Nuclear Medicine: Understanding

the Principles and Recognizing

the Basics
HOW IT WORKS
■ A radioactive isotope (radioisotope) is an unstable form of an element that emits radiation
from its nucleus as it decays. Eventually, the end product is a stable, nonradioactive isotope of
another element.
■ Radioisotopes can be produced artificially (most frequently by neutron enrichment in a
nuclear reactor or in a cyclotron) or may occur naturally. Naturally occurring radioisotopes
include uranium and thorium. The vast majority of radioisotopes are produced artificially.
■ Radiopharmaceuticals are combinations of radioisotopes attached (for the purposes of this
chapter) to a pharmaceutical that has binding properties that allow it to concentrate in certain
body tissues (e.g., the lungs, thyroid, or bones). Radioisotopes used in clinical nuclear medicine
are also referred to as radionuclides, radiotracers, or sometimes simply tracers.
■ Various body organs have a specific affinity for, or absorption of, different biologically active
chemicals. For example, the thyroid takes up iodine, the brain utilizes glucose, bones utilize
phosphates, and particles of a certain size can be trapped in the lung capillaries.
■ After the radiopharmaceutical is carried to a tissue or organ in the body, its radioactive
emissions allow it to be measured and imaged using a detection device called a gamma camera.
■ Table 1 outlines various radioisotopes and pharmaceuticals used in nuclear imaging.

TABLE 1 RADIOPHARMACEUTICALS USED IN NUCLEAR MEDICINE

RADIOACTIVE DECAY
■ Unstable isotopes attempt to reach stability by one or more of several processes. They may
undergo splitting (fission), or they may emit particles (alpha or beta particles) and/or energy
(gamma rays) in the form of radiation.
♦ Fission is a destructive process that occurs primarily in nuclear reactors.
♦ Alpha particles have a relatively high energy, are large, are strongly absorbed by adjacent
tissue, and can cause substantial damage to nearby molecules. They are not used diagnostically
in medicine.
♦ Beta particles are high energy, high-speed electrons or positrons (positive electrons) that
have a penetrating power between alpha particles and gamma rays. Their main disadvantage in
diagnosis is the relatively high radiation dose they deliver to the patient.
♦ Gamma decay involves the emission of energy from an unstable nucleus in the form of
electromagnetic radiation. Gamma rays are identical to “x-rays” except that gamma rays
originate from nuclei, whereas x-rays emanate from outside the nucleus.
♦ Radioisotopes undergo gamma decay at discrete energies. These energies are usually
expressed in the form of the electron volt (eV). Most radioisotopes produce energies in the range
of thousands (keV) to millions (MeV) of electron volts.
TABLE 2 TERMINOLOGY HALF-LIFE
■ In order for a radioisotope to be useful for medical diagnosis, it must be capable of emitting
gamma rays of sufficient energy to be measurable outside of the body. It also must have a half-
life that is long enough for it to still be radioactive after shipping and preparation, but sufficiently
short so as to decay soon after it is used for imaging.
■ The physical half-life of a radioisotope is the time required for the number of radioactive
atoms in a sample to decrease by 50%. Physical half-life is a property inherent to the
radioisotope. Most radioisotopes for medical use must have halflives of hours or days.
♦ Table 3 outlines the physical half-lives of some of the most commonly used radioisotopes.
■ Biologic half-life accounts for the biologic clearance of a radiopharmaceutical from an organ
or tissue. If a radiopharmaceutical is cleared from the body via the kidneys, but kidney function
is impaired, the radiopharmaceutical will have a longer biologic half-life than if kidney function
was normal.
■ The effective half-life is dependent on both the physical half-life and the biologic clearance

TABLE 3 PHYSICAL HALF-LIVES OF COMMONLY USED RADIOISOTOPES

NUCLEAR MEDICINE EQUIPMENT
■ By far, the most widely used radioisotope is technitium- 99m (abbreviated Tc-99m, the m
standing for metastable). It has a half-life of 6 hours, meaning that it loses roughly half of its
radioactivity in that time. It decays by emitting low-energy gamma rays rather than higher-
energy beta emission and is easily combined with a wide variety of biologically active
substances.
■ Radioisotope doses in nuclear scanning are typically in minute amounts—the microcurie or
millicurie level.

