- 1. THE SIX WISEMEN OF HINDOOSTAN Nuclear Medicine for
Bio-Engineering University of PittsburghAnna K. Chacko MD Professor
of Radiology, UPMC
2. What you will learn today
- How does it differ from other imaging modalities in
Radiology
- Looking at some organ systems through Nuclear Eyes
3. Nuclear Medicine and its subsets
- Two divisions of Nuclear Medicine.
- Looking at organ systems through Nuclear Eyes
- Nuclear Therapeutics - Targeting the disease with radionuclides
that are preferentially sequestered in pathologic tissue
- On the Horizon - Soon to be revealed
4. Normal Chest Radiograph Copyright 2007 by the American
Roentgen Ray Society --38-year-old woman with severe acute
respiratory syndrome Is this patient dead or alive?? 5. Looking at
Physiology/Pathophysiology
- This is a 38year old female who presented with shortness of
breath.Her chest x-ray was normal.Her lung function wasnot!!- her
lung scan revealed multiple emboli.
6. What does Nuclear Imaging do??It looks at Life or the lack
thereof 7. Definition of Life
- The consensus is that life is a characteristic of organisms
that exhibit all or most of the following phenomena:[9][10]
- 1.Homeostasis :Regulation of the internal environment to
maintain a constant state; for example, electrolyte concentration
or sweating to reduce temperature.
- 2.Organization :Being structurally composed of one or more
cells, which are the basic units of life.
- 3.Metabolism:Consumption of energy by converting chemicals and
energy into cellular components (anabolism) and decomposing organic
matter (catabolism). Living things require energy to maintain
internal organization (homeostasis) and to produce the other
phenomena associated with life.
- 4.Growth:Maintenance of a higher rate of synthesis than
catabolism. A growing organism increases in size in all of its
parts, rather than simply accumulating matter. The particular
species begins to multiply and expand as the evolution continues to
flourish.
- 5.Adaptation:The ability to change over a period of time in
response to the environment. This ability is fundamental to the
process of evolution and is determined by the organism's heredity
as well as the composition of metabolized substances, and external
factors present.
- 6.Response to stimuli : A response can take many forms, from
the contraction of a unicellular organism to external chemicals, to
complex reactions involving all the senses of higher animals. A
response is often expressed by motion, for example, the leaves of a
plant turning toward the sun (phototropism) and chemotaxis.
- 7.Reproduction:The ability to produce new organisms.
Reproduction can be the division of one cell to form two new cells.
Usually the term is applied to the production of a new individual
(either asexually, from a single parent organism, or sexually, from
at least two differing parent organisms), although strictly
speaking it also describes the production of new cells in the
process of growth.
8. Definition of Life
- The consensus is that life is a characteristic of organisms
that exhibit all or most of the following phenomena:
9. Imaging Modalities and What They Reflect
AnatomyPhysiologyMetabolismMolecular CT US MRI SPECT & PET 10.
Modality Fusion and Advantages Conferred
AnatomyPhysiologyMetabolismMolecular CT US MRI SPECT & PET
PET-CT/SPECT-CT 11. Six wise men of Hindoostan
- There were six men of Hindoostan,
- to learning much inclined,
- Who went to see an elephant,
- though all of them were blind,
- The first approached the elephant,
- Against his broad and sturdy side,
- "This mystery of an elephant
The second, feeling of the tusk, cried, "Ho, what have we here,
So very round and smooth and sharp? To me 'tis mighty clear, This
wonder of an elephant is very like a spear." The third approached
the elephant, and happening to take The squirming trunk within his
hands, thus boldly up and spake, "I see," quoth he, "the elephant
is very like a snake." The fourth reached out an eager hand, and
felt above the knee, "What this most wondrous beast is like is very
plain" said he, "'Tis clear enough the elephant is very like a
tree." The fifth who chanced to touch the ear said, "E'en the
blindest man Can tell what this resembles most; deny the fact who
can; This marvel of an elephant is very like a fan." The sixth no
sooner had begun about the beast to grope, Than seizing on the
swinging tail that fell within his scope; "I see," said he, "the
elephant is very like a rope. So six blind men of Hindoostan
disputed loud and long, Each in his own opinion exceeding stiff and
strong; Though each was partly in the right, they all were in the
wrong! 12. Systemic Disease
13. Malignancy 14. Infection
- The whole body In-111 labeled WBC images demonstrate increased
activity in the left knee. Bone marrow imaging is performed for
comparison at the same time of the WBC's study to assess the
distribution of normal marrow (although in this case it is known
there is no marrow in the region of the resected bone). There is
discordant uptake (increased indium-111 activity with no increase
in sulfur colloid activity) in the distal portion of remaining left
femur. This is consistent with osteomyelitis adjacent to the
femoral prosthesis..
15. Bone Marrow Scan
- The three major tissue that constitute the red marrow
include
- the hematopoietic (erythropoietic and myelopoietic) cells;
- the Reticuloendothelial cells; and
- the trabecular framework, that supports both cell types. The RE
cells generally parallel the blood forming cells.Therefore, the RE
cell images gives an indication of the state of thebone
marrow.
