NUCLEAR MEDICINE
Dean Ameena|
Scanning
LESSON: 1 ● Routine survey
○ begins 2 to 3 hours after the injection
○ takes 30 to 45 minutes
CLINICAL NUCLEAR MEDICINE
● The number of camera images acquired depends on
the indication for the examination.
● Patient preparation for nuclear medicine procedures
is minimal, with most tests requiring no special
Bone (skeletal) Studies
preparation.
● Bone scan
● The waiting time between dose administration and
● Bone marrow scan
imaging varies with each study.
● Joint scan
● After completion of a routine procedure, patients may
resume all normal activities.
BONE SCINTIGRAPHY
● Bone scintigraphy is generally a survey procedure
to evaluate patients with malignancies, diffuse
musculoskeletal symptoms, abnormal laboratory
results, and hereditary or metabolic disorders.
● Radiopharmaceuticals used for bone imaging can
localize in bone and also in soft tissue structures.
● Skeletal areas of increased uptake are commonly a
result of tumor, infection, or fracture.
The most common bone density measurement techniques
are as follows:
Bone Scan Principle
● Dual-energy x-ray absorptiometry (DXA)
● It is not entirely clear how 99mTc-labeled
○ most accurate and advanced technique
diphosphonates are incorporated into bone at the
molecular level.
● Dual photon absorptiometry (DPA)
○ earlier generation of DXA, is now in limited
● In area in which osteoblastic activity is increased,
use
active hydroxyapatite crystals with large surface areas
appear to be the most suitable sites for uptake of the
● Single-energy x-ray absorptiometry (SXA)
diphosphonate portion of the radiopharmaceutical.
○ uses a very low-dose x-ray source and
measures bone in the wrist or heel
Radiopharmaceutical
● Quantitative computed tomography (QCT)
● Adult dose
○ uses a conventional CT scanner with special
○ 20 mCi (740 MBa) of 99mTc
computer software
hydroxymethylene diphosphonate (HDP)
● Radiographic absorptiometry (RA)
○ 20 mCi (740 MBq) of 99mTc
○ uses a specialized x-ray technique of the
methylenediphosphonate (MDP)
hand to calculate bone density
● Pediatric dose
○ adjusted according to the patient's weight
AE | 1
NUCLEAR CARDIOLOGY 201TI Myocardial Perfusion Study
Principle
● Nuclear cardiology has experienced rapid growth in
recent year and currently compose a significant ● Stress thallium-201 study
portion of daily nuclear medicine procedures. ○ high sensitivity (about 90%)
○ specificity (about 75%)
● These noninvasive studies assess:
○ cardiac performance ● 201 TI
○ evaluate myocardial perfusion ○ analog of potassium
○ measure viability and metabolism ○ has a high rate of extraction by the
myocardium over a wide range of metabolic
● The stress test is performed with the patient using a and physiologic conditions
treadmill or stationary bicycle.