DETECTING AND MEASURING THE RADIOACTIVITY OF AN ISOTOPE

■ Geiger counters
♦ Geiger counters are used mostly to detect contaminations (e.g., spills) and are especially
good at detecting low levels of radioactivity. Their portability and sensitivity allow them to
survey relatively large areas for the presence or absence of radiation.
■ Scintillation detectors
♦ Scintillation is the process by which a material called a scintillator (the most common
compound being sodium iodide mixed with thallium) luminesces when excited by ionizing
radiation. The luminescence is in the form of a miniscule flash of light. A scintillation
detector receives the emitted light, intensifies its signal in a device called a photomultiplier and
converts that signal into an electrical pulse for further analysis by computer.
♦ Scintillation detectors have the capacity to convert ionizing radiation into electrical energy in
an amount proportional to the energy deposited in the crystal, which is key to their ability to
produce diagnostic images.
■ Gamma cameras
♦ A gamma camera uses one or more scintillation detectors made of crystals that scintillate in
response to gamma rays emitted from the patient. A computer reconstructs an image based on the
distribution and concentration of the radioisotope deposited in the target organ.
■ Images can be acquired either as static, whole body, or dynamic images (change in activity
in the same location over a period of time) or single-photon emission computed tomography
(SPECT) images.
■ SPECT imaging is a nuclear medicine study that is performed by using a gamma camera to
acquire multiple twodimensional (2D) images from multiple angles, which are then
reconstructed by computer into a three-dimensional (3D) dataset that can be manipulated to
demonstrate thin slices in any projection. To acquire SPECT scans, the gamma camera rotates
around the patient.
■ SPECT scans use the same radiopharmaceuticals as 2D (planar) images.
■ Any nuclear medicine study can be performed using SPECT. SPECT is especially used in
myocardial perfusion imaging, bone imaging, and functional brain imaging.
■ Most nuclear medicine scans have about 1 cm of resolution, meaning that they cannot
accurately detect lesions smaller than that.

NUCLEAR MEDICINE SAFETY

■ Radiopharmaceuticals are prescription drugs that require dispensing by a physician.
■ Each dose has to be assayed for its radioactivity before being administered to the patient.
Dose calibration is essential in ensuring that a safe and effective amount of radiopharmaceutical
is given. This is usually done by inserting a syringe containing the radiopharmaceutical into an
ionization chamber that converts the ionization of a sample into a measurable dose, depending
on the radioisotope used.
■ The performance of the dose calibrator itself must be evaluated at set intervals, utilizing a
series of tests to ensure that the calibrator is accurate and reliable.
■ A locked and controlled area is needed for the storage and preparation of
radiopharmaceuticals. Techniques need to be in place to ensure the material being injected is
sterile and free of pyrogens.
■ Spills of liquid radiopharmaceuticals sometimes occur accidentally, and there are prescribed
methods for containing and cleaning the spill, as well as disposing of the material used for the
cleanup. The area in which the spill has occurred may be monitored by using Geiger counters.
■ Although there is no absolute contraindication to the use of radiopharmaceuticals during
pregnancy, some radioisotopes (e.g., radioactive iodine) can cross the placenta and be
concentrated in the fetal thyroid. Similarly, women who are breastfeeding may have to suspend
breastfeeding for a period of time following administration of some radiopharmaceuticals since
the pharmaceutical may pass through breast milk to the child. Renal excretion of some
radioisotopes means they collect and concentrate in the urinary bladder of the mother and can
pose a potential risk by their proximity to the developing fetus.
■ Adverse reactions to the radiopharmaceutical itself are extremely rare and are related to the
pharmaceutical, such as those composed of human serum albumin, rather than the radioisotope.
■ Some types of radiotherapy utilizing radiopharmaceuticals administered at much higher
doses than for diagnostic studies may require the patient to be hospitalized in order to ensure
radiation safety. Patients may be assigned to private rooms without outside visitors for 24 hours.
The Nuclear Regulatory Commission no longer requires hospitalization for iodine-131 treatment
of the thyroid.
■ Patients treated with radioiodine (again in doses much larger than for diagnostic purposes) may
be warned to carry certification of their treatment since they may trigger radiation security
alarms at airports and elsewhere for up to 4 months after treatment.
■ Patients undergoing treatment with radiopharmaceuticals must follow instructions so that a
dose to other individuals can be maintained as low as is reasonably possible.

