Nuclear Principles

Types of Radiation
o Photonic (electromagnetic):
 Emission of photons (gamma ray or x-ray).
 Photon is electromagnetic wave.
o Particulate:
 Emission of beta particles (electrons) like positron and negatron.
 -particles:
 Negatron (e-): are utilized in ablation of thyroid gland (Graves’ disease, Toxic thyroid
nodules, and remnant thyroid tissue after thyroidectomy in papillary/follicular thyroid
cancer).
 Positron: converts into two photons utilized in PET scanning.
X-ray & Gamma Ray
o In x-ray: the ray generated from the x-ray generator hit the body giving us an image.
 Used in imaging in radiology (conventional radiography and CT scanning).
o In gamma ray: patient ingest of injected IV with a radioactive material that release photons when
exposed to gamma ray.
 Used in nuclear medicine. The letter (m) labels the isotope emitting gamma ray. M= metastable.
o So in gamma ray we give radioactive material, while in x-ray we don’t.

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 o Visible light vs Ultraviolet:
 Visible light wave length > ultraviolet wave length.
o Visible light vs X-ray & Gamma ray:
 X-ray & gamma ray have shorter wave length and  frequency.
 Visible light can’t pass through our body, while gamma & x-ray can pass our body (stopped by
metals).
o Radioactive isotopes:
 They are active, because they are unstable, and want to
become stable.
 When they become stable, they emit photons.
 Nucleus emit photon (gamma ray), or -particle
(electron). From electron orbits a photon is emitted
called x-ray.
In Summary:

º X-ray is emitted from outside the nucleus (electron shells) as seen in x-ray
tube.
º Gamma ray is a photon emitted form the nucleus of some radioactive
isotopes in the process of their decay like Technetium 99m (9Tc99m) and
Gamma ray (decay of
radioactive iodine (I131).
radioactive isotope)

Technetium 99m (Tc 99m)

o It is the main isotope used in general nuclear medicine imaging. It is used in more than 70-80% of
cases.
o It emits gamma ray only.
o Its half-life is 6 hours.
 Every 6h the half of the quantity disappear. After 4 half-lifes almost radiation stops.
o It can easily label different kind of pharmaceuticals, and become radiopharmaceutical.

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 o It is always given intravenously.
o So technetium is distributed according to the carrier (the pharmaceutical).
Radiopharmaceuticals
o Pharmaceuticals are chemical compounds that have pharmacokinetics but do not have
pharmacological effects.
o They are usually labeled with Tc99m.
o For each organ there is certain radiopharmaceuticals.
o In general, nuclear medicine images the function (physiology), not the anatomy as in conventional
radiology.
 For example, if I want to sturdy the kidney, I will make a substance that act like creatinine for
example. The kidney then will emit a photon called gamma ray (from technetium), that is
detected by gamma camera.
Gamma Camera
o It is a device that uses gamma rays to make an image of
radiopharmaceutical distribution and uptake in patients.
o Its crystal has a chemical propriety that if it is hit by a photon it will
scintillate.
o Scintillation means light production.
o The light is converted into electrical current which then is stored in the
computer as a dot.
 Action: gamma ray hit the crystal. Counteraction: light production. Scintillation of Gamma
Camera
o Gamma camera crystal:
 NalTI .
 ¼ - ½ thick, 3/8 most popular.
 10 - 21 diameter, rectangular popular.
 Sensitive to moisture and temperature.

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 o It is not enough to just detect radioactive levels & concentration; we need device to map radioactive
distribution.
Bone Isotope Scan
Introduction
o Main indication: bone metastases in cancer patients, especially in breast, prostate, lung cancers.
o Bone scan is one of the most commonly performed procedures in nuclear medicine.
o Bone scan often provides an earlier diagnosis and demonstrates more lesions than are found by
radiographic procedures.
o Bone scan has the advantage of screening the entire bone skeleton.
o  Sensitivity: Even a 5% bone turnover (destruction) can be detected by bone scan, whereas
radiographs require a minimum mineral loss of 50% before a lesion is visualized.
o  Specificity: bone scan is not specific in bone lesion detection. The differential diagnosis of any lesion
seen on bone scan is wide including tumor, infection and fracture. The diagnosis is usually made based
on clinical history, lesion location, number of lesions, correlation with lab and other imaging data
(x-ray, CT, MRI…).
Radiopharmaceuticals of Bone
o They are bone seeking agents.
o They are labeled with Tc99m.
o They are phosphate analogs (bisphosphonate).
o They are given intravenously.
Bone Composition
o 45-70% inorganic (minerals, hard):
 Calcium, phosphorus, magnesium.
 Crystalline form of apatite Ca10(PO4) (OH2)
o 25-30% organic (matrix):
 Built by osteoblasts.

