2. در مرکز پزشکی هسته ای دکتر دباغ – دکتر صادقی در خدمت شما هستیم مشهد، ملاصدرا 11 ، پلاک 1/4 www.DSNMC.ir Tel:+98(51) 38411524; +98(51)38472927

3. مرکز پزشکی هسته ای دکتر دباغ-دکتر صادقی  متخصصین این مرکز از اعضای هیئت علمی دانشگاه‌ علوم پزشکی مشهد بوده که با همکاری تکنولوژیست‌ها وپرستاران کارآزموده، به ارائه خدمات پزشکی هسته‌ای اشتغال دارند.  تجهیزات و دوربین گامای نصب شده در این مرکز از نوع پیشرفته Dual-Head Variable Angle با سرعت زیاد برای تصویربرداری با کیفیت بالا می باشد.  دیدگاه ها و چشم اندازهای مرکز نگرش اخلاقی و انسانی که به تبع آن نهایت سعی در رفتار و برخورد محترمانه نگرش اخلاقی و انسانی که به تبع آن نهایت سعی در رفتار و برخورد محترمانه تلاش در ارائه خدمات تخصصی با بهترین کیفیت ممکن تلاش در ارائه خدمات تخصصی با بهترین کیفیت ممکن ارتقاء کیفیت خدمات، متناسب با پیشرفت های علمی و تکنولوژیک جهان ارتقاء کیفیت خدمات، متناسب با پیشرفت های علمی و تکنولوژیک جهان ارائه خدمات تشخیصی و درمانی پزشکی هسته ای که تاکنون در ایران انجام نشده است. ارائه خدمات تشخیصی و درمانی پزشکی هسته ای که تاکنون در ایران انجام نشده است. مشهد، ملاصدرا 11 ، پلاک 1/4 www.DSNMC.ir Tel:+98(51) 38411524; +98(51)38472927

4. V. R. Dabbagh Kakhki, M.D. Nuclear Medicine Specialist Associate Professor DSNMC Nuclear Medicine Research Center (NMRC; MUMS) Clinical Applications of Nuclear Medicine in GU Tract a brief revew a brief review

5. Renal Cortical Imaging: DMSA Dynamic Renography : DTPA Direct Radionuclide Cystography (DRC): VCUG with Radioisotope Nuclear Medicine & GU

6. Dynamic Renography Technique: Dynamic Renography Technique:  Bolus injection of tracer  Obtained serial images Supine Supine posterior view posterior viewImaging:  Perfusion: 1-2 sec/view for 1-2min  Functional : 30 sec/view for 30 min

7. Dynamic Renography Technique: Dynamic Renography Technique: Imaging:  Perfusion: 1-2 sec/view for 1-2min  Functional : 30 sec/view for 30 min

10. Dynamic Renography Radiotracers Glomerular Filtration Tubular Secretion Extraction  99m Tc-DTPA>95% 20%  99m Tc-MAG3<5%95% 40-50%  99m Tc-EC <10% 90%  131 I-OIH20%80% ~100%

11. DTPA: Diethylenetriaminepentaacetic acid MAG3: Mercaptoacetylglycine EC: ethylenedicysteine OIH: Orthoiodohipuric acid

12. Dynamic Renography; Evaluates:   Renal perfusion   Renal function, renal morphology and size   GFR   ERPF Clinical applications:  Obstructive nephrouropathy  Reflux uropathy  Renal failure  Renal transplant  RVH

14. DTPA normal

18. Mean counts/second Renal perfusion time-activity for Tc-99m DTPA A curve can be generated that represents the perfusion only

19. Renogram

20. 1 2 3 1- Blood flow phase (20- 40 sec) Ao-to-Kid ~ 3” 2- Concentration phase (3-5 min) T peak < 5’ 3- Excretory(washout) phase

21. Relative (split) function DRF (Differential Renal Function)

22. DTPA normal

23. DTPA flow + Functional Phases GFR = 29 ml/’ Creat = 2.0 DRF: LK= 33% RK= 67%

24. Renal artery occlusion

25. Rt renal infarct

26. Normal Renogram

27. Renal Function   Creatinine Clearance: No accurate due to tubular excretion Overestimates GFR in chronic renal disease and decreased muscle mass No measure individual renal function unless catheterization of each kidney   Clearance of DTPA Plasma-sample : more accurate Camera-based   Relative uptake: DRF Normal:50/50 to 56/44 57/43 to 59/41: borderline 60/40: abnormal

28. Obstructive uropathy   Diuresis renography for Diagnosis Assesment of parenchymal damage Postsurgical evaluation   Anatomical imaging methods rely on demonstrating the structural abnormalities   Diuretic renography : Very useful : evaluate renal function and urodynamics in a single test but contributes little to determining etiology.

