Nuclear Medicine Procedures made easy

2. Radiopharmacy
Radionuclide : 99mTc t1/2: 6 hours
Energies: 140 keV
Type: γ, Generator
Radiopharmaceutical : MDP (methylene diphosphonate)
Adult Dose Range : 20–30 mCi (740–1110 MBq), pediatrics by
weight.
Method of Administration : Intravenous: with saline flush.

3. Indications 1
 Detection of primary and staging metastatic disease.
 Differentiation of monostotic (single bone) from polyostotic primary
bone tumors.
 Differentiation between osteomyelitis (inflammation of bone and bone
marrow) and cellulitis (inflammation of cellular or connective tissues).
A three-phase flow study is indicated. Three-phase studies examine
vascular, immediate blood pool, then osseous (osteoblastic) activity
distinguishing cellulitis (activity in flow and immediate phases) from
osteomyelitis (activity in third or all three phases).
 Evaluation of prosthesis concerning suspected
loosening, infections, avascular necrosis, and/or pain.

4. Indications 2
 Detection of occult fractures.
 Evaluation of bone pain and/or trauma.
 Detection and evaluation of arthritis and degenerative disk and/or joint
(osteoarthrosis) disease.
 Evaluation of response to chemotherapy, radiation therapy, antibiotic
therapy, and other treatment.
 Localization of sites for biopsy.

5. Contraindications
 Patient who has recently ingested contrast medium (particularly
barium) for a different study (X-ray).
 Patient who has recently (24–48 hours) had a technetium-based nuclear
medicine scan performed.
Patient Preparation
 Identify the patient. Verify doctor's order. Explain the procedure.
 Instruct patient to drink lots of fluids (hydrate well) and urinate often
before imaging.
 Instruct patient to return in 2–4 hours (usually 3 hours) after injection
for delayed statics, whole body imaging or SPECT.

6. Contraindications
 Patient who has recently ingested contrast medium (particularly
barium) for a different study (X-ray).
 Patient who has recently (24–48 hours) had a technetium-based nuclear
medicine scan performed.
Patient Preparation
 Identify the patient. Verify doctor's order. Explain the procedure.
 Instruct patient to drink lots of fluids (hydrate well) and urinate often
before imaging.
 Instruct patient to return in 2–4 hours (usually 3 hours) after injection
for delayed statics, whole body imaging or SPECT.

7. Equipment
Camera
Large field of view
Collimator
Low energy, high resolution, or low energy, all purpose
Computer Set-up
Flow
Dynamic, 2–4 seconds for 60 seconds with immediate blood pool image
Static Imaging

8. Artifacts
 Bladder may need lead shield or catheterization. Pubic lesions may be
obscured by bladder activity.
 Catheters or urine seepage, IV infiltration, and contaminated clothing or
linen cause hot spots.
 Patient movement or rotation may distort view.
 Imaging begun too soon or with patient not hydrating adequately
before imaging may show excessive activity in soft tissue.
 Degenerative joint disease, surgery, and old trauma may give false-
positives.
 Take laterals, obliques, and/or any other helpful positions if there is any
question about a visualization (better too many than too few, or needing
the patient to return at radiologist's request).

9. Patient History (The patient should answer the
following questions) 1
 Do you have history or family history of cancer?
 Have you had any chemotherapy or radiation therapy?
 Do you have any bone pain?
 Have you had any recent falls, fractures, breaks, or trauma?
 Do you have any old sports injuries?
 Have you had any recent surgery?

10. Patient History (The patient should answer the
following questions) 2
 Do you have a history of any kidney disease?
 Have you had any recent dental work?
 Have you had recent abnormal blood tests or lab work (e.g., tumor
markers, PSAs)?
 Have you had any previous scans or x-rays or have any scheduled
diagnostic tests (e.g., x-ray barium studies, CT with contrast)?
 Female: Are you pregnant or nursing?

