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 Nuclear Medicine
Technology:
Procedures and Quick Reference
Procedures and Quick Reference
Third fdition

PETE SHACKETT, BA, ARRT[N], CNMT

r "\
. . ._•.,,,.Wolters Kluwer
Philadelphia • Baltimore • New York • London
Buenos Aires • Hong Kong • Sydney • Tokyo
Acquisitions EdiiDr: Sharon Zinner
Development EdiiDr: Eric McDermott
Editorial Coordinator: Andrea Klingler
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Design Coordinator: Holly McLaughlin
Mcuu.i.factwing Coordinator: Beth Welsh
Prepress Vendor: 'INQ Technologies
Project Manager: Kalt Gayathrt

Third Edition

Copyright © 2020, 2009, 2000 Pete Shackett.

Printed in China

All rights reserved. This book is protected by copyright. No part of this book may be reproduced or trans-
mitted in any form or by any means, including as photocopies or scanned in or other electronic copies,
or utilized by any information storage and retrieval system without written permission from the copyright
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book prepared by individuals as part of their official duties as US government employees are not covered
by the abovementioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce
Square, 2001 Market Street, Philadelphia, PA 19103, via email at permissions@lww.com or via our website
at shop.lww.com (products and services).

9 8 7 6 5 4 3 2 1

Library of Coagreu Catalogbag-ia-hbllcaUoa Data

ISBN-13: 978-1-9751-1983-6

Cataloging in Publication data available on request from publisher.

This work is provided "as is," and the publisher disclaims any and all warranties, express or implied,
including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals' examina-
tion of each patient and consideration of, among other things, age, weight, gender, current or prior medical
conditions, medication history, laboratory data, and other factors unique to the patient. The publisher does
not provide medical advice or guidance, and this work is merely a reference tool. Healthcare professionals,
and not the publisher, are solely responsible for the use of this work including all medical judgments and
for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional
verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and
treatment options should be made and healthcare professionals should consult a variety of sources. When
prescribing medication, healthcare professionals are advised to consult the product information sheet (the
manufacturer's package insert) accompanying each drug to verify, among other things, conditions of use,
warnings, and side effects and identify any changes in dosage schedule or contraindications, particularly
if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the
maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any
injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise,
or from any reference to or use by any person of this work.

shop.lww.com
Contact Information

v
 It is unimaginably saddening to lose your loved one and closest
friend. That said, I would like to dedicate this third editi.on
with all my love to my extraordinary and lovely wife.

Carolyn Sue Howe Shackett

(June 24, 1955-July 24, 2018)

In addition, I dedicate this to our past canine gatekeeper,

Brandy, and to my present companion and "hunine"
gatekeeper, Daisy. They have all brought and still bring
home the genuine meaning of happiness and support.

In loving memory of my parents, Bertha and Wllfard Shackett

I also extend a debt ofgmtitude and appreciation post:humously in

memory of my immediate family: Robert Shackett, Virginia Garrity,
William Shackett, David Shackett, Winifred (Dolly) Duhaime, Carolyn's
brother Donald Howe, and her parents, Pauline and VUey Howe.
 Pete Shackett was born and raised in Newport, New HampshJre. He is
the youngest of six children (three brothers and two sisters) with incred-
ibly supportive parents (Bertha and Wilfard). At the age of five. one of
his brothers began teaching hhn how to play drums and at nine, began
teaching hJm how to play guitar. Pete spent his prcrhigh school and
high school years immersed in music and high school band, becoming
president of the band in his senior year.

In 1970, Pete received a Bachelor ofArts degree in Biology from Plymouth

St.ate College (now Plymouth St.ate University) of the University of
New HampshJre in Plymouth, New Hampshire. While studying under
oto Courtesy of Jbn Dr. Maiy G. Bilheimer, he received a science essay award for a treatise
~:ano Photography, entitled '"1he Sanitaiy S1gnificance of Fecal Coliforms in the Environment."
. Petersburg, FL.
From 1970 to 1996, Pete pursued a professional career in music as a
IOI:U!Wnter, singer, recording producer, drummer, acoustic, and electric guitarist. Most of his
usic was performed in and around New England until 1976; he moved to Florida to con-
ue his music career. He released an album of all original music in 1988 entitled "Grouper
epublic... The title song Grouper Republic was voted the official city song of Madeira Beach/
ohn's Pass Village, Florida in 2012.

1991, having growing issues with his voice and while taking prerequisite classes
t St. Petersburg JWlior College, he began volunteering at Bayfront Medical Center in
t. Petersburg as a patient transporter and shadowing in the nuclear medicine department.
e learned very early how a department was run and how to image patients. His friend Bud,
e Chief Technologist of the department at that time, in turn learned how to play guitar. In
994, he resumed study at Hillsborough Community College in Tampa, Florida, majortng in
uclear medicine under the direction and guidance of Dr. Max Lombardi. During his tenure
a student, he wrote a disquisition entitled "99m'fc-tetrofosmln: The Efficacy and Slgniflcance
f a New Myocardial Perfusion Radiopharmaceutical." The paper and presentation won an
:ward at the Flortda Nuclear Medicine Technologist conference 1n 1996 and was accepted for
ublication 1n the Journal of Nuclear Medicine TechnDlogy. Pete graduated with high honors
1996, earning the Award for Academic Excellence 1n Nuclear Medicine from Hillsborough
onununity College and elected to Who's Who Among Students at Amertcan Junior Colleges.

ppincott Williams & Wl1kin.s received a copy of the original manuscript for Nuclear Medldne
echnDlogy: Procedures and Quick Reference 1n 1998. The first edition of the book was pub-
bed 1n 2000. Pete continued to asstmilate information, ideas, and experience 1n the field of
uclear medicine during his 22 years of patient care. His second edition was released 1n 2008
th an update 1n 2013. This third edition has been the most gratlfy1ng and done 1n hopes of
on1ributlng to successful careers to all that may use it.

