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Medicine Bloc, 1 Sem A.Y.

11-12

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INTRODUCTION to NUCLEAR MEDICINE


Nuclear Medicine A subspecialty of Internal Medicine, utilizing radioisotopes Mostly used for diagnosis (85-90%) Used as treatment modalities (10-15%) Ranked as co-equal of radiology Deals with the use of radioisotopes o Expressed in millicurie (mCi) or microcurie (uCi) Nuclear Scans o Thyroid, Brain, CVS, Renal, Bone, Liver

2. TECHNETIUM (Tc)
Always need a partner (Sulfur Colloid) Emits electromagnetic energy T is 6 hours Safer Technetium with Sulfur Colloid o Used for liver scanning o The Sulfur Colloid needs to get into the liver bringing with it the technetium o Use of external device to produce a picture of the liver all of the abnormalities. The lesion, an abscess for example, will not take in the radioactive substance. Technetium Pyrophosphate o For bone scanning DTPA o For brain and kidney scanning Technetium phylate o Also for liver scan Tc sulfur colloid I131
Mostly particulate

Radiopharmaceuticals: Radioactive Medicine Radiopharmaceuticals undergo constant change; it is an unstable substance (continuous). Characteristics of Radiopharmaceuticals 1. No pharmacologic effect 2. Given at a very small dose (1-2cc) 3. Always have a radioactive substance Important Considerations in Choosing a Radiopharmaceutical 1. Type of energy* 2. Half Life* 3. Cost 4. Availability * 1 & 2 are major considerations

Mostly electromagnetic

T : 6 hrs
rays: safer
Note:

T : 8 days
and rays: harmful

In the process of decay/ disintegration, there is liberation of energy. Types of Energy 1. Particulate Composed of alpha and beta Have harmful effects (burn tissues) 2. Electromagnetic Composed of gamma radiation Used for the purpose of scanning 1. IODINE (I) Necessary for thyroid function and production of thyroid hormone Radioactive and pharmaceutical Through nuclear technique becomes an isotope I131 Isotopes of Iodine o Radioactive o Emits particulate energy o Half life (T ) is 8 days o Examples are I131, I123, I,125

Half Life (T ) is defined as the time to reach 50% of the original number of atom o Example: 10 mCi of Iodine after 8 days, it will be about 5 mCi In order to get the total duration of the radiopharmaceutical in the body, you multiply the half life by 10 o Example I131 (T of 8 days) 8 x 10 = 80 days (~3 months stay in the body) Therefore, if you give a radioactive iodine to a patient especially a female, advise her not to get pregnant for 1 year Technetium with a T of 6 hours o 6 x 10 = 10 hours (~<3 days) o Considering it uses electromagnetic energy, so it is good to use

3. THALIUM 101
Used for cardiovascular scan (myocardial scanning)

ALARA Concept (As long as reasonably achievable) Do not waste time and material when working with radioactive material Work with radiation efficiently

Gamma Camera The patient is put under this device Scintillation detecting unit o Scintillations are small pulses of electron Patient is the source of radiation

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Collimator Limits the field of view to the organ of interest Radiation pass thru the collimator , right through the crystal (Na Iodide Crystal) Na Iodide Crystal When this crystal is hit by radiation, it will liberate flashes of blue violet (scintillations)

THE THYROID GLAND

One of the earliest organ where nuclear medicine was used (1941) because of the availability iodine Produces thyroid hormones Thyroid hormones are needed by the body to regulate the internal environment

Photomultiplier tube and Pre-Amplifier Receives the scintillations and sent to the processing and display unit

5 Broad Categories of Tests in Nuclear Medicine/ Instrumentation


1. Dilution, Absorption and Excretion Studies 2. Concentration Studies (ex. Thyroid Uptake) 3. Dynamic Function Studies (Tracing the blood supply into a certain organ, ex. Renogram, Angiogram) 4. Organ System or Pool Visualization (ex. Brain and Cardiac Blood Pool Scanning) 5. In Vitro Test (belongs to nuclear medicine because of the use of radioisotopes in the performance of tests, ex. T3, T4, TSH or FT3, FT4) Radioactive Iodine Uptake Studies (Concentration Studies) .5 uCi I131 only for diagnostic purposes (ex. Thyroid uptake studies) I131 contraindicated in o Pregnancy o Children <18 y/o Uptake is done after 4 hours after the initial oral intake of I131 o Normal Value = 5-25% (4-hr) 25-45% (24-hr) Brain Scan Greatest value as a screening procedure in patients suspected of having intracranial lesions, compared to x-ray Highest percentage of (+) finding in brain scan o Meningioma o Astrocytomas (Grade 3 and 4) o Metabolic lesions Comparison Brain Scan 81.5 % Skull X-Ray 46.9% Arteriogram(invasive) 92.3% Air Study(invasive) 91.3%

