Nuclear Medicine: Manuals Medical imaging modalities ... · New trend 54 SPECT-CT Example: right...
Transcript of Nuclear Medicine: Manuals Medical imaging modalities ... · New trend 54 SPECT-CT Example: right...
Medical imaging modalities: comparison. Functional imaging.
Nuclear Medicine: aims, principles.
Univ. of Debrecen Department of Nuclear Medicine
2010 02
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Nuclear Medicine: Manuals
• Link to English reference manual:
http://www.auntminnie.com/index.asp?sec=ref&sub=ncm
• Lectures in English:
http://www.nmc.dote.hu/nmt_eng/oktatas_e.htm
• In Hungarian:
http://www.nmc.dote.hu/nmtk/index.html
• Book: A Nukleáris Medicina Tankönyve(Szerk. Szilvási I.; B+V Kiadó, 2002, 2010)
• Required reading:Taylor A., Alazraki N., and Schuster D.M.:A Clinician's Guide to Nuclear Medicine (2nd Edition)
The Society of Nuclear Medicine, Reston, 2006ISBN: 0972647872
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The clinical diagnostical possibilities in recent years:
Patient history!!!
Physical exam. (Palp., auscultation etc).!!! No idea???
Sampels Functional map’s Struktural analisis
(Chem.Lab) (Nuklear medicine: (Radiology)
molekular map )
Biochemical, Kamera, SPECT, PET Rtg, UH CT, MR
microbiological
data
„Multimodality”
methodes SPECT-CT PET-CT PET-MR?
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Source: „What is Nuclear Medicine?” (SNM)
Medical imaging, Historical paralells:
Surgery Internal med. Oncology
Medical imaging, Historical paralells:
Surgery Internal med. Oncology
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Targets and tools of medical
imaging
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First inventions: spontaneous
radioactivity ...
ANTOINE HENRI BECQUEREL(1852-1908)
1903 Nobel Laureate in Physics
„in recognition of the extraordinary
services he has rendered by his
discovery of spontaneous
radioactivity”
MARIE CURIE (1867-1934)
PIERRE CURIE (1859-1906)
1903 Nobel Laureates in Physics
„in recognition of the extraordinary
services they have rendered by their joint
researches on the radiation phenomena
discovered by Professor Henri Becquerel”
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The beginnings of NUCLEAR
MEDICINE: a Nobel priced idea
1924: Principle of radiotracer
applications:
Changing an atom in a molecule for its radioisotope
will not change its chemical
and biological behaviour significantly.
Consequence: the movement,
distribution, concentration of the
molecule can be measured with
radiation detectors.
György HEVESY (1885-1966)
1943 Nobel Laureate in
Chemistry„for his work on the use of
isotopes as tracers in the study
of chemical processes” 88
Selecting the radionuclide for imaging
C-11
N-13
O-15
F-18
e-
γγγγX-ray
Characteristic X-ray(following K-capture)
For external detection: electromagnetic radiation can be used!The main 2 groups of isotopes in nucl. Med.:
Gamma emittersgamma energy: 80-400 keV(if lower: attenuated inside the patientif higher: low detection sensitivity)
Positron emittersannihilation radiation:
2 ⋅ 511 keV
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Most common radionuclidesin Nuclear Medicine
NuclideEnergy
(keV)Half time Used for: Note
Tc-99m 141 6.03 h many generator
Tl-201 68-80 73.1 h myocardium cyclotron
I-131 364 8 days thyroid +therapy
I-123 159 13 h thyroid cyclotron
proteins,...
I-125 27-35 60 days in vitro!
F-18 Beta+ 110 min PET!
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Differencies between radiology and Nuclear medicine( only some exampels )
Radiology: (relatively closed)
Applied phyisics
First : instrument
Summ.X Ray, CT, MRI, US
Second: contrast. Mat.
Main Informations:
Structural, Anatomycal
Hybrid technics: CT +
(Common problem:
Nuclear medicine (opened disc.)
Applied molecular biology
First: radiopharmaceutical(FUNCTION, ORGAN OR TISSUE SELCTION)
Second: instrument Planar, SPECT, and PET cameras
Main info: functional,metabolic.
SPECT, PET
radiation burden )
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Effective doses (mSv)
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Scintigraphy
Complicated radiological
Simple X-ray
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Why Nucl. Med. is „opened” discipline?
example: Imaging brain receptors:PET ligands for imaging various receptor systems –MR structur is same!!
