheblood- brain-barrierandaccumulateinthebrain. Abnormalities associated with increased or decreased cerebral perfusionmaybeshownascorrespondingregions ofabnormaltracerdeposition. SPECTimagingisneeded todemonstratethesesubtledifferences,andtoprovide meaningfulanatomicassessment. InstrumentsandEquipment MS-2withfanbeamcollimator. Radiopharmaceutical 740Mbq(20mCi)99mTc-HMPAO(adultdose)or 740-1110MBq(20-30mCi)99mTc-ECD. TimeofImaging HMPAO-20minutesafterinjection. ECD-30-60minutesafterinjection. PatientPreparation None. Theinjectionisideallygiventhroughanindwell- ingvenouslineinaquiet,dimly-litroom. ImageAcquisition OnlySPECTimagesareacquired,using360orotation with2heads,96viewsperhead,15secondsperview. ImageAnalysis Reconstruct tomographic images using attenuation correction. Photograph SPECT images in trans- verse, saggital, and coronal planes and save SPECTreconstructionfilestodisk. Comments Thepreparationanduseof99mTc-HMPAOimposes severalspecialconsiderations. Thepresenceofany oxidantinthe99mTc-pertechnetategeneratoreluateused toformulatetheHMPAOcomplexmaypreventadequate labeling.Toavoidthisproblem,thegeneratormusthave beenelutedwithin24hourspriortotheelutionused forkitformulation. Onceformulated,the99mTc-HMPAOcomplexisunstable. Theprimarycomplexformedconvertswithtimetoa differentsecondarycomplexthatislesslipophilic,and thus unable to cross the blood-brain-barrier. In on sequence,99mTc-HMPAOmustbe injectedwithin30 minutesofformulation. Thismeansthateachdose mustbepreparedwhilethepatientiswaiting,andthat QCproceduresmustbecompletedexpeditiously. These factorsdonotapplytoECD.
  • 12. 500 CLINICAL PRACTICES Brain Death Evaluation Cerebralperfusionceasesupondeathofcerebraltissue. The best radionuclide evaluation of intracranial perfusionisobtainedusing99mTcHMPAO(exameta- zime). InstrumentsandEquipment Regularfieldofviewgammacamera,allpurposelow energycollimator,computer. Radiopharmaceutical 99mTcHMPAO. TimeofImaging Immediate. Dose 740MBq. PatientPreparation NonerequiredforHMPAO. Administration Intravenousinjection PatientPositioning Staticimagesintheanteriorandlateralprojections. Analog: None Digital-TechnicarePortableCamera Static Imaging: Acquire1immediate500Kstaticinquadrant format(128x128)e.g.SAQC,500K,Q1in theanteriorandlateralprojections. Acquireadditionalimagesbasedoninstruc tionsbythestaffphysician. Digital-SiemensOrbiterCamera Static Imaging: Acquire1immediate500Kanteriorandlateral magesin256x256matrix. Acquireadditionalimagesbasedoninstruc tionsbythestaffphysician. ImageProcessing ConverttechnicareimagestoSiemensformat andtransmitallimagestotheinterpretation roomcomputer. Photographallimagesandsubmittostaff physicianforinterpretation. Reference SHTsai,etal,JAMA248:591-592,1982(7/96). CSFisproducedinthebrain’slateralventricles,andre- absorbedmostlyalongthesuperiorsagittalsinus. In somepatientswithCSFshuntsorwhoarereceivingin- trathecalchemotherapy,thepatternofCSFflowmaybe importanttodocument. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimator.Setupthecameraforimaging Indium-111asfollows: 171keVphotopeakwitha30%window 245keVphotopeakwitha30%window Radiopharmaceutical 111InDTPA. TimeofImaging Immediate;delayedimagesat2-6hoursmaybe necessary. Dose 18.5MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Intrathecal(spinal)injectionofradio-pharmaceutical. Thisinjectionisperformedbythereferringphysician andrequiresaninformedconsent. Cerebral Spinal Fluid (CSF) (InformedConsentRequired)
  • 13. 501 NUCLEAR MEDICINE Note: In the case of CSF shunt patients special injectionsmayberequired. Checkwithstaffphysician. If a CSF specimen is needed, make sure that CSFiswithdrawnpriortoinjectionoftheradiopharma- ceutical. PatientPositioning Projections:Anterior;Posterior;Right&leftlateral projections. DataAcquisition SiemensOrbiter Analog: Acquire500Kor10minuteimages inthe4 format. Digital: Acquiredigitalimagesina256x256matrix forbackup. SpecialViews SpecialviewsmayberequiredinthecaseofCSFshunt patients. ImageProcessing Transmitalldigitalimagestotheinterpreta tionroomcomputer. Photographallimagesandsubmittostaff physicianforinterpretation. CSF Leak Determination NormallythereisnoCSFpresentinthenoseorears.The detectionofsignificantradioactivityinthoseareasafter anintrathecalinjectionof111InDTPAischaracteristicof aCSFleak. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimator.Setupthecameraforimaging 111Inasfollows: 171keVphotopeakwitha30%window 245keVphotopeakwitha30%window Radiopharmaceutical 111InDTPA. TimeofImaging 4hourspostinjection. Dose 18.5MBq-Adult Webster’sRule-Pediatric PatientPreparation Nasalpledgetsaretobeweighedandplacedpriorto injectionofthepatient.PlegletsareplacedbyanENT physician. Thisshouldbearrangedbythephysician requestingthestudy. Administration Intrathecal(spinal)injectionofradiopharmaceutical. Thisinjectionisperformedbythereferringphysicianand requiresaninformedconsent. PatientPositioning Anterior;Posterior;Right&leftlateralprojections. DataAcquisition SiemensOrbiter Analog: Acquire500Kor10minuteimages inthe4 format. Digital: Acquiredigitalimagesina256x256matrix forbackup. SpecialViews Asrequestedbystaffphysician. ImageProcessing Transmitalldigitalimagestotheinterpreta tionroomcomputer. Photographallimages andsubmittostaffphysicianforinterpretation. Comments Twobloodsamplesarewithdrawnfromthepatientin redtoptubes,thefirst15minutesfollowinginjection andthesecondsampleatthetimeofimaging(approxi-
  • 14. 502 CLINICAL PRACTICES mately4hourspostinjection). Plasmasamplesonthe twobloodsamplesareseparatedfromwholeblood bycentrifugation. Retainonemlofplasmafromboth samplesforcountingdetermination. Nasalpledgetsare removedatthetimeofimagingandplacedinappropriate countingvials,afterweighingagain. Countplasma samples and nasal pledgets in a well counter at the appropriatephotopeaksettingfor15minutespersample times2. NOTE:Weighbothbeforeandafterinsertioninappropri- atecountingvials! Reference Radionuclidecisternography:normalvaluesfornasal secretionofintrathecallyinjectedIndium-111DPTA. J NuclearMed1973;14:933-934. Gastrointestinal Cholescintigraphy Theiminodiaceticagentsareexcretedviahepatocytes andrapidlyclearedintogut.Inmostpatientswithacute cholecystitis,thecysticductiscompletelyblocked;thus, thereisnodemonstrationofthegallbladder. Thistest mayalsobeusedtoevaluateforsuspectedbileleak, biliaryatresia,andlivertransplantviability. InstrumentsandEquipment Largefieldofviewgammacameraequipped withlow energyparallelholecollimatorand computersystem. Radiopharmaceutical 99mTcDisofenin(DISIDA)ormebrofenin. TimeofImaging Immediatelypostinjection. Dose 37MBq PatientPreparation NPOpriortostudyforatleast4hoursbutnotmorethan 24hours. Ifthepatienthasfastedformorethan12-24 hours,administersincalideinadoseof20ng/kg.Thisis givenasaslowIVinjectionoveratleast3minutesto reducepotentialGIsideeffectsandtomaximizeits pharmacologicaleffect. Wait30-45minutesbefore injectingtheradiopharmaceutical.Sincalideisavailable intheRadiopharmacyas5mcglyophilizedvials. Reconstitutethevialwith5.0mlofsterilewaterfor injectionandusethefollowingformula: Patientweighinkg.X(0.02)=mltodraw Administration Intravenousinjectionofradiopharmaceutical. PatientPositioning Projections: Anterior DataAcquisition Analog: Needtobedeterminedbystaffphysician. Digital: Startingimmediatelyafterinjectionacquire 30secondimagesin128X128matrixfor45 minutes. Ifthegall-bladderhasnotbeendemonstrated bythattime,intravenousmorphinewilltypically begiveninadoseof0.4mg/kgwithimaging for an additional 45minutes aftermorphine administration. Insome cases, additional disofenin will be injected. Writeallimagedata to floppydisk and submit along with analog images for interpretation. ImageProcessing Prepareasavescreenofevery5thimagefor thefirst hourofimaging.Theformatofsave screensfordelayedimageswillbedetermined bythestaffphysician.Transmitallimagesto theinterpretationroomcomputerandsubmit photographsofallsavescreensforanalysis. SpecialViews Itmaybenecessarytoobtainposteriorand rightlateralviewstotriangulatethegallblad- der,andseparateitfromtheduodenum. NOTE: Ifbileleakissuspected,delayedimagesat severalhourspost-injectionmaybeneeded.
  • 15. 503 NUCLEAR MEDICINE Gastric Emptying Solid Phase Thisstudyisperformedtoassess gastricemptyingtime. InstrumentsandEquipment Largefieldofviewgammacamerawithalowenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTcsulfurcolloid. TimeofImaging Immediatelypostinjection. Dose 18MBq - Adult PatientPreparation Patientshouldbefastingforapproximately8hours priortothestudy. Administration 18MBqof99mTcsulfurcolloidismixedwith scrambledeggsoraneggsaladsandwichandfedto thepatient. PatientPositioning Anteriorandposteriorprojections. DataAcquisition Analog: Notrequired Digital: Acquire1minuteanteriorandposteriorimages ina256x256matrixatthefollowingtimes: immedi- atelyafteringestionofmeal,0,20,40,60,and90min- utes. The patient may get up between images. ImageAnalysis Drawregionsofinterestaroundthestomachinallimages, determine thenumberofcounts ineachimage,decay correctthedelayedimagestozerotimeand calculated ageometricmeancountateachtime. Calculate%emptyingat20,40,60,and90minutes. Prepare a labeled save screen for the 5 images and photograph. Submitalldigitaldataandphotographs to theinterpretationroomforanalysis. Comments Drapethepatientwithabsorbentpaper(chux)and havepatientweardisposalglobeswhileeatingmealto prevent contamination. Haveanemesisbasincloseathandforthosepatients whoare knowntohavesevereintolerancetosolidfood. Ifinitialimagesshowresidualactivityintheesophagus, havethepatientdrinkasmallamountofwater. Gastric Emptying and GE Reflux (Milk Study) - Liquid Phase To ascertain rate of gastric emptying and detect gastroesophagealreflux,andpresenceofpulmonary aspiration. Thisisusuallyperformedinchildren. InstrumentsandEquipment Gammacamerawithlowenergyallpurpose collimator andcomputersystem. Radiopharmaceutical 99mTcsulfurcolloid. Dose Determinetheusualquantityofformulathatthechild receives ataregularfeedingandadd0.1MBq (2.5mCi) or99mTcsulfurcolloid/mlformula(donotexceed12 MBq).Recordthetimerequiredtoingesttheformula. TimeofImaging Immediatelypostingestion. PatientPreparation Patientmustbefastingforpreviousnormal interval betweenfeedings.(e.g.iffed6timesdaily,shouldbe fastingfor4hours). Administration SeeDose.
  • 16. 504 CLINICAL PRACTICES PatientPositioning Anteriorsupineprojectiontoincludeentireabdomen andchest. DataAcquisition Analog: Nonerequired. Digital: Acquireserial30secondimagesina128x128 matrixfor1hour. ImageAnalysis Draw a region of interest around the stomach and determinethenumberofcountsinthe0,20,40,and60 minuteimages. Decaycorrectthedelayedimagesto zerotimeandcalculate%emptyingat20,40and60 minutes. Preparealabeledsavescreenforthe0,20, 40and60minutemagesandphotograph. Submitall digital data and photographs to the interpre- tationroomforanalysis. SpecialViews Asdeterminedbystaffphysician. Comments Ifthestudyisperformedtoevaluateforpossiblepulmo- naryaspiration,thedoseisusuallyadministeredinthe evening,with10minuteanteriorandposteriorimagesof thechestperformedthefollowingmorning.Inevalua- tionofaninfant,thedosecanbeadministeredinthe morningandimagingperformedintheafternoon. Labeled Red Blood Cell Scan (GI Bleeding) Thisstudyisperformedtofindaspecificbleedingsitein those patients who have active gastrointestinal hemorrhage. Patientsareoftenreferredbyangiography, whowillbepreparedtoperformanangiogramifa bleedingsiteisdetectedbyourstudy. Since99mTcRBC’s areanintravascularagent,extravasationintothegut willbedetectedbythismethod. InstrumentsandEquipment Largefieldofviewgammacamerawithlowenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTclabeledRBC’s. Note: RBClabelingisperformedwiththeUltraTag invitrolabelingkit. Dose Age+1 Age+7 x740MBq PatientPreparation None Administration IntravenousinjectionoflabeledRBC’s. TimeofImaging Immediatelypostinjection. PatientPositioning Anteriorsupineabdomenfromthepubicsymphysistohe diaphragmtoincludeinferiorportionofthe heartinthe uppermarginofthefieldofview. DataAcquisition Analog: Notrequired Digital: Acquireserial1minuteimagesina64x64 matrix. ImageAnalysis Preparealabeledsavescreenofevery5thimageand photograph. Submitalldigitaldataandphotographsto theinterpretationroomforanalysis. Comments Ifbleedingisnotdetectedontheinitialstudy,thepa- tientmayberecalledfordelayedimaging. Patientmay alsobereimagedifthereissomeclinicalevidenceofhem- orrhageintheinterval. Imageacquisitionparameters willdependonthetimeelapsedsinceinitiallabeling.
  • 17. 505 NUCLEAR MEDICINE Meckel’s Diverticulum ToaidinthedetectionanddiagnosisofMeckel’sdiver- ticula. 99mTc pertechnetate is normally excreted bygastricmucosa.Sinceover90%ofbleedingMeckel’s diverticulacontainectopicgastricmucosa,thistestisa sensitivemeansfordetection. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energy arallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTcPertechnetate. TimeofImaging Beginningimmediatelybeforeinjection. Dose Age+1 Age+7 x740MBq PatientPreparation Patientmustbefastingfrommidnighttheprevious nightwithnothingbymouthexceptwater. Administration Intravenousinjectionofradiopharmaceuticalisperformed withthepatientinpositionunderthecamera. PatientPositioning Anteriorsupineprojectiontoincludeentireabdomen withthepubicsymphysisatthelowermarginofthe camerafield. DataAcquisition Analog: Notrequired. Digital: Acquireserial1minuteimagesina128x128 matrixfor1hour. ImageAnalysis Preparealabeledsavescreenofevery5thimageand photograph. Submitalldigitaldataandphotographsto theinterpretationroomforanalysis. Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’s packageinserts.Thechoiceoftheradiopharmaceutical andthedoseforeachproceduredescribedinthisProce- dure Manual is made by the physician staff of this NuclearMedicineDivision,inordertoacquirethebest imagingresultswhilecomplyingwithMGHIsotopeand/ orPharmacyCommitteeguidelines. Thenameofthe nuclearmedicinephysicianorderinganytestthatislisted hereismaintainedinthefilesoftheradiopharmacywith thedataonthepatientandradiopharmaceutical. Liver Fat Determination Thepartitioncoefficientofxenonishigherinfatthanin othertissue. Followinginhalation,xenonentersthecir- culation,isdistributedinthebodytissues,andclears fromthosetissueswhenxenonadministrationceases. Xenonretentioncorrelateswithliverfat(triglyceride) content,whichisincreasedindiabetics,alcoholics,and obesity. InstrumentsandEquipment Largefieldofviewcamera.Allpurposecollimatorand computer. Radiopharmaceutical 133Xe Dose 370-740MBq PatientPreparation None Administration 133Xeviaclosedsystemfor5minutes. PatientPositioning Supineanterior,includeliverandlowerlung. DataAcquisition Analog: Notrequired
  • 18. 506 CLINICAL PRACTICES Digital: Serial15secondimagesina128x128 matrix,extendingfrominitialinhalation through15minutesofwashout. SpecialViews None ImageAnalysis DetermineT1/2ofwashoutfromtheliverfromaregion ofinterestdrawnaroundaportionofliverawayfrom lungbase. Comments T1/2greaterthan2.0min.correlateswithincreased triglyceride(>100mg/gm)inliverfat. Note: Thisprocedureisdoneroutinelyforindicationsthatare notspecificallylistedinthemanufacturer’spackage inserts.Thechoiceoftheradiopharmaceuticalandthe doseforeachproceduredescribedinthis Manualismade by the physician staffof the Division of Nuclear Medicine,inordertoacquirethebestimagingresults whilecomplyingwithMGHIsotopeand/orPharmacy Committeeguidelines.Thenameofthenuclearmedicine physicianorderinganytestthatislistedhereismain- tainedinthefilesoftheradiopharmacywiththedataon thepatientandradiopharmaceutical. References IntJNuclearMedBio9:17-23,1982. Liver/Spleen Imaging 99mTc Sulfur Colloid Theliverandspleencontainlargenumbersofevenly distributedreticuloendothelialcells,whichtrapthe 99mTcsulfurcolloid.Theprocedureisintendedprimarily tobeusedfordetection(ormonitoring)ofdisorderswhich disrupttheorganarchitecture. Functionalabnormalities maybeimpliedbytherelativeuptakeofeachorgan, especiallyincomparisontotheothertwolargeRES containingorgans(lungandbonemarrow). InstrumentsandEquipment Largefieldofviewgammacamerawithlowenergyhigh resolution. Radiopharmaceutical 99mTcsulfurcolloid. TimeofImaging 15minutespostinjection. Dose 148MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Intravenousinjection. PatientPositioning Acquireliverimagesinthefollowingsequence: Ant(Marker),Ant,RAO,RL,Post,LL DataAcquisition Analog: 1000Kperimage Digital: Acquirebackupimagesfor1000Kina256x256 matrix. ImageAnalysis Preparealabeledsavescreenofdigitaldataandphoto- graph. Submitalldigitaldata,analogdataandphoto- graphstotheinterpretationroomforanalysis. Comments Ifthespleenisbeingspecificallyevaluated,suchasfor infarctortrauma,obtainthefollowing: LAO30o,LAO60o,LPO30o,LPO 60o. Recorddataindigitalformat.
  • 19. 507 NUCLEAR MEDICINE Hepatic Hemangioma Imaging Hepatichemangiomasarelowflowlesionswithincreased vascularvolume,whichare“cold”ona99mTcsulfur colloidstudy,butwhichshowprogressive99mTcRBC accumulationovera60minuteperiod. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energypar- allelholecollimatorandcomputersystem. Radiopharmaceutical (1) 99mTc-SCifliver/spleenscanhasnotalready beenobtained. (2) 99mTclabeledRBC’s. TimeofImaging Obtain99mTc-SCscanfirst,andthen99mTc-RBCscan. Dose 37MBq99mTc-Sulfurcolloid(SC);740MBq99mTc-RBC. PatientPreparation IfpatienthasnothadaSCliver/spleenscan,obtainant, RAO,(R)lateralandposteriorviewsofliverat15min afterinjectionof27MBqofSC. Labelthepatient’sbloodusingthemodifiedinvivotech- niqueforlabelingRBC’swith99mTc. (Thisisthesame procedurethatisusedfor gated cardiac blood pool imaging.) Administration Intravenous“bolus”injectionofradiopharmaceutical. Startimagingimmediately. PatientPositioning Flowstudyimagesshouldbeacquiredintheprojec- tion that best demonstrates the abnormality (check99mTcSCliverscan,ultrasoundorCTfindings withstaffphysician). DataAcquisition Analog: Notrequired Digital: Acquireflowstudyina128x128matrixata 4secondframe rate16frames. Acquirestaticimagesina256x256matrix for1000kinthefollowingprojections: ANT,RAO,Rlateral,andposterior. Immediatelyfollowingcompletionofplanar images,acquireSPECTimagesofliver. Both planarandSPECTimagesarerepeated1-2 hourslater. ImageAnalysis Preparealabeledsavescreenoftheflowandstatic imagesandphotograph. Submitalldigitaldataand photographstotheinterpretationroomforanalysis. SpecialViews Additionalviewsmaybeneededtodelineatequestion- ableabnormalareas.Itmaybenecessarytoperform SPECTinsomepatients. Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. Thechoiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisManualis madebythephysicianstaffoftheNuclearMedicine Division,inordertoacquirethebestimagingresultswhile complyingwithMGHIsotopeand/orPharmacyCommit- teeguidelines.Thenameofthenuclearmedicinephysi- cianorderinganytestthatislistedhereismaintainedin the files of the radiopharmacy with the data on the patientandradiopharmaceutical. Hepatic Pump Intra-arterialchemotherapyofintrahepatictumorsisgiven viaanindwellingcatheter,orhepaticpump.Thistest consistsofinjectionofMAAtoassessthedistribution offlowfromthe pump. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energyhigh resolutionparallelholecollimatorandcomputersystem. TimeofImaging Immediatelyuponinjection. Radiopharmaceutical 99mTcMAA,99mTcSulfurColloid.
