Académique Documents
Professionnel Documents
Culture Documents
BY
DR ZOOL HILMI
2012
SIMPLE PHYSIC
Radionuclide
Decay mode
Half time
Energy (keV)
Production
method
Thallium-201
Electron capture
73.1 hr
69-83(94%) ,
135(3%) 167(10%)
Cyclotron
Gallium-67
Electron capture
78.3 hr
93(37%),185(20%),3
00(17%),395(5%)
Cyclotron
Indium-111
Electron capture
2.8 d
171(90%),245(94%)
Cyclotron
Iodine-123
Electron capture
13.2 hr
159
Cyclotron
Iodine-131
Beta minus
8d
364
Reactor
Technetium-99m
Isomeric
transition
6 hr
140
Generator
Cobalt-57
Electron capture
272 d
122
Cyclotron
Fluorine-18
Positron emitting
110 min
0.653 MeV
Cyclotron
Gallium-68
Positron emitting
68 min
1.9 MeV
Generator
Carbon-11
Positron emitting
20 min
0.96 MeV
Cyclotron
Nitrogen-13
Positron emitting
10 min
1.19 MeV
Cyclotron
Oxygen-15
Positron emitting
2 min
1.70 MeV
Cyclotron
Rubidium-82
Positron emitting
1.3 min
3.15 MeV
Generator
Coherent/Rayleigh/
classical scatter
Pair production
Photodisintegration
/xray
interaction with
matter
Photo electric
Compton scatter
Alpha
Electron
Decay
Beta
Positron
Electron
capture
Isomeric
transition
Gamma
Internal
conversion
-Neutron rich
-n/p high
-n= p + + v
-High proton
-n/p low
-n= n + + v
-High proton
-n/p low
-p + e = n + v
-Tc-99m = + Tc99
Q = EXPOSURE
AMOUNT OF ELECTRICAL CHARGE
PRODUCED
BY
IONIZING
ELECTROMEGNETIC RADIATION PER
MASS OF AIR
UNIT = C/Kg = Roentgen
1 R = 2.58 x 10 C/Kg
D = ABSORB DOSE
DIRECTLY IONIZATION CHARGE
PARTICLE DEPOSIT ENERGY BY
(EXCITATION/IONIZING) PER UNIT
MASS
UNIT = J/Kg
1 Gray = 1 J/ Kg
100 rad = 1 Gray
Rad = RADIATION ABSORB DOSE
SOURCE
SKIN DOSE
RADIATION EXPOSURE INCIDENT TO
PATIENT DUE TO RADIOLOGICAL
EXAMINATION
CHEST X RAY = 0.1 0.2 mGy
SKULL
= 1.5 mGy
ABDOMEN = 3 mGy
LUMBAR
= 10 mGy
H = EQUIVALENT DOSE
ICRP 1990
MEASURE OF RADIATION SPECIFIC
BIOLOGIC DAMAGE IN HUMAN
UNIT = Sievert
100 rem = 1 Sv = J/Kg
WR = RADIATION
FACTOR
XRAY///e
PROTON > 2 MeV
NEUTRON
LPHA
WEIGHTING
=1
=5
= 5 20
= 20
E = EFFECTIVE DOSE
ICRP 1990
MEASURE OF RADIATION AND
ORGAN SYSTEM SPECIFIC DAMAGE
IN HUMAN
UNIT = Sievert
100 rem = 1 Sv = J/Kg
K = KERMA
ENERGY CARRIED BY PHOTON (OR
OTHER
INDIRECT
IONIZING
RADIATION) TRANSFER ENERGY TO
CHARGE
PARTICLE
(
PE/COMPTON/PAIR PRODUCTION
PARATHYROID SCINTIGRAPHY
Parathyroid
imaging
PARATHYROID SCINTIGRAPHY
ANATOMY AND EMBRYOLOGY
ANATOMY
4 parathyroid glands
Measuring 6mm x 3mm
Weighing 35 40 gram
Rarely, may be only 2 glands or as many as 8
glands
EMBRYOLOGY
Pathophysiology
Hyperpathyroidism :
1. Primary hyperpathyroidism
2. Secondary hyperpathyroidism
3. Tertiary hyperpathyroidism
Hyperparathyroidism
Chief cells (single or multiple glands)synthesis
more and release more PTH
PTH synthesize, stored and secreted by
parathyroid glands
PTH responsible for calcium and phosphorus
homeostasis by its action on bone, small
intestine and kidneys
Tc-99m MIBI
Heart
GI
Kidney
Bladder
F
T
F
T
T
In performing Tl-201/Tc-99m
pertechnitate parathyroid studies, it is
best perform the pertechnitate study
first
In performing Tl-201/Tc-99m
pertechnitate parathyroid studies, it is
best perform the pertechnitate study
first
FALSE
Hyperparathyroidism
1. Tc-99m sestamibi is taken up by thyroid and
parathyroid tissue, but wash out more rapidly
from the thyroid.
2. Parathyroid adenoma in the region of the left
lower lobe of the thyroid.
3. > 90% predictive value for preoperative
localization of parathyroid adenoma, lower test
accuracy for hyperplasia and small tumors.
4. Thyroid follicular adenoma.
Parathyroid adenoma
1. Dual isotope imaging with subtraction, in the past using
Tl-201 and Tc-99m pertechnitate and recently using I-123
and Tc-99m sestamibi
2. I-123 by mouth. After a delay of 2 to 3 hours, an anterior I123 thyroid scan is obtained. Without moving the patient,
an image is obtained after IV injection of Tc-99m MIBI. The
I-123 image is computer subtracted from the Tc-99m MIBI
image.
3. The I-123 thyroid scan appears normal, although the left
lobe extends more inferiorly. The MIBI image shows an
asymmetrical bulbous configuration in the region of the
right lower pole of the thyroid. Subtraction demonstrates
focal radiotracer compatible with parathyroid adenoma at
the lower pole of the right thyroid.
4. Parathyroid, thyroid adenoma, thyroid carcinoma and
metastatic carcinoma.
ADRENAL SCINTIGRAPHY
ADRENAL SCINTIGRAPHY
Common indication
(Cushings syndrome)
is
hypercortisolism
Less common :
a) Hyperaldosterolism (Conns syndrome)
b) Adrenal virilizing tumors
ADRENAL
CORTEX
ZONA
GLOMERULOSA
ZONA
FASCICULATA
ALDOSTERONE
CORTISOL
CONNS
CUSHINGS
MEDULLA
ZONA
RETICULARIS
ANDROGENS
EPINEPHRINE
Mechanism
Spironolactone
Ketoconazole
Diuretic/oral contraception
Stimulate renin/angiotensin
Glucocorticoids
Suppression of ACTH
Decrease cholesterol
Hypercholesterolemia
HYPERALDOSTERONISM NP-59
PATTERN
SYMMETRICAL
BILATERALLY EARLY
IMAGING (BEFORE DAY 5)
-Bilateral autonomous
hyperplasia
-Secondary
aldosteronism
UNILATERAL EARLY
IMAGING (BEFORE
DAY 5)
SYMMETRICAL LATE
IMAGING (ON OR
AFTER DAY 5)
-Conns tumor
-aldosterone
secreting tumor
Normal adrenal
BILATERAL HYPERPLASIA
ASYMMETRIC
BILATERAL HYPERPLASIA
(SOME ASYMMETRY IS
COMMON)
BILATERAL
VISUALIZATION
ADRENAL
SCINTIGRAM
UNILATERAL
VISUALIZATION
ADENOMA
BILATERAL NON
VISUALIZATION
CARCINOID
DRUG THERAPY
BILATERAL HYPERPLASIA
ASSOSIATED WITH
UNILATERAL ADENOMA
ADRENAL REMNANT
AFTER
ADRENALECTOMY
Adrenocortical scintigraphy
1. A, Unilateral NP-59 uptake consistent with left
adrenal adenoma, concordant with the CT. B,
Bilateral adrenal hyperplasia, discordant with CT.
2. Uptake in the right adrenal bed region indicating
adrenal remnant. Discordant with the negative
CT.
3. Transport and receptors system for serum
cholesterol account for adrenal uptake.
Cholesterol is required for the production of
adrenal hormones.
4. Hyperaldosteronism (adrenal adenoma or
hyperplasia) and hyperandrogenism.
ADRENOMEDULLARY
SCINTIGRAPHY
Heart
Liver
Kidney
Bladder
MIBG scan
Heart
Liver
Kidney
Bladder
Thyroid blockade
Potassium perchlorate for emergency and
allergic to iodine= 400 mg
Compound
Daily dose
Capsules
Potassium iodate
170 mg
Potassium iodide
130 mg
Solution
Lugol 1%
False negative
Small &
Few somatostatin receptors
Non-secreting paraganglioma
Small (oat) cell bronchogenic carcinoma
Squamous carcinoma of the bladder
Medullary carcinoma of the thyroid
The heart
A. I-131 NP 59
B. In-111-Octreoscan
C. I-131 MIBG
1.
2.
3.
4.
5.
A. I-131 NP 59
B. In-111-Octreoscan
C. I-131 MIBG
1.
2.
3.
4.
5.
Neuroblastoma
1. Bone scan shows uptake symmetrically in the distal
femurs, cranial and facial bones. I-131 MIBG shows a large
area of midline abdominal uptake. Inspection of the bone
scan in the same area suggests a soft tissue left perirenal
density, best seen in the anterior view. In addition, diffuse
marrow/bone uptake is seen on the MIBG study.
2. The prominent mid line uptake on the MIBG is consistent
with neuroblastoma. Subtle bone uptake is seen in the
region. The symmetrical bone uptake in the distal femurs,
cranial and facial bone is very suggestive of tumor. The
MIBG confirms metastatic disease with extensive tumor in
the marrow/ bone from skull to feet.
3. First, primary neuroblastoma. Osteosarcoma metastatic to
the lung is another. Metastases of various tumors
occasionally are seen on bone scans, lung, colon and
breast.
4. Combination of Tc-99m bone scan and I-131 MIBG.
Octreoscan
1. In-111 octreoscan (octreotide), I-131 MIBG.
2. Prominent liver, spleen and kidney uptake is
seen with In-111 octreoscan.
3. Focal abnormal uptake in the right temporal
bone that correlates with CT.
4. Paraganglioma considering the patients
history, also meningioma or NET metastasis.
Pheochromocytoma
1. I-131 MIBG
2. Localization occurs through the norepinephrine
reuptake
mechanism.
It
localizes
in
catecholamine storage vesicles in presynaptic
adrenergic nerve ending and cells of the adrenal
medulla.
3. Sensitivity: 90%, specificity, 95% for detection of
pheochromocytoma.
4. Neuroblastoma (90%), carcinoid (50%) and
medullary thyroid carcinoma (25%).
NET
1. Peptide analogue of somatostatin and
octreotide. Binds to tumors with somatostatin
receptors.
2. NET
3. A, multiple metastases to both lobe of the liver.
Two large foci and one small focus of uptake
consistent with paraaortic tumor adenopathy.
Possible small tumor in right hilum. B,
prominent irregular uptake in the anterior
mediastinum and focal uptake in the lower lung
posteriorly.
4. Kidney and spleen.
Infection and
inflammation
Infection and
inflammation
Infection and
inflammation
Infection and
inflammation
Infection and
inflammation
Gallium 67
citrate
Radiolabeled
leukocytes
Indium-111
oxine
leukocyte
F18 FDG
Tc-99m
HMPAO
Tc-99m
Fenulesomab
Tc-99m
Sulesomab
Radiopharmaceutical
Gallium-67 citrate
Indium-111 oxine
leukocytes
Tc-99m HMPAO
labeled leukocytes
Production of
radionuclide
Cyclotron
Cyclotron
Generator
Decay mode
Electron capture
Electron capture
Isomeric transition
Half life
78hours
67hours
6hours
173, 247
140
Dose
5 mCi
5 10 mCi
Imaging time
48 hours
24 hours
1 - 4 hours
Normal
biodistribution
Radiopharmaceutical
Gallium-67
Indium-111
Thalium-201
Half life
78 hours
67 hours
72 hours
173, 247
Liver
Spleen
Marrow
Bone
Gastrointestinal
Liver
Spleen
Marrow
Lung
liver/spleen/ bladder
marrow
(lungs)
Radiopharmaceutical
-Gallium-67 citrate
-5 mCi
-IV
Instrumentation
Imaging procedure
Radiopharmaceutical
Instrumentation
Imaging procedure
Radiopharmaceutical
Instrumentation
Imaging procedure
Indications
Gallium-67
Severe leucopenia
Pediatric patients
Sarcoidosis
Cardiovascular infection
Osteomyelitis of extremities
including feet in non diabetic
Pneumocytic carinii
FUO
Immunosuppressed patient
with lung infections
Suspected low grade chronic
infections (fungal/protozoa)
Neonates
Osteomyelitis
Type of study
Sensitivity
%
Specificity
%
94
95
95
33
Gallium 67
81
69
Indium-111 oxine
leukocytes
88
85
87
81
MRI
95
87
Infections
Regions
Scans
Diabetic foot
Vertebral osteomyelitis
Ga-67/bone scan
F18-FDG
Tc-99m infecton
Cardiovascular
Renal
Intra cerebral
FUO
Ga-67
Post op fever=In-111 leukocytes
Ga-67
Diffuse
Intense
Mild
PCP
CMV
MAI
Treated PCP
Severe PCP
Interstitial pneumonitis
Focal
Nodal
Bacterial
Pneumonia
MAI
TB
Lymphoma
Gallium-67
Thallium-201
- ve
+ ve
Kaposis
sarcoma
+ ve
- ve
Infection
+ ve
+ ve
Lymphoma
Kaposis sarcoma
PCP
CMV
Normal CXR &
Abnormal
Gallium-67
Sarcoidosis
Pulmonary drug
toxicity
Lymphocytis
interstitial
pneumonitis
Gallium scan
100% sensitivity
Burkitts
lymphoma
Pyogenic acute
osteomyelitis
Pyogenic acute
arthritis
Bleomycin
Amiodarone
Gallium-67 lung
Busulfan
uptake
Nitrofurantoin
associated with
Cyclophosphamide
drugs
Methotrexate
Which leukocytes are labeled with In111 oxine and Tc-99m HMPAO?
Which leukocytes are labeled with In111 oxine and Tc-99m HMPAO?
In-111 binds to neutrophils, lymphocytes,
monocytes, erythrocytes and platelets.
Tc-99m HMPAO binds to neutrophils.
Lymphocytes
Leucocytes
Bacteria
Fungus
Tissue macrophage
Lymphocytes
Leucocytes
Bacteria
Fungus
Tissue macrophage
Lacrimal glands
Salivary glands
Lactating breast
Bone
Liver
Sarcoidosis
1. Patient A: lambda sign (hilar and paratracheal
nodal uptake). patient B: diffuse pulmonary
uptake.
2. Classic panda sign.
3. Either A or B. The panda sign can be seen at
any stage of the disease.
4. Sarcoidosis. Ga-67 scan is used to confirm the
clinical diagnosis and differentiate active
alveolitis from inactive fibrosis.
Intraabdominal abscess
1. Very increased uptake in the right lower quadrant
strongly suggests an intraabdominal abscess. Tumor
cannot be excluded.
2. Increased vascular permeability, bacterial uptake and
binding to leukocytes play a role, however, binding to
lactoferrin of degranulated neutrophils at the site of
infection is probably the primary mechanism.
3. Photopeak at 91 to 93, 185, 300 and 394 keV. The
lower three photopeaks are used for imaging. A
medium energy collimator should be used.
4. The recommended adult dose of Ga-67 is 5 mCi, half
life is 78 hours, imaging time is at 48 hours is routine.
If abscess suspected, imaging at 6 to 24 hours may
provide an early diagnosis.
Intraabdominal abscess
1. Tc-99m HMPAO binds only to neutrophils. In-111 oxine
binds to mixed leukocytes.
2. Normal bone marrow distribution of the radiolabeled
leukocytes.
