RADIOLOGY

NUCLEAR MEDICINE

Dr. Wenceslao S. Llauderes, MD.

17 MARCH 2015

Nuclear Medicine
RADIOACTIVE
Interaction of molecules or atoms inside the human body

Radiation is emitted by the patient which is then detected

to form the images
Radiopharmaceuticals
Portrays physiology, biochemistry or pathology in the body
without causing any physiological effect
Two parts:
Radionuclide radioactive portion; allows for external
detection
Pharmaceutical/biologically active molecule/carrier drug
acts as a carrier and determines localization and
biodistribution
131Iodine Radioactive Iodine131
Accumulates in the thyroid
Organ specific

3 Learning Objectives
1. To be able to differentiate Nuclear Medicine from
Radiology
2. Basic ideas of Nuclear Medicine Diagnostic Procedures
3. Basic ideas of Nuclear Medicine Therapeutic Procedures
NUCLEAR MEDICINE VS RADIOLOGY
What is Nuclear Medicine?
Branch of medicine utilizing radiopharmaceuticals to study
physiological processes and help diagnose, stage and treat
disease
Radio emits radiation
Pharmaceutical (Greek word: Greek pharmakeutikos (from
pharmakeutes druggist, from pharmakon drug)
Using drugs that emits radiation
Radiopharmaceuticals are also called radiotracers because
they trace a particular physiologic/pathologic process in the
body and trace means they do not pose alteration in the
body
As changes in physiology precede changes in anatomy, NM
procedures can identify abnormalities early in the disease
course where appropriate treatment can be given sooner and
a more successful prognosis is possible

Radiopharmaceuticals are safe

99.9% water
Radiotracers because they are given in subpharmacological
dose that trace a particular physiological or pathological
process in the body
Not enough to cause any pharmacodynamics effect,
change in physiology or cause allergic reactions
Radionuclide is in very small amounts not to cause any
physical damage
Gamma Camera
Does not emit radiation
Detects and captures the radiation emitted by the patient to
form images
Collimator the lens of the gamma camera

What is Radiation?
Release of energy
Has been around since the earth was formed 4,500 million
years ago
Can be detected measured and controlled
87% of radiation dose comes from natural resources, e.g.,
cosmic, food we eat, our homes
13% result of mans activities
Medical application to diagnosis and treat disease
Industrial application like inspection of welds, detection of
cracks in forged or cast metal
Research applications like dating of antiquities,
preservation of foodstuffs

How Nuclear Medicine Works

Antecubital vein
Most common route for injection of radioisotopes
When you inject, there would be a waiting time for the
radioisotopes to go the specific organ of interest
Once the radioisotopes go to the specific organ of interest, the
rays will now be picked up by the collimator and will process it
to form an image
Radiation is all around us
Everything in nature, every creature and every material
contains, and always has contained, radioactive substances
You are radioactive yourself, and so is classmate, your ipad,
your cellphone, and even me, your boyfriend, girlfriend
RADIATION = RELEASE OF ENERGY

How do drugs with radiation works inside the body?

The dose already titrated (not harmful to the human body) in
a tracer dose from the radiopharmaceutical supplier and
validated in the Nuclear Medicine department (dose
calibrator)
This radiotracer should be tagged with
bioelement/biological substance in a body for it to go to a
specific area of interest. Organ specific.
Tc99mPO4 (Technetium Pertechnetate)
PO4 behaves like iodine and go directly to thyroid gland
Tc99m HDP (hydro diphosphonate)
Affinity in bone formation
Used in evaluation of the skeletal system
Tc99m Sestamibi
Blow flow in the heart

Ionizing Radiation
Non-ionizing radiation the radiation you see in electronics
Radiation of sufficient energy to disrupt DNA strands
Photons (X-rays, gamma rays)
Particles (alpha, beta, neutrons)

How does nuclear medicine differ from radiology?

Radiology: gives information on anatomy
Radiation dose come from the outside
Nuclear Medicine: provides functional information
Radiation injected inside patients body
Nuclear Medicine: gives information on physiology

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Sources of radiation:

Atom
Basic building blocks of matter
If the proton and neutron stays inside the atom, it is stable, it
does not break energy and does not emit radiation
Once they are being bombarded with a certain another
element, the proton and neutron goes out of the cell and
becomes unstable and becomes radioactive
In the exam, UNSTABLE atom emits radiation!

