Nuclear Medicine Imaging and the treatment of Cancer.

Nuclear MedicineNuclear Medicine

Imaging and the treatment of Imaging and the treatment of CancerCancer

Gamma photons are the most energetic Gamma photons are the most energetic photons in the electromagnetic photons in the electromagnetic spectrum. Gamma rays (gamma spectrum. Gamma rays (gamma photons) are emitted from the nucleus photons) are emitted from the nucleus of some unstable (radioactive) atoms.of some unstable (radioactive) atoms.

Gamma RadiationGamma Radiation

What are the What are the properties of properties of gamma radiation? gamma radiation?

Gamma radiation is Gamma radiation is very high-energy very high-energy ionizing radiation.ionizing radiation.

Gamma photons Gamma photons have no mass and have no mass and no electrical no electrical charge--they are charge--they are pure pure electromagnetic electromagnetic energy.energy.


Because of their high energy, gamma Because of their high energy, gamma photons travel at the speed of light photons travel at the speed of light and can cover hundreds to and can cover hundreds to thousands of meters in air before thousands of meters in air before spending their energy. They can pass spending their energy. They can pass through many kinds of materials, through many kinds of materials, including human tissue including human tissue


What is the difference between What is the difference between gamma rays and x-rays?gamma rays and x-rays?

Gamma rays and x-rays, like visible, infrared, and Gamma rays and x-rays, like visible, infrared, and ultraviolet light, are part of the electromagnetic ultraviolet light, are part of the electromagnetic spectrum. While gamma rays and x-rays differ in spectrum. While gamma rays and x-rays differ in their origin. Gamma rays originate in the nucleus. X-their origin. Gamma rays originate in the nucleus. X-rays originate in the electron fields surrounding the rays originate in the electron fields surrounding the nucleus.nucleus.


How do we use gamma emitters? How do we use gamma emitters?

The penetrating power of gamma photons has The penetrating power of gamma photons has many applications. Gamma rays penetrate many many applications. Gamma rays penetrate many materials, they do not make them radioactive. materials, they do not make them radioactive. The three radionuclides by far most useful are The three radionuclides by far most useful are cobalt-60 and cesium-137 and technetium-99m.cobalt-60 and cesium-137 and technetium-99m.


Uses of Cesium-137:Uses of Cesium-137: cancer treatment cancer treatment Uses of Cobalt-60:Uses of Cobalt-60: sterilize medical equipment in sterilize medical equipment in

hospitals hospitals treat cancer treat cancer


Uses of Technetium-99m:Uses of Technetium-99m: TC-99m is the most widely used TC-99m is the most widely used

radioactive isotope for diagnostic radioactive isotope for diagnostic studies. (Technetium-99m is a shorter studies. (Technetium-99m is a shorter half-life version of technetium-99.) half-life version of technetium-99.) Different chemical forms are used for Different chemical forms are used for brain, bone, liver, spleen and kidney brain, bone, liver, spleen and kidney imaging and also for blood flow studies.imaging and also for blood flow studies.

Radioactive MeasurementsRadioactive Measurements

1. Competitive Binding Assays1. Competitive Binding Assays 2. Time Dependent Measurements2. Time Dependent Measurements 3. Radio Nucleotide Imaging3. Radio Nucleotide Imaging

Gamma Camera – scintillation cameraGamma Camera – scintillation camera 4. Tomography4. Tomography

SPECT imagingSPECT imaging PET imagingPET imaging

1. Competitive Binding 1. Competitive Binding AssaysAssays

No radioactive substance is given to No radioactive substance is given to the patientthe patient

Blood from a patient is mixed with a Blood from a patient is mixed with a radioactive substance in the radioactive substance in the laboratorylaboratory RadioimmunoassayRadioimmunoassay

Thyroid Hormone and Iron Binding Sites Thyroid Hormone and Iron Binding Sites most common.most common.

1. Competitive Binding 1. Competitive Binding AssaysAssays

2. Time Dependent 2. Time Dependent MeasurementsMeasurements

Radioactive Tracers are to the Radioactive Tracers are to the patient administered.patient administered.

Allows the volume of a compartment Allows the volume of a compartment to be measured.to be measured.

Intravenous PyelogramIntravenous Pyelogram

An Intravenous An Intravenous Pyelogram Pyelogram (IVP) is an x-(IVP) is an x-ray ray examination of examination of the kidneys, the kidneys, ureters, and ureters, and urinary urinary bladder. bladder.

Intravenous PyelogramIntravenous Pyelogram

HIDA ScanHIDA Scan This is a test This is a test

done to done to diagnose diagnose obstruction of obstruction of the bile ducts the bile ducts (for example, (for example, by a gallstone by a gallstone or a tumor), or a tumor), disease of the disease of the gallbladder, gallbladder, and bile and bile leaks. leaks.