29.   There are two protocols in use: F+20 : demonstrates a diuretic response F-15 :more decisive in detecting minor degrees of obstruction   If SKGFR<16ml/min only Whitaker test can be done Obstructive uropathy

30. No Obstruction

31. F+20

32. F-15

33. T 1/2 washout cts 100% 50% T 1/2 min

34. Quantitative t 1/2 diuretic response clearance  Washout half time <10 min No obstruction <10 min No obstruction Between 10 and 20 min Indeterminate Between 10 and 20 min Indeterminate >20 min Urinary obstruction >20 min Urinary obstruction

35. Diuretic Renal Scan Indications   Evaluate functional significance of hydronephrosis   Determine need for surgery obstructive hydronephrosis - surgical Rx non-obstructive hydronephrosis - medical Rx   Monitor effect of therapy

36. Diuretic Renal Scan Requirements  Rapidly cleared tracer  Well hydrated patient  Good renal function

37. pre-Lasix

38. post-Lasix No Obstruction

39. 3164897 3-wk old baby Lt hydronephrosis

40. 3164897 Lt UPJ obstruction

41. 3164897 Lt UPJ obstruction

42. Diuretic Renal Scan Interpretation  Interpret whole study, not T 1/2 alone  Visual (dynamic images)  Washout curve shape  T 1/2

43. Diuretic Renal Scan Pitfalls   False positive for obstruction Distended bladder Gross hydronephrosis Poorly functioning / immature kidney Dehydration   False negative Low grade obstruction Poorly functioning / immature kidney

44. Effect of catheterization (1) full bladder, no catheter

45. with catheter in bladder Effect of catheterization (2)

46. Whitaker test   Standard for obstruction   Invasive   Infusion : pressure> 22 cm H2O to achieve a pelvoureteral flow rate of 10 ml/min : Obs Indeterminate <15cm H2O : No Obs

48. Renal transplant scan ;   Essential part of transplant department.   Best tracer: 99m Tc-MAG3.   Perfusion and function analysis   Useful in DDx of transplant complications: ATN, Rejection, Cyclosporine toxicity, Obstructive disease,Urinoma, Lymphocele,…

49. Complications after renal transplantation  ATN Minutes to hours  Rejection Hyperacute Minutes to hours Hyperacute Minutes to hours Accelerated 1-5 days Accelerated 1-5 days Acute After 5 days (first 3 months) Acute After 5 days (first 3 months) Chronic Months to years Chronic Months to years  Cyclosporine toxicity Months  Surgical Urine leak, Hematoma, Wound infection, Urine leak, Hematoma, Wound infection, Obstruction, Lymphocele, RAS Obstruction, Lymphocele, RAS

50. Differential diagnosis of various complications Requires correlation of scintigraphic findings with Pt’s clinical course, physical findings, laboratory values, current therapy, prior scintigraphic findings, and results of other imaging tests.

51.  Since many of the complications are diagnosed from the patterns of changes in time, it is important to obtain a baseline study soon after transplantation. Follow-up studies should be performed always by the same technique.

52.  Two Aspects: Perfusion phase Perfusion phase Function Phase Function Phase  Choice; Tc99m-MAG3 Good quality perfusion images Good quality perfusion images High extraction rate High extraction rate Excellent imagesExcellent images Evaluation of collecting system, ureter and bladder Evaluation of collecting system, ureter and bladder Renal transplant scan : TRS

53. TRS: Perfusion  Images  Curves

54. TRS: Functional Phase  Images  Curves Uptake: Tc99m-MAG3: Max: before : 5 min Uptake: Tc99m-MAG3: Max: before : 5 min Parenchymal transit Parenchymal transit Excretion of the tracer Excretion of the tracer

