The document provides guidance for nuclear medicine professionals and patients on various nuclear medicine procedures and concepts. It covers 50 nuclear medicine procedures for different body systems like the endocrine, skeletal, and cardiac systems. Key radiation safety concepts are also defined to educate healthcare workers and address common patient concerns regarding nuclear medicine exams.

2.  Patient education about Nuclear Medicine
 Clear apprehensions of patients and common people about Nuclear
Medicine
 Assistance to healthcare professionals and patients:
oIn preparation for particular investigation, therapy or
palliation.
oGuide them about cessation of breast feeding and pregnancy.
oPost-procedure precautions to observed.
oExplanation of Nuclear Medicine terms in brief
 Guide General physicians, residents and MBBS trainees about:
What is nuclear medicine?
What a particular procedure is?
What are indications for a particular procedure?
Definition of terms used in Nuclear Medicine reports.
 Assist nuclear medicine professionals in:
Overall method of procedure to be performed.
Set of instructions to be given to the patient before, during
and after the procedure.
Type and amount of radioactivity to be used.
AIM AND OBJECTIVE OF THIS BOOK

3. Book can be used for :
 Educating patients by keeping them in waiting
room of Nuclear Medicine dept.
 Promote Nuclear Medicine by educating
general physicians.
 Can be used as ready reckoner by Nuclear
Medicine professionals .
 It can be kept in wards to be used by ward staff
to prepare patients and educate themselves about
radiation safety after the study.

4. CHAPTERS INCLUDED IN THIS BOOK
 Introduction to Nuclear Medicine
 Meet the Nuclear Medicine
 Common Apprehension about Nuclear
 Nuclear Medicine procedures
Chapter 6.1 Endocrine System
6.1.1 Thyroid Radioiodine Uptake
6.1.2 99mTc-Thyroid Scan
6.1.3 MIBG Scan
6.1.4 Medullary Thyroid imaging by DMSA (V)
6.1.5 T3 Suppression Test
6.1.6 TSH Stimulation Test
6.1.7 Perchlorate Discharge Test
6.1.8 Parathyroid Imaging
6.2 Skeleton System
6.2.1 Bone Scan
6.2.2 Bone Three Phase Scan
6.2.3 Bone Marrow Scan

5. Likewise there are fifty procedures are explained in this book
including PET and therapy
6.12 Positron Emission Tomography (PET)-CT
6.12.1 PET-CT Imaging of Brain
6.12.2 PET-CT Imaging of Myocardium
6.12.3 PET-CT Imaging of Whole Body
6.12.4 PET-CT Imaging of Bone (F-18 Bone Scan)
6.13 Therapy and Palliation
6.13.1 Palliative Treatment for painful bone Metastasis
6.13.2 I-131 Therapy for Thyroid Disease
6.13.3 MIBG Therapy for Neuro-Endocrine Disease
6.13.4 Radiosynovectomy/Radiosynoverthesis
6.13.4 P-32 Therapy for Myeloproliferative Disease
6.13.5 Radio-immunotherapy for B-cell Lymphoma with 90Y-
Radiolabelled Itribumomab Tiuxetan (Zaveline)

6. Chapter 7.Definitions of Common terminologies used in Nuclear
Medicine
7.1 Electromagnetic Radiation & Radioactivity
7.1.1 Electromagnetic Radiation
7.1.2 Radioactivity and Radioactive Materials
7.1.3 Radioisotopes
7.1.4 Generators
7.1.5 Half Life
7.1.6 Radiopharmaceutical
7.2 Radiation Safety
7.2.1 Energy
7.2.2 Exposure (X)
7.2.3 Exposure Rate (X˚)
7.2.4 Dose (D)
7.2.5 Dose Rate (D˚)
7.2.6 Relationship between Roentgen and Rad
7.2.7 Equivalent Dose(H)
7.2.8 Effective dose (E)
7.2.9 Cumulative Dose
7.2.10 Collective Dose

7. 7.2.11 Annual limit of Intake(ALI)
7.2.12 Derived Air Concentration (DAC)
7.2.13 Limits of contamination
7.2.14 Half Value Thickness or layer (HVT or HVL)
7.2.15 Tenth Value Thickness or layer (TVT or TVL)
7.2.16 Relationship between HVT and TVT
7.2.17 Exposure Rate constant
7.2.18 Discharge criteria for patient (as per Atomic energy Regulatory
Board, India).
7.2.19 Dose limits recommended by ICRP (2007)
7.3 Endocrine System
7.3.1 Grave’s Disease (Diffuse Toxic Goiter)
7.3.2 Plummers Disease (Toxic Multi Nodular Goiter)
7.3.3 Radioiodine Therapy
7.3.4 Toxic Multinodular Goitre
7.3.5 Thyroiditis
7.3.6 Hashimoto's thyroiditis
7.4 Skeletal System
7.4.1 Arthropathy
7.4.2 Avascular Necrosis
7.4.3 Hypertrophy
7.4.4 Leukaemia

