Procedure Flashcards
Radionuclides and Radiopharmaceutical’s
Production of Radionuclides
Procedure: Methods: Reactor:
An apparatus or structure in which fissile material ( 235U or 239 PU) can be made to undergo a controlled,self- sustaining nuclear reaction( fission) with the consequent release of energy. Fission is the breakup a heavy nucleus into two fragments of approximately equal mass, accompanied by the emission of 2 to 3 neurons. There is an energy release that appears as head and is usually removed by heat exchangers to produce release that appears as head and is usually removed by heat exchangers to produce electricity. ( I-131, Mo- 99 , Xe-133, Cs- 137) .
Methods: Accelerator:
A machine that uses electromagnetic fields to propel charged particles to nearly light speed and to contain them in well- defined beams.
Methods: Cyclotron:
An apparatus in which charged atomic and subatomic particles are accelerated by an alternating by an alternating electric field which following an outward spiral or circular path in a magnetic field. Cyclotron produced radionuclides are usually neutron deficient and therefore decay by B+ emission or electron capture. ( Ga-67,
I123, In 111, TI-201, C-11, N-13, O-15,F-18)
Methods Generator:
They provide a convenient source of short-lived radionuclides. In a generator, a longer- lived radionuclide, called the parent, decays to a shorter- lived radionuclide, called the daughter. The daughter can be removed periodically as it is replenished by decay of the parent. (Ga-68, Sr-82,Rb-82, and Mo-99/Tc-99). Some of these systems have been developed commercially and are supplied as sterile shielded, automatically operated devices.
Purity Radionuclide:
Defined as the fraction/ratio of total radioactivity present in its desired chemical form. If radiochemical impurities exceed certain limits in a given preparation, the distribution of the radio -pharmaceutical in the patient will be altered. Free pertechnetate can be visualized on images as increased tracer concentration in the stomach, thyroid and salivary glands.
Purity Chemical:
Tc-99 is present in 3 different chemical forms-bound Tc-99, unbound Tc-99 (free) and hydrolyzed reduced(HR) Tc-99. Because the bound Tc-99
Is the desired form, the others should be present on in very small quantities. Tc-99m pertechnetate and HR Tc-99 are radiochemical impurities.
Math for Purity:
% Radiochemical Impurity = CPM in part A /CPM in part +CPM in part B X 100%
% Labeling Ef ficiency = 100% radiochemical impurity.
Purity: Physical form:
Ex: Gas , Solution,Capsule
Radiopharmaceutical Characteristics: Method of Localization: Capillary Blockage:
Mechanical obstruction, physical trapping, of capillaries or pre-capillary arterioles in the lungs. Ex: Tc-99 MAA.
Radiopharmaceutical Characteristics: Method of Localization: Active Transport:
Another type of carrier-mediated transport across membranes. It unlike diffusion, it requires energy (ATP) for the transporters to function. Hence, it can go through of as a a motorized revolving door or pump. Ex: I-123,I-131, Thyroid-function/ imaging, Na/K pump in the heart muscle with Ti-201.
Radiopharmaceutical Characteristics: Method of Localization: Phagocytosis:
The process whereby the cell engulfs a particle and internalizes it. A prime example involves reticuloendothelial system(RES) cells, such as kupffer cells in the liver, phagocytizing colloid particles. EX: Sulfur colloid.
Radiopharmaceutical Characteristics: Method of Localization: Diffusion:
A type of carrier- medicated transport across membranes, can be thought of as a revolving door. Accordingly, it can be competitively inhibited by the presence of similar molecules that also fit into the carrier. Because there are a limited number of carriers, it is possible to achieve saturation. EX. Glucose FDG.
Radiopharmaceutical Characteristics: Method of Localization: Compartmentalization:
Introduction of (Rph) into well- defined body compartment, where it remains for an extended period. Ex. Tc-99m DTPA aerosol, Xe- 133.
Radiopharmaceutical Characteristics: Method of Localization: Chemisorption:
The binding of phosphate- type compounds onto the surface of bone. The strength of this binding is intermediate between chemical covalent bonding and hydrogen bonding l(absorption), hence the coined tern chemi-sorption. Ex: MDP and HDP.
Radiopharmaceutical Characteristics: Method of Localization: Receptor binding:
Refers to the “lock and Key” binding of a molecules to a specific General characteristics include, selectively, competitive inhibition by similar molecules and the possibility of being over saturated. Ex: In-111 capromab pendetide/a monoclonal murine lgG anitbody for prostate specific membrane antigen (PSMA), I-131 tositumomab and Y-90 ibritumomab/receptors no B-cells and non- Hodgkin’s cells.
Radiopharmaceutical Characteristics: Method of Localization: Antigen antibody:
Radiolabeled antibody binds to tumor- associated antigen. Ex. Using tumor- specific labeled to detect cancer or stage therapy.
Filtration:
A special case of diffusion involving transit of molecules through pores, or channels driven by a hydroelectric or osmosis pressure gradient. Ex: GFR by the kidney, DTPA.
Metabolism:
Used to describe all chemical reactions involved in maintaining the living state of the cells and organism. Can be divided into 2 categories- Catabolism: the breakdown of molecules to obtain energy, Anabolism: the synthesis of all compounds needed by the cells.
Sequestration:
The process whereby old or damaged RBC are removed from the circulation of the spleen, uptake of WBC’s in infection sties. Ex: Ultra Tag RBC’s taken up by spleen,In-111 WBC’s site of infections.
Half-Life: Physical(t1/2)
Defined as the period of time required to reduce the radioactivity level of a source to exactly one half its original value due solely to radioactive decay.
Half-life: Biological (Tb):
Defined as the period of time required to reduce the amount of a drug in an organ or the body to exactly one half its original value due solely to biological elimination.
Half-Life: Effective (Te):
Defined as the period of time required to reduce the radioactivity level of an internal organ or of the whole body to exactly one half its original value due to both elimination and decay.
Math: Te=T1/2+Tb
Biodistribution: Pharmacokinetics:
Described as what the body does to a drug, refers to the movement of drug into, through and out of the body; the time course of its absorption, bioavailability,distribution,metabolism and excretion..
Biodistribution: Critical Organs:
Refers to the part of the body most vulnerable to a given isotopes. For iodine, the critical organ is the thyroid gland.
Biodistribution: Target Organs:
A specific organ on which a hormone, drug, or the other substance acts upon it. Ex: Bone scan= Bone, Bladder.
Preparation and administration:
1: kit preparation
2: Labeling Process
3: Principles
Oxidation/reduction( redox):
A redox reaction is a type of chemical reaction that involves a transfer of electrons between two chemical species.
Oxidation:
Used to describe reactions in which an element combines with oxygen. Ex: reaction between magnesium and oxygen to from magnesium oxide involves the oxidation of magnesium. Technetium can exist in various oxidation states form 1-to 7+. The Tc5+ is the most common in 99m complexes.
Reduction:
From the Latin meaning “ To lead back” Anything that leads back to magnesium therefore involves reduction.
PH:
A figure expressing the acidity or alkalinity of a solution on a logarithmic scale on which 7 is neutral, lower values are more acid, and higher values more alkaline.
1: Time for reaction
2: Temperature
Compounding Techniques:
The creation of a particular pharmaceutical product to fit the unique need of a patient by combining or process appropriate ingredients using various tools. ( Solid pill to a liquid, avoid a non- essential ingredient that the patient is allergic to, or obtain the exact dose needed or deemed best of particular active pharmaceutical ingredients.)
Compounding techniques:
1: Venting
2: Heating
3: Mixing
USP 797 Regulations:
The objective of this document is to describe conditions and practices to prevent harm including death, to patients that could result from the following: 1) microbial contamination/ nonsterility. 2) excessive bacterial endotoxins. 3) Variability in the intended strength of correct ingredients that exceeds either monography limits for official articles or 10% for no official articles. 4) unintended chemical and physical contamination and 5.) incorrect types and qualities of ingredients in compounded sterile preparations (CSPs).
Factors that affect labeling quality:
B: She’ll life and storage
C: Quality Control
Radiochemical Purity:
The total amount or fraction of the desired radioactive compound.
