Positron emission

tomography
(PET)
 PET fundamentals

1 – Radionuclides emitting positrons – „electrons with

positive electrical charge” are used.
Positrons (e+ or ß+ particles) are produced as a result
of a ß+ decay:

p+ n + e+ + v
2 – A positron particle (e+), after scattering in
a tissue, annihilates with an electron (both
particles disappear) and as a result 2 gamma
rays arise, every one of 511 KeV energy
(masses of particles are changed to gamma
quanta energies). Both photons escape in
opposite directions.
3 – Two gamma rays are registered in detectors located
on opposite sides of a patient and connected with a
coincidence system, which passes only 2 rays coming
simultaneusly.

Detector
Coincidence 2 gamma
system rays

Detector
 Coincidence

Scintillation cristals
Radionuclides applied in PET studies

Radionuclide T½ Radiopharmaceutical

Fluor 18
F 109.7 min 18
FDG

Oxygen 15
O 2.07 min H215O
Nitrogen 13
N 9.97 min 13
NH3
Carbon 11
C 20.3 min 11
C-fatty acids,
aminoacids
Rubidium 82
Rb 1.25 min
Cuprum 62
Cu 9.8 min
 Parameters determined in PET studies
Metabolism of:
• glucose
• fatty acids
• aminoacids

Perfusion/blood flow
• regional tissue perfusion
• regional tissue blood flow (ml/min)

Expression of cellular receptors

 Usefulness of PET studies in
oncology

• Detection of neoplastic lesions

(e.g.differentiation between malignant and
benign lesions)
• Staging – detection of metastases
• Assessment of malignancy grade
• Detection of neoplastic recurrence.
• Evaluation of therapy effectiveness (e.g.
differentiation between malignant tissue and
scar or necrosis after chemo- or
radiotherapy).
 18
FDG
• Competes with serum glucose for
accumulation
• Tumors have increased concentrations
of glucose transporter proteins and/or
hexokinase enzymes
Normal
biodistribution
of FDG

Brain / Kidneys / Heart

Clinical usefulness in cardiology
18
FDG, 13NH3, 82Rb

Assessment of:
• mycardial viability
• myocardial perfusion
• effects of revascularisation
Clinical usefulness in neurology
18
FDG, H215O, 15O2, 13NH3

• Differential diagnosis of dementia (e.g. in early

Alzheimer’s disease).
• epilepsia – preoperative assessment of epileptic
foci
• Diagnosis of Parkinson’s disease
• stroke –assessment of metabolism
 Image fusion

Superposition of anatomical (CT or MR) and functional

(PET) images enables precise localisation of neoplastic
lesions and differentiation between physiological and
pathological uptake of radiopharmaceutical.
PET in configuration with CT or MR is at present the
most promising diagnostic imaging method.
 Practical applications of PET

• Oncological diagnostics - ab. 95% of all

studies

• Myocardial viability and other studies -

remaining 5%
Nuclear medicine diagnostics in diseases of digestive system

Basic diagnostic methods:

 scintigraphy of salivary glands
 scintigraphy of liver (and spleen)
 scintigraphy of blood pool in the liver
 dynamic scintigraphy of the hepatobiliary system
(cholescintigraphy)
 hepatic clearance determination
 scintigraphic investigation of the esophageal and gastric motility
(transport function)
 scintigraphic detection of intestinal bleeding.
Scintigraphy of salivary glands

Radiopharmaceutical:
99m
Tc-pertechnetate

Clinical applications:
1. Suspected neoplasm of a salivary gland.
2. Acute and chronic inflammatory diseases of salivary glands.
3. Patency impairment of salivary ducts.
4. Suspected Sjogren syndrome.
Static scintigraphy of liver (and spleen)

Radiopharmaceuticals:
Tc-colloid (particle diameter 0.3-1 micrometer)
99m

Clinical applications:
1. Suspected tumour of the liver (primary or metastatic).
2. Diffuse damage of the liver parenchyma, e.g. cirrhosis.
3. Suspected rupture, infarct or diffuse dysfunction of the spleen.
4. Localization of supranumerical spleen(s).
Scintigraphy of blood pool in liver.

