Nuclear Medicine Overview_part 2


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Nuclear Medicine Overview_part 2

  1. 1. NUCLEAR MEDICINE: OVERVIEW Jiraporn Sriprapaporn, M.D. Division of Nuclear Medicine Department of Radiology Siriraj Hospital
  2. 2. Thyroid ScanTechnique: Prep: No T4 at least 2 wks Tc-99m iv. or I-131 orally Static imaging at 20 min or 24 hr respectivelyIndications: Solitary thyroid nodule or MNG with dominant nodule (suspected CA) Congenital hypothyroid, R/O ectopic thyroid Substernal goiter (I-131) Hyperthyroidism with single thyroid nodule; R/O toxic adenoma Evaluate thyroid remnant post thyroid surgery
  3. 3. Thyroid Scan: TechniquesTc-99m thyroid scan I-131 thyroid scan For routine use !! For special purposes 2 mCi TcO4- IV 60-100 uCi I-131 is injected orally given Imaging at 20 mins Imaging at 24 hr. later later Trapping Trapping + Organification Withdraw T4 at least 2 wks before thyroid scan
  4. 4. Thyroid Scan S
  5. 5. I-131 Total-body Scan (TBS): TechniquesPatient preparation: Withdraw thyroid H (T4) 4-6wks prior to TBS, TSH > 30 mIU/LDiagnostic dose of I-131: 2-5 mCi orally givenAnterior and posterior whole-body imaging at 72hrs laterTBS can also performed after 3-7 d of RAI Rxdose
  6. 6. I-131 Total-body ScanThyroid T Lung metas. CBladder B
  7. 7. Bone Scan: IndicationsCancer patients: Bone scan is anextremely sensitive and cost effectivemodality for staging Evaluate patients with bone pain, increased alkaline phosphate, or hypercalcemia to rule out osseous metastasis.Infection: DDx cellulitis & osteomyelitisReflex sympathetic dystrophy (RSD)
  8. 8. Bone ScanR’pharm: Tc-99m MDP 20 mCi iv.Good hydration pi.Technique Whole-body: at 3 hr pi. 3-phase: Vascular, soft tissue, skeletal phasesUptake // flow & osteoblastic activityNature: nonspecificAdvantages: sensitive > X-ray, evaluateentire skeleton
  9. 9. Bone Scan-Related Terms3-phase bone scanSuperScanFlare phenomenonStress fractureOccult fracture
  10. 10. Normal Bone Scan
  12. 12. 3-Phase Bone Scan-AOM Soft-tissue delayed 3-hr Vascular phase
  13. 13. OSTEOSARCOMA Phase I : Vascular phase Phase II : Soft tissue phase Phase III : Bone phase
  14. 14. Brain Perfusion Study (SPECT)Tracer: Tc-99m neurolite (ECD)Dose: 20-25 mCi IV.Indications: Stroke Dementia Seizure
  15. 15. Normal Brain SPECT
  16. 16. Brain SPECT: Stroke 3DStroke at left temporoparietal region
  17. 17. Alzhiemer’s Disease
  18. 18. CARDIOLOGYMUGA study Tc-99m RBCMyocardial perfusion scintigraphy (MPS) Tl-201 Tc-99m MIBI Tc-99m tetrofosminMyocardial infarct imaging Tc-99m PYP (pyrophosphate)
  19. 19. Myocardial Perfusion StudyTo evaluate the presence of significantcoronary artery disease (CAD).Indications Suspected CAD Preoperative evaluation Evaluate extent of myoc ischemia & infarct Guide for treatment-med or revasc Pre-post revascularization procedures Risk stratification post MI
  20. 20. MPS: Information1. The presence or absence of significantCAD2. The extent and severity of ischemia orscarring of the myocardium3. Functional information about resting LVwall motion and LVEF. (gated SPECT)4. Information about the stress part of thestudy which can be treadmill exercise orpharmacological
  21. 21. Single vv Disease
  22. 22. GI SystemEsophageal transit Liver-spleen scantime Spleen scanGE reflux study Hepatobiliary scanGastric emptying Salivary scantimeGI bleeding study RBC scan Meckel’s diverticulum scan
  23. 23. GE Reflux StudyOther name: Milk scanTechnique: NPO Tc-99m phytate is orally taken. Dynamic imaging to cover E-G junctionIndications: Vomiting, failure to thrive,recurrent pneumoniaInterpretation: Regurgitation of theradioactivity from stomach into eso.