te Shackett presently resides, plays and writes music, and writes about nuclear medicine
d other subjects out of the Tampa Bay area 1n Florida.
vii
A special expression of gratitude and deepest respect to Dr. Max H. Lombardi, Director of
Nuclear Medicine Technology (Retired), Hill.sborough Community College, Tampa, F1orida,
for the opportunity of knowledge, encouragement, inspll"ation. and assistance. I also thank
Mr. Henry (Bud) Rogers, CNMI', past Chief Technologist, Bayfront Health (formerly Bayfront
Medical Center), St. Petersburg. F1ortda, now owner and operator of the Advanced Nuclear
Imaging mobile units. for all his past and continuing to this day support. Also, thank you to
the many technologists, students. nurses, and physicians who contributed opinions and infor-
mation during the development of the original manual and this second edition. I also honor
and thank posthumously Dr. Maiy G. Bllhehner for her understanding and contrtbutlons to
my education at the then-named Plymouth St.ate College of the University of New Hampshire
(now Plymouth State University).
For the first and second edition information that has endured the journey to the thJrd edi-
tion, a special thanks lingers for the mcredibly helpful radiologists of Pasadena Radiologist
Associates, PA. St. Petersburg, F1orida, for their many years of information (thinking out loud
for me) and support (Ors. Greg Arterburn, Kit Clarke, Ronnie Pollack, and, despite his reluc-
tance to discuss nuclear medicine, Brian Cornnell). Thanks also to Joseph Sutera, Bayfront
Health, and all the teaching teclmologtsts and the many program directors who contributed
ideas and opinions during the development of the first and second editions and the many peo-
ple that helped develop the language translations.
For the third edition, thank you for the considerable contrtbutions from the following:
Jason Cohen (SimonMed Imaging), Heather Whanam (Charlotte Heart and Vascular Institute),
Dr. Jasmin Trunzo Miller (Director of Nuclear Medicine at Keiser University, Lakeland, FL),
Chantel Corbett of Fusion Physics LLC, Harold Cleveland of Cardinal Health, Whitney Green
of PETNET Solutions, Karen Tinker-Emanuel and once again the "Bud-Meister." Thank you
to the many students of Nuclear Medicme Technology and reviewers who contrtbuted ideas to
the first, second, and third editions of this book.
I consider and give thanks to the contrtbuting people and mstitutions that chose to remain
anonymous, to the many physicians, technologists, and nursing staff too numerous to men-
tion at the various mstitutions for their continuing assistance, instruction, suggestions, obser-
vations, and insight. None were forgotten and all very much appreciated. At the risk of defying
professional medical standards, I would like to bring to the attention of the public my appre-
ciation for the editors and staff at Wolters Kluwer publishing company for their extraordinary
support and caring during one of my most dlffi.cult times in life. Their generosity and under-
standing was over and beyond anything expected within the writing community. Thank you.

viii
P1e intention of this book since its inception in 1998 has been to allow access to an amalga-
Uon of protocols from many institutions, technologists, physicians, and written resources.
department has a specific method of obtaining very sllnilar diagnostic llllages and results.
e book serves only as a guide and to provide examples in the performance of the procedures
eluded. The book is rwt intended to be the consummate and quintessential encyclopedia
nuclear medicine but rather a resource to be used for relatively quick access to informa-
on concernmg procedures and related material. The scope of the manual covers the basic
ta needed for most routine llnaging and includes a reference section of peripheral material
tilJzed on a daily basis by many personnel (not only nuclear medicine) within the hospital
d clinic settings. Tables, charts, and data are incorporated that are usually difficult to find
uickly or in any one source bearing in mind that the values given are taken from sources with
ues and ranges that vary greatly from one to another. The information provided is miniscule
comparison to the available amount of material and due to size constraints, must remain
. The hope is that the readers will pursue the references used for more specific information.
stltutional protocols and manufacturer's recommendations should always be followed as
tten when available. If ever there is a question, without question, discuss all related issues
th your radiologist or nuclear physician.

ix
About the Autlwr uU
Acknowl.edgments vtt1
Disclaimer ix

Section One: Procedures

General Nuclear Medicine Imaging
1 . Adl'ellocorti.cal. Scan •.•••••••••••••••••••••••••••••••••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••..•• 3
2. Adrenal Medulla: Pheochromocytoma Scan (mIBG) ............•..•..•..•..•..•..•..•..•..•..•..•..•..•. 8
3. Bone Dens:i.fy ••. ••. ••. ••. •••••••••••••••••••••••••••••••••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. ••. . 14
4. Bone Marrow S'tudy •.•••••••••••••••••••••••••••••••••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.. 20
5. Bone Scan (Skeletal Imagiilg) ................................................................................... 25
6. Brain. Scan/Death (Bram Flow) ................................................................................ 33
7. Brain. SPECT .••.••.••.••.•••••••••••••••••••••••••••••••••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.. 39
8. Cardiac: Gated First-Pass Stu.dy•••••••••••••••••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.••.. 45
9. Cardiac: MUGA. a:nd MUGA-X (Stress MUGA) ........................................................... 50
10. Cardiac: Mycardial Infarction (Ml) Sca:n .................................................................... 56
11 • Cardiac: Resting Test ............................................................................................... 60
12. Cardiac: Stress Test •..•..•..•..............................................................................•..•..•.. 67
13. Cardiac: Sy!npath.etic I:nn.ervation ......................................................................•..•.. 77
14. Cisternography ....•..•..•..•....................................................................................•..•.. 85
15. Cystography (Voiding Cystomethrogram): Direct and Indirect................................... 90
16. DaTscan. (1231 Brain. SPECI1 ...................................................................................... 96
17. Esophageal. Motllity (Transit T'ime) ......................................................................... 103
18. Gallium Scan ......................................................................................................... 108
19. Gastric Empty:tng Stu.dy ......................................................................................... 114
20. Gastroesophageal Reflux ........................................................................................ 123
21. Gastroin.testlnal Bleeding Scan............................................................................... 127
22. HiCla (Hepatobiliary or Gallbladder) Scan ................................................................ 132
23. LeVeen or Den.ver Sllunt Patency............................................................................ 142
24. liver SPECT (Hepatic Hemangtoma) ....................................................................... 146
26. liver/Spleen Scan .................................................................................................. 150
26. L'ung Perfusion....................................................................................................... 157
27. L'ung 'Transmission (a:nd 'I'ransn11ssion ScallS) ••.••.••.••.••.••.••.••.••••.••.••.••.••.••.••.••.••.••. 166
28. L'ungVentilation (Gas and Aerosol) ......................................................................... 170
29. Lymphoscintigraphy .............................................................................................. 176
30. Meckel's Divertl.culum ............................................................................................ 185
31 • OctreoScan® .......................................................................................................... 190
32. Parathyroid Scan ................................................................................................... 197
33. ProstaSctnt® Scan ................................................................................................. 206

x
 Contents xi

34. Renal: Cortical Imaging .............................................................................................. 214

