RADIO

250: ICC in Radiology and Nuclear Medicine

LEC 11: NUCLEAR MEDICINE
Exam 01| Dr. Cynthia Liao | September 3, 2013
OUTLINE
I.
Basic Physics and
Instrumentation of Nuclear
Medicine
A. Nuclear Medicine
B. Radionuclides and their
Radiations
C. Types of Radiation
D. Radiation Detectors
E.
Instrumentation
II.
Radiopharmaceuticals
A. Design Characteristics
B. Radiopharmaceutical
Production
C. Types of
Radiopharmaceuticals

III.

Clinical Applications
A. Thyroid Scintigraphy
B. Parathyroid Scan
C. Bone Scintigraphy
D. Labeled Leukocyte Scan
E.
GI Bleeding Scintigraphy
F.
Hepatobiliary Imaging
G. Renal Scintigraphy
H. Myocardial Perfusion
Scintigraphy
I.
Other Therapeutic
Applications
J.
Radiation Doses

I. BASIC PHYSICS AND INSTRUMENTATION OF NUCLEAR MEDICINE
A. Nuclear Medicine
Branch of medicine that uses the nuclear properties of matter in
the diagnosis and treatment of diseases.
Remember that the information obtained from nuclear imaging is
related to the physiologic functioning of the organ
o It is important to take note of function because problems here
occur earlier than anatomic or structural problems

B. Radionuclides and their Radiations
Radionuclide or radioisotope
o An element with radioactive properties
o Unstable
o Type of radiation, energy of radiation and half-life are physical
constants
These constants determine the suitability of a
radiopharmaceutical
Nuclide
o An atomic nucleus which may be stable or radioactive

C. Types of Radiation
Alpha Particles
o a Helium nucleus with 2 neutrons and 2 protons
o effective only for a short distance
o wont even go through the outer layer of skin
No need for shielding; air or a thin piece of paper can
interrupt its travel
o very damaging inside the body
Not suitable for imaging
But can be used for therapeutic purposes
o mostly used as poisons
o Examples: Po-210, radon-222, radium-226, and americium-241
Beta Particles
o consist of fast-moving charged electrons
o Negatron - negatively charged beta particle
n p + - + (read as: conversion or transformation of a
proton to a neutron via the emission of a negatron and
neutrino)
Example: I-131 (used for thyroid uptake)
o Positron - positively charged beta particle
+
p n+ + (read as: conversion or transformation of a
proton to a neutron via the emission of a positron and
neutrino)
annihilation produced gamma rays in opposite directions
Example: F18 (used for PET scan)
o if inhaled or consumed will cause a lot of damage
o Shielding: plastic
Gamma and x-ray (photons)
o Are the same thing; just differ in their origin
o electromagnetic radiations that travel at the speed of light
Gamma rays come from the nucleus of an atom
X-rays come from the electron shells

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o High penetrating power compared to alpha and beta particles

o Most important type of radiation when it comes to nuclear
imaging
o Examples: Tc99m (most common), I-125, I-131, Co-57, and Cs-
137
o Shielding: lead

D. Radiation Detectors
Ionization Chamber
o measures the total current resulting from multiple events
pocket dosimeters the ones usually carried by residents in
their pocket; this can measure the amount of radiation being
received by the body
dose calibrators measure dose of radiation in liquid that will
be administered to patient
Proportional Counter
o used in research to detect alpha and beta particles
GM (Geiger-Mller) Counter
o good for detecting low levels of activity
o area survey meters and area monitors
o used to measure contamination

E. Instrumentation
Gamma Scintillation Camera
o Collimator
The first part of the camera to be encountered by photons
after these leave the patient
Blocks oblique and incident gamma rays
o The scintillations are detected on photomultiplier tubes

Figure 1. Diagram of Gamma Camera

Figure 2. Collimator

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Single Photon Emission Computed Tomogaphy (SPECT)
o uses a gamma camera to record images at a series of angles
around the patient
o image reconstruction
o allows true 3-D image acquisition and display
Positron Emission Tomography (PET)
o Ring of detectors optimized for detection of 511 keV gamma
rays
o Positrons annihilation produces paired photons in opposite
directions
o Superior sensitivity and resolution
o Can be fused with CT (PET-CT)

II. Radiopharmaceuticals
a combination of
o a radioactive atom which allows external imaging
o a drug which directs the radiotracer to the desired target
o portray the physiology, biochemistry or pathology of a body
system without causing any perturbation of function


A. Design Characteristics of Radiopharmaceuticals
Gamma emission of suitable energy
Sufficient abundance of emission for external detection
Do not contain particulate radiation
Effective half-life
High specific activity
Free of toxicity and secondary effects
Do not dissociate in vitro or in vivo
Readily available with reasonable cost
Localize to the intended application
Rapid background clearance

