Nuclear medicine

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  • Stem cells are “non-specialized” cells that have the potential to form into other types of specific cells, such as blood, muscles or nerves. They are unlike 'differentiated' cells which have already become whatever organ or structure they are in the body. Stem cells are present throughout our body, but more abundant in a fetus.
    Medical researchers and scientists believe that stem cell therapy will, in the near future, advance medicine dramatically and change the course of disease treatment. This is because stem cells have the ability to grow into any kind of cell and, if transplanted into the body, will relocate to the damaged tissue, replacing it. For example, neural cells in the spinal cord, brain, optic nerves, or other parts of the central nervous system that have been injured can be replaced by injected stem cells. Various stem cell therapies are already practiced, a popular one being bone marrow transplants that are used to treat leukemia. In theory and in fact, lifeless cells anywhere in the body, no matter what the cause of the disease or injury, can be replaced with vigorous new cells because of the remarkable plasticity of stem cells. Biomed companies predict that with all of the research activity in stem cell therapy currently being directed toward the technology, a wider range of disease types including cancer, diabetes, spinal cord injury, and even multiple sclerosis will be effectively treated in the future. Recently announced trials are now underway to study both safety and efficacy of autologous stem cell transplantation in MS patients because of promising early results from previous trials.
    History
    Research into stem cells grew out of the findings of two Canadian researchers, Dr’s James Till and Ernest McCulloch at the University of Toronto in 1961. They were the first to publish their experimental results into the existence of stem cells in a scientific journal. Till and McCulloch documented the way in which embryonic stem cells differentiate themselves to become mature cell tissue. Their discovery opened the door for others to develop the first medical use of stem cells in bone marrow transplantation for leukemia. Over the next 50 years their early work has led to our current state of medical practice where modern science believes that new treatments for chronic diseases including MS, diabetes, spinal cord injuries and many more disease conditions are just around the corner.
    There are a number of sources of stem cells, namely, adult cells generally extracted from bone marrow, cord cells, extracted during pregnancy and cryogenically stored, and embryonic cells, extracted from an embryo before the cells start to differentiate. As to source and method of acquiring stem cells, harvesting autologous adult cells entails the least risk and controversy.
    Autologous stem cells are obtained from the patient’s own body; and since they are the patient’s own, autologous cells are better than both cord and embryonic sources as they perfectly match the patient’s own DNA, meaning that they will never be rejected by the patient’s immune system. Autologous transplantation is now happening therapeutically at several major sites world-wide and more studies on both safety and efficacy are finally being announced. With so many unrealized expectations of stem cell therapy, results to date have been both significant and hopeful, if taking longer than anticipated.
    What’s been the Holdup?
    Up until recently, there have been intense ethical debates about stem cells and even the studies that researchers have been allowed to do. This is because research methodology was primarily concerned with embryonic stem cells, which until recently required an aborted fetus as a source of stem cells. The topic became very much a moral dilemma and research was held up for many years in the US and Canada while political debates turned into restrictive legislation. Other countries were not as inflexible and many important research studies have been taking place elsewhere. Thankfully embryonic stem cells no longer have to be used as much more advanced and preferred methods have superseded the older technologies. While the length of time that promising research has been on hold has led many to wonder if stem cell therapy will ever be a reality for many disease types, the disputes have led to a number of important improvements in the medical technology that in the end, have satisfied both sides of the ethical issue.