COMMONLY USED NUCLEAR MEDICINE STUDIES

■ Commonly used nuclear medicine studies include:
♦ Bone scans
♦ Ventilation/perfusion scans
♦ Cardiac scans
♦ Thyroid scans
♦ HIDA scans
♦ GI bleeding (blood loss) scans

BONE SCANNING
■ Bone scans are the screening method of choice for the detection of osseous metastatic
disease and for diagnosing fractures before they become visible by conventional radiography.
■ Bone scans offer the advantage of being widely available and inexpensive and can facilitate
imaging of the entire skeleton at the same time. Although MRI scans may be more sensitive in
detecting osseous metastases, they are less widely available and usually much more expensive.
The disadvantages of bone scanning are poor spatial and contrast resolution.
■ Technetium-99m (Tc-99m) methylene diphosphonate (MDP) is the radiopharmaceutical
most frequently used for bone scanning. It combines a radioisotope, technetium 99m, with a
pharmaceutical (MDP) that directs the isotope to bone. Diphosphonates are rapidly removed
from the circulation and produce little background noise from uptake in soft tissues.
■ After the intravenous injection of the radiopharmaceutical, most of the dose is quickly
extracted by the bone. The remaining radiopharmaceutical is excreted by the kidneys and
subsequently collects in the urinary bladder. Less than 5% of the injected dose remains in the
blood 3 hours after injection.
■ In most instances, the entire body is imaged about 2 to 4 hours after injection, either by
producing one image of the whole body, multiple spot images of particular body parts, or both.
Anterior and posterior views are frequently obtained, since each view brings different
structures closer to the gamma camera for optimum imaging (e.g., the sternum on the anterior
view and the spine on the posterior view).
■ Unlike the convention used for viewing other studies in radiology, the patient’s right side is
not always on your left in nuclear scans. This can be confusing, so make sure you look for the
labels on the scan (Fig. 1).

