Nuclear Medicine Procedures

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Nuclear Medicine Procedures

  1. 1. 489 NUCLEAR MEDICINE Nuclear Medicine Procedures Clinical Practices Contents Radiopharmaceutical Dose Considerations 495 Bone 496 Central Nervous System (CNS) 498 Gastrointestinal 502 Three Phase Bone Scan 496 Bone Scan Spot Views 496 Whole Body Format Bone Scan (Single Pass Imaging) 497 Brain Imaging - Blood Brain Barrier Agents 498 Brain Imaging - SPECT Perfusion Imaging 499 Brain Death Evaluation 500 Cerebral Spinal Flow (CSF) 500 CSF Leak Determination 501 Cholescintigraphy 502 Gastric Emptying Solid Phase 503 Gastric Emptying and GE Reflux (Milk Study) - Liquid Phase 503 Labeled Red Blood Cell Scan (GI Bleeding) 504 Meckel’s Diverticulum 505 Liver Fat Determination 505 Liver/Spleen Imaging - 99mTc Sulfur Colloid 506 Hepatic Hemangioma Imaging 507 Hepatic Pump 508 LaVeen Shunt Patency 508 Parotid Gland Imaging 509
  2. 2. 490 CLINICAL PRACTICES Nuclear Medicine Procedures Clinical Practices Contents Genitourinary 510 Renal Function 510 DMSA Renal Imaging 511 Diuretic (Lasix) Renogram 511 Captopril Renal Scan for Evaluation of Renovascular Hypertension 512 Testicular Imaging 513 Radionuclide Cystogram 514 Lung 519 Lung Perfusion 519 Lung Ventilation 520 Pulmonary Aspiration 521 111In White Blood Cell Scan for Infection 518 Inflammation 517 67Ga Inflammation 517 99mTc White Blood Cell Scan for Infection 518 99mTc labeled RBC Volume Determination 515 Hematology 515 Bone Marrow 515
  3. 3. 491 NUCLEAR MEDICINE Nuclear Medicine Procedures Clinical Practices Contents Endocrine 521 Thyroid Imaging and Uptake (99mTc) 521 Thyroid Uptake and Imaging (123I) 522 123I Potassium Perchlorate Washout Test 523 Parathyroid Imaging 524 67Ga Tumor 525 111In Pentetreotide Imaging Tumor 524 IIodine - 131 MIBG Imaging of Adrenergic Tumors 524 Strontium - 89 Radiotherapy 527 Miscellaneous 527 Right to Left Shunt (MAA Technique) 530 Lymphoscintigraphy: Melanoma 531 Shilling Test Part I 532 Shilling Test Part II 534 Distribution of Schilling Test Results 1981-1984 535 Oldendorf Technique for Bolus Infection 537 Modified Method for the In Vivo Labeling of Red Blood Cells with Technitium 538 Single Photon Emission Computed Tomography 538 Quality Control Procedures for Scintillation Cameras 540 Quality Control Report Form 543 Daily Quality Control Log for Scintillation Cameras 544 111In Pentetreotide Imaging 529 131I Whole Body or Neck with Quantitation 526
  4. 4. 492 CLINICAL PRACTICES Nuclear Cardiovascular Procedures Clinical Practices Contents Tc-99m-MIBI Adenosine Stress 557 Tc-99m-MIBI Dipyridamole Stress 557 Tc-99-MIBI Dobutamine Stress 557 Myocardial Perfusion Imaging 550 Thallium - 201 Rest and Redistribution 550 Thallium - 201 Exercise Stress with Reinjection 552 Dipyridimole Thallium Stress Study with Reinjection 553 Thallium Adenosine/Dobutamine Stress with Reinjection 555 Tc-99m-MIBI Exercise Stress Study 555 Imaging of Ventricular Function 545 Gated Cardiac Blood Pool - Gated First Pass and Equilibrium 545 Ungated First Pass Ventriculogram 547 Exercise Radionuclide Ventriculogram 548 Gated SPECT - Myocardium 549 Gated SPECT - Cardiac Blood Pool 550 Imaging of Cellular Injury 545 Antimyosin Imaging of Infarct, Myocarditis, and Transplant Rejection 545
  5. 5. 493 NUCLEAR MEDICINE Nuclear Cardiovascular Procedures Clinical Practices Contents Vascular Shunt Imaging 558 Stress Testing and Cardiac Emergencies 560 Right to Left Shunt: Angiographic Method 558 Right to Left Shunt: MAA Technique 558 Left to Right Shunt 559 General Considerations 560 Patient Preparation 560 Indications for Stress Testing 561 Contraindications to Stress Testing 561 Bruce Protocol 561 Modified Bruce Protocol 562 MGH Modified Bruce 562 Dipyridamole-Thallium/Tc-99m-MIBI Test Protocol 562 Dobutamine-Test Protocol 562 Adenosine Stress Test 563 General Statement 564 Non Arrhythmia Ischemia, LV Failure, or Other Medical Problems 564 Arrhythmia and AV Conduction Abnormality 564 Management of Complications During Stress Testing 564
  6. 6. 494 CLINICAL PRACTICES
  7. 7. 495 NUCLEAR MEDICINE Nuclear Medicine Procedures Radiopharmaceutical Dose Considerations Standardadultdosesforspecificproceduresarelisted intherelevantsections. Somedoses (e.g.201TL) are normallyscaledwithinaspecificrangebybodyweight. Othersmayrequiremodificationasdeterminedby specificpatientfactors. Pediatric Pediatricdosagecanbedeterminedinoneofseveral ways. TheeasiestoftheseisWebster’sRule: Pediatric dose = age + 1 age + 7 Thisformulamaybeinaccurateininfants. Themost precisecorrectionusesrelativebodysurfacearea,esti- matedbyenteringheightandweightintoanomogram.A closeapproximationofthiscanbemadebyusingbody weight,sothat Pediatricdose = patientweight 70 kg Insomeoccasions,thecalculateddosemaybeinadequate forimagerequirements. Agoodexampleofthisis hepatobiliaryscanninginthenewborn,whichmayre- quire images at 24 hours after injection. The staff physicianshouldchecktheadequacyofcalculateddoses inchildrenlessthanoneyearold. Measuring Activity and Radiation Dose The FDA has mandated that all labeling of radiopharmaceuticalsmustbeprintedwith“LeSysteme Internationald’Units(SIunits)assoonaspossibleorat thenextlabelprinting. Thecurrentunitofmeasure (Curie)isstillincommonuse,butSIunitswillbethe primarysystemformeasuringactivityandradiationdose inthefuture. Adults iThenewsystemwasdevelopedbytheInternationalCom- mitteeofWeightsandMeasuresandwaspublishedin ts entirety in 1979. It has been adopted for radiopharmaceuticalsbymajornationsandiscurrently beingusedbymostofthem. Becquerel(Bq) IntheSISystem,theunitofactivityistheBecquerel (Bq),whichisequivalenttoonenucleartransitionper second. NotethattheBecquerelisaverysmallunitand thecuriesisaverylargeone. TheMegabecquerel(MBq) whichisonebillionBecquerels,orGigabecquerels(GBq) whichisonebillionBecquerels. Curies Thecuriesisequivalentto37billiontransitionsper second. Because the curies is so large, we would commonly use sub-units such as millicuries and microcuries. Arithmetically,thefollowingequalitiesexist: 1mCi = 37 MBq 1Rad = 0.01 GY or 1GY 100 Rad Possible Pregnancy Allwomenofchildbearingagemustbeaskedabout possible pregnancy before they are injected with a radiopharmaceutical. Ifthelastmenstrualperiodwaslessthanoneweekprior toinjection,itcanbesafelyassumedthatthepatientis notpregnant. Ifanyquestionarisescheckwiththe NuclearMedicinestaffphysician. X Adultdose X Adultdose =
  8. 8. 496 CLINICAL PRACTICES Three Phase Bone Scan Thisstudyisperformedtoevaluatebloodflowandsoft tissueabnormalitiestoaugmentstandardboneimages. InstrumentsandEquipment Largeorregularfieldofviewgammacamerawithlow energyhighresolutioncollimatorandcomputersystem. Radiopharmaceutical 99mTcMethyleneDiphosphonate(MDP). TimeofImaging Immediatelyuponinjectionofradiopharmaceutical. Dose Age+1 Age+7 PatientPreparation None Administration Intravenousinjectionofasmallvolumeof99mTcMDP usingthemodifiedOldendorftechnique. Use4-waystop- cock,appropriatebutterflyneedleandtubing,and saline flush. If area of interest is in upper limbs injectwithtourniquetonlytoavoidischemic-hyperemic response. Donotinjectinarmofinterest. All dynamicstudiesoftheextremitiesshouldincludeboth extremitiestoprovideanormalreference. Includea markeroftherightsideintheimagefield. PatientPositioning Flow study is performed over the area of interest designatedbyastaffphysician. DataAcquisition Analog-SiemensOrbiterandBodyScanCameras: Usinga9formatacquireimagesevery 5secondsfor9frames. Acquireanimmediatestaticimagefor1000K inthe9format. Digital-Allcameras Immediatelyuponinjectionacquireimagesina 128x128matrixevery2secondsfor32 Acquireimmediatestaticimageina256x matrixfor1000K. ImageProcessing Prepareasavescreenoftheflowimages-32 imagesononesheetoffilm. Labelthetimeofevery5thimage. Prepareasavescreenoftheimmediateimage -label:“immediate.” Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimages forinterpretation. SpecialViews Asrequestedbystaffphysician. DelayedImages Asperprotocolfor“BoneScanSpotViews.” Bone Scan Spot Views Toaidinthediagnosisandmanagementofprimaryand secondarybonedisease,andtoobtainhigherresolution imagesthanmaybepossiblewithwholebodyimaging. InstrumentsandEquipment Largefieldofviewgammacamerawithhighresolution parallelholecollimator. Ultrahighresolutioncollimator withMS-2. Radiopharmaceutical 99mTcMethyleneDiphosphonate(MDP). TimeofImaging Notlessthan21/2hourspostinjection. Dose Age+1 Age+7 Bone frames. 256 x740MBq x740MBq
  9. 9. 497 NUCLEAR MEDICINE DataAcquisition Analog-SiemensOrbiterandBodyCameras: Acquireallspotimagesinthe9format. Acquireanteriorchestimageforeither750K (Orbiters),or1100Konallothercameras. Recordthetimeandacquiretheremainderof imagesforthesametime. Digital-AllCameras Acquireimagesasdescribedabove-256x 256 matrix. ImageProcessing Prepareasavescreenoftheimagesusingthe generaldisplayifdigitalimagesareneeded. Labeleveryimage. Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimages forinterpretation. PatientPreparation Hydratethepatientwith2glasses ofwaterfollowing administrationofradiopharmaceutical.Patientisto urinatejustpriortostartingtheimagingprocedure.Have patientremoveallmetalobjects(jewelry,beltbuckle,etc.) andanyprosthesis. Administration Intravenousinjection. PatientPositioning Placepatientinthesupineposition. Projections: (Inthefollowingorder.) 1. Anteriorchest 2. Skull-bothlaterals 3. Rightandleftanteriorchesttoinclude shoulderand arms. 4. Anteriorpelvistoincludeiliaccrestsand hips. 5. Anteriortibiaetoincludeknees 6. Posteriorcervicalspine 7. Posteriorchest,thoracicandlumbarspine 8. Posteriorpelvisandproximalfemurs Includeamarkeroftherightsideineachimage. Comments Additionalviewsmaybenecessary.Theseshouldbehigh resolutionimages. Theimagesofspine,chestorpelvis, extremitiesandskullshouldbeacquiredfor1000K or15minutesmaximum. Havethepatienturinate againpriortoadditionalpelvicview. Whole Body Format Bone Scan (Single Pass Imaging) Toaidinthediagnosisandmanagementofprimaryand secondarybonedisease. Theradiolabel99mTcMDPis absorbedontohydroxyapatitecrystal,andconcentration onboneisdirectlyrelatedtoregionalbloodflowandnew boneformation. InstrumentsandEquipment SiemensDualHeadedBodyScannerwithhighresolution parallelholecollimatororSiemensMS-2withultra-high resolutionparallelholecollimator. Radiopharmaceutical 99mTcMethyleneDiphosphonate(MDP). TimeofImaging Atleast21/2hourspostinjection. Dose 740MBq-Adult-70kg Webster’sRule -Pediatric PatientPreparation Hydratethepatientwith2glassesofwaterfollowing administrationofradiopharmaceutical.Patientisto urinatejustpriortostartingimagingprocedure. Have patientremoveallmetalobjects(jewelry,beltbuckle,etc) andanyprosthesis. Administration Intravenousinjection. PatientPositioning Placepatientinsupinepositionontablewitharmsclose to sides and feet together and touching. Tape feet togetherlightlyinorderto assistpatientinholdingthis positionthroughoutthestudy. SpecialViews Asrequestedbystaffphysician.
