Mysterious Radiopharmaceutical Mysterious Radiopharmaceutical Localization: A Pictorial Interactive Localization: A Pictorial Interactive

ExhibitExhibitBruce J. Barron, MD,MHABruce J. Barron, MD,MHA

Usha A. Joseph, MDUsha A. Joseph, MDDavid Q. Wan, MDDavid Q. Wan, MD

Dorothy L. Rasberry, RT(N)Dorothy L. Rasberry, RT(N)

The University of Texas-Houston The University of Texas-Houston Medical SchoolMedical SchoolHouston, TexasHouston, Texas

OBJECTIVEOBJECTIVE

1)1) Learn The Standard QC Of RadiopharmaceuticalsLearn The Standard QC Of Radiopharmaceuticals

2)2) Recognize The Unusual Occurrences That Can Affect Recognize The Unusual Occurrences That Can Affect DistributionDistribution

3)3) Recognize Relatively Rare Disease States That Can Show Recognize Relatively Rare Disease States That Can Show Unusual DistributionUnusual Distribution

4)4) Know How To Follow Algorithm As An Aid To Know How To Follow Algorithm As An Aid To Determine Altered Distribution, Etiology And Determine Altered Distribution, Etiology And SignificanceSignificance

The production of radiopharmaceuticals can be complicated and The production of radiopharmaceuticals can be complicated and delicate. Most practicing nuclear medicine physicians and delicate. Most practicing nuclear medicine physicians and radiologists are aware of the common production problems or radiologists are aware of the common production problems or errors that can produce abnormal appearances on nuclear scans. errors that can produce abnormal appearances on nuclear scans. We all are aware of the problems free pertechnetate can cause: We all are aware of the problems free pertechnetate can cause: thyroid uptake, stomach uptake, choroid plexus uptake, etc. thyroid uptake, stomach uptake, choroid plexus uptake, etc. Fewer are aware of problems related to excessive aluminum, Fewer are aware of problems related to excessive aluminum, reduced hydrolyzed Technetium, renal insufficiency or reduced hydrolyzed Technetium, renal insufficiency or pharmaceuticals exceeding their expiration time. For example, pharmaceuticals exceeding their expiration time. For example, Tc-DTPA, more than 6 hours old can sometimes cause extensive Tc-DTPA, more than 6 hours old can sometimes cause extensive soft tissue uptake and give the erroneous suggestion of renal soft tissue uptake and give the erroneous suggestion of renal disease. Normal QC Procedures will now be reviewed to exclude disease. Normal QC Procedures will now be reviewed to exclude production errors as the cause of unusual findings. production errors as the cause of unusual findings.

Quality ControlQuality Control (QC) ensures continued good medical practice, (QC) ensures continued good medical practice, maintains uniformity of laboratory standards, meets regulatory maintains uniformity of laboratory standards, meets regulatory criteria for patient safety and maintains image quality. QC is criteria for patient safety and maintains image quality. QC is done after radiopharmaceutical (RP) manufacture; dose assay is done after radiopharmaceutical (RP) manufacture; dose assay is done prior to patient administration. done prior to patient administration. Radiopharmaceutical (RP)Radiopharmaceutical (RP) is radionuclide (RN) + chemical is radionuclide (RN) + chemical molecule + stabilizer and buffer; needs FDA approval pre-routine molecule + stabilizer and buffer; needs FDA approval pre-routine use and authorized user approval pre-patient administration.use and authorized user approval pre-patient administration.Chemical purityChemical purity is the fraction of wanted to unwanted chemical in is the fraction of wanted to unwanted chemical in the radiopharmaceutical, eg, Aluminum breakthrough (package the radiopharmaceutical, eg, Aluminum breakthrough (package material) in Mo99/Tc 99m generator; for Fission generators, material) in Mo99/Tc 99m generator; for Fission generators, maximum Al concentration is 10 ugm/ml of eluate.maximum Al concentration is 10 ugm/ml of eluate.

Calorimetric spot testing (Aurin tricarboxylic acid) Calorimetric spot testing (Aurin tricarboxylic acid) intensity of intensity of purple color of RP containing Al+3 visually should be less than purple color of RP containing Al+3 visually should be less than that of a standard of 10 ug/mlAl+3 . Increased Al concentration that of a standard of 10 ug/mlAl+3 . Increased Al concentration causes increased lung activity on Tc SC scan and increased liver causes increased lung activity on Tc SC scan and increased liver activity on bone scan.activity on bone scan.Tc 99 is daughter of Tc 99m by isomeric decay and poses no Tc 99 is daughter of Tc 99m by isomeric decay and poses no health or radiation hazard. It is not an impurity or contaminant, health or radiation hazard. It is not an impurity or contaminant, but can result in poor kit labeling.but can result in poor kit labeling.Radio chemical (RC)Radio chemical (RC) purity: purity: fraction of radioactivity in desired fraction of radioactivity in desired chemical form; i.e., bound vs. unbound or free Tc99m. USP chemical form; i.e., bound vs. unbound or free Tc99m. USP criteria requires 95% or more of Tc 99m to be in +7(stable) state criteria requires 95% or more of Tc 99m to be in +7(stable) state and 90-% of total radioactivity in specified/desired RC form. and 90-% of total radioactivity in specified/desired RC form. Most RP commercial kits have Stannous (Sn) ions to reduce +7 Most RP commercial kits have Stannous (Sn) ions to reduce +7 states to reactive III, IV and V states to combine with chelating states to reactive III, IV and V states to combine with chelating agents, exception: Sulfur colloid uses +7 state of Tc04.agents, exception: Sulfur colloid uses +7 state of Tc04.

Nitrogen flushing of vials prevents oxygen from reacting Nitrogen flushing of vials prevents oxygen from reacting directly with Sn ensures complete reduction of Tc04. Excess directly with Sn ensures complete reduction of Tc04. Excess oxygen by interacting with Sn, decreases the reducing power oxygen by interacting with Sn, decreases the reducing power of kit, increasing free technetium. Small amounts of oxygen of kit, increasing free technetium. Small amounts of oxygen can cause reoxidation of Tc 99m to +VII state, resulting in can cause reoxidation of Tc 99m to +VII state, resulting in impurities like Tc 04. Antioxidant (ascorbic acid) stabilizers impurities like Tc 04. Antioxidant (ascorbic acid) stabilizers added to kit prevent changes after RP preparation and added to kit prevent changes after RP preparation and subsequent oxidation to +VII state.subsequent oxidation to +VII state.Many Tc 99m compounds are chelates; Large amounts of Tc Many Tc 99m compounds are chelates; Large amounts of Tc 99m added to multivial kits causes radiolysis after kit 99m added to multivial kits causes radiolysis after kit preparation.preparation.RC impurity results in poor labeling and is caused by RC impurity results in poor labeling and is caused by radiolysis, decomposition, pH changes, light exposure, radiolysis, decomposition, pH changes, light exposure, temperature of reaction and reaction times, presence of temperature of reaction and reaction times, presence of oxidizing /reducing agentsoxidizing /reducing agents

Testing:Testing: Thin layer chromatography using solvents with known Thin layer chromatography using solvents with known migration patterns for RC and known impurities, i.e., Acetone migration patterns for RC and known impurities, i.e., Acetone solvent or Silica gel and saline solvent. Abnormal Colloid solvent or Silica gel and saline solvent. Abnormal Colloid formation and unwanted liver localization occurs with poorly formation and unwanted liver localization occurs with poorly prepared RP due to low concentration of ligands or formation of prepared RP due to low concentration of ligands or formation of hydrolysed or reduced Technetium (Tc02). Excess Sn ions can hydrolysed or reduced Technetium (Tc02). Excess Sn ions can form Tin Colloid. form Tin Colloid. RN purityRN purity : less than 0.15 uCi Mo99m/mCi in Tc99m eluate. : less than 0.15 uCi Mo99m/mCi in Tc99m eluate.Improper Technique:Improper Technique: Excessive delay before starting Excessive delay before starting chromatography increases reoxidation of Tc in sample giving false chromatography increases reoxidation of Tc in sample giving false results; if spots are not dry on filter before dipping in solvent, gives results; if spots are not dry on filter before dipping in solvent, gives spurious migration patterns; immersing strip in solvent beyond spurious migration patterns; immersing strip in solvent beyond sample decreases migration.sample decreases migration.

