Radionuclide Radiopharmaceutical Expected Normal Notes

Finding
In 111 WBC + Bones,  Pts blood withdrawn, WBC extracted, labelled with
Spleen Indium-111 oxine, injected back into patient  imaged
Photon Use: Localize (HOT), 24 hrs later
infection/
energy: 174, liver  If have increased uptake of focus in bone marrow 
247 keV inflammation need technetium-99m (tc-99m) sulfur colloid bone scan
(medium) to confirm marrow replacing process
 Critical organ: spleen
½ life: 2.8  Excretion: spleen
days (67 hrs)  Pharmacokinetics: cleared by RES
 No renal, no GI
 Labelled cells are neutrophils
Octreoscan + Spleen  Pentetreotide is DTPA conjugated form of ocreotide
(pentetreotide) > liver, (only binds to 2 of 5 somatostatin receptors)
Kidneys  Octreotide = somatostatin analog
Use: neuroendocrine  Shows neuroendocrine and some NON neuroendocrine
tumors (meningioma, astrocytoma, breast cancer, lymphoma,
Merkel cell)
 Critical organ: spleen
 Higher count study = VERY HOT SPLEEN AND KIDNEYS
 Can trigger hypoglycemia in insulinoma  have D50
ready
 Best for: carcinoid, gastrinoma, pheo (extra adrenal),
paraganglioma, medullary thyroid

DTPA  Intrathecal admin

0: LP
Use: CSF imaging 2-4 hrs: basal cisterns
4-24 hrs: sylvian fissure + interhemispheric cistern
24 hrs: cerebral convexities
 ProstaScint  Capromab = monoclonal antibody recognizes PSA
(Capromob Penetide) membrane antigen (PSMA)
 Localizes to soft tissue, NOT bone
Use: Prostate (rising  Critical organ = Liver
PSA, negative bone
scan)

Ga-67 Citrate + liver,  Critical organ: colon

bones,  Good at spinal infection
Photon Use: FUO, sarcoid, TB, light  Sarcoid: Panda and lambda sign (1-2-3)
energy (4 retroperioneal spleen,
peaks): 93, fibrosis, bleomycin/ lacrimal,
185, 288, amiodarone toxicity, breasts,
394 kev bronchogenic Ca, UC salivary
gland,
½ life: 78 kidneys  Lung: Drug rxn (bleomycin, amiodarone), IPF, PCP, PNA
hours and  Poor mans bone scan
bladder  Acute interstitial nephritis
 Produced in cyclotron via bombardment of Zn68, then
complexed with citric acid

Ga-68 DOTATATE + spleen  Neuroendocrine tumors

> liver,  Better than pentetreotide studies
adrenal,  Use Krenning scoring system
kidneys/  Discontinue short acting octreotide 12-24 hrs before
bladder, imaging in week before next dose of long acting (given
bowel, monthly)
pituitary,
salivary,
thyroid
F-18 fluorodeoxyglucose + brain,  Critical organ: Bladder
(FDG) heart,  Minimize brown fat: warm room, benzos, beta blockers
Photon kidneys/  High blood glucose (>200) = artificially low SUV b/c
energy: 511 Use: standard PET bladder, competes with FDG
(high) liver  Insulin = diffuse muscle uptake
 PET cold: BAC lung ca, carcinoid, RCC, peritoneal bowel/
½ life: 110 liver implants, mucinous, prostate, MALT
mins

sodium fluoride (Naf)  Critical organ: Bladder

 Better image quality and sensitivity than Tc99 MDP
Use: skeletal imaging (standard bone scan), more expensive

I-123 Iodide  Critical organ: thyroid

Photon Use: thyroid imaging

energy: 159
(low)

