nuclear medicine & positron emission tomography
DESCRIPTION
NUCLEAR MEDICINE & POSITRON EMISSION TOMOGRAPHY. Richard S.Kuebler,M.D.,J.D. Clinical Assistant Professor Academic Director of Nuclear Medicine LSUHSC Department of Radiology Acknowledgements for Lecture and Images Dan Fertel,M.D. Stephanie Casey,M.D.,M.P.H. References. Brant and Helms - PowerPoint PPT PresentationTRANSCRIPT
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NUCLEAR MEDICINE &NUCLEAR MEDICINE &POSITRON EMISSION POSITRON EMISSION
TOMOGRAPHYTOMOGRAPHYRichard S.Kuebler,M.D.,J.D.
Clinical Assistant Professor
Academic Director of Nuclear Medicine
LSUHSC Department of Radiology
Acknowledgements for Lecture and Images
Dan Fertel,M.D.
Stephanie Casey,M.D.,M.P.H.
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ReferencesReferences
• Brant and Helms
Fundamentals of Diagnostic Radiology
• Mettler and Guiberteau
Essentials of Clinical Nuclear Medicine
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Nuclear MedicineNuclear Medicine
• Diagnostic • Therapeutic
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Nuclear MedicineNuclear Medicine
• Use of radioactive isotopes
• Most common Technetium-99m – which has a 6 hour half life with good detector
• Others include Iodine-123, Indium-111, Gallium-67.
• Gamma camera imaging
• SPECT imaging
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Radionuclides= Isotopes attempting to reach stability by emitting Radionuclides= Isotopes attempting to reach stability by emitting radiationradiation
ATOM
Tc-99m
Radioactive decay
Gamma ray/photon emission (140KeV)
Gamma camera
Light pulse
Voltage Signal
Image
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Gamma CameraGamma Camera
• A gamma camera is a device used to image gamma radiation emitting radioisotopes, a technique known as scintigraphy
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Image on PACS
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Uses of Nuclear MedicineUses of Nuclear Medicine
• Heart: myocardial perfusion imaging where there has been further development for improvement, rather than decrease or replacement by other modalities. Use SPECT evaluation
• Bone scans, evaluate for metastatic bone cancer, osteomyelitis. Most common changes we see are arthritic, correlate with other studies.
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Radionuclides for ImagingRadionuclides for Imaging
• Normal Whole-body distribution
• Route of excretion
• Target/critical organ
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Normal Technetium DistributionNormal Technetium Distribution
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Cardiovascular Nuclear ImagingCardiovascular Nuclear Imaging
1. Heart wall motion
2. Myocardial Perfusion & Viability
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Heart wall motionHeart wall motion(Regional & Global Ventricular Function)(Regional & Global Ventricular Function)
• Tc-99m tagged red blood cells
• Evaluate left ventricular ejection fraction (nl > 50%)
• Tagged red blood cells also used for GI bleeding and hemangioma evaluation in the liver
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Equilibrium Radionuclide AngiographyEquilibrium Radionuclide Angiography
Gated equilibrium radionuclide angiograms (MUGA scans)
1. Performed with Tc-99m red blood cells
2. Common indications include assessment of LVEF & regional wall motion
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Myocardial Perfusion & ViabilityMyocardial Perfusion & Viability
• Originally thallium 201
• Now use Tc99m Cardiolite or Myoview
• SPECT Imaging
• Determine adequacy of blood flow to myocardium, especially in conjunction with exercise or pharmacoliogic stress
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Myocardial PerfusionMyocardial Perfusion• Stress/Exercise
• Increased Oxygen demand
• Dilate coronary arteries
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Normal heartNormal heart
Myocardial PerfusionRest = baseline perfusion Stress = maximal perfusion
s
H
V
Apex to base
Sep to Lat
Inf to Ant
ant
inf
sep latApexLAD
Cx
RCA
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IschemiaIschemia
Apical septal
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IschemiaIschemia
Inferior Wall
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Fixed defectFixed defect
Scar vs Hibernating myocardium
Delayed imaging or PET
Viability
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Fixed defect vs diaphragmFixed defect vs diaphragm
Liver, spleen, bowl activity – reconstruction artifact
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Breast attenuationBreast attenuation
Anterior or lateral wall defect
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Imaging for infectionImaging for infection
• Ga 67 Citrate: not used as much anymore, former use was for neoplasm (including lymphoma and lung cancer), inflammation, infection– Ga-67-----complexes with plasma transferrin----carried to sites of
inflammation– Incorporated into WBCs—bound by intracellular lactoferrin—then
migrate to inflammed areas– Taken up by microorganisms by binding to siderophores produced by
bacteria
• In-111 tagged white blood cells. Can also tag with Tc-99, but shorter half life.