  • 20. 508 CLINICAL PRACTICES Dose 37MBqof99mTcMAAin2mlvolume;37MBq of 99mTcsulfurcolloid. Administration 1stinjection: Inject99mTc-MAAin2mlofvolumeviathepump. 2ndinjection: Inject99mTcsulfurcolloidintravenously. PatientPositioning Acquireallimagesintheanteriorsupineposition. DataAcquisition Analog: Notnecessary Digital: Afterinjectionof99mTc-MAAacquirea 500Kimageina256x256matrix. Note: Recordthetimeittakestoacquirethis image. FifteenmunutesafterIVinjectionof99mTc sulfurcolloid,acquireasecondimageina 256x256matrixforthesametimeasthe 99mTc-MAAimage. ImageAnalysis Usingtheimagecalculatorsubtractthe99mTc-MAA imagefromthe99mTc-SCimage+99mTc-MAA. Pre- pare a labeled save screen of the three images. and photograph. Submitalldigitaldataandphotographsto theinterpretationroomforanalysis. Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. Thechoiceof theradiopharmaceuticaland thedoseforeachproceduredescribedinthis Manualis madebythephysicianstaffoftheNuclearMedicine Division,inordertoacquirethebestimagingresultswhile complying with MGH Isotope and/or Pharmacy Committeeguidelines.The name of the nuclear medicine physicianorderinganytestthatislistedhere ismaintainedinthefilesoftheradiopharmacywiththe dataonthepatientandradiopharmaceutical. LaVeen Shunt Patency ToassessthepatencyofaLaVeenperitoneal-jugularshunt byevaluatingclearanceofactivitythroughtheshunt followingtheintroductionoftracerintotheperitoneal cavity. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energypar- allelholecollimatorandcomputersystem. Radiopharmaceutical 99mTcMAA Dose 100MBq Technique Thecourseofthesubcutaneousshunttubingin the lateral abdomen and chest is located. Usingsteriletechnique,a20gaugeneedleis introducedintotheperitonealcavityonthe contra-lateralsidewiththeuseof1%lidocaine anesthesia. Informedconsent mustbeobtainedforthispro- cedure.Theradioisotopeisthenintroducedinto theperitonealcavity. Thepatientisthen rolled side to side and askedto take severaldeep breaths. Imaging Immediateanteriorimageoftheabdomenfor300K (256x256matrix). Subsequent300K(256x256matrix)anteriorimages ofchesttoincludetheupperabdomenandpositionof theshunttubingalongthelateralchestwallevery5 minutesuntilactivityisvisualizedinthelungs. Ifnoactivityisidentifiedinthelungsduringtheinitial 45minutes,delayedimagesforupto4hoursmaybe required. ImageAnalysis Preparealabeledsavescreenofalltheimagesand photograph. Submitalldigitaldataandphotographstotheinterpre- tationroomforanalysis. (InformedConsentRequired)
  • 21. 509 NUCLEAR MEDICINE Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. The choiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisProcedure ManualismadebythephysicianstaffoftheNuclear MedicineDivision,inordertoacquirethebestimaging resultswhilecomplyingwithMGHIsotopeand/or PharmacyCommitteeguidelines.Thenameofthenuclear medicinephysicianorderinganytestthatislistedhere ismaintainedinthefilesoftheradiopharmacywiththe dataonthepatientandradiopharmaceutical. Reference ClinNuclMed4:447-450;451-454,November1979. Parotid Gland Imaging Toaidintheassessmentoftumorsornodulesofthe parotidglands. InstrumentsandEquipment Regularfieldofviewgammacameraandcomputer system. Radiopharmaceutical 99mTcPertechnetate TimeofImaging Immediatelysinceflowstudyisneeded. Dose 185MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Usingthe modified Oldendorftechniqueinjectasmall bolusofactivityfortheflowstudy.Note:Usea4-way stopcockandappropriateneedle,tubingandsalineflush. PatientPositioning Placepatientinsupinepositionwithheadandneck hyperextended. Acquireflowandstaticimagesoftheheadandneck. DataAcquisition Analog: Notrequired Digital: Acquireananteriorflowstudyina128x128 matrixataframerateof30secondsperframe for300seconds(10frames). Acquireanterior,rightandleftlateralstatic viewsofthehead(128x128matrix)ataframe rateof60secondsperframefor600seconds (10frames). Afteracquiringinitialstatic imagesgivelemon andrepeatabovestaticacquisition. ImageAnalysis Sumtheinitialanddelayedstaticimagesusingthe imagecalculatorandpreparelabeledsavescreensforall threesetsofimages. Submitalldigitaldataandphotographstotheinterpre- tationroomforanalysis. SpecialViews Asdirectedbystaffphysician. Comments Givethepatient500mgofKCl04following thestudy. Reference RadionuclideSalivaryGlandImaging:SemNuclearMed Xl:258-265,1981.
  • 22. 510 CLINICAL PRACTICES Genitourinary Allowsrelativequantitationofperfusionandexcretory functionofkidneys. DTPAmeasuresglomerularfiltra- tionrate,whileMAG3showsmainlytubularfunction. Theinitialarrivaltimeofthetracerbolusrelatestorenal bloodflow. Thetransitthroughthekidneysreflects corticalandtubularfunction,andtheeventualclearance fromthecollectingsystemreflectsrenalpelvicand ureteral patency. 99mTc-glucoheptonateisrarelyemployed,butshowsa morecopmplexclearancewithpartialtubularbinding. InstrumentsandEquipment PreferredinstrumentOrbiterorMS-2withallpurposeor highresolutioncollimatorandinterfacedcomputer. Onrareroccasions,aportablescanmaybeperformed usingadivergingcollimatorinadults. Radiopharmaceutical 370MBq(10mCi)Tc99mMAG3or370MBq(10mCi)DTPA. Tolocalizethekidneysandvascularstructures(aorta)in aportablestudy,thepatientshouldbepre-injectedwith 37MBqDTPA. In a patient with renal failure use the aorta as a referencepoint. TimeofImaging Immediate PatientPreparation Hydratepatientwith12ounces ofwater30minutes priortostudy; havethepatientvoidpriortoinjection. ImageAcquisition Standardimagesareobtainedintheposteriorposition, centeredjustinferiortothekidneys. Inrenaltransplantpatients,anteriorimagescenteredover theiliacfossaareacquired. Inaportablestudy,positionthepatientinoneofthe lateraldecubituspositionsandapproachthepatientwith thecamerafromthepatient’sback. Dynamicimagesarerecordedin128x128matrixat 2 seconds per frame for 32 frames, followed by 30secondsperframefor64frames. ImageAnalysis Select“MGHRenal”fromtheprocessingprotocols. DefineCompositeImages Thedefaultimagingrangeis1to3minutes. Toselect anotherrange,choose “TimeRange”fromthecompos- itemenuandenterthestartingandendingpoints. Once defined,clickDONEtocontinue. DefineRegions Completedialogboxesisappropriate. Drawmanual regionsofinterestaroundthekindeysbyescapingwhen promptedtoselectanautomatedellipticalregionof interest. Draw semi-circular background regions surroundingandimmediatelyadjacenttothelower portionsofeachkidney. DefineStartPoint Once theregionsaredefined,theperfusioncurvesare shownontheleft. Thetriangularmarkeronthex-axis ofthecurveshouldbedraggedtothepositionwherethe aorticactivitystartstoincrease. Thisprocessingstepis importantbecausethisisthetimeusedasthestarting pointforallcalculations(Tmax,T1/2). Results ThefirstRESULTpage(curves)showtwographs:the leftgraphshowsperfusiondataandtherightgraphshows clearancedata. Iftheaorticcurvesextendbeyondthey-axisontheleft (perfusion)time-activitycurve,selectthegraphbyclick- ingonthemargin. Select“options”andclickonthey- axislabel. Select“rangesetautomatically”fromthe displayedmenu. Therightgraphdisplaysfourcurves,withbothwhole kidneyand“cortical”activityforeachkidney. Itmaybe desirabletoeliminatesomeofthesecurves,asina diureticstudy. Todeleteacurve,firstselectthegraphbyclickingonthe margin. Next,selectthecurvebyclickingontheappro- priatesymbolinthesmallrightwindow. Finally,clickon “curve”fromthe“DisplayAnalysis”andselecttheop- tion“deletecurve.” ThelastRESULTpageshowsthehalftimeanalysisfor kidney clearance. The menus on the left give five options (left kidney, left cortex, right kidney, right cortex,done). Renal Function
  • 23. 511 NUCLEAR MEDICINE TocalculatetheT1/2foranyoftheregions,clickonthe RO1. Thegraphontherightwilldisplaythecurvefor theappropriateregion. Dragthelefttriangularmarker onthex-axistothepositionofmaximumactivityfor thatcurve. Foradiureticrenogram,dragthetriangletothetimeof diureticinjection(20minutes). Next,dragtheright triangletotheendofthecurve. Theprogramwillthen displayabestfitcurvesuperimposedontheoriginaldata. Youarethengiventheoptiontoacceptorchangethe curvefitting. RepeatthisprocessforeachT1/2desired. ImageandDataDisplay SelecttheMGHRenalDisplayapplicationfromthe ProcessingProtocols. Theprogramwilldisplay32 dynamicflowimagesaswellassixcompositeclearance imagesevery5minutesfor30minutes. Ifadditionalimageswereobtainedbeyond30minutes,it isnecessarytocreateasavescreenmanuallyforthe delayedimages. Comments Inselectedpatients, delayedimagesmayberequired. 99mTcglucoheptonatemaybeusedatthediscretionof thestaffphysicianincasesinvolvingspecificquestions aboutrenalstructure. Theradio-pharmaceuticaldoseis370MBq(10mCi). ImagingissimilartoMAG3orDTPA,withadditional imagesat2hoursasdetermnedbythephysician. These lateimageswilltypicallyconsistofposterior,RPO,and LPOimages. Initialdataandprocessingisasperthe standardrenalprotocol. DMSARenalImaging Followingintravenousinjection,99mTc-DMSAisbound toplasmaproteins,andaccumulatesintherenalcortex. Thereisverylittleexcretionintheurine. At3hourspostinjection,roughly40%oftheinjected doseremainsinthekidneys. Thisallowsanatomic definitionoftherenalparenchymanoteasilyaffordedby otherrenalscanningagents. DMSAhasbeenmostwidelyusedintheevaluationof pyelonephritisandpost-infectiousscarringinchildren. InstrumentsandEquipment MS-2withallpurposeorhighresolutioncollimator;small fieldofviewcamerawithpinholecollimator. Radiopharmaceutical 185MBq99mTc-DMSA(adultdose). Timeofimaging 2-3hourspostinjection;noinitialimagesarerequired. PatientPreparation None ImageAcquisition Pinholeimagesofthekidneysinposterior,RPO,and LPOprojectionsfor5-10minuteseach,dependingon thepatient’sabilitytocooperate. Standardparallelcollimatorposteriorimageofthe kidneysacquiredfor10minutesor1000Kina256x256 matrixsize. SPECTacquisitionusing360orotationwith2heads, 96viewsperhead,15secondsperview. ImageAnalysis Preparelabeledsavescreenofpinholeandstandard planarimages. ReconstructandphotographSPECT imagesintransverse,saggital,andcoronalplanesand saveSPECTreconstructionfilestodisk. Diuretic (Lasix) Renogram Evaluationofhydronephrosis,inparticulartodifferentiate a dilated, nonobstructed system from a dilated, obstructedrenalcollectingsystem. Allrenalscansrequestedto“ruleoutobstruction”are potentialLasixstudies. Checkwithstaffphysicianto determineifaLasixstudyisindicated. InstrumentsandEquipment Orbiter or MS-2 camera with all-purpose or high resolutioncollimatorandinterfacedcomputer.
  • 24. 512 CLINICAL PRACTICES Radiopharmaceutical 370MBq(10mCi)99mTc-MAG3bybolusinjection; alternatively,370MBqof99mTc-DTPAmaybeused. TimeofImaging Immediate PatientPreparation Givepatients(otherthaninfants)approximately12ozs. offluidtodrink30minutespriortothestudy. HavenurseinsertaFoleycatheter. Thiswillremainin placeunclampedduringthestudy. Usuallyallnephrostomyorotherexternalrenaldraining devices(otherthantheFoley)shouldbeclamped;check withnuclearmedicinephysicianmonitoringstudy. ImageAcquisition Acquireposteriorimagescenteredjustbelowthe kidneysin128x128matrixsize. Dynamicimagesarerecordedat2sec/framex32frames, followed by 30 second images x 128 frames. ForaLasixstudy,imagingiscarriedoutforone hour,notthe30minutesofastandardrenalscan. Lasix(0.3mg/kg)istypicallyinjectedintravenously20 minutesafterradio-pharmaceuticalinjection. ImageAnalysis Splitfunctionquantitationandtime-activitycurvesare generatedasforthestandardrenal scan, except that theclearancephasetimeactivitycurvesshouldbedrawn to include the entire kidney including the renal pelvisbutexcludingtheureter. Toavoidconfusion,deletetheclearancecurvesforthe “cortical”regions. WhengeneratingtheT1/2data,besuretodragtheleft triangleonthex-axisoftheclearancecurvetothetime thatLasixwasgiven(typically20minutes)sothatan adequateevaluationofdiureticwashoutiscalculated. LabeltheframecorrespondingtothetimeatwhichLasix wasgiven. Comment Insomecases,imagingbeyondonehourmaybeneeded. Thenormalhalf-timeforclearanceoftracerfromthe kidneyROIis10minutesorless. Atimegreaterthan 20 minutes is abnormal, while 10-20 minutes is consideredindeterminate. By decreasing glomerular filtration in the stenotic kidney,anACEinhibitorsuchascaptoprildiminishes excretionofthetracerinthatkidney. Thiscreatesor increasesafunctionalasymmetrybetweenthenormal andabnormalkidneys. The study is probably of lesser value in assessing balancedbilateralrenalarterystenoses,becausethelack ofasymmetrymayrenderthesecasesinapparentonthe scan. Thestudyisperformedafteroraladministrationofan ACEinhibitor. Inselectedinstances,itmayberepeated onadifferentdaywithouttheuseofACEinhibitor (baseline study), should the captopril scan show a significantasymmetryinfunction. If a baseline study is to be performed, it should be delayedforatleast48hourstoensurethatthepharma- cologiceffectsofcaptoprilhavewornoff. InstrumentandEquipment OrbiterorMS-2withallpurposeorhighresolution collimatorandinterfacedcomputer. Radiopharmaceutical 370MBq(10mCi)Tc99mMAG3or370MBq(10mCi)DTPA. TimeofImaging Immediate PatientPreparation WithholdACEInhibitors Ifpossible,ACEinhibitorsshouldbewithheldpriortothe study(captopril-2days,enalopril-3days,lisinopril-4 days). Thisallowsthephysiologicallysimplestcondition, mirroringthevalidationofcaptoprilimaging. Insomepatients,itisnotfeasibletowithholdACE inhibitors prior to the study. In that case, the SNM consensuspositionpapersuggeststhatimagingproceed afteranadditionaldoseofcaptopril. Thereisasuggestionthatthesensitivityoftheexamin thissettingmaybecompromisedslightly. WithholdDiuretics Withholddiureticsforseveraldayspriortoimagingif feasible. Diureticsmaymakethepatientmoreproneto hypotension. Thereiscontroversyaboutwhetherornot diureticusedecreasesthe sensitivity of the study. Captopril Renal Scan for Evaluation of Renovascular Hypertension
  • 25. 513 NUCLEAR MEDICINE Ifdiureticsarenotwithheld,hydrationbecomesevenmore importantthanwouldotherwisebethecase. Allpatientsshouldbehydratedwith11/2to2glasses ofwaterorotherfluid30-60minutespriortothestudy. Patientsshouldrefrainfromeatingsolidfoodfor4hours priortotheexaminordertoensureabsorptionofthe captoprildose. Thepatient’sbaselinebloodpressureshouldbechecked andrecordedbeforetakinganyfurtheraction. IftheBP isnotelevated,consultwiththestaffphysicianabout howtoproceed. AnIVlineshouldbeplaced(butterflyisOK)inthe elderly,inpatientswithahistoryofheartdisease,stroke, orTIA’s. Thisisnotnecessaryinmostyoungerpatients. Captoprilisgiven25mgPO,andserialBPmeasurements recordedevery15-20minutesforonehour. Thedropin BPafterthisdosageisusuallymodest. Moresignificant hypotensioncanusuallybemanaged withrecumbencyandIVinitialvalueandtheyshouldbe asymptomaticbeforebeingallowedtoleavethesection. Alternatively,enalaprilatmaybegivenIVasa5minute infusion,monitoringbloodpressureandproceedingas below. At1hourfollowingcaptopriladministration,afinalBP shouldbecheckedandthepatientshouldvoidbefore beginningimaging. ImageAcquisition Imagesareobtainedintheposteriorposition,centered justinferiortothekidneys. Dynamicimagesarerecorded in128x128matrixat2secondsperframefor32frames, followedby30secondsperframefor64frames. ImageAnalysis Asperthe“RenalFunction”protocol6.1. Comments Theinterpretivecriteriaforabnormalstudiesdiffer betweenMAG3andDTPA: MAG3 Unilateralparenchymalretention(nottobeconfusedwith ureteral obstruction) is diagnostic of renovascular hypertension. Bilateralparenchymalretentionisanonspecificfinding, however. Unilateralretentioncanbequantifiedasa changeinthe20minute/peakratioof0.15orgreateror asanincreaseintheTmaxofatleast2minutesor40% between baselineandcaptoprilstudies. anadditionalbaselineexaminationwithoutcaptopril. Thestudyisconsideredformallypositiveiftheabsolute valueofthedifferenceinrenalfunctionincreasesby10% ormorefromthebaselinetocaptoprilstudy. Marked unilateraltracerretentionaftercaptoprilisalsoconsid- eredtoindicateapositivestudy. Adifferenceintheabsolutevalueofrenalfunction betweenbaseline andcaptoprilstudiesof between 5%to9%isconsideredanintermediateresponse,and thusnotdiagnostic. Note that with normal renal function and without hydronephrosis,thenormal20minute/peakratiois <0.3.Deviationfromthenormalvalueorasignificant asymmetry in excretion warrants a comparison baselineexam. DTPA A greater than 10% difference in renal function is consideredprovisionalyabnormal,andgenerallyrequires Testicular Imaging Toaidinthedifferentiationoftesticulartorsion(inwhich thereisdecreasedflow)frominflammatoryprocesses suchas epididymitis(inwhichthereisincreasedflow andECFspacetracerdistribution). InstrumentsandEquipment Largefieldofviewgammacamerawithlow energypar- allelholecollimatorandcomputersystem. Forverysmallchildrenasmallfieldofviewcamerawith aconvergingcollimatormaybenecessary. Thestudy shouldbediscouragedinneonatessinceitisoflittlevalue inthisagegroup. Radiopharmaceutical 99mTcPertechnetate. TimeofImaging Immediatelyuponinjection(requiresflowstudy). Dose 555MBq-Adult Webster’sRule-Pediatric Thisstudyshouldnotbedoneinchildrenyoungerthan sixmonths.
