CONCISE

MANUAL OF NUCLEAR
MEDICINE

FOR MEDICAL STIDENTS

EDITED BY PROF.DR.I.KOSTADINOVA
SOFIA, 2010

Nuclear medicine / NM /
NM is the branch of medicine, in which radiopharmaceuticals / RPh / are used in
the diagnosis and treatment of diseases.
Its development depends on:
1. Introduction and application of more and more NM-methods for diagnosis of the
diseases of heart, lungs, brain, gastro-intestinal tract, kidneys, bones, endocrine
glands, tumors, inflammation and for treatment of tumors, their recurrences and
metastases, retractable synovites and some heamatological diseases.
2. Innovation of imaging NM technique - from conventional scanners and planner
gamma cameras to tomographic gamma cameras- SPECT / single photon
emission computer tomography / and PET / positron emission tomography /.
3. Introduction of new radiopharmaceuticals / RPh/ for an early diagnosis of
functional changes of the investigated organs, before appearance of structural
changes, which can be visualized with other imaging methods / rentgenology,
sonography, CT /.
Radionuclide techniques are diverse and generally non-invasive, safe with low
radiation burden, but it is necessary to consider whether a procedure offers the most
effective way of solving a particular diagnostic problem. The quality of achieved
diagnostic information, availability of equipment, radiation dose of the patient, the
cost and the possibility of using alternative imaging methods without radiation are
the most important factors for making a decision.
Principles of NM
1. RPh can be applied in the investigation of all organs and systems.
2. The basis for its usage is the specific accumulation of RPh / labeled with
radioisotope chemical substances/ in different organs.
3. For the functional and metabolitic evaluation of some organs the most important
factors are the speed, degree of uptake and elimination of RPh.
4. The results obtained are displayed as planar or tomographic scintigrames /
distrbution of the activity in the investigated organ /, curves / radiography / or
counts per min.
/ radiometry /.
Classification of NM procedures
Diagnostic
Therapeutic
131
In vivo
In vitro
I- treatment
Imaging
Non-imaging
RIA
- thyrotoxicosis
-planar
-uptake tests
-hormones
- Ca thyroid
-tomographic - renography
- Tu markers
Bone pain paliation
SPECT
- clearances
- enzymes
/ 89Sr,32P,188Re,153Sm /
PET
- blood volume - vitamins
Hematological disorders
-hybrid
- others
Neuroendocrine Tu
PET/CT and SPECT/CT

BASIC TERMS IN NM
Radioisotope / radionuclide / - atoms with an equal atomic number but different
mass number which produce radiation, when decay. All isotopes of the given
element have equal chemical and biological properties. Every radionuclide has the
following characteristics:
- type of radioactive decay-alfa, beta, gamma rays /electromagnetic radiation/
- energy, which it emits
- half time / T1/2 /- this is time. for which half of the radionuclide decays
99m

Tc -produced from generator comprises 90% of the diagnostic activity of NMDepartment. The rest is due to 131 I, 51Cr, 201 Tl. 99mTc is a pure gamma emitter,
E=140 keV, T1/2-6h.
Unit of radioactivity
Bq-one disintegration per second. MBq=106 Bq. 37MBq=1mCi
RPh- any chemical compound containing radionuclide, administered to a patient for
diagnosis or therapy
Gamma camera-=Scintillation camera - imaging device with sodium iodine crystal
for detecting gamma-emitting radionuclides
Scintilation- the process by which ionizing radiation is converted to visible photones
Static Image=Scintigram-Procedure to produce and record an image of the
distribution of radionuclide in a patient's specific organ, using a gamma camera
Dynamic imaging- Acquisition of sequential time dependent scintigrams to
determine function and structure of the organ
SPECT-single photon emission computed tomography - construction of three
dimensional images displayed as organ sections, using gamma rays emitted from the
radionuclide/ most often 99mTc-compounds /incorporated in the investigated organs
PET- positron emission tomography- construction of three dimensional images
displayed as organ sections, using positrons emitted from the radionuclide
/ 18Fl, 13N, 15O, 14C-compounds /incorporated in the investigated organ.