35. Renal: Renogrrun ........................................................................................................ 219
36. Salivary Gland Imaging .............................................................................................. 230
37. Scin.timanunography .................................................................................................. 235
38. SPECT and Hybrid Imaging: An Overview ................................................................... 241
39. Testicular Scan .......................................................................................................... 252
40. Thyroid: Ectopic Tissue Scan ..................................................................................... 257
41 . Thyroid: Scan............................................................................................................. 262
42. Thyroid: Uptake ......................................................................................................... 268
43. Thyroid: Whole Body 131I Cancer Study ....................................................................... 277
44. White Blood Cell Scan (Leucocyte Scin.tigraphy) .......................................................... 283

Positron Emission Tomography

45. Positron Emission Tomography (PE"O: An Overview .................................................... 292
46. PET: Bone Scan-Skeletal Imaging 18F-Sodium F1uortde ............................................. 305
4 7. PET: Brain Imagtng-Anlyloid ..................................................................................... 315
48. PET: Brain Imaging 18F-FDG ....................................................................................... 322
49. PET: Cardiac Perfusion and Viability .......................................................................... 331
50. PET: Inflammation and Infection Imaging With 18F-FDG ............................................. 345
51 . PET: Neuroendocrtne Tumor Imaging with 68Ga-DafATATE ....................................... 354
52. PET: Oncology-Whole Body (Tumor) Imaging With 18F-FDG ....................................... 362
53. PET: Prostate Cancer-Axumin™ ............................................................................... 373
54. PET: Prostate Cancer-68Ga-PSMA ............................................................................. 381

Therapy
55. Therapy: 9 oY-Microspheres ......................................................................................... 390
56. Therapy: 177Lu-PSMA for Prostate Cancer ................................................................... 399
57. Therapy: Bone Palliation ............................................................................................ 406
58. Therapy: Intra-articular (Joint) Inflammation; Synovectomy ....................................... 413
59. Therapy: lntracavitary (Serosal) for Malignant Effusions ............................................. 418
60. Therapy: Lutathera® for Neuroendocrine Tumors ....................................................... 424
61 . Therapy: Polycythemia Vera ....................................................................................... 432
62. Therapy: Thyroid; Ablation ......................................................................................... 437
63. Therapy: Thyroid-Hyperthyroidism ........................................................................... 449
64. Therapy: Xoftgo®-Prostate Cancer ............................................................................. 457
65. Therapy: Zevalin®-RIT-NHL ...................................................................................... 464

Section Two: QUICK REFERENCE

A. Conversion Tables .......................................................................................................... 4 7 4
lb/kg .......................................................................................................................... 475
in/cm ......................................................................................................................... 475
Target Heart Rates (Cardiac Studies) .......................................................................... 476
mCi/MBq ................................................................................................................... 477
Miscellaneous Conversions ......................................................................................... 4 78
B. Radiopharmaceuticals ................................................................................................... 480
Standard Adult Nuclear Medicine Dose Ranges ........................................................... 481
Routine Medical Radionuclides ................................................................................... 484
Common Radioisotopes, Energies, and Decay-at a Glance......................................... 488
Equations................................................................................................................... 490
KI'I' Preparations (Overview) ........................................................................................ 492
Pediatrtc Dosing in Nuclear Medicine .......................................................................... 497
Radioactive Isotopes ................................................................................................... 504
xii Contents

C. Decay Tables of Routine Radionuclides ........................................................................ 530

Cesium-13 7 Decay Table ............................................................................................. 531
Cobalt-57 Decay Table ................................................................................................ 532
Fluortne-18 Decay Table ............................................................................................. 533
Gallium-67 Decay Table ............................................................................................. 534
Gallium-68 Decay Table ............................................................................................. 535
Indium-111 Decay Table ............................................................................................ 536
Iodine-123 Decay Table .............................................................................................. 537
Iodine-131 Decay Table .............................................................................................. 538
Molybdenum-99 Decay Table ...................................................................................... 539
Technetium-99m Decay Table .................................................................................... 540
Thallium-201 Decay Table .......................................................................................... 541
Xenon-133 Decay Table .............................................................................................. 542
D. Standard Drug Interventions ......................................................................................... 543
Calculations, Preparations, and Administration ........................................................... 544
Infusion Rate Tables ................................................................................................... 549
Side Effects of Common Drugs ................................................................................... 558
Drugs and Studies Affecting 1231 and 1311 Uptake .......................................................... 559
Drug Lists: .Ariticoagulants and ACE Inhibitors ........................................................... 562
.Aritacids Affecting Gastric Emptying Studies .............................................................. 564
Pain Medications Encountered in Some Studies.......................................................... 566
CT/MRI Contrast Information: A Primer ..................................................................... 569
E. Laboratory Tests ............................................................................................................ 575
Normal Ranges ........................................................................................................... 576
Enzymes and Hormones ............................................................................................. 583
F. Language Barrier Buster™/lnterpretech™ .................................................................... 587
Chinese ...................................................................................................................... 588
French ....................................................................................................................... 590
German ...................................................................................................................... 593
Italian ........................................................................................................................ 595
Japanese .................................................................................................................... 598
Polish ......................................................................................................................... 599
Portuguese ................................................................................................................. 60 I
Russian ...................................................................................................................... 604
Spanish...................................................................................................................... 606
G. Regulations .................................................................................................................... 610
Medical Event............................................................................................................. 611
Radiation Safety ......................................................................................................... 613
H. Patient Release Methods and Information for Thyroid Therapies ................................ 627
Methods of Patient Release .......................................................................................... 628
Patient Information for Thyroid Therapy (Inpatient) .................................................... 632
Patient Information for Hyperthyroid Therapy (Outpatient) ......................................... 632
I. Patient lfistory Sheets ................................................................................................... 633
Adrenocortlcal (NP59) and mIBG Scans ...................................................................... 634
Bone Scan .................................................................................................................. 635
Brain Scan (SPEC11 .................................................................................................... 636
Cardiac/MUGA Scan Rest/Stress/Redistribution ....................................................... 637
Gallium/Indium/Ceretec® Scan .................................................................................. 638
Gastric Emptying Scan ............................................................................................... 639
GI Bleeding/Meckel's .................................................................................................. 640
HIDAScan ................................................................................................................. 641
Lung Scan (Aerosol) .................................................................................................... 642
Lung Scan (Gas) ......................................................................................................... 643
 Contents xiii