Iodine Main raw material where thyroid hormone is synthesized Very important, there are places that have endemic goiter because of the lack of iodine Cretin lack of iodine during infancy Recommended daily allowance of iodine is 50200 ug/day, supplied by diet Process:
o o o o Iodine is extracted from our diet and converted into iodide It is trapped and organified by the thyroid gland Coupled with the amino acid tyrosine to form the thyroid hormones The thyroid hormones are found within the thyroglobulin and stored in thyroid follicles (they are not free) When you need your thyroid hormone, there is going to be enzymatic proteolysis of thyroglobulin releasing T3 and T4 in the circulation (T4 = 90%, T3 = 10%) In the circulation, the T3 and T4 are bound by binding globulins: Thyroxine binding globulin (TBG) Thyroxine binding prealbumin (TBPA) Albumin It is why, in diseased state, there will be alteration of T3 and T4, causing misinterpretation In pregnancy, there will be difficulty in detecting total T3 and T4, because of alteration in binding sites. What to do is to measure the free T3 and T4 to get the exact amount of thyroid hormone that is in the circulation

It is the thyroid thyroid gland that takes up iodine in the body Your salivary gland may also take a small amount of iodine, that is why there are times when there is uptake here (just give chewing gum and stimulate then remove the iodine) Behave exactly like iodine in the diet Iodine is the agent that is trapped and organified by the thyroid gland; it is the one that is called the real thing as far as the thyroid is concerned

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Factors that Influence the Iodine Cycle Thyroid Stimulating Hormone Hypothalamus that controls the pituitary Serum levels of thyroid hormone The effect of urinary steroids
* TSH-hypothalamus feed back mechanism. Pituitary gland send TSH so that thyroid gland produces T3 and T4. If there is enough T3 and T4, it signals the pituitary to stop producing TSH.

gland will not be able to absorb iodine anymore, hence, low uptake

Thyroid Uptake Studies


Based on the concept of trapping and retention of iodine by the thyroid gland (iodine is trapped and organified by the thyroid gland) When you substitute an iodine that is radioactive (I131), it will behave exactly the same manner as an iodine that is not radioactive Once the RAI (radioactive iodine) gets into the thyroid gland, you can scan the thyroid gland

Thyroid Scanning The second part of thyroid uptake Although this can be done separately, it is best to do together with uptake studies for practicality After thyroid uptake, ask patient to lie down on scanning table. No need to administer additional radiopharmaceutical, the one from the uptake study will do Radiopharmaceutical used is I131 o T of 8 days o Readily available

Clinical Indications of Thyroid Uptake Studies 1. Diagnosis of Hyperthyroidism 2. Diagnosis of Hypothyroidism 3. Thyroid Suppression Test

How Thyroid Uptake Study is Done RAIU (Radioactive Iodine Uptake) This is a measure of how the thyroid gland will take up the radioactive material of known quantity Patient is given 5-10 uCi of I131, orally administered wait for 4 hours read with uptake machine (expressed in percentage). o Normal Value: 5 25 % Patient is instructed to return the next day for a 24-hour uptake o Normal Value: 25 45% If 2% in the 4-hour uptake and only 10% in 24hour under functioning thyroid gland: hypothyroid patient If 60% in the 4-hour uptake and 90% in the 24hour hyperfunctioning thyroid gland: hyperthyroid patient Contraindicated in children <18 years old and pregnant women In General: LOW UPTAKE HYPOthyroid HIGH/ ELEVATED UPTAKE HYPERthyroid Exceptions: 1. Severe Iodine Deficiency elevated uptake even if hypothyroid 2. Patients taking anti-thyroid drug low uptake 3. Patients on thyroid hormone supplement low uptake 4. Patient who has received radioiodonated contrast material (IVP, etc) because thyroid

