International Atomic Energy Agency

RADIATION PROTECTION IN NUCLEAR MEDICINE

Part 0: Introduction to Nuclear Medicine

Nuclear Medicine
Diagnosis and Therapy with Unsealed Sources
Clinical Problem

Radiopharmaceutical

Instrumentation

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

Radiopharmaceuticals
Radionuclide Pharmaceutical Organ + Colloid Liver Parameter RE

Tc-99m

+ MAA

Lungs

Regional perfusion

+ DTPA

Kidneys

Kidney function

I-123 I-131

NaI NaI

Thyroid Thyroid

Uptake/ Therapy

F-18

FDG

Whole Body

Tumor Localization

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

History- Radionuclides
1896 Natural Radioactivity 1898 Radium 1911 Atomic Nucleus 1913 Model of the atom 1930 Cyclotron 1932 Neutron 1934 Artificial Radionuclide 1938 Production and Identification of I-131 1942 Nuclear Reactor 1946 Radionuclides Commercially Available 1962 Tc-99m in Nuclear Medicine 1970s F18-FDG for PET Imaging
Nuclear Medicine

Becquerel Curie Rutherford Bohr Lawrence Chadwick Joliot-Curie Fermi et al Fermi et al Harwell Harper Ido & Wolfe
4

Part 0. Introduction to Nuclear Medicine

Pioneers

Henri Becquerel

Ernest Rutherford

Maria Curie

Frederique Joliot-Irene Curie

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

Current Methods-Therapy
Radiopharmaceutical For treatment of Route of administration
Oral Oral IV IV or oral IV Intra-articular Intra-cavitary Intra-articular Intra-articular Intra-articular

Maximum activity
1 GBq 20 GBq 10 GBq 200 MBq 150 MBq 250 MBq 5 GBq 100 MBq 50 MBq 150 MBq

I-131 I-131 I-131 P-32 Sr-89 Y-90

iodide iodide MIBG phosphate chloride colloid

Y-90 spheres Er-169 colloid Re-186 colloid

Thyrotoxicosis Carcinoma of thyroid Malignancy Polycythaemia vera Bone metastases Arthritic conditions/ malignant effusions Hepatocellular Carcinoma Arthritic conditions Arthritic conditions

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

History-Therapy

1936 al 1936
1941 1942 1945 1958 1963

Therapeutic use of Na-24 (leukemia)

Hamilton et

Therapeutic use of P-32 (leukemia and Lawrence polycythemia vera) Therapeutic use of iodine in hyperthyroidism Hertz et al Therapeutic use of iodine in treatment of metastasis from thyroid cancer Therapeutic use of Au-198 in treatment of Muller malignant effusion Treatment of bone metastasis with P-32 Maxfield Medical synovectomy using Au-198 Ansell

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

I-131 Therapy
The absorbed dose to be delivered should be determined from uptake measurements, effective half-life of the radiopharmaceutical and the size of the thyroid. The radiopharmaceutical is administered p.o. Hyperthyroidism Cured after 3-4 months 1 year 85% 98% Hypothyroidism after <7 years after >7 years 14.8% 27.9%

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

Radiosynovectomy

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

Pain Palliation

Intravenous injection of a radiopharmaceutical which includes e.g. Sr-89 or Sm-153

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

10

Annual Numbers of Therapies with Radiopharmaceuticals in all Health-care Levels

(As per UNSCEAR Report 2008)

Number of Patients per million population Thyroid Malignancy: Hyperthyroidism: Polycythemia vera: Bone Metasstases: Synovitis: Others: Total 1950.1 4616.6 168.1 316.5 380.6 120.5 7552.4

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

11

Current Diagnostic Methods

Imaging (Planer/SPECT and PET Cameras)
Bone, Brain, Lungs , Thyroid, Kidneys, Liver/Spleen, Cardiovascular, Stomach/GI-tract, Tumours, Whole Body, Abscesses . Non-imaging (probes) Thyroid uptake, Renography, Cardiac Output, Bile Acid Resorption. Laboratory tests GFR, ERPF, Red Cell Volume/Survival, Absorption Studies (B12, iron, fat), Blood Volume, Exchangeable Electrolytes, Body Water, Bone Metabolism.. Radioimmunoassays (RIA) Radionuclide guided Surgery
Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

12

Annual Frequencies of Diagnostic Examinations

(As per UNSCEAR Report 2008)

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

13

Nuclear Medicine Examinations in Different Health Care Levels

(As per UNSCEAR Report 2008)

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

14

Annual Number and Collective Effective Radiation Dose from Diagnostic Nuclear Medicine Examinations
(As per UNSCEAR Report 2008)