Physical purityPhysical purity is fraction of total pharmaceutical in desired is fraction of total pharmaceutical in desired physical form; correct particle size distribution in MAA physical form; correct particle size distribution in MAA preparations or absence of particulate contamination in agent preparations or absence of particulate contamination in agent that is a true solution. that is a true solution. F18 FDGF18 FDG: Production expensive, Cyclotron or special : Production expensive, Cyclotron or special accelerators, complex/elaborate handling, usually comes as accelerators, complex/elaborate handling, usually comes as individual doses. individual doses. RP SterilityRP Sterility Absence of living organisms or metabolic products, Absence of living organisms or metabolic products, endotoxins. RP terminal sterilization is done using filters with endotoxins. RP terminal sterilization is done using filters with pores smaller than microorganisms, generally <22um, to trap pores smaller than microorganisms, generally <22um, to trap bacteria. USP testing is done using standard media, bacteria. USP testing is done using standard media, Thioglycollate and Soybean Casein, for different aerobic/ Thioglycollate and Soybean Casein, for different aerobic/ anaerobic bacteria and fungi.anaerobic bacteria and fungi.

Pyrogens:Pyrogens: Proteins/polysaccharide metabolites of Proteins/polysaccharide metabolites of microorganisms or contaminating substances cause febrile microorganisms or contaminating substances cause febrile reactions, appearing mins. to hrs. after RP administration, but reactions, appearing mins. to hrs. after RP administration, but usually not fatal. USP testing is with LAL (linulus amoebocyte usually not fatal. USP testing is with LAL (linulus amoebocyte lysate) preparations (containing blood of horseshoe crab) lysate) preparations (containing blood of horseshoe crab) become opaque with pyrogens. become opaque with pyrogens. pH testingpH testing is manufacturers/preparers responsibilities. is manufacturers/preparers responsibilities.Dose CalibratorsDose Calibrators four four basic testing ensures proper working.basic testing ensures proper working.AccuracyAccuracy is done annually using two different radioactive is done annually using two different radioactive sources. Greater than 10% variability in measured activity from sources. Greater than 10% variability in measured activity from standard / theoretical activity requires Recalibration.standard / theoretical activity requires Recalibration.

LinearityLinearity is done quarterly; response of calibrator over a is done quarterly; response of calibrator over a range of measured activities, i.e., Tc pertechnetate decay over range of measured activities, i.e., Tc pertechnetate decay over time, or using pre-calibrated lead attenuated sequential time, or using pre-calibrated lead attenuated sequential measurement of same specimen. Any deviation in observed measurement of same specimen. Any deviation in observed value indicates equipment malfunction or Non Linearity. value indicates equipment malfunction or Non Linearity. Precision /ConstancyPrecision /Constancy is done daily and indicates the ability to is done daily and indicates the ability to repeatedly measure the same long lived source , Cs 137, Ba repeatedly measure the same long lived source , Cs 137, Ba 133 or Co 57, over time. The observed values should be 133 or Co 57, over time. The observed values should be within 10% of the reference standard value.within 10% of the reference standard value.

Geometry Geometry is performed during acceptance testing of the is performed during acceptance testing of the calibrator using same amount of radioactivity in different calibrator using same amount of radioactivity in different volumes; if readings vary by greater than 10% in different volumes; if readings vary by greater than 10% in different volumes, correction factors are calculated based on the volumes, correction factors are calculated based on the commonly used daily volume.commonly used daily volume.Individual patient factorsIndividual patient factors can degrade or cause unexpected can degrade or cause unexpected findings on scan. Patient education may help, i.e., avoiding findings on scan. Patient education may help, i.e., avoiding exercise before and after FDG tracer injection, fasting state exercise before and after FDG tracer injection, fasting state prior to FDG injections; encouraging hydration after MDP prior to FDG injections; encouraging hydration after MDP injection.injection.

MisadministrationMisadministration is locally documented and records is locally documented and records maintained for 10 years. Major ones are reported to state and maintained for 10 years. Major ones are reported to state and NRC as needed.NRC as needed.Adverse Reaction:Adverse Reaction: Rare anaphylactic with HSA; occasional Rare anaphylactic with HSA; occasional allergic reactions to Tc 99m Sulfur Colloid from animal allergic reactions to Tc 99m Sulfur Colloid from animal protein (gelatin) stabilizer, occasional HAMA (Human protein (gelatin) stabilizer, occasional HAMA (Human antimouse antibody) reaction occursantimouse antibody) reaction occurs with repeated radio with repeated radio labeled antibodies administration. labeled antibodies administration. QC for gamma camerasQC for gamma cameras: complex devices with physical, : complex devices with physical, mechanical and electronic components with potential to mechanical and electronic components with potential to malfunction or breakdown.malfunction or breakdown.

Field uniformity,Field uniformity, intrinsic and extrinsicintrinsic and extrinsic, assesses uniformity of , assesses uniformity of the gamma camera across its entire field of view using a the gamma camera across its entire field of view using a radioactive source of appropriate energy with 1000 k to 5000 k radioactive source of appropriate energy with 1000 k to 5000 k counts collected. counts collected. Extrinsic floodExtrinsic flood is obtained is obtained dailydaily with collimator in place. A disk with collimator in place. A disk of uniformly distributed Co 57, or a flood source of a uniform of uniformly distributed Co 57, or a flood source of a uniform solution of Tc 99m in a phantom is placed on the gamma solution of Tc 99m in a phantom is placed on the gamma camera surface. camera surface. Intrinsic floodIntrinsic flood is usually done is usually done weeklyweekly using a point source of using a point source of radioactivity positioned five feet from the center of the non-radioactivity positioned five feet from the center of the non-collimated camera face. collimated camera face.

Flood imageFlood image showing a showing a highly uniform appearance or minor highly uniform appearance or minor mottlingmottling due to increased intensity corresponding to due to increased intensity corresponding to photomultiplier (PM) tubes indicates a well tuned camera photomultiplier (PM) tubes indicates a well tuned camera with proper photomultiplier tube and correction circuitry with proper photomultiplier tube and correction circuitry performance. Photomultiplier tube drift or failure of PM performance. Photomultiplier tube drift or failure of PM tube is seen as an area of decreased activity. Cracked crystal tube is seen as an area of decreased activity. Cracked crystal and damage to a collimator can be detected. Soft lead in and damage to a collimator can be detected. Soft lead in collimators can be dented resulting in bending and collimators can be dented resulting in bending and distortion of the septa. distortion of the septa. Spatial resolution and linearitySpatial resolution and linearity is evaluated weekly using a is evaluated weekly using a four quadrant bar phantom. Phantom center is placed at the four quadrant bar phantom. Phantom center is placed at the center of the camera and a uniform Tc 99m flood source is center of the camera and a uniform Tc 99m flood source is placed on the bar phantom. Four images at sequential 90 placed on the bar phantom. Four images at sequential 90 degrees rotations between positions are obtained, after degrees rotations between positions are obtained, after ensuring that the bars on the collimator are not positioned ensuring that the bars on the collimator are not positioned to give an interference pattern.to give an interference pattern.

Intrinsic spatial resolution (without collimatorIntrinsic spatial resolution (without collimator) a parallel line ) a parallel line equal spaced bar phantom requires two images since signals equal spaced bar phantom requires two images since signals from PM tubes are processed via two essentially independent from PM tubes are processed via two essentially independent positioning circuits (x and y), so degradation can occur in positioning circuits (x and y), so degradation can occur in selective directions. In a properly functioning camera, all selective directions. In a properly functioning camera, all groups of bars in the bar phantom should appear straight and groups of bars in the bar phantom should appear straight and parallel. Some distortion is typical at the edge of the field of parallel. Some distortion is typical at the edge of the field of view.view.An orthogonal hole test pattern requiring only one image can An orthogonal hole test pattern requiring only one image can also be used. When a problem is suspected, the procedure is also be used. When a problem is suspected, the procedure is repeated with and without the collimator. repeated with and without the collimator.

Spatial Resolution is expressed as Spatial Resolution is expressed as full width at half maximum full width at half maximum (FWHM)(FWHM) of a line spread function. A line spread function is of a line spread function. A line spread function is obtained by imaging a narrow line source of radioactivity obtained by imaging a narrow line source of radioactivity with with collimator (extrinsiccollimator (extrinsic) or ) or directly on the crystal face (intrinsic).directly on the crystal face (intrinsic). The resulting count profile or histogram perpendicularly The resulting count profile or histogram perpendicularly across it is called the line spread function. An ideal imaging across it is called the line spread function. An ideal imaging system with perfect spatial resolution shows the line spread system with perfect spatial resolution shows the line spread function as a single spike corresponding to the radioactive line function as a single spike corresponding to the radioactive line source, but practically a bell-shaped curve is seen. source, but practically a bell-shaped curve is seen. FWHM is the distance encompassed by the curve halfway FWHM is the distance encompassed by the curve halfway down from its peakdown from its peak; the narrower the peak the better the ; the narrower the peak the better the spatial resolution and improved ability to resolve objects close spatial resolution and improved ability to resolve objects close to one another. The intrinsic resolution of modern cameras is to one another. The intrinsic resolution of modern cameras is nearly nearly 3mm FWHM or less.3mm FWHM or less.