3. Abdominal imaging: Tc-99m HMPAO images are acquired
at 1 to 2 hours because hepatobiliary, intestinal and renal
clearance
occurs
subsequently,
complicating
interpretation. Extremity imaging: 2 to 6 hours. In-111
leukocytes: 24 hours. Four hour imaging for inflammatory
bowel disease because sloughing of intestinal mucosa
leukocytes may occur and 24 hour may be misleading.
4. Infection in the right lower quadrant overlying the
sacroiliac joint in the anterior view and lateral right of the
spine. The patient had a perforated appendix.
Pericarditis Ga-67
1. Abnormal uptake in myocardium, pericardium or both
consistent with pericarditis or myocarditis. The
patient developed a pericardial fraction rub the day
after the Ga-67 scan. Incidental note of normal liver
uptake and transverse and left colon clearance.
2. Ga-67 shows uptake not only with inflammation and
infection, but also in tumors that can sometimes be
the cause of persistent fever e.g.. lymphoma.
3. Large bowel = 4.5 rads.
4. Most pulmonary inflammatory and infectious
diseases. Uptake is nonspecific, although the pattern
of uptake and the clinical setting, e.g. AIDS may be
helpful in determine the differential diagnosis.
Osteomyelitis of spine
1. Bone scan shows increased uptake of the T11
vertebrae. In-111 oxine leukocyte shows
decreased uptake in the same region. Ga-67
shows increased uptake that matches the bone
scan in relative intensity.
2. Osteomyelitis fracture, infarction, metastasis,
orthopedic hardware, surgical defect, Pagets
disease, radiation therapy.
3. Osteomyelitis in this clinical setting. Many of the
diseases listed can be excluded by history and
radiographs.
4. As high as 40%.
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Skeletal imaging
Reduced hydrolyzed
technetium
Tc-99m
pertechnitate
Free pertechnetate
preparation,
there are 3 form
of technetium Chelated technetium
Liver
uptake in
bone scan
Reduced hydrolyzed
technetium
Excess amount of
aluminum in Tc-99m
MDP preparation
Excess amount of
stannous ion in Tc99m MDP
preparation
Excess amount of
aluminum in Tc-99m SC
preparation
Lungs uptake
Thyroid
Tc-99m pertechnetate
Gastric mucosa
Bone tumors
Benign
Malignant
Osteoid osteoma
Osteosarcoma
Ewings sarcoma
Fibrous dysplasia
Chondrosarcoma
Bilateral
increased
uptake of renal
in bone scan
Urinary tract
obstruction
Acute tubular
necrosis
Chemotherapy
Radiation nephritis
Thalassemia
Hypercalcemia
Nephrocalcinosis
Nephrotoxic
antibiotic
Bilateral
decreased
uptake of
renal in
bone scan
superscan
Tumors
Non tumor
Prostate
Renal failure
Lungs
carcinoma
Breast
carcinoma
Bladder
carcinoma
Nephrectomy
Lymphoma
Hyperparathyroidism
Osteomalacia
Fibrous dysplasia
Pagets disease
Renal osteodystrophy
Breast carcinoma
Tumors that
metastasize to
bone
Lungs carcinoma
Prostate carcinoma
Lymphoma
Thyroid carcinoma
Renal carcinoma
Neuroblastoma
Multiple myeloma
Tumors falsely
normal in bone
scan
Severe anaplastic
tumors
Lytic lesions
Metal artifact
Differential
diagnosis of
cold defect in
bone scan
Radiation changes
Barium in bowel
Early avascular necrosis
Multiple myeloma
Benign tumor
Cysts
Osseous metastasis
Tumor marrow
involvement
Dystrophic
calcification
Calcification of
dying or dead
tissue
Metastatic
calcification
Normal tissue
with
hypercalcemia
Heterotrophic
Bone
formation
-infection
-osteomyelitis
-cellulitis
-thrombophlebitis
-DVT
-osteosarcoma
-osteochondroma
Calcinosis
cutis
-calcinosis
cutis universalis
-calcinosis
cutis circumcripta
-calciphylaxis
-rabdhomyolysis
Histocytosis X
Disease in which there are focal accumulation
of macrophages in various organs including
bones
Triad:
1. Letterer-Siwe disease
2. Hand-Schuller-Cristian disease
3. Eosinophilic granuloma of bone
Fibrous dysplasia
Bone dysplasia's
a/w skeletal
tracer uptake
Osteogenic imperfecta
Albers-Schenberg
Disease (Marble Bones)
Englemanns disease
Malorheosthosis
Ribbings disease
Fibrous dysplasia
Osteogenic imperfecta
Osteopetrosis
Albers-Schenberg Disease (Marble Bones)
Englemanns disease
Ribbings disease
(multiple diaphyseal sclerosis)
Melorheostosis
Metabolic bone
disease
Pagets disease
(osteitis deformans)
Osteoporosis
osteomalacia &
Rickets
Hyperparathyroidism
Renal osteodystrophy
Hypertrophic
osteoathroplathy
Renal
osteodystrophy
Primary
hyperparathyroidism
Osteomalacia
Hyperparathyroid
Hyperparathyroid
Hyperparathyroid
Metabolic features:
Differentiating
features
Metabolic features:
No tracer in bladder
Metabolic features:
Uncommon: brown
tumor & ectopic
calcification
pseudofractures
Aluminum
induced
osteomalacia
Osteoporosis
Fracture
Long bone
uptake
Intense linear
uptake at site of
vertebral
fracture
High
background
activity
May be
low/patchy
uptake at axial
skeletal
Infection
Stress fracture
Fatigue fracture
Insufficient fracture
Cause by repeated
abnormal fracture
on normal bone
Resulting from
normal stress on
abnormal bone
Legg-Calve-Perthes
4. Bone scan
TTFTT
8. Bone scan
TFFTT
Malignancy
A. In multiple myeloma the MDP bone scan is usually
abnormal
B. Increased MDP bone scan uptake into metastatic
deposits 2 months after chemotherapy indicates
failure of response and progression of disease
C. A solitary rib hot spot in a cancer patient usually
represent benign disease
D. A rib hot spot which is present over a year is likely to
represent a simple healing fracture
E. A solitary area of abnormal uptake is a patient with a
known primary cancer with normal plain film
appearances is likely to be benign
Malignancy
TFFFT
Bone island
Osteopoikilosis
Fibrous dysplasia
Melorheostosis
Eosinophilic granuloma
Infection
A. Both infection and loosening of a hip prosthesis will show
both increased vascularity and uptake on delayed images
B. Increased activity in relation to a knee prosthesis one year
after surgery nearly always signifies infection or loosening
C. Cellulitis in the limb may cause increased uptake into bone
on a bone scan
D. Uptake of Gallium into a bone at the site of increased uptake
on a bone scan nearly always signifies infection
E. Bone scan are less sensitive in detecting osteomyelitis in
neonates because of their small size
Infection
FFTFF
Myelosclerosis
Histocytosis
Metastases from osteogenic sarcoma
Hyperparathyroidism
Hyperthyroidism
Ovary
Prostate
Lung
Lymphoma
Breast
Malignant melanoma
Ewings sarcoma
Multiple myeloma
Hypernephroma
Colon carcinoma
Renal
Thyroid
Multiple myeloma
Lung
Stress fractures
1. Increased activity in a linear pattern along the
posterior and medial aspect of both mid tibias.
2. Shin splints
3. B , focal ovoid activity posteromedial right tibia
at the junction of the proximal 2/3 and distal
1/3. C, focal fusiform activity posteromedially in
the right proximal tibia and linear activity along
the posteromedial left tibia proximally and more
prominently distally.
4. B, stress fracture. C, stress fracture and shin
splints
Pagets disease
1. Abnormal increased uptake in the entire left femur,
which appears bowed and widened and the distal
third of the left tibia, which tapers proximally.
2. A sharp leading edge, referred to as flame shaped
or :blade of grass, may be demonstrated on the lytic
phase on radiograph and bone scan.
3. Pagets
disease,
fibrous
dysplasia,
chronic
osteomyelitis, primary bone tumors.
4. High output congestive heart failure may occur. Once
believed to be the result of arteriovenous shunting
within the bone lesion, now hyperemia and increased
blood flow through the lesion and not shunting are
likely the causes.
Rib fractures
1. Patient A; focal increased uptake in multiple ribs
posterolaterally
and
the
costovertebral
junctions. Patient B; increased vertical linear
uptake in the sternum from the manubrium to
the xiphoid.
2. The uptake in adjacent (patient A) and the
vertical uptake in the sternum both have a
geometric and characteristic pattern.
3. Trauma or surgery
4. Patient A; multiple rib fracture. Patient B;
median sternnotomy for coronary artery bypass
grafting (CABG)
Osteomyelitis
1. First phase; arterial blood flow to the bone.
Second phase; blood pool. Third phase; delayed
phase or bone uptake at 3 hours after injection.
All three phases are typically focally increased
with osteomyelitis. With cellulitis only two
phases are positive.
2. Increased flow, blood pool and delayed uptake
to the left first digit distal phalanx.
3. Consistent with osteomyelitis of the digit.
4. Sensitivity and specificity 95% if the radiograph
is normal or has only suggestive changes of
osteomyelitis.
Lymphedema
1. The soft tissues of the left arm enlarged and
show abnormal increased soft tissue activity,
the left anterior ribs are uniformly more
intense than the right.
2. Venous or lymphatic obstruction, soft tissue
neoplasm, soft tissue injury.
3. Breast cancer.
4. Lymphedema secondary to axillary lymph
node dissection and left mastectomy
Renal position
1. The right kidney is not in the renal fossa.
Nonuniform activity is noted in the right
sacroiliac region, which extends beyond the
expected superior margin of the bone.
2. Congenital renal anomaly, pelvic kidney.
3. Anomalies of number
(supernumerary
kidney), position (malrotation) and fusion
(horseshoe)
4. Yes. Ureteropelvic junction obstruction,
vesicoureteral reflux, decrease function and
increase risk of trauma.
Fibrous dysplasia
1. A , shows increased uptake in the entire
mandible. B, shows intense increased uptake
in the mandible and maxilla which appear
deformed and overgrown.
2. Check the rest of the bone scan for other
sites
3. Fibrous dysplasia, cherubism.
4. Fibrous dysplasia.
Heterotopic ossification
1. Intense activity is seen overlying the right
acetabulum with a separate area of uptake
overlying the proximal right femur.
2. Urinary contamination; fracture with exuberant
callus; heterotopic ossifican or myositis
ossificans; soft tissue injury (contusion).
3. If urinary contamination is suspected; remove
clothing and overlying bed sheets; wash the
patients skin in the area of suspected
contamination.
4. Heterotopic ossification.
Superscan
1. Increased tracer in the large majority of the
visualized
bones,
with
nonuniform
involvement in both femurs, both humeri and
skull.
2. Soft tissue and GI tract.
3. The kidneys are not visualized, but faint
activity is seen in the urinary bladder. Little
soft tissue activity is seen.
4. Superscan.
hyperparathyroidism
1. Abnormal diffuse uptake in the lungs and stomach.
Poor visualization of small kidneys and bladder,
increased uptake in the shoulders, hips, knees and
ankle.
2. Hyperparathyroidism, metastatic calcification caused
by hypercalcemia, renal failure or metabolic bone
disease.
3. This particular pattern of metastatic calcification is
characteristic of long standing hyperparathyroidism.
4. Free Tc-99m pertechnetate has gastric, thyroid and
salivary gland uptake. The latter two are not seen in
this patient, who also shows large uptake.
Myocardial uptake
1. Horseshoe pattern of uptake in the anterior
chest that does not correspond to normal
bony anatomy and therefore is most likely
abnormal soft tissue uptake.
2. Cardiac uptake either the myocardium or
pericardium.
3. Tc-99m pyrophosphate
4. Idiopathic or secondary cardiomyopathy e.g..
due to cardiotoxic drugs, myocarditis or
pericarditis.
Cardiac
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Tc-99m sestamibi/tetrofosmin
do not redistribute and best
images are made 30 to 90
minutes after injection to allow
clearance
of
interfering
background activity from the
liver but before the activity
reaches the transverse colon.
Infarcts
and
hibernating
myocardium produce perfusion
defects on the rest images.
