Technetium Sulfur Colloid :Technetium Sulfur Colloid Natasha Dehombre


Objectives :Objectives List all 11 TC Sulfur Colloid procedures Discuss the Indications as well as the contraindications Explain Patient prep and doses Discuss methods of administration /localization for each procedure Review the acquisitions for each procedure Explain what is normal and abnormal Discuss sources of error


ProceduresTechnetium Sulfur Colloid can be used for 11 procedures :ProceduresTechnetium Sulfur Colloid can be used for 11 procedures Bone Marrow Study Cystography Esophageal Transit Time Gastric Emptying Scan Gastroesophageal Reflux assesment Gastrointestinal bleed scan LeVeen Denver Shunt Liver/Spleen Scan Lymphoscintigraphy Serosal intercavity infusion Synovectomy


Bone Marrow Study :Bone Marrow Study Technetium Sulfur Colloid localizes by: phagocytosis by the reticular cells of the liver, Spleen, bone marrow, and lungs. The adult dose ranges from: 12 - 15 mCi Technetium Sulfur Colloid is administered IV, straight stick, or Intravenous catheter flush. Some indication for the study include: Evaluation of functional capacity of bone marrow Evaluation of bone marrow space enlargement Assessment of bone marrow for metastasis


Bone Marrow Study :Bone Marrow Study There are no Contraindications for this study. When is comes to patient preparation it is important to: Identify the patient - Explain the procedure Void before imaging - Verify Dr’s order As for acquisitions we will set up: Statics-100,000 to 200,000 counts Whole Body- 10-12cm per minute


Bone Marrow StudyThe Difference between normal and abnormal studies are: :Bone Marrow StudyThe Difference between normal and abnormal studies are: In normal studies: majority of radiotracer will visualize in the axial skeleton Relative radiotracer uptake is roughly 82% liver, 10% spleen, 8% bone marrow Active physiologic bone marrow in sternum, vertebral column, shoulders, humerus, pelvis, and femoral heads. In abnormal studies: Enlarged bone marrow space will present activity through the rest of the bony skeleton Increased liver and spleen size Increased visualization outside normal regions may indicate extramedullary hematopoiesis


Bone Marrow Study :Bone Marrow Study During this procedure there can be sources of error or artifacts here is a description of some of the causes. Liver/spleen uptake will make visualization of lower rib cage, lower thoracic and perhaps upper lumbar vertebrae difficult to analyze Patients with suppressed RES will affect he diagnostic value of the test. Lung uptake may indicate colloid clumping with radiopharmaceutical due to aluminum contamination of antacids or androgen therapy Chemotherapy may cause irregular distribution, hepatomegaly, and /or greater than normal shift to spleen and bone marrow.


Bone Marrow Study :Bone Marrow Study During patient interview patients should answer the following questions Is there a History or family history of cancer? If so what type, how long? Do you have any known blood disorders? Do you have a history of Liver/Spleen disease? History of Malaria or tropical disease? Anemia of any kind? Any recent trauma Diabetic? Feeling lethargic? High or low blood pressure Previous MRI, CT, PET scans or Xrays? Surgery on the bones? Recent blood work results Females: pregnant? Nursing?


Toxicity to hematopoietically active bone marrow is a primary limitation of radionuclide therapy. Accurate patient-specific skeletal dosimetry is crucial to avoiding marrow toxicity and tumor underdosing. In current assessments of skeletal dose, deposition of particle energy is tracked within an infinite extent of trabecular spongiosa, with no allowance for particle escape to cortical bone. Paired-image radiation transport (shown here in a model constructed for the right proximal femur) provides a more realistic 3-dimensional geometry for particle transport at both macroscopic and microscopic levels of the skeletal site. :Toxicity to hematopoietically active bone marrow is a primary limitation of radionuclide therapy. Accurate patient-specific skeletal dosimetry is crucial to avoiding marrow toxicity and tumor underdosing. In current assessments of skeletal dose, deposition of particle energy is tracked within an infinite extent of trabecular spongiosa, with no allowance for particle escape to cortical bone. Paired-image radiation transport (shown here in a model constructed for the right proximal femur) provides a more realistic 3-dimensional geometry for particle transport at both macroscopic and microscopic levels of the skeletal site.