Metastases to Bone
■ Tc-99m MDP deposits in the greatest concentration in those areas of greatest bone turnover.
Radionuclide bone scanning is sensitive (60% to 90%) for metastases but not specific. Many
benign lesions also produce increased bone turnover and radiotracer uptake including fractures,
arthritis, and osteomyelitis.
■ Tc-99m MDP is normally cleared through the kidneys and collects in the urinary bladder.
Therefore, the kidneys will normally show increased uptake, especially on the posterior views
(the kidneys are located posteriorly in the body).
■ Conventional radiographs of the affected areas are then obtained to further characterize the
lesions seen on the bone scan. If the radiographs show either a benign cause for the increased
uptake (e.g., a healing fracture) or a clearly malignant bone lesion, no further studies are
needed.
■ If the conventional radiographs are normal or inconclusive, then another imaging examination
such as an MRI scan of the area or possibly a biopsy of the lesion may be needed.
■ Metastatic bone disease usually presents with a pattern of multiple, asymmetric focal areas
of increased uptake (“hot spots”) on bone scans. Even lytic metastases (e.g., those caused by
bronchogenic carcinoma) usually produce enough osteoblastic response to be positive on a bone
scan (Fig. 2).
■ The important exception is multiple myeloma. Bone scans will frequently be negative because
of the almost purely lytic nature of multiple myeloma unless there is an associated pathologic
fracture. Conventional radiographs of the axial and proximal appendicular skeleton (a bone or
metastatic survey) may be more useful in this disease than a bone scan (Fig. 3).
■ Two other abnormal patterns of uptake that can be seen with a bone scan include photopenic
lesions and superscans.
■ Photopenic lesions (photon-deficient lesions, cold spots) are areas of abnormally diminished
or absent radiotracer uptake on the bone scan. These might be caused by an interruption of the
blood supply so that no radiopharmaceutical can reach the area (e.g., avascular necrosis) or when
a process is so destructive that no bone-forming elements remain (e.g., renal or thyroid
metastases) (Fig. 4).
■ Superscans are produced when there is diffuse and relatively uniform uptake of
radioisotope in bones. This most often occurs when there is extensive involvement with
metastatic disease but can also be seen in bones with diffusely high turnover rates such as in
hyperparathyroidism.
♦ At first glance, a superscan may mimic the appearance of a normal bone scan. The clue to
this abnormality is decreased or absent uptake in the kidneys, because so much of the
radiopharmaceutical is extracted by the bone, very little reaches the kidneys in a superscan.
Prostate carcinoma may lead to the appearance of a superscan (Fig. 5).
■ Bone scans may be positive within 24 hours after a fracture. Depending on the fracture’s
rate of healing, the scan may revert to normal in as little as 6 months or may remain abnormal
forever (Fig. 6).

Osteomyelitis
■ A triple-phase bone scan may be done to differentiate cellulitis from adjacent osteomyelitis.
Images are obtained within the first minute after injection (flow phase), about 5 minutes after
injection (blood pool or tissue phase), and then 2 to 4 hours after injection (delayed or skeletal
phase) (Fig. 7).
■ Cellulitis will demonstrate increased uptake in the soft tissue on both the tissue phase and
the skeletal phase (Fig. 8).
■ Osteomyelitis will show clearance of the tracer from the soft tissues with progressive uptake
in the bone on the skeletal phase (Fig. 9).
PULMONARY VENTILATION/PERFUSION SCANS FOR PULMONARY
EMBOLISM
■ Immobilization, usually following surgery, is the risk factor most often associated with
pulmonary embolism. Other known risk factors include malignancy, thrombophlebitis, trauma to
the lower extremities, and stroke.
■ CT pulmonary angiography (CT-PA) has largely replaced nuclear medicine
ventilation/perfusion (V/Q) scans as the modality of choice in diagnosing pulmonary
thromboembolism.
■ Ventilation/perfusion scans are used primarily if CT-PA is not available or if the patient has a
contraindication to the administration of intravenous iodinated contrast material, such as
impaired renal function or severe allergy to contrast.
■ Chest radiographs should be obtained to aid in the interpretation of the V/Q scan and to rule
out another cause of the patient’s symptoms besides pulmonary embolism. In most cases of
pulmonary embolism, the initial chest radiograph is normal (Fig. 10).
■ If the chest radiograph is normal, then V/Q scanning may be diagnostic. If the chest
radiograph is abnormal, a CT-PA is usually performed.
■ The pulmonary perfusion study is performed using technetium-99m macroaggregated
albumin (MAA). The radioisotope is technetium-99m, and the pharmaceutical to which it is
bound is the macroaggregated albumin. The radiopharmaceutical is then injected
intravenously.
■ Macroaggregated albumin is prepared by heating human serum albumin. It can be produced to
a particle size that is extracted 80% or more during its passage through the pulmonary
vasculature. Although an average of about 350,000 MAA particles are injected, only about one
in a thousand lung capillaries are occluded with a usual injection, so the patient experiences no
symptoms from the injection.
■ Images of the lungs are obtained in multiple positions (e.g., anterior, posterior, right and left
lateral, and oblique projections) as soon as the radiopharmaceutical is injected.
■ The normal perfusion scan will show uptake throughout the lungs with photopenic areas
normally seen in the region of the hila and the heart, especially on the anterior projection (Fig.
11).
■ If the perfusion study is abnormal, then the ventilation scan is performed with the patient
breathing either radioactive xenon or krypton gas or an aerosol labeled with technetium-
99m.
■ In a normal ventilation scan, the radiotracer washes into the lungs homogeneously, usually
after the first deep breath. Most of the radiotracer will normally wash out of the lungs within two
minutes (Fig. 12). Pulmonary emboli should produce a segmental mismatch on the V/Q scan
in which ventilation is maintained but perfusion is absent. Depending on the number and size
of defects, correspondence between the ventilation and perfusion scans and the appearance of the
chest radiograph, the results of the lung scan are categorized as being normal, low,
intermediate, or high probability for pulmonary embolism (Fig. 13).
■ Not surprisingly, the combination of a relatively low clinical suspicion of PE and a low-
probability lung scan effectively excludes PE (<5% will actually have a pulmonary embolism).
The combination of a high clinical suspicion for PE and a high-probability V/Q scan almost
certainly indicates the presence of a PE (>95%). Unfortunately, a majority of patients remain
who have an intermediate clinical likelihood of having PE and intermediate lung scan
findings; these patients may require another type of study.
■ The Prospective Investigation of Pulmonary Embolism (PIOPED) clinical trials have been
performed to try to determine the most efficacious means of accurately diagnosing pulmonary
embolism.
■ The recommendations from the PIOPED trials attempt to combine clinical assessment and
diagnostic testing in various clinical scenarios to provide the most effective means of accurately
diagnosing pulmonary embolism.

