Bone Scans - Nuclear Medicine PDF

As stated, we're going to talk about skull imaging pertaining to nuclear medicine, bone scans in particular. 1:29 And we're going to go through some learning objectives. To get us started and then we'll go ahead and get into the meat of the presentation. 1:35 The first learning objective is to expla...

As stated, we're going to talk about skull imaging pertaining to nuclear medicine, bone scans in particular. 1:29 And we're going to go through some learning objectives. To get us started and then we'll go ahead and get into the meat of the presentation. 1:35 The first learning objective is to explain bomb characteristics and how these relate to perfusion bone imaging. 1:42 Next is differentiate between the different types of bone scans and their functions. 1:48 List the two common types of bone radiopharmaceuticals in their use and bone imaging as they fascinates. 1:53 Differentiate between the procedures involved in a total or whole body bone scan. 1:59 Limited bone, three phase bone and a bone scan. 2:05 Differentiate between a normal bone scan. A scan with mets. 2:09 Scan with a fracture or scan with an infection and explain the various technical parameters associated with each type of bone scan procedure. 2:13 So first things first, a little bit of background information regarding the bone sends them bone cells themselves. 2:23 There's three main types of bone cells. We have our osteoblasts, our osteoblasts and our astrocytes. 2:31 Of the three of those, the most important for what we're going to be discussing today is our osteoblasts, 2:38 because these are the the newly formed bone scans. 2:45 By definition, glass means it's a germ or a bud. It's an immature cell or tissue that later develops into a specialized cell or form. 2:50 When we get into the actual radiopharmaceutical and discuss how this works and how it targets the bone cells themselves, 2:59 that should make a little bit more sense because essentially what's happening is the radiopharmaceuticals designed to target areas of, 3:07 I guess you could say, cellular repair and rapid growth. 3:15 So it's really going to it's really going to try to highlight and target those osteoblasts. 3:19 Then you've got your osteoblasts, which are the cells that are involved in bone removal and then the osteo sites, 3:25 which are, I guess you could say, the more mature osteoblasts. 3:33 That's not so. By stating that the osteoblasts themselves are the most important doesn't necessarily 3:38 imply that the osteo class or osteo sites are are not important for what we're doing, 3:44 because that's not necessarily the case. But the osteoblasts are definitely the ones that play the primary role. 3:49 So just some general factors affecting bone development, growth and repair. 3:59 Is nutrition, exposure to sunlight, hormonal secretions and physical exercise. 4:03 We'll discuss a little bit of this. 4:10 I mean, it should make sense that, you know, we'll get into some of the discussion pertaining to the scans that we're performing. 4:12 You know, in health care, we always we always, you know, 4:19 we're trying to obtain a patient history to correlate why they're there and with the exam that they're actually having done. 4:22 So, you know, when we talk about nutrition, physical exercise, and I guess you could say general overall health, 4:29 it certainly makes sense that, you know, we're not going to be scanning patients that are otherwise, quote unquote, healthy. 4:35 Right. They're there for a reason. 4:41 Patients don't come to the doctor's office in the hospital because, you know, they're you know, they're looking for something different to do. 4:43 They're obviously going there because they're not well and they're trying to get better and get diagnosed or get treated and whatnot. 4:51 So, you know, certainly when when we do our scans, 4:57 we're going to be working with with patients who have some type of medical underlying medical condition or recent injury, 5:02 perhaps, that is impacting the overall health of their skeletal system. 5:09 Couple of characteristics pertaining to the bones. Something that that that I think many people outside of the medical profession 5:19 really don't understand is that the the bones themselves are not necessarily solid. 5:27 They're actually a very, very vascular type structure. 5:32 And as such, you know, they they are going to be very good at absorbing the radionuclide that we're that we are injecting. 5:37 There's there's two primary radionuclides that we use in in bone scan imaging, and they're both by phosphates and in nuclear medicine. 5:51 Just a little bit background, general background for the non-nuclear medicine techs who might be listening today. 6:00 Most of the time what we do is we administer the radiopharmaceutical into the bloodstream and then of course, 6:06 the blood flows to a particular area of the body. 6:13 And depending on whatever drug we happen to administer, it's going to target a specific organ of the body or organ system. 6:16 And the reason it does that is because of the makeup of the pharmaceutical itself and how it's chemically, 6:25 chemically similar to the chemical makeup of the organs in your body. 6:31 But the way that it gets there is through the blood. 6:38 So there has to be some basic clarity involved, Right? 6:41 That is the transportation mechanism getting into the blood. 6:46 And then the blood flows to the various areas of the body. 6:49 So obviously, it makes sense that in order for the bone agents to reach the bone, there has to be a level of vasculature there. 6:52 But, you know, I just I just kind of want to point that out. They're actually very, very vascular systems. 7:03 You know, red blood cells are produced and so on through the bone marrow. 7:09 And the bone is a very, very vascular organ. 7:13 No bones fell is. No bone cell is less than one millimeter from a capillary. 7:19 And so, again, think about that. You know, you capillaries are a vital vessel, if you will, within within the larger vascular system. 7:28 So to think that no bone scan is going to be less than one zero I'm sorry, 7:38 0.1 millimeters away from a capillary really kind of goes to illustrate how vascular they really are. 7:42 Bones are also made up of a salt material that is a hydroxy appetite Crystal. 7:51 We're going to talk about that here just a little bit, a little bit more as we go through this. 7:58 So now hydroxy appetite Crystal is an organic constituent of bone matrix and teeth, and it forms a lattice structure like a building. 8:04 So if you take a look at that illustration right there, you can see the first two slides are, you know, this crystal like formation. 8:12 And if you look at the the third illustration all the way on to the to the right side of your screen, that is this this lattice structure. 8:22 So you can see it's a very complex system of this crystal make up the crisscrosses and, 8:29 you know, kind of tends to support itself in a variety of angles. 8:39 You know, you kind of think of it much like a you know, a building, you know, has to be designed, 8:43 engineered in a way to provide, you know, strength to support all of its weight and structure itself. 8:50 And if you just had a couple of steel bars that were standing straight up, you know, it wouldn't have a great deal of stability. 8:58 So there has to be bars that kind of, you know, horizontally cross and connect through the vertically oriented structures. 9:05 And then, you know, there's some that are positioned at various angles that are connecting, you know, pieces from above to pieces below. 9:13 And it kind of what it does through that, 9:21 through that design is it tends to provide stability by distributing the overall strength and integrity and and to to its foundation. 9:24 So as such, you know, the bone is is from the cellular standpoint designed in a very, very similar manner to give it its strength and integrity. 