  • 26. 514 CLINICAL PRACTICES PatientPreparation None Administration Intravenousinjectionofasmallbolususingmodified Oldendorftechniqueandsalineflush.Use4-waystop- cockandappropriatebutterflyneedleandtubing. PatientPositioning Anteriorsupinewithtesticlescenteredinthefieldofview. DataAcquisition Analog: Acquirestaticimagesina9formatfor1000k withandwithout57-Cobaltlinesourcemarker. Staticimagesshouldconsistofthreeviews: anterior, midlinescrotalmarker,andtesticular marker. Digital: Acquireflowimagesat2secondframeratefor 32frames(128x128matrix). Acquirestaticimageswithandwithout57- Cobaltlinesourcemarkerfor1000Kina 256x256matrix. Staticimagesshouldconsistofthreeviews: anterior,midlinescrotalmarker,andtesticular marker. ImageAnalysis Preparelabeledsavescreensof the flow and static imagesandphotograph. Submitalldigitaldataand photographstotheinterpretationroomforanalysis. SpecialViews Asrequestedbystaffphysician. Comments Insettingupthepatientforthisprocedureplacethe patientinthesupinepositionwithhipsslightlyabducted. Apapertapesupport(bridge)isplacedacrossboththighs and under the scrotum so that the testicles are parallelandequaldistancefromthecollimator.Thepenis istaped(papertape)totheanteriorabdominalwallsoas nottooverliethe testicles.The57-Cobaltlinesourceis storedintheradiopharmacy. Thisprocedureisdoneroutinelyforindicationsthatare notspecificallylistedinthemanufacturer’spackage inserts.Thechoiceoftheradiopharmaceuticalandthe doseforeachproceduredescribedinthis Manualismade bythephysicianstaffoftheNuclearMedicineDivision, inordertoacquirethebestimagingresultswhilecom- plyingwithMGHIsotopeand/orPharmacyCommittee guidelines.Thenameofthenuclearmedicinephysician ordering any test that is listed here is maintained inthefilesoftheradiopharmacy withthe dataonthe patientandradiopharmaceutical. Radionuclide Cystogram Radionuclidecystographyhasproventobeaneffective andsafetechnic for the detection of vesicoureteral reflux. Ifonewishestoexaminethepatient(particu- larlypediatricpatients)duringthefilling,voidingandpost voidingphasesofthistest,theradionuclideVCUG provides monitoring of the patient with a reduced radiationburdencomparedtoconventionalx-ray. InstrumentsandEquipment Preferredinstrument,largefieldofviewcameralinked toacomputer;GAPorhighresolutioncollimator. Dose 18.5MBq(500mCi)of99mTcsulfurcolloid. PatientPreparation Thepatient’sbladderiscatheterizedandurinesentfor culture. AttachanIVinfusionsettothecatheterviaa3-way stopcock,connectedtoa500mlbottleofsaline. Thebottleshouldnotbe>100cmabovethetable. Covergammacameraandtablewithabsorbentpaper. Technique Positionpatientsupinewiththebladderinthelower portionoftheimagingfield. Inject99mTcsulfurcolloidviaIVtubingand openIV salinetocommencefillingbladder.
  • 27. 515 NUCLEAR MEDICINE ImageAcquisition Analog: None Digital: Acquireimageina128x128matrixevery20 seconds. Commenceimagingimmediatelyandcontinue untilvoidingiscomplete. ImageAnalysis Preparelabeledsavescreenandphotograph.Submitall digitaldataandphotographstotheinterpretationroom foranalysis. Thisprocedureisdoneroutinelyforindicationsthatare notspecificallylistedinthemanufacturer’spackage inserts. Thechoiceoftheradiopharmaceuticalandthe doseforeachproceduredescribedinthis Manualismade bythephysicianstaffoftheNuclearMedicineDivision, in order to acquire the best imaging results while complyingwithMGHIsotopeand/orPharmacyComittee guidelines. Thenameofthenuclearmedicinephysician orderinganytestthatislistedhereismaintainedinthe filesoftheradiopharmacywiththedataonthepatient andradio-pharmaceutical. Hematology Bone Marrow Thisstudyisusuallyobtainedtoassessbonemarrow distributioninpatientswithanemia,orasanadjunctto In-111WBCimaging. InstrumentsandEquipment Largefieldofviewscanninggammacamera withlowor energyparallelholecollimatorandcomputersystem. RadiopharmaceuticalandDose 370MBq-99mTcsulfurcolloid. TimeofImaging 15minpostinjection. PatientPreparation None Administration Intravenousadministration. PatientPositioning Anteriorandposteriorwholebody. Selectedspotviews may alternatively be needed per staff physician direction. DataAcquisition Analog: Acquireanalogimagesinthewholebodymode usingascanspeedof15centimetersperminute. Digital: Acquirewholebodyimagesina256x1024 matrix(MS-2)or384x1024matrixusingascan speedof15centimetersperminute. ImageAnalysis Preparelabeledsavescreenandphotograph. Submitalldigitaldataandphotographstothe interpretationroomforanalysis. SpecialViews Views of the extremities are needed to determine thedistributionofbonemarrowinlongbones,ifthisis notobviousonwholebodyimages.Minimum100Kor10 minuteimageswillberequired(recordwhich). 99mTc Labeled RBC Volume Determination Todeterminetheactualcirculatingredbloodcelland albuminvolumetoaidinthediagnosisofcertainhemato- logicdisordersinwhichthehematocritmaybeelevated. Radiopharmaceuticals 125Iradioiodinatedhumanserumalbumin:125I-RISA. 99mTcautologousredbloodcells0.37-1.11MBq: 99mTc-RBC’s. Dose 125I-RISA0.37MBq 99mTc-RBC’s 0.37-1.11MBq(100-300mCi)
  • 28. 516 CLINICAL PRACTICES PatientPreparation None Administration Inserta19guagebutterflyinfusionsetintoaperipheral veinineacharm.Attachastopcockand10mlofhep- arinizedsaline(10units/ml). Flushlines.Inject 0.37MBq of125I-RISAinrightarm,flushsyringewithbloodand notetime.Notetime. Inject3mlsofstannouspyrophosphatecontaining1mg stannouschlorideinrightarmandreheparinizetheline. Withdraw5mlbloodsamplesfromleftarmat15and30 minutesfollowinginjection. Withdrawanddiscard3mlsbloodbeforecollecting actualsamples.Reheparinizetheline. Twentytothirtyminutesfollowingintravenousstannous ionwithdrawn10mlsofbloodintoasyringecontaining 18-36MBq99mTcpertechnetate. Add100unitsof heparin, mix and incubate for 10 minutes at room temperature. (Seeattachedarticleonlabelingmethod.) Inaverticallaminarflowhood,transferthe99mTc-RBC’s toasterilepyrogenfreecentrifugetube(Corning50ml). Add10mlsofsaline,mixgently,andcentrifugeat 100xg(1200rpm)for5minutes.Removesupernatant anddiscard. Measure radioactivity on the RBC’s using a dose calibrator. Calculatethevolumeof99mTc-RBC’sthatis required. Withdraw1mlof 99mTc-RBC’sintoa1mlsyringeand capwithluercap(Paramedicalno.57-01). Withdraw appropriatevolumeforpatientdoseandcapasabove. Weigheachsyringeaccuratelyandrecordweights. Measureandrecord99mTc-RBC’sradioactivity. Inject the99mTc-RBC’sintheleftarm. Donotflushsyringe. Reweighandrecordweight. Withdrawbloodsamplesasdescribedaboveat15and 30minutesfollowinginjection. PreparationofStandards 125I: Withdraw0.2ml125I-RISAfromsamevialas thepatientdose. Expel0.1mlintoa100mlvolumetric flaskcontainingdilutealbuminsolution(topreventloss of125I-albuminonglassware). Mixanddilutetomark. Remove2x1mlsamplesforcounting. Dilution factor(99m Tc DF) = Wt. of cells injected Wt. of cells in STD ∩ 100 ml 1.0 ml 99mTc: ExpelcontentsofTBsyringecontaining99mTc- RBC’sintoa100mlvolumetricflaskcontainingdistilled waterandmixwell. Reweighandrecordsyringe. Dilutetomark,mixand withdraw2x1mlsamplesforcounting. SamplesPreparation: 125I-RISA: Spinwholebloodsamplesat100xgfor5 minutes.Remove duplicate1mlaliquotsofplasmaandtransferto countingtubes. Countfor appropriatetimetominimizestatisticalcounting erroralongwithstandard. 99mTc-RBC’s: Withdrawduplicate1mlwholebloodsamples. Transferto countertubes.Determinehematocritofwholeblood samples and record. Countforappropriatetimetominimize statistical countingalongwithstandard. Dilution factor(99m Tc DF)= Wt. of cellsinjected Wt.of cellsin STD ∩ 100ml 1.0 ml Interpretation PlotlogCPM/mlvstime. Determineyintercept(manuallyorusingcomputerfit). PlasmaVolume NetCPM(ISTD)x(IDF) = Plasmavolume NetCPM/mlplasmaatt=0 RBCVolume NetCPM/(TcSTDx(TcDF) =RBC volume (NetCPMpermlwholebloodatt=0)/(Hematocrit)
  • 29. 517 NUCLEAR MEDICINE NormalValues RBCVolume PlasmaVolume Males: 27-33ml/kg 49-59ml.kg Females:23-27 ml/kg Note: Ifthepatientismorethan20%underweightor overweightcorrectionsforleanbodymassshouldbe performedusingstandard nomograms. Inflammation 67Ga Inflammation Some infections and inflammatory processes are 67Gaavid.Thereisslowbloodclearanceandexcretion ofgallium,soimagingnormallyisnotstarteduntilafter 48 hours. Labeled WBC’s are preferred for intra- abdominalinfections. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputer. Setupthecam- eraforgalliumimagingusingthefollowingsettings: 96keVphotopeakwitha30%window 185keVphotopeakwitha30%window 300keVphotopeakwitha30%window Radiopharmaceutical 67Gacitrate TimeofImaging Allabdominalorwholebodyimagesshouldbeperformed 72hoursafterinjection. Chestimages maybeimaged at48hourspostinjection. Dose 185Mbq -Adult Webster’srule -Pediatric PatientPreparation Laxatives24hoursafterinjectionandenemasthenight beforeimaging. Thispatientpreparationisonlytobe usedforwholebodyorabdominalimaging. PatientPositioning Whenimagesareperformedtoascertainanunknown focusofinfectionorforfeversofundeterminedorigin, whole body images should be acquired in both the anteriorandposteriorprojections. DataAcquisition Analog: Acquirespotimagesfor500Kusinga4format. Acquirewholebodyscanimagesusingascan speedof10centimeters/minutesonscanning cameras. Digital: Acquirestaticspotimagesina256x256 matrixfor500K Acquirewholebodyimages ina256x1024or384x1024matrix. SpecialViews Asrequestedbystaffphysician.Insomecases,SPECT imagingmayberequired. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments Ifthepatientalreadyhas99mTconboard,onlythe296 keVphotopeakwitha30%windowcanbeusedfor galliumimaging. Imagesmaybeperformedearlierorlaterthan72hours atthediscretionofthenuclearstaffphysician.
  • 30. 518 CLINICAL PRACTICES 111In White Blood Cell Scan for Infection Thisscanisperformedtodemonstratespecificfociof infection,byuseofWBC’sfromthepatient,labeledwith 111In. Thisprocedureisespeciallyrecommendedfor patients with suspected abdominal and thoracic abscess(s). InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 111Inlabeledwhitebloodcells. TimeofImaging 24hourspostinjection. Dose 7.4MBq-Adult PatientPreparation 50ccofthepatient’sbloodmustbeobtainedfor celllabeling. Administration Intravenousadministratrionoflabeledwhitecells. PatientPositioning Placepatientinthesupineposition. Projections: WholeBodyImaging-anteriorandposterior views. SpotViews-Anteriorandposteriorspot viewsfromtheheadtotibias. DataAcquisition Analog: Acquireimagesonawholebodycamerain wholebodyformatusingascanspeedof8 centimeters/minute. Acquirespotviewsin9formatfor100Kor10 minuteswhichevercomesfirst. 99mTc White Blood Cell Scan for Infection Thisscanisperformedtodemonstratespecificfociof infection,byuseofWBC’sfromthepatient,labeledwith 99mTc. Thisprocedureisrecommendedforpatientswith suspected abdominal and thoracic abscess(s) and osteomyelitis. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTc-HMPAOlabeledwhitebloodcells. TimeofImaging 0.5-4andpossibly18-24hourspostinjection. Earlyimagingisrecommendedfortheevaluationof inflammatoryboweldisease. Dose 185-7.4370MBq-Adult Digital: Acquireimagesinthewholebodyformat (256x1024or284x1024matrix. Acquirespotimagesina256x256matrixfor sameinformationdensityaslistedabove. Use autocontourwithMS-2cameras. SpecialViews Asdeterminedbystaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments WhiteBloodCelllabelingisperformedbyeitherDr.Ronald J.CallahanorMr.StephenDragotakis.
  • 31. 519 NUCLEAR MEDICINE Lung PatientPreparation 50ccofthepatient’sbloodmustbeobtainedforcell labeling. Administration Intravenousadministratrionoflabeledwhitecells. PatientPositioning Placepatientinthesupineposition. Projections: WholeBodyImaging—anteriorandposterior views. SpotViews-Anteriorandposteriorspot viewsfromtheheadtotibias. DataAcquisition Analog: Acquireimagesonawholebodycamerain wholebodyformatusingascanspeedof12 centimeters/minute. Acquirespotviewsin9formatfor150Kor 10minuteswhichevercomesfirst. Digital: Acquireimagesinthewholebodyformat (256x1024or284x1024matrix. Acquirespotimagesina156x256matrixfor sameinformationdensityaslistedabove.Use autocontourwithMS-2cameras. SpecialViews Asdeterminedbystaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments WhiteBloodCelllabelingisperformedbyeitherDr.Ronald J.CallahanorMr.StephenDragotakis. Lung Perfusion Todemonstrate(bycapillaryblockade)perfusionofthe lungs,usuallytodiagnosepulmonaryemboli. Regional distributionreflectsthecontributionofeachareaoflung tototallungfunction. Theparticlesusedfortheradiolabelareapproximately 3 times the size of a RBC, and temporarily block 1/200,000ofthepulmonarycapillariesinthenormal adult. InstrumentsandEquipment Largefieldofviewgammacamerawithallpurpose collimatorandcomputersystem. TimeofImaging Immediatelypostinjection. Radiopharmaceutical 99mTcmacroaggregatedhumanalbumin(MAA), roughly 200,000-400,000particles. Reduce dose to 50,000-75,000 particles in adult suspectedofhavingpulmonaryhypertension,andto 5,000particlesinneonates. Dose Age+1 Age+7 PatientPreparation None Administration Intravenousinjectionwithpatientsupine. PatientPositioning Acquireperfusionimagesintheexactsequenceas statedbelow: LPO POST RPO RAO ANT LAO x740MBq (nolessthan37MBq)
  • 32. 520 CLINICAL PRACTICES DataAcquisition Analog: Acquiresallimagesfor1000Kor4min./view. In somecases,thiscanbereducedto750Kwiththe Digital: Acquireimagesina256x256matrixoncomputer. Inthecaseofaquantitativestudy,acquireimages intheposteriorandanteriorprojections. SpecialViews Asorderedbythestaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesand uptake resultsandphotograph. Submitdigitaldataandphotographstotheinterpreta- tionroomforanalysis. Comments Havepatienttakesix(6)deepbreathsbeforeinjection. Havepatienttake5-10deepbreathswhileinjecting. Imagepatientinthesupineposition. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. RegionalLungFunction UseAutomatedProgramforRegionalQuantitation. Incaseswherethepatientisimmobile,theperfusion imagesmaybeinthefollowingorder: POST LPO RPO LAO ANT RAO permissionofaphysician. Lung Ventilation Toassessregionalventilation,especiallyinpatients underevaluationforpulmonaryembolism,andinpatients formeasurementofregionallungfunction. 133Xeisan inertgaswhichisminimallyabsorbedbythebody tissues. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energy all purposecollimatorandcomputersystem. Radiopharmaceutical 133XeGas TimeofImaging Immediatelyuponinhalationof133Xe. Dose Age+1 Age+7 PatientPreparation None Administration InhalationofXenongas. PatientPositioning Supine,alwaysinsamepositionastheperfusionstudy willbedone. Projections: Posteriorprojectionunlessanotherprojection isspecificallyrequested. DataAcquisition Analog: Wash-in-30K Equilibrium-2images- 90seceach,begin ningafterwash-in. Washout-3imagesfor45secondseach. Retention-LPO,Posterior,andRPOimages for45secondseach. x740MBq
  • 33. 521 NUCLEAR MEDICINE ImageFormat: InitialBreath Equilibrum1 Equilibrium2 Washout(45sec) Washout(45sec) Washout(45sec) LPO(45) Posterior(45sec) RPO(45sec) Digital: Acquireinsamemanneraslungperfusion study. Comments Trytoperformstudyinsupineposition. Makesurepatienthascurrentchestx-ray,(donewithin 12hours)ifpulmonaryembolusevaluation. If the perfusion study was performed prior to the ventilationstudy, obtainabackgroundimage(99mTc scatter in the 133Xe window) for 120 seconds on computertosubtractfromthewashoutimages. ComputationalAnalysis Regional LungFunction Forquantitativeventilationdata,useautomatedprogram. Calculation-Dividethecountsfromeachregionbytotal countsintheentirelungfieldtoobtain%ofuptakein thespecificregion. Pulmonary Aspiration Todeterminewhetherthereisevidenceofgastroesoph- agealrefluxandpulmonaryaspirationofgastriccontents. Sincethisusuallyoccursduringsleep,itisnecessaryto studythepatient overnight. InstrumentsandEquipment Largefieldofviewgammacamerawithlowenergyall purposeparallelholecollimatorandcomputer. Radiopharmaceutical 99mTcsulfurcolloid. TimeofImaging Doneasfirstcaseinmorning. Dose 185MBq PatientPreparation None Administration Thisstudywillbedoneoninpatients. Ontheevening beforeimaging,thepatientisgiventheradiopharmaceu- ticalmixedwith15mlLipomulainamilkshakeor Meritene. PatientPositioning Projection: Anteriorandposteriorchest. DataAcquisition AnalogorDigital: Fifteenminuteanteriorandposteriorimagesof thechest,alongwithmarkerimageindicating locations of the sternal notch and xiphoid. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Endocrine Thyroid Imaging and Uptake (99mTc) Forfunctionandstructuralassessmentofthethyroid gland,using99mTcPertechnetatewhichisincorporated inthethyroidglandbutnotorganified. InstrumentandEquipment Regularfieldofviewcamerawithapinholecollimator and5mminsertandcomputer.
  • 34. 522 CLINICAL PRACTICES Radiopharmaceutical 99mTcPertechnetate(permitsrapiduptake andimag- ingcomparedtoI123whereimagingisusuallyperformed at24hours). Dose 370MBq - Adult Webster’sRule - Pediatric PatientPreparation None TimeofImaging 20minutespostinjection. Uptake: Countstandardinphantomatadistanceof 20cmwith pinholeinsertinplacefor2minutes. The20minute 99mTcpatientuptakeisthendeterminedbyrepeatcount- ing of the patient’s neck using the same counting geometry. StandardProjections Anterior6cmfromsurfaceofneck. Anterior57Cosupersternalnotchmarkerinconjunction with5cm57Comeasuremarkerparalleltothyroidlobes. Ifnecessaryrightanterioroblique,andleftanterior obliqueatadistancethatwillfill2/3ofpinholefieldof view. InformationDensity 250Kperimage 75Kperimagefor57Comarkerimages SpecialViews Itmaybenecessarytomarkareaswherenodulesare present,using99mTcwand. Comments SeeComputersectionforcalculationof%uptake. Have99mTcmarkingsourcesavailable. Haveaglassofwateravailabletobeusedinpalpationof thyroidgland. Acquire all computer images in quadrant format (128x128). Makeduplicatecopiesofallhardcopyimages.Fillout andsubmituptakecalculationsheetalongwithhardcopy imagesforinterpretation. Thyroid Uptake and Imaging (123I) Forfunctionandstructuralassessmentofthethyroid gland,using123Iwhichisnaturallyincorporatedinthe thyroidgland. InstrumentsandEquipment GEcameraandcomputer Pinholecollimatorwith5mminsert 57Cowandformarking Thyroidlogbook Thyroidfloppydisk Thyroidmagnetictape Sharpieformarkingpatient Radiopharmaceutical 123Isodiumiodide Dose 8MBq123I(1-2capsules)24hourspriortoscanning. PatientPreparation None TimeofImaging 24hours ComputerAcquisition Thyroidcapsulesarecountedinaneckphantomata distanceof20cmwithoutthepinholeinsertfor5min- utes.Uptakedeterminationinthepatientisperformed forthesametimeandcountinggeometry. Allimagesareacquiredin128x128(quadrantformat). Theyarestoredonathyroidfloppydiskandtransferred toathyroidmagnetictapeinbytemode(256)forlong termstorage.