Particles Size:
Radiopharmaceutical
MAA, Sulfur Colloid
Specific Activity:
Ex: (Millicuries per mas)
Color and clarity:
Of the kit and Labeling process.
Calculation of radiopharmaceutical and pharmaceutical dosage. A: Units
1: Conversions
2: Calculation
Math guide: Volume determination:
1: formula
2: Decay Tables
3: Concentration
4: Activity
Pharmaceutical and radiopharmaceutical administration preparation:
1: Syringe dose level
2: Needle selection 20g 18g
3: Shielding for use to help us with limit of radiopharmaceutical use..
Radiopharmaceutical label: Pertinent information:
1: Name of the radiopharmaceutical
2: Assay date and time
3: Lot number and expiration date
4: Concentration
5: Volume
6: Activity
Administration techniques: Routes:
The main ways of delivery are inhalation and Iv, while some applications for orally, IM,and via the spinal cord (intrathecal).
Administration techniques: Aseptic:
Technique involves maintaining the sterility of the needle hub as it is attached to the syringe and the needle itself and sanitizing the top of the radiopharmaceutical vial with alcohol.
Administration techniques: Uniform distribution ( Ex: mixing, agitation). :
Depends on the particular Radiopharmaceutical.
Administration techniques: Complication and reactions( Adverse Reaction):
A harmful and unintended response to a human medicine, occurring at doses normally used for the diagnosis or treatment of a disease. Adverse events in the administration of radiopharmaceutical products might continue to occur. The important thing is that the relevant staff should immediately document such reactions as soon as it occurs. Regular documentation and recording of such reactions as well as evaluation of the results will make a great contribution to the development of better radiopharmaceutical with less adverse effects.
Administration techniques: Documentation:
Pertinent information, such as the name of the radiopharmaceutical, lot number, activity and volume administered, time, date, person administering the dose, route of administration, and patient’s name, should be entered into the appropriate records.
Cardiac Procedure: Anatomy and Physiology:
Deoxygenated blood enters the right atrium from the superior and inferior vena Cava. During Ventricular diastole( relaxation/ filling phase) the tricuspid value opens allowing blood to flow into the right ventricle. Blood exits the right ventricle during Ventricular Systole(Contraction Phase) and travel through the pulmonary value into the pulmonary artery that leads into lungs. Newly oxygenated blood enters the left atrium by pulmonary veins. Blood passes across mitral valves into left ventricle during Ventricular diastole. Oxygenated blood is introduced to systematic circulation during ventricular systole by passing through aortic valve into aorta.
Coronary and Systemic Circulation:
Perfusion of blood into heart muscle is through Coronary Circulation. Begins at base of aorta where the right and left coronary arteries (RCA and LCA) originate. RCA exits aorta, follows right posterior sulcus and branches posteriorly ( posterior descending artery/PDA) toward apex. The RCA supplies the posterior and inferior areas of the myocardium. The LCA exits aorta at level of the left coronary sinus. It branches into the left descending artery (LAD) and left circumflex artery (LCX).LAD usually traverses down anterior heart surface to provide septal and anterior walls of myocardium with blood. Also, provides blood to apex, LCX services the lateral free wall. Perfusion of oxygenated blood to rest of body return of deoxygenated to the heart is (Systemic Circulation).
Conduction system:
Conduction (systole) and Relaxation (diastole)
SA node (Sinoatrial):
Electrical impulse that initiates contraction, pacemaker for the heart (60-100 beats).
Av node (atrioventricular)
Serves as ventricles “gate Keeper” allows only 40-60 impulses per min.
Bundle of His (Av bundle)
Collection of heart muscles specialized for electrical conduction; transmits impulses from Av node to right and left bundle branches.
Purkinie fibers:
Thermal branches for both bundle branches. They carry impulses to myocardial cells causing ventricular contraction.
Electrocardiogram (ECG) Graphics electrical heart activity: P Wave:
Atrial depolarization(activation), slowing of impulse is indicated by interval between P and QRS=PR interval.
Electrocardiogram (RCG) Graphic electrical heart activity: QRS Complex:
Indicates depolarization of ventilation Q waves is 1- deflection, R wave, is 1+ deflection, S wave is the rest.
Electrocardiogram (ECG) Graphic electrical heart activity: ST segment:
Rest period between de and depolarization ( relaxation).
Electrocardiogram (ECG) Graphic electrical heart activity: T wave:
Repolarization of Ventricles.
Coronary Artery Disease (CAD): Myocardial Ischemia:
Decreases blood flow to the myocardium causing narrowing or occlusion of the coronary artery. Angina pectoris(chest pain) is major symptom and ST depression on ECG.
Coronary Artery Disease (CAD):Myocardial Infarction (MI):
Results from total occurrence of the narrowing coronary artery by a blood clot. Injured and ischemic areas are viable from therapeutic intervention such as coronary artery bypass graft (CABG) surgery or percutaneous transluminal coronary angioplasty (PTCA).
Coronary Artery disease (CAD): Hibernating myocardium:
Chronic ischemic tissue that is viable yet appears to be nonfunctioning.
Coronary Artery Disease (CAD): Myocardial stunning:
A phenomenon that may occur after a patient experiences an acute episode of severe ischemia or an MI that is terminated by thrombolysis or revascularization.
Akinesis:
Absence of motion
Hypokinesis:
Decreased motion
Dyskinesis:
Segment of ventricle bulges out as remainder of ventricle contracts.
Stroke Volume (SV) :
Volume of blood ejected by either ventricle during Ventricular systole, SV=ED-ES
Cardiac Output (CO):
Volume of blood that the heart pumps per minute., CO=SV x HR
End Diastolic Volume (ED):
Capital of the Ventricle after it is completely filled with blood; largest volume reached during cycle.
End Systolic Volume(ES);
Residual capacity of the ventricle at the end of concentration; smallest volume reached during cycle.
Ejection Fraction (EF):
Percentage of blood ejected from the ventricle during each concentration EF=(ED-ES)/EDx100.
Good Blood Pool (MUGA): Selection:
Tagged red blood cells( RBC’s) by pyrophosphate(PYP) in combination with Tc-99m pertechnetate or a stannous chlorine kit(Ultra Tag).
Gated Blood Pool (MUGA): Dosage:
15-30mCi
Gated Blood Pool(MUGA): Administration:
Intravenous(IV), 3 methods to label RBC’s. In Vivo: Make cold pyp kit; 2-3ml normal saline into pyp vial. Mix then let sit for 5 mins. Next, inject 1-3 ml pyp. Wait/circulate for 20 mins. Next, inject 20-30mCi of pertechnetate into opposite arm ( 90% efficiency).
Gated Blood Pool( MUGA): Modified in Vivo/InVitro:
Make cold pyp kit, 2-3ml normal saline into pyp vial. Mix then let sit for 5 mins. Next inject patient with pyp; straight stick. 1.5ml for small patient or not no blood thinners, 3 ml of blood into a 5-10mins and reinject.
Gated Blood pool(MUGA): Biodistribution:
Compartmental, tagged, to and circulating with blood.
Gated Blood Pool(MUGA): patient preparation, Monitoring and Education. Indicators:
Evaluation of left/sometimes right wall motion( CHF), calculation of ejection fraction (EF),ventricular volume, cardiac output and diastolic function, assessment of CHF to ischemic or non ischemic causes,detection and evaluation of CAD,evaluation of patient’s heart before/ after surgery, chemotherapy or radiation. Contraindications: chest pain, unstable condition, severe arrhythmia and allergic to pyrophosphate or phosphate.
Gated Blood Pool(MUGA): Pregnancy and Nursing:
Must ask if pregnant or nursing if under 40 / 50years old.
Gated Blood Pool(MUGA): Dietary restrictions:
NPO 4-8 hrs before study.
Gated Blood Pool(MUGA): Adverse reactions/artifacts:
Arrhythmias, cold pyp oxidized if not used soon after mixing B-blockers, Ca2+ blockers may cause false negatives, Do not use chest ports as will show in pictures, should be done before any contrast type of exam, check clothing for articles, ECG in the way or pacemakers.
