Inflammatory and tumor Imaging and Therapy :Presented by: Gustavo Thondik Inflammatory and tumor Imaging and Therapy


Objectives :Objectives Discuss the evolution of infection imaging from Gallium-67 to Indium-111 to Technetium-99m Describe the imaging procedures for Parathyroid, Prostate, colorectal, neuroendocrine, adrenal and lung tumor


Inflammatory imaging :Inflammatory imaging There are many radiopharmaceutical used to imaging infectious condition Gallium 67 was first used in 1965 It is cyclotron produced by bombardment of zinc oxide target Ga-67 has a half-life of 78 hrs and decay by electron capture


Gallium Scan :Gallium Scan RADIPHARMACEUTICAL: Gallium citrate LOCALIZATION: Lysosomes of the WBC DOSE: Inflammation 5mCi Infection 5mCI Tumor 10mCIa METHOD OF ADMINISTRATION: IV straight stick Indications: Inflammation (abscesses), tumors, fiver of unknown origin, osteomyelitis, and pulmonary disorders. Contraindications: PT having other nuclear medicine study during the time period needed for Ga67 citrate. Patient cannot have contrast stuffy during the time period needed for gallium scan.


Slide 5:PATIENT PREPARATION: Id the pt, verify Dr’s order. Explain the procedure. Administer injection to the pt Instruct the pt to return for image at designated time 6,24,48,72,96,120 hrs Instruct the patient to return home or send back to hospital room to wait images. EQUIPMENT Camera Large field of view   Collimator: Medium to high energy, parallel hole.   Computer set up: Static: Peak gallium, window at 25% 1mill counts/image   Whole body: 10cm/min   SPECT: Circular or noncircular 360 degrees 64stops, 20-25 sec/stop: ROI centered.


Slide 6:PPROCEDURE: (Time 20-60min) Instruct pt to void on return to dept Place pt in supine position: check for attenuating material. Obtain static image: A/P of head, thorax, abdomen, pelvis, and mid-femur; also ant of extremities, Oblique’s of ROI, axillas for history of lymphoma. Collect 600k to 1mill counts according to protocol Whole body sweep: head to at least mid-femur. Center ROI   NORMAL RESULTS: Soft tissue activity at 6-24hrs, renal activity at 24hrs Some bowel activity that moves over time Lactoferrin content visualized lacrimal glands, salivary glands, external genitalia, breast, nasopharynx, bone marrow, spleen, and liver. Some early activity in sternum, lung, thymus, surgical wounds, and epiphyseal plates; thymus and spleen in children. At 48hrs and beyond, renal and lung activity light; lacrimal and salivaries dimly: some nasal activity present: liver, transverse colon, thoracic spine, sternum, scapula, tips, skeleton and genitalia still present


Slide 7:ABNORMAL RESULTS: Inflammation show up as a hot spot within 6hrs Also 6hrs scan for abdomen abscess Any bowel activity in the 4-6 hrs scan is significant in pt with AIDS having a fever. Large hematomas present as cold spots Benign sarcoidosis present as intense uptake in organs. Tumors are usually scanned are 24-48 hrs and beyond Can show AIDS-related pulmonary infections, neoplasia associated with Hodgkin’s disease, heapatomas from alcoholic cirrhosis, and malignant melanomas of bone, brain, and lungs. Persistent renal activity at 72 hrs may indicate inflammation, infection, acute tubular necrosis, acute pyelonephritis, interstitial nephritis, amyloidosis, or impaired renal function.


Slide 8:ARTIFACTS: Articles in the pocket, medallions necklaces, metal bottoms on shirts and blouses, belt buckle, and prostheses may cause attenuation. Pt not voiding before the scan. Bladder activity could mask ROI. Wrong collimator will burn film Care must be taken for analog cameras to have proper anatomy in view as picture hard to visualize on standard p-scopes. False positive results possible from intestinal, spleen, spine, or bladder activity.