  • 35. 523 NUCLEAR MEDICINE Comments PatientispalpatedbyThyroidFellowandNuclear MedicineResident. Ifitisaquestionofnodule,theareawillbemarkedfor scanning. Patientisplacedinsupinepositionwithneckextended. Marks are placed on suprasternal notch and for 4cmmarkersatlevelof thyroidgland. StandardImages Anterior,6cmfromcollimator-8minutes. Ifthethyroidisenlarged,itmaybenecessarytoimage at10cmtoincludetheentirethyroidinthefieldofview. Withoutmovingthepatient,multiple2secacquisitions aredoneinquadranttwowiththe57Cowandplaced overthemarks(SSN;4cmmarkers;noduleifmarked) (eg.SAQ,S,QZ;SAQS,Q2;SAQSQ2). Ifthereisaquestionofnoduleorifdeemednecessary bythephysician,bothanRAOandanLAOshouldbe performed. Thesearedoneina45oangleat6cmfor5 minutescenteringthenoduleinthefieldofview. PostScanAnalysis Transferimagesondisktomagnetictapeforlongterm storage. Usebytemode(256)ondesignatedthyroidtape. Recordallpertinentinformationinthyroidlogbook. Photographimagesonhardcopyusingthemultiformatter. Twocopiesareneeded:oneforThyroidLabandonefor NuclearMedicine. Theimagesrecordedareasfollows: MakeupNuclearMedicinefolderandgiveallpaper workandhardcopytoNuclearMedicineResident. Leavethreepolaroidimagesatthyroidclinic. 123I Potassium Perchlorate Washout Test InstrumentsandEquipment Regularfieldofviewgammmacamera. Collimator Pinholewith5mminsert. Radiopharmaceutical 123ISodiumIodide Dose 8-20MBq - Adult Webster’sRule - (Pediatric) StartingTime 45minutespost123Iadministration(capsuledose). 40 minutes after the tracer dose of 123I image the thyroidphantom. At 45 and 60 minutes post dose the patient will be imaged. PotassiumPerchlorate Adultdose: 400mg(2capsules). Pediatricdose: Webster’sRuleorcheckwithstaff physician. Afterinitialimageshavebeenobtained,dose thepatientwith400mgofPotassium Perchlorate. 40minutesafterthedoseofPotassium Perchloratethethyroidphantomisagainimaged. At45and60minutesafterthedoseof PotassiumPerchloratethepatientisimaged. StandardProjections Anteriorat6cmfromsurfaceoftheneck. ImagingTime Imagingtimeforallviews(bothpatientandphantom) willbefor5minutes. SpecialViews TobedeterminedbyStaffNuclearMedicinephysician. Comments Allimages(patient)willhaveuptakevaluescomputed usingthe“thyroid”programonthecomputer.
  • 36. 524 CLINICAL PRACTICES Parathyroid Imaging 99mTc-sestamibiaccumulatesinnormalandabnormal thyroid, as well as in enlarged parathryoid glands. Sestamibirapidlywashesoutfromnormalthyroidtis- sue;thus,delayedimagesshouldshowonlyabnormal uptake. InstrumentsandEquipment Largefieldofviewcamerawithallpurposeorhighreso- lutionparallelholecollimatorandinterfaced computer. Insomecases,imagingwitha5mmpinhole collimator mayberequired. Radiopharmaceutical 740MBq99mTc-sestamibi TimeofImaging Initial images immediately after injection. Delayedimagesapproximatelytwohoursafterinjection. ImageAcquisition Acquireimmediateanteriorplanarimageoftheneckand upperchest,sothatthemostsuperioraspectoftheheart isatthebottomofthefieldofview. Thisshouldberecordedfor5minutesin128x128 matrixsize. PerformSPECTacquisitionofneckandupperchest using360orotation,96viewsperhead,15secondsper view. Record5minutepinholeimageofneckintheanterior projection,withthepinholeapertureapproximately 10cmfromtheneck. Repeateachoftheseimagesatthetimeofdelayed imaging. ImageAnalysis Prepare labeled save screen of planar and pinhole images. ReconstructandphotographSPECTimagesinthe transaxial,coronal,andsaggitalplanes. Comments Inselectedcases,additionalobliqueimagesoftheneck maybeneeded. Ifamediastinalabnormalityisshown, delayedimagesmaynotbeneeded. Iodine-131 MIBG Imaging of Adrenergic Tumors LabeledMIBG(meta-iodobenzylguanidine)isaprecursor forseveraltypesofadrenergictumors,mostnotably pheochromocytomas. Inadults,about90%orpheochromocytomasliewithin theadrenalmedulla. Inchildren,upto30%maybe extra-adrenal. Radionuclideevaluationisusuallywarrantedonlywhen CTevaluationhasnotdemonstratedthesuspected tumor. Otheradrenergictumorsthatmaybeshownby MIBGimagingincludeparaganglioma,neuroblastoma,and carcinoid. Someinvestigatorsbelievethattheselatter tumorsmaybebettershownwithoctreotideimaging. InstrumentsandEquipment Largefieldofviewgammacamerawithparallelholehigh energy(400or511keV)collimator. Radiopharmaceutical 18MBq131IMIBG Timeofimaging 24and48hourspostinjection. Onselectedoccasions,72hourimagesmaybeneeded. PatientPreparation Thepatientmustbescreenedformedicationsthatmay interferewithMIBGuptake. Theseincludesympathomi- metics,calciumchannelblockers,reserpine,cocaine, tricyclicantidepressants,adrenergicblockers,andsome over-the-countercoldmedications (e.g., containing pseudoephedrine). Thyroidiodineuptakemustbeblockedbyadministering SSKIbeginning2daysbeforetraceradministration,and continuingfor5daysthereafter. Theusualdoseis6 dropsperday. Tumor
  • 37. 525 NUCLEAR MEDICINE ImageAcquisition Anteriorandposteriorspotviewsoftheneck,chest, abdomen,andpelvisshouldbeacquiredfor15minutes each,usinga128x128matrixsize. Imagesmustincludethebodyfromthebaseoftheskull totheinferiorbladder. ImageAnalysis Preparelabeledsavescreenofimages. Comments Itmaybenecessarytoinjectasecondradio-pharmaceu- ticalsuchas99mTc-DTPAorpertechnetate toprovide anatomicorientationforanyabnormalfindings. Reference McEwan AJ, Shapiro D, Sisson JC et al. Radio- iodobenzylguanidinefortheScintigraphicLocationand TherapyofAdrenergicTumors.JNuclMed1985;15:132- 153. 67Ga Tumor Certain primaryandsecondarytumordepositsare 67Ga avid. Thisradiolabelisusedmostcommonly inpatientswithlymphoma. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputer. Setupthecameraforgalliumimagingusingthefollow- ingsettings: 93keVphotopeakwitha30%window 185keVphotopeakwitha30%window 300keVphotopeakwitha30%window Radiopharmaceutical 67Gacitrate TimeofImaging 72hourspostinjection. Earlierimagesofthechestmaybeperformedatthestaff physician’sdiscretion. Dose 300MBq -Adult Webster’sRule -Pediatric PatientPreparation Laxativesstarted24hoursafterinjectionandenemas thenightbeforeimaging.Thispatientpreparationisto beusedonlyforabdominalorwholebodyimaging. Administration Intravenousinjectionoftheradio-pharmaceutical. PatientPositioning Projections: TotalBodySpotViews. Anteriorandposteriorheadwithneck included. Anteriorandposteriorchestwithaxillary areaincluded. Anteriorandposteriorabdomen. Anteriorandposteriorpelvisandupperlegs. TotalBodyScan: Underspecialcircumstances(determinedby thestaffphysician),imagingmaybeperformed inabodyscan modeusingascanspeedof 10cm/min. DataAcquisition Analog: Acquirespotimagesfor10minutesusinga9on one format. Digital: Acquirestaticspotimagesina256x256matrix. TotalBodyImaging: Scanspeedof10cm/minforanaloganddigital images.
  • 38. 526 CLINICAL PRACTICES SpecialViews Asrequestedbystaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments Ifthepatientalreadyhas99mTconboard,onlythe 300keVphotopeakwitha30%windowcanbeusedfor galliumimaging. Imagesmaybeperformedlaterthan72hoursatthe discretionofthenuclearmedicinestaffphysician. Note: Thisprocedureisdoneroutinelyusingdoses thataregreater thanthoselistedinthemanufacturer’s packageinserts. Thechoiceoftheradiopharmaceutical andthedoseforeachproceduredescribedinthis Manual is made by the physician staff of the Nuclear MedicineDivision,inorderto acquire the best results whilecomplyingwithMGHIsotopeand/orPharmacy Committee guidelines. The name of the Nuclear Medicinephysicianorderinganytestthatislistedhere ismaintainedinthefilesoftheradio-pharmacywiththe dataonthepatientandradio-pharmaceutical. 131I Whole Body or Neck with Quantitation InstrumentsandEquipment Thepreferredinstrumentisalargefieldofviewgamma cameraequippedwithultra-highenergycollimatorsand computersystem. Peakcamerafordualwindowacquisitionwith20% windowssetat364Kev(131I)and140Kev(99mTc). Radiopharmaceutical 131ISodiumIodide Dose 131IadministeredbyThyroidLab. Injectpatientwith40MBq99mTcPertechnetateIV. PatientPreparation None TimeofImaging 24-168hourspostoraladministration. PatientPositioning Anteriorandposteriordualwindowimagesof: Head,neckandupperchest Chestandupperabdomen Abdomenandpelvis Lowerextremities DataAcquisition Analog: Notrequired Digital: Fifteenminuteanteriorandposteriordualwin- dowimagesof: Head,neckandupperchest Chestandupperabdomen Abdomenandpelvis Lowerextremities. Use256x256matrix. Acquire 131Istandardphantomimagesfor 60seconds,anteriorandposterior. ImageAnalysis Formatimageswiththe131IdisplayMPEontheICON computer. Iftherearefocalareasofincreased131Iaccumulation, calculateuptakewiththe131IuptakeMPEontheICON computer. Prepare labeledsavescreensoftheimagesanduptake resultsandphotograph. Submitdigital dataandphotographstothe interpreta- tionroomforanalysis. Reference CastronovoFP,etal;DosimetricConsiderationsWhile AttendingHospitalizedI-131TherapyPatients.JNuc Med,September1982,Vol10,No.3.
  • 39. 527 NUCLEAR MEDICINE Miscellaneous Strontium - 89 Radiotherapy 89Srchlorideisindicatedforthepalliationofbonepain inpatientswithpainfulskeletalmetastases. Itisused inpatientsunresponsivetochemotherapyorhormonal therapy. Most patients considered for89Sr treatment have alreadyundergoneexternalbeamradiationtherapy. The bestresultshavebeeninpatientswithmetastaticbreast orprostatecancer,althoughothertumortypesmaybe treated. There may be a transient increase in bone pain at 36-72hoursfollowingtreatment. Thereliefofpain following89Srtherapytypicallyoccursin7-20days. Repeattreatmentdosesmaybegiveninthreemonthsin someselectedpatientswhorespondedtotheinitial treatment. 89Sr has a half-life of 50.5 days, and decays by a 1.4MeVemission,withoutsignificantgammaemissions. Inconsequence,89Srcannotbeimaged. 89Srbehaves biologicallyasacalciumanalog,withrapidbloodclear- anceanduptakeinbone. Inpatientswithextensivemetastaticdisease,morethan onehalfoftheinjecteddosemaylocalizeinbone. About two-thirdsofexcretionisurinary,andone-thirdfecal. Thereissignificanturinaryexcretionduringthefirst48 hoursaftertracerinjection. Indications Thepatientmustmeetthefollowingentrancecriteria for89Srtherapy: Documentedbonemetastasesunresponsiveto therapy. Lifeexpectancyofatleasttwomonths. Previousbonescanshowingmetastaticlesions, preferablywithinseveralmonthspriorto treatment. Evidencethatbonemarrowisnotseverelycom- promised,asindicatedbycurrent(within1 week)WBCcountof>3000andplateletcount of>60,000. Mustnotbeincontinentofurineorfeces. Mustbeabletogiveinformedconsent. Thisprocedurewillnotbedoneoninpatients becauseofthelogisticsofradiationsafety issues. Inrareinstances,amedicaldecisionmaybemadeto proceedwithtreatment,despitenoncompliancewithone ormoreofthecriteriaabove. SchedulingofProcedure Requests for 89Sr treatment from an attending physicianwillbehandleddirectlybyaNuclearMedicine staffphysician. TheNuclearMedicinephysicianwill completeaninformationform thatindicatesthepatient’s name,unitnumber,age,weight,anddiagnosis. Hematologicdatashouldbefaxedbythereferring physician’s office or obtained from PCIS prior to scheduling. Thestaffnuclearphysicianwillforwardthisinformation totheNuclearMedicinedivisionsecretarydesignatedto handle89Srtherapyrecordsforscheduling. ANuclear Medicine“SpecialStudies”formwillbecompletedand forwardedtothenuclearpharmacysothattheradiop- harmaceuticaldosecanbeordered. A89Srtreatment folderwillbemadeandkeptintheNuclearMedicine staffofficefilesthatcontainsallofthisrelevantdata, alongwithreportsofanyrelevantimagingstudies. Atthetimeofscheduling,aconfirmationformwillbe faxedtothereferringphysician’soffice. Thisform reviewstheprotocolforfollow-uphematologystudies thatwillbeobtainedbythereferringphysician. Consent Atthetimeoftreatment,theNuclearMedicinestaff physicianadministeringthetherapywilldiscussthe procedurewiththepatientandobtainwrittenconsent usingthe89SrTherapyconsentform. (InformedConsentRequired)
  • 40. 528 CLINICAL PRACTICES WrittenDirective TheNuclearMedicinestaffphysicianwillcompletethe writtendirectiveform,includingthefollowingdata: date,patientname, patientweight,patientdateofbirth, referringphysicianname, NuclearMedicinephysicianname, twomethodsofpatientidentityverification, dateandfindingsofthemostrecentbonescan, thepatient’shematocrit, WBCandplateletcounts, andtheadministereddoserequested. Dose 1.5-2.2MBq/kguptoamaximumof150MBq. Any dosage in this range reflects acceptable adequate dosage; the exact dosage within this range may be selectedbasedupontheamountofradiopharmaceutical available. Technique Insertasecurerouteofintravenousaccess,such asa20gaugeangiocathwithathreewaystop- cock. Infuseenoughnormalsalinetoconfirmthe adequacyofintravenousaccess. The89SrdosewillbegivenbytheNuclearMedi- cinestaffphysicianasaslowinjectionoverabout oneminute. Followingadministration,flushboththeinjection syringe and stopcock with at least 10 ml of saline. RemovetheIVsetupandwrapthesyringeand tubingintheimperviousdrapesusedforthe injection. This will be marked “Sr-89” and placed in storagefortransfertoRadiationSafety. Incase ofaspill,containthecontaminationandcallthe RadiationSafetyofficeat6-2425. Theroomusedforadministrationwillbemoni- toredforcontaminationfollowingeachinjection. Miscellaneous Follow-Up Itisrecommendedthatthepatient’speripheral bloodcountsbecheckedatleasteveryother weekfollowing89Sradministrationtoevaluate formarrowdepression. TheCBCshouldbecheckedmoreoftenif values fall below treatment thresholds. Plateletlevelstypicallyreachanadirofabout 70%ofthepre-existingvalueat3-4months followingtreatment. ThedepressionofWBCcountsismorevariable, butbloodcountsmaynotreturntopre-treat- mentlevelsforabout6months. Approximately2weeksaftertreatment,follow- upbloodcountswillbeverifiedbycontacting thereferringphysican’sofficeorfromPCIS. Records TheNuclearMedicinestaffphysicianwilldictatea report of the therapy administration, including the clinical history, laboratory values, and dosage administered. Acopyofthisreportwillberetainedinthepatientfolder keptintheNuclearMedicinestaffoffices. Acopyofthe written directive will be maintained in the nuclear pharmacycomputersystem,aswellasinthepatient folder. RadiationSafetyConsiderations and Precautions 89Srisexcretedviatheurineforaprolongedperiod,but mostactivityiswithinthefirstweek(andmostofthat intheinitial48hours). Thepatientshouldbeinstructed todoubleflushtoiletsduringthistime. Fecalmatter containsappreciableactivityforabout4days. Blood activityissignificantforabout24hours,andblood samplesshouldnotbedrawnduringthistimeexceptin anemergencysituation. Ifthepatientreturnstothehospitalfortreatmentwithin thefirstweekaftertherapy,urinespecimens,dressings, linens,andglovesshouldbeconsideredradioactive,and collectedbytheRadiationSafetyOffice. Surgicalor medicalproceduresmaybeperformedwithcareful attention to Universal Precautions. An autopsy or cremationshouldnotbeperformedunlessauthorizedby theRSO.
  • 41. 529 NUCLEAR MEDICINE Miscellaneous 111In Pentetreotide Imaging A variety of neuroendocrine tumors (insulinoma, gastrinoma,VIPoma,neuroblastoma,etc.)expresshigh concentrationsofsomatostatinreceptors. Inmanycases,thesepatientshavebeeneffectively treatedwiththesomatostatinanalog-Octreotide. In somesituations,tumorlocalizationcanbeachievedwith 111Inlabeled-Octreotide(OctreoScan). InstrumentsandEquipment Largefieldofviewgammacamerawithamediumenergy parallelholecollimatorandcomputersystem. Twenty%windowsshouldbesettoincludethe 172and245keVphotonsof111In. Radiopharmaceutical 111InlabeledOctreoScan TimeofImaging 4and24hoursafter. Insomecases,only24hourimagingwillbenecessary (seestaffphysician). Insomecases,48or72hourimagingmayberequiredto differentiatetumoruptakefromnormalbowelactivity (seestaffphysician). Dose Adults: 185MBqof111InlabeledOctreoScan(planar +SPECT). Children:Webster’srule(neveruse<37MBq). PatientPreparation BowelPrep: Mildlaxative(e.g.bisacodylor lactulose)afterinjection. Hydration: Patientshouldbewellhydrated(at least2glassesof water)toenhance renalexcretion. ConcurrentOctreotideTherapy: Discontinue24-48hourspriortoimaging(if possible) andmonitorpatientforsignsof withdrawal. Administration Intravenousinjectionoftheradiopharmaceutical. PatientPositioning Placethepatientinthesupinepositionandacquire thefollowingviews. PlanarImaging: Ant.&Post:head,neckandupperchest Ant.&Post:chestandupperabdomen Ant.&Post.:abdomenandpelvis Ant.&Post.:lowerextremities SPECT: Areaofinterest. DataAcquisition Analog: Acquirespotimagesin9formatfor500Kor10 minutes,whichevercomesfirst. Digital(planar): Acquireimagesina256x256matrix forthesame informationdensityasindicatedabove. SpecialViews Asdeterminedbystaffphysician. Inmostcases,SPECTwillberequired. SPECT(MS-2) Acquire96projectionsover360ooneachhead:20sec./ projectionina128x128matrix. Reconstruct the data usinga Butterworth filter (cutoff=0.4,order=7). Donotuseattenuationcorrection. ImageProcessing Prepare labeled save screens of all planar (general display)andSPECTdata(multi-viewdisplay)and photograph.Submitallanaloganddigitaldataand photographstotheinterpretationroomforanalysis.