9:38 So I mentioned that that it's you know, it's it's a crystal hydroxy apatite crystal. 9:49 And the radiopharmaceutical what it does is it actually localizes within within this hydroxy appetite crystal. 9:56 And as the cell begins to, I guess you could say, reproduce, then it really is going to target that new bone growth in nuclear medicine. 10:04 When we do these bone scans, 10:17 it's important to understand that the bone actually has to start to begin to to heal itself before any real imaging can take place. 10:18 And that actually happens very, very rapidly. 10:30 We'll make some comparisons to how beneficial it is to have a bone scan compared to a to an X-ray, at least in terms of the timeliness, 10:34 because it does allow a lot earlier imaging capability because of this, you know, 10:42 production of new bone growth during during the healing process that's occurring. 10:50 And that's really what we're that's really what we're looking for. 10:58 Whereas with a with a standard X-ray, oftentimes, you know, it it's looking at the point at which the bone is, you know, mostly healed. 11:02 So here we can see any type of abnormalities at a much earlier stage and get an earlier diagnosis. 11:14 Definitely one of the advantages. 11:19 So school functions, of course, include supporting the the the body and the various organs and the individual's whole, 11:23 of course, protecting the vital organs, movements, blood formation, as I mentioned before, bones being very vascular. 11:31 You know, they're they're constantly producing, producing blood and then, of course, mineral storage. 11:40 And, you know, 11:48 we see this a lot of times with with the elderly as as the bones begin to break down and they start to lose their various various mineral, 11:49 it leads to osteoporosis and various conditions associated with bone fragility. 11:57 And, you know, that starts to become much more noticeable at patients of varying of of later ages. 12:05 Excuse me. So some imaging concepts include detecting our subtle lesions at the earliest possible time. 12:13 Staging of skeletal disease, evaluating metabolic activity of skeletal disease. 12:24 We really don't have any role in diagnosing congenital bone diseases. 12:31 That's that's, you know, one of the, I guess you could say, disadvantages. 12:37 What I mean by congenital bone diseases are the types of bone diseases that are that a patient is typically born with. 12:42 You might think of osteogenesis imperfecta, for example, the brittle bone disease. 12:51 That's not something that we are going to diagnose. 12:59 Certainly that's something that that perhaps X-ray or other diagnostic imaging modalities might be able to diagnose. 13:02 But again, what we're looking for are, you know, what was, I guess you could say normal, healthy bone tissue that had at one point become compromised. 13:10 And now through that compromise in the tissue, it is it is attempting to heal itself. 13:21 So we're looking at more acquired bone diseases as opposed to the congenital ones. 13:28 30 to 50% of the bone must be calcified before tumors or infection can be detected with X-rays compared to a bone scan, 13:36 only about 1 to 2% of declassification is required in order to yield an abnormal bone scan. 13:45 So, I mean, that is a that is a major difference in, you know, the overall condition of the bone that has to be compromised, 13:53 30 to 50% in for X-ray to see it versus only 1 to 2% for nuclear medicine to see it. 14:03 So that is definitely an advantage that that nuclear mat has in when it comes to the acquired bone diseases so much, much earlier. 14:11 Which, of course, can benefit the patient, too. If we can get an earlier diagnosis as far as prepping the patient for an exam. 14:22 They need to be well hydrated. We're going to talk about this in just a little bit. 14:33 The importance of of patient hydration. 14:38 Essentially what we do is we eat, we tell the patient we need you to push extra fluids. 14:43 And it's not necessarily because we're working with radioactivity. 14:47 And you know that there's some underlying fear that the radioactivity is going to cause harm to the patient. 14:53 Of course, you know, we do have to abide by a layer of concepts and minimize the dose as much as possible. 15:00 So. But but that's not necessarily why we tell the patient this. 15:09 With our with the isotopes that we work with, again, understand that it's going to be transported to the bone through the bloodstream. 15:14 And it takes time for the for this isotope to settle in the bones. 15:26 It will discuss it on average takes about 2 to 4 hours. 15:33 Three is usually the average amount of time between the point of injection and the imaging time period. 15:38 You know, and then, you know, it could be up to 5 hours, but. 15:45 As it's circulating. I guess you could say the patient really needs to be drinking extra fluids because there's 15:51 going to be a certain portion of the isotope that does not completely settle in the bone. 15:57 So it stays in the vascular system, it stays in the bloodstream circulating throughout the body. 16:03 And that can show up as as background information, so to speak. 16:09 It can show up almost as a shadow like visualization on the scan, 16:14 where we have a very high concentration of the bone or a high concentration of the isotope in the bone. 16:20 And then we have to a lesser degree, kind of a shadow like effect of the soft tissue surrounding the bone. 16:27 And depending on what type of bone uptake we get relative to the concentration of soft tissue uptake. 16:35 It can significantly deteriorate the overall quality of our images. 16:47 So this is my lengthy, detailed, possibly overly detailed explanation as to why the patient needs to push fluids, 16:51 because the more fluids they drink, the more of that background uptake is going to be cleared out of the soft tissue. 17:01 Once it's in the bone, it kind of stays locked in there for a period of time because of its as its, 17:09 you know, uptake within the hydroxy appetite crystal structure. 17:16 But that soft tissue uptake will rapidly be cleared out. 17:21 So then there bladder fills up with urine and then we tell them to go empty their bladder and it leaves behind some really nice, 17:25 crisp and clear images of the skeletal structure without all of that background, soft tissue interference. 17:32 And you'll see how what that looks like once we get to the visual illustrations of all of this. 17:42 So, you know, it says here about 32 ounces that that's not necessarily, you know, a minimum. 17:49 You know, what I usually like to do is I just I ask the patient how much how much liquid do you typically drink, 17:57 you know, on a day to day basis and then tell him, 18:03 you know, you might need to double up on your fluid intake or, you know, drink about three or four extra glasses during this circulation phase. 18:08 So we'll get to that here in just a second. 18:15 The Radiopharmaceutical, there's two primary radiopharmaceuticals that we use, both of which are a type of diphosphate. 18:19 These dye phosphates localized in the hydroxy appetite by absorption and ion exchange within the within the matrix, 18:29 reflecting local osteoblasts, tick activity and cellular I'm sorry, skeletal vascular parity. 18:38 So there we are again with our with our osteoblasts. 18:45 We are focusing on those those newly formed bone cells that are trying to repair and replace the the compromised. 18:48 The two types specifically that we work with are in our called HTP, which stands for hydroxy diphosphate. 19:01 And then there's MDP, which is methylene diphosphate. 19:12 You know, it's really kind of six of one half dozen of the other. 19:17 There's advantages, and I don't want to say really disadvantages, you know, because the disadvantages are pretty minimal. 