Indium-111 :Indium-111 In-111 chloride was first used in 1970 It had an advantage over the Ga-67 – Not concentrate in GI tract In-111 oxine-labeled white blood cell (WBC) demonstrate be superior to In-111 chloride and Ga-67 In-111 has a physical half-life of 2.8 days (67.4 hrs) and it decay by electron capture Imaging performed 3-24 hrs after injection Doses: 500- 600 uCi In-111 WBC, Medium Energy collimators, 20% window


Technetium Tc-99 Exametazine (Ceretec) :Technetium Tc-99 Exametazine (Ceretec) It initially known as hexamethylpropylene amine oxine (HMPAO). Originally used for cerebral blood flow scintrgraphy In 1990, Tc-99m labeled leukocytes began used for inflammation/infection detection Doses: 10 mCi Anterior and posterior whole body images takes after 4-24 hrs delay Use Low energy collimators


Tumor imaging :Tumor imaging Ga-67 was used to diagnose lung tumors, mediastinal involvement, lymphoma and others tumors Receptor-specific radiolabeled monoclonal antibodies and their fragments has used to detect and treatment of tumors as colorectal, lung, prostate, no-Hodgkin’s lymphoma (NHL) Antibodies are immunoglobulins produced by B-lymphocytes or plasma cells in response to an antibody


Parathyroid :Parathyroid Primary hyperparathyroidism is common in women over 40 years old ( 1 in 500 women) Initially, parathyroid imaging was performed with thallium-201 and Tc-99m pertechnate Tc-99m Sestamibi has become standard imaging protocol Doses: 20 mCi Tc-99m Sestamibi Flow study- after injection Thyroid phase- after 15-20 min Parathyrodi phase- after 2 hrs Use pinhole or parallel-hole collimators


Prostate Cancer :Prostate Cancer Prostate cancer is the second cause of cancer death in men In-111 capromab pendetide (Prostatin) is a monoclonal antibody used in the diagnose of prostate cancer In-111 capromab penditide is an IgGI murine monoclonal antibody (mab) direct action to prostatic specific membrana antigen (PSMA) Doses: 5 mCi In-111 capromab pendetide The liver is the critical organ Contraindication: Hypotension, Hypertension Preparation: Laxative 24 hrs prior to imaging and urinary catheter Medium energy collimator, 15-20% window, 140 keV, Camera 128 x 128, 360 degree rotation


Indium In-111 prostascint :Indium In-111 prostascint


Colorectal Cancer :Colorectal Cancer Technetium-99m arcitumomab is used to diagnose colorectal cancer Tc-99m arcitumomab is antibody fragment (Fab) generated from IMMU- 4, a murine IgGI monoclonal antibody Doses: 20 -30 mCi, critical organ is the kidney Pt preparation- include adequate hydration prior injection Low-energy, high-resolution collimator or low-energy all purpose collimator 15-20 % window, 140 keV, 800,000 to 1 million planar or whole body images of chest, abdomen and pelvis 2-3 hrs after injection, 64 x 64 or 128 x 128 matris


Lung Cancer :Lung Cancer Technetium-99m depreotide is indicated for identification of somatostatin receptor-bearing pulmonary masses in pt with pulmonary lesions 15-20 mCi Tc-99m depreotide SPECT images after 2-4 hrs injection Pt arms extend should be extended above the head and immobilized LEAP, 15-20 % window, 128 x 128 matrix, 360 grades rotation


Theraphy :Theraphy Radioimmunotherapy – Combines killing efficiency of radiation with a monoclonal antibody engineered target proteins of tumor cells Lymphoma cancer is a hematologic malignancy categorized as Hodgkin’s lymphoma (HD) or no-Hodgkin’s lymphomas (NHLs). The NHL is the most prevalent Iodine I-131 Tositumomab (Bexxar)- A murine IgG2a lambda monoclonal antibody direct against the CD20 antigen found in on the surface of normal and malignant B-lynphocytes Y-90 ibritumomab Tiuxetan (Zevalin) – This antibody found in the B cells


Radionuclide Therapy of Bone Pain :Radionuclide Therapy of Bone Pain An effective palliative treatment for pt with osteoblastic bone metastasis and bone pain Use in treatment of bone pain: Sr-89 chloride; Sm-153 lexidroma and P-32 sodium phosphate Sr-89 chloride (Metastron): Activity target- osteoblastic bone lesions; Doses- 40 to 60 uCi/kg; IV; Critical organs- bone surface and red bone marrow Sm-153 lexidroma (Quadramet): Phosphate compound that concentrates in bone mineral; Doses- 1 mCi/kg; IV P-32 sodium phosphate: Distribute in bone as stable phosphate; 5 to 10 mCi; IV or Oral