Radiopharmaceutical:
Tc-labelled erythrocytes (patients own erythrocytes labeled in vivo).
99m

Clinical applications:
1. Suspected haemangioma of the liver, differentiation of the latter
from the metastatic tumour.
Dynamic scintigraphy of the hepatobiliary system (cholescintigraphy)

Radiopharmaceuticals:
Derivatives of iminodiacetic acids labeled with 99m
Tc (e.g. 99mTc-Hepida,
99m
Tc-Mebrophenin)

Clinical applications:
1. Obturations in the biliary system.
2. Differentiation of parenchymal from the mechanical (obturatory) jaundice.
3. Suspected acute cholecystitis
4. Suspected penetration of gall into the peritoneal space.
5. Dyskinesis of the biliary system.
6. Inborn malformations of biliary routes.
7. Suspected duodenal-gastric reflux of gall.
Hepatic clearance determination

Radiopharmaceutical:
99m
Tc-Hepida

Clinical applications:
Assessment of liver parenchyma secretory/excretory
performance.
Scintigraphic investigation of the esophageal and gastric motility

Radiopharmaceuticals:
Tc-DTPA
99m

Tc-colloid (administered orally in a small volume of fluid).

99m

Clinical applications:
Early detection of motility impairment - primary (e.g. achalasia) or
secondary (e.g. in sclerodermia, diabetic enteropathy).
Radionuclide detection of intestinal bleeding.

Radiopharmaceuticals:
Tc labeled erythrocytes
99m

Tc colloid
99m

Tc-DTPA
99m

Clinical applications:
Detection of intestinal bleeding foci (e.g. Meckel diverticulum).
 Diagnostic nuclear medicine in diseases of the heart
and circulatory system.

Basic diagnostic methods:

 myocardial perfusion imaging
 radionuclide angiocardiography – gated blood pool imaging
 radionuclide angiocardiography – the first pass imaging
 perfusion scintigraphy of leg muscles

Others:
 nuclear imaging of myocardial necrosis
 nuclear imaging of sympathetic innervation of the myocardium
 nuclear imaging of blood flow and metabolism of glucose or fatty acids in
myocardium
 thromboscintigraphy
 lymphoscintigraphy of lower extremities
Myocardial heart perfusion imaging

mechanism of the uptake by

Radiopharmaceutical myocytes (proportional to the
perfusion rate)

Radio thallium 201Tl chloride active transport via cellular

membranes – the transport system
by the sodium-potassium ATPase

Complex of radiotechnetium (99mTc) passive diffusion via cellular and

with metoxyisobuthyl (99mTc-MIBI) mitochondrial membranes –
accumulation proportional to
electrical membrane potential

Complex of radiotechnetium with passive diffusion via cellular

phosphine ((99mTc-tetrophosmin) membrane upon its electrical
potential
Myocardial heart perfusion imaging

Clinical applications:
1. Detection of coronary disease.
2. Evaluation of therapeutic effects of the acute infarct therapy.
3. Assessment of perfusion defects after the previous infarct.
4. Prognosing in the coronary disease.
5. Evaluation of the effectiveness of intravascular angioplasty or
surgical revascularization.
6. Evaluation of viability of myocardium.
7. Assessment of the effect of coronary artery stenosis on myocardial
perfusion.
Radionuclide angiocardiography – gated blood pool imaging.

Radiopharmaceutical:
Tc labeled erythrocytes (labeling in vivo) in circulation.
99m

Clinical applications:
1. Diagnostics of coronary disease.
2. Diagnosis of the cardiac aneurysm.
3. Monitoring of the functional state of the left ventricle.
4. Precise assessment of left ventricular function prior to surgical
intervention.
Radionuclide angiocardiography - first pass nuclear imaging

Radiopharmaceuticals:
Tc-pertechnetate,
99m

Tc-ethylenedicysteine (EC).
99m

Clinical applications:
1. Diagnostics of pathological shunts.
2. Assessment of heart ventricles contractility.
Perfusion scintigraphy of leg muscles

Radiopharmaceuticals:
TlCl
201

99m
Tc-MIBI

Clinical applications:
1. Diagnosis of lower extremities ischemia.
2. Assessment of the effectiveness of surgical therapy applied to
obturatory atherosclerosis (lower extremities).
Nuclear medicine diagnostics in diseases of the urinary system

Basic methods:

Dynamic scintigraphy of the urinary system (renoscintigraphy)

Static renal scintigraphy

Radionuclide cystography.