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

15

History-Diagnostics
1927 1935 1939 1948 1956 1957 1961 1962 1964 1965 1971 1970s Blood flow studies (Bi-214) Bone metabolism (P-32) Thyroid studies (I-131) Radiocardiography (Na-24) Renography (I-131) Liver scan (Au-198 colloid) Bone scan (Sr-85) Myocardium (Rb-86, Cs-131) Lung scan Brain scan (Tc99m-pertechnetate) Bone scan (Tc99m-complex) F18-FDG for PET Imaging Blumgart-Weiss Chiewitz-de Hevesy Hamilton et al Prinzmetal et al Taplin, Winter Friedell et al Fleming et al Carr et al Taplin et al Bollinger et al Subramanian et al Ido & Wolfe

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

16

GEORGE DE HEVESY 1885-1966

de Hevesy G & Paneth F. Die Lsligkeit des Bleisulfids und Bleichromats. Z. Anorg Chem 82, 323, 1913. de Hevesy G. III. The absorption and translocation of lead by plants. Biochem J, 17, 439, 1923. Chiewitz O. & de Hevesy G. Radioactive indicators in the study of phosphorous metabolism in rats. Nature 136, 754, 1935.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

17

Bone Scan
Single probe Scanner Gamma camera

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

18

Instrumentation in Nuclear Medicine

Activity Meter Sample Counters Survey Meters Single- and Multi-probe Systems Gamma Camera Single Photon Emission Computed Tomograph (SPECT) Positron Emission Tomograph (PET) Positron Emission TomographComputed Tomograph (PET-CT)
Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

19

Thyroid Uptake Measurement

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

20

History- Instruments
1908 1927 1944 1948 1950 1957 1963 1961 2000 Visual scintillation (ZnS) Geiger-counter Scintillation detector (ZnS+PM) Sodium iodide crystal Scanner Gamma camera Tomography PET PET-CT Crookes Geiger Curran Hofstadter Cassen Anger Kuhl Robertson Townsend

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

21

Pioneers

B. Cassen

H.O. Anger

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

22

Gamma Camera?

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

23

Gamma Camera

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

24

Nuclear Medicine Images

Nuclear imaging detects functional (vs. anatomical) properties of the human tissue. The imaging is done by tracing the distribution of radiopharmaceuticals within the body with a gamma camera

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

25

Bone Scan
Bone uptake of 99mTc MDP reflects bone metabolism and blood flow, and allows functional analysis of bone turnover The ability to image bone metabolism alterations enables detection of lesions such as: Bone metasasis Benign or malignant bone tumors Bone trauma A three-phase acquisition procedure is required in order to detect osteomelitis

Bone scans also facilitate follow-up of other bone disorders, such as Pagets disease
Intravenous injection of 400-600 MBq 99mTc MDP. Imaging 3h after injection
Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

26

Bone Scan

normal
Nuclear Medicine

pathologic
27

Part 0. Introduction to Nuclear Medicine

Lung Scan
A proportionately spread embolization of the pulmonary capillary bed yields an image reflecting the lung blood perfusion (Tc99m MAA). This image enhances the diagnosis of pulmonary emboli. Intravenous injection of 100 MBq Tc99m MAA. Immediate scanning. Ventilation studies (Tc99m -aerosols) reflect the regional and segmental ventilation. Study interpretation is performed in conjunction with perfusion findings, supporting the differential diagnosis of pulmonary emboli. Inhalation of 100 MBq Tc99m -aerosols. Immediate scanning.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

28

Lung Scan

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

29

Thyroid
Thyroid scintigraphy (I123, I131 or Tc99m pertechnetate) offers structural and functional information by displaying the thyroid image and calculating uptake, organ volume etc. Pinhole SPECT studies offer superior contrast resolution image over the planar image, enhancing thyroid nodules detection and evaluation. Intravenous injection of 100 MBq Tc99m pertechnetate or 30 MBq I-123 po.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

30

Thyroid Scan

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

31

Cerebral Blood Flow

99mTc HMPAO or similar compound retained in the brain in proportion to regional cerebral blood flow.

Localizes predominately in the gray matter and does not show redistribution.

Enhances detection of :
Brain dementia such as Alzheimers disease, seizure localization Foci, Cerebral vascular problems such as cerebral ischemia, trauma and brain death Intravenous injection of 800 MBq min later
Nuclear Medicine

99mTc

HMPAO. Tomography 30

Part 0. Introduction to Nuclear Medicine

32

Cerebral Blood Flow

normal

Alzheimers disease

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

33

Kidney Function
Determination of kidney clearance of Cr51-EDTA or Tc-99m DTPA. Dynamic renal scintigraphy reflects renal blood perfusion, uptake and excretion. The acquisition yields a series of images. By calculating count rate in a defined ROI, a renogram is created, providing quantitative data. Different radiopharmaceuticals, such as Tc99m-MAG3, Tc99m-DTPA and I123Hippuran, are used for renal clearance and function assessment.