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Gallium scan – Ga-67Gallium scan – Ga-67• Photon poor- grainy images• Image 24-48 hours• Bowel activity• Sarcoidosis• FUO• Diskitis/spinal Osteomyelitis• Opportunistic infections
– Need CXR correlation
– PCP – intense activity– Kaposi’s sarcoma – no activity– Normal CXR-Normal Ga-67
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Gallium and FUO ImagingGallium and FUO Imaging• Value in its nonspecificity
• Will detect pathology other than just infection
• Neoplasia
• Initial imaging should be with In-111 WBC and then followed with Gallium,if necessary (especially if FUO for less than two weeks)
• If patient has had systemic antibiotics,may get false negative with Gallium scan
• Better in children-WBC require phlebotomy
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In-111 WBC scanIn-111 WBC scan
• Image 12-24 hr• No bowel/renal
activity• Bacterial infections• Prosthetic joint
infection – map with Tc-sulfur colloid
• Diabetic foot infection
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In-111 Oxine LeukocytesIn-111 Oxine Leukocytes• High sensitivity and specificity for acute
infections.
• Lower for chronic infections
• Attracted to site of infection by chemotaxis
(directed migration)
• Not specific for infection, accumulates in any inflammatory response that attracts lekocytes.
• Occasionally in neoplasia
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Bone scan Tc99m-MDPBone scan Tc99m-MDP
• Increased osteoid formation/mineralization of osteoid(osteogenesis)
• Increased blood flow
• Can be affected by administed drugs
• Always obtain radiographic correlation
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Bone Scan - MetastasisBone Scan - Metastasis
• Quality of life• Therapeutic decision making
• Multifocal areas increased activity• Red marrow: thorax, ribs, pelvis, limbs, skull
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Bone Scan - MetastasisBone Scan - Metastasis
• For a lytic lesion to be visualized by radiography localized demineralization of 30-50% must occur
• Bone scans usually demonstrate metastatic lesions much earlier than radiography
• False negative bone scan:– Multiple Myeloma– Renal cell carcinoma– Thyroid carcinoma
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Bone Scan - MetastasisBone Scan - Metastasis
• 80% of patients with known neoplasms & bone pain have metastasis documented by the bone scan
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Bone scan – Lumbar fractureBone scan – Lumbar fracture
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Bone scan 3-phaseBone scan 3-phase
• Flow • Blood pool
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Bone scan 3-phaseBone scan 3-phase• Delay
• 3–phase positive:• Osteomyelitis
• Acute fractures• Bone tumors
• Cellulitis – 2-phase• Shin splints – delay only
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Bone scan - ArthriticBone scan - Arthritic
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Uses of Nuclear MedicineUses of Nuclear Medicine
• Thyroid, Iodine-123 or Technitium-99
• Liver-spleen, largely replaced by CT or MRI
• Biliary, filling gallbladder, biliary ducts
• Renal scan
• Brain scans, replaced by CT
• Others
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Thyroid scanThyroid scan
• Thyroid Scan using Tc99 pertechnitate or I-123
• Radioactive Iodine uptake using I-123 or I-131
• Normal uptake in our area 5-15% for 6 hours and 10-30% for 24 hours (10-40% for 24 hours in North and Midwest)
• Total body I-131 used for thyroid cancer evaluation
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Thyroid scanThyroid scan• Hypo or hyperfunction• Nodules• Ectopic thyroid• Organification defect
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Total body I-131Total body I-131
• Post-thyroidectomy• Postradioiodine
Therapy imaging• I-131: treatment of
Graves’ disease and multinodular goiter
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Hepatobiliary Imaging Tc99 IDAHepatobiliary Imaging Tc99 IDA(cholecystokinin injection)(cholecystokinin injection)
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Hepatobiliary Imaging Hepatobiliary Imaging (morphine injection)(morphine injection)
• 1 hr – Gallbladder not visualized
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Renal scan Tc-99m MAG3Renal scan Tc-99m MAG3
• Renal function, images similar to IVP• Indications: Renal srtery stenosis
• Acute tubular necrosis, obstruction, pyelonephritis
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Brain scan, brain death (TC99)Brain scan, brain death (TC99)
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Uses of Nuclear MedicineUses of Nuclear MedicineLymphatic mappingLymphatic mapping
• 99m-Tc Sulfur Colloid
• Breast carcinoma and melanoma
• Injection for lymph node localization for biopsy (sentinal node)
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Liver scan: Tc99 Sulfur colloidLiver scan: Tc99 Sulfur colloid
• Hepatocellular disease
• Confirmation of specific space occupying lesions – ie, focal nodular hyperplasia
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Radiology Evaluation of CancerRadiology Evaluation of Cancer
• Plain Films and Associated Studies
• CT Scan
• MRI
• Nuclear Medicine
• Ultrasound
• PET
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Positron Emission Tomography Positron Emission Tomography - PET- PET
• Radionuclide with excess protons
• Decay
• Positrons
• Positron + electron collision
• Annihilation reaction generates two 511-keV gamma photons
• PET detector ring for localization & imaging
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Type of Pet ScannersType of Pet Scanners
• PET Scanner
• PET/CT Fusion Scanner
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PET – CT Fusion ScannerPET – CT Fusion Scanner
• Combination of Positron Emission Tomography (PET) and Helical CT