B. Radiopharmaceutical Production
Generator
o E.g. Technetium
Nuclear Reactor
o E.g. I-131
Cyclotron
o Produce pharmaceuticals usually used for PET scan

C. Types of Radiopharmaceuticals
99m

Technetium-labeled Radiopharmaceuticals

99m
Table 1. List of Technetium-labeled Radiopharmaceuticals
Agent
Application
Localization
Sodium pertechnetate
Meckels
Trapping
diverticulum,
salivary and
thyroid scan
Sulfur colloid
Liver/spleen,
Kupffer cell uptake
bone marrow
Pyrophosphate
AMI
Uptake in
microcrystalline
deposits (Ca
phosphate)
Macroaggregated
Pulmonary
Blood flow,
albumin (MAA)
perfusion, liver
capillary blockage
intraarterial
perfusion
diphosphonate
skeletekal
Chemoadsorption
RBC
Ventriculography, RBC labeling, blood
GI bleeding,
pool distribution
hepatic
hemangioma
Diethylenetriamine
Renal, lung
Glomerular
pentaacetic acid (DTPA) ventilation, GFR
filtration (100%),
desposition in
bronchoalveolar
spaces

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Mercaptoacetyltriglycine
(MAG3)
Dimercaptosuccinic acid
(DMSA)
Iminodiacetic acid
(HIDA) derivative
Sestamibi
Tetrofosmin

Exametazime (HMPAO)

Renal dynamic
scan
Renal cortical
Hepatobiliary
Myocardial
perfusion, breast
Myocardial
perfusion

Fanolesomab

Cerebral
perfusion, WBC
labeling
Infection

Depreotide

Tumor imaging

Tubular secretion
(100%)
Cortical binding
(40%)
Hepatocyte uptake
Lipid soluble,
retained in
mitochongria
because of
negative
transmembrane
potential, blood
floor, tumor
viability
Lipophilic, binds to
nucleus and
mitochondria
Antibody-antigen
binding to
activated
leukocytes
Binding to
somatostatin
receptors

Non-Tc99m labeled agents

99m
Table 2. List of non-Tc labeled Radiopharmaceuticals
Agent
Application
Localization
I-131 sodium iodide
Thyroid cancer
Selectively trapped
sign, thyroid
and organified by
uptake function,
the thyroid and
treatment of
incorporated into
Graves disease,
thyroid hormone
toxic nodule,
thyroid CA
I-131
Adrenal
Norepinephrine
metaiodobenzylguanidine medullary
analogue
imaging, neural
crest tumor
I-131 tositumomab
B-cell lymphoma
imaging and
therapy

Gallium-67 citrate
o Localization relates to increased iron binding
o Iron analog (bind to transferrin receptor)
o Lactoferrin transport
o Application:
inflammatory disease
FUO
tumor imaging
Thallium-201
o K analog
o Absence of ideal photopeaks
o Half-life: 73h
o Biologic clearance: kidneys and intestines
o Application:
myocardial perfusion
tumor imaging

III. Clinical Applications
Diagnosis and monitoring of disease
Treatment of disease

A. Thyroid Scintigraphy
The radiopharmaceutical is taken up through the Na-I symporter
(NIS) which can be found in thyroid follicular cells and in the
salivary glands.

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Provides a visual display of functional thyroid tissue following the
administration of a radionuclide
Provides valuable information regarding both thyroid anatomy
and function and can play an integral role in the diagnosis and
management of thyroid disease.
Thyroid uptake
o Measurement of the fraction of an administered amount of
radioactive iodine that accumulates in the thyroid at selected
times following ingestion
Also taken up by salivary glands
Determination of thyroid gland status
Estimate residual thyroid post-surgery
o A whole body scan is done so we can see metastases to areas
such as the lymph nodes and lungs

o 64-year old female with high PTH

99m
o
Tc-pertechnetate study
99m
o
Tc-sestamibi scan
o Parathyroid adenoma

Figure 5. Parathyroid scan

Figure 3. Scintigram of normal thyroid

Differential diagnosis of thyrotoxicosis
o Graves disease
In Graves disease, there is enhanced tracer activity; the
pyramidal lobe is also seen (when normally it is not)
o Multinodular goiter
o Autonomous nodes

Figure 4. Estimate of residual thyroid post-surgery

B. Parathyroid Scan
For localization of hyperfunctioning parathyroid tissue (adenoma
or hyperplasia) and ectopic parathyroid gland
Scan includes the chest to account for ectopic parathyroids
99m

Tc-Sestamibi Parathyroid Imaging

Case:

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C. Bone Scintigraphy
Provides earlier diagnosis or demonstrates more lesions than are
found by conventional radiological methods
Clinical indications:
o Primary tumours (e.g. Ewing's sarcoma, osteosarcoma)
Staging, evaluation of response to therapy and follow-up
o Secondary tumours (metastases)
Staging and follow-up of neoplastic diseases