Cardiac AngiographyCardiac Angiography

Coronary angiography is Coronary angiography is performed to detect performed to detect obstruction in the coronary obstruction in the coronary arteries of the heart. arteries of the heart. During the procedure a During the procedure a catheter is inserted into an catheter is inserted into an artery in your groin and artery in your groin and then threaded carefully then threaded carefully into the heart. The blood into the heart. The blood vessels of the heart are vessels of the heart are then studied by injection of then studied by injection of contrast media through the contrast media through the catheter. A rapid catheter. A rapid succession of X-rays is succession of X-rays is taken to view blood flow. taken to view blood flow.

The arrow indicates The arrow indicates a blockage in the a blockage in the right coronary right coronary artery.artery.

Cerebral AngiogramCerebral Angiogram This image taken This image taken

before angioplasty: before angioplasty: This patient had This patient had episodes of weakness, episodes of weakness, leading to the leading to the angiogram. The angiogram. The angiogram shows a angiogram shows a very narrowed artery very narrowed artery supplying the right side supplying the right side of brain. This vessel is of brain. This vessel is within the skull on the within the skull on the surface of the brain surface of the brain

Cerebral Cerebral angiogram taken angiogram taken after angioplasty: after angioplasty: The narrowing is The narrowing is less severe and the less severe and the branches beyond branches beyond the narrowing fill the narrowing fill better better

3. Radionucleotide Imaging3. Radionucleotide Imaging

Image is generated Image is generated using radioactive using radioactive decay from an decay from an organorgan

Usually a function Usually a function of time.of time.

Provide functional Provide functional informationinformation


Single detectors Single detectors are used for are used for thyroid studies.thyroid studies.


Scintillation Scintillation CameraCamera

Shows two Shows two dimensional datadimensional data

Studies physiologic Studies physiologic functionfunction

Ventilation-Ventilation-Perfusion Scan of a Perfusion Scan of a lung looking for a lung looking for a blood clot.blood clot.

A bone scan is used to A bone scan is used to find bone problems, find bone problems, such as cancer, such as cancer, infections, or infections, or fractures, to check fractures, to check joint replacements, joint replacements, and to find joint and to find joint problems, such as problems, such as arthritis. arthritis.

A small amount of A small amount of injected radioactive injected radioactive matter (tracer) and a matter (tracer) and a camera to form an camera to form an image. image. Bone scan looking forBone scan looking for

metastatic bone cancer.metastatic bone cancer.

Looking for fibrous Looking for fibrous dysplasia that is a dysplasia that is a congenital, non-congenital, non-hereditary skeletal hereditary skeletal disorderdisorder

Patients are often Patients are often asymptomatic. asymptomatic. Others experience Others experience pain, pathologic pain, pathologic fractures and bone fractures and bone deformitydeformity

Imaging of Acute Imaging of Acute Osteomyelitis in the Osteomyelitis in the Diabetic FootDiabetic Foot

A 65 year old male A 65 year old male with a history of non-with a history of non-insulin dependent insulin dependent diabetes mellitus, diabetes mellitus, alcohol abuse, and alcohol abuse, and severe peripheral severe peripheral vascular disease vascular disease presented with a non-presented with a non-healing ulcer of the left healing ulcer of the left first toe.first toe.

This Indium White This Indium White Blood Cell Scan Blood Cell Scan demonstrates demonstrates areas of infection areas of infection in the abdomen in the abdomen after surgery for after surgery for colon cancer. colon cancer.

http://www.mikety.net/PtEd/Images/Indium.jpeg

4. Tomography4. Tomography

The fourth class of imaging is the The fourth class of imaging is the tomographic reconstruction of body tomographic reconstruction of body slices.slices. Single-photon emission computer Single-photon emission computer

tomography - SPECT scantomography - SPECT scan Position Emission Tomography – PET Position Emission Tomography – PET

scanscan

SPECT SCANNERSPECT SCANNER

SPECT ImagingSPECT Imaging

The use of a brain SPECT scan is based on the The use of a brain SPECT scan is based on the principal of blood flow. principal of blood flow.

Areas of increased blood flow take up more Areas of increased blood flow take up more Radioactive tracer than areas of less blood flow.Radioactive tracer than areas of less blood flow.

Blood flow in the brain is directly related to brain Blood flow in the brain is directly related to brain activity. activity.