55. Nuclear medicine testing   Obtain a baseline study soon after transplantation   ATN: Perfusion is better than function, decreased uptake, delayed transit, diminished clearance   AR: Decreased perfusion, tracer uptake, delayed transit and decreased clearance   CR: low uptake, normal parenchymal transit with absent or minimal cortical retention   Cyc toxicity: Mild : like CR Severe: like ATN   RVH caused by RAS can not differentiated from CR unless challenged by ACEI s. ( pattern of CR changes to a pattern of AR)

57. Acute rejection Perfusion Phase Functional phase

58. Surgical complications  US and Tc99m-MAG 3 images  Diuretic renography : Differentiate obstruction from simple pelvocalyceal dilatation

59. Lymphocele

60. Urinary Leak

61. Radionuclide Cystogram

62. Indications  Evaluation of children with recurrent UTI 30-50% have VUR 30-50% have VUR  F/U after initial VCUG  Assess effect of therapy / surgery  Screening of siblings of reflux pts.

63. Methods  Tc-99m S.C. or TcO4  via Foley  can do at any age  VUR during filling  catheterization  Tc-99m DTPA or Tc-99m MAG3  i.v.  no catheter  info on kidneys  need pt cooperation  need good renal fct Advant. Disadv. Direct Indirect

64. Direct Cystography  1 mCi S.C. in saline via Foley  Fill bladder until reversal of flow (bladder capacity = (age+2) x 30 (bladder capacity = (age+2) x 30  Continuous imaging during filling & voiding  Post void image  Record volume instilled volume instilled volume voided volume voided pre- and post- void cts pre- and post- void cts

65. RN Cystogram vs. VCUG  Lower radiation dose (5 vs 300 mrad to ovary)  Smaller amount of reflux detectable  Quantitation of post-void residual volume  Cannot detect distal ureteral reflux  No anatomic detail  Grading difficult Advantages Disadvantages

66. Normal cystogram filling voiding post-void

67. VUR - filling phase A

68. VUR - voiding phase & post- void B

69. Post void residual volume voided vol x post-void cts pre-void cts - post void cts RV =

70. Reflux nephropathy 16% 84%

71. Vesicoureteral reflux  Conventional method : X-ray micturating cystography Excellent delination of bladder and urethral anatomy Excellent delination of bladder and urethral anatomy Grading of the reflux Grading of the reflux  An alternative method : radionuclide cystography  Technique: Direct & Indirect Direct & Indirect Direct: The same as radiological VCUG Direct: The same as radiological VCUG Indirect: At the end of DTPA or MAG 3 renal scan, lesser sensitivity, no for initial screening test, a positive study is reliable but a negative study should be confirmed by direct cystography Indirect: At the end of DTPA or MAG 3 renal scan, lesser sensitivity, no for initial screening test, a positive study is reliable but a negative study should be confirmed by direct cystography

72. Radionuclide cystography:  Advantages: High sensitivity. High sensitivity. Low radiation.(50 to 200 times less radiation to gonads comapred to the contrast cystography Low radiation.(50 to 200 times less radiation to gonads comapred to the contrast cystography Quantification ( post voiding residue). Quantification ( post voiding residue).  Disadvantages: Poor grading ability. Poor grading ability. No anatomic detail of the urerthra No anatomic detail of the urerthra * VCUG is reserved for the initial work up of male patients to exclude an anatomical abnormality, such as PUV. * VCUG is reserved for the initial work up of male patients to exclude an anatomical abnormality, such as PUV. Text

73. Radionuclide cystography: Indications:  Initial screening to detect reflux in girls with UTI  Follow up of patients with reflux.  Screening of siblings  Serial evaluation of children with neuropathic bladder who are at risk to develop reflux

76. Renal infection  Radiopharmaceuticals: 99m Tc-DMSA 99m Tc-DMSA 99m Tc-glucoheptonate 99m Tc-glucoheptonate 67 Ga 67 Ga 111 In-WBC or 99m Tc-WBC 111 In-WBC or 99m Tc-WBC

77. Renal sonography  Commonly used in the evaluation and management of UTI  Non-invasive imaging  Detection of hydronephrosis, and congenital anomalies  Detection of renal abscesses, pyeonephrosis and abnormalities of the perinephric space  Changes secondary to acute pyelonephritis may also be recognized