INSTRUMENTATION IN NUCLEAR MEDICINE

Conventional Gamma camera / single or double head / for a functional
scintigraphic visualization

Hybrid imaging- for both functional / scintigraphic / and morphologic / CT /

imaging

SPECT/CT using gamma RPh

PET/CT using positron RPh

Advantages of hybrid imaging

Gives complex information for the structure and function of the organs
Shortens the time for making diagnosis and consequently the initiation of
therapy
The scintigraphic images are with a higher quality because of a correction of
the attenuated gamma rays through CT

A precise localization of the pathological changes is possible and absolutely

necessary for surgery and radiotherapy

Differences between SPECT/CT and PET/CT

They use different emitters: SPECT-only gamma emitted radioisotopes and

PET-positron emitted.
Most often used isotopes for SPECT are 99mTc and 131I and for PET- 18F
and 11C.
The most common use of CT in both techniques is for a higher quality and a
higher specificity of the scintigraphic image because of the attenuation
correction of the attenuated gamma rays and a possibility for a precise
localization.
Final result is a higher diagnostic accuracy.
Hybrid images

PET/CT in a patient with Ca ovarii

SPECT/CT in a patient with bone meta

NUCLEAR MEDICINE IN ENDOCRINOLOGY

I.Thyroid
1.Thyroid Scintigraphy
- Principle- RPh / 99mTc, 131 I, 123 I / is selectively captured in the thyroid in
accordance with the funtional and morphological status
- Indications-in differentiation of the thyroid nodules, to elucidate the reasons for
tyreotoxicosis, thyroidites, evaluation of goitres, retrosternal masses and the
effect of therapy.

The thyroid nodules could be hot, cold or warm in accordance with the degree of
uptake of RPh in the nodule and in rest of the thyroid parenchyma

Cold nodule of thyroid

Hot nodule of thyroid

2.Thyroid uptake test- the used RPh / 99mTc, 131 I, 123 I / is captured in the thyroid
in accordance with the funtional state of the thyroid / hormonal production /. A
percent of thyroid uptake is calculated, compared with the standard / 100% / as a
quality index of the function of thyroid.
131 I, 123 I are used for the determination of the doses of activity, required for
treatment of thyreotoxicoses.
3.Perchlorate discharge test
It assesses organic binding of iodine by the thyroid and proves defect in synthesis
of the hormones/ in patients with hypothyreoidism / as a sequence of the
decreased or absent activity of the enzyme peroxidase.
4."In vitro" tests / without radiation burden for patient / for an evaluation of
thyroid function:
- TSH - very sensitive for assessing thyroid status. Low TSH suggests
Hyperthyroidism, high values-hypothyroidism
- T4, T3 and free hormones, which are more precise- FT4 , FT3
- Thyreoglobulin-it is useful in assessing patients with treated thyroid carcinoma
to assess the effect of treatment and to detect metastasis and recurrence
5.Suppressive thyroid scintigraphy / with addition of thyroxine before and during
Scintigraphy /. It is applied for assessment of some "hot" thyroid nodule-if it is
compensated or non-compensated / if the rest of the parenchyma is visualized or
not /
6.Whole body scintgraphy with 131I - to evaluate a patient with differentiated
thyroid carcinoma - looking for metastases, recurrence and to follow the effect of
therapy. The whole evaluation of the patient comprises history, clinical check up,
lung X-ray, serum level of thyreoglogulin.

A Patient with differentiated thyroid carcinoma and treatment with 131I

a/ before therapy
b/ after therapy
II. Parathyroid scintigraphy
It is applied pre-surgically to localized parathyroid, which are hyperfunctioning
/ according to the level of parathyroid hormone /.
Normal parathyroid glands are not visible on the scans. Imaging is carried out using
subtraction scan technique. Initially 99mTc-pertechnetate is injected to outline the
thyroid, then 99mTc-MIBI to outline thyroid plus parathyroid. subtraction is
perform to visualize parathyroid tissue / adenomas which size is more than 300mg /
III. Adrenal glands
1. Scintigraphy of adrenal cortex - it is a test of adrenal function and localization of
tumor, after a biochemical diagnosis has been made. Physical enlargement of an
adrenal is readily determined by CT, but such enlargement is commonly difficult
to evaluate functionally. Scintigraphy with 131I - cholesterol is performed in:

2.

adrenal hyperplasia / Cushing's Syndrom-bilateral uptake /

in adenoma / unilateral uptake/
carcinoma-usually no uptake
Scintigraphy of adrenal medulla - with 131I-MIBG. It is useful for localization of
phaemochromocytomas/ including metastases /, also neuroblastomas end
paragangliomas. Higher activity is used for treatment.

