Radiation Protection in Nuclear Medicine

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Radiation Protection in Nuclear Medicine

  1. 1. International Atomic Energy Agency RADIATION PROTECTION IN NUCLEAR MEDICINE Part 0: Introduction to Nuclear Medicine
  2. 2. NUCLEAR MEDICINE Diagnosis and therapy with unsealed sources Clinical problem Radiopharmaceutical Instrumentation Nuclear Medicine Part 0. Introduction to Nuclear Medicine 2
  3. 3. RADIOPHARMACEUTICALS Radionuclide Pharmaceutical Organ Parameter + colloid Liver RES Tc-99m + MAA Lungs Regional perfusion + DTPA Kidneys Kidney function Nuclear Medicine Part 0. Introduction to Nuclear Medicine 3
  4. 4. HISTORY-RADIONUCLIDES 1896 Natural radioactivity Becquerel 1898 Radium Curie 1911 Atomic nucleus Rutherford 1913 Model of the atom Bohr 1930 Cyclotron Lawrence 1932 Neutron Chadwick 1934 Artificial radionuclide Joliot-Curie 1938 Production and identification of I-131 Fermi et al 1942 Nuclear reactor Fermi et al 1946 Radionuclides commercially available Harwell 1962 Tc99m in nuclear medicine Harper Nuclear Medicine Part 0. Introduction to Nuclear Medicine 4
  5. 5. PIONEERS Henri Becquerel Ernest Rutherford Maria Curie Frederique Joliot-Irene Curie Nuclear Medicine Part 0. Introduction to Nuclear Medicine 5
  6. 6. CURRENT METHODS-THERAPY Radiopharmaceutical For treatment of Route of Maximum administration activity I-131 iodide Thyrotoxicosis Oral 1 GBq I-131 iodide Carcinoma of thyroid Oral 20 GBq I-131 MIBG Malignancy IV 10 GBq P-32 phosphate Polycythaemia vera IV or oral 200 MBq Sr-89 chloride Bone metastases IV 150 MBq Y-90 colloid Arthritic conditions Intra-articular 250 MBq malignant effusions Intra-cavitary 5 GBq Er-169 colloid Arthritic conditions Intra-articular 50 MBq Re-186 colloid Arthritic conditions Intra-articular 150 MBq Nuclear Medicine Part 0. Introduction to Nuclear Medicine 6
  7. 7. HISTORY-THERAPY 1936 Therapeutic use of Na-24 (leukemia) Hamilton et al 1936 Therapeutic use of P-32 (leukemia and Lawrence polycythemia vera) 1941 Therapeutic use of iodine in hyperthyroidism Hertz et al 1942 Therapeutic use of iodine in treatment of metastasis from thyroid cancer 1945 Therapeutic use of Au-198 in treatment of Muller malignant effusion 1958 Treatment of bone metastasis with P-32 Maxfield 1963 Medical synovectomy using Au-198 Ansell Nuclear Medicine Part 0. Introduction to Nuclear Medicine 7
  8. 8. I-131 THERAPY The absorbed dose to be delivered should be determined from uptake measurements, effective half-life of the radio- pharmaceutical and the size of the thyroid. The radiopharmaceutical is administered p.os. Hyperthyroidism Cured after Hypothyroidism 3-4 months 1 year after <7 years after >7 years 85% 98% 14.8% 27.9% Nuclear Medicine Part 0. Introduction to Nuclear Medicine 8
  9. 9. RADIOSYNOVECTOMY Nuclear Medicine Part 0. Introduction to Nuclear Medicine 9
  10. 10. PAIN PALLIATION Intravenous injection of a radiopharmaceutical which includes e.g. Sr-89 or Sm-153 Nuclear Medicine Part 0. Introduction to Nuclear Medicine 10
  11. 11. ANNUAL FREQUENCY-THERAPY (Sweden 1995) Number of patients per 1000 population Thyroid (tumours & hyperthyroidism) 0.39 Polycythemia vera 0.034 Other tumours 0.003 Others 0.001 Total 0.428 about 3% of all nuclear medicine Nuclear Medicine Part 0. Introduction to Nuclear Medicine 11