½ life: 13
hours
 MIBG + brown  Can also use 131, but use 123 more often (better for
(metaiodobenzylguanidine, fat, nasal imaging, can gie higher dose
norepinephrine analog
labeled to I-123 or I-131)
mucosa,  Analog of norepi
salivary  Critical organ: bladder
Use: gland,  NO renal uptake
pheochromocytoma, heart,  Block thyroid beforehand w/ Lugol’s iodine or
neuroblastoma, liver, perchlorate or SSKI
carcinoid, bowel,  Better for bone mets than normal bone scan
paraganglioma, bladder  Better for pheos than octreotide
medullary thyroid ca,  Hold meds: Ca channel blocker, labetolol, reserpine,
ganglioneuroma, NOT tricyclic antidepressents, sympathomimetics
ganglioneurblastoma kidneys  Best for: Pheos (arenal), neuroblastoma

Ioflupane (DaTSCAN) -

Use: Parkinsonism
syndrome
(Parkinsons, MSA,
progressive
supranuclear palsy)

I – 131 Nai  Critical organ: thyroid

 Contraindicated in severe thyrotoxicosis pregnancy (6-12
Photon Use: Thyroid cancer months) - pump & dump (use PTU during pregnancy for
energy: 365 treatment, hyperpara)
(high) hyperparathyroidism  Beta emission (Damage thyroid tissue) and gamma
emission (362 kev photopeak for imaging)
½ life: 8 days  Inexpensive
 Doesn’t work: medullary Ca, prior I-131, hx of
methimazole tx
 Can cause pulmonary fibrosis in pt w/ lung mets,
damage to salivary glands in pts w/ Sjogrens
 If uptake in liver  post tx scan
 Dialysis  give immediately after dialysis to maximize
I131, dialysate can go in sewer, tubing stays in storage
 Can worsen thyroid eye disease after rx
 Need to get TSH up  stop thyroid hormone + give
recombinant TSH thyrogen
 Dosing depends on stage of disease (100 thyroid, 150
thyroid + nodes, 200 distal)
  NRC limit is 33 mCi
Thallium – Use: Toxoplasma +  Critical organ: renal cortex
201 chloride (negative on Thall), thyroid,  Behaves like potassium  crosses membrane by active
Lymphoma, Kaposi salivary, transport (NaK pump)
Photon sarcoma, Tumor, lungs, Brain
energy: 69- Necrosis, Cardiac heart,  If use w/ gallium, need to do Thallium first
80 skeletal,  + thallium, - HMPAO = tumor
½ life: 73 liver,  - thallium, + HMPAO = necrosis
hours spleen,  - thallium = NOT toxo
bowel,  + thallium = lymphoma
kidneys/ Cardiac
bladder  Redistributes, need to image immediately
 Lung/ Heart ratio  if more uptake in lungs, then
multivessel or high grade LAD/LCx lesion
Xenon - 127 Use: Lung  post  Photon energy: 125, 167 (low)
perfusion scanning  ½ life: 73 hrs
Xenon – 133 Use: Lung ventilation  Physical ½ life is 5.2 days, but biologic ½ life is 30
seconds (beath it out)  essential to do 1st part of test
Photon (can only do 1 view b/c so fast)
energy: 81  Air trapping = COOPD
(low)  Liver uptake = fatty liver
 Need to use this agent for lung quant
½ life: 125  Homogenous activity in lung
hours (5.2
days)
Tc-99m Pertechnetate Thyroid
 use if recent thyroid blocker on board (iodine)
Photon Use: Meckel’s,  If takes up on Tc but NOT iodine on 24 hr imaging 
energy: 140 parathyroid congenital enzyme deficiency, propylthiouracil
keV subctraction, Meckel: taken up by gastric mucosal cells
testicular, thyroid  Pre-treatment:
½ life: 6 (Positive Meckel’s)
o Pentagastrin (enhance uptake of pertechnetate
hours by gastric mucosa)
o H2 blocker (Cimetidine, ranitidine) to block
secretion of pertech out of gastric cells to make
stick around longer
o Glucagon (slows gastric motility)
Testicular
 Ddx: early torsion (nubbin sign), late torsion/ abscess
Normal scrotal (look same with increased activity and central
photopenia), acute epididymitis
Labeled RBC + heart,  “Tinning”
vessels, o In Vivo  Tin injected in pt, Tc-99m
Use: GI Bleed, spleen pertechnetate injected, tin binds to Hgb then
hemangioma, spleen reduces to Tc (only get 60-80% bound, fails due
(heat damaged RBCs), to heperanized tubing or recent IV contrast)
cardiac o In vivo – In vitro  Tin injected into pt, after 15-
30 mins, pull 3-5 cc of blood into syringe w/ Tc-
99m and add anticoagulant  reinject 10 mins
later
o In Vitro  blood withdrawn, added to kit,
reienjected (most expensive, most accurate)
+GI Bleed  Hemangioma  HOT on delays, not on immediate flow
or pool
MUGA
 Basically angiogram of the heart  estimate EF
Sulfur Colloid + Bones,  Excretion: hepatic
Technetium-99m sulfur Liver,  Target organ: liver, spleen
colloid
spleen,  Pharmacokinetics: rapid extraction by liver, spleen and
Use: marrow
Lymphoscintigoraphy,  Colloid shift in severe liver disfunction (shifts into spleen
gastric emptying, and bone)
liver/ spleen scan, GI  Diffuse pulmonary activity = axcess aluminum in colloid
bleed  Renal activity = CHF, renal transplant rejection
Liver
 FNH is only hot mass!
Infection
 + Tc WBC & – on Tc Sulfur Colloid = infection
Lympho
 10-50 nm
MDP  Critical organ: bladder
(methylene  Free Tc  salivary, thyroid, stomach
diphosphonate)  Mechanism: phosphate binding to bone (chemisorption),
distribution based on blood flow and osteoblastic
Use: classic bone scan activity

