tag:blogger.com,1999:blog-74086891645443599272024-03-10T23:22:57.595-04:00NuCleaR MuNkeEThe interesting, the weird and the technical world of Nuclear Medicine, geared towards students. It's a blog for students who are in their clinical practicum .... or for those who are just curious.Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.comBlogger34125tag:blogger.com,1999:blog-7408689164544359927.post-32696423630398188322014-02-06T14:03:00.000-05:002014-02-06T14:04:46.545-05:00Erdheim Chester Disease<span style="font-family: Verdana, sans-serif;">A lot of times when you read a requisition, you come across a lot of diseases, syndromes and terms, especially acronyms, that medical personnel use to which you have no clue what they mean sometimes. If it piques your interest you would look them up and if it is really pertinent to the case you would pay attention to what is written.</span><br />
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<span style="font-family: Verdana, sans-serif;">Well reading Erdheim Chester disease on the requisition, I really did not give a second thought (just another disease process), until I saw this.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyfEBx9wvfjmZ8XnPJ_v4S7UAJnDy2pS1jEbf8qqyKE5morI7Sf1wEC9qJIq8qyTfJYnz3J-iLrErHpkL2cERiY-hiWBzFK6_KCKVMMsX-dWvKZcED_uqNKoASw4GhC0b0s2QBWqg8Ohc/s1600/erdheimchester+TB+report.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjyfEBx9wvfjmZ8XnPJ_v4S7UAJnDy2pS1jEbf8qqyKE5morI7Sf1wEC9qJIq8qyTfJYnz3J-iLrErHpkL2cERiY-hiWBzFK6_KCKVMMsX-dWvKZcED_uqNKoASw4GhC0b0s2QBWqg8Ohc/s1600/erdheimchester+TB+report.jpg" height="240" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Total body bone scan of a patient with Erdheim Chester disease. The patient had complained of localized pain in the femurs.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghh_ckIuiJ3bOjFBtP1tRhqMPDXEQwPtOVXHqH7610mKzaMA5VS2e4ltodtFLJ43lCixn4hvaWfonIpE-gvPtpX6rEun8AfkGTS_z-TgdihUF7mUXo3l8OzFNSJvDCG8qqdTQvOk_QCis/s1600/Erhdheimer+arms.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEghh_ckIuiJ3bOjFBtP1tRhqMPDXEQwPtOVXHqH7610mKzaMA5VS2e4ltodtFLJ43lCixn4hvaWfonIpE-gvPtpX6rEun8AfkGTS_z-TgdihUF7mUXo3l8OzFNSJvDCG8qqdTQvOk_QCis/s1600/Erhdheimer+arms.jpg" height="96" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Additional images of the arms, for completeness. </td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhw71XrJEeLCImHf8uBQV33K-Am2XnPY7n_-MdZnS8JRNT4h3-LsBf5w5aWpkJX__aDSsCSXOYo8Iir71LERaZL_sONxrbipeGWlxBw6uBsxdtezufrXkxgRZE8ud8RXLdBdkKXn24iFkw/s1600/L+arm+erdheimer.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhw71XrJEeLCImHf8uBQV33K-Am2XnPY7n_-MdZnS8JRNT4h3-LsBf5w5aWpkJX__aDSsCSXOYo8Iir71LERaZL_sONxrbipeGWlxBw6uBsxdtezufrXkxgRZE8ud8RXLdBdkKXn24iFkw/s1600/L+arm+erdheimer.jpg" height="89" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Additional images of arms to document both dorsal and ventral views... I know, I know... I didn't label them, and the fingers were cut off on the view, but they didn't really involve in completing the whole case.</td></tr>
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<span style="font-family: Verdana, sans-serif;">So what is <span id="goog_1664269474"></span><a href="https://www.blogger.com/"><span id="goog_1664269478"></span>Erdheim Chester Disease (ECD)<span id="goog_1664269479"></span></a><span id="goog_1664269475"></span>? Click on the link and find out a little more, but what is interesting is that pathologists do not know how to classify this disease because it is so rare. The bottom line is, it is a disease in which there is an accumulation of <a href="https://www.blogger.com/"><span id="goog_1664269482"></span>histiocytes <span id="goog_1664269483"></span></a>depositing themselves into loose connective tissue. It eventually causes thickening and progresses into dense fibrotic tissue over time. The symptoms tend to be variable, but the one presented in this case was discomfort in the thighs and femurs, fatigue and intermittent back pain. We performed a flow and blood pool sequence of the lower body and there was a marked increase in perfusion in the blood flow and blood pool in the distal femurs*.</span><br />
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dytT6jz0N1F1iIOLCbuu3lL4z89Z19Skhahu8kHYjORN4AHHCF4o4cPInGhe5KW9Donfylj-llqnJcrCwAUOg' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi92-BIF7oPkzR9FJayUu9dV-aS1bzW2w1DNXci9G5BvokFWVr-VMlxmW6H8VBduKaR3zoscLDsMgNP5ay7lahqKzC4sk09I42dSJPLT-mZWBlr4WICsLd9X9zmoQicD6Z-h6QmY20wteA/s1600/BP+erdheimchester+disease.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi92-BIF7oPkzR9FJayUu9dV-aS1bzW2w1DNXci9G5BvokFWVr-VMlxmW6H8VBduKaR3zoscLDsMgNP5ay7lahqKzC4sk09I42dSJPLT-mZWBlr4WICsLd9X9zmoQicD6Z-h6QmY20wteA/s1600/BP+erdheimchester+disease.jpg" height="255" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Blood pool image after the injection of Tc99m-MDP. The distal femurs demonstrate an increased perfusion.</td></tr>
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<span style="font-family: Verdana, sans-serif;">The patient overall seemed healthy, when interviewed during the examination, except for the minor complaints mentioned above. The images were checked with the radiologist upon completion of the bone scan and was released. </span></div>
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<span style="font-family: Verdana, sans-serif;">So at the end of the day the lesson learned is, not to dismiss diseases, syndromes or terms so readily because it may provide an opportunity to learn.</span><br />
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<span style="font-family: Verdana, sans-serif;">*Note: When we performed the total body bone scan we saw what was presented and then went back to review the flow and blood pool study more closely. </span></div>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com7tag:blogger.com,1999:blog-7408689164544359927.post-73389186607778165152014-01-24T10:33:00.002-05:002014-01-24T10:35:14.654-05:00Yttrium-90 Bremsstrahlung Imaging<div class="separator" style="clear: both; text-align: left;">
<span style="font-family: Verdana, sans-serif;">Yttrium-90 imaging is probably not the first thing that comes to mind when scanning in Nuclear Medicine as an isotope, namely because it is outside of the realm of our usual Technetium-99m based radiopharmaceuticals. I have written about Y-90 and </span><a href="http://www.youtube.com/watch?v=rRMHyaoVUCg" style="font-family: Verdana, sans-serif;">Theraspheres</a><span style="font-family: Verdana, sans-serif;"> in the past blogs (parts </span><a href="http://nuclearmunkee.blogspot.ca/2012/05/theraspheres.html" style="font-family: Verdana, sans-serif;">I</a><span style="font-family: Verdana, sans-serif;"> and </span><a href="http://nuclearmunkee.blogspot.ca/2012/10/therasphere-part-deux.html" style="font-family: Verdana, sans-serif;">II</a><span style="font-family: Verdana, sans-serif;">), but this time instead of discussing the treatment aspect, we will look at the imaging aspect of using Y-90 and its </span><a href="http://www.ndt-ed.org/EducationResources/HighSchool/Radiography/bremsstrahlung_popup.htm" style="font-family: Verdana, sans-serif;">Bremmsstrahlung</a><span style="font-family: Verdana, sans-serif;"> x-rays that it produces.</span></div>
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<span style="font-family: Verdana, sans-serif;">Imaging was performed on a patient who was diagnosed with </span><a href="http://emedicine.medscape.com/article/197319-overview" style="font-family: Verdana, sans-serif;">hepatocellular carcinoma</a>. <span style="font-family: Verdana, sans-serif;">Early in the treatment</span><span style="font-family: Verdana, sans-serif;"> planning with computed tomography (CT) and interventional <a href="http://www.nlm.nih.gov/medlineplus/ency/article/003327.htm">arteriography</a>, a large mass was localized in segment <a href="http://www.radiologyassistant.nl/en/p4375bb8dc241d/anatomy-of-the-liver-segments.html">4A/B</a> in the liver. Majority of the vascularity was provided by the left hepatic artery. The <a href="https://www.blogger.com/"><span id="goog_1664269430"></span>middle hepatic artery and gastroduodenal arteries<span id="goog_1664269431"></span></a> were then coiled embolized to limit perfusion. This patient was on the third treatment cycle of Y-90 Therasphere. The growth of the liver lesion was stabilized with the first two treatments but there were some suspicions of new metastases.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8NGQpYQ4o9cBUd6qm07JqjZ4IqVc85jKogeLjTfPBnkZheIGmpFR6A_IHZREkq8IQ8oL5XFG4-dHobuqtdYd2SUNlAoMdR468OKDvRx4W1GN4CQZWh5STORV25bEMTaO2nLMb4Mqexyc/s1600/Common+Hepatic+Artery.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi8NGQpYQ4o9cBUd6qm07JqjZ4IqVc85jKogeLjTfPBnkZheIGmpFR6A_IHZREkq8IQ8oL5XFG4-dHobuqtdYd2SUNlAoMdR468OKDvRx4W1GN4CQZWh5STORV25bEMTaO2nLMb4Mqexyc/s1600/Common+Hepatic+Artery.jpg" height="300" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Finding the common hepatic artery during the arteriogram. Quite honestly, I can not figure how the interventional radiologists navigate through the arteries like that... There are no google maps for this!</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwmzFydShWKXqDn084fAvIrKk9c3P9Iag3rEJxmktHINFyJoDzFIHoBxRxr_ZcVUWsYVhTPRRsfOpfqpN85mzMnq2FGpdmTue-EIhd4BkWZ4KhICsUBz6AYsV0RPtyirttSgHBRpBRl8o/s1600/Right+Hepatic+Artery.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhwmzFydShWKXqDn084fAvIrKk9c3P9Iag3rEJxmktHINFyJoDzFIHoBxRxr_ZcVUWsYVhTPRRsfOpfqpN85mzMnq2FGpdmTue-EIhd4BkWZ4KhICsUBz6AYsV0RPtyirttSgHBRpBRl8o/s1600/Right+Hepatic+Artery.jpg" height="260" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 The right hepatic artery. Notice the blush within the lesion as the contrast was infused. I find this quite amazing to see in person. In the end the interventional radiologists decide to use the left hepatic artery to infuse the Tc-99m MAA to determine the lung shunt fraction and in turn was used to infuse the Y-90. </td></tr>
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<span style="font-family: Verdana, sans-serif;">What we wanted to accomplish was to ensure that the Y-90 Theraspheres that we were infusing had truly localized within the liver segments that we wanted to treat. In the past we had indirectly measured the activity using a dose rate meter (Bicron - mSv/hr) to examine the exposure rates to various parts of the chest and abdomen after the infusion. The tricky part of the whole thing was that we had never scanned Bremmsstrahlung x-rays before.</span><br />
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<span style="font-family: Verdana, sans-serif;">Luckily there is an array of information on the internet, but the problem is trying to decipher all this information. The Y-90 Bremsstrahlung spectrum looks very different, when low energy all purpose (LEAP), medium energy (ME) and high energy (HE) collimators are fitted onto the gamma camera.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm0YX4kjV_Wv1ga81QVdC0o64vJdRW8vep1Xc7ZpttZr1WOX63oYGxoMpSZBIAui2KLEswV_8Xjb9SJIYQ2Vfehr643A_a0670j0Q1cIBPIzOKqMOq5mXjQGHh1o4h4XjSPrNkG5qqyHI/s1600/Y90+Bremsstrahlung+Spectra.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgm0YX4kjV_Wv1ga81QVdC0o64vJdRW8vep1Xc7ZpttZr1WOX63oYGxoMpSZBIAui2KLEswV_8Xjb9SJIYQ2Vfehr643A_a0670j0Q1cIBPIzOKqMOq5mXjQGHh1o4h4XjSPrNkG5qqyHI/s1600/Y90+Bremsstrahlung+Spectra.jpg" height="400" width="265" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Top: Represents the Bremsstrahlung spectra on a gamma camera without collimation. Second: Represents the spectra with a low energy all purpose (LEAP) collimator. Third: The spectra with a medium energy (ME) collimator. Bottom: The spectra with a high energy (HE) collimator. Note 1: If anyone who is reading this - can someone confirm what the lower peak is? (It's a scatter peak of some sort - it may be a dumb question, but I need to ask it for my knowledge). Note 2: Diagram was taken from: <a href="https://www.blogger.com/"><span id="goog_1664269447"></span>Planar Gamma Camera Imaging and Quantitation of Yttrium-90 Bremsstrahlung<span id="goog_1664269448"></span></a></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPC3OeFCg-cYoSyMrH4WzSPJcQYm0JiB_J2JSAzV9mn5ge8z3mb_1d-s-16X2nJ1rPt2y1R8HJrEQGZa-68KQ74_yc46YUNNCaJCuulc28RMmDDEYBgbui9D-reKTFols5JFhrF9ufteM/s1600/Y90+Sepctra.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjPC3OeFCg-cYoSyMrH4WzSPJcQYm0JiB_J2JSAzV9mn5ge8z3mb_1d-s-16X2nJ1rPt2y1R8HJrEQGZa-68KQ74_yc46YUNNCaJCuulc28RMmDDEYBgbui9D-reKTFols5JFhrF9ufteM/s1600/Y90+Sepctra.jpg" height="244" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 4 There is a characteristic x-ray photopeak between 75 - 79 keV with collimation. This is the range where we decide to use our window for imaging. However, note on the far right in Fig. 3 TOP, and in Fig. 4 another interesting peak occurs on around 180 - 210 keV. This is probably the result of septal penetration due to some high energy Bremsstrahlung x-rays.</td></tr>
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<span style="font-family: Verdana, sans-serif;">Furthermore, where do we centre the energy window and how big should the window be? There is a characteristic x-ray peak, as indicated above, around 75 keV. But what is interesting is that some protocols use a </span><span id="goog_78240661" style="font-family: Verdana, sans-serif;"></span><a href="http://www.blogger.com/" style="font-family: Verdana, sans-serif;"><span id="goog_78240665"></span>79 keV peak with a 26% window<span id="goog_78240666"></span></a><span id="goog_78240662" style="font-family: Verdana, sans-serif;"></span><span style="font-family: Verdana, sans-serif;">, while others use a </span><a href="http://www.blogger.com/" style="font-family: Verdana, sans-serif;"><span id="goog_78240669"></span>90 keV peak and a window width of 15%<span id="goog_78240670"></span></a><span style="font-family: Verdana, sans-serif;">. So what is the optimal imaging parameter in regards to the energy peak and energy window? I am not really sure, and I think it really has to do with the testing that we need to do on our camera system (Seimens Symbia T-6) to figure this out in terms of sensitivity, resolution and target to background ratios. However we did not have the luxury of time to test these parameters. When we first started the trial, it was never our intention to image the Y-90 Therasphere patients, and this patient was a "one off".</span></div>
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<span style="font-family: Verdana, sans-serif;">However there is some agreement with respect to the collimation. From what I have read between ME and HE collimators, generally speaking, most have used the ME's. In our case, the administered dose was approximately 2.03 GBq and imaging was performed 3 days later, we opted for the ME's since there were not going to be any significant differences between sensitivity and resolution between ME and HE collimators for equivalent energy windows (ie. whether we were using a 26% or 15% window). </span><br />
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<span style="font-family: Verdana, sans-serif;">So these are our results:</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZ0oMFf1UANqmYd_57YfB8aWhTwRbu_EGi17bIs5zOLf399511J8HNCzf9kV0G-DUv4uijLLg5m4Oo_9QDdGNs8NC3raeri_aRbv1pfqjBoQkR85jeSD1Mvu4Oij_AthBMur-hLVRiCbQ/s1600/fused+y90+coronal.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZ0oMFf1UANqmYd_57YfB8aWhTwRbu_EGi17bIs5zOLf399511J8HNCzf9kV0G-DUv4uijLLg5m4Oo_9QDdGNs8NC3raeri_aRbv1pfqjBoQkR85jeSD1Mvu4Oij_AthBMur-hLVRiCbQ/s1600/fused+y90+coronal.jpg" height="164" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 5 Coronal fused section from the SPECT/CT (Symbia T-6) with localization in the segment 4 of the liver</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUhGlzDQz7gqev2YwHkIfcIVD05rMNdMZ3goVgD4MzEE1ScwEedWaYIy-yQLqfPGNqrw5rMcxg0Un0-sunpC-Yum2i83x9aQukjriVEdaMILdE1tzpSQm0hoKQxlfapjerPbCDpd9t8Uc/s1600/fused+sagittal+y90.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiUhGlzDQz7gqev2YwHkIfcIVD05rMNdMZ3goVgD4MzEE1ScwEedWaYIy-yQLqfPGNqrw5rMcxg0Un0-sunpC-Yum2i83x9aQukjriVEdaMILdE1tzpSQm0hoKQxlfapjerPbCDpd9t8Uc/s1600/fused+sagittal+y90.jpg" height="168" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 6 Sagittal fused section from the SPECT/CT (Symbia T-6)</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-ujMllh_z6elph9VwkYebTM6Q6olvLXxSRukKwtTv4t3soyRjJgKnMgW69JuvUoZ9O1XKarBbT_GsqBoSwzQRbMdQ7VVdrlkAusC-xoldtSCt-h2MshyphenhyphenU3vfR9a_ebTBdlMFIwzdaoSk/s1600/fused+trans+y90.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg-ujMllh_z6elph9VwkYebTM6Q6olvLXxSRukKwtTv4t3soyRjJgKnMgW69JuvUoZ9O1XKarBbT_GsqBoSwzQRbMdQ7VVdrlkAusC-xoldtSCt-h2MshyphenhyphenU3vfR9a_ebTBdlMFIwzdaoSk/s1600/fused+trans+y90.jpg" height="197" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 7 Transaxial fused section from the SPECT/CT (Symbia T-6)</td></tr>
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<span style="font-family: Verdana, sans-serif;">The <a href="https://www.blogger.com/"><span id="goog_97500899"></span>MIP<span id="goog_97500900"></span></a> after reconstruction looks like a "big blob". It didn't look too bad with regards to the planar images which we also obtained. We had captured them to quickly examine the target lesion to background liver fraction.</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglSO0IU4J7qt67Mq6cxQHCnCvYk7t-XnH2p7NTKJESXOmRFAqRDTu0cD11vGr1CQ7Jr9jz_CAagTptfowLLSpRG62HuG1nmqDvDOc3VmCD9BxGdY6XaSj2IWJwOt-_Dj8x9MIFJRBjpn8/s1600/Y90+anterior.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEglSO0IU4J7qt67Mq6cxQHCnCvYk7t-XnH2p7NTKJESXOmRFAqRDTu0cD11vGr1CQ7Jr9jz_CAagTptfowLLSpRG62HuG1nmqDvDOc3VmCD9BxGdY6XaSj2IWJwOt-_Dj8x9MIFJRBjpn8/s1600/Y90+anterior.jpg" height="256" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 8 Anterior image. We imaged for 600 secs and obtained approximately 700K to 1700K total counts (posterior/anterior images respectively)</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcPCqcz6hOYd_eVYZxxDFAZpEz9b7_hqeBRo25RzpZQlU-veIVX4M3xTnIjBuHOF_OxsmYhdWaU3jLOGsPdKQYWLXyiF1vMuvbgTvwT3YFIBgjakqVknG-A9oj9f_Z5pLOFhGM9ZK_HaQ/s1600/y90+report.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhcPCqcz6hOYd_eVYZxxDFAZpEz9b7_hqeBRo25RzpZQlU-veIVX4M3xTnIjBuHOF_OxsmYhdWaU3jLOGsPdKQYWLXyiF1vMuvbgTvwT3YFIBgjakqVknG-A9oj9f_Z5pLOFhGM9ZK_HaQ/s1600/y90+report.jpg" height="175" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 9 A quick target lesion to liver background ratio was calculated to determine the amount that remained in the liver 3 days after the infusion</td></tr>
