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General Nuclear Medicine Part 1
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General Nuclear Medicine Part 1

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  • 1. For Medical Students
  • 2. Introduction to Nuclear MedicineBone scanKUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  • 3. Nuclear medicine is a medical specialtywhich uses very small amount of aradioactive substance or a chemicalcompound labelled with a radioactivesubstance, called “radiopharmaceutical”or tracers to image or treat diseases. J SRIPRAPAPORN
  • 4. Endocrinology eg. Thyroid scan, Parathyroid scanCardiovascular system eg.Myocardial perfusion scan,Radionuclide venographyGenitourinary system eg. Renogram, Testicular scan,Radionuclide cystographyPulmonary system eg. Perfusion/ Ventilation lung scanSkeletal system eg. Bone scanGastrointestinal system eg. Liver scan, Hepatobiliaryscan, GE reflux studyTumor imaging eg. Ga-67 scan for Lymphoma, I-131scan for pheochromocytoma, Tc-99m MIBI forparathyroid adenoma J SRIPRAPAPORN
  • 5. Functional*SensitiveQuantitativeVery safeMinimally invasiveLow radiation exposureScreeningFollow-up J SRIPRAPAPORN
  • 6. Not widely availableGive minimal radiationGenerally non-specificRequire NM instrument &radiopharmaceuticalsHigher cost than routine X-rayor U/S J SRIPRAPAPORN
  • 7. Low cost Tc-99mAvailablePure gamma emitterOptimal gamma energy (100-200 keV) * 140Optimal half life *6 hrSafeChemically active * Tc-99m is the most ideal agent ! J SRIPRAPAPORN
  • 8. Radiopharmaceutical Patient Gamma Camera Images J SRIPRAPAPORN
  • 9. Radioisotopes eg. I-131, Tc-99m Radiolabeled compounds eg. Tc-99m MDP for Bone scan, Tc-99m MAA for Lung scan* 1 Organ Many R’pharmaceuticals 1 R’pharmaceutical Many organs J SRIPRAPAPORN
  • 10. Planar gamma cameraSPECT = Single PhotonEmission ComputedTomographyPET = Positron EmissionTomographyPET/CT J SRIPRAPAPORN
  • 11. J SRIPRAPAPORN
  • 12. PET:Metabolic imagingUsing positron-emittingradionuclidesBiological tracers (C, N, O, F)More sensitiveBetter imagesWhole body evaluation J SRIPRAPAPORN
  • 13. Introduction to Nuclear MedicineBone scanKUB system• Renal scan & renogram• Testicular scan• Radionuclide cystographyLung scan Radionuclide venography J SRIPRAPAPORN
  • 14. Tracer : 99mTc-MDPMechanism: Adsorption to the hydroxyapatitehydroxyapatite crystalRoute : IV injectionTechnique : Patient preparation : none After inj: good hydration & frequent voiding Imaging 3 hr. post injection Views : Whole-body, anterior and posterior & static images as requiredVisualization : The skeletal system J SRIPRAPAPORN
  • 15. Indications : Bone metastases*; tumor staging, evaluate bone pain in cancer patients Undetermined bone pain (wo CA Hx) Infection; osteomyelitis Bone trauma; stress fractureAdvantages: Sensitive > plain X-ray * Whole-body evaluation Low radiation J SRIPRAPAPORN
  • 16. ANT POST ANT POST J SRIPRAPAPORN
  • 17. Diffusely increased axialskeletal uptake with low or novisualized renal uptakeDiffuse metastatic disease Primary: prostate*, breast, lungMetabolic bone disease Hyperparathyroidism Renal osteodystrophy J SRIPRAPAPORN
  • 18. Phase 1; Vascular phase: 60 s dynamic immediately pi.Phase 2; Soft-tissue (blood-pool) phase: 5 min pi.Phase 3; Delayed (bone) phase: 3 hr pi.INDICATIONS: Infection: DDx acute osteomyelitis vs cellulitis Avascular necrosis Tumors: primary tumor Others J SRIPRAPAPORN
  • 19. Soft-tissue delayed 3-hrVascular phase J SRIPRAPAPORN
  • 20. Phase I : Vascular phasePhase II : Soft tissue phasePhase III : Bone phase J SRIPRAPAPORN
  • 21. Introduction to Nuclear MedicineBone scanKUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  • 22. Renal scintigraphyTesticular scanRadionuclide Cystography J SRIPRAPAPORN