● Under stress, uptake peaks within 1 minute
● During the stress test the patient's heart rate,
electrocardiogram (ECG or EKG), blood pressure, ● Uptake in the heart ranges
and symptoms are continuously monitored. ○ from about 1% of the injected dose at rest
○ to about 4% with maximum exercise
Exercise Radionuclide Angiography ○ Regions of the heart that are infarcted or
Principle underperfused at the time of injection appear
as areas of decreased activity
● Gated radionuclide angiography (RNA)
○ used to measure: Radiopharmaceutical
■ left ventricular ejection fraction
■ evaluate left ventricular regional ● Adult dose for a
wall motion ○ stress study
● RNA requires that the blood be labeled with an ○ 3 mCi (111 MBq) of 201TI thallous chloride
appropriate tracer such as 99mTc. administered intravenously at peak stress
● The technique is based on imaging using a ○ 1 mCi (37 MBq) of 201TI is administered
multi-gated acquisition (MUGA) format. intravenously before the delayed study,
generally 3 to 4 hours after stress rest study
Radiopharmaceutical
○ 4 mCi (148 MBq) of 201Tl administered
● Adult dose intravenously before the rest study
○ 25 to 40 mCi (1110 MBq) of 99mTC-labeled
red blood cells ● Pediatric dose
○ based on the patient's body surface area ○ 300 mCi (11.1 MBq) of 201TI thallous
chloride
● Pediatric dose
○ adjusted according to the patient's weight ● Obese patients
○ 99mTc sestamibi should be used in place of
Scanning 201 TI
● Imaging can begin immediately after the injection Scanning
and takes about 1 hour
● Obtained include the anterior planar image of the
● Obtained in the anterior, left lateral, and left chest and heart
anterior oblique position
● Followed by a 180-degree SPECT study
AE. 2
99mTc Sestamibi Myocardial Perfusion Study ● 201T| myocardial perfusion scan
Principle ● 99mTc sestamibi first-pass study
● 99mTc sestamibi myocardial perfusion scan
● 99mTc sestamibi ● 99mTc pyrophosphate (PYP) myocardial infarct scan
○ has a slightly lower fractional extraction ● Rest 201T| can with infarct quantitation
than thallium, particularly at high flow rates
○ has favorable biologic properties for CENTRAL NERVOUS SYSTEM
myocardial perfusion imaging
● For patients with diseases of the central or
○ it is used to assess myocardial salvage peripheral nervous systems, nuclear medicine
resulting from therapeutic intervention in techniques can be used to:
acute infarction
○ assess the effectiveness of surgery or
● A first-pass flow study can be performed with a rest radiation therapy
or stress 99m Tc sestamibi myocardial perfusion
scan. ○ document the extent of involvement of the
brain by tumors
● A first-pass study evaluates heart function, ejection
fraction, during the short time (in seconds) that it ○ determine progression or regression of
takes the injected bolus to travel through the left lesions in response to different forms of
ventricle. treatment
Radiopharmaceutical ● Brain perfusion imaging is useful in the
evaluation of patients with:
● Adult dose ○ Stroke
○ stress study ○ Transient ischemia
○ Other neurologic disorders
○ 10 to 30 mCi (370 to 1100 MBq) of 99mTc ○ Alzheimer's disease
sestamibi administered intravenously at ○ Epilepsy
peak stress rest study ○ Parkinson's disease
○ 10 to 30 mCi (370 to 1100 MBq) of 99mTc ● Radionuclide cisternography is particularly useful
sestamibi administered intravenously before in the diagnosis of:
the rest study ○ CSF leakage after trauma or surgery
Scanning ○ normal-pressure hydrocephalus
● SPECT imaging Brain SPECT Study Principle
○ 30 to 60 minutes after injection of the dose,
for both stress and rest studies ● Some imaging agents are capable of penetrating the
intact blood-brain barrier.
● When needed, more delayed images can be obtained
for up to 4 to 6 hours after injection ● The regional uptake and retention of the tracer are
related to the regional perfusion.
● A 2-day protocol provides optimum image quality,
but the 1-day protocol is more convenient for ● Note that before the imaging agent is injected, the
patients, technologists, and physicians patient is placed in a quiet, darkened area and
instructed to close the eyes.
Cardiovascular Studies
○ These measures are helpful in reducing
● Aortic/mitral regurgitant index uptake of the tracer in the visual cortex.
● Cardiac shunt study
● Dobutamine multiple gated acquisition (MUGA)
● Rest MUGA
● Rest MUGA-ejection fraction only
● Exercise MUGA
● Stress testing (myocardial perfusion)
AE. 3
Radiopharmaceutical Thyroid Scan Principle
● Adult dose ● 99mTc pertechnetate or 123l can be used to image
○ 20 mCi (740 MBq) of 99mTc the thyroid gland.
ethylcysteinate diamer (ECD)
● 99mTc pertechnetate is trapped by the thyroid gland
○ 20 mCi (740 MBq) of 99mTc but, unlike iodine-131, is not organified into the gland.
hexamethy|propyleneamine-oxime 123| is organified into the gland.
(HMPAO)
● Imaging is used to determine the relative function in
● Pediatric dose different regions within the thyroid, with special
○ based on weight emphasis on the function of nodules compared to the
rest of the gland.
