Nuclear Medicine: The Essentials

CONTENTS
Contributors vii
Series Foreword ix
Preface xi
Chapter 1 Basics of Nuclear Medicine Physics and Radiation Safety 1
The Atomic Structure 1
Radioactive decay 1
Isomeric transition 2
Positron decay 2
Electron capture 2
Characteristic X-rays 3
Radioactivity 3
Universal decay table 3
Radioactivity Equilibrium 4
Interaction of radiation with matter 4
Radiation safety 5
Radiation exposure limits 5
Release of patients following I-131 therapy 6
Radiation Safety Fundamentals 6
Radiation monitoring 6
Radiation exposure to pregnant personnel 6
Area designation and posting 6
Controlled area 6
Restricted area 6
Radiation area 7
High radiation area 7
Radioactive materials 7
Ordering, receipt, and disposal of radioactive materials 7
Radiation safety surveys 7
Waste disposal 7
Spill of radioactive materials 8
Minor spills 8
Major spills 8
Medical events 8
Chapter Self-Assessment Questions 9
Chapter 2 Basics of Radiochemistry 11
Introduction 11
Basic Concepts of Radionuclide 11
Atomic nucleus 11
Forces in the nucleus 12
Isotopes and radioactive decay 12xiv Contents
Interaction of radiation with matter 12
Production of radionuclides 13
Basic Concepts of Radiolabeling 13
Isotopic labeling 13
Nonisotopic labeling 13
Specific activity 13
Radiochemistry for positron emission tomography tracers 14
Radionuclide selection 14
Radiochemistry with positron emission tomography radionuclides 14
Radiolabeling with F-18 14
Nucleophilic reactions 14
Electrophilic reactions 16
Radiolabeling using prosthetic agents 16
Automation radiosynthesis 16
Radiolabeling with C-11 17
Radiolabeling with other positron emission tomography radionuclides 17
Radiopharmaceuticals 18
Quality Control of Radiopharmaceuticals 18
Chapter Self-Assessment Questions 21
Chapter 3 Basics of Instrumentation 22
Introduction 22
Gas detectors 22
Geiger–Muller survey meters 23
Scintillation detectors 25
Pulse height analyzer 26
Gamma cameras 26
Collimator geometry 27
Scintillation crystal 28
Photomultiplier tubes 28
Energy and position logic computer 28
Single-photon emission computed tomography 28
Single-photon emission computed tomography image quality 28
Positron emission tomography 29
Problems with reconstruction of positron emission tomography images 29
Positron emission tomography/computed tomography instrumentation 30
Time of flight positron emission tomography/computed tomography 31
Chapter Self-Assessment Questions 32
Chapter 4 Thyroid Imaging and Therapy 34
Introduction 34
Hyperthyroidism 34
Background 34
General diagnostic and treatment algorithm 34
Role of nuclear imaging 34
Radioiodine therapy 36
Side effects and radiation precautions 37
Thyroid Cancer 37
Background 37
Treatment overview 37
Role of nuclear imaging and therapy 40Contents xv
Radioiodine scans 41
Radioiodine therapy 42
Post-therapy scans 43
Side effects and radiation precautions 43
Non-iodine avid disease 43
Conclusion 44
Chapter Self-Assessment Questions 46
Chapter 5 Parathyroid Scintigraphy 48
Background 48
Parathyroid scintigraphy 48
Chapter Self-Assessment Questions 53
Chapter 6 Neuroendocrine Tumor Imaging and Therapy 55
Introduction 55
Background 55
Somatostatin receptors 55
Somatostatin receptor imaging 56
Somatostatin receptor therapy 57
Clinical Trials of Peptide Receptor Radionuclide Therapy 57
Phase I or II experience 57
177
Lu-Dotatate Therapy 58
Patient selection 58
Future directions and controversies 60
Performing the therapy 63
Efficacy 64
Neuroblastoma 64
Pheochromocytoma or paraganglioma 64