19:20 But, you know, different hospitals are going to have different preferences based off of their protocol, 19:28 which they prefer to use, the FDP versus the MDP. 19:32 So really one is one is nearly as is good as the other. 19:37 And it's they're they're both very commonly used. 19:42 Both the MDP and the HDP are tagged with Tech Museum 99 M again, the nuc med techs will understand how this process works, 19:48 but, you know, just a brief explanation for the non-nuclear people who might be listening. 19:58 Radiopharmaceuticals in nearly all cases are are made up of two components. 20:03 We have the radionuclide itself, the radioactive isotope, which, you know, is either naturally occurring or, 20:13 you know, it comes from a generator or cyclotron or, you know, it's radioactive. 20:21 And then the other component is a pharmaceutical, just a regular, normal pharmaceutical, just like any other drug that you would get at the drugstore. 20:29 And what we do is we combine and this is what we refer to as tagging. 20:41 We tag or combine the radionuclide, the radioactive isotope with the non radioactive drug to create a radioactive drug or a radiopharmaceutical. 20:47 And we can do this with a number of different isotopes. 21:01 But the primary isotope that we work with in nuclear medicine is technically AM 99 M and we do this we use Technium for. 21:04 I don't. Don't quote me on this, but I would say probably around 90% of our diagnostic studies, it's very, very prevalent. 21:17 It's it's inexpensive. It's easy to manufacture. 21:27 A couple of the advantages of it is, one, it's a gamma emitter. 21:32 And as a gamma emitter, it's it's pretty energetic and it has the ability to travel great distances without losing its energy. 21:37 So from a diagnostic perspective, that's very important to us because these are going to be injected into the patient's bloodstream. 21:48 So of course, the patient is the radioactive source and as such the radioactivity resides in the patient 21:54 and has to actually penetrate through the patient's body and do so in a manner that 22:01 is is is capable of penetrating through the various body tissues and still travel the 22:08 remaining distance between the patient and the detector and reach our imaging detector. 22:14 And so a gamma is very effective at being able to do that. 22:21 The other advantage of working with a gamma is, say, 22:26 opposed to a beta or an alpha particle is that the gamma is are not nearly as ionizing as beta's or alphas. 22:28 So one they they travel large distances so they can penetrate through the patient's body to reach the detector for imaging purposes. 22:40 And to as they're in the body, they're not going to ionize the body tissue nearly to the degree that a beta or a gamma would. 22:46 So it's not nearly as damaging to the tissue itself. 22:54 And that's that's essentially why we use TAC as the primary radionuclide within our radiopharmaceuticals. 22:59 Of course, it's the MVP or the FDP, 23:05 the diphosphate phosphates that we talked about before that are going to attach themselves to the hydroxy appetite. 23:07 So if the is a drug, essentially if if the drug, 23:13 the pharmaceutical is bound or tagged to the radionuclide and then it's in administered into the patient's body, 23:18 the blood is going to carry it to whatever organ it needs to go based off of chemical structure of the pharmaceutical. 23:25 And then, of course, the radioactivity basically makes the patient glow from the inside out. 23:32 That's how that works. A critical organ in our bone imaging is our bladder wall. 23:38 That's because as this breaks down, it's the isotope is going to be filtered out of the body by the kidneys and then ultimately into the bladder. 23:44 And then they they empty their bladder. 23:55 And but as as that is as that is breaking down and leaving the body there, they're getting a lot of exposure to the bladder wall. 23:58 We need to inject our patient away from the region of interest. 24:07 And the reason for this is, you know, we it's not like we're going to if if, say, the patient has, you know, an injury to the lower leg. 24:11 Right. We're not going to inject it into the bone of the lower leg. 24:22 You know, we injected in the bloodstream and we look to see to what degree is blood flowing to promote healing to that area of the skeletal system. 24:25 And how are those cells reproducing, thereby taking up more of the radioactive isotope? 24:35 And we're looking at comparing and contrasting the amount of uptake within various areas of the skeletal system. 24:40 So typically, a area of concern most of the time is what we consider to be a hotspot. 24:47 And this is in an additional collection of radioactivity within within a certain area of the body. 24:55 We also have what are called cold spots, and these are deficiencies of radioactive uptake, and that could be problematic in certain situations. 25:02 But most of the time, what we're looking for of these hot spots, 25:10 we inject away from the region of interest because, you know, we don't want any infiltration, 25:14 we don't want an overabundance of isotope collection within the area that we're concerned about, you know, kind of hanging out underneath the skin. 25:18 You know what I mean? If we infiltrate, if we if we don't get the dose in the bloodstream, 25:28 then it's just going to hang out in the soft tissue underneath the skin and be taken up by the lymph system. 25:33 And if we're trying to image, say, the lower leg and that happens to be the area that we injected, it's going to show up very, very hot. 25:40 But then we don't know, is it hot because of infiltration or is it hot because of the patient's condition? 25:49 And so, you know, we try to inject in an area that's not necessarily in direct proximity to our area of concern. 25:56 So I mentioned that the skull, the system is very vascular. 26:08 It's targeting newborn bone formation through the osteoblasts activity. 26:12 There's going to be an increase in uptake with bone damage and repair, most commonly in Metz. 26:18 We're talking, you know, metastatic cancer. Bone cancer is not typically the primary cancer. 26:23 The vast majority of the time it is secondary. Certainly, that's not to say that the patient should never have metastatic bone marrow. 26:31 I'm sorry, bone cancer, that's primary. It's just not common. 26:40 So oftentimes the patient has, you know, prostate cancer or breast cancer or lung cancer or something like that. 26:45 That's the primary. 26:53 And then it metastasizes to the bones and you'll see that that those bone nets are going to are really going to light up for us on our images. 26:54 They're very, very noticeable. There's there can be decreased areas of uptake with impaired or no blood flow if there's some type of bone infarct, 27:04 if there is complete destruction or avascular necrosis or if there's abscesses. 27:17 So that's where we're most likely to see are areas of decreased uptake or those cold spots, if you will, in some infiltration may occur. 27:22 And it's not unusual to see the injection site. 27:32 Again, you know, we're sticking a needle in the patient's arm accessing a vein. 27:35 And if the if if the access site isn't if the isotope doesn't make it 100% into the vein and there's a little bit of infiltration at that point, 27:40 we will see a hotspot in their arm or on their hand. And, you know, it's just important to note that that's the area of injection. 27:51 Hopefully, though, the most of most of the isotope hopefully got itself into circulation, otherwise we won't get a good scan. 27:59 So our next topic of discussion is technical parameters. 28:09 I'm not going to spend a whole lot of time on this other than, you know, noting that we have a couple different types of detector sizes. 28:13 Our smaller detectors are small field of view in our larger detectors, in a large field of view. 28:21 In most cases, the large field view our stationary cameras where our small field of view are more our mobile cameras that can be taken to, let's say, 28:27 the ICU or an area of the hospital or where the patient happens to be if the 28:38 patient's not stable enough to come down to the nuclear medicine department. 