Scanning
Radiopharmaceutical
● Imaging begins 30 minutes after 99mTc ECD
injection or 1 hour after 99mTc HMPAO injection. ● Adult dose
○ 5 mCi (185 MBq) of 99mTc pertechnetate
● Tomographic images of the brain are obtained.
○ 0.5 to 1.5 mCi 123 T 123
Central Nervous System Studies
● Pediatric dose
● Brain perfusion imaging-SPECT study ○ adjusted according to the patient's weight
● Brain imaging-acetazolamide challenge study
● CNS shunt patency Scanning
● CSF imaging-cisternography/ ventriculography
● 201T| scan for recurrent brain tumor ● Scanning should start 20 minutes after the
● 99mTC HMPAO scan for determination of brain death injection.
ENDOCRINE SYSTEM ● A gamma camera with a pinhole collimator is
used to obtain:
● The endocrine system organs, located throughout ○ anterior
the body, secrete hormones into the blood stream. ○ left oblique
○ right anterior oblique thyroid image
● The endocrine system consists of the thyroid, ○ 6-inch (15-cm) anterior neck image
parathyroid, pituitary, and suprarenal gland, the
islet cells of the pancreas, and the gonads. 131| Thyroid Uptake Measurement Principle
● Nuclear medicine procedures have played a ● Radioiodine is concentrated by the thyroid gland in a
significant part in the current understanding of the manner that reflects the ability of the gland to handle
function of the endocrine glands and their role in stable dietary iodine.
health and disease.
○ Therefore 131/ uptake is used to estimate
● Thyroid imaging is performed to evaluate the the function of the thyroid gland by
○ sIZe; measuring its avidity for administered
○ shape; radioiodine.
○ nodularity; and
○ functional status of the thyroid gland ● Uptake conventionally is expressed as the percentage
of the dose in the thyroid gland at a given time after
● Imaging is used to screen: administration.
○ thyroid cancer
● 131| uptake measurement is of value in distinguishing
○ to differentiate: between:
■ Hyperthyroidism ○ Thyroiditis (reduced uptake)
■ Nodular goiter ○ Graves' disease or Plummer's disease,
■ Solitary thyroid nodule (increased uptake)
■ Thyroiditis
AE. 4
● It is also used to determine the appropriateness of a Scanning
therapeutic dose of 131l in patients with:
○ Graves' disease ● Neck imaging
○ Residual or recurrent thyroid carcinoma ○ starts 24 hours after administration of the
○ Thyroid remnant after thyroidectomy dose
Radiopharmaceutical ● Total-body imaging
○ begins 48 hours after dose administration
● All doses of 131| sodium iodide are administered
orally. ● Images are obtained of the anterior planar neck.
● Adult dose ● Total-body images are of the anterior and posterior
○ 3 to 5 MCi (148 to 222 kBq) of 131| (for a whole body.
standard uptake test)
Endocrine Studies
● Pediatric dose
○ adjusted according to the patient's weight ● Adrenal cortical scan (NP-59)
● Adrenal medullary scan (mIBG)
● A standard dose is counted with the thyroid probe, in ● Ectopic thyroid scan (131// 1231)
the morning of the scan, and is used a 100% of ● Thyroid scan (99mTc pertechnetate)
maximum counts. ● 131| thyroid uptake measurement
● 123| thyroid uptake/ scan
● Measurements are obtained using an uptake probe ● 131| neck/ total body iodine scan
consisting of a 2X2 inch (5X5 cm) sodium iodide ● Parathyroid scan
photomultiplier tube assembly fitted with a flat-field ● Indium-111 pentetreotide scan
lead collimator
GASTROINTESTINAL SYSTEM
Neck/ Total-Body 131/ Scan Principle
● The gastrointestinal system, or alimentary canal,
● A neck or total-body 131| scan is recommended for: consist of the mouth, oropharynx, esophagus,
○ locating residual thyroid tissue stomach, small bowel, colon, and several
○ recurrent thyroid cancer cell in patients with accessory organs (salivary glands, pancreas, liver,
thyroid carcinoma and gallbladder).