Normal Thyroid Gland on Scan Extremely variable There maybe asymmetry of both lobes The isthmus may be absent and there may be presence of pyramidal lobe When interpreting the scan, concentrate on the uptake of isotope, if its increased or decreased Abnormal scans consist of: o Decreased uptake which is called COLD AREAS (areas that do not have an uptake) or NONFUNCTIONAL AREA o Increased in isotope uptake more than the rest of the gland or HOT AREAS o Patchy uptake heterogeneous isotope uptake; normal uptake, interspersed with poor uptake

Indications for Thyroid Scanning 1. Determination of thyroid size, function and position 2. Diagnosis of thyroid nodules in the differentiation of acute thyroiditis from hemorrhage into the glands 3. Work up of patient with known cancer of the thyroid 4. Evaluation of masses in the cricoid region, neck and mediastinum * for Dr. D, thyroid scan is the test that
will give much information

1. Diagnosis of Thyroid Nodules Diffuse goiter is symmetrically enlarged o Non-toxic with normal function o Toxic hyperthyroidism A goiter that present as a nodule Nodular Goiter o In the thyroid scan, the normal thyroid has a uniform isotope activity o In a nodule, it appears as a cold area (no uptake) cold nodule
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Case 1: A patient has a nodule on the left lobe. In the thyroid scan, it will appear that it has no uptake so it is called cold area DDx: - Carcinomatous Process (15 20%) - Benign thyroid tumor (ex. Adenoma) - Cyst (may contain only blood or fluid; benign) Proceed now to FNAB Case 2: A patient comes to you with the same nodule, also on the left side but this time, when you set the patient for scanning, it turned out to be concentrating more than the surrounding tissueintense in uptake. It means that this nodule is so active that it took up most of the radioactive material that was given to the patient. You call this a hot nodule. There is only one diagnosis AUTONOMOUSLYFUNCTIONING THYROID ADENOMA This is autonomousa rebel. It doesnt want to listen to the highest centers or to the control mechanism (TSH or hypothalamus) Patient may be toxic or nontoxic Management could either be surgery or irradiation Not malignant Patient could be hyperthyroid Case 3: A patient has a sudden enlargement of the nodule with accompanying fever and neck pain Usually, goiters are not painful in most cases. If there is pain, you think of an inflammatory process thyroiditis DDx: Hashimotos Thyroiditis -heterogeneous/patchy isotope uptake - nodule itself is painful, the thyroid gland is in temporary disarray (portions are functioning, some are not) - patient has neck pain, fever, you can feel a tender nodule

2. Differentiation of Acute Thyroiditis from Hemorrhage Into the Glands If there is hemorrhage in the gland, it will present as cold area When there is pain in the nodule in the thyroid gland, accompanied by body malaise, ask if patient is taking flu-like medications diagnostic of Hashimotos Thyroiditis You can distinguish this from thyroiditis by history. Ex. A patient has a nodule, went to a manghihilot, pressend on the nodule using a spoon and after the procedure, patient began to experience pain. Now you have an idea that there is hemorrhage. The pressure may be too much that bleeding/ hemorrhage into the nodule and therefore you call it HEMORRHAGE INTO THE CYST. Another way to distinguish is by 4-hour and 24hour thyroid scan o Thyroiditis: low isotope uptake o Hemorrhage: normal uptake because only a portion of the gland is affected 3. Work Up of the Patient with Known Cancer of the Thyroid Example: nodule on the right lobe. Scan showed that it is a cold area. You suspect that nodule is cancerous then you request FNAB which revealed carcinoma. Total thyroidectomy was done. Scan 6 weeks after surgery and you would just see remnants. Repeat scan after 6 months, giving a higher I131 dose, including scanning of whole body to find out if there is any metastasis or recurrence 4. Evaluation of Masses in the Cricoid Region, Neck and Mediastinum Whenever you have a nodule in the neck, though it may not be in the thyroid region, try to do a thyroid scan