BONE SCINTIGRAPHY / BS /
- It is the most requested isotope study in NM, because of the high sensitivity for
lesion detection and the posibility to survey the whole body.
- It is applied in oncology, orthopedics, rheumathology and endocrinology
- BS is a functional test of bone metabolism that complements the anatomical details
from the other imaging methods and displays pathological changes earlear than
structural changes occur.
- 99mTc-MDP is most often used and reflects osteoblastic activity and skeletal
vascularity.
- It has a lower specificity as many conditions demonstrate increased tracer
accumulation-malignant and benign tumors, infections, trauma, metabolic
disorders, but in most of them typical pattern is recognized, which suggest a specific
diagnosis.
- Standart protocol for bone scintigraphy includes imaging 2-4 h p.i.
- Dynamic scintigraphy / 3 phase bone scan / permits evaluation of the vascular,
blood pool and osseous phases.
Indications
I.Tumors
-

Metastatic disease detection of meta from extraosseous primaries /prostate,

breast, lung,etc./, detection of areas at risk for pathologic fractures, monitoring
after therapy
Primary bone tumors-the osseous involvement in scintigraphy is often more
extensive than conventional radiogrphs, which could be due to relative
hyperemia in the surrounding tissue.

II. Infection-3-phase bone scintigraphy is very useful, as early phases reflect the
hyperemia and the delayed images-the extend of reactive bone formation
III. Trauma-the uptake of tracer steadily increases with time due to increased
vascularity and bone turnover in the fracture-within 72h all of them are
demonstrable.
- Stress fractures-result from repetitive, prolonged muscular action on the bone
that is unaccutomed to such stress.BS is highly sensitive to the early detection of
stress-related bone and tendinous injuries, where radiographs are often negative.

A patient with prostate cancer and multiple bone metastasis

IV. Joint disease-arthritic changes result in increased accumulation in the involved
areas, which estimates the extend of disease seen in rheumatoid arthritis, psoriatic
arthritis, ankylosing spondylitis.
-Osteonecrosis involves interruption of blood supply to bone with resultant cellular
death, associated with aseptic necrosis due to trauma, steroids, radiation,
alcoholism, etc. In the early avascular phase there is decreased tracer accumulation
and in the later stages-an increased tracer uptake is seen due to reparation and
revascularization.
- Joint prosthesis-BS is valuable in the early detection of infection and loosening of
the prosthesis in patients who have undergone arthroplasty. Focal uptake may
indicate loosening of the prosthesis, whereas a diffuse increase of the activity is more
likely to indicate infection / could be proved by an additional leucocyte
scintigraphy/
NUCLEAR MEDICINE IN CARDIOLOGY
Several radionuclide techniques are used to study the heart- myocardial perfusion
scintigraphy, radionuclide ventriculography and a new method-gated SPECT.
I.
Myocardial perfusion scintigraphy
Uptake of the radiopharmaceutical / 99mTc-MIBI, 201 Tl / is proportional to the
blood flow and in this way it displays myocardial vitality. If there is disturbance in
the blood supply or myocardial cells are damaged, then an abnormality is seen on
the image.

Coronary deficiency is detected by comparing exercise and rest images.

- In reversible myocardial ischaemia / stenocardia / there is a hypoperfusion
/ decreased uptake of RPh / is seen in exercise, while rest images are normal.
- In non-reversible ischaemia /myocardial scar/ decreased uptake of RPh is seen in
both exercise and rest images.
Indications are to assess:
- atypical chest pain
- investigation of myocardial vitality
- differentiation of reversible from non-reversible ischaemia
- in cardiomyopathy
- pre- and post-CABG surgery and early diagnosis of restenosis
The accuracy of the scintigraphy / 90% / is higher than ECG and especially if
SPECT technique is applied.

A patient with a combination of reversible and non-reversible myocardial ischaemia

II.
Radionuclide ventriculography
It is performed to assess myocardial kinetics and ventricular function. 99mTclabelled erythrocytes are used. Serial scintigrams are performed, from endsystole to
enddiastole, in synchronization with ECG.
The left ventricular ejection fraction is a useful index of ventricular function and
normally is 64+/- 8%.