  10. 10. 498 CLINICAL PRACTICES Analog-SiemensDualHeadedBodyScanner: Acquireanalogimagesinthewholebodymode. ScanSpeedDetermination(SiemensBodyScan): Scanpatientat224cm/min. Calculatetotalcountsinanteriorimage. Multiplyresultsby224,dividebydesiredtotal I.D.(300,000toobtaincorrectscanspeedin cms/minwhichisaround14cm/min. Carefullyscan,contouringanteriordetector. Note:DoNOTexceed18cm/min. Digital-SiemensDualHeadedBodyScannerorMS-2: Acquireanalogimagesinthewholebodymode. ScanSpeedDetermination-Asabovewithbody scanner. WhenusingMS-2withultra-highresolution collimator:mutiplyscanspeedby0.6. Alwaysuseauto-contourwithMS-2.(Seebelow.) SpecialViews (Totalbodybonescansmayrequireextraviews) Analog-SiemensOrbitersandBodyCameras: Acquireanalogextraviewsin9 formatfor750K ontheSiemensorbitercameraor1100Konall othercameras. Digital-AllCameras: Acquireimagesasdescribedabove-256x256 matrix. ImageProcessing Prepareasavescreenofthewholebodyusing thedualintensitydisplay. Prepareasavescreenofthespotimagesusing thegeneraldisplay. Labeleveryimage. Writescanspeedonfilms. Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimagesfor interpretation. Projections AnteriorandPosterior DataAcquisition Brain Imaging Blood Brain Barrier Agents Normally99mTcDTPAandglucoheptonate(GHA)donot crossthebloodbrainbarrier(braincapillaryendothelium). The BBB is disrupted in most inflammatory, ischemic,neoplasticortraumaticcerebraldisorders, resulting in focal accumulation of the radiolabel. 99mTcDTPAandGHAhavebeenusedinthepastas brainimaging agentsbecauseofrapidrenal(andblood) clearance which results in a potentially high target/non-targetratio. InstrumentsandEquipment Regularfieldorlargefieldofviewgammacamerawith lowenergyallpurposecollimatorandcomputersystem. Aconvergingcollimatormaybeneededforspecialviews. Radiopharmaceutical 99mTcDTPAorGlucoheptonate. TimeofImaging Dynamicimagesrecordedimmediatelyupon injection. Delayedimagesarerecordedatleast3hourslater. Dose 740MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Intravenousinjectionofasmallbolususingmodified Oldendorftechnique. Setup4-waystopcock,appropri- atebutterflyneedleandtubing,andsalineflush. PatientPositioning Patientshouldbepositionedsothataminimalamount offacialactivityispresentinthefieldofview. Central Nervous System (CNS)
  11. 11. 499 NUCLEAR MEDICINE Projections Flowstudyisusuallyrecordedintheanteriorprojection. StaticImages: Anterior Posterior Rightlateral Leftlateral Vertex DataAcquisition Digital FlowImages: Acquireimagesata3secondframeratefor oneminutein128x128matrix. StaticImages: Acquireanimmediate500Kstaticin256x256 matrix. Usuallyanteriorview. DelayedImages: (Minimumof3hrspostinjection). Acquirestaticimagesin256x256matrix. ImageProcessing Prepareasavescreenoftheimagesusingthe generaldisplay. Labeleveryimage. Transmitallrawdataandsave-screenstothe interpretationroomcomputer. Submitfilmsofallanaloganddigitalimages forinterpretation. Comments Patientconditionorthenatureofthesuspecteddisease mayrequiremodificationoftechnique. Delayedimages beyond3hourspostinjectionmaybeindicated. Brain Imaging SPECT Perfusion Imaging Followingintravenousinjection,99mTc-HMPAO (exemetazime)and99mTc-ECD(bicisate)crosstheblood- brain-barrierandaccumulateinthebrain. Abnormalities associated with increased or decreased cerebral perfusionmaybeshownascorrespondingregions ofabnormaltracerdeposition. SPECTimagingisneeded todemonstratethesesubtledifferences,andtoprovide meaningfulanatomicassessment. InstrumentsandEquipment MS-2withfanbeamcollimator. Radiopharmaceutical 740Mbq(20mCi)99mTc-HMPAO(adultdose)or 740-1110MBq(20-30mCi)99mTc-ECD. TimeofImaging HMPAO-20minutesafterinjection. ECD-30-60minutesafterinjection. PatientPreparation None. Theinjectionisideallygiventhroughanindwell- ingvenouslineinaquiet,dimly-litroom. ImageAcquisition OnlySPECTimagesareacquired,using360orotation with2heads,96viewsperhead,15secondsperview. ImageAnalysis Reconstruct tomographic images using attenuation correction. Photograph SPECT images in trans- verse, saggital, and coronal planes and save SPECTreconstructionfilestodisk. Comments Thepreparationanduseof99mTc-HMPAOimposes severalspecialconsiderations. Thepresenceofany oxidantinthe99mTc-pertechnetategeneratoreluateused toformulatetheHMPAOcomplexmaypreventadequate labeling.Toavoidthisproblem,thegeneratormusthave beenelutedwithin24hourspriortotheelutionused forkitformulation. Onceformulated,the99mTc-HMPAOcomplexisunstable. Theprimarycomplexformedconvertswithtimetoa differentsecondarycomplexthatislesslipophilic,and thus unable to cross the blood-brain-barrier. In on sequence,99mTc-HMPAOmustbe injectedwithin30 minutesofformulation. Thismeansthateachdose mustbepreparedwhilethepatientiswaiting,andthat QCproceduresmustbecompletedexpeditiously. These factorsdonotapplytoECD.
  12. 12. 500 CLINICAL PRACTICES Brain Death Evaluation Cerebralperfusionceasesupondeathofcerebraltissue. The best radionuclide evaluation of intracranial perfusionisobtainedusing99mTcHMPAO(exameta- zime). InstrumentsandEquipment Regularfieldofviewgammacamera,allpurposelow energycollimator,computer. Radiopharmaceutical 99mTcHMPAO. TimeofImaging Immediate. Dose 740MBq. PatientPreparation NonerequiredforHMPAO. Administration Intravenousinjection PatientPositioning Staticimagesintheanteriorandlateralprojections. Analog: None Digital-TechnicarePortableCamera Static Imaging: Acquire1immediate500Kstaticinquadrant format(128x128)e.g.SAQC,500K,Q1in theanteriorandlateralprojections. Acquireadditionalimagesbasedoninstruc tionsbythestaffphysician. Digital-SiemensOrbiterCamera Static Imaging: Acquire1immediate500Kanteriorandlateral magesin256x256matrix. Acquireadditionalimagesbasedoninstruc tionsbythestaffphysician. ImageProcessing ConverttechnicareimagestoSiemensformat andtransmitallimagestotheinterpretation roomcomputer. Photographallimagesandsubmittostaff physicianforinterpretation. Reference SHTsai,etal,JAMA248:591-592,1982(7/96). CSFisproducedinthebrain’slateralventricles,andre- absorbedmostlyalongthesuperiorsagittalsinus. In somepatientswithCSFshuntsorwhoarereceivingin- trathecalchemotherapy,thepatternofCSFflowmaybe importanttodocument. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimator.Setupthecameraforimaging Indium-111asfollows: 171keVphotopeakwitha30%window 245keVphotopeakwitha30%window Radiopharmaceutical 111InDTPA. TimeofImaging Immediate;delayedimagesat2-6hoursmaybe necessary. Dose 18.5MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Intrathecal(spinal)injectionofradio-pharmaceutical. Thisinjectionisperformedbythereferringphysician andrequiresaninformedconsent. Cerebral Spinal Fluid (CSF) (InformedConsentRequired)
  13. 13. 501 NUCLEAR MEDICINE Note: In the case of CSF shunt patients special injectionsmayberequired. Checkwithstaffphysician. If a CSF specimen is needed, make sure that CSFiswithdrawnpriortoinjectionoftheradiopharma- ceutical. PatientPositioning Projections:Anterior;Posterior;Right&leftlateral projections. DataAcquisition SiemensOrbiter Analog: Acquire500Kor10minuteimages inthe4 format. Digital: Acquiredigitalimagesina256x256matrix forbackup. SpecialViews SpecialviewsmayberequiredinthecaseofCSFshunt patients. ImageProcessing Transmitalldigitalimagestotheinterpreta tionroomcomputer. Photographallimagesandsubmittostaff physicianforinterpretation. CSF Leak Determination NormallythereisnoCSFpresentinthenoseorears.The detectionofsignificantradioactivityinthoseareasafter anintrathecalinjectionof111InDTPAischaracteristicof aCSFleak. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimator.Setupthecameraforimaging 111Inasfollows: 171keVphotopeakwitha30%window 245keVphotopeakwitha30%window Radiopharmaceutical 111InDTPA. TimeofImaging 4hourspostinjection. Dose 18.5MBq-Adult Webster’sRule-Pediatric PatientPreparation Nasalpledgetsaretobeweighedandplacedpriorto injectionofthepatient.PlegletsareplacedbyanENT physician. Thisshouldbearrangedbythephysician requestingthestudy. Administration Intrathecal(spinal)injectionofradiopharmaceutical. Thisinjectionisperformedbythereferringphysicianand requiresaninformedconsent. PatientPositioning Anterior;Posterior;Right&leftlateralprojections. DataAcquisition SiemensOrbiter Analog: Acquire500Kor10minuteimages inthe4 format. Digital: Acquiredigitalimagesina256x256matrix forbackup. SpecialViews Asrequestedbystaffphysician. ImageProcessing Transmitalldigitalimagestotheinterpreta tionroomcomputer. Photographallimages andsubmittostaffphysicianforinterpretation. Comments Twobloodsamplesarewithdrawnfromthepatientin redtoptubes,thefirst15minutesfollowinginjection andthesecondsampleatthetimeofimaging(approxi-
  14. 14. 502 CLINICAL PRACTICES mately4hourspostinjection). Plasmasamplesonthe twobloodsamplesareseparatedfromwholeblood bycentrifugation. Retainonemlofplasmafromboth samplesforcountingdetermination. Nasalpledgetsare removedatthetimeofimagingandplacedinappropriate countingvials,afterweighingagain. Countplasma samples and nasal pledgets in a well counter at the appropriatephotopeaksettingfor15minutespersample times2. NOTE:Weighbothbeforeandafterinsertioninappropri- atecountingvials! Reference Radionuclidecisternography:normalvaluesfornasal secretionofintrathecallyinjectedIndium-111DPTA. J NuclearMed1973;14:933-934. Gastrointestinal Cholescintigraphy Theiminodiaceticagentsareexcretedviahepatocytes andrapidlyclearedintogut.Inmostpatientswithacute cholecystitis,thecysticductiscompletelyblocked;thus, thereisnodemonstrationofthegallbladder. Thistest mayalsobeusedtoevaluateforsuspectedbileleak, biliaryatresia,andlivertransplantviability. InstrumentsandEquipment Largefieldofviewgammacameraequipped withlow energyparallelholecollimatorand computersystem. Radiopharmaceutical 99mTcDisofenin(DISIDA)ormebrofenin. TimeofImaging Immediatelypostinjection. Dose 37MBq PatientPreparation NPOpriortostudyforatleast4hoursbutnotmorethan 24hours. Ifthepatienthasfastedformorethan12-24 hours,administersincalideinadoseof20ng/kg.Thisis givenasaslowIVinjectionoveratleast3minutesto reducepotentialGIsideeffectsandtomaximizeits pharmacologicaleffect. Wait30-45minutesbefore injectingtheradiopharmaceutical.Sincalideisavailable intheRadiopharmacyas5mcglyophilizedvials. Reconstitutethevialwith5.0mlofsterilewaterfor injectionandusethefollowingformula: Patientweighinkg.X(0.02)=mltodraw Administration Intravenousinjectionofradiopharmaceutical. PatientPositioning Projections: Anterior DataAcquisition Analog: Needtobedeterminedbystaffphysician. Digital: Startingimmediatelyafterinjectionacquire 30secondimagesin128X128matrixfor45 minutes. Ifthegall-bladderhasnotbeendemonstrated bythattime,intravenousmorphinewilltypically begiveninadoseof0.4mg/kgwithimaging for an additional 45minutes aftermorphine administration. Insome cases, additional disofenin will be injected. Writeallimagedata to floppydisk and submit along with analog images for interpretation. ImageProcessing Prepareasavescreenofevery5thimagefor thefirst hourofimaging.Theformatofsave screensfordelayedimageswillbedetermined bythestaffphysician.Transmitallimagesto theinterpretationroomcomputerandsubmit photographsofallsavescreensforanalysis. SpecialViews Itmaybenecessarytoobtainposteriorand rightlateralviewstotriangulatethegallblad- der,andseparateitfromtheduodenum. NOTE: Ifbileleakissuspected,delayedimagesat severalhourspost-injectionmaybeneeded.
  15. 15. 503 NUCLEAR MEDICINE Gastric Emptying Solid Phase Thisstudyisperformedtoassess gastricemptyingtime. InstrumentsandEquipment Largefieldofviewgammacamerawithalowenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTcsulfurcolloid. TimeofImaging Immediatelypostinjection. Dose 18MBq - Adult PatientPreparation Patientshouldbefastingforapproximately8hours priortothestudy. Administration 18MBqof99mTcsulfurcolloidismixedwith scrambledeggsoraneggsaladsandwichandfedto thepatient. PatientPositioning Anteriorandposteriorprojections. DataAcquisition Analog: Notrequired Digital: Acquire1minuteanteriorandposteriorimages ina256x256matrixatthefollowingtimes: immedi- atelyafteringestionofmeal,0,20,40,60,and90min- utes. The patient may get up between images. ImageAnalysis Drawregionsofinterestaroundthestomachinallimages, determine thenumberofcounts ineachimage,decay correctthedelayedimagestozerotimeand calculated ageometricmeancountateachtime. Calculate%emptyingat20,40,60,and90minutes. Prepare a labeled save screen for the 5 images and photograph. Submitalldigitaldataandphotographs to theinterpretationroomforanalysis. Comments Drapethepatientwithabsorbentpaper(chux)and havepatientweardisposalglobeswhileeatingmealto prevent contamination. Haveanemesisbasincloseathandforthosepatients whoare knowntohavesevereintolerancetosolidfood. Ifinitialimagesshowresidualactivityintheesophagus, havethepatientdrinkasmallamountofwater. Gastric Emptying and GE Reflux (Milk Study) - Liquid Phase To ascertain rate of gastric emptying and detect gastroesophagealreflux,andpresenceofpulmonary aspiration. Thisisusuallyperformedinchildren. InstrumentsandEquipment Gammacamerawithlowenergyallpurpose collimator andcomputersystem. Radiopharmaceutical 99mTcsulfurcolloid. Dose Determinetheusualquantityofformulathatthechild receives ataregularfeedingandadd0.1MBq (2.5mCi) or99mTcsulfurcolloid/mlformula(donotexceed12 MBq).Recordthetimerequiredtoingesttheformula. TimeofImaging Immediatelypostingestion. PatientPreparation Patientmustbefastingforpreviousnormal interval betweenfeedings.(e.g.iffed6timesdaily,shouldbe fastingfor4hours). Administration SeeDose.
