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Nuclear Medicine a guide for healthcare professionals and patients (1)


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Title: Nuclear Medicine a guide for healthcare professionals and patients (1)

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  • Patient education about Nuclear Medicine
  • Clear apprehensions of patients and common
    people about Nuclear
  • Medicine
  • Assistance to healthcare professionals and
  • In preparation for particular investigation,
    therapy or palliation.
  • Guide them about cessation of breast feeding and
  • Post-procedure precautions to observed.
  • Explanation of Nuclear Medicine terms in brief
  • Guide General physicians, residents and MBBS
    trainees about
  • What is nuclear medicine?
  • What a particular procedure is?
  • What are indications for a particular procedure?
  • Definition of terms used in Nuclear Medicine
  • Assist nuclear medicine professionals in
  • Overall method of procedure to be performed.
  • Set of instructions to be given to the patient
    before, during
  • and after the procedure.
  • Type and amount of radioactivity to be used.

  • Book can be used for
  • Educating patients by keeping them in waiting
    room of Nuclear Medicine dept.
  • Promote Nuclear Medicine by educating general
  • Can be used as ready reckoner by Nuclear
    Medicine professionals .
  • It can be kept in wards to be used by ward staff
    to prepare patients and educate themselves about
    radiation safety after the study.

  • Introduction to Nuclear Medicine
  • Meet the Nuclear Medicine
  • Common Apprehension about Nuclear
  • Nuclear Medicine procedures
  • Chapter 6.1 Endocrine System
  • 6.1.1 Thyroid Radioiodine Uptake
  • 6.1.2 99mTc-Thyroid Scan
  • 6.1.3 MIBG Scan
  • 6.1.4 Medullary Thyroid imaging by DMSA (V)
  • 6.1.5 T3 Suppression Test
  • 6.1.6 TSH Stimulation Test
  • 6.1.7 Perchlorate Discharge Test
  • 6.1.8 Parathyroid Imaging
  • 6.2 Skeleton System
  • 6.2.1 Bone Scan
  • 6.2.2 Bone Three Phase Scan
  • 6.2.3 Bone Marrow Scan

Likewise there are fifty procedures are explained
in this book including PET and therapy
6.12 Positron Emission Tomography (PET)-CT
6.12.1 PET-CT Imaging of Brain 6.12.2 PET-CT
Imaging of Myocardium 6.12.3 PET-CT Imaging of
Whole Body 6.12.4 PET-CT Imaging of Bone (F-18
Bone Scan) 6.13 Therapy and Palliation 6.13.1 Pall
iative Treatment for painful bone
Metastasis 6.13.2 I-131 Therapy for Thyroid
Disease 6.13.3 MIBG Therapy for Neuro-Endocrine
Disease 6.13.4 Radiosynovectomy/Radiosynoverthesis
6.13.4 P-32 Therapy for Myeloproliferative
Disease 6.13.5 Radio-immunotherapy for B-cell
Lymphoma with 90Y- Radiolabelled Itribumomab
Tiuxetan (Zaveline)
Chapter 7.Definitions of Common terminologies
used in Nuclear Medicine 7.1 Electromagnetic
Radiation Radioactivity 7.1.1 Electromagnetic
Radiation 7.1.2 Radioactivity and Radioactive
Materials 7.1.3 Radioisotopes 7.1.4 Generators
7.1.5 Half Life 7.1.6 Radiopharmaceutical
7.2 Radiation Safety 7.2.1 Energy 7.2.2 Exposure
(X) 7.2.3 Exposure Rate (X) 7.2.4 Dose (D)
7.2.5 Dose Rate (D) 7.2.6 Relationship
between Roentgen and Rad 7.2.7 Equivalent
Dose(H) 7.2.8 Effective dose (E)
7.2.9 Cumulative Dose 7.2.10 Collective Dose
7.2.11 Annual limit of Intake(ALI)
7.2.12 Derived Air Concentration (DAC) 7.2.13
Limits of contamination 7.2.14 Half Value
Thickness or layer (HVT or HVL) 7.2.15 Tenth
Value Thickness or layer (TVT or TVL) 7.2.16
Relationship between HVT and TVT 7.2.17 Exposure
Rate constant 7.2.18 Discharge criteria for
patient (as per Atomic energy Regulatory
Board, India). 7.2.19 Dose limits
recommended by ICRP (2007) 7.3 Endocrine
System 7.3.1 Graves Disease (Diffuse Toxic
Goiter) 7.3.2 Plummers Disease (Toxic Multi
Nodular Goiter) 7.3.3 Radioiodine Therapy
7.3.4 Toxic Multinodular Goitre 7.3.5 Thyroiditis
7.3.6 Hashimoto's thyroiditis 7.4 Skeletal
System 7.4.1 Arthropathy 7.4.2 Avascular
Necrosis 7.4.3 Hypertrophy 7.4.4 Leukaemia
7.4.5 Lymphoma 7.4.6 Multiple Myeloma 7.4.7 Metas
tasis 7.5 Genito-Urinary System 7.7.1 DTPA Scan
7.7.2 DMSA Scan 7.7.3 Effective renal plasma
flow (eRPF) 7.7.4 Glomerular Filtration
Rate (GFR) 7.7.5 Renovascular
Hypertension 7.7.6 Pyelonephritis 7.7.7 Urinary
tract infection 7.6 Cardiac System 7.6.1 Coronary
Artery Disease 7.6.2 Myocardial perfusion
Study/Imaging 7.6.3 Multigated
Acquisition 7.6.4 Hibernating Myocardium 7.6.5
Stunned Myocardium 7.6.6 Myocardium
Ischemia 7.6.7 Myocardium Infarction 7.6.8
Stroke Volume 7.6.9 Ejection Fraction 7.6.10 PCI
7.6.11 METS
  • Some of the questions include
  • Will Nuclear Medicine Scans have some side
  • Will a Nuclear Medicine scan make me
  • Are there people who should not undergo Nuclear
    Medicine Scans?
  • What are Radiation effects and Risk estimates in
    Nuclear Medicine scans?
  • What is the probability of causing Carcinoma by
    Nuclear Medicine scans?
  • How much radiation exposure dose will I get in
    my procedure?

