เวชศาสตร์นิวเคลียร์

Nuclear Medicine
• โดย ร.ศ. พ.ญ. สุ นันทา เชี่ยววิทย์

สาขาเวชศาสตร์นิวเคลียร์ ภาควิชารังสีวิทยา
คณะแพทยศาสตร์ศิริราชพยาบาล
 Organ Imaging
• Perfusion-Ventilation Lung scan
• Renal scan and renogram
• Oncology
 Lung scan
• Perfusion: เลือดทีม่ าเลีย้ ง
• Ventilation: ทางเดินหายใจ
Bronchoplmonary segment
 Perfusion lung scan
สารเภสั ชรังสี : Tc-99m MAA 3 - 10 mCi IV. ขนาด
Particle 10 - 30 micron
หลักการ: MAA particles จะไปค้างอยูท่ ี่ปอดในระดับ Pre-
capillary arterioles (Capillary blockade) โดยมีการ
กระจายตัวในปอดตามกระแสเลือด Pulmonary artery
: ถ้ามีการอุดกั้นของหลอดเลือดที่ไปปอด ปอดส่ วนปลายจะขาด
เลือด MAA particles ไปไม่ถึง จึงเห็นเป็ นรอยแหว่งแบบ
Segmental defect
การเตรียมตัวผู้ป่วย: ให้ผปู ้ ่ วยนอนราบอย่างน้อย 10 นาทีก่อนฉี ดยา เพื่อให้เลือด
กระจายตัวอย่างสม่าเสมอ (Apex = Base)
การแปลผลร่ วมกับ CXR ภายใน 24 ชัว่ โมง
 Ventilation Lung scan
หลักการ: เมื่อสูดอากาศที่มีสารเภสัชรังสี เข้าไปในทางเดินหายใจ ภาพการตรวจ
จะแสดงการกระจายตัวของสารเภสัชรังสี ตั้งแต่ Trachea -> -> ->
Alveoli
: ถ้าสิ่ งที่สูดเข้าไปเป็ น Particle ควรมีขนาดเล็ก ไม่ตกค้างใน
ทางเดินหายใจส่ วนต้น
สารเภสั ชรังสี : 1. Radioaerosol : Phytate, DTPA
2. Xenon-133 (Xe-133)
3. Technegas: ไม่ตกค้างใน main bronchus
เทคนิคการถ่ ายภาพ Perfusion และ Ventilation lung scan
: ถ่ายภาพ Static 6 - 8 views
(anterior, posterior, both lateral and both
posterior oblique)
 ผูป้ ่ วยที่ควรลดจานวน particle
• การตรวจ perfusion study เป็ นการตรวจที่มีความปลอดภัยสู ง
แต่อย่างไรก็ตามควรต้องระมัดระวังเป็ นพิเศษ ใน ผูป้ ่ วยที่มีภาวะ
ดังต่อไปนี้
• ภาวะ pulmonary hypertension : เนื่องจากภาวะนี้ทาให้
เส้นเลือดในปอดมีขนาดเส้นผ่าศูนย์กลางเล็กลง ทาให้เมื่อ ให้ MAA
แก่ผปู ้ ่ วยจะทาให้เกิดการอุดตันของหลอดเลือดในปอดได้เพิ่มขึ้น
มากกว่าคนปกติ
• ภาวะ right – to – left shunt : เนื่องจากมี particle หลุด
เข้าไปในระบบหมุนเวียนโลหิ ต และทาให้เกิดการอุดตันที่หวั ใจและ
สมอง
Normal perfusion and ventilation lung
scan
• Homogeneous distribution throughout the lung
• Ventilation scan => activity in trachea, bronchus and
stomach
Perfusion defect
• Nonsegmental (hilar, blunting of costophrenic sulcus)
• Segmental
* Small < 25% segment
* Moderate 25% -75% segment
* Large > 75% segment
Normal perfusion-ventilation
 Indications of Lung scan

Detection of pulmonary embolism (PE)