Indications are abnormalities of ventricular movements: conduction disturbances,

hypokinesia, aneurysm, following the effect of treatment.
III.
Gated SPECT
99mTc-MIBI is used and it gives a complex information - for myocardial perfusion,
kinetics, ejection fraction / global and regional /, and as a final result-for myocardial
viability.
IV.
PET scintigraphy gives data for myocardial perfusion and metabolism.
Positron emitters are used-18Fl-FDG, 13N, 15O,11C.
It is the most accurate method among all visualized ones to reflect myocardial
viability and the effect of revascularization / bypass surgery /.
V. Intracoronary radionuclide therapy
It is well known that the frequency of coronary restenosis after revascularization is
very high-up to 40%. If a beta emitter is installed in the coronary graft /90Y, 188Re/
this frequency can be reduced to 20%.
LUNGS SCINTIGRAPHY
It gives information for the perfusion / blood supply / and ventilation.
I. Perfusion scintigraphy
Principle-after injection of 99mTc-macroagregates of human serum albumin /MAA/,
it loges into the terminal arteriolo-capillary bed in proportion to the regional blood
flow. Reduced activity in the lung image indicates reduced perfusion, which may be
due to pulmonary embolism /PE/, but also to chronic obstructive airways disease,
pneumonia, tumor or pleural effusion. Normal lung scintigraphy rules out /PE/ in
100%, but typical picture is reduced or absent uptake in 2 or more segments. To
avoid making a positive diagnosis of PE, ventilation imaging in addition is helpful.
In PE, ventilation remains normal, whereas perfusion is impaired, unlike other
diseases.

Normal perfusion scintigraphy of the lung

A patient with pulmonary embolism

II. Ventilation scintigraphy

Most often 99mTc-technegas or 133Xe as a gaseous inhalating agents is used. Images
record regional ventilation of the lungs. Mismatched defects with perfusion
/ perfusion defects with normal ventilation / characterize PE.

III. Radionuclide diagnosis of lung tumors

Tumor seeking agents like 67Ga or 99mTc-MIBI are logged in tumors and their
metastases and recurrences. This diagnostics is used, when for the other visualized
methods, it is difficult to differentiate vital tumor from scar.
RADIONUCLIDE LABELLED BLOOD CELLS
Using radionuclide methods, blood cells-erythrocytes, leukocytes, platelets are
labeled with application in hematology, internal medicine, surgery.
.Red blood cells
1.Erytrokinetics-it can be used for following the processes of distribution, rate and
site of destruction and red cell survival, using "in vitro" labeled erythrocytes with
51Cr-sodium chromate.
Indication:
- In hemolytic anemia for determining the localization of destruction of red cells.
If the spleen is a site of destruction, a splenectomy is proposed and appropriate
treatment effect is achieved.
-In cases with unclear anemia for elucidating their pathogenesis and as a result - to
undertake the optimal treatment
2.Blood volume determination, using 51Cr-sodium chromate.
Its measurement is helpful for proof the diagnosis of true polycythaemia, where red
cell volume is increased and plasma volume is normal or decreased. It could be
differentiated from relative polycythaemia, where red cell volume is normal, but
plasma volume is decreased and from secondary polycythaemia, where plasma
volume is increased.
3.Labeled red blood cells are also used for localization of hemorrhage in the
abdomen and for radionuclide ventriculography.
II. Labeled leucocytes with 99mTc-HMPAO or 99mTc-monoclonal antigranulocyte's
antibodies
Radionuuclide imaging is useful to detect active foci of infection, when there are no
obvious localizing signs and ultrasound and CT are often unhelpful. The advantage
of the method is that it is very specific and can search infection in the whole body,
noninvasively. Another applications are patients with abdominal abscess /after
surgery/, colonic inflammation / Croh'n disease, ulcerohaemorragic colitis / and
osteomyelitis.
III. Labeled platelets
1. Thrombokinetics- following the processes of distribution, rate and site of
destruction and platelet survival, using "in vitro" labeled platelets with 11Inoxine or 51Cr-sodium chromate.
Indication:
- In essential thrombocytopenia /Werlhoff disease / for determining the
localization of destruction of platelets. If the spleen is a site of destruction, a
splenectomy is proposed with appropriate treatment effect.
- In cases with unclear thrombocytopenia for elucidating their pathogenesis and as

a result - to undertake the optimal treatment

2. For visualization of active thrombosis in the big vessels and in the heart. US can
detect all thrombosis-non active and active. The last are haemodinamically
active and are responsible for brain and heart events.