12. Radiopharmacy
Radionuclide : 99mTc-sestaMIBI
(2-methoxy-isobutylisonitril), t1/2: 6 hours
Energies: 140 keV
Type: γ, generator
Adult Dose Range: 15–30 mCi (555–1110 MBq) 20 -- 10
Radionuclide : 201TI-thallous chloride, t1/2: 73 hours
Energies: 68–80 keV
Type: γ, accelerator
Adult Dose Range: 2–5 mCi (74–185 MBq). 3 -- 1
Method of Administration: Intravenous

13. Indications 1
 Detection and evaluation of coronary artery
disease.
 Evaluation for coronary bypass surgery or
angioplasty.
 Detection and evaluation for viable or hibernating
myocardial tissue (particularly with thallium).
 Evaluation of physical indicators: Myocardial
infarction, chest pain, shortness of breath, history or
family history of heart disease.

14. Indications 2
 Evaluation of laboratory indicators: Elevated levels
of creatine phosphokinase, lactate
dehydrogenase, and the newer tests for troponin
and myoglobin (specific indicators for heart
damage).
 Evaluation of the heart because of abnormal
results on related studies.

15. Contraindications 1
 Patient experiencing chest pain, or have
documented acute myocardial infarction within
2–4 days of test.
 Patient should discontinue chemical stressors,
e.g., caffeine, Persantine, theophylline, Viagra 24
to 48 hours.

16. Contraindications 2
 Patient on heart medications. Some
cardiologists prefer to hold all heart medications
until after test (check with cardiologist).
 Patient with extreme illness; high blood
pressure, arrhythmias, congestive heart failure,
acute myocarditis, severe mitral or aortic stenosis,
systemic illness, or neurologic or physical
conditions that may hamper the stress test.

17. Patient Preparation 1
 Identify the patient. Verify doctor's order.
Explain the procedure.
 Instruct patient to be NPO for 4–12 hours.
 Diabetics; monitor blood sugar and adjust, delay
insulin after exercise.
 Instruct patient to ingest no caffeine, dairy
products, or sugar.
 Patient should be well rested and avoid
strenuous exercise the day of test before exam.

18. Patient Preparation 2
 Some doctors prefer to hold heart medications
until after test (check with cardiologist).
 Obtain a signed consent form.
 Remove cardiac monitor from in-patient.
 Shave and wipe chest.
 fatty meal 15 min after injection to reduce GB
uptake.

19. Patient Preparation 3
 Some doctors prefer to hold heart medications
until after test (check with cardiologist).
 Start IV setup, flush IV, ensure patency.
 Obtain a baseline blood pressure

20. Equipment
Camera
Large field of view
Collimator
Low energy, all purpose, or low energy, high
resolution
Single Photon Emission Computed Tomography
(SPECT)

21. Procedure 1
 Position patient on treadmill or supine for pharmacologic
stress.
Perform stress test by exercise or pharmacology in the
presence of a physician. Heart rate should be between 85% and
100% of maximum (220 minus age of patient).
Sestamibi: Help patient get down from treadmill, wait 35–45
minutes to image.
 Thallium: wait 15 minutes to image. Redistribution images
taken in 3–4 hours if a 1-day protocol. 24-hour imaging may be
requested for viability study of myocardium.

22. Procedure 2
 Position patient supine with heart in center field of view.
 Processing: Images are processed to show myocardium of
left ventricle in vertical long axis, horizontal long axis, and short
axis views.
 Imaging in anterior, left anterior oblique, left lateral

23. Protocols 1
One-Day
Thallium: The stress is performed first (~3 mCi), wait 10–15
minutes and image, then 3–4 hours later the rest is completed.
Some do a 24-hour delay rest study with a 1 mCi reinjection
(wait 5–20 minutes to image), looking for viable or hibernating
stunned tissue.
Sestamibi: Both tests are done on the same day. Either rest or
stress can be done first; however, most prefer to do resting
pictures first (e.g., in the morning), then set up for the stress
(treadmill or pharmacological). The first study is done with a
low dose, ~8 mCi, followed by the second (an hour or more
later) with a high dose, ~25–30 mCi.

24. Protocols 2
Two-Day
Thallium: Both tests are done with thallium but on different
days.
Sestamibi: Both tests are done with sestamibi but on different
days. Some do the stress test first. If no defects are
observed, there is no need for the rest study. Others do both
tests, regardless.