Gated Blood Pool(MUGA): Medications:
Discontinue any cardiac meds and caffeine 4hrs prior.
Gated Blood Pool(MUGA): Age specific/other considerations:
N/A
Gated Blood Pool(MUGA): Lab Values:
N/A
Gated Blood Pool(MUGA): Imaging Techniques: Anatomical Landmarks
Once the camera is positioned correctly (LAO,40*), there should be a nice separation between ventricles nearly straight up and down.
Gated Blood Pool(MUGA): Views:
Position camera anterior,LAO(35-60* looking for best septal wall separation for EF calculation, slightly tilt(5-10%) to camera can help), LLAT and sometimes RLAT or RAO displaying anterior and inferior wall moniton/apex..
Gated Blood Pool(MUGA); Patient Detector Orientation;
Supine.
Gated Blood pool(MUGA) Fusion Imaging
N/A
Gated Blood Pool(MUGA): Instrumentation: Detector System:
Low energy/ all-purpose or high res parallel hole collimator.
Gated Blood Pool (MUGA): Instrumentation: Data acquisition:
Collect for 300-600 beats: image or go by preset time(5-10min/image).
Gated Blood Pool (MUGA): Instrumentation: Data analysis:
Draw regions of interest, calculate EF(ED-ES/EDx100), calculate SV ( ED-ES), calculate CO(SVxHR).
Gated Blood Pool(MUGA): Instrumentation: Data analysis: Normal:
Good tag with blood,circulation in major vessels and heart should present clearly, septal image should show easily definable separation between right/left ventricles. Dynamic shows fair amount of motion in all (septal, anterior, lateral inferior, apex) walls no defects. Left Vent EF= 50-70% or better. Right vent EF, 35-45% or less. Below 30% indicates servers impairment. Regional wall abnormalities indicates CAD.
Gated Blood Pool (MUGA): instrumentation: Data analysis: Abnormal:
Dynamic shows one or more walls with abnormal movements (dyskinesia), decreased wall motion ( hypokinesis) or no movement (akinesia). Low EF,35-45% or less. Below 30% indicates several impairment. Regional wall abnormalities indicates CAD.
Gated Blood pool (MUGA): Ancillary Equipment:
3 to 5 lead ECG. Check R-R wave,adjust acquisition parameters accordingly. Make sure there is a good HR for gate.
Myocardial Perfusion (MPI) (Stress): Selection:
Tc- 99m Sestamibi, Tc-99m Tetrofosmin and TI-201 Thallous Chloride.
Myocardial Perfusion (MPI)(Stress): Dosage:
Sestamibi and Tetrofosmin, 20-30mCi; Thallous Chloride 3-5mCi
Myocardial Perfusion (MPI)(Stress): Administration:
Intravenous (IV) or butterfly setup.
Myocardial Perfusion (MPI)(Stress): Biodistribution:
Sestamibi-passive transport into myocardial mitochondrial in proportion to blood flow. Tetrofosmin-same; binds to myocytes. Thallous Chloride-distributes with Na/K pump within 20 mins of injection, then seeps out myocardium and redistributes.
Myocardial Perfusion (MIP)(Stress): patient preparation,monitoring and Education: Indicators:
Detection and evaluation of coronary artery disease(CAD), suspected or known coronary artery stenosis, evaluation of possible candidates for coronary bypass surgery or angiogram, evaluation of physical indicators( acute myocardial infection,chest pain, SOB, history or family history of heart disease) and determination of prognosis after a myocardial infection.
Myocardial Perfusion (MPI)(Stress): Indicators. Contraindications:
Chest-pain, documented acute MI within 2-4 days prior, has no discontinued chemical stressors( caffeine theophylline,viagra)24 to 48 prior, on heart medications, extremely high BP, arrhythmias, CHF, etc.
Myocardial Perfusion (MPI)(Stress): pregnant and nursing:
N/A however is patient is under 40/50 years old must ask.
Myocardial Perfusion (MPI)(Stress): Dietary restrictions:
NPO for 4-12hrs. Clear liquids and crackers for Sestamibi and Tetrofosmin, noting at all for Thallium. Orange juice allowed for diabetics; may need to monitor blood sugar and adjust. Ingest no caffeine, dairy products, or sugar.
Myocardial Perfusion (MPI)(Stress): Adverse Reactions/artifacts:
Most common attenuation:(men) left hemidiaphragm affecting inferior wall,(women) left breast affecting anterior wall. Bier activity close to heart can mask inferior wall defects, patient not able to reach 85% of max HR, left arm down to the side instead of above the head, Test should be discontinued of patients experiences angina, severe SOB, fall in BP, ischemic ECG changes, arrhythmias etc:
Myocardial Perfusion (MPI)(Stress): Medications:
Some doctors prefer to hold heart medications until after test( check with cardiologist)
Myocardial Perfusion (MPI)(stress): Age Specific/other considerations:
Be well rested and avoid strenuous exercise the day of test and before exam.
Myocardial Perfusion (MPI)(Stress): lab values:
N/A not need for this test.
Myocardial Perfusion (MPI)(Stress): Imaging Techniques:Anatomical Iandmarks
N/A
Myocardial Perfusion (MPI)(Stress): Views:
SPECT imaging so RAO to LPO
Myocardial Perfusion (MPI)(Stress): Patient Detector Orientation:
Supine with heart in the center FOV .
Myocardial Perfusion (MPI)(Stress): Fusion Imaging
N/A not for this tests.
Myocardial Perfusion (MPI)(Stress): Instrumentation: Detector System:
Low/Energy/all purpose or low energy/ high res parallel hole.
Myocardial Perfusion (MPI)(Stress): Instrumentation: Data acquisition:
Tc-99 window at 140kev, TI-201 at 167kev at 20% (static) Timed for 300 secs. (SPECT)- 180*, 32 or 64 projections at 20-40sec/frames,8frames/cycle of gated, matrix at 64x64.
Myocardial Perfusion (MPI)(Stress): Data analysis:
Imaging processed to show myocardium of left ventricle in vertical, horizontal and shot axis views; bulls eye pilot and EF information.
Myocardial Perfusion (MPI)(Stress): Instrumentation: Data analysis: Normal:
Heterogeneous uptake throughout the myocardium of the left ventricle. Normal left ventricular end diastolic volume is 70ml, end-systolic volume is 2ml. Normal heart 80%, RVEF: 40-60%. No deviations in full contraction of heart, all walks contracting in a coordinated measure.
Myocardial Perfusion (MPI)(Stress): Instrumentation:Data analysis: Abnormal:
Defect(area of little to no uptake in localized area) in stress but not rest;the myocardium is ischemic and reversible. Defect in both stress and rest in the same area; most likely infracted and considered a fixed defect. Enlarged right ventricle possible pulmonary hypertension. Bone uptake on images; possible multiple myeloma.
Myocardial Perfusion (MPI)(Stress): Instrumentation: Ancillary equipment:
Prep patient with a 10-12leads ECG; run standing, lying or sitting test sheets: Treadmill: Monitor Hr, BP, ECG changes and patient closely. Inject and flush on physician order( when target HR is obtained or about 1min before patient gives out). Maintain exercise for 60/90second after infection.
Myocardial Perfusion (MPI)(Rest): Selection:
Tc-99 Sestamibi, TC-99m Tetrofosmin and TI-201Thallous Chloride.
Myocardial Perfusion (MPI)(Rest): Dosage:
Sestamibi and Tetrofosmin,8-30Mci; Thallous Chloride 2-5mci.
Myocardial Perfusion (MPI)(Rest): Administration:
Intravenous (IV) or butterfly setup.
Myocardial Perfusion (MPI)(Rest): Biodistribution:
Sestamibi-passive transport into myocardial mitochondria in proportion to blood flow. Tetrofosmin- same; binds to myocytes. Thallous chloride distribution with Ma/K pump within 20 minutes of injection, then seeps out of myocardium and redistributes.