Llver/Spleen Scan ...................................................................................................... 644

Miscellaneous Worksheet ............................................................................................ 645
Octreoscan®, Netspot®, Lutathera® .............................................................................. 646
PE'f Scan (General) ..................................................................................................... 647
ProstaScint®, l 77Lu-PMSA, Xo:figo® ............................................................................ 648
Renal/Renogrrun/Captopril Scan ............................................................................... 649
ScintimamI11ography .................................................................................................. 650
Thyroid Uptake and Scan ........................................................................................... 651
Zevalin® ...................................................................................................................... 653
.J. Abbreviations Commonly Used in Nuclear Medicine .................................................... 654
K. Coding ............................................................................................................................ 677
Nuclear Medicine Imaging CPI' Codes 2019 ................................................................ 678
Radiophannaceutical HCPCS (Healthcare Common Procedure Coding System) ........... 683
L. Anatomical Images ......................................................................................................... 687
Brain.......................................................................................................................... 688
Cardiac System .......................................................................................................... 692
Endocrine System ...................................................................................................... 694
Gastrointestinal System ............................................................................................. 695
Hepatobiliary System.................................................................................................. 697
Lungs ......................................................................................................................... 699
Lymphatic System ...................................................................................................... 700
Miscellaneous Systems ............................................................................................... 701
Renal System ............................................................................................................. 704
Skeletal System .......................................................................................................... 705
Vascular System ......................................................................................................... 709
References .......................................................................................................................... 711
Acknowledgxnent of Trademarks ......................................................................................... 716
The Reality of Practlcing Nuclear Medicine .......................................................................... 720
Index .................................................................................................................................. 721
Proced ures
General Nuclear Medicine Imaging

Positron Emission Tomography

Therapy
 1 • Adrenocortical Scan
2. Adrenal Medulla-Pheochromocytoma Scan (mIBG)
3. Bone Density-Densitometry
4. Bone Marrow Study
5. Bone Scan-skeletal Imaging
6. Brain Scan/Death-Brain Flow
7. Brain SPECT~Single Photon Emission Computed Tomography)
8. Cardiac: Gated First-Pass Study-(First-Transit .Radionuclide Anglocardlography)
9. Cardiac: MUGA and MUGA-X (Stress MUGA)-Equilibrium Radionuclide
Angiography (ERNA)
10. Cardiac: Mycardial Infarction (MI) Scan
11 . Cardiac: Resting Test-(Perfusion)
12. Cardiac: Stress Test~erfusion, Usually With Cardiac Rest Test)
13. Cardiac: Sympathetic Innervation-(1281-mIBG)
14. Cisternography
15. Cystography (Voiding Cystourethrogram): Direct and Indirect
16. DaTsca.n (1231 Brain SPECI'.l
1 7. Esophageal Motility-(T:ransit Time) (Uquid. and Semisolid Meals)
18. Gallium Scan
19. Gastric Empt:y:tng~Solid and Llquid)
20. Gastroesophageal Reflux
21 • Gastrointestinal Bleeding Scan
22. IDDA Scan-(Hepatobiliaiy or Gallbladder Scan) with Ejection Fraction
23. LeVeen or Denver Shunt Patency
24. IJ.ver SPECI'~epatlc Hemangioma)
25. IJ.ver/Spleen Scan-and Hepatic Arterial Perfusion Scintlgraphy (HAPS) Procedure
28. Lung Perfusion-(Usually Performed With Lung Ventilation) and Quantlta.tion
27. Lung Transmission-{and Transmission Imaging)
28. Lung Ventila~ and Aerosol (Usually Performed With Lung Perfusion)
29. Lymphoscintigraphy-(Lymphangtogram)
30. Meckel's Diverticulum
31 . OcfJ:'eoScan<D-Neuroendocrine Somatosta.tin Tum.or Imaging
32. Parathyroid Scan~Dual-Isotope Subtraction Technique and Single-Isotope Single
and 1\vo-Phase)
33. Prosta.Scint<rl Scan--{Radioimmunosclntigraphy (RISJ)
34. Renal: Cortical Imagtng-(99DTc-DMSA)
36. Renal: Renograrn-(Diurettc, and Captopril, Tubular Function, Effective Renal
Plasma Flow, and Glomerular Filtration Rate)
38. Salivary Gland Imaging
37. Sctnttmammography~reast Imaging)
38. SPECT Imaging: An Overview-(Single Photon Emission Computed Tomography)
39. Testicular Scan-(Scrotal Imaging)
40. Thyroid: Ectopic Tissue Scan~Substernal)
41. Thyroid: Scan-(Usually in Conjunction Wlth Thyroid Uptake)
42. Thyroid: Uptake-(Usually in Conjunction With Thyroid Scan)
43. Thyroid: Whole Body 1311 Cancer Study-(and rh1SH Augmentation)
44. White Blood Cell Scan-{111In-oxime and 99mTc-HMPAO Leukocyte Sctntlgraphy)

2
HHHH ~
drenocortical Scan
ADIOPHARMACY

adionuclide Quality Control

1311 t : 8.1 days
112
Energies: 364 keV
fype: ~, y. fission product
adiopharmaceutical
is1J-6-JHodomethyl-19-norcholesterol
(NP-59 or 1311-lodocholesterol). Available
for t.magtng since 1975 and, last lmawn,
remains under an Investtgational New
Drug (IND) application.
ocalization
Compartmental, blood flow, into the
adrenal cortex, bound to and transported
by plasma low-density lipoproteins.
Taken up by low-density lipoprotein
receptors on adrenocortical cells.
Cholesterol is the main precursor in the
production of adrenocortical steroid; NP-
59 is a cholesterol analogue.
• Done at factory, NP-59>90%.
• Assay dosage in dose calibrator for activify.
Adult Dose Range
• 2 mCl (74 MBq).
• Some rccomm.cnd 1.0 mC1 (37 MBq) per
1.73 m 2 body surface area.
Method of Administration
• Intravenous slow injection over
2-3 minutes.
• Observe patient for 30 minutes after
injection for reaction to injection.
• Injection may be required to be
performed by a physician as per
institution protocol.