8. 7.4.5 Lymphoma
7.4.6 Multiple Myeloma
7.4.7 Metastasis
7.5 Genito-Urinary System
7.7.1 DTPA Scan
7.7.2 DMSA Scan
7.7.3 Effective renal plasma flow (eRPF)
7.7.4 Glomerular Filtration Rate (GFR)
7.7.5 Renovascular Hypertension
7.7.6 Pyelonephritis
7.7.7 Urinary tract infection
7.6 Cardiac System
7.6.1 Coronary Artery Disease
7.6.2 Myocardial perfusion Study/Imaging
7.6.3 Multigated Acquisition
7.6.4 Hibernating Myocardium
7.6.5 Stunned Myocardium
7.6.6 Myocardium Ischemia
7.6.7 Myocardium Infarction
7.6.8 Stroke Volume
7.6.9 Ejection Fraction
7.6.10 PCI
7.6.11 METS

9. CHAPTER 3:COMMON APPREHENSIONS ABOUT NUCLEAR MEDICINE
Some of the questions include:
 Will Nuclear Medicine Scans have some side effects?
 Will a Nuclear Medicine scan make me radioactive?
 Are there people who should not undergo Nuclear
Medicine Scans?
 What are Radiation effects and Risk estimates in Nuclear
Medicine scans?
 What is the probability of causing Carcinoma by Nuclear
Medicine scans?
 How much radiation exposure dose will I get in my
procedure?

10. Myocardial perfusion study evaluates the heart’s function and blood flow to the
muscles of heart (myocardium). A stress myocardial perfusion scan is used to assess the
blood flow to the myocardium when it is stressed by exercise or medication. It determines
the areas of the myocardium which have decreased blood flow and thereby damages
occurred into the myocardium with what extent. In myocardial perfusion imaging
radiopharmaceutical (also called as tracer) either thallium or technetium labeled compounds
is administered intravenously. Perfusion imaging identifies areas of relatively reduced
myocardial blood flow associated with ischemia or scar. The relative regional distribution of
perfusion can be assessed at rest, during cardiovascular stress, or both [44].
Indications [45]
 Diagnosis of coronary artery disease
 Evaluation of known coronary disease; location and extent of ischemia
 Determine the cause for change in symptom pattern in patients with known coronary
artery disease.
 Evaluate the effectiveness of medical therapy
 Risk stratification post-myocardial infarction
 Pre-operative evaluation for major non-cardiac surgery in patient with known coronary
disease.
 Assessment after percutaneous transluminal coronary angioplasty or coronary artery
bypass grafting
Guide to rehabilitation therapy
CHAPTER 6.5.1 MYOCARDIAL PERFUSION STUDY

11. Instructions to the patient
Patients may require to stay in the dept for 3-5 hrs depending on the number of patients appointed and the
study protocol in their case.
They can drink 01 glass of water/milk before the test in the morning. If their appointment is after 1000 h, they
can have light breakfast before 0600 h. Idea is to have 04 hrs fasting before the test.
Patients are advised to bring their breakfast alongwith them. They are required to eat preferably a light fatty
meal after exercise and before imaging.
They should bring all previous medical documents on date of appointment.
Female patients should inform about their LMP, Lactation and any chance of pregnancy. If breast-feeding,
there is no need to stop it for 99mTc radiopharmaceuticals i.e. if 99mTc-SestaMIBI is used upto 1110
MBq (30 mCi) [20] and 201Tl <80MBq of activity [46]. However if 201Tl is used upto 111 MBq,
breastfeeding should be stopped for 96 hrs and counseling should be done by radiation safety
officer [20].
Some medications such as beta-blockers may prevent achievement of maximum heart rate nitrate or
calcium channel blockers may mask or prevent cardiac ischemia, limiting the test’s ability to detect coronary
disease. [45] Cardiac medications should be withheld if the examination is performed to detect coronary
disease. Cardiac medication should be taken as usual when the examination is performed to determine the
effectiveness of medical therapy [44]. Such interruption should ideally last for five half-lives of the drug [46]. In
general, the decision on whether to interrupt drug administration should be left to the referring physician.
List of some common cardiac medications which may need to stop for time mentioned against each:
Medication Half life Derived five half life
Beta Blockers
Tab Atenolol 6-7 hrs[47] 30-35 hrs
Tab Carvidelol 7-10 hrs[48] 35-50 hrs
Tab Metoprolol 3-7 hrs[49] 15-35 hrs
Tab Trimolol 2.5–5 hrs[50] 12.5–25 hrs
Calcium Channel Blocker
Tab Amlodipine 30-50 hrs[51] 150 – 250 hrs
Tab Nifedipine 02 hrs[52] 10 hrs
Nitrates
Glyceryl Trinitrate 03 min[53] 15 minutes