54% - Radon
15% - Medical
11% - Internal
8% - Terrestrial
8% - Cosmic
3% - Consumer Products
1% - Other Sources

Ionizing Radiation Exposure with Medical Imaging

Your
Comparable
approximate
to natural
effective
background
radiation
radiation for:
dose is:
Computed
Tomography
(CT) - Spine
CHEST:
Computed
Tomography
(CT) Chest
Computed
Tomography
(CT) Chest Low
Dose
Radiography
Chest
DENTAL:
Intraoral X-ray
HEART:
Coronary
Computed
Tomography
Angiography
(CTA)
Cardiac CT for
Calcium Scoring
MENS
IMAGING:
Spine
Densitometry
(DEXA)
NUCLEAR
MEDICINE:
Position
Emission
Tomography
Computed
Tomography
(PET/CT)
Nuclear Scan
Imaging
WOMENS
IMAGING:
Spine
Densitometry
(DEXA)
Mammography

Types of Radiation
Alpha particles
241Am, 226Ra, 228Th
Cannot penetrate the skin
Can go inside the mouth internal hazard
Beta particles
3H, 14C, 90Sr
Can penetrate the skin
Used in therapeutic procedures
Radioactive iodine treatment
Gamma rays
137Cs, 60Co, 192Ir
Highly penetrable
Used with shield
Used in diagnostic procedures
Neutrons
252Cf, 239Pu

**Additional
lifetime risk
of fatal
cancer from
examination:

6 mSv

2 years

Low

7 mSv

2 years

Low

1.5 mSv

6 months

Very Low

0.1 mSv

10 days

Minimal

0.005 mSv

1 day

Negligible

12 mSv

4 years

Low

3 mSv

1 year

Low

0.001 mSv

3 hours

Negligible

Penetrating Power of Alpha, Beta Particles and Gamma Rays

25 mSv

8 years

Moderate

0.1 mSv

10 days

Minimal

0.001 mSv

3 hours

Negligible

0.4 mSv

7 weeks

Very Low

NUCLEAR MEDICINE DIAGNOSTIC PROCEDURES

In what fields of medicine are NM procedures helpful?
Endocrinology
Oncology
Cardiology
Nephrology
Gastroenterology
Pulmonology
Neurology
Infectious diseases
Orthopedics and Rheumatology
Ophthalmology and ENT
Pediatrics
Surgery (General, Transplant, Urology)
The Thyroid Gland
Imaged with 131I or 99mTc-pertechnetate
Thyroid Scan
Used to evaluate the size of the thyroid gland and the
function of the thyroid gland (hyperthyroid or
hypothyroid)

Note for pediatric patients: Pediatric patients vary in size. Doses

given to pediatric patients will vary significantly from those given to
adults.
* The effective doses are typical values for an average-sized adult.
The actual dose can vary substantially, depending on a person's size
as well as on differences in imaging practices.
** Legend:

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Thyroid Disease
36-year-old- female presenting with an anterior neck mass
Solid mass on PE, moves when swallowing
39-year-old- female presenting with an anterior neck mass,
palpitations and tremors
Scan shows a hot nodule, the rest of the gland is not
visualized
Nodular toxic patient

SPECT/CT
Fusion of SPECT images with CT for better localization of
radiotracer uptake
Ex. Planar image shows uptake in the region of the neck
Thyroid bed?
Cervical bone mets?
Parathyroid Scintigraphy
Uses Tc-99m sestamibi which localize in mitochondria
Allows for detection of parathyroid adenomas

Lingual Thyroid
8-year-old male with a mass in the root of the tongue
Scan shows a midline functioning thyroid tissue in the base of
the tongue
You cannot use CT Scan in ectopic thyroid (not an organ
specific) because it will only tell you that theres a mass but it
will not tell you the exact location