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  Collagen
 Cellular elements
o 5-25% water.
Mechanism of Localization (Osteoblastic Reaction)
o The radiopharmaceutical binds to the hydroxyapatite [Ca3(Po4)2] structure of bone tissue.
o Bone remodeling (bone injury) results in more accumulation of hydroxyapatite. So, more
radiopharmaceutical will deposit in that region giving “hot” area (active lesion or osteoblastic lesion).
o 50% of injected dose localizes in the bone and the remain dose is cleared by the kidneys.
º Osteoblastic Reaction: seen on CT image of
vertebra as osteolytic lesion (left) due to
metastases, develops osteoblastic reaction (right),
which is a way that bone use to defend against
cancer by forming more bone (become more
white).
º We don’t see the osteolytic lesion, but we see the reaction against it.
º In some cancers when there is a pure osteolysis, there is no osteoblastic reaction  false
negative bone scan. Such as thyroid cancer, renal cell carcinoma, and multiple myeloma. MM
no osteoblastic reaction at all.

Whole Body Bone Scan

o Attention should be made to injection site and growth plates in children.

º After giving the patient the radioactive substance

wait for 2 h till the soft tissues clear up, making the
Image clear, except for kidneys & urinary bladder.

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 º Adult bone scan.
º More distribution of isotope is seen in axial bone skeleton as more blood
flow goes their secondary to presence of red marrow.
º In children all skeleton is fill with red marrow, and become lower when
growing up.

º Bone scan for a child.

º Growth plates (yellow circle) are seen.
º Isotope distribution is uniform in axial and appendicular skeleton as
red marrow is located in both.

Bone Metastases
o Approximately 50% of malignant tumors can metastasize to the bone.
o Bone is the 3rd most common site for metastatic disease (after lung and liver) and is more commonly
found in adult patients (> 40 years of age).
o Bone scan is an extremely important staging and restaging tool during management of cancer
patients.
o Bone scan gives early diagnosis of bone metastasis in the entire bone skeleton.
o Prostate, breast and lung cancers in adults and neuroblastoma in children have propensity to
metastasize to bone. Cancers do bone mets.
o Most cancers metastasize to bone result in partial or complete osteoblastic reaction.
o Colon cancer and gynecological cancers rarely metastasize to bone. Cancers don’t do bone mets.
o Bone scan is not helpful in diagnosis of bone sarcoma (diagnose by x-ray) as there is wide
differential diagnosis.
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  However, bone scan is required to stage bone sarcoma as 25% of metastases in sarcoma are
seen in bone skeleton and 75% are seen in the lungs.
o About 80% of patients with known cancer and bone pain have metastases documented by bone scan.
o 30 – 50% of patients with metastatic bone disease do not have bone pain.
o The hallmark of metastatic bone disease is multiple foci of increased osteoblastic activity in bony
skeleton.

º Bone sarcoma.
º No bone metastasis
º Note: normal growth plate uptake (yellow circle).

º Diffuse multiple foci of increased uptake in axial

skeleton = bone metastasis.

Stress Fractures
o It is a fracture (involving less than 50% of the cortex) that is difficult to visualize on a plain x-ray.

º Foot pain: stress fracture in right 2nd metatarsal.

º Stress fractures seen in extremities.
º Appears normal on x-ray.

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 o Fatigue fracture: is due to increased repeated stress on normal bone, such as training for a race.
o Insufficiency fracture: is due to usual stress on abnormal bone, such as is seen in osteoporosis.

º Fatigue stress fracture in the right tibia.

º Insufficiency stress fracture in the right hip.

º Postmenopausal woman.

º Stress fracture.
º Several foci of increased uptake in several consecutive ribs due to rib
stress fractures.

º Acute Osteomyelitis.
º Child with fever and knee pain.
º Focal uptake.

o Bone isotope scan now is not used a lot due to appearance of MRI  more specific and show details
about soft tissue.

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 Bone Densitometry
Bone Mass & Bone Density
o Bone Mass indicates the amount of mineralized tissue in bone.
o Bone Density indicates the mass of bone defined either by length (g/cm), area (g/cm2) or volume
(g/cm3).
o Bone mass measurements are currently considered to be the most valuable objective indicator of
fracture risk.

