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Radiology
DESIRABLE CHARACTERISTICS OF RADIONUCLIDES FOR emitted by the patient would then be passing through the collimator ->
IMAGING Only those that has perpendicular read to the collimator would reach the
- Minimum particulate emission sodium iodide crystals -> covert photons into light energy -> light
- Primary photon between 50-500 keV energy goes to photomultiplier tube and converted to current ->
Tc-99m = 140 keV These pulses go through the multichannel analyzer -> Convert electric
Technetium is the most suitable radioisotope that we use in nuclear energy into pixels, processed to an image
imaging -Constant bombardment of radiation coming from the patient
- Physical half-life greater than the time required to prepare material cumulatively will collect and from pixels and can form the image of the
for injection organ you are trying to image.
- Effective half-life longer than imaging time -It takes time when you take and image, depending on the organ.
- Suitable chemical form and activity Kidneys: 6-30 min
- Low toxicity
Whats the difference between a radionuclide from the SCOPE OF NUCLEAR MEDICINE
radiopharmaceutical? 1. Diagnostic
Radiopharmaceutical: Radioisotope or radionuclide coupled to a -In-vivo procedures
pharmaceutical component. -Imaging (scanning)
The pharmaceutical component gives the specificity for the radionuclide -Non-imaging (uptake studies)
to be taken up by the organ that you want to visualize. -In-vitro procedures
-Radioimmunoassay (RIA)
RADIOPHARMACEUTICAL -Immunoradiometric assays (IRMA)
1. Free of any toxicity or secondary effects
2. Should not dissociate in-vitro or in-vivo 2. Therapeutic
3. Should be readily available or easily compounded -Benign diseases (e.g. hyperthyroidism, hemophilic/arthritic
4. Should have reasonable cost joints)
-Malignant diseases (e.g. thyroid cancer, liver cancer, lymphoma)
Radiopharmaceutical Half-life -Palliation (e.g. metastatic bone pains)
Tc-99m 6 hrs.
CLINICAL APPLICATIONS
I-123 13.2 hrs. Endocrinology
Xenon-133 (Xe-133) 5.2 days -Hormonal assays
-Uptake measurements
Gallium-67 (Ga-67) 78.3 hrs. -Organ imaging
Indium-111 (In-111) 2.8 days
Oncology
Thallium-201 (Tl-201) 73.1 hrs. -Bone scan
-Scintimammography
Fluorine-18 (F-18) 110 mins. - Whole body iodine scan
Ga-68 68 mins. - Bone marrow scintigraphy
-Lymphoscintigraphy
Carbon-11 (C-11) 20 mins.
Nitrogen-13 (N-13) 10 mins. Cardiology
Oxygen-15 (O-15) 2 mins. -Myocardial perfusion imaging
-Radionuclide ventriculography
Rubidium-82 (Rb-82) 1.3 mins.
Nephrology / urology
Gastroenterology / hepatobiliary
Neurology
Pulmonary
Ophthalmology
Infectious disease
THYROID SCINTIGRAPHY
Evaluation of morphology and function of the thyroid gland
Isotopes Used:
1. Tc-99m pertechnate: trapped by thyroid gland
2. I-131: trapped and organified
INDICATIONS
UNSEALED RADIONUCLIDES USED FOR THERAPY: 1. Relate structure to function
- Phosphorus-32 (P-32), Yttrium-90 (Y-90) Nodular or diffuse enlargement
- I-131, I-131 MIBG, I-131 lipiodol 2. Determine function of a palpable nodule
- Strontium-89 (Sr-89), Samarium-153 (Sm-153), Hot or cold nodule
Rhenium-186 (Re-186) Post-therapy evaluation for toxic adenoma
3. Locate ectopic thyroid tissue
BASIC COMPONENTS OF A GAMMA CAMERA Lingual thyroid
Collimator 4. Evaluation of the neck or substernal mass
Scintillation crystal Thyroglossal duct cyst
Photomultiplier tubes 5. Assist in evaluation of hyperthyroidism
Preamplifiers
Pulse height analyzer NORMAL THYROID SCAN
Digital correction circuitry -Uniformly distributed tracer
Control console -No labeling defects seen
Picture archiving system -Inject Technetium, wait for 15 minutes, and position the patient in the
How are images formed in nuclear medicine imaging? camera. We try to see whether the thyroid takes up radioisotope
Introduce radioisotope IV, orally -> Position the patient in gamma uniformly.
camera (gamma camera head is composed of the collimator, sodium -A normal thyroid gland would have a uniform distribution of the
iodide crystals, and the photomultiplier tubes) -> Radioisotope being radiotracer throughout the thyroid gland.
