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ONCOLOGY By Michael Townsend Oncology Ga67 Tumor, Planar Ga67 Tumor, SPECT Monoclonal Antibody Imaging Peptide Imaging Breast Imaging Lymphoscintigraphy / SLN ... – PowerPoint PPT presentation

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  • By
  • Michael Townsend

  • Ga67 Tumor, Planar
  • Ga67 Tumor, SPECT
  • Monoclonal Antibody Imaging
  • Peptide Imaging
  • Breast Imaging
  • Lymphoscintigraphy / SLN location
  • Tumor PET

Ga67 Tumor, Planar
  • Ga67 has been found to be efficacious in a few
    histologic types of cancer. These include
    bronchogenic carcinoma, Hodgkins and
    non-Hodgkins lymphoma, and in primary hepatomas.
  • Concentration of gallium may be found in other
    tumor types but with low sensitivity and

Ga67 Tumor, Planar
  • Indications
  • Staging and post therapy imaging in
  • 1. Lung carcinoma
  • 2. Hodgkins disease
  • 3. Non-Hodgkins lymphoma
  • 4. Hepatocellular carcinoma
  • 5. Melanoma
  • 6. Leukemia

Ga67 Tumor, Planar
  • Ga67 needs a medium energy large field of view
    collimator for the 184 and 296 keV energes.
  • Dosage range 5-10 mCi

Ga67 Tumor, Planar
  • Patient Prep
  • 5-10 mCi (10 mCi in Shackett) of Ga67 citrate is
    given intravenously.
  • Imaging begins 72 hours post injection
  • If the area of interest is in the abdomen, the
    patient should have cleansing enemas the day
    before and the morning of the examination
  • Patient should be instructed to void on return to
    the department

Ga67 Tumor, Planar
  • Contraindications
  • Patients cannot have other nuclear medicine
    studies during the time period for the gallium
  • Patients cannot have contrast studies during the
    time period needed for the gallium scan

Ga67 Tumor, Planar
  • Equipment
  • Collimator- medium to high energy, parallel hole
  • Statistics peak for gallium, with windows at
    25, 1000 Kcounts per image
  • Whole body 10cm/min. Head to mid-femur

Ga67 Tumor, Planar
  • Abnormal results
  • Large hematomas present as cold spots
  • Can show neoplasia associated with Hodgkins
    disease, hepatomas from aloholic cirrhosis, and
    malignant melanomas of bone, brain and lung.

Ga67 Tumor, SPECT
  • Malignant tissue has an affinity for Ga67, so
    small lymph nodes involved with malignancy can be
    visualized. These can be visualized on whole
    body images but show up better on SPECT.
  • CT scans usually reports lymph nodes larger than
    1 cm are abnormal. But Ga67 scans can visualize
    lymph nodes less than 1 cm that are involved with

Ga67 Tumor, SPECT
  • Patient Prep, indications contraindications are
    the same as the whole body scan but dosage may be
    increased for statistics
  • Protocol circular or non-circular, 360o, 64
    stops, 20-25 sec/stop

Monoclonal Antibody Imaging
  • Monoclonal antibodies are frequently referred to
    as the magic bullet
  • Monoclonal antibodies are used to either image
    the cancer or other diseases or treat the cancer

Monoclonal Antibody Imaging
  • The most studied tumor-associated antigen is the
    onco-fetal antigen carcinoembryonic antigen
    (CEA). CEA antigen is present is the majority of
    colorectal carcinomas

Monoclonal Antibody Imaging
  • Clinical imaging studies
  • Colon cancer In-111 CYT 103 (OncoScint)
  • Melanoma In-111 labeled antimelanoma antibody
    cocktail (225.28S and 763.24T) administered
  • Ovarian carcinoma In-111 OncoScint
  • Neuroblastomas In-111 OctreoScan
  • Lymphoma (non-Hodgkins) Bexxar or Zevalin
  • For complete list, look in Sodee (685 691)

Monoclonal Antibody Imaging
  • OnocScint
  • Detection of colorectal or ovarian carcinomas
  • Detection of breast, non-small cell lung,
    pancreatic, gastric and esophageal cancers
  • Evaluation of elevated serum CEA

Monoclonal Antibody Imaging
  • OncoScint
  • In-111 chloride satumomab pendetide (4-6 mCi)
  • Contraindications Patients with human anti-mouse
    antibody (HAMA) titer gt100 ng/ml
  • Collimator medium energy, general purpose or
    all purpose

Monoclonal Antibody Imaging
  • OncoScint
  • Set for Indium peaks (173 and 247) with 15-20
  • Statics 600 seconds or more perview (gt 1000
  • Whole body 10cm/min or slower
  • SPECT 360o, 60 projections, 40 sec/frame

Monoclonal Antibody Imaging
  • OncoScint
  • Procedure
  • Administer with IV butterfly for 5 minutes and
  • Physician or nurse should be available for
    possible allergic reaction (1 mg epinephrine
  • Follow vital signs, baseline, and 5, 15, 30, 60
    minutes after injection