Osteoporosis

o Causes:
 Primary (95%): occurs mainly in postmenopausal women and
the elderly.
Bone mass
 Secondary (5%): to long-term steroids, chronic renal failure, loss

rheumatoid arthritis and hyperparathyroidism.

o Fractures:
 The most common osteoporotic-related fractures are those involving:
 Spine (thoracic and lumbar vertebral bodies).
 Femur (the neck and intertrochanteric regions).
 Wrist (distal radius).
 Risk sites:
 Femoral neck
 Vertebral bodies
 Distal radius
 Assumption:
 Bone mass is an important determinant of fractures, and hence bone mass
measurements may help reduce the number of fractures by identifying high risk
patients, who can then receive effective prophylaxis.

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  Bone densitometry can be used to document bone mass changes over time, monitoring
the course of a disease and response to therapy.
o Dual energy x-ray absorptiometry (DEXA):
 DEXA utilizes an x-ray tube as the radiation source.
 The device is pulsed alternatively at two energies-
usually 70 and 140 keV.
 Low energy beam is for soft tissue attenuation
calculation.
 High energy beam is for bone attenuation calculation.
 Then, soft tissue will be subtracted form calculation of pure bone density.
 The radiation dose from the procedure is only about 1/1000 of that from a routine spine film.
 The radiation dose to the patient is 1-10 microSv. Not dangerous.

 Measurement:
 Lumbar spine (L1-L4).
 Total femur.
 Femoral neck.
 Wrist (optional).
Distal Third of Forearm Lumbar, femur total & Left hip scanning Lumbar spine scanning
neck scanning

o WHO:
 World Health Organization study group has established a clinical definition for osteoporosis
based on a BMD (bone mineral density) measurement of the spine, hip or forearm expressed in
standard deviation (SD) units called T-scores.

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o T-score:
measured BMD - young adult mean BMD
 T-score =
young adult standard deviation
 T-score is calculated by taking the difference between a patient’s measured BMD and the mean
BMD of healthy young adults (20–29-year-old).
 T-score is applied for primary osteoporosis particularly in postmenopausal women.
 T-score is ≤ -2.5 at the spine, hip, or forearm; the patient is classified as having
osteoporosis. This patient has high risk for fracture.
 T-score is between -2.5 and -1 at the spine, hip, or forearm; the patient is classified as
having osteopenia. This patient has intermediate risk for fracture.
 T-score is ≥ -1 the patient is classified as normal. This patient has low risk for fracture.
o Z-score:
measured BMD - age matched mean BMD
 Z-score =
age matched standard deviation
 It is comparing the patient’s BMD with mean BMD expected for the patient’s peers (same age).
 It is applied for children and young adults (younger than 40 y for female and 50 y for male).
 Normal is as low as -2.
 Value of less than -2 is considered “less than expected range for patients’ age”
suggestive of secondary osteoporosis.
Osteopenia Osteopenia

Normal

Normal

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 Renal Isotope Scan

o Static renal scan.

o Dynamic renal scan.
Static Renal Scan (DMSA Scan)
o The Radiopharmaceutical is Tc99m- DMSA.
o It is given intravenously. Left Right
o It binds sufficiently to the renal tubules permitting good renal cortical
imaging.
Normal DMSA scan
o Image is obtained in 2 hours.
Posterior view
o Gamma camera is placed posteriorly (closest view to kidneys). Other
views are complementary.
o Functional, not anatomical.

Acute Pyelonephritis (AP) in Children

o The main clinical application of DMSA scan is in acute pyelonephritis in children.

o DMSA scan is highly sensitive for the detection of renal scarring (long-term sequela of acute
pyelonephritis).
o Intravenous urography and renal U/S have a low sensitivity for renal scarring detection.
o Pathophysiology:
 In acute stage of AP, segmental renal  infection causes inflammatory process which results in
edema.
  Edema causes focal vasculature pressure; resulting in  ischemia.
 Later, ischemia  resolves completely in most patients or may progress, and  scar develops
in few patients.
 DMSA scan is usually performed several months (6 months) post-acute infection.
o On DMSA scan, the scar manifests as focal cortical defect.

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o The presence of renal scarring usually mandates prolonged prophylactic antibiotics to prevent further
attacks of AP and further scarring.

º Focal cortical defect in the left lower pole = renal scar.