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
Myocardial
perfusion imaging
parasympathetic
sympathetic
SA NODES
heart rate
ATRIUM
contractility
conduction velocity (
receptor )
VENTRICLE
CORONARY ARTERY
Constriction ( receptor )
Dilatation ( receptor )
Coronary artery
AV node
branch
Acute marginal
Branch (AM)
Posterior
descending
Artery (PDA)
Marginal
branches
Obtuse M1
& M2
Left anterior
Descending (LAD)
Diagonal
branches
D1 & D2
Septal
branches
CORONARY CIRCULATION
CORONARY ARTERY
VASCULAR DISTRIBUTIONS
Septum
Anterior wall
Apex
Lateral wall
Posterior wall
Posterior inferior wall
Apex
Inferior wall
Posterior inferior wall
Right ventricular wall
Anterior wall
Septum
Posterolateral wall
CONDUCTION SYSTEM
SA ( sinoatrium node )
Pacemaker of heart
Posterior wall of right atrium
Depolarize spontaneously 70-80 time/ min
Contraction of atrium
(interatrium septum)
(interventricular septum)
AV ( atrioventricular node )
( AV bundle )
PURKINJE FIBRES
INNERVATION
parasympathetic
sympathetic
SA NODES
heart rate
ATRIUM
contractility
conduction velocity (
receptor )
VENTRICLE
CORONARY ARTERY
Constriction ( receptor )
Dilatation ( receptor )
STROKE VOLUME
volume of blood pumped by left ventricle in 1
minute
SV ( STROKE VOLUME ) x HR ( HEART RATE )
VENTRICLE CONTRACTILITY
EF = EDV ESV X 100
EDV
ECG STAT
DR ZOOL HILMI
6 chest leads = V1 to V6
6 limb leads = I, II, III, aVR, aVL, aVF
-
INTERPRETATION OF ECG
RATE
RHYTHM
AXIS
P WAVE
PR INTERVAL
QRS COMPLEX
Q WAVE
ST SEGMENT
T WAVE
QT INTERVAL
U WAVE
RATE
Tachycardia > 100 beats /min
Bradycardia < 60 beats/min
Heart rate = 300/ no of large square btw 2 R
Irregular rhythm HR = no of intervals btw QRS
complexes in 10 seconds X 6 (lead II = 25 cm
=10 seconds = 50 large square)
IMPORTANT
PR = 3 5 SMALL SQUARE / 0.12 0.2 SECONDS
QRS 3 SMALL SQUARE / 0.12 SECONDS
BBB > 3 SMALL SQUARE
QT < 11 SMALL SQUARE OR < 0.44 SECONDS OR
< 0.5 RR INTERVAL
CORRECTED QT = QT/RR
RHYTHM
Lead II
Sinus rhythm = originates in the sinus node and
conduct to the ventricle
CARDIAC AXIS
LEAD I
LEAD II
LEAD III
NORMAL
AXIS
RIGHT AXIS
DEVIATION
LEFT AXIS
DEVIATION
+
+
+/-
+/+
+
-
CARDIAC AXIS
LEAD I
AVF
NORMAL
LEFT AXIS
+ & (LEAD II -)
RIGHT AXIS
INDETERMINATE
RIGHT AXIS
LVH
RVH
INFERIOR MI
LATERAL MI
LEFT ANTERIOR
FASCICULAR BLOCK
LEFT POSTERIOR
FASCICULAR BLOCK
Tall R waves
Prominent U waves
Exaggerated sinus arrhythmia
Sinus bradycardia
Wandering atrial pacemaker
Wenckebach phenomenon
Junctional rhythm
1st degree heart block
ST segment elevation(high take off, benign early
repolarization)
P WAVE
Atrial depolarization
Characteristic of the P wave:
positive in leads I and II
Best seen in lead II and V1
Commonly biphasic in lead V1
< 3 small square (0.12s)in duration
< 2.5 small square (0.25mV) in amplitude
NORMAL ECG
P WAVE
Bifid P, in lead II , notch with peak to peak interval
of > 1 mm = mitral stenosis
P WAVE
Large negative
deflection = left atrial
enlargement
PR INTERVAL
Electrical impulse conducted through the AV
node, the bundle of His and bundle branches
and the Purkinje fibers
QRS COMPLEX
Ventricular depolarization
Not > 2 small square (0.10 s)
BBB > (0.12 s) wide QRS
Q wave : any initial negative deflection
R wave : any positive deflection
S wave : any negative deflection after R wave
Non pathological Q wave seen at: leads I, III,
aVL, V5 and V6
ST SEGMENT
QRS complex terminates at the J point or ST
junction
ST segment lies between the J point and the
beginning of the T wave
Period between the end of ventricular
depolarization and the beginning of the
repolarization
ST SEGMENT
Leads V1 to V3, rapidly S wave merges directly
with the T wave, making the J point indistinct
and the ST segment difficult to identify
EARLY REPOLARISATION
T WAVE
Ventricular repolarization
Normal T is ASYMMETRICAL
SYMMETRICAL, Inverted T = myocardial
ischemia
Tall T wave = MI and hyperkalemia
T wave < 2/3 amplitude of R
T wave amplitude < 10 mm
QT INTERVAL
Total
time
for
depolarization
and
repolarization of the ventricle
Beginning of the QRS complex to the end of
the T wave
0.35 0.45 s
U WAVE
Small deflection that follows the T wave
Most prominent in leads V2 to V4
Prominent U = athletes/ hypokalemia/
hypercalcemia
PROMINENT U WAVE
CONDITIONS AFFECTING
THE LEFT SIDE OF THE
HEART
2. LVH
dilatation
and
Biphasic P wave in V1
TAHCYCARDIA
TAHCYCARDIA
Divided into 2:
1. Supraventricular
tachycardia
2. Ventricular
tachycardia
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
From atria or sinoatrial node
1. Sinus tachycardia
2. Atrial fibrillation
3. Atrial flutter
From atrioventricular node
1. Atrioventricular re-entrant tachycardia
2. Atrioventricular nodal re-entrant tachycardia
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
At the atrium
Above bundle of
His
Narrow complex
tachycardia
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
SINUS TACHYCARDIA
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
SINUS TACHYCARDIA
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
SINUS TACHYCARDIA
Normal P wave in
inferior lead II,III
and aVF
Atrial rate 100-200
bpm
Regular ventricular
rhythm
Ventricular rate 100200 bpm
ATRIAL FIBRILATION
ATRIAL FIBRILATION
NO P WAVES IN AF
ATRIAL FIBRILATION
Mapping
R
waves
against a piece of paper
usually
confirm
diagnosis
May be paroxysmal,
persistent
or
permanent
Treatment : Digoxin
ATRIAL FIBRILATION
ATRIAL FIBRILATION
IRREGULARLY IRREGULAR
NO P WAVE
ATRIAL FLUTTER
ATRIAL FLUTTER
Re-entry circuit in the
right
atrium
with
secondary activation of
left atrium
Atrial contraction 300
bpm
Broad
and
appear
sawtooth best seen at
inferior leads and V1
ATRIAL FLUTTER
JUNCTIONAL TACHYCARDIA
JUNCTIONAL TACHYCARDIA
Negative P waves in
inferior leads
JUNCTIONAL TACHYCARDIA
PR interval < 3 ss
P
wave
negative
deflection in lead II
SUPRAVENTRICULAR TACHYCARDIA
(SVT)
JUNCTIONAL TACHYCARDIA
WOLF PARKINSON
WHITE SYNDROM
Atrioventricular reentrant tachycardia
Electrical signal reenters the atria over
an abnormal extra
pathway
JUNCTIONAL TACHYCARDIA
WOLF
PARKINSON
WHITE SYNDROM
This extra pathway
allows electrical signals
to pass between the
ventricles and atria
Signals on this extra
pathways causing the
atria and ventricles to
beat too fast
JUNCTIONAL TACHYCARDIA
WOLF PARKINSON
WHITE SYNDROM
Short PR interval < 3
small square
Slurred upstroke to
the QRS indicating
pre-excitation (delta
wave)
Broad QRS
VENTRICULAR TACHYCARDIA
At the ventricle
Below bifurcation
bundle of His
Broad
QRS
complex
tachycardia
VENTRICULAR TACHYCARDIA
VENTRICULAR TACHYCARDIA
ATRIOVENTRICULAR CONDUCTION
BLOCK
Delayed 1st degree block
Intermittently blocked 2nd degree block
Completely blocked 3rd degree block
Causes:
1. MI
2. Degeneration of His Purkinje system
3. Lyme disease, diphtheria
4. Surgery
5. Congenital disorder
Prolonged PR
MOBITZ TYPE II
AV BLOCK SUMMURY
1st DEGREE AV BLOCK
All P waves conducted with prolonged PR
2nd DEGREE AV BLOCK
Some P waves not conducted
Mobitz type I : Progressive PR prolongation
Mobitz type II : Constant PR interval
3rd DEGREE AV BLOCK
No P waves conducted
COMPLETE RBBB
QRS prolongation (
0.12s)
Slurred S wave in
lead V6 and/or rSR
pattern in lead V1
Overall positive QRS
complex in lead V1
(a must)
RBBB
COMPLETE LBBB
QRS prolongation (
0.12s)
Broad R waves in
lead I and V6 with
no Q waves
Broad S waves in the
septal leads
LBBB
HYPERKALAEMIA
Potassium
concentration rises
above
5.5-6.5
mmol/L
Classic
tall,
symmetrically
narrow and peaked T
waves
HYPOKALEMIA
Serum potassium <
2.7 mmol/L
Broad, flat T waves
ST depression
QT
interval
prolongation
STEMI
STEMI
STEMI
STEMI
STEMI
Normal Q wave
STEMI
STEMI
Viable myocardium
STEMI
ECG
ONSET
RESOLUTION
HYPERACUTE T WAVE
CHANGES
< 5 MINUTES
HOURS
ST ELEVATION
< 20 MINUTES
HOURS TO 3 DAYS
HOURS
HOURS
Q WAVE FORMATION
9 HOURS TO 2 DAYS
PERMANENT
T WAVE INVERSION
VARIABLE
WEEKS
STEMI LOCALISATION
NSTEMI/UNSTABLE ANGINA
NSTEMI/UNSTABLE ANGINA
T INVERSION
NSTEMI/UNSTABLE ANGINA
NSTEMI/UNSTABLE ANGINA
SUMMARY
COMPLETE OCCLUSION
(STEMI)
PARTIAL OCCLUSION
(NSTEMI)
ST ELEVATION
ST DEPRESSION
Q WAVES
T INVERSION
NO Q WAVES
FULL THICKNESS MI
NON Q WAVE MI
Q WAVE MI
PARTIAL THICKNESS MI
TRANSMURAL MI
SUBENDOCARDIAL MI
Pyrophosphate
Glucarate
Antimyosin
Teboroxime
Myocardial perfusion
imaging (MPI)
Fatty acid
NOET
Infarct avid
Single photon
N13
Metabolic
PET
Thallium
Rb82
FDG
O15
Tetrofosmin
Sestamibi
Cardiac scan
Neuronal
Radionuclide
ventriculography
C11epinephrine
Planar
PET
Tc-99m labeled
C11hydroxyephdrine
MIBG
C11phenylephrine
Tc-99m DTPA
Tc-99m RBC
MUGA
First pass
Tc-99m serum
Human albumin
Tc-99m
pertechnitate
Thalium-201
Tc-99m Sestamibi
( Cardiolite )
Tc-99m Tetrofosmin
( Myoview )
Chemical
Element cation
Isonitrile cation
Diphosphine cation
Preparation
cyclotron
Generator/kit
Generator/kit
Mode of decay
Electron capture
Isomeric transition
Isomeric transition
Half life
73 H
6H
6H
Principle emissions
Mechanism of uptake
Active transport
Passive diffusion
Passive diffusion
Myocyte localization
Cytosol
Mitochondria
Mitochondria
Redistribution
Yes
No
No
Extraction fraction
85%
60%
50%
3%
1.5%
1.2%
Body clearance
Renal
Hepatic
Hepatic
Highest radiation
absorbed dose
Kidney
( rads/3mCi )
Colon
( rads/30mCi )
Gallbladder
( rads/30mCi )
Imaging time
Stress
Rest
10 min
3-4 hrs
15-30 min
30-90 min
5-15 min
30 min
WHAT IS REDISTRIBUTION?
REDISTRIBUTION
Only occurs with Tl 201
Is misnomer
Tl 201 exits the myocardium more slowly from
ischemic segments
In delayed imaging, more rapid exit of Tl 201
from normal segments result in equilibrium
among normal and ischemic segment
STUNNED MYOCARDIUM
Myocardium with persistent contractile
dysfunction despite restoration of perfusion
after ischemia
Improves with time
Normal by perfusion imaging
Absence of ventricular contraction on wall
motion studies
Increased uptake by FDG
WHAT IS HIBERNATING
MYOCARDIUM?
HIBERNATING MYOCARDIUM
Chronically ischemic myocardium that is still
viable
Appears cold on immediate Tl 201 imaging
Absence of ventricular contraction on wall
motion studies
Increased uptake of FDG compared to
perfusion imaging
Improved perfusion on reinjection of Tl 201
Normal scan
Stress (top) and rest (bottom) MPI images from normal male subject
ISCHEMIC MYOCARDIUM
Reduced Tl 201 myocardial uptake on post
stress images
Improves uptake on the rest images
Apical ischemia
Stress (top) and rest (bottom) MPI images from a subject with apical
ischemia.
SCAR IMAGES ?
SCAR
Reduced Tl 201 myocardial uptake post stress
images
Reduced uptake on the rest images
Antero-apical infarct
Stress (top) and rest (bottom) MPI images from a patient with prior
extensive antero-apical MI and no residual ischemia.
MYOCARDIAL IMAGING
RADIOPHARMACEUTICAL
DOSE ( mCi )
IMAGING TECHNIQUE
TYPE OF STUDY
Tl Cl
2-3
Planar or SPECT
Perfusion
Tc 99m sestaMIBI
10-30
Planar or SPECT
Perfusion
Tc 99m teboroxime
15-30
Planar or SPECT
Perfusion
Tc 99m PYP
10-15
Planar
Infarct
In labeled antimyosin
antibody
2-3
Planar
Infarct
RbCl
60
PET
Perfusion
NH
15-20
PET
Perfusion
F-FDG
5-10
PET
Metabolism
Specificity
Myocardial
Perfusion Scan
93%
88%
Stress
Echocardiography
81%
82%
Exercise Stress
Test
68%
77%
CONTRAINDICATIONS FOR
MYOCARDIAL PERFUSION
Chest pain
Ventricular arrhythmia at rest
Very high BP
Allergy to pharmacological stress drugs
Third degree heart block
Severe valvular disease ( aortic valve stenosis )
Dobutamine
X3
Treadmill exercise
X2
Resting blood flow
X1
50
100
% diameter narrowing
STRESS PROTOCOLS
1. PHYSICAL EXERCISE
2. PHARMACOLOGICAL STRESS
Acute MI
Unstable angina
Severe tachyarrhythmias and bradyarrhythmias
Uncontrolled symptomatic heart failure
Critical aortic stenosis
Acute aortic dissection
Pulmonary embolism
Poorly controlled HPT
Myoview counseling
Stop medications:
At the appointment date :
1. Aspirin
2. OHA/insulin
2 days prior :
1. Neulin (theophylline)
2. Beta blockers
3. Viagra
3 days prior :
1. Nitrates/trimetazidine
PHARMACOLOGIC STRESS
Dipyridamole
Adenosine
Dobutamine
STRESS PROTOCOLS
1.PHYSICAL EXERCISE
2. PHARMACOLOGICAL STRESS
PHYSICAL EXERCISE
Treadmill or bicycle
ECG 10-12 lead used
Run baseline ECG
Start exercise
Monitor HR, BP, ECG changes till target HR is
achieved > 85% of ( 220-AGE )
Radiotracer is injected when target HR is reached
Maintain exercise for 1 minute
STRESS PROTOCOLS
1. PHYSICAL EXERCISE
2.PHARMACOLOGICAL
STRESS
PHARMACOLOGICAL STRESS
1. ADENOSINE
2. DOBUTAMINE
3. DIPYRIDAMOLE
Dobutamine
adrenergic agonist
Synthetic catecholamine
1 affinity
Short plasma half life
Cause ionotrophic/chronotrophic effect due
to high O2 demand cause by artery stenosis
Infusion rate (40-50 g/kg/min)
Dobutamine
Can be used in asthma patients
Side effect:
Supraventricular and ventricular arrhythmia
Palpitation
SOB
GI symptom
Chest pain
Dobutamine
Contraindications:
ST depression
Ventricular tachycardia
Systolic BP > 220 mmHg
Adenosine
Dypiridamole
Dobutamine
Mechanism of
action
Direct
Indirect
Indirect
Half life
< 10 s
30 60 min
2 min
Onset of action
Seconds
2 min
1 2 min
0.6%
16%
NA
ADENOSINE ( % )
DIPYRIDAMOLE ( % )
Flushing
37
Dyspnea
35
Chest pain
25
20
GI symptoms
15
Headache
14
12
Dizziness
12
A-V block
ST wave changes
Arrhythmia
Hypotension
Bronchospasm
0.1
0.15
MI
0.0001
0.05
Death
0.5
Stress (top) and rest (bottom) MPI images from a female subject
showing a reduction in counts anteriorly in both stress and rest
images.
Reporting MPI
PET Cardiac
IMAGING OF INFARCT
1. Tc pyrophosphate is the infarct avid imaging
procedure of choice
2. Pyrophosphate uptake is taken more around the
infarct than in the infarct
3. Myosin monoclonal antibody is useful only in
imaged within 2-3 days after administration
4. Pyrophosphate is taken up by bone
5. Images are acquired after 48 hours in myosin
antibody
IMAGING OF INFARCT
1. Tc pyrophosphate is the infarct avid imaging
procedure of choice
2. Pyrophosphate uptake is taken more around the
infarct than in the infarct
3. Myosin monoclonal antibody is useful only in
imaged within 2-3 days after administration
4. Pyrophosphate is taken up by bone
5. Images are acquired after 48 hours in myosin
antibody
FTFTF
CONTRAINDICATION FOR
MYOCARDIAL PERFUSION IMAGING (
EXERSICE STRESS )
1.
2.
3.
4.
5.