28:44 And this slide also is saying that, you know, with certain cameras, 28:49 be it small field of view or large field of view, we have a number of different column that we may be working with. 28:53 And in those kilometers can be taken off of the machine and replaced with other column meters. 29:01 So, for example, if we're working with a small field of view camera, what that's saying is because the field of view is very. 29:06 Limited. We may not be able to actually see the entire area of the body that we're hoping to see. 29:13 So we may have to make multiple passes over, you know, various areas of the body in order to see everything. 29:20 And, you know, with that, we'll use a low energy, high resolution or a general purpose column meter. 29:28 And, you know, like I said, different kilometers for different purposes. 29:35 In the last bullet point there is, you know, 29:40 we also have what's called a pinhole kilometer that can be put on the detector to increase the overall magnification. 29:42 If we're if we're trying to focus in on a very targeted, specific area and trying to magnify it to see it more clearly. 29:48 So, you know, that's just lots of kilometers for lots of different purposes. 29:58 Now, before we actually get to doing the scan, a couple of things that the patient needs to do for us. 30:06 First and foremost, you know, if we've already injected him and during that, you know, 2 to 4 hour circulation phase, we've told them to push fluids. 30:14 Their bladder is going to start to fill up. So we do need to tell them, 30:23 empty your bladder frequently and especially one last time before we bring them into our imaging room and lay him down on the table. 30:27 We want them to have an empty bladder, particularly if we're imaging the pelvis or doing a whole body slash total body bone scan. 30:35 Certainly if we're, you know, 30:44 if we're just imaging the hands or the feet and the bladder is not going to be in our field of view or in our region of interest, 30:45 then we really don't need to worry about it other than patient comfort considerations. 30:53 So if nothing else, you know, just just tell the patient I need you to empty your bladder. 30:59 It usually works out best that way. 31:03 If the patient has prostate cancer, the patient may need to be capitalized because even if we tell them to empty their bladder, 31:06 you'll notice that that they they rarely ever squeeze all of the urine out. 31:15 There's always going to be a little bit of bladder uptake which can mask out different areas of the pelvis that we may need. 31:22 We may be concerned about for imaging purposes. So if we're concerned about them having mats to the pelvis, 31:30 we may simply ask to have the patient catheter ized to completely drain the bladder 31:37 in order to see the the pelvis and its it's clear state clothes are not a problem. 31:43 The patient does not need to disrobe. Certainly, inpatients are probably going to be in a hospital gown. 31:51 But, you know, we do deal with a lot of outpatients. They do not have to take their clothes off. 31:56 The photons that we're working with are energetic enough. 32:01 They're not only going to pass through the body tissue, but they're also going to pass through the clothes that the patient's wearing. 32:04 That being said, if the patient is wearing a belt, that's, you know, we usually want them to take that off because of the belt buckle. 32:10 If they're wearing steel toed boots, if they have keys, a pocket knife, loose change, stuff like that, 32:18 that's in their pockets, we ask them to empty any type of objects out of their pockets, particularly those that are metal, 32:26 because the metal is going to serve as an attenuate or if the patient is wearing a large, you know, 32:32 pendant of sorts on a necklace, you know, that could be an attenuate or we want that out of there. 32:40 Those things are carry. You know what you need to consider. Try to make the patient as comfortable as possible, because the more comfortable they are, 32:47 the less likely they are going to move and the less likely they move, 32:56 the better the pictures come out there, the pictures come out, the better the diagnosis. 33:00 So we want to make them comfortable for that reason as well. 33:04 As you know, it's just the right thing to do. Our scans take many times 20 to 30 minutes. 33:07 So it's you know, it's it's it's lengthy and it'll vary depending on what areas of the body we're imaging. 33:14 But it's not uncommon at all for the patient to be laying on a relatively not relatively a very thin and very thin table with limited padding. 33:22 And oftentimes the patients are much larger than the width of the table, and it leads to pain, you know, discomfort in their back and nakedness. 33:37 And, you know, they want to wiggle around and a good mini cushion, give them a blanket, 33:45 give them all these things that are going to make them more comfortable. So they hold still. 33:49 You'll notice the patients oftentimes are going to kind of wiggle their feet back and forth because, 33:53 you know, they just kind of do this subconsciously. 33:59 And if especially if we're imaging the lower legs and the feet, we need that area of the body help still. 34:02 So what we can do is we can just put some tape around their feet or some type of a foot band. 34:08 They can leave their socks on. 34:14 You know, if we are focusing on the feet, we probably are going to want them to have them take their shoes off, but they can leave their socks on. 34:17 You just get some tape and wrap a couple of layers of tape around their feet or some type of of a band. 34:23 You can take a tourniquet and make a make a band out of a tourniquet. 34:28 It very easily. And it just kind of helps to support and stabilize their feet. 34:31 So now finally getting to the Good stuff. 34:36 We're going to talk about show you some images of different types of bone scans and why we do the different types. 34:39 Now, I did mention an injection that's going to be given to the patient. 34:47 We're going to give them usually ballpark, 15 to 20 militaries of Tech Museum, 34:52 99 M, MDP or HDP, depending upon the radiopharmaceutical that your hospital uses. 34:57 We inject them into a vein and we tell the patient, Hey, you can go home for the next 3 to 4 hours. 35:05 You can go elites, right? You send them on their way. It doesn't really matter where they go, what they do. 35:12 The amount of radioactivity in their body is very limited. Oftentimes they go back to work. 35:17 Sometimes they just go home, they go shopping, whatever. 35:22 You know, patients do what they're going to do and you tell them to come back in about 3 to 4 hours. 35:26 We're actually we're not going to leave it vague like that. We're going to say come back at this time. 35:31 But the general protocols, 3 to 4 hours. And we're also going to tell them, of course, to drink some extra fluids. 35:36 And, um, you know, 35:43 that that's going to help reduce the amount of soft tissue uptake that hasn't settled in the bones and drastically improve our overall image quality. 35:46 Again, because the patient is drinking extra fluids, their bladders going to fill up and we are going to tell them to empty their bladder frequently. 35:58 One thing worth noting there, you know, you might be thinking, holy cow. 36:08 If if this radioactivity is being removed from their body, do we really want them using the bathroom and, 36:14 you know, urinating radioactivity and putting that into the public sewers? 36:22 Well, one of the things that to make note of is that the NRC, the Nuclear Regulatory Commission, 36:30 considers human waste exempt from any type of storage or decay. 36:37 So most of what we administer to the patient is going to be excreted through the urine. 