 Skull sutures  renal osteodystrophy

 Breast uptake  focal, cancer
 Renal cortex hotter than lumbar spine 
hemochromatosis
 Diffuse renal uptake  chemo, obstruction
 Liver uptake  too much Al+3, hepatoma, amyloid, liver
necrosis
 Spleen  auto-infarct (sickle)
  Lung  osteosarcoma
 Single lesion  usually benign, except sternum in BrCa
 Honda sign  sacral insuff
 Diffuse skeletal  free Tc, bisphosphonate
 Fx in elderly  image 1 week later
 Muscle  Rhabdo
 Tramline long bones  Hypertroph Osteoarthro (HOA)
 Myositis ossificans  image until mature (cold), take
out
 AVN  Early and late cold, middle hot
 Osteoid osteoma  double density
 ABC  donut sign
 3 phase  hot on flow + pool = cellulitis, hot on all 3 =
osteo
HMDP

Use: Bone imaging

Sestamibi  Sestamibi depends on mitochondrial density and blood
flow, passively cross cells
Use: Parathyroid, Parathyroid
breast  Technique: Dual phase + Dual tracer
Dual phase: early (10 min) and late (3 hrs) 
sestamibi likes blood flow and lots of
mitochondria
False positives: thyroid nodules, H&N ca,
lymphadenopathy
Dual tracer: Sestamibi (or thallium chloride) +
second agent that only goes to thyroid (I-123 or
Pertechnetate)  subtraction  anything left
over could be parathyroid adenoma