Sinus bradycardia
Third degree heart block
Ventricular arrhythmias
Aortic stenosis
Unstable angina
CONTRAINDICATION FOR
MYOCARDIAL PERFUSION IMAGING (
EXERSICE STRESS )
1. Sinus bradycardia
2. Third degree heart block
3. Ventricular arrhythmias
4. Aortic stenosis
5. Unstable angina
FTTTT
CARDIAC SCINTIGRAPHY
1. LAO best for left ventricle
2. RAO 30 best for right ventricle
3. For assessing RV ejection fraction, inject the
tight bolus
4. For shunt quantification, inject over 3
seconds
5. First pass takes 15 seconds
CARDIAC SCINTIGRAPHY
1. LAO best for left ventricle
2. RAO 30 best for right ventricle
3. For assessing RV ejection fraction, inject the
tight bolus
4. For shunt quantification, inject over 3
seconds
5. First pass takes 15 seconds
TTFFT
CARDIAC SCINTIGRAPHY
1. MIBI is more prone for liver uptake
2. Tetrofosmin is easier to prepare than MIBI
3. Stannous pyrophosphate and pertechnate
are mixed before administrating in vein
4. MUGA scan are better than LIST studies
5. Acquisition begins with R wave of each cycle
CARDIAC SCINTIGRAPHY
1. MIBI is more prone for liver uptake
2. Tetrofosmin is easier to prepare than MIBI
3. Stannous pyrophosphate and pertechnate
are mixed before administrating in vein
4. MUGA scan are better than LIST studies
5. Acquisition begins with R wave of each cycle
TTFTT
THALLIUM 201
1. Decays by electron capture to Tl 203
2. Mainly produce gamma photon of 135 and
167 keV
3. After IV administration 15% is localized in the
myocardium
4. All the thallium ions enter the myocytes by
the sodium potassium ATPase pump
5. Extraction of thallium is reduced in acidosis
THALLIUM 201
1. Decays by electron capture to Tl 203
2. Mainly produce gamma photon of 135 and 167
keV
3. After IV administration 15% is localized in the
myocardium
4. All the thallium ions enter the myocytes by the
sodium potassium ATPase pump
5. Extraction of thallium is reduced in acidosis
FFFFF
FEATURES OF HIBERNATING
MYOCARDIUM
1. Reversible
2. FDG PET is the standard for assessing
myocardial viability
3. Adverse cardiac events in these patients are
higher if treated with revascularization
4. Decreased uptake in FDG
5. Decreased perfusion in thallium scans
FEATURES OF HIBERNATING
MYOCARDIUM
1. Reversible
2. FDG PET is the standard for assessing
myocardial viability
3. Adverse cardiac events in these patients are
higher if treated with revascularization
4. Decreased uptake in FDG
5. Decreased perfusion in thallium scans
TTFFT
THALLIUM SCINTIGRAPHY
1. Involves a lower radiation dose than Tc99m
MIBI scanning
2. Reverse redistribution is commonly due to
artifact
3. Injection is performed at peak exercise
4. There is increased uptake in areas of
myocardial infarction
5. Is more sensitive than cardiac stress testing
THALLIUM SCINTIGRAPHY
1. Involves a lower radiation dose than Tc99m MIBI
scanning
2. Reverse redistribution is commonly due to
artifact
3. Injection is performed at peak exercise
4. There is increased uptake in areas of myocardial
infarction
5. Is more sensitive than cardiac stress testing
FTTFT
THALLIUM 201
1. Kidney is the critical organ
2. Distribution is proportional to perfusion
3. Physical half life is 24 hours, making it low
dose
4. Images are of high resolution
5. High signal to noise ratio
THALLIUM 201
1. Kidney is the critical organ
2. Distribution is proportional to perfusion
3. Physical half life is 24 hours, making it low
dose
4. Images are of high resolution
5. High signal to noise ratio
TTFFF
Nitrogen 13 ammonia
Rubidium 82
Potassium 38
Oxygen 15 labeled water
Inhaled 15 CO2
Kidney
Lungs
Salivary glands
Skeletal muscle
Liver
STRESS TESTING
1. Adenosine combined with exercise improves
detection of perfusion defects
2. Dobutamine avoided if patient has asthma
3. Adenosine should be avoided if patient has
bifascicular block or LBBB
4. Bradyarrhythmia is reduced by exercise
5. Dipyridamole has the highest sensitivity and
specificity among pharmacological agents
STRESS TESTING
1. Adenosine combined with exercise improves
detection of perfusion defects
2. Dobutamine avoided if patient has asthma
3. Adenosine should be avoided if patient has
bifascicular block or LBBB
4. Bradyarrhythmia is reduced by exercise
5. Dipyridamole has the highest sensitivity and
specificity among pharmacological agents
TFFTF
Graves disease
Thyroid ca
Bronchogenic ca in lung
Lymphoma of lung
Brain in encephalitis
MYOCARDIAL PERFUSION
SCINTIGRAPHY
1. The physical properties of thallium 201 are such that
its use is preferable to that of Tc99m labeled
compounds in myocardial perfusion imaging
2. The effective dose from Tl 201 myocardial perfusion
scan is one of the highest in diagnostic imaging and
roughly equates to 3 barium enemas
3. The uptake of Tl 201 relies solely on regional
myocardial perfusion
4. Tl 201 is a Na analogue
5. Tl 201 remains irreversibly fixed to the myocardium
within a few minutes of injection
MYOCARDIAL PERFUSION
SCINTIGRAPHY
1. The physical properties of thallium 201 are such that
its use is preferable to that of Tc99m labeled
compounds in myocardial perfusion imaging
2. The effective dose from Tl 201 myocardial perfusion
scan is one of the highest in diagnostic imaging and
roughly equates to 3 barium enemas
3. The uptake of Tl 201 relies solely on regional
myocardial perfusion
4. Tl 201 is a Na analogue
5. Tl 201 remains irreversibly fixed to the myocardium
within a few minutes of injection
FTFFF
Myocardial infarction
Hibernating myocardium
Cardiomyopathy
Cardiac sarcoidosis
Dobutamine
CONCERNING PHARMACOLOGICAL
STRESSOR AGENTS
1. Dipyridamole reduces uptake of myocardial
perfusion agents to myocardial
2. Adenosine may be use as a cardiac stressor
3. Caffeine intake should be restricted before an
exercise myocardial perfusion
4. Aminophylline may reverse chest pain caused
by dipyridamole
5. Dipyridamole is a potent coronary
vasodilator
CONCERNING PHARMACOLOGICAL
STRESSOR AGENTS
1. Dipyridamole reduces uptake of myocardial
perfusion agents to myocardial
2. Adenosine may be use as a cardiac stressor
3. Caffeine intake should be restricted before an
exercise myocardial perfusion
4. Aminophylline may reverse chest pain caused by
dipyridamole
5. Dipyridamole is a potent coronary vasodilator
FTTTT
RADIONUCLIDE VENTRICULOGRAPHY
1. Radionuclide ventriculography is a more accurate and
reproducible method for measuring ejection fraction than
echocardiography
2. Assumptions for the calculation of ejection fraction are
greater for echocardiography than they are for
radionuclide ventriculography
3. In severe left ventricular dysfunction the volume of
injected radiopharmaceutical is reduced to avoid overload
4. Exercise ventriculography is not possible because there is
too much motion of the patient
5. It is not possible to measure RV ejection fraction using
gated equilibrium technique
RADIONUCLIDE VENTRICULOGRAPHY
1. Radionuclide ventriculography is a more accurate and
reproducible method for measuring ejection fraction than
echocardiography
2. Assumptions for the calculation of ejection fraction are
greater for echocardiography than they are for
radionuclide ventriculography
3. In severe left ventricular dysfunction the volume of
injected radiopharmaceutical is reduced to avoid overload
4. Exercise ventriculography is not possible because there is
too much motion of the patient
5. It is not possible to measure RV ejection fraction using
gated equilibrium technique
TTFFF
Disadvantages
High radiation
Poor imaging characteristics
with a low photopeak of 69
80 keV
High scatter fraction
LAD ischemia
1. Severe decreased perfusion in the majority of
the anterior wall, apex and septum which
normalizes on the rest image indicating
extensive severe ischemia.
2. LAD territory.
3. Transient cavity dilatation.
4. VT, angina related ST abnormalities,
decreased systolic pressure and level of
exercise achieved.
Apical infarct
1. Fixed stress and rest severe apical perfusion
defect. Heart and cavity size appear normal.
2. Myocardial infarction, apical thinning and
attenuation.
3. Small apical lateral scar.
4. Technical factors, operator error and
interpretation error
Breast attenuation
1. Mild fixed anteroseptal hypoperfusion that
demonstrates uniform brightening on gated
SPECT, indicating normal myocardial wall
thickening on gated images.
2. Apparent decreased tracer in the upper
portions of the heart is most obvious on the
left anterior oblique and lateral frames.
3. Normal perfusion study with normal wall
thickening and breast attenuation.
4. Assessment of regional wall motion/ wall
thickening and LVEF
Adenosine stress
1. A. adenosine is infused IV for 6 minutes (140
g/kg/min) after 3 min the tracer is injected and
adenosine is continued for 3 more minutes. B.
adenosine is cleared from circulation <10 sec. return
to baseline blood flow levels occurs in 2 to 3 minutes
after stopping the infusion. C. stop infusion
2. Sinus node disease, 2nd to 3rd degree block,
bronchospastic lung disease and adenosine allergy
3. Small to moderate severe fixed defect at the apex on
both stress and rest images consistent with infarct.
Mildly improved perfusion of the anterior and lateral
walls at rest compared with stress consistent with
mild anterolateral ischemia.
4. Whenever adequate exercise stress is not possible.
Viability
1. Extensive fixed defects involving the anterior
wall, apex, septum extending to the lateral
wall.
2. Myocardial infarction vs. hibernating
myocardium.
3. In hibernating myocardium, blood flow and
function e.g.. contractility are chronically
reduced.
4. Blood flow is normal with reduced function.
Bulls eye
1. A polar plot is constructed by layering short axis slices
one on top of the other with the apex forming the
center and the base of the heart being the outermost
portion.
2. Misregistration use of inappropriate reference
database.
3. Stress; hypoperfusion of the anterior, lateral and
inferior walls. Rest; normalized perfusion of the
anterior and lateral walls and incomplete
normalization of the inferior wall. Most consistent
with ischemia of the LCX and infarct of the right RCA.
4. Include location and extent, severity and reversibility
for each perfusion abnormality. If gated SPECT is
performed, include LVEF, wall motion with or without
wall thickening fractions.
Inadequate stress
1. Severe fixed defect involving the both entire
lateral wall
2. Dilated left ventricular cavity at both stress
and rest.
3. LCX artery
4. False negative studies for ischemia may result
LBBB
1. Dipyridamole or adenosine
2. Exercise or dobutamine. Methods of stress that
result in increased heart rate can be associated
with false positive findings of septal reversibility
in patient with LBBB
3. These agents do not result in an increased in
heart rate.
4. The mild decreased activity in the anterior wall
appears fixed and likely is caused by breast
attenuation in light of the reported normal wall
motion.
Dobutamine stress
1. Dobutamine stress; patients who are not
candidate for either exercise; asthma
2. Angina and inability to tolerate dobutamine
3. Mild fixed anteroseptal perfusion defect with
decreased wall thickening. Severe fixed
inferior defect with absent wall thickening.
Dilate LV. No reversibility. Myocardial
thickening and wall motion signify
functioning viable myocardium.
Breast attenuation
1. Tc-99m sestamibi, tetrofosmin and not Tl-201
because the GB is seen.
2. Mild fixed defect in the anterior wall.
Projection images; decreased uptake in the
half of the heart at stress and rest
3. Breast attenuation, anterior wall infarction.
4. Assessment of regional wall motion, wall
thickening and EF
Bowel activity
1. Dipyridamole inhibits the action of adenosine
diaminase, increasing endogenous adenosine, a
potent coronary artery vasodilatation. Coffee, tea,
caffeine containing soft drinks or chocolate,
theophylline and aminophylline.
2. Dipyridamole is infused for 4 minutes. Tracer is given
3 minutes after completion of dipyridamole infusion.
Side effects can be reversed with aminophylline.
3. Mild to moderate fixed defect of the anterior wall.
Severe, mostly fixed defect involving the entire
inferior wall but small area of reversibility in the
inferioapical region. Dilated LV.
4. Obtained delayed SPECT to allow additional hepatic
clearance or movement of bowel activity, have the
patient drink water.
Brain scintigraphy
Brain imaging
Brain imaging
Brain imaging
Brain imaging
CSF imaging
CSF imaging
CSF imaging
FDG
RADIOPHARMACEUTICALS
F-18 FDG
PATIENT PREPARATION
UNDERSTANDING THE
REPORT
Seizures
Diaschisis
POTENTIAL PROBLEMS
False positive
False negative
Thyroid disease
PATIENT PREPARATION
Seizures
Diaschisis
POTENTIAL PROBLEMS
Age of infarct
Luxury perfusion
PATIENT PREPARATION
- Tc-99m pertechnitate / DTPA bolus (20 mCi) for cerebral blood flow
- Tc-99m HMPAO / ECD (15 30 mCi), delayed images from 20 min to 2 hours post
injection
No specific preparation
Absent of cerebral blood flow
UNDERSTANDING THE
REPORT
POTENTIAL PROBLEMS
Barbiturates or
hypothermia
False negative
Continuum of
brain death
PATIENT PREPARATION
UNDERSTANDING THE
REPORT
Multiinfarct
dementia or
Alzheimers
disease
PATIENT PREPARATION
No special preparation
Normal brain
UNDERSTANDING THE
REPORT
POTENTIAL PROBLEMS
False negative
Radionuclide Cysternogram
RADIOPHARMACEUTICALS
PATIENT PREPARATION
UNDERSTANDING THE
REPORT
Indium-111 DTPA
3 days half life
Study requires 24 72 hours
- LP is performed
- In-111 DTPA (9-18 MBq) into intrathecal
- Image at 1-4 hr, 24 hr, up to 48 72 hr
- Lumbar puncture should be informed to patient before
procedure
- LP and radiotracer administration under fluoroscopic
guidance
Normally radiotracer reaches basal cisterns by 1 hr,
frontal poles and Sylvian fissures by 2 6 hr
Convexity by 12 hr
Sagittal sinus by 24 hr
Lumbar puncture
Overlapping
patterns
POTENTIAL PROBLEMS
Cysternography protocol
CSF leak
RADIOPHARMACEUTICALS
PATIENT PREPARATION
UNDERSTANDING THE
REPORT
Indium-111 DTPA
3 days half life
- Before the exam, labeled cotton pledgets are placed into the nasal
cavity and/or ears by ENT
- In-111 DTPA is introduced into the thecal sac via LP (9 18 MBq)
- Patient lies supine or in Trendelenberg
- Image at 1 4 hr
- Patient may be asked to Valsalva to increased CSF pressure
- The pledgets usually withdrawn when leak is detected or at 4 24 hr
and weighed and counted for radioactivity
- Plasma sample is collected to calculate a pledget to plasma
radioactivity ratio because CSF is absorbed into the blood stream
and will appear in normal nasal secretions
- Further delayed up to 72 hr
-
POTENTIAL PROBLEMS
PATIENT PREPARATION
UNDERSTANDING THE
REPORT
POTENTIAL PROBLEMS
Peri shunt injection injecting not into reservoir will cause false
positive
Pricks disease
Multiinfarct dementia
Alzheimers disease
Huntingtons disease
Wilsons disease
AIDS dementia
Brain death
Stroke
Tumor
Trauma
TIA
Cortical cerebral imaging
Epilepsy
Dimentia
AIDS
PSY
Movement disorder
Alzheimer
Schizo
Attention deficit
Huntingtons
chorea
Lewi body
Obsessive compulsive
Pricks disease
Multi infarct
Parkinson
Brain
Brain perfusion
Brain tumors
Metabolism
Cysternography
Tc-99m
glucoheptonate
IMP
I-123 iodoamphetamine
F-18 FDG
F-18 FDG
Tc-99m DTPA
Indium-111 pentreotide
Tc-99m DTPA
Tc-99m ECD
Ethyl cysteinate dimer
Tc-99m sestamibi
Tc-99m HMPAO
Thallium-201
Indium-111
DTPA
CNS
Diffusible lipophilic
Tc-99m HMPAO
Non diffusible
Tc-99m pertechnetate
Tc-99m ECD
Tc-99m DTPA
F-Flurodopa
FDG
Tc-99m HMPAO
Tc-99m ECD
Accumulation
Frontal
thalamus
cerebellum
parietal
occipital
Extraction
80%
60-70%
1 hour 5%
Good brain to background
ratio
Imaging time
Excretion
Renal and GI
Dementia
Temporoparietal
hypoperfusion
Frontotemporal
hypoperfusion
Multiple
focal defects
Pricks
Alzheimer
AIDS
Pseudodepressive
Parkinson
Lewy body
Chronic alcoholism
Creutzfeldt-Jakob
Schizo
Multi infarct
Progressive
supranuclear palsy
Normo pressure
hydrocephalia
Frontotemporal
degeneration
Brain SPECT
A. The distribution of Tc-99m HMPAO reflects regional
glucose metabolism
B. Tc-99m HMPAO has to be used within 30 min of being
prepared
C. It is helpful to create images in the axis of temporal
lobes when investigating temporal lobe epilepsy
D. Bright light or loud sounds at the time of injection
may alter the distribution of Tc-99m HMPAO
E. It is possible to accurately assess the size of lateral
ventricles with brain blood flow tracer
Brain SPECT
FTTTF
Concerning dementia
A. Increased accumulation of cerebral blood flow tracer
is seen in the frontal lobes in Pricks disease
B. Abnormalities in Alzheimers disease are often
bilateral and predominantly effect temporal and
parietal lobe
C. AIDS dementia complex usually shows no
abnormalities on brain SPECT imaging
D. Typical blood flow changes are seen in the basal
ganglia in asymptomatic patients with Huntingtons
chorea
E. A characteristic pattern of reduced rCBF is seen in
idiopathic Parkinsons disease
Concerning dementia
FTFTF
Pearl
A hot nose may be seen on the flow phase
images and delayed images as a result of
shunting of the blood from the internal to the
external carotid system that supplies the face
and the nose in patients with severe carotid
stenosis, brain death, psychoactive drug use
and use of other drugs that cause nasal
congestion.