  12. 12. CURRENT DIAGNOSTIC METHODS • Imaging Bone, Brain, Lungs , Thyroid, Kidneys, Liver/spleen, Cardiovascular, Stomach/GI-tract, Tumours, Abscesses …. • Non-imaging (probes) Thyroid uptake, Renography, Cardiac output, Bile acid resorption…. • Laboratory tests GFR, ERPF, Red cell volume/survival, Absorption studies (B12, iron, fat), Blood volume, Exchange- able electrolytes, body water, bone metabolism….. • Radioimmunoassays (RIA) • Radioguided Surgery Nuclear Medicine Part 0. Introduction to Nuclear Medicine 12
  13. 13. ANNUAL FREQUENCIES-DIAGNOSIS (Sweden, 1998) 35 30 Frequency (%) 25 20 15 10 5 0 ne n d b ey io es ng ai La oi rd dn ob Bo Lu Br yr Ca Th Ki Pr 15 examinations/1000 population Nuclear Medicine Part 0. Introduction to Nuclear Medicine 13
  14. 14. Health-care level I Country 1970-79 1980-84 1985-90 Country 1970-79 1980-84 1985-90 Argentina 11.5 Kuwait 13.1 Australia 3.8 8.9 8.3 Luxembourg 23.5 Austria 18.0 Netherlands 11.6 Belgium 36.8 New Zealand 5.6 7.3 7.5 Bulgaria 13.0 Norway 3.9 9.3 Canada 12.6 Romania 3.0 3.5 Czech Rep. 13.6 18.3 22.9 Sweden 9.8 12.6 Denmark 14.0 14.2 13.4 Switzerland 44.9 Finland 12.6 17.7 USSR 3.9 France 9.0 6.9 United Kingdom 6.8 Germany 31.1 39.7 39.8 United States 25.7 Italy 6.0 7.3 Yugoslavia 6.1 Japan 8.3 Average 11 6.9 16 Total annual number of nuclear medicine examinations per 1000 population (UNSCEAR) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 14
  15. 15. Health-care level II Country 1970-79 1980-84 1985-90 Country 1970-79 1980-84 1985-90 Barbados 1.0 Iraq 1.2 Brazil 1.7 Jamaica 2.8 2.0 China 0.6 Peru 0.2 Cuba 0.8 Tunisia 1.0 Ecuador 0.5 0.8 Turkey 2.5 India 0.1 0.2 Average 0.9 0.1 0.5 Health-care level III Country 1970-79 1980-84 1985-90 Country 1970-79 1980-84 1985-90 Egypt 0.07 0.21 0.48 Sudan 0.12 0.28 0.28 Myanmar 0.54 0.36 0.11 Thailand 0.25 0.18 0.26 Average 0.25 0.25 0.30 Health-care level IV Country 1970-79 1980-84 1985-90 1970-79 1980-84 1985-90 Ethiopia 0.014 0.10 Average 0.014 0.10 Total annual number of nuclear medicine examinations per 1000 population (UNSCEAR) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 15
  16. 16. HISTORY-DIAGNOSTICS 1927 Blood flow studies (Bi-214) Blumgart-Weiss 1935 Bone metabolism (P-32) Chiewitz-de Hevesy 1939 Thyroid studies (I-131) Hamilton et al 1948 Radiocardiography (Na-24) Prinzmetal et al 1956 Renography (I-131) Taplin, Winter 1957 Liver scan (Au-198 colloid) Friedell et al 1961 Bone scan (Sr-85) Fleming et al 1962 Myocardium (Rb-86, Cs-131) Carr et al 1964 Lung scan Taplin et al 1965 Brain scan (Tc99m-pertechnetate) Bollinger et al 1971 Bone scan (Tc99m-complex) Subramanian et al Nuclear Medicine Part 0. Introduction to Nuclear Medicine 16
  17. 17. GEORGE DE HEVESY 1885-1966 de Hevesy G & Paneth F. Die Lösligkeit des Bleisulfids und Bleichromats. Z. Anorg Chem 82, 323, 1913. de Hevesy G. III. The absorption and translocation of lead by plants. Biochem J, 17, 439, 1923. Chiewitz O. & de Hevesy G. Radioactive indicators in the study of phosphorous metabolism in rats. Nature 136, 754, 1935. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 17
  18. 18. MINERAL METABOLISM Göran C. H. Bauer Arvid Carlsson Bertil Lindquist MINERAL METABOLISM (1961) ..studies of bone by isotope techniques have now reached beyond the stage of methodology to give data of immediate physiological and clinical importance. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 18
  19. 19. BONE SCAN Single probe Scanner Gammacamera Nuclear Medicine Part 0. Introduction to Nuclear Medicine 19