Window setting: Window setting: A symmetrical window centered at the A symmetrical window centered at the energy peak of the radiopharmaceutical. For Tc 99m, usually energy peak of the radiopharmaceutical. For Tc 99m, usually a 20% window centered at 140 kev is used, with an acceptance a 20% window centered at 140 kev is used, with an acceptance range from 126-154 kev. range from 126-154 kev. A narrower window of 10-15% A narrower window of 10-15% results in higher resolution imagingresults in higher resolution imaging. In newer gamma . In newer gamma cameras with energy correction circuitry, an asymmetrical cameras with energy correction circuitry, an asymmetrical window may reduce Compton scatter, but not in older window may reduce Compton scatter, but not in older cameras, due to the problem of non-uniform response across cameras, due to the problem of non-uniform response across the crystal. Generally reconfirm window setting for each the crystal. Generally reconfirm window setting for each radionuclide used daily and then reconfirm before imaging radionuclide used daily and then reconfirm before imaging each patient. each patient. Setting the energy window (peaking the cameraSetting the energy window (peaking the camera) ) is done by using a is done by using a radioactive source in air.radioactive source in air. Patient should not Patient should not be used as a radioactive source, since patient spectrum can be used as a radioactive source, since patient spectrum can include scatter, which can shift the perceived location of the include scatter, which can shift the perceived location of the photo peak. photo peak.

False positiveFalse positive because of artifacts and because of artifacts and false negativesfalse negatives due to due to loss of resolution occur with incorrect window settings leading loss of resolution occur with incorrect window settings leading to image degradation. In cameras with capability to image to image degradation. In cameras with capability to image multiple photo peaks simultaneously, need to ensure that image multiple photo peaks simultaneously, need to ensure that image data from the different photo peaks are correctly registered data from the different photo peaks are correctly registered together on the clinical image.together on the clinical image.Abnormal appearances of radiopharmaceutical problems Abnormal appearances of radiopharmaceutical problems described above are generally known. What happens when described above are generally known. What happens when none of the above situations apply? It can be frustrating to find none of the above situations apply? It can be frustrating to find the cause of aberrant patterns of uptake.the cause of aberrant patterns of uptake.One new abnormality that few are aware of is a potential One new abnormality that few are aware of is a potential problem with F-18-FDG. There is a small probability that free problem with F-18-FDG. There is a small probability that free F-18 may cause bony uptake or other alterations on the scan. F-18 may cause bony uptake or other alterations on the scan. The production of F-18-FDG at the cyclotron pharmacy The production of F-18-FDG at the cyclotron pharmacy involves several stepsinvolves several steps, including:including:

PrecursorPrecursor

1,3,4,6-Tetra-1,3,4,6-Tetra-OO-acetyl-2--acetyl-2-OO-trifluoromethane-sulfonyl--trifluoromethane-sulfonyl--D-mannopyranose (mannose triflate)-D-mannopyranose (mannose triflate)

M.F.:M.F.: CC1515HH1919FF33OO1212SS

Mol. Wt.:Mol. Wt.: 480.37480.37

AcOAcO = CH= CH33CO- (Protecting Group)CO- (Protecting Group)

OTf OTf = CF= CF33SOSO22- (Leaving Group)- (Leaving Group)

OO

TfTf

OAcOAcAcOAcO

AcOAcO

OAcOAc

OO

PRODUCTION OF [PRODUCTION OF [1818F]FDGF]FDG

KK++

KryptofixKryptofix®®[2.2.2][2.2.2][[1818F]F]--

CHCH33CN (acetonitrile)CN (acetonitrile)

++

HeatHeat10 min.10 min.

Tetra-acetyl [Tetra-acetyl [1818F]FDGF]FDG(fluorinated intermediate(fluorinated intermediate)

1818F LabelingF Labeling

OO

TfTf

OAcOAcAcOAcO

AcOAcO

OAcOAc

OO

HCl (Acid) + HeatHCl (Acid) + HeatOrOrNaOH (Base) + Room TempNaOH (Base) + Room Temp

++

2 min. Base or2 min. Base or10 min. Acid10 min. Acid

HydrolysisHydrolysis

OO

1818FF

OAcOAcAcOAcO

AcOAcO

OAcOAc

Crude Crude 1818F[FDG]F[FDG]

OO

1818FF

OHOH OHOH

OHOH

OHOH

Crude Crude 1818F[FDG]F[FDG]

PurificationPurification

• Removal of free Removal of free 1818FF• pH AdjustmentpH Adjustment• Removal of KryptofixRemoval of Kryptofix• Removal of intermediate productRemoval of intermediate product

Final Product:Final Product:

2-[2-[1818F]Fluoro-2-Deoxy-F]Fluoro-2-Deoxy-DD-glucose-glucose

M.F.:M.F.: CC66HH11111818FOFO55

Mol. Wt.:Mol. Wt.: 181.26181.26

The last step (hydrolysis) is crucial to remove the intermediate The last step (hydrolysis) is crucial to remove the intermediate products and form deoxyglucose. Failure to perform this last products and form deoxyglucose. Failure to perform this last step creates a component that is very sticky. As one would step creates a component that is very sticky. As one would suspect, this would cause a hang-up of tracer in IV lines and suspect, this would cause a hang-up of tracer in IV lines and prolong intense retention by the lungs. This could prevent prolong intense retention by the lungs. This could prevent adequate uptake by pathologic lesions. Recently a large adequate uptake by pathologic lesions. Recently a large number of such doses went out to customers in Houston, Texas. number of such doses went out to customers in Houston, Texas. Failure to do timely QC will result in this product being Failure to do timely QC will result in this product being delivered before results of QC are in. While we are talking of delivered before results of QC are in. While we are talking of FDG, a phenomenon common to any dose infiltrated upon FDG, a phenomenon common to any dose infiltrated upon injection is unexpected benign lymph node uptake. Careful injection is unexpected benign lymph node uptake. Careful inspection of the injection site and co-registration of PET and inspection of the injection site and co-registration of PET and CT make the cause more obvious. Technologists are asked to CT make the cause more obvious. Technologists are asked to include the injection site in the field of view or comment on the include the injection site in the field of view or comment on the occurrence on the technologist form.occurrence on the technologist form.

Paramount to evaluate any unusually appearing tracer Paramount to evaluate any unusually appearing tracer localization is to systematically evaluate certain localization is to systematically evaluate certain parameters. Meticulous detective work will usually pay parameters. Meticulous detective work will usually pay off. Sometimes, your answer may actually indicate an off. Sometimes, your answer may actually indicate an unusual disease process rather than error in unusual disease process rather than error in administration or production.administration or production.There are several steps one must go through as part of There are several steps one must go through as part of this detective process. The first step is to ask the patient if this detective process. The first step is to ask the patient if they had another recent nuclear medicine scan; for they had another recent nuclear medicine scan; for example, if the patient had a myocardial perfusion test, it example, if the patient had a myocardial perfusion test, it is not uncommon to see bowel uptake on a subsequent is not uncommon to see bowel uptake on a subsequent lung or bone scan; or bowel on ventilation study if the lung or bone scan; or bowel on ventilation study if the isotope used was Tl-201. Keep in mind the energy ranges isotope used was Tl-201. Keep in mind the energy ranges of each of the isotopes and this will help eliminate certain of each of the isotopes and this will help eliminate certain ones.ones.

We have now eliminated previous scans as a cause of We have now eliminated previous scans as a cause of abnormality. Another interesting phenomenon is liver and abnormality. Another interesting phenomenon is liver and spleen uptake on a bone scan. We know that high aluminum spleen uptake on a bone scan. We know that high aluminum levels could cause that. The next question to ask is “Were levels could cause that. The next question to ask is “Were other patients affected?” If the answer is yes, that leads us other patients affected?” If the answer is yes, that leads us down one pathway; we promptly call the pharmacy and ask down one pathway; we promptly call the pharmacy and ask them to check the aluminum level in the pertechnetate used to them to check the aluminum level in the pertechnetate used to make the kit. We are surprised to find out that QC was make the kit. We are surprised to find out that QC was perfect. We now have a dilemma. We have four patients, perfect. We now have a dilemma. We have four patients, children and adults with liver and spleen uptake on a bone children and adults with liver and spleen uptake on a bone scan. Could they all have hemosiderosis? Unlikely, but the scan. Could they all have hemosiderosis? Unlikely, but the next step is to figure out what other agent can cause liver and next step is to figure out what other agent can cause liver and spleen uptake. Tc-99m Sulfur-Colloid could possibly give spleen uptake. Tc-99m Sulfur-Colloid could possibly give bone marrow uptake as part of the scan, but in our patients it bone marrow uptake as part of the scan, but in our patients it was definitely a bone scan. The next step is to go to the was definitely a bone scan. The next step is to go to the pharmacy. Were there any Tc-sulfur colloid dose made at the pharmacy. Were there any Tc-sulfur colloid dose made at the same time? same time?