COMMON DISEASES EVALATED BY SPECT COMMON DISEASES EVALATED BY SPECT

Attention Deficit Hyperactive DisorderAttention Deficit Hyperactive Disorder Autism, Aspergers syndromeAutism, Aspergers syndrome Unipolar and Bipolar DepressionUnipolar and Bipolar Depression Anxiety states - Panic, Anxiety states - Panic, Obsessive-Compulsive DisorderObsessive-Compulsive Disorder Epilepsy and Non-epileptic seizure equivalentsEpilepsy and Non-epileptic seizure equivalents Post Traumatic Stress DisorderPost Traumatic Stress Disorder Migraine and common headaches Migraine and common headaches SchizophreniaSchizophrenia Dementia and memory loss- Stroke- Multiple Dementia and memory loss- Stroke- Multiple

Sclerosis- Parkinson's DiseaseSclerosis- Parkinson's Disease

SPECT ImageSPECT Image

Blood flow to the brain is Blood flow to the brain is represented on a color represented on a color scale, dark areas have no scale, dark areas have no flow and bright yellow flow and bright yellow areas have good blood areas have good blood flow. flow.

The dark "butterfly-The dark "butterfly-shaped" area in the center shaped" area in the center of the brain is normal, but of the brain is normal, but the dark area on the right the dark area on the right of each picture is the of each picture is the region of impaired blood region of impaired blood supply (ischemia) that supply (ischemia) that corresponds to the corresponds to the patient's acute stroke.patient's acute stroke.

Prior to t-PA, the Prior to t-PA, the SPECT scan showed a SPECT scan showed a large area of the brain large area of the brain that has lost its blood that has lost its blood supply (arrow).supply (arrow).

Several hours after Several hours after treatment with t-PA, the treatment with t-PA, the blood flow has blood flow has dramatically improved, dramatically improved, although there is still a although there is still a small area ischemia small area ischemia (arrow).(arrow).

PET ScannerPET Scanner

Image of heart which has Image of heart which has had a mycardial had a mycardial infarction. The arrow infarction. The arrow points to "dead" points to "dead" myocardial tissue. myocardial tissue. Therefore, the patient Therefore, the patient will not benefit from will not benefit from heart surgery, but may heart surgery, but may have other forms of have other forms of treatment prescribed. treatment prescribed.

Normal PET scan of Normal PET scan of a heart.a heart.

PET image showing PET image showing malignant breast mass malignant breast mass that was not revealed by that was not revealed by conventional imaging conventional imaging techniques such as CT, techniques such as CT, MRI, and mammogramMRI, and mammogram

PET image of same patient PET image of same patient with enlarged left axillary with enlarged left axillary lymph nodes (indicated by lymph nodes (indicated by arrows), which through arrows), which through biopsy were found to be biopsy were found to be metastatic. The whole metastatic. The whole body scan reveals a mass body scan reveals a mass in the left breast (indicated in the left breast (indicated by arrow), that was by arrow), that was malignant and malignant and subsequently removedsubsequently removed

Normal Brain Normal Brain Image of the brain of a 9 Image of the brain of a 9 year old female with a year old female with a history of seizures poorly history of seizures poorly controlled by medication. controlled by medication. PET imaging identifies the PET imaging identifies the area (indicated by the area (indicated by the arrows) of the brain arrows) of the brain responsible for the responsible for the seizures. Through surgical seizures. Through surgical removal of this area of the removal of this area of the brain, the patient is brain, the patient is rendered "seizure-free". rendered "seizure-free".

PET measurements of PET measurements of cerebral blood flow cerebral blood flow (CBF) and oxygen (CBF) and oxygen extraction by the brain extraction by the brain (OEF) before (top (OEF) before (top row)and after (bottom row)and after (bottom row) angioplasty of a row) angioplasty of a focal severe stenosis of focal severe stenosis of an artery at the base of an artery at the base of the brain (supraclinoid the brain (supraclinoid internal carotid artery). internal carotid artery).

65 year old male with brain tumors 65 year old male with brain tumors imaged imaged

here with a PET scan. here with a PET scan.

Treatment of CancerTreatment of Cancer

Radioactivity is very effective in the Radioactivity is very effective in the treatment of certain cancers. treatment of certain cancers.

The choice is basically do you The choice is basically do you administer the radiotherapy administer the radiotherapy externally or internally. externally or internally.

External Beam TherapyExternal Beam Therapy

External beam therapy (EBT) is a method for External beam therapy (EBT) is a method for delivering a beam of high-energy x-rays to the delivering a beam of high-energy x-rays to the location of the patient's tumor. location of the patient's tumor.

The beam is generated outside the patient and The beam is generated outside the patient and is targeted at the tumor site. is targeted at the tumor site.

These x-rays can destroy the cancer cells and These x-rays can destroy the cancer cells and careful treatment planning allows the careful treatment planning allows the surrounding normal tissues to be spared.surrounding normal tissues to be spared.