Medullary thyroid cancer 64
Conclusion 64
Chapter Self-Assessment Questions 67
Chapter 7 Central Nervous System 68
Introduction 68
Clinical Applications 68
Cerebrospinal fluid flow imaging 68
Brain death 69
Epilepsy 70
Movement disorders 70
Cerebrovascular disease 71
Parametric brain SPECT or PET mapping 72
Chapter Self-Assessment Questions 77
Chapter 8 Bone Scintigraphy 78
Introduction 78
Normal Biodistribution 78
Clinical Applications 78
Bone vascularity and viability 79
Prosthesis evaluation 80xvi Contents
Metabolic bone disease 80
Malignant disease 82
Extra-Osseous Uptake 83
Chapter Self-Assessment Questions 84
Chapter 9 Infection and Inflammation 85
Introduction 85
Basic principles of imaging labeled white blood cell scintigraphy 85
Basic principles of imaging FDG 86
Clinical imaging strategies in selected clinical settings 87
Systemic infection and inflammation 87
Localized or organ specific infection and inflammation 89
Novel and future aspects 92
Nuclear medicine aspects of COVID-19 92
Chapter Self-Assessment Questions 97
Chapter 10 Cardiovascular Nuclear Medicine 99
Myocardial Function 99
Myocardial perfusion 100
Myocardial Viability 103
Infective, Inflammatory, and Deposition-Related Conditions 104
Chapter Self-Assessment Questions 108
Chapter 11 Pulmonary Scintigraphy 109
Introduction 109
Clinical Aspects of Pulmonary Embolism 109
Overall Imaging Strategies in Pulmonary Embolism 110
Practical Aspects of V/Q Scan 110
Interpretation of V/Q Scintigraphy—Pulmonary Embolism or No Pulmonary
Embolism 111
Non-Pulmonary Embolism Use 113
Take Home Points 114
Chapter Self-Assessment Questions 115
Chapter 12 Gastrointestinal & Hepatobiliary Scintigraphy 116
Gastrointestinal Functional Studies 116
Gastric Emptying Scintigraphy 116
Scintigraphic Principle 116
General Study Protocol 117
Interpretation and Reporting 117
Gastroesophageal Reflux and Pulmonary Aspiration 117
Scintigraphic principle 118
General study protocol 118
Interpretation and reporting 118
Small Bowel and Colon Transit Studies 118
Procedure 118
Protocols 118
Image analysis 119
Salivary Gland Function 120
Protocol 122
Applications 122Contents xvii
Meckel’s Scintigraphy 123
Scintigraphic principle 123
General study protocol 123
Interpretation and reporting 124
Biliary Acid Recirculation 124
Scintigraphic principle 124
General study protocol 124
Protein-losing Enteropathy 124
Scintigraphic principle 124
General study protocol 125
Interpretation and reporting 125
Gastrointestinal Bleeding Scintigraphy 125
Scintigraphic principle 126
General study protocol 126
Interpretation and reporting 126
Hepatobiliary and splenic scintigraphy 127
Cholescintigraphy 127
Radiopharmaceuticals 128
Indications 128
Contraindications 128
General study protocol 128
Postprandial epigastric pain 128
Postsurgical complications 129
Biliary atresia 130
Choledochal cysts 131
Liver function and surgical planning pre-liver resection 131
Liver Assessment Before Selective Internal Radiation Therapy 132
Other applications 132
Splenic Scintigraphy 133
Indications 133
Protocol 133
Acknowledgment 134
Chapter Self-Assessment Questions 135
Chapter 13 Renal Scintigraphy 136
Radiopharmaceuticals 136
Technetium-99m diethylenetriaminepentaacetic acid 136
Iodine-131 orthoiodohippurate 136
Technetium-99m mercaptoacetyltriglycine 136
Technetium-99m dimercaptosuccinic acid 136
Fluorine-18 fluorodeoxyglucose 137
Normal Renal Function 137
Clinical Applications 137
Renal failure 137
Renal infection 137
Renal obstructive disease 138
Renovascular disease 139