12. Procedure
On arrival of patient on date of appointment, a detailed history of the patient is obtained.
He/she is taken for fixing IV cannula.
Patient undergoes either physical or pharmaceutical stress.
At the peak of exercise, patient is administered with radiopharmaceutical (250-350* MBq
(6.75-9.5 mCi) 99mTc-Sestamibi or 74-148* MBq (02-04 mCi) of 201TlCl).
He/ She is sent for having breakfast. An oily/fatty breakfast is advised in case 99mTc-
Sestamibi radiopharmaceutical is used, for draining out the liver, as it may interfere in
imaging of myocardium, being an adjacent organ.
Imaging should begin 30–60 min after injection to allow for hepatobilliary clearance;
longer delays are required for resting images and for stress with vasodilators alone
because of the risk of higher sub diaphragmatic 99mTc activity. However, the time of
imaging for 201Tl is 15-20 min, because it does not accumulate in liver and have renal
clearance.
Rest injection of radiopharmaceutical (03 times the radioactivity injected at stress) is
given 02 hrs after stress. In case of 201Th no second injection is given due to its
redistribution property.
Imaging of rest begins after 45 min – 01 hr of rest injection.
In some cases, if there is fixed defect seen in inferior wall of myocardium, prone imaging
may also be performed.

13. Fig 6.5.1: Normal myocardial perfusion study. Myocardial image is provided by the full thickness of the left ventricular myocardium. The
right ventricular free wall and atrial walls are much thinner structures but define the outline of their cavities. Three sets of images of left
ventricle is displayed for three dimensional view of heart: (1) a view generated by slicing perpendicular to the long axis of the left
ventricle (short axis), (2) a view of long-axis tomograms generated by slicing in the vertical plane (vertical long axis), (3) a view of long-
axis tomograms generated by slicing in the horizontal plane (horizontal long axis). Images are serially displayed for different sections of
the heart.
Figures below illustrates the image of heart showing short axis, horizontal long axis and vertical long axis and their ways of slicing for
better understanding of above images.

14. Fig 6.5.2: Reversible perfusion defect in LAD territory. Images are serially displayed for stress and rest comparing short axis, vertical
long axis and horizontal long axis views. Black arrows depicts reversibility

15. CHAPTER 7.5 Genito-Urinary System
7.5.1 DTPA Scan
99mTechnetium labeled Diethylene triamine pentaacetic acid (DTPA) is used to see
glomerular filtration rate (GFR). DTPA is a heavy metal chelate cleared through Glomerular
filtration. Following intravenous injection of 99mTc DTPA, normal peak cortical uptake occurs
by 3-4 minutes. By 5 minutes, the collecting system is seen; the bladder is typically
visualized by 10-15 minutes.
7.5.2 DMSA Scan
A DMSA scan is a radionucleotide scan that uses dimercaptosuccinic acid in assessing
the renal function, it is now the most reliable test for the diagnosis of Acute pyelonephritis
[145]. The major clinical indications for this investigation are the detection and/or evaluation
of a renal scar, the small or absent kidney, an occult duplex system, certain renal masses,
systemic hypertension or suspected vasculitis[146].
7.5.3 Effective renal plasma flow (eRPF)
Effective renal plasma flow (eRPF) is a measure used in renal physiology to
calculate renal plasma flow (RPF) and hence estimate renal function.
ERPF = RPF x extraction ratio
Where renal plasma flow (RPF) is the volume of plasma that reaches the kidneys per
unit time and extraction ratio is the ratio of compound entering the kidney that got
excreted into the final urine.
7.5.4 Glomerular Filtration Rate (GFR)
Glomerular filtration rate (GFR) is the volume of fluid filtered from
the renal (kidney) glomerular capillaries into the Bowman's capsule per unit time. GFR can
be calculated by measuring any chemical that has a steady level in the blood, and is freely
filtered but neither reabsorbed nor secreted by the kidneys.
The GFR is typically recorded in units of volume per time, e.g., milliliters per
minute ml/min.
There are several different techniques used to calculate or estimate the glomerular
filtration rate (GFR or eGFR)

16. Source of Information/References
 Society of Nuclear Medicine & Molecular Imaging
procedure guidelines
 European Association of Nuclear Medicine procedure
guidelines
 ACR–SNM–SPR practice guideline
 International Atomic Energy Agency guidelines for
radiation safety
 Ell PJ, Gambhir SS: Nuclear Medicine in Clinical
Diagnosis and Treatment; volume III, ISBN 0-443-
07312-0
 Ziessman Harvey A., O’Malley Janis P., Thrall James
H., Nuclear Medicine: The Requisites in radiology, Third
Edition. ISBN 978-0-323-02946-9
 Many other Nuclear Medicine books
 Several websites