CARDIAC SCANNING
■ Nuclear myocardial scans are used to detect myocardial ischemia and infarction. The
examinations typically consist of both perfusion and ECG-gated, wall-motion studies. The
studies can also determine left ventricular ejection fraction, regional wall motion, and end-
systolic left ventricular volume.
■ Nuclear myocardial imaging is associated with an excellent predictive value in that normal
scan results are associated with an annual rate of severe cardiac events (myocardial infarction or
cardiac death) of <1%.

Myocardial Perfusion Scanning

■ Myocardial perfusion imaging rests on the twin presumptions that, first, a radiopharmaceutical
can be delivered to a cell only if there is adequate perfusion of that cell and, second, that the
myocardial cell itself must be viable to take up the radiotracer. Abnormalities of either
perfusion or viability will therefore display decreased uptake of radiotracer.
■ A nuclear myocardial scan is usually performed with a stress test consisting of a resting scan
and a poststress scan. The stress may be pharmacologic (e.g., produced by adenosine,
dobutamine, or dipyridamole) or induced by exercise (e.g., treadmill or exercise bicycle). Most
studies involve exercise rather than pharmacologic stress.
■ Exercise stress is carried out using a graded increase in either treadmill exercise or an
exercise bicycle, usually up to 85% of a patient’s peak heart rate in order to obtain an adequate
study. Pharmacologic stress may be used in patients with arthritis or in poor physical condition.
Rest-only studies may be done in patients for whom both pharmacologic and exercise stress are
contraindicated.
■ The risk associated with the test comes from the stress portion rather than the radioactivity of
the isotope. About 1 in 10,000 deaths occur as a result of the stress, and about 4 in 10,000
patients have a myocardial infarction from the test.
■ The radiopharmaceuticals used in stress tests include technetium-99m sestamibi (Cardiolite),
thallium-201 or Tc-99m teboroxine. Imaging protocols are different for the different agents and
for the equipment by which images are acquired.
■ Images are displayed in a standardized format, usually in color. In the short axis view, the
wall segments form a circle. In the vertical long axis view, there is a U shape with the opening
to the right. In the horizontal long axis view, the opening of the U is down (Fig. 14). Wall
thickness is generally uniform in the same image. Wall Motion
■ Myocardial wall motion is assessed using ECG-gated SPECT images. ECG gating allows for
gated images to be replayed in a continuous loop (cine loop) that aids in the display of wall
motion. Technetium-99m–labeled red blood cells (RBCs) can be used as an imaging agent to
assess wall motion.
■ ECG gating (also called cardiac triggering) is a technique used in imaging studies to time the
acquisition of data based on a pulse derived from the patient’s ECG tracing. Acquiring data
from a single cardiac cycle would not provide enough counts to produce a diagnostic image for
nuclear cardiac studies, so counts are acquired at the same phase of the cardiac cycle over dozens
or hundreds of heart beats.
■ The type of scan that demonstrates wall motion and from which the cardiac ejection fraction
can be calculated is called a MUGA scan (MUGA stands for MUltiple Gated Acquisition
Scan). It is also called gated blood pool imaging. MUGA scans can be performed at rest or after
stress or both.
■ MUGA scans may be used in patients with congestive heart failure to assess cardiac function,
in patients about to undergo chemotherapy with a cardiotoxic drug, to assess the effectiveness of
cardiac surgery or drugs, and for outcome prediction in coronary artery disease.
■ In normal people, the left ventricular ejection fraction (LVEF) falls within a range of 50%
