ENDONCRINE GLANDS RADIOISOTOPE IMAGING...
Transcript of ENDONCRINE GLANDS RADIOISOTOPE IMAGING...
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
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: (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 - +
ADRENAL CORTEX
HYPOTHALAMIC PITUITARY ADRENAL AXIS
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
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(Cohn’s)
Tumor left adrenal gland
RADIO-CHOLESTEROL 131I-NP59 SCANS
liver
bowel
A patient with Cushing’s Syndrome131I-NP59 study
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
A patient with Cushing’s 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 Cushing’s 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 500µCi (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
PHEOCHROMOCYTOMA“Ectopic”
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
SarcoidosisWegener’s 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 NEUROBLASTOMA
tumor tumor
tumortumor
Skull metastasisPrimary Tumor
Recurrent Neuroblastoma in a 6 month old boy
FDG-PET INNEUROBLASTOMA
Recurrent Tumor
Neuroblastoma at diagnosis and 6mos after chemotherapy
FDG-PET IN NEUROBLASTOMAEFFECT OF THERAPY
FDG-PET CT-Scan MIBG
Baseline
After Chemotherapy
A 17 year old girl with right shoulder pain
FDG-PET INHEPATOBLASTOMA
CT Scan FDG - PET
necrotictumor
necrotictumor
Active viable tumor
PITUITARY GLAND TUMORS
PET: 11C-BROMOCRYPTINESPECT: SOMATOSTATIN analogue
(111I-OCTREOTIDE)