Distribution of osteoblastic activity prior to radiometabolic
89
153
186
therapy ( Sr, Sm-EDTMP, Re-HEDP)
o Non neoplastic diseases:
Osteomyelitis
Perthe's Disease, Avascular necrosis
Metabolic disorders (Paget, osteoporosis)
Arthropathies
Fibrous dysplasia and other rare congenital conditions
Stress fractures, Shin splints
Loose or infected joint prosthesis
Low back pain, sacroilitis
Reflex sympathetic syndrome
Any other bone injuries
Uptake mechanism:
o Increased blood flow
o Increased bone osteogenesis
Advantages:
o Very sensitive
o Whole body survey
o Inexpensive
Disadvantages:
o Poor specificity
o Not suitable alone in special entities of osteomyelitis
67
Gallium citrate
o Taken up by normal bone as well as marrow
o Uptake mechanism:
binding to transferrin/lactoferrin in activated leukocytes and
bacterial siderophores
Leakage through vessels with increased permeability
o Required whenever equivocal bone scan results are present
chronic osteomyelitis
vertebral osteomyelitis
diabetic foot infections
joint prostheses and patients with suspected reinfection
o Septic Arthritis
Swelling and pain in the left knee region
A whole body scan was done for this patient; this revealed
lesions in the lumbar vertebra, indicating early developing
lumbar osteomyelitis from TB

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Figure 6. Bone scintigraphy aka. Bone scan

D. Labeled Leukocyte Scan
Procedure of choice to diagnose most cases of skeletal infections
67
and almost replaced Ga scintigraphy
Uptake mechanism: chemotaxis
Assumption: bone marrow distribution is uniform and
symmetrical and that an area of focally increased uptake is
diagnostic of infection
In a meta-analysis of data on infections of the vertebral column
published between 1984 and 2004:
99m
o
Tc-WBCs had a 100% specificity
Case:
o 55-year old patient with a history of swelling and pain in the left
knee region.
o Bone biopsy showed the case as early developing vertebral
osteomyelitis due to tuberculosis
o Patient with a history of trauma and possible osteomyelitis at
the level of the right ankle
Bone scan shows increased uptake in the posterior calcaneus.
99m

Tc-HMPAO WBC scan is normal and excludes the

possibility of osteomyelitis.

E. GI Bleeding Scintigraphy
to locate the bleeding site
o Requested if there is melena or hematochezia
o Less invasive than angiography
to determine who requires aggressive treatment versus those
who can be medically managed
99m

Tc-labeled autologous RBCs

o 80% of bleeding sites are detected
o Cinematic images are helpful for determining tracer flow
Criteria for diagnosis:
o Activity appears where there was none before
o It is increasing over time
o It conforms to the intestinal anatomy
o It has movement (antegrade or retrograde)
Accuracy
o Sensitivity: 93%
o Specificity: 95%
o Angiography: 1 ml/min
o GI bleed scintigraphy: 0.05 to 0.1 ml/min

Figure 7. Hepatobiliary scintigraphy. Persistent hepatogram without
intestinal passing of the bile. Also note the urinary bladder activity.

F. Hepatobiliary Imaging
a.k.a. cholescintigraphy
Functional assessment of the hepatobiliary system
o Evaluation of suspected acute cholecystitis
Cholelithiasis results in an obstructed cystic duct
The gallbladder cannot be seen even if morphine is given
Morphine sulfate causes the constriction of the sphincter of
Oddi. There will be preferential flow of bile going up. If the
cystic duct is open, bile will go to the gallbladder.
o Evaluation of suspected chronic biliary tract disoders
o Evaluation of common bile duct obstruction
o Detection of bile extravasation
o Evaluation of congenital abnormalities of the biliary tree
Ex. biliary atresia
Iminodiacetic acid analog of bilirubin; used as
radiopharmaceutical
The liver cells take up bile salts, bilirubin conjugation
and synthesis produced bile goes to the cystic duct and
gallbladder duodenum (enterohepatic circulation)
In biliary atresia, uptake of radiopharmaceutical will only
be up to the liver. Gallbladder and intestines wont be
seen. No intestinal activity after 24 hours.
No intestinal activity after 24 hours
Accuracy for acute cholecystitis
o Sensitivity: 95%
o Specificity: 99%
o Sonograms are equivocal for diagnosis of acute cholecystitis
Case:
o 20-year old male in a motorcycle accident
o Laceration in R liver lobe extending to the hepatic surface
o Liver scan was done which showed actively extravasating bile at
the site of bile distruption
o Increased activity along the right liver lobe and within the
peritoneum.