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<span style="font-family: Verdana, sans-serif;">In the end we decided to use the <a href="https://www.blogger.com/"><span id="goog_97500919"></span>MD Anderson's protocol<span id="goog_97500920"></span></a>. It was a shot:</span></div>
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<u><span style="font-family: Verdana, sans-serif;">NM Planar & SPECT Y-90 Bremsstrahlung Imaging:</span></u></div>
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<span style="font-family: Verdana, sans-serif;">– 79keV/26% window, MELP collimation, 128x128 matrix, 4.8 mm2 pixels, 128 </span></div>
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<span style="font-family: Verdana, sans-serif;">So we did all this, BUT some might say... what about imaging the patient on the PET/CT unit? Well I wish we could, as you know, Y-90 is a beta emitter and this is certainly within the realm of possibilities, and with it, a huge array of literature on this as well. We thought about it, but we couldn't get imaging time on the PET/CT unit... so we opted for regular gamma camera imaging. QED.</span></div>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-26205730276051784742013-12-10T13:23:00.001-05:002013-12-10T13:23:45.409-05:00I'll Be Back - 2014Sorry... I have been neglecting my BLOG.... not really, but I have some interesting cases to post for the students. Just getting the time to work through the cases is difficult - but I'm still keen.<br />
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My last post was March 2013... shame, I know. My New Years resolution is to update this Blog on a regular basis, since in the New Year I'll have some flexibility in developing educational content for the school that I am moonlighting with now.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcfK-lVeXPuBxcqD5RRIbLSTQkcPpGWfCMfOV3zbjscDQD1K3cJPF5p5PshW0LS7LnMB3fauVefSTCzkpQ8jXNd4zFXLhXoQxIQ-XozdCNn0q9RpeYQvTg26-hqkRY8OTTJ0HiCRSyCWk/s1600/PET+foot.JPG" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcfK-lVeXPuBxcqD5RRIbLSTQkcPpGWfCMfOV3zbjscDQD1K3cJPF5p5PshW0LS7LnMB3fauVefSTCzkpQ8jXNd4zFXLhXoQxIQ-XozdCNn0q9RpeYQvTg26-hqkRY8OTTJ0HiCRSyCWk/s400/PET+foot.JPG" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Here is something that we do not see very often. Really interesting location for lymphoma. I assure you that this was not from a spill practical training course.</td></tr>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-91955055792971745922013-03-19T11:47:00.002-04:002013-03-19T11:49:41.863-04:00In-111 Pentetreotide Imaging<span style="font-family: Verdana, sans-serif;">I have had a lot questions with regards to <a href="http://www.cancer.gov/drugdictionary?cdrid=43127">In-111 pentetreotide</a> imaging by my students since we have block bookings once a month to accomodate some of the physicians' requests for these scans. Sometimes when </span><span style="font-family: Verdana, sans-serif;">I start talking about </span><a href="http://www.alomone.com/upload/newsletters/pathways%202%20papers/somatostatin%20and%20the%20somatostatin%20receptors%20versatile%20regulators%20of%20biological%20activity.pdf" style="font-family: Verdana, sans-serif;">somatostatin and somatostatin receptors</a><span style="font-family: Verdana, sans-serif;"> I get this glazed look in their eyes.</span><br />
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<span style="font-family: Verdana, sans-serif;">The best place to start would be to look at the <a href="http://interactive.snm.org/docs/SRS_Final_V2_0.pdf">Society of Nuclear Medicine procedural guidelines</a> (SNM), since it would provide a grand overview of what this type imaging is all about.</span><br />
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<span style="font-family: Verdana, sans-serif;">We need to make the distinction between pentetreotide versus octreotide when discussing the imaging aspects, however. In nuclear medicine the In-111 pentetreotide is the compound that we work with, because it has a <a href="http://www.chemicalland21.com/specialtychem/perchem/CHELATING%20AGENTS.htm">DTPA chelator</a> attached to it to allow it to bind to the indium-111 isotope. Essentially pentetreotide (In-111-DTPA-D-Phe) is a conjugated form of a <a href="http://www.preservearticles.com/2011101015128/what-is-somatostatin-and-what-are-its-functions.html">somatostatin </a>analog. Octreotide on the other hand is just a peptide (an octapeptide to be exact) that mimics the natural somatostatin that is found within our bodies. Basically, octreotide is a synthetic version of the natural ones within our bodies.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiM1z6wrnw_OSelw5OvALzeUUEfxbJLxD5bzZOKoOvAkqViIZe-5yju8sxMRSYhC3U6ae5KPRCgb67pcMPrJjMMSD3WgoRk4u-aoFfUQh78LXSlZkaIWQwOamWIWocqk2BYlFilZ8Zjm40/s1600/Octreoscan-01.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiM1z6wrnw_OSelw5OvALzeUUEfxbJLxD5bzZOKoOvAkqViIZe-5yju8sxMRSYhC3U6ae5KPRCgb67pcMPrJjMMSD3WgoRk4u-aoFfUQh78LXSlZkaIWQwOamWIWocqk2BYlFilZ8Zjm40/s1600/Octreoscan-01.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 <span style="font-family: Verdana, sans-serif;">This is the pentetreotide peptide. For those who would want to know what it looks like.</span></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3N5C4EcOHiCYHoiL3bOqm2QC9FYeMwNjbhV3dFZUdSQX01QJPtUumH5t59ZyY159TD-cK7LJIa6_fXlzOdvb7Btv4g2Yggazv51QwvB74zG_yVS02ERCltLopQGZyQ43OUEkfjCC3_rY/s1600/500px-Octreotide.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="316" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh3N5C4EcOHiCYHoiL3bOqm2QC9FYeMwNjbhV3dFZUdSQX01QJPtUumH5t59ZyY159TD-cK7LJIa6_fXlzOdvb7Btv4g2Yggazv51QwvB74zG_yVS02ERCltLopQGZyQ43OUEkfjCC3_rY/s320/500px-Octreotide.png" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 2 This is the structure for Octreotide. <span style="color: red;">I will say this:</span> <i>I am not a radiochemist, or a radiopharmacist and I did not take organic nor inorganic chemistry. However, I made sure our radiopharmacist was okay with these images before posting.</i></span></td></tr>
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<span style="font-family: Verdana, sans-serif;">Here are some images that we have acquired recently. It will help us with the discussion.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbkqulzdx4BfGYPeewmyE98C12TdeaZnKUORlNC1MKo5S9WtH0PJfKsnsw87WtoG8wF1e122CqcWTvnzlHN64yrWPqCW18E_UNYHrKCxZzmxswmgUBek8MgmYI7V5plSGFXKb-Pkx28MI/s1600/Octreo+WB+1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="231" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbkqulzdx4BfGYPeewmyE98C12TdeaZnKUORlNC1MKo5S9WtH0PJfKsnsw87WtoG8wF1e122CqcWTvnzlHN64yrWPqCW18E_UNYHrKCxZzmxswmgUBek8MgmYI7V5plSGFXKb-Pkx28MI/s400/Octreo+WB+1.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 3 A 24 hour In-111 pentetreotide scan of a patient with gastrinoma. Notice a focal uptake in the midline of the body, along with a faint uptake in the liver. You can see it better in the whole body images on the right.</span></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKh21WLAaxl0IY19S4b_I7EH85XGAzRbKMiNkasCYqDeu3JJexsKi_vyYraqBMRz7hiyzKng7jBwNZRp2plnfjnkO1fokQfkaW1uSCxwbYHgfXHCCqrvk3N4t-PxyNm0udVH5jK7o7fHI/s1600/Octreo+WB+2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgKh21WLAaxl0IY19S4b_I7EH85XGAzRbKMiNkasCYqDeu3JJexsKi_vyYraqBMRz7hiyzKng7jBwNZRp2plnfjnkO1fokQfkaW1uSCxwbYHgfXHCCqrvk3N4t-PxyNm0udVH5jK7o7fHI/s400/Octreo+WB+2.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 4 Another 24 hour whole body imaging. Note the focal uptake in the midline of the body. This patient was being worked up for insulinoma.</span></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjPgEHOWFK0ghsM3u7XTGyYJi0VMFvGmbicvSpR27I2C2xu3gR9Bhxck8LmaRCZxQASaRzPAJ2LS_6_IAvVXnr_t4O00r5l0uxzX4WFDjZRF_ym41h4I3EwQCSIWhNcNm1KcKmW49RRSo/s1600/Octreo+wb+3.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="280" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjjPgEHOWFK0ghsM3u7XTGyYJi0VMFvGmbicvSpR27I2C2xu3gR9Bhxck8LmaRCZxQASaRzPAJ2LS_6_IAvVXnr_t4O00r5l0uxzX4WFDjZRF_ym41h4I3EwQCSIWhNcNm1KcKmW49RRSo/s400/Octreo+wb+3.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 5 As above, imaging was performed at 24 hours. However note the uptake in the thyroid.</span></td></tr>
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<span style="font-family: Verdana, sans-serif;">Majority of the patients that come to see us receive an In-111 pentreotide injection for some type of neuroendocrine imaging. Most of them involve the gastroenteropancreatic (GEP) tumours such as the <a href="http://emedicine.medscape.com/article/283039-overview">insulinomas</a>, <a href="http://emedicine.medscape.com/article/184332-overview">gastrinomas</a>, <a href="http://emedicine.medscape.com/article/125910-overview">VIPomas (vasoactive intestinal polypetide secreting tumour)</a> and other times we get the occasional request for <a href="http://www.medicinenet.com/carcinoid_syndrome/page3.htm">carcinoids</a>. </span><br />
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<span style="font-family: Verdana, sans-serif;">Patient preparation is fairly straight forward, but one thing that is interesting is the decision to infuse glucose in patients in those suspected of insulinoma. This is to prevent the potential problem of <a href="http://www.medicinenet.com/hypoglycemia/article.htm">hypoglycemia</a> during the injection. It is not common practise and it is the decision of the radiologist to incorporate this in their standard of practise with these cases. We do not do it at our site. The one thing that we do screen for are medications, such as the use of Octreotide as a therapeutic agent. Since Octreotide is the synthetic form of somatostatin within our bodies, it's more potent and effective in suppressing gastrin, cholecystokinin, glucagon, TSH, pancreatic polypeptide, secretin, growth hormone, TSH and vasoactive intestinal peptide. Careful consideration of the time when the patient had taken the Octreotide is important as we want to ensure good uptake of the In-111 pentetreotide. More patient preparation information can be reviewed in the <a href="http://interactive.snm.org/docs/SRS_Final_V2_0.pdf">SNM guidelines</a>, or in the <a href="http://www.eanm.org/publications/guidelines/EJNMMI_111In-Pentetreotide_GL.pdf">European Association of Nuclear Medicine guidelines as well.</a></span><br />
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<span style="font-family: Verdana, sans-serif;">The imaging of these patients are fairly straight forward as well. Whole body scanning is generally done at 24 hours, but before when we had purchased our SPECT/CT, the standard of practise was to perform whole body imaging as well as, a standard SPECT at 48 hours. The SPECT/CT was a bit of a game changer for us, since our radiologists were comfortable with the images obtained at 24 hours that included the SPECT/CT.</span><br />
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<span style="font-family: Verdana, sans-serif;">Not all these tumours are created equally. In order to be visualized they require a number of somatostatin receptors on the tumours themselves. There are 6 known receptors: SSTR1, SSTR2a, SSTR2b, SSTR3, </span><span style="font-family: Verdana, sans-serif;">SSTR4, SSTR5. Note there are also subtypes as well. With the "lock and key" method of visualization, the sensitivity of the tumours will vary. For example, there is better sensitivity in <a href="http://www.mdpi.com/2072-6694/4/2/504">g</a></span><span style="font-family: Verdana, sans-serif;"><a href="http://www.mdpi.com/2072-6694/4/2/504">astroenteropancreatic neuroendocrine tumors</a> (<i>download the PDF, it's free</i>), except for insulinomas as the result of the lower incidence of somatostatin receptors, especially those of the SSTR2. The sensitivity is approximately 25-60% in comparison to the other tumours in this category. The best practise for our department is that our radiologists screens the requisitions before we begin the bookings and the ordering of indium-111 for compounding. </span><br />
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<span style="font-family: Verdana, sans-serif;">I want to touch upon one thing however and it is the biodistribution of the </span><span style="font-family: Verdana, sans-serif;">In-111 pentreotide. Generally the normal uptake of In-111 pentreotide occur in the pituitary glands, the thyroid, liver, spleen, kidney, bladder and sometimes gallbladder. Bowel is also seen but more so after 24 hours post injection. If you look at Figure 5 in comparison to the other images, there is the obvious uptake in the thyroid bed. I personally have not seen this very often, so my initial inclination was "abnormality" since medullary thyroid cancers and pituitary adenomas express high amounts of somatostatin receptors. Upon reviewing the finalized report, it did not mention the uptake in the thyroid bed, but rather indicating no evidence of any octreotide avid pancreatic tumours or metastases; the biodistribution was normal. Further review into the patient history, just recently, had the patient to undergo an urgent thyroid ultrasound and aspiration for pre-op staging. This patient had a previous biopsy of the left thyroid as well, but it had unsatisfactory cellularity in the sample for any type of determination. The CT work up report for this patient also noted a left thyroid nodule.</span><br />
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<span style="font-family: Verdana, sans-serif; text-align: center;">I'm not aware of any recent results in regards to the identification of the nodule, but this is something that I will be following up for my own education. This may be a potential occurrence of an incidental finding for thyroid carcinoma.... who knows?</span><br />
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-65949646504071896982013-02-19T11:08:00.000-05:002013-02-19T11:08:57.460-05:00Ewing's Sarcoma<span style="font-family: Verdana, sans-serif;">Sorry about the long hiatus, but here is something that came up a couple of weeks ago which was a bit tragic for the patient, but at the same time quite an interesting case.</span><br />
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<span style="font-family: Verdana, sans-serif;">I personally have not seen a gallium whole body scan like this, and likewise with the other technologists in the department. This patient was being worked up for <a href="http://emedicine.medscape.com/article/990378-overview">Ewing's sarcoma</a>. </span><br />
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<span style="font-family: Verdana, sans-serif;">When the patient arrived in our department, they were in a considerable amount of pain. We limited the <a href="http://www-pub.iaea.org/MTCD/publications/PDF/te_1597_web.pdf">SPECT/CT</a> to only 1 bed as oppose to our regular whole body SPECT/CT which covers 2 to 3 bed positions on our <a href="http://www.medical.siemens.com/webapp/wcs/stores/servlet/ProductDisplay?productId=138598&storeId=10001&langId=-1&catalogId=-1&catTree=100001">Symbia T6</a>. Having said that, it was quite obvious where the tumour was located.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlSis7H7-0Rmg6qyMYdZLgmNtnz334bPXj34JHogJZj5eJ1p2hk_g_iKLbxuMjfeFGulCaoZX6pWXMrVxy8RBj7sVlbeOi63xPEA5MgvRSDh6Zb6DlML9auf9igpvPFxvSWdvVoveHSXI/s1600/Ga+WB+Ewing%2527s.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlSis7H7-0Rmg6qyMYdZLgmNtnz334bPXj34JHogJZj5eJ1p2hk_g_iKLbxuMjfeFGulCaoZX6pWXMrVxy8RBj7sVlbeOi63xPEA5MgvRSDh6Zb6DlML9auf9igpvPFxvSWdvVoveHSXI/s320/Ga+WB+Ewing%2527s.jpg" width="275" /></a></td></tr>
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<tr><td class="tr-caption" style="font-size: 12.800000190734863px;"><span style="font-family: Verdana, sans-serif;">Fig. 1 Ga-67 whole body image of a patient being worked up for Ewing's sarcoma. The right thoracic area has intense gallium uptake.<br /></span></td></tr>
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<span style="font-family: Verdana, sans-serif;">The right thorax contained majority of the gallium uptake, with little evidence of metastases outside of the area. However, the CT demonstrated a much clearer extent of the disease involvement with the spine and the surrounding bony structures. The patient originally was asymptomatic, but as the disease started to spread, a rapid loss in weight occurred and discomfort emerged from the right posterior region of the back.</span><div class="separator" style="clear: both; text-align: center;">
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhaFSP7TZhvjJIewZFQnjFBHhrgB8PNn31cDvUdgzKEECbWKAT2YAoc2JVX8JjVCFTV-uL0ohhU9UgQoSHtxrR6Efqu5YTmFiqa3E9-1P_4IlPcvHC60EXVeQ7hRbpgZe0F5uClKPspF0E/s1600/transaxial+ewings.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="227" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhaFSP7TZhvjJIewZFQnjFBHhrgB8PNn31cDvUdgzKEECbWKAT2YAoc2JVX8JjVCFTV-uL0ohhU9UgQoSHtxrR6Efqu5YTmFiqa3E9-1P_4IlPcvHC60EXVeQ7hRbpgZe0F5uClKPspF0E/s320/transaxial+ewings.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 2 Transaxial CT slice. Notice the periosteal reaction in the posterior rib and spine.</span></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxCIFsm_E0G4KP538d-FFcIzf9IIqCUgSAPQ-Ss4THxbZBWXQjSdQXNOPzbxGcXhTO2wIFYzDV6dsOA1rQ8DXYyysvYXK3jE5_g4aVOMn0QYeIAYT-NGeHiH9UTbVqlufzHyxsVJa7cHo/s1600/sagittal+ewings+ct.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhxCIFsm_E0G4KP538d-FFcIzf9IIqCUgSAPQ-Ss4THxbZBWXQjSdQXNOPzbxGcXhTO2wIFYzDV6dsOA1rQ8DXYyysvYXK3jE5_g4aVOMn0QYeIAYT-NGeHiH9UTbVqlufzHyxsVJa7cHo/s320/sagittal+ewings+ct.jpg" width="172" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 3 Sagittal slice with an almost complete opacification of the right lung. Most of the lung has collapsed due to the right sided mass and effusion.</span></td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSZ6kGn2eayRFb2DB31FpJnKRjwcAAF2uLd_ggsWZVtRZNdC272zJMoADX-LuSKj0URYgtoc0nBRTNm9xWmkNUk44rqCrWL3-Wj1tfs53jO3jOkZ78wlmwEFZqKQ6fdHTZ79755Dp_JtQ/s1600/Coronal+ewings+ct.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhSZ6kGn2eayRFb2DB31FpJnKRjwcAAF2uLd_ggsWZVtRZNdC272zJMoADX-LuSKj0URYgtoc0nBRTNm9xWmkNUk44rqCrWL3-Wj1tfs53jO3jOkZ78wlmwEFZqKQ6fdHTZ79755Dp_JtQ/s320/Coronal+ewings+ct.jpg" width="196" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 4 A coronal slice further depicting the multiple lytic changes in the right sided ribs as well as the invasion of the tumour into the spinal canal.</span></td></tr>