Cystography :Cystography Technetium Sulfur Colloid localizes in two ways, Direct (retrograde) and indirect (antegrade) Direct localization (retrograde): -Compartmental, flows with saline and urine Indirect localization (antegrade): -Compartmental, blood (bound to protein and some red blood cells


Cystography :Cystography Adult Dose Range includes: Direct- .5-1 mCi Indirect- 3-10mCi Children’s dose range is adjusted to weight Technetium Sulfur Colloid is administered Direct(retrograde) by injection into foley catheter or Indirect (antegrade) by intravenous injection, butterfly or IV catheter. Some indications for the study includes: Evaluation/detection of vesicoureteral reflux Quantification of post void bladder residual Evaluation of management and continuing assessment of patients with reflux


Cystography :Cystography The only contraindication for this study is that indirect method is not recommended in patients with known significant renal dysfunction. When dealing with patient Prep it is important to: Identify patient -verify Dr’s order Explain procedure -signed consent PT must void before -catheterize pt for exam direct cystography


Cystography :Cystography As for Acquisitions, we will set up Direct flow: 1or2 sec. frames for 30 seconds to 1 minute during filling and voiding segments. Statics: 120 second images, bladder at full capacity and post void. Indirect flow and static: images during void and post void.


CystographyThe Difference between normal and abnormal studies are: :CystographyThe Difference between normal and abnormal studies are: In normal studies: No visualization of reflux of solution and tracer past bladder during filling and/or voiding. (normal valve action at ureterovesical junction depends on oblique entry of ureter into bladder, active ureter paraistalisis ) All or nearly all solution is voided from bladder In abnormal studies: Significant activity in upper urinary tracts during filling, at full capacity and/or while voiding Reflux is associated with causing UTI’s especially in pediatric patients Bacterial infections of the kidneys can present with fever, leukocytosis, and bacteremia.


Cystography :Cystography During this procedure there can be sources of error or artifacts here is a description of some of the causes. Recent contrast radiographic studies may interfer with results. Contamination of area by infusion leakage, etc Indirect method: reflux may be missed during filling phase, which is not imaged. Kidneys may retain radiotracer. Patient may not be able to hold contents of bladder for two hours until imaging or void on command


Cystography :Cystography During patient interview patients should answer the following questions Do you have a history or family history of renal obstruction or disease? History or family history of cancer? History of ureter, bladder, or urethra infections or obstructions? Any pains or problems with micturition? Adult female: Pregnant? Nursing?


Intravenous (indirect) radionuclide cystogram Retrograde (direct) radionuclide shows bilateral bladder to ureter reflux. cystogram shows bladder to left ureter At the time of urination (curve 1 reflux. registered above bladder) activity grow above both ureters and kidneys (other curves). :Intravenous (indirect) radionuclide cystogram Retrograde (direct) radionuclide shows bilateral bladder to ureter reflux. cystogram shows bladder to left ureter At the time of urination (curve 1 reflux. registered above bladder) activity grow above both ureters and kidneys (other curves).


Esophageal Transit Time :Esophageal Transit Time Technetium Sulfur Colloid localization is compartmental; esophagus to stomach The Patient dose ranges from 150-300 microcuries The methods of administration for this study include: Po in 15 ml of water, one bolus swallow Alternative: PO using 1.35 mCi TC99m SC in 50ml of apple sauce


Esophageal Transit Time :Esophageal Transit Time Some indications for this study includes: Evaluation of esophageal sphincter dysfunction Evaluation of dysphagia and decreased esophageal motility attributed to achalasia (delay in peristalsis and marked esophageal retention) Evaluation of PT’s who cannot tolerate manometry or with equivical or negative manometry results having reasonable suggestion of disease. Evaluation of clinical management by monitoring for serial changes or response to therapy Evaluation of swallow functioning due to abnormal results on related studies.


Esophageal Transit Time :Esophageal Transit Time Esophageal transit time has no contraindications. When is comes to patient preparation it is important to: Identify the PT Verify Dr’s order Explain procedure Ensure PT fasted for 8hrs or over night Instruct PT as to cooperation with swallowing As for acquisitions we will set up: Flow- .23 seconds/15 seconds for 1 minute Dynamic- 15sec/frame for 9 minutes


Esophageal Transit TimeThe Difference between normal and abnormal studies are: :Esophageal Transit TimeThe Difference between normal and abnormal studies are: In normal studies: Low count rates or none detectable 5-10 seconds after first swallow Transit rates >90% after 1 to 8 swallows <4% of the maximal activity in esophagus by 10 minutes. In abnormal studies: Transit Rates 5-40% after 8 swallows In patients with achalasia or scleroderma, transit may be reduced to 20-40% Diffuse esophageal spasm has significantly reduced transit Rate for first half of study, then normal after 20 swallows


Esophageal Transit Time :Esophageal Transit Time During this procedure there can be sources of error or artifacts here is a description of some of the causes. Inability to swallow or aspiration of dose Regurgitation with or without aspiration Attenuating articles or clothing


Esophageal Transit Time :Esophageal Transit Time During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and how long? History or esophageal motility dysfunction? Had any therapy Trouble swallowing? Pain when swallowing? Feel that you must swallow many times to get food down? Have any abdominal pain? History of Raynaud’s phenomenon? History of systemic sclerosis? History of reflux esophagitis? Recent or planned esophageal manometry study? Recent Barium x-ray study? Females: Pregnant? Nursing?