Quantitative lung function
Detection of right-to-left shunt
 Pulmonary embolism
• เป็ นภาวะที่เกิดจากการที่มี emboli มาอุดตันในหลอดเลือดของ
ปอด โดยมากมักมีสาเหตุมาจากการที่ผปู ้ ่ วยมีภาวะ deep
venous thrombosis อยูก่ ่อน การวินิจฉัยภาวะ
pulmonary embolism จากการอาการทางคลินิกทาได้
ยาก เนื่องจากอาการหอบเหนื่อย เจ็บหน้าอก ไอ อาจพบได้ในโรค
อื่นๆ สาหรับการเจาะเลือดตรวจดูระดับ D-dimer และภาพถ่าย
เอกซเรย์ปอด (chest x-ray) พบว่าไม่มีความจาเพาะเจาะจง
 Ventilation – Perfusion
scintigraphy
 เป็ นการตรวจที่มีประโยชน์ในการช่วยวินิจฉัยภาวะนี้ เนื่องจากเป็ นวิธีที่
noninvasive และ มีความแม่นยาค่อนข้างสู ง
 โดยลักษณะที่ typical ของ lung scan ใน pulmonary
embolism จะมีลกั ษณะที่เรี ยกว่า “segmental ventilation –
perfusion mismatch defect” กล่าวคือ ใน perfusion scan
จะเห็นperfusion defect (คือบริ เวณที่ไม่มี activity ของสารเภสัชรังสี )
ซึ่ งเป็ นผลมาจากการที่มี emboli อุดในหลอดเลือดปอด โดย perfusion
defects ดังกล่าวมีลกั ษณะเป็ น segment , multiple และ
peripheral กล่าวคือ มีลกั ษณะเป็ นรู ปสามเหลี่ยม ฐานอยูด่ า้ นริ มนอกของปอด(
ตามลักษณะการแตกแขนงของหลอดเลือด) และมักมี defect มากกว่าหรื อเท่ากับ 2
defects ขึ้นไป และการตรวจ Ventilation ปกติ (segmental V/Q
mismatched defects)
 Cause of V/Q mismatch
Vasculitis
Mass lesion (Lymph node, Tumor)
compress vessel
Pulmonary artery atresia or
stenosis
 MODIFIED PIOPED CRITERIA FOR
COMBINED V/Q SCAN
INTERPRETATION
HIGH PROBABILITY> 80%
• Two or more large mismatched segmental
defects
INTERMEDIATEPROBABILITY > 20% - 80%
• One moderate mismatched segmental defect
with a normal radiograph
• One large and on moderate mismatched
• Difficult to categorize as high or low probability
Not meeting the stated criteria for high or low
probability
 MODIFIED PIOPED CRITERIA
FOR COMBINED V/Q SCAN
INTERPRETATION
LOW PROBABILITY <20%
• Non segmental perfusion defects : cardiomegaly,
enlarge mediastinum or aorta
• Any perfusion defect substantially smaller than a
corresponding radiographic abnormality
• Matched ventilation and perfusion defects with a
normal chest radiograph
• Small subsegmental perfusion defects
NORMAL
• No perfusion defect
 Conventional angiography
• Invasive, time consuming, more
expensive, and less available. In
addition, a chronic central mural
thrombus that is easily seen with CT
scanning may be missed at pulmonary
angiography
 CT scanning
• Shows emboli directly, noninvasive,
cheaper, and widely available
• High radiation dose
Recommendations for diagnosis

• CXR should be obtained first

• Normal or near normal CXR, or if there is
edema, a V/Q scan is indicated.
• Significantly abnormal CXR or clinically
unstable, pulmonary CTA should be
performed absent contraindications such as
renal insufficiency
• CTA or V/Q results are discordant with
Doppler ultrasound or clinical assessment
 Case demonstration
• 46 year old female: Acute dyspnea and
hypoxia. Chest radiograph shows mild
basilar atelectasis
 Case demonstration