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<span style="font-family: Verdana, sans-serif;">Overall the disease state was quite extensive with an extra large parenchymal mass filling up much of the right hemithorax, measuring up to 13 cm in thickness. The disease may have started in the spine or in one of the ribs and over time became invasive. A further MRI of the spine was performed to assess the spinal canal and spinal cord as the patient began to have bilateral leg weakness and tingling in the feet.</span><div>
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<span style="font-family: Verdana, sans-serif;">Generally with Ewing's sarcoma it often occurs during childhood and can start anywhere in the body. However it tends to target the long bones, that are </span><span style="background-color: white; color: #333333; line-height: 19px;"><span style="font-family: Verdana, sans-serif;">hard, dense bones that provide strength, structure, and mobility. Almost a third of the patients have some metastases to other locations, generally to the lungs and in to other bones. Click on the above link (Ewing's sarcoma) for more information.</span></span><span style="font-family: Verdana, sans-serif;"><br /></span><div style="text-align: center;">
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com2tag:blogger.com,1999:blog-7408689164544359927.post-70501714196380490692013-01-10T13:45:00.000-05:002013-09-04T09:49:41.281-04:00Liver Spleen Scan Using Denatured Red Blood Cells<div class="separator" style="clear: both; text-align: left;">
<span style="font-family: Verdana, sans-serif;">Denatured red blood cell scans are few and far between, but when something like this comes along, it piques everyone's interest. </span></div>
<span style="font-family: Verdana, sans-serif;"><br /></span><span style="font-family: Verdana, sans-serif;">With this case here, the ordering physician was inquiring about the multiple intra abdominal deposits and had asked whether these deposits were related to </span><a href="http://www.diagnosticimaging.com/case-studies/content/article/113619/1513623" style="font-family: Verdana, sans-serif;">splenules</a><span style="font-family: Verdana, sans-serif;">, caused by some kind of <a href="http://www.medscape.com/viewarticle/559459_3">splenosis</a>. We are uncertain about the patient history since the technologist performing the scan did not inquire about the previous history of trauma or any <a href="http://www.medterms.com/script/main/art.asp?articlekey=3886">iatrogenic</a> events that may have potentially caused the spleen to rupture. Previous ultrasounds or CT imaging were not performed at our facility and the patient did not bring any CD's with previous imaging from outside sources. But thinking back, this patient must have some form of imaging done or otherwise, how did the physician know of the abdominal deposits? At any rate this is what we got with respect to the imaging. </span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span><span style="font-family: Verdana, sans-serif;">After the initial reinjection of the denatured cells, a flow and blood pool images were acquired. The delayed imaging was performed 20 minutes post injection, using a 2 bed SPECT/CT protocol.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtHWWIFTS3_rLIZqJu9foG7HYwKWi3KBQ97esmxac1fWHjObytrTpvD8F5KCbePM5wDFvx_6dArRUoYfWVlNqaV40OjW30P5VS-3Vv0o21Jhm4MbYANLbiGwEuPGtyZs-fSodyZi5p3vM/s1600/ant+bp+splenules+(1).jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjtHWWIFTS3_rLIZqJu9foG7HYwKWi3KBQ97esmxac1fWHjObytrTpvD8F5KCbePM5wDFvx_6dArRUoYfWVlNqaV40OjW30P5VS-3Vv0o21Jhm4MbYANLbiGwEuPGtyZs-fSodyZi5p3vM/s320/ant+bp+splenules+(1).jpg" width="260" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Anterior blood pool, after the denatured red blood cell injection.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKcIk-YJPd5VDwEUSCxyeH2Jp_1LLtpVkRVk4nevIuy-fDGNx2UTJxaNlpsSbeiwaFNSd12JBAemUucI0skDlRTf_tPrCGiVDrpgXOsCxrzVpbr4i96_Zq2lZ1VlgCJU4XpeVMzxfbXf8/s1600/post+bp+splenules.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhKcIk-YJPd5VDwEUSCxyeH2Jp_1LLtpVkRVk4nevIuy-fDGNx2UTJxaNlpsSbeiwaFNSd12JBAemUucI0skDlRTf_tPrCGiVDrpgXOsCxrzVpbr4i96_Zq2lZ1VlgCJU4XpeVMzxfbXf8/s320/post+bp+splenules.jpg" width="265" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Posterior blood pool acquisition.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj87q-DdiTG-3q0WmvO8EQS874Mq4rXSST9mWHKZ67nnPqBPrAvTgjBWy-Vr862qnodKq-XUnztyRZWtUZThLInR50R7gBeVsZjeE2BkqPGnvknfQSQf6eBq1q8pm4n1hkgV84HbvAy-PI/s1600/splenule2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj87q-DdiTG-3q0WmvO8EQS874Mq4rXSST9mWHKZ67nnPqBPrAvTgjBWy-Vr862qnodKq-XUnztyRZWtUZThLInR50R7gBeVsZjeE2BkqPGnvknfQSQf6eBq1q8pm4n1hkgV84HbvAy-PI/s320/splenule2.jpg" width="216" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Coronal slice. Multiple foci of activity. Note the activity over the dome of the liver and the perihepatic regions.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuNbvMfH68JIwD1mIu_7e7Euq1CJvONOndWbbl8FKH5O0Z9OLPtoXdzTnxtZjMFBOZVAvtcDLBXvOkLDx8hdUlEZxHAXy7lENAB7XkzgA8Jlma6MzKBRfpV-8l7moSJ6OlrZNFHy2Iv08/s1600/splenules3.1.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhuNbvMfH68JIwD1mIu_7e7Euq1CJvONOndWbbl8FKH5O0Z9OLPtoXdzTnxtZjMFBOZVAvtcDLBXvOkLDx8hdUlEZxHAXy7lENAB7XkzgA8Jlma6MzKBRfpV-8l7moSJ6OlrZNFHy2Iv08/s320/splenules3.1.jpg" width="264" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 4 Multiple uptake within the peritoneal cavity.</td></tr>
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dwlPGIo_UPmgJL0Fd_vVTue5TR4X6IRYT8bVwqFAXsfXdIK9kWoCr9-low1UiVC-agj71Kf5-nmYvrOa9tzFg' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
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<span style="font-family: Verdana, sans-serif;">The <a href="http://radiopaedia.org/articles/maximum-intensity-projection-mip">MIP</a> display above might not seem like very much, but there are multiple foci of tracer uptake scattered throughout the peritoneal cavity and the perihepatic region. The largest and the most intense nodules occur in the splenic fossa along with multiple nodules tracking along the colon.</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDYfB-sDIv1FNsI1JW-b3olvqNVvm3GBpJlRkM06uli4rM4sMHklDtoRYvzQP3i-umJvUedQdNn18-TneORyE4EuJanCdAOqLDBNoWoY0rjDlGdsfKsZn43mTp3bN3lOzhvo1-py2Nbnc/s1600/fused+splenules+(1).jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDYfB-sDIv1FNsI1JW-b3olvqNVvm3GBpJlRkM06uli4rM4sMHklDtoRYvzQP3i-umJvUedQdNn18-TneORyE4EuJanCdAOqLDBNoWoY0rjDlGdsfKsZn43mTp3bN3lOzhvo1-py2Nbnc/s320/fused+splenules+(1).jpg" width="253" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 5 SPECT/CT acquisition was performed to localize the denatured red blood cell uptake.</td></tr>
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<span style="font-family: Verdana, sans-serif;">There is also focal activity in nodules adjacent to the liver as well as further nodules in the lateral right hepatic border and in the hepatorenal space. Overall a lot of diffuse uptake can be observed, which is highly suggestive of splenosis.</span></div>
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<span style="font-family: Verdana, sans-serif;">We have a <a href="http://en.wikipedia.org/wiki/Good_manufacturing_practice">GMP</a> approved radiopharmacy and all of the blood work is performed on site. I must admit in the past, sometimes the labeling worked and sometimes it did not, however we have tweaked the procedure a little bit, and the information below is how we label and denature our red blood cells to ensure a quality scan.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span><span style="font-family: Verdana, sans-serif;"><b style="background-color: yellow;">Preparation of Radiolabeled Red Blood Cells Using the UltraTag <i>In Vitro</i> Method:</b></span><br />
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<span style="font-size: 12pt; line-height: 115%;"> <strong>Purpose:<o:p></o:p></strong></span></div>
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The aim of this document is to provide information on the preparation and quality control of <sup>99m</sup>Tc-labeled red blood cells using the UltraTag® in vitro method.<o:p></o:p></div>
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<span style="font-size: 12pt;"> <strong>Responsibilities:<o:p></o:p></strong></span></div>
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It is the responsibility of the radiopharmacy technician to perform this procedure under strict aseptic conditions and as outlined in this protocol.<o:p></o:p></div>
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It is the responsibility of the radiopharmacist or the quality control technician to ensure that the correct RBC preparation procedure is followed and the final product meets the required specifications.<o:p></o:p></div>
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<span style="font-size: 12pt; line-height: 115%;"> <strong>Materials:<o:p></o:p></strong></span></div>
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- lead glass syringe holder (3 mL size)<o:p></o:p></div>
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- syringe lead pig<o:p></o:p></div>
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- vial lead pig<o:p></o:p></div>
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- sterile 15 mL plastic centrifuge tubes<o:p></o:p></div>
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- sterile 18 or 21 gauge needles<o:p></o:p></div>
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- sterile 5 mL and 3 mL syringes<o:p></o:p></div>
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- sterile saline 0.9 % for injection USP<o:p></o:p></div>
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- UltraTag® kit<o:p></o:p></div>
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- <sup>99m</sup>Tc sodium pertechnetate (370 – 1000 MBq)<o:p></o:p></div>
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<span style="font-size: 12pt;"> <strong>Procedure:<o:p></o:p></strong></span></div>
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<b><i>4.1. </i></b><b><i>Area setup</i></b>:<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Turn on laminar flow hood and wipe down surface of the hood with 70% isopropyl alcohol and a clean Kendall wipe. Spray and wipe with 70% IPA the materials needed to be placed in the hood.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Don hair cover, face mask, gloves and gown.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Turn on water bath and set the temperature at 50<sup>o</sup>C, if preparing denatured RBC.<o:p></o:p></div>
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<b><i>4.2. </i></b><b><i>Precautions:<o:p></o:p></i></b></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>During the labeling procedure, blood and blood components of the patient, who could potentially be infected with pathogens, need to be handled. To prevent contamination of the operator, double-gloving using waterproof gloves is recommended.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Since the cells have to be reinjected into the patient, <b>strict aseptic conditions</b> are required for the labeling procedure.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Simultaneous labeling of blood products from multiple patients is discouraged in order to prevent possible cross-contamination. At all times correct identification of the patient’s blood products should be guaranteed.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>During the labeling care should be taken not to damage the cells, as this would result in leakage of the radioactivity from the cells, increased lung uptake and increased liver uptake.<o:p></o:p></div>
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<b><i>4.3. </i></b><b><i>Radiolabeling of RBC with <sup>99m</sup>Tc</i></b>:<o:p></o:p></div>
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<i>Note: The UltraTag</i><i>® kit has 3 components:<o:p></o:p></i></div>
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a)<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span><b><i><u>10 mL reaction vial</u></i></b> containing stannous chloride, dihydrate (SnCl2•2H2O) 50 µg, minimum, stannous chloride, dihydrate (SnCl2•2H2O) 96 µg, theoretical, tin chloride (stannous, stannic) dihydrate, as stannous chloride, maximum dihydrate 105 µg, 3.67 mg sodium citrate dihydrate and 5.50 mg anhydrous dextrose.<o:p></o:p></div>
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b)<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span><b><i><u>Syringe I:</u></i></b> 0.6 mL contains 0.6 mg sodium hypochlorite (NaOCl). Protect from light.<o:p></o:p></div>
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c) <b><i><u>Syringe II:</u></i></b> 1 mL contains 8.7 mg citric acid monohydrate, 32.5 mg sodium citrate dihydrate and 12.0 mg anhydrous dextrose. <o:p></o:p></div>
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<b><span lang="EN">4.3.1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Collect patient's blood sample (1 - 3 mL) using heparin or ACD as an anticoagulant. The amount of ACD should not exceed <b>0.15 mL of ACD per mL of blood</b>. The recommended amount of <b>heparin is 10-15 units per mL of blood</b>. DO NOT USE EDTA OR OXALATE AS AN ANTICOAGULANT.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Using a large-bore needle (19 to 21 gauge), transfer 1.0 to 3.0 mL of anticoagulated whole blood to the <b>reaction vial</b> and gently mix to dissolve the lyophilized material. Allow to react for 5 min at room temperature.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Add contents of <b>Syringe I</b>, mix by gently inverting four to five times.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Add the contents of <b>Syringe II</b> to the reaction vial. Mix by gently inverting four to five times.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.5.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Place the vial in a lead shield fitted with a lead cap. Add 370 to 925 MBq (10 to 25 mCi) sodium pertechnetate Tc-99m (in a volume of up to 3 mL) to the reaction vial. Use fresh generator eluate to avoid in-growth of <sup>99</sup>Tc.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.6.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Mix by gently inverting reaction vial four to five times. Allow to react for 20 minutes with occasional mixing.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.7.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Take a sample to assay labeling efficiency immediately prior to injection (see <b>4.4.2</b>). <o:p></o:p></span></div>
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<span lang="EN">If LE > 90%, proceed to step <b>4.3.8 for denatured RBC</b> or step <b>4.3.9. for normal RBC</b>.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.8.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Heat the tagged cells in a water bath with a little agitation at 49 - 50<sup>o</sup>C for <b>no more than 15 min</b>. Proceed to step <b>4.3.9</b>.<o:p></o:p></span></div>
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<b><span lang="EN">4.3.9.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></span></b><span lang="EN">Mix gently prior to withdrawal of patient dose. Aseptically transfer the <sup>99m</sup>Tc-labeled red blood cells to a syringe for administration to the patient. <b>Use a large bore needle to prevent hemolysis.<o:p></o:p></b></span></div>
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<b>4.3.10.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b>Assay for radioactivity. Prepare labels and paper work using Pinestar.<o:p></o:p></div>
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<b>4.3.11.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b><sup>99m</sup>Tc-labeled red blood cells should be injected within 30 minutes of preparation or as soon as possible thereafter.<o:p></o:p></div>
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<b>4.3.12.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b>Clean up the laminar flow hood. Place radioactive waste in the waste disposal bin in the hot lab and non-radioactive sharps waste and blood/plasma in the sharps waste container. Remove the equipment from the laminar flow hood and wipe the surface down with 70% isopropyl alcohol using a lint-free cloth. <o:p></o:p></div>
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<b><i>4.4. </i></b><b><i>Quality control:<o:p></o:p></i></b></div>
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<b>4.4.1.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b><u>Visual inspection (performed routinely)</u>: <o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>At the end of the procedure and before collecting the radiolabeled RBC in the syringe for patient administration, a visual inspection for clumps, clots and aggregates should be performed by gently rotating the tube. <o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>In case of aggregates, they should be dissolved by gently shaking or pipetting the sample.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>If clumps cannot be dissolved, the preparation should not be injected.<o:p></o:p></div>
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<b>4.4.2.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b><u>Labeling efficiency (LE) (performed routinely):<o:p></o:p></u></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Transfer 0.2 mL of the <sup>99m</sup>Tc-labeled RBC to a 15 mL centrifuge tube containing 2 mL of 0.9% NaCl. Centrifuge for five minutes and carefully pipet off the diluted plasma. Measure the radioactivity in the plasma and red blood cells separately in a dose calibrator. Calculate labeling efficiency as follows:<o:p></o:p></div>
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<i>% LE = (Activity RBC x 100)/(Activity RBC + Activity Plasma)<o:p></o:p></i></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span><b>LE = 90 - 98 %<o:p></o:p></b></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>If LE < 90 %, further quality control should be performed, such as microscopic inspection and test for cell viability (see 4.4.3).<o:p></o:p></div>
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<b>4.4.3.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b><u>Trypan blue exclusion test for cell viability (recommended periodically):<o:p></o:p></u></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Take a small sample (0.2 mL) from the radiolabeled RBC and dilute it with 1 ml of saline for injection.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>In a small tube mix 50 ul 0.4 % trypan blue solution and 50 ul of the radiolabeled RBC sample.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Put a drop of this mixture in a hemocytometer and place it under the microscope.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Check for clumps and microaggregates of cells.<o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>Calculate the percentage of blue stained cells from the total cell number. This is the percentage of damaged cells. <o:p></o:p></div>