• PET detects area of increased metabolic activity as indicated by uptake of radioactive glucose (tumor, infection)
• PET data is then “fused” with CT data to produce an image showing increased glucose uptake superimposed upon the exquisite anatomic detail of helical CT
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Uses of PETUses of PET
• Brain
• Cardiac
• Oncology
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Cancers evaluated with PETCancers evaluated with PET
• Lung
• Lymphoma
• Melanoma
• Colorectal
• Breast
• Esophagus
• Head and Neck
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Also Also
• Thyroid carcinoma: Approved for history of only 1 type of thyroid carcinoma (Follicular) with negative I-131 scan and rising tumor markers
• GU malignancies (Renal, Prostate, Cervical and Ovarian)
• Under review for sarcomas
• Outpatient procedure
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Uses of PETUses of PET• Diagnosis of cancer (especially lung)
• Staging of cancer
• Restaging of cancer
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NoteNote
• Use of PET scan for treatment response may not be covered
• Except in Breast Cancer and certain type of thyroid carcinoma (follicular)
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F-18 FDGF-18 FDG
• Fluoro-deoxyglucose
• F-18 on a glucose (sugar) molecule
• 110 minute half life
• Cyclotron produced, now commercially available
• Competes with glucose
• Cancers are glucose active
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PreparationPreparation
• NPO 4-6 hours, except water• May take medications• No regular insulin within 4 hours of administration• Patients on certain insulin preparations may have half
dose• Take serum glucose level, needs to be below 200 (Need
to reschedule if above 200)
• Elevated glucose level competes with F-18FDG• Elevated insulin levels = increased muscle uptake
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F-18 FDGF-18 FDG
• Tumors – increased # glucose transporters - energy source
• F-18 FDG: interact with glucose receptors
• Phosphorylated inside cell: F-18 FDG 6P– Blocked from further metabolism and trapped
in cell
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PET Image QuantificationPET Image Quantification
• SUV: Standard Uptake Value– Based on ROI radioactivity/administered
activity/body weight
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Physiologic uptake or accumulationPhysiologic uptake or accumulation
• Brain
• Salivary glands
• Pharynx, larynx
• Liver, Spleen, Bone marrow
• Heart
• GI, including colon
• Renal excretion, ureters, bladder
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NormalNormal
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NormalNormal
• Brain• Heart• Liver• Bowl
• Urinary system• Bone marrow
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NormalNormal
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NormalNormal
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Artifactual uptakeArtifactual uptake
• Muscle
• Fat (Brown Fat)
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ArtifactualArtifactual
• Larynx activity
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Artifactual, MuscularArtifactual, Muscular
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Artifactual FatArtifactual Fat
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Increased marrow uptake due to Increased marrow uptake due to chemotherapychemotherapy
G-CSF – postchemotherapy
Marrow stimulation
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Pick’s DiseasePick’s Disease
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MelanomaMelanoma
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MelanomaMelanoma
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Lung CarcinomaLung Carcinoma
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Lung CarcinomaLung Carcinoma
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Lung cancerLung cancer
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Lung carcinomaLung carcinoma
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Breast carcinomaBreast carcinoma
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Breast carcinomaBreast carcinoma
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Breast carcinomaBreast carcinoma
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LymphomaLymphoma
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LymphomaLymphoma
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LymphomaLymphoma
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LymphomaLymphoma
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LymphomaLymphoma
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Liver Mets from Colon CaLiver Mets from Colon Ca
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Liver Mets from Colon CaLiver Mets from Colon Ca
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Liver Mets from Colon CaLiver Mets from Colon Ca
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Rectal carcinomaRectal carcinoma
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Rectal carcinomaRectal carcinoma
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Rectal carcinomaRectal carcinoma
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Rectal carcinomaRectal carcinoma
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Rectal carcinomaRectal carcinoma
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Esophageal carcinomaEsophageal carcinoma
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Esophageal carcinomaEsophageal carcinoma
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Diffuse Metastatic diseaseDiffuse Metastatic disease
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NoteNote
• Not all cancers have positive PET Scans
• Not all positive PET scans are cancers
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