Gastric Emptying :Gastric Emptying The Localization of Technetium Sulfur Colloid for this procedure is compartmental; moved along with food through gastrointestinal tract The adult dose for this study is: 100uCi- 1 mCi In this study TC99m SC is administered in two ways, Solid and liquid: In solid administration: Radiotracer is usually mixedwith 1 or 2 whole eggs or egg whites (or oatmeal, beef stew, liver, some use sandwich) In Liquid administration: Radiotracer mixed into 120cc water or other (orange juice, milk) for liquid and ingested orally


Gastric Emptying :Gastric Emptying Some indications for this study include Determination of delayed gastric emptying with quantitation of gastric emptying rate evaluation of mechanical obstruction Evaluation of anatomic obstruction (pyloric, postsurgical, post-radiotherapy) Evaluation of suspected tumors or surgery The contraindications for this study include: Allergy to eggs; use oatmeal, baby food, sweet potatoes, chicken or beef livers, or beef stew Hypoglycemic patient


Gastric Emptying :Gastric Emptying When dealing with patient Prep it is important to: Identify the PT Verify Dr’s order Explain the procedure Ensure diabetics receive orange juice 2 hrs before test if necessary Ensure PT to be NPO 4-12 hours before examination Physician to discontinue sedatives 12 hours before examination. As for acquisition, we will set up: Statics Preset for 60-120 seconds or 50,000 counts Dynamics Preset for 60sec/image, 60-90 minutes


Gastric EmptyingThe Difference between normal and abnormal studies are: :Gastric EmptyingThe Difference between normal and abnormal studies are: In normal studies: Liquid (50%) at 10-56 minutes or 80% in 1 hr with an adult mean of 40 minutes. Solid (50%) movement out of stomach within a lower limit of 32 minutes to an upper limit of 120 minutes with an adult mean Terminate study before 60 minutes if gastric emptying becomes > or equal to 95% T1/2 (50%) for infant given breast milk: 25-45 minutes, or formula or bovine milk: 60-90 minutes In abnormal studies: Very little or no movement in stomach after 60 minutes. Cause of delayed gastric emptying are mechanical obstruction or altered function Rapid emptying may occur in cases of “dumping syndrome”


Gastric Emptying :Gastric Emptying During this procedure there can be sources of error or artifacts here is a description of some of the causes. Burnt eggs; nonuniform mixing of radiotracer Too much or too little food/ water Inconsistent amount of food will yield inconsistent data. Each patient should receive the same type, same amount Patient allergies or intolerance to eggs or food Patient unable to eat or may vomit or aspirate food and dose Belt buckles or buttons


Gastric Emptying :Gastric Emptying During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type? When? Diabetic? Abdominal pains? If so where and since when? Bloated or acid burning after eating? Nausea and or vomiting? History of ulcers? Hiatal hernia? Gastric surgery? On any medications? Relgan or Domperidone? Had previous related tests? Female: Pregnant? Nursing?


Gastroesophageal Reflux :Gastroesophageal Reflux The Localization of Technetium Sulfur Colloid for this procedure is compartmental, esophagus to gastrointestinal tract The adult dose range for this study is 300uCi to 2mCi; 1 mCi or more if acidified orange juice is used. The methods of administration for this study includes: Oral (PO) in water, orange juice, milk, wet oatmeal, or saline total of 300ml PO with acidified orange juice (150ml orange juice and 150ml of 0.1 normal HCI) to delay gastric emptying time and propose the PT to reflux Ingested through a nasogastric tube if Pt has a history of esophageal motility dysfunction or for children


Gastroesophageal Reflux :Gastroesophageal Reflux Some indications for this study include: Detection and quantitation of gastroesophageal reflux Evaluation of Pt’s with diaphragmatic hernia Evaluation of Pt’s with heartburn regurgitation, or bilious vomiting Evaluation of children with asthma, chronic lung disease, or aspiration pneumonia There are no contraindications for this study


Gastroesophageal Reflux :Gastroesophageal Reflux When dealing with patient Prep it is important to: Identify the PT -Verify Dr’s order Explain the procedure Ensure Pt has fasted for 8 hours or overnight As for acquisition, we will set up: Statics 30sec/image; some go for 300,000-500,000 counts


Gastroesophageal refluxThe Difference between normal and abnormal studies are: :Gastroesophageal refluxThe Difference between normal and abnormal studies are: In normal studies or equal to 4-5% refluxed radiotracer Activity will appear to be refluxing up the esophagus towards the mouth For pulmonary aspiration, activity in the lungs. Detection of aspitation during esophageal reflux exams is 0-25%


Gastroesophageal Reflux :Gastroesophageal Reflux During this procedure there can be sources of error or artifacts, here is a description of some of the causes. Inability to swallow or aspiration of dose Esophageal retention Regurgitation with or without aspiration Attenuating articles or clothing Patient with known esophageal varices (potentially life-threatening condition involving dilation of distal esophageal blood vessels usually associated with chronic obstruction of venous drainage from esophageal veins into the hepatic portal system caused by cirrhosis of the liver and alcoholism) perhaps not enough for a contraindication, but consideration may be given to this condition


Gastroesophageal Reflux :Gastroesophageal Reflux During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? History of esophageal motility disfunction? Feel burning or pain in upper abdomen or lower chest after eating? Have liver disease? Stomach disease or problem? After a meal, does it taste like gastric juices when you belch (mini-vomit)? Female: Pregnant? Nursing?