Treatment of Toxic Diffuse Goiter Medical Treatment only temporary use/ palliative treatment o Done especially if patient is too toxic to do surgery or radioactive treatment because patient might go into thyroid storm Anti-thyroid drugs may cause depression of the bone marrow o PTU o Methimazole o Neomethazole o Carbimazole o Thiamizole o Side effect: Agranulocytosis ergo, for temporary use only Surgery always with risk o Subtotal Thyroidectomy
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Definitive but destructive Complications - Hemorrhage - Anesthetic complications - Injury to the Recurrent Laryngeal Nerve Barium Enema Studies o Uses 8 rads only Radioactive Iodine (RAI) o For Toxic Goiter
Patient with hyperthyroidism whose thyroid scan reveals a very intense isotope activity In the scan, there is rapid uptake of isotopes in both lobes If scan reading shows homogenous distribution of isotopes in both lobes, no hot or cold aread 4 hr = 63% 24 hr = 82% Clinically, patient has symptoms of weight loss, anxiety, tremors, palpitation, irritability and exophthalmos dx: diffuse toxic goiter/ toxic diffuse goiter Graves Disease - exophthalmos - goiter - hyperthyroid - skin changes at times

o o

Treatment of Thyroid Cancer


Patient with a nodule (cold area). Do FNAB of cold nodule Ask patient to have surgery done o Total/ Near Total Thyroidectomy done by a nuclear medicine specialist and endocrinologist o Lobectomy and/ or Isthmusectomy Do scan for residual thyroid tissue in the thyroid bed (after 6 weeks) Sometimes, if patient is young, it is recommended to do Radioactive Iodine Ablation (total destruction) to be sure that there is no metastasis o Dosage: 50 200 mCi o Dose that affects reproductive capability of patient (sterility) o Aims to destroy all the thyroid tissue in the body so there wont be recurrence Total Thyroid Hormone Supplementation in Thyroid CA o 300 mCi or 3 tabs/ day Only TOXIC DIFFUSE GOITER and THYROID CANCER are treated with RAI.

o o o

The use of radioactive material in the treatment of thyroid certain conditions (hyperfunctioning thyroid) If patient is too toxic, do medical treatment first Destructive because you burn thyroid tissues Agent of choice is I131
Principle based on trapping and organification retention Has particulate energy that destroys thyroid tissues Administer per orem in capsule form or liquid Majority of iodine that will be administered will be taken up by the thyroid gland (intense uptake) Thyroid will slowly decrease in size. Patient will improve but will have to succumb to life-long thyroid hormone replacement therapy or go into hypothyroidism (the only real side effect of RAI)

**Nodules, Thyroiditis, Simple Goiter are NOT treated with RAI. Research on treatment of Osteoarthritis with RAI is ongoing.

o o o o

GOAL: control hyperfunctioning thyroid gland DOSAGE: 10 2 mCi or 1 tabs/day Success Rate: 95-98% Definitive but destructive Indications for the Use of RAI
Diffuse Toxic Goiter/ Graves Disease Toxic Multinodular Goiter AFTA hot nodule

No other complications like sterility or anemia because dosage is small


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THE LIVER
Liver Scan Screening tool only due to its machines limited resolution Dominant Liver Cell Populations 1. Parenchymal (Polygonal) Cells - Perform metabolic function of liver - 85% of liver cell population 2. Reticuloendothelial Cells (Kupffer Cells) - Phagocytize foreign particles - 15% of liver population - Radioactive colloids from the blood Principles of Liver Scanning Radioactive colloids administered IV are phagocytized by the RES (Kupffer cells). Particles accumulate in the Kupffer cells and remain there long enough to perform scintillation scans Lesions >2 2.5 can now be localized Radiopharmaceutical used: o Technetium Sulfur Colloid Ideal Properties 1. Short physical T 2. Lack of Particulate Radiation because Tc is used 3. 140 Kev suitable for scanning Procedures of Liver Scanning Inject IV after (-) skin test to drug that is being used o 1-2 mCi of Tc sulfur colloid Wait for 20-30 minutes Take multiple views of liver o Anterior, right lateral, posterior, oblique

Serial liver scanning can be done to detect whether chemotherapy is effective (if lesion is getting smaller) 7. Work-up of patient with diffuse hepatic disease Cirrhosis, Hepatitis