Brain death
1. Flat EEG :hypothermia/ barbiturates/ depressive
drugs
2. Deep coma/ no spontaneous breathing/ no
brain stem reflex
3. Tc-99m DTPA/ Tc-99m pertechnetate or Tc-99m
HMPAO/ Tc-99m ECD
4. Tc-99m DTPA no blood flow to cerebral cortex,
Tc-99m HMPAO shows salivary gland/ normal
brain perfusion cerebral cortical activity seen
Cerebral infarct
1. F18- FDG is dependent on glucose metabolism
2. SPECT Tc-99m HMPAO/ ECD are cerebral
perfusion agents that are lipid soluble, distribute
according to blood flow (gray to white matter
ratio, 3:1 to 4:1) and fix intracellularly
3. Wedge shape severe decreased metabolism in
the left posterior parietal region
4. Cerebral hemorrhage/ infarct/ neoplasm
Seizure disorder
1. Decreased metabolism in the left temporal lobe.
2. Temporal lobe infarct, benign mass or lower
grade tumor, post RT changes, interictal left
temporal lobe seizure focus.
3. Interictal left temporal lobe seizure focus.
4. Conformation of the location of the seizure
focus in a candidate for temporal lobe
lobectomy. Study is an alternative to surgical
depth electrode placement.
Alzheimers disease
1. Multiinfarct, Alzheimer's disease, AIDs related,
substance abuse, alcoholism, Parkinsons
disease, Pricks, Creutzfeldt-Jacob disease,
depression, metabolic.
2. Diagnostic pattern using Tc-99m HMPAO, ECD or
FDG PET: multiinfarct dementia or Alzheimers.
3. Hypometabolism (decreased FDG uptake) of the
posterior parietal and temporal lobes bilaterally
and to a lesser extent the frontal lobes.
4. Alzheimers disease > 80%
Pricks disease
1. Alzheimers disease, multiinfarct, late stage
Parkinsons disease, metabolic, drug related and
depression.
2. The lipophilic Tc-99m HMPAO or ECD, cross the
intact BBB and have rapid intracellular uptake in
proportion to cerebral blood flow. They are fixed
intracellularly. Subsequent imaging provide a
snapshot of the blood flow pattern at the time
of injection.
3. Alzheimers, multiinfarct or Pricks disease
4. Decreased blood flow in the frontal cortex
bilaterally as a result of frontal lobe dementia.
Herpes Encephalitis
1. Increased uptake in the temporal lobe
2. Increased blood flow in this region
3. Seizure focus (ictal injection), infection or
tumor
4. Herpes encephalitis
Huntingtons disease
1. Hypometabolism of the basal ganglion
2. Progressive
motor
abnormalities
of
involuntary choreiform movements and
akinetic rigidity with progressive cognitive
deteriotion
3. Neuronal degeneration in the striatum, with
the caudate more involved than the putamen
4. Huntingtons disease
CSF leak
1. In-111 or Tc-99m DTPA
2. Intrathecal injection
3. Activity in the region of the nose, indicating
CSF leak, probably at the cribriform plate
4. Anterior views. With the use of nasal
pledgets placed in the superior, middle and
inferior nasal turbinates
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
Thyroid
function
Thyrotoxicosis
Increased
thyroid
uptake
Graves disease
Normal
thyroid
uptake
Antithyroid drugs
PTU/CBZ
Hashitoxicosis
Decreased thyroid
uptake
Expended iodide pool
Thyrotoxic phase of
subacute thyroiditis
Thyrotoxicosis factitia
Antithyroid drugs
Struma ovarii
Euthyroid
Rebound after
antithyroid drug
withdrawal
Recovery from
subacute
thyroiditis
Hypothyroid
Hashimotos
disease
Hashimotos
disease after RAI
therapy
Subacute
thyroiditis
Hypothyroidism:
primary/secondary
Thyroid adenoma
Solitary cold
nodule in
thyroid scan
Parathyroid adenoma
Lymphoma
TB
Colloid cyst
Metastatic carcinoma
Primary thyroid
carcinoma
Nodules
Cold
15 20%
Indeterminate
15 20%
MNG
5%
Hot
<1%
Discordant
nodule
(thyroid
adenoma)
Reverse discordant
nodule
(thyroid adenoma/
Hashimotos
thyroiditis/
thyroglassal duct)
Causes of
hyperthyroidism
Graves Disease
Toxic multinodular Goitre
Toxic adenoma
Thyroiditis
Hashimotos
Subacute (De Quervains)
Silent (post partum)
Antithyroid drugs
Surgery
Radioiodine
Self limiting
Symptomatic
Factitious
Treatment of causes
Treatment Choices
Antithyroid drugs (thionamides)
inhibit thyroxine production
immunomodulation
Surgery
reduce thyroid bulk to decrease thyroxine
production
Radioiodine
same principle as surgery
reactor produced
T 8.02 days
eta and gamma emitter
eta - 606 keV max, 191 keV mean
Beta-particle emission tissue range
0.8mm (local therapeutic effect)
gamma - 364 & 637 keV
Clinical Form : Sodium Iodide
131I
Decreased thyroxine
production
Contraindications
Pregnant women
a. cross the placenta accumulate in the
fetal thyroid gland severe neonatal
hypothyroidism
b. irradiation risk of thyroid cancer
c. retained activity in maternal bladder direct
exposure to the fetus
Lactating mother
Patients Preparation
No solid foods or drink dairy products for at least two
hours before and after treatment.
Low iodine diets for about 3 - 7 days
GD patients should be counseled regarding the risks of
ophthalmopathy.
Render patients euthyroid before treatment with 131I
or thyroidectomy.
- older patients (> 5060 years old)
- very thyrotoxic patients (symptomatic)
- patients with cardiac problems.
Patients Preparation
Follow drug interactions notes
Antithyroid drugs - resumed 3 to 10 days
following
treatment, or earlier, if clinically necessary
Beta blockers medications - to reduce symptoms
which may occur during treatment:
propranolol, 80160 mg/day, or
atenolol, 50150 mg/day, or
diltiazem 30 180mg/day (bronchospasm)
Doses
Two common approaches:
1. Fixed Dose
2. Calculated Dose - based on the size of the
thyroid & percentage uptake at 24 h.
Doses
Although treatments based on dose calculations
appear efficacious, they have not proven superior to
the use of empirically selected administered
activities.
Fixed dose advantages simple & successful
outcome in an acceptable number of patients.
Initial Therapy
Graves
Disease
-block
Antithyroid
Subacute
Thyroiditis
-block
Steroids until
resolution of
symptoms
Toxic adenoma
(Plummer Disease)
-block
Antithyroid
Hyperfunctioning
Multinodular
Goiter
-block
Antithyroid
Graves Disease
-blockers
Carbimazole or PTU
Modulate therapy
until normalization
of TSH, FT3, FT4
(18 24 months)
Withdrawal of -blocker
Progressively reduce
Carbimazole or PTU
-blockers
Carbimazole or PTU
Size of goiter
Tracheal compression
Narcosis risks
Complications of thyroid surgery
Fixed dose
Vary but are commonly in the range of
185555 MBq (515 mCi)
Depending on the size of the gland
131I
Hyperfunctioning
Multinodular
Goiter
Incidence of:
temporary recurrent laryngeal nerve palsy
2.3%
temporary hypoparathyroidism
14.4%
Permanent recurrent laryngeal nerve palsy
1.1%
permanent hypoparathyroidism
2.4%
Neither the initial clinical diagnosis nor a history of previous
treatment significantly influenced the rate of complications.
Bron LP, O'Brien CJ. Br J Surg. 2004 May;91(5):569-74.
(Freitas JE. Therapeutic options in the management of toxic and nontoxicnodular goiter.
Semin Nucl Med 2000; 30(2):8897. )
Outcomes
Euthyroid
Hypothyroid
transient
permanent
early
late
Hyperthyroid
Side Effects
Generally it is mild, infrequent and self-limiting.
General
Thyroid tenderness
Salivary gland swelling
Nausea
NSAIDs
Side Effects
Severe side effects > likely in patient with large goitre risk of
tracheal compression.
Ophthalmopathy
Ophthalmopathy may be particularly severe in 3%
to 5% of patients with GD.
Progression of ophthalmopathy - approximately
15% of patients especially:
- who smoke
- have pre-existing eye disease
- high levels of TSH-receptor antibody
- severe manifestations of thyroid disease
Side Effects
Prednisone, 0.40.5 mg/kg per day,
beginning immediately after radioiodine
treatment, continued for one month,
and then tapered over three months,
has been shown to be effective in a
randomized controlled trial.
(Bartalena L, Marcocci C, Bogazzi F, et al. Relation between therapy for hyperthyroidism and
the course of Graves ophthalmopathy. N Engl J Med 1998; 338(2):7378. )
Referral
to
recommended.
Ophthalmologist
is
Side Effects
Cancer Risk
remains controversial
Ron et al, a study of >35,000 hyperthyroid
patients found that the incidence of
thyroid cancer in RAI-treated patients over
a 27-year period was not significantly
different from its incidence in the general
population.
Genetic Effects to Offspring
no evidence that exposure to radioiodine
affects the long-term outcomes of
subsequent pregnancies and offspring.
Follow up
To assess the need for
- further 131Iodine treatment
- L-thyroxine replacement
Symptoms of uncontrolled hyperthyroidism
should be described, and patients should be
informed to seek medical attention if such
symptoms occur.
4 to 6 weeks and at regular intervals
thereafter.
Temperature
CNS
GI/liver dysfunction
Cardiovascular dysfunction
Heart failure
Precipitant history
37.2-37.6
37.7-38.2
10
38.3-38.7
15
38.8-39.3
20
39.4-39.9
25
>40
30
Mild agitation
10
Moderate delirium/psychosis
20
Seizure/coma
30
Diarrhea/vomiting/abd pain
10
Unexplained jaundice
20
99-109
110-119
10
120-129
15
130-139
20
>140
25
Pedal edema
Bibasilar rates
10
APO
15
AF
20
negative
positive
10
Score >45 suggestive of thyroid storm, 25 44 supports the diagnosis and < 25 unlikely thyroid storm
Introduction
Thyroid cancer- most common malignant
tu of endocrine system & accounts for 1%
of all newly diagnosed cancer cases.
Most thyroid cancers originate from
thyroid follicular cells .
Type of thyroid malignancy :
papillary ca 80%,
follicular ca 15% may be of conventional
or oncocytic (Hurthle cell) type.[4]
Follicular ca develop either from preexisting benign follicular adenomas or
directly, bypassing the stage of adenoma.
2%
3%
Schematic representation of thyroid ca origin and its putative progression. Oncocytic adenoma
and ca are considered to be variants of follicular adenoma and ca. Papillary ca may be of the
classical type or manifests as one of its variants, including oncocytic variant of papillary ca
Papillary Ca
Activating mutations of BRAF, RET or RAS genes
seen in 70% papillary ca.
Genes mutations rarely overlap in the same
tumor, suggesting that activation MAPK signaling
is essential for tumor initiation
Alteration of a single effector of the pathway is
sufficient for cell transformation
BRAF
Mol p/way in thyroid papillary ca & typical microscopy & clin feat of tu assoc with specific
mutations
BRAF mutation
Involve nucleotide 1799 and result in a val-to-glut
substitution at residue 600 (V600E).
Other mech include K601E point mut, small inframe insertions or del surrounding codon 600,[14
16] & AKAP9-BRAF rear which is more common in
papillary ca a/w radiation exposure.[17]
RET/PTC
Fusion between the 3-portion of the RET
receptor tyrosine kinase gene and the 5-portion
of various genes.
Two most common rear types, RET/PTC1 and
RET/PTC3, are paracentric inversions, because
both RET and its respective fusion partner, H4 or
NCOA4 (ELE1), reside on the long arm of
chromosome 10.[3639]
RET/PTC 1
Two most common rear types RET/PTC 1 & RET/PTC 2 are
paracentric inversions bcoz both RET & its respective fusion
patner, H4 or NCOA4(ELE1), reside on the long arm of chr 10
RET/PTC 3
RET/PTC 3
RET/PTC
Most of these rare RET/PTC seen in papillary
ca fr pts with a h/o environmental or
therapeutic exposure to ionizing radiation,[40
46] & in children & young adult.
In papillary ca assoc/w exposure to ionizing
radiation (i.e. post Chernobyl), RET/PTC1 a/w
classic papillary histology, RET/PTC3 more
common in solid variant
RET/PTC 2 t(10;17)(q11.2;q23)
RET/PTC 2 t(10;17)(q11.2;q23)
RET/PTC 5 t(10;14)(q11.2q32)
RET/PTC 5 t(10;14)(q11.2q32)
RET/PTC 6 t(7;10)(q32;q11.2)
RET/PTC 6 t(7;10)(q32;q11.2
RET/PTC 7 t(1;10)(p13;q11.2)
RET/PTC 7 t(1;10)(p13;q11.2)
RET/PTC 8 t(10;14)(q11.2;q22.1)
RET/PTC 8 t(10;14)(q11.2q22.1)
RET/PTC 9 t(10;18)(q11.2;q21)
RET/PTC 9 t(10;18)(q11.2;q21)
RFP/RET t(6;10)(p21;q11.2)
RFP/RET t(6;10)(p21;q11.2)
RET/PTC
ELKS-RET and HOOK3-RET fusions identified in
papillary ca with no apparent h/o of radiation
exposure.[47,48]
ELKS/RET - t(10;12)(q11.2;p13.3)
ELKS/RET - t(10;12)(q11.2;p13.3)
HOOK3/RET t(8;10)(p11.21;q11.2)
HOOK3/RET t(8;10)(p11.21;q11.2)
RAS
RAS genes (HRAS, KRAS and NRAS) encode G-proteins
important in the intracellular transduction of signals arising
from cell membrane receptors.
In its inactive state, RAS protein is bound to GDP.
Upon activation, it releases GDP and binds GTP, activating
MAPK and PI3K/AKT.
RAS
PAX8-PPAR
PIK3CA
PTEN
Oncocytic Ca
TP53
CTNNB1 ( Beta catenin)
RAS
BRAF
PIK3Ca
PTEN
Medullary Thyroid Ca
RET is activated by point mutation vs chr rear in
papillary ca.
Germline mutations in specific functional regions of
RET found in almost all pts with familial medullary ca.
MEN 2A & familial medullary ca, mutations are
typically located in the extracellular domain, within the
cysteine-rich region.[124]
90% of MEN 2A mutations affect a single codon 634,
whereas in familial medullary ca they are more evenly
distributed along the cysteine rich region.[125]
Summary
FNA dx of thyroid nodules can be improved by
testing for BRAF, RET/PTC and other mutations.
BRAF, RET/PTC and RAS mutations correlate with
specific phenotypical features of papillary ca.
BRAF is a reliable diagnostic marker for
malignancy and an independent prognostic
marker for tumor recurrence and more
aggressive behaviour of papillary carcinomas.
These are lymph nodes that
received cancer cells fr the
primary ca in the thyroid gld
Summary
PAX8-PPAR & RAS mut correlate with specific
phenotypical feat of follicular ca.
Limitations..Papillary
ca
(~30%),
conventional follicular cas (~20%) & oncocytic
follicular ca (>50%) do not harbour any of the
known mutations.
Lymphoma
Parathyroid adenoma
TB
Wegners granulomatous
Metastatic adenocarcinoma
Hyperthyroidism/ thyroiditis
1. Graves disease, toxic nodules, thyroiditis,
iatrogenic thyroid hormone ingestion, iodine
induced, trophoblastic tumors, Hashitoxicosis
and struma ovarii.