These cancers are commonly treated.These cancers are commonly treated. Breast Cancer Breast Cancer Colorectal Cancer (Bowel Cancer)Colorectal Cancer (Bowel Cancer) Head and Neck CancerHead and Neck Cancer Lung CancerLung Cancer Prostate CancerProstate Cancer

High Energy X-RaysHigh Energy X-Rays

Linear Particle AcceleratorLinear Particle Accelerator

Zapping Cancer Proton Beam Zapping Cancer Proton Beam Therapy Proves Effective in Therapy Proves Effective in Targeting TumorsTargeting Tumors

Aug. 17, 2004Aug. 17, 2004 — A new kind of radiation is proving — A new kind of radiation is proving effective in the fight against cancer. Proton beam therapy, effective in the fight against cancer. Proton beam therapy, according to doctors, zeroes in on tumors with impressive according to doctors, zeroes in on tumors with impressive results and without the devastating side effects of results and without the devastating side effects of traditional radiation therapy.traditional radiation therapy.

"We can shape the beam more accurately, hitting targets with "We can shape the beam more accurately, hitting targets with more precision," said Dr. Jerry Slater, clinical director of more precision," said Dr. Jerry Slater, clinical director of Loma Linda's Proton Therapy Center in Southern California. Loma Linda's Proton Therapy Center in Southern California.

"You don't feel any pain," said Ron Leuck, who is being treated "You don't feel any pain," said Ron Leuck, who is being treated for prostate cancer with the new therapy. for prostate cancer with the new therapy.

During the treatment, a rotating scaffold three stories high During the treatment, a rotating scaffold three stories high aims computerized ray guns directly at his tumor. aims computerized ray guns directly at his tumor.

..

Proton Beam Proton Beam Radiotherapy Radiotherapy

This form of external This form of external beam irradiation beam irradiation involves directing involves directing radiation through the radiation through the front of the eye in front of the eye in order to reach the order to reach the intraocular tumor. intraocular tumor.

When compared to When compared to low-energy eye-plaque low-energy eye-plaque radiation therapy, It is radiation therapy, It is easier to treat tumors easier to treat tumors that are surrounding that are surrounding the optic nerve with the optic nerve with protons. protons.

BrachytherapyBrachytherapy Brachytherapy is where Brachytherapy is where

radioactive seeds or radioactive seeds or sources are placed in sources are placed in or near the tumor or near the tumor itself, giving a high itself, giving a high radiation dose to the radiation dose to the tumor while reducing tumor while reducing the radiation exposure the radiation exposure in the surrounding in the surrounding healthy tissues. healthy tissues.

The term "brachy" is The term "brachy" is Greek for short Greek for short distance.distance.

BrachytherapyBrachytherapy

Brachytherapy is not new. Throughout this Brachytherapy is not new. Throughout this century, several types and routes of century, several types and routes of implantation of radioactive seeds have been implantation of radioactive seeds have been used to treat cancer.used to treat cancer.

Radioactive Iodine seeds were widely used Radioactive Iodine seeds were widely used during the 1970s and 1980s. during the 1970s and 1980s.

Brachytherapy sources can be divided into Brachytherapy sources can be divided into permanent and temporary groups.permanent and temporary groups.

Permanent sources tend to have lower energy Permanent sources tend to have lower energy and shorter half-lives.and shorter half-lives.

The advantage of these lower energies is The advantage of these lower energies is enhanced safety. enhanced safety.

The disadvantage is that anatomical The disadvantage is that anatomical adjustments cannot be made once the sources adjustments cannot be made once the sources are placed. are placed.

Currently, Currently, temporary temporary implants consist implants consist primarily of 192Ir primarily of 192Ir and 137Cs. and 137Cs.

Currently, the 2 most Currently, the 2 most common permanent common permanent radioactive sources for radioactive sources for brachytherapy seeds brachytherapy seeds are 125I and 103Pd.are 125I and 103Pd.

The lower the energy The lower the energy emitted by the emitted by the photons, the higher photons, the higher the energy transfer. the energy transfer.

The higher the energy The higher the energy transfer, the higher transfer, the higher the radiobiologic the radiobiologic effect, which can lead effect, which can lead to lower total doses. to lower total doses.

Prostate CancerProstate Cancer

The prostate gland The prostate gland is just beneath the is just beneath the male bladder.male bladder.

Cancer is common.Cancer is common.

The prostate gland can be felt with The prostate gland can be felt with a digital rectal exam, Cancer is a digital rectal exam, Cancer is sometimes detected this way. sometimes detected this way.

67 year old male with metastatic prostate cancer.67 year old male with metastatic prostate cancer.

Iridium 192 is used for Iridium 192 is used for high–dose rate high–dose rate treatment of prostate treatment of prostate cancer. During the cancer. During the implantation, hollow implantation, hollow needles are inserted needles are inserted transperineally. The transperineally. The needles are then needles are then connected to an connected to an automated remote-automated remote-controlled loading controlled loading machine. The total machine. The total irradiation time is irradiation time is usually only 5-10 usually only 5-10 minutes. minutes.

Temporary seed placement is shown Temporary seed placement is shown here. here.

Nuclear Medicine Imaging and the treatment of Cancer.

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