  • 42. 530 CLINICAL PRACTICES Miscellaneous Normally,thereisminimalrighttoleftshuntingandmost ofaninjecteddoseofradiolabeledalbuminmicropheres shouldbetrappedinthelungs. Thepercentagefoundoutsidethelungrelatestothe extentofR-Lshunting. InstrumentsandEquipment Regularorlargefieldofviewgammacameraequipped withageneralallpurposecollimatorandinterfacedtoa computer. Radiopharmaceutical Macroaggregatedalbumin(lessthan100,000particles labeledwith99mTc. The number of particles is reduced for infants and children. Dose 150MBq -adult Webster’srule -pediatric TimeofImaging Immediatelyafterinjection. PatientPreparation None Administration Intravenousinjection. PatientPosition Supine Right to Left Shunt (MAA Technique) DataAcquisition QualitativeTechnique Acquireanteriorimageofbrain,palmarimage ofhand,orotherprojectionsasindicatedby staffphysician. Usea256x256matrixandacquireeach imagefor5minutes. QuantitativeTechnique Acquirewholebodyanteriorandposterior digitalimageusingeithertheSiemensbody cameraorMS-2at5cm/min. Drawregionsofinterestoverthewholebody andthelungs. Determinethenumberofcountsineachregion andcalculategeometricmeans. Calculatethedegreeofshuntingusingthe relation: AmountofR-LShunt=1-[Lung/WholeBody] NOTE: Thisprocedureisroutinelyperformedusing doses that are greater than those listed in the manufacturer’spackageinserts. Thechoiceofthe radiopharmaceutical andthedose for eachprocedure describedinthis Manualismadebythephysicianstaff ofthe NuclearMedicineDivision,inordertoacquirethe best results while complying with MGH Isotope and/orPharmacyCommitteeguidelines.Thenameofthe Nuclear Medicine physician ordering any test that is listed here is maintained in the files of the radiopharmacywiththedataonthepatientdoseof radiopharmaceutical. Reference Editorial:AmRevRespDisease1977;115:553-557
  • 43. 531 NUCLEAR MEDICINE Miscellaneous Lymphoscintigraphy: Melanoma En bloc lymph node resection is done in high risk melanomapatientsinaattempttoreducerecurrent disease. Whentheprimarylesionisonthetrunk,lymphaticdrain- agemaybetoeitheraxillaryand/oringuinalregion,as wellastoothernodalgroupssuchassupraclavicular andpara-aorticnodes. Lymphoscintigraphyisemployedtoidentifythenodal group or groups at highest risk, and to localize the sentinelnode(s). InstrumentsandEquipment Largefieldofviewcameraequippedwithhighresolution orallpurposecollimatorandcomputer. Radiopharmaceutical Filtered99mTcsulfurcolloid. Dose 5-10MBqin4insulinsyringesasfollows: 1.25-2.5MBqpersyringein0.2mlvolumepersyringe. Supplies Sterileprepkit,non-sterilegloves,Betadine,57Co “thyroid”marker. Administration Usinginsulinsyringes,fourtosixintradermalinjections aremadearoundthebiopsysite. DataAcquisition Analog: Notrequired Digital: Uptothreesequential5minuteimagesina 128x128matrix. Theinitialimagesmustincludethesiteof injection. Thesubsequentimagesshouldincludedetected drainagepathways. Ifthelesionistruncal,bothaxillaryandinquinal regionsshouldbeevaluated. At2hoursafterinjection,additional5minute posteriorandanteriorimagesmaybeacquired. Identifythetipsoftheshouldersandiliaccrests withthe57Comarker. Aphysicianwilllocalize thesentinelnode(s),andmakeanyskinmarks asneeded. ImageAnalysis Preparelabeledsavescreensofallimagesandphoto- graph. Submitalldigitaldataandphotographstothe interpretationroomforanalysis. Interpretation Asrequestedbythereferringphysician,thepath(s)and nodalgroup(s)whichdraintheinjectionsitemaybeiden- tified,andthelocationofthesentinelnode(s)notedand markedonthepatient. Reference JournalNucMed1993;34:1435-1440
  • 44. 532 CLINICAL PRACTICES Miscellaneous Schilling Test Part I OrallyadministeredvitaminB12iseitherabsorbedfrom the intestine or excreted in the feces. If, however, two hours after an oral dose of the vitamin B12, apatientreceivesanintramuscularinjectionofthe vitamin, he will excrete <30% of the oral dose in hisurine. Byemployingthis“flushing”techniquewith anoraldoseofradioactivelabeledvitaminB12,urinary excretionofthevitaminandconsequentlybodilyabsorp- tioncanbeeasilymonitored. Lessthan7%excretion indicatesmalabsorption. InstrumentsandEquipment Rubratope-57(~0.5mCi/capsule)Squibb Copatope -57(~0.01mCi/ml)Squibb CyanocobalaminInjection,USP(1,000mcg/ml),Wyeth 24-hourSpecimenCollectionContainers,Sage GammaCounter,Micromedic2/200 Specimen 24hoururine PatientPreparation Discusstheprotocolwiththepatient. ThepatientMUSTbeNPO—exceptforwaterforat least8hourspriortotestingandSHOULDNOTreceive aninjectionofvitaminB12within24hoursofthetest. Mostconvenientisafastfrommidnightwiththetest beginningafter8a.m. ScheduletestMondaythruThursday. Fridayscheduling requiresstorageoftheurinecollectionovertheweek- endandisdiscouraged. Administration Confirmpatientpreparation. PERSONALLYgivetothepatientandwatchhim swallowaRubratope-57capsule. Inpatients Leave with the patient a 24 hour specimen collection container labeled with his name, floorandunitnumberaswellasthestartand completiondateandtime. Informthepatientandremindtheattendingnurse or unit coordinator of the remaining test procedures. Thepatientmayeatalightbreakfastofjuice, coffee and toast one hour after taking the Rubratope-57capsule. Outpatients Givethepatienta24hourspecimencollection containerlabeledasdescribedunder“Inpatients” and a copy ofthe“SchillingTestInstructions” completedasindicated.(Seebelow.)Explainthe collectionandinstructionsasnecessary. Informthepatientthatonhisreturntothelabo- ratory2hourslaterhewillreceiveanintramus- cularinjectionofvitaminB12(cyanocobalamin -1,000mcg). Itistheresponsibilityofthetech- nologist to find an appropriate person to administertheB12shot. Ifnoonecanbefound inareasonableperiodoftime,thensendthe patienttoMedicalWalk-InUnitwithaninter-clinic referralslipsignedbyDr.Fischman. The Medical Walk-In Unit will provide and administertheB12shot. Acquiringbreakfastandreturningofthe24-hour urinesamplearetheresponsibilitiesofthepatient. Assay Recordvolumeof24hoururinecollection. Aliquotthree,2mlsamplesofthecollectionintogamma countingtubes. Alsoaliquota2mlsampleofthepatient’sbackground urine* and a 2 ml sample of Cobatope - 57 diluted 1mlto2mlswithdistilledwater. **Thisaliquotrepresents2%oftheradioactivitycon- tainedinRubratope-57capsuleofthesamelotnumber. Countalltubes(10)asfollows:
  • 45. 533 NUCLEAR MEDICINE Miscellaneous Input(A=Assay;;S=Stat;T=Tape): A ASSAYNo.:1 COMMENT:return COUNTINGTIME(MIN.):10 ISOTOPE(I=IODINE;C=COBALT):C NO.TUBES:10 TUBESIZE(S=8X50;L=12X75):S BACKGROUNDCOUNTS(CPM): A:return B:return 001, 10, 019227 - DILUTEDCO-57 002, 10, 000131 - BACKGROUND 003, 10, 000671 - SAMPLE#1 004, 10, 000657 - SAMPLE#1 CRYSTALB 005, 10, 000674 - SAMPLE#1 006, 10, 019147 - DILUTEDCO57 007, 10, 000136 - BACKGROUND 008, 10, 000836 - SAMPLE#2 009, 10, 000851 - SAMPLE#2 CRYSTALA 010, 10, 000847 - SAMPLE#2 EXAMPLEOF2PATIENTS (10TUBES) Calculations % Excretion = Average CPM (Sample ) − CPM (Backgr CPM (Diluted Rubratope − 57) − C NORMALRANGE:>10%excretion(borderline7-9%) IfExcretionisNormal Pourremainingurinedowntheradioactive wastesink,flushwithwaterandrecord microcuriesdisposedofonradioactive wastelog. Reportresults. IfExcretionisAbnormal SendanaliquotofurinetotheChemistryLab foracreatininelevel. Discardremainingurineandrecordmicrocuries disposedofonradioactivewastelog. Reportresults. Includecreatinineresultsasng/ml. Commentoncompletionofcollectionas necessary. CommonInterferences • Laxatives, enemas or barium studies administered during the test. • Gamma emitting isotopes administered before or during the test e.g. ISOTOPE SCAN T1/2 - physical Iodine - 131,123 Thyroid 8 days, 13 hours Technetium-99m Brain 6 hours Technetium-99m Bone 6 hours Technetium-99m Renal 6 hours Technetium-99m Lung 6 hours Gallium - 67 Whole body 3 days
  • 46. 534 CLINICAL PRACTICES Miscellaneous Schilling Test Part II IfPartIoftheSchillingtestdocumentsmalabsorptionof vitaminB12,PartIIisperformedtotestforintrinsic factordeficiencyasthecauseofmalabsorption. Adoseofcommercialintrinsicfactorisgivenalongwith theradioactiveVitaminB12. Normalpercentexcretionindicatesintrinsicfactor deficiency. Abnormalexcretioneliminatesintrinsicfactordeficiency as the cause of malabsorption but is otherwise indiscriminate. InstrumentsandEquipment IntrinsicFactorConcentrate(1N.F.x1unit/capsule), Squibb. SeePartI. Specimen 24hoururine PatientPreparation Exceptforthefollowingchanges,proceedasoutlined inPartI. PERSONALLY givetothepatientandwatchhim swallowaRubratope-57capsulealongwithanintrinsic factorcapsule. NORMALRANGE:SameasPartI References SchillingRF.IntrinsicfactorstudiesII.TheEffectof GastricJuiceontheUrinaryExcretionofRadioactivity AftertheOralAdministrationofRadioactivityB12. J LabandClinMed;1953:42:860. Med1955;45:926. ALLOW AT LEAST 3 DAYS BETWEEN PART I AND PART II SchillingRF,ClatanoffDV,andKorstDR.Intrinsic factorstudiesIII.FurtherObservationsUtilizingthe UrinaryRadioactivityTestinSubjectswith Achlorhydia,PerniciousAnemiaorTotalGastrectomy.J LabandClin SCHILLINGTESTINSTRUCTIONS X=STARTINGTIME/INGESTIONOF57CoCAPSULE AFTERSWALLOWINGTHEVITAMINB12CAPSULE: Youmayeatalightbreakfast(coffee,tea,juice,toast) ATX+1HOURAM Youmustreturntothelabat X+2HOURSAM STARTINGNOW, Saveallofyoururineforthenext24hoursinthe containerprovided. Returnthecollectedurineatyourconveniencetomor- rowbetween8:00a.m.and5:00p.m. SHOULDANYOFYOURURINEFORTHENEXT24 HOURSBEDISCARDEDBYMISTAKE,PLEASENOTETHE TIMEANDTHEAPPROXIMATEAMOUNTLOST. PLEASEHANDLETHECOLLECTEDURINEWITHCARE. THEMATERIALCONTAINEDWITHINTHECAPSULEYOU HAVESWALLOWEDISSLIGHTLYRADIOACTIVE.PART OFTHISMATERIALISEXCRETEDINYOURURINE. ANYSPILLAGESHOULDBETHOROUGHLYWIPED-UP ORWASHEDOFFOFTHEAREAINVOLVED.
  • 47. 535 NUCLEAR MEDICINE Miscellaneous DISTRIBUTIONOFSCHILLINGTESTRESULTS1981-1984 N=417 0 1.25 2.5 3.75 5 6.25 7.5 8.75 10 11.25 12.5 13.75 15 16.25 17.5 18.75 0 10 20 30 40 50 60 % EXCRETION CONCLUSION:Distributionsuggeststheadditionofaborderlinerange. NormalRange: >10% Excretion Borderline: 7-9%Excretion
  • 48. 536 CLINICAL PRACTICES Miscellaneous Procedure for Counting Samples for The Schilling Test UsingMicromedics2/200ScintillationCounter TheMicromedicsscintillationcounterisadualsodium iodide detector system designed primarily for radioimmunoassayworkandotherlimitedinvitronuclear medicinestudiesusingverylowlevelsof125Ior57Co. Itisnotsuitableforgeneralgammascintillationcount- ingduetolackofsufficientshieldingbetweendetectors andnon-linearityathighercountingrates. Itisnotsuitablefor99mTcredbloodcellvolumestudies aswenowperformthem. GeneralInformation The system should be left on at all times. Test tube holdersmustbeloadedontothelefthandsideofthe countersurfacewithpositionnumber1attherightside oftherack. Only12mmx74mmplastictubesshouldbeused.Caps whichprotrudeabovethelinepositionedatthetopof thetubescannotbeused.Corkstopperswhichcanbe pushedintothetubebelowthismarkshouldbeused. Uncappedsamplesshouldnotbecountedinthissystem duetothepossibilityofspillageandcontamination. Thesystemhasnostorageordatahandlingcapabilities. Alldatamustbeenteredatthebeginningofeachassay. Backgroundcountratesmustbedeterminedforeach detectorandvaluesenteredatthebeginningofeach assay. Theenteredvaluewillthenbesubtractedfrom allcounts. Countingtimescanbesetfrom0.1to25minutes. Out- put from the system includes assay number, tube number,countingtimeandbackgroundcorrectedcounts perminutewithamaximumofsixdigits. Allinputandoutputtothesystemisthroughthekey- board/printer. The cap-lock must be depressed at alltimes. BackgroundLevelDetermination Placetenuncappedtubesinarackandplaceonleftside ofcountersurface. Placerackasfarforwardaspos- sible. Releaseretainingarmandallowittogoforwarduntil contactwithtuberackismade.Clearalltesttuberacks fromrightsideofcountersurface. Press“teletypeinput”buttonlocatedoncontrolpanel Usingtheprinterkeyboard,respondasindicatedbelow Someentriesmustbefollowedbyareturnothersdonot. PrinterOutput OperatorResponse Input(A-Assay;S=Stat;T=Tape): A AssayNo.: (enterany#) Comment: BG, Date CountingTime(min): 1 Isotope(I=Iodine;C=Cobalt) C No.Tubes: 10 TubeSize: L BackgroundCounts(CPM): A: 0 B: 0 Press“Start”ButtononControlPanel-Assaywill proceedautomatically. Tocalculatebackgroundlevelstobeenteredinassays performedduringthedaydeterminetheaveragecpmfrom theoutputdataasfollows: Averageofpositions1to5isthebackgroundlevelfor detector“B.” Averagepositions6to10isthebackgroundlevelforde- tector“A.” Record thesevaluesinthedailylogbook.
  • 49. 537 NUCLEAR MEDICINE Miscellaneous DailyConstancyUsing129ISealedSources Obtain129Isourceslabeled“A”and“B.” Placesource“A”inpositionnumber6. Placesource“B”inpositionnumber1. Leaveotherpositionsempty. Proceedasaboveforbackgrounddeterminationexcept enterthefollowing: Comment: 129I,Date Isotope(I=Iodine;C=Cobalt) I No.Tubes: 6 BackgroundCounts(CPM): A: (enter#’sfromabove) B: (enter#’sfromabove) OutputData: Valuefromposition#1isthe129IcountsfordetectorB. Valuefromposition#6isthe129IcountsfordetectorA. Recordthesevaluesinthedailylogbook. CountingofSchillingSamples Loadsamplesasusual. Proceedasabove. Enterthefollowing: Input(A=Assay;S=Stat;T=Tape): A AssayNo.: (enterany#) Comment: PtNames,etc,Date CountingTime(min): 25 Isotope(I=Iodine;C=Cobalt) C No.Tubes: (enter#oftubes) Tubesize: L BackgroundCounts(CPM): A: (enterBGfromabove) B: (enterBGfromabove) Oldendorf Technique for Bolus Infection Thesubject’sarmispositionedslightlyelevated.Ablood pressurecuffisplacedontheupperarmandinflatedto about100mmofmercury,providedthatthisisbelow thesystolicbrachialarterialpressure. Thecuffisleftinplaceforaboutthreeminutes,causing adistentionofthevenouspoolinthedistalarmanda riseinthevenousbloodpressureinthedistalarmto exceedthecuffpressure. Thenthecuffpressureisfurtherincreaseduntilitsub- stantiallyexceedsthesystolicpressure(200-300mmHg). Thecirculationinthedistalarmisthuscutoffwiththe venouspoolstillinthedistendedcondition. Withthearmcirculationthusinterrupted,theradiophar- maceuticalisinjectedintotheantecubitalvein.Therate ofinjectionneednotberapid,sincethecirculationis completely interrupted by the inflated cuff. Asmallneedleispreferred. After the injection has been completed, the cuff is removedabruptlywhilefullyinflated. Theneedleisremovedlater. Nopressureisappliedtotheinjectionsitesincethismight impairvenousdrainage. Thecollapsingvenouspoolacceleratesdeliveryofthe bolusofinjectedradionuclidetotherightheart. Aftertheisotopeisinthevein,removalofthecuffcan bedelayedforperiodsofaslongasoneminutetopermit a final check of the instrumentation since the radionuclidedoesnotleavethedistalarmuntilthecuff isreleased.
  • 50. 538 CLINICAL PRACTICES Miscellaneous Injectthecontentsofonevialofstannouspyrophosphate containing1milligramofstannouschloridedihydrate. Twentyminuteslater,attacha4-waystopcock(MEDEX No.MX421)toabutterflysetandflushlinewitha heparin solution containing 10 units per milliter (100unitsin10mlnormalsalineattachedtoonearmof the stopcock). Insert a butterfly needle set into the patient’speripheralvein. Affixa6mlshieldedsyringecontaining740MBqof 99mTcpertechnetatetothefreeportonthestopcock. Withdraw3mlofwholebloodthroughtheheparinized catheterintothe syringecontainingthepertechnetate. Invertgentlyseveraltimes. Flushthecatheterusingthediluteheparinsolution. Incubatetheredbloodcellsandpertechnetateforatleast tenminuteswithoccasionalmixing. Injectusingbolustechniqueforflowstudies. Removeinjectionapparatusanddisposeinradioactive waste. Modified Method for The In Vivo Labeling of Red Blood Cells with Technitium Single Photon Emission Computed Tomography SinglePhotonEmissionComputedTomography(SPECT) hasbeendemonstratedtoimproveimagecontrastin studieswhereoverlyingorunderlyingactivitymakes standard planar scintigraphy difficult to interpret. TherawdataforaSPECTstudyconsistsofasetof projectionscollectedbyagammacameracapableof rotatingaroundthelongaxisofthepatient. Thesepro- jectionscanbecollectedovereither180or360degrees. SPECTrequiresanincreasedvigilanceinbothquality controlproceduresandpatientdatacollectionprocedures. Anactivequalitycontroleffortisnecessarytoensure adequatecamerauniformity,patientpositioning,isotope peakingandotherrelateditemswhichsimplydonot matterasmuchinconventionalplanarimaging. NecessaryQualityControl Acurrentvaliddatacalibrationsetconsistingof:center ofrotation(COR)data,gain(mm/pixel),anduniformity correctionmask. Radiopharmaceuticals All TimeofImaging Consistentwithstandardplanarstudyrequirements strikingabalancebetweenadequatecountdensityand patientmotionartifacts. Maximumpatienttoleranceisapproximately40minutes, but most SPECT acquisitions are between 20-30minutes. PatientPreparation Thepatientshouldunderstandtheimportanceofholding stillfortheentirestudy.Thecamera’smotionshouldbe demonstratedtothepatientduringpositioning.