Bone Scintigraphy
A significant fraction of patients with known malignancy
develop osseous metastases
Breast CA (as of October 2012 is the most prevalent
cancer in the country) 50-85%
Lung Carcinoma 30-50%
Kidney 80%
Prostate 50-75%
Hodgkins lymphoma 50-75%
Thyroid cancer 40%
Uses 99mTc MDP/HDP
A 5% bone turnover ca be detected by bone scan while a 50%
minimum mineral loss is required before lesion is visualized on
radiographs
MRI is more sensitive but a whole body MRI is too expensive
and impractical
Skeletal image
(PBKTL) Lead Kettle
Organs that frequently metastasize to the bone
Most painful cancer (late evening or early morning
pattern)
It is painful because inside the bone theres a lot of
nerve endings, the metastasis/cancer cells develop
inside the bone marrow so theres a
pressure/expansion towards outside painful stimuli

Determining functionality of the thyroid nodules:

Likelihood of thyroid cancer in cold nodules: 15-20%
Likelihood of thyroid cancer in hot nodules: <1%
Differentiating Graves disease from other causes of thyrotoxicosis
Detect benign ectopic thyroid tissue
Lingual thyroid
Thyroiditis
You cannot visualize the thyroid gland because it is
inflamed. The tracer cannot go inside.
You can only see the background
Thyroid Cancer
Nuclear Medicine can help in staging and treatment
Whole body scan with I-131
Whole Body I-131 Scan
A 45-year-old female diagnosed with metastatic follicular
thyroid carcinoma, s/p thyroidectomy and RAI therapy
Multiple functioning metastatic thyroid tissues to the bones

Sentinel Node Mapping/Localization

Lymph node spread of cancers follows an orderly progression
Absence of metastasis in the sentinel node gives a high
likelihood that cancer has not spread to the rest of the body
Decreases lymph node dissection when unnecessary
Reduces risk of lymphedema
Sentinel node first lymph node or group of nodes draining
from a cancer site

NUCLEAR MEDICINE THERAPEUTIC PROCEDURES

Staging (2-5 mCi of 131I)

Scintimammography
Uses 99mTc-sestamibi to detect cancer cells in the breasts
and axillae
Not meant to replace mammography
Gold standard is FNAB
Used in patients with abnormal mammograms, dense breasts,
and post-operatively

Treatment (100-200 mCi 131I)

Renal Scintigraphy
Evaluate perfusion, cortical and excretory functions
Used also to evaluate functional transplanted kidney
Transplanted kidney is placed in the anterior aspect
Hepatobiliary Scan (HIDA)
Evaluate blood flow to the liver, hepatic extraction, biliary
excretion, biliary tree patency and gallbladder contraction
Help diagnose acute and chronic cholecystitis,, biliary atresia
Biliary atresia
Typically demonstrate relatively good hepatic uptake
with no evidence of excretion into the bowel at 24
hours.
A normal (or negative) HIDA is visualization of the
gallbladder within 1 hour of tracer injection. Lack of
visualization of the GB within 4 hours after the injection
constitutes a positive study and indicates the presence
of cholecystitis or cystic duct obstruction.
Provide information on post-surgical bile drainage and biliary
leakage

Thyroid Gland
Imaged with 131I or 99mTc-pertechnetate
Thyroid cancer
Likelihood:
Cold nodules: 15-20%
Hot nodules: <1%
Nuclear medicine can help in staging and treatment
Whole body scan with I-131

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Tc 99m-labelled RBC [GI Bleeding (RBC-tagged) Scintigraphy)

Indicated for gastro-intestinal bleeding even to a very
minimal bleeding as rate of 0.1 ml/min
Other notes: detects and localized ACTIVE gastrointestinal
bleeding as little as 0.05-0.1 ml/min
Compared to angiography which detects rates of
1ml/min or greater
Localization of the bleeding site helps the
angiographer to determine which vessel (celiac,
superior mesenteric, inferior mesenteric) to embolize
Can detect intermittent bleeding
Can detect possible location of severe bleeding obscuring the
muscoa

Dual Energy X-ray Absorptiometry (DEXA)

Basis for the WHO criteria for categorizing osteopenia and
osteoporosis

Gastrointestinal Bleeding
Tc99m-labelled RBCs are intravenously injected
Intraluminal extravasation of RBC indicates site of bleeding
Minimal detectable bleeding rate of 0.1ml/min
Intermittent bleeding
Severe bleeding obscuring the musoca
35-year old male with hematochezia
Active GI bleeding in midabdomen
Possibly the jejunum