Renal scan for parenchymal anatomy and function evaluation uses Tc99m-DMSA

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

34

Kidney Function (Tc99m-DTPA)

It is ideal to mark the background region in such a manner as to exclude the arteries and calycial region.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

35

Kidney Function (Tc99m-DMSA)

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

36

First Pass Study

Intravenous high activity (400-800 MBq) Tc-99m bolus
tracer injection, followed by a short acquisition (4-20 frames per second during 1 minute) demonstrates Myocardial function eliminating background activity bias.

First pass procedures facilitates:

Wall motion imaging LV and RV ejection fraction calculations Detection of left to right intracardial shunts Cardiac output calculations Ventricle volume calculations Transit times calculations

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

37

Shunt Quantification

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

38

ECG-Gated Blood-pool Scanning

Red blood cell labeling (Tc99m), followed by gated acquisition and measurement of the corresponding dynamic blood volume count rate changes, enables LV and RV blood volume quantification. The analysis of ventricular wall motion, systolic/diastolic functions, and Ejection Fraction, has application for CAD evaluation, risk stratification, and monitoring of cardiotoxicity in chemotherapy treatments. Intravenous injection of 600-800 MBq Tc99m , scanning 10-15 min later.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

39

ECG-Gated Blood-pool Scanning

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

40

Myocardial Perfusion

201Tl

accumulation in the myocard depends on blood flow and cellular metabolism, hence, reflects regional perfusion and viability of the cardiac muscle. The evaluation of a patient suspected or known for C.A.D. is based on image interpretation or quantitative analysis from reconstructed tomographic slices, which also yields regional perfusion information. The examination is performed under maximum stress condition and after rest. Injected activity 70-100 MBq 201Tl. Tomographic study.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

41

Myocardial Perfusion
Stress Rest

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

42

Tomographic Slices
coronal

sagittal

transversal

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

43

Myocardial Perfusion

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

44

Myocardial Perfusion
The physical properties offered by 99mTc MIBI or Tetrofosmin facilitate evaluation of myocardial perfusion and function by enabling performance of gated SPECT perfusion studies initiated with first pass acquisition. The assessment of a patient with known or suspected C.A.D. is based on quantitative analysis and coronary artery regional perfusion evaluation, drawn from a set of reconstructed tomographic slices. Injected activity 800-1000 MBq. Gated tomographic acquisition

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

45

ECG-Gated Myocardial Perfusion

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

46

Gated SPECT

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

47

PET
Positron Emission Tomography
Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

48

Annhilation
511 keV -

positron

511 keV

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

49

Radionuclides
Radionuclide Half-life

Particle energy (mean

0.39 MeV

C-11 N-13 O-15 F-18 Cu-62 Ga-68 Rb-82

Nuclear Medicine

20.4 min 10 min 2.2 min 110 min 9.2 min 68.3 min 1.25 min
Part 0. Introduction to Nuclear Medicine

0.83 MeV 1.5 MeV

50

Pioneers

Michel Ter-Pogossian prepares a radiopharmaceutical for an examination of Henry Wagner Jr with one of the first PETscanners (1975).

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

51

PET-Scanner

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

52

Cyclotron

Stanley Livingstone and Ernest Lawrence with their 8 MeV cyclotron (1935)
Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

53

Cyclotron in Hospitals

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

54

F18-FDG

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

55

FDG in Cardiology

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

56

FDG in Oncology

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

57

FDG in Neurology

Alzheimers disease

Normal

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

58

Rb-82 generators
Produce rubidium Rb 82 chloride injection for intravenous administration. The eluate is sterile and nonpyrogenic

Rb-82

Rb-82 is used for noninvasive investigation of myocardial perfusion with PET imaging

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

59

The Future Diagnostic Methods

New radiopharmaceuticals based on positron emitters. Radiopharmaceuticals with high specificity. More advanced application programs which improve both sensitivity and specificity of the examination.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

60

Multimodality Imaging
PET

CT
Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

61

Generator-based PET Radiopharmaceuticals

Ge-68/Ga-68 and Sr-82/Rb-82 generators

have potential for PET radiopharmaceuticals in molecular imaging

Potential use of Ga-68 labeled peptides in

PET imaging

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

62

Therapeutic Radiopharmaceuticals

Molecular targeted radiotherapies Lu-177 and Y-90 labeled compounds for

peptide receptor radionuclide therapy (PRRT)

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

63

The Future Instrumentation

Improved performance of the gamma camera Improved detection of positron emitters More sophisticated methods for reconstruction and correction of tomographic examinations Advanced electronic reporting systems.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

64

NUCLEAR MEDICINE - UNCLEAR MEDICINE?

No! Nuclear medicine is an efficient diagnostic and therapeutic tool and is justified from a medical point of view.

Nuclear Medicine

Part 0. Introduction to Nuclear Medicine

65