Myocardial Perfusion (MPI)(Rest): Indicators:
Detection and evaluation of coronary artery disease (CAD), suspected or known coronary artery stenosis, evaluation of possible candidates for coronary bypass surgery or angioplasty, evaluation of physical indicators ( acute myocardial infarction, chest pain, SOB, history or family history of heart disease) and determination of prognosis after a myocardial infection. Contraindications: On chemical (caffeine, theophylline, Viagra)24 to 48 prior, taking heart medications until after test, NPO for 4- 12 hrs and severe arrhythmias.
Myocardial Perfusion (MPI)(Rest): pregnancy and nursing:
N/A
Might have to ask if under 40/50 year old.. depends on the test..
Myocardial Perfusion (MPI)(Rest): Dietary Restrictions:
NPO 4-12hrs (No caffeine, dairy products or sugar).
Myocardial Perfusion (MPI)(Rest): Adverse Reactions/artifacts:
Not being NPO for 4+hrs articles in pockets, medallions, necklaces, heart monitors, pacemakers, or metal buttons cause artifacts. If patient has left arm down to side, it may cause unwanted attention. Possible shield gall bladder b/c of uptake with Sestamibi.
Myocardial Perfusion (MPI)(Rest):Medications:
Some doctors prefer to hold heart medications until after test (check with cardiologist).
Myocardial Perfusion (MPI)(Rest): Age Specific/other Considerations:
Be well rested and avoid strenuous exercise the day of test and before exam.
Myocardial Perfusion (MPI)(Rest): Lab Values:
N/A not need..
will be done before surgery if need after test.
Imaging Techniques: Anatomical Landmarks:
N/A
Imaging Techniques: Views:
SPECT imaging so RAO to LPO
Imaging Techniques: Patients Detector Orientation:
Supine with heart in the center FOV and left arm over head if possible. If arm is down at side because of problems with shoulder or recent surgery, both images(stress/rest) should be taken the same way.
Imaging Techniques: Fusion Imaging
N/A
Imaging Techniques: Procedure: Thallium:
Rest only; patient waits 5-20 after injection before image.
Imaging Techniques: Procedure: Sestamibi
Patient waits 45-60 mins after injection before image. Give patient a cold glass of water to clear Thyroid, live and bowel.
Imaging Techniques: procedure: Tetrofosmin:
Patient waits 5-30 minutes after injection before imagine (give water). Images may include a static ANT Picture first, (300seconds). Start SPECT images with camera RAO to LPO.
Imaging Techniques: Procedure: Other Protocols: Thallium (Only):
Stress is done first, imaged as soon as possible, then imaged again 3-4hrs later(sometimes with a small reinjection of 1 mCi). Rest study is completed using its ability to redistribute. Some perform a 24 hr delay study with a 1MCi reinjection (wait 5-20 mins to image), looking for hibernating tissue.
Imaging Techniques: procedures: Thallium-Thallium:
Both tests are done with Thallium but on different days.. This is a two day tests..
Imaging Techniques procedure: Thallium- Sestamibi (dual energy/ dual isotopes):
Thallium rest study (3Mci) is done first ( inject,wait 20 mins, image) followed quickly ( within the hour) by the stress test using Mibi.
Imaging Techniques procedure: Sestamibi-Sestamibi:
Both tests are done with Mibi but on different days. The stress can be done first but If no defects are observed, so choose to not do rest study.
Imaging Techniques procedure: MIBI MIBI
Both tests are done on the same day. Either rest or stress can be done; however, most prefer to do resting first then stress. The first study is done with a low dose (8mCi) and the second(an hr or more later) with a high dose (25-30 mCi).
Instrumentation: Detector System:
Low energy/ all-purpose or low energy/ high res parallel- hole.
Instrumentation: Data acquisition:
Tc-99m window at 140 keV, TI-201 at 167 KeV at 20%. (static)-Timed for 300secs. (SPECT)- 180*,32 or 64 projections at 20-40sec/frame, 8 frames/cycle if gated,matrix at 64x64.
Instrumentation: Data analysis:
Computer analysis of left ventricle showing the vertical long, horizontal long and shot axis. Usually done at the same time as stress images; the results of the two are compared.
Instrumentation: Data analysis: Normal:
Heterogeneous uptake of the left ventricular myocardium or right ventricle myocardium if requested.
Instrumentation: Data analysis: Abnormal:
Areas of little to no uptake exhibiting a cold spot. If the lack of uptake matches the stress results in the same area , it may be infarcted myocardium or severe ischemic tissue.
Instrumentation:Data analysis: Ancillary equipment:
N/A
Endocrine: Thyroid Imaging: Selection:
I-123 and I-131 as capsules, Tc-99m pertechnetate.
Endocrine: Thyroid Imaging: Dosages:
I-131: 1uCi-10mCi depending on the patient and reason for scan. Usually 5-30uCi for uptake and scan,2-5mCi for whole imaging and/or treatment of the patients, I-123: 100-450uCi Tc-99m: 2-10mCi.
Endocrine: Thyroid Imaging: Administration:
I-123 and I-131 capsule Oral(PO), Tc-99m by intravenous (IV).
Endocrine: Thyroid Imaging: Biodistribution:
Active transport; Tc-99 trapped but not organified. iodine organified by the thyroid and held in cells or follicular Lumen. T=3-5days.
Endocrine: Thyroid Imaging: Patient Preparation: Indicates:
Evaluations of thyroid anatomy(Ex: position, goiter,surgery,cold or hot nodules.): Detection, localization and evaluation of hyperthyroidism and hypothyroidism metastases from thyroid cancer. Differentiation of benign from malignant nodules, independent functioning nodules, benign ectopic tissue. Evaluations of abnormal thyroid serum lab results, sub clinical and subacute disease processes. Abnormal finding on other diagnostic tests.
Endocrine: Thyroid Imaging: Indicates: Contraindications:
Pregnant or nursing females, interfering recent contrast studies or patient has no discontinued thyroid or interfering medication, vitamins, or iodinated food products.
Endocrine Thyroid Imaging: Pregnancy and nursing:
N/A
Must asks if patient is under 40/50 years old.
Endocrine Thyroid Imaging: Dietary Restrictions:
Refrain from eating foods that containing iodine such as cabbage, turnips, greens seafood, Kelp or large amounts of table salt.
Endocrine: Thyroid Imaging: Adverse reactions/artifacts:
Compton scatter and down scatter from contaminated may contribute, Tc-99m not as accurate because of low uptake, high neck bkg, concentrations in extra-thyroid tissues and trapping without organification. Improper collimator and computer changes. Careless marker placement. Patient movement.
Endocrine Thyroid Imaging: Medications:
Physician to instruct patient to discontinue thyroid meds, contrast material, Butadiene or amiodarone( antiarrhythmics).
Endocrine Thyroid Imaging: Age specific/ other considerations:
N/A
Endocrine Thyroid Imaging: Lab Values:
N/A
Endocrine Thyroid Imaging: Imaging Techniques: Anatomical Landmarks:
Thyroid cartilage,
Supranational notch
Endocrine Thyroid Imaging: imaging Techniques: Views:
RAO and LAO
Endocrine: Thyroid: Imaging Techniques: Patient- Detector orientation:
Supine with pillow under shoulders and chin up.
Endocrine Thyroid: Fusion Imaging:
N/A
Endocrine: Thyroid: Procedure:
Tc-99: Administrator injection to patient; wait 15-20 mins before imaging. Give patient water. place patient supine with pillow under shoulders and chin up. Using the LEHR collimator, obtain ANT views(300 secs or 100,000) depending on protocol) with or without markers as per protocol( thyroid cartilage and superasternal, maker strip, right side,ets.)RAO and LAO and perhaps a “pull-back” image(more distant) for ectopic thyroid tissue are optional images of a pinhole not available. Using a pinhole collimator if available, take all.
Endocrine:Thyroid: Procedure: I-123:
Same as procedure above without injection. Image 50,000 to 100,000 counts or 8- 10 mins per image. Images can be taken from 3-36 hrs after admin of capsules(usually 4- 6 hours or 24 hours). peak camera for radio-tracer.
Endocrine Thyroid: I-131:
Same as procedure above without injection. Usually used to locate residual and recurrent cancers. 24,48,72 hr pictures may be the most useful. Collect 100,000 counts over thyroid and whole body of cancer is suspected. Check peak and collimators.