[F-18]-memantin(NMDA-receptor)
[F-18] fluoro-2-deoxy-glucose
O
OH
F
HO
OH
HO
N
SCH3NH2
FH2C
CH3
Cl
OH
Cl
OCH3
NHN
O CH2CH3
N
N
N
F
O
OCH2CH3
O
CH3
NH3C
H
H Cl
NO
Ph
[C-11]-raclopride(dopamine D2
receptor)
[C-11]-McN 5652(serotonin
transporter)
[C-11]-b-CPPIT(dopamine
transporter)
[C-11]-flumazenil(benzodiazepine-
receptor)
Source: G. von Schulthess, University Hospital, Zürich
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Medical & biological applications of radionuclides
the main fields of Nuclear Medicine
Medical applications
(nuclear medicine)
Research applications
(nuclear medicine)
Diagnostics
Therapy
„In vivo”
imaging
„In vitro”
Application of diagnostic
methods for research
„Molecular imaging”
Combination of analitical
laboratory methods with
radiotracer technique
„In vivo”
non-imaging
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The Structure of full Nuclear Medicine workplace (in 2009)
PET
PlanarSPECT
CT
Trans
lationLiquidPET-CT
Cell
labell
Fluoro
Pain
killing
Synovior
thesis
Immuno
Zevalin
I.In vivo II.In vitro III.Therapy
RIAHigh dos
Jodine
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Thyroid scintigraphy in 196-70 years
1.Beginnings of clinical (In vivo) nuclear medicine:
Thyroid imaging with rectilinear scanner
Result: large nodal struma
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Fields of Nuclear Medicine:
1 A. „In vivo” imaging
Hal Anger (Berkeley)with his positron camera
Developer of the scintillation camera
1957: Anger camera
Principle:
many photomultiplier tubes „see”
the same large scintillation
christal; an electronic circuit
decodes the coordinates of each
event
(„ Anger resistant matrix”)
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Planar Gamma cameras (1970-80 )
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Selecting the „ideal” human radionuclide :
• Should allow imaging with gamma camera:- gamma emitter- energy from 80 to 400 keV
(lower : absorbed in the patienthigher: bad detector sensitivity)
• Half time: ~ hours(shorter: difficulties with productionlonger : high patient dose)
• Should be linked to a suitablecompound.
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Emission imaging: Study types
Static:imaging an equilibrium distribution
Dynamic:series of images following the accumulation /
metabolic pathways / secretion of a radiopharmaceutical
Whole body:static images connected
Tomographic:single photon emission computed tomography (SPECT)
positron emission tomography (PET)
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Examples of in vivo „single photon isotope” studies:
Malignant thyroid tumour
99mTc-Pertechnetate
decreased activity with pertechnetate
increased MIBI accumulation
99mTc-MIBI
Examples of in vivo „single photon isotope” static studies
Case of Parathyroid adenoma
(More „cell specific” maps )
99mTc- fyton (organ-Cuppfer cell -specific agent)
Examples of in vivo „single photon isotope” static studies :
Nodular lesions of the liver in cirrhosis
Examples of in vivo „single photon isotope” static studies
Breast scintigraphy: 99mTc-MIBI („mitochondrial map”)
tu
Examples of in vivo „single photon isotope” static studies
Case of Pulmonary embolisation (Two lung functions re imaged.)
PERF: perfusion images with [Tc-99m] macroaggregated albumin
INH: after inhalation of [Tc-99m] DTPA aerosol
Examples of in vivo „single photon isotope” static studies
Case of lung abscess: 67Ga-citrateExamples of in vivo „single photon isotope” static studies
Static kidney : by Tc-99m DMSA (organ specific )
(in vitro 99m Tc-HMPAO labelled leucocytes- cell specific map
Examples of in vivo „single photon isotope” static studiesExample: Crohn disease in actíve stage by in vitro labelled leucocytes
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Examples of in vivo „single photon isotope” Dynamicstudies
Kidney
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Results of normal dynamic kidney study
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Examples of in vivo „single photon isotope” Dynamic studies
Gall bladder emptiing: reduced contractility
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Examples of in vivo „single photon isotope” Dynamic studies
Monitor bile excretion process - from a single view- at various times
Result of
Hepatobiliary
scintigraphy
Tomographic reconstruction
1. Projections
2. Filtered backprojection
Advantages vs. CT:
- functional imaging- a wide range imaged
reslicing is possible
Drawbacks:
- poor resolution- attenuation- scatter
SPECT
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Planar Gamma cameras and SPECTs
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Whole body bone scintigram by double headed SPECT
Spot images by planar
Gamma camera
Examples of in vivo „single photon isotope” static studies
Examples of in vivo „single photon isotope” static studies: SPECT
Brain perfusion SPECT (Tc-99m HM-PAO)
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Examples of in vivo „single photon isotope” static studies: SPECT
Case:Lung tumor with 111In-Somatostatine-receptor scintigraphy
Examples of in vivo „single photon isotope” static SPECT studies:
Cardiological SPECT (Special sofwares are needed.)
Myocardium: „bull’s eye” display (polar map)Reversible defects by cardio C SPECT :
short axis slices
Cardio SPECT-Reversible defect: bull’s eye maps
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Dual isotope study: Transaxial slice
[Tc-99m] Phytate [In-111] Octreotide Fused images
tumornormal
parenchyma
Case of Carcinoid tu. (Two cell functions framed in same time!)