2. Aid in the DD of hyperthyroidism
3. A nonimaging gamma probe obtains
counts/time from neck and a phantom counting
activity equal to the orally administered dose to
convert to gamma probe counts Ci % RAIU =
neck (Ci) divided by the total administered
dose (Ci) after background correction.
4. Subacute thyroiditis based on the history of
neck tenderness, laboratory finding and RAIU.
Graves disease
1. Scan appearance may be similar. With the large goiter the
scan often has a plumper appearance with convex
borders. The pyramidal lobe may be seen as in this case.
2. Surgery is seldom performed because of the high risk. PTU
and CBZ sometimes are used initially who require cooling
down most of the patients are treated with RAI after 6 to
12 months of antithyroid medication. Many patients are
treated initially with I-131.
3. I-131 uptake (10 Ci), I-123 scan and uptake (300 Ci) and
Graves disease therapy; I-131 (5-15 mCi)
4. Short term; occasional exacerbation of hyperthyroidism
and thyroid storm. Long term; hypothyroidism. There is no
increased incidence of secondary cancers or reduction in
fertility.
Lingual thyroid
1. Tc-99m pertechnetate is taken up by thyroid
follicular cells like iodine but not organified. I123 taken up and organified.
2. Lower radiation exposure to the pediatric
patient.
3. Focal uptake at the base of the tongue.
Normal is submandibular glans and mouth.
No thyroid in the neck.
4. Lingual thyroid.
Gastric emptying
studies
Gastrointestinal
bleeding studies
Gastrointestinal
bleeding studies
Gastrointestinal
bleeding studies
Gastrointestinal
bleeding studies
False positives:
Free pertechnetate seen at
stomach
Renal excretion of breakdown
products
Penile
blood
pool,
transplanted
kidney
and
varices.
Gastrointestinal
bleeding studies
False negatives:
Small bowel bleeding
Rectal bleeding obscured by
bladder activity
A stationary abnormal focus
could represent clotted blood
Overnight fasting
Radionuclide
Feeding meal
Imaging
Cimetidine
Pentagastrin
Increases rapidity, duration and intensity of Tc99m pertechnitate uptake
Increased mucin producing cells
Increases intestinal motility
Glucagon
Antiperistalsis
Decreased bowel peristalsis
Prevent tracer washout from diverticulum
Tc-99m RBC
Criteria for
diagnosis of
bleeding site with
Tc-99m RBC
Tc-99m RBC
Tc-99m SC
Tc-99m SC
Meckels Diverticulum
False negatives:
Meckels diverticulum
Lack of sufficient gastric
imaging
mucosa.
Recent barium study or
bladder.
Meckels
Hepatobiliary
Hepatobiliary
Hepatobiliary
Hepatobiliary
Hepatobiliary
Hepatobiliary
Nonvisualization of the GB at 1
hour but visualization at 4
hours after morphine is most
likely
due
to
chronic
cholecystitis.
Look for either RIM sign or
cystic duct sign of acute
cholecystitis if the GB is not
seen by 1 hour. A RIM sign
increases the likelihood of
complicated
cholecystitis
(gangrene, abscess or rupture)
Hepatobiliary
Hepatobiliary
False positive
Fasting longer than 24 hours
may cause GB distend with
viscous bile. CCK can contract
GB,
Severe illness, pancreatitis,
chronic cholecystitis and rapid
biliary to bowel transit.
Hepatobiliary
False negatives:
Mistake with duodenum, renal
pelvis and cystic or common
bile duct
Cystic duct
Gallbladder
Spincter of oddi
Patient preparation
Radiopharmaceutical
Patient positioning
Supine
Instrumentation
Collimator: LEGP
Window : 15% 140 keV
Imaging protocol
Radiopharmaceutical
Mechanism of uptake
Indication
Tc-99m HIDA
Hepatocyte uptake
Cholescintigraphy
Tc-99m RBC
Cavernous hemangioma
Tc-99m MAA
Xe-133
Lipid soluble
Gallium-67 citrate
Tumor/abscess
F-18 FDG
Glucose metabolism
tumor
CCK
Contracts gallbladder
Relaxes sphincter of Oddi
Gastrointestinal
actions of CCK
Stimulates intestinal
motility
Inhibits gastric emptying
Reduces gastrointestinal
sphincter tone
Stimulates hepatic bile
secretion
Stimulates pancreatic
enzyme secretion
Morphine sulphate
Constricting sphincter of Oddi
Increases intraluminal biliary pressure
IV 0.04 mg/kg when GB not filled by 60
minutes
Should not be given to :
1. Poor clearance to the bowel
2. Significant retention of radiotracer in biliary
duct
False positive of
Acute
Cholecystitis
Morphine
DM
Atropine
Nifedipine (CCB)
IBS
Indomethacin
Pancreatic insufficiency
Progesterone
Crohns disease
Oral contraception
Celiac disease
Octreotide
Achalasia
Theophylline
Obesity
Benzodiazepine
Cirrhosis
Phentolamine
Pregnancy
Dyspeptic syndrome
Truncal vagotomy
Flow
Uptake
Clearance
Focal
nodular
hyperplasia
Hepatic
adenoma
Hepatocellul
ar carcinoma
Increased
Immediate
Delayed
Normal
none
Increased
Delayed
Delayed
Causes of Focal
Liver Defects
Cyst
Benign and malignant
tumor
Abscess
Hematoma
Laceration
Radiation therapy
Infarction
Cirrhosis
Fatty infiltration
Dilated bile duct
Arm injection
Increased focal
uptake in Tc-99m SC
Leg injection
focal nodular hyperplasia
Budd-Chiari syndrome
Cirrhosis
Metastases
Lymphoma/leukemia
Liver heterogeneity
of Tc-99m SC
Hepatitis
Chronic passive congestion
Cirrhosis
Parenchymal liver disease
Fatty metamorphosis
Normal HIDA
Normal HIDA
Acute cholecystitis
for
for
the
for
Meal content
Time of day
Gender
Position
Stress
Exercise
GI bleeding studies
A. Tin colloid studies are better at detecting bleeding
sites proximal to the ligament of Treitz than distal to it
B. Delayed images on a tin colloid scan may be of value
in separating liver and spleen activity from bowel
activity
C. In vitro labeling of RBC gives fewer false positive tests
than in vivo
D. Bleeding must be continuous to be detected on a
labeled RBC study
E. 51 Cr-chromate labeled RBC can detect bleeding
down to 1-2 mls per day
GI bleeding studies
FFTFT
Concerning cholescintigraphy
A. Failure to visualize the GB by 4 hr with normal activity
appearing in the bowel is highly suggestive of GB
disease
B. Chronic Cholecystitis can be distinguished from
acalculous cholecystitis
C. Giving CCK before isotope is more likely to
demonstrate the GB than giving morphine
D. Common duct obstruction should be excluded if
visualization of bowel activity is delayed beyond 1
hour
E. GB emphysema has a typical rim sign appearance
Concerning cholescintigraphy
TFTTT
Concerning cholescintigraphy
A. Cholescintigraphy has greater specificity than
ultrasound at detecting bile duct obstruction
B. Following cholecystectomy, an abnormal
accumulation of HIDA outside biliary tree likely
due to bile leak
C. US is more sensitive than cholescintigraphy at
detecting bile leak
D. Cholescintigraphy can diagnose afferent loop
obstruction after gastroenterostomy
E. Ascites can be detected
Concerning cholescintigraphy
TTFTT
In pediatric cholescintigraphy
A. Phenobarbitone is used to maximise hepatic of
tracer
B. Neonate hepatitis can be distinguished from
Rotor syndrome
C. Choledocal cyst can be distinguished from
pancreatic cyst
D. Cholescintigraphy is more accurate in diagnosing
biliary atresia in children > 3 months than in
neonates
E. Dilated intrahepatic ducts are often seen in
patients with biliary atresia
In pediatric cholescintigraphy
TTTFF
6. Tc-99m HIDA
TTTTF
Meckels Diverticulum
1. Meckels can. The radiopharmaceutical is taken up and
secreted by gastric mucosa.
2. Pentagastrin increases rapidity, intensity and duration of
uptake. It is used with glucagon, which is antiparistaltic
that inhibits rapid dispersion effect of pentagastrin.
Cimetidine, a histamine antagonist, increases and
prolonged uptake because of inhibition of Tc-99m
pertechnetate secretion from gastric mucosal cells.
3. Increasing focal uptake in the mid abdomen suspicious for
Meckels diverticulum, however, atypical timing of uptake
lessens the certainty. The uptake should be coincident
with gastric uptake in cases of Meckels diverticulum. This
may be false positive scan.
4. Acid and pepsin secretion by the gastric mucosa produces
inflammation and ulceration of adjacent bowel mucosa.
Diabetic gastroparesis
1. Consistent with severe diabetic gastroparesis. Obstruction
cannot be ruled out.
2. Normal values are meal specific and depend on its
volume/composition, the method of acquisition,
attenuation correction, processing and quantification.
Normal values must be determines in each clinic or results
of a published method should be followed closely.
3. Solid or semisolid gastric emptying meals are more
sensitive for detection of mild to moderate delay in
emptying than studies conducted after a liquid meal.
4. Activity is detected with greatest efficiency close to the
camera. The anterior view alone underestimates emptying
and posterior view overestimates it because of variable
attenuation as the meal moves through the stomach from
the posterior gastric fundus to the more anterior gastric
antrum.
Gastroesophageal reflux
1. Vomiting, pulmonary symptoms, asthma,
pneumonia, sudden death, failure to thrive
and anemia.
2. 24 hours pH monitoring.
3. Tc-99m sulfur colloid 1 mCi in the childs
usual feeding, formula or milk
4. 5 to 10 second/frame.
Gastrointestinal bleeding
1. Tc-99m labeled RBC study. Abnormal focal
uptake appearing simultaneously at two sites
in the right abdomen, increasing in intensity
and changing in pattern with time.
2. Caecum and ascending colon.
3. Review images an a computer in cinematic
mode.
4. Acute bleeding due to angiodisplasia,
diverticula, neoplasm, IBD and ischemia.
Rectal bleeding
1. Abnormal activity accumulate early in the lower
midline pelvis. The appearance is changing over
time and seems to decrease and then increase
again.
2. To differentiate activity in the rectum from
bladder and penis, in this patient the activity is
seen in the rectum.
3. Positive for gastrointestinal bleeding is not the
answer. Localization is critical. The 90 minute
lateral view confirms that this is rectal bleeding.
4. New activity, increases in amount over time and
moves intraluminally.
Pulmonary aspiration
1. Recurrent pneumonia, cough, asthma, apnea or
sudden infant death.
2. Tc-99m sulfur colloid in a small volume of fluid
placed on the tongue and allowed to mix with
oral secretion and swallowed.
3. Poor bolus progression noted in the dynamic
esophageal swallow study with entrance into
the main bronchi bilaterally and then into the
right lower lobe.
4. The milk study is very sensitive for reflux,
however it is insensitive for aspiration. The
salivagram is sensitive for small amounts of
pulmonary aspiration.
Choledocal cyst
1. A. Good hepatic uptake and clearance into the
gallbladder, common hepatic and proximal common
bile duct at 60 minutes. No biliary to bowel transit. B.
the gallbladder contracts with sincalide infusion,
however focal increasing accumulation of radiotracer
occurs just medial to the proximal portion of the
common bile. The proximal common duct activity
empties into the duodenum.
2. Likely choledocal cyst. Partial biliary obstruction also
would cause radiotracer retention within the more
proximal biliary duct.
3. Cholangitis, sepsis, pancreatitis or obstruction.
4. Congenital anomaly. Localize dilatation of the biliary
tract, either fusiform or diverticular outpouching.
Surgery is the appropriate therapy.
Acute cholecystitis
1. A. Abnormal. B. No. C, yes
2. A. Sensitivity 98%, specificity 95%, B greater
than 90%.
3. The few direct comparisons published have
shown cholescintigraphy superior to US.
4. Prolonged fasting, hyperalimentation, chronic
cholecystitis and hepatic insufficiency.
Morphine augmented
cholescintigraphy
1. Morphine produces contraction of the sphincter
of Oddi, which increases intraluminal common
bile duct pressure. Bile and excreted radiotracer
then preferentially flow through the cystic duct
into the GB if the cystic duct is pattern.
2. Exclude drug allergy. Do not give if evidence of
common duct obstruction.
3. The accuracy is at least as good, if not better
than the delayed imaging method.
4. IV 0.04 mg/kg morphine. Images are acquired
for an additional 30 minutes.
Biliary leak
1. Rapid bile leakage probably originating from
the region of the ligated cystic duct and
extending toward the right colonic gutter
with time, over the dome of the liver.
2. Rapid biliary leak.
3. Cystic duct ligature after cholecystectomy,
surgical
anastomosis,
trauma
and
inflammatory processes.
4. Confirm that fluid collection seen by
anatomical imaging modalities are biliary in
nature.
Biliary atresia
1. Phenobarbital, 5mg/kg/day for 3 to 5 days
before study.
2. Inflammatory, infections and metabolic causes
for neonatal hepatitis and biliary atresia.
3. A. delayed blood pool clearance as the result of
hepatic insufficiency. Biliary clearance at 50
minutes and increasing through 120 minutes. B.
good liver function. No secretion into biliary
duct during the initial 120 minutes or at 5 and
24 hours. Case B consistent with biliary atresia.
Case A with neonatal hepatitis.
4. Sensitivity 97% and specificity 82%.
RIM sign
1. Increased incidence of false positive in patients who
have been fasting more than 24 hours
2. Nonvisualization of GB after 60 minutes. After
morphine, no filling of the GB occurs. Increased
uptake is seen in the region of the GB fossa, which
persists after most of the liver has washout (RIM sign)
3. Nonvisualization of the GB after morphine is
consistent with acute cholecystitis. The RIM sigh is
very specific for acute cholecystitis and confirms
diagnosis.
4. The RIM sign indicates severe acute cholecystitis
which is associated with an increased incidence of GB
gangrene and perforation.
Genitourinary scan
General
General
General
General
Testicular
imaging
Testicular
imaging
Epididymitis
should
be
diffusely hot on all images and
frequently focal hot in the
region of the epididymitis.
Increased
flow
to
one
hemiscrotum and a rim of
testicular activity with a cold
center (halo sign) can be a
delayed torsion but also can be
testicular abscess, hematoma
or tumor
DTPA
MAG 3
HIPPURAN
DMSA
GLUCOHEPTONATE
Tc-99m DTPA
Tc-99m MAG 3
Glomerular filtration
100%
Tubular secretion
100%
Extraction fraction
20%
40 50%
Poor
Good
Protein bound
No
Yes
Immediate
Immediate
No
Yes
30 60 SECONDS
1-3 MINUTES
COLLECTING
SYSTEM
CORTICAL
LIVER
KIDNEY
lungs
ADRENAL
Pre surgical
insult
Autoimmune
rejection
Complication of
renal transplant
Vasomotor nephropathy
resolution ATN
Minutes to hours
Hyperacute rejection
Minutes to hours
Accelerated rejection
1 5 hours
Acute rejection
Chronic rejection
Months to years
Cyclosporine rejection
Months
Urine leak
Days or weeks
Hematoma
Infection
Lymphocyle
2 4 months
Surgical
Vascular occlusion
Vascular
Infarct
Renal obstruction
Vesicoureteroreflux
Days/months/years
2. MAG 3 scintigraphy
A. Best method for assessment of scarring in
children
B. Prolonged transit time in dilated system
C. Reliable for diagnosis of obstruction in renal
failure
D. Prolonged parenchymal transit time in renal
artery stenosis
E. Patients are dehydrated before study
2. MAG 3 scintigraphy
FTFTF
3. Renal scintigraphy
A. For captopril test, ACE inhibitors should on
the day of the test
B. MAG 3 is used for assessing renal scarring
C. DMSA is superior to MAG 3 for both dynamic
and structural assessment
D. Radiation is lower for MAG 3
E. 100% of MAG 3 is excreted by tubular
secretion
3. Renal scintigraphy
FTFTF
4. Renal scintigraphy
A. DMSA images are acquired within one hour
of injection to avoid artifacts
B. DTPA is isotope of choice for dynamic renal
scans
C. Kidney/background ratio is better for MAG 3
than DTPA
D. I 123 can be produced only by cyclotron
E. Hippuran is completely cleared by glomerular
filtration
4. Renal scintigraphy
FFTTF
5. Renal scintigraphy
A. The glomerular filtration rate of DTPA is 500
ml/min
B. DTPA is completely cleared by tubular
filtration
C. The maximum diuresis occurs within 2
minutes of diuretic administration
D. Images are acquired between 5-10 minutes
for perfusion in transplants
E. Post void film is indicated in cases of stasis
5. Renal scintigraphy
FFFFT
Horseshoe kidney
Renal agenesis
Column of bertin
Individual renal function
UTIs
Hypertension
Renal transplantation
Renal trauma
Reflux
Tumor
Radiation
Chemotherapy
Papillary necrosis
Multiple myeloma
Amyloidosis
Hypovolaemia
Hypoplastic kidney
Recent contrast angiogram
After extracorporeal shock wave lithotripsy
Severe cyclosporine toxicity
State of hydration
Renal function
Dose of diuresis
Radiopharmaceutical
Bladder capacity
Urinoma
1. A photopenic region, best seen on early images, involves
most of the left renal fossa. Only the upper pole is
functioning. Urinary clearance into the left renal pelvis
appears displaced medially by the photopenic defect. The
right pelvic and uppe2/3 of the ureter fill. Poor clearance
bilaterally. Delayed images show increased uptake in the
region of the initial cold defect and inferior to it.