  • 51. 539 NUCLEAR MEDICINE Miscellaneous PatientPositioning Thegoalisobtaintheminimumradiuscircleaboutthe patientthatcontainsalloftheareaofinterestineach projection. Usuallythepatient’sforearmsareelevatedabovetheir headandrest ontheirforehead. Abouthalfwaythrough thestudy,thepositionofthearmsarecarefullyswitched. Thisdecreasesoverallthepatienttocameradistance andallowsasmallerradiustobeused. Atleastonecompletemanualrotationofthecameraat thefinalradiusofrotationmustbeperformedtoensure patientsafetyandcameraclearanceduringtheimaging sequence. Withthenewercameras,auto-contouringispossible(see sectiononautocontouringforSPECTacquisitions). FinalSPECTChecklist Priortoinitiatingthescan,afinalcheckmustbemade ofallcameracontrols: SPECTOrientation PeakandWindow(15%)Set MagSetting: Center MakesurethatCORanduniformitycorrections arecurrent. Setnumberofprojections Settimeperprojection Set180or360degreeacquisition Recordpatientdata NumberofAngles FullcirclerotationswiththeMS-2camerasare acquiredwith96anglesfireachhead. Half circle collections are also acquiredwith96 anglesforeachhead. TimeperImage Theaccompanyingchartindicatestotalstudy times for combinations ofimagetimesand numberofangles. DegreesofRotation Generally201Tlisimagedover180degrees. Allotherradiopharmaceuticalsareimages over360degrees. FloodCollection Allstudiesmustbefloodcollectedusingthe currentcalibrationdataset. Ifthereareques- tionsaboutthis, pleasechecktoseewhichdata setiscurrent. Thisstepisimportant. ComputationalAnalysis Afteracquisition,theprojectiondataisreconstructed usingastandardfilteredbackprojectionalgorithm. Priortoreconstruction,makesurethatthefloodandCOR correctionsareturnedonandthatdatafromthecorrect numberofcameraheadsisbeingreconstructed. Formostapplications,anorder=7Butterworthfilteris used for reconstruction. The frequency cut-off is dependentontheparticularradiopharmaceuticalthatis beingimaged. Asageneralguide,thefollowingvalueshaveprovento beuseful: Bone 0.7, Brain 0.6, 67Ga and 111In 0.4. Different filters can be tested with filter selection routineontheICONcomputer. Ifyouarenotsureofthe correctfiltertouse,makeyourbestguessandreview theresultswiththestaffphysician. ForbrainSPECTstudies,attenuationcorrectionshould beperformedusingtheChangalgorithmontheICON computer. SPECTdataacquiredforotherareasofthebodyshould notbeattenuationcorrected. DataAcquisition BecauseSPECTcollectionsrequirespecifyingmany pieces of information a study should be planned aheadoftime. Thefollowingchoicesmustbemade: MatrixSize Most SPECT studies are acquired with a 128x128 matrix, however for low count collections(e.g.,201Tl)a64x64matrixmaybe preferable.
  • 52. 540 CLINICAL PRACTICES Miscellaneous Quality Control Procedures for Scintillation Cameras Policy Goals Thequalitycontrolprogramhastwogoals: Examinationofthecamerasforpotential safety hazards. Examinationoftheperformanceofscintillation cameraswhenimagingtestobjects. Qualityassuranceandsafetycheckswillbemadein accordwiththeprotocolsdescribedbelow,underthe directionoftheoperationmanager. Theoperation managerwillreviewtheperformanceoftheinstruments daily,monthly,and/orquarterlyandrecordtheresultsof his/herreview. In the event that a malfunction or safety hazard is detected, the operation manger is responsible for initiatingactionstoremedytheproblem. Iftheproblemisdeemedtobeserious,eitherintermsof degradedimagequalityorposesasafetyhazard,the operation manager will terminate the use of the instrumentuntiltheproblemisremedied. Thequalityassuranceandsafetyprogramincludes checksoneachcamerawhichareperformeddaily, beforethestartofpatientexaminations,andmonthly and/orquarterlyasindicatedbelow.Theresultsofthese checksandmeasurementswillbepreservedasarecord and will be available for quarterly review with aradiologicalphysicist. DailyCameraQualityControl QualityControlistobeperformedpriortothestartof patientstudies. Eachtechnologistwillberesponsible forperformingdailyQContheircamera,oritwillbeup totheindividualwhomaybeusingthecamerafirst. QCistobeperformedinaccordancewiththehandout youreceived. Thiswillconsistofanextrinsicuniformity floodperformeddailywithresolutionphantomperformed onceaweek. TherearepredefinedacquisitionssetupnamedDAILY QConeachsystem.Thisinformationistobedocumented inthebinderassignedtoeachcamera. EachcamerahasaPatientheadernamed“DailyQC”, withthenameofthecamera.Pleaseselectthisheader toacquireallfloodsinordertomakerecordkeepingand backingupsimple. Ifyouhaveanyquestions,please consultoperationmanager,George Desko. ScintillationCameraSafety Reportanyproblems totheoperationmanagerimmediately. Protocol Checkthemovementofthecamerahead.Doesitmove smoothlyandrespondtothecontrols? Arethereany looseknobsordialsordialsontheconsole? Checkfor frayedorcutcables. Areallcablesfixedinplaceso thatmovementofpersonnelorpatientsinthevicinity arenotimpeded? Ifthecamerascansinarectilinearmotion,thismove- ment should also be checked. If the camera head rotatesforSPECTimaging,checkthattherotationwill notbeimpededbyobjectsinitspath. Makesurethat noobjectsimpedethescanmotion. Thecameraheadshouldalsobecheckedtoensurethat thecollimatorisfirmlyattached;thereshouldbenoloose ormissingattachmentfixtures(e.g.,nutsorbolts).Check thepatientbed.Makesurethatitisclearofextraneous objectsandfirmlysetinplace. Safetychecksshouldbeperformeddaily.
  • 53. 541 NUCLEAR MEDICINE Miscellaneous DailyProcedures Thedailyprocedurechecksthe: Energyspectrum, Fieldofuniformity, and Imagedisplayand/orphotographysystem Mostcameraswillbecheckedwithauniformflood phantom,withthe99mTc-collimatorinplace. Protocol Placethecameraheadsothatthecollimatorisfacing upwardandlevel. Anintrinsicfloodcanbeperformed instead,checkwiththeoperationsmanagerfordetails. Placeanabsorbentsheetonthecollimatortoprotect againstradioactivecontamination. Placethefloodsourceontheabsorbentsheetsothat thecenterofthesourcecoincideswiththecenterofthe collimator. Setthepulseheightwindowto20%andcenteritonthe photopeakforeither57Cobalt-57or99mTc-asappro- priate. Checkthecenteringofthepeakandrecordthe setting.Thissettingshouldnotchangemuchfromday today. Ifunusualchangesarenoted,informtheopera- tions manager. Record and inspect a pulse height spectrum. Verifythatthephotopeakisclearlyviable. Notethecountrate. Thiscountrateshouldbelessthan 20,000 CPSanditshouldnotvaryappreciablyfromday todayifthesamefloodsourceandcollimatorareused. Reportvariationsincountrateof10%ormoretothe operationmanager. Forsmallfield-of-viewcameras: 1millioncountsshouldberecorded. Forlargefield-of-viewcameras: Atleast3millioncountsshouldbe recorded. Inspectthefloodimage. Wheninspectingtheuncorrected floodimage,somevariationisacceptable,butthereshould benoregionswhichareverydarkorlight. Thecorrec- tionfloodshouldappearuniform. PlaceafilmrecordingofthefloodimageintheQCbinder foreachcamera. QuarterlyProcedures StationaryCameras For each camera and each collimator used on that camera,acquirea20millioncountfloodwithand/orwith- outthecorrectioncircutryswitchedon. (Switchingthis circuitonandoffisnotpossibleonsomecameras.) Useacomputerizedacquisitionanddisplayifavailable. ForSPECTcameraswithmultipleheads,uniformity measurementsshouldbemadeforeachhead. Inspecttheimagesfordefects. Defectsappearingat thesamelocationprobablyarisefromnonuniformity problemsinthecamera. Defectswhichappearona single image or move from place to place indicate damagetothecollimator(s). If the computerized data system has QC software, removethecollimatoranduseapointsourcetomeasure uniformity and run that program to determine the integralanddifferentialuniformity. Theoperation managerand/orphysicistshouldreviewthesedatafor the quarterly report and ensure that the camera is operatingwithinspecifications. PlacerecordingofthisinformationintheQCbinderfor eachcamera. Foreachcamera,measurethedesignatedresolutionphan- tom.Usuallythisprocedurewillbeperformedwiththe collimatorremoved.Barphantomsorlinephantomscan beused.Ifcomputerizedacquisitionand/oranalysisis availableitshouldbeused. Quality Control Procedures for Stationary and SPECT Cameras Acquireafloodimage. Iftherearecorrectioncircuits, recordthefloodtwice,withthecircuitsswitchedoff andon(ifapplicable). Ifthecameraisconnectedtoa computerizeddatasystem,itshouldbeused. Inaddi- tionifanalogimagesareusedforpatientstudies,the floodimageshouldalsoberecordedusingthatdisplay.
  • 54. 542 CLINICAL PRACTICES Miscellaneous Forbarpatterns,collect20millionevents. Useanappropriatesource,sothecountrateisbelow 20,000cps. Examinethepatterns. Arelinesvisiblein allquadrants?Allbutone? Inthelattercase,compare withacceptancetestingorlastquarterlycheck.Check theimageforlinearity.Nonlinearityisevidentwhenthe linesarewavy. Barrelorpincushiondistortionmayalso bepresentandshouldbenoted. UsetheSPECTcollimatorforclinicalimagingwith99mTc. Usetheclinicalreconstructionparametersusedforbrain imagingwith99mTc. Checkresolutionagainstacceptancedata.Imagesofrod sourcesshouldberound. Checkuniformitywithattenuationcorrection. Bullseye patternsshouldnotbevisible. RecordimagesandplaceinQCbinder. MonthlyProcedures SPECTCameras Performthecenterofrotationprocedure,asdescribed bythemanufactureroftheSPECTcamera. AcquireandreconstructimagesofSPECTresolution/ uniformity(Jasczak)phantom. Ifpossible,placethe phantomonanextendersothatitdoesnotrestonthe patientbed. Insomecasesyoumayusethepatient headrestassupport,withthephantomtapedinplace. Settheradiusinrotation(orpositionheadsonmultiple cameras) to 10 cm, or just big enough to clear the phantom. Manually test the head rotation to ensure that the cameracanrotatefreely. Acquireatleast500,000eventsateachangle. Usea clinicalacquisitionprocedure,makingsurethatthe acquisitionisperformedin128x128formatandwith atleast64angularsteps.Keepthecountrateunder 20,000cps.
  • 55. 543 NUCLEAR MEDICINE Camera Number: Manufacturer: Date: Evaluation of uniformity: Evaluation of Resolution: Evaluation of Linearity: Evaluation of SPECT performance: 1) Uniformity 2) Resolution Reviewed by: Operation Manager: Physicist: QUALITY CONTROL REPORT for SCINTILLATION CAMERAS
  • 56. 544 CLINICAL PRACTICES DAILY QUALITY CONTROL LOG for SCINTILLATION CAMERAS CAMERA NAME / NUMBER: DATE ENERGY COUNT COLLIMATOR SAFETY FLOOD SIGNATURE SETTING RATE CHECK QUALITY
  • 57. 545 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Imaging of Cellular Injury Antimyosin Imaging of Infarct, Myocarditis, and Transplant Rejection Antimyosinisanantibodyfragmentdirectedagainst cardiacmyosin. Cardiacmyosinisonlyavailablefor bindingwithitsantibodywhenthecardiacmusclecells havebeendamaged.Undersuchconditions,holes developinthecellmembraneandthemyosinfibrils becomeexposedcirculatingantimyosin. Becauseantimyosinbindstomyosininareasofirrevers- iblydamagedcardiacmusclecells,itcanbeusedasa marker for myocardial cell necrosis in infarction, myocarditis,andhearttransplantrejection. InstrumentsandEquipment Large field of view camera with medium energy collimator. Radiopharmaceutical 111-Inantimyosin TimeofImaging Imagingperformed72hourspostinjectionforplanar imaging. IfSPECTisused,itshouldbeperformedat48 hourspostinjection. Dose 111-Inantimyosin = 74MBq PatientPreparation None PatientImaging StaticImages: Anteriorand45oLAOviews,20 minuteseach. SPECT: Optionalonstaffphysiciandiscretion. PriortoSPECTimaging,planaranteriorand LAOimagesshouldberecordedfor10minutes each. Imaging of Ventricular Function Gated Cardiac Blood Pool Gated First Pass and Equilibrium Toevaluateoverallsizeandglobalandregionalfunction by use of an intravascular label and a scintillation cameraoperatedinsynchronytothepatient’scardiac contractions. InstrumentsandEquipment Regularorlargefieldofviewcameraaccompaniedbya computer.Usegeneralallpurposecollimatorforentire study. Radiopharmaceuticals 99mTcRedBloodCells 99mTchumanserumalbumin(HSA)maybeusedfor: portable studies; otherpatientswhohavelimitedI.V.access, afterapprovalbystaffphysician. TimeofImaging Initiateuponinjectionoflabeledredcells. Dose 740MBq - Adult Webster’sRule - Pediatric NUCLEAR CARDIOLOGY
  • 58. 546 CLINICAL PRACTICES Nuclear Cardiovascular Procedures PatientPreparation 99mTcRedBloodCells Reconstitute vial of stannous pyrophosphate with 3millilitersofsaline.Dispenseentirevialofreconstituted solutionintosyringeandinjectintravenouslyintopatient. Wait20minutes. Insert19gaugebutterflyintorightarmveinandwith- drawnexactly3mlofbloodintoshielded6ccsyringe containing740MBqTc99mwithheparinandsalineand invertseveraltimes.Allowtoincubateinsyringeforat least10minutes. Pleasenotethatsyringesaretobekeptwarminspecial holder-refertotaggingprocedure. Whiletaggingisoccurringplaceelectrodesonpatient; onebeloweachclavicleandoneovertheleftsidebelow theribcage. 99mTchumanserumalbuminwillbepreparedbythe Radiopharmacy. Administration Bolusinjectionwith10mlsalineflush. PatientPositioning GatedflowstudyusingOldendorftechniqueinthe30o rightanterioroblique(RAO). 30o-60oleftanterioroblique(LAO),whicheverbest showsuniformseptalthickness.(ThisinsuresLVEF measurementifstudyterminatedearly.) Anterior. LeftPosteriorOblique(LPO)withpatientprone,[patient maybedoneprone],patientmaybedoneonrightside onlyasalastresort. Theleftventricleshouldbeinthe horizontalpositionandseenin itslongaxis. DataAcquisition Acquire5cmCo57markerimage,duringLAOprojection. TechnicareCamera/ONseries Type“POP”andselectUtilitiespartition. UnderUtilitiesselect“Cardiac”. Insertaprepared patientdiskandmountindrive. Tocreateanewstudyheadertype(WRITE)andselect (CREATE A NEW STUDY), and type in patient information. Depress CTRL 1 (Function Button 1) and follow commands. IftheECGtracingandintervalarecorrectsayyesand remembertheintervalasthiswillbetypedinagainfor theleftsideofflowstudy. BeforeinjectionisbeingdoneusingOldendorftechnique pressreturnandtypeingivenintervalagainandpress return. Inject. Astheactivitybeginstofillinthelungswaitapproxi- mately4sec.andpressCTRLS.Thiswillautomatically stopacquiringtherightsideofstudy. Presscamerastart/stoptoacquireleftsideofstudy. (In somecasesthepatientstransittimewillbeextremely rapidorslow,useyourowndiscretionforstartingand stoppingacquisition). Whenthisiscompletedwriteinformationtodisk. Type (WRITE)andselectcurrentstudy(C)youwillhave 3 choices under current study, select New Set and answerquestions. Labelforimages: Viewcompleted. Startingimagenumber: H Byte(B)orWord(W): W NumberofFrames: e.g.32forFirstPass andLAO. Tocompletetheother3viewstypeMGAQandanswer thefollowingquestions: Continueprocessingcommands: N Stop acquisition: D Stopping density: 300 for Ant.,andLPO,200forLAO. Enabletracking: N Frames: 18frames perviewforAnt andLPO; 32forLAO. Writetodiskonlythefirst16frames. TransfertoSiemensICONsystemusingNUMAcomputer.
  • 59. 547 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures ComputationalAnalysis Ejectionfractionanalysisisrequireduponcompletionof thestudy. IfprocessingTechnicareSystem thenfollowstepsbelow. Torecallanimageset: ToType(READ)andselect(CURRENT)study. Chooseimagesetnumber. Startingimagenumber: H1 RecalltheLAOviewtodotheejectionfractionanalysis. Normalizeentiresetofframes(CNTNH1,H1:16). GradientMICAisroutinelyusedforanalysis. DoSUMframes—tochecknumberofcounts/frames. If thedifferenceisglobalcountsbetweenthefirstandlast frameexceeds15%,thenperformcountnormalization (CNTN)priortotheejectionfractionanalysis. Type(MICAG)andanswerquestions. Frames: (H1:16) Wishtosmoothimages: (Y) Createbackground:Backgroundshouldbe takenatabout3o’clocktotheleftventricle avoidingtheaortaandspleen. Afterbackgroundsubtractionsetboxtoencompass entireleftventricleavoidsurroundingstructures. Once youhavedonethisthecomputerwillautomaticallystep througheachframeandcalculateanejectionfraction. Photographtheresult. Alongwithejectionfractionanalysis,strokevolume imagesoftheanteriorandLAOshouldbetakenwith originaldate. Todoastrokevolume(MOV)theend systolicframetoH2,andpress(CTRL3),function button3. Comments: ObtainstrokevolumeofeachAnteriorand LAOprojectionandphotographalongwithendsystolic andenddiastolicimages. SiemensICONSystem TakediscfromO-NcomputerandinsertinNUMA Systemcomputerininterpretationroom.Followscreen instructionandselectTechnicare5.25floppyoptionto transferdataandregisterpatientinICONdatabase. Oncepatient’sstudyhasbeentransferredtoICON system,useAuto-EFprogramtoobtainejectionfraction measurement.Auto-EFoutputshouldbeconfirmedby visualinspectionofthedataandifquestionablerepeated usingmanualmode. Torecorddatatodeterminerightandleftventricular functionwithin30secondsofinjection. Thisprocedure canbedoneatrestorinconjunctionwithexerciseor pharmacologicstress. InstrumentsandEquipment Gammacamerawithallpurposeparallelholecollimator orwiththe30degreeslantparallelholecollimator. Computerequippedwithafixeddiskdrive(torecorddata athighrates)(MCS-560orequivalentwithaWinchester drive). Radiopharmaceutical Tc-99mRBC;Tc-99mDTPA. TimeofImaging Inconcertwithinjection. Dose 555MBq - Adult Webster’sRule - Pediatric PatientPreparation None(withDTPAorpre-administrationofstannous solutionifRBC’sareused). Administration Oldendorfinjectionthroughalargeantecubitalvein. Dataacquisitionshouldcommencepriortoinjection. Ungated First Pass Ventriculogram NUCLEAR CARDIOLOGY
  • 60. 548 CLINICAL PRACTICES Nuclear Cardiovascular Procedures PatientPositioning Patientisplacedsupine. Thecameraisrotatedtoa 30degreeRAOpositionwhentheparallelholecollima- torisusedorintheanteriorpositionwiththeslanthole collimatorrotatedtoachievea30degreeRAOposition. Checklocationoftheheartinthefieldbymovingasource fromtherightsternalbordertothepointofmaximal impulseoftheLVandfromthexiphoidtotheangleof Louis. DataAcquisition Set camera for Tc-99m with a 30% window. Set computerforadiskacquisition(DSKAQ)forapresettime of50milliseconds/frameinahexant(64x64)acquisition foratotal1200frames(60seconds)inbytemode. Startcomputer1-2secondspriortoinjection. Afteracquisitioniscompleted—computer willprovide message“RECONFIGURATIONDATASET”—onlyafter thisiscompletedcanthedatabereviewed. ComputationalAnalysis Performread+1,1,H1:100toaddtothefirst100frames (3seconds)ofdatatoflagtheregionoftheRAandRV. DrawtheRAandRVregionsofinterest. Performread+ 1,1000,H2:100toadd100framesofdataforassess- mentofLAandLV. PerformSETRwithRH1,etc.toflagatriaandventricles. ThecurvesforRVandLVwillhavetobegenerated separately,sincethecurveprogramcanonlyhandle256 frames. Smooththecurves3times. Analyzeforthepeakcounts (enddiastole)andminimumcounts(endsystole)/cardiac cycle. Todiscloseabnormalitiesincardiacfunctionthatmight notnormallybeseenwithoutphysiologicstress. InstrumentsandEquipment Regularfieldofviewcamerawithcomputer. 12lead ECGmachine.GAPcollimator. TimeofImaging ImmediatelyafterinjectionoflabeledRBC’s. Dose 25MBq - Adult Webster’sRule - Pediatric PatientPreparation Injectpyrophosphateinsaline. Wait20minutesthen tagredbloodcellsasdescribedpreviouslyinthegated cardiacprotocol. Exercise Radionuclide Ventriculogram Administration Thefirstpasstechniquedoesnothavetobedoneinthis procedureunlessthereisaquestionregardingright ventricular function or valvular disease. Must be performedinexerciselaboratory. PatientPositioning ObtainaroutineANTandLAOgatedstudy. Placepatientinasupinepositionforthestress,andhave theECG techplacetheremainingleadsonthepatient. ObtainanLAOview,for3minutes. Thiswillbeyour pre-exercise. Checkwithcardiaccoordinatororcardiacfellowto determineifanLPOisnecessary. Thiscanbedoneup oncompletionoftheexerciseportionoftest. DataAcquisition UseGAPcollimatorand30%windowfor exercise portion. (POP)Utilitiespartitionandselect(Cardiac)set. For acquiring the stress, function button numbers 6and8areused. Uponcompletionofthepre-exercisestudy,theECGtech willsettheinitialresistanceontheergometerto25watts (150KPM). Radiopharmaceuticals 99mTcRedBloodCells.
