General Nuclear Medicine Part 1

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General Nuclear Medicine Part 1

  1. 1. For Medical Students
  2. 2. Introduction to Nuclear MedicineBone scanKUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  3. 3. Nuclear medicine is a medical specialtywhich uses very small amount of aradioactive substance or a chemicalcompound labelled with a radioactivesubstance, called “radiopharmaceutical”or tracers to image or treat diseases. J SRIPRAPAPORN
  4. 4. Endocrinology eg. Thyroid scan, Parathyroid scanCardiovascular system eg.Myocardial perfusion scan,Radionuclide venographyGenitourinary system eg. Renogram, Testicular scan,Radionuclide cystographyPulmonary system eg. Perfusion/ Ventilation lung scanSkeletal system eg. Bone scanGastrointestinal system eg. Liver scan, Hepatobiliaryscan, GE reflux studyTumor imaging eg. Ga-67 scan for Lymphoma, I-131scan for pheochromocytoma, Tc-99m MIBI forparathyroid adenoma J SRIPRAPAPORN
  5. 5. Functional*SensitiveQuantitativeVery safeMinimally invasiveLow radiation exposureScreeningFollow-up J SRIPRAPAPORN
  6. 6. Not widely availableGive minimal radiationGenerally non-specificRequire NM instrument &radiopharmaceuticalsHigher cost than routine X-rayor U/S J SRIPRAPAPORN
  7. 7. Low cost Tc-99mAvailablePure gamma emitterOptimal gamma energy (100-200 keV) * 140Optimal half life *6 hrSafeChemically active * Tc-99m is the most ideal agent ! J SRIPRAPAPORN
  8. 8. Radiopharmaceutical Patient Gamma Camera Images J SRIPRAPAPORN
  9. 9. Radioisotopes eg. I-131, Tc-99m Radiolabeled compounds eg. Tc-99m MDP for Bone scan, Tc-99m MAA for Lung scan* 1 Organ Many R’pharmaceuticals 1 R’pharmaceutical Many organs J SRIPRAPAPORN
  10. 10. Planar gamma cameraSPECT = Single PhotonEmission ComputedTomographyPET = Positron EmissionTomographyPET/CT J SRIPRAPAPORN
  11. 11. J SRIPRAPAPORN
  12. 12. PET:Metabolic imagingUsing positron-emittingradionuclidesBiological tracers (C, N, O, F)More sensitiveBetter imagesWhole body evaluation J SRIPRAPAPORN
  13. 13. Introduction to Nuclear MedicineBone scanKUB system• Renal scan & renogram• Testicular scan• Radionuclide cystographyLung scan Radionuclide venography J SRIPRAPAPORN
  14. 14. Tracer : 99mTc-MDPMechanism: Adsorption to the hydroxyapatitehydroxyapatite crystalRoute : IV injectionTechnique : Patient preparation : none After inj: good hydration & frequent voiding Imaging 3 hr. post injection Views : Whole-body, anterior and posterior & static images as requiredVisualization : The skeletal system J SRIPRAPAPORN
  15. 15. Indications : Bone metastases*; tumor staging, evaluate bone pain in cancer patients Undetermined bone pain (wo CA Hx) Infection; osteomyelitis Bone trauma; stress fractureAdvantages: Sensitive > plain X-ray * Whole-body evaluation Low radiation J SRIPRAPAPORN
  16. 16. ANT POST ANT POST J SRIPRAPAPORN
  17. 17. Diffusely increased axialskeletal uptake with low or novisualized renal uptakeDiffuse metastatic disease Primary: prostate*, breast, lungMetabolic bone disease Hyperparathyroidism Renal osteodystrophy J SRIPRAPAPORN
  18. 18. Phase 1; Vascular phase: 60 s dynamic immediately pi.Phase 2; Soft-tissue (blood-pool) phase: 5 min pi.Phase 3; Delayed (bone) phase: 3 hr pi.INDICATIONS: Infection: DDx acute osteomyelitis vs cellulitis Avascular necrosis Tumors: primary tumor Others J SRIPRAPAPORN
  19. 19. Soft-tissue delayed 3-hrVascular phase J SRIPRAPAPORN
  20. 20. Phase I : Vascular phasePhase II : Soft tissue phasePhase III : Bone phase J SRIPRAPAPORN
  21. 21. Introduction to Nuclear MedicineBone scanKUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  22. 22. Renal scintigraphyTesticular scanRadionuclide Cystography J SRIPRAPAPORN
