Introduction to Nuclear Medicine

Robin Greenspan, MD

Intro to Nuc Med: Outline

Pre-lecture Quiz Learning objectives Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

Question 1 (Best answer)

Nuclear Medicine A. Utilizes Nuclear magnetic resonance B. Utilizes sealed sources of radioactivity to irradiate patients C. Utilizes open sources of radionuclides administered to patients. D. Both B and C

Question 2 (Best answer)

Nuclear Medicine A. Is used for the diagnosis of disease B. Is used for the treatment of disease C. Both A and B

Question 3 (True or False)

A radiopharmaceutical A. Causes chemical pharmacological effects. B. Can be a substrate labeled with a radioactive atom. C. A radiopharmaceuticals chemical form determines its imaging physics. D. A radiopharmaceuticals radionuclide determines its biologic properties (bio-distribution).

Question 4 (Best answer)

The power of Nuclear Medicine is A. Fine anatomic detail. B. Physiologic imaging. C. Targeted radiotherapy. D. A and B. E. B and C. F. All of the above.

Question 5 (True or False)

Regarding collimation A. The lead collimator eliminates scatter. B. The lead collimator has holes that only allow parallel rays to reach the crystal. C. The lead collimator is between the crystal and the photomultiplier tubes. D. PET uses coincidence detection for electronic collimation.

Question 6 (True or False)

Gamma camera energy analysis A. Can distinguish between radionuclides for imaging. B. Decreases scatter in the image. C. Uses a position logic circuit. D. Evaluates the strength of the PMT signals.

Question 7 (True or False)

Regarding camera image formation A. Photons are analyzed and counted one at a time. B. Planar imaging refers to image slices in a single plane. C. SPECT stands for Special Proton Emission Computed Tomography D. Image fusion adds the anatomic detail of CT or MRI to the functional data of SPECT or PET.

Question 8 (True or False)

Regarding QC A. Stands for Quality Control B. Represents good laboratory practice, but is not required C. Only some of the equipment in nuclear medicine have QC programs D. Technologist review of studies for artifacts and completeness prior to submission is part of QC.

Question 9 (Select all correct answers)

Which are essential in your approach to interpreting nuclear images? A. Determining radiopharmaceutical used B. Determining technologist and camera C. Noting the order the images were obtained D. Systematic approach

Question 10 (True or False)

Regarding SPECT myocardial perfusion A. The technologist, not the radiologist, must review the raw data for QC. B. Stress images are assessed for perfusion defects and compared to rest. C. Systolic function data cannot be obtained from this study. D. The final interpretation of the images is independent of the history and stress data.

Intro to Nuc Med: Outline

Pre-lecture Quiz Learning objectives Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

Learning Objectives
Define Nuclear Medicine Understand basic Nuc Med principles Understand the Power of Nuc Med is physiologic imaging and targeted therapy Understand the basics of Nuc Med image formation and importance of QC Develop an organized approach to images

Intro to Nuc Med: Outline

Pre-lecture Quiz Learning objectives Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

What is Nuclear Medicine?

The branch of medicine that employs open sources of artificial radionuclides in the diagnosis and treatment of disease. Excludes sealed sources (Co-60, Cs-137) used in Radiation Oncology.

Question 1
Nuclear Medicine A. Utilizes Nuclear magnetic resonance B. Utilizes sealed sources of radioactivity to irradiate patients C. Utilizes open sources of radionuclides administered to patients. D. Both B and C

Question 2
Nuclear Medicine A. Is used for the diagnosis of disease B. Is used for the treatment of disease C. Both A and B

Intro to Nuc Med: Outline

Pre-lecture Quiz Learning objectives Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

Basic Nuc Med Principles

Unstable nucleus radioactive decay Releasing ionizing radiation
rays = electromagnetic; discrete energy, imaging - particles = electron; mm range, damage, therapy + particles = positive antimatter electron, combo w/ e- 2 annihilation photons, 511 kev, PET

