ENDONCRINE GLANDS RADIOISOTOPE IMAGING GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal...

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Transcript of ENDONCRINE GLANDS RADIOISOTOPE IMAGING GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal...

  • ENDONCRINE GLANDSRADIOISOTOPE IMAGING AND THERAPY

    THYROID GLAND TRAPPING MECHANISM : 99mTc-04Na ()IODINATION: 123I (), 131I (), 125I (Auger e-)METABOLISM: 18FDG, 201TI (x), 99mTcMIBI ()

    PARATHYROIDS METABOLISM (K): 201TI(x), 99mTc-MIBI ()

    ADRENAL CORTEX STEROIDOGENESIS: 131I(123I) CHOLESTEROL

    ADRENAL MEDULLA NORADRENALIN SYNTHESIS: 131I(123I) MIBG

    PITUITARY GLAND RECEPTORS: 18F-BROMOCTYPTINE111In- 99mTc-OCTREOTIDE

    RVH (RENIN) ACE-INHIBITORS 99mTc-MAG3/LASIX

    SOMATOSTATIN RECEPTOR IMAGING: 111In-OCTREOTIDE

  • EMBRYOLOGY OF THE ADRENAL GLANDS

  • ADRENAL IMAGINGCORTEX: 131I(123I) CHOLESTEROL or NP-59

    (On/Off Dexamethasone Suppression)

    Carcinomas Do Not Visualize

    MEDULLA: 131I (123I) META-IODO-BENZYL-GUANIDINE or MIBG

    Carcinomas Visualize with MIBG

    MEDULLA also:111In-SOMATOSTATIN ANALOGUE

    or Octreotide

  • ADRENAL GLANDS

    Normalglands

    lesionresponseto DXM

    suppressionNP-59imaging

    CORTEX: 1) Hydrocortisone: (Cushings)

    a) Hypertrophy (bilateral)... hypertrophic + +b) Tumor (benign) suppressed - +

    2) Aldosterone: Aldosteronoma (Cohns).. suppressed - +3) Androgens: ....Congenital Adrenal Hypertrophy - +4) Carcinomas NL - -

    2) Carcinomas (Neuroblastoma) NL - +

    Octreo orMIBG

    imagingMEDULLA:1) Norepinephrine: Pheochromocytoma.. NL - +

  • ADRENAL CORTEX

  • HYPOTHALAMIC PITUITARY ADRENAL AXIS

  • ADRENOCORTICAL SCINTIGRAPHY PROTOCOL

    PATIENT PREPARATIONDEXAMETHASONE 8 mg/day from day -5 to day +3LUGOLS SOLUTION 5 drops/day from day -2 to day + 8

    INJECTIONDay 1: 0.5-1.0 mCi 131I(123I) CHOLESTEROL (NP-59)

    IMAGING Days +2 (+3) : Scan on dexamethasone suppressionDays +5 (+7) : Scan off dexamethasone suppression

    FOR BETTER LOCALIZATIONa) MAG3 Renal Scanb) SPECT/CT

  • CORTICAL SCINTIGRAPHY NP-59

    48 hours24 hours

    On Dexamethasone

    Normal Adrenals

  • CORTICAL SCINTIGRAPHY NP-59

    Off Dexamethasone

    Normal Adrenals

  • ADRENOCORTICAL IMAGINGUSE OF RENAL SCAN TO LOCALISE LESIONS

    MAG3 RENAL SCAN

    Appropriate localization

    Normal Adrenals

  • ADRENOCORTICAL ADENOMA NP59 FUSION

    Adrenal Scan Renal Scan Fusion Image+

    + =

    =

  • Children with virulism131I-NP59 studies

  • CONGENITAL ADRENAL HYPERTROPHY

    NP-59 scans from 3 children with Congenital Adrenal Hypertrophy

  • ECTOPIC ADRENAL TISSUEIN TESTES OR OVARIES

    NP-59 scans from 3 children with suspected Ectopic Adrenal tissue in the testes

  • Patient hypertensiver/o aldosterone producing tumor (s)