to 80%. With stress, the LVEF may decrease in patients with coronary artery disease. There
should be no abnormal regions of cardiac wall motion. Patients with infarctions may show global
or local areas of decreased motion (akinetic or hypokinetic regions) or outward bulging of the
ventricular wall during systole (dyskinetic regions).
■ A nuclear scan after a myocardial infarction can demonstrate whether viable myocardium is
present, which in turn, helps determine whether bypass surgery, stenting, or angioplasty will be
most effective in treatment (Figs. 15 and 16).

THYROID SCINTIGRAPHY
■ Thyroid scans are used to determine the functioning of thyroid nodules, to help differentiate
Graves disease from toxic nodular goiters (Plummer disease), to diagnose thyrotoxicosis, to
image metastases from thyroid cancer and, sometimes, to establish a mediastinal mass as being
thyroid in origin.
■ A thyroid scan is an image of the thyroid gland. Thyroid scans can be combined with a
measurement of radioactive thyroid uptake, which is a measure of the gland’s functional
ability to concentrate and clear iodine.
■ Patients with hyperthyroidism will show elevated thyroid uptakes, whereas patients with
hypothyroidism will show decreased uptakes. The normal range of thyroid uptake varies but is
generally between 10% and 35%. Radioactive uptake studies have been largely replaced by
blood tests for thyroxine (T4) and thyroid-stimulating hormone (TSH).
■ Thyroid scans are done using either radioactive iodine or technetium-99m pertechnetate.
Both iodine and pertechnetate are trapped in the thyroid gland. The radiopharmaceutical is
administered either by mouth or, less commonly, intravenously.
■ The normal thyroid gland is butterfly shaped and is homogeneous in its uptake of
radiotracer. Nodules of increased activity will show increased uptake (hot nodules) compared
with the remainder of the thyroid, whose function may be suppressed by the hot nodule. Nodules
of decreased activity will show decreased or no uptake (cold nodules) relative to the
remainder of the thyroid gland (Fig. 17).
■ Thyroid nodules are common. They are more common in women than men. They increase
in frequency with advancing age, so a solitary nodule in a younger person is of more concern
than in an older individual.
■ About 85% of all thyroid nodules are cold, with 15% being hot or warm. The overwhelming
percentage of cold nodules (85%) are benign, whereas 95% of hot nodules are benign.
Ultrasound, combined with fine-needle aspiration, is used to definitively diagnose thyroid cancer
in cold nodules (Fig. 18).
■ An enlarged thyroid gland is called a goiter. There are many causes of a thyroid goiter,
including nontoxic goiters (multinodular colloid goiters), Graves disease, Plummer disease (toxic
nodular goiter), and Hashimoto thyroiditis.
■ In nontoxic multinodular colloid goiters, the gland is enlarged and takes up radiotracer
heterogeneously. In Graves disease the gland is enlarged with uniform and intense increased
uptake. The thyroid may also be enlarged in the early phase of thyroiditis (Fig. 19).
■ Thyroid cancer typically presents as a dominant, solitary nodule. The presence of multiple
nodules reduces the likelihood of malignancy (Fig. 20).
■ Radioisotope scans can also demonstrate metastases from thyroid carcinoma distant from
the gland itself. Follicular and papillary thyroid carcinomas may show increased tracer uptake
in the lungs, lymph nodes, and skeleton (Fig. 21).
■ Radioiodine is also used in much higher doses than for diagnostic purposes for the ablation of
the gland in Graves disease and for the treatment of thyroid cancer. Iodine-131 (I-131) is usually
utilized as the radioisotope for treatment. Radioiodine is also used in the treatment of thyroid
carcinoma metastases from tumors that demonstrate the ability to take up radioisotope.