  16. 16. 504 CLINICAL PRACTICES PatientPositioning Anteriorsupineprojectiontoincludeentireabdomen andchest. DataAcquisition Analog: Nonerequired. Digital: Acquireserial30secondimagesina128x128 matrixfor1hour. ImageAnalysis Draw a region of interest around the stomach and determinethenumberofcountsinthe0,20,40,and60 minuteimages. Decaycorrectthedelayedimagesto zerotimeandcalculate%emptyingat20,40and60 minutes. Preparealabeledsavescreenforthe0,20, 40and60minutemagesandphotograph. Submitall digital data and photographs to the interpre- tationroomforanalysis. SpecialViews Asdeterminedbystaffphysician. Comments Ifthestudyisperformedtoevaluateforpossiblepulmo- naryaspiration,thedoseisusuallyadministeredinthe evening,with10minuteanteriorandposteriorimagesof thechestperformedthefollowingmorning.Inevalua- tionofaninfant,thedosecanbeadministeredinthe morningandimagingperformedintheafternoon. Labeled Red Blood Cell Scan (GI Bleeding) Thisstudyisperformedtofindaspecificbleedingsitein those patients who have active gastrointestinal hemorrhage. Patientsareoftenreferredbyangiography, whowillbepreparedtoperformanangiogramifa bleedingsiteisdetectedbyourstudy. Since99mTcRBC’s areanintravascularagent,extravasationintothegut willbedetectedbythismethod. InstrumentsandEquipment Largefieldofviewgammacamerawithlowenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTclabeledRBC’s. Note: RBClabelingisperformedwiththeUltraTag invitrolabelingkit. Dose Age+1 Age+7 x740MBq PatientPreparation None Administration IntravenousinjectionoflabeledRBC’s. TimeofImaging Immediatelypostinjection. PatientPositioning Anteriorsupineabdomenfromthepubicsymphysistohe diaphragmtoincludeinferiorportionofthe heartinthe uppermarginofthefieldofview. DataAcquisition Analog: Notrequired Digital: Acquireserial1minuteimagesina64x64 matrix. ImageAnalysis Preparealabeledsavescreenofevery5thimageand photograph. Submitalldigitaldataandphotographsto theinterpretationroomforanalysis. Comments Ifbleedingisnotdetectedontheinitialstudy,thepa- tientmayberecalledfordelayedimaging. Patientmay alsobereimagedifthereissomeclinicalevidenceofhem- orrhageintheinterval. Imageacquisitionparameters willdependonthetimeelapsedsinceinitiallabeling.
  17. 17. 505 NUCLEAR MEDICINE Meckel’s Diverticulum ToaidinthedetectionanddiagnosisofMeckel’sdiver- ticula. 99mTc pertechnetate is normally excreted bygastricmucosa.Sinceover90%ofbleedingMeckel’s diverticulacontainectopicgastricmucosa,thistestisa sensitivemeansfordetection. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energy arallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTcPertechnetate. TimeofImaging Beginningimmediatelybeforeinjection. Dose Age+1 Age+7 x740MBq PatientPreparation Patientmustbefastingfrommidnighttheprevious nightwithnothingbymouthexceptwater. Administration Intravenousinjectionofradiopharmaceuticalisperformed withthepatientinpositionunderthecamera. PatientPositioning Anteriorsupineprojectiontoincludeentireabdomen withthepubicsymphysisatthelowermarginofthe camerafield. DataAcquisition Analog: Notrequired. Digital: Acquireserial1minuteimagesina128x128 matrixfor1hour. ImageAnalysis Preparealabeledsavescreenofevery5thimageand photograph. Submitalldigitaldataandphotographsto theinterpretationroomforanalysis. Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’s packageinserts.Thechoiceoftheradiopharmaceutical andthedoseforeachproceduredescribedinthisProce- dure Manual is made by the physician staff of this NuclearMedicineDivision,inordertoacquirethebest imagingresultswhilecomplyingwithMGHIsotopeand/ orPharmacyCommitteeguidelines. Thenameofthe nuclearmedicinephysicianorderinganytestthatislisted hereismaintainedinthefilesoftheradiopharmacywith thedataonthepatientandradiopharmaceutical. Liver Fat Determination Thepartitioncoefficientofxenonishigherinfatthanin othertissue. Followinginhalation,xenonentersthecir- culation,isdistributedinthebodytissues,andclears fromthosetissueswhenxenonadministrationceases. Xenonretentioncorrelateswithliverfat(triglyceride) content,whichisincreasedindiabetics,alcoholics,and obesity. InstrumentsandEquipment Largefieldofviewcamera.Allpurposecollimatorand computer. Radiopharmaceutical 133Xe Dose 370-740MBq PatientPreparation None Administration 133Xeviaclosedsystemfor5minutes. PatientPositioning Supineanterior,includeliverandlowerlung. DataAcquisition Analog: Notrequired
  18. 18. 506 CLINICAL PRACTICES Digital: Serial15secondimagesina128x128 matrix,extendingfrominitialinhalation through15minutesofwashout. SpecialViews None ImageAnalysis DetermineT1/2ofwashoutfromtheliverfromaregion ofinterestdrawnaroundaportionofliverawayfrom lungbase. Comments T1/2greaterthan2.0min.correlateswithincreased triglyceride(>100mg/gm)inliverfat. Note: Thisprocedureisdoneroutinelyforindicationsthatare notspecificallylistedinthemanufacturer’spackage inserts.Thechoiceoftheradiopharmaceuticalandthe doseforeachproceduredescribedinthis Manualismade by the physician staffof the Division of Nuclear Medicine,inordertoacquirethebestimagingresults whilecomplyingwithMGHIsotopeand/orPharmacy Committeeguidelines.Thenameofthenuclearmedicine physicianorderinganytestthatislistedhereismain- tainedinthefilesoftheradiopharmacywiththedataon thepatientandradiopharmaceutical. References IntJNuclearMedBio9:17-23,1982. Liver/Spleen Imaging 99mTc Sulfur Colloid Theliverandspleencontainlargenumbersofevenly distributedreticuloendothelialcells,whichtrapthe 99mTcsulfurcolloid.Theprocedureisintendedprimarily tobeusedfordetection(ormonitoring)ofdisorderswhich disrupttheorganarchitecture. Functionalabnormalities maybeimpliedbytherelativeuptakeofeachorgan, especiallyincomparisontotheothertwolargeRES containingorgans(lungandbonemarrow). InstrumentsandEquipment Largefieldofviewgammacamerawithlowenergyhigh resolution. Radiopharmaceutical 99mTcsulfurcolloid. TimeofImaging 15minutespostinjection. Dose 148MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Intravenousinjection. PatientPositioning Acquireliverimagesinthefollowingsequence: Ant(Marker),Ant,RAO,RL,Post,LL DataAcquisition Analog: 1000Kperimage Digital: Acquirebackupimagesfor1000Kina256x256 matrix. ImageAnalysis Preparealabeledsavescreenofdigitaldataandphoto- graph. Submitalldigitaldata,analogdataandphoto- graphstotheinterpretationroomforanalysis. Comments Ifthespleenisbeingspecificallyevaluated,suchasfor infarctortrauma,obtainthefollowing: LAO30o,LAO60o,LPO30o,LPO 60o. Recorddataindigitalformat.
  19. 19. 507 NUCLEAR MEDICINE Hepatic Hemangioma Imaging Hepatichemangiomasarelowflowlesionswithincreased vascularvolume,whichare“cold”ona99mTcsulfur colloidstudy,butwhichshowprogressive99mTcRBC accumulationovera60minuteperiod. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energypar- allelholecollimatorandcomputersystem. Radiopharmaceutical (1) 99mTc-SCifliver/spleenscanhasnotalready beenobtained. (2) 99mTclabeledRBC’s. TimeofImaging Obtain99mTc-SCscanfirst,andthen99mTc-RBCscan. Dose 37MBq99mTc-Sulfurcolloid(SC);740MBq99mTc-RBC. PatientPreparation IfpatienthasnothadaSCliver/spleenscan,obtainant, RAO,(R)lateralandposteriorviewsofliverat15min afterinjectionof27MBqofSC. Labelthepatient’sbloodusingthemodifiedinvivotech- niqueforlabelingRBC’swith99mTc. (Thisisthesame procedurethatisusedfor gated cardiac blood pool imaging.) Administration Intravenous“bolus”injectionofradiopharmaceutical. Startimagingimmediately. PatientPositioning Flowstudyimagesshouldbeacquiredintheprojec- tion that best demonstrates the abnormality (check99mTcSCliverscan,ultrasoundorCTfindings withstaffphysician). DataAcquisition Analog: Notrequired Digital: Acquireflowstudyina128x128matrixata 4secondframe rate16frames. Acquirestaticimagesina256x256matrix for1000kinthefollowingprojections: ANT,RAO,Rlateral,andposterior. Immediatelyfollowingcompletionofplanar images,acquireSPECTimagesofliver. Both planarandSPECTimagesarerepeated1-2 hourslater. ImageAnalysis Preparealabeledsavescreenoftheflowandstatic imagesandphotograph. Submitalldigitaldataand photographstotheinterpretationroomforanalysis. SpecialViews Additionalviewsmaybeneededtodelineatequestion- ableabnormalareas.Itmaybenecessarytoperform SPECTinsomepatients. Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. Thechoiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisManualis madebythephysicianstaffoftheNuclearMedicine Division,inordertoacquirethebestimagingresultswhile complyingwithMGHIsotopeand/orPharmacyCommit- teeguidelines.Thenameofthenuclearmedicinephysi- cianorderinganytestthatislistedhereismaintainedin the files of the radiopharmacy with the data on the patientandradiopharmaceutical. Hepatic Pump Intra-arterialchemotherapyofintrahepatictumorsisgiven viaanindwellingcatheter,orhepaticpump.Thistest consistsofinjectionofMAAtoassessthedistribution offlowfromthe pump. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energyhigh resolutionparallelholecollimatorandcomputersystem. TimeofImaging Immediatelyuponinjection. Radiopharmaceutical 99mTcMAA,99mTcSulfurColloid.
  20. 20. 508 CLINICAL PRACTICES Dose 37MBqof99mTcMAAin2mlvolume;37MBq of 99mTcsulfurcolloid. Administration 1stinjection: Inject99mTc-MAAin2mlofvolumeviathepump. 2ndinjection: Inject99mTcsulfurcolloidintravenously. PatientPositioning Acquireallimagesintheanteriorsupineposition. DataAcquisition Analog: Notnecessary Digital: Afterinjectionof99mTc-MAAacquirea 500Kimageina256x256matrix. Note: Recordthetimeittakestoacquirethis image. FifteenmunutesafterIVinjectionof99mTc sulfurcolloid,acquireasecondimageina 256x256matrixforthesametimeasthe 99mTc-MAAimage. ImageAnalysis Usingtheimagecalculatorsubtractthe99mTc-MAA imagefromthe99mTc-SCimage+99mTc-MAA. Pre- pare a labeled save screen of the three images. and photograph. Submitalldigitaldataandphotographsto theinterpretationroomforanalysis. Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. Thechoiceof theradiopharmaceuticaland thedoseforeachproceduredescribedinthis Manualis madebythephysicianstaffoftheNuclearMedicine Division,inordertoacquirethebestimagingresultswhile complying with MGH Isotope and/or Pharmacy Committeeguidelines.The name of the nuclear medicine physicianorderinganytestthatislistedhere ismaintainedinthefilesoftheradiopharmacywiththe dataonthepatientandradiopharmaceutical. LaVeen Shunt Patency ToassessthepatencyofaLaVeenperitoneal-jugularshunt byevaluatingclearanceofactivitythroughtheshunt followingtheintroductionoftracerintotheperitoneal cavity. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energypar- allelholecollimatorandcomputersystem. Radiopharmaceutical 99mTcMAA Dose 100MBq Technique Thecourseofthesubcutaneousshunttubingin the lateral abdomen and chest is located. Usingsteriletechnique,a20gaugeneedleis introducedintotheperitonealcavityonthe contra-lateralsidewiththeuseof1%lidocaine anesthesia. Informedconsent mustbeobtainedforthispro- cedure.Theradioisotopeisthenintroducedinto theperitonealcavity. Thepatientisthen rolled side to side and askedto take severaldeep breaths. Imaging Immediateanteriorimageoftheabdomenfor300K (256x256matrix). Subsequent300K(256x256matrix)anteriorimages ofchesttoincludetheupperabdomenandpositionof theshunttubingalongthelateralchestwallevery5 minutesuntilactivityisvisualizedinthelungs. Ifnoactivityisidentifiedinthelungsduringtheinitial 45minutes,delayedimagesforupto4hoursmaybe required. ImageAnalysis Preparealabeledsavescreenofalltheimagesand photograph. Submitalldigitaldataandphotographstotheinterpre- tationroomforanalysis. (InformedConsentRequired)
  21. 21. 509 NUCLEAR MEDICINE Note: Thisprocedureisdoneroutinelyforindications thatarenotspecificallylistedinthemanufacturer’spack- ageinserts. The choiceoftheradiopharmaceuticaland thedoseforeachproceduredescribedinthisProcedure ManualismadebythephysicianstaffoftheNuclear MedicineDivision,inordertoacquirethebestimaging resultswhilecomplyingwithMGHIsotopeand/or PharmacyCommitteeguidelines.Thenameofthenuclear medicinephysicianorderinganytestthatislistedhere ismaintainedinthefilesoftheradiopharmacywiththe dataonthepatientandradiopharmaceutical. Reference ClinNuclMed4:447-450;451-454,November1979. Parotid Gland Imaging Toaidintheassessmentoftumorsornodulesofthe parotidglands. InstrumentsandEquipment Regularfieldofviewgammacameraandcomputer system. Radiopharmaceutical 99mTcPertechnetate TimeofImaging Immediatelysinceflowstudyisneeded. Dose 185MBq-Adult Webster’sRule-Pediatric PatientPreparation None Administration Usingthe modified Oldendorftechniqueinjectasmall bolusofactivityfortheflowstudy.Note:Usea4-way stopcockandappropriateneedle,tubingandsalineflush. PatientPositioning Placepatientinsupinepositionwithheadandneck hyperextended. Acquireflowandstaticimagesoftheheadandneck. DataAcquisition Analog: Notrequired Digital: Acquireananteriorflowstudyina128x128 matrixataframerateof30secondsperframe for300seconds(10frames). Acquireanterior,rightandleftlateralstatic viewsofthehead(128x128matrix)ataframe rateof60secondsperframefor600seconds (10frames). Afteracquiringinitialstatic imagesgivelemon andrepeatabovestaticacquisition. ImageAnalysis Sumtheinitialanddelayedstaticimagesusingthe imagecalculatorandpreparelabeledsavescreensforall threesetsofimages. Submitalldigitaldataandphotographstotheinterpre- tationroomforanalysis. SpecialViews Asdirectedbystaffphysician. Comments Givethepatient500mgofKCl04following thestudy. Reference RadionuclideSalivaryGlandImaging:SemNuclearMed Xl:258-265,1981.