    131I-NP59 study

  • Aldosteronoma of the left adrenal gland(Cohns)

    Tumor left adrenal gland

    RADIO-CHOLESTEROL 131I-NP59 SCANS

    liver

    bowel

  • A patient with Cushings Syndrome131I-NP59 study

  • CUSHINGS ADENOMA LEFT ADRENALSUPPRESSION OF THE RIGHT ADRENAL

    bowel

    bowel

    liverliver

    Left adrenal cortical tumor. What about the right adrenal?

    The right adrenal is suppressed

  • A patient with Cushings Syndrome131I-NP59 study

  • ADRENOCORTICAL HYPERPLASIA

    liver

    Both adrenal glands large/prominent off Dexamethasone

  • Patient hypertensiver/o aldosterone producing tumor (s)

    131I-NP59 study

  • R/O ALDOSTERONOMA:

    Bilateral Adrenal Hyperplasia

    Tc-99m-MAG3 I-131-NP59

  • RADIO-CHOLESTEROL 131I-NP59 SCANS INTERPRETATION DEPENDS ON PATIENT PREPARATION

    IF NO DEXAMETHASONE WAS GIVEN = THE STUDY IS NORMAL ON LOW DOSE DEXAMETHASONE = BILAT. ADRENAL HYPERPLASIA

    ON HIGH DOSE DEXAMETHASONE = BILATERAL ADENOMAS

    Tc-99m-MAG3 I-131-NP59

  • A patient with Cushings Syndrome131I-NP59 study

  • ADRENOCORTICAL ADENOMA NP59

    bowel

    liver

    Left adrenal gland large/prominent Right adrenal suppressed

  • ADRENAL MEDULLA

  • EMBRYOLOGY OF THE ADRENAL MEDULLA

  • IMAGING ADRENAL MEDULARY LESIONS 131/123I meta-iodo-benzyl guanidine (MIBG)

    It is associated with the neurosecretory granules of the cytoplasmic portion of the adrenal medulla

    INDICATIONS Pheochromocytomas: sensitivity 85%, specificity > 99%

    Neuroblastomas: Sensitivity is greater than 90%

    for soft tissue, bone, or bone marrow involvement

    METHOD

    Patient preparation: Stop medications with sympathetic action

    Inject 500Ci (5-10mCi) 131I (123I)-MIBG and scan at 48hr (+72hr)

    LESION LOCALIZATION

    MAG3 Renal Scan or SPECT/CT

  • A patient with hypertension is studied to exclude Pheochromocytoma

  • MIBG NORMAL STUDIES

    Total body studiesbecause

    pheochromocytomas may involve

    the adrenal glands,sympathetic ganglia,

    or other sites

    Normal Adrenal

    visualization

  • MIBG NORMAL STUDY

    PHYSIOLOGIC ADRENAL VISUALIZATION

    24Hr (low count image) 48Hr 48Hr Repeat Study

  • PHEOCHROMOCYTOMA

  • SENSITIVITY OF MIBG FOR PHEOCHROMOCYTOMA

    15yo boy with Pheo (k=autotransplanted kidney) 75yo man with recurrentmalignant metast Pheo

    Cancer 1984; 34(2):86

  • A patient with clinical and laboratory findingssuggesting Pheo

    and a CT showing lesion in the left adrenal

  • PHEOCHROMOCYTOMA

    Anterior

    Posterior

    MIBG study

  • PHEOCHROMOCYTOMA

    MIBG study

    48hr post 0.750mCi 131I-MIBG

  • ADRENAL MEDULLARY PHEOCHROMOCYTOMA

  • PHEOCHROMOCYTOMAEctopic

    MIBG studyRenal Scan

  • 57yo man s/p L adrenalectomy for Pheochromocytoma

  • MALIGNANT METASTATIC PHEOCHROMOCYTOMA

    Ant

    Ant Ant Ant

    Post Post

    MIBG study

  • MALIGNANT PHEOCHROMOCYTOMA METASTATIC TO LUNGS

    45yo woman s/p resection of pheochromocytoma

  • 123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA

    10yo boy with laboratory presentation raising the question of Pheochromocytoma.

