ENDONCRINE GLANDS RADIOISOTOPE IMAGING...

ENDONCRINE GLANDSRADIOISOTOPE IMAGING AND THERAPY

THYROID GLAND TRAPPING MECHANISM : 99mTc-04Na (γ)IODINATION: 123I (γ), 131I (β), 125I (Auger e-)METABOLISM: 18FDG, 201TI (x), 99mTcMIBI (γ)

PARATHYROIDS METABOLISM (K): 201TI(x), 99mTc-MIBI (γ)

ADRENAL CORTEX STEROIDOGENESIS: 131I(123I) CHOLESTEROL

ADRENAL MEDULLA NORADRENALIN SYNTHESIS: 131I(123I) MIBG

PITUITARY GLAND RECEPTORS: 18F-BROMOCTYPTINE111In- 99mTc-OCTREOTIDE

RVH (RENIN) ACE-INHIBITORS 99mTc-MAG3/LASIX

SOMATOSTATIN RECEPTOR IMAGING: 111In-OCTREOTIDE

EMBRYOLOGY OF THE ADRENAL GLANDS

ADRENAL IMAGINGCORTEX: 131I(123I) CHOLESTEROL or NP-59

(On/Off Dexamethasone Suppression)

Carcinomas Do Not Visualize

MEDULLA: 131I (123I) META-IODO-BENZYL-GUANIDINE or MIBG

Carcinomas Visualize with MIBG

MEDULLA also:111In-SOMATOSTATIN ANALOGUE

or Octreotide

ADRENAL GLANDS

Normalglands

lesionresponseto DXM

suppressionNP-59imaging

CORTEX: 1) Hydrocortisone: (Cushing’s)

a) Hypertrophy (bilateral).….. hypertrophic + +b) Tumor (benign)…………… suppressed - +

2) Aldosterone: Aldosteronoma (Cohn’s).. suppressed - +3) Androgens: ……....Congenital Adrenal Hypertrophy - +4) Carcinomas ………………………… NL - -

2) Carcinomas (Neuroblastoma)…………… NL - +

Octreo orMIBG

imagingMEDULLA:1) Norepinephrine: Pheochromocytoma….. NL - +

ADRENAL CORTEX

HYPOTHALAMIC PITUITARY ADRENAL AXIS

ADRENOCORTICAL SCINTIGRAPHY PROTOCOL

PATIENT PREPARATIONDEXAMETHASONE 8 mg/day from day -5 to day +3LUGOL’S SOLUTION 5 drops/day from day -2 to day + 8

INJECTIONDay 1: 0.5-1.0 mCi 131I(123I) CHOLESTEROL (NP-59)

IMAGING Days +2 (+3) : Scan on dexamethasone suppressionDays +5 (+7) : Scan off dexamethasone suppression

FOR BETTER LOCALIZATIONa) MAG3 Renal Scanb) SPECT/CT

CORTICAL SCINTIGRAPHY NP-59

48 hours24 hours

On Dexamethasone

Normal Adrenals

CORTICAL SCINTIGRAPHY NP-59

Off Dexamethasone

Normal Adrenals

ADRENOCORTICAL IMAGINGUSE OF RENAL SCAN TO LOCALISE LESIONS

MAG3 RENAL SCAN

Appropriate localization

Normal Adrenals

ADRENOCORTICAL ADENOMA NP59 FUSION

Adrenal Scan Renal Scan Fusion Image+

+ =

=

Children with virulism131I-NP59 studies

CONGENITAL ADRENAL HYPERTROPHY

NP-59 scans from 3 children with Congenital Adrenal Hypertrophy

ECTOPIC ADRENAL TISSUEIN TESTES OR OVARIES

NP-59 scans from 3 children with suspected Ectopic Adrenal tissue in the testes

Patient hypertensiver/o aldosterone producing tumor (s)

131I-NP59 study

Aldosteronoma of the left adrenal gland(Cohn’s)

Tumor left adrenal gland

RADIO-CHOLESTEROL 131I-NP59 SCANS

liver

bowel

A patient with Cushing’s Syndrome131I-NP59 study

CUSHING’S ADENOMA LEFT ADRENALSUPPRESSION OF THE RIGHT ADRENAL

bowel

bowel

liverliver

Left adrenal cortical tumor. What about the right adrenal?