PET/Position Emission Tomography

Established possibility of tumor especially in areas, difficult to
access (lungs, abdominal areas)
Can be used as a screening tool if the nodule is benign or
malignant
Can used as a monitoring tool if chemotherapy/intervention
is working
Assess different tissue metabolism and function
Quantification of cancer cell metabolism
Metabolic change before anatomic change
Dependent on signal intensity rather than lesion site
Evaluation of distorted anatomy
Questions PET can answer
Where is the tumor?
Is it benign or malignant?
What is the extent of the disease?
Is the treatment working?
Has the cancer recurred?
CASE:
This is a case of a 59-year-old, F, breast cancer
S/P MRM
For chemotherapy and radiotherapy
Interpretation:
Extensive metastatic disease involving the lungs, liver,
bones, and multiple lymph node stations from the
supraclavicular nodes down to the femoral nodes
After chemotherapy:
No evidence of hypermetabolic malignant disease
from head to midthigh

Myocardial Perfusion Imaging

Detect and diagnose coronary artery disease
Provide prognosis and risk stratification for known coronary
artery disease
Assess functional significance of known coronary artery
disease
Detect myocardial viability
The risk of cardiac death and myocardial infarction in a
patient with normal stress perfusion study is <1% annually.
(Jaret BL, Wackers FJ)
Myocardial Viability Study
Viable myocardium in patients with chronic ischemic LV
dysfunction
Evaluate dysynergic myocardium
Viable myocardium despite low perfusion
Benefit with revascularization
Lung Perfusion Scan
Detection of pulmonary embolism

PET/CT
Combination of CT scanning and Position Emission
Tomography
Better localization of lesions
PET exhibits radioactivity from hypermetabolism within the
lesions
Most of PET studies in the world utilize fusion of PET and CT
images
More specific than a PET study
Radionuclide Therapies
Rely on beta particle emission from radionuclide sources to
exert local destructive effect
Distribution of the radiopharmaceutical to a particular tissue
or organ makes the therapy highly targeted and specific
Example:
Only thyroid tissues accumulate significant amounts of
radioiodine. The radioiodine only ablates thyroid tissues
(and consequently and functioning thyroid carcinomas) in
the body leaving other vital organs unharmed

V/Q Scan and Pulmonary Embolism

Identify ventilation-perfusion mismatch
Modified PIOPED criteria:
Normal
Low or very low probability
Intermediate probability
High probability
Management: give heparin
Bone Mineral Density Testing
For all women over the age of 65 and men over the age of 70
Early or surgical menopause
History of fragility fractures
Family history of osteoporosis
Hormonal treatment for breast/prostate cancer
Prolonged and high-dose steroid therapy
Strong smoking and alcohol consumption
Chronic rheumatoid arthritis, chronic kidney disease,
hyperparathyroidism
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Therapeutic Nuclear Medicine

131I hyperthyroidism, toxic goiters, thyroid cancer
Rhenium-188 or Yttrium for radiosynovectomy
Selective internal radiation therapy (SIRT), for liver cancer
Strontium for bone palliation
Radioimmunotherapy (Zevalin) for lymphoma
I-131 MIBG for pheochromocytomas

131I

Treatment for Thyroid Cancer

Extensively used for the treatment of well-differentiated
thyroid carcinomas (papillary and follicular type)
Not useful for anaplastic and medullary types
Post-surgical ablation reduces rate of local recurrence
Ablation of remaining normal tissues allows patients to be
followed with serum thyroglobulin and RAI whole body scans
Patients with residual or recurrent disease have improved
survival with 131I treatment

IN SUMMARY
Radiology VS. Nuclear Medicine
Radiology anatomy
Radiation source outside
Risk of radiation minimal
Nuclear Medicine physiology
Radiation source inside the patient
Risk of radiation minimal
Nuclear Medicine Diagnostic Procedures
Thyroid scan, bone scan, myocardial perfusion scan
Nuclear Medicine Therapeutic Procedures
Radioactive Iodine Treatment for Thyroid Diseases
For Hyperthyroidism/For Differentiated Thyroid
Cancer

Source:
Dr. Llauderes PPT slide and lecture notes
MARKINOTES

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