Endocrine Thyroid: Instrumentation: Detector System:
Low energy, high res or LEAP and pinhole for Tc-99m and I-123. High energy, parallel hole for I-131.
Endocrine: Thyroid: Data acquisition:
30% window at 364 keV for I-131,20%. Window at 159 KeV for I-123, 20% window at 140keV for Tc-99m; 50,000 to 100,000counts.
Endocrine Thyroid: Data analysis: Normal:
(Euthyroid) Homogeneous uptake of radio-tracer. Left lobe smaller then right lobe or having pyramidal lobe. Straight or convex outer margins. Uptake equal or greater then that of salivary( water or lemon given to reduce salivary uptake)Tc-99m shows on soft tissue, brain stomach mucosa,nasopharynx, bladder. I-123 and I-131 shows in nasopharynx, salivary glands, stomach, colon, bladder and lactating breasting breasts.
Endocrine Thyroid: Instrumentation: Data Analysis: Abnormal:
Plummer’s disease: autonomous multi modular goiter, nodules,solitary or multiple, cold or hot(solitary: adenoma, thyroiditis; multiple: goiter). non visual of thyroid gland caused by(Ex: subacute thyroiditis; patient on contraindicated meds.) Graves, disease: Enlarged gland, high uptake( LATS- long acting thyroid stimulator). Cold nodules on iodine scan can be clarified by, pertechnetate. Cold means non-vascular and can be malignant. Hot means vascularized and more likely to be benign.
Endocrine Thyroid: Instrumentation:
Ancillary equipment
Endocrine Thyroid Uptake: selection:
I-123 and I-131 as capsules, Tc-99m Pertechnetate.
Endocrine Thyroid Uptake: Dosage:
I-131: 1uCi- 10mCi depending on the patient and reason for scan. Usually 5-30uCi for uptake and scan, 2-5 mCi for whole imaging and/ or treatment of patients. I-123: 100-450uCi. Tc-99m: 2-10mCi.
Endocrine Thyroid Uptake: Administration:
I-123 and I-131 Caupsule(PO), Tc-99m by Intravenous (IV).
Endocrine Thyroid Uptake: Biodistribution:
Active transport, Tc-99m trapped but not organified. Iodine organified by thyroid and held in cells or follicular lumen. T=3-5 days.
Endocrine Thyroid Uptake: Patient Preparation: Indicators:
Evaluation of thyroidal radioactive iodine uptake( This provides an index of thyroid trapping and iodine organification as a % radioactive tracer into thyroid tissue over a period of time; dependent on thyroid function.) evaluation of(before hypothyroidism and independently functioning nodules, evaluation of( before appearance of typical symptoms) subacute disease processes (toxic goiter,thyroiditis etc.) When used with Thyroid scan: Detection and localization of metastasis from cancer, differentiation of benign/ malignant nodules, evaluation of function diversity within a hyperthyroid gland, detect and localization of benign ectopic tissue.
Endocrine Thyroid Uptake: Contraindications:
Allergic to iodine, has not discontinued thyroid or other interfering meds, discontinue thyroid med for too long, radiologic studies with iodine contrast performed within 6-8weeks of study.
Endocrine Thyroid Uptake: Pregnancy and Nursing:
N/A
Must ask if patient under 40/50 years old.
Endocrine Thyroid Uptake: Dietary Restrictions:
Refrain from eating iodine- containing foods such as cabbage, turnips,greens, soybeans,shellfish,Kelp or large amounts of table salt. Some require this as a 3to 10days protocol before administration of the capsules.
Endocrine Thyroid Uptake: Adverse reactions/artifacts:
Capsule not assayed in dose calibrator for activity/counted before administration. Tc-99m not as accurate because of low uptake, high neck bkg, concentrations in extra- thyroid tissues and trapping without organification. Placement of probe must be consistent with department protocol or reading can be false positive or negative. Patient on interfering food or medications .
Endocrine Thyroid Uptake: Medications:
Physician to instruct patient to discontinue thyroid meds, contract material, betadine or amiodarone(antiarrhythmics). Thyroid stimulator: Thyroid Antagonists.
Endocrine Thyroid Uptake: Age specific/ other considerations:
N/A
Endocrine Thyroid Uptake: Lab Value:
Calcitonin (400ng/L) High= Medullary carcinoma of the thyroid, some non- thyroid tumors. T4 Thyroxine (4.5-11.5mg/dL) High= Hyperthyroidism, thyroiditis, Low= Hypothyroidism,hypoproteinemia. T3 triiodothyronine (25-35%) High= Hyperthyroidism, TBG deficiency low= Hypothyroidism, pregnancy, TBG excess. TSH Thyroid stimulating hormone(3-5m/IU/L) High= primary hypothyroidism Low=Hyperthyroidism.
Endocrine Thyroid Uptake: Imaging Techniques: Anatomical Landmarks:
Probe for thyroid- facing thyroid 25-30 cm from patients neck, probe for bkg- facing thigh 25-30 cm.
Endocrine Thyroid Uptake: Imaging Techniques: Views:
Camera for thyroid: ANT and Close.
Endocrine Thyroid Uptake: Patient - Detector orientation:
Supine
Endocrine Thyroid Uptake: Fusion Imaging:
N/A
Endocrine Thyroid Uptake: Procedure:
Assay capsules in dose calibrator or syringe with Tc-99m. Then, Tc-99m count in neck phantom for “standard” inject and wait 20 mins. Calculate 20 min decay(Tc-99m is rarely used for uptake). Count capsules in neck photon with probe or camera; can serve as the “standard “. Count room bkg and record counts.
Endocrine Thyroid Uptake: Imaging Techniques: Probe for Thyroid:
Facing thyroid gland(Usually 25-30cm from patient’s neck), 1 minute; can be counted twice then averaged. Record counts.
Endocrine Thyroid Uptake: Imaging Techniques: Camera for Thyroid:
Place patient in supine position, pillow under shoulders to extend neck with camera ANT and close( EX: 10cm (record position to use for 24 hrs uptake)), thyroid centered; start count or camera(1 min count, can be twice then averaged) then record counts.
Endocrine Thyroid Uptake: Probe for patient bkg:
Position probe usually facing thigh, (25-30cm), start counts, one minute can be twice than average, record counts/applies to 24 hour uptake too.
Endocrine Thyroid Uptake: Camera for patient bkg:
Position camera over patient size . Use same distance as from thyroid (10 cm). Start counting or camera(1minute counts, can be twice than average). Then record counts.
Endocrine Thyroid Uptake: Camera/probe for standard:
Count Standard in neck phantom at same distance as patient. If there is no capsule, use original of capsule and apply, to Decay factors.
Endocrine Thyroid Uptake: Camera/ Probe for room bkg:
Ensure no patient under camera or probe not facing any source of activity. Start cutting or camera, (1 minute count, can be twice than average, then record counts.
Must Calculate uptake:
Endocrine Thyroid Uptake: Instrumentation: Detector System:
Flat–field scintillation probe with pulse - height analyzer, LEAP or Low energy/ high res.
Endocrine Thyroid Uptake: Data Acquisition:
30% window at 364keV for I-131, 20% window at 159keV for I-123, 20% window at 140keV for Tc-99m.
Endocrine Thyroid Uptake: Data analysis: Normal:
4-6hour= 5to 20%, 24hrs = 7 to 35%, Tc99m: 20 mins=4%.
Endocrine Thyroid Uptake: Instrumentation: Abnormal:
At 24hrs, less then 7% indicates hypothyroidism especially with concordant history. More then 35% indicates hyperthyroidism with concordant history.
Endocrine Thyroid Uptake: Factors that increase uptake:
Hyperthyroidism, early Hashimoto’s recovery from subacute thyroiditis, rebound from anti-thyroid drugs, enzyme defects, starvation, iodine deficiency, TSH, tumor-secreted stimulators, pregnancy.
Endocrine Thyroid Uptake:Factors that decreases uptake:
Hypothyroidism, iodine overload(radiographic contrast),subacute or autoimmune thyroiditis, thyroid hormone therapy, ectopic secretion of thyroid hormone, renal failure.