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<span style="font-family: Symbol; mso-bidi-font-family: Symbol; mso-fareast-font-family: Symbol;">·<span style="font-family: 'Times New Roman'; font-size: 7pt;"> </span></span>If a preparation has > 10 % blue-stained cells, it should not be released for injection into the patient. <o:p></o:p></div>
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<b>4.4.4.<span style="font-family: 'Times New Roman'; font-size: 7pt; font-weight: normal;"> </span></b><u>Sterility (recommended periodically):<o:p></o:p></u></div>
<span style="font-family: Calibri; font-size: 11pt; line-height: 115%; mso-ansi-language: EN-US; mso-bidi-font-family: 'Times New Roman'; mso-bidi-language: AR-SA; mso-fareast-font-family: Calibri; mso-fareast-language: EN-US;">Sterility of the final preparation should be tested periodically, especially in case of any modification to the procedure.</span><!--EndFragment--><br />
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<span style="font-family: Verdana, sans-serif;"><span id="goog_1249259181"></span>So there you have it.</span><br />
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<span style="font-family: Verdana, sans-serif;">NB: Someone had mentioned that I forgot to add steps 5.3.8, 5.4.2, 5.4.3. Everything is contained within the blog. I just mislabeled the numbered steps. The "5" should have been a "4" in the body of the blog. Apologies, it has been corrected..</span></div>
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<span style="font-family: Verdana, sans-serif;"><br /></span><span style="font-family: Verdana, sans-serif;"><br /></span>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com2tag:blogger.com,1999:blog-7408689164544359927.post-78006009769997229202012-12-20T10:21:00.001-05:002012-12-20T10:23:57.896-05:00Split Renal Function in a Pelvic Kidney<span style="font-family: Verdana, sans-serif;">This is an interesting case in that it involved a patient to be injected with two different renal imaging agents: <a href="http://www.gehealthcare.com/gecommunity/tip_tv/subscribers/sup_material/supplement/969.pdf">DTPA and DMSA</a>.</span><br />
<span style="font-family: Verdana, sans-serif;"><br /></span><span style="font-family: Verdana, sans-serif;">The radiation oncologists wanted to asses the renal function within this patient, prior to having radiation therapy for <a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001908/">endometrial cancer</a>. The big problem was that the patient has a left pelvic kidney, and they feared that it would be ablated during the treatment. The CT image below details where the kidney lies within the pelvis.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZ-SkespNUjOOAoB7sLx5BDa115xtFXgZgF8712GhJ7_wCk8jUVJUfCuLTpEz34PqVGD4cRaYnxbDJKz5sw3aU9ElnDQV6MPzr9GHqZUNF87y3X3wrtXYRkFcAm7iGNtB6VTfBXc86Q8o/s1600/Sagittal+Renal.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgZ-SkespNUjOOAoB7sLx5BDa115xtFXgZgF8712GhJ7_wCk8jUVJUfCuLTpEz34PqVGD4cRaYnxbDJKz5sw3aU9ElnDQV6MPzr9GHqZUNF87y3X3wrtXYRkFcAm7iGNtB6VTfBXc86Q8o/s320/Sagittal+Renal.jpg" width="248" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Sagittal slice of the patient. Note the ovoid shaped organ on the bottom right of the image just below the sacrum.</td></tr>
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<span style="font-family: Verdana, sans-serif;">The assessment of renal function in our department generally includes the determination of <a href="http://www.urology-textbook.com/kidney-glomerular-filtration-rate.html">glomerular filtration rate (GFR) </a>and the <a href="http://www.academicjournals.org/cro/PDF/Pdf2011/Feb/Dostbil%20et%20al.pdf">split renal function</a> (differential renal function) to help the clinicians determine the implications of residual kidney function if a kidney or kidneys are irradiated. It is also used to determine whether a person is a good candidate for kidney donation, since our hospital is a major organ transplant centre. The assessment of renal function is a routine procedure for us. </span><br />
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<span style="font-family: Verdana, sans-serif;">We perform our renal scans mainly with DTPA, along with corresponding blood samples at time 0 pre-injection, 1 hour post injection and at 3 hours post injection. We combine this with the Gates analysis method to get an idea of the overall kidney function. The images below are what we have obtained using the DTPA and blood sampling method. All dynamic and static images with respect to the kidneys are performed in the supine position.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhL953VQd9CCx33z0859aA3vzWGHlbgSbKS1CoSkX8zmzDk9P74btDlvlyx9dA1vUrM9vM1IMmLSsWY5c7os9Ht841ERmxKtPrkKGygq0tTiY0uqkaC7Odg1hWHAB598_PgGdwXhqtzSxY/s1600/report+gfr.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="200" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhL953VQd9CCx33z0859aA3vzWGHlbgSbKS1CoSkX8zmzDk9P74btDlvlyx9dA1vUrM9vM1IMmLSsWY5c7os9Ht841ERmxKtPrkKGygq0tTiY0uqkaC7Odg1hWHAB598_PgGdwXhqtzSxY/s400/report+gfr.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Both camera and blood sampling methods are used to determine the GFR. Regions of interest (ROI's) are drawn over the kidneys, bladder and aorta as per protocol. Associated background regions are drawn corresponding to each kidney.</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Split renal function (differential) is primarily determined by the camera method.</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 4 The renal dynamic and static images are made into reports to assess drainage from the kidneys as well as to determine the quality of the injection (ie. an interstitial injection?). However if you look carefully on the top row of images the left pelvic kidney, over time, becomes obscured by the bladder.</td></tr>
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<span style="font-family: Verdana, sans-serif;">We perform continuous imaging over a 20 minute period and then static views of pre and post void kidneys (standing), along with the injection site to assess for residual activity. </span></div>
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<span style="font-family: Verdana, sans-serif;">In this case here, a</span><span style="font-family: Verdana, sans-serif;">s you can see from the images above, the assessment of the right kidney seems to be straight forward, but the problem is the assessment of the left pelvic kidney. In Fig. 3, over time, it becomes obscured by the bladder. </span></div>
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<span style="font-family: Verdana, sans-serif;">(Note, I have tried to load the dynamic acquisition to demonstrate this more clearly, but could not get the correct intensity to illustrate this event)</span></div>
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<span style="font-family: Verdana, sans-serif;">The problem is, our reporting radiologist could not be confident in reporting the GFR values nor the split renal function, since the regions of interest (ROI's) would incorporate the expanding bladder and would result in an inaccurate estimation of these values.</span><br />
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<span style="font-family: Verdana, sans-serif;">Essentially our reporting radiologist spoke with the requesting radiation oncologists to consult them with regards to the imaging. To make a long story short, in the end, the GFR values were not as important as the split renal function. Thus to avoid the bladder uptake, DMSA was used to scan the kidneys again and a <a href="http://en.wikipedia.org/wiki/Geometric_mean">geometric mean</a> was used to determine the split renal function. Below are the images of the DMSA scan.</span><br />
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<tr><td class="tr-caption" style="text-align: center;">Fig. 5 Anterior and posterior images of the kidneys were obtained using DMSA. A geometric mean was used to better estimate the split renal function. Imaging was performed in the supine position.</td></tr>
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<span style="font-family: Verdana, sans-serif;">The use of the DMSA essentially limited the amount of bladder activity seen, but provided good parenchymal imaging to allow for the split renal function to be calculated.</span></div>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-71465226721004237132012-11-02T13:55:00.002-04:002012-11-02T14:22:19.172-04:00Takayasu Arteritis and PET/CT<span style="font-family: Verdana, sans-serif;"><a href="http://www.medicinenet.com/takayasu_disease/article.htm">Takayasu arteritis</a> is one of the indications that we perform an <a href="http://medical.med.tokushima-u.ac.jp/jmi/vol54/pdf/v54_n3-4_p345.pdf">F18 FDG PET/CT</a> scan on, primarily as a research protocol. This is one of those <a href="http://jnm.snmjournals.org/content/46/6/917.full.pdf">research studies</a> that we do not do very frequently but once in awhile they pop up on our list. </span><br />
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<span style="font-family: Verdana, sans-serif;">What is interesting about this condition, besides the name, is that this is a rare condition that causes <a href="http://www.medicinenet.com/vasculitis/article.htm">vasculitis</a> in the large vessels, such as the <a href="http://www.innerbody.com/image_cardov/card31-new.html">aorta and it's branches</a>. </span><br />
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<span style="font-family: Verdana, sans-serif;">The <a href="http://rheumatology.oxfordjournals.org/content/41/1/103.full.pdf">history of Takayasu arteritis</a> is pretty interesting as well. Originally this vascular disease was reported by Dr. Mikito Takayasu, an ophthalmologist in 1908 at the 12th Annual Meeting of the Japan Opthalmology Society. It basically came about with the appearance of "coronary anastomosis" in the eyegrounds and arteriovenous anastomosis around the papila of a 21 year old woman that Dr. Takayasu was examining. Further investigation lead others to report "pulselessness" in their patients which is another clinical feature. The radial, brachial and carotid pulses are absent in these patients as the result of the ischemic cerebrovascular circulation. There's more, but if you click on the link at the start of this paragraph, you can read the rest.</span><br />
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<span style="font-family: Verdana, sans-serif;">So here is what it looks like in PET:</span><br />
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<tr><td class="tr-caption" style="text-align: center;">Fig. 1 FDG PET imaging of a patient with Takayasu arteritis. Abnormal increased activity are identified along the brachiocephalic and proximal right and left common carotid arteries.</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 2 A fused image denoting the areas of uptake with anatomical features.</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Sagittal fused image with uptake through the common carotid artery.</td></tr>
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<span style="font-family: Verdana, sans-serif;">The preparation for the Takayasu arteritis scans are fairly similar to the other oncological preps that we do in the department except for the fact that we scan with the arms down, we wait for a 90 minute uptake (since the appearance of the inflamed arteries are very subtle thus maximizing the uptake time is essential) and we use an ideal body weight (IBW) calculation. The cut off glucose measurement is around 11.0mmol/l. This is slightly higher than the normal cut off of 9.8mmol/l for the rest of our scans. Imaging is taken from the base of the skull to mid thigh, but 4 minutes per bed for the PET as oppose to the 3 minutes per bed with most of our oncological studies.</span></div>
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<span style="text-align: center;"><span style="font-family: Verdana, sans-serif;">As you can see in Fig. 1, there is abnormal increased activity identified along the brachiocephalic and proximal right and left common carotid arteries. There is also increased activity in the descending aorta at the L2-L3 vertebra, which I did not capture on my screen shots. PET/CT would probably not be the first choice in terms of imaging with a suspected case of Takayasu arteritis, the more likely options would be CT angiography or MRI to examine the nature of the large vessels.</span></span></div>
Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-35353042415015350172012-10-31T09:53:00.003-04:002013-01-02T09:51:48.195-05:00Sarcoid versus Scleroderma<span style="font-family: Verdana, sans-serif;">I always get mixed up when it comes to sarcoids and sclerodermas when written on a requisition. Currently we perform imaging on these patients to help the clinicians to determine the extent of their patient's disease, but I still get confused as to the nature of the disease and their processes. So this portion of the blog is partly to help me and anyone out there that are in the same position. I have tried to put this into a chart format, but it doesn't translate well into the blog.</span><br />
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<span style="font-family: Verdana, sans-serif;"><b style="background-color: yellow;">Sarcoid:</b></span><br />
<span style="font-family: Verdana, sans-serif;">This is an inflammatory disease that can potentially affect multiple organs within the body. It most often starts within the lungs or lymph nodes, but it does not limit it self to these areas. The inflammation (<a href="http://www.umm.edu/altmed/articles/sarcoidosis-000146.htm">sarcoidosis</a>) is not necessarily caused by an autoimmune response, since this is not an autoimmune disease, but the cause of this inflammation is uncertain. The most distinguishing feature about sarcoids is that they deposit <a href="http://en.wikipedia.org/wiki/Granuloma">granulomas</a> (microscopic lumps of inflammation). They sometimes clear up on their own or they can become fibrotic if they remain in the body if they do not heal.</span><br />
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<span style="font-family: Verdana, sans-serif;">The most famous entertainer to die from sarcoidosis was <a href="http://www.people.com/people/article/0,,20218110,00.html">Bernie Mac</a>. His condition was primarily localized to his lungs, but sarcoids, like I mentioned before can affect any organ. Here at our facility we image and follow these patients when they become part of the <a href="http://www.health.gov.on.ca/english/providers/program/ohip/bulletins/4000/bul4464_3.pdf">CADRE</a> study. CADRE represents the Cardiac FDG-PET Registry Study. As part of the cardiac program, we look at the extent of their disease via a whole body PET/CT, which we append to their Tc-99m myocardial perfusion studies. Along with the whole body PET/CT, we will perform a quick FDG viability study of their heart while in the department. Most of these patients have their cardiac workup prior to coming to PET. Approximately <a href="http://jnm.snmjournals.org/content/53/2/241.full.pdf">25% of all sarcoids</a> involve the heart, and about 13-25% of all sarcoids deaths are related to cardiac insufficiencies such as heart failure, ventricular tachyarythmia or conduction disturbances.</span><br />
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<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Extensive uptake of FDG within the thorax, liver, spleen and both kidneys, correlating with the patients known sarcoidosis.</td></tr>
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<span style="font-family: Verdana, sans-serif;">We also perform <a href="http://emedicine.medscape.com/article/361490-overview">gallium-67 whole body</a> imaging to localize the areas of inflammation, in particular the lungs. But quite honestly, we do not perform these routinely, and having said that, I don't think I have ever seen one that was positive.</span><br />
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<span style="font-family: Verdana, sans-serif;"><b>UPDATE January 2, 2012:</b> I will take back that last comment about not seeing a positive gallium scan for sarcoidosis. The image below was taken 48 hours post Ga-67 injection. A whole body gallium scan was performed and there was uptake within the lungs consistent with sarcoidosis.</span><br />
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<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Uptake in the hilum and the lungs, consistent with sarcoidosis</td></tr>
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<span style="font-family: Verdana, sans-serif;"><b style="background-color: yellow;">Scleroderma:</b></span><br />
<span style="font-family: Verdana, sans-serif;">This is the result of inflammation in <a href="http://www.courseweb.uottawa.ca/medicine-histology/english/ss_basictissues/connective_tissue.htm">connective tissue</a> featuring the formation of scar tissue (fibrosis) in the skin and organs of the body. <a href="http://www.medicinenet.com/scleroderma/article.htm">Scleroderma</a> is an autoimmune disease, as the result of an overactive immune system. They have specific antibody markers such as <a href="http://www.medicinenet.com/antinuclear_antibody/article.htm">ANA</a>, <a href="http://en.wikipedia.org/wiki/Anti-centromere_antibodies">anticentromere</a> or antitopoismerase in their blood stream which suggests autoimmunity.</span><br />
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<span style="font-family: Verdana, sans-serif;">We perform gallium imaging for scleroderma, but rarely. I have not come across this condition with regards to the patient's history for PET/CT imaging.... yet.</span><br />
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<span style="font-family: Verdana, sans-serif;">I do not have any images to show from our facility and there isn't much on the web either.</span>
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<span style="font-family: Verdana, sans-serif;"><br /></span>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-61701517544544095692012-10-22T13:08:00.001-04:002012-11-02T03:52:22.591-04:00I-131 Uptake in Teratoma<div class="separator" style="clear: both; text-align: center;">