Different from X-rays = electromagnetic radiation from X-ray producing machine

Basic Nuc Med Principles

Radionuclide = radioactive nucleus/atom Radiopharmaceutical = Radioactive tracer
Either a radioactive isotope of a biological active atom (123I-), or its analog (99mTcO4-), or a substrate labeled with a radionuclide (99mTc-MDP) Chemical form determines biologic properties Radionuclide label determines physical properties
emitters for camera imaging: 99mTc, 123I, 111In, 201Tl, 67Ga, Each emits photon(s) of characteristic energy. + emitters for PET: 18F, 13N, 15O, 11C - emitters for therapy: 131I, 90Y

Question 3 (True or False)

A radiopharmaceutical A. Causes chemical pharmacological effects. F B. Can be a substrate labeled with a radioactive atom. C. A radiopharmaceuticals chemical form determines its imaging physics. F D. A radiopharmaceuticals radionuclide determines its biologic properties (bio-distribution). F

Radiopharmaceuticals for Imaging

99mTc

(NaTcO4): multiple 99mTc-MDP: bone 99mTc-MAA: lung perf 99mTc-DTPA: renal, vent 99mTc-MAG3 : renal 99mTc-DMSA : renal 99mTc-GH : renal 99mTc-HMPAO: brain perf 99mTc-WBC: infection 99mTc-IDA: biliary 99mTc-SC: RE system 99mTc-RBC: blood pool 99mTc-MIBI: myo perf/tumor 99mTc-tetrafosmin: same

123I

(NaI): thyroid 131I (NaI): thyroid Ca 131I-MIBG: adrenergic 201Tl (TlCl): myo perf/tumor 111In-DTPA: CSF flow 111In-WBC: infection 111In-Octreoscan: neurendo 111In-Prostascint: ProsCa 67Ga citrate: infxn/tumor 133Xe: lung vent 81mKr : lung vent
18FDG:

glucose metabolism

Basic Imaging principles

Nuclear medicine uses
external detection of administered radiotracers to map (image) their bio-distribution to provide physiologic, functional imaging Compare the images to known normal physiologic patterns of uptake, distribution and excretion to make diagnoses.

Power of Nuclear Imaging: Physiologic Imaging

Radiotherapy
Radionuclides for therapy emit beta (-) particles (131I, 90Y); deposit energy w/in mm Therapeutic Radiopharmaceuticals Target particular organs or disease
I-131: hyperthyroidism, thyroid Ca Y-90 Zevalin (monoclonal Ab): lymphoma Strontium-89 and Samarium-153: bone mets

Question 4 (Best answer)

The power of Nuclear Medicine is A. Fine anatomic detail. B. Physiologic imaging. C. Targeted radiotherapy. D. A and B. E. B and C. F. All of the above.

Intro to Nuc Med: Outline

Pre-lecture Quiz Learning objectives Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

Imaging System Basics

Scintillation detectors Collimation Position and Energy analysis Planar versus tomographic imaging QC

Scintillation Detectors
Most nuclear imaging devices use Scintillation Detectors:
Scintillation crystal: emits light on interaction w/ rays or annihilation photons Coupled with Photomultiplier tube(s) to convert light to electrical signal

Gamma camera one crystal and PMT array

PET multiple crystals in ring and PMT array around

Collimation
Converts isotropic radiation to preferred direction to create image. Gamma cameras use Lead collimator w/holes in front of crystal. Blocks all but parallel rays. Functions like objective lens. PET uses Electronic collimation by coincidence detection of 180o apart annihilation photons. Creates lines of response for reconstruction.

Gamma Camera Energy Analysis

Each radionuclide emits rays of characteristic energy. If ray has scatter interaction within the patient, changes direction and loses energy. To the camera, appears as if from wrong location, bad data (d and e) Would like to eliminate scattered photons from image If have more than one radionuclide in patient, (different energy photons), want separate images. Energy Analysis allows.