Renal transplant assessment 139
Renal Cancer 140
Chapter Self-Assessment Questions 142xviii Contents
Chapter 14 Positron Emission Tomography (PET), PET/CT, and PET/MRI 143
Introduction 143
Radiopharmaceuticals and instrumentation 143
Positron emission tomography radiopharmaceuticals 146
Technical considerations 148
Other positron emission tomography radiopharmaceuticals in oncologic
applications 150
Myocardial perfusion positron emission tomography tracers 151
Clinical applications in oncology 152
Genitourinary malignancies 157
Prostate 158
Breast cancer 159
Cardiology applications 163
NeuroPET 164
Interictal seizure localization 165
Summary 168
Chapter Self-Assessment Questions 178
Chapter 15 Lymphoscintigraphy 179
Lymphoscintigraphy Principles 179
Cancer lymphatic drainage 180
Lymphedema 180
Reverse Lymphatic Mapping 180
Chapter Self-Assessment Questions 183
Chapter 16 Radio-Theranostics 184
Introduction 184
Radio-theranostic pairs 184
Pseudo–radio-theranostic pairs 185
Radio-theranostics in the clinic 187
Summary 192
Chapter Self-Assessment Questions 194
Chapter 17 Essentials of Pediatric Nuclear Medicine 195
Introduction 195
Radiopharmaceutical Dosage and Radiation Dose 195
Distraction Techniques, Sedation, and General Anesthesia 196
Thyroid 196
Congenital hypothyroidism 196
Graves’ disease 200
Differentiated thyroid cancer 200
Urinary Tract 202
Congenital anomalies of the kidneys and urinary tracts 202
Dimercaptosuccinic Acid 213
Voiding cystography 213
Hepatobiliary System and Spleen 215
Neonatal biliary atresia 215
Other pediatric-specific hepatobiliary and splenic pathologies 215
Gastrointestinal Tract 216Contents xix
Gastroesophageal reflux scintigraphy, gastric emptying scintigraphy, and
radionuclide salivagram 216
Ectopic gastric mucosa in a Meckel diverticulum 219
Musculoskeltal System 221
Bone stress injuries: Stress reactions and stress fractures 221
Back pain and spondylolysis 221
Non-accidental trauma 223
Complex regional pain syndrome 229
Functional Imaging in Pediatric Oncology 229
Metaiodobenzylguanidine in neuroblastoma 229
18F-FDG PET/CT in pediatric neoplasms 232
Infection and Inflammation 232
Central Nervous System 239
Epilepsy 239
Nuclear medicine cerebrospinal fluid shunts 239
Conclusion 239
Chapter Self-Assessment Questions 247
Chapter 18 Quality Assurance of Nuclear Medicine Instrumentation 248
Introduction 248
Gamma Camera Uniformity Test 248
Resolution and Linearity 249
Center of rotation 249
SPECT system performance evaluation 249
Quality assurance of CT scanners 249
Quality assurance of PET scanners 250
Blank scans 250
Normalization scans 250
Radioactivity concentration calibration 250
PET/CT performance evaluation 251
Summary of Quality Assurance of Nuclear Medicine Instrumentation 251
Chapter Self-Assessment Questions 252
Chapter 19 Nuclear Medicine Procedures in the Pregnant and Lactating Patient 253
Introduction 253
What Are the Risks of Radiation in Pregnancy? 253
Recommendations regarding fetal radiation exposure 253
Radiopharmaceutical distribution and dosimetry in the pregnant patient 253
Imaging for suspected pulmonary embolism in pregnancy 255
Radioiodine distribution and dosimetry in the pregnant patient 257
Example Cases of
131
I Treatments in Pregnant Patients from the United States
Nuclear Regulatory Commission Office of Nuclear Material Safety
and Safeguards 258
Decision-Making Regarding Imaging with Radiopharmaceuticals in
the Pregnant Patient 260
Radioisotopes and the lactating patient 260
Chapter Self-Assessment Questions 264
Index 267