BONE SCAN

(SKELETAL IMAGING)BY

DR. ASHRAF ANAS ZYTOON MD, PHD, FJRS

MENOUFIYA UNIVERSITY - EGYPT

Radiopharmacy

Radionuclide : 99mTc t1/2: 6 hours

Energies: 140 keV

Type: γ, Generator

Radiopharmaceutical : MDP (methylene

diphosphonate)

Adult Dose Range : 20–30 mCi (740–1110 MBq),

pediatrics by weight.

Method of Administration : Intravenous: with

saline flush.

Indications 1

Detection of primary and staging metastatic disease.

Differentiation of monostotic (single bone) from polyostotic primary bone tumors.

Differentiation between osteomyelitis (inflammation of bone and bone marrow) and cellulitis (inflammation of cellular or connective tissues). A three-phase flow study is indicated. Three-phase studies examine vascular, immediate blood pool, then osseous (osteoblastic) activity distinguishing cellulitis (activity in flow and immediate phases) from osteomyelitis (activity in third or all three phases).

Evaluation of prosthesis concerning suspected loosening, infections, avascular necrosis, and/or pain.

Indications 2

Detection of occult fractures.

Evaluation of bone pain and/or trauma.

Detection and evaluation of arthritis and degenerative disk and/or joint (osteoarthrosis) disease.

Evaluation of response to chemotherapy, radiation therapy, antibiotic therapy, and other treatment.

Localization of sites for biopsy.

Contraindications Patient who has recently ingested contrast medium

(particularly barium) for a different study (X-ray).

Patient who has recently (24–48 hours) had a technetium-based nuclear medicine scan performed.

Patient Preparation Identify the patient. Verify doctor's order. Explain the

procedure.

Instruct patient to drink lots of fluids (hydrate well) and urinate often before imaging.

Instruct patient to return in 2–4 hours (usually 3 hours) after injection for delayed statics, whole body imaging or SPECT.

Contraindications Patient who has recently ingested contrast medium

(particularly barium) for a different study (X-ray).

Patient who has recently (24–48 hours) had a technetium-based nuclear medicine scan performed.

Patient Preparation Identify the patient. Verify doctor's order. Explain the

procedure.

Instruct patient to drink lots of fluids (hydrate well) and urinate often before imaging.

Instruct patient to return in 2–4 hours (usually 3 hours) after injection for delayed statics, whole body imaging or SPECT.

Equipment

CameraLarge field of view

CollimatorLow energy, high resolution, or low energy, all purpose

Computer Set-upFlowDynamic, 2–4 seconds for 60 seconds with immediate blood pool image

Static Imaging

Artifacts

Bladder may need lead shield or catheterization. Pubic lesions may be obscured by bladder activity.

Catheters or urine seepage, IV infiltration, and contaminated clothing or linen cause hot spots.

Patient movement or rotation may distort view.

Imaging begun too soon or with patient not hydrating adequately before imaging may show excessive activity in soft tissue.

Degenerative joint disease, surgery, and old trauma may give false-positives.

Take laterals, obliques, and/or any other helpful positions if there is any question about a visualization (better too many than too few, or needing the patient to return at radiologist's request).

Patient History (The patient should answer the following questions) 1

Do you have history or family history of cancer?

Have you had any chemotherapy or radiation therapy?

Do you have any bone pain?

Have you had any recent falls, fractures, breaks, or

trauma?

Do you have any old sports injuries?

Have you had any recent surgery?

Patient History (The patient should answer the following questions) 2

Do you have a history of any kidney disease?

Have you had any recent dental work?

Have you had recent abnormal blood tests or lab work

(e.g., tumor markers, PSAs)?

Have you had any previous scans or x-rays or have any

scheduled diagnostic tests (e.g., x-ray barium studies, CT

with contrast)?

Female: Are you pregnant or nursing?