Gamma Camera Energy Analysis

Brightness of light to energy of photon PMT signal strength light brightness Sum all PMT signals energy of photon Send PMT sum to PHA, Pulse Height Analyzer PHA determines if falls in correct energy window, and should be counted or discarded

Gamma Camera Position Analysis

Light brightest and PMT pulse strongest at site of photon Centroid of PMT pulse strength locates of photon by Position Logic Circuit Each incident photon analyzed for energy and position, if counted updates that pixel in image matrix by one count

Question 5 (True or False)

Regarding collimation A. The lead collimator eliminates scatter. F B. The lead collimator has holes that only allow parallel rays to reach the crystal. C. The lead collimator is between the crystal and the photomultiplier tubes. F D. PET uses coincidence detection for electronic collimation.

Question 6 (True or False)

Gamma camera energy analysis A. Can distinguish between radionuclides for imaging. B. Decreases scatter in the image. C. Uses a position logic circuit. F D. Evaluates the strength of the PMT signals.

Planar vs Tomographic Imaging

Planar imaging
Single view or projection at a time Dynamic vs Static
Dynamic: serial images over time Static: single images, often in different views

Tomographic imaging
Volumetric imaging Sliced in 3 orthogonal planes

Tomographic Imaging
SPECT
Single Photon Emission Computed Tomography Gamma camera head(s) rotate around patient. Projection images Q few degrees. Recon like CT.

PET
Cylindrical detector array Reconstructs lines of coincidence

Tomographic Fusion Imaging

Nuclear images map a physiologic process, so lack anatomic detail Computer fusion SPECT or PET with CT or MRI = powerful combo of anatomic detail and physiology Hybrid scanners: PET/CT, SPECT/CT (PET/MR)

Question 7 (True or False)

Regarding camera image formation A. Photons are analyzed and counted one at a time. B. Planar imaging refers to image slices in a single plane. F C. SPECT stands for Special Proton Emission Computed Tomography. F D. Image fusion adds the anatomic detail of CT or MRI to the functional data of SPECT or PET.

Quality Control (QC)

Every step of the way, for every instrument, every study, required (regulations & accreditation) Survey meter (sent for calibration annually) Dose calibrator (daily, quarterly and annual tests) Radiopharmaceutical (manufacturer) Gamma Camera (daily, manufacturer specified) PET scanner (daily, manufacturer specified) Uptake probe All images (motion, resolution, biodistribution)

Question 8 (True or False)

Regarding QC A. Stands for Quality Control B. Represents good laboratory practice, but is not required. F C. Only some of the equipment in nuclear medicine have QC programs. F D. Technologist review of studies for artifacts and completeness prior to submission is part of QC.

Intro to Nuc Med: Outline

Pre-lecture Quiz Learning objectives Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

Image Interpretation:
Organized Approach
Radiopharmaceutical and type of study? Findings Common errors: Specific studies

Radiopharmaceutical; study type?

Relative count density and spatial resolution
High: Short T1/2, give more: Tc-99m, I-123 Low: Long T1/2, give less: In-111, Ga-67, I-131 OR Rapid dynamic images (1-5 sec/Fr)

Number, type and sequence of images

Series: dynamic planar vs tomographic slices Statics: orientation or view

Biodistribution: what organs or structures?

