1. Diagnostic Applications of Nuclear Technology
Dr Harsh Mahajan, MD
Mahajan Imaging
New Delhi, INDIA

2. What is Nuclear Medicine ?
Nuclear Medicine is a branch of Medicine that deals with the use of Radioactive substances in research, diagnosis and treatment
Small amounts of radioactive material is used to diagnose and determine the severity of a variety of diseases, including many types of cancers, heart disease, gastrointestinal, endocrine, neurological disorders and other abnormalities within the body

3. How is it different from Radiology ?
In radiology, the radiation is generated by external sources like X-rays and anatomical images of the body are obtained
In Nuclear Medicine, the radiation is emitted from within the body and captured by the Gamma Camera or the PET CT camera
Here the emphasis is on imaging the function of the body or a system and for such reason, it is called a physiological imaging modality

4. Is nuclear medicine safe?
In a Nuclear Medicine diagnostic procedure, small amounts of radiopharmaceuticals are introduced into the body by injection, swallowing or inhalation
The amount of the radiopharmaceutical that is used is chosen to provide the lowest radiation exposure to a patient while ensuring an accurate medical evaluation.

5. Why Nuclear Medicine ?
Functional information about every major organ system
Cost effective
Minimum radiation dose; comparable to diagnostic X-Ray
Safe and painless

6. Why Nuclear Imaging
Nuclear Imaging detects functional (vs. anatomical) properties of the human tissue.
The imaging is done by tracing the distribution of Radiopharmaceuticals within the body
Radioisotope is an isotope that emits gamma rays: e.g. 131I, 99m Tc
Radiopharmaceutical is a Radioisotope bound to a Biological system/organ specific agent

7. Integrated PET/CT Imaging Systems
PET imaging
Diagnostic multi slice CT Scanner

8. Clinical Applications of Nuclear Medicine
Pulmonary: Emboli, Split function
Cardiac: Perfusion, viability, infarction, LVEF
Skeletal: Tumor, infection
Oncology: PET, Gallium, Thallium
Endocrine: Thyroid, parathyroid
Gastro intestinal: bleeding, gallbladder function
Genito-urinary: RAS, obstruction, reflux
Neuro imaging: Dementia, movement disorders, tumor, seizure and brain death

9. Lung Ventilation
Lung Perfusion

10. Baseline
Post Thrombolysis

11. Myocardial Perfusion Imaging (Cardiac Imaging)

12. CARDIAC RADIONUCLIDEIMAGING
PERFUSION IMAGING: STRESS MYOCARDIAL PERFUSION IMAGING (MPI)
VIABILITY IMAGING: CARDIAC PET (FDG)

13. Cardiac Applications
Diagnose Coronary Artery Disease
Measure Effectiveness of Bypass Surgery
Measure Effectiveness of Therapy for Heart Failure
Detect Heart Transplant Rejection
Select Patients for Bypass or Angioplasty
Identify Patients at High Risk of Heart Attacks going to Surgery for Other Reasons

14. SPECT Anatomy – Vertical Long Axis
Normal Vertical Long Axis*
Stress AB
Ant AA
Rest IB
Inf
SPECT Anatomy
These slides show the coronary anatomy and the corresponding SPECT views: short axis, horizontal long axis, and vertical long axis. IA
99mTc- Sestamibi Perfusion Imaging

15. Normal Myocardial perfusion scan

16. Reversible ischemia

17. Fixed Perfusion Defect

18. Cardiac PET/CT (18F-Flourodeoxy glucose FDG) for Viability

19. Mismatched perfusion and metabolism in hibernating myocardium
MPI
FDG

20. RESTING MPI
FDG PET

21. Positive predictive value- 74%, Negative predictive value - 86%,
Viability assessment by PET
Sensitivity - 94%,
Specificity - 95%,
Positive predictive value- 74%,
Negative predictive value - 86%,
Accuracy - 89%.
(NEJM, J Am Coll Cardiol, Am Heart J, Am J Cardiol, Circulation, Eur J Nucl Med).