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Radiology
-What if we dont see a thyroid glands if you do a thyroid scan? DDx:
Post-thyroidectomy
-This is what you call the hot nodule. Cold nodule: hypo functioning
HYPOFUNCTIONING NODULE nodules. Hot nodule: area of increased uptake compared to the rest of
Case: the thyroid gland. There is increased uptake of the radiotracer in that
36 years old female presenting with an anterior neck mass palpable nodule. Usually these patients would be presenting with
Solid mass on PE, moves when swallowing symptoms of hyperthyroidism.
Doctor requested for a thyroid scan, and you see an area of decreased
uptake. LINGUAL THYROID
Possible differentials for a hypofunctioning nodule: Malignancy when it -8 year old male with a mass in the root of the tongue
replaces normal thyroid tissue, Cyst, Colloid or Adenoma, Hematoma, -Scan shows a midline functioning thyroid tissue in the base of the
Fibrosis. tongue
-Usually seen in pediatric patients. When they stick out their tongue,
Other images for hypo functioning nodule:
It could almost fill up the entire lobe of the thyroid gland. It could be
very large, and of different sizes.
You wouldnt see any uptake in the anterior neck, because this lingual
thyroid would be the only functioning thyroid tissue. Theres a failure of
development of the thyroid gland. Usually it starts from the tongue, goes
down, descends and is situated in the anterior neck during the
embryological stage. In this patient, theres failure of descent.
It could also be Should you operate on this patient? Better not, because its the only
multinodulor. Several nodules replacing the thyroid tissue. functioning thyroid tissue that the patient has. If you take it out, the
patient becomes hypothyroid. Unless if there are obstructive symptoms
TOXIC ADENOMA already, operate on the patient and give synthetic thyroid hormone.
30 year old male with s/s of hyperthyroidism
PE shows palpable mass on right side of neck These patients usually present as hypothyroid. This lingual thyroid cant
produce enough hormone for the body.
EVALUATION POST-THYROIDECTOMY
-Identifies any remnant or residual thyroid in a post-thyroidectomy
patient
-Scan shows solitary hot nodule with non- visualization of the rest of
the gland
-Probably, patient had a left lobectomy. Theres compensation of the
remnant thyroid tissue -> Symptoms of hyperthyroidism to compensate
for the loss of the contralateral lobe
-What if patient did not have surgery? Toxic Adenoma. Right lobe is
hyperactive, and depresses the activity of the contralateral lobe. Thats
why you cant visualize the left lobe.
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Radiology
I-131 WHOLE BODY SCINTIGRAPHY 2. Pre-treatment of selected patients with ATDs to deplete thyroid
-Post-surgical or post therapy procedure in the evaluation of hormone stores.
patients with well differentiated thyroid carcinoma. 3. Physician must explain the procedure, treatment, complication
-Evaluate for functioning thyroid residual/remnant in the neck and side effects, therapeutic alternatives and expected
-Detection of thyroid cancer metastases. outcome to the patient. Radiation exposure. The patient usually
-Detection of thyroid cancer recurrence. needs to follow radiation precautions after receiving therapy.
-Applicable only in well differentiated thyroid 4. Consent is obtained prior to therapy
carcinomas such as papillary and follicular including Hurthle cell 5. DYSGEUSIA (altered or distorted sense of taste) are very
CA. uncommon side effects. Candies or sour foods induce salivation.
6. Small (1-5%) chance of mildly painful radiation thyroiditis after
THERAPEUTIC NUCLEAR MEDICINE treatment. Swelling when iodine concentrates in the thyroid glands
THYROID after the procedure.
7. The form should also explain likelihood of eventual
Benign I-131 therapy for patients with Graves disease and Toxic
hypothyroidism.
adenoma
8. OPHTHALMOPATHY may worsen or develop after therapy for
Graves disease especially in smokers. Steroids minimize
Malignant Treat patients with well differentiated thyroid
Ophthalmopathy.
carcinoma
9. Patients with severe hyperthyroidism may occasionally
-I-131 therapy for ablation of post-surgical residual thyroid tissue in the
experience an exacerbation of symptoms within the 1st 2 weeks
neck and eradication of functioning local and distant thyroid metastasis.
after I-131 therapy. Some experience exacerbation of palpitations,
easy fatigability and tremors after therapy.
