Nuclear Medicine Imaging Procedures Research Articles

Summary: Appropriate Use Criteria for the Use of Nuclear Medicine in Fever of Unknown Origin.

The diagnostic work-up of patients with fever of unknown origin (FUO) begins with a thorough history and physical examination, complete blood count with differential, chest x-ray, urinalysis and culture, electrolyte panel, liver enzymes, erythrocyte sedimentation rate, and C-reactive protein level. Additional imaging procedures, including nuclear medicine tests, are generally used as second-line procedures, with 18F-FDG PET and PET/CT assuming increasingly important roles in the diagnostic work-up. The Society of Nuclear Medicine and Molecular Imaging, the Infectious Diseases Society of America, and the American College of Nuclear Medicine convened an autonomous expert work group to comprehensively review the published literature for nuclear imaging in adults and children with FUO and establish appropriate use criteria (AUC). This process was performed in accordance with the Protecting Access to Medicare Act of 2014, which requires that all referring physicians consult AUC by using a clinical decision support mechanism before ordering advanced diagnostic imaging services. The complete findings and discussions of the work group were published on January 8, 2023, and are available at https://www.snmmi.org/ClinicalPractice/content.aspx?ItemNumber=15666 The AUC in the final document are intended to assist referring health care providers in appropriate use of nuclear medicine imaging procedures in patients with FUO. The work group noted limitations in the current literature on nuclear medicine imaging for FUO, with the need for well-designed prospective multicenter investigations. Consensus findings from published data and expert opinions were used to create recommendations in common clinical scenarios for adults and children. Included in the complete document is a discussion of inflammation of unknown origin (IUO), a recently described entity. In view of the fact that the criteria for FUO and IUO are similar (except for fever > 38.3°C [100.9°F]) and that the most common etiologies of these 2 entities are similar, it is the expert opinion of the work group that the recommendations for nuclear medicine imaging of FUO are also applicable to IUO. These recommendations are included in the full guidance document. This summary reviews rationale, methodology, and main findings and refers the reader to the complete AUC document.

EANM practice guidelines for an appropriate use of PET and SPECT for patients with epilepsy

Epilepsy is one of the most frequent neurological conditions with an estimated prevalence of more than 50 million people worldwide and an annual incidence of two million. Although pharmacotherapy with anti-seizure medication (ASM) is the treatment of choice, ~30% of patients with epilepsy do not respond to ASM and become drug resistant. Focal epilepsy is the most frequent form of epilepsy. In patients with drug-resistant focal epilepsy, epilepsy surgery is a treatment option depending on the localisation of the seizure focus for seizure relief or seizure freedom with consecutive improvement in quality of life. Beside examinations such as scalp video/electroencephalography (EEG) telemetry, structural, and functional magnetic resonance imaging (MRI), which are primary standard tools for the diagnostic work-up and therapy management of epilepsy patients, molecular neuroimaging using different radiopharmaceuticals with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) influences and impacts on therapy decisions. To date, there are no literature-based praxis recommendations for the use of Nuclear Medicine (NM) imaging procedures in epilepsy. The aims of these guidelines are to assist in understanding the role and challenges of radiotracer imaging for epilepsy; to provide practical information for performing different molecular imaging procedures for epilepsy; and to provide an algorithm for selecting the most appropriate imaging procedures in specific clinical situations based on current literature. These guidelines are written and authorized by the European Association of Nuclear Medicine (EANM) to promote optimal epilepsy imaging, especially in the presurgical setting in children, adolescents, and adults with focal epilepsy. They will assist NM healthcare professionals and also specialists such as Neurologists, Neurophysiologists, Neurosurgeons, Psychiatrists, Psychologists, and others involved in epilepsy management in the detection and interpretation of epileptic seizure onset zone (SOZ) for further treatment decision. The information provided should be applied according to local laws and regulations as well as the availability of various radiopharmaceuticals and imaging modalities.

Enhancing Nuclear Medicine Practice in Saudi Arabia: Advocating for Comprehensive Guidelines and Local Diagnostic Reference Levels.