CARDIAC PERFUSION

(MI SCAN)

Radiopharmacy

Radionuclide : 99mTc-sestaMIBI (2-methoxy-isobutylisonitril), t1/2: 6 hoursEnergies: 140 keVType: γ, generatorAdult Dose Range: 15–30 mCi (555–1110 MBq) 20 -- 10

Radionuclide : 201TI-thallous chloride, t1/2: 73 hoursEnergies: 68–80 keVType: γ, acceleratorAdult Dose Range: 2–5 mCi (74–185 MBq). 3 -- 1

Method of Administration: Intravenous

Indications 1 Detection and evaluation of coronary artery disease.

Evaluation for coronary bypass surgery or angioplasty.

Detection and evaluation for viable or hibernating myocardial tissue (particularly with thallium).

Evaluation of physical indicators: Myocardial infarction, chest pain, shortness of breath, history or family history of heart disease.

Indications 2

Evaluation of laboratory indicators: Elevated levels of creatine phosphokinase, lactate dehydrogenase, and the newer tests for troponin and myoglobin (specific indicators for heart damage).

Evaluation of the heart because of abnormal results on related studies.

Contraindications 1

Patient experiencing chest pain, or have documented acute myocardial infarction within 2–4 days of test.

Patient should discontinue chemical stressors, e.g., caffeine, Persantine, theophylline, Viagra 24 to 48 hours.

Contraindications 2

Patient on heart medications. Some cardiologists prefer to hold all heart medications until after test (check with cardiologist).

Patient with extreme illness; high blood pressure, arrhythmias, congestive heart failure, acute myocarditis, severe mitral or aortic stenosis, systemic illness, or neurologic or physical conditions that may hamper the stress test.

Patient Preparation 1

Identify the patient. Verify doctor's order. Explain the procedure.

Instruct patient to be NPO for 4–12 hours.

Diabetics; monitor blood sugar and adjust, delay insulin after exercise.

Instruct patient to ingest no caffeine, dairy products, or sugar.

Patient should be well rested and avoid strenuous exercise the day of test before exam.

Patient Preparation 2

Some doctors prefer to hold heart medications until after test (check with cardiologist).

Obtain a signed consent form.

Remove cardiac monitor from in-patient.

Shave and wipe chest.

fatty meal 15 min after injection to reduce GB uptake.

Patient Preparation 3

Some doctors prefer to hold heart medications until after test (check with cardiologist).

Start IV setup, flush IV, ensure patency.

Obtain a baseline blood pressure

Equipment

Camera

Large field of view

Collimator

Low energy, all purpose, or low energy, high resolution

Single Photon Emission Computed Tomography (SPECT)

Procedure 1

Position patient on treadmill or supine for pharmacologic stress.

Perform stress test by exercise or pharmacology in the presence of a physician. Heart rate should be between 85% and 100% of maximum (220 minus age of patient).

Sestamibi: Help patient get down from treadmill, wait 35–45 minutes to image.

Thallium: wait 15 minutes to image. Redistribution images taken in 3–4 hours if a 1-day protocol. 24-hour imaging may be requested for viability study of myocardium.

Procedure 2 Position patient supine with heart in center field of

view.

Processing: Images are processed to show myocardium of left ventricle in vertical long axis, horizontal long axis, and short axis views.

Imaging in anterior, left anterior oblique, left lateral

Protocols 1One-Day

Thallium: The stress is performed first (~3 mCi), wait 10–15 minutes and image, then 3–4 hours later the rest is completed. Some do a 24-hour delay rest study with a 1 mCi reinjection (wait 5–20 minutes to image), looking for viable or hibernating stunned tissue.

Sestamibi: Both tests are done on the same day. Either rest or stress can be done first; however, most prefer to do resting pictures first (e.g., in the morning), then set up for the stress (treadmill or pharmacological). The first study is done with a low dose, ~8 mCi, followed by the second (an hour or more later) with a high dose, ~25–30 mCi.

Protocols 2Two-Day

Thallium: Both tests are done with thallium but on different days.

Sestamibi: Both tests are done with sestamibi but on different days. Some do the stress test first. If no defects are observed, there is no need for the rest study. Others do both tests, regardless.