G. Renal Scintigraphy
Radionuclides

Figure 8. Radionuclides for Renal Imaging

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Table 3. Role of radiopharmaceuticals in renal function.
Clinical Indication
Radiopharmaceutical Interventions
Renal Artery
Stenosis
MAG3/DTPA
Captopril
Renovascular
Hypertension
Renal Scarring
DMSA

Pyelonephritis
DMSA

Urinary Reflux
Sulfur colloid

Obstruction
MAG3/DTPA
Furosemide
Renal
DMSA/DTPA/MAG3

Insufficiency/Failure
Renal Tumors
DMSA

*DTPA a purely glomerular uptake; for GFR determination and
renal scan; DMSA mostly cortical uptake, also a tubular agent;
MAG3 purely tubular agent

Serial Scan
o Pre-antibiotic therapy and post-antibiotic therapy
DTPA study
o Obstructed flow
Normal time activity curve
Short extraction, immediately followed by elimination
Seen as a downsloping
If there is an obstruction:
There is tracer retention
The slope flattens or upslopes

Acute Pyelonephritis
Lesions resolve after the administration of antibiotics
Important to monitor this disease, especially in pediatric patients

Figure 10. Left kidney has normal kidney function. Right kidney
cannot eliminate tracer. There is further increase in activity in the R
kidney.

Figure 11. Time-activity curve. Normal activity: short extraction
period of trace follwed by elimination. Obstructed: tracer retention
within the kidney (upslope instead of downslope).

Transplant evaluation
Can assess many complications:
o Acute rejection
o Acute tubular necrosis or vasomotor nephropathy
o Vascular problems
o Obstruction

Figure 9. Normal vs. Cortical Scarring on Renal Scintigraphy. R kidney
is smaller due to scarring.

rd
Figure 12. Normal renal transplant study. Highest activity at the 3
minute. Within 20 mins, tracer is already in the bladder.

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Figure 13. Normal time-activity curve. There is short extraction
nd
followed by elimination. The 2 curve represents the activity in the
urinary bladder. Activity in the bladder increases as the kidney
excretes the tracer.

H. Myocardial Perfusion Scintigraphy (MPS)
Requested when:
o There is equivocal stress test (since the test can be a false
positive)
o Involvement of the inferior wall
Diagnosis of coronary artery disease
Myocardial viability assessment (using thallium)
Risk assessment (prognosis) in patients
Monitoring treatment effect
Shows regional perfusion
Ventricular wall motion
Accurately calculates reproducible LVEF
Sensitivity and specificity for both THALLIUM and TECHNETIUM
o No significant difference in sensitivity and specificity for CAD
detection between Tl-201 and Tc-99m agents.
o ~90% Overall test sensitivity
o ~60% test specificity
Modalities for Stress Testing
o Exercise
Maximal
Submaximal
Symptom limited
o Pharmacological stress
given if the patient cannot do exercise; however, we should
expect that there will be a greater number of adverse
reactions
drug is injected during peak exercise
Vasodilators (Adenosine, Dipyridamole)
Are usually short-acting
If you see adverse effects with adenosine, just stop the
administration of the drug. In a few seconds, effects will
wane off.
Dipyridamole has a longer half-life
Inotropic (Dobutamine Atropine)
in combination with SPECT

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st
nd
Figure 14. MPS with SPECT. 1 column: stress images. 2 column:
resting images. There should be homogenous radiotracer
distribution. SPECT image shows the irreversible heterogeneous
tracer distribution even in the resting images, which indicates that
the LV is not being perfused (infarction).

Inducible Ischemia

Figure 15. Inducible Ischemia. There are reversible defects after
resting; the color reappears and the hole is not permanent.
Ischemia was induced by stress and reversed after resting.

I. Other Therapeutic Applications
Bone pain palliation
89
o Sr-chloride
153
o
Sm-lexidronam (ethylenediamine-tetramethylene
phosphonate [EDTMP])
Intra-articular radiosynovectomy
32
o P-colloid
90
o Y-silicate colloid
Radioimmunotherapy for non-Hodgkins lymphoma
90
o Y-Ibritumomab Tiuxetan
131
o I-Tositumomab
Polycythemia Vera
32
o P-sodium phosphate
Differentiated thyroid carcinoma
131
o I - NaI

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Hyperthyroid therapy
131
o I NaI capsule or liquid
Transarterial hepatic radioembolization
90
o Y-microspheres

J. Radiation Doses

Table 4. Typical Effective Radiation Doses

END

Josh: Toxic trans. Pang-residents daw. Na-disappoint ata si maam. :P

Bobbie: :-| (a runny nose!)

Camille: Sawa na ko mag-trans. Huhu. Nood kayong Fate. Support
Daisies Jow and me! And Bea O! And the rest of MedRhythmics! And
Epimers! And 2016 MSS members! Lahat na! Love thy neighbor. It
makes the world go round. J

Gusto ko ng cebu lechon.

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