Leucocyte scintigraphy in a a patient with active ulcerohaemorragic colitis

NUCLEAR MEDICINE IN GASTROENTEROLOGY
I. Liver and hepatobiliary imaging
1. Liver scintigraphy
Radionuclide imaging with 99mTc-sulfurcolloid provides a non-invasive method of
examining size, shape, position and function and to a limited extend, the presence of
localized lesions. It is used less frequently compared to ultrasound and CT for
detecting the presence of cysts, metastases, abscesses and primary tumors in the
liver. Diffuse liver disease and the presence or absence of splenic lesions can also be
determined by this imaging. Relative enlargement of the left lobe and usually the
spleen suggest diffuse liver disease. Localized lesions in the liver from 1-3 cm,
depending on their site can be visualized as cold areas.
2. Hepatobiliary imaging
It is carried out to follow the function of the hepatocytes / including liver transplant/
and the patency of inta- end extrahepatic bile ducts. The main indication is acute
cholecystitis although post surgical problems like bile leakage and biliary reflux can
be identified. Visualization of the gall bladder is highly specific/ more than 95% / for
excluding acute cholecystitis. Delayed excretion into the gut suggests hepatocellular
disease, absent excretion to the gut with increased urinary excretion suggests
complete surgical obstruction.
.Gastrointestinal bleeding
Rational: the injected RPh / 99mTc-colloid or 99mTc-red blood cells / is localized in
the site of active bleeding. As little as 0.1 ml may be detected and the source
localized, but if bleeding occurs during the time of investigation. This methods are

non-invasive, but a disadvantage is that they provide less anatomical details than
endoscopic methods.
Ectopic gastric mucosa in Meckel's diverticulum can be detected, following an
injection of 99mTc. The investigation has no analog among the other imaging
methods and its accuracy is very high / about 90% /.
III. Oesophageal scintigraphy
1. Visualization of oesophageal transit
The passage of the radioactive bolus / 99mTc-colloid / through the oesophagus is
followed from the mouth to the stomach. The speed / transit time / and the way of
transit is visualized for an exclusion of local retention. Indication-pain in the region
of oesophagus and ahalasia.
2. Visualization of oesophageal reflux
After intake of the radioactivity, serial images of its passage are taken. Regions of
interests from the oesophagus and stomach are taken. There is a reflux, when more
than 4% of radioactivity of the stomach is registered in the oesophagus. Indicationspain in the region of oesophagus and suspicion of pulmonary aspiration of gastric
contents in adults and infants / aspiration pneumonia /.
III.
Stomach scintigraphy
Gastric emptying studies are helpful in elucidating post gastrectomy problems due
to rapid emptying e.g.dumping syndrome and also slow emting e.g.diabetic
gastroparesis. Solid and liquid studies / with radioactive labeled liquid and solid
substances / may be carried out. Liquid emptying is more rapid than solid one.
V. Salivary glands
The parotid and submandibular glands can be imaged using 99mTc-pertechnetate.
Uptake by the glands is calculated on the computer with a stimulation of excretion
with lemon juice. This excretion is normally visible on the computer graphs. If there
is obstruction, then the emptying curve is normal. In Sjogren's syndrom, uptake is
reduced and excretion is not detected.
RADIONUCLIDE METHODS IN NEPHROLOGY AND UROLOGY
I. Imaging methods
1. Dynamic renal scintigraphy-after i.v. application of RPh / 99mTc-MAG3,
99mTc-EC /, consecutive images of kidneys are acquired, which reflect perfusion,
function, size, position and structure of each kidney. Renographic curves are ploted
after delineating the "ROI" over kidneys and background. Normally a renogram
curve rises to a maximum at 3-5 min. / Tmax./ and declines to less than half
maximum / T1/2 / by 16 min. Uptake of each kidney between 1-2 min. is a useful
indication of the relative function of each kidney / normally 45-55% / of total.