    MRI is negative. Patient allergic to iodine.

  • 123I-MIBG SPECT/CT Pheochromocytoma

    10 yo child with hypertension + lab work suggesting Pheochromocytoma

  • 123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA

  • MULTI-ENDOCRINE NEOPLASIA

  • MULTIPLE ENDOCRINE ADENOMATOSIS (MEA)

    Familial SyndromesCommon: Neuroectodermal origin of glands involved

    (informational coding)

    1 Multiple Endocrine Neoplasia type I (MEN-I)Parathyroid AdenomaPancreatic Islets (Zollinger-Ellison Syndrome)Pituitary (Hypo or Hyper Function)

    2 Multiple Endocrine Neoplasia type II (MEN-II)Parathyroid Adenoma

    PheochromocytomaMedullary Thyroid Carcinoma

  • A Child with a history of resected Medullary thyroid carcinoma

  • BILATERAL PHEOCHROMOCYTOMASMEN-II

    MIBG study

    24hr 48hr 96hr

  • A Child with a history of resected Medullary thyroid carcinoma and Pheochromocytoma

  • RECURRENT PHEOCHROMOCYTOMAMEN-IIMIBG study

    11/17 off medication7/14 while taking Labetalol

  • 27yo man s/p thyroidectomy at age 15y for Medullary carcinomaand bilateral adrenalectomy at age 20y for pheochromocytomas

  • RECURRENT PHEOCHROMOCYTOMAMEN-IIb

    MIBG study

  • NEUROBLASTOMA

  • NM studies in NEUROBLASTOMA

    Bone Scan/(Liver-Renal scans)

    MIBG Total Body Imaging/Therapy

    Antibody Imaging/Therapy

    Somatostatin-analogue (Octreotide)

  • NEUROBLASTOMAPrimary Tumor calcified

  • A 10 mo old child with proptosis

  • NEUROBLASTOMA PRIMARY TUMOR

    Tc-99m MDP Bone scan

    AND METASTASIS TO BONES

  • JNM 25(7): 773

  • A child with Neuroblastoma. Evaluate for metastases

  • NEUROBLASTOMA Primary

    VISCERAL METASTASIS

    131I-MIBG

    Anterior Posterior

  • NEUROBLASTOMA WITH VISCERAL METASTASIS

    131I-MIBG STUDYAND TcSC, TcDTPA

    SC+DTPA

  • A child with Neuroblastomaand positive bone marrow biopsy

  • NEUROBLASTOMA WITH BONE MARROW METASTASIS

    131I-MIBG

    Posterior total body images to better show the bone marrow

  • 111In-OCTREOTIDE SCINTIGRAPHY

    Somatostatin(14AA) Octreotide=Oligopeptide analogue(8AA)

    CarcinoidGastrinomaInsulinomaGlucagonomaParaganglioma

    Non-Small Cell Lung cancerMeningiomas PheochromocytomaApudomas non specifiedMedullary thyroid carcinoma

    Tumors with membrane somatostatin receptors Granulomatous Autoimmune

    SarcoidosisWegeners TuberculosisGraves Thyroid Exophthalmos

  • 111In-OCTREOTIDE SCINTIGRAPHY

  • A child with Neuroblastoma

  • 111In-OCTREOTIDE SCINTIGRAPHYNEUROBLASTOMA

    Bone metastases of neuroblastoma

  • FDG-PET INNEUROBLASTOMA

  • FDG-PET IN NEUROBLASTOMA

    FDG accumulates within most neuroblastomas

    It also accumulates within neuroblastomaswhich are MIBG negative

  • A child with Neuroblastoma

  • MIBG and FDG-PET in NE