16. Head & Neck
17. Brain Imaging
- Glucose powers the brain, and evidence indicates that a
progressively diminishing capacity to make use of glucose-
contributing to the dysfunction which is Alzheimers disease. The
imaging technique uses 18FDG for evaluating the disease.
18. Brain Imaging
- An HIV positive patient's brain showing abnormal uptake of
fluorodeoxyglucose labeled with18FDGin the left parietal region.
MRI showed a lesion at this site, but could not distinguish between
toxoplasmosis and lymphoma, both of which may present in HIV
positive patients. Uptake indicates that the patient has a
lymphoma--
- Toxoplasmosis has no uptake of fluorodeoxyglucose
19. Brain Imaging - Iodine-123 dopamine transporter ligand
- Images from nuclear medicine can help in diseases such as
suspected Parkinson's disease, where the dopamine transporters are
diminished in the basal ganglia. Imaging these gives an indication
of the degree of severity of the disease. The test uses a dopamine
transporter ligand labeled with iodine-123, which shows where the
dopamine transporters are situated.
Uptake of ioflupane, a cocaine analogue, labeled with 123I,
which binds to sites of dopamine transporters in the basal ganglia.
Uptake occurs in the caudate nuclei but not in the putamen, which
is typical of Parkinson's disease. 20. Brain Death 21. Thyroid
Hormone The iodide cycle
- Ingested iodide is trapped in the thyroid, oxidized, and bound
to tyrosine to form iodotyrosines in Thyroglobulin (TG); coupling
of iodotyrosyl residues forms T4 and T3. Hormone secreted by the
gland is transported in serum. Some T4 is deiodinated to T3. The
hormone exerts its metabolic effect on the cell and is ultimately
deiodinated; the iodide is reused or excreted in the kidney. A
second cycle goes on inside the thyroid gland, with deiodination of
iodotyrosines generating iodide, some of which is reused without
leaving the thyroid.
22. Thyroid Cancer
- Well-differentiated thyroid cancer metastatic to the
lungs.
- Iodine 131 scan used for surveillance
23. Thyroid disease Normal thyroidMulti nodular goiter Multi
nodular goiter Sublingual thyroid 24. Parathyroid Imaging
- Parathyroid glands are responsible for Calcium and phosphorus
homeostasis.This is done through the production of parathyroid
hormone
- Adenomas of the parathyroid glands are known to produce
problems with the Ca++ balance in the body.These when associated
with hyperparathyroidism can lead to loss of bone mineral
(Osteoporosis)among other symptoms.
25. The Thorax
26. Lung Scan
- The lung receives venous (deoxygenated blood) from the body and
facilitates the exchange of Oxygen for Carbon Dioxide. With lung
scans these two functions- perfusion and ventilation are
evaluated
27. Myocardial Scan
- Various types of studies can be performed to assess the
function and the viability of the myocardium (Heart Muscle).In the
MPI study, the state of the myocardium at rest is compared with the
state under stress.If a reversible defect is identified, the
patient is likely to benefit from intervention (stenting or
CABG)
28. Recent article
- Will CT overtake nuclear medicine in myocardial perfusion?
- It's not enough that sidelined nuclear reactors are restricting
the supply of technetium for cardiac SPECT. Or that reimbursements
for SPECT procedures are falling. Now the besieged modality has to
contend with a challenge from CT.
29. Liver -Spleen Gall Bladder Bowel Stomach Kidneys and the
Genitourinary tract Adrenals Prostate Testes 30. Testicular Scan -
TORSION
- The testes are suspended in the scrotum by a single bundle of
tissues that also carries the blood supply to and from the testes.
If the testicle rotates, the bundle kinks, and the blood supply is
shut off. The resulting situation is an emergency because the
testis will die within hours if the blood supply is not
restored.
31. Testicular Scan - INFECTION
- On physical examination, it is difficult to distinguish testis
from epididymis because of localized swelling. For this reason the
condition is frequently misdiagnosed as epididymis. Therefore,
imaging of the scrotum is very important for the diagnosis of the
specific etiology of the patients presenting with acute scrotum.
Prompt differential diagnosis should be made between acute
testicular torsion and acute infections of testis and epididimytis,
sincetorsion of the testicle is a true surgical emergency of the
highest order .
32. Prostate Cancer
- Whole Body ProstaScint Scan of a Patient with Rising PSA while
Undergoing Hormonal Therapy. ProstaScint activity in a left
supraclavicular lymph node and in many central abdominal lymph
nodes (arrows) indicates a high likelihood of metastatic disease
and hormone resistant tumor.
- ProstaScint is a radioimmunoconjugate of a monoclonal antibody
directed against Prostate Specific Membrane Antigen, expressed in
malignant prostatic tissue
33. Gall Bladder Scan
- The agent used for scanning the gall bladder follows a path
similar to the production and distribution of Bile.
- = Iminodiacetic acid.The function of the gallbladder is
assessed by evaluating the GB Ejection Fraction after administering
a drug which should make the gallbladder contract.
34. GI bleeding Study
- The agent used for Gastrointestinal bleeding is Red Blood cells
labeled with Tc 99mO4.
