Image studies of a 25-year-old man for a renal scan with a recent history of hypertension are presented. Images of the urinary tract obtained after administration of 250 MBq 99m Tc DTPA are shown. The answer to the image studies are also provided.
Background: Radioisotope manufacturers, nuclear camera manufacturers, standard guidelines for myocardial perfusion imaging, all assume rapid isotope uptake followed by an essentially static retention mechanism. Contrariwise, the historic first nuclear cardiology study found measurement of nuclear isotope blood flow kinetics to be diagnostic of heart disease. No clinical investigations appear to have followed that classic finding. We assessed the clinical diagnostic utility of time course myocardial perfusion measurements following single injections. Method: One hundred twenty patients suspected of having heart disease underwent Sestamibi stress images taken at 5 and at 60 minutes following completion of cardiac stress. Quantitative (FHRWW) redistribution differences between the images were assessed. FHRWW results were compared with angiographic findings. Result : Parabolic regression of stenosis on redistribution yielded an effect size of R(CI95%) = 0.72 to 0.95, (P=3.8x10-8). Fifteen percent of individuals with 'normal' appearing 60 minute SPECT images were noted to having coronary artery disease using both redistribution data and coronary angiography requiring stent placement. These individuals had 'wash in' of Sestamibi (isotope uptake greater at 60 minutes than 5 minutes) and signaled patients at risk of undergoing an acute cardiac event due to vulnerable plaques or tight lesions placing significant amounts of myocardium at risk of infarction. One of the individuals who did not require cardiac catheterization based upon the FHRWW data, underwent coronary angiography based upon rest-stress results AND had a major adverse event as a result of the subsequent cardiac catheterization. There was no detectable CAD, confirming the FHRWW findings and the need for caution in individuals undergoing invasive procedures. Conclusion: Dynamic 'uptake/release' models appear to be a superior alternative to the common 'uptake/retention' models of technetium-99m isotopes used in nuclear myocardial perfusion imaging. This sequential quantitative diagnostic model, reinforces the work by Blumgart, enabling more accurate diagnosis of coronary artery disease and providing for intervention in individuals requiring stents or bypass, whom would otherwise be missed on rest-stress imaging protocols while avoiding unnecessary coronary angiography among individuals with 'normal' Sestamibi redistribution.
Synopsis of a pilot project of 30 patients to gain preliminary information on C-MET and FLT PET-CT imaging in patients with high grade glioma who have received 2-3 cycles of temozolomide chemotherapy following surgery and radiotherapy.
The key features of Canine elbow dysplasia, a developmental orthopaedic condition that commonly affects young 4-8 month old dogs from large breeds like German Shepherds, Bernese Mountains, Labradors, Rottweilers and Golden Retrievers are discussed. The diagnosis, treatment methodologies and management regime for the same are highlighted.
A number of Product Information leaflets (PIs) state that the user may test the radiochemical purity of reconstituted {99m}Tc-radiopharmaceuticals prior to administration to the patient. Due to discontinued manufacture of the commonly specified Instant Thin Layer Chromatography-Silica Gel (ITLC-SG) media, ARPANSA has conducted comparison tests on alternative media that may be suitable for the measurement of the radiochemical purity of some commonly used {99m}Tc-radiopharmaceuticals. A variety of commercially available media were tested with a range of {99m}Tc-radiopharmaceuticals, and suitable replacement papers have been proposed.
Some of the challenges at the interface between the pre-clinical development of targeted therapeutics for haematological cancers and assessment by functional imaging are discussed. By incorporating molecular imaging techniques into pre-clinical testing, it is hoped that the translation of new therapies to patient care will become more streamlined.
Purpose of the report: In nuclear medicine, we perform studies and acquire images on our patients and often have little knowledge of what happens to the patient after they leave the department and what role our imaging plays in their treatment. With the increase in sentinel node imaging being performed in the department, the primary purpose of this study was to undertake a case study to give both myself and my colleagues a better understanding of not only the impact that our imaging had on the subsequent surgery, but the impact that the procedure had on the patient and their long-term outcome. The secondary purpose was to explore the aetiology of lymphoedema and the impact that it had on patients that suffer from it. Materials and methods: Consent was obtained from a patient to attend her nuclear medicine appointment and surgery and obtain images to use for the case study. Conclusion: All the information gathered for this project indicates that the SN biopsy procedure represents a huge step forward in the treatment of breast cancer, as it can help a woman's long term physical and psychological well being by not subjecting her to an unnecessary ALND and its resultant lymphoedema.