Gastrointestinal Bleed :Gastrointestinal Bleed Technetium Sulfur Colloid localizes by: Compartmental, tagged to and circulating with blood. The Adult Dose range for this study is: 10-20mCi For this procedure the methods of administration are: Intravenous injections, or drawing, tagging and reinjection of tagged red blood cells


Gastrointestinal Bleed :Gastrointestinal Bleed Some indications for this study include: Detection and localization of bleeding sites in patients with active or intermittent gastrointestinal bleeding. Detection and localization of secondary blood loss as in blood pooling in peritoneal cavity or ruptured arterial venous supplies Detection and localization of actively bleeding sites for patients with portal hypertension and hypertension to abdominal collateral vessels Some contraindications for this study include: Patients with contrast studies under way Medically unstable patient (uncontrolled hypotension)


Gastrointestinal Bleed :Gastrointestinal Bleed When dealing with patient Prep it is important to: Identify the PT -Verify Dr’s order Explain the procedure Obtain signed consent for blood work Instruct Pt to empty bowel and bladder before beginning procedure If possible have Pt’s or attending nurse look for active signs of bleeding Check Pt’s current vital signs (blood pressure and heart rate) and assess for orthostatic hypotension Obtain lab work and information concerning recent blood transfusion


Gastrointestinal Bleed :Gastrointestinal Bleed As for acquisition, we will set up: Flow: 2-5sec/frame, 60-180 seconds Dynamics: 60sec/frame for 60 minutes Statics: 500,000 counts- 2 million counts


Gastrointestinal BleedThe Difference between normal and abnormal studies are: :Gastrointestinal BleedThe Difference between normal and abnormal studies are: In normal studies: Heart vascular space of liver and spleen and great vessels prominent Soft tissue uptake Is light and homogeneous Bladder, bowel, and penile activity not unlikely In abnormal studies: Flow-focal area of increased activity may also be present Dynamic study-focal area that may or may not move with time. Statics-focal area peristalses with time. Blood pool may persist in anbdominal cavity and may or may not move If little or no movement it may be vascular activity or pool in abdominal cavity. Typical focal areas of active bleeding include ascending, transverse, descending sigmoid colon Uptake with no change overtime may be inflammatory bowel disease or bad tag excreted into bowel


Gastrointestinal Bleed :Gastrointestinal Bleed During this procedure there can be sources of error or artifacts, here is a description of some of the causes. Bad radiotracer tag could lead to poor results. Do a thyroid image to confirm bad tag. Belt buckles articles in clothing, necklaces etc. may attenuate the image A full bladder may mask the imaging area Mesenteric varices, uterine or penile blood pool hepatic hemangioma, accessory spleen, and/or renal pelvis of transplanted kidney may may be interpreted as false positives Intermittence of bleeding compounds the problem of detection


Gastrointestinal Bleed :Gastrointestinal Bleed During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? History of bleeding? Are you bleeding now? If so for how long? What is the color of the stool? Do you have active history of internal or external hemorrhoids (non bleeding or actively bleeding)? Taking aspirin or blood thinners? Do you have pain? History of diverticulitis, Crohn’s disease or other diseases? Colostomy or other surgery? Ever had endoscopy, CT, upper GI, Barium enema, colonoscopy? Recent blood transfusions Recent lab work? Female: Pregnant? Nursing?


LeVeen Shunt or Denver Shunt Patency :LeVeen Shunt or Denver Shunt Patency Technetium Sulfur Colloid in this study localizes: compartmentally, peritoneal cavity to blood circulation. The adult dose range for this procedure: 3mCi Methods of administration include: Intraperitoneal injection with local anesthetic by physician Typically lower left quadrant. Can be guided by ultrasonography to localization of ascites Usually administered in 7-10 mL of normal saline solution.