  20. 20. INSTRUMENTATION IN NUCLEAR MEDICINE • Activity meter • Sample counters • Single- and multi-probe systems • Gamma camera • Single Photon Emission Computed Tomograph (SPECT) • Positron camera (PET) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 20
  21. 21. KIDNEY CLEARANCE (plasma samples) Cr51-EDTA, 300 kBq Plasma samples at 180-240 min 1000.0 100.0 cpm/ml Clearance (Cl) is calculated: 10.0 Cl = A / C p (t) * dt 1.0 0 0 100 200 300 Time (min) A is injected activity Cp is activity concentration in plasma Nuclear Medicine Part 0. Introduction to Nuclear Medicine 21
  22. 22. THYROID UPTAKE MEASUREMENT Nuclear Medicine Part 0. Introduction to Nuclear Medicine 22
  23. 23. HISTORY-INSTRUMENTS 1908 Visual scintillation (ZnS) Crookes 1927 Geiger-counter Geiger 1944 Scintillation detector (ZnS+PM) Curran 1948 Sodium iodide crystal Hofstadter 1950 Scanner Cassen 1957 Gamma camera Anger 1963 Tomography Kuhl Nuclear Medicine Part 0. Introduction to Nuclear Medicine 23
  24. 24. PIONEERS B. Cassen H.O. Anger Nuclear Medicine Part 0. Introduction to Nuclear Medicine 24
  25. 25. GAMMA CAMERA? Nuclear Medicine Part 0. Introduction to Nuclear Medicine 25
  26. 26. GAMMA CAMERA Nuclear Medicine Part 0. Introduction to Nuclear Medicine 26
  27. 27. NUCLEAR MEDICINE IMAGES  Nuclear imaging detects functional (vs. anatomical) properties of the human tissue.  The imaging is done by tracing the distribution of radiopharmaceuticals within the body with a gamma camera Nuclear Medicine Part 0. Introduction to Nuclear Medicine 27
  28. 28. BONE SCAN Bone uptake of 99mTc MDP reflects bone metabolism and blood flow, and allows functional analysis of bone turnover  The ability to image bone metabolism alterations enables detection of lesions such as: Bone metasasis Benign or malignant bone tumors Bone trauma  A three-phase acquisition procedure is required in order to detect osteomelitis  Bone scans also facilitate follow-up of other bone disorders, such as Paget’s disease  Intravenous injection of 400-600 MBq 99mTc MDP. Imaging 3h after injection Nuclear Medicine Part 0. Introduction to Nuclear Medicine 28
  29. 29. BONE SCAN normal pathologic Nuclear Medicine Part 0. Introduction to Nuclear Medicine 29
  30. 30. LUNG SCAN A proportionately spread embolization of the pulmonary capillary bed yields an image reflecting the lung blood perfusion (Tc99m MAA). This image enhances the diagnosis of pulmonary emboli. Intravenous injection of 100 MBq Tc99m MAA. Immediate scanning. Ventilation studies (Tc99m -aerosols) reflect the regional and segmental ventilation. Study interpretation is performed in conjunction with perfusion findings, supporting the differential diagnosis of pulmonary emboli. Inhalation of 100 MBq Tc99m -aerosols. Immediate scanning. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 30
  31. 31. LUNG SCAN Nuclear Medicine Part 0. Introduction to Nuclear Medicine 31
  32. 32. THYROID Thyroid scintigraphy (I123, I131 or Tc99m pertechnetate) offers structural and functional information by displaying the thyroid image and calculating uptake, organ volume etc. Pinhole SPECT studies offer superior contrast resolution image over the planar image, enhancing thyroid nodules detection and evaluation. Intravenous injection of 100 MBq Tc99m pertechnetate. Scanning 15 min later. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 32
  33. 33. THYROID SCAN Nuclear Medicine Part 0. Introduction to Nuclear Medicine 33
