Nuclear medicine

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  • One of the first experiments was performed by Blumgard and Weiss in 1943. By injecting a small amount of radioactivity into the arm vein of a subject and monitoring the appearance of radioactive signal with a detector on the contralateral side, they were able to measure the transit time of blood from the venous to the arterial circulation.
    This experiment illustrates what we call the "tracer principle"
  • Fused image of prior patient
  • Nuclear medicine

    1. 1. Nuclear Medicine- Research & Clinical Applications
    2. 2. What is Nuclear Medicine Radiology (X-ray/CT) Nuclear Medicine PET/SPECT Transmission Image Anatomical Image Emission Image Functional Image Radiation Source Imaging Instrument Imagining Instrument rays Diagnosis Diagnosis/Therapy
    3. 3. SPECT + CT Computer Correlated Image CT X-Ray CT Radionuclide Emission SPECT
    4. 4. Radioactive Tracers in Medicine Inject Radioactive Material Detect Radioactivity Measure function of the body Inject nanomolar concentrations Does not perturb the function of the body Can be measured noninvasively Nuclear medicine uses radiotracers for functional assessments of the human body
    5. 5. What is Nuclear Medicine Nuclear Medicine Tripod Physician Diagnosis (80%) Therapy (20%) Radiopharmacist Radiophysicist (RSO) + Nuclear Medicine Technologists QC of instrumentation Radiation Dosimetry + RN Therapy+ Imaging Radionuclide Chemical Radiopharmaceutical (Targeted) Preparation of radiopharmaceuticals QC of chemicals Biomedical Engineer Design/Service/ Maintenance
    6. 6. WHAT CAN WE VISUALIZE ?
    7. 7. Evaluation of Renal function & Structure DTPA Scan DMSA Scan
    8. 8. Vesicoureteric Reflux (VUR)
    9. 9. 99mTc-MDP Bone Scanning • To see for Bony Metastasis in • Breast Cancer patients • Prostate Cancer Patients • Osteomyelitis • Bone inflammation • Bone infection
    10. 10. Prostate Cancer –Bone Metastases Low Backache (L5-S1)
    11. 11. 99mTc-Ciprofloxacin Imaging (Bone infection)
    12. 12. Gastrointestinal Studies GER HIDA -Norma l Atresia Colloid Shift Cirrhosis
    13. 13. Cardiology Applications Thallium Scan Normal Study 99mTc-labelled- RBC-MUGA study Abnormal Study-Wall motion defect
    14. 14. 99mTc-Sestamibi Scintimammography (Tumor Imaging)
    15. 15. Emergency -NM Procedures GI-Bleeding Testicular Torsion Scan PTE-Scan
    16. 16. Positron Emission Tomography BALJINDER SINGH Department of Nuclear Medicine, PGIMER, Chandigarh
    17. 17. PET PHYSICS Positron Decay: A ZXN  A Z-1YN+1 + e+ + v Positron Annihilation: e+ + e-  γ + γ
    18. 18. PET Radiopharmaceuticals Nuclide Half-life Tracer Application O-15 2 mins Water Cerebral blood flow C-11 20 mins Methionine Tumour protein synthesis N-13 10 mins Ammonia Myocardial blood flow F-18 110 mins FDG Glucose metabolism Ga-68 68 min DOTANOC Neuroendocrine imaging Rb-82 72 secs Rb-82 Myocardial perfusion
    19. 19. Positron Annihilation β− ν β+ 511 keV 511 keV Positron emitting radio- pharmaceutical BGO or LSO detector array Body Positron Emission Tomography (PET) 11 C-Carbon 13 N-Nitrogen 15 O-Oxygen 18 F-Fluorine
    20. 20. Production-Labeling of 18F-FDG in process
    21. 21. Patient being positioned for PET study
    22. 22. FDG • Most widely used PET tracer • Glucose utilization • Taken up avidly by most tumours CH2HO HO HO O OH 18 F CH2HO HO HO O OH OH glucose 2-deoxy-2-(F-18) fluro-D-glucose
    23. 23. FDG Metabolism FDG FDG -6-P Radio- active Glucose 18 F-FDG Radioactive Glucose 18 F-FDG X Glucose Glucose Glucose Glucose-6- Phosphate Unlike glucose, FDG is trapped
    24. 24. PET IN TUMOR IMAGING Lymphomas, Breast, Colorectal, Non-small cell lung carcinoma, Head and neck, Brain, Melanomas maximally studied and benefited Also useful in cancer in other locations such as in the Ovaries, Bladder, Thyroid, Pancreas, etc.
    25. 25. Lymphoma Patient with lymphoma with infra and supra-diaphragmatic lymph node involvement. PET allows complete staging with just one test and serves as the basis to check treatment efficacy
    26. 26. Lung Cancer Lung Cancer Solitary Pulmonary Nodule
    27. 27. Lung Cancer
    28. 28. Colon Carcinoma Patient with colon carcinoma and multiple liver, bone and soft tissue metastases, whose diagnosis using the usual methods would have been much more difficult, costly and uncomfortable for the patient. With just one PET study, complete staging is possible.
    29. 29. Breast Cancer Patient with breast cancer and metastatic lymph node involvement. This involvement is often difficult for the usual diagnosis methods to detect
    30. 30. Melanoma
    31. 31. PET Imaging – Cardiology Applications Assess myocardial viability Confirm myocardial ischemia Pre-transplantation assessment Diagnosis of cardiomyopathy
    32. 32. Myocardium perfusion and metabolism study with 13N-Amonium and FDG respectively, with a match pattern in which it can be seen that there is absence of both perfusion and metabolism in the antero-septal region, indicating lack of myocardium viability, and therefore discarding the possibility of revascularization treatment (by-pass). Non-viable Myocardium