● A neck scan is usually performed 1 to 3 months after Liver/ Spleen Scan Principle
a thyroidectomy to check for residual normal thyroid
tissue. ● Liver and/or spleen scanning is used to evaluate:
○ the liver for functional disease (e.g.,
● After the residual thyroid tissue has been ablated, ; cirrhosis, hepatitis, metastatic disease) for
total-body 131/ scan is performed to check for the residual splenic tissue following splenectomy
metastatic spread of the cancer.
● Imaging techniques:
Radiopharmaceutical ○ Ultrasonography
○ CT
● Adult dose ○ MRI
○ for a total-body 131/ scan ○ Nuclear Medicine
○ 3 mCi (111 MBq) of 131| administered orally ○ Scintigraphy
● for a neck scan ● Uptake of a radiopharmaceutical in the liver, spleen,
○ 1 mCi (37 MBq) of 131| sodium iodide and bone marrow depends on blood flow and the
administered orally functional capacity of the phagocytic cells.
● Pediatric dose ● In normal patients:
○ adjusted according to the patient's weight ○ 80% to 90% of the radiopharmaceutical is
localized in the liver
○ 5% to 10% in the spleen
○ the rest in the bone marrow
AE. 5
Radiopharmaceutical Radiopharmaceutical
● Adult dose ● Adult dose
○ 6 mCi (222 MBq) of 99mTc sulfur colloid ○ 10 mCi (370 MBq) of 99mTc MAG3
injected intravenously
● Pediatric dose
○ 6 mCi (222 MBq) of 99mTc albumin colloid ○ adjusted according to the patient's weight
injected intravenously
Scanning
● Pediatric dose
○ adjusted according to the patient's weight ● Imaging is initiated immediately after the injection.
Scanning ○ Because radiographic contrast media may
interfere with kidney function, renal canning
● Images obtained may be planar standard (anterior, should be delayed for 24 hours after contrast
posterior, right and left anterior oblique, right and studies.
left lateral, right posterior oblique, and a marker
view), life-size, or SPECT ● Images are often taken over the posterior lower back,
centered at the level of the twelfth rib.
Gastrointestinal Studies
● Transplanted kidneys are imaged in the anterior
● Anorectal angle study pelvis.
● Colonic transit study
● Colorectal/ Neorectal emptying study ● Patient need to be well hydrated, determined by a
● Esophageal scintigraphy specific gravity test, before all renal studies.
● Gastroesophageal reflux (adults and children) study
● Gastric emptying study Genitourinary Studies
● Small-bowel transit study
● Hepatic artery perfusion scan ● Dynamic renal scan
● Hepatobiliary scan ● Dynamic renal scan with furosemide
● Hepatobiliary scan with gallbladder ejection fraction ● Dynamic renal scan with captopril
● Evaluation of human serum albumin for protein-losing ● Pediatric furosemide renal scan
gastroenteropathy ● 99mTc dimercaptosuccinic acid (DMSA) renal scan
● Liver/spleen scan Residual urine determination
● Liver hemangioma study ● Testicular scan
● Meckel's diverticulum scan ● Voiding cystography
● Salivary gland study
GENITOURINARY NUCLEAR MEDICINE IN VITRO AND IN VIVO HEMATOLOGIC STUDIES
● Genitourinary nuclear medicine studies are ● The two types of nonimaging nuclear medicine
recognized as reliable, noninvasive procedures for procedures are as follows:
evaluating the anatomy and function of the
systems in nephrology, urology, and kidney ● In vitro
transplantation. ○ radioimmunoassay for quantitating
biologically important substances in the
Dynamic Renal Scan Principle serum or other body
● Renal scanning is used to assess renal perfusion and ● In vivo
function, particularly in renal failure and renovascular ○ evaluation of physiologic function by
hypertension and after renal transplantation. administering a small tracer amount of
radioactive materials to the patient and
● 99mTc mertiatide (MAG3) is secreted primarily by the subsequently counting specimen for urine,
proximal renal tubules, and is not retained in the blood, feces, or breath.
parenchyma of normal kidneys.
