Title: Nuclear Medicine a guide for healthcare professionals and patients
1(No Transcript)
2AIM AND OBJECTIVE OF THIS BOOK
- Patient education about Nuclear Medicine
- Clear apprehensions of patients and common
people about Nuclear - Medicine
- Assistance to healthcare professionals and
patients - In preparation for particular investigation,
therapy or palliation. - Guide them about cessation of breast feeding and
pregnancy. - 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
reports. - 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.
3- Book can be used for
- Educating patients by keeping them in waiting
room of Nuclear Medicine dept. - Promote Nuclear Medicine by educating general
physicians. - 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.
4CHAPTERS INCLUDED IN THIS BOOK
- 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
5Likewise 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)
6Chapter 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
77.2.11 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
87.4.5 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
9CHAPTER 3COMMON APPREHENSIONS ABOUT NUCLEAR
MEDICINE
- Some of the questions include
- Will Nuclear Medicine Scans have some side
effects? - Will a Nuclear Medicine scan make me
radioactive? - 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?
10CHAPTER 6.5.1 MYOCARDIAL PERFUSION
STUDY
- 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
11- 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
breast-feeding, - 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
or - 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.
12- 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
organ. - 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
of - 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
13Fig 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.
14Fig 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
15CHAPTER 7.5 Genito-Urinary
System
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)
16Source 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
17Thank You