  24. 24. Ge Reflux Study (Milk Scan)
  25. 25. Gastric Emptying:Technique: Tc-99m phytate, In-111 Chloride Liquid vs solid meal Dynamic imaging for 90 min curvesIndications: Dyspepsia, eating disorders Diabetes After GI surgery: to evaluate gastric outlet obstruction or "dumping" syndrome.
  26. 26. Gastric Emptying Study
  27. 27. Normal Solid-LiquidGastric Emptying StudyLIQUID SOLID Lag phase
  28. 28. GI Bleeding StudyTechnique: NPO Tc-99m RBC, Tc-99m phytate iv. Dynamic imaging for at least 1 hr.Indication: Lower GI bleedingMech: ExtravasationPositive: Active bleeding- hot spot,move along peristalsis
  29. 29. Positive GI Bleeding •Tc-99m RBC •Hepatic flexureExtravasation of the tracer into bowel lumen Focal area of increased activity, move // bowelmovementPattern depends on site of bleeding & bowelperistalsis
  30. 30. Meckel’s Diverticulum ScanTechnique: NPO Tc-99m pertechnetate IV. Serial imaging upto 2 hrs.Mech: Ectopic gastric localization No active GI bleeding requiredIndication: Lower GI bleeding in small childrenPositive: Abnormal intraabdominal hot spot // gastricactivity
  31. 31. Meckel’s Diverticulum Stomach M Bladder
  32. 32. Liver Spleen ScanTechnique: No prep required Tc-99m phytate iv. Static planar imaging 6 views + SPECTUses: Evaluate the size & shape of the liver & spleen, also function (hepatocellular dysfunction (colloid shift) To evaluate SOL-nonspecific !
  33. 33. Liver Scan
  34. 34. Hepatobiliary ScintigraphyTechnique: NPO at least 4 hr. Tc-99m DISIDA iv. Mech: Hepatocytes Dynamic imaging for at least 1 hrIndications: Acute RUQ pain- acute cholecystitis Biliary tract obstruction, neonatal Jx Bile leakInterpretation:Normal-visualize biliary tract,GB, small bowel within 1 hr.
  35. 35. Hepatobiliary Scintigraphy Acute Cholecystitis
  36. 36. Rim sign in acute cholecystitiscurvilinear band of increased activity along the hepatic margin abovethe GB fossa.The rim sign is identified in about 20-30% of patients with acutecholecystitis,The PPV for acute cholecystitis is about 95% when a rim sign isidentified in association with non-visualization of the GB at one hour[9].Approximately 40% of patients who demonstrate the rim sign willhave complicated cholecystitis
  37. 37. Rim sign in acute cholecystitisRefers to increased pericholecystic hepatic activitywithout GB visualization.The rim sign appears as curvilinear band of increasedactivity along the hepatic margin above the GB fossaand is usually identified early in the examination.It may be due to increased flow and/or impairedhepatocyte radionuclide excretion.The rim sign is identified in about 20-30% of patientswith acute cholecystitis,The PPV for acute cholecystitis is about 95% when a rimsign is identified in association with non-visualization ofthe GB at one hour [9].Approximately 40% of patients who demonstrate therim sign will have complicated cholecystitis (extensivenecrosis, perforated or gangrenous GB), thus thepresence of this sign indicates the need for moreemergent surgery.
  38. 38. Cystic duct signThe dilated cystic duct sign refers to a nubbinof activity projecting from the proximal end ofthe common bile duct medial to thegallbladder fossa.It is believed to represent the a patent cysticduct distal to the site of obstruction.This sign is observed in about 7% of patientswith acute cholecystitis and should not bemistaken for a small, shrunken gallbladder.