    CCSVI Clinic
    CCSVI Clinic has been on the leading edge of MS treatment for the past several years. We are the only group facilitating the treatment of MS patients requiring a 10-day patient aftercare protocol following neck venous angioplasty that includes daily ultrasonography and other significant therapeutic features for the period including follow-up surgeries if indicated. There is a strict safety protocol, the results of which are the subject of an approved IRB study. The goal is to derive best practice standards from the data. With the addition of ASC transplantation, our research group has now preparing application for member status in International Cellular Medicine Society (ICMS), the globally-active non-profit organization dedicated to the improvement of cell-based medical therapies through education of physicians and researchers, patient safety, and creating universal standards. For more information please visit http://www.neurosurgeonindia.org/
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Nuclear medicine

  1. 1. Nuclear Medicine
  2. 2. General concept <ul><li>Radiopharmaceutics </li></ul><ul><li>mCi, MBq (1mCi = 37MBq) </li></ul><ul><li>Planar image and SPECT image </li></ul><ul><li>Clinical presentation </li></ul>
  3. 3. Neurology imaging <ul><li>99m Tc-HMPAO : cross to BBB and fix in the brain proportionally to perfusion </li></ul><ul><li>18 FDG : glucose metabolism </li></ul><ul><li>99m Tc-TRODAT : dopamine transporter </li></ul><ul><li>111 In-DTPA, 99m Tc-DTPA : CSF dynamics, V-P shunt patency study </li></ul>
  4. 4. Brain Perfusion Scan <ul><li>CVD : as early as 2 hours after the onset of symptoms, evaluate prognosis, </li></ul><ul><li>Seizure : localize the seizure focus </li></ul><ul><li>Brain tumor : an ancillary role </li></ul><ul><li>Dementia : early detect </li></ul><ul><li>Neuro-psychiatric </li></ul>
  5. 7. Radionuclide Cisternography <ul><li>NPH : communicating hydrocephalus , </li></ul><ul><li>a delay in CSF absorption over </li></ul><ul><li>the convexity </li></ul><ul><li>CSF leakage </li></ul>
  6. 8. 1 h 2 h 4 h 6 h 24 h 48 h
  7. 9. Endocrine imaging <ul><li>Thyroid scan : 99m TcO 4 - , 123 I, 131 I, 201 Tl </li></ul><ul><li>Parathyroid scan : 99m TcO 4 - / 201 Tl </li></ul><ul><li>subtraction, 99m Tc-MIBI </li></ul><ul><li>Adrenal cortex scan : NP-59 </li></ul><ul><li>Adrenal medulla scan : 131 I-MIBG </li></ul>
  8. 10. Thyroid scintigraphy <ul><li>Thyroid nodule </li></ul><ul><li>Congenital hypothyroidism </li></ul><ul><li>Thyroid cancer follow up </li></ul><ul><li>131 I treatment </li></ul>
  9. 13. I 131
  10. 15. Parathyroid scintigraphy <ul><li>Detection and localization of parathyroid adenoma </li></ul>
  11. 17. Adrenal medulla scintigraphy <ul><li>131 I-MIBG : via the norepinephrine reuptake mechanism into catecholamine storage vesicles of adrenergic nerve ending. </li></ul><ul><li>Confirm lesion discovered by CT and localize extraadrenal pheochromocytoma, </li></ul><ul><li>Neuroblastoma, paraganglioma </li></ul>
  12. 19. Cardiovascular imaging <ul><li>Perfusion agents : 99m Tc-MIBI, 201 Tl </li></ul><ul><li>Viability agents : 18 FDG, 201 Tl </li></ul><ul><li>Multi-gated cardiac function (MUGA): 99m Tc-RBCs </li></ul><ul><li>Infarct agents : 99m Tc-pyrophosphate </li></ul><ul><li>Angio-venography : 99m Tc-RBCs </li></ul>
  13. 20. 201 Tl
  14. 21. Myocardial perfusion scintigraphy <ul><li>Pharmacologic stress test : Dipyridamole, Adenosine </li></ul><ul><li>Homogeneous, heterogeneous </li></ul><ul><li>Reversible redistribution </li></ul><ul><li>Fixed defect </li></ul><ul><li>Reverse redistribution </li></ul>
  15. 28. MUGA (radionuclide ventriculography ) <ul><li>For evaluation of ventricular size, RVEF, LVEF, regional wall motion </li></ul>
  16. 30. Angio-venography <ul><li>Lower extremities edema </li></ul><ul><li>Detection and route out DVT, venous insufficiency, inflammation process, varicose vein, </li></ul>
  17. 31. Subcutaneous radionuclide Venography
  18. 32. Subcutaneous radionuclide Venography