Purpose of the report : The main goal of this study was to evaluate the effects of the application of intravenous (IV) iodine contrast media on semiquantitative values of Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography (FDG PET/CT) imaging in Extrapulmonary Tuberculosis (EPTB) patients. Materials and method: Nine patients diagnosed with EPTB infection were recruited. Whole body PET and non-enhanced CT were acquired for about 58.3 (mean; ranging from 30-86) min following the intravenous injection of 357.7 (mean; ranging from 145-592) MBq of FDG and subsequently enhanced CT images were acquired utilising 100 mL of iodine contrast media without positional change. PET images were reconstructed using both CT image datasets and the maximum standardised uptake values (SUVmax) were obtained from 5 different organs or tissues; heart, liver, spleen, urinary bladder and lesion. Result : The mean percentage differences of SUVmax between enhanced and non-enhanced PET/CT for all investigated tissues were found to be 0.305 plus or minus 2.457% for heart, 0.013 plus or minus 0.592% for liver, -0.059 plus or minus 1.808% for spleen, 0.122plus or minus 0.654% for urinary bladder and -3.789 plus or minus 18.457% for lesion. These changes were found to be statistically insignificant. Conclusion: This study demonstrates that utilisation of iodine contrast media in the CT component of PET/CT imaging scan will not cause significant changes on SUVmax values in the diagnosis of EPTB infection.
The key aspects and features of the Australian 99Molybdenum Survey undertaken to collect information from the nuclear medicine community on its current 99Molybdenum needs and to assess ways of better utilisation are discussed. Other details of the survey are highlighted.
An 85-year-old male with a history of recent urosepsis and Gram negative septicaemia, was investigated for pyrexia of unknown origin (PUO). 67Ga - citrate imaging including SPECT/CT revealed an infected focus around a left apical plombage performed over 50 years ago for pulmonary tuberculosis. Subsequent CT imaging demonstrated a bronchopleural fistula in the left extrapleural space.
Aim: Increasing demand for 18F-FDG PET brain studies for investigation of dementia in a financially capped environment resulted in a prolonged waiting list for appointments. Our Department instituted a policy where all patients were to be triaged using brain SPECT prior to receiving a PET appointment. This study reviews the cost-effectiveness of this policy. Method: 222 consecutive patients referred for SPECT/PET brain studies for dementia in a six month period were included. Scan reports were classified into 4 grades: Normal, No diagnostic pattern, Suggestive of dementia, or Abnormal. Patients with diagnostic abnormality on SPECT did not proceed to PET. 114 patients proceeded to PET and these results were compared to SPECT. Reporting for both SPECT and PET was performed using 3-plane slices and Neurostat 3D-SSP (Stereotactic Surface Projection). Sub-analysis for age was performed for patients 65 years and under compared over 65 years. Results : Brain SPECT provided definitively abnormal results in 66 of 222 patients (30%). In patients aged 65 years and under, the percentage rose to 33%, compared to 29% in those over 65. Non diagnostic or suggestive patterns were seen in 133 of 222 (60%) with SPECT compared to only 18 of 114 patients (16%) with PET. In patients 65 years and under, PET provided equally high levels of Normal and Abnormal scans (approximately 40% each), whilst in those over 65 years, Abnormal scans were found in 63% and Normal scans in 23%. The potential Medicare cost of SPECT + PET triage was $232,080 compared to $203,796 for PET only, if FDG PET for dementia were funded at the same rate as 18F-FDG PET for epilepsy. Conclusion: Brain SPECT imaging provides definitive diagnosis in around 30% of patients regardless of age, producing a modest impact on the waiting list. 18F-FDG PET provides greater diagnostic certainty with most patients receiving either a clear Normal or Abnormal result. Additionally, if 18F-FDG PET for dementia were Medicare funded, SPECT triage would not be cost-effective.
In July 2009 a survey of nuclear medicine diagnostic administered activities to paediatric patients was undertaken. Eight hospital-based centres in Australia received and responded to the survey conducted on behalf of the Australian and New Zealand Society of Nuclear Medicine. They were asked to indicate the minimum and maximum activities they administer to paediatric patients. Minimum (Amin) and maximum (Amax) reference activities for 50 procedures were calculated as the median of the distribution of activities. When compared with those originally established in 1999 from a survey of the same eight centres, a reduction in Amax was observed for many procedures (40%), while there was a similar proportion of increases and decreases in Amin between the two surveys. The introduction of paediatric reference activities in 1999 may have been a factor in the reduction of Amax values. With large variations remaining among centres however, there may still be scope for review of administered activities.
Gamma camera malfunction is a major source of imaging artifacts in the every day nuclear medicine practice. These artifacts can be avoided by routine quality control of the equipment as well as routine review of the images after each acquisition. We report perfusion defect in the myocardial perfusion scan of a patient due to spontaneous malfunction of a photomultiplier tube (PMT). This PMT malfunction was detected by reviewing the raw acquired projections and was due to a loose connection in the PMT circuit. After correcting the malfunction, the scan was repeated and the defect disappeared. This case shows the importance of raw data reviewing after each image acquisition to avoid any gamma camera related artifact.
The Technical Standards Committee (TSC) of the Society has undertaken national Australian dose calibrator surveys in 1991, 1994, 1996, 1998, 2000, 2003, 2005 and 2007/08. The TSC instigated a similar survey in 2009 in collaboration with the Quality Control Office of ARI. Measurements were recorded on 126 calibrators at 90 institutions and the results of the survey are presented.