Tc-99m MDP Bone Scan

Ga-67 Scan

38 yo M Gym teacher 3 wks right foot pain Neg Xrays

Flow

Blood pool

Delay

PLANTAR

SPECT: Tc-99m MDP Bone

Biodistributions
Tc-99m sestimibi

In-111 WBC

In-111 Octreoscan

I-123 MIBG

I-131 Iodide

I-123 Iodide Thyroid Scan

Tc-99m RBC GI Bleed Scan Tc-99m MAG3 Renal Scan F-18 FDG Tc-99m DTPA aerosol and Tc-99m MAA V/Q Lung Scan

Findings
Requires knowledge of normal biodistribution, physiology and anatomy to notice deviations Dynamic (flow, renal, GI bleed, etc.) Timing of appearance and clearance (time/Fr) To detect changes over time, compare 1st to last, or look down columns instead of rows. Abnormal later images, reverse review for timing

Common errors:
What is not there: Anything missing?
Tc-99m MDP Bone scan No kidneys, bladder or soft tissue Superscan in Renalosteodystrophy

Search satisfaction:
Dont stop after 1st or 2nd abnormality

Question 9 (Select all correct answers)

Which are essential in your approach to interpreting nuclear images? A. Determining radiopharmaceutical used B. Determining technologist and camera C. Noting the order the images were obtained D. Systematic approach

Approach for Specific Studies

Skeletal and other Whole Body Imaging Myocardial Perfusion SPECT Imaging V/Q Hepatobiliary

Skeletal and Whole Body Imaging

Performed in scanning mode anterior and posterior down body. Look for abnl increase or decrease Top-down search, correlate views Always note renal and soft tissue activity on bone scan

Tc-99m MDP Bone Scan: Hot skull, L scapula, L1, sacrum. Pagets Dz

Myocardial Perfusion SPECT

Rest and Stress SPECT acquired separately
Tracers injected at rest, and at peak symptomlimited treadmill or vasodilator stress

Stress images acquired with ECG gating Projection data reconstructed and reoriented into standard planes along LV axes.

Myocardial Perfusion SPECT

Raw data 1st (artifacts, etc.) Slices: Look for stress defects, TID
Confirm in 2 to 3 planes: SA, VLA, HLA Assess size, severity, location, reversibility (ischemia) Quantitation to confirm

Gated images:
Global and regional wall motion, thickening LVEF and volumes

History and stress test data

Question 10 (True or False)

Regarding SPECT myocardial perfusion A. The technologist, not the radiologist, must review the raw data for QC. F B. Stress images are assessed for perfusion defects and compared to rest. C. Systolic function data cannot be obtained from this study. F D. The final interpretation of the images is independent of the history and stress data. F

Ventilation/Perfusion Imaging
Ventilation imaging performed 1st
Breathes aerosol of 99mTc DTPA (1-2 mCi) Localizes by airflow and wet impaction Acquire ventilation images in multiple views

Perfusion imaging performed 2nd

Inject 99mTc MAA IV while supine (4-6 mCi) Localizes by temporary microembolization Acquire perfusion images in same views

Ventilation/Perfusion Imaging
Review CXR or Chest CT 1st Review all Perfusion images
Defects present? Size (Lobar, segmental, subsegmental, small) Location

Compare to Vent & CXR: match/mismatch Assign probability by PIOPED II criteria Mult segmental mismatches = hallmark of PE

86 yo F with acute dyspnea and elevated D-dimer

Clear CXR Mult bilat segmental mismatched perfusion defects High probability for PE

Hepatobiliary (dynamic) Imaging

Study images in order acquired, ie, flow, dynamic, statics Flow:
Timing of arrival of arterial bolus in kidneys and spleen, later liver (portal) Abnormal arterial hyperemia?

Dynamic: do organs appear in normal sequence and timing? Unexpected activity?

Hepatobiliary Scan 99mTc Choletec

Anterior flow: Liver appears later (portal flow)

Anterior dynamic hepatic phase: Liver uptake Bile ducts GB, bowel Hepatobiliary clearance

Intro to Nuc Med: Outline

Definition Basic Nuclear Medicine principles Imaging system basics Image interpretation: Organized approach

Learning Objectives
Define Nuclear Medicine Understand basic Nuc Med principles Understand the Power of Nuc Med is physiologic imaging and targeted therapy Understand the basics of Nuc Med image formation and importance of QC Develop an organized approach to images

Thank you for your attention.