  22. 22. 510 CLINICAL PRACTICES Genitourinary Allowsrelativequantitationofperfusionandexcretory functionofkidneys. DTPAmeasuresglomerularfiltra- tionrate,whileMAG3showsmainlytubularfunction. Theinitialarrivaltimeofthetracerbolusrelatestorenal bloodflow. Thetransitthroughthekidneysreflects corticalandtubularfunction,andtheeventualclearance fromthecollectingsystemreflectsrenalpelvicand ureteral patency. 99mTc-glucoheptonateisrarelyemployed,butshowsa morecopmplexclearancewithpartialtubularbinding. InstrumentsandEquipment PreferredinstrumentOrbiterorMS-2withallpurposeor highresolutioncollimatorandinterfacedcomputer. Onrareroccasions,aportablescanmaybeperformed usingadivergingcollimatorinadults. Radiopharmaceutical 370MBq(10mCi)Tc99mMAG3or370MBq(10mCi)DTPA. Tolocalizethekidneysandvascularstructures(aorta)in aportablestudy,thepatientshouldbepre-injectedwith 37MBqDTPA. In a patient with renal failure use the aorta as a referencepoint. TimeofImaging Immediate PatientPreparation Hydratepatientwith12ounces ofwater30minutes priortostudy; havethepatientvoidpriortoinjection. ImageAcquisition Standardimagesareobtainedintheposteriorposition, centeredjustinferiortothekidneys. Inrenaltransplantpatients,anteriorimagescenteredover theiliacfossaareacquired. Inaportablestudy,positionthepatientinoneofthe lateraldecubituspositionsandapproachthepatientwith thecamerafromthepatient’sback. Dynamicimagesarerecordedin128x128matrixat 2 seconds per frame for 32 frames, followed by 30secondsperframefor64frames. ImageAnalysis Select“MGHRenal”fromtheprocessingprotocols. DefineCompositeImages Thedefaultimagingrangeis1to3minutes. Toselect anotherrange,choose “TimeRange”fromthecompos- itemenuandenterthestartingandendingpoints. Once defined,clickDONEtocontinue. DefineRegions Completedialogboxesisappropriate. Drawmanual regionsofinterestaroundthekindeysbyescapingwhen promptedtoselectanautomatedellipticalregionof interest. Draw semi-circular background regions surroundingandimmediatelyadjacenttothelower portionsofeachkidney. DefineStartPoint Once theregionsaredefined,theperfusioncurvesare shownontheleft. Thetriangularmarkeronthex-axis ofthecurveshouldbedraggedtothepositionwherethe aorticactivitystartstoincrease. Thisprocessingstepis importantbecausethisisthetimeusedasthestarting pointforallcalculations(Tmax,T1/2). Results ThefirstRESULTpage(curves)showtwographs:the leftgraphshowsperfusiondataandtherightgraphshows clearancedata. Iftheaorticcurvesextendbeyondthey-axisontheleft (perfusion)time-activitycurve,selectthegraphbyclick- ingonthemargin. Select“options”andclickonthey- axislabel. Select“rangesetautomatically”fromthe displayedmenu. Therightgraphdisplaysfourcurves,withbothwhole kidneyand“cortical”activityforeachkidney. Itmaybe desirabletoeliminatesomeofthesecurves,asina diureticstudy. Todeleteacurve,firstselectthegraphbyclickingonthe margin. Next,selectthecurvebyclickingontheappro- priatesymbolinthesmallrightwindow. Finally,clickon “curve”fromthe“DisplayAnalysis”andselecttheop- tion“deletecurve.” ThelastRESULTpageshowsthehalftimeanalysisfor kidney clearance. The menus on the left give five options (left kidney, left cortex, right kidney, right cortex,done). Renal Function
  23. 23. 511 NUCLEAR MEDICINE TocalculatetheT1/2foranyoftheregions,clickonthe RO1. Thegraphontherightwilldisplaythecurvefor theappropriateregion. Dragthelefttriangularmarker onthex-axistothepositionofmaximumactivityfor thatcurve. Foradiureticrenogram,dragthetriangletothetimeof diureticinjection(20minutes). Next,dragtheright triangletotheendofthecurve. Theprogramwillthen displayabestfitcurvesuperimposedontheoriginaldata. Youarethengiventheoptiontoacceptorchangethe curvefitting. RepeatthisprocessforeachT1/2desired. ImageandDataDisplay SelecttheMGHRenalDisplayapplicationfromthe ProcessingProtocols. Theprogramwilldisplay32 dynamicflowimagesaswellassixcompositeclearance imagesevery5minutesfor30minutes. Ifadditionalimageswereobtainedbeyond30minutes,it isnecessarytocreateasavescreenmanuallyforthe delayedimages. Comments Inselectedpatients, delayedimagesmayberequired. 99mTcglucoheptonatemaybeusedatthediscretionof thestaffphysicianincasesinvolvingspecificquestions aboutrenalstructure. Theradio-pharmaceuticaldoseis370MBq(10mCi). ImagingissimilartoMAG3orDTPA,withadditional imagesat2hoursasdetermnedbythephysician. These lateimageswilltypicallyconsistofposterior,RPO,and LPOimages. Initialdataandprocessingisasperthe standardrenalprotocol. DMSARenalImaging Followingintravenousinjection,99mTc-DMSAisbound toplasmaproteins,andaccumulatesintherenalcortex. Thereisverylittleexcretionintheurine. At3hourspostinjection,roughly40%oftheinjected doseremainsinthekidneys. Thisallowsanatomic definitionoftherenalparenchymanoteasilyaffordedby otherrenalscanningagents. DMSAhasbeenmostwidelyusedintheevaluationof pyelonephritisandpost-infectiousscarringinchildren. InstrumentsandEquipment MS-2withallpurposeorhighresolutioncollimator;small fieldofviewcamerawithpinholecollimator. Radiopharmaceutical 185MBq99mTc-DMSA(adultdose). Timeofimaging 2-3hourspostinjection;noinitialimagesarerequired. PatientPreparation None ImageAcquisition Pinholeimagesofthekidneysinposterior,RPO,and LPOprojectionsfor5-10minuteseach,dependingon thepatient’sabilitytocooperate. Standardparallelcollimatorposteriorimageofthe kidneysacquiredfor10minutesor1000Kina256x256 matrixsize. SPECTacquisitionusing360orotationwith2heads, 96viewsperhead,15secondsperview. ImageAnalysis Preparelabeledsavescreenofpinholeandstandard planarimages. ReconstructandphotographSPECT imagesintransverse,saggital,andcoronalplanesand saveSPECTreconstructionfilestodisk. Diuretic (Lasix) Renogram Evaluationofhydronephrosis,inparticulartodifferentiate a dilated, nonobstructed system from a dilated, obstructedrenalcollectingsystem. Allrenalscansrequestedto“ruleoutobstruction”are potentialLasixstudies. Checkwithstaffphysicianto determineifaLasixstudyisindicated. InstrumentsandEquipment Orbiter or MS-2 camera with all-purpose or high resolutioncollimatorandinterfacedcomputer.
  24. 24. 512 CLINICAL PRACTICES Radiopharmaceutical 370MBq(10mCi)99mTc-MAG3bybolusinjection; alternatively,370MBqof99mTc-DTPAmaybeused. TimeofImaging Immediate PatientPreparation Givepatients(otherthaninfants)approximately12ozs. offluidtodrink30minutespriortothestudy. HavenurseinsertaFoleycatheter. Thiswillremainin placeunclampedduringthestudy. Usuallyallnephrostomyorotherexternalrenaldraining devices(otherthantheFoley)shouldbeclamped;check withnuclearmedicinephysicianmonitoringstudy. ImageAcquisition Acquireposteriorimagescenteredjustbelowthe kidneysin128x128matrixsize. Dynamicimagesarerecordedat2sec/framex32frames, followed by 30 second images x 128 frames. ForaLasixstudy,imagingiscarriedoutforone hour,notthe30minutesofastandardrenalscan. Lasix(0.3mg/kg)istypicallyinjectedintravenously20 minutesafterradio-pharmaceuticalinjection. ImageAnalysis Splitfunctionquantitationandtime-activitycurvesare generatedasforthestandardrenal scan, except that theclearancephasetimeactivitycurvesshouldbedrawn to include the entire kidney including the renal pelvisbutexcludingtheureter. Toavoidconfusion,deletetheclearancecurvesforthe “cortical”regions. WhengeneratingtheT1/2data,besuretodragtheleft triangleonthex-axisoftheclearancecurvetothetime thatLasixwasgiven(typically20minutes)sothatan adequateevaluationofdiureticwashoutiscalculated. LabeltheframecorrespondingtothetimeatwhichLasix wasgiven. Comment Insomecases,imagingbeyondonehourmaybeneeded. Thenormalhalf-timeforclearanceoftracerfromthe kidneyROIis10minutesorless. Atimegreaterthan 20 minutes is abnormal, while 10-20 minutes is consideredindeterminate. By decreasing glomerular filtration in the stenotic kidney,anACEinhibitorsuchascaptoprildiminishes excretionofthetracerinthatkidney. Thiscreatesor increasesafunctionalasymmetrybetweenthenormal andabnormalkidneys. The study is probably of lesser value in assessing balancedbilateralrenalarterystenoses,becausethelack ofasymmetrymayrenderthesecasesinapparentonthe scan. Thestudyisperformedafteroraladministrationofan ACEinhibitor. Inselectedinstances,itmayberepeated onadifferentdaywithouttheuseofACEinhibitor (baseline study), should the captopril scan show a significantasymmetryinfunction. If a baseline study is to be performed, it should be delayedforatleast48hourstoensurethatthepharma- cologiceffectsofcaptoprilhavewornoff. InstrumentandEquipment OrbiterorMS-2withallpurposeorhighresolution collimatorandinterfacedcomputer. Radiopharmaceutical 370MBq(10mCi)Tc99mMAG3or370MBq(10mCi)DTPA. TimeofImaging Immediate PatientPreparation WithholdACEInhibitors Ifpossible,ACEinhibitorsshouldbewithheldpriortothe study(captopril-2days,enalopril-3days,lisinopril-4 days). Thisallowsthephysiologicallysimplestcondition, mirroringthevalidationofcaptoprilimaging. Insomepatients,itisnotfeasibletowithholdACE inhibitors prior to the study. In that case, the SNM consensuspositionpapersuggeststhatimagingproceed afteranadditionaldoseofcaptopril. Thereisasuggestionthatthesensitivityoftheexamin thissettingmaybecompromisedslightly. WithholdDiuretics Withholddiureticsforseveraldayspriortoimagingif feasible. Diureticsmaymakethepatientmoreproneto hypotension. Thereiscontroversyaboutwhetherornot diureticusedecreasesthe sensitivity of the study. Captopril Renal Scan for Evaluation of Renovascular Hypertension
  25. 25. 513 NUCLEAR MEDICINE Ifdiureticsarenotwithheld,hydrationbecomesevenmore importantthanwouldotherwisebethecase. Allpatientsshouldbehydratedwith11/2to2glasses ofwaterorotherfluid30-60minutespriortothestudy. Patientsshouldrefrainfromeatingsolidfoodfor4hours priortotheexaminordertoensureabsorptionofthe captoprildose. Thepatient’sbaselinebloodpressureshouldbechecked andrecordedbeforetakinganyfurtheraction. IftheBP isnotelevated,consultwiththestaffphysicianabout howtoproceed. AnIVlineshouldbeplaced(butterflyisOK)inthe elderly,inpatientswithahistoryofheartdisease,stroke, orTIA’s. Thisisnotnecessaryinmostyoungerpatients. Captoprilisgiven25mgPO,andserialBPmeasurements recordedevery15-20minutesforonehour. Thedropin BPafterthisdosageisusuallymodest. Moresignificant hypotensioncanusuallybemanaged withrecumbencyandIVinitialvalueandtheyshouldbe asymptomaticbeforebeingallowedtoleavethesection. Alternatively,enalaprilatmaybegivenIVasa5minute infusion,monitoringbloodpressureandproceedingas below. At1hourfollowingcaptopriladministration,afinalBP shouldbecheckedandthepatientshouldvoidbefore beginningimaging. ImageAcquisition Imagesareobtainedintheposteriorposition,centered justinferiortothekidneys. Dynamicimagesarerecorded in128x128matrixat2secondsperframefor32frames, followedby30secondsperframefor64frames. ImageAnalysis Asperthe“RenalFunction”protocol6.1. Comments Theinterpretivecriteriaforabnormalstudiesdiffer betweenMAG3andDTPA: MAG3 Unilateralparenchymalretention(nottobeconfusedwith ureteral obstruction) is diagnostic of renovascular hypertension. Bilateralparenchymalretentionisanonspecificfinding, however. Unilateralretentioncanbequantifiedasa changeinthe20minute/peakratioof0.15orgreateror asanincreaseintheTmaxofatleast2minutesor40% between baselineandcaptoprilstudies. anadditionalbaselineexaminationwithoutcaptopril. Thestudyisconsideredformallypositiveiftheabsolute valueofthedifferenceinrenalfunctionincreasesby10% ormorefromthebaselinetocaptoprilstudy. Marked unilateraltracerretentionaftercaptoprilisalsoconsid- eredtoindicateapositivestudy. Adifferenceintheabsolutevalueofrenalfunction betweenbaseline andcaptoprilstudiesof between 5%to9%isconsideredanintermediateresponse,and thusnotdiagnostic. Note that with normal renal function and without hydronephrosis,thenormal20minute/peakratiois <0.3.Deviationfromthenormalvalueorasignificant asymmetry in excretion warrants a comparison baselineexam. DTPA A greater than 10% difference in renal function is consideredprovisionalyabnormal,andgenerallyrequires Testicular Imaging Toaidinthedifferentiationoftesticulartorsion(inwhich thereisdecreasedflow)frominflammatoryprocesses suchas epididymitis(inwhichthereisincreasedflow andECFspacetracerdistribution). InstrumentsandEquipment Largefieldofviewgammacamerawithlow energypar- allelholecollimatorandcomputersystem. Forverysmallchildrenasmallfieldofviewcamerawith aconvergingcollimatormaybenecessary. Thestudy shouldbediscouragedinneonatessinceitisoflittlevalue inthisagegroup. Radiopharmaceutical 99mTcPertechnetate. TimeofImaging Immediatelyuponinjection(requiresflowstudy). Dose 555MBq-Adult Webster’sRule-Pediatric Thisstudyshouldnotbedoneinchildrenyoungerthan sixmonths.