- = Normally the bowel should not show any tracer.When this shows
up - the site of the GI bleeding has been discovered.
35. Renal Scan
- Kidneys are one of a set several organs that maintain blood
pressure (BPr).When a patient presents with High BPr, the kidneys
are investigated.When the blood supply to the kidney is
compromised, it responds by raising BPr. The kidneys integrity is
studied by using nuclear medicine following administration of a
drug that provokes a response from a compromised kidney.
Normal Captopril study 36. Liver-Spleen Scan
- The liver, spleen, bone marrow and to some extent the lungs are
the repository of Reticuloendothelial cells which serve as police
functioning to get rid of harmful agents in the body.These cells
are called Kupffer cells.Colloidal sulfur particles labeled with Tc
99m are injected i.v. These particles are ingested by the RE cells
and images of the organs are produced
37. Meta-iodo-benzyl guanidine
- Since MIBG structurally resembles norepinephrine, it enters
neuroendocrine cells by an active uptake mechanism and is stored in
the neurosecretory granules, resulting in a specific concentration
in contrast to cells of other tissues. MIBG scintigraphy is used to
image tumours of neuroendocrine origin, particularly those of the
sympathoadrenal system (phaeochromocytomas, paragangliomas and
neuroblastomas), although other neuroendocrine tumours (carcinoids,
medullary thyroid carcinoma, etc.) are also visualized.
38. Meta-iodo-benzyl guanidine
- Patient with medullary thyroid cancer with positive MIBG
scan
39. In111 pentetreotide
- Indium-111 Pentetreotide is a cyclic octapeptide analog of
somatostatin. DTPA allows labeling with In-111. Excreted primarily
by the renal system. In-111 pentetreotide imaging is a sensitive
method for detecting presence of tumors such as glucagonomas,
vipomas, carcinoids, nonfunctioning islet cell tumors.
40. Theragnostics
- Pene F, Courtine E, Cariou A, Mira JP.Crit Care Med. 2009
Jan;37(1 Suppl):S50-8.
- Theragnostics is a treatment strategy that combines
therapeutics with diagnostics. It associates both a diagnostic test
that identifies patients most likely to be helped or harmed by a
new medication, and targeted drug therapy based on the test
results. Bioinformatics, genomics, proteomics, and functional
genomics are molecular biology tools essential for the progress of
molecularTheragnostics . These tools generate the genetic and
protein information required for the development of diagnostic
assays.Theragnosticsincludes a wide range of subjects, including
personalized medicine, pharmacogenomics, and molecular imaging to
develop efficient new targeted therapies with adequate benefit/risk
to patients and a better molecular understanding of how to optimize
drug selection. Furthermore,Theragnosticsaims to monitor the
response to the treatment, to increase drug efficacy and safety. In
addition,Theragnosticscould eliminate the unnecessary treatment of
patients for whom therapy is not appropriate, resulting in
significant drug cost savings for the healthcare system. However,
the introduction ofTheragnosticstests into routine health care
requires both a demonstration of cost-effectiveness and the
availability of appropriate accessible testing systems. This review
reports validation studies in oncology and infectious diseases that
have demonstrated the benefits of such approach in well-defined
subpopulations of patients, moving the field from the drug
development process toward clinical practice and routine
application. Theragnostics may change the usual business model of
pharmaceutical companies from the classic blockbuster model toward
targeted therapies.
41. Six wise men of Hindoostan
- There were six men of Hindoostan,
- to learning much inclined,
- Who went to see an elephant,
- though all of them were blind,
- The first approached the elephant,
- Against his broad and sturdy side,
- "This mystery of an elephant
The second, feeling of the tusk, cried, "Ho, what have we here,
So very round and smooth and sharp? To me 'tis mighty clear, This
wonder of an elephant is very like a spear." The third approached
the elephant, and happening to take The squirming trunk within his
hands, thus boldly up and spake, "I see," quoth he, "the elephant
is very like a snake." The fourth reached out an eager hand, and
felt above the knee, "What this most wondrous beast is like is very
plain" said he, "'Tis clear enough the elephant is very like a
tree." The fifth who chanced to touch the ear said, "E'en the
blindest man Can tell what this resembles most; deny the fact who
can; This marvel of an elephant is very like a fan." The sixth no
sooner had begun about the beast to grope, Than seizing on the
swinging tail that fell within his scope; "I see," said he, "the
elephant is very like a rope. So six blind men of Hindoostan
disputed loud and long, Each in his own opinion exceeding stiff and
strong; Though each was partly in the right, they all were in the
wrong! 42. WHATS NEW ON THE HORZON!?!
- Compressive/compressed sensing - allowing the construction of
large and accurate/fine resolution/great replicability data sets
from SPARSE ones.
- Increasing concerns over radiation burden through medical
procedures
- The use of Thorium reactors - unlimited supplies of
energy.
- WHAT DOES THIS MEAN FOR US - TRUE HEALTHCARE REFORM. - A BRAVE
NEW FUTURE FOR THE YOUNGER GENERATIONS OR THE GENERATIONS AS YET
UNBORN.