Breast:
 false positives (fibroadenoma, fibrocystic,
inflammation), false negative (lesion< 1 cm or deep,
medial breast or near heart)
Cardiac
 Does not redistribute, imaging done 3-90 mins after
 False positive at septum = LBBB
 If cant exercise  give regadenoson (coronary
vasodilator, specific to adenosine receptor)
 Dobutamine can give galse positives in LBBB
 Uptake in liver + bowel = need to exercise harder
  Stunned myocardium = perfusion normal, contractility
bad (will get better)
 Hibernating = perfusion decreased, contractility
decreased (chronic), NOT an infarct  take up FDG
more intensely than myocardium, redistribute thallium
MAA  Tracer in brain = shunt (ASD, VSD etc)
 Size = 10 micrometers (want small so don’t block
Use: Lung perfusion arterioles)
(most common)  Reduce particle amt w/ children, 1 lung, RL shunt,
pulm htn (normal dose of Tc, reduced MAA)
 Clumped MAA = focal hot spot
 Can be used to quantify cardiac shunt
DTPA V/Q (aerosolized):
 Requires patient to breath through mouth guard with
Use: lung aerosol, nose clamp for several minutes
renal function, shunt  Can NOT do quantification with aerosol
studies  Slower washout, multiple projections
 Clumping common
Brain:
 Lipophobic (angiotracer), stays in blood (doesn’t cross
BBB)
 No SPECT
 Can be repeated without delay
 Main use = shunt studies (also NPH, brain death)
 Hot Nose sign (secondary sign)  due to perfusion
through external carotid to maxillary branches
Renal
 Estimates GFR (all filtered)
Preserved brain function  Critical organ = bladder
 Renal artery stenosis = decreased tracer uptake

 Renal transplant vs ATN vs cyclosporing toxicity (see

Normal shunt study Mag 3)
HMPAO  SPECT  mimics metabolism (Lipophilic), crosses BBB
 Main use = dementia + seizure focus (hot during seizure,
Use: brain blood flow cold interiectal)
 FAST washout
 Uptake favors frontal lobe, thalamus, cerebellum
 Acetazolamide (Diamox) study  vasodilator, areas will
be hypointense, look worse (evaluate for
cerebrovascular reserver)

ECD (bicisate)  SPECT  mimics metabolism ( Lipophilic), crosses BBB

 Main use = dementia + seizure focus (hot during seizure,
Use: brain blood flow cold interictal)
 SLOW washout (more rapid clearance from blood pool)
 Uptake favors parietal and occipital lobes
 Acetazolamide (Diamox) study  vasodilator, areas will
be hypointense, look worse (evaluate for
cerebrovascular reservoir)
MAG3  Secreted  estimates effective renal plasma flow
(ERPF)
Use: Renal tubular  Critical organ: bladder
function  Renal Artery stenosis = tracer retention

 ATN (immediate post op): nl perfusion, delayed

excretion
 Cyclosporin toxicity (late): nl perfusion, delayed
excretion
 Acute rejection (immediate post op): poor perfusion,
excretion delayed
*Obtain all renal images (DTPA, MAG3 etc..) posteriorly,
unless horsehoe or transplant kidney
GH  Filtered
Glucoheptonate

Use: Renal structural/

functional imaging
DMSA  Critical organ = kidney (all other renal imaging is
bladder)
Use: renal cortical  Binds to renal cortex, cleared slowly
function  Preferred in peds due to lower dose to gonads
 Acute pyelonephritis  decreased uptake
 Scar (or mass)  decreased uptake
 Column of Bertin (hot) vs Mass (cold)
Tetrofosmin (See cardiac sestamibi)  clears from liver more rapidly

Use: cardiac
HMPAO WBC  Shorter ½ life than In-WBC, limits delayed imaging, lower
dose than In-WBC, smaller blood sample
Use: Infection (kids  Normal GI and GB uptake, obscures activity
and small parts) 
lower absorbed dose
and shorter imaging