Diagnostic reference levels(DRLs) were initially introducedbythe International Commission on Radiation Protection (ICRP). It refers to the measured quantity ofadministered activity (MBq) in nuclear medicine imaging studies and is a type of investigation level. DRL is recommended to prevent excessive radiation exposure to patients while maintaining adequate image quality. It should not be implemented as a dose constraint or dose limit.The Saudi Food and Drug Authority (SFDA) is the primary government body responsible for reporting national diagnostic reference levels (NDRLs) for diagnostic medical imaging technologies in Saudi Arabia. Only NDRLs for computed tomography, general X-ray, and mammography have been published and enforced locally.This study aims to establish local DRLs for nuclear medicine imaging procedures at King Abdulaziz University Hospital, Saudi Arabia, preparing for compliance proof once required by local authorities. Data were collected from all machines, and sixcommon protocols were studied, with datafrom 50 patientsof standard body size for each identified protocol. The study was conducted retrospectively, and the 50thpercentile was then calculated for each scan. Both protocols for renal scansadministered the lowest doses to patients (130 MBq and 148 MBq), respectively. The highest dose administered to patients was found to be in bone scans (1110 MBq). The study establishes local DRLs for nuclear medicine imaging in our institution. Median activity dosages in renal, thyroid, and parathyroid imaging were comparable to locally and internationally published DRLs. However, they are higher in cardiac and bone imaging comparedto local Saudi DRL and DRL in the European Union and the USA, likely due to the adopted protocols. These highlight the need for modifying the protocols to fulfill optimization efforts. These findings serve as a foundation for compliance with future regulatory requirements, ensuring patient safety and maintaining imaging quality in Saudi healthcare.

Nationwide survey on radiation doses received by patients in nuclear medicine imaging procedures

National diagnostic reference levels (DRLs) are essential tools for optimizing protocols and protecting patients from an unjustified radiation exposure. The aim of this study was to conduct a nationwide survey of adult patient doses received from nuclear medicine (NM) procedures and to update national DRL (NDRL) values for most common procedures. Data on the radioactivity administered to standard adult patients were collected from all Lithuanian hospitals using NM applications in practice, between 2017 and 2022. Twelve of the most commonly performed NM diagnostic procedures: myocardial perfusion scintigraphy (two parts), thyroid scintigraphy, lung perfusion scintigraphy, bone scintigraphy, dynamic renal scintigraphy (divided into two procedures), parathyroid scintigraphy, hepatobiliary scintigraphy, lymphoscintigraphy, neuroendocrine tumour scan, and oncology positron emission tomography/computed tomography (PET/CT) imaging were included. The 75th percentile of the dose distribution was estimated for establishing NDRLs. During the data collection period, the NM imaging equipment was upgraded. The procedures were completed with 12 single photon emission computed tomography (SPECT) and SPECT/CT gamma cameras (2 with cadmium zinc telluride (CZT) detectors), 2 cardiac-centred gamma cameras with CZT detectors, and 2 PET/CT scanners. Data were collected on 7979 activities administered to the patients. For each procedure, depending on its frequency, 50–580 administered radiopharmaceutical activities were selected. Based on the collected data, NDRLs were updated in 2021 for three procedures. A large part of the procedures were performed with scanners manufactured between 2008 and 2011. In the past few years, the main Lithuanian hospitals that provide NM services have updated their SPECT/CT systems. In the future, the data collection process should be continued in order to reassess DRLs with respect to new scanning systems (e.g. with CZT detectors and newer PET/CT technology). Variations in the prescribed radiopharmaceutical activities showed that optimization and harmonization procedures may be performed in some hospitals.

Nuclear odontology: Pictorial essay

There is increased demand by the general dentist and oral surgeon’s for Nuclear Medicine (NM) imaging procedures both for initial diagnosis and follows up of patients with different dental and facial disorders. There are several procedures in NM including bone scan, gallium scan and PET scan which can offer important diagnostic information complementing the information obtained from other imaging modalities in particular a better understanding of the pathophysiology of the disease and therapy monitoring.

Guide for Nuclear Medicine Applications During the COVID-19 Outbreak.

