RADIATION PROTECTION IN NUCLEAR MEDICINE

International Atomic Energy Agency RADIATION PROTECTION IN NUCLEAR MEDICINE Part 0: Introduction to Nuclear Medicine NUCLEAR MEDICINE Diagnosis and therapy with unsealed sources Clinical problem Radiopharmaceutical Instrumentation Nuclear Medicine Part 0. Introduction to Nuclear Medicine 2 RADIOPHARMACEUTICALS Radionuclide Pharmaceutical Organ Parameter + colloid Liver RES Tc-99m + MAA Lungs Regional perfusion + DTPA Kidneys Kidney function Nuclear Medicine Part 0. Introduction to Nuclear Medicine 3 HISTORY-RADIONUCLIDES 1896 1898 1911 1913 1930 1932 1934 1938 1942 1946 1962 Natural radioactivity Radium Atomic nucleus Model of the atom Cyclotron Neutron Artificial radionuclide Production and identification of I-131 Nuclear reactor Radionuclides commercially available Tc99m in nuclear medicine Becquerel Curie Rutherford Bohr Lawrence Chadwick Joliot-Curie Fermi et al Fermi et al Harwell Harper Nuclear Medicine Part 0. Introduction to Nuclear Medicine 4 PIONEERS Henri Becquerel Ernest Rutherford Maria Curie Frederique Joliot-Irene Curie Nuclear Medicine Part 0. Introduction to Nuclear Medicine 5 CURRENT METHODS-THERAPY Radiopharmaceutical For treatment of Route of administration Oral Oral IV IV or oral IV Intra-articular Intra-cavitary Intra-articular Intra-articular Maximum activity 1 GBq 20 GBq 10 GBq 200 MBq 150 MBq 250 MBq 5 GBq 50 MBq 150 MBq I-131 I-131 I-131 P-32 Sr-89 Y-90 iodide iodide MIBG phosphate chloride colloid Er-169 colloid Re-186 colloid Thyrotoxicosis Carcinoma of thyroid Malignancy Polycythaemia vera Bone metastases Arthritic conditions malignant effusions Arthritic conditions Arthritic conditions Nuclear Medicine Part 0. Introduction to Nuclear Medicine 6 HISTORY-THERAPY 1936 1936 1941 1942 1945 1958 1963 Therapeutic use of Na-24 (leukemia) Therapeutic use of P-32 (leukemia and polycythemia vera) Therapeutic use of iodine in hyperthyroidism Therapeutic use of iodine in treatment of metastasis from thyroid cancer Therapeutic use of Au-198 in treatment of malignant effusion Treatment of bone metastasis with P-32 Medical synovectomy using Au-198 Hamilton et al Lawrence Hertz et al Muller Maxfield Ansell Nuclear Medicine Part 0. Introduction to Nuclear Medicine 7 I-131 THERAPY The absorbed dose to be delivered should be determined from uptake measurements, effective half-life of the radiopharmaceutical and the size of the thyroid. The radiopharmaceutical is administered p.os. Hyperthyroidism Cured after 3-4 months 1 year 85% 98% Hypothyroidism after <7 years after >7 years 14.8% 27.9% Nuclear Medicine Part 0. Introduction to Nuclear Medicine 8 RADIOSYNOVECTOMY Nuclear Medicine Part 0. Introduction to Nuclear Medicine 9 PAIN PALLIATION Intravenous injection of a radiopharmaceutical which includes e.g. Sr-89 or Sm-153 Nuclear Medicine Part 0. Introduction to Nuclear Medicine 10 ANNUAL FREQUENCY-THERAPY (Sweden 1995) Number of patients per 1000 population Thyroid (tumours & hyperthyroidism) Polycythemia vera Other tumours Others 0.39 0.034 0.003 0.001 Total about 3% of all nuclear medicine 0.428 Nuclear Medicine Part 0. Introduction to Nuclear Medicine 11 CURRENT DIAGNOSTIC METHODS • Imaging Bone, Brain, Lungs , Thyroid, Kidneys, Liver/spleen, Cardiovascular, Stomach/GI-tract, Tumours, Abscesses …. • Non-imaging (probes) Thyroid uptake, Renography, Cardiac output, Bile acid resorption…. • Laboratory tests