Objectives: To develop methodology to predict lobar lung function based on SPECT/CT ventilation and perfusion (V/Q) scanning in candidates for lobectomy for lung cancer. Methods: This combines two development areas from our group: quantitative SPECT based on CT derived corrections for scattering and attenuation of photons, and SPECT V/Q scanning with lobar segmentation from CT. Six patients underwent baseline pulmonary function testing (PFT) including spirometry, measurement of DLCO and cardiopulmonary exercise testing. A SPECT/CT V/Q scan was acquired at baseline. Using in-house software each lobe was anatomically defined using CT to provide lobar ROIs which could be applied to the SPECT data. From these, individual lobar contribution to overall function was calculated from counts within the lobe and post-operative FEV 1, DLCO and VO2 peak were predicted. This was compared with the quantitative planar scan method using 3 rectangular ROIs over each lung. Results: Post-operative FEV 1 most closely matched that predicted by the planar quantification method, with SPECT V/Q over-estimating the loss of function by 8% (range-7 - +23%). However, post-operative DLCO and VO2(peak) were both accurately predicted by SPECT V/Q (average error of 0 and 2% respectively) compared with planar. Conclusions: More accurate anatomical definition of lobar anatomy provides better estimates of post-operative loss of function for DLCO and VO2 peak than traditional planar methods. SPECT/contraindications provides the tools for accurate anatomical definition of the surgical target as well as being useful in producing quantitative 3D functional images for ventilation and perfusion. (author abstract)
The understanding of bone with respect to age related conditions including fracture, is presented. An attempt is made to unravel the complexity of this biological tissue using radiological techniques to assess age-related change.
Purpose of the report: The purpose of the present study was to assess in our series of patients the relevance of both Serum Thyroglobulin (STg) and 131Iodine whole body scan (IWBS) in the follow up of Differentiated thyroid cancer (DTC) and look at the change in the management protocol, based on the results of the investigations. Materials and Methods: Our study group comprised of all consecutive studies in patients with DTC who underwent thyroidectomy and Iodine ablation (IA) and followed up between January 2003 and May 2006 with STg and IWBS stimulated TSH. The data was retrieved from the clinical network of our hospital. The treatment policy for DTC was total thyroidectomy, and lymph node dissection if indicated. At 4 - 6 weeks after surgery, IWBS was performed 48 hours after the administration of 74 MBq 131Iodine orally on empty stomach. A total of 1055 IWBS studies were performed during this period. Analysis of IWBS paired with STg concurrently was carried out. Results: IWBS was performed concurrently with STg in 787 studies (404 patients,135 males and 269 females, ratio 1:2 respectively, age:10- 85 years), mean follow up was 2 years. Results of STg assay and IWBS were concordant in majority of studies i.e. 517 (65.7%). A total of 333(64.4%) were Tg-ve, Scan -ve (subgroup A1) and 184 (35.6%) Tg +ve, Scan +ve (subgroup A2). In subgroup A1, STg and IWBS agreed with each other during follow up. Among subgroup A2, 107 (58.2%) had residual thyroid on IWBS. There were 102 (55.4%) studies in which STg was >10 ng/ml out of which 64 (63%) were associated with metastases i.e.18 (28.1%) lymph node, 26 (40.6 %) bone and 20 (31.3%) lung metastases. In patients with STg <10 ng/ml (n=82), 69 (84.1%) had predominantly residual thyroid and 13 (15.9%) showed lymph node8 and/or skeletal metastases5. A total of 270 (34.3%) were discordant studies. In Tg-ve, Scan +ve pairs (n= 112 (41.5%, subgroup B1), it was noted that 101 (90.2%) studies revealed residual thyroid on IWBS. In 11(9.8%) with negative STg, functioning metastases were demonstrated on IWBS. Among Tg+veScan-ve pairs (n=158 (58.5%), subgroup B2), majority of them, 102 (64.6%) had STg <10ng/ml. Conclusion: From our experience it appears to be prudent to do both IWBS and stimulated STg at least in the first two years of follow up as it was found to be complementary to each other.
In 1998 diagnostic reference activities were derived from a survey of nuclear medicine procedures in Australia and New Zealand. In November/ December 2008 a repeat survey of diagnostic administered activities was undertaken on behalf of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) in order to derive new reference activities to better reflect the practice of nuclear medicine in Australia and New Zealand today. A total of 77 responses were received in 2008 compared with 96 in 1998. The survey form identified 77 procedures for which practices were asked to indicate the activities routinely administered to a standard 70 - 80 kg adult. The reference activity was calculated as the 75th percentile of the distribution of activities for procedures for which a minimum of five responses were received. The Most Common Activity and the percentage change between the 1998 and 2008 reference activities were also calculated. While decreases in diagnostic reference levels have been reported for radiology procedures, the survey showed no downward trend in nuclear medicine reference activities since 1998. However the establishment of reference activities may have been a factor in a reduction in the highest administered activities observed in many procedures.
The case study of a 66-year-old female who suffered a fracture with minimal trauma and subsequently underwent dual energy X-ray absorptiometry of the lumbar spine and femoral neck to assess bone density, is presented. A raised parathyroid hormone level of 11 pmol/L led to the incidental detection of a breast carcinoma using 99mTc which was used for imaging another organ, proved to be a significant and valuable finding.