A viral pneumonia rapidly spread from Wuhan, China to all countries in late 2019. In February 2020, WHO named as Coronavirus Disease 2019 (COVID-19) and declared the pandemic on March 11, 2020. To prevent the spread of COVID-19, Ministry of Health of Republic of Turkey and international institutions have published documents defining hygiene rules. After the lung computerized tomography (CT) findings which are important in the diagnosis of COVID-19 are described, protection measures against infection were defined in radiology departments. There is no publication involving protection measures for diagnostic and therapeutic procedures in nuclear medicine (NM) (appointment, patient acceptance, imaging and treatment procedures, disinfection etc). There are two reports on CT findings suggesting COVID-19 in 18F--fluorodeoxyglucose positron emission tomography/CT scan. These lung findings detected in hybrid images will be helpful in the early diagnosis of pulmonary involvement. Infected cases may be asymptomatic and can unintentionally disseminate the virus to surrounding people. This advisory guide has been prepared to avoid infection risk in NM clinics. During the COVID-19 outbreak, staff must use proper personal protective equipment and patients should be evaluated as the elective case according to clinical status. A questionnaire should be made for COVID-19. In cancer cases requiring urgent treatment, radionuclide treatment (RNT) should be planned according to the COVID-19 test result. If the result is negative, RNT can be applied; but if not or if the symptoms are present, RNT must be postponed. Following imaging procedures, scanners and room surfaces should be cleaned by personnel with proper disinfection training.

Modern thyroid surgery - the surgeon's endocrine-surgical understanding and his responsibility for the extent of surgery and complication rate

Die hohe Qualität der Schilddrüsenchirurgie impliziert ein endokrin-chirurgisches Verständnis des Operateurs mit dem Ziel einer bestmöglichen Ergebnisqualität. Das beinhaltet ein befundadäquates Resektionsausmaß und eine möglichst niedrige Komplikationsrate. Der Chirurg sollte frühzeitig in die Operationsindikation eingebunden sein und auch selbst die Diagnostik, speziell den Schilddrüsen- und Halslymphknotenultraschall, sowie die Interpretation der Schnittbild- und nuklearmedizinischen Verfahren beherrschen. Im Besonderen sollte er über zeitgemäße Radikalitätsprinzipien in der Chirurgie Bescheid wissen.Bei der gutartigen Struma ist eine individualisierte Operationsstrategie anzuwenden: Solitärknoten können auch einer gewebeschonenden Knotenresektion unterzogen werden. Bei multinodulärer Knotenstruma ist nicht zwingend eine totale Thyreoidektomie notwendig, die Vermeidung eines permanenten Hypoparathyreoidismus hat Priorität. Bei Rezidivstrumen ist oft die einseitige Operation des dominanten Befundes zu bevorzugen. Auch besteht zunehmend der Trend, die Indikation zur Entfernung der Schilddrüsenlappen seitengetrennt zu stellen. Die Basedow Struma erfordert eine Thyreoidektomie. Auch die hypertrophe Thyreoiditis Hashimoto kann eine Operationsindikation darstellen.Die Radikalitätsprinzipien bei maligner Struma haben sich ebenfalls deutlich gewandelt als auch die strenge Indikation zur Radiojodtherapie. Das gilt speziell für papilläre Mikrokarzinome und minimal invasive follikuläre Tumortypen. Selbst bei medullären Schilddrüsenkarzinom stehen die Radikalitätsprinzipien im Hinblick auf synchrone oder metachrone laterale Halsdissektion in Diskussion.Der Hypoparathyreoidismus stellt derzeit das Hauptproblem in der radikalen Schilddrüsenchirurgie dar. Recurrensparese und Nachblutung sind durch die subtile Operationstechnik selten geworden. Spezielle extrazervikale Operationszugänge sind nach wie vor in der Erprobungsphase und unter strengen Studienbestimmungen nur Zentren vorbehalten. Die Radiofrequenzablation stellt für gewisse Läsionen wie Zysten und autonome Adenome bei chirurgischer Kontraindikation ein alternatives Ablationsverfahren dar.

Estimation of the radiation dose in pregnancy: an automated patient-specific model using convolutional neural networks.

