Chapter 23 Inflammatory/Tumor/Oncology Imaging and Therapy PDF

Chapter 23 Inflammatory/Tumor/Oncology Imaging and Therapy Copyright © 2017 Elsevier Inc. All rights reserved.  Objectives  Explain the role nuclear medicine plays in the diagnosis and treatment of infections and tumors.  Discuss the e...

Chapter 23 Inflammatory/Tumor/Oncology Imaging and Therapy Copyright © 2017 Elsevier Inc. All rights reserved.  Objectives  Explain the role nuclear medicine plays in the diagnosis and treatment of infections and tumors.  Discuss the evolution of infection imaging from 67 Ga to 111In to 99mTc.  Describe the imaging procedures for parathyroid, prostate, colorectal, neuroendocrine, adrenal, breast, and lung tumors.  Describe radioimmunotherapy in lymphomas and radionuclide therapies for metastatic bone pain and other maladies. Copyright © 2017 Elsevier Inc. All rights reserved. 2  Key Terms  Antibodies  Neuroblastoma  Antibody fragment  Non-Hodgkin (Fab) lymphoma (NHL)  Cancer  Pheochromocytoma  Hodgkin lymphoma  Radioimmunotherapy (HD)  Radiosynoviorthesis  Murine (RSV)  Murine monoclonal  Somatostatin antibody (mab) Copyright © 2017 Elsevier Inc. All rights reserved. 3  Inflammatory Imaging  67 Ga-Citrate  111 In-Oxine–Labeled White Blood Cells  99 mTc-Exametazime (Ceretec) Copyright © 2017 Elsevier Inc. All rights reserved. 4  Inflammatory Imaging: Clinical Indications  Fever of unknown origin (FUO)  Retroperitoneal fibrosis  Suspected osteomyelitis or diskitis  Pulmonary and mediastinal inflammation/infection  Lymphocytic or granulomatous inflammatory processes (e.g., sarcoidosis/tuberculosis)  Drug-induced pulmonary toxicity  Acute or chronic inflammation/infection Copyright © 2017 Elsevier Inc. All rights reserved. 5  67 Ga-Citrate 1. Complete a comprehensive patient assessment, including review of clinical history, current medications, laboratory tests, and recent imaging procedures. 2. Explain imaging procedure, including multiple imaging days, time requirements for each imaging set, and physical requirements (supine position, arm position, etc.) during the imaging procedure. 3. Inject the patient with the appropriate activity and discharge to home with written instructions for imaging days and times, bowel prep (if indicated), and contact information should the patient have additional questions. Copyright © 2017 Elsevier Inc. All rights reserved. 6  67 Ga-Citrate 4. For the initial imaging sequence, perform a whole body (WB) scan with additional static images or SPECT or SPECT/CT of the area of interest using a medium- or high-energy collimator. a. Count rate for the WB images should be in the range of 1 to 2 million counts. b. Static images should be acquired for 800,000 to 1 million counts. c. SPECT images are acquired at 64 × 64 or 128 × 128 matrix; 360- degree rotation with 3- to 6-degree sampling for 40 to 50 seconds/stop. d. Obtain CT images as per manufacturer’s protocol. 5. Repeat imaging sequence as directed by the interpreting physician for all subsequent imaging sets. 6. Process the images as per institution’s protocol for filtration and display. Copyright © 2017 Elsevier Inc. All rights reserved. 7  67 Ga Radionuclide Characteristics Principal Radiations Nuclide Production Half-Life meV % Ga 67 67 Zn(p,n)67G 78 hours 0.093 40 a 68 Zn(p,2n)67 Ga 0.184 24 0.296 22 0.388 7 Copyright © 2017 Elsevier Inc. All rights reserved. 8  Radiation Dosimetry for 67Ga- Citrate Organ Ga-Citrate (rad/5 mCi) 67 Whole body 1.3 Skeleton 2.2 Liver 2.3 Bone marrow 2.9 Spleen 2.65 Kidney 2.05 (calyx) Ovary 1.4 Testes 1.2 Stomach 1.1 Small intestine 1.8 Upper colon 4.5 Copyright © 2017 Elsevier Inc. All rights reserved. 9  111 In-Oxine–Labeled White Blood Cells 1. Complete a comprehensive patient assessment including review of clinical history, current medications, laboratory tests, and recent imaging procedures. 2. Explain imaging procedure, including blood labeling technique, time requirements for imaging, and physical requirements (supine position, arm position, etc.) during the imaging procedure. 3. Blood labeling may be performed by a local radiopharmacy or in-house. 4. Withdraw a minimum of 50 ml of blood using a large bore needle (18 to 20 gauge). 5. Label blood sample and complete appropriate paperwork before sending to radiopharmacy or labeling in-house. Copyright © 2017 Elsevier Inc. All rights reserved. 