  23. 23. Cortical renal scan Renal scar in children with UTIRenal scan and renogram To evaluate (split) renal blood flow & renal function To evaluate urinary drainageDiuretic renography To evaluate urinary tract obstructionCaptopril renography To detect renovascular HT (RVHT)Radionuclide cytography To detect VU reflux J SRIPRAPAPORN
  24. 24. J SRIPRAPAPORN
  25. 25. Tracers : 99mTc-DTPA, 99mTc-MAG3, etcRoute: IV injectionTechnique : Good hydration Dynamic study for 30 min. in posterior view (native kidneys), anterior view for transplanted kidney. renogram (3 phases)Uses : Separate renal function Urinary tract obstruction-Diuretic Renogram Renovascular hypertension-Captopril renogram Others J SRIPRAPAPORN
  26. 26. L R LT RT Flow: 1-2 min Posterior Renograms or Renal time-activity curvesRenal Scan-30 min J SRIPRAPAPORN
  27. 27. J SRIPRAPAPORN
  28. 28. Severity of urinary tract obstruction A A-Severe obstruction, good B renal function B-Severe C obstruction, reduced function C-Less severe Normal obstruction, reduced function Time-activity curve J SRIPRAPAPORN
  29. 29. Deterioration of renal function after chronic urinary tract obstruction Normal Time-activity curve J SRIPRAPAPORN
  30. 30. Diuretic Renograms Furosemide Injection Obstructed Non-bstructed Normal Time-activity curve J SRIPRAPAPORN
  31. 31. J SRIPRAPAPORN
  32. 32. Diuretic Renography T1/2 < 10 min J SRIPRAPAPORN USA 6-07
  33. 33. Tracer : Tc-99m pertechnetate IV.Positioning : Special*Imaging : Flow and static imagesAim : To DDx Acute testicular torsion VSAcute epididymoorchitisTesticular Torsion flow & uptakeAcute epididymo-orchitis flow &uptake (inflammation) J SRIPRAPAPORN
  34. 34. J SRIPRAPAPORN
  35. 35. Introduction to Nuclear MedicineBone scan KUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  36. 36. Perfusion Lung Scan Ventilation Lung Scan Tracer : Tracers : • 99mTc-MAA • 133Xe • 99mTc aerosol- 99mTc-DTPA, 99mTc-phytate Route : IV injection • Technegas Technique : Planar Route : Inhalation images 6 views; Technique : Planar anterior, posterior, images 6 views as in Rt. lateral, Lt. lateral perfusion study RPO,LPO J SRIPRAPAPORN
  37. 37. Pulmonary embolism*Pulmonary hypertensionRight-to-left shuntPrior thoracic surgery To determine lung function in the affected lung & the potential consequence of removal of diseased lung J SRIPRAPAPORN
  38. 38. Tracer: Tc-99m MAA, particle size=10-30 uMechanism: Lodged in precapillary arterioles inproportion to regional blood flowDose: 2-5 mCi, 200,000-600,000 particles,block < 1/1000 arteriolesRoute: IV (Not draw blood back into syr !)Imaging: 6 views, Ant, Post, RPO, LPONormal: Uniform distribution J SRIPRAPAPORN
  39. 39. PE Segmental perfusion defects J SRIPRAPAPORN
  40. 40. J SRIPRAPAPORN
  41. 41. Multiple hot spotsTechnique: DrawingPt’s blood into Tc-99m MAA syringeform clumping hotspots J SRIPRAPAPORN
  42. 42. Tracers: Gaseous agents: Xe-133 (washin-equilibrium-washout) Xe-127 Kr-81m (Rb-85m generator) Radioaerosol (particulate agents): 0.5 um 99mTc-DTPA, 99mTc-SC, 99mTc-phytate Technegas: 99mTc labeled fine carbon particles (by heating 99mTcO4- in a graphyte crucible at 1500 C in pure argon atmosphere for 15 sec), size = 0.02 um J SRIPRAPAPORN
  43. 43. J SRIPRAPAPORN
  44. 44. O2 J SRIPRAPAPORN
  45. 45. J SRIPRAPAPORN
  46. 46. J SRIPRAPAPORN
  47. 47. J SRIPRAPAPORN
  48. 48. Perfusion lung scan Ventilation lung scan CXR within 24 hrsCriteria: Modified PIOPED criteria * Normal High Nondiagnostic Very-low probability J SRIPRAPAPORN
  49. 49. Uniform distribution ofthe radioactivityNo V/Q defectNormal Q scan isvirtually exclude PE !No extrapulmonaryaccumulation J SRIPRAPAPORN
  50. 50. J SRIPRAPAPORN