The conceptus dose during diagnostic imaging procedures for pregnant patients raises health concerns owing to the high radiosensitivity of the developing embryo/fetus. The aim of this work is to develop a methodology for automated construction of patient-specific computational phantoms based on actual patient CT images to enable accurate estimation of conceptus dose. We developed a 3D deep convolutional network algorithm for automated segmentation of CT images to build realistic computational phantoms. The neural network architecture consists of analysis and synthesis paths with four resolution levels each, trained on manually labeled CT scans of six identified anatomical structures. Thirty-two CT exams were augmented to 128 datasets and randomly split into 80%/20% for training/testing. The absorbed doses for six segmented organs/tissues from abdominal CT scans were estimated using Monte Carlo calculations. The resulting radiation doses were then compared between the computational models generated using automated segmentation and manual segmentation, serving as reference. The Dice similarity coefficient for identified internal organs between manual segmentation and automated segmentation results varies from 0.92 to 0.98 while the mean Hausdorff distance for the uterus is 16.1mm. The mean absorbed dose for the uterus is 2.9mGy whereas the mean organ dose differences between manual and automated segmentation techniques are 0.07%, - 0.45%, - 1.55%, - 0.48%, - 0.12%, and 0.28% for the kidney, liver, lung, skeleton, uterus, and total body, respectively. The proposed methodology allows automated construction of realistic computational models that can be exploited to estimate patient-specific organ radiation doses from radiological imaging procedures. • The conceptus dose during diagnostic radiology and nuclear medicine imaging procedures for pregnant patients raises health concerns owing to the high radiosensitivity of the developing embryo/fetus. • The proposed methodology allows automated construction of realistic computational models that can be exploited to estimate patient-specific organ radiation doses from radiological imaging procedures. • The dosimetric results can be used for the risk-benefit analysis of radiation hazards to conceptus from diagnostic imaging procedures, thus guiding the decision-making process.

Establishment of age-specific reference levels and achievable doses for children and adults undergoing nuclear medicine exams

Reference levels (RLs) and achievable doses (ADs) have been investigated for routine nuclear medicine and molecular imaging procedures across various hospitals. The RLs and ADs were then set at 75th and 50th percentile of the data collected respectively. The minimum and maximum administered activities (in MBq) were asked for 99mTc-DTPA, 99mTc-DMSA, 99mTc-HIDA, 99mTc-MDP, 99mTc-Pertechnetate (for thyroid imaging) and 18F-FDG (whole body imaging), 99mTc-Sestamibi cardiac scan (rest and stress) 2-day protocols, 99mTc-parathyroid and 99mTc-labeled GI bleeding. The pediatrics were divided into three age groups of (> 1–5), (> 5–10) and (> 10–15) years. The observations show that, in most of cases, children are administered higher quantities of radiopharmaceuticals than recommended by guidelines. However, the adults are given right amount of does in most of the imaging procedures. It is shown that findings of the study can enable facilities to compare their radiation doses to the international guidelines and adjust them according to patient body size and weight to get image quality corresponding to right radiation dose.

Rational and reliable diagnosis of periprosthetic hip and knee joint infection using two nuclear-medicine methods: 99mtc-ciprofloxacin and 99mTc-MDP scintigraphy

Background/Aim. There is a constant and dramatic in-crease in hip and knee prosthetic implantations worldwide. However, a decrease in the percentage of failed (infected) prosthetic implantations is not significant (0.5% up to 2%). The real challenge is whether prosthetic joint loosening was caused by aseptic inflammation or by infection. The aim of the present study was to attempt to distinguish sterile inflammation from infection in patients with a painful hip or knee prosthetic joint. Another objective was to determine the accuracy of cumulative bone scintigraphy with methylenediphosphonate (MDP) and ciprofloxacin in diagnosis of periprosthetic joint infection (PJI). Methods. Three-phase bone scintigraphy with 99mTc-MDP and 99mTc-ciprofloxacin was used. The patient selection criterion for this study was a suspicion of PJI followed by painful and limited movement of the prosthetic joint, accompanied by elevated unspecific inflammatory factors. Forty five patients with 39 implanted hips and 24 knee prostheses were included and evaluated. All prosthetic joints were examined (although some of them were asymptomatic) and underwent plain radiography. An average time span between the two nuclear medicine imaging procedures was 3?5 days. Three-phase 99mTc-MDP bone scintigraphy was performed first. Scintigraphy with 99mTc-ciprofloxacin was necessarily involved calculation of the accumulation index. The obtained results were confirmed by microbiological findings as a gold standard. Statistical analysis of the results was performed using SPSS version 20 software (descriptive statistics, ?2-test). Sensitivity, specificity, and predictive values were also calculated. Results. Microbiologically confirmed PJI was found in 16 out of 39 hip prostheses. Positive scintigraphy was obtained in 15 out of 39 prosthetic hip joints. PJI was found using scintigraphy of the knee, and microbiologically con-firmed in all 13 out of 24 suspected joints. Estimated sensitivity/specificity of 99mTc-MDP bone scintigraphy alone (for both joints) was 90%/69%, for 99mTc-ciprofloxacin scintigraphy it was 93%/97%, and for cumulative results it was 96.5%/97%. Conclusion. Cumulative 99mTc-MDP scintigraphy with 99mTc-ciprofloxacin scintigraphy increases the ability of differentiation between aseptic loosening and PJI, with high accuracy of 97%.