The right adrenal is suppressed

A patient with Cushing’s Syndrome131I-NP59 study

ADRENOCORTICAL HYPERPLASIA

liver

Both adrenal glands large/prominent off Dexamethasone

Patient hypertensiver/o aldosterone producing tumor (s)

131I-NP59 study

R/O ALDOSTERONOMA:

Bilateral Adrenal Hyperplasia

Tc-99m-MAG3 I-131-NP59

RADIO-CHOLESTEROL 131I-NP59 SCANS INTERPRETATION DEPENDS ON PATIENT PREPARATION

IF NO DEXAMETHASONE WAS GIVEN = THE STUDY IS NORMAL ON LOW DOSE DEXAMETHASONE = BILAT. ADRENAL HYPERPLASIA

ON HIGH DOSE DEXAMETHASONE = BILATERAL ADENOMAS

Tc-99m-MAG3 I-131-NP59

A patient with Cushing’s Syndrome131I-NP59 study

ADRENOCORTICAL ADENOMA NP59

bowel

liver

Left adrenal gland large/prominent Right adrenal suppressed

ADRENAL MEDULLA

EMBRYOLOGY OF THE ADRENAL MEDULLA

IMAGING ADRENAL MEDULARY LESIONS 131/123I meta-iodo-benzyl guanidine (MIBG)

It is associated with the neurosecretory granules of the cytoplasmic portion of the adrenal medulla

INDICATIONS• Pheochromocytomas: sensitivity 85%, specificity > 99%

• Neuroblastomas: Sensitivity is greater than 90%

for soft tissue, bone, or bone marrow involvement

METHOD

Patient preparation: Stop medications with sympathetic action

Inject 500µCi (5-10mCi) 131I (123I)-MIBG and scan at 48hr (+72hr)

LESION LOCALIZATION

MAG3 Renal Scan or SPECT/CT

A patient with hypertension is studied to exclude Pheochromocytoma

MIBG NORMAL STUDIES

Total body studiesbecause

pheochromocytomas may involve

the adrenal glands,sympathetic ganglia,

or other sites

Normal Adrenal

visualization

MIBG NORMAL STUDY

PHYSIOLOGIC ADRENAL VISUALIZATION

24Hr (low count image) 48Hr 48Hr Repeat Study

PHEOCHROMOCYTOMA

SENSITIVITY OF MIBG FOR PHEOCHROMOCYTOMA

15yo boy with Pheo (k=autotransplanted kidney) 75yo man with recurrentmalignant metast Pheo

Cancer 1984; 34(2):86

A patient with clinical and laboratory findingssuggesting Pheo

and a CT showing lesion in the left adrenal

PHEOCHROMOCYTOMA

Anterior

Posterior

MIBG study

PHEOCHROMOCYTOMA

MIBG study

48hr post 0.750mCi 131I-MIBG

ADRENAL MEDULLARY PHEOCHROMOCYTOMA

PHEOCHROMOCYTOMA“Ectopic”

MIBG studyRenal Scan

57yo man s/p L adrenalectomy for Pheochromocytoma

MALIGNANT METASTATIC PHEOCHROMOCYTOMA

Ant

Ant Ant Ant

Post Post

MIBG study

MALIGNANT PHEOCHROMOCYTOMA METASTATIC TO LUNGS

45yo woman s/p resection of pheochromocytoma

123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA

10yo boy with laboratory presentation raising the question of Pheochromocytoma.

MRI is negative. Patient allergic to iodine.