78. Cortical imaging: 99m Tc-DMSA  Cortical agent  Trapped in the cytoplasm of the proximal tubular cells  An indicator of functioning tubular renal mass.  Advantages : (over IVP and US) Pyelonephritis and renal scars: more sensitive Pyelonephritis and renal scars: more sensitive Tc99m-DMSA : 94%Tc99m-DMSA : 94% Intravenous pyelography :76%Intravenous pyelography :76% US: 65%US: 65% Defects on DMSA scan become apparent before on IVP or US Defects on DMSA scan become apparent before on IVP or US Lower radiation dose (as compared to the IVP) Lower radiation dose (as compared to the IVP) Is not affected by overlying bowel gas or bones Is not affected by overlying bowel gas or bones Avoids possible allergic reaction Avoids possible allergic reaction

79. DMSA Renal scan; Clinical applications;  Renal size, shape and location  Renal cortical assessment.  Determining DRF (most accurate noninvasive method)  Infectious disease and distinguish upper from lower UTI(Early detection and follow up of pyelonephritis; most sensitive,95% Vs 76%)  Follow up of patients(serial scans)  Congenital renal anomaly(Ectopia,..)  Vascular lesions (infarct)  DDx of pseudomass from SOL.  Renal trauma  Confirm the total absence of function in dysplastic kidney

80. Acute pyelonephritis in DMSA scan  Single or multiple areas of decreased cortical uptake  No loss of volume  Diffusely decreased uptake in an enlarged kidney Diminished uptake may be due to both focal tubular cell dysfunction and ischemia Diminished uptake may be due to both focal tubular cell dysfunction and ischemia A mature cortical scar is usually associated with contraction, cortical thinning, loss of volume and marked reduction in uptake A mature cortical scar is usually associated with contraction, cortical thinning, loss of volume and marked reduction in uptake

81. Normal DMSA Renal Scan

89. Renal Morphology Scan (Renal Cortical Scintigraphy) Evaluation of Renal Infection

90. UTI  VUR risk factor for PN, risk factor for PN, not all pts w PN have VUR not all pts w PN have VUR  PN may lead to scarring >>> ESRD, HTN early Dx and Rx necessary early Dx and Rx necessary  Clinical & laboratory Dx of renal involvement in UTI unreliable

91. Renal Cortical Scintigraphy Indications  Determine involvement of upper tract (kidney) in acute UTI (acute pyelonephritis)  Detect cortical scarring (chronic pyelonephr.)  Follow-up post Rx

92. Renal Cortical Scintigraphy Procedure  Tracers Tc-99m DMSA Tc-99m DMSA Tc-99m GHA Tc-99m GHA  Acquisition 2-4 hrs post-injection 2-4 hrs post-injection parallel hole posterior parallel hole posterior pinhole post. + post. oblique (or SPECT) pinhole post. + post. oblique (or SPECT)  Processing: relative fct

93. Renal Cortical Scintigraphy Interpretation  Acute PN single or multiple “cold” defects single or multiple “cold” defects renal contour not distorted renal contour not distorted diffuse decreased uptake diffuse decreased uptake diffusely enlarged kidney or focal bulging diffusely enlarged kidney or focal bulging  Chronic PN volume loss, cortical thinning volume loss, cortical thinning defects with sharp edges defects with sharp edges  Differentiation of AcPN vs. ChPN unreliable

94. Renal Cortical Scintigraphy “Cold Defect “  Acute or chronic PN  Hydronephrosis  Cyst  Tumors  Trauma (contusion, laceration, rupture, hematoma)  Infarct

95. DMSA Normal

96. Normal DMSA pinhole LPO RPO

97. Acute pyelonephritis DMSA post L LPO post R RPO LEAP Defect in Right Kidney

98. Renal Cortical Scintigraphy Congenital Anomalies  Agenesis  Ectopy  Fusion (horseshoe, crossed fused ectopia)  Polycystic kidney  Multicystic dysplastic kidney  Pseudomasses (fetal lobulation, hypertrophic column of Bertin)

99. DMSA horseshoe kidney

100. DMSA LK Agenesis

101. Crossed ectopia 74% 26%

103. Scrotal scintigraphy;  If the diagnosis of testicular torsion is established : surgery  When the diagnosis is uncertain, imaging studies should be rapidly obtained  Tracer: Technetium pertechnetate ( 99m TcO4)  Easy, simple and takes only 10 minutes  DDx of acute torsion from other complications ( epididymitis) ( epididymitis)  Scintigraphy can confirm the clinically suspected diagnosis of torsion and direct the patient to surgery  Scintigraphy can minimize unnecessary exploration in patients with an inflammatory cause of their pain.  For chronic or painless disorders of the scrotum US is the method of choice.