  • Myocardial perfusion study evaluates the hearts
    function and blood flow to the muscles of heart
    (myocardium). A stress myocardial perfusion scan
    is used to assess the blood flow to the
    myocardium when it is stressed by exercise or
    medication. It determines the areas of the
    myocardium which have decreased blood flow and
    thereby damages occurred into the myocardium with
    what extent. In myocardial perfusion imaging
    radiopharmaceutical (also called as tracer)
    either thallium or technetium labeled compounds
    is administered intravenously. Perfusion imaging
    identifies areas of relatively reduced myocardial
    blood flow associated with ischemia or scar. The
    relative regional distribution of perfusion can
    be assessed at rest, during cardiovascular
    stress, or both 44.
  •  Indications 45
  • Diagnosis of coronary artery disease
  • Evaluation of known coronary disease location
    and extent of ischemia
  • Determine the cause for change in symptom
    pattern in patients with known coronary
  • artery disease.
  • Evaluate the effectiveness of medical therapy
  • Risk stratification post-myocardial infarction
  • Pre-operative evaluation for major non-cardiac
    surgery in patient with known coronary
  • disease.
  • Assessment after percutaneous transluminal
    coronary angioplasty or coronary artery
  • bypass grafting
  • Guide to rehabilitation therapy

  • Instructions to the patient
  • Patients may require to stay in the dept for 3-5
    hrs depending on the number of patients appointed
    and the
  • study protocol in their case.
  • They can drink 01 glass of water/milk before the
    test in the morning. If their appointment is
    after 1000 h, they
  • can have light breakfast before 0600 h. Idea
    is to have 04 hrs fasting before the test.
  • Patients are advised to bring their breakfast
    alongwith them. They are required to eat
    preferably a light fatty
  • meal after exercise and before imaging.
  • They should bring all previous medical documents
    on date of appointment.
  • Female patients should inform about their LMP,
    Lactation and any chance of pregnancy. If
  • there is no need to stop it for 99mTc
    radiopharmaceuticals i.e. if 99mTc-SestaMIBI is
    used upto 1110
  • MBq (30 mCi) 20 and 201Tl lt80MBq of activity
    46. However if 201Tl is used upto 111 MBq,
  • breastfeeding should be stopped for 96 hrs and
    counseling should be done by radiation safety
  • officer 20.
  • Some medications such as beta-blockers may
    prevent achievement of maximum heart rate nitrate
  • calcium channel blockers may mask or prevent
    cardiac ischemia, limiting the tests ability to
    detect coronary
  • disease. 45 Cardiac medications should be
    withheld if the examination is performed to
    detect coronary
  • disease. Cardiac medication should be taken as
    usual when the examination is performed to
    determine the
  • effectiveness of medical therapy 44. Such
    interruption should ideally last for five
    half-lives of the drug 46. In
  • general, the decision on whether to interrupt
    drug administration should be left to the
    referring physician.