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVJBRoO3dFJRv7_91hXmU32ypSfGBlggQkxG4TyLA8JbwBKzmaCAd0RGloc0CD9Qk8_tugJaw4ZirL1SrxRzcWJ3LLo-mEb9arr4-ABobuTNX0ok65YWNoq5nXJ6_JudSp-Xqo53NXu3Q/s1600/WBI+Teratoma.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjVJBRoO3dFJRv7_91hXmU32ypSfGBlggQkxG4TyLA8JbwBKzmaCAd0RGloc0CD9Qk8_tugJaw4ZirL1SrxRzcWJ3LLo-mEb9arr4-ABobuTNX0ok65YWNoq5nXJ6_JudSp-Xqo53NXu3Q/s1600/WBI+Teratoma.jpg" /></a></td></tr>
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Fig 1 WBI scan performed 10 days post 125mCi treatment of I-131 therapy for thyroid Ca.</div>
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<span style="font-family: Verdana, sans-serif;">A whole body iodine scan was performed 10 days post I-131 therapy for a patient who was diagnosed with <a href="http://www.medicinenet.com/thyroid_cancer/article.htm">thyroid cancer</a>. For the most part the scan seems relatively normal, with residual activity within the thyroid bed and salivary glands. The liver is within normal limits. However in the lower left hemipelvis, there appears to be an increased I-131 avidity. Of course to investigate this further we performed a SPECT/CT.</span><br />
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<span style="font-family: Verdana, sans-serif;">Above is the MIP for the SPECT (doesn't look like much), but when fused with the CT, the following is presented.</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9-87WH2jIlxD0MZhr7GmgBARsTgB9WyusQf7ktJfQD1S75uaoSyfxlMwiCYIYGs6DoBFdWCWBuBLbNqeoxZJD_lLO8Eu3R6_wdDig51hypXGw_M_9Ql2c4C3Tmwz7-4xMWTsqVF-We6g/s1600/Sagittal+Teratoma.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh9-87WH2jIlxD0MZhr7GmgBARsTgB9WyusQf7ktJfQD1S75uaoSyfxlMwiCYIYGs6DoBFdWCWBuBLbNqeoxZJD_lLO8Eu3R6_wdDig51hypXGw_M_9Ql2c4C3Tmwz7-4xMWTsqVF-We6g/s1600/Sagittal+Teratoma.jpg" /></a></td></tr>
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Fig. 2 Sagittal section of the I-131 activity. The fat containing mass measures approximately </div>
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5.8 x 3.3 cm.</div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifAQBDnS7K1RxRj9Ay-hpd-BLUVt6rKS93lzcStp0h8x8r8Y0IpzcuJsLa45h0zuiew3qTviKHEO1fJ8T-6VsnEp8i7a7imhCnWPCtVZ_TQRo6hMpokoAvjVoCPDM8NEKlq1CwjeFbDX4/s1600/Coronal+Teratoma.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="241" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEifAQBDnS7K1RxRj9Ay-hpd-BLUVt6rKS93lzcStp0h8x8r8Y0IpzcuJsLa45h0zuiew3qTviKHEO1fJ8T-6VsnEp8i7a7imhCnWPCtVZ_TQRo6hMpokoAvjVoCPDM8NEKlq1CwjeFbDX4/s320/Coronal+Teratoma.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Coronal section, noting the uptake in the lower left hemipelvis.</td></tr>
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<span style="font-family: Verdana, sans-serif;">The I-131 fat containing lesion within the left pelvis is in keeping with a left ovarian <a href="http://radiographics.rsna.org/content/21/2/475.full.pdf">teratoma</a>. These are also know as an ovarian dermoids. Most dermoids/teratomas are benign, and they contain a mix bag of mature and immature tissue such as skin, hair, thyroid tissue, sweat glands, blood, cartilage and even teeth! Generally the appearance of fat within the teratoma along with an irregular component of coarse calcifications help to distinguish these entities when imaging with CT and MRI. The <a href="http://www.google.ca/search?q=ovarian+dermoid&sugexp=chrome,mod%3D0&um=1&ie=UTF-8&hl=en&tbm=isch&source=og&sa=N&tab=wi&ei=G3iFULPoHpHW0gHnqYCwCA&biw=1300&bih=639&sei=HXiFULyiEc3h0wHUqIGYDQ">gross anatomy</a> is quite interesting to look at, since they are varied in nature with respect to their appearance and construction.</span></div>
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<br />Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-82232006053278158262012-10-15T11:58:00.000-04:002013-01-23T15:12:28.029-05:00PET Melanoma<div class="separator" style="clear: both; text-align: center;">
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<span style="font-family: Verdana, sans-serif;">Needless to say this patient presented to our department with late stage <a href="http://www.medicinenet.com/melanoma/article.htm">melanoma</a>. A new lung nodule had presented itself on the right lung from a chest x-ray and a PET/CT study was ordered and performed according to departmental protocol.</span></div>
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<span style="font-family: Verdana, sans-serif;">The patient has had extensive surgery to remove the melanoma from the lower back, along with excision of lymph nodes. The patient also had a previous bout <a href="http://www.youtube.com/watch?v=pkMvYE6TJZg">Bowen's disease</a> over the right breast with further metastasis to the left axillary nodes. Upon follow up with the medical oncologist, post surgery, a chest x-ray was performed and it noted a right solitary lung nodule. </span></div>
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<span style="font-family: Verdana, sans-serif;">The PET/CT was performed and the following images demonstrate extensive and diffuse metabolically active metastatic <a href="http://cancer.about.com/od/cancerglossary/g/adenopathy.htm">adenopathy</a>, as well as skeletal, pulmonary, liver, splenic and small bowel metastases.</span></div>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Multiple foci of metabolic activity of F18-FDG</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0tb1dbz_31Nj78cOeREnAT7FT88xwO4V6DUpoG7qNWCeD5YwoMVFWfNd_M3avdzOYvjltUlyF60dGfVlm-1sVe7G31xxZbnNMxaJPBaX9XyFp3k0LXANnk4Bxt7dH8YWb10USHCpg-pU/s1600/Melanoma+sagittal+fused.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi0tb1dbz_31Nj78cOeREnAT7FT88xwO4V6DUpoG7qNWCeD5YwoMVFWfNd_M3avdzOYvjltUlyF60dGfVlm-1sVe7G31xxZbnNMxaJPBaX9XyFp3k0LXANnk4Bxt7dH8YWb10USHCpg-pU/s320/Melanoma+sagittal+fused.jpg" width="140" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Sagittal fused image of the patient, noting multiple F18 FDG uptake in the spine</td></tr>
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<span style="font-family: Verdana, sans-serif;">At our facility for indications of <a href="http://www.emedicinehealth.com/solitary_pulmonary_nodule/article_em.htm">single pulmonary nodule</a> (SPN) or for <a href="http://www.emedicinehealth.com/non-small-cell_lung_cancer/article_em.htm">non small cell carcinoma</a> (NSCLC) we normally scan from the top of the head to mid thigh. If they have had a previous <a href="http://www.med.harvard.edu/aanlib/home.html">MRI of the head</a> to determine brain metastases, then we will scan from the base of the skull to mid thigh. However in this case, the patient has had a previous history of melanoma, we decided to scan from the top of the head to their feet. This is our normal protocol with regards to melanoma patients. Basically we performed our melanoma protocol on the patient referred for a lung indication. </span><br />
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<span style="font-family: Verdana, sans-serif;">Generally it takes about 30-35 minutes to scan from the top of the head to their feet depending on the height of the patient. Considering that our PET/CT is an old Seimens Biograph with a 2 slice CT, it does take up a bit of time with respect to the CT acquisition. In addition to this, we do not have the the <a href="http://www.iss.infn.it/topem/TOF-PET/timeofflightpet.pdf">time of flight (ToF)</a> capabilities to decrease our acquisition times of our PET. However, we are replacing our Biograph with a new machine, since the 2 slice Biograph has come to the end of life for servicing. Anyone interested in a PET/CT unit for training or for a back up?</span><br />
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-3899975993087093262012-10-05T11:28:00.001-04:002012-10-05T11:28:57.754-04:00Normal Uptake on WBI<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjL2hA9PBkOw5XMhgpgiAhkk0EF_exyE4EO3hRCacBlUCnDjI4lj2B90nSOgCOXHSWjNzdsSpIfsbRoyLjeh5Z2zx6j3NBdqOfZzkQ2dIeMZvRDFadxi2uFcfcN3oQyWHogzX1LwRHLK3U/s1600/WBI+Scan.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjL2hA9PBkOw5XMhgpgiAhkk0EF_exyE4EO3hRCacBlUCnDjI4lj2B90nSOgCOXHSWjNzdsSpIfsbRoyLjeh5Z2zx6j3NBdqOfZzkQ2dIeMZvRDFadxi2uFcfcN3oQyWHogzX1LwRHLK3U/s320/WBI+Scan.jpg" width="276" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Whole body iodine, 10 days post administration of a therapeutic dose of I-131.<br />
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<span style="font-family: Verdana, sans-serif;">Whole body iodine (WBI) imaging was performed on a patient who was administered 3.7GBq of I-131 ten days prior for <a href="http://emedicine.medscape.com/article/282276-overview">papillary carcinoma</a>. A total <a href="http://www.nlm.nih.gov/medlineplus/ency/article/002933.htm">thyroidectomy </a>was also performed as part of the treatment process earlier in the year.</span><br />
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<span style="font-family: Verdana, sans-serif;">For the most part the thyroid bed was unremarkable as well as the rest of the image, except for a focal uptake in the right upper quadrant. Generally the technologists are fairly cautious at our facility, since a metastatic survey was being performed, a SPECT/CT of the area was also included in the study.</span></div>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Coronal section of the SPECT/CT, noting the uptake within the liver. Most likely being gallbladder uptake of the I-131.</td></tr>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Transaxial CT used in conjuction with the SPECT to localise the I-131 uptake.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYBmmqsOsIPZgCQFvXi9yjmobs56raxZL_TxNa-1CxBWj16GP6FriHpwiWp86fCje7JR8xY7VNy7b4hwjqnK2IzUGd7Bb2rkFVp1MLiInnim1m-ToSMNuw81i3kODkcPsEEXPGq73p4X0/s1600/Fused+transaxial+.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="209" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgYBmmqsOsIPZgCQFvXi9yjmobs56raxZL_TxNa-1CxBWj16GP6FriHpwiWp86fCje7JR8xY7VNy7b4hwjqnK2IzUGd7Bb2rkFVp1MLiInnim1m-ToSMNuw81i3kODkcPsEEXPGq73p4X0/s320/Fused+transaxial+.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 4 Fused transaxial SPECT/CT, confirming the uptake of the radioactive iodine is inside the gallbladder.</td></tr>
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<span style="font-family: Verdana, sans-serif;">Why is this interesting? Well for one thing, this is something that we do not normally see on our WBI images. Normally we see diffuse liver uptake in this area, but it is not totally uncommon to visualise the gallbladder. This is well documented in the <a href="http://synapse.koreamed.org/Synapse/Data/PDFData/0063JKMS/jkms-20-521.pdf">literature</a> and the article does discuss some possibilities of what can potentially cause this normal uptake. Conditions such as <a href="http://emedicine.medscape.com/article/171886-overview">cholecystitis</a>, hypokinetic gallbladder function due to <a href="http://www.medicinenet.com/gallstones/article.htm">stones</a> or an abnormal gallbladder morphology are just some of the potential reasons. Most often an ultrasound is ordered to confirm or correlate if there are any underlying issues that may be involved with the gallbladder.</span></div>
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<span style="font-family: Verdana, sans-serif;">Bottomline, gallbladder uptake is normal. It is not commonly seen, but from a technical perspective we would rather be "safe than sorry" by performing extra imaging such as a SPECT/CT. Iodine is not the best isotopes to image with and with high energy collimators, it would have been tough to identify based on static images.</span></div>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-73473332157795684362012-10-02T12:04:00.001-04:002012-10-29T09:22:59.595-04:00Therasphere Part Deux<div class="separator" style="clear: both; text-align: justify;">
<span style="font-family: Verdana, sans-serif; text-align: left;">Our first patient, who has a long standing history of </span><a href="http://emedicine.medscape.com/article/282814-overview" style="font-family: Verdana, sans-serif; text-align: left;">hepatocellular carcinoma (HCC)</a><span style="font-family: Verdana, sans-serif; text-align: left;">, was excluded as a surgical candidate to remove the tumour in the right lobe of the liver because the patient suffers from portal hypertension and low platelets. The alternative consideration was for </span><a href="http://www.medicinenet.com/chemo_infusion_and_chemoembolization_of_liver/article.htm" style="font-family: Verdana, sans-serif; text-align: left;">transcatheter arterial chemoembolization (TACE)</a><span style="font-family: Verdana, sans-serif; text-align: left;"> to treat the tumour, however somehow this patient ended up in the trial study of </span><a href="http://nuclearmunkee.blogspot.ca/2012/05/theraspheres.html" style="font-family: Verdana, sans-serif; text-align: left;">Yittrium-90 Theraspheres</a><span style="font-family: Verdana, sans-serif; text-align: left;"> at our facility (click on link for further reading)</span></div>
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<span style="font-family: Verdana, sans-serif;">A <a href="http://www.dartmouth.edu/~anatomy/Abdomen/vessels/angiograms/sma.htm">mesenteric angiography</a> and embolization was performed as the first step of the selective internal radiation therapy. The reasoning is to ensure the blood flow localizes into the tumour site while sparing normal healthy sites when the Y-90 is delivered. The mircocatheters where inserted through the right femoral artery and threaded to the <a href="http://www.dartmouth.edu/~anatomy/Abdomen/vessels/angiograms/celiac.htm">right hepatic and left hepatic arteries</a> for the arteriography. The right gastric artery, which arose from proximal left hepatic artery, was embolized with vortex coils. Furthermore the <a href="http://www.dartmouth.edu/~anatomy/Abdomen/vessels/angiograms/celiac.htm">gastroduodenal artery</a> was emoblized as well, leaving patent the common hepatic artery, the left and right hepatic arteries.</span><br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbjPloBQEgc7cpMPdBvgWWAyMUHiNtnefj5BaWD5JA6lbMDtzLQIMY8TD0cayrJXOJAeHUzYqCsql-nxD9VEALj-WsyljOzLuyov_XsESk32KVk_40rcXI9AjYu8Bdo_bhvwpTImBv0ag/s1600/RHA+Infusion.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="281" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbjPloBQEgc7cpMPdBvgWWAyMUHiNtnefj5BaWD5JA6lbMDtzLQIMY8TD0cayrJXOJAeHUzYqCsql-nxD9VEALj-WsyljOzLuyov_XsESk32KVk_40rcXI9AjYu8Bdo_bhvwpTImBv0ag/s320/RHA+Infusion.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Infusion of contrast through the right hepatic artery. Note the embolization coils below.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9uRW8PbT3kQhJljGWhvihSelxY7U1Tc0k_LXcothoQHzGdFs_wb4f1U432M_a5kcJFefYSPEzoPigG0mQdN-M0GLIFkskA6JiDVp_SeGfs-PTOX-LQ3F1Vi1Qv5pIB8ZyUlAGUhRQHgc/s1600/RHA+Infusion2.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="276" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9uRW8PbT3kQhJljGWhvihSelxY7U1Tc0k_LXcothoQHzGdFs_wb4f1U432M_a5kcJFefYSPEzoPigG0mQdN-M0GLIFkskA6JiDVp_SeGfs-PTOX-LQ3F1Vi1Qv5pIB8ZyUlAGUhRQHgc/s320/RHA+Infusion2.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Infusion of contrast through the right hepatic artery, outlining the tumour in the right lobe.</td></tr>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEg9uRW8PbT3kQhJljGWhvihSelxY7U1Tc0k_LXcothoQHzGdFs_wb4f1U432M_a5kcJFefYSPEzoPigG0mQdN-M0GLIFkskA6JiDVp_SeGfs-PTOX-LQ3F1Vi1Qv5pIB8ZyUlAGUhRQHgc/s1600/RHA+Infusion2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"></a></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHZFe1cHaP9mR4CSR8_cgdHv-T5XQlkJSZqtjF0R0mv3ynCaus_00EwAP3ddAOr5hu_TkMC2eV7cc__fFf2qM9hPfK3x7TkU0MSWJ62_FnhZgGonNodBzcr9OJS80AHU9GPR_2TCmdD5g/s1600/RHA+infusion+4.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="276" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhHZFe1cHaP9mR4CSR8_cgdHv-T5XQlkJSZqtjF0R0mv3ynCaus_00EwAP3ddAOr5hu_TkMC2eV7cc__fFf2qM9hPfK3x7TkU0MSWJ62_FnhZgGonNodBzcr9OJS80AHU9GPR_2TCmdD5g/s320/RHA+infusion+4.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 The right lobe tumour is now fully visualized, with limited shunting. However there is still extraneous vascularity. Thus the lung shut fraction is calculated to quantitate the amount.<br />
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<span style="font-family: Verdana, sans-serif; font-size: small;">After the embolization process, Tc-99m MAA was injected through the microcatheter for the lung shunt study. After the injection, the patient was stabilzed for transport to Nuclear Medicine, and the following images were taken.</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDFwB-pvXdzYfb-ub-30jwYTAhqv2XfPkSv2QhkNx_18-Y4EoELitv7J593pIGGBA-S3sxm4xmpmHXv2lU6FRDQGzx19ikd1meildiGBKqeoxueGdboIg_jP9B3Uoj0iWyOqmybQfpC-k/s1600/MAA+Imgaes.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDFwB-pvXdzYfb-ub-30jwYTAhqv2XfPkSv2QhkNx_18-Y4EoELitv7J593pIGGBA-S3sxm4xmpmHXv2lU6FRDQGzx19ikd1meildiGBKqeoxueGdboIg_jP9B3Uoj0iWyOqmybQfpC-k/s320/MAA+Imgaes.jpg" width="316" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 4 Anterior and posterior images were taken to determine any major shunting of blood to the lungs or stomach.<br />
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlxBPaaxS5jOeveh0ZFY7nVDo7CjfLUKT2FosFpzFqJQG0XeMsKyDfBZF5Ha1tsUMGEMWAFcaIlMb3q6jBW4-bkpEDCgwTQiH-rhIUmmmB1kJdXo6m7qCTdM0lziiNO5gTycBWiyWITVw/s1600/LSF+Report.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="310" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhlxBPaaxS5jOeveh0ZFY7nVDo7CjfLUKT2FosFpzFqJQG0XeMsKyDfBZF5Ha1tsUMGEMWAFcaIlMb3q6jBW4-bkpEDCgwTQiH-rhIUmmmB1kJdXo6m7qCTdM0lziiNO5gTycBWiyWITVw/s320/LSF+Report.jpg" width="320" /></a></div>
Fig. 5 Regions of interest were drawn over the lungs and liver and a geometric mean was calculated to determine the lung shunt fraction (LSF).<br />
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<span style="font-family: Verdana, sans-serif;"><a href="http://nuclearmunkee.blogspot.ca/2012/05/theraspheres.html">Lung shunt fraction</a> was calculated to be 3.0%. There is no cut off with regards to the LSF value to be excluded from the treatment. However it is the discretion of the interventional radiologist who will be administering the Y-90 to determine the patient's inclusion within the treatment study.</span><br />
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<span style="font-family: Verdana, sans-serif;">Two weeks after the initial angiography and embolization, the Y-90 theraspheres were adminstered. Based on the size and volume of the tumour which the interventional radiologist calculated prior to the administration, we wanted to give approximately 2.5Gbq of Y-90 to deliver 120Gy to the tumour site.</span><br />