PROPERTY: Make use of beta energy emitted by the radioisotopes. I-
10. There is no evidence of an increased risk of thyroid carcinoma
131 also has gamma ray used for imaging at 354-360 units
or malignancy, an increased risk of infertility or an increased
incidence of birth defect caused by I-131. It is important that
RADIOIODINE IN THERAPY
patients follow precautions for radioactive iodine therapy.
11. There exists a small risk of pre-existing or coexisting thyroid cancer
BENIGN THYROID CONDITIONS in patients with toxic nodular goiter and Graves disease
-Employed in thyroid therapy for hyperthyroidism 12. A final item to consider including on the informed consent form is
-I-131 is a beta-emitting radionuclide that most experts recommend waiting 6-12 months after I-131
-Physical half-life of 8.1 days therapy before trying to conceive.
-A principal gamma ray of 364 keV 13. I-131 therapy is always contraindicated in pregnant women.
-A principal betaparticle with a maximum energy of 0.61 MeV Thorough hx for pregnancy! Ask for the LMP
-Average energy of 0.192 MeV
-Mean range of tissue of 0.4 mm. Max range in tissue =2.4 mm FACTORS AFFECTING I-131 EFFECTIVENESS
INDICATED FOR: Dose itself
Uptake into the organ
-For hyperthyroidism (Graves disease, toxic nodular goiter), recurrent
disease, and those contraindicated to anti-Thyroid Drugs (such as Over-all gland size
Methimazole, PTU) and Surgery. Transit through the thyroid
Status of iodine sufficiency (or deficiency)
NOT INDICATED FOR Radiation sensitivity
-Severe Acute Thyroiditis
-Silent painless thyroiditis DOSE CALCULATION
-Post-partum thyroiditis Fixed dose vs calculated dose vs empirical dose.
-Thyrotoxicosis factitia
-Hyperthyroxinemia
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Radiology
o Stage IV: any T, any N, M1 3. Patient operated on however no thyroid hormones or
-More than 45 years of age you already have stage 3 and 4 radioactive iodine therapy
THERAPEUTIC OPTIONS (skipped) **This shows that patients who had surgery + radioactive iodine
-Standard therapy + levothyroxine suppression had decreased death rate and
-Depending on clinical evaluation and risk factors lower recurrence rates.
-Surgery may range from lobectomy-Lower incidence of complications
but 5-10% will have a recurrence CANCER DEATH RATES AFTER THYROID REMNANT
Total or near total thyroidectomy (TT/ NTT)-Advocated due to high ABLATION (skipped)
incidence of multicentric involvement of both lobes and dedifferentiation
of cell types, after which, ablate the thyroid remnants
Micropapillary CA
-<1 cm
-Treatment: lobectomy or near total thyroidectomy
-But some develop metastasis years after being diagnosed
Stage III
-Total thyroidectomy plus removal of involved lymph nodes or other
extrathyroidal sites
-I-131 ablation IF the tumor demonstrates uptake of this isotope
-Thyroid hormone suppression
Stage IV
-The most common sites of metastases are the LYMPH NODES,
Graph for comparison of 3 patients who had undergone surgery: LUNGS, AND BONES. Treatment of lymph nodes is often curative but
1. Patient after undergoing thyroidectomy received radioactive for distant metastases, especially skeletal, may produce significant
iodine therapy palliation.
2. Patient who been operated on was given levothyroxine; and -TT
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Radiology
-I-131 I-131 TREATMENT AND FOLLOW-UP
-External beam radiation if I-131 uptake is minimal
-Thyroid hormone suppression
-Stage IV well differentiated thyroid carcinoma = metastasis
-Radioactive iodine therapy may not be enough
-Subject patients to external beam radiation therapy especially if there
are lesions in the bone.
-This patient has papillary thyroid carcinoma and had a scan prior to
radioactive iodine therapy showing lesions in the lungs, skull,
physiologic uptake in the intestines and the urinary bladder. The patient
received a dose of 150 mCi. More lesions may appear on post therapy
whole body scan after therapy.
-We usually evaluate patients 6 months after treatment with another
whole body scan to check.
-If still with metastatic lesions and thyroglobulin levels are still elevated
after 6 months, repeat radioactive therapy
SPECT-CT
High dose
o Failure of 36% and success of 63.4% with a
o p-value of 0.027 which is significant This is a patient with metastatic lesions in the lungs After treatment,
there is clearing of the lesions after radioactive iodine therapy.