The answer was yes. We assayed the sulfur colloid vialThe answer was yes. We assayed the sulfur colloid vial and and the expected activity was short. After having the the expected activity was short. After having the technologist demonstrate his/her technique, we learned our technologist demonstrate his/her technique, we learned our answer. The technologist took Tc-pertechnetate to add to answer. The technologist took Tc-pertechnetate to add to the sulfur colloid vial. He drew up a sulfur colloid dose, but the sulfur colloid vial. He drew up a sulfur colloid dose, but somehow used the same syringe to draw up the somehow used the same syringe to draw up the pertechnetate forpertechnetate for making the MDP kit. Thus, all 4 patients making the MDP kit. Thus, all 4 patients had liver and spleen uptake without pathology. had liver and spleen uptake without pathology. A similar story occurred when a bone scan revealed uptake A similar story occurred when a bone scan revealed uptake in the bowel and brain. Review revealed no previous in the bowel and brain. Review revealed no previous studies, no history of shunts. Was there activity in the studies, no history of shunts. Was there activity in the stomach and thyroid? No. Back to the pharmacy; sure stomach and thyroid? No. Back to the pharmacy; sure enough, there was a freshly made ceretec dose. Once again enough, there was a freshly made ceretec dose. Once again we rationalized that the patient received a mixture of two we rationalized that the patient received a mixture of two doses. The same syringe must have been used to make both doses. The same syringe must have been used to make both kits.kits.

It is more difficult when you are sure the dose was It is more difficult when you are sure the dose was prepared correctly. A patient was given an injection of prepared correctly. A patient was given an injection of Tc-Ultra tag RBC as part of a MUGA study. The Tc-Ultra tag RBC as part of a MUGA study. The problem was that his heart didn’t visualize. Was there an problem was that his heart didn’t visualize. Was there an interfering drug such as heparin?interfering drug such as heparin?We repeated the study the next day with the patient off of We repeated the study the next day with the patient off of medications. Again, no cardiac uptake. In this case no medications. Again, no cardiac uptake. In this case no unknown cause was proven. However, the patient did unknown cause was proven. However, the patient did have a high cold agglutinin titer. Another example have a high cold agglutinin titer. Another example occurred when a patient sent for a DMSA had unusual occurred when a patient sent for a DMSA had unusual uptake. Instead of having renal uptake, the patient had uptake. Instead of having renal uptake, the patient had predominantly liver and spleen uptake. Did thepredominantly liver and spleen uptake. Did the phantom phantom strike again? No. Was there a lot of aluminum? – No. strike again? No. Was there a lot of aluminum? – No. After ruling out a radiopharmaceutical error andAfter ruling out a radiopharmaceutical error and searching “Dr Google”, we found our pattern to represent searching “Dr Google”, we found our pattern to represent acute cortical necrosis. acute cortical necrosis.

Another DMSA study showed diffuse bony uptake and again Another DMSA study showed diffuse bony uptake and again no kidneys.no kidneys. What could be going wrong? There was no history of a bone What could be going wrong? There was no history of a bone scan. The QC came out good. Again, Dr. Google came to the scan. The QC came out good. Again, Dr. Google came to the rescue. This was a DMSA “super scan”, rarely seen in patients rescue. This was a DMSA “super scan”, rarely seen in patients with chronic renal failure and on dialysis.with chronic renal failure and on dialysis.Another interesting case was a woman injected for a bone scan. Another interesting case was a woman injected for a bone scan. She had a remote history of cancer. The scan showed uptake She had a remote history of cancer. The scan showed uptake in the joints and kidneys and no bones. Serendipitously, there in the joints and kidneys and no bones. Serendipitously, there was uptake in the breast. The technologist insisted MDP was was uptake in the breast. The technologist insisted MDP was given. However, the whole body scan looked like a DTPA scan given. However, the whole body scan looked like a DTPA scan we had once used for joint imaging . After re-measuring the we had once used for joint imaging . After re-measuring the DTPA vial and MDP vials, we noted that nothing was missing DTPA vial and MDP vials, we noted that nothing was missing from the MDP vial. Presto, we had our answer. from the MDP vial. Presto, we had our answer. The breast uptake actually corresponded to a breast cancer The breast uptake actually corresponded to a breast cancer recurrence. This was a serendipitous finding. recurrence. This was a serendipitous finding.

The presence of bowel uptake on a bone scan generally is due to The presence of bowel uptake on a bone scan generally is due to a prior heart study. Be aware that other causes, including GI a prior heart study. Be aware that other causes, including GI bleed and ischemic bowel can cause this finding.bleed and ischemic bowel can cause this finding.Adequate FDG PET scanning requires a fast of at least 4-5 Adequate FDG PET scanning requires a fast of at least 4-5 hours. A blood sugar screen picks out some with elevated blood hours. A blood sugar screen picks out some with elevated blood sugar related to diabetes or inadequate fast. We have numerous sugar related to diabetes or inadequate fast. We have numerous cases of PET scans demonstrating significant muscle uptake. cases of PET scans demonstrating significant muscle uptake. Their blood sugars are in acceptable ranges. However, when Their blood sugars are in acceptable ranges. However, when questioned, they inevitably give a history of stopping for a bagel questioned, they inevitably give a history of stopping for a bagel or doughnut on the way to their scan. Their peak insulin action or doughnut on the way to their scan. Their peak insulin action corresponded to their FDG injection. In such cases, glucose is corresponded to their FDG injection. In such cases, glucose is driven into the muscle.driven into the muscle.One common occurrence which should be thought of early is skin One common occurrence which should be thought of early is skin contamination. Patients, after having urinated, often have hot contamination. Patients, after having urinated, often have hot fingers and spots may result when they touch their skin. fingers and spots may result when they touch their skin. Technologists may also cause contamination by spilling a drop of Technologists may also cause contamination by spilling a drop of radiopharmaceutical on the patient or leakage from the syringe.radiopharmaceutical on the patient or leakage from the syringe.

Another recent occurrence has been the uptake in the spleen on Another recent occurrence has been the uptake in the spleen on bone scans. We are aware of classic functional asplenic and bone scans. We are aware of classic functional asplenic and splenic uptake on bone scan in patients with sickle cell disease.splenic uptake on bone scan in patients with sickle cell disease.What else can cause splenic uptake? We are aware of uptake in What else can cause splenic uptake? We are aware of uptake in patients with sickle cell disease and functional asplenia. The patients with sickle cell disease and functional asplenia. The uptake is presumed to be due to excess iron in the spleen. uptake is presumed to be due to excess iron in the spleen. Multiple myeloma has also been reported to occasionally cause Multiple myeloma has also been reported to occasionally cause splenic uptake, more commonly in men. After researching our splenic uptake, more commonly in men. After researching our patient’s history, we found he had a portal vein thrombosis and patient’s history, we found he had a portal vein thrombosis and splenic artery remobilization. The exact mechanism of uptake in splenic artery remobilization. The exact mechanism of uptake in the spleen is unclear.the spleen is unclear.

Algorithm For Determining Etiology Of Algorithm For Determining Etiology Of Abnormal Rp DistributionAbnormal Rp Distribution

1.1. Check for other recent Nuclear Medicine Check for other recent Nuclear Medicine StudiesStudies

2.2. Were other patient studies affected?Were other patient studies affected?

3.3. Check for problems with QCCheck for problems with QC

4.4. Check medical historyCheck medical history

5.5. Check for other radiopharmaceuticals Check for other radiopharmaceuticals prepared or used that dayprepared or used that day

6.6. Check camera QCCheck camera QC

7.7. Check patient labs and windowingCheck patient labs and windowing

8.8. When in doubt, check GoogleWhen in doubt, check Google

Sites Of Tc-MDP DepositionSites Of Tc-MDP Deposition

1.1. New bone formationNew bone formation

2.2. Heterotopic ossificationHeterotopic ossification

3.3. MicrocalificationMicrocalification

A. InfarctionA. Infarction

B. HypercalcemiaB. Hypercalcemia

4.4. Sites containing Fe or heavy metalsSites containing Fe or heavy metals

5.5. Newly forming collagen (scar)Newly forming collagen (scar)

6.6. AmyloidosisAmyloidosis

7.7. Lymph nodes when dose infiltratedLymph nodes when dose infiltrated

8.8. Calcifying liver metastasesCalcifying liver metastases

CONCLUSION: After reviewing normal Quality Control CONCLUSION: After reviewing normal Quality Control procedures and common mistakes which lead to unusual procedures and common mistakes which lead to unusual patterns, you should be able to mentally walk through the patterns, you should be able to mentally walk through the steps required to sort out the problem. Technical problems steps required to sort out the problem. Technical problems should be excluded before assigning a pathologic process to an should be excluded before assigning a pathologic process to an unusual pattern.unusual pattern.