BILIARY SCANNING HIDA Scans

■ Cholescintigraphy is performed using technetium-99m which was originally coupled to
iminodiacetic acid (IDA). This was referred to as a HIDA scan, in which the H stands for
“hepatic” or “hepatobiliary.” Even though other radiopharmaceuticals besides iminodiacetic acid
may now be used for the test, it is still often referred to as a HIDA scan. The HIDA scan is the
most frequently used nuclear medicine liver study.
■ HIDA scans are generally indicated in cases of suspected acute cholecystitis, in which an
ultrasound examination may be equivocal. They are also used to demonstrate postoperative
biliary leaks.
■ The patient has nothing by mouth for 3 to 4 hours before the study. After intravenous injection,
the radiopharmaceutical binds to protein, is taken up by the liver and then rapidly excreted from
the liver, similar to bile.
■ In a normal HIDA scan, the bile ducts contain radiotracer within 10 minutes, and there is
radiotracer in the duodenum by 60 minutes, indicating patency of the common bile duct. Filling
of the normal gallbladder occurs within 30 to 60 minutes, which confirms the patency of the
cystic duct. Delayed images in several hours are usually obtained to reduce false positive results
(Fig. 22).
■ Except in rare exceptions, visualization of the gallbladder excludes acute calculus
cholecystitis.
■ Cholescintigraphy is very sensitive and extremely specific for acute cholecystitis. One of its
disadvantages is that it can take several hours to perform, and an acutely ill patient may need a
diagnosis sooner. To shorten the time needed to complete the study, morphine sulfate can be
administered intravenously. Morphine causes constriction of the sphincter of Oddi, increasing
pressure in the common duct and speeding the filling of the cystic duct. The gallbladder should
fill normally within 30 minutes of morphine administration (Fig. 23).
■ Cholescintigraphy is also used to demonstrate bile leaks in patients who have undergone
laparoscopic cholecystectomy, liver transplant, or trauma. After the radiopharmaceutical is
injected, the abdomen is scanned to image radiotracer outside of the normal confines of the
biliary system (Fig. 24).
GI BLEEDING SCANS
■ Localization of bleeding from the lower gastrointestinal tract can be problematic using either
endoscopy or imaging studies.
■ Utilizing technetium 99m coupled to red blood cells (RBCs), the site of bleeding can be
localized. An initial flow study is frequently performed, and static imaging of the abdomen
usually lasts for about 90 minutes. Only about 2 to 3 mL of extravasated blood is needed for
detection (Fig. 25).
■ Abnormal studies will demonstrate an extravascular focus of increased radiotracer uptake
within the bowel that increases over time. Because blood irritates the intestine, peristalsis is
more rapid than normal. The focus of increased uptake must move through the bowel over the
course of serial images (Fig. 26). Positron Emission Tomography (PET)
■ Positron emission tomography (PET) scans operate on a molecular level to produce three-
dimensional images that depict the body’s biochemical and metabolic processes. They are
performed using a positron (positive electron)–producing radioisotope attached to a targeting
pharmaceutical.
■ Radioisotopes used in PET imaging include fluorine-18, carbon-11, and oxygen-15. These
isotopes have short halflives (all less than 2 hours), and because they are produced in a
cyclotron, earlier PET scanners required an onsite cyclotron. Fluorine-18 has the benefit of
allowing production in an offsite cyclotron.
■ The most commonly used target molecule in PET scanning is an analog of glucose called
fluorodeoxyglucose (FDG) (also called FDG-PET). The concentration of this glucose analog
in bodily tissues gives a measure of metabolic activity.
■ Many PET scanners incorporate the presence of a CT scanner, which allows for the fusion
(called co-registration) of the functional PET dataset on the anatomic dataset of CT scan
images. The PET and CT scans are done sequentially without moving the patient, which
minimizes patient motion between the two studies and improves the quality of the image.
■ By fusing the PET and CT images, the anatomic location of the functional abnormality is
determined (Fig. 27).
■ PET scans are similar to scans using SPECT except that SPECT scans measure the
radiotracer’s emitted gamma radiation directly, whereas PET tracers produce positrons.