IDA (iminodiacetic  IDA mimics bilirubin’s uptake, transport, excretion

acid) analogs   Need higher doses of tracer if pt has hyperbilirubinemia
DISIDA, Mebrofenin  Prep: diet control (NPO 4 hrs) but eaten w/ 24 hrs (can
(good for high give CCK if haven’t eaten in over 24 hrs)
bilirubin), PIPIDA  Rim sign (curbed area of increased activity in GB fossa) =
angry GB
Use: Cholecystitis  Cystic duct sign (nub of activity in cystic duct)= acute
(acute, chronic), bile cholecystitis
leak, biliary atresia,  Acute cholecystitis
hepatitis Normal HIDA (GB filling) o If don’t see GB by 30-60 minutes 
morphine 0.04 mg/kg or standard 2 mg
dose administered IV over 2-3 minutes
o Sincalide infused at 0.02 ug/kg
 Chronic cholecystitis = delayed filling GB and low EEF
(<30% w/ CCK)
o CCK dose = 0.02 microgram/kg over 60
min, wait 2 hrs, start exam
o Morphine = 0.02 – 0.04 mg/kg over 30-
60 min, give if don’t see GB by 1 hr
 Biliary atresia  give phenobarbitol to prime liver 5
mg/kg x 5 days (5 for 5 keeps the liver alive)
 Hepatocyte dysfnction  no bowel activity, persistent
 blood pool
 Common duct obstruction  no bowel activity, blood
pool goes away normally
Rb82 Chloride  NaK pump
 Very Short half life
½ life: 75 Use: myocardial  Similar to thallium
seconds perfusion  *Made with generator
Nitrogen 13 Use: myocardial
perfusion, PET
½ life: 10
minutes

Radiopharmaceutical Analog ½ life Energy, kEv (principle)

99
mTc 6 hours 140 (low)
123
I Iodine 13 hours 159 (low)
131
I Iodine 8 days 364 (high)
201
TI Potassium 73 hours 69-80 (spectrum of characteristics XR (low)
133
Xe 5.2 days 81 (low)
67
Ga Iron 78 Hours 93, 185, 300
111
IN 67 Hours 173, 247
18
F Sugar 110 minutes 511 (high)
82
Rb 75 seconds

Treatment Radionuclide ½ life Use Notes

Strontium – Sr 89 (Metastron) 50.5 days (14 days Bone pain  Complexes with hydroxyapatite in areas where bone turnover is high
in bone)  Worst myelotoxicity
 Pure beta emitter
 8-12 weeks for full recovery
 Renal excretion
Samarium – Sm 153 (Quadramet) 46 hours Bone Pain  Complexes with hydroxyapatite in areas where bone turnover is high
 Beta + gamma decay (can use for imaging)
 Renal excretion
Radium – Ra 223 (Xofigo) 11 days Bone Pain (prostate  Similar to calcium  absorbed into bone matrix at sites of active bone mineralization
cancer)  Alpha emitter
 Less hematologic malignancy
 Survival benefit in prostate Ca
 Long ½ life
 GI excretion
Yttrium-90 1.67 days Liver tumors  Pure Beta emitter
 Need to do 99mTc MAA hepatic arterial injection  look for shunt fraction (<10% ideal)
Critical Organ Tracer
Liver In-ProstaScint
I-131 MIBG
Sulfur Colloid (IV)
Gallbladder wall HIDA
Renal Cortex Thallium
DMSA
Proximal Colon Sulfur Colloid (oral)
Sestamibi
Bladder MAG3
I123 MIBG
MDP
Stomach Pertechnetate
Spleen Octreotide
Damaged RBCs
InWBC
Ga 68 (dotatate)
Distal Colon Gallium 67

Production Mode Radionuclides Decay Mode

67
Cyclotron Ga, 111 In, 125 I, 18 F Positron or EC
131
Fission I, 133 Xr, 99 Mo Beta minus
125 89
Neutron Activation I, Sr Beta minus
99m
Generator Tc, 82 Rb, 68Ga Isometric positron

Method of Localization Tracer

133
Compartmental Xe, 99mTc RBC
Tc99
Phagocytosis m Sulphur Colloid
131
Active Transport I NaI and 18F (facilitated diffusion(
90
Embolization Y spheres, 99mTc MAA
99m
Chemisoprtion Tc MDP