25. Patient History (The patient should
answer the following questions.)
 Do you have a history of or family history of heart
disease?
 Do you have a history of heart attacks?
 Have you had any chest pain?
 Have you been short of breath, had trouble
breathing, or do you have asthma?

26.  Do you or did you smoke?
 Do you have a pacemaker?
Have you had any recent surgery?
 Have you had any recent chemotherapy?
 Do you have high blood pressure or diabetes?
 What medications are you presently taking?

27.  Have you had any prior ECG tests or related
tests (e.g., echocardiography, stress tests, etc.)?
 Do you have the results of recent lab work
(e.g., CPK, LDH, Cholesterol
Troponin, Myoglobin, C-reactive protein)?
 Female: Are you pregnant or nursing?

28. Artifacts
 Attenuation artifacts: Men ---- most common is
left hemidiaphragm affecting inferior wall;
Women ---- most common is left breast affecting
anterior wall.
 Bowel activity close to heart during imaging
may mask inferior wall defects.
 Patient may not reach 85% maximum heart rate.
 If patient has left arm down to side, it may
cause unwanted attenuation.

30. Radiopharmacy
Radionuclide : 123I t1/2: 13.1 hours
Energies: 159 keV
Type: γ, accelerator
Radionuclide : 131I t1/2: 8.1 days
Energies: 364 keV
Type: γ, accelerator
Radionuclide : 99mTc t1/2: 6 hours
Energies: 140 keV
Type: γ, generator

31. Adult Dose Range
131I: 2–5 mCi (74–185 MBq) for whole body imaging
123I: 100–450 µCi
99mTc-: 2–5 mCi (average 5 mCi)
Method of Administration
123I and 131I capsule Oral (PO)
99mTc by intravenous injection

32. Indications
 Evaluation of thyroid anatomy, e.g., position, goiter
(enlarged gland due to inadequate iodine supply), surgery,
cold or hot nodule(s).
 Detection and evaluation of hyperthyroidism and
hypothyroidism.
 Detection and localization of metastases from thyroid
cancer.

33. Indications
Differentiation of benign from malignant nodules.
 Detection and localization of benign ectopic thyroid tissue.
 Evaluation of abnormal thyroid serum laboratory results.
 Evaluation of thyroiditis.
 Evaluation of thyroid because of abnormal findings on
other diagnostic images, e.g., US, X-ray images, PET, MRI, CT.

34. Patient Preparation
 Identify the patient. Verify doctor's order. Explain the
procedure.
 Patient to discontinue thyroid medications and avoid
contrast material.
 Refrain from eating foods containing iodine such as
cabbage, turnips, greens, seafood, kelp, or large amounts
of table salt.
 123I and 131I: Patient will be returning at 24-48 hours for
imaging.

35. Equipment
Camera
Large field of view
Collimator
Low energy, high resolution, or low energy, all purpose
and pinhole for 99mTc and 123I.
High energy, parallel hole for 131I.

36. Procedure
99mTcO4-
Injection to patient; wait 15 to 20 minutes before imaging.
Give patient water (optional lemon to clear salivary glands).
Place patient in supine position with pillow under shoulders
and chin up.
Obtain anterior views (with and without markers as per
protocol, RAO and LAO (more distant) for ectopic thyroid
tissue are optional images.
131I Capsule
Usually used to locate residual and recurrent cancers. 24-,
48-, and 72-hour pictures may be the most useful. Image over
thyroid and whole body if cancer is suspected.

37. Patient History (Answer the following questions )
 Do you have a history or family history of cancer?
 Do you have a history of thyroid disease?
 Are you presently taking any iodine-containing medications,
thyroid hormones, antithyroid drugs?
 Have you had any surgery?
 Do you have difficulty swallowing?
 Do you have any swelling or tenderness in the neck?
 Have you had any recent weight loss or gain?

38. Patient History (Answer the following questions )
 Have you recently experienced fevers?
 Have you had any recent change in your overall energy
levels?
 Have you had any thyroid therapy, chemotherapy, or
radiation therapy?
 Are you sensitive to cold or heat?
 Have you had any tests using iodine or radiographic contrast?
 Are you pregnant or nursing?