Scar in the left upper pole

º Renal scar.
Scar in the left lower pole

o Renal scarring & VUR:

 30% of patients with renal scarring have vesicoureteral reflux.
 Renal scarring plays a major role in kidney damage in VUR.
 All children diagnosed with VUR must undergo DMSA scan to estimate the renal damage
already took place if any.

º Renal scar in VUR.

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 º Ectopic kidney.
º Right pelvic kidney on Tc99m-DMSA scan.

º Crossed fused ectopia.

º Horse-shoe kidney.

Split Function

o Split function is the relative contribution of each kidney to total renal function.
o It lies between 45–55%.
o However, individual split function below 40% is considered abnormal due to renal atrophy or
impairment.

º Split function.

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 º Split function.

Dynamic Renal Scan

o Main indication: to detect obstruction.

Radiopharmaceuticals

o Filtered agents (DTPA).

o Tubular agents (MAG3).
o MAG3 is better and more expensive than DTPA.
o MAG3 is better used in neonates and renal impairment.

Technique

o Perfusion phase: (vascular phase)

 30-60 images are taken over 1 minute immediately post Perfusion phase
injection.
 This phase gives an idea about renal vasculature.
 Qualitative.
o Uptake phase:
 Image is taken every 1 minute.
 This phase represents radiopharmaceutical extraction from Uptake & excretion phase

blood stream.
 Peak uptake is expected in 4-6 minutes post injection.
o Excretion phase:
 Image is taken every 1 minute.
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  Images will continue for total time of 30 minutes from the start point.
 IV Lasix is given at 15 minutes from start point.
 Excretion is expected immediately after uptake peaking. Significant spontaneous excretion is
expected before giving Lasix.

Renogram and Split Function

o It is a curve called time-activity curve.

o It is generated by the computer (time against images).
o Split function is analyzed within 4-6 minutes post injection.
o Split function means how much each kidney contributes to total renal function.
o Normal limit of split function is 50% ± 5% for each kidney with a total of 100%.

º Renogram.
º Peak at 5 minutes then excretion happen.
º Each kidney has renogram, so 2 in total.

Clinical Application

o Dilated collecting system (hydronephrosis):

 This entity could be:
 Obstructive hydronephrosis:
 Children: congenital (pelvi-uretric junction stenosis).
 Adults: stone disease.
 Non-obstructive hydronephrosis:
 Vesicoureteral reflux.
 Post-resolution of obstruction (resolved obstruction).
o Residual function in atrophic kidney.

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 º Coronal CT scan.
º In yellow: pelvis. In green: kidney.
º Not the hydronephrosis.

º Hydronephrosis.
º Dilated pelvis.

o In children who have PUJ stenosis, even if stenosis stopped, hydronephrosis persist, and we can
discover that by ultrasound or CT scan.
o Ultrasonography:
 Ultrasonography is a sensitive method of identifying a dilated collecting system.
 But It cannot reliably determine if this is due to significant mechanical obstruction or merely
nonobstructive hydronephrosis.
Obstructive Hydronephrosis Non-obstructive Hydronephrosis

º Lasix plays essential role in differentiating
between obstructive from non-obstructive
hydronephrosis.
º Initially there would be accumulation of
radiopharmaceutical in dilated collecting
system.
º If there is obstruction, there would be no or
poor response to Lasix and dilated collecting
system will stay full.
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º IVU, ultrasound and pre-Lasix stage of dynamic
renal scan will demonstrate dilated collecting
system.
º By increasing urine flow using Lasix,
intrapelvic pressure will increase resulting in
emptying of dilated collecting system
(stimulated excretion).
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 Clinical Indications

o All children with hydronephrosis should be evaluated by dynamic renal scan to differentiate
obstructive from non-obstructive hydronephrosis.
o Any adult patient with equivocal renal obstruction should undergo dynamic renal scan.
o Dynamic renal scan is used to follow patients with managed (treated) obstructive hydronephrosis
(post-treatment evaluation).

º Obstructed hydronephrosis.
º Not the right kidney does no excretion.
Hydronephrosis
º The straight line crossing the curves is the
lasix.
º The normal is early peaking + spontaneous
After surgery
excretion.

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 º Non-obstructive hydronephrosis.

º Obstructive vs non-obstructive hydronephrosis.

Residual Function in Atrophic Kidney

o Dynamic renal scan is very sensitive tool to estimate the residual function in atrophic kidneys.
o Non-visualized kidneys on IVU and ultrasound can be visualized on dynamic renal scan.
o The kidney is considered non-functional if its split function is 10% and less.

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