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<span style="font-family: Verdana, sans-serif;"><a href="http://www.nordion.com/therasphere/home_intl/index.asp">Nordion</a> which supplies the theraspheres, has an excel worksheet to help with the ordering of the Y-90 dose to ensure the proper calibration of the actual dose.</span><br />
<span style="font-family: Verdana, sans-serif;">In the end, the amount that we calculated (approximation) of the dose delivered to the tumour site was about 2.49GBq, based on a 1.7% residual activity remaining in the Y-90 administration vial. Overall the tumour received 120.7Gy with the lungs receiving approximately 3.73Gy, based on the LSF value.</span><br />
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<span style="font-family: Verdana, sans-serif;">Having worked through our first patient it is important to address the fact that most Nuclear Medicine technologists are accustomed to working with radioactive materials. However the interventional radiology (IR) technologists and some IR doctors do not. </span><span style="font-family: Verdana, sans-serif;">The dose rate is quite high with respect to the Y-90 vial.... but we normally do not tell them how high it really is. </span><span style="font-family: Verdana, sans-serif;">Thus it is a good idea that you get them on board with respect to working with radioactive materials and how to handle these materials without causing too much of a mess. The reason why, is that they are most likely going to set up the Y-90 administration set, since they have much more experience than Nuclear Medicine technologists in a sterile field. Plus it will be the IR doctors (at least at our site), that will be injecting the Y-90.</span></div>
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<tr><td class="tr-caption" style="text-align: center;">Fig. 6 An unassembled administration set. Everything is performed in a sterile field. I will endeavour to update this image, once everything is connected together, when our next patient arrives. Which should be in 2 weeks time.</td></tr>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-63990563486970837512012-08-23T15:08:00.002-04:002012-08-23T15:08:28.280-04:00Summer Hiatus OverSorry about not posting anything since May. The "kids" are now coming back to clinical training at the hospital and there will undoubtedly be lot's to post.<br />
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Stay tuned. Will report on our first Therasphere patient coming on September 11. It will be interesting.<br />
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Performing EC20 patients at the moment. Will be having a look at that as well and explaining what we are doing.<br />
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Lot's of interesting stuff coming down the pipe.Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-49954256670947176912012-05-17T12:45:00.002-04:002012-05-17T12:45:45.257-04:00Bone Scans and CPR<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
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<span style="font-family: Verdana, sans-serif;">So what's wrong with this picture? There are several things as you can note with multiple rib fractures and a sternal fracture as well. Originally the patient was to have scans on the hands and wrist as indicated on the requisition. A total body scan was performed with locals of the hands and wrist. The locals were unremarkable, but the chest and ribs are very remarkable.</span></div>
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<span style="font-family: Verdana, sans-serif;">Some clues for you. No recent thoracic surgery or recent motor vehicle accident. The patient walked into the department with no deficits. However, and this might give it away, he did recently have a heart attack.</span></div>
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<span style="font-family: Verdana, sans-serif;">If you have guessed it, this person was a recipient of <a href="http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.6301495/k.940B/CPRguidelines.htm">CPR</a> administration a month earlier after he had a heart attack. The delivery of chest compressions from the CPR contributed to the current presentation. If this was me, forget the CPR, just use the AED's and zap away!</span></div>
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<span style="font-family: Verdana, sans-serif;">Click here for another example that I found online in regards to <a href="http://rad.usuhs.edu/medpix/kiosk_image.html?mode=pt&pt_id=12767&imageid=47684&quiz=no#pic">bone scans and CPR</a>.</span></div>
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<br /></div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-26674111844735556212012-05-16T13:54:00.001-04:002012-10-29T09:24:32.563-04:00Theraspheres<span style="font-family: Verdana, sans-serif;">Just got back from Chicago... (fun town), on a training seminar in regards to <a href="http://www.nordion.com/therasphere/home_intl/index.asp">TheraSpheres</a>. For those in the United States and Europe, this might be routine practise in treating liver cancers (<a href="http://emedicine.medscape.com/article/282814-overview">hepatocellular carcinoma HCC</a>), but not so much here in Canada. There are only a few places in Canada that are performing these procedures (BC, Alberta) but not sure what type of volumes they have in regards to this type of treatment. The Nordion sales reps have stated that they have some type of involvement within these regions.</span><br />
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<span style="font-family: Verdana, sans-serif;"><b><i>At any rate what is a TheraSphere?</i></b> They are glass beads with <a href="http://www.perkinelmer.com/CMSResources/Images/44-74001tch_yttrium90.pdf">Yittrium-90</a> attached to the surface. The beads themselves are biocompatible and insoluble and have a mean size between 20 - 30um. These beads are injected through a femoral line while undergoing a hepatic angiogram in Interventional Radiology (IR) and the beads are deposited close to the site of the liver lesion that you want to treat.</span></div>
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<span style="font-family: Verdana, sans-serif;">What's tricky about this is, figuring out the blood supply to the region of the liver in and around the tumour site(s). For the most part the blood flow to the liver is fairly predictable, but with respect to some patients it's a bit more complicated because of a variety of arterial variants, parasitization of flow, accessory arteries, retrograde blood flow etc. that if not found with a thorough investigation, the deposition of the TheraSpheres will not go entirely to the tumour, but elsewhere within the body. This is not a good thing, since adverse reactions may potentially occur. The case studies illustrated these quite well at the training seminar. However, for the most part Yittrium-90 <a href="http://www.webmd.com/cancer/radioembolization-uses-benefits-risks">radioembolization</a> of the HCC tumours has several advantages in that it has a lower toxicity profile in comparison to transarterial <a href="http://www.medicinenet.com/chemo_infusion_and_chemoembolization_of_liver/article.htm">chemoembolization</a>.</span></div>
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<span style="font-family: Verdana, sans-serif;">So what does TheraSpheres have to do with Nuclear Medicine? Well for the most part we assay and deliver the Yittrium-90 to the angiography suite, and from there the IR techs and the IR doctors take care of the rest with respect to the injection and the clean up. This will vary from site to site, depending upon the level of comfort and training in dealing with radioactive materials.</span></div>
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<span style="font-family: Verdana, sans-serif;">However even before this occurs, Nuclear Medicine is important in determining extra hepatic shunting to the lungs or gastrointestinal tract as part of the selection process in figuring out who are good candidates for this treatment.</span></div>
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<span style="font-family: Verdana, sans-serif;">150MBq of Tc-99m MAA is injected with a microcatheter into the hepatic artery after coil embolization of all visible non hepatic arterial flow. Basically, whatever blood flow that doesn't deal with the liver, they get clamped down with coils, in order to figure extrahepatic flow. The image below is an example of this type of imaging.</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIFOYrC0w9svFZGxv_2XVIcDQiSkd04n6ouwUBXCvEVb1CfOmdQR4PkZ0VqD63C-II3Ur4X90sHYzovTQjQ30fn7S2IXyK_RhRUc6PaleZ-J_BG6gRQhPf6WSpVXR6-XU_MwDTHw8WG0A/s1600/MAA+Shunting.gif" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="206" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgIFOYrC0w9svFZGxv_2XVIcDQiSkd04n6ouwUBXCvEVb1CfOmdQR4PkZ0VqD63C-II3Ur4X90sHYzovTQjQ30fn7S2IXyK_RhRUc6PaleZ-J_BG6gRQhPf6WSpVXR6-XU_MwDTHw8WG0A/s400/MAA+Shunting.gif" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 1 ROI's drawn over the lungs and liver to determine the counts for geometric calculations to determine the Lung Shunt Function (LSF)</span></td></tr>
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<span style="font-family: Verdana, sans-serif;">Anterior and posterior images are taken to determine regions of interest (ROI) to find out the Lung Shunt Fraction (LSF). The geometric means are calculated from the lungs and liver using the numbers from the ROI's and are used in this equation:</span></div>
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<span style="font-family: Verdana, sans-serif;"><b style="background-color: yellow;">LSF = Lungs / (Liver + Lungs) *100</b></span></div>
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<span style="font-family: Verdana, sans-serif;">The reason why this is important is because it helps in determining the dosimetry calculations for pre and post treatment. This is important since you need to know how much radiation to give given a specific volume of liver that you plan to treat without affecting other parts of the body (ie. lungs).</span></div>
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<span style="font-family: Verdana, sans-serif;">There is the question of planar versus SPECT/CT imaging with MAA. At the training seminar, planar imaging was described, but others have suggested performing SPECT/CT. Since at our site we have limited experience with this protocol, we would need to speak to the IR doctors and the Nuc Med doctors to figure out what they want.</span></div>
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<span style="font-family: Verdana, sans-serif;">The current imaging protocol for Tc-99m MAA:</span></div>
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<span style="font-family: Verdana, sans-serif;"><b style="background-color: yellow;">Static Imaging Protocol (Northwestern Hospital, Chicago):</b></span></div>
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<span style="font-family: Verdana, sans-serif;"><b><u>Dosage:</u></b></span></div>
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<span style="font-family: Verdana, sans-serif;">- 37 -185 MBq Tc-99m MAA, injected in IR and the patient delivered to Nuclear Medicine</span></div>
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<span style="font-family: Verdana, sans-serif;"><b><u>Equipment:</u></b></span></div>
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<span style="font-family: Verdana, sans-serif;">- Any large FOV dual detector gamma camera, with LEAP or LEHR collimation</span></div>
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<span style="font-family: Verdana, sans-serif;"><b><u>Imaging:</u></b></span></div>
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<span style="font-family: Verdana, sans-serif;"><i>Option 1: </i> The patient is positioned supine under the gamma camera and 4 images are acquired. Anterior and posterior images of the abdomen and of the thorax are acquired separately</span></div>
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<span style="font-family: Verdana, sans-serif;"><i>Option 2:</i> The patient is positioned supine under the gamma camera and a whole body scan is acquired</span></div>
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<span style="font-family: Verdana, sans-serif;"><b><u>Camera Parameters:</u></b></span></div>
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<span style="font-family: Verdana, sans-serif;">- Acquisition matrix = 256 X 256</span></div>
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<span style="font-family: Verdana, sans-serif;">- Zoom = 1.45 or less to ensure all activity visible in FOV; total counts >1M</span></div>
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<span style="font-family: Verdana, sans-serif;">- Counting time - 5mins per 74 MBq administration of Tc-99m</span></div>
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<span style="font-family: Verdana, sans-serif;"><b style="background-color: yellow;">SPECT/CT Imaging Protocol (<a href="http://jnm.snmjournals.org/content/50/5/688.full.pdf">University Hospital Essen, Essen</a>)</b></span></div>
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<span style="font-family: Verdana, sans-serif;"><b>Dosage:</b></span></div>
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<span style="font-family: Verdana, sans-serif;">150 MBq Tc-99m MAA</span></div>
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<span style="font-family: Verdana, sans-serif;"><b>Equipment:</b></span></div>
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<span style="font-family: Verdana, sans-serif;">- Dual headed gamma camera, with SPECT/CT capability</span></div>
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<span style="font-family: Verdana, sans-serif;"><b>Imaging:</b></span></div>
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<span style="font-family: Verdana, sans-serif;">- 30 minutes post injection of Tc-99m MAA, anterior and posterior planar images of the whole body </span></div>
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<span style="font-family: Verdana, sans-serif;">- SPECT/CT afterwards</span></div>
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<span style="font-family: Verdana, sans-serif;"><b>Camera Parameters:</b></span></div>
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<span style="font-family: Verdana, sans-serif;">- SPECT - 128 X 128 matrix</span></div>
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<span style="font-family: Verdana, sans-serif;">- 128 frames (25 secs/frame)</span></div>
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<span style="font-family: Verdana, sans-serif;">- CT - 130 keV, 17 mAs, 5mm slices</span></div>
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<span style="font-family: Verdana, sans-serif;">There is also talk about PET/CT imaging as well. Since Yittrium-90 is a beta emitter, having the patient come back the following day after treatment allows imaging of the distribution and deposition of the microspheres within the body. </span></div>
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<span style="font-family: Verdana, sans-serif;">Anyway, there is a lot to know about this procedure and I am only scratching the surface. At our facility we have had some experience with this many years ago, but now there is a real push with some of the doctors at the hospital to revisit this type of treatment again.</span></div>
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<span style="font-family: Verdana, sans-serif;">Stay tuned........</span></div>
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<span style="font-family: Verdana, sans-serif;"><b>Update</b>: Check out <a href="http://nuclearmunkee.blogspot.ca/2012/10/therasphere-part-deux.html">Theraspheres Part Deux</a>, in this blog site. We've performed out first LSF and treatment.</span></div>
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Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com1tag:blogger.com,1999:blog-7408689164544359927.post-42249286030132387172012-05-03T11:36:00.001-04:002012-05-04T10:16:50.138-04:00Unusual Gallium Localization - B-Cell Lymphoma<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmBq639mQ2L3QASst6LYfyceGdvg19-3yZSj834WtHLy8k__ZhwXVmdhm8vywUnYF3xjTEu-RZYagY5RqJHqkPB2zge9tRhof4gs7Y7_ojMm8l9OA_3Lv1lZjrNkCgjiGB15kB-7YxPP4/s1600/Lymphoma+Right+Arm.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjmBq639mQ2L3QASst6LYfyceGdvg19-3yZSj834WtHLy8k__ZhwXVmdhm8vywUnYF3xjTEu-RZYagY5RqJHqkPB2zge9tRhof4gs7Y7_ojMm8l9OA_3Lv1lZjrNkCgjiGB15kB-7YxPP4/s400/Lymphoma+Right+Arm.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 1 Post 72 hour whole body gallium imaging for a 74 year old patient, with B cell lymphoma</span></td></tr>
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<span style="font-family: Verdana, sans-serif;">Gallium scans, in general, are fairly routine in helping clinicians to understand the extent of certain <a href="http://www.emedicinehealth.com/lymphoma/article_em.htm">lymphomas</a> in their patients. For the most part PET imaging is the standard of care in many parts of the world, but with limited access to this type of imaging in certain provinces, we still rely on gallium (ole faithful).</span></div>
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<span style="font-family: Verdana, sans-serif;">What is interesting about the image above is the location of the gallium avid tumours. I personally have never seen uptake in the actual arm itself. The images above describes the uptake in the right infraclavicular lymph nodes, right axillary lymph nodes, soft tissues lateral to the mid shaft of the humerus and soft tissues posterior/lateral to the distal shaft of the humerus. A SPECT/CT was performed, which included the arms and thorax. The sagittal slice reconstruction below helps in clarifying the location of the tumours in the arm.</span></div>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDvpAyw3BVRQMqR1R7nkDs-_z6CEMiaCpU_S76y9wliTAJMysT0HxtcUngqxQm_Nog-h0Jf4kNim0nA06l15XSHbQ12kRFBwctH2yWOaJmE4YENo735NF0rmrs3ai5pxYYXkHJQXxHsm4/s1600/Lymphoma+R+Sagittal.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjDvpAyw3BVRQMqR1R7nkDs-_z6CEMiaCpU_S76y9wliTAJMysT0HxtcUngqxQm_Nog-h0Jf4kNim0nA06l15XSHbQ12kRFBwctH2yWOaJmE4YENo735NF0rmrs3ai5pxYYXkHJQXxHsm4/s400/Lymphoma+R+Sagittal.jpg" width="242" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><span style="font-family: Verdana, sans-serif;">Fig. 3 Sagittal reconstruction of the right arm localizing the gallium avid tumours. The video below is the 2-bed SPECT scan of the patient.</span></td></tr>
