ENDONCRINE GLANDS RADIOISOTOPE IMAGING...

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ENDONCRINE GLANDS RADIOISOTOPE IMAGING AND THERAPY THYROID GLAND TRAPPING MECHANISM : 99m Tc-0 4 Na (γ) IODINATION: 123 I (γ), 131 I (β), 125 I (Auger e - ) METABOLISM: 18 FDG, 201 TI (x), 99m TcMIBI (γ) PARATHYROIDS METABOLISM (K): 201 TI(x), 99m Tc-MIBI (γ) ADRENAL CORTEX STEROIDOGENESIS: 131 I( 123 I) CHOLESTEROL ADRENAL MEDULLA NORADRENALIN SYNTHESIS: 131 I( 123 I) MIBG PITUITARY GLAND RECEPTORS: 18 F-BROMOCTYPTINE 111 In- 99m Tc-OCTREOTIDE RVH (RENIN) ACE-INHIBITORS 99m Tc-MAG 3 /LASIX SOMATOSTATIN RECEPTOR IMAGING: 111 In-OCTREOTIDE

Transcript of ENDONCRINE GLANDS RADIOISOTOPE IMAGING...

Page 1: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

ENDONCRINE GLANDSRADIOISOTOPE IMAGING AND THERAPY

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

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

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

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EMBRYOLOGY OF THE ADRENAL GLANDS

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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

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ADRENAL GLANDS

Normalglands

lesionresponseto DXM

suppressionNP-59imaging

CORTEX: 1) Hydrocortisone: (Cushing’s)

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

2) Aldosterone: Aldosteronoma (Cohn’s).. suppressed - +3) Androgens: ……....Congenital Adrenal Hypertrophy - +4) Carcinomas ………………………… NL - -

2) Carcinomas (Neuroblastoma)…………… NL - +

Octreo orMIBG

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

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ADRENAL CORTEX

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HYPOTHALAMIC PITUITARY ADRENAL AXIS

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ADRENOCORTICAL SCINTIGRAPHY PROTOCOL

PATIENT PREPARATIONDEXAMETHASONE 8 mg/day from day -5 to day +3LUGOL’S 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

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CORTICAL SCINTIGRAPHY NP-59

48 hours24 hours

On Dexamethasone

Normal Adrenals

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CORTICAL SCINTIGRAPHY NP-59

Off Dexamethasone

Normal Adrenals

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ADRENOCORTICAL IMAGINGUSE OF RENAL SCAN TO LOCALISE LESIONS

MAG3 RENAL SCAN

Appropriate localization

Normal Adrenals

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ADRENOCORTICAL ADENOMA NP59 FUSION

Adrenal Scan Renal Scan Fusion Image+

+ =

=

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Children with virulism131I-NP59 studies

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CONGENITAL ADRENAL HYPERTROPHY

NP-59 scans from 3 children with Congenital Adrenal Hypertrophy

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ECTOPIC ADRENAL TISSUEIN TESTES OR OVARIES

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

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Patient hypertensiver/o aldosterone producing tumor (s)

131I-NP59 study

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Aldosteronoma of the left adrenal gland(Cohn’s)

Tumor left adrenal gland

RADIO-CHOLESTEROL 131I-NP59 SCANS

liver

bowel

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A patient with Cushing’s Syndrome131I-NP59 study

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CUSHING’S ADENOMA LEFT ADRENALSUPPRESSION OF THE RIGHT ADRENAL

bowel

bowel

liverliver

Left adrenal cortical tumor. What about the right adrenal?

The right adrenal is suppressed

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A patient with Cushing’s Syndrome131I-NP59 study

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ADRENOCORTICAL HYPERPLASIA

liver

Both adrenal glands large/prominent off Dexamethasone

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Patient hypertensiver/o aldosterone producing tumor (s)

131I-NP59 study

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R/O ALDOSTERONOMA:

Bilateral Adrenal Hyperplasia

Tc-99m-MAG3 I-131-NP59

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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

Page 24: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

A patient with Cushing’s Syndrome131I-NP59 study

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ADRENOCORTICAL ADENOMA NP59

bowel

liver

Left adrenal gland large/prominent Right adrenal suppressed

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ADRENAL MEDULLA

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EMBRYOLOGY OF THE ADRENAL MEDULLA