  26. 26. 514 CLINICAL PRACTICES PatientPreparation None Administration Intravenousinjectionofasmallbolususingmodified Oldendorftechniqueandsalineflush.Use4-waystop- cockandappropriatebutterflyneedleandtubing. PatientPositioning Anteriorsupinewithtesticlescenteredinthefieldofview. DataAcquisition Analog: Acquirestaticimagesina9formatfor1000k withandwithout57-Cobaltlinesourcemarker. Staticimagesshouldconsistofthreeviews: anterior, midlinescrotalmarker,andtesticular marker. Digital: Acquireflowimagesat2secondframeratefor 32frames(128x128matrix). Acquirestaticimageswithandwithout57- Cobaltlinesourcemarkerfor1000Kina 256x256matrix. Staticimagesshouldconsistofthreeviews: anterior,midlinescrotalmarker,andtesticular marker. ImageAnalysis Preparelabeledsavescreensof the flow and static imagesandphotograph. Submitalldigitaldataand photographstotheinterpretationroomforanalysis. SpecialViews Asrequestedbystaffphysician. Comments Insettingupthepatientforthisprocedureplacethe patientinthesupinepositionwithhipsslightlyabducted. Apapertapesupport(bridge)isplacedacrossboththighs and under the scrotum so that the testicles are parallelandequaldistancefromthecollimator.Thepenis istaped(papertape)totheanteriorabdominalwallsoas nottooverliethe testicles.The57-Cobaltlinesourceis storedintheradiopharmacy. Thisprocedureisdoneroutinelyforindicationsthatare notspecificallylistedinthemanufacturer’spackage inserts.Thechoiceoftheradiopharmaceuticalandthe doseforeachproceduredescribedinthis Manualismade bythephysicianstaffoftheNuclearMedicineDivision, inordertoacquirethebestimagingresultswhilecom- plyingwithMGHIsotopeand/orPharmacyCommittee guidelines.Thenameofthenuclearmedicinephysician ordering any test that is listed here is maintained inthefilesoftheradiopharmacy withthe dataonthe patientandradiopharmaceutical. Radionuclide Cystogram Radionuclidecystographyhasproventobeaneffective andsafetechnic for the detection of vesicoureteral reflux. Ifonewishestoexaminethepatient(particu- larlypediatricpatients)duringthefilling,voidingandpost voidingphasesofthistest,theradionuclideVCUG provides monitoring of the patient with a reduced radiationburdencomparedtoconventionalx-ray. InstrumentsandEquipment Preferredinstrument,largefieldofviewcameralinked toacomputer;GAPorhighresolutioncollimator. Dose 18.5MBq(500mCi)of99mTcsulfurcolloid. PatientPreparation Thepatient’sbladderiscatheterizedandurinesentfor culture. AttachanIVinfusionsettothecatheterviaa3-way stopcock,connectedtoa500mlbottleofsaline. Thebottleshouldnotbe>100cmabovethetable. Covergammacameraandtablewithabsorbentpaper. Technique Positionpatientsupinewiththebladderinthelower portionoftheimagingfield. Inject99mTcsulfurcolloidviaIVtubingand openIV salinetocommencefillingbladder.
  27. 27. 515 NUCLEAR MEDICINE ImageAcquisition Analog: None Digital: Acquireimageina128x128matrixevery20 seconds. Commenceimagingimmediatelyandcontinue untilvoidingiscomplete. ImageAnalysis Preparelabeledsavescreenandphotograph.Submitall digitaldataandphotographstotheinterpretationroom foranalysis. Thisprocedureisdoneroutinelyforindicationsthatare notspecificallylistedinthemanufacturer’spackage inserts. Thechoiceoftheradiopharmaceuticalandthe doseforeachproceduredescribedinthis Manualismade bythephysicianstaffoftheNuclearMedicineDivision, in order to acquire the best imaging results while complyingwithMGHIsotopeand/orPharmacyComittee guidelines. Thenameofthenuclearmedicinephysician orderinganytestthatislistedhereismaintainedinthe filesoftheradiopharmacywiththedataonthepatient andradio-pharmaceutical. Hematology Bone Marrow Thisstudyisusuallyobtainedtoassessbonemarrow distributioninpatientswithanemia,orasanadjunctto In-111WBCimaging. InstrumentsandEquipment Largefieldofviewscanninggammacamera withlowor energyparallelholecollimatorandcomputersystem. RadiopharmaceuticalandDose 370MBq-99mTcsulfurcolloid. TimeofImaging 15minpostinjection. PatientPreparation None Administration Intravenousadministration. PatientPositioning Anteriorandposteriorwholebody. Selectedspotviews may alternatively be needed per staff physician direction. DataAcquisition Analog: Acquireanalogimagesinthewholebodymode usingascanspeedof15centimetersperminute. Digital: Acquirewholebodyimagesina256x1024 matrix(MS-2)or384x1024matrixusingascan speedof15centimetersperminute. ImageAnalysis Preparelabeledsavescreenandphotograph. Submitalldigitaldataandphotographstothe interpretationroomforanalysis. SpecialViews Views of the extremities are needed to determine thedistributionofbonemarrowinlongbones,ifthisis notobviousonwholebodyimages.Minimum100Kor10 minuteimageswillberequired(recordwhich). 99mTc Labeled RBC Volume Determination Todeterminetheactualcirculatingredbloodcelland albuminvolumetoaidinthediagnosisofcertainhemato- logicdisordersinwhichthehematocritmaybeelevated. Radiopharmaceuticals 125Iradioiodinatedhumanserumalbumin:125I-RISA. 99mTcautologousredbloodcells0.37-1.11MBq: 99mTc-RBC’s. Dose 125I-RISA0.37MBq 99mTc-RBC’s 0.37-1.11MBq(100-300mCi)
  28. 28. 516 CLINICAL PRACTICES PatientPreparation None Administration Inserta19guagebutterflyinfusionsetintoaperipheral veinineacharm.Attachastopcockand10mlofhep- arinizedsaline(10units/ml). Flushlines.Inject 0.37MBq of125I-RISAinrightarm,flushsyringewithbloodand notetime.Notetime. Inject3mlsofstannouspyrophosphatecontaining1mg stannouschlorideinrightarmandreheparinizetheline. Withdraw5mlbloodsamplesfromleftarmat15and30 minutesfollowinginjection. Withdrawanddiscard3mlsbloodbeforecollecting actualsamples.Reheparinizetheline. Twentytothirtyminutesfollowingintravenousstannous ionwithdrawn10mlsofbloodintoasyringecontaining 18-36MBq99mTcpertechnetate. Add100unitsof heparin, mix and incubate for 10 minutes at room temperature. (Seeattachedarticleonlabelingmethod.) Inaverticallaminarflowhood,transferthe99mTc-RBC’s toasterilepyrogenfreecentrifugetube(Corning50ml). Add10mlsofsaline,mixgently,andcentrifugeat 100xg(1200rpm)for5minutes.Removesupernatant anddiscard. Measure radioactivity on the RBC’s using a dose calibrator. Calculatethevolumeof99mTc-RBC’sthatis required. Withdraw1mlof 99mTc-RBC’sintoa1mlsyringeand capwithluercap(Paramedicalno.57-01). Withdraw appropriatevolumeforpatientdoseandcapasabove. Weigheachsyringeaccuratelyandrecordweights. Measureandrecord99mTc-RBC’sradioactivity. Inject the99mTc-RBC’sintheleftarm. Donotflushsyringe. Reweighandrecordweight. Withdrawbloodsamplesasdescribedaboveat15and 30minutesfollowinginjection. PreparationofStandards 125I: Withdraw0.2ml125I-RISAfromsamevialas thepatientdose. Expel0.1mlintoa100mlvolumetric flaskcontainingdilutealbuminsolution(topreventloss of125I-albuminonglassware). Mixanddilutetomark. Remove2x1mlsamplesforcounting. Dilution factor(99m Tc DF) = Wt. of cells injected Wt. of cells in STD ∩ 100 ml 1.0 ml 99mTc: ExpelcontentsofTBsyringecontaining99mTc- RBC’sintoa100mlvolumetricflaskcontainingdistilled waterandmixwell. Reweighandrecordsyringe. Dilutetomark,mixand withdraw2x1mlsamplesforcounting. SamplesPreparation: 125I-RISA: Spinwholebloodsamplesat100xgfor5 minutes.Remove duplicate1mlaliquotsofplasmaandtransferto countingtubes. Countfor appropriatetimetominimizestatisticalcounting erroralongwithstandard. 99mTc-RBC’s: Withdrawduplicate1mlwholebloodsamples. Transferto countertubes.Determinehematocritofwholeblood samples and record. Countforappropriatetimetominimize statistical countingalongwithstandard. Dilution factor(99m Tc DF)= Wt. of cellsinjected Wt.of cellsin STD ∩ 100ml 1.0 ml Interpretation PlotlogCPM/mlvstime. Determineyintercept(manuallyorusingcomputerfit). PlasmaVolume NetCPM(ISTD)x(IDF) = Plasmavolume NetCPM/mlplasmaatt=0 RBCVolume NetCPM/(TcSTDx(TcDF) =RBC volume (NetCPMpermlwholebloodatt=0)/(Hematocrit)
  29. 29. 517 NUCLEAR MEDICINE NormalValues RBCVolume PlasmaVolume Males: 27-33ml/kg 49-59ml.kg Females:23-27 ml/kg Note: Ifthepatientismorethan20%underweightor overweightcorrectionsforleanbodymassshouldbe performedusingstandard nomograms. Inflammation 67Ga Inflammation Some infections and inflammatory processes are 67Gaavid.Thereisslowbloodclearanceandexcretion ofgallium,soimagingnormallyisnotstarteduntilafter 48 hours. Labeled WBC’s are preferred for intra- abdominalinfections. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputer. Setupthecam- eraforgalliumimagingusingthefollowingsettings: 96keVphotopeakwitha30%window 185keVphotopeakwitha30%window 300keVphotopeakwitha30%window Radiopharmaceutical 67Gacitrate TimeofImaging Allabdominalorwholebodyimagesshouldbeperformed 72hoursafterinjection. Chestimages maybeimaged at48hourspostinjection. Dose 185Mbq -Adult Webster’srule -Pediatric PatientPreparation Laxatives24hoursafterinjectionandenemasthenight beforeimaging. Thispatientpreparationisonlytobe usedforwholebodyorabdominalimaging. PatientPositioning Whenimagesareperformedtoascertainanunknown focusofinfectionorforfeversofundeterminedorigin, whole body images should be acquired in both the anteriorandposteriorprojections. DataAcquisition Analog: Acquirespotimagesfor500Kusinga4format. Acquirewholebodyscanimagesusingascan speedof10centimeters/minutesonscanning cameras. Digital: Acquirestaticspotimagesina256x256 matrixfor500K Acquirewholebodyimages ina256x1024or384x1024matrix. SpecialViews Asrequestedbystaffphysician.Insomecases,SPECT imagingmayberequired. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments Ifthepatientalreadyhas99mTconboard,onlythe296 keVphotopeakwitha30%windowcanbeusedfor galliumimaging. Imagesmaybeperformedearlierorlaterthan72hours atthediscretionofthenuclearstaffphysician.
  30. 30. 518 CLINICAL PRACTICES 111In White Blood Cell Scan for Infection Thisscanisperformedtodemonstratespecificfociof infection,byuseofWBC’sfromthepatient,labeledwith 111In. Thisprocedureisespeciallyrecommendedfor patients with suspected abdominal and thoracic abscess(s). InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 111Inlabeledwhitebloodcells. TimeofImaging 24hourspostinjection. Dose 7.4MBq-Adult PatientPreparation 50ccofthepatient’sbloodmustbeobtainedfor celllabeling. Administration Intravenousadministratrionoflabeledwhitecells. PatientPositioning Placepatientinthesupineposition. Projections: WholeBodyImaging-anteriorandposterior views. SpotViews-Anteriorandposteriorspot viewsfromtheheadtotibias. DataAcquisition Analog: Acquireimagesonawholebodycamerain wholebodyformatusingascanspeedof8 centimeters/minute. Acquirespotviewsin9formatfor100Kor10 minuteswhichevercomesfirst. 99mTc White Blood Cell Scan for Infection Thisscanisperformedtodemonstratespecificfociof infection,byuseofWBC’sfromthepatient,labeledwith 99mTc. Thisprocedureisrecommendedforpatientswith suspected abdominal and thoracic abscess(s) and osteomyelitis. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputersystem. Radiopharmaceutical 99mTc-HMPAOlabeledwhitebloodcells. TimeofImaging 0.5-4andpossibly18-24hourspostinjection. Earlyimagingisrecommendedfortheevaluationof inflammatoryboweldisease. Dose 185-7.4370MBq-Adult Digital: Acquireimagesinthewholebodyformat (256x1024or284x1024matrix. Acquirespotimagesina256x256matrixfor sameinformationdensityaslistedabove. Use autocontourwithMS-2cameras. SpecialViews Asdeterminedbystaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments WhiteBloodCelllabelingisperformedbyeitherDr.Ronald J.CallahanorMr.StephenDragotakis.