2. The cold defect is a urinoma with an attenuating mass
effect. Over time the radioactive urine enters this space
and mixed with the nonradioactive urinoma. Activity in
the region of the urinoma increases over time while the
earlier seen kidney and background activity have cleared.
3. Activity urinary leak and urinoma.
4. Urinary tract obstruction.
Bilateral obstruction
1. Left kidney; delayed and decreased cortical uptake, no
clearance into the calyces or pelvis. Right kidney;
prompt uptake and clearance into the collecting
symptom, faint persistent visualization of the right
ureter and, poor response to furosemide.
2. Before furosemide; high grade obstruction on the left
and HN on the right, suspicious of obstruction. A
furosemide high grade obstruction on the left and
obstruction on the right.
3. Filling of the renal collecting system.
4. Percent radiopharmaceutical uptake by each kidney
divided by total renal uptake between 1 and 3
minutes (before clearance into the pelvicalycial
system)
Radionuclide cystography
1. Tc-99m DTPA and Tc-99m SC
2. Radionuclide cystography is more sensitive in detection of
VUR and results in 50 to 200 times less radiation exposure
to gonads compared with the contrast study.
3. The direct method is commonly used and requires urinary
catheterization and installation of radiotracer into the
bladder through catheter. The indirect method is
performed after routine DTPA/MAG3. when the bladder is
full, a prevoiding image is obtained, followed by dynamic
images during and after voiding.
4. Grading criteria are similar to those used with contrast
cystography, however the radionuclide studys limited
resolution does not permit assessment of calyceal
morphology. Mild reflux; confined to the ureter.
Moderate; reaches the pelvicalyceal system. Severe;
distorted collecting system and dilated tortuous ureter.
Unilateral obstruction
1. Good symmetrical cortical uptake and prompt
excretion into collecting systems bilaterally.
Retention of activity in left renal collecting
system, apparent cutoff in the upper ureter and
very poor response of furosemide. The right side
shows a prominent collecting system but washes
out spontaneously before furosemide.
2. HN of the left kidney. TRO obstruction.
3. Consistent with significant obstruction of the left
kidney.
4. Dehydration, renal insufficiency, inadequate
diuretic dose, full bladder and large collecting
system.
Renal scan
1. Tc-99m DTPA, Tc-99m MAG3 and I-131 hippuran.
2. DTPA; glomerular filtration, MAG3; tubular secretion
and hippuran; 20% glomerular and 80% tubular.
3. DTPA is inexpensive, provides a good image quality
but has low extraction efficiency (10-20%) and poor
poor quality images with renal insufficiency. MAG 3
has a high extraction rate (60%), good target to
background and good quality images with renal
insufficiency. Hippuran has good extraction efficiency,
high target to background, poor image quality, poor
cortical/collecting system differentiation and delivers
a high radiation dose in renal insufficiency.
4. No . A dose of 5 mCi is needed for good blood flow
images.
Diuretic renography
1. Bilateral cortical uptake and excretion into collecting
systems. Retention in the right collecting system at 30
minutes with good post furosemide washout.
2. Good response to surgical correction with no obstruction.
3. Not with certainty. Ureteral nonvisualization is not
diagnostic of ureteropelvic junction obstruction because a
standing column of ureteral urine can prevent radiotracer
entry.
4. It measures pressure flow relationships and requires
fluoroscopically guided trocar or spinal needle insertion
into the renal pelvis. Basal and pressure measurements
during infusion of a contrast solution at a rate are
recorded. Obstruction pressure is defined as greater than
15cm water, no obstruction as less than 10 to 12 cm
water.
Transplanted kidney
1. Rapid leakage of urine just inferior to the
transplanted kidney and extravasating into the
scrotum.
2. Urinary leak caused by disruption of surgical
anastomosis.
3. Hematomas and abscess occur in the early
postoperative course, whereas lymphoceles
generally are noted 4 to 8 weeks after surgery.
4. ATN, acute rejection or obstruction. Cyclosporin
toxicity usually occurs months after transplant.
ATN
1. ATN, accelerated acute rejection, urinary leak
and urinary obstruction.
2. The second postoperative week. Accelerated
rejection may occur during the first week in
patients who have had previous transplants or
received multiple transfusion.
3. Normal blood flow, very poor function, no
excretion. Base of penis seen inferiorly.
4. The pattern of normal blood flow but poor
function during the first week after
transplantation is typical of ATN
Testicular torsion
1. Tc-99m pertechnetate, initial blood flow and
then tracer distributes in the extracellular fluid
space.
2. Acute epididymitis, testicular torsion or torsion
of the testicular appendage.
3. Developmental abnormality of testicular
descent and attachment predisposes to
spermatic cord torsion. The most common
anatomical abnormality is bell clapper testis.
4. Decreased blood flow to the right testicle and a
photopenic right testicle consistent with acute
testicular torsion.
Captopril renography
1. With renal artery stenosis, glomerular filtration decreases
and GFR drops. Renin released from juxtaglomerular
convert angiotensin I to angiotensin II. Angiotensin II
causes vasoconstriction of the glomerular efferent
arterioles, rising filtration and maintaining GFR. ACE
inhibitor blocks conversion of angiotensin I to II resulting
in decreased in a decrease GFR.
2. The right kidney is small but with good function. With
captopril cortical retention persists, consistent with renin
dependent renovascular HPT of the right kidney. This is
confirmed by the renal cortical time activity curves.
3. Yes. The accuracy of I-131 hippuran, Tc-99m DTPA and Tc99m MAG 3 are similar.
4. Sensitivity 90% and specificity 95%. Sensitivity is less for
detection of renin dependent HPT if the patient has been
taking an ACE inhibitor chronically or renal insufficiency.
Pyelonephritis
1. 40% of DMSA binds and fixes to functioning
proximal cortical renal tubules.
2. Diagnosis of pyelonephritis or renal scarring.
3. Decreased uptake in the lower half of the
right kidney on initial imaging (A). Repeat
SPECT show normalization of uptake. A,
Pyelonephritis. B, Renal scarring
4. DMSA in the early stages of infection is the
best
predictor
of
renal
sequalae.
Identification of pyelonephritis will increase
the duration of antibiotic therapy.
Lung scintigraphy
Lungs perfusion
Lungs perfusion
Lungs perfusion
Lungs perfusion
Lung perfusion
Lungs
Perfusion
Tc-99m human
Albumin microspheres
ventilation
Tc-99m MAA
Macroaggregated
albumin
Xenon 133
Radioactive
gases
Xenon 127
Krypton 81m
Radioaeresols
Tc-99m DTPA
Tc-99m
technigas
Xenon 133
Tc-99m DTPA
Mode of decay
Beta minus
Isometric
Half life
5.5 days
6 hours
30 seconds
45 minutes
Photo energy
81 keV
140 keV
No
Yes
Yes
-/+
No
No
Tc-99m MAA
Size
10 90 m
200000 - 500000
48h
Injection
Safety
Terminology
V/Q match defect
V/Q mismatch
Triple match
Segmental defect
Reversed mismatch
None
Dosage
Collimator
LEGP
Photopeak
Positioning
Patient is seated
Place nose clamps on patient and connect
mouthpiece for several minutes
Center camera over chest posteriorly
Patient breathes continuously through
mouthpiece for several minutes
Acquisition
None
Dosage
Collimator
LEGP
Photopeak
Positioning
Acquisition
None
Patient precaution
Dosage
Collimator
LEGP
Photopeak
Acquisition
Understanding probability
Potential problems
False positive
Conditions that can mimic high probabilityvasculitis / pulmonary arterial anomalies i.e.
hypoplasia and stenosis
V/Q scan
probability for
PE
High
Intermediate
Low
High
97%
88%
56%
Intermediate
66%
28%
16%
Low
40%
16%
4%
Technegas (ventilation)
DTPA (perfusion)
Primary ventilation
abnormality
Causes of perfusion
defect
Pneumonia
Atelectasis
Pulmonary edema
Asthma
COPD
Bullae
Mass effect
Tumor
Adenopathy
Pleural effusion
Iatrogenic
Surgery
Radiation fibrosis
Acute PE
Chronic PE
Vasculitis
V/Q mismatched
defect
Mediastinal or hilar
adenopathy
hypoplasia or aplasia of
pulmonary artery
Post radiation therapy
Bronchogenic carcinoma
Septic/drug abuse
COPD
Pneumonia
V/Q reversed
mismatched defect
Mucus plugging
Pneumonectomy
Mediastinal fibrosis
Unilateral lung
perfusion
abnormality
Pneumothorax
Tumors
Mucous plug
Pulmonary embolus
Pulmonary artery stenosis
Swyer-James syndrome
Massive pleural effusion
Pacemaker
Bullae
Trauma
Non segmental
defect
Tumors
Hemorrhage
Cardiomegaly
Hilar adenopathy
Atelectasis
Pleural effusion
Pneumonia
Perfusions defect
ventilation
CXR
Probability category
2 segments
Mismatch
clear
high
<2
Mismatch
clear
Intermediate
Match
LL zone
Intermediate
Match
UL zone
Low
Match
Clear
Low
>3
N/A
Clear
Low
1-3
N/A
Clear
Very low
N/A
Shows anatomical
reason for perfusion
abnormality
Very low
N/A
N/A
Normal
Moderate to large
Multiple
Small (<25% of a segments)
Non segmental
None
Wells clinical prediction rule for the diagnosis of pulmonary embolism (PE)
Variable
Points
1.5
1.5
Previous DVT or PE
1.5
Hemoptysis
Malignancy
Risk category
Cumulative score
Low
<2
Intermediate
2-6
High
>6
Risk category
Cumulative score
PE unlikely
PE likely
>4
Dyspnea (73%)
Atypical
presentations of PE
Fever
Productive cough
Seizures
Syncope
Wheezing
AMI
Acute stroke
DIC
Advanced age
Conditions
associated with DDimer production
Heart failure
Connective tissue disease
Infection
Malignancy
Post operative
Pregnancy
Renal failure
Trauma
Sickle cells
DVT
IV drug abuse
Congenital rubella syndrome
Histoplasmosis
Thymolipoma
Haematogenous metastases
SLE
TB
Sarcoidosis
Retrosternal goitre
Radiation pneumonitis
Anomalous pulmonary artery
Bronchial carcinoma
Congenital lobar emphysema
Haemangioendoliomatosis
Concerning PE
A. A single perfusion defect separated from the
pleural surface by a rim of normal perfusion is
rarely due to embolus
B. Normal perfusion exclude clinically significant PE
C. The combination of clinical impression and lung
scan results is a better predictor of PE than
either taken alone
D. Patients with a low probability scan and no
evidence of venous thrombosis may be safely
left untreated
E. He particle count of Tc-99 MAA may need to be
increased in patients with pulmonary
hypertension to achieved diagnostic images
Concerning PE
TTTTF
Bullous emphysema
Beckwith-Wiedmann syndrome
Following a Blalock-Taussig shunt
Pleural effusion
Swyer-James syndrome
Pulmonary atelectasis
PE
Alveolar proteinosis
Bronchogenic carcinoma
Pleural effusion
A. Low probability
B. Intermediate probability
C. High probability
1.
2.
3.
4.
5.
A. Low probability
B. Intermediate probability
C. High probability
1. Clear CXR with multiple matched V/Q
defects. A
2. Single large segmental V/Q mismatch. B
3. Perfusion defect < radiological infiltrate. A
4. Multiple small perfusion defect. A
5. Perfusion defects equal to radiographic
infiltrate. B
6. Lobar V/Q mismatch. C
PE
Non embolic disease such as COPD
Pulmonary hypertension
Pleural fluid
Asthma
Regarding V/Q
A. Kr-81m is generator produced
B. Rb-81 is cyclotron produced
C. Albumin macroaggregates remain in the
pulmonary capillary bed for weeks, limiting the
number of follow up perfusion scans that can be
safely performed.
D. The biologic half life of MAA is longer than
albumin microspheres
E. A patient with high pretest probability of PE, the
negative predictive value of a normal scan
exceeds 95%
Regarding V/Q
TTFFT
Regarding V/Q
A. In a patient with low pretest probability of PE,
the positive predictive value of positive scan
exceeds 95%
B. The presence of the triad has a positive
predictive value of PE exceeding 95%
C. V/Q scan is nondiagnostic in most patients with
pulmonary edema
D. Most patients with PE show infiltrate or effusion
on properly exposed CXR
E. Absence of perfusion to an entire lung is
common with PE
Regarding V/Q
FFFFF
Pearl
One way to determine whether radioactivity
outside of the lungs is caused by free Tc-99m
or shunted Tc-99m MAA is to image the brain.
Free pertechnetate should localize in the
brain, whereas Tc-99m MAA particles that gain
access to the systemic circulation will lodge in
the first capillary bed that they encounter,
including the capillary bed in the brain.
High probability of PE
1. Perfusion is decreased in the right lower lobe
except for the superior segment. Ventilation is
truncated in the right lower lobe consistent with
subpulmonic effusion
2. High probability for PE. Mismatch between
perfusion and ventilation is evident in the basal
segment. The perfusion defect is considerably
larger than the effusion on the X-ray
3. > 90%
4. Most common : Normal
5. Next most common : atelectasis
2.
3.
4.
Multiple perfusion defects in upper and lower lung fields. Many appear
segmental e.g.., the lateral of the right lower lobe, superior segment of
the left lower lobe. Ventilation shows extensive diffused clumping within
the air ways throughout both lung fields making determination of
matching or mismatching difficult. The study was interpreted as
intermediate probability since ventilation study could not be interpreted,
however the segmental perfusion defect pattern is suspicious for
embolus
Tc-99m DTPA aerosol provide (0.1 0.5 m) normally distribute on firs
impact within alveoli. With airway turbulence e.g.., asthma or COPD,
particles impact proximally within bronchi and appear as focal hot spot
Tc-99m DTPA aerosol ventilation is performed first. The patient breathes
in less than 1 mCi at tidal volume until an adequate count rate is
obtained the sixfold larger Tc-99m MAA perfusion dose (5 mCi)
overwhelms the retained ventilation dose, allowing the two consecutive
Tc-99m studies
Xe-133 an inert gas, is advantageous for patients with COPD and asthma.