Gastrointestinal Transit Scintigraphy in a Case of Syringomyelia.

Syringomyelia is a rare degenerative disease affecting the spinal cord and brain stem causing progressive neurological dysfunction. The presence of gastrointestinal symptoms in these patients is common, although references related to nuclear medicine imaging procedures in this pathology are limited, focusing on the study of gastric emptying. We present a 47-year-old male patient diagnosed with syringomyelia and persistent digestive symptoms who underwent gastrointestinal transit scintigraphy to assess the extent of dysmotility. Liquid gastric emptying and small-bowel transit were normal. Large bowel showed poor activity in descending and rectosigmoid colon, being compatible with generalized slow colon transit.

Molekulare Bildgebung bei neurologischen Erkrankungen

In neurodegeneration and in neuro-oncology, the standard imaging procedure, magnetic resonance imaging (MRI), shows limited sensitivity and specificity. Molecular imaging with specific positron-emission tomography (PET) and single-photon emission computed tomography (SPECT) tracers allows various molecular targets and metabolic processes to be assessed and is thus a valuable adjunct to MRI. Two important examples are referred to here: amino acid transport for neuro-oncological issues, and the recently approved PET tracers for detecting amyloid depositions during the preclinical stage of Alzheimer's disease. This review discusses the clinical relevance and indications for the following nuclear medicine imaging procedures: amyloid PET, (18)F-fluorodeoxyglucose (FDG)-PET, and dopamine transporter (DaT)-SPECT for the diagnosis of dementia and the differential diagnosis of Parkinson's disease, in addition to amino acid PET for the diagnosis of brain tumors and somatostatin receptor imaging in meningioma.

Overview of ICRP Committee 3: protection in medicine.

Committee 3 of the International Commission on Radiological Protection (ICRP) develops recommendations and guidance for protection of patients, staff, and the public against radiation exposure when ionising radiation is used for medical diagnosis, therapy, or biomedical research. This paper presents a summary of the work that Committee 3 has accomplished over the past few years, and also describes its current work. The most recent reports published by the Commission that relate to radiological protection in medicine are 'Radiological protection in cone beam computed tomography' (Publication 129), 'Radiation dose to patients from radiopharmaceuticals: a compendium of current information related to frequently used substances' (Publication 128, in cooperation with Committee 2), 'Radiological protection in ion beam radiotherapy' (Publication 127), 'Radiological protection in paediatric diagnostic and interventional radiology' (Publication 121), 'Radiological protection in cardiology' (Publication 120), and 'Radiological protection in fluoroscopically guided procedures outside the imaging department' (Publication 117). A new report on diagnostic reference levels in medical imaging will provide specific advice for interventional radiology, digital imaging, computed tomography, nuclear medicine, paediatrics, and hybrid (multi-modality) imaging procedures, and is expected to be published in 2016. Committee 3 is also working on guidance for occupational radiological protection in brachytherapy, and on guidance on occupational protection issues in interventional procedures, paying particular attention to the 2011 Commission's recommendations on the occupational dose limit for the lens of the eye (Publication 118). Other reports in preparation deal with justification, radiological protection in therapy with radiopharmaceuticals, radiological protection in medicine as related to individual radiosusceptibility, appropriate use of effective dose (in cooperation with other Committees), and guidance for healthcare practitioners on radiological and patient protection. Committee 3 has also suggested specific priorities for research on radiological protection in medicine to the Commission.