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<iframe allowfullscreen='allowfullscreen' webkitallowfullscreen='webkitallowfullscreen' mozallowfullscreen='mozallowfullscreen' width='320' height='266' src='https://www.blogger.com/video.g?token=AD6v5dx_g3DBpqqHyO3UhdrxKtGOTAm966L7yAI36Zq8AOMScDO8c8_8_lequ-Rz-BAefC2e3YstAMLoK1tCsxmLIA' class='b-hbp-video b-uploaded' frameborder='0'></iframe></div>
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<span style="font-family: Verdana, sans-serif;">The patient initially presented with <a href="http://www.medicinenet.com/anemia/article.htm">anemia</a>. Upper and lower gastrointestinal investigations did not reveal anything out of the ordinary, but the blood work for hemoglobin, <a href="http://www.medicine.mcgill.ca/physio/vlab/bloodlab/mcv-mchc_n.htm">mean corpuscular volume (MCV)</a> and ferritin results were abnormal. The lumps and nodules in the right arm have been present for 8 years, and it was only recently that they began to grow in size, but were not painful. The patient was diagnosed with diffuse <a href="http://emedicine.medscape.com/article/202677-overview">B cell lymphoma</a> and is currently undergoing treatment.</span></div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-53889533668141005522012-05-03T09:37:00.000-04:002012-05-03T10:30:23.519-04:00McCune Albright Syndrome<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVDdBqtp8sdR4BhlHKZ22soL09XoW3n4Fv2rhpVtLnoY-n9jw90EGazDkJAMELZs3ki3u-_ZUPS7XtU7mX5iZEBjID0ShEucd_hzfyuX3Q4uQ2_X5IDnkmAZV5fIRLi2lbzagMT11o8cM/s1600/McCune+Albright+Syndrome.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="328" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgVDdBqtp8sdR4BhlHKZ22soL09XoW3n4Fv2rhpVtLnoY-n9jw90EGazDkJAMELZs3ki3u-_ZUPS7XtU7mX5iZEBjID0ShEucd_hzfyuX3Q4uQ2_X5IDnkmAZV5fIRLi2lbzagMT11o8cM/s400/McCune+Albright+Syndrome.jpg" width="400" /></a></div>
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<span style="font-family: Verdana, sans-serif;">Sorry about the appearance of the image... I was not able to invert the colour scheme.</span></div>
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<span style="font-family: Verdana, sans-serif;">However, this patient presented to our department to determine if osteomyelitis was present in her right upper jaw. In short, our doctors were unable to decide if the site had osteomyelitis, because of other confounding circumstances such as the patient's recent dental work in the same area. It was tough because they were unsure if there was some type of odontogenic infection occurring as well. Plus the extent of the underlying bone that was involved in this infection was difficult to resolve given the patient's underlying bony lesions. The sulphur colloid (bone marrow images) and the delayed In-111 WBC images are not included for viewing because the interesting point about this case, is the actual total body bone scan itself.</span></div>
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<span style="font-family: Verdana, sans-serif;"><a href="http://emedicine.medscape.com/article/127233-overview">McCune Albright Syndrome</a> (polyostotic fibrous dysplasia) is a genetic disorder that affects the bones and pigmentation of the skin. It is not a common disorder and the exact number of cases in the United States and internationally is not known. However what is interesting are the multiple abnormal foci of increased activity noted within the bones, this in keeping with the nature of the syndrome. Anyway I thought this was more interesting than the osteomyelitis component of this case.</span></div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-72557151897845029442012-05-02T14:07:00.000-04:002012-05-03T08:44:42.704-04:00A Weird Incidental Finding<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-HD-LVDSSczzw6_Ge1rkwyYaW2wyr2ZZMuIDt-S9CtQaqEoXO5b_LJoj6eBjzIVfIIWQ0sMbxC_ToBzeZ3N6mPoHePgpM9KfOdHibtuFmgMEWiSzmnTtSh1zBH9fOAMAxnZIkYhpV2h4/s1600/Bladder+Hernia+TBBS.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi-HD-LVDSSczzw6_Ge1rkwyYaW2wyr2ZZMuIDt-S9CtQaqEoXO5b_LJoj6eBjzIVfIIWQ0sMbxC_ToBzeZ3N6mPoHePgpM9KfOdHibtuFmgMEWiSzmnTtSh1zBH9fOAMAxnZIkYhpV2h4/s320/Bladder+Hernia+TBBS.jpg" width="273" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Total body bone scan of a patient diagnosed with renal cell carcinoma.</td></tr>
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As a technologist what would you do after the <a href="http://www.skeletalscintigraphy.com/content/soft-tissue-pathology">total body bone scan</a> (TBBS) was complete? I think one of our main duties are to review the images to see if there are any asymmetrical bone uptake relating to the patient's history and to take extra pictures if needed. With respect to the images above, there are a few spots, in particular the spine, but other than that nothing too remarkable to talk about. Unless you take a closer look at the pelvis. Is this contamination or is this "something else"? Well it has to be something else or else it wouldn't be on this blog.<br />
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So, what are our options to figure out, what's going on in the pelvis?<br />
a. Take a quick lateral view, to see if this is truly contamination<br />
b. SPECT or SPECT/CT<br />
c. Squat view on the camera (ie. have the patient sit on the camera) to separate bone versus soft tissue<br />
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Since we have a hybrid system, we SPECT/CT'ed the pelvis. So the question you are asking yourself right now is, why did we opt to do this? Well if you look at urine contamination on patients in general, it usually looks more "drawn out" - dribbling with smaller spots. Also in this TBBS the margins of the "spot" below the bladder proper, are smooth and well defined... so it doesn't really fit with our pre notion of what contamination would look like. Plus, we had the time and we needed the "billings" and the workload units, so we did it... <i>I am joking of course (as someone pointed out)</i> .... And this is what we got:<br />
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The SPECT is interesting. The "spot" is anterior to the bladder, but really not on the surface of the skin. Below is the CT transaxial slice of the pelvis from the SPECT/CT.<br />
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA24i4AnyX9AzmOVtAcyyNiZg9jJ-I63bSF7cxfdtD2L2QomIRcKoE2U2vDB21CMOK4fJAgak1kJdQjQuYek45gji6yKp6FOJiHo_8hRyv73s2H1IfZ2KIehjp5Fsq3iELDD4OthL_n4k/s1600/Bladder+Hernia+trans+CT.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="195" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiA24i4AnyX9AzmOVtAcyyNiZg9jJ-I63bSF7cxfdtD2L2QomIRcKoE2U2vDB21CMOK4fJAgak1kJdQjQuYek45gji6yKp6FOJiHo_8hRyv73s2H1IfZ2KIehjp5Fsq3iELDD4OthL_n4k/s320/Bladder+Hernia+trans+CT.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Transaxial CT image of the pelvis from the SPECT/CT scan. Notice the "pear" shaped bladder.</td></tr>
</tbody></table>
<br />
Notice the <a href="http://www.med-ed.virginia.edu/courses/rad/gu/anatomy/bladder.html">bladder in the pelvis</a> <i>(click on link for normal looking bladder)</i>. It looks like a "pear" with the most anterior lobe shifted to the right extending beyond the pubic bone. Is this still contamination? Here's another look with the sagittal slices for SPECT, CT and fused SPECT/CT slices.<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhi1vAI2d6ciUF3BgyOSxbokvqjAOtKGIlaEr9HPOYKuNVGzVjBunFcMbVQqPakWYnVuEGtQw9if_yRbIIE_9jL8V88sbowKSTXn3uWi6FJF1HqKG7mP_8IoTSxvRH5HKTNYMyb1Un6mY/s1600/Bladder+Hernia+Spect+sag.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhi1vAI2d6ciUF3BgyOSxbokvqjAOtKGIlaEr9HPOYKuNVGzVjBunFcMbVQqPakWYnVuEGtQw9if_yRbIIE_9jL8V88sbowKSTXn3uWi6FJF1HqKG7mP_8IoTSxvRH5HKTNYMyb1Un6mY/s1600/Bladder+Hernia+Spect+sag.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Sagittal SPECT view of the pelvis. Notice the bladder and the anterior ovoid "spot".</td></tr>
</tbody></table>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqrVmWupF-8xJ2dSLErNhpl3LWF9XvdsjRTFs99JzdNalEjb3XINigHTBfrj4zUV00q1lsnmF3y_cviks_BpxvRmc-Jro3p5_DIl8blrachyphenhyphenWNFJPbLVOIMyDRa9UyWQ1br3hmflyneuk/s1600/Bladder+Hernia+CT+sag.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgqrVmWupF-8xJ2dSLErNhpl3LWF9XvdsjRTFs99JzdNalEjb3XINigHTBfrj4zUV00q1lsnmF3y_cviks_BpxvRmc-Jro3p5_DIl8blrachyphenhyphenWNFJPbLVOIMyDRa9UyWQ1br3hmflyneuk/s1600/Bladder+Hernia+CT+sag.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 4 Sagittal CT slice of the pelvis. The bladder has a flaccid phallic appearance.</td></tr>
</tbody></table>
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnCyB_ZCLQRNviGG4OxTiE7FXPkP3Z3zF3OHHZDkCP1XBDswxpLgSrTIjd0ExNKRjyiX-brmsWP2DEyYCq971LDjbJzEAOKBCd1y9lzHVCuAuy52BpykK6GV5rV_8FvTpMDhr9FRPsiCc/s1600/Bladder+Hernia+fused+sag.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjnCyB_ZCLQRNviGG4OxTiE7FXPkP3Z3zF3OHHZDkCP1XBDswxpLgSrTIjd0ExNKRjyiX-brmsWP2DEyYCq971LDjbJzEAOKBCd1y9lzHVCuAuy52BpykK6GV5rV_8FvTpMDhr9FRPsiCc/s1600/Bladder+Hernia+fused+sag.jpg" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 5 Fused SPECT/CT sagittal slice. Everything is starting to make a little bit more sense.</td></tr>
</tbody></table>
<br />
Well if you haven't figured it out now, the "spot" that you actually see is the bladder. The bladder has herniated out and dropped below the pelvic floor... the patient has a <i><u>herniated bladder</u></i>! This is something that we normally do not see very often.<br />
<br />
The indication for this patient was to have a metastatic work up, because they were re-diagnosed with <a href="http://emedicine.medscape.com/article/281340-overview">renal cell carcinoma (RCC)</a>, this time in the right kidney. The bone scan was included in the work up for metastases in the bones. There were no clear cut evidence for this, but there were a lot of expressions of degeneration in the joints and notice one kidney is missing... the left one on the TBBS. The left kidney had been removed in 2009 as the result of RCC. Even though there were no bony evidence of metastases, the separate CT scans showed a large liver lesion indicating the progression of his disease from his right kidney (images not shown).</div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com3tag:blogger.com,1999:blog-7408689164544359927.post-57331675242616745352012-05-01T11:09:00.001-04:002012-05-15T14:09:06.219-04:00Certification Exam - Student QuestionsOkay here's one... regulations are not my strong point but since we have a Corporate Radiation Safety Office (CRSO), who gets on everyone's case, they generally have a good grasp on the regulations.<br />
<br />
Q1. <br />
<br />
<i>1) Can you
clarify what exactly is the difference between thyroid monitoring, thyroid
screening and thyroid bioassay for nuclear medicine workers handling radioactive
iodine? I thought they were all pretty much the same thing but it seems like
the CNSC considers them three different things. <br /><br />2) There are a few
different documents that have some conflicting information on them about how
much radioactive iodine a nuc med worker can be exposed to before they must
participate in thyroid screening program. I think that some of these documents
are older and that the rules have changed...I just wanted to make sure I am
learning the most up to date regulations for the exam: According to document
RD-52, you must participate in a thyroid screening program if you are exposed to
2MBq (benchtop), 200MBq (fumehood) or 20,000MBq (glove box) of volatile I-131 or
I-125 and your screening must take place within 1 to 5 days....is this correct?
According to another document INFO-0546 it said you must participate in thyroid
bioassay if you manipulate greater than 5MBq (benchtop), 50MBq (capsule form),
50MBq (fumehood) or 500MBq (glove box) of volatile I-131 or I-125 in a time
period of 3 months and your bioassay must take place within 1 week. Is
INFO-0546 still relevant? </i><br />
<br />
A1. The response from CRSO:<br />
<br />
<br />
<div style="margin: 0px 0px 0px 36pt; text-indent: -18pt;">
<span style="font-family: 'Times New Roman', serif; font-size: small;"><span style="font-size: 12pt;"><span style="color: #1f497d; font-family: Arial, sans-serif; font-size: x-small;"><span style="font-size: 10pt;">1)</span></span><span style="color: #1f497d; font-family: Arial, sans-serif;"> </span><span style="color: #1f497d; font-family: Arial, sans-serif; font-size: x-small;"><span style="font-size: 10pt;">Your best reference is CNSC RD-58 “thyroid
screening for radioiodine”. To sum it up: The term thyroid monitoring isn’t
really used anymore. Your two main terms are thyroid screening and thyroid
bioassay. The term “screening” refers to a routine program that can detect the
presence of iodine in the thyroid above or below certain threshold levels.
Essentially what you all do in Nuc Med on a routine basis. Thyroid bioassay is
done to quantify not just the presence but the resulting committed effective
dose, if one of the screening levels were exceeded. That calculation can only be
performed by somebody certified by the CNSC.</span></span></span></span></div>
<div style="margin: 0px 0px 0px 36pt; text-indent: -18pt;">
<span style="font-family: 'Times New Roman', serif; font-size: small;"><span style="font-size: 12pt;"><span style="color: #1f497d; font-family: Arial, sans-serif; font-size: x-small;"><span style="font-size: 10pt;"><br /></span></span></span></span></div>
<div style="margin: 0px 0px 0px 36pt; text-indent: -18pt;">
<span style="font-family: 'Times New Roman', serif; font-size: small;"><span style="font-size: 12pt;"><span style="color: #1f497d; font-family: Arial, sans-serif; font-size: x-small;"><span style="font-size: 10pt;">2)</span></span><span style="color: #1f497d; font-family: Arial, sans-serif;"> </span><span style="color: #1f497d; font-family: Arial, sans-serif; font-size: x-small;"><span style="font-size: 10pt;">RD-58 has the current requirements and they
are the 2, 200, 20000 MBq and they were implemented this year. The 5, 50, 500
MBq are now old numbers.</span></span></span></span></div>
<br />
Click on the link <a href="http://nuclearsafety.gc.ca/pubs_catalogue/uploads/RD-58_pdf_e.pdf">CNSC RD-58</a> for documentation.<br />
<br />
There you have it!!!!!Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-69215605544491203792012-04-25T09:25:00.002-04:002012-04-25T09:41:52.598-04:00Certification Exam - Student Questions<span style="font-family: Verdana, sans-serif;"><b>Q2<span style="font-size: x-small;">.</span> <span style="font-size: 10pt;">When doing myocardial perfusion study, patients are
asked to fast for 3/4 hours before the study, either rest/stress. For stress,
the purpose is to minimize the possibility of vomitting right? But what is the
purpose of fasting during
rest??</span></b></span><br />
<div _fallwcm="1" class="bdyItmPrt" id="divBdy">
<div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr" style="font-family: Verdana, sans-serif;"><br /></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;">A2. <i>I thought they taught you this already at the school and in clinical. </i></span></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;"><i><br /></i></span></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;"><i>Anyway one of the main reasons why they need to fast for both rest and stress is to reduce the gut uptake. Remember the biodistribution of sestamibi is uptake in the liver. If they have eaten in the morning there is potential of obscuring the inferior portion of the left ventricle due to gallbladder secretions that help with the digestion of food. The secretions into the small bowel can cause the loops of bowel to limit the visualization of the inferior wall.</i></span></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;"><i><br /></i></span></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;"><i>However, with Myoview they claim that there is less liver uptake when imaging.... but most facilities still recommend that the patients fast before having their myocardial perfusion imaging.</i></span></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;"><i><br /></i></span></span></div>
<div dir="ltr" style="font-size: 10pt;">
<span dir="ltr"><span style="font-family: Verdana, sans-serif;"><i>Check this article out. It's an older article.</i></span></span></div>
<div dir="ltr">
<span dir="ltr"><span style="font-family: Verdana, sans-serif; font-size: x-small;"><i><br /></i></span></span></div>
<div dir="ltr">
<a href="http://www.blogger.com/goog_1195165536"><i><span dir="ltr"><span style="font-family: Verdana, sans-serif;">Myocardial Technetium-99m-Tetrofosmin and </span></span><span style="font-family: Verdana, sans-serif;">Technetium-99m-Sestamibi Kinetics in Normal</span></i></a><br />
<div dir="ltr">
<span style="font-family: Verdana, sans-serif;"><a href="http://jnm.snmjournals.org/content/38/3/428.full.pdf"><i>Subjects and Patients with Coronary Artery Disease</i></a></span><br />
<span style="font-family: Verdana, sans-serif;"><i><br /></i></span><br />
<span style="font-family: Verdana, sans-serif;"><i>And check this out as well, <a href="http://www.quantamn.com.br/nvoste2/index.php/cases/62-case-12">quantum</a>, this gives an explanation of some of the things that I mentioned above in a case study.</i></span></div>
</div>
<div dir="ltr">
<span style="font-family: Verdana, sans-serif;"><i><br /></i></span></div>
</div>
<div dir="ltr" style="font-size: 10pt;">
<span style="font-family: Verdana, sans-serif;"><i>I will follow up again with this answer with more details, later on.... but for the time being I'll leave with this. The SNM guidelines do not provide much of an explanation.</i></span></div>
</div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-66231243430679989782012-04-23T09:09:00.000-04:002012-04-25T09:42:35.836-04:00Certification Exam - Student Questions<div style="text-align: justify;">
It's going to be busy the next couple of weeks, since most of the students will be cramming for their certification exam. I've been working on a few cases but haven't posted up anything just yet... so sorry about that, BUT to replace the case studies I will be posting the questions posed by the students to help them study for their exam. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b>Q1. If a breastfeeding women just had a bone scan, do you tell them to stop
breastfeeding for 24 hours? Where do I find the correct interruption times for