Patient History (The patient should answer the following questions.) Do you have a history of or family history of heart disease?

Do you have a history of heart attacks?

Have you had any chest pain?

Have you been short of breath, had trouble breathing, or do you have asthma?

Do you or did you smoke?

Do you have a pacemaker?

Have you had any recent surgery?

Have you had any recent chemotherapy?

Do you have high blood pressure or diabetes?

What medications are you presently taking?

Have you had any prior ECG tests or related tests (e.g., echocardiography, stress tests, etc.)?

Do you have the results of recent lab work (e.g., CPK, LDH, Cholesterol Troponin, Myoglobin, C-reactive protein)?

Female: Are you pregnant or nursing?

Artifacts Attenuation artifacts: Men ---- most common is left hemidiaphragm affecting inferior wall; Women ---- most common is left breast affecting anterior wall.

Bowel activity close to heart during imaging may mask inferior wall defects.

Patient may not reach 85% maximum heart rate.

If patient has left arm down to side, it may cause unwanted attenuation.

THYROID SCAN

RadiopharmacyRadionuclide : 123I t1/2: 13.1 hoursEnergies: 159 keVType: γ, accelerator

Radionuclide : 131I t1/2: 8.1 days Energies: 364 keV Type: γ, accelerator

Radionuclide : 99mTc t1/2: 6 hoursEnergies: 140 keVType: γ, generator

Adult Dose Range131I: 2–5 mCi (74–185 MBq) for whole body

imaging

123I: 100–450 µCi

99mTc-: 2–5 mCi (average 5 mCi)

Method of Administration123I and 131I capsule Oral (PO)

99mTc by intravenous injection

Indications Evaluation of thyroid anatomy, e.g., position,

goiter (enlarged gland due to inadequate iodine supply), surgery, cold or hot nodule(s).

Detection and evaluation of hyperthyroidism and hypothyroidism.

Detection and localization of metastases from thyroid cancer.

IndicationsDifferentiation of benign from malignant nodules.

Detection and localization of benign ectopic thyroid tissue.

Evaluation of abnormal thyroid serum laboratory results.

Evaluation of thyroiditis.

Evaluation of thyroid because of abnormal findings on other diagnostic images, e.g., US, X-ray images, PET, MRI, CT.

Patient Preparation Identify the patient. Verify doctor's order.

Explain the procedure.

Patient to discontinue thyroid medications and avoid contrast material.

Refrain from eating foods containing iodine such as cabbage, turnips, greens, seafood, kelp, or large amounts of table salt.

123I and 131I: Patient will be returning at 24-48 hours for imaging.

Equipment

Camera

Large field of view

Collimator

Low energy, high resolution, or low energy, all purpose and pinhole for 99mTc and 123I.

High energy, parallel hole for 131I.

Procedure99mTcO4-

Injection to patient; wait 15 to 20 minutes before imaging. Give patient water (optional lemon to clear salivary glands).

Place patient in supine position with pillow under shoulders and chin up.

Obtain anterior views (with and without markers as per protocol, RAO and LAO (more distant) for ectopic thyroid tissue are optional images.

131I CapsuleUsually used to locate residual and recurrent

cancers. 24-, 48-, and 72-hour pictures may be the most useful. Image over thyroid and whole body if cancer is suspected.

Patient History (Answer the following questions )

Do you have a history or family history of cancer?

Do you have a history of thyroid disease?

Are you presently taking any iodine-containing medications, thyroid hormones, antithyroid drugs?

Have you had any surgery?

Do you have difficulty swallowing?

Do you have any swelling or tenderness in the neck?

Have you had any recent weight loss or gain?

Patient History (Answer the following questions )

Have you recently experienced fevers?

Have you had any recent change in your overall energy levels?

Have you had any thyroid therapy, chemotherapy, or radiation therapy?

Are you sensitive to cold or heat?

Have you had any tests using iodine or radiographic contrast?

Are you pregnant or nursing?