Local study (Barrenechea)
o Philippine setting Follow-up whole body scan (WBS) 8 months later showed
o Mostly papillary: 67% clearing of the lung mets
o 44% success using 50 mCi
o 75% success using 100 mCi OTHER DEVELOPMENTS IN THE MANAGEMENT OF TCA
(Skipped)
SUCCESS OF THERAPY -Use of recombinant human TSH-both for diagnosis and treatment
-Absence of radioactivity in the thyroid bed on scintiscan after using 3-5 avoids the discomfort of hypothyroidism, recent studies claim 100%
mCi of I-131 which is usually done 3-6 months after ablation using high successful ablation without sacrificing the quality of life.
dose of radioactive iodine -Use of Omeprazole / antiemetics
-After radioactive iodine therapy, request for a post therapy whole body -Thyroxine as replacement rather than suppressive in selected cases
scan to check where your iodine concentrated. Pre-treatment scanning (levothyroxine)
may result to scanning reaction and patients may not respond well
therapy.
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Radiology
OTHER OPTIONS -May either make use of Yttrium-90, Rhenium-186, or Erbium-169
-Clinical trials evaluating new approach should also be considered After injection to the joint area, there is pannus or scar formation in the
-Chemotherapy with Bleomycin (Harada) or with Doxorubicin alone or joint area to decrease inflammatory process. Also used in patients with
Doxo with Cisplatin (Shimaoka) and chemotherapy (Gottlieb) have been hemophilic arthrosis.
tried for advanced thyroid CA (usually chemotherapy has no role in the
management of well differentiated thyroid carcinoma.) HEPATOCELLULAR CARCINOMA
-Use of Sorafenib in locally recurrent or metastatic, progressive, -Adjunctive treatment of inoperable hepatocellular CA to see if survival
differentiated DTC that is refractory to radioactive iodine treatment. time can be prolonged as well as reduce incidence of recurrence in
patients after resection of primary tumor
MEDULLARY CANCER -Isotopes used are I-131 lipiodol, Rhenium-188 lipiodol, and Yttrium-
-Total thyroidectomy 90 microspheres (delivered directly to the tumor)
-Radioactive iodine has no place in the treatment
-Palliative chemotherapy may help RADIOIMMUNOTHERAPY
-External radiation: no evidence that it provides any survival advantage
-Type of targeted therapy that delivers radiation directly to the cancer
-The ablation of thyroid remnants or residuals is left upon the discretion
cells.
of the attending physician. The pros and cons should be weighed in
-We couple an antibody which is directed towards an antigen. More
favor of the patients welfare, considering risk factors, and economics.
commonly used is Yttrium. Commonly used in patients diagnosed with
-Most physicians do routine ablation considering it has more beneficial
NHL.
effects than risks.
-ZEVALIN- treatment of NHLCoupled with Yttrium
-Monoclonal antibody directed against CD 20 antigen found in 90% of B
Indications for ABLATIVE TREATMENT WITH I-131 AFTER
cells (target)
SURGERY are:
-Targets CD20 antigen found in the B-cell and the Yttrium-90 would
-Distant metastases
attack the surrounding B-cells with the high energy beta radiation
-Incomplete resection of the tumor
reducing cellular damage almost to the molecular level
-Complete excision of tumor but with high risk of mortality associated
-Relapsed of refractory, low grade or follicular B-cell non-
with the tumor or with high risk of relapse due to age, histology, or extent
Hodgkins lymphoma (NHL)
of the disease
-Previously untreated follicular NHL, who achieve a partial or
-Elevated serum thyroglobulin over 10 ng/ml
complete response to first-line chemotherapy
-Differentiated thyroid cancers, namely papillary, follicular, or mixed are
prevalent in the Philippines mostly among the female population. The
CONCLUSION
old notion that it is an indolent disease is not always true and we should
-Nuclear medicine uses safe, non-invasive tools for assessing
not be too complacent about the disease.
metabolic tissue function.
-Well-differentiated thyroid cancers, namely papillary and follicular, as
-Some procedures allow imaging of entire body in one study.
well as mixed tumors, should be taken care of by the nuclear medicine
-Helpful even in cases of altered anatomy
physician after NTT or Total thyroidectomy.
-Aid in choosing appropriate therapeutic plans
-It requires an ideal follow-up of 10 years.
RADIOSYNOVIORTHESIS
-For the efficient local treatment of chronic inflammatory joint disease
-For haemophilic arthropathy
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