AE. 6
Hematologic Studies Radiopharmaceutical
● Plasma volume measurement ● Adult dose
● Schilling test ○ 15 to 30 mCi (555 to 1,110 MBq) of 133Xe
● Red cell mass gas administered by inhalation
● Red cell survival
● Red cell sequestration Scanning
IMAGING FOR INFECTION ● Imaging starts immediately after inhalation of the
xenon gas begins in a closed system to which
● Imaging for infection is another useful nuclear oxygen is added and carbon dioxide is withdrawn.
medicine diagnostic tool.
● When 133Xe gas is used, the ventilation study must
● Imaging procedure such as gallium-67 scans, and precede the 99mTc perfusion scan.
111In-labeled white cell scans are both useful for
diagnosis and localization of infection and ● Posterior and anterior images are obtained for the
inflammation. first breath equilibrium, and washout.
Infection Studies ● If possible, left and right posterior oblique images
should be obtained between the first breath and
● 67 Ga gallium scan equilibrium.
● 111|n white blood cell scans
● 99mTc HMPAO 99mTc Macroaggregated Albumin Lung Perfusion Scan
● Post total hip Radiopharmaceutical:
● knee replacement surgery
● Adult dose
RESPIRATORY IMAGING ○ 4 mCi (148 MBq) of 99mTc MAA
● Respiratory imaging commonly involves: ● Pediatric dose
○ demonstration of pulmonary perfusion ○ adjusted according to the patient's weight
using limited transient capillary blockade
99mTc Macroaggregated Albumin Lung Perfusion Scan
○ assessment of ventilation using an inhaled Scanning:
radioactive gas or aerosol
● Imaging starts 5 minutes after the injection.
● Lung imaging is most commonly performed:
○ to evaluate pulmonary emboli ● Eight images should be obtained:
○ chronic obstructive ○ anterior, posterior, right and left lateral,
○ pulmonary disease right and left anterior oblique, and right
○ chronic bronchitis and left posterior oblique.
○ emphysema asthma
○ lung carcinoma ● All patients should have a chest radiograph within 24
○ lung transplant evaluation hours of the lung scan.
133Xe Lung Ventilation Scan Principle Respiratory Studies
● Lung ventilation scans are used in combination with ● 99mTc DTPA lung aerosol scan
lung perfusion scans. ● 99m Tc MAA lung perfusion scan
● 133Xe lung ventilation scan
● The gas used for a ventilation study must be
absorbed significantly by the lungs and diffuse easily.
● Xenon-133 has adequate imaging properties, and the
body usually absorbs less than 15% of the gas.
AE. 7
THERAPEUTIC NUCLEAR MEDICINE
● Radioiodine is a treatment in practically all adults
with Graves' disease, except those who are
pregnant or breast-feeding.
● High-dose 131| therapy (30 mCi or more) is used in
patients with residual thyroid cancer or thyroid
metastases.
● Phosphorus-32 in the form of sodium phosphate
can be used to treat polycythemia, a disease
characterized by the increased production of red
blood cells.
● 32P chromic phosphate colloid administered into
the peritoneal cavity is useful in the postoperative
management of ovarian and endometrial cancers.
● Skeletal metastases occur in more than 50% of
patients with breast, lung, or prostate cancer in
the end stages of the disease.
● Strontium-99 is often useful for managing patients
with bone pain from metastases when other
treatments have failed.
Therapeutic Procedures
● 131| therapy for hyperthyroidism and thyroid cancer
● 32P therapy for polycythemia
● 32P intraperitoneal therapy
● 32P intrapleural therapy
● 89Sr bone therapy
SPECIAL IMAGING PROCEDURE
● Special imaging procedures include:
○ Dacryoscintigraphy
○ LeVeen shunt patency test
○ Sentinal node studies for melanoma or
breast cancer
○ Lymphoscintigraphy of the limbs
TUMOR STUDIES
● 67 Ga tumor scan
● 99mTc sestamibi breast scan
● 111|n OncoScint (satumomab pendetide) scan
● 111|n ProstaScint (capromab pendetide) scan
● 99mTc CEA gastrointestinal scan
● 99mTc verluma for small cell lung cancer
● 111|n Octreoscan
AE. 8