Under the Beam: Dialysis Interventions

Nuclear medicine and molecular imaging procedures play an important role in the diagnosis, assessment, and treatment of many diseases. These include diseases of the heart, skeleton, brain, and kidneys as well as applications in oncology. The following article discusses various nuclear medicine diagnostic and therapeutic applications, and the technology behind them. Finally, radiation safety in the context of nuclear medicine will be discussed. It is important that all members of the nuclear medicine team are equipped to provide an appropriate discussion of the benefits and risks of nuclear medicine to our patients and their families.

An overview of nuclear medicine imaging procedures.

Nuclear medicine imaging is not generally well understood by nurses who work outside this area. Consequently, nurses can find themselves unable to answer patients' questions about nuclear medicine imaging procedures or give them proper information before they attend for a test. This article aims to explain what is involved in some common diagnostic nuclear medicine imaging procedures so that nurses are able to discuss this with patients. It also addresses some common issues about radiation protection that nurses might encounter in their usual working routine. The article includes links to videos showing some typical nuclear medicine imaging procedures from a patient's point of view and links to an e-Learning for Healthcare online resource that provides detailed information for nurses.

2013 Medicare Proposal Outlines New Reporting Rules

2013 Medicare Proposal Outlines New Reporting Rules

Nuclear Medicine Procedures in the Diagnosis of Orthopedic Infections

Nuclear medicine imaging procedures provide a unique physiological view of disease processes that may frequently precede anatomic changes visualized by other modalities. Orthopedic infections are particularly well served by these procedures because the presence of traumatic deformities or hardware i

Radiation doses originating from diagnostic procedures during the treatment and follow-upof children and adolescents with malignant lymphoma

Children with malignant lymphoma undergo many diagnostic procedures that involveexposure to ionising radiation. In addition, many, but by no means all, undergo furtherexposure to ionising radiation during radiotherapy. While therapeutic radiation exposuresare prescribed, the extent of radiation exposure arising from diagnostic procedures utilisedin such children is largely unknown. We completed an audit of the radiation doses arisingfrom diagnostic imaging procedures performed in a cohort of children with malignantlymphoma.The cumulative effective radiation dose associated with radiographic and radioisotopicprocedures was derived for 81 children and adolescents with malignant lymphoma duringtheir diagnosis, treatment and follow-up. Thirty-eight of the 42 patients (90%) withHodgkin lymphoma were alive at study termination, with follow-up periods ranging from1.9 to 11.7 years (median 5.3). Thirty-three of the 39 patients (85%) with non-Hodgkinlymphoma were alive at study termination with follow-up periods ranging from 2.4 to 12.3years (median 7.5). The median effective dose was 518 mSv for patients with Hodgkinlymphoma and 309 mSv for those with non-Hodgkin lymphoma. The maximumeffective dose was 1.7 Sv. The principal contributors to the effective dose werecomputed tomography (CT) and nuclear medicine imaging procedures using 67Ga. Protocols for the management of children and adolescents with malignant lymphomashould be reviewed in order to reduce the radiation detriment without loss of essentialdiagnostic information.

Imaging of Inflammation by PET, Conventional Scintigraphy, and Other Imaging Techniques

Nuclear medicine imaging procedures play an important role in the assessment of inflammatory diseases. With the advent of 3-dimensional anatomic imaging, there has been a tendency to replace traditional planar scintigraphy by CT or MRI. Furthermore, scintigraphic techniques may have to be combined with other imaging modalities to achieve high sensitivity and specificity, and some may require time-consuming labeling procedures. On the other hand, new developments such as combined SPECT/CT increase the diagnostic power of scintigraphy. Also, the advent of PET had a considerable impact on the use of nuclear medicine imaging techniques. In this review, we aim to provide nuclear medicine specialists and clinicians with the relevant information on rational and efficient use of nuclear medicine imaging techniques in the assessment of patients with osteomyelitis, infected vascular prostheses, metastatic infectious disease, rheumatoid arthritis, vasculitis, inflammatory bowel disease, sarcoidosis, and fever of unknown origin.

An automated method for preparation of [ 18F]sodium fluoride for injection, USP to address the technetium-99m isotope shortage

The worldwide shortage of technetium-99m has created an immediate and urgent need for access to [ 18F]sodium fluoride for PET imaging of bone metastasis. In order to facilitate global availability of [ 18F]sodium fluoride for diagnostic nuclear medicine imaging procedures, a straightforward method for rapid production of [ 18F]sodium fluoride for injection, USP, using a modified GE Tracerlab FX-FN is presented.