Delayed filling and clearance in regions of obstructive disease can be
seen. Disadvantage : only posterior views are possible because of rapid
exhalation
High probability of PE
1. Perfusion: decreased right lower lobe except for
the superior segment. Ventilation: normal
except for mildly truncated right lower lobe
consistent with subpulmonic effusion
2. High probability of PE. Mismatch between
perfusion and ventilation in the basal segments.
The perfusion defect is considerably larger than
the pleural effusion on the radiograph
3. > 80%
4. Most common: normal, next most common:
atelectasis
Stripe sign
1. Decreased perfusion in the right upper lobe
(apical and anterior segment). Stripe sign of the
posterior segment of the right upper lobe. Normal
ventilation
2. Two segmental mismatched. High probability of PE
3. Its presence signifies perfused lung tissue
between a perfusion defect and the adjacent
pleural surface. Its presence can be use to classify
a segment as not related to PE.
4. Usually a manifestation of airway obstruction. The
sign has been correlated with CT and PET showing
spared perfusion of the cortex of the lung in
asthma and emphysema
A : without
attenuation
corrected
B : with attenuation
corrected
HG = high grade
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Ur Metser, MD, Einat Even-Sapir, MD, PhD, Semin Nucl Med 37:206-222 2007
Brown Fat
Sedation
Adrenergic blocking agents
Inflammation
Tumor hypoxia
Acute radiation
Recent chemotherapy
Recent surgery
Benign lesion
Necrosis
Mucinous , bronchoalveolar
carcinoma
Hyperglycemia
High insulin
Chronic radiation
Scar
Prior chemotherapy
History
Course of action
Prior surgery
Chemotherapy
Radiation therapy
Reschedule scan
Insulin administration
Breastfeeding
Colorectal cancer
Melanoma
Hepatocellular carcinoma
Renal cell carcinoma
Lymphoma
Lung carcinoma
PET sensitivity in 1 node is 75%
Pet sensitivity for mediastinal involvement is
91%
Adrenal is most common metastasis site
Lung carcinoma
Epidemiology
UK = 38000 cases
22000 men and 16000 women
Death = 34000 per annum
Peak incidence in Europe 60-70 years
3 x more common in men
Lung carcinoma
Oat cell
Intermediate cell
Squamous cell
50%
Bronchoalveolar
Adenocarcinoma
15%
Acinar
Papillary
Solid
Large
Cell
Anaplastic
10%
Bronchial derived
Lung carcinoma
Symptoms
Cough
Hemoptysis
Dyspnea
Chest pain
Recurrent chest infection
Lung carcinoma
Signs
Finger clubbing
Nicotine staining
Cervical sympathetic (Horners syndrome)=
partial ptosis/ miosis (pupil constriction)/
enopthalmos/ anhydrosis
Wasting of hand
Lung carcinoma
Differential diagnosis
Benign
tumors-papilloma/
carcinoid/
leiomyoma
Metastasis
Primary malignant-mesothelioma/ soft tissue
sarcoma
Chronic lung abscess
Radiographic artifact-nipple shadow
Lung carcinoma
Investigation
CXR
Sputum cytology
Bronchoscopy
CT
MRI
Bone scan
Indirect laryngoscopy
Lung function test
TNM
Ia
T1 N0 M0
Ib
T2 N0 M0
IIa
T1 N1 M0
IIb
T2 N1 M0
T3 N0 M0
IIIa
T3 N1 M0
T1-3 N2 M0
IIIb
T4 N0-2 M0
T1-4 N3 M0
IV
Any T Any N M1
Breast carcinoma
Epidemiology
UK = 45000 cases
325 arising in men
12000 death per annum
Peak age incidence 50-70 years
Breast carcinoma
Etiology
Family history
Menstruation > 12 or stop >55 years
On HRT
Women with no borne children
Women have had children late > 30 years
Overweight
Alcohol
Breast carcinoma
Classification
Breast carcinoma
Differential diagnosis
Fibroadenoma
Breast abscess
Fat necrosis
Galactocoele
Breast carcinoma
Investigations
Mammography
FNA
Ultrasound
MRI
Excision biopsy
GIST
Mesenchymal neoplasm
70% arise from stomach
25% arise from small intestine
Express growth factor receptor with tyrosine
kinase activity (c-kit) detect by CD117
Highly malignant
Resistant to conventional treatment
Staging TNM
(Gastrointestinal)
Colon carcinoma
Epidemiology
UK = 36000 cases, 22000 men and 16000
women
3rd commonest
16000 deaths per annum
Occur 50 years of age
Colon carcinoma
Etiology
Colon carcinoma
Symptoms
Colon carcinoma
Investigations
Digital PR examination
Double contrast barium enema
Colonoscopy
CT
MRI
Colon carcinoma
DUKES Staging
Dukes A/ stage A invasion into but not
through bowel wall
Dukes B/ stage B involving bowel wall but
not lymph nodes
Dukes C/ stage C involvement of nodes
Dukes D/ stage D - metastasis
Colorectal carcinoma
1. Increased uptake consistent with tumor in the
liver corresponding to CT mass. No other liver
lesions or metastases are seen elsewhere.
2. Surgical resection is planned. The preoperative
FDG PET scan is used to determine the presence
of any other metastases in the liver or
elsewhere.
3. a. increased serum CEA
with normal
conventional imaging. b. equivocal lesion with
conventional imaging. c. preoperative staging
before curative resection.
4. Negative scan. No evidence of tumor.
Colorectal carcinoma
1. Large abnormal region of increased uptake in
the pelvis consistent with recurrent tumor. A
large tumor is present in the left pelvis adjacent
to the bladder in addition to multiple small sites
of tumor uptake.
2. Tc-99m CEA is superior to CT in extrahepatic
abdomen and pelvis but equal to CT in detecting
tumor in the liver.
3. Rising serum CEA level with negative CT findings.
Potentially resectable recurrent disease, usually
in the liver, done to exclude other metastases
that would preclude surgery.
4. In-111 Oncoscint and FDG PET
Prostate carcinoma
Epidemiology
UK = 35000 cases = 12% cancer cases and
10000 deaths per annum
Age over 70 years
2nd most common after lung carcinoma
Prostate carcinoma
Symptoms
Prostatic outflow obstructive symptoms: poor
stream/ frequency/ terminal dribble/ nocturia
Erectile dysfunction
Haematospermia
Bone pain
Hypercalcemia
Prostate carcinoma
Investigations
Prostate carcinoma
1. In-111 labeled monoclonal antibody directed
against the prostate specific membrane antigen,
a glycoprotein expressed by normal and prostate
cancer cells.
2. CT and MRI sensitivity ranges from 5% - 20%.
Accuracy of In-111 ProstaScint is 70%.
3. Paraaortic upper abdominal uptake consistent
with tumor adenopathy. Focal uptake in the left
upper chest consistent with tumor.
4. Recurrent tumor limited to the prostate bed or
metastatic pelvic nodes require radiation ports.
Extrapelvic metastases require systemic therapy.
Cervical carcinoma
Epidemiology
UK = 2700 cases, 900 deaths per annum
Age 40 50 years
24000 carcinoma in citu (CIN III)
Cervical carcinoma
Etiology
HPV
Intercourse at early age
Lower socioeconomic group
Oral contraceptive
Miscarriage
Smoking
Cervical carcinoma
Symptoms
Vaginal bleeding
Vaginal discharge
Hematuria
Low back pain
Renal failure due
obstruction
to
bilateral
ureteral
Cervical carcinoma
Investigations
Cervical cytology
Biopsy
CT scan
MRI
Cervical carcinoma
Cervical carcinoma
Ovarian carcinoma
Epidemiology
UK = 6600 cases
2.3 % of all cancer cases
4400 cases deaths per annum
Ovarian carcinoma
Pathology
Common appearance
Psedomucinous cyst
Serous cyst
Microscopic appearance
Epithelial adenocarcinoma
Germ cell tumors
Ovarian carcinoma
Investigation
Serum CA 125
CXR
Ultrasound
CT scan
Hodgkins Lymphoma
Epidemiology
UK = 1500 cases, 850 men and 650 women
with 350 deaths per annum
Two peak incidence in young 20 30 years
and over 70 year
Hodgkins Lymphoma
Etiology
Epstein Barr virus
Hodgkins Lymphoma
Symptoms
B symptoms:
1. Fever > 38C
2. Weight loss > 10%
3. Night sweat
Hodgkins Lymphoma
Sign
Hodgkins Lymphoma
Differential diagnosis
Infection: pyogenic/ TB or viral
Leukemia
carcinoma
Hodgkins Lymphoma
Investigations
Blood count
ESR
Serum LDH
Alkaline phosphatase
Marrow
CXR
CT/ MRI
PET scan
Biopsy
Blood count
ESR
Serum LDH
Alkaline phosphatase
CSF - DLBCL
Marrow
CXR
CT/ MRI
PET scan
Biopsy
Hodgkins Lymphoma
Classic HD
Nodular
lymphocyte
predominant
Lymphocyte rich
Lymphocyte depleted
Mixed cellularity
Nodular sclerosis
Lymphoblastic
High grade
Curable
Aggressive and urgent
treatment
Follicular
Lympho
plasmacytoid
Low grade
Indolent
Respond well to chemo but
difficult to cure
Burkitts
DLBCL
Sezary syndrome
Peripheral T cell
MALT
Mantle cell
Lymphocytic
Adult T cell
leukemia
Anaplastic
large cell
T cell
Angiocentric
Angioimunoblastic
Mycosis fungoides
Hodgkins disease
1. FDG is glucose analog. Increased FDG uptake occurs
with increased glucose metabolism. Is taken up
intracellularly and phosphorylated similar to glucose,
however, unlike glucose, it can not be metabolized
further and is intracellularly trapped.
2. a. intense multifocal uptake bilaterally in the neck,
upper chest and parasternal regions. b. uptake limited
to the left neck. Study a. abnormalities are caused by
muscle tension. Diazepam 5 mg was take just before
study b.
3. 110 minutes. 2. 10 and 20 minutes. It is important to
remember that the half life of positron are very short.
4. 3.2 rads/ 5 mCi to urinary bladder. Brain and heart.
Intracranial lymphoma
1. Tl-201 was used. Tc-99m sestamibi also can
be used, however it is taken up by choroid
plexus and could pose diagnostic problems in
some cases.
2. Tumor, particularly lymphoma, versus
infection, usually toxoplasmosis or infection
e.g.. CMV or herpes simplex.
3. Malignant lymphoma.
4. 90% sensitivity and false negative < 10%.
Lymphoma
1. CT scan is in indeterminate, but FDG PET
demonstrates a complete response.
2. CT assessment of tumor response is based on a
decreased in the size of the mass or complete
resolution. Post therapy residual masses are common
and CT cannot differentiate residual tumor from post
therapy fibrosis and necrosis.
3. Multiple high energy photopeak: 185, 300, 394
resulting poor image resolution, need delayed images
from 2 to 3 days.
4. Study completed 2 hours after injection. FDG PET
target to background ratio higher and image quality
superior to Ga-67.
Hodgkins disease
1. The bone scan shows mild increased uptake
at L3. The Ga-67 scan shows abnormal
uptake in the L3 vertebral body, bilateral
neck, mediastinum, right paratracheal
regions, posterior thorax, right lung base and
liver.
2. Bone scan.
3. Hodgkins
disease,
TB
or
atypical
mycobacteria; Hodgkins disease likely.
4. Stage IV.
Axillary LNs
Sentinel node
Is the first lymph node bed which a tumor cell
would come if it penetrated into lymphatic
fluid.
If axillary sentinel node is tumor free < 3%
chance of any tumor metastasis
Radiopharmaceutical= Tc-99m SC injected
subdermally/ periareolar/ intradermal or
peritumoral
Scintimammography
1. Tc-99m sestamibi lipophilicity allows it to enter the
cell where it is concentrated in the mitochondrial
region related to charge.
2. Patient A has prominent focal uptake in a right breast
mass. Patient B has definite focal uptake at the
periphery of the breast prosthesis.
3. Accuracy of conventional mammography: sensitivity,
70% to 95%; positive predictive value for cancer, 20%
- 30%. Scintimammography trial: sensitivity/
specificity, 75%/83%
4. Most false negative findings are in lesions less than 1
cm. False positive findings occur in fibroadenomas
and benign and malignant tumors other than breast
cancer
Scintimammography
1. The 5 year survival rate for breast cancer
decreases with axillary node involvement.
Adjuvant chemotherapy is indicated.
2. A sentinel node biopsy drained by the
lymphatics in a nodal basin.
3. If the sentinel node biopsy is tumor negative, no
axillary dissection is needed. If positive, axillary
dissection is performed.
4. Tc-99m sulfur colloid is often used. It is injected
around the lesion or biopsy site. Imaging usually
is performed. At surgery a gamma probe is used
to help locate the sentinel node.
Thyroid carcinoma
PET sensitivity for poorly differentiated
carcinoma > 90%
Benefits for: anaplastic and Hurtle cell variant
of follicular
Esophageal carcinoma
Colorectal carcinoma
Melanoma
PET sensitivity > 90% and specificity 87%
PET alter treatment 20 26%
Breast carcinoma
False negative:
1. Well differentiated
2. Slow growing : lobular/tubular/DCIS
Ovarian carcinoma
PET sensitivity for staging and restaging (5090%)
PET specificity 60-80%
PET alters management 15% cases
Mucinous
cystadenocarcinoma
PET false ve in
ovarian carcinoma
Well differentiated
cystadenocarcinoma
Disseminated peritoneal
carcinomatosis
Borderline tumors
Stage I tumors confined to
the ovary
Testicular carcinoma
PET sensitivity 84%
PET negative predictive value is 94%
Neuroendocrine tumor
Radionuclide therapy
Hepatocellular ca
I-131 lipiodol
Bone metastasis
Rhenium 188
Yittrium 90 microsphere
Rhenium 188 HEDP
Phosphorus 32 phosphate
Samarium 153 EDTMP
Strontium 89 chloride
Yittrium 90 citrate
Hyperthyroid / thyroid ca
I-131 NaI
Polycythemia vera
Phosphorus 32 phosphate
HD
NHD
Hepatocellular
Melanoma
Lungs
Head & neck
Soft tissue sarcoma
Abd & pelvic tumors
Tumor imaging
Gallium - 67
DMSA(V)
MTC
Tc-99m
FDG
I-131
Thyroid ca
Tumor specific
MIBI/tetrofosmin
MTC
Breast
Non specific
NP-59
Adrenal cortex
MIBG
Adrenal medulla
MTC
Breast
Brain
Bone
MTC
Karposi sarcoma
Thallium-201
Peptide
I-111 pentreotide
Somatostatin
MTC
Tc-99m CEA
Colorectal
Monoclonal
Tc-99m Neo Tect
Somatostatin
Lungs ca
Organ specific
In-111 satumomab (onco scint)
Ovarian
colorectal
Cold
Thyroid
I-123
Tc-99m pertechnetate
Hot
Liver
Tc-99m SC
Bone
Tc-99m MDP
Tc-99m HDP
Brain
Tc-99m DTPA
Tc-99m glucoheptonate
Hepatocyte
Tc-99m HIDA
I-111 zevalin
NHD
In-111 capromab
Prostate
Which malignant tumors useful for Ga67 for diagnosis, staging and re
staging?
Which malignant tumors useful for Ga67 for diagnosis, staging and re
staging?
Hodgkins disease
Lymphoma
Hepatoma
Melanoma
Non HD
Multicentric disease with a
highly variable clinical course
and high incidence of
extranodal tumor
involvement.
Abdominal involvement of
mesenteric and
retroperitoneal nodes is
common.
Variable clinical course that
can be indolent or rapid lethal
Inner canthus
Radiosynovectomy
Reference
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Biersack, H,Jurgen. Freeman, L,M. 2007, Clinical nuclear medicine
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Krishnamurthy, G,T. Krishnamurthy, S. 2009, 2nd edition, Nuclear
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Thrall, J, M. Ziessman, H,A. 2001, 2nd edition, The Requisites .
Ziessman, H,A. Case review nuclear medicine.
Elgazzar A,H. 2006, The pathophysiologic basis of nuclear
medicine .
Sharp, P,F. Gemmell, H, G. 2005, 3rd edition, Practical nuclear
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