  31. 31. 519 NUCLEAR MEDICINE Lung PatientPreparation 50ccofthepatient’sbloodmustbeobtainedforcell labeling. Administration Intravenousadministratrionoflabeledwhitecells. PatientPositioning Placepatientinthesupineposition. Projections: WholeBodyImaging—anteriorandposterior views. SpotViews-Anteriorandposteriorspot viewsfromtheheadtotibias. DataAcquisition Analog: Acquireimagesonawholebodycamerain wholebodyformatusingascanspeedof12 centimeters/minute. Acquirespotviewsin9formatfor150Kor 10minuteswhichevercomesfirst. Digital: Acquireimagesinthewholebodyformat (256x1024or284x1024matrix. Acquirespotimagesina156x256matrixfor sameinformationdensityaslistedabove.Use autocontourwithMS-2cameras. SpecialViews Asdeterminedbystaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments WhiteBloodCelllabelingisperformedbyeitherDr.Ronald J.CallahanorMr.StephenDragotakis. Lung Perfusion Todemonstrate(bycapillaryblockade)perfusionofthe lungs,usuallytodiagnosepulmonaryemboli. Regional distributionreflectsthecontributionofeachareaoflung tototallungfunction. Theparticlesusedfortheradiolabelareapproximately 3 times the size of a RBC, and temporarily block 1/200,000ofthepulmonarycapillariesinthenormal adult. InstrumentsandEquipment Largefieldofviewgammacamerawithallpurpose collimatorandcomputersystem. TimeofImaging Immediatelypostinjection. Radiopharmaceutical 99mTcmacroaggregatedhumanalbumin(MAA), roughly 200,000-400,000particles. Reduce dose to 50,000-75,000 particles in adult suspectedofhavingpulmonaryhypertension,andto 5,000particlesinneonates. Dose Age+1 Age+7 PatientPreparation None Administration Intravenousinjectionwithpatientsupine. PatientPositioning Acquireperfusionimagesintheexactsequenceas statedbelow: LPO POST RPO RAO ANT LAO x740MBq (nolessthan37MBq)
  32. 32. 520 CLINICAL PRACTICES DataAcquisition Analog: Acquiresallimagesfor1000Kor4min./view. In somecases,thiscanbereducedto750Kwiththe Digital: Acquireimagesina256x256matrixoncomputer. Inthecaseofaquantitativestudy,acquireimages intheposteriorandanteriorprojections. SpecialViews Asorderedbythestaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesand uptake resultsandphotograph. Submitdigitaldataandphotographstotheinterpreta- tionroomforanalysis. Comments Havepatienttakesix(6)deepbreathsbeforeinjection. Havepatienttake5-10deepbreathswhileinjecting. Imagepatientinthesupineposition. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. RegionalLungFunction UseAutomatedProgramforRegionalQuantitation. Incaseswherethepatientisimmobile,theperfusion imagesmaybeinthefollowingorder: POST LPO RPO LAO ANT RAO permissionofaphysician. Lung Ventilation Toassessregionalventilation,especiallyinpatients underevaluationforpulmonaryembolism,andinpatients formeasurementofregionallungfunction. 133Xeisan inertgaswhichisminimallyabsorbedbythebody tissues. InstrumentsandEquipment Largefieldofviewgammacamerawithlow energy all purposecollimatorandcomputersystem. Radiopharmaceutical 133XeGas TimeofImaging Immediatelyuponinhalationof133Xe. Dose Age+1 Age+7 PatientPreparation None Administration InhalationofXenongas. PatientPositioning Supine,alwaysinsamepositionastheperfusionstudy willbedone. Projections: Posteriorprojectionunlessanotherprojection isspecificallyrequested. DataAcquisition Analog: Wash-in-30K Equilibrium-2images- 90seceach,begin ningafterwash-in. Washout-3imagesfor45secondseach. Retention-LPO,Posterior,andRPOimages for45secondseach. x740MBq
  33. 33. 521 NUCLEAR MEDICINE ImageFormat: InitialBreath Equilibrum1 Equilibrium2 Washout(45sec) Washout(45sec) Washout(45sec) LPO(45) Posterior(45sec) RPO(45sec) Digital: Acquireinsamemanneraslungperfusion study. Comments Trytoperformstudyinsupineposition. Makesurepatienthascurrentchestx-ray,(donewithin 12hours)ifpulmonaryembolusevaluation. If the perfusion study was performed prior to the ventilationstudy, obtainabackgroundimage(99mTc scatter in the 133Xe window) for 120 seconds on computertosubtractfromthewashoutimages. ComputationalAnalysis Regional LungFunction Forquantitativeventilationdata,useautomatedprogram. Calculation-Dividethecountsfromeachregionbytotal countsintheentirelungfieldtoobtain%ofuptakein thespecificregion. Pulmonary Aspiration Todeterminewhetherthereisevidenceofgastroesoph- agealrefluxandpulmonaryaspirationofgastriccontents. Sincethisusuallyoccursduringsleep,itisnecessaryto studythepatient overnight. InstrumentsandEquipment Largefieldofviewgammacamerawithlowenergyall purposeparallelholecollimatorandcomputer. Radiopharmaceutical 99mTcsulfurcolloid. TimeofImaging Doneasfirstcaseinmorning. Dose 185MBq PatientPreparation None Administration Thisstudywillbedoneoninpatients. Ontheevening beforeimaging,thepatientisgiventheradiopharmaceu- ticalmixedwith15mlLipomulainamilkshakeor Meritene. PatientPositioning Projection: Anteriorandposteriorchest. DataAcquisition AnalogorDigital: Fifteenminuteanteriorandposteriorimagesof thechest,alongwithmarkerimageindicating locations of the sternal notch and xiphoid. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Endocrine Thyroid Imaging and Uptake (99mTc) Forfunctionandstructuralassessmentofthethyroid gland,using99mTcPertechnetatewhichisincorporated inthethyroidglandbutnotorganified. InstrumentandEquipment Regularfieldofviewcamerawithapinholecollimator and5mminsertandcomputer.
  34. 34. 522 CLINICAL PRACTICES Radiopharmaceutical 99mTcPertechnetate(permitsrapiduptake andimag- ingcomparedtoI123whereimagingisusuallyperformed at24hours). Dose 370MBq - Adult Webster’sRule - Pediatric PatientPreparation None TimeofImaging 20minutespostinjection. Uptake: Countstandardinphantomatadistanceof 20cmwith pinholeinsertinplacefor2minutes. The20minute 99mTcpatientuptakeisthendeterminedbyrepeatcount- ing of the patient’s neck using the same counting geometry. StandardProjections Anterior6cmfromsurfaceofneck. Anterior57Cosupersternalnotchmarkerinconjunction with5cm57Comeasuremarkerparalleltothyroidlobes. Ifnecessaryrightanterioroblique,andleftanterior obliqueatadistancethatwillfill2/3ofpinholefieldof view. InformationDensity 250Kperimage 75Kperimagefor57Comarkerimages SpecialViews Itmaybenecessarytomarkareaswherenodulesare present,using99mTcwand. Comments SeeComputersectionforcalculationof%uptake. Have99mTcmarkingsourcesavailable. Haveaglassofwateravailabletobeusedinpalpationof thyroidgland. Acquire all computer images in quadrant format (128x128). Makeduplicatecopiesofallhardcopyimages.Fillout andsubmituptakecalculationsheetalongwithhardcopy imagesforinterpretation. Thyroid Uptake and Imaging (123I) Forfunctionandstructuralassessmentofthethyroid gland,using123Iwhichisnaturallyincorporatedinthe thyroidgland. InstrumentsandEquipment GEcameraandcomputer Pinholecollimatorwith5mminsert 57Cowandformarking Thyroidlogbook Thyroidfloppydisk Thyroidmagnetictape Sharpieformarkingpatient Radiopharmaceutical 123Isodiumiodide Dose 8MBq123I(1-2capsules)24hourspriortoscanning. PatientPreparation None TimeofImaging 24hours ComputerAcquisition Thyroidcapsulesarecountedinaneckphantomata distanceof20cmwithoutthepinholeinsertfor5min- utes.Uptakedeterminationinthepatientisperformed forthesametimeandcountinggeometry. Allimagesareacquiredin128x128(quadrantformat). Theyarestoredonathyroidfloppydiskandtransferred toathyroidmagnetictapeinbytemode(256)forlong termstorage.
  35. 35. 523 NUCLEAR MEDICINE Comments PatientispalpatedbyThyroidFellowandNuclear MedicineResident. Ifitisaquestionofnodule,theareawillbemarkedfor scanning. Patientisplacedinsupinepositionwithneckextended. Marks are placed on suprasternal notch and for 4cmmarkersatlevelof thyroidgland. StandardImages Anterior,6cmfromcollimator-8minutes. Ifthethyroidisenlarged,itmaybenecessarytoimage at10cmtoincludetheentirethyroidinthefieldofview. Withoutmovingthepatient,multiple2secacquisitions aredoneinquadranttwowiththe57Cowandplaced overthemarks(SSN;4cmmarkers;noduleifmarked) (eg.SAQ,S,QZ;SAQS,Q2;SAQSQ2). Ifthereisaquestionofnoduleorifdeemednecessary bythephysician,bothanRAOandanLAOshouldbe performed. Thesearedoneina45oangleat6cmfor5 minutescenteringthenoduleinthefieldofview. PostScanAnalysis Transferimagesondisktomagnetictapeforlongterm storage. Usebytemode(256)ondesignatedthyroidtape. Recordallpertinentinformationinthyroidlogbook. Photographimagesonhardcopyusingthemultiformatter. Twocopiesareneeded:oneforThyroidLabandonefor NuclearMedicine. Theimagesrecordedareasfollows: MakeupNuclearMedicinefolderandgiveallpaper workandhardcopytoNuclearMedicineResident. Leavethreepolaroidimagesatthyroidclinic. 123I Potassium Perchlorate Washout Test InstrumentsandEquipment Regularfieldofviewgammmacamera. Collimator Pinholewith5mminsert. Radiopharmaceutical 123ISodiumIodide Dose 8-20MBq - Adult Webster’sRule - (Pediatric) StartingTime 45minutespost123Iadministration(capsuledose). 40 minutes after the tracer dose of 123I image the thyroidphantom. At 45 and 60 minutes post dose the patient will be imaged. PotassiumPerchlorate Adultdose: 400mg(2capsules). Pediatricdose: Webster’sRuleorcheckwithstaff physician. Afterinitialimageshavebeenobtained,dose thepatientwith400mgofPotassium Perchlorate. 40minutesafterthedoseofPotassium Perchloratethethyroidphantomisagainimaged. At45and60minutesafterthedoseof PotassiumPerchloratethepatientisimaged. StandardProjections Anteriorat6cmfromsurfaceoftheneck. ImagingTime Imagingtimeforallviews(bothpatientandphantom) willbefor5minutes. SpecialViews TobedeterminedbyStaffNuclearMedicinephysician. Comments Allimages(patient)willhaveuptakevaluescomputed usingthe“thyroid”programonthecomputer.
  36. 36. 524 CLINICAL PRACTICES Parathyroid Imaging 99mTc-sestamibiaccumulatesinnormalandabnormal thyroid, as well as in enlarged parathryoid glands. Sestamibirapidlywashesoutfromnormalthyroidtis- sue;thus,delayedimagesshouldshowonlyabnormal uptake. InstrumentsandEquipment Largefieldofviewcamerawithallpurposeorhighreso- lutionparallelholecollimatorandinterfaced computer. Insomecases,imagingwitha5mmpinhole collimator mayberequired. Radiopharmaceutical 740MBq99mTc-sestamibi TimeofImaging Initial images immediately after injection. Delayedimagesapproximatelytwohoursafterinjection. ImageAcquisition Acquireimmediateanteriorplanarimageoftheneckand upperchest,sothatthemostsuperioraspectoftheheart isatthebottomofthefieldofview. Thisshouldberecordedfor5minutesin128x128 matrixsize. PerformSPECTacquisitionofneckandupperchest using360orotation,96viewsperhead,15secondsper view. Record5minutepinholeimageofneckintheanterior projection,withthepinholeapertureapproximately 10cmfromtheneck. Repeateachoftheseimagesatthetimeofdelayed imaging. ImageAnalysis Prepare labeled save screen of planar and pinhole images. ReconstructandphotographSPECTimagesinthe transaxial,coronal,andsaggitalplanes. Comments Inselectedcases,additionalobliqueimagesoftheneck maybeneeded. Ifamediastinalabnormalityisshown, delayedimagesmaynotbeneeded. Iodine-131 MIBG Imaging of Adrenergic Tumors LabeledMIBG(meta-iodobenzylguanidine)isaprecursor forseveraltypesofadrenergictumors,mostnotably pheochromocytomas. Inadults,about90%orpheochromocytomasliewithin theadrenalmedulla. Inchildren,upto30%maybe extra-adrenal. Radionuclideevaluationisusuallywarrantedonlywhen CTevaluationhasnotdemonstratedthesuspected tumor. Otheradrenergictumorsthatmaybeshownby MIBGimagingincludeparaganglioma,neuroblastoma,and carcinoid. Someinvestigatorsbelievethattheselatter tumorsmaybebettershownwithoctreotideimaging. InstrumentsandEquipment Largefieldofviewgammacamerawithparallelholehigh energy(400or511keV)collimator. Radiopharmaceutical 18MBq131IMIBG Timeofimaging 24and48hourspostinjection. Onselectedoccasions,72hourimagesmaybeneeded. PatientPreparation Thepatientmustbescreenedformedicationsthatmay interferewithMIBGuptake. Theseincludesympathomi- metics,calciumchannelblockers,reserpine,cocaine, tricyclicantidepressants,adrenergicblockers,andsome over-the-countercoldmedications (e.g., containing pseudoephedrine). Thyroidiodineuptakemustbeblockedbyadministering SSKIbeginning2daysbeforetraceradministration,and continuingfor5daysthereafter. Theusualdoseis6 dropsperday. Tumor
  37. 37. 525 NUCLEAR MEDICINE ImageAcquisition Anteriorandposteriorspotviewsoftheneck,chest, abdomen,andpelvisshouldbeacquiredfor15minutes each,usinga128x128matrixsize. Imagesmustincludethebodyfromthebaseoftheskull totheinferiorbladder. ImageAnalysis Preparelabeledsavescreenofimages. Comments Itmaybenecessarytoinjectasecondradio-pharmaceu- ticalsuchas99mTc-DTPAorpertechnetate toprovide anatomicorientationforanyabnormalfindings. Reference McEwan AJ, Shapiro D, Sisson JC et al. Radio- iodobenzylguanidinefortheScintigraphicLocationand TherapyofAdrenergicTumors.JNuclMed1985;15:132- 153. 67Ga Tumor Certain primaryandsecondarytumordepositsare 67Ga avid. Thisradiolabelisusedmostcommonly inpatientswithlymphoma. InstrumentsandEquipment Largefieldofviewgammacamerawithmediumenergy parallelholecollimatorandcomputer. Setupthecameraforgalliumimagingusingthefollow- ingsettings: 93keVphotopeakwitha30%window 185keVphotopeakwitha30%window 300keVphotopeakwitha30%window Radiopharmaceutical 67Gacitrate TimeofImaging 72hourspostinjection. Earlierimagesofthechestmaybeperformedatthestaff physician’sdiscretion. Dose 300MBq -Adult Webster’sRule -Pediatric PatientPreparation Laxativesstarted24hoursafterinjectionandenemas thenightbeforeimaging.Thispatientpreparationisto beusedonlyforabdominalorwholebodyimaging. Administration Intravenousinjectionoftheradio-pharmaceutical. PatientPositioning Projections: TotalBodySpotViews. Anteriorandposteriorheadwithneck included. Anteriorandposteriorchestwithaxillary areaincluded. Anteriorandposteriorabdomen. Anteriorandposteriorpelvisandupperlegs. TotalBodyScan: Underspecialcircumstances(determinedby thestaffphysician),imagingmaybeperformed inabodyscan modeusingascanspeedof 10cm/min. DataAcquisition Analog: Acquirespotimagesfor10minutesusinga9on one format. Digital: Acquirestaticspotimagesina256x256matrix. TotalBodyImaging: Scanspeedof10cm/minforanaloganddigital images.