NDICATIONS
Detection and localization of adrenal glands.
Evaluation of documented primary hyperaldostcronism (PA).
Differentiation in PA between aldosterone-produclng adenoma (APA or Conn syndrome)
and bilateral adrenal hyperplasia (BAH).
Detection and localization of abnormal adrenal function in adrenocorticotroplc hormone
(ACT'H}-independent Cushing syndrome.
Detection and localization of adrenal incidental.omas.
Evaluation of adrenal lesions visualized on other imaging techniques.
3
4 SECTION 1 Procedures

• Evaluation of virilization and/or amenorrhea secondaiy to suspected adrenal hyperandrogenism.

• Evaluation for biopsy or surgical intervention.

CONTRAINDICATIONS
• Allergy to iodine may be a consideration, although doses are small.
• Patient taking interfering medications.
• Pregnancy or nursing. Follow institutional guidelines.

PATIENT PREPARATION

Before Day of Injection

• Physician instructs the patient to take SSKI (saturated solution potassium iodide) or Lugol
solution to block free iodine uptake in thyroid. This is administered I drop, t.i.d., beginning
the day before radiotracer administration and continuing for I 0 days after injection. If there
is an allergy to iodine, perchlorate may be used.
• Physician instructs the patient to take bisacodyl (e.g., Dulcolax®) 10 mg orally (PO),
b.1.d. x 3 days before imaging, to reduce bowel activity. Patient may be required to take
laxatives and/or enemas on afternoons before imaging days; check with radiologist.
• Physician instructs patients with atopic history (genetic disposition to hypersensitivity or
allergy to medications such as iodine or steroids) to be treated with oral antihistamine (e.g.,
BenadrylQ!I 50 mg) 1 hour before injection of radiotracer.

Day of Injection
• Identify the patient. Verify the doctor's order. Explain the procedure.
• Obtain signed consent from the patient and a prescription for the iodine.
• Ensure that the patient is not taking the following drugs: steroids, antlhypertensives,
reserpine, tricyclic antidepressants, sympathomimetics (adrenergic, stimulates release of
epinephrine), and diuretics as per physician's order.

EQUIPMENT

Camera
• Large field of view

Collimator
• Medium or high energy, parallel hole

Computer Setup
Statics
131
• 1: 50,000 to 100,000 counts or up to 20 min/image, 10%-20% window at 364 keV

Single Photon Emission Computed Tomography (SPECTJ or SPECT/CT

• 360°, 64 stops at 20 sec/stop, step and shoot or continuous

PROCEDURE {TIME: -45 MIN/SESSION)

Single Isotope: NP-59

• Begin imaging 5 days (120 hours) after injection, followed by images on day 6 and 7 if required.
• Place the patient in supine position, with camera posterior and the kidneys centered (.... 12th rib).
 CHAPTER 1 Adrenocortical Scan 5

• Collect statics to at least 100,000 counts or 5-20 minutes each.

• Obtain lateral and posterior views with markers along the spine on one of the imaging days
to allow for determination of depth of each adrenal gland (5 µCi 131 I capsule or store injection
syringe for markers until imaging is done).
• Record percent uptake using regions of interest (ROls) for counts and correcting for depth
differences. (Some processing systems have this software.]
• Determine whether SPECT images need to be taken. Check with radiologist.

Dual Isotope: NP-59 and 99mTc-DTPA

• Begin imaging 48 hours after injection and repeat at 2- to 3-day intervals until results are
satisfactory.
• Place the patient in supine position, with camera posterior and renal area centered.
• Collect 131 I images up to 20 minutes (1200 seconds].
• Change energy window; without moving the patient, inject 5 mCi 9 9m'fc-DTPA
(diethylenetriarninepentaacetic acid] and collect 500,000-1,000,000 counts for subtraction
image (computer protocol].
• Proceed with anterior views of the chest and abdomen if the adrenals are not visualized.

Procedure for Adrenocortical Scan With Suppression

• 1bis scan differentiates bilateral hyperplasia from adenoma in hyperaldosteronisrn and
hyperandrogenism. Unilateral visualization indicates adenoma. Bilateral visualization
is indicative of hyperplasia. Dexarnethasone suppresses pituitary ACIH secretion, thus
embellishing NP-59 uptake into the ACIH-independent zona glomerulosa, while inhibiting NP-
59 uptake into the ACIH-dependent zona fasciculata-reticularis including the ACIH-dependent,
glucocortlcoid-productng part of the adrenal cortex. 1bis prevents the masking of uptake by the
zona glomerulosa of the adrenal cortex, which is responsible for aldosterone production.
• Patient preparation is the same. Administer 2-4 mg dexamethasone b.i.d. beginning
2-7 days before injection of nuclide and continuing until completion of the study.
• Scan using same procedures; however, begin imaging 24-48 hours after injection.

Procedure for Adrenocortical Scan With ACTH Augmentation

• Patient preparation is the same. Administer 50 IU of ACTH IV daily beginning 2 days before
radiotracer injection.
• Scan using single isotope or dual isotope procedures.

NORMAL RESULTS
• Visualization of both adrenal glands with the right slightly superior to the left.
• On posterior trnage, most normal patients present with the right adrenal gland showing
greater intensity than the left because of the difference in depth and because the left adrenal
gland is partially shielded by the kidney.
• Liver and gallbladder present brightly. If there is interference, laterals or SPECT can help
localize. A fatty meal or cholecystokinin can also diminish the activity in the gallbladder.
• Colon may also visualize. Cathartics can be used to reduce colon activity.
• Dexamethasone will suppress about 50% of adrenal uptake of NP-59 that is ACTH
dependent. These studies will show only faint visualization or bilateral nonvisualization by
day 5. Imaging may be discontinued after the 24- or 48-hour studies.

ABNORMAL RESULTS
• In the nonsuppression study, faint visualization or nonvisualizatlon (usually bilateral)
indicates adrenal carcinoma.
• Asymmetric, bilateral, intense uptake suggests autonomous, ACTH-independent cortical
nodular hyperplasia.
6 SECTION 1 Procedures

• Cushing syndrome produces BAH causing bilateral visual uptake ofNP-59.