36:43 And it would be really more of a health hazard to have the patient collect their urine and to store their urine or to 36:49 transport their urine back to the nuclear medicine department to be stored and decayed for the isotope to break down. 36:59 That's just not that's not healthy. It's not safe. It's not practical. 37:07 So for those reasons, human waste is considered exempt. 37:11 And remember, we're working with very minuscule amounts of radioactivity that, you know, 37:14 in many cases is in line with most of your typical X-rays in terms of overall exposure. 37:20 So it's it's fairly minimal. 37:28 And the one of the advantages to in working with techniques M isotope or techniques in radiopharmaceuticals, 37:31 rather, is that technology has a six hour half life. So every 6 hours the amount of activity that's presence being broken down. 37:38 And remember, there's going to be when this is administered to the patient, 37:46 the majority of the isotope is going to be is going to stay in the body and collect in the organ, 37:50 and then only a portion is going to be urinated out and the patients are already coming back two or 3 hours later. 37:55 So we're nearly halfway through the first half life. And it's breaking down, breaking down, breaking down. 38:01 So it's really not anything to be overly concerned about, you know, as far as that goes. 38:06 Otherwise, the NRC would not make that stipulation. 38:13 So again, they're emptying their bladder right before being scanned. 38:17 And the reason why is because of that bladder uptake. 38:21 If you'll see here what a full bladder looks like. I believe I have that on my next slide. 38:26 And, you know, it's almost like staring directly into the sun. 38:31 It's going to be so bright, so intense that you're not going to be able to see anything, anything around it. 38:36 You know, it kind of blasts out everything else. 38:45 So, you know, using that illustration, if you've ever stared at the sun, it really obstructs your ability to see. 38:48 And you've got this kind of break glow shining in your eyes afterwards. 38:53 So it's very much going to be like that. 38:59 It really just kind of takes over that hot bladder and does not allow you to see anything, you know, around the area. 39:02 So they empty that bladder out. There's significantly less radioactivity within that bladder wall, 39:11 and it allows us to see the pelvis much more clearly Once we lay them down on our table, we're going to do a scan that takes about 20 to 30 minutes. 39:18 Again, that's just kind of an average time frame. 39:26 If you're just doing a couple of spot images of a particular area of the body, they might only be there 10 minutes. 39:30 If you're doing a total body bone scan that requires additional spots afterwards, 39:36 you know, they very well could be there upwards of 45 minutes or longer. 39:41 So it really does kind of depend on average time. Again, those about 20 to 30 minutes. 39:45 So here's what I was talking about regarding a patient having a full bladder. 39:50 The illustration on the left, you can see that big hot spot right in the center of the pelvis. 39:55 That's the patient's bladder. And if I'm being 100% honest, this is only a partially full bladder. 40:00 I've seen bladders that are a heck of a lot worse than this. You can kind of see. 40:06 Let me get my pointer here. You can see, you know, even there's there's kind of empty area of the bladder, you know, even up here. 40:11 So this is only partially full. If that bladder were really full, then, you know, all of this would be incredibly intense and it would be very, 40:20 very difficult to see if there were hot spots anywhere within the skull structure of the pelvis. 40:30 So what we do is we tell them to empty their bladder and it goes from something like this to something like this. 40:35 And you can see a much smaller amount of urine in the bladder there. 40:42 And all we would have to do is bring up the intensity level on our computer screen, 40:47 you know, in order to see the uptake in the bone a little bit more clearly. 40:55 This is, you know, the intensity on this image is turned down just a little bit. 40:59 But, you know, this looks like pretty typical skeletal uptake without any major without any major concerns. 41:04 This is the interior image and this is the posterior. I'm sorry. 41:10 I put my. This is the answer. Your image. And this is the posterior and pointed there with my with my mouse. 41:16 Without realizing you, you couldn't see it without the green pointer being on there. 41:23 So. Okay. 41:27 Total body or whole body imaging. It's interchangeable terminology there. 41:32 NUC med techs use both of the terms and it really is applying the same thing. 41:36 In this case, what we do and this is getting into the different protocols. 41:41 We're going to talk briefly about total whole body imaging, limited bones, three phase bones and SPECT. 41:44 So the first is our total body. We inject the radiopharmaceutical. 41:52 We scan the patient 2 to 3 hours post dose, 5 hours maximum. 41:56 After 5 hours, this starts to kind of break down in the patient's body and we start seeing less activity within the skeletal system. 42:01 Not to mention we're really close to that first half life where, you know, it's naturally just decaying, decaying, decaying. 42:11 So we really want to try to target that. 3 hours really is ideal. 42:18 That time frame there, we lay the patient supine on the table, give them a pillow cushion, 42:24 give them some arm supports on the side of the table, put a binder around their feet. 42:31 You know, that's stuff that we've already discussed. 42:37 Try to make them comfortable, offer more blankets, make them comfortable as possible, and try and minimize patient motion. 42:39 We position the camera as close to the patients as possible. Resolution is going to be best at the face of the detector. 42:46 So we try to get that camera, you know, 42:53 just an inch or so away from the patients and then just kind of move it at the appropriate distance along the contour of the patient's body. 42:56 You will see a little bit of increased activity within the scapula and rib, you know, section that they connect. 43:05 I'll show you that here in just a bit. 43:14 And then, you know, there's certainly specific areas of the body where there's naturally going to be a little bit of increased uptake, 43:16 and that's one of them. And you'll see what's normal uptake throughout what's what's normal expected distribution versus what's abnormal. 43:23 And then if we do see anything abnormal, 43:32 we can always do some spot images afterwards in our cameras around to a lateral view, do some oblique imaging. 43:35 You know, the standard total body acquisition is going to be one detector head anteriorly, one detector head posteriorly. 43:43 So we're getting anterior posterior simultaneously. 43:51 And then we have the ability to reposition our detector heads at various angles to get our obliques as well as our laterals. 43:55 One of the advantages, of course, with nuclear medicine over X-ray is we can acquire all the images that we want 44:03 and the patient's not getting any additional radiation exposure because, 44:09 again, the camera doesn't produce radiation. The patient receives the radiation through the injection. 44:13 And at the point of the injection, that's their highest amount of exposure. And it's ticking from there. 44:18 So we can take all the images we want following the point of the injection, and there's no additional exposure. 44:23 So here's our first bone scan image. This is a total body bone scan, and this is considered normal. 44:32 Note the arrow that I have on the screen there that represents a little bit of additional uptake to the distal portion of the maneuver team. 44:39 This is a photo panic uptake. It's referred to as the medallion effect. 