BibliographyBibliography

1.1. Thrall, J.H., Zeissman, H.A.,: Nuclear Thrall, J.H., Zeissman, H.A.,: Nuclear Medicine: The Requisite 2nd Edition, Pages Medicine: The Requisite 2nd Edition, Pages 27 – 31; 48-62, Mosby, Inc. 2001.27 – 31; 48-62, Mosby, Inc. 2001.

2.2. Wilson, M.A.:L Nuclear Medicine Textbook, Wilson, M.A.:L Nuclear Medicine Textbook, pgs. 385-413 Lippincott-Raven Publishers, pgs. 385-413 Lippincott-Raven Publishers, 1998. 1998.

CASE STUDIESCASE STUDIES

NOW WE ARE READY TO BEGIN. NOW WE ARE READY TO BEGIN. You will be shown a case and You will be shown a case and given several possible reasons given several possible reasons for the scan appearance. The for the scan appearance. The following slide will reveal the following slide will reveal the answer and mechanism.answer and mechanism.

CASE 1

CASE 1CASE 1

The preceding case may be due The preceding case may be due to:to:

Free PertechnetateFree Pertechnetate

High Aluminum ContentHigh Aluminum Content

Wrong RadiopharmaceuticalWrong Radiopharmaceutical

Renal InsufficiencyRenal Insufficiency

ANSWER CASE 1ANSWER CASE 1RENAL INSUFFICIENCYRENAL INSUFFICIENCY

THIS PATTERN OF INCREASED THIS PATTERN OF INCREASED SOFT TISSUE UPTAKE MORE SOFT TISSUE UPTAKE MORE TOWARD THE PERIPHERY IS TOWARD THE PERIPHERY IS SIMILAR TO THAT PATTERN SEEN SIMILAR TO THAT PATTERN SEEN ON CT SCANS. HEART UPTAKE ON CT SCANS. HEART UPTAKE MAY BE DUE TO AMYLOIDOSIS.MAY BE DUE TO AMYLOIDOSIS.

CASE 2

CASE 2CASE 2THE ABNORMALITY ON THIS PET THE ABNORMALITY ON THIS PET CT STUDY IS DUE TO:CT STUDY IS DUE TO:CONCURRENT CONTRAST CONCURRENT CONTRAST ADMINISTRATIONADMINISTRATIONNON-FASTING STATENON-FASTING STATEWRONG RADIOPHARMACEUTICALWRONG RADIOPHARMACEUTICALRADIOPHARMACEUTICAL RADIOPHARMACEUTICAL PROBLEMPROBLEM

ANSWER CASE 2ANSWER CASE 2

THIS IS THE RESULT OF THIS IS THE RESULT OF INCOMPLETE PRODUCTION INCOMPLETE PRODUCTION PROCESS OF F-18-FDG. THE PROCESS OF F-18-FDG. THE RESULTING COMPOUND WAS RESULTING COMPOUND WAS STICKY LEADING TO UPTAKE IN STICKY LEADING TO UPTAKE IN THE IV LINES AND LUNGS.THE IV LINES AND LUNGS.

CASE 3

CASE 3CASE 3

WHAT IS THE MAJOR PROBLEM WHAT IS THE MAJOR PROBLEM WITH THESE IMAGES OF A MUGA WITH THESE IMAGES OF A MUGA SCAN?:SCAN?:

FREE PERTECHNETATEFREE PERTECHNETATE

POOR HEART VISUALIZATIONPOOR HEART VISUALIZATION

WRONG WINDOWWRONG WINDOW

GATING PROBLEMGATING PROBLEM

CASE 3 CONTINUEDCASE 3 CONTINUEDA FOLLOW-UP SCAN TWO WEEK A FOLLOW-UP SCAN TWO WEEK LATER ALSO REVEALED POOR LATER ALSO REVEALED POOR CARDIAC UPTAKE. WHICH OF THE CARDIAC UPTAKE. WHICH OF THE FOLLOWING GOOD CONTRIBUTE FOLLOWING GOOD CONTRIBUTE TO THIS?:TO THIS?:FREE PERTECHNETATEFREE PERTECHNETATERECENT HEPARING INJECTIONRECENT HEPARING INJECTIONPOOR PREPARATIONPOOR PREPARATIONCOLD AGGLUTININSCOLD AGGLUTININS

CASE 3 ANSWERCASE 3 ANSWER

WHILE RECENT HEPARIN WHILE RECENT HEPARIN ADMINISTRATION IS THE MOST ADMINISTRATION IS THE MOST COMMON REASON, THIS PATIENT COMMON REASON, THIS PATIENT HAD NOT RECEIVED ANY. THIS HAD NOT RECEIVED ANY. THIS PATIENT HAD A HIGH TITER OF PATIENT HAD A HIGH TITER OF COLD AGGLUTININS WHICH COLD AGGLUTININS WHICH PRESUMAMBLY MAY BE THE PRESUMAMBLY MAY BE THE CAUSE.CAUSE.

CASE 5

CASE 5CASE 5

THE PROBLEM WITH THIS THE PROBLEM WITH THIS VENTILATION STUDY IS:VENTILATION STUDY IS:

OLD XENONOLD XENON

WRONG ENERGY WINDOW WRONG ENERGY WINDOW SELECTEDSELECTED

CAMERA MALFUNCTIONCAMERA MALFUNCTION

BULLOUS DISEASEBULLOUS DISEASE

ANSWERS CASE 5ANSWERS CASE 5

WHENEVER THE PATTERN IS NOT WHENEVER THE PATTERN IS NOT SHARP, STAND BACK AND LOOK SHARP, STAND BACK AND LOOK AT THE IMAGES. IN THIS CASE A AT THE IMAGES. IN THIS CASE A WRONG WINDOW WAS SELECTED WRONG WINDOW WAS SELECTED ALLOWING VISUALIZATION OF ALLOWING VISUALIZATION OF THE PHOTOMULTIPLIER TUBES.THE PHOTOMULTIPLIER TUBES.

Interesting Image – Abnormal Windowing Causing Polka Dot Effect

CASE 6

CASE 6CASE 6THIS CASE IS INCLUDED AS UNUSUAL THIS CASE IS INCLUDED AS UNUSUAL USE OF AN ISOTOPE. TYPICALLY IN-USE OF AN ISOTOPE. TYPICALLY IN-111-DTPA IS USED FOR 111-DTPA IS USED FOR CISTERNOGRAPHY. FOR CISTERNOGRAPHY. FOR IDENTIFICATION OF A SPINAL CSF IDENTIFICATION OF A SPINAL CSF LEAK. LABELED TC-HSA USED TO BE LEAK. LABELED TC-HSA USED TO BE AVAILABLE. IN THIS CASE THE LEAK AVAILABLE. IN THIS CASE THE LEAK WAS IDENTIFIED ON CT AND WAS IDENTIFIED ON CT AND AUTOLOGOUS RBCS WERE LABELED AUTOLOGOUS RBCS WERE LABELED AS PART OF THE BLOOD PATCH AS PART OF THE BLOOD PATCH WHICH WAS DELIVERED. THIS SCAN WHICH WAS DELIVERED. THIS SCAN SHOWS THE EFFECTIVE AREA OF SHOWS THE EFFECTIVE AREA OF DISTRIBUTION OF THE PATCHDISTRIBUTION OF THE PATCH

CASE 7Case 7

CASE 7CASE 7

WHERE ARE THE WHERE ARE THE ABNORMALITIES?:ABNORMALITIES?:

LUNGSLUNGS

BRAINBRAIN

KIDNEYSKIDNEYS

SALIVARY GLANDSSALIVARY GLANDS

CASE 7CASE 7

WHAT IS THE CAUSE?WHAT IS THE CAUSE?