• Unilateral, intense uptake in the presence of known Cushing syndrome is highly suggestive
of adrenal cortical adenoma.
• No uptake bilaterally in the presence of known Cushing syndrome is suggestive of carcinoma.
• In primary aldosteronism, bilateral symmetrical early visualization indicates BAH, unilateral
early visualization indicates aldosterone-secreting adenoma (Conn tumor or APA), and
bilateral late visualization or nonvisualization is usually nondiagnostic.
• Incidentally discovered (nonhyperfunctioning) adrenal mass lesion, with increased uptake on
the same side, indicates benign nonhyperfunctioning adenoma; reduced uptake indicates a
malignant lesion or infarction.
• In the suppression study, failure to suppress uptake with dexamethasone indicates adenoma
if unilateral and hyperplasia if bilateral.
• In androgen excess (hyperandrogenism), also done with suppression, bilateral early
visualization indicates BAH and unilateral early visualization indicates adrenal adenoma.
'Ibis syndrome occurs secondary to polycystic ovarian disease and is also produced by
primary adrenal cortical (zona reticularts) hyperplasia but rarely by adrenal tumors.

ARTIFACTS
• Attenuating articles in clothing.
• Images not taken for enough counts.
• Focal areas of interest usually linger over time and grow in intensity. False-positive results
can be limited by delayed images and lateral views.
• Bilateral uptake in patients with unilateral disease-spironolactone and other diuretics.
• Early bilateral uptake in patients with no disease or unilateral disease----oral contraceptives.
May occur even with dexamethasone suppression.

NOTE
• The adrenal cortex makes up about 90% of the adrenal gland. It contains three zones: (l) The
zona glomerulosa, which is the outermost, produces aldosterone, the principal mineralocortlcoid
hormone. (2) The zona fasciculata produces cortisol, the principal glucocorticoid hormone. (3)
The zona reticularis produces androgenic steroids, principally androstenedione.
• The adrenal medulla secretes the catecholamines epinephrine and norepinephrine.
• Secretion from the adrenal cortex is controlled by AC1H from the anterior pituitary. The
exception is aldosterone from the zona glomerulosa, which is controlled by angiotensin
II, blood volume, and electrolyte concentrations. Cholesterol is stored in the cortex as the
metabolic precursor for the synthesis of adrenocorticosteroids, e.g., aldosterone. NP-59 uses
the s1milarity to cholesterol for uptake into the cortex. Increased AC1H increases the uptake,
occurring gradually over a period of days.
• Adrenal venous sampling (AVS) is considered the standard of reference for determining the
cause of primary aldosteronism. AVS is technically difficult particularly in cannulation of the
right adrenal vein which directly drains into the inferior vena cava.

PATIENT HISTORY
The patient should answer the following questions. (Or use complete patient history in reference section.)
Do you have a history of hypertension or hypotension? y N
Do you have a history or family history of cancer? y N
Have you had any recent weight gain? y N
Have you experienced hirsutism (abnormal hair growth)? y N
 CHAPTER 1 Adrenocortical Scan 7

Have you had any chemotherapy or radiation therapy? y N

Have you had any recent examinations such as computed tomography (CT). ultrasonography (US), or y N
magnetic resonance imaging (MRI)?
If so, when and what facility?
What medications are you currently taking?
Have you had any recent blood or laboratory work done (of interest will be cholesterol levels, ACTH. y N
aldosterone, catecholamines and metabolites, plasma renin activity, blood sugar)?
Female patients:
Are you pregnant or nursing? y N
When was your last menstrual period?
Have you experienced amenorrhea (suppression of menstruation)? y N
Other department-spe<:ific questions:

STUDENTS
Explain the relevancy of each of the above patient history questions to this particular scan.
Can you think of others that would be helpful for the interpretation of this type of study?

SUGGESTED READINGS
Chan HF. Chen LF. Use ofNP-59 (1311-iodocholesterol) scan as a potential alternative to adrenal venous sampling in
the :Investigation of pr:lmaly aldosteronlsm: a 5-year retrospective study. Hong KDng J Radio{. 2014: 17(3).
Datz FL. Handbook ofNudear MedJ.dne. 2nd ed. St. Louis: Mosby; 1993.
Early PJ, Sodee DB. Prlru::qiles and Practtce ofNuclear Medldne. 2nd ed. St. Louis: Mosby; 1995.
Kowalsky RJ, Falen SW. Radtophannaceuttcals t.n Nuclear Pharmacy and Nuclear Medtctne. 2nd ed. Wash1ngton. DC:
American Pharmacists Association; 2004.
Mettler FAJr, Guiberteau MJ. Essenttals qfN~ Medicine Imaging. 6th ed. Pbiladelph!a. PA: Elsevier-Saunders: 2012.
Murray JPC. Ell PJ. eds. Nudear Medidne in CUnlcal.Dtagnos(s and Treatment. Vols 1 and 2. New York: Churchlll
I.Mngstone, 1994.
Wilson MA. Textbook ofNuclear Medldne. Philadelphia: Upplncott-Raven; 1998.

NOTES
 ~HArTfR

Adrenal Medulla
Pheochromocytoma Scan (mlBG

RADIO PHARMACY

Radionuclide norepinephrlne into the chromafftn cells

1231 t
of the adrenergic tissue and stored in
• 112: 13.2 hours adrenergic granules.
Energies: 159 keV
Type: EC. y, accelerator Quality Control
• or 1311 t 112: 8.1 days
Energies: 364 keV • 1231- and ts•1-m1BG > 90%
Type: ~-, y, fission product
Adult Dose Range
Radiopharmaceutical •
181
1: 500 (J.Ci (18.5 :MBq), l mCi
•
125
1- or 1511-mIBG (-met.a- (37 MBq) for suspected metastatic
iodobenzylguanidine). Both pheochromocytoma
123
pharmaceuticals, 1231-lobenguane and • 1: 3-15 mCi (111-555 MBq)
1s 11-1obenguane, are FDA (U.S. Food

and Drug Administration) approved. Method of Administration

Also known as iobenguane sulfate or • Intravenously injected slowly over
AdreView™. 5 minutes, if possible followed by a 10
saline flush.
Localization
• Blood flow, guanethidine analogue
absorbed. much the same as

INDICATIONS
• Detection and localization of benign and malignant intra-adrenal and extra-adrenal
pheochromocytomas (usually benign chromaffln cell tumors of the sympathoadrenal
system that produce and secrete catecholamines, e.g., norepinephrlne and epinephrine,
producing hypertension and orthostatlc [standing] hypotenslon). These occur within the