Endocrine Thyroid Uptake: Instrumentation:
Ancillary equipment…
Parathyroid: Selection:
Tc-99m/Tc04 Pertechnetate,TI-201 Thallous Chloride, Tc-99m Sestamibi,Tc-99m Tetrofosmin, I-123 Sodium Iodide.
Parathyroid: Dosage:
Tc04: 5-12mCi, TI-201: 2-3mCi, Tc-99m: 16-30mCi,I-123: 200-300uCi.
Parathyroid: Administration:
Intravenous (IV),I-123: month(PO).
Parathyroid: Biodistribution:
Tc04: Active transport into normal thyroid. TI-201: Distributes with Na/K pump,enters thyroid and parathyroid tissue with blood flow. Tc-99m: Passive transport in proportion to blood flow, prolonged Mibi retention within parathyroid. I-123: Organified in cells or follicular lumen.
Parathyroid: Patient Preparation: Indicates:
Detection/localization of primary and secondary cancer. Identification of single/ multiple adenomas or glandular hyperplasia in patients with newly diagnosed hypercalcemia and elevated(PTH) levels. Localization of cancer for surgery candidate or tissue after surgery for persistent or recurrent hyperparathyroidism ( elevated serum calcium and PTH).
Parathyroid: Patient Preparation: Indicates : Contraindications:
Patients on calcium meds, thyroid meds or received recent iodine contrast studies, patients should be off of thyroid meds for five days, contra study; 7 to 10 days. Patient is prone to movement’s or claustrophobia.
Parathyroid: Pregnancy and Nursing:
N/A
Parathyroid: Dietary restrictions:
N/A
Parathyroid: Adverse reactions/artifacts:
No patient movement is critical in subtraction method and with use of pinhole collimator. May not visualize ectopic tissue or abnormal tissue<300mg in size. Adenomas can wash out quickly in two-phase or fail to present.
Parathyroid: Adverse reactions/ artifacts: Flase-positive:
Patient motion, thyroid disease, multi modular goiter(MNG),uptake in cervical lymph node, extravasation causing ancillary lymph node uptake and carcinomas. Images should be corrected with an ultrasound.
Parathyroid: Adverse reactions/artifacts: False -negatives:
Parathyroid hyperplasia. Interference from medications,rad, contact studies. Depending on camera, for severe claustrophobic patients, points camera outward and seat patient with chin on camera/ ROI in view and secure with tape ensuring no movement.
Parathyroid: Medications:
Patient should be off thyroid meds for 5 days.
Parathyroid: Age
Specific/other considerations:
N/A
Parathyroid: Lab Values:
N/A
Parathyroid: imaging Techniques: Anatomical Landmarks:
Position camera anterior over extended neck mediastinum.
Parathyroid: Imaging Techniques: Views
ANT, RAO, LAO.
Parathyroid: patient Detector Orientation:
Supine, pillow under shoulders, head back,neck extended.
Parathyroid: Fusion imaging
N/A
Parathyroid: Imaging Techniques: procedure: Dual- Isotopes Subtraction Technique:
Place patient supine, pillow under shoulders, head back, neck extended. position camera ANT over neck and mediastinum. Remove any attenuation items, immobilize head if necessary. Instruct patient to remain motionless during acquisition. Inject TI-201. procedure A: within 2-3 mins of injection, obtain a 300 sec image with pinhole looking for uptake between heart and thyroid. Immediately follow with a 900 sec image of thyroid centered in FOV. Follow with injection of 5-10mCi of Tc04, obtain 900 second image. Run subtraction program, if necessary, to separate TI-201 from Tc04.
Parathyroid: Imaging Techniques: Dual-Isotopes with I-123 or Tc04 and Sestamibi/Tetrofosmin:
I-123: Patient given 200-300uCi PO. At 3-4hrs after admin, take a single image with 300,000- 500,000 counts or 300 sec using 10% window for I-123( image used for digital subtraction or visual comparison). Patient is then injected with Mibi or Tetrofosmin. After 15 mins, patient is imaged with two 600 secs ANT pictures; one using 10% window for Tc-99 and the other for I-123. Imaging can also include RAO and LAO angles. 3hrs after injection, image using the same parameters again. Normalize I-123 images to the Tc-99m images, subtract the I-123 from the Tc-99m images.
TcO4 inject 1-2 mCi pertechnetate. At 15mins,take 300 sec using 10% window at 140keV; this is used for subtraction. Patient is then injected with Mibi or Tetrofosmin. Imaging and processing as above.
Parathyroid: Imaging Techniques: Procedure: Single-Isotopes Two-Phase:
Injected patient with either Mibi or Tetrofosmin. Wait 15 mins to obtain image. Remove any intuition materials, please patient as instructed above. Position camera ANT over extended neck and Mediastinum. Using LEAP/LEHR collimator,acquire 300-600 sec ANT,RAP,LAO 30*images. Obtain marker image:Thyroid cartilage and supranational notch(SNN) if protocol.( Be sure to include salivary glands to mediastinum with ANT images!) Repeat images at 1.5-hrs after injection. Repeat images at 4-6hrs after injection if there are questionable images. SPECT may also be a consideration; acquire at 3 mins after injection and delay at 2hrs.
Parathyroid:Instrumentation: Detector System:
Pinhole, LEAP or Low energy, high res:
Parathyroid: Instrumentation: Data Acquisition Planar:
128x128 or 64x64 matrix, 1 million counts or 300-900sec/image SPECT-360, 128 x128 matrix,64stops, 20-25sec/stop.
Parathyroid: Instrumentation: Data analysis: Normal: Dual- Isotopes subtraction Technique:
No increased TI-201 activity within or outside normal thyroid tissue. Normal parathyroid does not accumulate TI-201 or Tc-99m activity. Mibi and Tetrofosmin initially hetero uptake by thyroid, salivary, heart, gut. Delays; hetero washout, no focal points of uptake. I-123 uptake in thyroid tissue as in a normal thyroid study as normal para tissue does not accumulate I-123.
Parathyroid: Instrumentation: Data analysis: Normal:Single-Istope Two Phase:
Initially, hetero uptake by thyroid, salivary, heart and gut. Delays; hetero washout, no focal points of lingering uptake.
Parathyroid: Instrumentation: Data analysis: Abnormal: Dual-Isotopes Subtraction Technique:
Areas of increased TI-201 within and out normal thyroid tissue. Increased focal areas of Mibi/Tetrofosmin uptake after subtraction of I-123 especially on delays.
Parathyroid: Instrumentation: Data analysis: Abnormal: Single Isotopes Two phase:
Washout of thyroid tissue with focal areas of increased activity on delayed images anywhere from salivary glands to mediastinum. Obliques help define position of abnormalities in neck area.
Surgery- Focal areas are usually located by small hand- held gamma probe. Once resected, the tissue should at least 20% to50% higher then bkg tissue.
Parathyroid: Instrumentation: Data analysis:
Ancillary equipment
Neuroendocine/OctreoScan: Selection:
In-111 Pentetreotide, long acting analog of the hormone somatostatin receptors, concentrating in tumors cells with a density of receptors.
Neuroendorcine/OctreoScan: Dosage:
6 mCi
Neuroendocine/OctreoScan: Administration:
Intravenous (IV) and 10 ml of flush.
Neuroendocine/OctreoScan: Biodistribution:
Extravasation and chemical bonding to somatostatin receptors, concentrating on tumors cells with a density of receptors.
Neuroendocrine/OctreoScan/ Patient Preparation: Indicators:
Detection and localization of somatostatin receptors on primary and metastatic neuroendocrine tumors(EX: carcinoid, pituitary, small cell carcinoma of the lung, pheochromocytoma,ets.) Detection and localization of endocrine pancreatic tumors,paragangliomas and neuroblastoma. Evaluation of elevated tumor markers, patients with history of cancer or known somatostatin receptors type cancer, pre or post surgery and receptors status(therapy)
Neuroendocrine/OctreoScan: Contraindications:
Patients with severely impaired renal function. Do not inject through total parenteral nutrient(TPN) admixtures or TPN IV catheters B/C the sugars may cause a glycolysis- In-111 Pentetreotide conjugate to form.