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1. „In vivo” imaging
BB. With positron emitters (Brief history)
Principle: Two 511 keV photons resulting from annihilation
fly in opposite directions.Their coincident detection determines the line of annihilation.
• Michel M. Ter-Pogossian, Mallinckrodt Institute
• Michael E. Phelps, UCLA4242
Possibilities to Produc artificial radioactive materials
Stanley Livingstone and Ernest Lawrence with their 8 MeV cyclotron(1935)
• In nuclear reactors
(high neutron flux)
• Using accelerators(circular: cyclotron)expensive!
Ernest Lawrence(Berkeley)inventor of the cyclotron
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PET - advantages
• Coincidence detection at 180°:- higher sensitivity- better signal/noise ratio
• Easier attenuation correction(sum of the two paths inside =body thickness)
• More physiologic radiopharmaceuticals(C-11, N-13, O-15, F-18)
*
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The structure of PET camera
Detector system
Coincidenc circuit !!
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3 dimensional cine display of PET study made by FDG
on dedicated PET camera (1996)
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Functional vs. structural imaging:Case: Low-grade recidive glioma (FDG) PET+MRI fusion made by software )
PET Center,
Debrecen
Based on conventional methods: Stage I
Role of PET in oncology:Tumor staging
FDG-PET shows stage IIIS
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2
3
4
1 2
3 4
Summed coronal slices Transaxial slices 48
Previous and recent PET , PET-CT tools
Negatív iontöltéső Ciklotron ( PET TRACE) árnyékolás nélkül
Targetkamrák
Gyorsító mágnes
Ionbevezetés helye
Praeclinical PET- SPECT
PET - CT
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Recent trends in multimodality in vivo imaging:
2007.: start of Gemini TOF 64 slice PET-CT in Debrecen :Step forward in oncology and cardiology
PET tracers: FDG, 11C-metionin
18F-FDG TF PET-CT in mal. tumor diagnostics:
remnant of colon cancer
• Rectum tu. Lokális recidíva?
Dr. Fekésházy A. képanyaga
5118F-FDG TF PET-CT in mal. Tumor follow up) 5252
Tumor localization for targeted radiation therapy by
PET-CT
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New trend
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SPECT-CT Example: right suprarenal adenoma
Radiopharm.: 131I-Nor-cholesterolEgésztest vizsgálat
CT SPECT SPECT/CT
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More special softwares for 3D volume-rendered fusion images
Protocols in the CardIQ Fusion software (a–d). The main protocols include tools
for image coregistration, epicardial contour detection,
coronary artery segmentation.56
Fields of Nuclear Medicine:
2 In vitro” concentration measurements
ROSALYN YALOW
(1921-)
1977 Nobel Laureate in Medicine
„for the development of
radioimmunoassays of peptide
hormones”
1960: Yalow and Berson developed a radioassay for
measuring Insulin concentration from plasma samples
(saturation analysis)
RIA: radioimmunoassay
(competitive protein binding;
the ligand is labeled)
IRMA: immunoradiometric assay
(„sandwich” assay)
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In vitro isotope (RIA) lab- different tools, ecquipments (1980 )
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Fields of Nuclear Medicine:
3. Therapy with unsealed radiactive preparations
Principle:
Beta-emitting radiopharmaceuticals go directly to the cells
or tissue to be destroyed or deactivated
Very specific radiopharmaceuticals are needed
Unsealed preparation:
One that mixes in the patients’ body on a molecular level
(e.g. after intravenous injection)
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Radionuclide therapy
The administration of open radionuclides for therapeutical purposes. The radiopharmaceuticals get right to the cells to be destroyed, and act there locally.
Generally beta- (rarely alpha-) radiating nuclides are used, as beta radiation reaches only a small neighborhood of its source.
Most common aims of radionuclide therapy:
• Intracavital therapy (uterus, abdomin cav. Intraarticular)
• Radioimmunotherapy * • Palliative therapy of bone metastases*
• Radioiodine therapy of hyperthyreosis*• Radioiodine therapy of thyroid carcinoma metastases*
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Exampels of Intracavital therapy-The injection of radionuclides right into some cavity
(not through the blood stream or lymphatic drains
• SynoviumIndication: Chronic synovitisMechanism: Irradiating the cells of the synovial membrane decreases fluid production.- The choice from beta-emitting radionuclides depends on the size of the synovial cavity.
• PleuraIndication: Palliative therapy in order to reduce fluid collection caused by tumors (cancers of the breast and lung, lymphoma) or inflammation.
• PeritoneumIndication: Palliative therapy in order to reduce ascites caused by tumors.(Mesothelioma, ovarian adenocc.)(Also: radioimmunotherapy )
• Intrathecal therapyIndication: Leukemia with thecal involvement Mechanism: Fagocytosis of the arachnoid membrane cells.
• CystsIndication: Cystic degeneration of a brain tumor, high risk of surgical treatment.
Colloidal radiopharmaceuticals are administered, labeled by: Rhenium-186, Erbium-169, Yttrium-90, Phosphor-32, Gold-198