    33. 33. Patient with acute myocardial infarction (AMI) history and PET mismatch pattern in which lack of perfusion can be seen laterally with metabolism persistence, compatible with viable myocardial tissue. After revascularization surgery, myocardium recovery is observed, together with perfusion and metabolism normalization Viable Myocardium
    34. 34. Nuclear Medicine in Therapy  Radio-iodine was first used in the treatment of metastasized thyroid carcinoma in 1943.  Its success in terms of tumor response, quality of life improvement and survival was considered a ‘miracle’, as in those days metastatic cancer was generally fatal.  Inspired by this, many efforts have been made to apply radioisotope therapy to other tumors.
    35. 35. One of the most important difference between targeted radionuclide therapy and external beam irradiation is the finite (restricted) range of ionizing particles emitted. Targeted radionuclide therapy involves the use of radiolabeled tumor-seeking molecules to deliver a cytotoxic dose of radiation to tumor cells.
    36. 36. 1. Beta-particle emitters 2. Alpha-particle emitters 3. Auger electron Radionuclides that decay by the following three general categories of decay have been studied for therapeutic potential :
    37. 37. Advantages of Targeted Radionuclide Therapy Tumor specific, with sparing of healthy tissue (low toxicity). No limit to the absorbed dose (no limit to the number of treatment). Radiation can be delivered to subclinical tumors and metastases that are too small to be imaged and thereby untreated by surgical excision and external beam therapy.
    38. 38. Established therapies 1. Hyperthyroidism- (I-131) 2. Thyroid carcinoma (I-131-High Dose) 3. Bone metastases (32P, 89Sr, 153 Sm) 4. I-131- MIBG therapy (Neuroblastoma, Pheos) 5. Lipiodol therapy (Iodine-131-HCC) 6. Synovectomy (short range B-emitters) Newer Therapies 1. Radio-peptide therapy (177Lu, 90Y) 2. Radio-immunotherapy of lymphoma 3. Microsphere therapy for liver cancer (90Y)
    39. 39. Nuclear Medicine (PET/SPECT) Drug Development • Development of New Tracers for human use (Diagnostic & Therapeutic). • Drug Development (Pharmaceuticals) • In clinical trials, PET Technology evaluates whether a drug has a biological effect • How the effect compared with other agents, whether the drug reached the target organ • Whether it did so at an effective concentration. • Of particular utility in the development of new anti-cancer therapy
    40. 40. Nuclear Medicine (Biomarker Imaging) • Provides an opportunity to interrogate the target/tissue of interest – in a temporal fashion (dynamic studies)- Proof of Target (POT) • Answers questions around distribution (target or compound) -POT • Structural and functional consequences of intervention with novel therapies - POM • These approaches –facilitate better and faster decision making-POE • Testing of therapies in the appropriate patient population • Provides robust endpoints for regulatory submission
    41. 41. Biomarkers- Three Categories •
    42. 42. NM – Imaging Cuts down the cost of Drug Development Cost involvement – around 800 $ (million) Time line - 10-12 years Shortening the Drug Discovery/Development process Increasing the Efficiency of the testing methods Facilitating the Transition between the Preclinical testing and clinical evaluation of the drugs NM Imaging methods are more easily applied than the traditional methods as more realistic animal models of human disease can be created
    43. 43. Conclusion • Role of Imaging in drug development is valued • Impact of numerous Imaging modalities including SPECT/PET/dceMRI/CE-US is significant • As we head in to the era of personalized medicines • Imaging has role in drug development, diagnosis, stratification and monitoring of patients in the treatment setting
    44. 44. Nuclear Medicine Nuclear medicine began approximately 50 years ago and has evolved into a major medical specialty for both diagnosis and therapy of different disease conditions 3,900 hospital-based nuclear medicine departments in USA alone Perform over 10 million nuclear medicine imaging and therapeutic procedures each year. India has close to 200 Nuclear Medicine Centers (0.5 million NM- Procedures catering to the need of 1.2 billion population ( Look at the Scope of expansion of NM –India) Despite its integral role in patient care, nuclear medicine is still often confused with other imaging procedures, including general radiology, CT, and MRI.
    45. 45. Challenges-Trained Technical Manpower ? Interdisciplinary Groups Radiochemists Radiopharmacists Biomedical Engineers Physicists Imaging Experts Toxicologists Pharmacologists Dosimetrists Nuclear Medicine Physicians Molecular Biologists Genomics/Proteomics Experts Hybridoma Experts •Initiation of Leaderships of Universities/academic/research Institutes •Technical courses to generate the technical manpower •Inter-institutional teaching/research collaborations •Organization of thematic Training workshops/seminars (students/faculty participation) •Achieving the target of Personalized Medicine

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