HISTORY: A 62-year-old man with known

case deep vein thrombosis and clinical
suspect pulmonary embolism
 Pulmonary CTA VS V/Q
lung scan
• Diagnostic algorithms using either CTPA or V/Q scanning :
comparably safe to exclude the diagnosis of pulmonary
embolism
• Negative multidetector CTPA study : ruled out the diagnosis of
pulmonary embolism without the need to routinely exclude the
presence of deep vein thrombosis
• Multidetector CTPA : significant radiation exposure that
potentially increases risk of secondary malignancies
• Excluding low risk patients for pulmonary embolism as defined
by clinical scoring systems and D-dimer testing would enhance
the yield of V/Q scanning diagnostic testing
 Recommendations for
diagnosis PE
• CXR should be obtained first
• Normal or near normal CXR, or if there is
edema, a V/Q scan is indicated.
• Significantly abnormal CXR or clinically
unstable, pulmonary CTA should be
performed absent contraindications such as
renal insufficiency
• CTA or V/Q results are discordant with
Doppler ultrasound or clinical assessment
right-to-left
shunt
Renal scan and renogram
 Renal function
• Remove liquid waste from the blood in
the form of urine
• Keep a stable balance of salts and other
substances in the blood
• Produce erythropoietin, a hormone that
aids the formation of red blood cells
• Regulate blood pressure
 Renal scan & Renogram
Excretory function
*passive filtration
* active secretion by tubule
Radiopharmaceutical
1. Glomerular filtration agents:
Tc-99m EDTA, Tc-99m DTPA ( GFR )
2. Renal tubular agents:
I-123/ I-131 Hippuran ( ERPF )
Tc-99m MAG3 ( MAG3 clearance )
3. Renal cortical agent:
Tc-99m DMSA
 Radiopharmaceutical
Filtered agents: Tc 99m DTPA, Cr 51 EDTA
- glomerular filtration ~20% of total renal
plasma flow
- not bound to plasma protein or other
blood component
- freely filtered and must not be actively or
passively reabsorbed or secreted
Radiopharmaceutical
Secreted agents: Tc 99m MAG3, I123 and I131 OIH
- higher concentration in kidney, better
kidney to background ratio than glomerular filtration
agent
- MAG3 similar excretory process by renal tubule and
bile
- relative proportion of renal and biliary excretion
varies according to chemical structure, binding plasma
protein and relative renal and liver function
-The ratio of OIH clearance average 90% to PAH(
para-amino hippuric acid)
- The renal extraction of of MAG3 is 60% of OIH,
MAG3 clearance is 54% of PAH clearance
 Radiopharmaceutical
• Bound agent: Tc 99m DMSA
- bound irreversible to renal
parenchyma and not be excreted into
urine
- active transport mechanism same as
kidney and liver
- delayed imaging for 3 hours because
slow transfer activity from blood to
kidney
 Radiopharmaceutical
Radiopharm Glomerular Tubular Tubular
aceutical filtration Secretion Secretion

Tc99m DTPA >95% - -

Tc99m <5% 95% -
MAC3
I131 OIH 20% 80% -
Tc99m GHA 40-60% - 20%
Tc99m Some - 60%
DMSA
Radiopharmaceutical Extraction Fraction Clearance
Tc99m DTPA 20% 100-120 ml/min
Tc99m MAC3 40-50% 300 ml/min
I131 OIH 100% 500-600 ml/min
 Acquisition
• Supine position
• Renal blood flow ( angiogram) : 1-3
sec/frame for 1 minute
• Dynamic image :1 minute/frame for 30
minute
 Normal renal scan
• Symmetrical renal blood flow 3 seconds
after peak aorta activity
• Symmetrical renal uptake
• Excreted activity in the collecting
system and urinary bladder
 Renogram curve
• Time activity curve, X= Time (min) Y= activity
in kidney (count/min)
• Process by ROI at both kidneys
1. Vascular phase (tracer appearance)
2. Second phase (build up phase)
3. Third phase(excretory phase)
• Transit time= time between injection and
peak of curve (normal3-5 minutes)
 Indication for renal scan
• Obstructive uropathy (diuretic
renogram)
• Evaluation of split renal function
• Evaluation of renal scar and
pyelonephritis
 Basic principle of diuresis
renography
 Act principle at luminal phase of the
epithelial cells in the ascending loop of
Henle, blocking active reabsoption of
chloride and sodium
 Limited fluid reabsoption in proximal
convoluted tubule
 Basic principle of diuresis
renography
• Response maximal 15 minute after
diuretic injection
• Dose 0.5 mg/kg ( 40 mg adult dose )
 Urinary tract obstruction
• Obstruction: no change in curve(continue to rise)
and pelvic retention
 Poor blood flow, Poor uptake of the tracer (+),
retention of the tracer in dilated collecting system
• Unobstructed dilated collecting system: rapid
washout of the tracer from collecting system
(response to lasix)
• Incomplete tracer washout : partial or low grade
obstruction or renal impaired function
Renogram curve of outflow tract obstruction
 Diuretic Renography
• Post Lasix Half-time Excretion
= < 10 minutes is NORMAL
= > 20 minutes is OBSTRUCTED
> 10 but < 20 is INDETERMINATE
or PARTIAL OBSTRUCTION
 Diuretic curve analysis:

False positive Dehydration

Massive dilatation
Poor renal function
Full bladder effect
Mechanism of decreased uptake of
DMSA in acute pyelonephritis
• Decreased renal blood flow
• Dysfunction distal tubular cell
membrane transport
Pattern of uptake on DMSA scan

• Normal study : Homogeneous thoughout the

kidney except for low activity in the areas of
collecting system
• Acute pyelonephritis : areas of focal ( single
or multiple ) or diffuse decreased cortical
uptake without evidence of volume loss
• Scar : defects in uptake with cortical thinning
and decreased volume
 Timing after infection subside for
evaluation renal cortical scar

• 6 month
 Oncology
• F18 FDG PET/CT
POSITRON PRODUCTION
 Half-Lives of Positron-
Emitting Isotopes
Radioisotopes Half-Life (minutes)

Oxygen-15 (O-15) 2
Nitrogen-13 (N-13) 10
Carbon-11 (C-11) 20
Fluorine-18 (F-18) 110
 PET Agents for Cancer Imaging
• Metabolism
– Glucose : [18F]FDG
– Amino acid : [11C]methionine, [18F]fluorotyrosine
– Nucleotides : [18F]TAFAD, F-18-FLT
– Hypoxia : [18F]misonidazole, [18F]FETNIM,
Cu-68- ATSM
• Receptor
– Estrogen : [11C, 18F]estrogen derivatives,
[18F]tamoxifen
• Anticancer agents
– Cisplatin, etc
 Reasons for FDG Uptake by
Tumor Cells
• Increased rate of glycolysis
• Increase in glucose transporter proteins
such as Glut 1
• Increased levels of hexokinase trapping of
FDG by phosphorylation
• Decreased glucose-6-phosphatase which
dephosphoralates FDG allowing it to leave
the cell
 Imaging Protocol
Patient
- Fast 4 hrs prior to exam
- Inject tracer
- Start scan 60 min later

CT
PET - Topogram (scout)
- Brain (10 min) - CT scan (1 min)
- Body (20 min)
What Are the Advantages of PET/CT?

Advantages of CT

• high spatial resolution

Advantages of PET

• better lesion characterization

• enhanced lesion detection
Patient Prep – Scan for Cancer
• No caloric intake for 4 hours prior to
scan
• Water or non-calorie drinks are
encouraged
• Check blood glucose
• Warm, comfortable, No chewing, No
talking
 Dose and Scan Protocol
• 10-15 mCi FDG adults whole body
• Pediatrics – 140 uCi/kg with 500
uCi minimum
• Have patient urinate first, promote
comfort
FDG in Normal Tissues
• Brain
• Head and neck (larynx, thyroid, salivary
glands and small muscles and lymphoid
tissue)
• Heart
• Muscles
• GI tract
• Renal
• Liver
FDG in Normal Tissues
– Breast
– Vascular
– Osteophytes and joints
– Bone marrow
– Thymus
– Brown fat
Normal PET/CT
 Advantage of PET
• Evaluate suspicious lesions detected on other
exams: benign or malignant
• Staging
• Diagnose disease before structural changes
• Identify distant, occult metastases
• Monitoring response
• Recurrence cancer
• Prognosis and plan of treatment
 Clinical indications of 18F-
FDG PET/CT in oncology
• Evaluating the extent of disease in known malignancies
(staging/restaging)
• Detecting tumor recurrence, in the presence of elevated tumor
markers but no clinical or morphological evidence of disease
• Searching for an unknown primary when metastatic disease is the first
clinical presentation or when patients present with paraneoplastic
syndrome
• Differentiating benign from malignant lesions
• Evaluating disease response to chemotherapy or radiotherapy
• Selecting tumor region for biopsy guidance-surgical planning.
• Radiotherapy planning
 Lesion Characterization

47 year old man with multiple trauma from a

motorcycle accident who was incidentally discovered
to have a pulmonary nodule
 Lesion Characterization

84 year old man with chronic cough found to have

a 13 mm nodule on CXR
 Enhanced Detection

I-131 FDG PET

47 year old man with biopsy proven recurrent
thyroid cancer 3 months after thyroidectomy
 Initial staging

A 68-year-old man who came for initial staging of non-small cell lung cancer. MIP
image (left panel) and fused images (right panel) of 18F-FDG PET/CT showed the
primary tumor (arrow head) with mediastinal nodal involvement (yellow arrow) and
extra-thoracic right adrenal metastasis (black arrow).
 Unknown Primary

68 year old man who presented with right neck mass

 Recurrent Disease

QuickTime™ and a
decompressor
are needed to see this picture.