Neuroendocrine/OctreoScan: Pregnancy and Nursing:
N/A
Neuroendocrine/ OctreoScan: Dietary Restrictions:
Instruct patient to hydrate well before/after injection. Physician to order mild laxatives evening before infection and continued with light meals and clear liquids until all images completed.
Neuroendocrine/ OctreoScan: Adverse reactions/ artifacts:
Patients with impaired renal function,pediatrics or have insulinoma( can become severely hypoglycemic/should have IV glucose infusion available. Do NOT administer in TPN mixtures or inject in TPN catheters. Glaze-positive results(especially in lungs) can occur as a result of inflammatory reactions,radiation therapy,etc. Flase-negative may be possible from poor somatostatin tag, poor affinity to tumor.
Neuroendocrine/OctreoScan: Medications:
Octreotide therapy patients should suspend the medications for 72hours before injection of radiopharmaceutical.
Neuroendocrine/OctreoScan: Age Specific/other considerations: Study prep-Day1:
Purchase 4 bottles of magnesium citrate. Eat a light breakfast on morning of infection and be well hydrated. After injection, drink a bottle and drink plenty of clear liquids until scan is completed. Eat a light dinner followed by 2nd bottle and plenty of clear liquids until after the 24hr scan.
Neuroendocrine/Octreoscan: Study Prep- Day 2:
After 24 hours scan, eat light lunch and dinner. After evening meal, drink 3nd bottle and plenty of liquids until the 48hrs scan.
Neuroendocrine/OctreoScan: Study Prep-Day3:
After 48hour scan, eat lunch and dinner after the dinner, evening meal,drink 4th bottle and plenty of liquids until the 72hr scan.
Neuroendocrine/OctreoScan: patient preparation: Lab Values:
N/A
Neuroendocrine/OctreoScan: Imaging Techniques: Anatomical Landmarks:
N/A
Neuroendocrine/OctreoScan: Imaging techniques: Views:
Whole body
Neuroendocrine/ OctreoScan: Imaging techniques: Patient Detector Orientation:
Supine
Neuroendocrine/OctreoScan: Imaging Techniques:Fusion Imaging:
N/A
Neuroendocrine/ OctreoScan: imaging Techniques: Procedure:
Instruct patient to void before scan begins and between multiple procedures. Place patient in supine position on table,check for attenuating items.
Images: Obtain at 4hours( Whole body, static and/or planar of abdomen),24hour ( whole body, planer, and /or SPECT with liver,spleen and kidney in FOV; some require SPECT chest, abdomen and pelvis),48hours(same)and 72hours(same).
Neuroendocrine/OctreoScan: Instrumentation: Detector System:
Medium energy, general purpose or medium energy,all purpose.
Neuroendocrine/OctreoScan: Instrumentation: Data acquisition: Statics:
Abdomen-500,000 counts or 15min/image.
Whole body: 512x1024 matrix,10cm/min or longer(minimum 30 mins),head to pelvis.
SPECT: 360*,64 stop, 45-60sec/stop, 64x64 matrix.
Neuroendocrine/OctreoScan: Instrumentation: Data analysis: Normal:
Excretion is almost exclusively renal;50% at 6hrs,85% at 24hrs, and 90% at 48hrs( hence the need for hydration). Uptake seen in blood pool, pituitary, liver, GB,spleen,kidneys and bladder. Planar images at 4 and 24hrs can differentiate bowel contents from true uptake or fecal contamination; clarity at 48 hrs. Pituitary and normal thyroid present at 24 hrs.
Neuroendocrine/ OctreoScan: Instrumentation: Abnormal:
Focal areas of uptake; particularly visible as time and biologic activity diminishes bkg distribution.
Neuroendocrine/OctreoScan: Instrumentation:
Ancillary equipment
Adrenal Imaging: Selections:
I-123 or I-131 mIBG,I-123 iobenguane and I-131 iobenguane.
Adrenal Imaging: Dosage:
I-131 500uGi(1mCi for suspected metastasis pheochromocytoma). I-123 3-15 mCi.
Adrenal Imaging: Administration:
Intravenous (IV) slowly over 5 mins
Adrenal Imaging: Biodistribution:
Blood flow, guanethidine along absorbed the same as norepinephrine into the chromaffin cells of the adrenergic tissue and stored in granules.
Adrenal Imaging: Patient Preparation: indicates:
Detection and localization of benign or malignant intravenous-adrenal and extra-adrenal pheochromocytoma(usually benign chromaffin cells tumors of the sympathoadrenal system that secrete catecholamines: EX: (noroehhrine and epinephrine), sites of hormonal overproduction, neuroectodermal(nerve tissue) tumors, neroblastomas and other Neuroendocrine tumors. Differentiating Neuroendocrine and no Neuroendocrine tumors,previously diagnosed pheochromocytoma, staging,evaluating chemotherapy and surgery.
Adrenal Imaging: Patient Preparation: Contraindications:
Allergy to iodine may be a consideration and taking medications.
Adrenal Imaging: Patient Preparation:,Pregnancy and Nursing:
N/A
Adrenal Imaging: Patient Preparation: Dietary Restrictions:
N/A
Adrenal Imaging: patient preparation: Adverse Reactions/artifacts:
Attenuating articles in clothing, images not taken for enough counts, aggressive chemotherapy may hinder visual of some Mets. FALSE-POSITIVE: Caused by recent surgical sites, X-ray therapy to lungs, bleomycin-induced pulmonary changes. FLASE-NEGATIVE: due to lesions too close to a large primary, metastatic mass, or tissue with high normal uptake. No or low tumor uptake, lack of granules and loss of tumor capacity to absorb tracer. Focal areas usually linger over time and grow in intensity; limit false P’s with delays.
Adrenal Imaging: patient preparation: Medications:
Ideally, no medications 2-3 weeks before the examination.
Adrenal Imaging: Patient Preparation: Age Specific/ other considerations: Before Day of Injection:
Physician instructs patient to take saturated solution potassium iodide (SKKI) or lugol’s solution to block free iodine uptake in thyroid. Admin 1drop,beginning the day before radiopharmaceutical administration,continuing for 6 days after injection. If allergic to iodine, perchlorate may be used. Physician instructs patient to take prescribed laxative days before imaging to reduce bowel activity: patient with atopic history(hypersensitivity or allergy to meds like iodine or steroids) to be treating with oral antihistamines 1hour before infection.
Adrenal Imaging: Patient Preparation: LAB Values:
N/A
Adrenal Imaging: Imaging Techniques: Anatomical Landmarks:
N/A
Adrenal Imaging: Imaging Techniques: VIEWS:
ANT/POST
Adrenal Imaging : Imaging Techniques: Patient Detector Orientation:
Supine.
Adrenal Imaging: Imaging Techniques: Fusion Imaging:
N/A
Adrenal Imaging: Imaging Techniques: Procedure:
Ensure patient is off meds and has taken thyroid blocker night before. instruct to empty bladder and lay supine.
Adrenal Imaging : Imaging Techniques: I-131 MIBG at 24,48 and possibly 72hrs.
Acquire ANT/POST images of head/neck, thorax abdomen and pelvis. Set whole body sweep slow (10cm/min or less). Static images of areas of interest of preferred or protocol:should run at least 100,000 counts or 5-20mins. Acquire lateral views of abnormal uptake to aid in localization. Acquire marker images. If protocol (on axillae,lower ribs and iliac crests). Use 5uci I-131 capsules for markers. Acquire SPECT if protocol or requested.
Adrenal Imaging:Imaging Techniques: I-123 MIBGat24,48and possibly 72hours.
Same imaging procedures as above. Acquire static (chest, posterior mid thorax,Kidneys centered and lumbar) of at least 500k counts or 15 mins each.
Adrenal Imaging: Imaging Techniques: Instrumentation: Detector System:
I-131: Medium energy/general purpose or medium energy/high resolution. I-123: LEAP or low energy/high resolution:
Adrenal Imaging: Imaging Techniques: Instrumentation: Data Acquisition: Statics:
I-13:=100 K counts up to 20 min/images= I-123=500K or 15 min. Whole body: 5-10 cm/min,head to pelvis.