FREE PERTECHNETATEFREE PERTECHNETATE

PROBLEM WITH HMPAOPROBLEM WITH HMPAO

RIGHT TO LEFT SHUNTRIGHT TO LEFT SHUNT

RECENT DTPA RENAL SCANRECENT DTPA RENAL SCAN

ANSWER CASE 7ANSWER CASE 7

THE PROBLEM IS VISUALIZATION THE PROBLEM IS VISUALIZATION OF KIDNEYS AND BRAIN (NOT OF KIDNEYS AND BRAIN (NOT CHOROID PLEXUS). THIS IS DUE CHOROID PLEXUS). THIS IS DUE TO SIGNIFICANT RIGHT TO LEFT TO SIGNIFICANT RIGHT TO LEFT SHUNTING.SIGNIFICANT LUNG SHUNTING.SIGNIFICANT LUNG UPTAKE IS NOT SEEN WITH DTPA UPTAKE IS NOT SEEN WITH DTPA OR HMPAO INJECTIONSOR HMPAO INJECTIONS

CASE 8

CASE 8CASE 8

THE ABNORMALITY ON THIS THE ABNORMALITY ON THIS LUNG PERFUSION SCAN IS:LUNG PERFUSION SCAN IS:

RADIOPHARMACEUTICAL RADIOPHARMACEUTICAL PROBLEMPROBLEM

GI BLEEDGI BLEED

PREVIOUS SESTAMIBI STUDYPREVIOUS SESTAMIBI STUDY

NORMAL BOWELNORMAL BOWEL

ANSWER CASE 8ANSWER CASE 8IN THIS CASE THE BOWEL ACTIVITY IN THIS CASE THE BOWEL ACTIVITY WAS DUE TO A CARDIAC PERFUSION WAS DUE TO A CARDIAC PERFUSION STUDY THE DAY PRIOR. HEART STUDY THE DAY PRIOR. HEART UPTAKE IS GENERALLY NOT SEEN ON UPTAKE IS GENERALLY NOT SEEN ON VENTILATION IMAGING. IF KIDNEY OR VENTILATION IMAGING. IF KIDNEY OR BOWEL UPTAKE IS SEEN, IT IS MOST BOWEL UPTAKE IS SEEN, IT IS MOST LIKELY SECONDARY, LIKE A RECENT LIKELY SECONDARY, LIKE A RECENT THALLIUM SCAN SINCE ENERGIES OF THALLIUM SCAN SINCE ENERGIES OF XE AND TL ARE CLOSEXE AND TL ARE CLOSE

REFERENCE CASE 8REFERENCE CASE 8

GUPTA RG, BARRON BJ AND GUPTA RG, BARRON BJ AND LAMKI LK. Visualization of the LAMKI LK. Visualization of the Kidneys on Xe-133 Ventilation Kidneys on Xe-133 Ventilation Images of a Ventilation-Images of a Ventilation-Perfusion Scan. Clin Nucl Med Perfusion Scan. Clin Nucl Med 26;11:1-3, 200126;11:1-3, 2001

CASE9

CASE 9CASE 9THIS IS A PET/CT STUDY. WHICH THIS IS A PET/CT STUDY. WHICH OF THE FOLLOWING BEST OF THE FOLLOWING BEST EXPLAIN THE TRACER EXPLAIN THE TRACER DISTRIBUTION?DISTRIBUTION?PATIENT RAN THE TRIALTHALONPATIENT RAN THE TRIALTHALONPATIENT HAD A DOUGHNUT ON PATIENT HAD A DOUGHNUT ON THE WAY TO THE SCAN CENTERTHE WAY TO THE SCAN CENTERPATIENT HAS MYOSITISPATIENT HAS MYOSITISPATIENT HAS RHABDOMYOLYSISPATIENT HAS RHABDOMYOLYSIS

ANSWER CASE 9ANSWER CASE 9THIS PATIENT HAD ATE A THIS PATIENT HAD ATE A DOUGHNUT 45 MINUTES PRIOR DOUGHNUT 45 MINUTES PRIOR TO HER INJECTION OF F-18-FDG. TO HER INJECTION OF F-18-FDG. THIS COINCIDED WITH HER THIS COINCIDED WITH HER INSULIN SURGE AT THE TIME OF INSULIN SURGE AT THE TIME OF INJECTION WHICH PUSHED INJECTION WHICH PUSHED GLUCOSE INTO SKELETAL GLUCOSE INTO SKELETAL MUSCLE AND HEART. A CASE OF MUSCLE AND HEART. A CASE OF RHABDOMYOLYSIS ON BONE RHABDOMYOLYSIS ON BONE SCAN IS SHOWN BELOW.SCAN IS SHOWN BELOW.

INTERESTING CASEINTERESTING CASE

THIS CASE IS ALSO SHOWN TO THIS CASE IS ALSO SHOWN TO SHOW PHYSIOLOGIC MUSCLE SHOW PHYSIOLOGIC MUSCLE UPTAKE. THIS PATIENT HAD END-UPTAKE. THIS PATIENT HAD END-STAGE LUNG DISEASE AND WAS STAGE LUNG DISEASE AND WAS USING HIS ACCESSORY USING HIS ACCESSORY RESPIRATORY MUSCLES.RESPIRATORY MUSCLES.

CASE 10

CASE 10CASE 10

WHAT IS WRONG WITH THIS WHAT IS WRONG WITH THIS BONE SCAN?BONE SCAN?

FREE PERTECHNETATEFREE PERTECHNETATE

WRONG RADIOPHARMACEUTICALWRONG RADIOPHARMACEUTICAL

PRIOR RENAL SCANPRIOR RENAL SCAN

IMAGING DONE TOO SOONIMAGING DONE TOO SOON

CASE 10CASE 10IN THIS CASE,A QUESTION CAME US IN THIS CASE,A QUESTION CAME US AS TO WHETHER THE RIGHT RP WAS AS TO WHETHER THE RIGHT RP WAS GIVEN. NO OTHER BONE SCAN GIVEN. NO OTHER BONE SCAN LOOKED LIKE THAT. INVENTORY OF LOOKED LIKE THAT. INVENTORY OF THE MDP VIAL REVEALED NOTHING THE MDP VIAL REVEALED NOTHING MISSING. HENCE, THE WRONG RP MISSING. HENCE, THE WRONG RP WAS GIVEN. SERENDIPITOUSLY, WAS GIVEN. SERENDIPITOUSLY, UPTAKE WAS SEEN IN THE BREAST UPTAKE WAS SEEN IN THE BREAST AND THE PATIENT WAS AND THE PATIENT WAS SUBSEQUENTLY FOUND TO HAVE SUBSEQUENTLY FOUND TO HAVE BREAST CANCER.BREAST CANCER.

CASE 11

CASE 11CASE 11

WHAT ARE THE ABNORMALITIES WHAT ARE THE ABNORMALITIES ON THIS BONE SCAN?ON THIS BONE SCAN?

BOWEL UPTAKEBOWEL UPTAKE

BRAIN UPTAKEBRAIN UPTAKE

RIGHT TO LEFT SHUNTRIGHT TO LEFT SHUNT

WRONG RADIOPHARMACEUTICALWRONG RADIOPHARMACEUTICAL

CASE 11CASE 11BRAIN AND BOWEL UPTAKE SUGGEST BRAIN AND BOWEL UPTAKE SUGGEST A PREVIOUS STUDY OR POSSIBLY A A PREVIOUS STUDY OR POSSIBLY A COMBINATION OF RPS. A CAREFUL COMBINATION OF RPS. A CAREFUL INVESTIGATION REVEALED THAT THE INVESTIGATION REVEALED THAT THE TECHNOLOGIST MAY HAVE USED THE TECHNOLOGIST MAY HAVE USED THE SAME SYRING TO MAKE UP BOTH SAME SYRING TO MAKE UP BOTH KITS. THIS LED TO CROSS-KITS. THIS LED TO CROSS-CONTAMINATION OF THE VIALS. THE CONTAMINATION OF THE VIALS. THE OTHER KIT WAS TC-99M-ECD. OTHER KIT WAS TC-99M-ECD. COINCIDENT RADIATION EFFECT IS COINCIDENT RADIATION EFFECT IS NOTED IN THE SPINE.NOTED IN THE SPINE.

INTERESTING CASEINTERESTING CASE

BOWEL UPTAKE ON A BONE SCAN BOWEL UPTAKE ON A BONE SCAN FROM PREVIOUS DAY’S MIBI FROM PREVIOUS DAY’S MIBI SCANSCAN

CASE 12

CASE 12CASE 12

WHAT ARE THE ABNORMALITIES WHAT ARE THE ABNORMALITIES ON THIS BONE SCAN?ON THIS BONE SCAN?

LIVER AND SPLEEN UPTAKELIVER AND SPLEEN UPTAKE

FREE PERTECHNETATEFREE PERTECHNETATE

NORMAL FOR PEDI PATIENTNORMAL FOR PEDI PATIENT

ABNORMAL RENAL UPTAKEABNORMAL RENAL UPTAKE

CASE 12CASE 12

HOW WOULD YOU TRY TO FIND HOW WOULD YOU TRY TO FIND THE CAUSE OF THE LIVER AND THE CAUSE OF THE LIVER AND SPLEEN UPTAKE?SPLEEN UPTAKE?