LeVeen Shunt or Denver Shunt Patency :LeVeen Shunt or Denver Shunt Patency Some indications for this study include: Evaluation of LeVeen shunt (peritoneavenous) patency (shunts ascitic fluid from the peritoneal cavity to the venous circulation using a low pressure valve activated by breathing exercises, inserted into the abdominal wall with collection tube inserted through the jugular vein into the superior vena cava Evaluation of increasing ascites secondary to the use of implanted shunt ex. Increased sodium consumption, inadequate diuretic agents, worsening liver or heart failure


LeVeen Shunt or Denver Shunt Patency :LeVeen Shunt or Denver Shunt Patency The only contraindication for this procedure is: Patients with pulmonary hypertension may be a consideration with Technetium MAA When dealing with patient Prep it is important to: Identify the PT - Verify Dr’s order -Explain procedure Prepare Pt for intraperitoneal injection Supplies for procedure: 20-ga needle 25-ga needle (2) 3 cc syringes 1% lidocaine 3-way stop cock Sterile gloves Sterilization solution/ swabs (3) 4x4 sterile gauzes Arrange for paracentesis by physician


LeVeen Shunt or Denver Shunt Patency :LeVeen Shunt or Denver Shunt Patency As for acquisition, we will set up: Flow: Denver shunt; 3 sec/frame for 60 seconds. Injection directly into pump Statics: 180-300 sec/image or 500,000 counts Dynamic: 10 minutes/frame for 6 frames Whole Body Sweep Check length of patient, patient orientation, 8-10cm/ minute


LeVeen or Denver Shunt PatencyThe Difference between normal and abnormal studies are: :LeVeen or Denver Shunt PatencyThe Difference between normal and abnormal studies are: In normal studies: Lung and/or shunt tubing present within 60 minutes. Usually this is a rapid visualization (within 10-30 minutes of injection) Liver is the target organ within 30 minutes. This method is not presently used as much because of the difficulty of separating the liver from the ascities In abnormal studies: No activity in the liver after 4 hour delays, indicating obstruction Activity stops at abdominal pump; very little or no activity in tubing (indicating valve failure or obstruction in tubing.


LeVeen or Denver Shunt Patency :LeVeen or Denver Shunt Patency During this procedure there can be sources of error or artifacts, here is a description of some of the causes. Risk of infection with injection, Patient should be monitored Jewelry, medallions, buttons items in shirt pockets, or belt buckles can cause artifacts. Also note any surgically implanted devices. If little or no visualization of the lungs with visualization of the superior vena cava and right heart, check Pt history for compromising diseases, operations and cancers If no visualization of radiotracer in abdomen check needle and radiotracer tag


LeVeen or Denver Shunt Patency :LeVeen or Denver Shunt Patency During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? Have abdominal pain? Abdominal distension? If so more so than before or after surgery? Female: Pregnant? Nursing?


Intraperitoneal administration of the tracer with scanning time up to 3 hours. Good clearance from peritoneum and tracer uptake in the lungs proves shunt patency. :Intraperitoneal administration of the tracer with scanning time up to 3 hours. Good clearance from peritoneum and tracer uptake in the lungs proves shunt patency.


Liver/Spleen Scan :Liver/Spleen Scan Technetium Sulfur Colloid localizes by: phagocytosis by the reticular cells of the liver, Spleen, bone marrow, and lungs The adult dose ranges from: 2-7mCi The methods of administration for this procedure are: Intravenous, IV injection or IV catheter and flush. Invert syringe before administering the dose to mix particles


Liver/Spleen Scan :Liver/Spleen Scan Some indications for this study include: Assessment of anatomy, size and relative position of liver and spleen Assessment of hepatomegaly, splenomegaly, splenic infarcts, accessory spleen or splenosis Assessment of benign mesenchymal (kupffer cells) focal lesions (hemangioma, hamartoma) and hepatocellular focal nodular hyperplasia Assessment of chronic liver or spleen disease Detection and assessment of hepatic or splenic trauma Evaluation for liver disease, chronic anemia, leukemia, or other blood disorders. Evaluation of hepatic infaction


Liver/Spleen Scan :Liver/Spleen Scan The only contraindication for this procedure is: Study should be performed before any iodinated or barium containing contrast agents. Particularly barium in the colon may result in artificial defects with the liver and spleen. When is comes to patient preparation it is important to: Identify the patient Verify Dr’s order Explain the procedure If available write concentrations of alanine amino tranferase, lactate dehydrogenase, and total bilirubin on history sheet


Liver/Spleen Scan :Liver/Spleen Scan As for acquisition, we will set up: Flow: 1-3 sec/frame for 1 minute followed by immediate static pool (60 seconds or 500,000 counts) Statics 500,000 – 1 million counts SPECT 120 stops at 30 sec/stop


Liver/Spleen ScanThe Difference between normal and abnormal studies are: :Liver/Spleen ScanThe Difference between normal and abnormal studies are: In normal studies: Flow-Because liver is fed 75% by portal system, there should be -6 second delay from aorta presenting to liver presenting. Liver will show dimly at first from aortic flush Statics-Liver and spleen should have equal heterogeneous distribution with little or no bone marrow uptake Relative radiotracer uptake is 85% in liver, 10% spleen and 5% bone marrow In abnormal studies: Colloid shifting presents in marrow, spleen, lungs, and kidneys. These may be caused by severe liver dysfunction Hotspots: tumors, superior vena cava obstruction, Budd-Chiari syndrome (hepatic thrombosis) Cold spots: metastatic tumors, hepatomas, adenomas, abscess, cyst, infarction. Accumulation in renal transplant indicates rejection of that organ