64 year old man s/p laryngectomy, now has dysphagia

 72-year-old man known case anorectal cancer unexplained elevation of
CEA , 18F-FDG PET/CT scan showed recurrent avid disease at the residual
surgical bed soft tissue density (yellow arrow).
benign or
malignant
 Diagnose
disease
before
structural
changes
Hodgkin
Lymphoma
with
anterior
mediastinum
after
treatment
Hodgkin lymphoma. initial staging showed nodal involvement above and below the
diaphragm. 18F-FDG PET/CT after four cycles of chemotherapy showed complete
metabolic resolution of the disease with small non–FDG-avid residual soft tissue
 Hodgkin's lymphoma. (A) The maximum intensity projection (MIP) PET pretreatment scan shows bulky
left axillary adenopathy (arrows) and hypermetabolic splenic lesions - disease upstaged (block arrow).
(B) MIP image of the same patient done after two cycles of chemotherapy (interim response assessment)
shows complete metabolic resolution. The fused PET/CT image in the pretreatment scan (C) shows
hypermetabolic left axillary nodes. The interim scan in (D) shows residual morphologic nodes with no
significant FDG uptake. Hypermetabolic splenic lesions in (E) show complete metabolic and
morphologic resolution in (F)
 Monitoring Response

63 year old man stage 3A lung cancer, has received

4 cycles of chemotherapy
Adenocarcinoma of the distal esophagus. (A) Pretreatment MIP image shows
hypermetabolic mass in the distal esophagus (arrow) and hypermetabolic metastatic
mediastinal nodes (dashed arrow). (C and E) Fused PET/CT images showing the same.
(B) Response assessment PET scan done after three cycles of neoadjuvant
chemotherapy (NACT) shows complete metabolic and morphologic regression of the
mass with partial metabolic and morphologic regression of the mediastinal nodes
(dashed arrow) on MIP. (D), (F) The same is depicted in fused PET/CT images (arrow
in d and dashed arrow in F)
Accurate tumor border
 Tumor high glucose avid
• Lymphoma Colorectal
cancer
• Breast cancer Esophageal
cancer
• Head & neck cancer Melanoma
• Brain tumors Cervical cancer
• Testicular (Germ Cell) cancer
• Thyroid cancer Lung cancer
• Sarcoma
 False positive
• Granulomatous disease
• Inflammatory or infectious process
• Healing from recent radiotherapy,
surgery, biopsy, or injection site reaction
• Physiologic uptake (e.g.: stomach,
cecum, bowel)
Fibronodular infiltration
with FDG uptake
Post radiation change
 False negative
• Microscopic disease
• Non-glucose avid tumors:
Bronchoalveolar carcinoma
• Diabetes mellitus high blood glucose
 A 56 year old male patient,
asymptomatic, in whom a right
pulmonary mass was incidentally
detected on screening chest X ray.
Subsequent CT scan of the chest
demonstrates a right upper lobe mass
with additional paratracheal,
aortopulmonary, subcarinal and
bilateral hilar lymphadenopathy.
Cytology :Adenocarcinoma.
A 67 year old female patient with an incidental finding of a mass in
the right lung on screening CT.
Subsequent CECT revealed a left hilar soft tissue mass with post-
stenotic atelectasis and mediastinal LNs.
There was evidence of additional lymph node involvement in the right
lung and a soft tissue mass in the left adrenal gland.
Bronchial brush cytology showed poorly differentiated carcinoma.
PET/CT findings
FDG–PET/CT for initial staging shows centrally located left lung FDG
avid tumour and FDG avid mediastinal nodes. There is no evidence of
FDG uptake of the right pulmonary micronodule. Adrenal gland
lesion without FDG uptake.
Impression: Centrally located, left lung cancer with ipsilateral
mediastinal tumour involvement. Left-sided adrenal adenoma.
Follow-up
Additional imaging and treatment: Surgery with curative intent.
Consequences of the current PET/CT examination reported here
Downstage of disease and change in treatment plan.
Cancer F-18 FDG PET/CT
reimbursed in Thailand

• Lung cancer : initial staging

• Colon cancer : recurrent colorectal
cancer with curative intent