44:47 So, you know, here we have, you know, the the clavicle area, you know, connecting itself there to the to the sternum. 44:51 And it just, you know, oftentimes shows up as a little bit of an increased area of uptake. 45:02 Notice there, that's you know, that's really throughout the anterior posterior views. 45:08 That is your pretty standard bone uptake. There's really nothing that standing out as being abnormal. 45:12 This is what we want to see is what we like to see. 45:18 And this is what the patient wants to hear. You know that there's no major areas of concern. 45:21 It's not uncommon to have a little bit. Of increased activity like in the joints, particularly the shoulders. 45:28 You can kind of see that here and here. 45:35 That's just a little bit of arthritis, so the joints can show up a little hot. 45:39 Sometimes we'll also see it in the knees, not so much in this in this acquisition, but that's essentially what that would look like. 45:44 Now, by contrast, we have in bone scan image number two, an elderly male patient complaining of bone pain who has a history of prostate cancer. 45:55 So we know now that the patient's got a history of cancer. And that's one of the indications for performing a bone scan, 46:06 because if the patient has cancer someplace, it can very easily metastasize to the bones. 46:11 And so that's kind of standard protocol. If they have a history of cancer, we're going to do a total body. 46:18 And here you can see those areas of increased uptake throughout the skeleton. 46:24 You can see many of them here in the spine. You can see various areas of uptake in the ribs. 46:30 You can see some in the humerus. Over here, you can see a major, major area of increased uptake here in the. 46:36 This is the posterior view. So this would be left pelvis. 46:46 Right pelvis. This, of course, is bladder uptake. 46:50 You know, there's a little bit of something going on here in the lumbar spine. 46:55 You know, that's something we would probably want to get some spots of. You know, get some obliques and things of that nature going on. 47:01 We would probably oblique the ribs to see, you know, is this it's really hard to tell exactly is this on the spine or is this more on the rib? 47:09 So some oblique, oblique views would help there. We got a little something going up here in the right shoulder. 47:18 You know, that doesn't necessarily match what's going on over here. 47:24 So, you know, potentially this could be arthritis, but it also could be metastatic lesions. 47:28 And if I can jump back to the previous slide, usually if it is arthritis, we usually see some symmetry. 47:33 Usually the left and the right will match. 47:40 So this in the patient with Mets, this would be a little bit more concerning because it's not a direct match. 47:43 So that would be probably a little bit higher probability for Mets. 47:52 Not 100%, but more than likely. But this is definitely met throughout. 47:56 Certainly, you know, we have advanced cases such as the image illustrated here. 48:04 This poor person is in really bad shape. This is not the kind of diagnosis that you're going to want to have. 48:10 I mean, you can see that throughout the skeleton. You can see it throughout the ribs. 48:17 You can see a lot of different uptake going on in the shoulders. Again, that doesn't necessarily match. 48:21 You see it on both sides of the pelvis. You see it in the hips, You see it, you know, going down, you know, the femur. 48:26 You see it in the humerus. You know, you see it in the lower leg. 48:34 This is this is widespread. If if this were my acquisition station and I turned my intensity way down, 48:40 then what that would do is it would allow me to see what's going on in the spine a lot more clearly as well. 48:50 And I would I fully suspect that with a patient who has this much wide spread mets to the skeleton, 48:56 that if I turn my intensity down, we would see Mets like mad throughout here as well. 49:04 But this this poor guy here is in really bad shape. And there's probably not a lot that we can do to help the patients. 49:11 You know, I want to say that definitively. Perhaps some chemotherapy radiation treatment. 49:18 Know who knows? But a lot of times when patients have a condition such as this, as advanced as it is, 49:24 then it's it's going to be palliative treatment just to make them more comfortable. 49:30 80% of patients with no neoplasms and bone pain will have Mets should visualize on their scan. 49:35 30 to 50% of patients with Mets will have no pain. 49:43 So that's one of the reasons doctors really need to be on the ball in diagnosing your patients early. 49:47 And, you know, if if even if the patient's not having any pain, if there's a history of cancer, you know, 49:54 they really should probably have a a bone scan done just to see if it's metastasizing anywhere or if there's 50:01 any inclination of spread to any of the other vital organs via a CT scan or something to that effect. 50:08 Get them in for a bone scan and see if you can get that diagnosis quickly. 50:16 Bone scans are 95% sensitive in detecting Mets, so if the Mets are there, we're very likely going to see it. 50:20 Lesions can be tested, I'm sorry, detected six months earlier than on X-ray. 50:28 And, you know, we've kind of discussed that already is usually having an increased uptake of radiopharmaceutical to the metastatic lesions. 50:34 Again, if you know, that kind of goes back to the 95% sensitivity. 50:43 So if the bone mets are there that you know, that body tissues trying to repair and there's you know cancer is a overproduction of cells. 50:46 Right. So as those cells are being reproduced and growing rapidly, you know particularly the bone sites or the bone cells, 50:54 there's going to be rapid uptake of isotopes to that area. 51:05 So what we want to do is, you know, we definitely want to get that initial baseline study done to see what they look like at at and, 51:09 you know, I guess you could say at zero time or the point of diagnosis and then we want to do regular follow ups afterwards. 51:18 So that's really up to the ordering physician. Are they going to do three month follow ups, six month follow ups, one year follow ups? 51:25 You know, oftentimes, you know, we want to see to what degree were the metastatic lesions treated following therapy, 51:31 see if it made any difference period of time later. So we will get those kind of frequent fliers, so to speak, you know, when doing bone scans. 51:41 Both scandal reform is a super scam and this is a condition where it is metastatic. 51:52 But, you know, with this particular type of cancer, instead of it showing up as multiple hotspots or random hotspots throughout the skeleton, 51:58 there is a rapid increase in uptake of the radiopharmaceutical throughout the entire skeleton. 52:09 And I mean, it is hot, hot, hot. So, you know, compare this illustration of the super scan to. 52:17 You know, our normal hoops are normal bone scan uptake. 52:25 So you see, you know, this is kind of light and crisp and clear, but the bones are certainly visualized versus, 52:30 you know, that super scan where they are, you know, it's blazing like a fire. 52:40 One of the indications, too, about a super scan is that there's going to be very faint to absent kidney uptake because, again, 52:46 there's so much in the bones, the kidneys, you know, there's not much in in background for the kidneys see them filter out. 52:55 And oftentimes this is caused due to Mets or it occurs in Mets, particularly from prostate, breast cancer and hypoparathyroidism. 53:03 Next is limited bone scans. Limited by nature is just the idea of doing an image of a particular area of the body, not necessarily the whole body. 53:17 So, you know, as far as administering the drugs, say, manner, you inject them, 53:26 wait 2 to 3 hours, bring them back, and you're going to take images of the area of concern. 53:32 So, for example, in this illustration on the left, you can see that the patient has a rib fracture. 