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Nuclear Medicine Nuclear Medicine in in
Oncology Oncology
Dr. Deniz BEDELDr. Deniz BEDEL
WorkflowWorkflow
Radioactivity is given to the patient orally/i.v
These are either the radioactive forms of the elements that are used in the body or organ specific agents
When the agents are accumulated or caught by the target organ, images are obtained by the gamma cameras
The half life of these radiopharmaceuticals are short and eliminated from the body in hours
What is Nuclear Medicine ?What is Nuclear Medicine ?
Images obtained with gamma cameras when radioactivity is given to the patients
Bone scintigraphy: Dark areas are the bone metastases.
Why Do We Use This Method? Why Do We Use This Method?
Non-invazive
Radiology can give information on anatomical details but not function
Functional Evaluation Functional Evaluation
Tumors and Radiopharmaceuticals Tumors and Radiopharmaceuticals
Primary tumor Radiopharmaceutical
Differentiated thyroid carcinoma
123I or 99mTc-pertechnetate
Medullary thyroid carcinoma 99mTc-V-DMSA
Lymphoma 67Ga citrate
Neuroendocrine tumors 111In-octreotide
Neural crest tumors 123I-MIBG
Breast carcinoma 99mTc-MIBI
Primary bone tumors 99mTc-MDP
Differentiated Thyroid CancerDifferentiated Thyroid Cancer
• RadiopharmaceuticalsRadiopharmaceuticals– I-123I-123 – I-131 I-131
• Whole body imaging is used for Whole body imaging is used for detection of residual thyroid tissue and detection of residual thyroid tissue and metastases. metastases.
I-131I-131
Lymphoma imaging using Lymphoma imaging using Gallium-67 Gallium-67
Lymphoma imaging using FDG
Gastroenteropancreatic Gastroenteropancreatic Neuroendocrine Tumors (GEP-NET) Neuroendocrine Tumors (GEP-NET)
• Radioactive somatostatin analogues (Radioactive somatostatin analogues (In-111 In-111 octreotide, Lu-177 DOTA-TATE)) i is used s used because of the presence of somatostatin because of the presence of somatostatin receptors receptors
Primary gastrinomaPrimary gastrinomaIn-111 octreotide In-111 octreotide
Neural Crest TumorsNeural Crest Tumors
• I-131 MIBG resembles noradrenaline I-131 MIBG resembles noradrenaline
• Whole body imaging enables multifocal Whole body imaging enables multifocal or extraadrenal tumor detection or extraadrenal tumor detection
Pheocromacytoma -MIBGPheocromacytoma -MIBG
Neuroblastoma imaging using Neuroblastoma imaging using I-131-MIBG I-131-MIBG
MIBG Bone scan
Bone metastases Detection Bone metastases Detection
• Generally seen as increased radioactivity on bone Generally seen as increased radioactivity on bone scintigraphyscintigraphy
• Rarely (2%) cases may show ‘photopenic’ lesions Rarely (2%) cases may show ‘photopenic’ lesions (renal cell ca, melanoma)(renal cell ca, melanoma)
• Rutine bone scintigraphy Rutine bone scintigraphy – Prostate CaProstate Ca– Breast CaBreast Ca– Lung CaLung Ca
Multiple metastasesMultiple metastases
Sentinel lymph node detection Sentinel lymph node detection
• It is the first lymph node where the It is the first lymph node where the tumor drainstumor drains
• Colloidal particle injectionColloidal particle injection
• Drainage imagesDrainage images
• Intraoperative gamma probe Intraoperative gamma probe
Sentinel nodeSentinel node
Sentinel node intraoperativeSentinel node intraoperative
PETPET
• Positron emission tomographyPositron emission tomography
• Functional and whole body imagingFunctional and whole body imaging
• Evaluation of tumor metabolism via Evaluation of tumor metabolism via radioactive glucose or aminoacids radioactive glucose or aminoacids
PET
Tumor localisation ,
Differentiation between benign / malign
Detection of tumour viability after treatment
18F-florodeoxyglucose (FDG)
FDG Hexokinase
FDG-6-fosfat
Cell
Glucose
Transporter
Hexokinase
Glucose-6-phosphatase
Glycolysis
FDG FDG FDG-6-PO4
FDG PETFDG PET
Glucose-6-isomerase
PET/CT
PETPET
Shorter Shorter Less radiation Less radiation
Better resolution Better resolution Better lesion detection Better lesion detection
RADIONUCLIDE RADIONUCLIDE THERAPY THERAPY
Radionuclide Therapy Radionuclide Therapy TherapyDifferentiated thyroid cancer
Neuroblastoma stage III-VMalign pheochromacytoma
GEP-NET Tumors
Painful bone metastases
Myeloproliferative diseases (polistemia
vera)
Radionuclide Synovectomy
RadiopharmaceuticalI-131
I-131 MIBG
In-111 octreotide,Y-90 DOTATOC,Lu-177 DOTA-TATE
P-32, Sr-89, Sm-153 EDTMP,Re-186 HEDP
P-32
P-32, Re-186, Sm-153, Re-188,Au-198
Radio-iodine ThreapyRadio-iodine Threapy
• Differentiated thyroid cancerDifferentiated thyroid cancer
• Post-op.Post-op.
• Ablation of functional thyroid tissueAblation of functional thyroid tissue
• 100-200 mCi100-200 mCi
• In-patientIn-patient
MIBG therapyMIBG therapy
• Pheocromacytoma and neuroblastoma Pheocromacytoma and neuroblastoma
• Rarely medullary thyroid cancerRarely medullary thyroid cancer
• Pre or post-opPre or post-op
• Pallation or curative Pallation or curative
Lymphoma imaging using Lymphoma imaging using 111111In-In-Anti-CD20 (Anti-CD20 (ZevalinZevalin®®))
Wiseman et al. Cancer 2002;94:1349–1357
4 hours
66 hours
139 hours
Abdominal CT
Abdominal SPECT
Anterior gamma camera scans
Gastroenteropancreatic Gastroenteropancreatic Neuroendocrine Tumours (GEP-NET)Neuroendocrine Tumours (GEP-NET)Lu-177 DOTA-TATE
Treatment of Painful Bone Treatment of Painful Bone Metastases Metastases
• Alternative to analgesics, Alternative to analgesics, non-steroidal anti-non-steroidal anti-inflainflamatuary treatmentmatuary treatment, radiotherapy, , radiotherapy, chemotherapy or hormone therapychemotherapy or hormone therapy
• 3232P and P and 8989Sr Sr (beta)(beta)
• 153153Sm-EDTMPSm-EDTMP (beta and gamma) (beta and gamma)
Radionuclide Synovectomy
Radiolabeled colloidsRadiolabeled colloids
Intra articular injectionIntra articular injection
Combination of glucocorticoidsCombination of glucocorticoids
Hemophilic ArthritisHemophilic Arthritis
Rheumatoid ArthritisRheumatoid Arthritis
Intra articular pigmented villonodular synovitis Intra articular pigmented villonodular synovitis (PVNS)(PVNS)