22. Skeletal Imaging
Bone Scan
Tc-99M MDP (Methylene Diphosphonate)
Increased activity in areas of bone formation
Tumor, infection, occult fractures
Planar or SPECT
Single phase or Triple Phase

24. Metastatic Breast Cancer
dddddddddd

25. Thyroid Scan: Vascular cold nodule

26. SESTAMIBI
PARATHYROID
IMAGING
PARATHYROID
ADENOMA
Tc 99m
Sestamibi
Subtracted image

27. Tc 99m labelled Leukocyte scan
To detect active focus of infection
To assess response to therapy
Intra-abdominal abscesses
Peri prosthetic infection

28. Genitourinary System Renal Scan- DTPA/MAG3 Diuretic Renal scintigraphy
Captopril scinitgraphy
Renal cortical Scan-DMSA
Radionuclide cystogram-Direct (DRCG)/Indirect
Renal Transplant evaluation
Testicular Scan
Peritoneography
Leukocyte scan
4/7/2019

29. Normal DTPA Scan
4/7/2019

30. Left PUJO
4/7/2019

31. Normal DMSA Scan
4/7/2019

32. Bilateral renal scarring
4/7/2019

33. What is PET CT?

34. PET/CT- Anato-metabolic imaging
PET/ CT is combination of the two state of the art imaging modalities, PET and CT, where PET provides metabolic information about the tumor, complementary to anatomic imaging obtained by CT

35. Integrated PET/CT Imaging Systems
Diagnostic CT Scanner
Multislice (2 – 4 slices/rotation originally, now 8,16, …., 64)
0.5 seconds/rotation, helical Scan – 17 seconds/meter

36. Clinical Applications for PET/CT
Oncology -80%
Neurology-10%
Brain Tumors
Dementias
Epilepsy
Neuropsychiatric disorders
Cerebrovascular disease
Cardiology-5%
Myocardial perfusion
Myocardial viability
Infection Imaging-5%
Osteolmyelitis
Peri-prosthetic infection
PUO

37. Is it safe?
Totally safe, non invasive, painless
No side effects
Total radiation dose is less than 1 ½ standard whole body CT scans.
As half life of FDG is -110min, family members are not at risk for exposure

38. Benefits of PET CT Cancer  change in function change in anatomy
Disease picked up before structural changes/ despite structural distortions (Improved tumor detection, localization, precise staging, better recurrence monitoring and response to therapy)
One stop imaging of Function and structure (Shorter investigation time, improved patient convenience of a single scan)
Provides more diagnostic information than either modality by itself
Lower Radiation Burden to patient

39. Normal PET CT PET CT Fused

40. How can pet ct make a difference?
Early Detection and staging
Assessing the Effectiveness of Chemotherapy
Restaging
Checking for recurrences
Surveillance

41. Case
41 year /F,
Left breast lump since 2 months
FNAC: Infiltrating Ductal Carcinoma
USG abdomen: Fatty infiltration with no focal mass lesion

44. PET/CT In
Infection imaging

45. Peri-Prosthetic Infection on PET CT

46. Ga-68 DOTA NOC PET/CT

47. Peptide synthesis module
Ge68/Ga68 generator
Parent T1/ days
Daughter T1/2- 68 min
4/7/2019 54

48. Presented with c/o pain abdomen Multiple liver lesions detected on USG
CASE
51 yrs/F
Presented with c/o pain abdomen
Multiple liver lesions detected on USG
Raised chromogranin A levels
Liver biopsy: metastasis from NET ? Primary
4/7/2019 55

49. Ga DOTA NOC
4/7/2019 56

50. Prostate specific membrane antigen (PSMA) PET CT in Prostate Cancer
4/7/2019

51. Ca P with rectal infiltration and bone and nodal metastases

52. PET/CT in Neurology

53. Normal FDG PET study of Brain
Normal Brain of a 90 yr old
Normal Brain of a month old

54. BRAIN TUMOR

55. Post Th. CT scan of brain tumor
PET CT for therapy assessment
Post Th. CT scan of brain tumor
Only one viable tumor on
PET

56. EPILEPTOGENIC FOCUS IN RIGHT FRONTAL CORTEX
EPILEPSY
ICTAL SPECT
INTERICTAL SPECT
EPILEPTOGENIC FOCUS IN RIGHT FRONTAL CORTEX

57. Advanced Alzheimer’s Disease
Diffuse hypometabolism out of
Proportion to atrophy on CT
Characteristic sparing of
Sensorimotor and occipital cortices
and cerebellum

58. FRONTO-TEMPORAL DEMENTIA

59. Take Home Message
Safe
Diagnoses disease often before it shows up on other tests
Detection of unusual and unexpected sites of metastasis
Gold standard for monitoring treatment response
Modality of choice to identify recurrence and metastatic disease in follow up patients
Reduces ineffective or unnecessary surgical or medical treatments and hospitalization
Significantly reduces multiple medical costs and avoids needless pain to the patient

60. Thank You