  • 23. Cortical renal scan Renal scar in children with UTIRenal scan and renogram To evaluate (split) renal blood flow & renal function To evaluate urinary drainageDiuretic renography To evaluate urinary tract obstructionCaptopril renography To detect renovascular HT (RVHT)Radionuclide cytography To detect VU reflux J SRIPRAPAPORN
  • 24. J SRIPRAPAPORN
  • 25. Tracers : 99mTc-DTPA, 99mTc-MAG3, etcRoute: IV injectionTechnique : Good hydration Dynamic study for 30 min. in posterior view (native kidneys), anterior view for transplanted kidney. renogram (3 phases)Uses : Separate renal function Urinary tract obstruction-Diuretic Renogram Renovascular hypertension-Captopril renogram Others J SRIPRAPAPORN
  • 26. L R LT RT Flow: 1-2 min Posterior Renograms or Renal time-activity curvesRenal Scan-30 min J SRIPRAPAPORN
  • 27. J SRIPRAPAPORN
  • 28. Severity of urinary tract obstruction A A-Severe obstruction, good B renal function B-Severe C obstruction, reduced function C-Less severe Normal obstruction, reduced function Time-activity curve J SRIPRAPAPORN
  • 29. Deterioration of renal function after chronic urinary tract obstruction Normal Time-activity curve J SRIPRAPAPORN
  • 30. Diuretic Renograms Furosemide Injection Obstructed Non-bstructed Normal Time-activity curve J SRIPRAPAPORN
  • 31. J SRIPRAPAPORN
  • 32. Diuretic Renography T1/2 < 10 min J SRIPRAPAPORN USA 6-07
  • 33. Tracer : Tc-99m pertechnetate IV.Positioning : Special*Imaging : Flow and static imagesAim : To DDx Acute testicular torsion VSAcute epididymoorchitisTesticular Torsion flow & uptakeAcute epididymo-orchitis flow &uptake (inflammation) J SRIPRAPAPORN
  • 34. J SRIPRAPAPORN
  • 35. Introduction to Nuclear MedicineBone scan KUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  • 36. Perfusion Lung Scan Ventilation Lung Scan Tracer : Tracers : • 99mTc-MAA • 133Xe • 99mTc aerosol- 99mTc-DTPA, 99mTc-phytate Route : IV injection • Technegas Technique : Planar Route : Inhalation images 6 views; Technique : Planar anterior, posterior, images 6 views as in Rt. lateral, Lt. lateral perfusion study RPO,LPO J SRIPRAPAPORN
  • 37. Pulmonary embolism*Pulmonary hypertensionRight-to-left shuntPrior thoracic surgery To determine lung function in the affected lung & the potential consequence of removal of diseased lung J SRIPRAPAPORN
  • 38. Tracer: Tc-99m MAA, particle size=10-30 uMechanism: Lodged in precapillary arterioles inproportion to regional blood flowDose: 2-5 mCi, 200,000-600,000 particles,block < 1/1000 arteriolesRoute: IV (Not draw blood back into syr !)Imaging: 6 views, Ant, Post, RPO, LPONormal: Uniform distribution J SRIPRAPAPORN
  • 39. PE Segmental perfusion defects J SRIPRAPAPORN
  • 40. J SRIPRAPAPORN
  • 41. Multiple hot spotsTechnique: DrawingPt’s blood into Tc-99m MAA syringeform clumping hotspots J SRIPRAPAPORN
  • 42. Tracers: Gaseous agents: Xe-133 (washin-equilibrium-washout) Xe-127 Kr-81m (Rb-85m generator) Radioaerosol (particulate agents): 0.5 um 99mTc-DTPA, 99mTc-SC, 99mTc-phytate Technegas: 99mTc labeled fine carbon particles (by heating 99mTcO4- in a graphyte crucible at 1500 C in pure argon atmosphere for 15 sec), size = 0.02 um J SRIPRAPAPORN
  • 43. J SRIPRAPAPORN
  • 44. O2 J SRIPRAPAPORN
  • 45. J SRIPRAPAPORN
  • 46. J SRIPRAPAPORN
  • 47. J SRIPRAPAPORN
  • 48. Perfusion lung scan Ventilation lung scan CXR within 24 hrsCriteria: Modified PIOPED criteria * Normal High Nondiagnostic Very-low probability J SRIPRAPAPORN
  • 49. Uniform distribution ofthe radioactivityNo V/Q defectNormal Q scan isvirtually exclude PE !No extrapulmonaryaccumulation J SRIPRAPAPORN