Presentations of Liver Scan Variants of Normal Liver Shape o Triangular shape most common shape of the liver o Triangular with Convex Inferior Border o Large Left Lobe with Hilar Indentation o Triangular with Hilar Indentation o Square-shaped Liver o En Chapeau des Gendarunes Shape (due elevated diaphragm) o IN SCAN Horizontal line: uniform uptake of isotope (lighter in color) With grid cross line: no uptake (darker) Cold Area no uptake of isotope, no viable liver cell (ex. Amebic Liver Abscess) Based on intact parenchymal cells as well as the RES (Kupffer)

Liver Imaging Patterns Diagnosis Scintigram


Cirrhosis Patcy Focal Multifocal

Explanation
Non-specific

Hemangioma
Hepatoma Metastasis

Focal
Focal Focal Multifocal N (for Normal or No focus?) Focal

No uptake because this is only a collection of blood vessels, no liver tissues 1o Hepatocellular malignancy, CA cells cant function efficiently Originates from other sites, not of liver origin

Abscesses

Indications for Liver Scanning 1. Evaluation of liver size, shape and position 2. Detection of focal space-occupying lesion (SOL) such as tumors, cysts and abcesses (seen better in CT Scan, MRI, etc.) 3. Evaluation of abdominal masses 4. Pre-operative evaluation of hepatic metastasis in patient with known malignancies Ex. If you want to do surgery on a patient with CA, you must screen liver first because there may already be metastasis to other organs, like the lungs poor prognostic factor 5. Localization of hepatic lesions for biopsy or abscesses for drainage Not done anymore, replaced by ultrasound (US)-guided biopsy 6. Follow up of patient undergoing chemotherapy or radiation therapy

Contains nothing but pus, necrotic debris, RBC, no viable liver cells to take up isotope

Cyst Hematoma

Focal Focal

Fluid-containing Blood-containing

* Liver scan is a non-specific testall the defects are the same for different diseases) used more as a screening tool. It is sensitive because it can detect abnormalities, but cant tell you the exact abnormality/ies

For Scanning Purposes: Category/ Division of Liver Diseases 1. Diseases which produces DISCREET defects All except Hepatitis and Cirrhosis 2. Diseases which involve the liver DIFFUSELY Hepatitis and Cirrhosis only

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Discreet Defects All metastatic, all organs of the body with metastasis produce this kind of defect to the liver a. Breast b. GIT c. Lung d. GUT e. Pancreas f. Cervix g. Uterus Hepatoma o Appearance on liver scan cannot be distinguish from metastasis o Liver mass in patient with cirrhosis is highly suggestive of hepatoma o A large liver mass o Ex. Alcoholic, 30-year old patient, (+) Hx of liver cirrhosis in stable condition with PE: marked weight loss, palpated mass on abdomen. Management: Send patient for liver scan, appreciate discreet liver mass, consider hepatocellular carcinoma. o Liver CA loves to sit on top of a cirrhotic liver Abscess o Clinical profile of patient 1. Fever over 101oF septic fever pattern: wide fluctuations 2. Liver tenderness 3. RUQ pain 4. Weight loss, anemia 5. Leukocytosis o Two types of Liver Abscess 1. AMEBIC - used to occur almost exclusively to males but not anymore - often a solitary lesion in R lobe - Clinical Findings: Pleurisy
Abscess penetrates thru the diaphragm and lower portion of the lungs Abscess is in communication with lungs so patient spits out anchovy sauce-like vomitus

Cysts Benign Neoplasm o Hemangioma o Adenoma o Mesenchymal Tumor

Diffuse Involvement Cirrhosis hallmark on liver scan Mild Cirrhosis o Minimally decreased liver and spleen uptake Moderate Cirrhosis o Hepatosplenomegaly o Colloid uptake from R going to L (R to L shunting of isotope) o More uptake on the L, ergo, hypertrophy of the left lobe o Rib markings (maybe visualized) o Specific and marrow uptake increased because they are of the RES of the body Hepatitis Temporary condition when the liver is inflamed (cloudy swelling) Liver is temporarily incapacitated, has a function symmetrical isotope uptake of the entire liver spleen and marrow uptake because they are the other RES organs of the body

Dear Section C & Friends, Thank you for allowing us to get a copy of your transcriptions. God bless you more guys!! , Section B2

Diarrhea

2. PYOGENIC - bacterial - space-occupying lesions are multiple Located on both lobes No sex predilection - Clinical Findings: Obstructive Jaundice

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