  34. 34. CEREBRAL BLOODFLOW  99mTc HMPAO or similar compound - retained in the brain in proportion to regional cerebral blood flow.  Localizes predominately in the gray matter and does not show redistribution.  Enhances detection of : Brain dementia such as Alzheimers disease, seizure localization Foci, Cerebral vascular problems such as cerebral ischemia, trauma and brain death Intravenous injection of 800 MBq 99mTc HMPAO. Tomography 30 min later Nuclear Medicine Part 0. Introduction to Nuclear Medicine 34
  35. 35. CEREBRAL BLOODFLOW normal Alzheimers disease Nuclear Medicine Part 0. Introduction to Nuclear Medicine 35
  36. 36. KIDNEY FUNCTION • Determination of kidney clearance of Cr51-EDTA or Tc-99m DTPA. • Dynamic renal scintigraphy reflects renal blood perfusion, uptake and excretion. The acquisition yields a series of images. By calculating count rate in a defined ROI, a renogram is created, providing quantitative data. Different radiopharmaceuticals, such as Tc99m-MAG3, Tc99m-DTPA and I123- Hippuran, are used for renal clearance and function assessment. • Renal scan for parenchymal anatomy and function evaluation uses Tc99m-DMSA Nuclear Medicine Part 0. Introduction to Nuclear Medicine 36
  37. 37. KIDNEY FUNCTION (Tc99m-DTPA) It is ideal to mark the background region in such a manner as to exclude the arteries and calycial region. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 37
  38. 38. KIDNEY FUNCTION (Tc99m-DMSA) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 38
  39. 39. FIRST PASS STUDIES • Intravenous high activity (400-800 MBq) Tc-99m bolus tracer injection, followed by a short acquisition (4-20 frames per second during 1 minute) demonstrates Myocardial function eliminating background activity bias. • First pass procedures facilitates: • Wall motion imaging • LV and RV ejection fraction calculations • Detection of left to right intracardial shunts • Cardiac output calculations • Ventricle volume calculations • Transit times calculations Nuclear Medicine Part 0. Introduction to Nuclear Medicine 39
  40. 40. SHUNT QUANTIFICATION Nuclear Medicine Part 0. Introduction to Nuclear Medicine 40
  41. 41. ECG-GATED BLOODPOOL SCANNING • Red blood cell labeling (Tc99m), followed by gated acquisition and measurement of the corresponding dynamic blood volume count rate changes, enables LV and RV blood volume quantification. The analysis of ventricular wall motion, systolic/diastolic functions, and Ejection Fraction, has application for CAD evaluation, risk stratification, and monitoring of cardiotoxicity in chemotherapy treatments. • Intravenous injection of 600-800 MBq Tc99m , scanning 10-15 min later. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 41
  42. 42. ECG-GATED BLOODPOOL SCANNING Nuclear Medicine Part 0. Introduction to Nuclear Medicine 42
  43. 43. MYOCARDIAL PERFUSION • 201Tlaccumulation in the myocard depends on blood flow and cellular metabolism, hence, reflects regional perfusion and viability of the cardiac muscle. • The evaluation of a patient suspected or known for C.A.D. is based on image interpretation or quantitative analysis from reconstructed tomographic slices, which also yields regional perfusion information. • The examination is performed under maximum stress condition and after rest. • Injected activity 70-100 MBq 201Tl. Tomographic study. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 43
  44. 44. MYOCARDIAL PERFUSION Stress Rest Nuclear Medicine Part 0. Introduction to Nuclear Medicine 44