104. Acute testicular torsion Scintigraphic findings  The findings depend on the time Early torsion: Decreased activity in the region of the involved testicle Early torsion: Decreased activity in the region of the involved testicle Late torsion: Increased scrotal activity but relatively decreased activity in the region of the ischemic testicle “ bull’s eye” Late torsion: Increased scrotal activity but relatively decreased activity in the region of the ischemic testicle “ bull’s eye”  Acute epididymitis & epididymoorchitis: Increased activity Increased activity  Scrotal scintigraphy is not the imaging of choice in most other conditions affecting the scrotal contents.

105. Scrotal scintigraphy;  SS for acute testicular torsion Sensitivity and specificity > 95% Sensitivity and specificity > 95% False negative False negative Spontaneous detorsionSpontaneous detorsion Incomplete twistsIncomplete twists Inguinal testisInguinal testis

106. Normal Late Torsion Early torsion

107. Renovascular Hypertension Renovascular Hypertension  Defined as stenotic lesions of the renal arteries that induce elevated BP and potentially improve after revascularization  Anatomic stenosis is not equivalent to the diagnosis of RVH  Significant morbidity from renal artery angioplasty or revascularization  A functional diagnosis is needed before proceeding with therapy  Discrepancies between scintigraphy and angiography Involving the small vessels Involving the small vessels RAS incidentally in a substantial proportion of elderly Pts RAS incidentally in a substantial proportion of elderly Pts  The prevalence of RVH<1%

108. Captopril Renal Scan (ACE inhibition renography) Advantages:  Best screening test for RVH  Best predictor of response to surgery, angioplasty and captopril therapy  Determine which Pts have hemodynamically significant stenoses enough to cause HTN  Avoided unnecessary arteriograms  Detection of RVH whatever the level of arterial obstruction  High accuracy  Sensitivity: 80-90%  Specificity:90-95% Techniques:  Post Captopril scan ( 50mg orally,..)  Base line scan  Positive if GFR or Curve worsening Mechanism:  Inhibition of ACE, releasing efferent arteriole constriction.

110. Criteria of positivity  10% rise in cortical retention ratio  Increase in the Time to peak  Worsening in DRF ( relative uptake)  MPTT

111. Criteria of positivity  Shape of curve: a worsening of at least one grade

112. Baseline StudyPost-captopril Study Pre- and post captopril excretion curves of the right kideny

114. Selection of patients for evaluation  Diagnosis of RVH can be made only after the patient responds to revascularization  The tests can not be used as a mass screening procedure: The incidence of RVH is low and therefore post test probability of a positive test still has a low probability of RVH. The incidence of RVH is low and therefore post test probability of a positive test still has a low probability of RVH. CRS appears to have improved sensitivity and specificity to the point where it is practical to screen selected patients. CRS appears to have improved sensitivity and specificity to the point where it is practical to screen selected patients.

115. Indication of ACE inhibition renography  Accelerated or malignant HTN  Abrupt or recent onset HTN  Onset under age 30 or over age 55  Refractory HTN  Abdominal or flank bruits  Unexplained azotemia  Worsening renal function during therapy with ACEI s  End organ damage ( LVH, retinopathy)  Occlusive disease in other vascular beds  Previous hypertensive urogram suggestive of RAS  Unilateral small kidney

116. Aspirin Renography  Inhibition of PG synthesis would decrease renin : An effect similar to captopril  Aspirin reduces both renal blood flow and glomerular filtration - Similar sensitivities to ACEI scintigraphy Renal blood flow PGE2 Renin

117. V.R.Dabbagh; DSNMC; www.DSNMC.ir