SPECT: 360*,64 stops at 20/sec/stop.
Adrenal Imaging: Imaging Techniques: Data analysis: Normal:
Uptake occurs in pituitary,salivary glands,thyroid,liver,spleen. GB will be visualized in patients with renal failure. Kidney and bladder will visualize due to excretion, heart with normal catecholamine levels. Heart and adrenal medulla are seen more clearly with I-123. No skeletal uptake that normal uptake areas diminish over time.
Adrenal Imaging: Imaging Techniques: Abnormal:
Focal areas of increased activity that increase over,time; sporadic,unilateral tumors show intense focal uptake. Mets disease is visualized in axial skeleton, heart, lung, mediastinum, lymph nodes and liver. Images at 72 hrs provide maximal contrast between foci of activity and bkg.
Adrenal Imaging: Imaging Techniques: Ancillary Equipment:
N/A
Tumors: Whole Body/PET/CT: Selection:
FDG/F-18,a glucose analogue.
Tumor: Whole Body/PET-CT: Dosage:
4-20 mCi, adjust by weight or body surface for peds.
Tumor: Whole Body/PET-CT: Administration:
Intravenous (IV) butterfly or indwelling catheter. Should be admin in a site contralateral to the area of interest. Steps: Assay dose,record amounts and time. Administer injection, flush with 10cc saline, remove catheter, record time. Assay the syringe after injection, record amount and time.
Tumor: Whole Body/PET/CT: Biodistribution:
Trapped in the tissue as a phosphate with distribution mapped as glucose metabolism. FDG does not undergo tubular reabsorption in the kidneys and thus, is excreted in the urine.
Tumor: Whole Body/PET-CT: patient Preparation: indicators:
Detection, localization and staging of primary, metastatic and/or recurrent tumors. Differentiation between benign and malignant tumors,recurrent malignant disease form therapy induced changes, staging of patients with known malignant tumors, localization of lesions for biopsy or radiation therapy and evaluation of oncologic therapies of known or residual malignancies.
Tumor Whole body/PET-CT: patient preparation: Contraindications:
High glucose levels will hinder tumor uptake(>200mg:dl). FDG does present well In all kinds of tumors. Patient too agitated,uncooperative or claustrophobic to remain still. Drug and/ or food ingestion bears specific consideration for each study; either could be contamination. Too much muscle activity before exam.
Tumor:Whole Body: Patient preparation: Pregnancy and nursing:
N/A
Tumors: Whole Body: Patient Preparation: Dietary Restrictions:
NPO at least 6 hrs except water before test. This reduces insulin levels to base levels and uptake in certain organs (EX: heart). This includes no gum, candy, soda, or anything that contains sugar. Patient is to hydrated before(Two 8 ounce cups).
Tumor: Whole Body: Patient Preparation: Adverse reactions/artifacts:
N/A
Tumor: Whole Body: Patient Preparation: Medications:
No Caffeine, alcohol,or nicotine products with 24hours of exams.
Tumor: Whole Body: Patient preparation: Age specific/ other considerations:
Blood sugar level should be 200 MG/DL, before injection allies for better FDG uptake. Patients, with blood sugar problems not taking, insulin in the morning and be scheduled for the earliest exam time. Patient is to avoid vigorous exercising within 24 hours of exam. After injection, patient should be kept warm, comfortable and resting during uptake phase until imaging time. Remind patient not to move or speak during this time. Patient to remove all metal articles from person.
Tumor Whole Body: patient;preparation: Lab Values:
N/A
Tumors: Whole Body: patient; Preparation: Imaging Techniques: Anatomical Landmarks
Base of skull to mid-thigh, “Eyes to thighs”
Tumors: Whole Body: Imaging Techniques: VIEWS:
Whole Body
Tumors: Whole Body: Imaging Techniques: Patient Detector orientation:
Supine, arms up( arms down of head/ neck neoplasms), use head holder.
Tumors: Whole Body: Imaging Techniques: Fusion Imaging:
Yes
Tumors: Whole Body: Imaging Techniques:Procedure:
Image at 45 minutes, range of (30–90) after injection for Malibu Alek Uptake. Some wait longer for target to backgrounds; ratio to improve. Patient to avoid before, Lay supine, supine, align with laser to landmark, arms up, use head holder.
Tumor: Whole Body: Imaging Techniques: Procedure: For dedicated PET cameras:
Limited field tomographic images: Acquire transmission image(some require 125 million counts over15-20mins). On some systems, this can be done before or after emission imaging. Emission image: 6 to 15 mins per bed position,collecting 5-15 million counts,depending on area of interest.
Tumor:Whole Body: Imaging Techniques: procedure: PET/CT:
Some scans require ingesting oral contrast arrival. Studies that do not are (cardiac,brain,head and neck cancer studies). Scout ( topogram)image at 120 kV, 10mA.CT (attenuation correction) imaging at 140keV,auto for (100-200lbs) normal size patient or (200-400IBs) large patient). PET imaging at 3 mins FOV 100-200lbs) normal or 5 min FOV 200-400Ib for large patient.
Tumor Whole Body: Instrumentation: Detector System:
2D-3D dedicated PET imaging.
Tumor:Whole Body: Instrumentation: Data acquisition:
Dedicated PET: photopeak 300-650keV for BGO, 435-665KeV for Nal( CPET). Bed acquisition times per bed ( usually 6-8beds).
Tumors: whole Body: Instrumentation: Data analysis:
Images filtered/reconstructed in transverse, coronal, and Sagittal planes. PET studies can be fused with CT. There may be four groups of images in each study(EX: scout 2D,AC,2D NAC, and CTAC.Erase scout then save and send images.
Tumors: Whole Body: PET/CT: Instrumentation: Data analysis: Normal:
Uptake pretty much everywhere, only going to focus on main areas. Brain, high in gray, low and white, cortex and basal ganglia. Thyroid Camby high with Graves’ disease or thyroiditis),Myocardium (even despite fasting), aorta( bandlike in thoracic aorta),liver,spleen,stomach,bowel( ascending colon appearing tubular) esophagus,kidneys, bladder,and bone marrow(can be high after stimulating agents). Brown fat( females and cold environment). Low uptake in lung, breast, testes and penis. Increased uptake in surgical wounds( up to 6 months after surgery). No activity in pancreas, prostate,lymph nodes or breast implants. After cancer therapy, uptake common in axial skeletal, brown fat(posterior neck/shoulders) and costovertebral joints.
Tumor: Whole Body: Instrumentation:Data analysis: Abnormal:
High uptake in the larynx, esophagus, colorectal, melanoma. Moderate uptake in thyroid,lung, breast. Low uptake in brain, renal/ bladder and prostate. Variable uptake in head/neck,skeletal,uterine,cervical and testicular. Increased uptake in infections and inflammatory tissue(pneumonia,cellulite and osteomyelitis). Increased uptake in trauma(recent surgery,fracture,graft,radiation therapy). An SUV of 2.5 is suggestive of malignancy.
Tumor:Whole Body: Instrumentation:
Ancillary equipment:
Lymphoscintigrapy: Radiopharmaceutical: Selection:
Tc-99m Sulfur Colloid (Filtered).
Lymphoscintigraphy: Radiopharmaceutical: Dosage:
200uCi to 2mCi,450uCi to 1mCi is typical for 2 to 6 injections. Up to 7mCi total.
Lymphoscinigraphy: Administration: For Melanoma:
2 to 6 subcutaneous or intravenous injections producing a wheal around the cancer, surgery site or ROI (within 5mm). Volume should not exceed 0:25ml per injection site.
Lymphoscintigraphy: For breast lesions:
I tra glandular injection,4 to 6, placed in tissue surrounding the lesion(within 1-3mm) found by palpation. 3,6,9,and 12 o’clock position.
Lymphoscintigraphy: Administration: Intradermmal Injections:
Because of the nature of the lymphatic system in the breast, injections can only be intradermal and not deep at the position of the lesion or site. Peri- Aurelia can be done at 3,6,9 and 12 o’clock positions.
Lymphoscintigraphy: Administration: for Lymphedema:
Subcutaneous injections, 2sites per limb.