Normal dynamic kidney scintigraphyq visualizing structure and function of kidneys

Pathological renographic curves:
- hydroneophrotic type - when there is a mechanical or functional obstacle for the
urine drenage / e.g. stones in pyelocalices /
- nephrectomy type - when there is no kidney function
- isostenuria type - in renal insufficiency
Indications: All types of diffuse kidneys diseases, hypertension, suspicion of altered
kidneys function
2. Static imaging / scintigraphy /
99mTc-DMSA is used to image the renal parenchyma / tubular cells /. A lesion
within the renal parenchima will show a "cold"area / tumor,cyst,abcessus,
pyelonephritis/ .
While many such lesions are better imaged by other means, e,g. US or CT,
radionuclide imaging is particularly useful in the diagnosis of chronic
pyelonephritis and scarring, detection of small residual amounts of renal tissue,
abnormalities such as horseshoe and pelvic kidney.
3. Captopril renography
It is used when unilateral renal artery stenosis is suspected. Boths Captopril / with
25mg Captopril given orally / renograophy and baseline study are performed.
Captopril decreases the GFR of the stenotic kidney and a delay in the time to peak
will be seen, compared with the other side.
4. Diuretic nepgrography
It is performed to distinguish obstructive / in kidney stones or tumor / from nonobstructive hydrenephrosis / dilatation of the pelviocalical system of the kidney /.

Usually it is performed at the end of the standard renogram by injection of

Frusemide. Normally a prompt fall in the curve will be shown in response to the
diuretic/ non-obstructive hydronephrosis /, while in obstructive hydronephrosis - the
rising of the renogram curve contiues.
5. Renal transplant renography
Radionuclide studies are useful for non-invasive sequential monitoring of blood flow
and functionq following renal transplantation. Acue tubular necrosis, vascular
occlusion, rejection, ureteric obstruction and urinary extravasation can be
identified.
6. Ureteric reflux
It may be demonstrated if the patient / child / micturates during the renographic
study. This is much less invasive than the alternative radiological technique.
7. Testicular scintigraphy
The differentiation of causes of a painful testicle can be clinically difficult. Torsion
requires prompt surgery, while orchiepididimites - antiinflammatory drug
administration. Radionuclide flow and tissue phases of imaging following i.v.
injection of 99mTc-pertechnetate will demonstrate reduced blood supply to torsion
while in orchiepididimites increased activity is registered.
II. Non-imaging methods
1. Non-imaging nephrography-non invasive method for determination of kidneys
function, using only renographic curves.
It is performed on apparatus with two scintilation probes, using 131I-hippurate,
which makes this method less expensive than dynamic renal scintigraphy / on
gamma camera /, but it is also less accurate.
Indications are the same, as dynamic renal scintigraphy.
3. Renal clearances determination
- Tubular secretion / Effective renal plasma flow / can be assessed using
99mTc-MAG3 which investigation usually is combined with dynamic renal
scintigraphy on gamma camera
- Glomerular filtration rate can be assessed using 51Cr-EDTA. No urine collection
is required and the preparation is simple and more reliable than creatinine
clearance, esp. in paediatrics.
4. Residual urine determination.
The test is performed in patients with prostate hypertrophy. Normally less than
20ml residual urine is in bladder. In values more than 100 ml - surgery
/ e.g. prostatectomy / has to be performed in order to prevent acute renal
insufficiency.
5. Therapeutic methods for a palliation of pain in bone matastases

Principle-the used RPh accumulate in the sites of bone metastases, corresponding to

their perfusion and metabolism / metabolitic curitherapy /. This therapy is applied
as a palliative treatment in patients with prostatic carcinoma, who have not
responded to conventional therapy and in patients with breast, lungs, kidneys,
bladder, etc. carcinoma / 32P, 89P, 186Re, 153Sm /. Confirmation of bony metastases
by bone scanning is advised prior to therapy. 32P is rarely applied, as it induces
myelosupression. Contraindications-in advanced leucopenia / Le bellow 2600/ and
thrombocitipenia / Thr-bellow 60000 /.
Most applicable is 89Sr, whish is effective in up to 80% of the patients with a
duration of the effect-about 6 months.
Advantages:
- one dose application during the whole therapeutic period
- specific uptake in bone metastases
- in 30% of the patients the appearance of new metastases can be delay or stop
- no adverse effects, typical for narcotics, radiotherapy and chemotherapy
- prolongation of life can be achieved
CENTRAL NERVOUS SYSTEM IMAGING
1. Imaging the integrity of blood-brain barrier
99mTc-DTPA is used less frequently nowadays compared with CT or MRI. It is
based on the selective permeability of the blood-brain barrier, which excludes the
radiopharmaceutical from normal brain tissue. In abnormal conditions, when there
is a disturbance of the microcirculation in the brain, the blood-brain barrier is
disturbed and the abnormality / subdural haematoma, tumor, abscess / is seen as
increased activity. Sensitivity is 90%, but CT or MRI dive better resolution of
details.
2. Perfusion brain scintigraphy
Brain perfusion can be visualized, using 99mTc-HMPAO and tomographic gamma
camera. It is reduced in dimentias / Alzheimer's disease, epilepsy, strokes and
migreine / and the treatment effect can be monitored.
NUCLEAR ONCOLOGY
It uses RPh for diagnosis of tumors, its metastases and recurrences and to monitor
the effect of treatment. It is the most active developing trend in nuclear medicine.
1. Using of conventional RPh.
No perfect tumor specific RPh has been described yet, some however are more
specific than others.