  • 50. J SRIPRAPAPORN
  • 51. Nonuniform distributionPerfusion and/ orventilation defect Segmental or nonsegmental defectExtrapulm accumulation J SRIPRAPAPORN
  • 52. Clinicals : Unreliable- dyspnea, pleuritic chestpain, hemoptysisLAB: D-dimer > 500 ng/mlABG: HypoxemiaECG: tachycardia, nonspecific ST-T change,S1Q3T3 (rare)CXR: Normal*, oligemia, othersVQ lung scan: VQ defectPulmonary CTA : clotPumonary angiography: clot (gold standard) J SRIPRAPAPORN
  • 53. Typical scintigraphic findings Segmental perfusion defects Normal V scan No corresponding abnormal radiographic findingsV/Q mismatched defects J SRIPRAPAPORN
  • 54. Ant Post LPO RPO J SRIPRAPAPORN
  • 55. Tc-99m MAAperfusion lung scanPresence ofradiotracer in thebrain and kidneysPrecaution: LimitedMAA particles. J SRIPRAPAPORN
  • 56. Introduction to Nuclear MedicineBone scan KUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  • 57. J SRIPRAPAPORN
  • 58. http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_causes.htm http://www.youtube.com/ watch?v=I0yJTkW9y9s J SRIPRAPAPORN
  • 59. Clinicals : UnreliableLab tests : D-dimerColor Doppler ultrasonographyRadionuclide Venography (RNV)In-111 labeled plateletIn-111 labeled antifibrin AbTc-99m labeled peptides (Acutect)CT/MR venographyContrast Venography *** [Gold standard] J SRIPRAPAPORN
  • 60. DVT, Compression, Doppler Lower Extremity. This image shows a side by side, of the common femoral vein with and without compression. Since the vein does not fully collapse, this is an evidence of a DVT. Clot is also seen, as well as a filling defect in the vessel of the noncompressed vein with color Doppler. (Photo contributor: Stephen J. Leech, MD, RDMS.) J SRIPRAPAPORN
  • 61. Ascending Rdn Venography:Tc-99m SC, Tc-99m phytate, Tc-99m MAA*** Tc-99m RBC Venography J SRIPRAPAPORN
  • 62. Tracers : Tc-99m MAA, Tc-99m phytateUses : Venous occlusion (DVT)-proximal deep veins**Technique IV. injection of the tracer into pedal veins of both feet Imaging: during on and off tourniquet over both ankles Multiple overlapping static or whole-body images upto IVC level* If MAA RNV + Q lung scan (same setting) J SRIPRAPAPORN
  • 63. Inject a tracer via (bilateral) foot veinsOn tourniquets above ankles to visualize deep veinsand off tourniquets for superficial veinsMultiple overlapping static images upto IVC level orwhole-body image J SRIPRAPAPORN
  • 64. Abrupt termination of the flowPresence of filling defectIrregular or asymmetric flowAbnormal colaterallsNonfilling of the deep veins, with +veother signs J SRIPRAPAPORN
  • 65. J SRIPRAPAPORN
  • 66. J SRIPRAPAPORN
  • 67. Contrast Venography Radionuclide VenographyMost reliable for Dx (gold Reliable results esp.std.) proximal vNeed skilled team SimplerGood anatomic Poorer anatomic detailsvisualization (calf iliac (Good for proximal veins)veins & IVC) Less invasiveMore Invasive SafePotential risks More suitable for frequentNot suitable for frequent F/UF/U Provide information aboutNot provide information associated PE (Tc-99mabout associated PE MAA) J SRIPRAPAPORN
  • 68. Or blood-pool radionuclide venographyequilibrium stageInject the radiotracer via any veinNeed high-resolution collimatorImage quality depends on labelingefficiency J SRIPRAPAPORN
  • 69. J SRIPRAPAPORN
  • 70. ADVANTAGES DISADVANTAGES Do not need foot Image quality depends on vein access, easier labeling efficiency Possible less Not direct evaluation of painful venous flow Less anatomical details Concomitant Q lung scan is impossible. J SRIPRAPAPORN
  • 71. SUMMARYWhat is Nuclear Medicine? Principle Advantages & DisadvantagesBone scanKUB systemV/Q lung scanRadionuclide venography J SRIPRAPAPORN

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