  • 61. 549 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Patientsshouldexerciseatasteadyrateof60revolu- tionsperminute,for1minutestage. Whenpatientreaches75%ofpredictedmaximum(CTRL 6) and follow commands, obtain an LAO view for 3minutes. Whenthisiscomplete,positioncamerafor ananteriorviewforthesametime,using(CTRL6). CTRLF),thiswillallowthelastcardiaccycletobe completed. Depress(CTRL8).Itwillthenask“LABELFORIMAGES” andfillinlabel,eg.PREEX,anteriorandLAO,andhit return. Studywillnowbewrittentodisc. ItisimportantthattheECGelectrodesaresecurelyon patientsothatthereisnoartifactsignaldetectedby computer. Irregulargatingcancausemisinterpretation ofastudy. Thisstudymaybeperformedwithpharmacologicalstress usingdobutamineandeitherplanarorSPECTimagingof thecardiacbloodpool.Detailsofthedobutaminestress protocolandSPECTimagingofthecardiacbloodpool aregivenbelow. ComputationalAnalysis Ejectionfractionanalysisshouldbeperformedonthepre- exercise,pre-maxandmaximumexerciseviews.Stroke volumeimagesontheanteriorandLAOviewsshouldbe takenalso. Gated SPECT - Myocardium Toassessregionalwallthickeningandmotionaswellas globalleftventricularfunctionsimultaneouslywith myocardialperfusion. InstrumentsandEquipment SiemensorbiterorMS-3withanallpurposeparallelhole collimator. Radiopharmaceutical Tc-99m-MIBI. Dose 900MBq - adult WebstersRule - Pediatric PatientPreparation None Administration InjectTc-99m-MIBIwiththepatientatrest. PatientPositioning SupineonSPECTimagingtable. DataAcquisition SetcamerapulseheightanalyzerforTc-99mwitha20% window. Choosepre-setacquisitionprotocolforgated SPECTfromICONmenu.Pre-setacquires64anglesat 8s/view. Besuredataarestoredasindicatedbycomputerdisplay andaudiblesignalbeforeattemptingtoreconstructand viewimages. ComputationalAnalysis ScansareviewedusinggatedSPECTdisplayprogram whichpermitsvisualaswellassemi-quatitativeanalysis (regionalwallthickeningandglobalejectionfraction)of thedata. Regionswithreducedbloodflowatrestwillappearas zonesofreducedtraceractivityandsomaybedifficult toanalyze.GatedSPECTofthecardiacbloodpool(see below)maybemoreappropriateinsuchcases. NUCLEAR CARDIOLOGY
  • 62. 550 CLINICAL PRACTICES Nuclear Cardiovascular Procedures Gated SPECT - Cardiac Blood Pool Toassessglobalandregionalwallmotionofrightand leftventricles. InstrumentsandEquipment SiemensorbiterorMS-3withanallpurposeparallelhole collimator. Radiopharmaceutical Tc-99m-RBC’s(modifiedinvitrolabel). Dose 900MBq - adult WebstersRule - Pediatric PatientPreparation None Administration InjectTc-99m-RBC’swiththepatientatrest. Thallium - 201 Rest and Redistribution Toevaluatemyocardialperfusionatrest,usingaradiola- belwhichistakenuprapidlybynormalmyocardialcells. Testisusefultoevaluatemyocardialviabilitywhichis indicated either by a reversible rest defect or fixed defectofonlymild/moderateintensity. InstrumentsandEquipment Regularfieldofviewcamerawithallpurposecollimator andcomputer. PatientPositioning SupineonSPECTimagingtable. DataAcquisition SetcamerapulseheightanalyzerforTc-99mwitha20% window. Choosepre-setacquisitionprotocolforgated SPECTfromICONmenu.Pre-setacquires64anglesat 8s/view. Besuredataarestoredasindicatedbycom- puterdisplayandaudiblesignalbeforeattemptingto reconstructandviewimages. ComputationalAnalysis ScansareviewedusinggatedSPECTdisplayprogram whichpermitsvisualaswellassemi-quatitativeanalysis (regional wall motion and contraction by Fourier Analysiswhichcreatesphaseandamplitudeimages)of thedata. UseinplaceofgatedSPECTTc-99m-MIBIincasewere restingperfusiondefectsarelikely. Myocardial Perfusion Imaging Radiopharmaceutical Thallous-201Chloride Dose weight < 180 lb - 80 MBq weight 180-200lb - 100MBq weight > 200 lb - 120 MBq DONOTEXCEED130MBqTOTALADMINISTEREDDOSE. TimeofImaging 10minutespostinjectionofThallium-201;Delays completed3-4hourslater.
  • 63. 551 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures SPECTAcquisition Number of angles to collect. Half circle (180o) collections use64angles. Timeperimage:Formen>200lbs; Women>175lbs. Initial Delay MS-3: 25s/view-stressand 20s/viewrest Orbiter: 20s/view-stressand 15s/viewrest ElScint: 20s/view-stressand 15s/viewrest PatientPreparation It is not necessary for patient to fast before test. Patientshouldbeinjectedintheuprightpositionwhen possible. Ifpatientisonanintra-aorticballoonpump checkwithphysicianaboutwhetherornotpatientshould remainonpumpforthestudy. Maybeperformedat bedside. Administration Directlyintoavein,ifnotpossibleaperipherallinemay beusedprovidingnomedicationisrunningthroughit. Consultnurseifyouarenotpositive. PatientPositioning Planar,typicallyportable. InitialAnteriorH1,DelayH2 LAO50oH5,DelayH6 LAO70oH9,DelayH10 DataAcquisition Using80keVTl201photopeakwith25%window, 10minutesperview. Ifpeakcountdensityofleftventriclereaches400counts/ pixelontheinitialviewinlessthan10minutes,take remainingimagesfortheshortertimeinterval. Record timeforimagesonclinicsheet. Timeper image: Formen<200lbs;Women<175lbs. Initial Delay MS-3: 15s/view-stressand 10s/viewrest Orbiter: 11s/view-stressand 8s/viewrest ElScint: 11s/view-stressand 8s/viewrest 64x64x8matrix SpecialPlanarViews ItmaybenecessarytoobtainanadditionalLAOimage with patient in a right lateral decubitus position to eliminatediaphragmaticattenuation. Comments Thallium-201isalowenergyisotope. Attenuationis usuallyseeninheavyormuscularpeople,andespecially inwomen. Efforttoreduceattenuationshouldbemade byplacingthebreasttowardthecenterofthecheston obliqueviews. Recordtimeofinjectionandtimeof delayedimaging. ComputationalAnalysis Planar: Normalizationofimagesforinterpretationandrecording onfilm. Readinitialanddelayeddatasets(usually writtentogetherinthedelayedsetondisk). MOVQ1to Q2,MOVQ3toQ4. Usethebaselineknobtodeterminetheupper10%of countsinthemyocardiumintheinitialanddelayed images. Ratio the baseline counts of the initial to delayed. Usetheratiovaluetomultiplythedelayed imageinthatprojection. SPECT: Imagesarereconstructedbythetechnologistatthework stationofeachcomputer.ForTl-201SPECTreconstruc- tiondefaultparametersare:Butterworthfilterwithcut- off=0.5andorder=8. UseComparisondisplayoptiontophotographwhichis accomplishedovernetworklinkfromMac-ICONtoHelios printer. NUCLEAR CARDIOLOGY
  • 64. 552 CLINICAL PRACTICES Nuclear Cardiovascular Procedures Note: Thisprocedureisdoneroutinelyusingdosesthat aregreaterthanthoselistedinthemanufacturer’spack- ageinserts. Thechoiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisManualis madebythephysicianstaffofNuclearCardiology,in ordertoacquirethebestresultswhilecomplyingwith MGHIsotopeand/orPharmacyCommitteeguidelines.The nameofthenuclearcardiologyphysicianorderingany testthatislistedhereismaintainedinthefilesofthe radiopharmacy with the data on the patient and radiopharmaceutical. Thallium-201 Exercise Stress with Reinjection See also Stress Testing and Cardiac Emergencies Toassessmyocardialperfusionbyaradiolabelwhichis takenupbyintactmyocardiumroughlyinproportionto bloodflow. Inconjunctionwithastresstest,coronarybloodflow reservecanbejudged. InstrumentsandEquipment Any regular field of camera accompanied with a computerusinggeneralallpurposecollimator(GAP). ForSPECTuseOrbiter,ElScintorMS-3. Radiopharmaceutical Thallous-201Chloride Dose weight < 180 lb. - 80 MBq weight 180-200lb. - 100MBq weight > 200 lb. - 120 MBq DONOTEXCEED130MBqTOTALADMINISTEREDDOSE. TimeofImaging Commencingnotmorethanfiveminutesafterinjection. PatientPreparation Patientshouldbefastingbeforeexamandremainfast- ingexceptforwateruntilinitialimagesarecompleted. Start I.V. with 0.9% saline, except in the case of a hypertensivepersonwereD5Wistobeused. Insert21gaugeintracathintorightarm,avoidusingthe antecubitalfossaunlessabsolutelynecessary. Mustbe performedinexerciselaboratory. Administration Wheninstructedbythecardiologist,injectthethallium intothediaphragmoftheI.V.tubingclampingoffthe tubingproximaltothediaphragmtopreventthethallium frombackingupintothetubing. Onceinjected,openI.V.fullyandletrununtilpatientis movedtostretcher,thenI.V.canbesloweddown. Once the2minuteECGiscompleteremoveallelectrodes exceptthelimbleads,andmovepatientundercamera forimaging. PatientPositioning Planar: InitialimagesanteriorH1,50oLAOH5,70oLAOH9. DelayedimagesanteriorH2,50oLAOH6,70oLAO H10. SPECT: PatientsupineonimagingtableofSPECTcamera. DataAcquisition Planar: Using80keVTl-201photopeakwith25%window, 10 minutes per view; if peak count density of left ventriclereaches400counts/pixelontheinitialviewin lessthan10minutes,takeremainingimagesforthesame timeinterval. Writedigitaldatatodiscandrecordtime forimagesonclinicsheet. SPECT: Number of angles to collect. Half circle (180o) collections use64angles.
  • 65. 553 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Timeperimage:Formen>200lbs, Women>175lbs. Initial Delay MS-3: 25s/view-stressand 20s/viewrest Orbiter: 20s/view-stressand 15s/viewrest ElScint: 20s/view-stressand 15s/viewrest Timeperimage: Formen<200lbs,Women<175lbs. Initial Delay MS-3: 15s/view-stressand 10s/viewrest Orbiter: 11s/view-stressand 8s/viewrest ElScint: 11s/view-stressand 8s/viewrest 64x64x8matrix Whenpatientreturnsabout2-4hourslater,asecond injectionof37MBqofthalliumisadministeredwiththe patientsittingquietly. Approximately5minutesafterinjection,thesecond seriesofimagesarerecordedinthesamepositionsas theinitialseries. Retrievetheinitialstudyfromdiskand recorddelayedimages. ComputationalAnalysis Planar Normalizationofimagesforinterpretationandrecording onfilm: Readinitialanddelayeddatasets(usuallywrit- tentogetherinthedelayedsetondisk). MOVQ1toQ2, MOVQ3toQ4. Usethebaselineknobtodeterminethe upper10%ofcountsontheinitialandonthedelayed images. Usetheratiovaluetomultiplythedelayed imageinthatprojection. SPECT Imagesarereconstructedbythetechnologistatthework stationofeachcomputer.ForTl-201SPECTreconstruc- tiondefaultparametersare:Butterworthfilterwith cutoff=0.5 and order=8. Use Comparison display option to photograph which is accomplished over networklinkfromMac-ICONtoHeliosprinter. Note: Thisprocedureisdoneroutinelyusingdosesthat aregreaterthanthoselistedinthemanufacturer’spack- ageinserts. Thechoiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisProcedure ManualismadebythephysicianstaffofNuclearCardi- ology,inordertoacquirethebestresultswhilecomply- ingwithMGHIsotopeand/orPharmacyCommittee guidelines. The name of the nuclear cardiology physicianorderinganytestthatislistedhereismain- tainedinthefilesoftheradiopharmacywiththedataon thepatientandradiopharmaceutical. Dipyridimole Thallium Stress Study with Reinjection Radiopharmaceutical Thallium201; Persantine-useIVinfusionpumpand administertotaldoseof0.56mg/Kg over4min(142 mcg/Kg/minX4min). InstrumentsandEquipment StandardTl-201threeviewimageswithregularfieldof viewcameraandcomputer. TimeofImaging 0min- Begininfusion,monitorHR,BP,ECG Q1min (notesideeffects)—severesymptoms(chestpain, nausea/vomit, profound drop in BP, etc. reversed AminophyllineIV,25-250mg(usually50mg). 4min- D/CPersantineinfusion. Continue0.9%NS infusion. ContinuetomonitorBP/P.Exercisebywalking atzerogradeontreadmilltoraiseBPtoatleastbaseline level. 10min-InjectTl201. ContinueIVinwideopendripfor 2minuteandthenmaintainopenat1mlperminute. 18min-Beginimaging. Dose weight < 180 lb. - 80 MBq weight180-200lb. - 100MBq weight > 200 lb. - 120 MBq Thallium201IV74MBq,use20-22angiocath,maintain 0.9%NSdrip. NUCLEAR CARDIOLOGY
  • 66. 554 CLINICAL PRACTICES Nuclear Cardiovascular Procedures PatientPreparation Patientsshouldbefastingpriortothisexamination. Nothingtoeatordrinkforatleast6hours,andnomajor mealforatleast12hours. Alightmealorclearliquids areacceptableupto6hoursbeforetheexamination. PersantinebyIVinfusionpump(142mcg/Kg/minX4min). RestingBP-HRx2. PatientPositioning Supineontablewithperipheraland12leadECG. Administration FillinfusionsyringewithPersantineandsalinetoatotal volumeof50ml. Flushline(15mlvol);andbegininfusion4minutes. Totaldose: 0.56mg/kgover4minutes. Comments AminophyllinereversesthesideeffectsofPersantine. Usually no more than 100 mg need to be given IV. ALLpatientsaretobegiven50mgAminophyllineat completionoffirstimage. DataAcquisition Planar: Using80keVThallium-201photopeakwith25%win- dow,10minutesperview;ifpeakcountdensityofleft ventriclereaches400counts/pixelontheinitialviewin lessthan10minutes,take remainingimagesforthe shortertimeinterval. Recordtimeforimagesonclinic sheet. SPECT: Numberofanglestocollect. Halfcircle(180o)use64 angles. Timeperimage.Formen>200lbs,Women>175lbs. Initial Delay MS-3: 25s/view-stress and20sviewrest Orbiter: 20s/view-stressand 15s/viewrest ElScint: 20s/view-stressand 15s/viewrest Timeperimage: Formen<200lbs, Women<175lbs. Initial Delay MS-3: 15s/view-stressand 10s/viewrest Orbiter: 11s/view-stressand 8s/viewrest ElScint: 11s/view-stressand 8s/viewrest 64x64x8matrix ComputationalAnalysis Planar: Normalizationofimagesforinterpretationandrecording onfilm: Readinitialanddelayeddatasets(usuallywrit- tentogetherinthedelayedsetondisk). MOVQ1toQ2, MOVQ3toQ4. Usethebaselineknobtodeterminethe upper10%ofcountsofinitialtodelayed. Usetheratio valuetomultiplythedelayedimageinthatprojection. SPECT: Imagesarereconstructedbythetechnologistatthework stationofeachcomputer. ForTl-201SPECTreconstruc- tiondefaultparametersare:Butterworthfilterwith cutoff=0.5 and order=8. Use Comparison display option to photograph which is accomplished over networklinkfromMac-ICONtoHeliosprinter. Note: Thisprocedureisdoneroutinelyusingisotope doses that are greater than those listed in the manufacturer’spackageinserts. Thechoiceofthe radiopharmaceuticalandthedoseforeachprocedure describedinthisProcedureManualismadebythephysi- cianstaffofNuclearCardiology,inordertoacquirethe bestresultswhilecomplyingwithMGHIsotopeand/or PharmacyCommitteeguidelines.Thenameofthenuclear medicinephysicianorderinganytestthatislistedhereis maintainedinthefilesoftheradiopharmacywiththe dataonthepatientandradiopharmaceutical. AlternativeFormsofPharmacologicalStress AdenosineandDobutamine.
  • 67. 555 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Thallium Adenosine/Dobutamine Stress with Reinjection AdenosineStressTests RecommendedProtocol The patient walks on the treadmill at 0% grade at 0.7-1.7MPHdependingonphysicalcondition. Assoonasthepatientbeginswalkinganditisclearhe/ shecanmaintaintheselectedpacebeginadenosine infusion(140ug/Kg/minX5minbyIVinfusionpump). At2minutesofadenosineinfusioninjecttracer(thallium orTc-99m-MIBI)andcontinueinfusionfor3additional minutesprovidednoadverseeffectsoccur. Discontinueadenosineafterthe5thminuteofinfusion butcontinuetohavethepatientwalkfor2additional minutesafteradenosinehasbeenturnedoff. Exceptions/SpecialCases Patientswhohavehadastentplacedwithin4weeksof thetestmaywalkonthetreadmillat1.0-1.5MPHand 0%grade.Ifthepatientcannotwalkthenarmweights maybeusedinstead. Elderly(>80yearsold)oranyseverelydebilitated patientwhocannotwalkorusearmweightsandwho maybeathigherriskforhighgradeheartblockwith adenosineshouldbeconsideredfordipyridamoleinstead. DobutamineStressTests Stage Dose Duration(min) 1 10mcg/kg/min 3 2 20mcg/kg/min 3 3 30mcg/kg/min 3 4 40mcg/kg/min 3 Patientsarestudiedinthesupineposition;noexerciseis performed.DobutamineisgivenbyIVinfusionpump. Dobutaminesolutionis250mgdobutaminein50mlN/S (5mg/ml). Isotope(Tl-201orTc-99m-MIBI)isinjectedat11:00of theprotocol,orearlieriflimitingsymptomsdevelop. Atropine0.25-0.5mgIVmaybegivenatthediscretion of the test supervisor if the heart rate response toDobutamineiswellbelow85%predictedmaximum. Maximumdose=2.0mg. Metoprolol2.5-10.0mgmaybegivenIVtoreverse Dobutamine-relatedside-effectsorischemicECG changes. See also Stress Testing and Cardiac Emergencies Toassessmyocardialperfusionbyaradiolabelwhichis takenupbyintactmyocardiumroughlyinproportionto bloodflow. Inconjunctionwithastresstest,coronary bloodflowreservecanbejudged. The stress test employed will vary with clinical circumstancesandmayuseanyofthefollowing: Treadmillexercise Adenosine Dipyridamole Dobutamine. InstrumentsandEquipment Any regular field of camera accompanied with a computerusinghighresolutioncollimatoronMS-3, Gap collimatoronElscintandOrbiter.ForSPECTuseOrbiter, ElScintorMS-3. Radiopharmaceutical Tc-99m-MIBI Dose 296MBqatstressand888MBqatrest. Tc-99m-MIBI Exercise Stress Study NUCLEAR CARDIOLOGY
  • 68. 556 CLINICAL PRACTICES Nuclear Cardiovascular Procedures TimeofImaging Commencingatleast30minutesafterstressinjection andatleast60minutesafterrestinjection.Ifhepatic activityexceeds myocardialactivity,imagingshouldbe delayedanadditional30minutes,wheneverpossible. PatientPreparation Patientshouldbefasting beforeexamandremainfast- ingexceptforwateruntilinitialimagesarecompleted. Start I.V. with 0.9% saline, except in the case of a hypertensivepersonwereD5Wistobeused. Insert 21 gauge intracath into right arm, avoid using the antecubitalfossaunlessabsolutelynecessary. Thepatientshouldbeaskedtorefrainfromeating(as muchaspossible)betweeninitialanddelayedimages. Administration Wheninstructedbythecardiologist,injectthetracerinto thediaphragmoftheI.V.tubingclampingoffthetubing proximaltothediaphragmtopreventthetracerfrom backingupintothetubing. Onceinjected,openI.V.fullyandletrununtilpatientis movedtostretcher,thenI.V.canbesloweddown. PatientPositioning Planar: InitialimagesanteriorH1,50oLAOH5,70oLAOH9. DelayedimagesanteriorH2,50oLAOH6,70oLAO H10. SPECT: PatientsupineonimagingtableofSPECTcamera. DataAcquisition Planar: Using140keVTl-201photopeakwith20%window. Targetmeancountdensityoverleftventricleof700 counts/pixelontheinitialviewinlessthan10minutes, take remaining images for the same time interval. Writedigitaldatatodiscandrecordtimeforimageson clinicsheet.Use64x64wordmodematrix.Whilea precisemeancountdensityisdificulttodetermine,the 700CTS/MINfigureshouldapplytonormalmyocardium, notforexample,toa“hot”Papillarymuscle. SPECT: BecauseanSPECTcollectionrequiresspecifyingmany piecesofinformationanSPECTstudyshouldbesetup aheadoftime. Thefollowingparametersare“hard-wired”inpre-defined protocols: Numberofanglestocollect. Halfcircle(180o)use64 angles. Timeperimage.Formen>200lbs,Women>175lbs. Initial Delay MS-3: 25s/view-stressand 20s/viewrest Orbiter: 20s/view-stressand 15s/viewrest ElScint: 20s/view-stressand 15s/viewrest Timeperimage.Formen<200lbs,Women<175lbs. Initial Delay MS-3: 15s/view-stressand 10s/viewrest Orbiter: 11s/view-stressand 8s/viewrest ElScint: 11s/view-stressand 8s/viewrest 64x64x8matrix After completion of initial scans the patient, while sittingquietly,isgiven asecondinjectionof888MBqof Tc-99m-MIBI. The patient returns 1-2 hours later and the second seriesofimagesarerecordedinthesamepositionsas theinitialseries. Retrievetheinitialstudyformdiskand recorddelayedimages. ComputationalAnalysis Planar: Normalizationofplanarimagesforinterpretationand recordingonfilm: Readinitialanddelayeddatasets (usuallywrittentogetherinthedelayedsetondisk). MOVQ1toQ2,MOVQ3toQ4.Usethebaselineknobto determinetheupper10%ofcountsontheinitialandon thedelayedimages. Usetheratiovaluetomultiplythe delayedimageinthatprojection.