CHECK OTHER BONE SCANS FOR CHECK OTHER BONE SCANS FOR THE DAYTHE DAY

CHECK FOR PREVIOUS STUDYCHECK FOR PREVIOUS STUDY

CHECK FOR ABNORMAL LABSCHECK FOR ABNORMAL LABS

DO QC AGAINDO QC AGAIN

CASE 12CASE 12

A CHECK OF OTHER BONE SCANS A CHECK OF OTHER BONE SCANS REVEALED THEY ALL HAD LIVER REVEALED THEY ALL HAD LIVER AND SPLEEN UPTAKE. AGAIN AND SPLEEN UPTAKE. AGAIN OUR INVESTIGATION REVEALED OUR INVESTIGATION REVEALED CROSS CONTAMINATION OF CROSS CONTAMINATION OF DOSES WITH POTTENTIALLY DOSES WITH POTTENTIALLY BOTH SC AND MDP IN THE SAME BOTH SC AND MDP IN THE SAME VIAL.VIAL.

CASE 13

CASE 13CASE 13THIS IS A RENAL SCAN ON A CHILD THIS IS A RENAL SCAN ON A CHILD WITH CHRONIC RENAL WITH CHRONIC RENAL INSUFFICIENCY. WHAT ARE THE INSUFFICIENCY. WHAT ARE THE ABNORMALITIES:ABNORMALITIES:

BONE UPTAKEBONE UPTAKE

MILD LIVER AND SPLEEN UPTAKEMILD LIVER AND SPLEEN UPTAKE

NO SIGNIFICANT KIDNEY UPTAKENO SIGNIFICANT KIDNEY UPTAKE

ALL OF THE ABOVE.ALL OF THE ABOVE.

CASE 13 CASE 13

ALL OF THE ABOVE ARE ALL OF THE ABOVE ARE CORRECT. WHAT IS THE CAUSE?CORRECT. WHAT IS THE CAUSE?

1. OLD DMSA1. OLD DMSA

PRIOR STUDYPRIOR STUDY

CROSS CONTAMINATIONCROSS CONTAMINATION

DMSA SUPERSCANDMSA SUPERSCAN

CASE 13CASE 13

THIS IS A CASE OF DMSA THIS IS A CASE OF DMSA SUPERSCAN IN A PATIENTSUPERSCAN IN A PATIENT WITH WITH CHRONIC RENAL INSUFFICIENCY CHRONIC RENAL INSUFFICIENCY ON DIALYSIS. THIS IS A RARE ON DIALYSIS. THIS IS A RARE PATTERN, BUT SHOULD BE PATTERN, BUT SHOULD BE RECOGNIZED. SEE NEXT CASE.RECOGNIZED. SEE NEXT CASE.

CASE 14

CASE 14CASE 14

IN THIS DMSA SCAN, THE BEST IN THIS DMSA SCAN, THE BEST EXPLANATION FOR THIS EXPLANATION FOR THIS PATTERN IS:PATTERN IS:

WRONG PHARMACEUTICALWRONG PHARMACEUTICAL

INCOMPLETE INCUBATION TIMEINCOMPLETE INCUBATION TIME

ALUMINUM CONTAMINATIONALUMINUM CONTAMINATION

POOR RENAL UPTAKE DUE TO POOR RENAL UPTAKE DUE TO ACUTE CORTICAL NECROSISACUTE CORTICAL NECROSIS

CASE 14CASE 14

ACUTE CORTICAL NECROSIS ACUTE CORTICAL NECROSIS CAUSES DECREASED DMSA CAUSES DECREASED DMSA DEPOSITION IN THE CORTEX. DEPOSITION IN THE CORTEX. VICARIOUS EXCRETION IS SEEN VICARIOUS EXCRETION IS SEEN BY THE LIVER.BY THE LIVER.

Case 15

CASE 15CASE 15WHAT IS THE CAUSE OF WHAT IS THE CAUSE OF BACKGROUND ACTIVITY ON THE BACKGROUND ACTIVITY ON THE VENTILATION AND PERFUSION VENTILATION AND PERFUSION LUNG SCAN?LUNG SCAN?RECENT PRIOR STUDYRECENT PRIOR STUDYTRACER BREAKDOWN/ TRACER BREAKDOWN/ DISSOCIATIONDISSOCIATIONSHUNTSHUNTFATTY SOFT TISSUESFATTY SOFT TISSUES

CASE 15CASE 15

IN THIS CASE THE PATIENT JUST IN THIS CASE THE PATIENT JUST HAD A DTPA STUDY FOR HIS HAD A DTPA STUDY FOR HIS RENAL TRANSPLANT, WHICH RENAL TRANSPLANT, WHICH WAS POORLY FUNCTIONING. WAS POORLY FUNCTIONING. BACKGROUND SOFT TISSUE BACKGROUND SOFT TISSUE ACTIVITY IS DUE TO POOR ACTIVITY IS DUE TO POOR CLEARANCE.CLEARANCE.

CASE 15Case 16

CASE 16CASE 16

WHAT IS WRONG WITH THIS WHAT IS WRONG WITH THIS HIDA SCAN DISTRIBUTION?HIDA SCAN DISTRIBUTION?

NOTHINGNOTHING

SPLENIC UPTAKE SUGGESTS SC SPLENIC UPTAKE SUGGESTS SC INSTEAD OF HIDAINSTEAD OF HIDA

ABNORMAL BLOOD POOLABNORMAL BLOOD POOL

BIG SPLEENBIG SPLEEN

CASE 16CASE 16

TC-HIDA (CHOLETEC) DOES NOT TC-HIDA (CHOLETEC) DOES NOT GENERALLY GO TO SPLEEN. THIS GENERALLY GO TO SPLEEN. THIS OFTEN CAN BE MISCONSTRUED OFTEN CAN BE MISCONSTRUED AS A MASS. THE CT SHOWED AN AS A MASS. THE CT SHOWED AN UNUSUAL CONFIGURATION TO UNUSUAL CONFIGURATION TO THE LEFT LOBE OF THE LIVER THE LEFT LOBE OF THE LIVER THAT WRAPPED AROUND THE THAT WRAPPED AROUND THE SPLEEN.SPLEEN.

CASE 17

CASE 17CASE 17

WHAT IS THE CAUSE OF THE WHAT IS THE CAUSE OF THE ABNORMAL FINDINGS ON THE ABNORMAL FINDINGS ON THE LUNG PERFUSION STUDY?LUNG PERFUSION STUDY?

PREVIOUS LIVER SPLEEN SCANPREVIOUS LIVER SPLEEN SCAN

INCREASED ALUMINUM CONTENTINCREASED ALUMINUM CONTENT

FATTY LIVER/SPLEENFATTY LIVER/SPLEEN

RADIOPHARMACEUTICAL RADIOPHARMACEUTICAL ALTERATIONALTERATION

CASE 17CASE 17

IN THIS CASE THE MAA WAS IN THIS CASE THE MAA WAS FOUND TO BE OVER 8 HOURS FOUND TO BE OVER 8 HOURS OLD SINCE PREPARATION AND OLD SINCE PREPARATION AND WAS USED BECAUSE NO OTHER WAS USED BECAUSE NO OTHER DOSE WAS AVAILABLE. DOSE WAS AVAILABLE. BREAKDOWN OF TRACER INTO BREAKDOWN OF TRACER INTO SMALLER PARTICLES OCCURS SMALLER PARTICLES OCCURS RESULTING IN LUNG, LIVER AND RESULTING IN LUNG, LIVER AND SPLEEN ACTIVITY.SPLEEN ACTIVITY.

UNUSUAL MAA PATTERNSUNUSUAL MAA PATTERNSHETEROGENEOUS UPTAKE OF MAA CAN BE HETEROGENEOUS UPTAKE OF MAA CAN BE DUE TODUE TOPOOR NUMBER OF PARTICLES (USUALLY POOR NUMBER OF PARTICLES (USUALLY DUE TO INFILTRATED DOSE)DUE TO INFILTRATED DOSE)AIR EMBOLIAIR EMBOLIFAT EMBOLIFAT EMBOLISEPTIC EMBOLISEPTIC EMBOLIAMNIOTIC FLUID EMBOLIAMNIOTIC FLUID EMBOLIVASCULITIS.VASCULITIS.ALWAYS CHECK THE INJECTION SITE IF THE ALWAYS CHECK THE INJECTION SITE IF THE PATTERN OF UPTAKE DOES NOT MAKE PATTERN OF UPTAKE DOES NOT MAKE SENSE.SENSE.

Case 18

CASE 18 CASE 18

WHAT IS THE CAUSE OF THIS WHAT IS THE CAUSE OF THIS SPLENIC UPTAKE?SPLENIC UPTAKE?