USES OF PET SCANS

■ PET scanning is most often used in the diagnosis and treatment follow-up of cancer. It is
frequently used to locate hidden metastases from a known tumor or to detect recurrence.
Oncologic PET scans make up about 90% of the clinical use of PET.
♦ Some tumors take up more of the radiotracer than others and are referred to as FDG-avid
tumors.
■ Because of their ability to measure function, PET scans are also used in analyzing brain and
heart function and to measure regional blood flow. In the brain, areas of high radiotracer
activity correspond to areas of increased brain activity. By using compounds that bind to
certain neuroreceptors in the brain, PET has been used to study psychiatric disorders and
substance abuse. It has also been used extensively in Alzheimer disease and epilepsy.
■ In the heart, PET scans are being used in the diagnosis of coronary artery disease, in part
because they offer superior resolution to perfusion imaging. Completely infarcted areas can
be differentiated from ischemia by utilizing both perfusion and PET imaging. This differentiation
is important in determining a course of treatment because there is little benefit in revascularizing
completely infarcted muscle.

Safety Issues and PET Scans

■ PET scans expose the body to ionizing radiation. When combined with a CT scan that also
utilizes ionizing radiation, the radiation dose can be significant. As with all diagnostic tests that
utilize ionizing radiation, the benefits provided by the data obtained from the test must be
weighed against its potential risks.
■ False-positive findings may occur with inflammatory processes, in benign neoplasms, and in
hyperplastic but benign tissue, all of which are FDG avid (Fig. 28).
■ False-negative findings may occur if the tumor is very small, has necrosed, or is composed of
certain cell types, such as prostate carcinoma, some thyroid cancers, lobular breast cancers, well-
differentiated hepatocellular carcinomas, and some skeletal metastases.

PET Scan Images

■ There is physiologic (normal) uptake of FDG in the salivary glands, thyroid, brown fat,
thymus, the liver, GI tract, kidneys and urinary bladder, and the uterus (see Fig. 27).
■ FDG-avid lesions are those that show abnormally increased uptake of the radiopharmaceutical
(Figs. 29 and 30).
■ Box 1 indicates those tumors that are especially avid at taking up FDG during PET scans.
BOX 1 FDG-AVID TUMORS Lung cancer Breast cancer Colon cancer recurrences Nodal metastases from
head and neck cancers Brain tumor necrosis versus residual or recurrent tumor Pancreatic cancer Lymphoma staging