  • 69. 557 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures SPECT: Imagesarereconstructedbythetechnologistatthework stationofeachcomputer.ForTc-99m-MIBISPECT reconstructiondefaultparametersare:Butterworth filterwithcutoff=0.6andorder=8. UseComparison displayoptiontophotographwhichisaccomplishedover networklinkfromMac-ICONtoHeliosprinter. Tc-99m-MIBI Adenosine Stress Tc-99m-MIBI Dipyridamole Stress Tc-99-MIBI Dobutamine Stress See Thallium Adenosine/Dobutamine Stress with Reinjection And Tc-99m-MIBI Exercise Stress Study See also Stress Testing and Cardiac Emergencies See Dipyridimole Thallium Stress Study with Reinjection And Tc-99m-MIBI Exercise Stress Study See also Stress Testing and Cardiac Emergencies And Tc-99m-MIBI Exercise Stress Study See also Stress Testing and Cardiac Emergencies See Thallium Adenosine/Dobutamine Stress with Reinjection NUCLEAR CARDIOLOGY
  • 70. 558 CLINICAL PRACTICES Nuclear Cardiovascular Procedures Vascular Shunt Imaging Right to Left Shunt Angiographic Method Prematureappearanceofinjectedlabelontheleftside ofthecirculationisanindicationofR->Lshunt;itmay be difficult to isolate the level of the shunt. InstrumentsandEquipment RegularfieldofviewAngercameraequippedwithanall purposecollimatorinterfacedtoacomputer. Radiopharmaceutical 99mTc-labeledDTPAorRBC. TimeofImaging Immediately Dose 400-800MBq - adult Webster’srule - pediatric PatientPreparation None Administration BolusinjectionusingOldendorftechnicandangiocath. PatientPosition Supine. AnteriorView. DataAcquisition Analog - None Digital- 64X64matrix 0.3secondsDSKAQfor200framesaftercompletionor acquisition. Datareconfigurationanalysisisrequired. ThistechniqueprovidesqualitativedetectionofR-Lshunt. RecommendperformanceofstudyinLAOprojectionto detectprematureappearanceofleft-atrial/ventricular activity. Quantificationrequiresmuchstricteracquisitionterms. ComputationalAnalysis SUMfirst,50frames. Setregionsoversuperiorvena cava,rightatrium,rightventricle,rightandleftlungs. Generatecurvesfromeachregionforreview. Reference Peteretal,Circulation1981;64:572-577 Right to Left Shunt MAA Technique Thereisminimalnormalphysiologicalshunting;thusmost ofinjectedalbuminmicropheresshouldbetrappedinthe lung. Thepercentagefoundoutsidethelungrelatesto theextentofR-Lshunt. InstrumentsandEquipment RegularorlargefieldofviewAngercamerawithall purposecollimatorinterfacedtoacomputer. Radiopharmaceutical Macroaggregatedalbumin(lessthan100,000particles labeledwith99mTc;reducedifinfantorchild. Dose 150MBq - adult Webster’srule - pediatric TimeofImaging Immediatelyafterinjection.
  • 71. 559 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures PatientPreparation None Administration Intravenousinjection. PatientPosition Supine DataAcquisition Qualitativetechnique: Anteriorimageofbrain,palmarimageofhand,orother projectionsasindicatedbystaffphysicianfor5minutes. Quantitativetechnique: ObtainwholebodyimageoncomputerusingScanning WholeBodyCameraat5cm/min. Flagwholebodyandlungs. DetermineSUMRforeach. AmountofR-LShunt=1-[Lung/WholeBody] Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. Thechoiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisProcedure ManualismadebythephysicianstaffofNuclearCardi- ology,inordertoacquirethebestimagingresultswhile complyingwithMGHIsotopeand/orPharmacyCommit- teeguidelines.Thenameofthenuclearmedicinephysi- cianorderinganytestthatislistedhereismaintainedin the files of the radiopharmacy with the data on the patientandradiopharmaceutical. Reference Editorial:AmRevRespDisease1977;115:553-557 Left to Right Shunt Todeterminethepresenceandmagnitudeofanintracar- diacorsystemic-pulmonaryshunt. Thestudyisusually performedwiththepatientatrest,butmaybeperformed duringaphysiologicalmaneuverdesignedtoincreasethe magnitudeoftheshunt. InstrumentsandEquipment Gamma camera with an all purpose parallel hole collimator. Computerequippedwithafixeddisk(to recordathighdatarates). Radiopharmaceutical Tc-99mRBC(washed). Useconventionalmodifiedin-vivoapproach,butwash cells in syringe and re-suspend in saline prior to re-injection. Themaximumvolumeoftheinjectateshouldbe<3ml. Dose 370MBq - adult WebstersRule - Pediatric PatientPreparation None Administration Oldendorfinjectionthroughalargeante-cubitalvein, preferablyintherightarm. Data collection should start prior to injection. The qualityoftheveinandtheoptimizationofinjectionare criticaltoasuccessfulstudy,sincethedetectionofshunt dependsonassessmentofthetransitofthebolusthrough thecardiacchambers. Apoorinjectionmakesthis determinationdifficult,orimpossible. PatientPositioning RAO30degreeview-unlessthechestradiographor EKG indicates marked cardiac rotation. In those instances,thepatientshouldbepositionedtoproducea viewcomparabletotheRAO30degreeposition.Ifthere isanydoubtaboutthepositionoftheheart,thepatient shouldreceiveasmalldose(eg37MBq)ofradiopharma- ceuticalandpositioningoptimizedusingthepersistence modeofthecomputer. NUCLEAR CARDIOLOGY
  • 72. 560 CLINICAL PRACTICES Nuclear Cardiovascular Procedures DataAcquisition SetcamerapulseheightanalyzerforTc-99mwitha30% window. Setcomputerdiskacquisitionforapresettimeof100 millseconds/frameinhexant(64x64)formatforatotal of600frames(60seconds)inbytemode. Startcomputer1-2secondspriortoinjection. Comments Afteracquisitioniscompleted,thecomputerwillsay: “RECONFIGURATIONDATASET”; onlyafterthisis completedcanthedatabereviewed. Stress Testing and Cardiac Emergencies ComputationalAnalysis Perform a DSID to review the data, determine the adequacyofthebolusvisually,andselecttheframesfor additiontosetregions. Oncompletionofthisprelimi- nary review, use the Read+. command to add the requiredframestoidentifythesuperiorvena-cava,right atriumandventricle,leftventricleandlungs. Separateregionsshouldbesetovereachoftheseareas, and the respective time-activity curves generated. Ifthefull-width-halfmaximumcountdensitycurvefrom thesuperiorvenacavaexceeds3seconds,thebolusis poorandthestudywillhavetoberepeated. Thestudyispositiveforashuntifthepulmonarycurves show a second peak at the time of filling of the left ventricle. A second peak is often seen in the right ventricularcurve,duetooverlapoftherightandleft ventriclesintheRAO30degreeposition. General Considerations Proper preparations and careful precautions are essential for the production of the highest quality electrocardiographicmonitoringandfortheprevention ofuntowardcomplications. Carefulconsiderationofindicationsandcontraindications oftestingisessential. Thepurposeofastresstestin anygivenpatientshouldbeclear. Thesupervisorofthe testmustbefullyfamiliarwiththeentireprocedureas wellaswiththeinterpretationofthetest. Cardiopulmonaryresuscitationequipmentincludinga defibrillatorandcommonlyusedemergencycardiacdrugs areessentialandmustbereadilyavailable. Medicalaswellasparamedicalpersonnelworkinginthe exerciselaboratoryshouldbecapableofproviding cardiopulmonaryresuscitation. Before the stress test is performed, an informed consentformshouldbeobtained. PatientPreparation Patients should be instructed to come to the stress laboratoryeitherafteranovernightfastoratleastfour hours after a light meal. They should be dressed comfortablywithlightweightshoesandtheexercise laboratoryshouldbekeptatacomfortabletemperature rangingfrom68-74oFwith40-60%humidity. Acarefulhistoryshouldbeobtainedandabriefphysical examinationshouldbeperformed,focusingonthe cardiopulmonarysystem. Thesupervisorofthetestmustevaluateitspurposeand carefullyconsiderindicationsandcontraindicationsto testing. Acarefulsearchmuchbemadeforfactorswhich may produce false positive or false negative ECG responses. Theentiretestingprocedureshouldbeexplainedtothe patientindetail. Thismayincludeabriefdemonstration ofactuallywalkingonthetreadmill. Thepatientshould be instructed to immediately report unusual or significant symptoms, e.g. chest pain, dizziness,
  • 73. 561 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures lightheadedness, etc. The patient may request the terminationofexerciseprematurelywhenevernecessary. Afterthesigningofinformedconsent,theskinmustbe preparedproperly.Thesuperficialkeratinizedlayerof epidermisshouldberemovedbygentleskinabrasionwith adentalburr,emeryboard,fine-grainsandpaper,or vigorousrubbingwithgauze.Thisshouldbewashedaway bylightcleansingwithalcoholorotherorganicsolvents. Thiseliminatesexcessivelipidcontent. Excessively vigorousdebridementshouldbeavoidedinorderto preventedemaformationandanincreaseinelectrical resistanceattheelectrode-skininterface. A12-leadsystem,modifiedforuseintheexercising patient,isthenapplied. Resting12-leadelectrocardio- gramsarethenobtainedinthesupineandstanding positions. Followingthisa12-leadelectrocardiogramis obtainedwith30secondsofhyperventilation. Indications for Stress Testing Diagnosisofischemia. Evaluationoftheextentandlocationofischemia. Angiographiccorrelation. Evaluationoftheefficacyofmedicaltherapy. FollowupofCABGorPTCA. Evaluationofprognosisinpatientswithrecentor remotemyocardialinfarction. Pre-opfornon-cardiacsurgery. Assessforarrhythmia. Evaluationoffunctionalcapacity. Establishmentofabaselinepriortobeginningan exerciseprogram. Screeningofpatientswithcardiacriskfactorsor thoseinvolvedinhigh-riskactivitiesoroccupations, e.g.airlinepilots. Contraindications to Stress Testing Absolute Acutemyocardialinfarction. Unstableorcrescendoangina. Seriouscardiacarrhythmias(ventriculartachycar- dia,advancedorcompleteAVblock). Acutecardiacillnessessuchasmyocarditis, pericarditis,endocarditisorrheumaticfever. Criticalaorticstenosis. Acuteorseverecongestiveheartfailure. Markedarterialhypertension(BP>180/100). Acutepulmonaryembolismorinfarction. Anyacute,serious,oruncontrollednon-cardiac disorder. Inabilitytogiveinformedconsent. Protocols for Stress Testing Bruce Protocol Stage Speed Grade Duration (mph) (%) (min) 1 1.7 10 3 2 2.5 12 3 3 3.4 14 3 4 4.2 16 3 5 5.0 18 3 6 5.5 20 3 7 6.0 22 3 NUCLEAR CARDIOLOGY
  • 74. 562 CLINICAL PRACTICES Nuclear Cardiovascular Procedures Stage Speed Grade Duration (mph) (%) (min) 1 1.7 0 3 2 1.7 5 3 3 1.7 10 3 4 2.5 12 3 5 3.4 14 3 6 4.2 16 3 7 5.0 18 3 8 5.5 20 3 9 6.0 22 3 ModifiedBruceProtocol MGHModifiedBruce Stage Speed Grade Duration (mph) (%) (min) 1 1.7 0 3 2 1.7 10 3 3 2.5 12 3 4 3.4 14 3 5 4.2 16 3 6 5.5 20 3 Dipyridamole-Thallium Tc-99m-MIBI Test Protocol 0-4 min Dipyridamoleinfusionof0.56mg/kg over4min. 4-6 min Recline. 6-11min Lowleveltreadmillexercise, orarmweights,ifable. Isotopeisinjectedat10:00in patientswhocompletetheexercise protocol,orinthoseunableto exercise. Inpatientswhoareabletoexercise, butunabletocompletetheexercise protocol,thalliumisinjectedone minutepriortothetermination ofexercise. 50-100mgAminophyllineareinjected IVaftercompletionoftheinitial anteriorimage,ofearlierifsymptoms warrant. Dobutamine-Test Protocol Stage Dose Duration(min) 1 10mcg/kg/min 3 2 20mcg/kg/min 3 3 30mcg/kg/min 3 4 40mcg/kg/min 3 Patientsarestudiedinthesupineposition;noexercise isperformed. Isotope(Tl-201toTc-99m-MIBI)isinjectedat11:00of theprotocol,orearlieriflimitingsymptomsdevelop. Atropine0.25-0.5mgIVmaybegivenatthediscretion of the test supervisor if the heart rate response to Dobutamineiswellbelow85%predictedmaximum. Maximumdose=2.0mg Metoprolol2.5-10.0mgmaybegivenIVtoreverse Dobutamine-relatedside-effectsorischemicECG changes.
  • 75. 563 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Adenosine Stress Test The patient walks on the treadmill at 0% grade at 0.5-1.7MPHdependingonphysicalcondition. Assoonasthepatientbeginswalkinganditisclearhe/ shecanmaintaintheselectedpacebeginadenosinein- fusion(140ug/Kg/min)usingIVinfusionpump. At2minutesofadenosineinfusioninjecttracerandcon- tinueinfusionfor3additionalminutesprovidednoad- verseeffectsoccur. Discontinueadenosineafterthe5thminuteofinfusion butcontinuetohavethepatientwalkfor1-2additional minutesafteradenosinehasbeenturnedoff. Exceptions/SpecialCases Patientswhohavehadastentplacedwithin8weeksof thetestmaywalkonthetreadmillat1.0-1.5MPHand 0%grade. Ifthepatientcannotwalkthenarmweights maybeusedinstead. Elderly(>80y-o)oranyseverelydebilitatedpatient whocannotwalkorusearmweightsandwhomaybeat higherriskforhighgradeheartblockwithadenosine shouldbeconsideredfordipyridamoleinstead. EndpointsatwhichtoTerminate StressTesting AbsoluteIndications Patientrequest. Significant,reproduciblereductionofbloodpressureand/ orheartrateduringincreasingworkloads. Significantsymptomsorsigns: severechestpain,ataxia, vertigo,visualorgaitdisturbances. Seriousarrhythmias: newventriculartachycardia, ventricularfibrillation. Acutemyocardialinfarctionortransmuralischemia. Malfunctioningequipment,e.g.treadmill,ECGmonitor, etc. Markedhypertension(systolicbloodpressure>220 mmHgordiastolicpressure>110). Urgent(i.e.Relative)Indications Lessserioussymptoms: significantchestpain,dizziness, markedfatigueordyspnea. Legcrampsorclaudication. Marked(2mmormore)horizontalordown-slopingST segmentdepressionormarked(2mmormore)ST segmentelevation. FrequentormultifocalPVCsandpersistingsupraven- triculartachyarrhythmias. CriteriaforPositive ECGResponsetoStress > 1mmofhorizontalordown-slopingSTsegment depression. UpslopingSTsegmentdepression>2mmbeyond0.08 secondsfromtheJpoint. AncillarySignsofStress-InducedIschemia Exercise-inducedhypotension. InvertedUwaves. Ventriculartachycardiaprovokedbymildexercise. Exercise-inducedtypicalangina. IncreasedRwaveamplitude(?). New third or fourth heart sound or heart murmur immediatelyafterexercise. FactorswhichMayCauseFalsePositive StressECGResponses Drugs:digitalis,diuretics,antidepressants,sedatives, estrogen. Electrolyteimbalance:hypokalemia. Pre-existingECGabnormalities:nonspecificST-T changes,leftventricularhypertrophy,leftbundlebranch block,rightventricularhypertrophy,rightbundlebranch block(rightprecordialleads),Wolf-Parkinson-White syndrome. Cardiacdisorders:mitralvalveprolapsesyndrome,Wolf- ParkinsonWhiteSyndrome,cardiomyopathy,myocardi- tis,pericarditis,hypertensiveheartdisease,rheumatic heartdisease. Miscellaneous: femalegender,hyperventilation,food- glucoseintake,pectusexcavatum. NUCLEAR CARDIOLOGY
  • 76. 564 CLINICAL PRACTICES FactorswhichMayCauseFalseNegative StressECGResponses1 Drugs: antianginals, procainamide, quinidine, phenothiazines. Inadequateexerciseorheartrateresponse(lessthan85% predictedmaximum). Improperleadsystem. Single-vesselcoronaryarterydisease. Miscellaneous: leftaxisdeviation,leftanteriorhemiblock. Nuclear Cardiovascular Procedures Management of Complications During Stress Testing General Statement For the safety of patients, we have developed the followingguidelinesintheeventofclinicalinstability. The condition will be discussed with the referring physicianandifnecessary,patientswillbesenttothe EmergencyRoomafterinitialstabilization,oremergently asappropriate. 1 Chang,E.K.ExerciseElectrocardiography-Practical Approach,WilliamsandWilkins,1983. (SBP>220mmHG,orDBP>110aftertreatment.) Othermedicalconditionsthatastaffphysicianfeelsthat itisunsafetosendthepatienthome:(e.g.:Acuteasthma, psychosis,seizure). ArrhythmiaandAVConduction Abnormality Highdegreeofmalignantarrhythmiathatisdiagnosed bystresstest. PacemakermalfunctionorAICDmalfunctionduringstress test. NewonsetofhighdegreeA-Vblock. Newonsetofarrhythmia:Atrialfibrillation,atrialflutter, supraventriculartachycardia,junctionalrhythm,brady- cardiaortachycardiathatpersist. Cardiacarrest.....FollowACLSguidelines. AcopyofspecificACLSguidelinesfortreatmentof theaboveconditionsislocatedintheworkareaofthe stresslab. NonArrhythmia Ischemia,LVFailure,orOtherMedical Problems ECGand/orclinicalevidenceofevolvingsevereischemia or acute myocardial infarction despite appropriate therapy. Congestive heart failure not responding to initial treatment. Hypotension that is not responsive to the initial treatment. Markedlypositivestresstestandastaffphysicianfeels thatitisunsafetosendthepatienthome. Extremehypertensionthatisnotrespondingtoinitial treatment.

×