Liver/Spleen Scan :Liver/Spleen Scan During this procedure there can be sources of error or artifacts, here is a description of some of the causes. Tape marker due to clothes or camera to prevent movement and distortion of holes in marker For females breast may cause attenuation. Patient can hold them up out of FOV or they can be tapped Lung uptake caused by aluminum contamination of antacids or virilizing androgen therapy, or large colloid size may indicate colloid clumping within radiopharmaceutical Increased spleen uptake caused by nitrosources, recent halothane or mrthylcellulose Decreased spleen uptake caused by chemotherapy, epinephrine, and antimalarials Deep lesions may be missed Deep respirations may blur images


Liver/Spleen Scan :Liver/Spleen Scan During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? History of liver /spleen disease? History of tropical diseases? Abdominal pains? Recent trauma? Feeling lethargic? High blood pressure? Diabetic? Had any previous related scans X-ray’s or recent barium studies? Surgery on liver or spleen? Recent blood work results? Assess Pt for jaundice and possible alcohol abuse Hepatic artery catheter? Had radiation chemotherapy? Pregnant or nursing? Taking birth control pills?


Slide 62:99mTc-Sulfur colloid SPECT (fused with simultaneously acquired CT) scan in patient with enhancing liver mass. Colloid uptake in mass typical of focal nodular hyperplasia


Lymphoscintigraphy :Lymphoscintigraphy Technetium Sulfur Colloid localizes by: Compartmental, phagocytosis The Adult Dose range for this study: 200uCi- 2 mCi; 450uCi- 1 mCi is typical, two to six injections some up to 7 mCi total. Methods of administration: For Melanoma: injections, 2-6 subcutaneous and/or intradermal. For breast lesions: intraglandular injection 4-6 injections placed into tissue surrounding lesion found by palpitation, needle aspiration or ultrsound. For lymphedema: Injections, 2 sites per limb, subcutaneous


Lymphoscintigraphy :Lymphoscintigraphy Some indication for the study include: Evaluation of staging (spreading) of cancers Evaluation of lymphatic kinetics Detection of metastatic invasion of the lymph nodes Evaluation of node resection Evaluation of chronic lymphedema of swollen extremity Differentiation of primary and secondary lymphedema This study does not have any contrindications


Lymphoscintigraphy :Lymphoscintigraphy When is comes to patient preparation it is important to: Identify the patient Verify Dr’s order Explain the procedure Wipe area with alcohol pad, shave if necessary; clean area with Betadine or chosen sterilizing solution For breast study patient is to bring mammograms and any related studies with her (outpatient) or make previous related studies available (inpatient) For breast study Patient is instructed to massage area of injection after injections and between imaging sessions For lymphedema, physician to instruct patient to wear elastic stockings. These should be removed 3-4 hours before study.


Lymphoscintigraphy :Lymphoscintigraphy As for acquisition, we will set up: Flow: 30-60 sec/frame, 10-15 minutes Immediate Statics: Collect for 5 minutes (300 seconds) every 5 minutes for up to 30 minutes Whole Body: Set for 10-15 cm/minute Delay: 40,000-200,000 counts or 5 minutes each


LymphoscintigraphyThe Difference between normal and abnormal studies are: :LymphoscintigraphyThe Difference between normal and abnormal studies are: In normal studies: The radiotracer enters the lymphatic systems through normal channels and proceeds through the system into the major lymphatic beds. Visualizing the sentinel node or nodes is normal within the first Half hour After 4 hours a chain of activity should visualize in the inguinal, iliac, and/or pre-aortic regions Liver should also be present A biopsy of those nodes, once removed will yield the result In abnormal studies: None or only some of the expected nodes visualizing Continuity of chain interrupted or abdominal pathway created by tumor replacement of node or lymphatic obstruction Enlargement of chain width because of lymphoma, congestion, or lymphadenitis Unexpected intensity difference; reduced in malignant lymphoma or increased in congestion and lymphadenitis


Lymphoscintigraphy :Lymphoscintigraphy During this procedure there can be sources of error or artifacts, here is a description of some of the causes. A “star” artifact, caused by the intensity of the injection site(s), may obscure nodes in the proximaity from presenting properly Injection sites that are too distant from the ROI may obscure primary nodes close to the lesion. the injection (s) may not migrate as expected if there is intervening scar tissue from a prior surgery or injury One view of the presenting nodes may not be enough to properly locate the nodes or node multiple views including anterior, posterior, oblique, and laterals may be needed Some nodes are small or weak in intensity. Enough counts and care must be taken to locate all that might be present


Lymphoscintigraphy :Lymphoscintigraphy During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? Is this a pre surgery or post surgery study? Had any surgery in area of interest? Where is the site/sites under scrutiny? Had recent biopsies? Had past or recent related scans PET, CT, MRI etc? History of lymphedema? Female: Pregnant? Nursing?