  51. 51. Nonuniform distributionPerfusion and/ orventilation defect Segmental or nonsegmental defectExtrapulm accumulation J SRIPRAPAPORN
  52. 52. Clinicals : Unreliable- dyspnea, pleuritic chestpain, hemoptysisLAB: D-dimer > 500 ng/mlABG: HypoxemiaECG: tachycardia, nonspecific ST-T change,S1Q3T3 (rare)CXR: Normal*, oligemia, othersVQ lung scan: VQ defectPulmonary CTA : clotPumonary angiography: clot (gold standard) J SRIPRAPAPORN
  53. 53. Typical scintigraphic findings Segmental perfusion defects Normal V scan No corresponding abnormal radiographic findingsV/Q mismatched defects J SRIPRAPAPORN
  54. 54. Ant Post LPO RPO J SRIPRAPAPORN
  55. 55. Tc-99m MAAperfusion lung scanPresence ofradiotracer in thebrain and kidneysPrecaution: LimitedMAA particles. J SRIPRAPAPORN
  56. 56. Introduction to Nuclear MedicineBone scan KUB system• Renal scan-renogram• Testicular scan• Radionuclide cystographyLung scanRadionuclide venography J SRIPRAPAPORN
  57. 57. J SRIPRAPAPORN
  58. 58. http://www.nhlbi.nih.gov/health/dci/Diseases/pe/pe_causes.htm http://www.youtube.com/ watch?v=I0yJTkW9y9s J SRIPRAPAPORN
  59. 59. Clinicals : UnreliableLab tests : D-dimerColor Doppler ultrasonographyRadionuclide Venography (RNV)In-111 labeled plateletIn-111 labeled antifibrin AbTc-99m labeled peptides (Acutect)CT/MR venographyContrast Venography *** [Gold standard] J SRIPRAPAPORN
  60. 60. DVT, Compression, Doppler Lower Extremity. This image shows a side by side, of the common femoral vein with and without compression. Since the vein does not fully collapse, this is an evidence of a DVT. Clot is also seen, as well as a filling defect in the vessel of the noncompressed vein with color Doppler. (Photo contributor: Stephen J. Leech, MD, RDMS.) J SRIPRAPAPORN
  61. 61. Ascending Rdn Venography:Tc-99m SC, Tc-99m phytate, Tc-99m MAA*** Tc-99m RBC Venography J SRIPRAPAPORN
  62. 62. Tracers : Tc-99m MAA, Tc-99m phytateUses : Venous occlusion (DVT)-proximal deep veins**Technique IV. injection of the tracer into pedal veins of both feet Imaging: during on and off tourniquet over both ankles Multiple overlapping static or whole-body images upto IVC level* If MAA RNV + Q lung scan (same setting) J SRIPRAPAPORN
  63. 63. Inject a tracer via (bilateral) foot veinsOn tourniquets above ankles to visualize deep veinsand off tourniquets for superficial veinsMultiple overlapping static images upto IVC level orwhole-body image J SRIPRAPAPORN
  64. 64. Abrupt termination of the flowPresence of filling defectIrregular or asymmetric flowAbnormal colaterallsNonfilling of the deep veins, with +veother signs J SRIPRAPAPORN
  65. 65. J SRIPRAPAPORN
  66. 66. J SRIPRAPAPORN
  67. 67. Contrast Venography Radionuclide VenographyMost reliable for Dx (gold Reliable results esp.std.) proximal vNeed skilled team SimplerGood anatomic Poorer anatomic detailsvisualization (calf iliac (Good for proximal veins)veins & IVC) Less invasiveMore Invasive SafePotential risks More suitable for frequentNot suitable for frequent F/UF/U Provide information aboutNot provide information associated PE (Tc-99mabout associated PE MAA) J SRIPRAPAPORN
  68. 68. Or blood-pool radionuclide venographyequilibrium stageInject the radiotracer via any veinNeed high-resolution collimatorImage quality depends on labelingefficiency J SRIPRAPAPORN
  69. 69. J SRIPRAPAPORN
  70. 70. ADVANTAGES DISADVANTAGES Do not need foot Image quality depends on vein access, easier labeling efficiency Possible less Not direct evaluation of painful venous flow Less anatomical details Concomitant Q lung scan is impossible. J SRIPRAPAPORN
  71. 71. SUMMARYWhat is Nuclear Medicine? Principle Advantages & DisadvantagesBone scanKUB systemV/Q lung scanRadionuclide venography J SRIPRAPAPORN

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