123I-MIBG SPECT/CT Pheochromocytoma

10 yo child with hypertension + lab work suggesting Pheochromocytoma

123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA

MULTI-ENDOCRINE NEOPLASIA

MULTIPLE ENDOCRINE ADENOMATOSIS (MEA)

Familial SyndromesCommon: Neuroectodermal origin of glands involved

(informational coding)

1 Multiple Endocrine Neoplasia type I (MEN-I)Parathyroid AdenomaPancreatic Islets (Zollinger-Ellison Syndrome)Pituitary (Hypo or Hyper Function)

2 Multiple Endocrine Neoplasia type II (MEN-II)Parathyroid Adenoma

PheochromocytomaMedullary Thyroid Carcinoma

A Child with a history of resected Medullary thyroid carcinoma

BILATERAL PHEOCHROMOCYTOMASMEN-II

MIBG study

24hr 48hr 96hr

A Child with a history of resected Medullary thyroid carcinoma and Pheochromocytoma

RECURRENT PHEOCHROMOCYTOMAMEN-IIMIBG study

11/17 off medication7/14 while taking Labetalol

27yo man s/p thyroidectomy at age 15y for Medullary carcinomaand bilateral adrenalectomy at age 20y for pheochromocytomas

RECURRENT PHEOCHROMOCYTOMAMEN-IIb

MIBG study

NEUROBLASTOMA

NM studies in NEUROBLASTOMA

Bone Scan/(Liver-Renal scans)

MIBG Total Body Imaging/Therapy

Antibody Imaging/Therapy

Somatostatin-analogue (Octreotide)

NEUROBLASTOMAPrimary Tumor calcified

A 10 mo old child with proptosis

NEUROBLASTOMA PRIMARY TUMOR

Tc-99m MDP Bone scan

AND METASTASIS TO BONES

JNM 25(7): 773

A child with Neuroblastoma. Evaluate for metastases

NEUROBLASTOMA Primary

VISCERAL METASTASIS

131I-MIBG

Anterior Posterior

NEUROBLASTOMA WITH VISCERAL METASTASIS

131I-MIBG STUDYAND TcSC, TcDTPA

SC+DTPA

A child with Neuroblastomaand positive bone marrow biopsy

NEUROBLASTOMA WITH BONE MARROW METASTASIS

131I-MIBG

Posterior total body images to better show the bone marrow

111In-OCTREOTIDE SCINTIGRAPHY

Somatostatin(14AA) Octreotide=Oligopeptide analogue(8AA)

CarcinoidGastrinomaInsulinomaGlucagonomaParaganglioma

Non-Small Cell Lung cancerMeningiomas PheochromocytomaApudomas non specifiedMedullary thyroid carcinoma

Tumors with membrane somatostatin receptors Granulomatous Autoimmune

SarcoidosisWegener’s TuberculosisGraves’ Thyroid Exophthalmos

111In-OCTREOTIDE SCINTIGRAPHY

A child with Neuroblastoma

111In-OCTREOTIDE SCINTIGRAPHYNEUROBLASTOMA

Bone metastases of neuroblastoma

FDG-PET INNEUROBLASTOMA

FDG-PET IN NEUROBLASTOMA

FDG accumulates within most neuroblastomas

It also accumulates within neuroblastomaswhich are MIBG negative

A child with Neuroblastoma

MIBG and FDG-PET in NEUROBLASTOMA

tumor tumor

tumortumor

Skull metastasisPrimary Tumor

Recurrent Neuroblastoma in a 6 month old boy

FDG-PET INNEUROBLASTOMA

Recurrent Tumor

Neuroblastoma at diagnosis and 6mos after chemotherapy

FDG-PET IN NEUROBLASTOMAEFFECT OF THERAPY

FDG-PET CT-Scan MIBG

Baseline

After Chemotherapy

A 17 year old girl with right shoulder pain

FDG-PET INHEPATOBLASTOMA

CT Scan FDG - PET

necrotictumor

necrotictumor

Active viable tumor

PITUITARY GLAND TUMORS

PET: 11C-BROMOCRYPTINESPECT: SOMATOSTATIN analogue

(111I-OCTREOTIDE)