Lymphoscintigraphy after the peritumoral injection. For 1 hr after the injection, dynamic lymphoscintigraphy was performed every 5 min in the anterior and lateral views and then until 2 hr prior to surgery at an interval of 3-6 hr, with static images obtained to monitor the residual radioactivity. :Lymphoscintigraphy after the peritumoral injection. For 1 hr after the injection, dynamic lymphoscintigraphy was performed every 5 min in the anterior and lateral views and then until 2 hr prior to surgery at an interval of 3-6 hr, with static images obtained to monitor the residual radioactivity.


Therapy: Intercavitary (Serosal) :Therapy: Intercavitary (Serosal) Technetium Sulfur Colloid localizes by: Compartmental to serosal cavity, Macrophages consume colloid particles and become fixed on serosal compartmental lining The adult dose Ranges from: 2-3mCi Technetium Sulfur Colloid is administered: Intracath placement is into cavity of concern through which the therapy is administered


Therapy: Intercavitary (Serosal) :Therapy: Intercavitary (Serosal) Some indication for the study include: Palliation by reduction of recurrent effusion in serosal cavities secondary to malignant disease, especially those not successfully treated with sclerosing agents such as tetracycling Prevention of recurrence of malignant disease on serosal surfaces Treatment of cystic neoplasms Treatment of malignant ascites(especially ovarian source) Some contraindications include: Patients with intraperitoneal infection Patients with >6monthe life expectancy Detection of the presence of loculated fluid


Therapy: Intercavitary (Serosal) :Therapy: Intercavitary (Serosal) When is comes to patient preparation it is important to: Identify the patient Verify Dr’s order Explain the procedure The written directive must be signed by authorized user Obtain a signed consent from the patient Patients receiving intrapleural administration must have a thoracentesis to remove the effusion


Therapy: Intercavitary (Serosal) :Therapy: Intercavitary (Serosal) As for acquisition, we will set up: Statics 250,000 counts or 180 second images


Therapy: Intercavitary (Serosal)The Difference between normal and abnormal studies are: :Therapy: Intercavitary (Serosal)The Difference between normal and abnormal studies are: In normal studies: Palliation of the pain caused by excess fluid within affected cavity. Maximum effect occurs at 3 month. Dose may need repeating Temporary therapeutic treatment (remission) of cancer causing the production if excess fluid within the affected cavity Serosal cavity present as thoroughly and evenly perfused with radiotracer In abnormal studies: Little no palliative relief of pain and/or cancer causing the production of excess fluid within the affected cavity Images may have clumping or subspaces with more activity than others


Therapy: Intercavitary (Serosal) :Therapy: Intercavitary (Serosal) During this procedure there can be sources of error or artifacts, here is a description of some of the causes. Do not use as IV injection, radiotherapy colloid will localize in the liver. The preparation should be a cloudy, brownish green colloidial suspension. Any leakage from the therapy site must be treated as radioactive spill and cleaned in accordance with precautions pertaining to beta emitters There are newer non radioisotopic drugs being used for therapy as well as newer Y90 labeled monoclonal antibody and microsphere therapies


Therapy: Intercavitary (Serosal) :Therapy: Intercavitary (Serosal) During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? Presently experiencing pain? If so for how long? Feel you have fluid build up? If so how long? Have results of any other related examinations? Results of any recent laboratory tests? Had any other therapy? If so what type and when? Female: Pregnant? Nursing?


Therapy: Intra-articular (Joint) Synovectomy :Therapy: Intra-articular (Joint) Synovectomy Technetium Sulfur Colloid localizes by: Compartmentalization to synovial cavity The adult dose: 1mCi (weight Based) Method of administration: Injection through needle placement into a joint (synovial) cavity. Some indications include: Palliation of joint pain caused by rheumatoid arthritis Palliation of joint pain caused by hemophilic arthropathy Palliation of joint pain caused by villondular synovitis


Therapy: Intra-articular (Joint) Synovectomy :Therapy: Intra-articular (Joint) Synovectomy For this procedure there are no contraindications When is comes to patient preparation it is important to: Identify the patient Verify Dr’s order Explain the procedure The written directive must be signed by authorized user Obtain a signed consent from the patient Patients with hemophilia are usually given factor VIII before therapy at 24 and 72 hours after therapy. This is also required In known cases of factor IX deficiency Patient must bring laboratory results and recent X-ray films of area of interest