8
 CHAPTER 2 Adrenal Medulla 9

adrenal medulla and are frequently associated with hereditary multiple endocrine neoplasia
(MEN) types 2A and 2B, neuroftbromatosis, von Hippel-Lindau disease, Carney triad, and
familial pheochromocyt.oma.
• Localization of site(s) of hormonal overproduction.
• Detection and localization of neuroectodermal (nerve tissue) tumors.
• Detection and localization of neuroblastomas [malignant hemorrhagic tumors of cells
resembling neuroblasts of the sympathetic system, especially the adrenal medulla, and
usually occurring in childhood).
• Detection and localization of other neuroendocrine tumors that share the property of amine
precursor uptake in decarboxylation (APUD), such as
• Carcinoid (argentaffin cells of the intestinal tract, bile ducts, pancreas, bronchus, or ovary
that secrete serotonin) tumors
• Medullary thyroid tumors
• Paragangliomas (tumors of the adrenal medulla, chromaffin cells, and the paraganglia)
• Merkel cell skin tumors
• Chemodectomas (tumors of the chemoreceptor system)
• Small cell lung carcinoma
• Schwannoma
• Evaluation of myocardial norepinephrine receptors.
• Distinguishing neuroendocrine tumors from nonneuroendocrtne tumors.
• Detection and localization of metastatic deposits from previously diagnosed
pheochromocytoma.
• Staging of the disease.
• Evaluation of chemotherapy and to exclude subclintcal relapse in bone marrow or bone pain.
• Evaluation of surgery.

CONTRAINDICATIONS
• Allergy to iodine may be a consideration, although doses are small.
• Patient taking interfering medications.
• Pregnancy or nursing. Follow institutional guidelines.

PATIENT PREPARATION

Before Day of Injection

• Three days prior to injection, physician may (if applicable) instruct patient to discontinue
the use of certain medications including trtcyclic antidepressants, anti.hypertensives,
cocaine products, sympathomimetics, and decongestants containing pseudoephedrine,
phenylpropanolamine and phenylephrtne.
• Physician instructs the patient to take SSKI (saturated solution potassium iodide) or Lugol
solution to block free iodine uptake in thyroid. This is administered 1 drop, t.i.d., beginning
the day before radiotracer administration and continuing for 6 days after injection. If there is
an allergy to iodine, perchlorate may be used.
• Physician instructs the patient to take bisacodyl (e.g., Dulco~ 10 mg PO, b.i.d. x 3 days
before imaging, to reduce bowel activity. Patient may be required to take laxatives and/or
enemas on afternoons before imaging days; check with radiologist.
• Physician instructs patients with atopic history (genetic disposition to hypersensitivity or
allergy to medications such as iodine or steroids) to be treated with an oral antihistamine
(e.g., Benadcyl® 50 mg) 1 hour before injection ofradiotracer.

Days of Injection
• Identify the patient. Verify doctor's order. Explain the procedure.
• Obtain signed consent from patient and a prescription for the iodine.
10 SECTION 1 Procedures

• Ensure that the patient is not taking the following drugs: steroids, antihypertensives,
reserpine, tricycllc antidepressants, sympathomimetics (adrenergic, stimulates release of
epinephrine),and diuretics as per physician's order. Ideally, no medications for 2-3 weeks
before the examination (see Drugs to Withhold).

EQUIPMENT

Camera
• Large field of view

Collimator
131
• 1: High energy, general purpose, or high energy, high resolution
• 1: Low energy, all purpose, or low energy, high resolution
123

Computer Setup
Statics
131
• 1: 100,000 counts or 10 to 20 mill/image, 20% window at 364 keV, 512 x 512 or
256 x 256 matrix
• 123!: 500,000 counts or 10 to 20 min/image, 20% window at 159 keV, 512 x 512 or

256 x 256 matrix

Whole Body
• 5--10 cm/min, image at least head to pelvis, same setup

Single Photon Emission Computed Tomography ISPECTJ or SPECT/CT

• 360°, 120 or 60 stops at 25-45 sec/stop, 1311: 20% window at 364 keV, 1231: 20% window at
159 keV, 128 x 128 or 64 x 64 matrix, step and shoot or continuous, circular or noncircular
orbit.

PROCEDURE {TIME: -30-60 MIN/SESSION)

• Ensure patient is off medications and has taken thyroid blocker the night before.
• Instruct patient to empty the bladder.
• Place patient in supine position.

131
1-mlBG: Images at 24, 48, and Possibly 72 Hours
• Acquire anterior/posterior images of the head/neck, thorax, abdomen, and pelvis.
• Set whole-body sweep slow (10 cm/minor less).
• Acquire static images of areas of interest if preferred or protocol. Statics should run at least
100,000 counts or 5-20 minutes.
• Acquire lateral views of abnormal uptake to aid in localization.
• Acquire marker images if protocol (on axillae, lower ribs, and iliac crests). Use 5 µCi 1811
capsule or perhaps store injection syringe for markers until imaging is done.
• Acquire SPECT images if protocol or requested.

123
1-mlBG: Images at 24 Hours, 40 Hours, and Possibly 72 Hours
• Same imaging procedures as above.
• Acquire statics of at least 500 k counts or 15 minutes each.
• Statics should at least include the chest, posterior mid-thorax, kidneys centered, and
lumbar.
 CHAPTER 2 Adrenal Medulla 11

■ Whole-body sweep at 10 cm/min or less, anterior/posterior, head to pelvis.

■ SPECT images at 45-60 sec/stop.

NORMAL RESULTS
■ Uptake occurs in the pituitary, salivary glands, thyroid, liver, and spleen.
■ The gallbladder will be visualized in patients with renal failure.
■ The kidneys and bladder will visualize because of the renal excretion.
■ The heart is visualized in patients with normal catecholamine levels.
■ Diffuse lung activity and nasal, neck muscle, and bowel activity may present in some
patients.
■ The normal adrenal medulla seldom visualizes (30%-40% on delayed images) and is of low
intensity.
■ The heart and adrenal medulla are visualized more clearly with 1231-mlBG.
■ There should be no skeletal uptake.
■ Areas of normal uptake diminish in intensity over time.