  19. 33. Gastrointestinal imaging <ul><li>Liver-spleen scintigraphy : 99m Tc-sulfur colloid </li></ul><ul><li>Cholescintigraphy : 99m Tc-DISIDA </li></ul><ul><li>GI bleeding : 99m Tc-RBC </li></ul><ul><li>Ectopic gastric mucosal scan : 99m TcO 4 - </li></ul><ul><li>Gastric empty time </li></ul>
  20. 34. Liver-spleen scan <ul><li>99m Tc-sulfur colloid : Liver (Kupffer’s cell)85%, Spleen 10%, Bone marrow 5% </li></ul><ul><li>Detect the space-occupying lesion and evaluate its reticuloendothelial function, D.D. FNH from the other lesion </li></ul><ul><li>splenic infarct, accessory spleen. </li></ul><ul><li>99m Tc-RBC scan for hemangioma </li></ul>
  21. 37. Cholescintigraphy <ul><li>biliary obstruction, D.D. of biliary atresia and neonatal hepatitis, bile leakage </li></ul><ul><li>Normal : liver (5 mins), intrahepatic biles ducts (10-15 mins), common bile, gall bladder and duodenum duct (15-30 mins), small intestine (>30 mins) </li></ul>
  22. 39. 24 h 6 h 1 h 4 h 30 m 15 m 5 m 2 h
  23. 40. 24h 7h 2h 4h 1h 30m 15m 5m
  24. 42. Skeletal imaging <ul><li>99m Tc-MDP (bone hydroxyapatite crystal) </li></ul><ul><li>Regional blood flow, tissue extraction, osteoblastic activity </li></ul><ul><li>Metastases, osteomyelitis, AVN, stress fx, occult bone trauma, joint prosthesis… </li></ul><ul><li>sensitivity high, specificity moderate </li></ul>
  25. 43. Three phase bone scan
  26. 50. Oncologic imaging <ul><li>67 Ga, 201 Tl, 99m Tc-MIBI, 18 FDG </li></ul>
  27. 51. 67 Ga scan <ul><li>Bind to transferrin and accumulate in a wide variety of malignant neoplasms and their metastases </li></ul><ul><li>Inflammatory image </li></ul><ul><li>Detection and staging of Hodgkin’s disease, non-Hodgkin’s lymphoma, melanoma, lung cancer, hepatoma, leukemia, gastric cancer, esophageal cancer… </li></ul>
  28. 52. 67 Ga scan
  29. 53. 67 Ga scan
  30. 55. Renal imaging <ul><li>Glomerular agents : 99m Tc-DTPA </li></ul><ul><li>Tubular agents : 99m Tc-MAG3 </li></ul><ul><li>Cortical agents : 99m Tc-DMSA </li></ul><ul><li>Diuretic renography </li></ul><ul><li>Captopril renography </li></ul>
  31. 56. Renal scan ( 99m Tc-DTPA) <ul><li>Baseline : GFR, quantitative renal function </li></ul><ul><li>Lasix : ddx of non-obstructive dilatation & mechanical obstruction, </li></ul><ul><li>Capoten : renovascular hypertension </li></ul>
  32. 59. Renal scan ( 99m Tc-DMSA) <ul><li>Children APN, renal scarring, renal infarct, renal trauma, horseshoe kidney, ectopic kidney, renal cyst, renal abscess, renal tumor. </li></ul>
  33. 61. Pulmonary imaging <ul><li>Perfusion image : 99m Tc-MAA (10~90um) </li></ul><ul><li>Ventilation image : 133 Xe, 99m Tc-DTPA aerosol </li></ul><ul><li>PIOPED interpretation criteria </li></ul><ul><li>V/Q mismatch </li></ul>
  34. 62. Pulmonary imaging <ul><li>pulmonary embolism, F/U pulmonary embolism after anti-coagulant therapy, perfusion change secondary to lung tumor, pre-operative evaluation for pneumonectomy, post-operative F/U… </li></ul>
  35. 63. ANT LEFT LPO POST RPO RIGHT
  36. 66. Salivary gland scintigraphy <ul><li>99m TcO 4 - </li></ul><ul><li>Symmetric gland accumulation, drainage, increased or decreased function. </li></ul><ul><li>Salivary gland function, dry mouth, Sjogren’s syndrome, parotid tumor, NPC post radiation therapy… </li></ul>
  37. 68. Lymphoscintigraphy <ul><li>99m Tc-sulfur colloid </li></ul><ul><li>Lymphatic obstruction </li></ul><ul><li>Detect sentinel lymph node (melanoma, breast cancer…) </li></ul>
  38. 70. Testicular/scrotal scintigraphy <ul><li>99m-TcO 4 - </li></ul><ul><li>D/D testicular torsion from epididymitis, </li></ul><ul><li>hydrocele, hematocele, abscess... </li></ul>
  39. 71. Gastric empty scintigraphy <ul><li>99mTc-sulfur colloid in eggs (solid meal) </li></ul><ul><li>Half-empty time (solid meal,60 土 30min; </li></ul><ul><li>liquid meal, 30 土 15min) </li></ul><ul><li>Gastric outlet obstruction or function obstruction, DM gastroparesis, s/p vagotomy, gastrinoma… </li></ul><ul><li>Follow up and evaluation of the effectiveness of treatment. </li></ul>

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