  45. 45. TOMOGRAPHIC SLICES coronal sagittal transversal Nuclear Medicine Part 0. Introduction to Nuclear Medicine 45
  46. 46. MYOCARDIAL PERFUSION Nuclear Medicine Part 0. Introduction to Nuclear Medicine 46
  47. 47. MYOCARDIAL PERFUSION • The physical properties offered by 99mTc MIBI or Tetrofosmin facilitate evaluation of myocardial perfusion and function by enabling performance of gated SPECT perfusion studies initiated with first pass acquisition. The assessment of a patient with known or suspected C.A.D. is based on quantitative analysis and coronary artery regional perfusion evaluation, drawn from a set of reconstructed tomographic slices. • Injected activity 800-1000 MBq. Gated tomographic acquisition Nuclear Medicine Part 0. Introduction to Nuclear Medicine 47
  48. 48. ECG-GATED MYOCARDIAL PERFUSION Nuclear Medicine Part 0. Introduction to Nuclear Medicine 48
  49. 49. GATED SPECT Nuclear Medicine Part 0. Introduction to Nuclear Medicine 49
  50. 50. PET Positron Emission Tomography Nuclear Medicine Part 0. Introduction to Nuclear Medicine 50
  51. 51. ANNIHILATION 511 keV positron + - + 511 keV Nuclear Medicine Part 0. Introduction to Nuclear Medicine 51
  52. 52. RADIONUCLIDES Radionuclide Halflife Particle energy (mean) C-11 20.4 min 0.39 MeV N-13 10 min 0.50 MeV O-15 2.2 min 0.72 MeV F-18 110 min 0.25 MeV Cu-62 9.2 min 1.3 MeV Ga-68 68.3 min 0.83 MeV Rb-82 1.25 min 1.5 MeV Nuclear Medicine Part 0. Introduction to Nuclear Medicine 52
  53. 53. PIONEERS Michel Ter-Pogossian prepares a radiopharmaceutical for an examination of Henry Wagner Jr with one of the first PET- scanners (1975). Nuclear Medicine Part 0. Introduction to Nuclear Medicine 53
  54. 54. PET-SCANNER Nuclear Medicine Part 0. Introduction to Nuclear Medicine 54
  55. 55. PET WITH GAMMA CAMERA Nuclear Medicine Part 0. Introduction to Nuclear Medicine 55
  56. 56. CYCLOTRON Stanley Livingstone and Ernest Lawrence with their 8 MeV cyclotron (1935) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 56
  57. 57. CYCLOTRONS IN HOSPITALS Nuclear Medicine Part 0. Introduction to Nuclear Medicine 57
  58. 58. F18-FDG Nuclear Medicine Part 0. Introduction to Nuclear Medicine 58
  59. 59. FDG IN CARDIOLOGY Nuclear Medicine Part 0. Introduction to Nuclear Medicine 59
  60. 60. FDG IN ONCOLOGY Nuclear Medicine Part 0. Introduction to Nuclear Medicine 60
  61. 61. FDG IN NEUROLOGY Alzheimers disease Normal Nuclear Medicine Part 0. Introduction to Nuclear Medicine 61
  62. 62. THE FUTURE Diagnostic methods •New radiopharmaceuticals based on positron emitters. •Radiopharmaceuticals with high specificity. •More advanced application programs which improve both sensitivity and specificity of the examination. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 62
  63. 63. MULTIMODALITY IMAGING PET CT Nuclear Medicine Part 0. Introduction to Nuclear Medicine 63
  64. 64. THE FUTURE Instrumentation • Improved performance of the gamma camera • Improved detection of positron emitters • More sophisticated methods for reconstruction and correction of tomographic examinations • Advanced electronic reporting systems. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 64
  65. 65. NUCLEAR MEDICINE - UNCLEAR MEDICINE? No! Nuclear medicine is an efficient diagnostic and therapeutic tool and is justified from a medical point of view. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 65

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