10  111 In-Oxine–Labeled White Blood Cells 6. If labeling product in-house, follow the approved protocol for labeling 111In-oxine or 99mTc-HMPAO. 7. Correctly identify the patient before reinjecting the labeled blood product using a large bore needle (18 to 20 gauge, if possible). 8. At the appropriate time interval, ask the patient to void and remove any articles of clothing or metal objects that may cause attenuation artifacts on the images. 9. Perform an initial whole-body and/or static image protocol followed by a SPECT or SPECT/CT of the selected area. Note: Imaging parameters depend on radiopharmaceutical used for labeling. 10. Perform the delayed imaging protocol as per the interpreting physician’s request. Note: The delayed protocol may include additional static and SPECT or SPECT/CT images, as requested. 11. Process the SPECT or SPECT/CT images as per institution protocol. Copyright © 2017 Elsevier Inc. All rights reserved. 11  111 In Radionuclide Characteristics Principal Radiations Nuclide Half-Life keV % In 111 67.4 hours 171 90.0 247 94.2 Copyright © 2017 Elsevier Inc. All rights reserved. 12  Radiation Dosimetry for 111In-Labeled White Blood Cells Organ 111 In-Labeled White Blood Cells (rad/mCi) Whole body 0.50 to 0.53 Liver 1 to 5 Spleen 18 to 20.4 Copyright © 2017 Elsevier Inc. All rights reserved. 13  99m Tc-Exametazime (Ceretec)  Requires the withdrawal of 40 to 50 ml of the patient’s blood  The adult administered dose is 7 to 25 mCi (259 to 925 MBq).  Anterior and posterior whole-body images are acquired after a delay of 4 to 24 hours.  A high-resolution, low-energy collimator is recommended.  Low count rate on delayed images may benefit from the use of a low-energy, all-purpose collimator.  Additional static images and SPECT or SPECT/CT imaging can be helpful. Copyright © 2017 Elsevier Inc. All rights reserved. 14  Radiation Dosimetry for 99mTc Leukocytes Radiopharmaceutical Administered Activity Organ Receiving the Effective Dose MBq (mCi) Largest Radiation mSv/MBq (rem/mCi) Dose mGy/MBq (rad/mCi) Radiation Dosimetry: Adults 99m Tc-exametazime 185 to 370 IV 0.15 0.017 (HMPAO) leukocytes (5 to 10) Spleen (0.56) (0.063) Radiation Dosimetry: Children (5 Years Old) 99m Tc-exametazime 3.7 IV 0.48 0.054 (HMPAO) leukocytes (0.1 to 0.2) Spleen (1.8) (0.020) Copyright © 2017 Elsevier Inc. All rights reserved. 15  Tumor Imaging  Parathyroid  Prostate Cancer  Colorectal Cancer  Neuroendocrine Tumors  Pheochromocytoma and Neuroblastoma  Breast Cancer  Lung Cancer Copyright © 2017 Elsevier Inc. All rights reserved. 16  Parathyroid  Radionuclide: 99mTc-sestamibi  Average adult dose – 20 mCi (740 MBq)  Flow study – acquired immediately after injection  First (thyroid) phase – begins 15 to 20 minutes post injection  Second (parathyroid) phase – 2 hours post injection Copyright © 2017 Elsevier Inc. All rights reserved. 17  Prostate Cancer  Indium-111–capromab pendetide (ProstaScint)  an IgG1 murine monoclonal antibody (mab) directed toward prostate-specific membrane antigen (PSMA), a glycoprotein expressed by prostate epithelium  Procedure is performed over 96 to 120 hours  Day 1: Injection of 5 mCi (185 MBq) 111In–capromab pendetide infused over 3 to 5 minutes  Blood pool activity can be imaged 30 minutes to 4 hours  For optimal targeting and minimal blood pool activity, imaging should be performed at 96 to 120 hours post injection Copyright © 2017 Elsevier Inc. All rights reserved. 18  Colorectal Cancer  Technetium-99m-arcitumomab (CEA-Scan) is used in the diagnostic evaluation of recurrent or metastatic colorectal cancer.  Dose: 20 to 30 mCi (740 to 1110 MBq)  Anterior/posterior 800,000 to 1 million planar or whole-body images of the chest, abdomen, and pelvis are acquired 2 to 5 hours post-injection. Copyright © 2017 Elsevier Inc. All rights reserved. 19  Neuroendocrine Tumors  Indium-111-pentetreotide (OctreoScan) is used to visualize primary neuroendocrine tumors and neuroendocrine metastasis.  Dose: 6 mCi (222 MBq) for an adult and 0.14 mCi/kg (5 MBq/kg) for children  Images are acquired at 4, 24, and 48 hours. Copyright © 2017 Elsevier Inc. All rights reserved. 20  Pheochromocytoma and Neuroblastoma  Pheochromocytomas – catecholamine-secreting tumors from the pheochromocytes of the adrenal medulla  Neuroblastomas – malignant tumors of the sympathetic nervous system and are found most often in infants and children (