  38. 38. 526 CLINICAL PRACTICES SpecialViews Asrequestedbystaffphysician. ImageAnalysis Preparelabeledsavescreensoftheimagesanduptake resultsandphotograph.Submitdigitaldataandphoto- graphstotheinterpretationroomforanalysis. Comments Ifthepatientalreadyhas99mTconboard,onlythe 300keVphotopeakwitha30%windowcanbeusedfor galliumimaging. Imagesmaybeperformedlaterthan72hoursatthe discretionofthenuclearmedicinestaffphysician. Note: Thisprocedureisdoneroutinelyusingdoses thataregreater thanthoselistedinthemanufacturer’s packageinserts. Thechoiceoftheradiopharmaceutical andthedoseforeachproceduredescribedinthis Manual is made by the physician staff of the Nuclear MedicineDivision,inorderto acquire the best results whilecomplyingwithMGHIsotopeand/orPharmacy Committee guidelines. The name of the Nuclear Medicinephysicianorderinganytestthatislistedhere ismaintainedinthefilesoftheradio-pharmacywiththe dataonthepatientandradio-pharmaceutical. 131I Whole Body or Neck with Quantitation InstrumentsandEquipment Thepreferredinstrumentisalargefieldofviewgamma cameraequippedwithultra-highenergycollimatorsand computersystem. Peakcamerafordualwindowacquisitionwith20% windowssetat364Kev(131I)and140Kev(99mTc). Radiopharmaceutical 131ISodiumIodide Dose 131IadministeredbyThyroidLab. Injectpatientwith40MBq99mTcPertechnetateIV. PatientPreparation None TimeofImaging 24-168hourspostoraladministration. PatientPositioning Anteriorandposteriordualwindowimagesof: Head,neckandupperchest Chestandupperabdomen Abdomenandpelvis Lowerextremities DataAcquisition Analog: Notrequired Digital: Fifteenminuteanteriorandposteriordualwin- dowimagesof: Head,neckandupperchest Chestandupperabdomen Abdomenandpelvis Lowerextremities. Use256x256matrix. Acquire 131Istandardphantomimagesfor 60seconds,anteriorandposterior. ImageAnalysis Formatimageswiththe131IdisplayMPEontheICON computer. Iftherearefocalareasofincreased131Iaccumulation, calculateuptakewiththe131IuptakeMPEontheICON computer. Prepare labeledsavescreensoftheimagesanduptake resultsandphotograph. Submitdigital dataandphotographstothe interpreta- tionroomforanalysis. Reference CastronovoFP,etal;DosimetricConsiderationsWhile AttendingHospitalizedI-131TherapyPatients.JNuc Med,September1982,Vol10,No.3.
  39. 39. 527 NUCLEAR MEDICINE Miscellaneous Strontium - 89 Radiotherapy 89Srchlorideisindicatedforthepalliationofbonepain inpatientswithpainfulskeletalmetastases. Itisused inpatientsunresponsivetochemotherapyorhormonal therapy. Most patients considered for89Sr treatment have alreadyundergoneexternalbeamradiationtherapy. The bestresultshavebeeninpatientswithmetastaticbreast orprostatecancer,althoughothertumortypesmaybe treated. There may be a transient increase in bone pain at 36-72hoursfollowingtreatment. Thereliefofpain following89Srtherapytypicallyoccursin7-20days. Repeattreatmentdosesmaybegiveninthreemonthsin someselectedpatientswhorespondedtotheinitial treatment. 89Sr has a half-life of 50.5 days, and decays by a 1.4MeVemission,withoutsignificantgammaemissions. Inconsequence,89Srcannotbeimaged. 89Srbehaves biologicallyasacalciumanalog,withrapidbloodclear- anceanduptakeinbone. Inpatientswithextensivemetastaticdisease,morethan onehalfoftheinjecteddosemaylocalizeinbone. About two-thirdsofexcretionisurinary,andone-thirdfecal. Thereissignificanturinaryexcretionduringthefirst48 hoursaftertracerinjection. Indications Thepatientmustmeetthefollowingentrancecriteria for89Srtherapy: Documentedbonemetastasesunresponsiveto therapy. Lifeexpectancyofatleasttwomonths. Previousbonescanshowingmetastaticlesions, preferablywithinseveralmonthspriorto treatment. Evidencethatbonemarrowisnotseverelycom- promised,asindicatedbycurrent(within1 week)WBCcountof>3000andplateletcount of>60,000. Mustnotbeincontinentofurineorfeces. Mustbeabletogiveinformedconsent. Thisprocedurewillnotbedoneoninpatients becauseofthelogisticsofradiationsafety issues. Inrareinstances,amedicaldecisionmaybemadeto proceedwithtreatment,despitenoncompliancewithone ormoreofthecriteriaabove. SchedulingofProcedure Requests for 89Sr treatment from an attending physicianwillbehandleddirectlybyaNuclearMedicine staffphysician. TheNuclearMedicinephysicianwill completeaninformationform thatindicatesthepatient’s name,unitnumber,age,weight,anddiagnosis. Hematologicdatashouldbefaxedbythereferring physician’s office or obtained from PCIS prior to scheduling. Thestaffnuclearphysicianwillforwardthisinformation totheNuclearMedicinedivisionsecretarydesignatedto handle89Srtherapyrecordsforscheduling. ANuclear Medicine“SpecialStudies”formwillbecompletedand forwardedtothenuclearpharmacysothattheradiop- harmaceuticaldosecanbeordered. A89Srtreatment folderwillbemadeandkeptintheNuclearMedicine staffofficefilesthatcontainsallofthisrelevantdata, alongwithreportsofanyrelevantimagingstudies. Atthetimeofscheduling,aconfirmationformwillbe faxedtothereferringphysician’soffice. Thisform reviewstheprotocolforfollow-uphematologystudies thatwillbeobtainedbythereferringphysician. Consent Atthetimeoftreatment,theNuclearMedicinestaff physicianadministeringthetherapywilldiscussthe procedurewiththepatientandobtainwrittenconsent usingthe89SrTherapyconsentform. (InformedConsentRequired)
  40. 40. 528 CLINICAL PRACTICES WrittenDirective TheNuclearMedicinestaffphysicianwillcompletethe writtendirectiveform,includingthefollowingdata: date,patientname, patientweight,patientdateofbirth, referringphysicianname, NuclearMedicinephysicianname, twomethodsofpatientidentityverification, dateandfindingsofthemostrecentbonescan, thepatient’shematocrit, WBCandplateletcounts, andtheadministereddoserequested. Dose 1.5-2.2MBq/kguptoamaximumof150MBq. Any dosage in this range reflects acceptable adequate dosage; the exact dosage within this range may be selectedbasedupontheamountofradiopharmaceutical available. Technique Insertasecurerouteofintravenousaccess,such asa20gaugeangiocathwithathreewaystop- cock. Infuseenoughnormalsalinetoconfirmthe adequacyofintravenousaccess. The89SrdosewillbegivenbytheNuclearMedi- cinestaffphysicianasaslowinjectionoverabout oneminute. Followingadministration,flushboththeinjection syringe and stopcock with at least 10 ml of saline. RemovetheIVsetupandwrapthesyringeand tubingintheimperviousdrapesusedforthe injection. This will be marked “Sr-89” and placed in storagefortransfertoRadiationSafety. Incase ofaspill,containthecontaminationandcallthe RadiationSafetyofficeat6-2425. Theroomusedforadministrationwillbemoni- toredforcontaminationfollowingeachinjection. Miscellaneous Follow-Up Itisrecommendedthatthepatient’speripheral bloodcountsbecheckedatleasteveryother weekfollowing89Sradministrationtoevaluate formarrowdepression. TheCBCshouldbecheckedmoreoftenif values fall below treatment thresholds. Plateletlevelstypicallyreachanadirofabout 70%ofthepre-existingvalueat3-4months followingtreatment. ThedepressionofWBCcountsismorevariable, butbloodcountsmaynotreturntopre-treat- mentlevelsforabout6months. Approximately2weeksaftertreatment,follow- upbloodcountswillbeverifiedbycontacting thereferringphysican’sofficeorfromPCIS. Records TheNuclearMedicinestaffphysicianwilldictatea report of the therapy administration, including the clinical history, laboratory values, and dosage administered. Acopyofthisreportwillberetainedinthepatientfolder keptintheNuclearMedicinestaffoffices. Acopyofthe written directive will be maintained in the nuclear pharmacycomputersystem,aswellasinthepatient folder. RadiationSafetyConsiderations and Precautions 89Srisexcretedviatheurineforaprolongedperiod,but mostactivityiswithinthefirstweek(andmostofthat intheinitial48hours). Thepatientshouldbeinstructed todoubleflushtoiletsduringthistime. Fecalmatter containsappreciableactivityforabout4days. Blood activityissignificantforabout24hours,andblood samplesshouldnotbedrawnduringthistimeexceptin anemergencysituation. Ifthepatientreturnstothehospitalfortreatmentwithin thefirstweekaftertherapy,urinespecimens,dressings, linens,andglovesshouldbeconsideredradioactive,and collectedbytheRadiationSafetyOffice. Surgicalor medicalproceduresmaybeperformedwithcareful attention to Universal Precautions. An autopsy or cremationshouldnotbeperformedunlessauthorizedby theRSO.
  41. 41. 529 NUCLEAR MEDICINE Miscellaneous 111In Pentetreotide Imaging A variety of neuroendocrine tumors (insulinoma, gastrinoma,VIPoma,neuroblastoma,etc.)expresshigh concentrationsofsomatostatinreceptors. Inmanycases,thesepatientshavebeeneffectively treatedwiththesomatostatinanalog-Octreotide. In somesituations,tumorlocalizationcanbeachievedwith 111Inlabeled-Octreotide(OctreoScan). InstrumentsandEquipment Largefieldofviewgammacamerawithamediumenergy parallelholecollimatorandcomputersystem. Twenty%windowsshouldbesettoincludethe 172and245keVphotonsof111In. Radiopharmaceutical 111InlabeledOctreoScan TimeofImaging 4and24hoursafter. Insomecases,only24hourimagingwillbenecessary (seestaffphysician). Insomecases,48or72hourimagingmayberequiredto differentiatetumoruptakefromnormalbowelactivity (seestaffphysician). Dose Adults: 185MBqof111InlabeledOctreoScan(planar +SPECT). Children:Webster’srule(neveruse<37MBq). PatientPreparation BowelPrep: Mildlaxative(e.g.bisacodylor lactulose)afterinjection. Hydration: Patientshouldbewellhydrated(at least2glassesof water)toenhance renalexcretion. ConcurrentOctreotideTherapy: Discontinue24-48hourspriortoimaging(if possible) andmonitorpatientforsignsof withdrawal. Administration Intravenousinjectionoftheradiopharmaceutical. PatientPositioning Placethepatientinthesupinepositionandacquire thefollowingviews. PlanarImaging: Ant.&Post:head,neckandupperchest Ant.&Post:chestandupperabdomen Ant.&Post.:abdomenandpelvis Ant.&Post.:lowerextremities SPECT: Areaofinterest. DataAcquisition Analog: Acquirespotimagesin9formatfor500Kor10 minutes,whichevercomesfirst. Digital(planar): Acquireimagesina256x256matrix forthesame informationdensityasindicatedabove. SpecialViews Asdeterminedbystaffphysician. Inmostcases,SPECTwillberequired. SPECT(MS-2) Acquire96projectionsover360ooneachhead:20sec./ projectionina128x128matrix. Reconstruct the data usinga Butterworth filter (cutoff=0.4,order=7). Donotuseattenuationcorrection. ImageProcessing Prepare labeled save screens of all planar (general display)andSPECTdata(multi-viewdisplay)and photograph.Submitallanaloganddigitaldataand photographstotheinterpretationroomforanalysis.