GFR, ERPF, Red cell volume/survival, Absorption studies (B12, iron, fat), Blood volume, Exchangeable electrolytes, body water, bone metabolism….. • Radioimmunoassays (RIA) • Radioguided Surgery Nuclear Medicine Part 0. Introduction to Nuclear Medicine 12 ANNUAL FREQUENCIES-DIAGNOSIS (Sweden, 1998) 35 30 25 20 15 10 5 0 Bo ne Lu ng Ki dn ey Ca rd io Th yr oi d Br ai n Pr ob es Part 0. Introduction to Nuclear Medicine Frequency (%) 15 examinations/1000 population Nuclear Medicine La b 13 H e a lth -c a re le v e l I C o u n try A rg e n tin a A u s tra lia A u s tria B e lg iu m B u lg a ria Canada C ze c h R e p . D e n m a rk F in la n d F ra n c e G e rm a n y Ita ly Japan 1 9 70 -7 9 3 .8 1 8 .0 1 9 80 -8 4 8 .9 1 9 85 -9 0 1 1 .5 8 .3 3 6 .8 1 3 .0 1 3 .6 1 4 .0 1 2 .6 3 1 .1 6 .0 1 8 .3 1 4 .2 1 7 .7 9 .0 3 9 .7 1 2 .6 2 2 .9 1 3 .4 6 .9 3 9 .8 7 .3 8 .3 C o u n try K uw a it L u x e m b o u rg N e th e rla n d s N ew Z e a la n d N o rw a y R o m a n ia Sw eden S w itze rla n d USSR U n ite d K in g d o m U n ite d S ta te s Y u g o s la via 1 9 70 -7 9 1 9 80 -8 4 1 9 85 -9 0 1 3 .1 2 3 .5 1 1 .6 7 .5 9 .3 3 .5 1 2 .6 5 .6 3 .9 9 .8 4 4 .9 7 .3 3 .0 3 .9 6 .8 2 5 .7 6 .1 A verag e 11 6.9 16 T o ta l a n n u a l n u m b e r o f n u c le a r m e d ic in e e x a m in a tio n s p e r 1 0 0 0 p o p u la tio n (U N S C E A R ) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 14 H e a lth -ca re le ve l II C o u n try 1 9 70 -7 9 B a rb ad o s B ra zil C h in a Cuba 0 .8 E cu a do r 0 .5 In d ia 1 9 80 -8 4 1 9 85 -9 0 1 .0 1 .7 0 .6 0 .8 0 .2 C o u n try Ira q Ja m a ica P e ru T un isia T u rke y A ve ra g e 1 9 70 -7 9 2 .8 1 9 80 -8 4 1 9 85 -9 0 1 .2 2 .0 0 .2 1 .0 2 .5 0 .5 0 .1 0 .9 0 .1 H e a lth -ca re le ve l III C o u n try 1 9 7 0 -7 9 E g yp t 0 .0 7 M ya n m a r 0 .5 4 1 9 8 0 -8 4 0 .2 1 0 .3 6 1 9 8 5 -9 0 0 .4 8 0 .1 1 C o u n try S udan T h a ila n d A v e ra g e 1 9 7 0 -7 9 0 .1 2 0 .2 5 0 .2 5 1 9 8 0 -8 4 0 .2 8 0 .1 8 0 .2 5 1 9 8 5 -9 0 0 .2 8 0 .2 6 0 .3 0 H e a lth -ca re le ve l IV C o u n try E th io p ia 1 9 7 0 -7 9 1 9 8 0 -8 4 0 .0 1 4 1 9 8 5 -9 0 0 .1 0 A v e ra g e 1 9 7 0 -7 9 1 9 8 0 -8 4 0 .0 1 4 1 9 8 5 -9 0 0 .1 0 T o ta l a n n u a l n u m b e r o f n u c le a r m e d ic in e e x a m in a tio n s p e r 1 0 0 0 p o p u la tio n (U N S C E A R ) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 15 HISTORY-DIAGNOSTICS 1927 1935 1939 1948 1956 1957 1961 1962 1964 1965 1971 Blood flow studies (Bi-214) Bone metabolism (P-32) Thyroid studies (I-131) Radiocardiography (Na-24) Renography (I-131) Liver scan (Au-198 colloid) Bone scan (Sr-85) Myocardium (Rb-86, Cs-131) Lung scan Brain scan (Tc99m-pertechnetate) Bone scan (Tc99m-complex) Blumgart-Weiss Chiewitz-de Hevesy Hamilton et al Prinzmetal et al Taplin, Winter Friedell et al Fleming et al Carr et al Taplin et al Bollinger et al Subramanian et al Nuclear Medicine Part 0. Introduction to Nuclear Medicine 16 GEORGE DE HEVESY 1885-1966 de Hevesy G & Paneth F. Die Lösligkeit des Bleisulfids und Bleichromats. Z. Anorg Chem 82, 323, 1913. de Hevesy G. III. The absorption and translocation of lead by plants. Biochem J, 17, 439, 1923. Chiewitz O. & de Hevesy G. Radioactive indicators in the study of phosphorous metabolism in rats. Nature 136, 754, 1935. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 17 MINERAL METABOLISM Göran C. H. Bauer Arvid Carlsson Bertil Lindquist MINERAL METABOLISM (1961) ..studies of bone by isotope techniques have now reached beyond the stage of methodology to give data of immediate physiological and clinical importance. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 18 BONE SCAN Single probe Scanner Gammacamera Nuclear Medicine Part 0. Introduction to Nuclear Medicine 19 INSTRUMENTATION IN NUCLEAR MEDICINE • Activity meter • Sample counters • Single- and multi-probe systems • Gamma camera • Single Photon Emission Computed Tomograph (SPECT) • Positron camera (PET) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 20 KIDNEY CLEARANCE (plasma samples) Cr51-EDTA, 300 kBq Plasma samples at 180-240 min 1000.0 100.0 Clearance (Cl) is calculated:  cpm/ml 10.0 Cl = A / C 0 p (t) * d t 1.0 0 100 200 300 Time (min) A is injected activity Cp is activity concentration in plasma Nuclear Medicine Part 0. Introduction to Nuclear Medicine 21 THYROID UPTAKE MEASUREMENT Nuclear Medicine Part 0. Introduction to Nuclear Medicine 22 HISTORY-INSTRUMENTS 1908 1927 1944 1948 1950 1957 1963 Visual scintillation (ZnS) Geiger-counter Scintillation detector (ZnS+PM) Sodium iodide crystal Scanner Gamma camera Tomography Crookes Geiger Curran Hofstadter Cassen Anger Kuhl Nuclear Medicine Part 0. Introduction to Nuclear Medicine 23 PIONEERS B. Cassen H.O. Anger Nuclear Medicine Part 0. Introduction to Nuclear Medicine 24 GAMMA CAMERA? Nuclear Medicine Part 0. Introduction to Nuclear Medicine 25 GAMMA CAMERA Nuclear Medicine Part 0. Introduction to Nuclear Medicine 26 NUCLEAR MEDICINE IMAGES  Nuclear imaging detects functional (vs. anatomical) properties of the human tissue. The imaging is done by tracing the distribution of radiopharmaceuticals within the body with a gamma camera  Nuclear Medicine Part 0. Introduction to Nuclear Medicine 27 BONE SCAN Bone uptake of 99mTc MDP reflects bone metabolism and blood flow, and allows functional analysis of bone turnover  The ability to image bone metabolism alterations enables detection of lesions such as: Bone metasasis Benign or malignant bone tumors Bone trauma  A three-phase acquisition procedure is required in order to detect osteomelitis  Bone scans also facilitate follow-up of other bone disorders, such as Paget’s disease  Intravenous injection of 400-600 MBq 99mTc MDP. Imaging 3h after injection Nuclear Medicine Part 0. Introduction to Nuclear Medicine 28 BONE SCAN normal Nuclear Medicine pathologic 29 Part 0. Introduction to Nuclear Medicine LUNG SCAN A proportionately spread embolization of the pulmonary capillary bed yields an image reflecting the lung blood perfusion (Tc 99m MAA). This image enhances the diagnosis of pulmonary emboli. Intravenous injection of 100 MBq Tc99m MAA. Immediate scanning. Ventilation studies (Tc99m -aerosols) reflect the regional and segmental ventilation. Study interpretation is performed in conjunction with perfusion findings, supporting the differential diagnosis of pulmonary emboli. Inhalation of 100 MBq Tc99m -aerosols. Immediate scanning. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 30 LUNG SCAN Nuclear Medicine Part 0. Introduction to Nuclear Medicine 31 THYROID Thyroid scintigraphy (I123, I131 or Tc99m pertechnetate) offers structural and functional information by displaying the thyroid image and calculating uptake, organ volume etc. Pinhole SPECT studies offer superior contrast resolution image over the planar image, enhancing thyroid nodules detection and evaluation. Intravenous injection of 100 MBq Tc99m pertechnetate. Scanning 15 min later. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 32 THYROID SCAN Nuclear Medicine Part 0. Introduction to Nuclear Medicine 33 CEREBRAL BLOODFLOW  99mTc HMPAO or similar compound retained in the brain in proportion to regional cerebral blood flow.  Localizes predominately in the gray matter and does not show redistribution.  Enhances detection of : Brain dementia such as Alzheimers disease, seizure localization Foci, Cerebral vascular problems such as cerebral ischemia, trauma and brain death Intravenous injection of 800 MBq min later Nuclear Medicine 99mTc HMPAO. Tomography 30 Part 0. Introduction to Nuclear Medicine 34 CEREBRAL BLOODFLOW normal Alzheimers disease Nuclear Medicine Part 0. Introduction to Nuclear Medicine 35 KIDNEY FUNCTION • Determination of kidney clearance of Cr51-EDTA or Tc-99m DTPA. • Dynamic renal scintigraphy reflects renal blood perfusion, uptake and excretion. The acquisition yields a series of images. By calculating count rate in a defined ROI, a renogram is created, providing quantitative data. Different radiopharmaceuticals, such as Tc99m-MAG3, Tc99m-DTPA and I123Hippuran, are used for renal clearance and function assessment. • Renal scan for parenchymal anatomy and function evaluation uses Tc99m-DMSA Nuclear Medicine Part 0. Introduction to Nuclear Medicine 36 KIDNEY FUNCTION (Tc99m-DTPA) It is ideal to mark the background region in such a manner as to exclude the arteries and calycial region. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 37 KIDNEY FUNCTION (Tc99m-DMSA) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 38 FIRST PASS STUDIES • Intravenous high activity (400-800 MBq) Tc-99m bolus tracer injection, followed by a short acquisition (4-20 frames per second during 1 minute) demonstrates Myocardial function eliminating background activity bias. • First pass procedures facilitates: • • • • • • Wall motion imaging LV and RV ejection fraction calculations Detection of left to right intracardial shunts Cardiac output calculations Ventricle volume calculations Transit times calculations Nuclear Medicine Part 0. Introduction to Nuclear Medicine 39 SHUNT QUANTIFICATION Nuclear Medicine Part 0. Introduction to Nuclear Medicine 40 ECG-GATED BLOODPOOL SCANNING • Red blood cell labeling (Tc99m), followed by gated acquisition and measurement of the corresponding dynamic blood volume count rate changes, enables LV and RV blood volume quantification. The analysis of ventricular wall motion, systolic/diastolic functions, and Ejection Fraction, has application for CAD evaluation, risk stratification, and monitoring of cardiotoxicity in chemotherapy treatments. Intravenous injection of 600-800 MBq Tc99m , scanning 10-15 min later. • Nuclear Medicine Part 0. Introduction to Nuclear Medicine 41 ECG-GATED BLOODPOOL SCANNING Nuclear Medicine Part 0. Introduction to Nuclear Medicine 42 MYOCARDIAL PERFUSION • • 201Tl • • accumulation in the myocard depends on blood flow and cellular metabolism, hence, reflects regional perfusion and viability of the cardiac muscle. The evaluation of a patient suspected or known for C.A.D. is based on image interpretation or quantitative analysis from reconstructed tomographic slices, which also yields regional perfusion information. The examination is performed under maximum stress condition and after rest. Injected activity 70-100 MBq 201Tl. Tomographic study. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 43 MYOCARDIAL PERFUSION Stress Rest Nuclear Medicine Part 0. Introduction to Nuclear Medicine 44 TOMOGRAPHIC SLICES coronal sagittal transversal Nuclear Medicine Part 0. Introduction to Nuclear Medicine 45 MYOCARDIAL PERFUSION Nuclear Medicine Part 0. Introduction to Nuclear Medicine 46 MYOCARDIAL PERFUSION • The physical properties offered by 99mTc MIBI or Tetrofosmin facilitate evaluation of myocardial perfusion and function by enabling performance of gated SPECT perfusion studies initiated with first pass acquisition. The assessment of a patient with known or suspected C.A.D. is based on quantitative analysis and coronary artery regional perfusion evaluation, drawn from a set of reconstructed tomographic slices. • Injected activity 800-1000 MBq. Gated tomographic acquisition Nuclear Medicine Part 0. Introduction to Nuclear Medicine 47 ECG-GATED MYOCARDIAL PERFUSION Nuclear Medicine Part 0. Introduction to Nuclear Medicine 48 GATED SPECT Nuclear Medicine Part 0. Introduction to Nuclear Medicine 49 PET Positron Emission Tomography Nuclear Medicine Part 0. Introduction to Nuclear Medicine 50 ANNIHILATION 511 keV positron + + 511 keV Nuclear Medicine Part 0. Introduction to Nuclear Medicine 51 RADIONUCLIDES Radionuclide Halflife Particle energy (mean) 0.39 MeV 0.50 MeV 0.72 MeV 0.25 MeV 1.3 MeV 0.83 MeV 1.5 MeV 52 C-11 N-13 O-15 F-18 Cu-62 Ga-68 Rb-82 Nuclear Medicine 20.4 min 10 min 2.2 min 110 min 9.2 min 68.3 min 1.25 min Part 0. Introduction to Nuclear Medicine PIONEERS Michel Ter-Pogossian prepares a radiopharmaceutical for an examination of Henry Wagner Jr with one of the first PETscanners (1975). Nuclear Medicine Part 0. Introduction to Nuclear Medicine 53 PET-SCANNER Nuclear Medicine Part 0. Introduction to Nuclear Medicine 54 PET WITH GAMMA CAMERA Nuclear Medicine Part 0. Introduction to Nuclear Medicine 55 CYCLOTRON Stanley Livingstone and Ernest Lawrence with their 8 MeV cyclotron (1935) Nuclear Medicine Part 0. Introduction to Nuclear Medicine 56 CYCLOTRONS IN HOSPITALS Nuclear Medicine Part 0. Introduction to Nuclear Medicine 57 F18-FDG Nuclear Medicine Part 0. Introduction to Nuclear Medicine 58 FDG IN CARDIOLOGY Nuclear Medicine Part 0. Introduction to Nuclear Medicine 59 FDG IN ONCOLOGY Nuclear Medicine Part 0. Introduction to Nuclear Medicine 60 FDG IN NEUROLOGY Alzheimers disease Normal Nuclear Medicine Part 0. Introduction to Nuclear Medicine 61 THE FUTURE Diagnostic methods •New radiopharmaceuticals based on positron emitters. •Radiopharmaceuticals with high specificity. •More advanced application programs which improve both sensitivity and specificity of the examination. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 62 MULTIMODALITY IMAGING PET CT Nuclear Medicine Part 0. Introduction to Nuclear Medicine 63 THE FUTURE Instrumentation • Improved performance of the gamma camera • Improved detection of positron emitters • More sophisticated methods for reconstruction and correction of tomographic examinations • Advanced electronic reporting systems. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 64 NUCLEAR MEDICINE - UNCLEAR MEDICINE? No! Nuclear medicine is an efficient diagnostic and therapeutic tool and is justified from a medical point of view. Nuclear Medicine Part 0. Introduction to Nuclear Medicine 65