53:37 Get my pointer here again. Rib fractures are really easy to diagnose because they show up as a linear pattern. 53:46 So a person is not just necessarily going to break one single rib. 53:54 They're going to break a number of ribs and it shows up almost as a straight line from one rib. 53:59 Right down the chain. So if you see this line going straight down like as such, and you can see a bilateral hip fracture, 54:05 I'm sorry, bilateral rib fracture on the right illustration, you know, same same type of presentation there. 54:13 The Blue Arrow I have illustrates the acromion process. 54:22 It's the tip of the scapula overlying the rib. And that is something that, you know, oftentimes will show up as a hotspot. 54:27 And that's not necessarily in the case indicating any type of abnormal condition. 54:36 That's pretty standard uptake for for that situation. 54:41 So, yeah, taking the spot of the ribs and again, we could always do some laterals and we can do some obliques if need be just to get a little bit 54:45 more clarity as far as what rib it is we're looking at or how close to the spine might it be, 54:53 or is there an abnormality in the spine where the rib connects or whatnot? 54:58 Another limited bone scan that's very common are for younger people, particularly our athletes, people who run cross-country track and so forth. 55:05 They oftentimes come to us with shin splints and so we will do a limited view of the lower legs. 55:15 And, you know, this is this is pretty standard to see this. 55:22 So, you know, they're having pain in the lower legs. You know, there's no history of cancer. 55:25 We're not concerned about mats. We're just concerned about an injury to the legs. 55:30 Just that constant impact, repetitive impact that shows up in that manner. 55:33 Here we see a fractured foot, fractured left foot. Note the difference between, you know, the uptake in the right versus the uptake in the left. 55:43 You know, it's certainly much more noticeable. And this is why it's really important when doing limited bone scans. 55:53 We want to get the contralateral view right. 55:59 We want to know if they're having pain on the right side of their body. 56:02 Not only are we going to image that, but we're also going to image the area of the body that is that is not experiencing 56:07 the pain because we want to be able to compare what is normal to what is abnormal. 56:15 So here we do the anterior view of both right and left, showing the left as hot. 56:19 And then we did a spot view, a limited lateral view of that of that left foot. 56:25 Okay. So these are some of the points that I already made. 56:34 You know, diagnosis depends on the location extent and the age of the fracture. 56:38 If if there is an injury, if positive, within 24 hours of injury. 56:44 If. Let me rephrase. If the if the scan shows positive within 24 hours of injury, 56:51 that usually suggests that there is some pathology going on, that it's not necessarily a fracture. 56:58 80% will be positive. 80% of injuries will be positive between 24 to 72 hours and 95% of injuries will show positive after 72 hours. 57:05 Some stress fractures may take 7 to 10 days, depending on the severity. 57:20 And as I said, rib fractures are linear. Kind of getting close to the end here. 57:24 We just a couple more minutes for you. 57:31 Three phase bone scan is is done mainly to differentiate between a condition known as cellulitis versus osteomyelitis. 57:34 And this is infection. Cellulitis is infection in the soft tissue surrounding the bone. 57:42 And osteomyelitis is an infection that may be present in the soft tissue, but has ultimately spread to the bone. 57:47 So we do a three phase bone scan in three phases, hence the name where we are going to inject the patients with our isotope. 57:55 And as we inject, we collect a series of images that usually take about 60 seconds and there's going to be a series of individual frames. 58:04 So for example, if we're doing a 60 minute flow acquiring images, 58:14 then we might get 30 images that are 2 seconds apiece showing the blood flow to the area of concern. 58:21 Usually the lower leg, the feet, possibly the hands, something to that effect. 58:28 Then once that images is finished being acquired, we will then do what's called a blood pool. 58:35 And we're taking a single image of the isotope or maybe a couple of images of the isotope 58:41 that is just kind of circulating there in the area of concern within the soft tissue, 58:48 at which point after we've acquired the flow I'm sorry, after we've acquired the flow and the blood pool, 58:54 we then send the patient on their merry way for, you know, the 2 to 4 hour period and bring them back, at which point, 59:01 hopefully the isotope has settled in the bones and then we're going to take an image of the same area of the body. 59:08 This time, looking at the bones, some docs might want to do what's called a four phase bone scan, 59:15 and that's kind of a generic term that's used where they bring them back, you know, up to 24 hours later to see. 59:20 To what degree does the isotope still remain in the body? You know, some docs say that it's useful. 59:29 Some docs say that it's not really useful. Standard protocol is just to do the three phase. 59:35 You usually get all the information you need within that, within that three phase scan. 59:40 So here's what a three phase would look like. On the left, you can see the flow to the feet. 59:46 And again, as I said, this is that you were imaging at the point of injection. 59:50 So you'll see during the first couple of frames there's not a lot going on because it has to flow in the blood, 59:56 get pumped out of the heart, and then to the extremity and into the soft tissue. 1:00:03 So these are like, you know, two second frame, two second frame, two second frame. 1:00:08 And we're not getting a lot of information. But what we can start to see is as this flows to the lower leg in the feet, 1:00:12 we we do kind of early on start to see a little bit of increased uptake to the potential area of concern. 1:00:20 And immediately when the flow is over, we do what's called the blood pool. 1:00:27 And at that point the majority of the isotope has really begun to concentrate in the area of concern. 1:00:32 And and then we can we can see if there's those hot spots. 1:00:38 So this is going to be the anterior view. This is going to be the right foot. 1:00:42 It's position right into your left. This is going to be left posterior, right. 1:00:49 And then here we have our lateral. So we got the right foot here, the right foot here, right foot here and the right foot here. 1:00:53 And then we send them on their way, bring them back 3 hours later. 1:01:02 And then here we have the the right foot on the anterior view. 1:01:05 And then we get the lateral of the right foot over here. 1:01:09 So with a three phase bone scan, I mentioned that differentiating between cellulitis and osteomyelitis. 1:01:12 In the way that we can differentiate using the three phase is that with cellulitis, 1:01:19 it's going to show up hot on the flow and also on the on the blood pool. 1:01:25 But with. And with cellulitis, I let me. 1:01:32 I think I may have spoken incorrectly with with cellulitis. 1:01:37 It's going to show up hot on the flow in the blood pool with osteomyelitis. 1:01:42 It's also going to show up hot on the delayed images because, again, differentiating between the two. 1:01:47 Cellulitis is a soft tissue infection. Osteomyelitis is the bone infection in addition to the soft tissue. 1:01:53 So it makes sense that the bone images which show up hot on the on the three hour delay. 1:01:59 That is going to need to be treated with with antibiotics. 1:02:07 And the treatment for osteomyelitis is much more extensive than the antibiotic treatment for cellulitis. 1:02:11 Lastly, we have our SPECT images. SPECT stands for Single Photon Computed tomography, single Photon emission computed tomography, rather. 