  42. 42. 530 CLINICAL PRACTICES Miscellaneous Normally,thereisminimalrighttoleftshuntingandmost ofaninjecteddoseofradiolabeledalbuminmicropheres shouldbetrappedinthelungs. Thepercentagefoundoutsidethelungrelatestothe extentofR-Lshunting. InstrumentsandEquipment Regularorlargefieldofviewgammacameraequipped withageneralallpurposecollimatorandinterfacedtoa computer. Radiopharmaceutical Macroaggregatedalbumin(lessthan100,000particles labeledwith99mTc. The number of particles is reduced for infants and children. Dose 150MBq -adult Webster’srule -pediatric TimeofImaging Immediatelyafterinjection. PatientPreparation None Administration Intravenousinjection. PatientPosition Supine Right to Left Shunt (MAA Technique) DataAcquisition QualitativeTechnique Acquireanteriorimageofbrain,palmarimage ofhand,orotherprojectionsasindicatedby staffphysician. Usea256x256matrixandacquireeach imagefor5minutes. QuantitativeTechnique Acquirewholebodyanteriorandposterior digitalimageusingeithertheSiemensbody cameraorMS-2at5cm/min. Drawregionsofinterestoverthewholebody andthelungs. Determinethenumberofcountsineachregion andcalculategeometricmeans. Calculatethedegreeofshuntingusingthe relation: AmountofR-LShunt=1-[Lung/WholeBody] NOTE: Thisprocedureisroutinelyperformedusing doses that are greater than those listed in the manufacturer’spackageinserts. Thechoiceofthe radiopharmaceutical andthedose for eachprocedure describedinthis Manualismadebythephysicianstaff ofthe NuclearMedicineDivision,inordertoacquirethe best results while complying with MGH Isotope and/orPharmacyCommitteeguidelines.Thenameofthe Nuclear Medicine physician ordering any test that is listed here is maintained in the files of the radiopharmacywiththedataonthepatientdoseof radiopharmaceutical. Reference Editorial:AmRevRespDisease1977;115:553-557
  43. 43. 531 NUCLEAR MEDICINE Miscellaneous Lymphoscintigraphy: Melanoma En bloc lymph node resection is done in high risk melanomapatientsinaattempttoreducerecurrent disease. Whentheprimarylesionisonthetrunk,lymphaticdrain- agemaybetoeitheraxillaryand/oringuinalregion,as wellastoothernodalgroupssuchassupraclavicular andpara-aorticnodes. Lymphoscintigraphyisemployedtoidentifythenodal group or groups at highest risk, and to localize the sentinelnode(s). InstrumentsandEquipment Largefieldofviewcameraequippedwithhighresolution orallpurposecollimatorandcomputer. Radiopharmaceutical Filtered99mTcsulfurcolloid. Dose 5-10MBqin4insulinsyringesasfollows: 1.25-2.5MBqpersyringein0.2mlvolumepersyringe. Supplies Sterileprepkit,non-sterilegloves,Betadine,57Co “thyroid”marker. Administration Usinginsulinsyringes,fourtosixintradermalinjections aremadearoundthebiopsysite. DataAcquisition Analog: Notrequired Digital: Uptothreesequential5minuteimagesina 128x128matrix. Theinitialimagesmustincludethesiteof injection. Thesubsequentimagesshouldincludedetected drainagepathways. Ifthelesionistruncal,bothaxillaryandinquinal regionsshouldbeevaluated. At2hoursafterinjection,additional5minute posteriorandanteriorimagesmaybeacquired. Identifythetipsoftheshouldersandiliaccrests withthe57Comarker. Aphysicianwilllocalize thesentinelnode(s),andmakeanyskinmarks asneeded. ImageAnalysis Preparelabeledsavescreensofallimagesandphoto- graph. Submitalldigitaldataandphotographstothe interpretationroomforanalysis. Interpretation Asrequestedbythereferringphysician,thepath(s)and nodalgroup(s)whichdraintheinjectionsitemaybeiden- tified,andthelocationofthesentinelnode(s)notedand markedonthepatient. Reference JournalNucMed1993;34:1435-1440
  44. 44. 532 CLINICAL PRACTICES Miscellaneous Schilling Test Part I OrallyadministeredvitaminB12iseitherabsorbedfrom the intestine or excreted in the feces. If, however, two hours after an oral dose of the vitamin B12, apatientreceivesanintramuscularinjectionofthe vitamin, he will excrete <30% of the oral dose in hisurine. Byemployingthis“flushing”techniquewith anoraldoseofradioactivelabeledvitaminB12,urinary excretionofthevitaminandconsequentlybodilyabsorp- tioncanbeeasilymonitored. Lessthan7%excretion indicatesmalabsorption. InstrumentsandEquipment Rubratope-57(~0.5mCi/capsule)Squibb Copatope -57(~0.01mCi/ml)Squibb CyanocobalaminInjection,USP(1,000mcg/ml),Wyeth 24-hourSpecimenCollectionContainers,Sage GammaCounter,Micromedic2/200 Specimen 24hoururine PatientPreparation Discusstheprotocolwiththepatient. ThepatientMUSTbeNPO—exceptforwaterforat least8hourspriortotestingandSHOULDNOTreceive aninjectionofvitaminB12within24hoursofthetest. Mostconvenientisafastfrommidnightwiththetest beginningafter8a.m. ScheduletestMondaythruThursday. Fridayscheduling requiresstorageoftheurinecollectionovertheweek- endandisdiscouraged. Administration Confirmpatientpreparation. PERSONALLYgivetothepatientandwatchhim swallowaRubratope-57capsule. Inpatients Leave with the patient a 24 hour specimen collection container labeled with his name, floorandunitnumberaswellasthestartand completiondateandtime. Informthepatientandremindtheattendingnurse or unit coordinator of the remaining test procedures. Thepatientmayeatalightbreakfastofjuice, coffee and toast one hour after taking the Rubratope-57capsule. Outpatients Givethepatienta24hourspecimencollection containerlabeledasdescribedunder“Inpatients” and a copy ofthe“SchillingTestInstructions” completedasindicated.(Seebelow.)Explainthe collectionandinstructionsasnecessary. Informthepatientthatonhisreturntothelabo- ratory2hourslaterhewillreceiveanintramus- cularinjectionofvitaminB12(cyanocobalamin -1,000mcg). Itistheresponsibilityofthetech- nologist to find an appropriate person to administertheB12shot. Ifnoonecanbefound inareasonableperiodoftime,thensendthe patienttoMedicalWalk-InUnitwithaninter-clinic referralslipsignedbyDr.Fischman. The Medical Walk-In Unit will provide and administertheB12shot. Acquiringbreakfastandreturningofthe24-hour urinesamplearetheresponsibilitiesofthepatient. Assay Recordvolumeof24hoururinecollection. Aliquotthree,2mlsamplesofthecollectionintogamma countingtubes. Alsoaliquota2mlsampleofthepatient’sbackground urine* and a 2 ml sample of Cobatope - 57 diluted 1mlto2mlswithdistilledwater. **Thisaliquotrepresents2%oftheradioactivitycon- tainedinRubratope-57capsuleofthesamelotnumber. Countalltubes(10)asfollows:
  45. 45. 533 NUCLEAR MEDICINE Miscellaneous Input(A=Assay;;S=Stat;T=Tape): A ASSAYNo.:1 COMMENT:return COUNTINGTIME(MIN.):10 ISOTOPE(I=IODINE;C=COBALT):C NO.TUBES:10 TUBESIZE(S=8X50;L=12X75):S BACKGROUNDCOUNTS(CPM): A:return B:return 001, 10, 019227 - DILUTEDCO-57 002, 10, 000131 - BACKGROUND 003, 10, 000671 - SAMPLE#1 004, 10, 000657 - SAMPLE#1 CRYSTALB 005, 10, 000674 - SAMPLE#1 006, 10, 019147 - DILUTEDCO57 007, 10, 000136 - BACKGROUND 008, 10, 000836 - SAMPLE#2 009, 10, 000851 - SAMPLE#2 CRYSTALA 010, 10, 000847 - SAMPLE#2 EXAMPLEOF2PATIENTS (10TUBES) Calculations % Excretion = Average CPM (Sample ) − CPM (Backgr CPM (Diluted Rubratope − 57) − C NORMALRANGE:>10%excretion(borderline7-9%) IfExcretionisNormal Pourremainingurinedowntheradioactive wastesink,flushwithwaterandrecord microcuriesdisposedofonradioactive wastelog. Reportresults. IfExcretionisAbnormal SendanaliquotofurinetotheChemistryLab foracreatininelevel. Discardremainingurineandrecordmicrocuries disposedofonradioactivewastelog. Reportresults. Includecreatinineresultsasng/ml. Commentoncompletionofcollectionas necessary. CommonInterferences • Laxatives, enemas or barium studies administered during the test. • Gamma emitting isotopes administered before or during the test e.g. ISOTOPE SCAN T1/2 - physical Iodine - 131,123 Thyroid 8 days, 13 hours Technetium-99m Brain 6 hours Technetium-99m Bone 6 hours Technetium-99m Renal 6 hours Technetium-99m Lung 6 hours Gallium - 67 Whole body 3 days
  46. 46. 534 CLINICAL PRACTICES Miscellaneous Schilling Test Part II IfPartIoftheSchillingtestdocumentsmalabsorptionof vitaminB12,PartIIisperformedtotestforintrinsic factordeficiencyasthecauseofmalabsorption. Adoseofcommercialintrinsicfactorisgivenalongwith theradioactiveVitaminB12. Normalpercentexcretionindicatesintrinsicfactor deficiency. Abnormalexcretioneliminatesintrinsicfactordeficiency as the cause of malabsorption but is otherwise indiscriminate. InstrumentsandEquipment IntrinsicFactorConcentrate(1N.F.x1unit/capsule), Squibb. SeePartI. Specimen 24hoururine PatientPreparation Exceptforthefollowingchanges,proceedasoutlined inPartI. PERSONALLY givetothepatientandwatchhim swallowaRubratope-57capsulealongwithanintrinsic factorcapsule. NORMALRANGE:SameasPartI References SchillingRF.IntrinsicfactorstudiesII.TheEffectof GastricJuiceontheUrinaryExcretionofRadioactivity AftertheOralAdministrationofRadioactivityB12. J LabandClinMed;1953:42:860. Med1955;45:926. ALLOW AT LEAST 3 DAYS BETWEEN PART I AND PART II SchillingRF,ClatanoffDV,andKorstDR.Intrinsic factorstudiesIII.FurtherObservationsUtilizingthe UrinaryRadioactivityTestinSubjectswith Achlorhydia,PerniciousAnemiaorTotalGastrectomy.J LabandClin SCHILLINGTESTINSTRUCTIONS X=STARTINGTIME/INGESTIONOF57CoCAPSULE AFTERSWALLOWINGTHEVITAMINB12CAPSULE: Youmayeatalightbreakfast(coffee,tea,juice,toast) ATX+1HOURAM Youmustreturntothelabat X+2HOURSAM STARTINGNOW, Saveallofyoururineforthenext24hoursinthe containerprovided. Returnthecollectedurineatyourconveniencetomor- rowbetween8:00a.m.and5:00p.m. SHOULDANYOFYOURURINEFORTHENEXT24 HOURSBEDISCARDEDBYMISTAKE,PLEASENOTETHE TIMEANDTHEAPPROXIMATEAMOUNTLOST. PLEASEHANDLETHECOLLECTEDURINEWITHCARE. THEMATERIALCONTAINEDWITHINTHECAPSULEYOU HAVESWALLOWEDISSLIGHTLYRADIOACTIVE.PART OFTHISMATERIALISEXCRETEDINYOURURINE. ANYSPILLAGESHOULDBETHOROUGHLYWIPED-UP ORWASHEDOFFOFTHEAREAINVOLVED.
  47. 47. 535 NUCLEAR MEDICINE Miscellaneous DISTRIBUTIONOFSCHILLINGTESTRESULTS1981-1984 N=417 0 1.25 2.5 3.75 5 6.25 7.5 8.75 10 11.25 12.5 13.75 15 16.25 17.5 18.75 0 10 20 30 40 50 60 % EXCRETION CONCLUSION:Distributionsuggeststheadditionofaborderlinerange. NormalRange: >10% Excretion Borderline: 7-9%Excretion
  48. 48. 536 CLINICAL PRACTICES Miscellaneous Procedure for Counting Samples for The Schilling Test UsingMicromedics2/200ScintillationCounter TheMicromedicsscintillationcounterisadualsodium iodide detector system designed primarily for radioimmunoassayworkandotherlimitedinvitronuclear medicinestudiesusingverylowlevelsof125Ior57Co. Itisnotsuitableforgeneralgammascintillationcount- ingduetolackofsufficientshieldingbetweendetectors andnon-linearityathighercountingrates. Itisnotsuitablefor99mTcredbloodcellvolumestudies aswenowperformthem. GeneralInformation The system should be left on at all times. Test tube holdersmustbeloadedontothelefthandsideofthe countersurfacewithpositionnumber1attherightside oftherack. Only12mmx74mmplastictubesshouldbeused.Caps whichprotrudeabovethelinepositionedatthetopof thetubescannotbeused.Corkstopperswhichcanbe pushedintothetubebelowthismarkshouldbeused. Uncappedsamplesshouldnotbecountedinthissystem duetothepossibilityofspillageandcontamination. Thesystemhasnostorageordatahandlingcapabilities. Alldatamustbeenteredatthebeginningofeachassay. Backgroundcountratesmustbedeterminedforeach detectorandvaluesenteredatthebeginningofeach assay. Theenteredvaluewillthenbesubtractedfrom allcounts. Countingtimescanbesetfrom0.1to25minutes. Out- put from the system includes assay number, tube number,countingtimeandbackgroundcorrectedcounts perminutewithamaximumofsixdigits. Allinputandoutputtothesystemisthroughthekey- board/printer. The cap-lock must be depressed at alltimes. BackgroundLevelDetermination Placetenuncappedtubesinarackandplaceonleftside ofcountersurface. Placerackasfarforwardaspos- sible. Releaseretainingarmandallowittogoforwarduntil contactwithtuberackismade.Clearalltesttuberacks fromrightsideofcountersurface. Press“teletypeinput”buttonlocatedoncontrolpanel Usingtheprinterkeyboard,respondasindicatedbelow Someentriesmustbefollowedbyareturnothersdonot. PrinterOutput OperatorResponse Input(A-Assay;S=Stat;T=Tape): A AssayNo.: (enterany#) Comment: BG, Date CountingTime(min): 1 Isotope(I=Iodine;C=Cobalt) C No.Tubes: 10 TubeSize: L BackgroundCounts(CPM): A: 0 B: 0 Press“Start”ButtononControlPanel-Assaywill proceedautomatically. Tocalculatebackgroundlevelstobeenteredinassays performedduringthedaydeterminetheaveragecpmfrom theoutputdataasfollows: Averageofpositions1to5isthebackgroundlevelfor detector“B.” Averagepositions6to10isthebackgroundlevelforde- tector“A.” Record thesevaluesinthedailylogbook.

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