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

LESION LOCALIZATION

MAG3 Renal Scan or SPECT/CT

Page 29: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

A patient with hypertension is studied to exclude Pheochromocytoma

Page 30: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

MIBG NORMAL STUDIES

Total body studiesbecause

pheochromocytomas may involve

the adrenal glands,sympathetic ganglia,

or other sites

Normal Adrenal

visualization

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MIBG NORMAL STUDY

PHYSIOLOGIC ADRENAL VISUALIZATION

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

Page 32: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

PHEOCHROMOCYTOMA

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SENSITIVITY OF MIBG FOR PHEOCHROMOCYTOMA

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

Cancer 1984; 34(2):86

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A patient with clinical and laboratory findingssuggesting Pheo

and a CT showing lesion in the left adrenal

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PHEOCHROMOCYTOMA

Anterior

Posterior

MIBG study

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PHEOCHROMOCYTOMA

MIBG study

48hr post 0.750mCi 131I-MIBG

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ADRENAL MEDULLARY PHEOCHROMOCYTOMA

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PHEOCHROMOCYTOMA“Ectopic”

MIBG studyRenal Scan

Page 39: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

57yo man s/p L adrenalectomy for Pheochromocytoma

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MALIGNANT METASTATIC PHEOCHROMOCYTOMA

Ant

Ant Ant Ant

Post Post

MIBG study

Page 41: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

MALIGNANT PHEOCHROMOCYTOMA METASTATIC TO LUNGS

45yo woman s/p resection of pheochromocytoma

Page 42: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA

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

MRI is negative. Patient allergic to iodine.

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123I-MIBG SPECT/CT Pheochromocytoma

10 yo child with hypertension + lab work suggesting Pheochromocytoma

Page 44: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA

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MULTI-ENDOCRINE NEOPLASIA

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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

Page 47: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

A Child with a history of resected Medullary thyroid carcinoma

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BILATERAL PHEOCHROMOCYTOMASMEN-II

MIBG study

24hr 48hr 96hr

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

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RECURRENT PHEOCHROMOCYTOMAMEN-IIMIBG study

11/17 off medication7/14 while taking Labetalol

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

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RECURRENT PHEOCHROMOCYTOMAMEN-IIb

MIBG study

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NEUROBLASTOMA

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NM studies in NEUROBLASTOMA

Bone Scan/(Liver-Renal scans)

MIBG Total Body Imaging/Therapy

Antibody Imaging/Therapy

Somatostatin-analogue (Octreotide)

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NEUROBLASTOMAPrimary Tumor calcified

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A 10 mo old child with proptosis

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NEUROBLASTOMA PRIMARY TUMOR

Tc-99m MDP Bone scan

AND METASTASIS TO BONES

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JNM 25(7): 773

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A child with Neuroblastoma. Evaluate for metastases

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NEUROBLASTOMA Primary

VISCERAL METASTASIS

131I-MIBG

Anterior Posterior

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NEUROBLASTOMA WITH VISCERAL METASTASIS

131I-MIBG STUDYAND TcSC, TcDTPA

SC+DTPA

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A child with Neuroblastomaand positive bone marrow biopsy

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NEUROBLASTOMA WITH BONE MARROW METASTASIS

131I-MIBG

Posterior total body images to better show the bone marrow

Page 64: ENDONCRINE GLANDS RADIOISOTOPE IMAGING …radiology.med.miami.edu/documents/2009ENDO_3_ADRENAL.pdfENDONCRINE GLANDS. RADIOISOTOPE IMAGING AND THERAPY. ... Both adrenal glands large/prominent

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

SarcoidosisWegener’s TuberculosisGraves’ Thyroid Exophthalmos

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111In-OCTREOTIDE SCINTIGRAPHY

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A child with Neuroblastoma

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111In-OCTREOTIDE SCINTIGRAPHYNEUROBLASTOMA

Bone metastases of neuroblastoma

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FDG-PET INNEUROBLASTOMA

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FDG-PET IN NEUROBLASTOMA

FDG accumulates within most neuroblastomas

It also accumulates within neuroblastomaswhich are MIBG negative

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A child with Neuroblastoma

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MIBG and FDG-PET in NEUROBLASTOMA

tumor tumor

tumortumor

Skull metastasisPrimary Tumor

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Recurrent Neuroblastoma in a 6 month old boy

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FDG-PET INNEUROBLASTOMA

Recurrent Tumor

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Neuroblastoma at diagnosis and 6mos after chemotherapy

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FDG-PET IN NEUROBLASTOMAEFFECT OF THERAPY

FDG-PET CT-Scan MIBG

Baseline

After Chemotherapy

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A 17 year old girl with right shoulder pain

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FDG-PET INHEPATOBLASTOMA

CT Scan FDG - PET

necrotictumor

necrotictumor

Active viable tumor

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PITUITARY GLAND TUMORS

PET: 11C-BROMOCRYPTINESPECT: SOMATOSTATIN analogue

(111I-OCTREOTIDE)

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