Determination of renal clearances (non-imaging method)

Dynamic scintigraphy of the urinary system (renoscintigraphy)

Radiopharmaceuticals:

• 99m
Tc-DTPA (diethylene triaminepentacetic acid) – leaves the
circulatory system only by renal glomerular filtration,

• I-hippuran (OIH-orthoiodohippuric acid) - leaves the circulatory

131/123

system both by glomerular filtration and active secretion in the proximal

part of nephrons,

• 99m
Tc-EC (ethylenedicysteine) – leaves the circulatory system by
glomerular filtration and by active secretion in nephrons.

• 99m
Tc-MAG3 (mercaptoacethyltriglycine) – leaves the circulatory system
only by means of active secretion in nephrons.
 Dynamic scintigraphy of the urinary system (renoscintigraphy)

Clinical applications:
• Differentiation of nephrogenic from essential hypertension.
• Evaluation of renovascular hypertension
• Diagnostics of obturatory uro- and nephropathy.
• Evaluation of renal “damage” caused by diseases and
malformations of kidneys and excretory parts of the urinary
system.
• Functional evaluation of the transplanted kidney.
• Determination of functional capacity of the urinary system, both
as a whole and by using data from dynamic studies, of each
kidney separately.
Static renal scintigraphy

Radiopharmaceuticals:
Tc-DMSA (dimercaptosuccinic acid) – taken up and cumulated
99m

in the renal cortex.

Clinical applications:
1. Detection of renal scars.
2. Differentiation between pseudotumours and neoplastic tumours
of kidneys.
Radionuclide cystography

Radiopharmaceuticals:
Tc-DTPA or similar substances (see above)
99m

Clinical applications:
Diagnostics of urinary vesco-ureteric refluxes
Determination of renal clearances (non-imaging method)
Radiopharmaceuticals used for renoscintigraphy
and kidney clearance determination

• 99m
Tc-DTPA  RS + ~GFR
• 99m
Tc-EC  RS + ~ERPF
• 99m
Tc-MAG3  RS + ~ERPF
• 131
I-hippuran (OIH)  ERPF
Nuclear medicine diagnostics in diseases of the respiratory system

Diagnostic methods:
 lung perfusion scintigraphy
 lung ventilation scintigraphy
Lung perfusion scintigraphy

Radiopharmaceutical:
Tc-microspheres (small albumin spheres of 15-30 micrometer in
99m

diameter)

Clinical applications:
1. Suspected pulmonary embolism
2. Lung’s neoplasms
3. Congenital malformation of lungs and pulmonary vessels
Lung ventilation scintigraphy

Radiopharmaceuticals:
Radioactive aerosols (99mTc-DTPA, 99mTc-colloid).
Radioactive noble gases (133Xe, 81Kr).

Clinical applications:
1. Suspected pulmonary embolism (as an investigation
supplementary to the perfusion imaging).
2. Obturatory diseases of the respiratory system.
 Nuclear medicine diagnostics of skeletal system

Basic diagnostic procedure:

Bone scintigraphy

Radiopharmaceutics:
Biphosponate complexes labeled with 99mTc (99mTc-MDP, 99mTc-HEDP).

Clinical applications:
1. Suspected neoplastic metastases to the skeleton
2. Primary bone tumours
3. Diagnostics of osteomyelitis
4. Detection of some bone traumas
5. Diagnostics of complications after arthroprotesis implantation
6. Suspected impairment of skeleton blood supply
7. Skeletal pain of unknown origin
8. Diagnostics of arthritis