Non-specific RPh- they are used as a screening markers: 99mTc-MDP for bone
scintigraphy, 99mTc-macroagregated albumin for lung scintigraphy, 99mTccolloid for bone marrow and liver scintigraphy, 99mTc-DMSA for kidney
scintigraphy, 99mTc-pertechnetate for thyroid scintigraphy. The tumor is
visualized as a "cold" lesion.
- Tumor seeking RPh: 99mTc-MIBI, 67Ga-citrate, 201Tl for bone, thyroid, brain ,
lymphoma, breast, lung's scintigraphy. The tumor is visualized as a "hot"lesion
and radioactivity decreases with regression of the disease / favorable effect of
therapy /
- Specific RPh- it specifically accumulates in only one tumor - e.g.131 I in thyroid
carcinoma and metastasis.
2. Radioimmunoscintigraphy
Monoclonal antibodies to various tumor constituents can be labeled antibodies
l;abeled and used for imaging primary and metastatic sites and have potential for
therapy /radioimmunotherapy/. Useful results have been obtained in gastrointestinal
and ovarian tumors and melanoma, mostly used labeled antibodies labeled with
131I, 123I or 111In.
3. PET scintigraphy
Using metabolic markers such as 18Fl-FDG, 15O, 11C, 14N, an image of the tumor,
its metastases and recurrence can be visualized, based on their higher metabolic
activity / increased perfusion, O2, glucose than the normal tissue /.
RADIOIMMUNOANALYSIS / RIA /
These methods belong to non-imaging methods "in vitro". Using them, the level of
different biologically active substances, usually in serum were determined, without
any radioactive burden to the patient.
Berson and Yallow measured the quantity of insuline in the blood of a patient with
diabetes and they were awarded with the Nobel prize for a medicine in 1977.
Nowadays about 200 substances can be measured due to existence of the ready made
kits, produced from different firms. The concentrations of antigens / substances
which has to be determined / most often are in the range of nanograms / 10-9 g / or
picograms / 10-12g /. Bigger concentrations are measured with the methods of
biochemistry and immunology.
Basis for RIA is the reaction Antigen /Ag/- Antibody / Ab /, which intensity depends
on the concentration of the substances, which is measured, using radioactive
indicator. The principle is as follows: competition between non-labeled Ag / the
substance from the patient, which has to be measured /and labeled Ag /from the kit /
for not enough quantity of the Ab. One radioimmune kit consists from Ab; labeled
Ag and standarts / non-labeled Ag, which concentration is known /. The reaction
runs as follows:
Ag + Ag* + Ab
125I is most often used radionuclide for labeling of Ag. Usually 0,1-0,2 ml serum are
enough for the measurement of biologically active substances, which could be:

1. Hormons of the thyroid, ovaries, suprarinals, hypophysis, pancreas, e.g. T3, T4,
TTH, estradiol, prolactine, cortisol, insuline.
2. Tumor markers- these are highly specific antigens for the diagnosis of tumors,
their metastases and recurences and for monitoring the effect of treatment- PSA,
CA15-3, CA125, etc.
3. Plasma proteins-thyreoglobuline
4. Vitamines-B12
5. Enzimes - gastrine
6. Drugs-digoxine
Trends for developing of RIA are:
1. More and more substances are measured using RIA
2. Development of ultramicrometods, using less quantity of serum /below 0,1ml/
3. Development of kits for measuring 2 substances at the same time
4. Computarisation of the whole measurements