  • Procedure
  • On arrival of patient on date of appointment, a
    detailed history of the patient is obtained.
  • He/she is taken for fixing IV cannula.
  • Patient undergoes either physical or
    pharmaceutical stress.
  • At the peak of exercise, patient is administered
    with radiopharmaceutical (250-350 MBq
  • (6.75-9.5 mCi) 99mTc-Sestamibi or 74-148 MBq
    (02-04 mCi) of 201TlCl).
  • He/ She is sent for having breakfast. An
    oily/fatty breakfast is advised in case 99mTc-
  • Sestamibi radiopharmaceutical is used, for
    draining out the liver, as it may interfere in
  • imaging of myocardium, being an adjacent
  • Imaging should begin 3060 min after injection to
    allow for hepatobilliary clearance
  • longer delays are required for resting images
    and for stress with vasodilators alone \
  • because of the risk of higher sub
    diaphragmatic 99mTc activity. However, the time
  • imaging for 201Tl is 15-20 min, because it
    does not accumulate in liver and have renal
  • clearance.
  • Rest injection of radiopharmaceutical (03 times
    the radioactivity injected at stress) is
  • given 02 hrs after stress. In case of 201Th no
    second injection is given due to its \
  • redistribution property.
  • Imaging of rest begins after 45 min 01 hr of
    rest injection.
  • In some cases, if there is fixed defect seen in
    inferior wall of myocardium, prone imaging

Fig 6.5.1 Normal myocardial perfusion study.
Myocardial image is provided by the full
thickness of the left ventricular myocardium. The
right ventricular free wall and atrial walls are
much thinner structures but define the outline of
their cavities. Three sets of images of left
ventricle is displayed for three dimensional view
of heart (1) a view generated by slicing
perpendicular to the long axis of the left
ventricle (short axis), (2) a view of long-axis
tomograms generated by slicing in the vertical
plane (vertical long axis), (3) a view of
long-axis tomograms generated by slicing in the
horizontal plane (horizontal long axis). Images
are serially displayed for different sections of
the heart. Figures below illustrates the image
of heart showing short axis, horizontal long axis
and vertical long axis and their ways of slicing
for better understanding of above images.

Fig 6.5.2 Reversible perfusion defect in LAD
territory. Images are serially displayed for
stress and rest comparing short axis, vertical
long axis and horizontal long axis views. Black
arrows depicts reversibility
CHAPTER 7.5 Genito-Urinary
7.5.1 DTPA Scan 99mTechnetium labeled
Diethylene triamine pentaacetic acid (DTPA) is
used to see glomerular filtration rate (GFR).
DTPA is a heavy metal chelate cleared through
Glomerular filtration. Following intravenous
injection of 99mTc DTPA, normal peak cortical
uptake occurs by 3-4 minutes. By 5 minutes, the
collecting system is seen the bladder is
typically visualized by 10-15 minutes. 7.5.2
DMSA Scan A DMSA scan is a radionucleotide scan
that uses dimercaptosuccinic acid in assessing
the renal function, it is now the most reliable
test for the diagnosis of Acute pyelonephritis
145. The major clinical indications for this
investigation are the detection and/or evaluation
of a renal scar, the small or absent kidney, an
occult duplex system, certain renal masses,
systemic hypertension or suspected vasculitis146
. 7.5.3 Effective renal plasma
flow (eRPF) Effective renal plasma flow (eRPF) is
a measure used in renal physiology to
calculate renal plasma flow (RPF) and hence
estimate renal function. ERPF RPF x extraction
ratio Where renal plasma flow (RPF) is the volume
of plasma that reaches the kidneys per unit time
and extraction ratio is the ratio of compound
entering the kidney that got excreted into the
final urine. 7.5.4 Glomerular Filtration
Rate (GFR) Glomerular filtration rate (GFR) is
the volume of fluid filtered from
the renal (kidney) glomerular capillaries into
the Bowman's capsule per unit time. GFR can be
calculated by measuring any chemical that has a
steady level in the blood, and is freely filtered
but neither reabsorbed nor secreted by the
kidneys. The GFR is typically recorded in units
of volume per time, e.g., milliliters per
minute ml/min. There are several different
techniques used to calculate or estimate the
glomerular filtration rate (GFR or eGFR)
Source of Information/References
  • Society of Nuclear Medicine Molecular Imaging
    procedure guidelines
  • European Association of Nuclear Medicine
    procedure guidelines
  • ACRSNMSPR practice guideline
  • International Atomic Energy Agency guidelines
    for radiation safety
  • Ell PJ, Gambhir SS Nuclear Medicine in
    Clinical Diagnosis and Treatment volume III,
    ISBN 0-443-07312-0
  • Ziessman Harvey A., OMalley Janis P., Thrall
    James H., Nuclear Medicine The Requisites in
    radiology, Third Edition. ISBN 978-0-323-02946-9
  • Many other Nuclear Medicine books
  • Several websites

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