all the radioisotopes??</b></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<i>A1. According to the literature, there is no cessation of breast feeding for mothers who just had a bone scan. However, other radioisotopes like Ga-67 requires at least 1 month, but this effectively stops any type of breast feeding since there will be latching issues later on.</i></div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
<b><i>References: </i></b></div>
<div style="text-align: justify;">
1. <a href="http://www.pciphysics.com/docs/BreastFeedingDelayChart2009.pdf">http://www.pciphysics.com/docs/BreastFeedingDelayChart2009.pdf</a></div>
<div style="text-align: justify;">
2. <a href="http://nrc-stp.ornl.gov/narmtoolbox/nureg1556vol9_rev2_012408.pdf">http://nrc-stp.ornl.gov/narmtoolbox/nureg1556vol9_rev2_012408.pdf</a> (see Appendix U, page U-9)</div>
<div style="text-align: justify;">
3. <a href="http://jnm.snmjournals.org/content/41/5/863.full.pdf">Journal Nuclear Medicine, vol 41 p. 863-873, 2000</a></div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-10524773358447914562012-03-26T13:56:00.001-04:002012-03-26T15:16:46.356-04:00Adrenal Hyperplasia and PET/CT<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr3rByTXuRGSYVhWvoqWfhn1o_dEWIF8A9dTSIYuY3bJyyxsyqRQg3DdLTaHdNaNwPLxb6xZx76y2UL7rtdlX-XdtfyWYGYEri__BxCAK4wKBna7HhrBYdZuR8aLNw9dtBMqMDnb-izmY/s1600/CT+Cushing's.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhr3rByTXuRGSYVhWvoqWfhn1o_dEWIF8A9dTSIYuY3bJyyxsyqRQg3DdLTaHdNaNwPLxb6xZx76y2UL7rtdlX-XdtfyWYGYEri__BxCAK4wKBna7HhrBYdZuR8aLNw9dtBMqMDnb-izmY/s320/CT+Cushing's.jpg" width="176" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 1 Coronal CT image. Note the "inverted Y" shaped tissues just above the kidneys. <a href="http://radiographics.rsna.org/content/21/4/995.full.pdf">This is what typical adrenal glands look like on CT.</a> Click on the link for more in depth information.</td></tr>
</tbody></table>
<div class="separator" style="clear: both; text-align: center;">
</div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiuW6wRq8_minXVCsj_htR8AnKZ0YvSaLb7Gm_osbl72MyzalkDkJEU1rroO-YfXr5f_9joFoXaaz7WIdUMIz_BMXNIAMb9P49LoWcQa1_fUzvKVsLuNFgbaaMA3WzLZLEhAdUpZ-ztJWU/s320/PET+Cushings.jpg" style="margin-left: auto; margin-right: auto;" width="184" /></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 2 Same section of the coronal plane corresponding to the previous CT. Note the F18 FDG uptake above the renal poles, midline to the body.</td></tr>
</tbody></table>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEif7tlPvjo-VhtQLlgjVkAsJZOB60FQg252evDdP2zGWb3VaNiFPfI8CtkTmndGAp2S5h3EOQP03IFaQczRiNR9K4sHRM_pQh9UmRmTTItuMsALm30iRlhZ5PrAt6odtkF_pX6NW6xTYJE/s1600/Fused+Cushing%2527s.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEif7tlPvjo-VhtQLlgjVkAsJZOB60FQg252evDdP2zGWb3VaNiFPfI8CtkTmndGAp2S5h3EOQP03IFaQczRiNR9K4sHRM_pQh9UmRmTTItuMsALm30iRlhZ5PrAt6odtkF_pX6NW6xTYJE/s320/Fused+Cushing%2527s.jpg" width="179" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 3 Fused CT and PET image of the two images. Note the metabolically active regions above the poles of the kidney, midline to the body. Expand the image to get a closer look.</td></tr>
</tbody></table>
<br />
<div style="text-align: justify;">
Generally, PET/CT requisitions must be approved by our physicians and they have to follow certain guidelines for approval as set out by local government who sponsors some of the costs. However some patients do not fall within these guidelines and as the result they must go through another route. Well this is one of those patients that have gone through this "other" route to have their scan.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
The case history is interesting. Originally the patient presented with fatigue and proximal leg weakness with a long history of hypertension and <a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001440/">dyslipidemia</a>. However, recently the hypertension has been uncontrollable and had developed <a href="http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001510/">hypokalemia</a>, weight gain, bruising, and diabetes. Blood work was also performed to correlate these findings (<a href="http://www.nlm.nih.gov/medlineplus/ency/article/003694.htm">dexamethasone suppression test</a>). To make a long story short, they suspected that <a href="http://www.medicinenet.com/cushings_syndrome/article.htm">Cushing's Syndrome</a> may be the cause. </div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
Cushing's Syndrome tends to be rare often affecting maybe 2 to 4 cases per million inhabitants per year. The problem with this condition is that, there is too much <a href="http://www.vivo.colostate.edu/hbooks/pathphys/endocrine/adrenal/gluco.html">glucocorticoids</a> being produced by the <a href="http://users.rcn.com/jkimball.ma.ultranet/BiologyPages/A/Adrenals.html">adrenal glands</a> (adrenal cortex), in particular <a href="http://www.nlm.nih.gov/medlineplus/ency/article/003693.htm">cortisol</a>. Cortisol affects the body's pathways in the following:</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: left;">
<span style="background-color: yellow;"><i><b>1.</b> Stimulates gluconeogenesis in the liver</i></span></div>
<div style="text-align: left;">
<span style="background-color: yellow;"><i><b>2.</b> Mobilization of amino acids from extra hepatic tissues to act as substrates for gluconeogenesis</i></span></div>
<div style="text-align: left;">
<span style="background-color: yellow;"><i><b>3.</b> Inhibition of glucose uptake in muscle and adipose tissue to allow for glucose conservation</i></span></div>
<div style="text-align: left;">
<span style="background-color: yellow;"><i><b>4.</b> Stimulation of fat breakdown from adipose tissue. Basically the fatty acids are used for energy production in tissue (muscle) and the glycerols from the fat are used for other substrates for gluconeogenesis</i></span></div>
<div style="text-align: left;">
<i style="background-color: yellow;"><br /></i></div>
<div style="text-align: justify;">
The glucocorticoids have an immune and anti inflammatory response as well, often given in therapeutic doses to treat arthritis and dermatitis.</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: justify;">
So how do you produce too much glucocorticoids? There are a couple of ways:</div>
<div style="text-align: justify;">
<br /></div>
<div style="text-align: left;">
<i style="background-color: yellow;"><b>1. </b> The <a href="http://bcs.whfreeman.com/thelifewire/content/chp42/4202b.swf">negative feedback loop among the hypothalamus, pituitary gland and the adrenal glands do not work</a>. Basically there is too much adrenocorticotropic hormone (ACTH) being produced by the pituitary thus influencing the adrenal glands to produce more glucorticoids</i></div>
<div style="text-align: left;">
<i style="background-color: yellow;"><b>2.</b> There is/are tumour(s) within the adrenal glands</i></div>
<div style="text-align: left;">
<i style="background-color: yellow;"><b>3. </b> There is/are ectopic tumour(s) elsewhere in the body producing cortisol</i></div>
<div style="text-align: left;">
<i style="background-color: yellow;"><b>4.</b> There is/are ectopic tumour(s) elsewhere in the body producing ACTH</i></div>
<div style="text-align: left;">
<i style="background-color: yellow;"><br /></i></div>
<div style="text-align: left;">
Getting back to this case, the patient had a "radiological work up" to figure out what was wrong. The ultrasounds did not give any indication of any tumours in the adrenals but the initial MRI had discovered a micro adenoma on the anterior pituitary which may have contributed to the increased ACTH levels in the system. Consultation with the patient began to remove the adenoma in the coming months. </div>
<div style="text-align: left;">
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Once the micro adenoma was removed, the patient had some of the symptoms go away, but they had returned a couple of weeks later. Another series of radiological work ups were performed to figure out if an ectopic source could be the cause. A CT scan was performed and again no adrenal tumours were found and other gross anatomy were unremarkable. It was at this point that the clinicians decided to come and see us in the PET/CT department. It was basically to assess any remnant tumour(s) in the pituitary as well as any potential ectopic lesions in the rest of the body.<br />
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The PET/CT scan was negative for residual activity in the head and neck region (images not posted), nothing metabolically active in the chest, but in the abdomen there was bilateral diffuse uptake in the adrenal glands, with a maximum SUV value of 4.6 (see Fig. 2 and 3) There was also smooth thickening of the adrenals which correlated with a previous CT scan. Even though there wasn't any other discoveries of ectopic sources, the information presented by the PET/CT suggested of an <i><u>underlying adrenal hyperplasia</u></i> that may be contributing to the patient's recurring symptoms. Here are the transaxials from the study.<br />
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<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7bS1DfmopSJtPeP8u54GWfHo8xEEcC2Ad0eZcVxs7D9bfvC0E_ROmcH_O3_4uiMGENakNVc_eoad88gDTzFHDPCNVlm26IhR9A7Ouu6VCLc2A5bRgTpawPVBzmjg2cVT9Dj8vV79dtNg/s1600/Transaxial+Cushings.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="240" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj7bS1DfmopSJtPeP8u54GWfHo8xEEcC2Ad0eZcVxs7D9bfvC0E_ROmcH_O3_4uiMGENakNVc_eoad88gDTzFHDPCNVlm26IhR9A7Ouu6VCLc2A5bRgTpawPVBzmjg2cVT9Dj8vV79dtNg/s320/Transaxial+Cushings.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 4 Transaxial CT slice. Note the adrenals (beside the descending aorta) and slightly above the renal poles.</td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-dlX96Jf8xiC1_BPz_JDapZ-aykfpvxlF4nNAyMkXayVu0FFzEKy4H7auHn9oPT6gUysLsEEBY35lLhIjKo5spK6JuUuzOrWvfG7GCRg4Hyh3BNyqDAWe1uOfLCA7FtEGF27AlrcQdZA/s1600/PET+trans+Cushings.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="234" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh-dlX96Jf8xiC1_BPz_JDapZ-aykfpvxlF4nNAyMkXayVu0FFzEKy4H7auHn9oPT6gUysLsEEBY35lLhIjKo5spK6JuUuzOrWvfG7GCRg4Hyh3BNyqDAWe1uOfLCA7FtEGF27AlrcQdZA/s320/PET+trans+Cushings.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 5 Bilateral metabolic activity towards the midline of the image corresponding to the CT slice in Fig. 4. </td></tr>
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<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCNuftPER8H5jw7JpGmZmMWOhYCCtlY0vno64KwfkvLaOAWQGtod4ZTk_DOyYksCf-FMvbxFqGjLUtdWUQW9B3APTW5P2Aj_P-ku5NezY0Zn0u7elpiuQ4KG0LQXBPNNPEWy_uRbz_Sk4/s1600/Fused+Trans+Cushings.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" height="227" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjCNuftPER8H5jw7JpGmZmMWOhYCCtlY0vno64KwfkvLaOAWQGtod4ZTk_DOyYksCf-FMvbxFqGjLUtdWUQW9B3APTW5P2Aj_P-ku5NezY0Zn0u7elpiuQ4KG0LQXBPNNPEWy_uRbz_Sk4/s320/Fused+Trans+Cushings.jpg" width="320" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Fig. 6 Fused image depicting bilateral adrenal gland activity.</td></tr>
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Overall the adrenal glands do not regularly show up on the PET/CT scans and only become so when they are overtly over active. I have only been able to find a handful of articles that describe this metabolic appearance. </div>
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However, from a general Nuclear Medicine perspective, <a href="http://erc.endocrinology-journals.org/content/14/3/587.full.pdf">adrenal gland imaging</a> can be performed using iodine labeled radiopharmaceuticals, such I-131 NP-59 for adrenal cortical imaging and with I-131 MIBG for adrenal medullary imaging. To improve imaging with MIBG, I-123 can also be used as well. The I-131 NP-59 imaging was not performed in this case since this is not readily available in Canada due to restrictions from Health Canada.</div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0tag:blogger.com,1999:blog-7408689164544359927.post-46898317233071085272012-03-21T13:57:00.000-04:002012-03-26T14:11:37.419-04:00Arterial Injection<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBO2L5ETZN5RcRd1dBIAsNpRePLMpX3aG3xZHy1DMouVzg4aUtcAupwvW-1SD_KVR_DF0tqFPmxLP9UEVgqmAvrjhSz40mDOq0SWfXOI-2MmPqCCxNS_BAIqZe4huFLcHoY7VpmioNclg/s1600/Arterial+Injection.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="316px" kba="true" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhBO2L5ETZN5RcRd1dBIAsNpRePLMpX3aG3xZHy1DMouVzg4aUtcAupwvW-1SD_KVR_DF0tqFPmxLP9UEVgqmAvrjhSz40mDOq0SWfXOI-2MmPqCCxNS_BAIqZe4huFLcHoY7VpmioNclg/s320/Arterial+Injection.jpg" width="320px" /></a></div>
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What's going on with these total body bone images? If the title didn't give it away, then you probably know that the Tc99m-MDP injection went into the arterial system rather than into the venous side. We call it the Michael Jackson sign, for the "gloved one". A student had injected in the left antecubital fossa ... did they notice that the vein was pulsating rhythmically? ... not sure.</div>
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This is typical of an arterial injection with a high amount of tracer deposition distal to the injection site. We know that the <a href="http://www.drugs.com/pro/mdp.html">MDP</a> had been prepared correctly since there are no choroid plexus, thyroid, salivary or gastric uptake that would result from <a href="http://www.healthimaginghub.com/medical-imaging-radiology-education-cme/radiology-teaching-files/2011/09/21/431-free-pertechnetate.html">free pertechnetate</a>. Furthermore bone uptake is visible. Now as with an interstitial injection with such a large dose, we would normally see uptake in the lymph nodes on the side that the injection was given... but the image did not pick up any lymph nodes (trust me .. I know it's hard to see)</div>
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What other conditions may have caused this type of uptake? Soft tissue uptake in bone scans can result from:</div>
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Increased blood flow</div>
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Soft tissue calcification</div>
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Neoplasm</div>
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Inflammatory process</div>
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Hyperparathyroidism</div>
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<a href="http://www.medicinenet.com/scleroderma/article.htm">Scleroderma</a></div>
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<a href="http://www.medicinenet.com/polymyositis/article.htm">Polymyositis</a></div>
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<a href="http://www.medicinenet.com/amyloidosis/article.htm">Amyloidosis</a></div>
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<br /></div>Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com1tag:blogger.com,1999:blog-7408689164544359927.post-55810870468293408692012-03-21T13:43:00.000-04:002012-05-02T13:57:13.617-04:00Muscle Uptake on MDP Bone Scan<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhs3QCBBKqLiQriP8i11gYFtPY72zojscDQneTON7oQoHZnpkMWAcu7BhnsAqLVRPzZ3Gvttll8ab7cXO7pbpxQA_yy7WnLL-9x3JfLiNGHx01cIPvPMWWZi_Ue5_v8VHFmUm_2PPdwY0Y/s1600/MDP+Muscle+Uptake.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="303" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhs3QCBBKqLiQriP8i11gYFtPY72zojscDQneTON7oQoHZnpkMWAcu7BhnsAqLVRPzZ3Gvttll8ab7cXO7pbpxQA_yy7WnLL-9x3JfLiNGHx01cIPvPMWWZi_Ue5_v8VHFmUm_2PPdwY0Y/s400/MDP+Muscle+Uptake.jpg" width="400" /></a></div>
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This is an interesting scan, because not often do we come across muscle uptake in our bone scans. For the most part we shouldn't see muscle uptake at all, however it is not uncommon, and there has been several journaled articles relating to this fact. Having "googled" the topic, it appears that there are several conditions that can cause this extra osseous uptake. There has also even been one case in which <a href="http://www.ncbi.nlm.nih.gov/pubmed/8070166">exercise prior to the bone scan</a> has caused muscle uptake.</div>
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On a quick note, here are some interesting articles (<a href="http://radiographics.rsna.com/content/23/2/341.full.pdf">Radionuclide Bone Imaging: An Illustrative Review</a>) in regards to screening pathological conditions and as well <a href="http://www.seminarsinnuclearmedicine.com/article/S0001-2998(10)00014-0/abstract">Nonosseous, Nonurologic Uptake on Bone Scintigraphy: Atlas and Analysis</a> that provides some of the pathways in which Tc99m MDP are involved with non osseous uptake.</div>
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With this patient here, you can see if you expand the image, that there are diffuse muscle and soft tissue uptake throughout the body: hip flexors, quadriceps, calf muscles, deltoids, triceps and breast tissue. The patient had been suffering from left sided flank pain and had undergone several examinations to determine the nature of the pain. This person also has had a previous liver transplant and heart transplant as the result of being diagnosed with <a href="http://emedicine.medscape.com/article/942618-overview">glycogen storage disease (GSD) type IIIA</a> at an early age. We are not really sure how the Tc99m MDP got into the muscles and other soft tissues, but conditions such as <i><a href="http://www.nlm.nih.gov/medlineplus/ency/article/000428.htm">polymyositis</a></i>, <i><a href="http://www.wheelessonline.com/ortho/myositis_ossificans_sterners_tumor">myositis ossificans</a></i> or <i><a href="http://www.medicinenet.com/amyloidosis/article.htm">amyloidosis</a></i> can cause this appearance. However there are a slew of conditions that can also cause this, some of which may be pathological in nature whereas other may be more technical, like too much reduced hydrolyzed in the radiopharmaceutical.</div>
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In the end, the left sided flank pain may have been attributed to a 12th rib fracture, as noted on the bone scan. A SPECT acquisition was also performed to determine the location. Furthermore in the final report, the diffuse uptake in soft tissue was discussed with the referring physician about the possibility of an underlying <a href="http://www.nlm.nih.gov/medlineplus/myositis.html">myositis</a> or <a href="http://www.nlm.nih.gov/medlineplus/ency/article/003103.htm">anasarca</a>.</div>
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<br />Munkeehttp://www.blogger.com/profile/14073530719890358951noreply@blogger.com0