ABNORMAL RESULTS

■ Focal areas of increased activity that increase more over time oocur.
■ Sporadic, unilateral tumors show focal intense uptake.
■ Metastatic disease is visualized in the axial skeleton, heart, lung, mediastinum, lymph
nodes, and liver.
■ Neuroblastomas may arise in any location of sympathetic nervous system tissue but most
often are visualized as an abdominal mass, metastasizing early to bone and bone marrow.
■ Images at 72 hours will provide maximal contrast between foci of activity and background.
■ Localizes in pheochromocytoma, neuroblastoma, and also carcinoid, medullary thyroid
carcinoma, and paraganglioma.

ARTIFACTS

■ Attenuating articles in clothing.

■ Images not taken for enough eounts.
■ Aggressive chemotherapy may hinder the visualization of some metastasis.
■ False-positive results may be caused by recent surgical sites, x-ray therapy to the lungs, and
bleomycin-induce pul onary changes.
■ False-negatives can Be due to lesions too close to large primary or metastatic mass or
tissue with high normal uptake. No or low tumor uptake related to tumor heterogeneity,
ischemic necrosis in tumor mass, lack of granules, loss of tumor capacity to absorb tracer,
or pharmaceutical inhibition.
■ Focal areas of interest usually linger over time and grow in intensity. Limit false-positive
results by delayed images (with obliques and laterals).
■ Because of the nature of the disease and because they are off medications, patients may be
agitated and not lie still.

DRUGS TO WITHHOLD (IDEALLY, NO MEDICATIONS

2-3 WEEKS BEFORE THE EXAMINATION)

For 3 Weeks (Affect Reuptake Mechanism Presenting With Absence of Uptake by

the Salivary Glands and Heart and May Inhibit Uptake in Pheochromocytoma)
■ Tricyclic antidepressants: e.g., reserpine
■ Sympathomimetics: e.g., dobutamine, dopamine, norepinephrine
12 SECTION 1 Procedures

For 2 Weeks (Affect Depletion of Storage Vesicle)

• Amphetamines
• Angiotensin-converting enzyme (ACE) inhibitors (captopril, enalapril)
• Angiotensin receptor blockers (ARBs) (irbesartan, valsartan)
• Bretyllum tosylate
• Calcium channel blockers (nifedipine, nicardipine, amlodipine)
• Cocaine
• D:lgoxin
• Fenoterol
• Guanethidine
• Halopertdol
• Imipramine
• Insulin
• Phenothiazine
• Pseudoephedrine (nasal decongestants)
• Phenylpropanolamine (diet-control drugs)
• Phenylephrtne (nasal decongestants)
• Salbutamol
• Terbutaline
• Thiothixene
• Xylometazoline
Alpha- and beta-adrenergic blocking drugs will not affect study with the exception of labetalol
(affects both reuptake and storage depletion).

NOTE
• mIBG is similar to the catecholamine norepinephrine. Epinephrine and norepinephrine
are hormones that regulate smooth muscle tone, heart rate and force of contraction,
and physiologic responses associated with stress. Pheochromocytomas produce excess
amounts of these hormones resulting in hypertension and other symptoms associated with
overabundance of catecholamines.
• Renal and skeletal imaging with 99m'fc agents can be used in conjunction with this test to aid
in localization. Their injections can be timed for optimal scan times at the 24- or 48-hour
images with two sets of images taken by changing the energy windows to suit the radiotracer.

PATIENT HISTORY
The patient should answer the following questions. (Or use complete patient history in reference section.)
Do you have a history or family history of cancer? y N
If so, what type and for how long?
Do you have a history of hypertension or hypotension? y N
Do you have palpitations? y N
Have you felt anxiety or apprehension? y N
Have you experienced excessive diaphoresis (sweating)? y N
Do you have headaches? y N
Have you experienced a flushed face? y N
Do you experience nausea or vomiting? y N
 CHAPTER 2 Adrenal Medulla 13

Have you experienced tingling of extremities? y N

Are you taking oral contraceptives? y N
Have you had any recent surgery? y N
If so. where and when?
Have you had any chemotherapy or radiation therapy? y N
Are there any recent or planned positron emission tomography (PET). computed tomography (CT). y N
ultrasonography (US). magnetic resonance imaging (MRI}. or nuclear medicine (NM) scans?
What medications are you taking?
Have you had any recent laboratory reports {with attention to adrenocorticotropic hormone. y N
aldosterone, catecholamines. and metabolites. Na. I()?
Female: Are you pregnant or nursing? y N
Other department-specific questions:

STUDENTS
Explain. the relevancy of each of the above patient histoiy questions to this particular scan.
Can you think of others that would be helpful for the interpretation of this type of study?

SUGGESTED READINGS
Datz FL. Handbook ofNudear Medlcine. 2nd ed. St. Louts: Moaby; 1993.
Early PJ, Sodee DB. Prlndp1.es and Practtt:e ofNudslr Medldne. 2nd ed. St. Louts: Mosby; 1995.
FaITcll MB, Mantel ES, Basso DA. et al. (}ulck-R.eference Protocol Mwwalfar Nudslr Medlctne Technolagfsts. Reston, VA:.
Society of Nuclear Medicine and Molecular Imaging; 2014.
https:/ /www.iDs!deradiology.eom.au/mibg-scan/.
Kowalsky RJ. Falen SW. Radtopharmaceut tnNuclear Pharmacy and Nuclear Medictne. 2nd ed. Wasbington. DC:
American Pharmacists Assodation; 2004.
Mettler FA Jr. Guiberteau MJ. Essen1tals of Nudssr Mer1Jcln£ Imaging. 6th ed. Phfladelpb!a. PA: Elsevier-&wnders; 2012.
MUITa,Y IPC, Ell PJ, eds. Nudea.r Medldne in CUnlcal Dlagnosfs and Treatment. Vole 1 and 2. New York: Churchill
!Jvingstone; 1994.
Saha GB. l'\uu:famentals ofNuclear Pharmacy. 7th ed. Cham, Switzerland: Springer Intemattcmal Publishing AG; 2018.
Weissleder R. Rieumont MJ, Wlttenberg J. Prtmer ofDtagnostie Imaging. 2nd ed. St. Louis: Mosby; 1997.
Wilson MA. T~k ofNuclear Medictne. Philadelphia: Lippincott-Raven: 1998.

NOTES
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