1:02:17 And what we're looking to do is see the super super in position of the bones. 1:02:26 We want to look at overlying and underlying structures and we want to be able to see things very clearly because as described before, 1:02:30 when we have these overlying and underlying structures and oftentimes it becomes difficult to see what exactly is it that we're looking at. 1:02:37 Again, as you know, as as the ribs connect to the spine, you know, are we looking at an injury of the rib or are we looking at an injury to the spine? 1:02:46 And so that will require views at varying angles in order to get a better a better idea of where that injury is located. 1:02:55 And so Spex does that very well for us, because what it does is it collects a series of images at varying angles. 1:03:03 That's the whole purpose. 1:03:11 We're spinning the camera essentially 360 degrees around the patient and looking at all of these different angles to see the area of concern. 1:03:13 And in this illustration, this is a spec bone scan of the the. 1:03:23 The spine. 1:03:30 And you can see on slide number or frame number 13, 14 and 15 that there is this little red arrow pointing to this hot spot here in the spine. 1:03:33 And it doesn't show up in all of the views, 1:03:48 but it really shows up good in these views at the angle at which the camera is positioned relative to the patient. 1:03:50 And so that's what we're looking for. If a patient comes to us and they're complaining of pain in their back or pain in their pelvis. 1:03:58 And a lot of times we do specs on the younger patients. 1:04:05 You know, it just it's it's very, very beneficial on on some of these younger kids who might have some of these underlying conditions that are, 1:04:10 you know, a mild injury that just isn't showing up all that well on a traditional bone scan. 1:04:22 You know, maybe it's something we just overlooked because we didn't get all the angles we needed. 1:04:27 But at any rate. 1:04:33 We will we will do the scan and if there's any injury, it should show up on or some disease process should show up on one of those frames. 1:04:36 In this case, interestingly enough, this actually ended up being a patient that had a history of renal cancer. 1:04:45 And and the hotspot is showing up on the spine right here. 1:04:52 So I don't know to what degree whether or not this patient had a total body bone scan. 1:04:55 They they they probably did, I would suspect, because of the risk of metastases. 1:05:01 And this actually is a single metastatic lesion to the spine. 1:05:07 But that is probably what was recommended to follow that up with a total body bone scan to see if there was any other lesions there. 1:05:13 So this is a little bit of an unusual case for first SPECT. 1:05:23 We usually don't do specs for cancer. Like I said, we'll do total bodies for cancer, but I thought that was at least just that. 1:05:28 Just kind of an interesting case to show you there. Last couple of factors or last slide, a couple of factors affecting the bone scan I mentioned. 1:05:35 Hydration is very important. Just kind of backing up a couple of slides here, 1:05:45 you can see during the blood pool images of the three phase bone scan that all that soft 1:05:49 tissue uptake that I had mentioned that needs to essentially kind of work itself out. 1:05:55 You know, that's the stuff here, all of the shadowy kind of stuff. 1:06:01 With the patient doubling up on their fluids, look at how it cleared out of that soft tissue. 1:06:06 And then we can focus just on the area of concern. That's the difference. 1:06:10 That's why we want the patient to really push those fluids. 1:06:15 The isotope stays locked into the bone, but it clears out of that soft tissue and allows us to focus just on that area. 1:06:19 Clearly. Decreased renal function can lead to an increase in the background with poor target to non-target ratio and the soft tissue uptake. 1:06:26 We patients who are heavier patients who are obese will have a higher degree of scatter and they really, really are going to need to push the fluids. 1:06:42 Oftentimes obese patients are diabetic. They have poor blood flow and all sorts of conditions that are going to lead 1:06:52 to an increased area of soft tissue uptake and and less uptake in the bone. 1:06:58 So you're going to get a lot of that shadowy effect in those in those larger obese patients. 1:07:04 So they really need to do you really need to instruct them to push the fluids in the tagging process, 1:07:09 making up the radioactivity, making up the drug itself. 1:07:16 If there's a poor tag that could lead to all sorts of problems, that's really another conversation for another day. 1:07:20 Talking about how to make up the drugs, 1:07:26 but just know if you don't have that good brown or that good bind or tag between the isotope and the drug, they can compromise your images. 1:07:28 Elderly patients often show arthritis. Children often show hot joints due to due to their rapid growth. 1:07:39 The growth plates are going to show up and become visualized very commonly. 1:07:46 So that's something to look out for. It's not a problem. 1:07:51 It's not a, you know, a concerning diagnosis. 1:07:55 It's simply natural, natural bone growth because the bones are developing and there's that osteoblasts tick activity occurring at a rapid rate. 1:07:59 You're going to see some hot spots there. The injection to scan time interval is very important. 1:08:09 You know, you need to give enough time to to circulate a minimum of 2 hours. 1:08:15 Oftentimes three is what we're really shooting for. And that could be extended all the way up to 5 hours if needed. 1:08:20 And again, you know, empty instruct the patients to empty their bladder. 1:08:25 Um, we do the contralateral images for symmetry. 1:08:30 Remember, we want to see the normal healthy area of the body relative to the unhealthy area of the body. 1:08:34 So we can make a comparison. We talked about, you know, that there can be normal distribution of varying levels, increased areas of uptake, 1:08:40 which is still considered normal uptake in different areas of the body, such as the skull, the shoulders, the anterior ends of the ribs. 1:08:50 You can see a little bit of increased activity. It appears that is normal in the spine areas of the lung bones, so on and so forth. 1:08:58 So a lot of this this stuff we've already discussed. 1:09:08 One of the things that we did is the breast tissue shadow, particularly ladies who have very dense breasts and very large breasts. 1:09:11 Oftentimes it'll show up as a almost as a well, a shadow of the breasts, you know, in, you know, overlying the chest area. 1:09:19 That that is certainly not uncommon to see. Again, pushing fluids will help reduce that. 1:09:30 But those are just some additional additional things that might show up on there. 1:09:36 So recent or healing surgical wounds can show up as well. 1:09:40 It's very important to get a good diagnosis, a good patient history up front and write down anything that the patient says 1:09:45 might be related to their condition to determine whether or not a hotspot. 1:09:53 It can be correlated to the pain or injury that they that they know. 1:09:58 And that's it, ladies and gentlemen. So here's a list of the references this information came from. 1:10:05 That wraps up our bone scan imaging for today. I appreciate your time and I hope that I hope that this lecture and presentation, you know, 1:10:13 provided the information that you were looking for and you learn something from it. 1:10:23 So, again, thank you very much for your time and I hope you all stay healthy and during this difficult time. 1:10:26 And my best to all of you. Thank you. And thank you, Dr. Smith, for your presentation. 1:10:33 On behalf of SRT, thank you for completing this SRT live recording program. 1:10:39 Have a great rest of your day.