Therapy: Intra-articular (Joint) Synovectomy :Therapy: Intra-articular (Joint) Synovectomy As for acquisition, we will set up: Statics 250,000 counts or 180 second images


Therapy: Intra-articular (Joint) Synovectomy :Therapy: Intra-articular (Joint) Synovectomy In normal studies: Reduction of pain associated with the affected joint Reduction of inflammation within the affected joint Reduction of degradation of cartilage and bone within the affected joint Improvement of the function of the affected joint Joint space presents as thoroughly and evenly perfused with radiotracer In abnormal studies: Little or no palliative effect felt in affected joint Images may have clumping or subspaces with more activity that others


Therapy: Intra-articular (Joint) Synovectomy :Therapy: Intra-articular (Joint) Synovectomy During this procedure there can be sources of error or artifacts, here is a description of some of the causes. Extravasation of therapy dose or misplacement of needle will, depending on extent, negatively affect the usefulness of the therapy Do not use IV injection. Radiotherapy colloid will localize in the liver. The preparation should be a cloudy brownish green colloidal suspension


Therapy: Intra-articular (Joint) Synovectomy :Therapy: Intra-articular (Joint) Synovectomy During patient interview patients should answer the following questions: Do you have a history or family history of cancer? If so what type and for how long? History of joint disease? Experiencing pain at present? Results of previous lab tests and/or recent scan results? What other means of therapy are u currently undergoing? Recent operations? Female: Pregnant? Nursing?


Summary :Summary We were able to discuss all 11 Tc99m SC prodecures, Bone Marrow Study Cystography, Esophageal Transit Time, Gastric Emptying Scan, Gastroesophageal Reflux assessment, Gastrointestinal bleed scan, LeVeen Denver Shunt, Liver/Spleen Scan, Lymphoscintigraphy, Serosal intercavity infusion, Synovectomy Also we were able to discuss the indication as well as the contraindications for all 11 procedures Took a good look at the precautions that should be taken while performing certain procedures as well as the acquisition for each We were also able to determine what the essential patient preparations were as well as how to determine what normal and abnormal studies look like


Question1 :Question1 How does Technetium Sulfur Colloid localize in the bone marrow ?


Answer :Answer phagocytosis by the reticular cells of the liver, Spleen, bone marrow, and lungs.


Question 2 :Question 2 What are some indications for a cystograph?


Answer :Answer Some indications for the study includes: Evaluation/detection of vesicoureteral reflux Quantification of post void bladder residual Evaluation of management and continuing assessment of patients with reflux


Question 3 :Question 3 In which procedure is Tc99m SC administered in both solid and liquid?


Answer :Answer Gastric Emptying


Question 4 :Question 4 Where would Tc99m SC localize in a gastroesophageal reflux study


Answer :Answer The Localization of Technetium Sulfur Colloid for this procedure is compartmental, esophagus to gastrointestinal tract


Question 5 :Question 5 What test/scan would be performed given these indications? Detection and localization of bleeding sites in patients with active or intermittent gastrointestinal bleeding. Detection and localization of secondary blood loss as in blood pooling in peritoneal cavity or ruptured arterial venous supplies Detection and localization of actively bleeding sites for patients with portal hypertension and hypertension to abdominal collateral vessels


Answer :Answer Gastrointestinal Bleed


Question 6 :Question 6 What does ETT stand for?


Answer :Answer Esophageal Transit Time


Question 7 :Question 7 What test/scan is this?


Answer :Answer Liver /spleen scan


Question 8 :Question 8 How does TC99m SC localize in a liver /spleen scan?


Answer :Answer Technetium Sulfur Colloid localizes by: phagocytosis by the reticular cells of the liver, Spleen, bone marrow, and lungs


Question 9 :Question 9 Name indications for a Lymphoscintigraphy study


Answer :Answer Some indication for the study include: Evaluation of staging (spreading) of cancers Evaluation of lymphatic kinetics Detection of metastatic invasion of the lymph nodes Evaluation of node resection Evaluation of chronic lymphedema of swollen extremity Differentiation of primary and secondary lymphedema


Question 10 :Question 10 These are indications for which type of scan? Palliation of joint pain caused by rheumatoid arthritis Palliation of joint pain caused by hemophilic arthropathy Palliation of joint pain caused by villondular synovitis A) Therapy: Intercavitary (Serosal) B) Therapy: Intra-articular (Joint) Synovectomy C)Palliative therapy D)Palliative joint therapy


Answer :Answer B) Therapy: Intra-articular (Joint) Synovectomy


References :References Nuclear Medicine Technology: Procedures and quick Reference second edition Pete Shackett 2000 351west camden street BaltimoreMD 21201 Nuclear Medicine and PET/CT sixth edition technologies and techniques edited by Paul E Christian, Kristen M. Waterstram-Rich Rochester Institute of Technology Rochester, New York