FUNCTIONAL ASPLENIAFUNCTIONAL ASPLENIA

MULTIPLE MYELOMAMULTIPLE MYELOMA

INCREASED ALUMINA IN ELUATEINCREASED ALUMINA IN ELUATE

PRIOR LIVER SCANPRIOR LIVER SCAN

CASE 18CASE 18IN THIS CASE, PREVIOUS SCAN, IN THIS CASE, PREVIOUS SCAN, ALUMINA EXCESS AND SICKLE ALUMINA EXCESS AND SICKLE CELL HAD BEEN RULED OUT. CELL HAD BEEN RULED OUT. OTHER CAUSES MAY BE DUE TO OTHER CAUSES MAY BE DUE TO MULTIPLE MYELOMA OR SPLENIC MULTIPLE MYELOMA OR SPLENIC EMBOLIZATION. LIVER UPTAKE IS EMBOLIZATION. LIVER UPTAKE IS ALSO NOTED AND MAY BE DUE ALSO NOTED AND MAY BE DUE TO KNOWN LIVER METASTASIS. TO KNOWN LIVER METASTASIS. ALUMINUM LEVELS WERE ALUMINUM LEVELS WERE NORMALNORMAL

CASE 19

CASE 19CASE 19THIS IS A LABELED WBC SCAN IN THIS IS A LABELED WBC SCAN IN A YOUNG MAN WITH FEVER. A YOUNG MAN WITH FEVER. WHAT IS THE EXPLANATION FOR WHAT IS THE EXPLANATION FOR THE FINDINGS IN THE SOFT THE FINDINGS IN THE SOFT TISSUES?TISSUES?WBC CLUMPINGWBC CLUMPINGPOOR LABELINGPOOR LABELINGWAIT TIME INADEQUATEWAIT TIME INADEQUATEMULTIPLE SEPTIC EMBOLIMULTIPLE SEPTIC EMBOLI

CASE 19CASE 19

MULTIPLE SEPTIC EMBOLI WILL MULTIPLE SEPTIC EMBOLI WILL GIVE SUCH A PATTERN. THE GIVE SUCH A PATTERN. THE ETIOLOGY OF THIS DISORDER ETIOLOGY OF THIS DISORDER WAS NEVER DETERMINED. WAS NEVER DETERMINED. CLUMPING GENERALLY PROVIDES CLUMPING GENERALLY PROVIDES BIGGER AND HOTTER AREAS OF BIGGER AND HOTTER AREAS OF UPTAKEUPTAKE

CASE 20

CASE 20CASE 20THIS BONE SCAN HAS AN THIS BONE SCAN HAS AN UNUSUAL BAND OF INCREASED UNUSUAL BAND OF INCREASED ACTIVITY IN THE PELVIC REGION. ACTIVITY IN THE PELVIC REGION. WHAT COULD BE THE CAUSE?WHAT COULD BE THE CAUSE?URINE CONTAMINATIONURINE CONTAMINATIONFAT NECROSISFAT NECROSISCELLULITISCELLULITISTUMORTUMOR

CASE 20CASE 20

URINE CONTAMINATION AND URINE CONTAMINATION AND CELLULITIS MAY GIVE SOFT CELLULITIS MAY GIVE SOFT TISSUE UPTAKE, BUT IS TISSUE UPTAKE, BUT IS UNUSUAL IN THIS MANNER. THIS UNUSUAL IN THIS MANNER. THIS IS A SOFT-TISSUE TUMOR.IS A SOFT-TISSUE TUMOR.

THANKS TO DR. L.M. LAMKI FOR THANKS TO DR. L.M. LAMKI FOR THE CASETHE CASE

CASE 21

CASE 21CASE 21

WHY DOES THIS BONE SCAN WHY DOES THIS BONE SCAN LOOK OUT OF FOCUS?LOOK OUT OF FOCUS?

PREVIOUS STUDYPREVIOUS STUDY

WINDOW SETTINGWINDOW SETTING

SEPTAL PENETRATIONSEPTAL PENETRATION

INTERFERING RADIATIONINTERFERING RADIATION

CASE 21CASE 21

IN THIS CASE THE PATIENT HAD IN THIS CASE THE PATIENT HAD RADIATION SEEDS PLACED IN HIS RADIATION SEEDS PLACED IN HIS RIGHT LUNG. THIS CAUSED RIGHT LUNG. THIS CAUSED SCATTER AND OUT OF FOCUS SCATTER AND OUT OF FOCUS APPEARANCE.APPEARANCE.

Case 22

CASE 22CASE 22

What is the cause of this What is the cause of this abnormal distribution?abnormal distribution?

Arterial InjectionArterial Injection

InfiltrationInfiltration

TumorTumor

Skin contaminationSkin contamination

Answer CASE 22Answer CASE 22

THIS IS AN EXAMPLE OF AN THIS IS AN EXAMPLE OF AN ARTERIAL INJECTION, DONE ARTERIAL INJECTION, DONE UNINTENTIONALLY IN A PATIENT UNINTENTIONALLY IN A PATIENT WITH POOR VENOUS ACCESS.WITH POOR VENOUS ACCESS.

CASE 23

CASE 23CASE 23

WHAT ARE THE POSSIBLE WHAT ARE THE POSSIBLE EXPLANATIONS OF THE EXPLANATIONS OF THE ABNORMAL FINDINGS ON THIS ABNORMAL FINDINGS ON THIS BONE SCAN?BONE SCAN?

HYPERCALCEMIAHYPERCALCEMIA

AMYLOIDAMYLOID

PREVIOUS V/Q SCANPREVIOUS V/Q SCAN

FREE PERTECHNETATEFREE PERTECHNETATE

CASE 23CASE 23

THIS CASE IS AN EXAMPLE OF THIS CASE IS AN EXAMPLE OF HYPERCALCEMIA. CARDIAC HYPERCALCEMIA. CARDIAC UPTAKE MAY REPRESENT UPTAKE MAY REPRESENT MYOCARDIAL INFARCTION MYOCARDIAL INFARCTION (UNLIKELY IN THIS CASE) , (UNLIKELY IN THIS CASE) , AMYLOID OR CALCIFIC AMYLOID OR CALCIFIC PERICARDITIS. THIS PATIENT PERICARDITIS. THIS PATIENT HAD HYPERCALCEMIA.HAD HYPERCALCEMIA.

CASE 24

CASE 24CASE 24THIS IS A THALLIUM SCAN FOR THIS IS A THALLIUM SCAN FOR PARATHYROID ADENOMA PARATHYROID ADENOMA EVALUATION. WHAT IS THE EVALUATION. WHAT IS THE CAUSE OF THE HETEROGENEOUS CAUSE OF THE HETEROGENEOUS UPTAKE?UPTAKE?THYROID CANCERTHYROID CANCERTHALLIUM 201 COMPLEXESTHALLIUM 201 COMPLEXESABNORMAL WINDOW SETTINGABNORMAL WINDOW SETTINGSEPSISSEPSIS

CASE 24CASE 24

THIS IS ANOTHER EXAMPLE OF THIS IS ANOTHER EXAMPLE OF ABNORMAL WINDOWING GIVING ABNORMAL WINDOWING GIVING A UNIQUE HETEROGENEOUS A UNIQUE HETEROGENEOUS PATTERN. IN THIS CASE, THERE PATTERN. IN THIS CASE, THERE WAS NO THALLIUM 201 MAP WAS NO THALLIUM 201 MAP STORED.STORED.

CASE 25CASE 25

WHAT ARE THE ABNORMALITIES WHAT ARE THE ABNORMALITIES IN THIS HIDA SCAN?IN THIS HIDA SCAN?

RIM SIGNRIM SIGN

FREE PERTECHNETATEFREE PERTECHNETATE

PERITONITISPERITONITIS

NONE OF THE ABOVE NONE OF THE ABOVE

CASE 25CASE 25

THIS IS A CASE OF THE RIM SIGN THIS IS A CASE OF THE RIM SIGN IN A PREGNANT WOMAN. THE IN A PREGNANT WOMAN. THE BIRTH SAC IS OUTLINED BY BIRTH SAC IS OUTLINED BY TRACER UPTAKE. THE PATIENT TRACER UPTAKE. THE PATIENT WAS NOT OPERATED ON FOR 2 WAS NOT OPERATED ON FOR 2 DAYS AND GANGRENOUS DAYS AND GANGRENOUS CHOLECYSTITIS WAS FOUND.CHOLECYSTITIS WAS FOUND.

CONTACT INFO:CONTACT INFO:Bruce J. Barron, M.D.Bruce J. Barron, M.D.

Professor of RadiologyProfessor of Radiology6431 Fannin, Ste. 2.1326431 Fannin, Ste. 2.132Houston, Texas 77030Houston, Texas 77030

Email: Email: Bruce.J.Barron@uth.tmc.eduBruce.J.Barron@uth.tmc.edu713/704-1787 (Office)713/704-1787 (Office)

713/704-1596 (Fax)713/704-1596 (Fax)