  39. 39. Ventilation-Perfusion Lung Scan Indications: Pulmonary embolism Pulmonary hypertension Rt-to-Lt shunt* Tracer: Tc-99m MAA-Tc-99m phytate or DTPA aerosol Views: 6 planar images [+ head (brain) & posterior abdomen (kidneys)] Interpretation:Ventilation,perfusion,CXR
  40. 40. Incorrect Inj Technique Multiple hot spots Technique: Drawing Pt’s blood into Tc-99m MAA syringe form clumping hot spots
  41. 41. Interpretation of V/Q Lung ScanPerfusion lung scanVentilation lung scanCXR within 24 hrsCriteria: Modified PIOPED criteria Normal High-intermediate-low probability
  42. 42. Normal Lung ScanVENTILATION PERFUSION
  43. 43. Pulmonary Embolism
  44. 44. Right-to-Left Shunt Tc-99m MAA perfusion lung scan Presence of radiotracer in the brain and kidneys Precaution: Limited MAA particles.
  45. 45. Quantitative Lung Function Study
  46. 46. Radionuclide Venography Tracers : Tc-99m MAA, Tc-99m phytate Uses : 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)
  47. 47. Radionuclide Venography
  48. 48. Genitourinary SystemRenal scintigraphy Tracers: Tc-99m DTPA (GFR), Tc-99m MAG3, I-131 OIH (ERPF), Tc-99m DMSA Diuretic renography: to R/O mechanical urinary tract obstruction. Captopril renography: RVHT Tc-99m DMSA scan: renal scarringTesticular scintigraphyRadionuclide cystography Direct vs indirect method
  49. 49. Renal ScintigraphyTo evaluate renal ADVANTAGESperfusion No renal toxicityTo evaluate split renal Safe for Pts. withfunction-relative function renal insufficiency(%) No allergyTo evaluate urinarydrainage DISADVANTAGES DDx functional vs mechanical urinary tract Limited anatomical obstruction (good renal details function!)
  50. 50. Renal Scintigraphy LT RT L R Flow: 1-2 min Posterior Renograms or Renal time-activity curves Renal Scan-30 min
  51. 51. Poor Renal Function
  52. 52. Urinary Tract Obstruction
  53. 53. Diuretic Renography Diuretics: Furosemide Dose: 0.5-1 mg/Kg IV Timing: 20-30 minutes following radiotracer injectionInterpretation Good response: T1/2 < 10 min Equivocal response: T1/2 10-20 min Poor response: T1/2 > 20 min
  54. 54. Tumor ImagingTracers: Nonspecific tumor agents: Ga-67 citrate, Tl-201, Tc-99m MIBI Specific tumor agents: I-131 somatostatin receptor agent, I-131 MIBG*Indications: Staging-Ga & lymphoma Monitoring therapy: Ga & lymphoma, MIBI & OSM Detect recurrent tumor DDx viable vs fibrosis Guide for Bx
  55. 55. Ga-67 Scan
  56. 56. Tc-99m MIBI Scan Normal DTC s/p TT & RAI Rx with Lt cervical LN metas. Abnormal
  57. 57. Parathyroid ScanSensitive modality to detect parathyroidadenoma (or hyperplasia), also ectopic.Sensitivity for adenoma is > 95% and forhyperplasia is between 75 to 85%.Many patients with hyperparathyroidismpresent with bone pain, renal stones, orhypercalcemia.Technique: Single isotope-Tc-99m sestamibi Dual isotopes- MIBI & TcO4-
  58. 58. Parathyroid Adenoma Tc-99m Tc-99m MIBI
  59. 59. I-131 MIBG ScanTechnique: Prep: • Lugol’s solution to block thyroid uptake of free iodide • Avoid drugs interfering MIBG uptake I-131 MIBG 0.5-1 mCi iv. Whole-body imaging at 24, 48, (72) hrsIndications:Pheo, NBM, carcinoids, MTCInterpretation: Normal: adrenal medulla, salivary liver, kidneys, bladder, bowel, heart
  60. 60. I-131 MIBG Scan in NBM ANT POST3 yo girl, NBM stage IV with multiple bone metas 2-44Pretreatment staging
  61. 61. MiscellaneousLymphoscintigraphySentinel node mappingBone marrow imaging