Monoclonal Antibody Imaging
  • OncoScint
  • Procedure
  • Image at 72, 96 and 120 hours post injection.
  • Patient should void before imaging
  • Statics 10 minutes per view. Ant-post views of
    thorax, abdomen and pelvis.
  • SPECT may be done at 72 hours if planar appears

Monoclonal Antibody Imaging
  • OncoScint
  • Normal Results
  • Activity in the liver, spleen, bone marrow and
    blood pool
  • Bowel activity may be present because of
    radiotracer in stool
  • Activity in kidneys, bladder, male genitalia and
    female nipples

Monoclonal Antibody Imaging
  • OncoScint
  • Abnormal Results
  • Increased extrahepatic uptake (equal to liver) in
  • Persistent and stationary over time with delayed
    scans, particularly over lymph nodes or organ of
  • If trying to isolate hepatic tumors a background
    subtraction technique with Tc99m Sulfur Colloid
    (1mCi) can be used
  • Background vascularity will decrease on 96 and
    120 hour images except for liver, which shows
    lesions then as less activity than normal tissue

Monoclonal Antibody Imaging
  • There are tons of other studies that deal with
    monoclonal antibodies. Going through all of them
    would be painfully boring to everyone here.
  • Other studies include OctreoScan, Bexxar and
    Zevalin to name a few.
  • OctreoScan can be found in Shackett p 188

Peptide Imaging
  • The advantages of peptide imaging are
  • it rarely produces an allergic-type reaction,
  • has a low radiation associated with its use,
  • and is much less expensive than the comparable
    monoclonal antibody techniques
  • The first Tc99m peptide introduced was AccuTect
    which detected venous thrombosis.

Peptide Imaging
  • There are other peptides, but in the interest of
    time Ill discuss one.
  • NeoTect used to tell if a pulmonary nodule is
    benign or malignant
  • NeoTect binds with somatostatin receptors that
    are present on many malignant tumors

Peptide Imaging
  • NeoTect
  • Like the monoclonal antibodies, NeoTect may
    induce anaphylactic shock, so a nurse epinephrine
    should be present at injection.
  • Patients should drink at least 8 o.z. of water
    before administration
  • Images are acquired 2-4 hours after injection.
    SPECT images are required for optimal images of
    the chest.

Breast Imaging
  • Thallium-201 localized in malignant breast tissue
    and in metastatic breast carcinomatous sites.
    Tc99m Sestamibi has been shown to show up in the
    same spots.
  • Images can be found in Sodee 814-816

Breast Imaging
  • For Breast metastases
  • No patient prep
  • Administer 3 mCi Tl-201 or 25 mCi Tc99m sestamibi
  • Begin imaging 20 minutes post injection.
  • Set camera for Tl-201 (80 keV) or Tc99m (140 keV)
  • Statics should be over 1000K
  • Whole body should be 20 to 25 minutes

Breast Imaging
  • For Static Breast Imaging
  • Same prep and dosage as metastatic imaging
  • Place patient in supine position and inject in
    the opposite are of the affected breast
  • With triple-head camera place one camera head in
    the anterior position and the other two heads in
    the obliques
  • Inject 3 mCi Tl-201 or 25 mCi Tc99m sestamibi

Breast Imaging
  • For Static Breast Imaging
  • The arms should be over the patients head.
    Include the axillae and the breast in the field
    of view. Begin imaging 2 minutes post-dose and
    take 2 to 10 minute acquisitions
  • Perform RAO and LAO views of the affected breast
    and axilla. Repeat views for 2 minutes each with
    marker on suspected mass and nipple

Breast Imaging
  • For Static Breast Imaging
  • If needed, tape the breast to avoid
    superimposition on liver or heart
  • Thallium-201 in breast carcinoma imaging has a
    96 sensitivity and no false positive results
    were obtained in preliminary tests
  • Tl-201 and Tc99m sestamibi can find malignant
    brain tumors with metabolically active remnants
    following radiation therapy. CT and MRI have
    been unable to differentiate viable tumor from
    radiation effects in brain tissue

Lymphoscintigraphy / SLN node
  • Is performed for evaluation of
  • Spread of cancers, (e.g. lymphatic leukemia,
    reticulum cell carcinoma, Hodgkins disease and
  • Lymphatic kinetics, particularly for cancers
  • And detection of metatstatic inavasion of the
    lymph nodes

Lymphoscintigraphy / SLN node
  • Patient prep
  • Wipe area with alocohol pad, shave if necessary
    clean area with Betadine
  • For breast, patient is to bring mammograms and
    any related studies with her or make previous
    studies available
  • For breast, patient is instructed to massage area
    of injection after injections and between imaging

Lymphoscintigraphy / SLN node
  • Radiopharamceutical Tc99m Sulfur Colloid. 200
    uCi to 2 mCi.
  • Method of administration
  • For melanoma, 2-6 subcutaneous and/or
    intradermal, producing a wheal, placed around
    cancer site, surgery or region of interest.
    Volume should not exceed .25 mL per injection

Lymphoscintigraphy / SLN node
  • Method of administration (cont.)
  • For breast, four placed in tissue surrounding
    lesion, as much as 4 mL per syringe at 3, 6, 9
    and 12-oclock positions around tumor site.
    Lidocane or sedation may be given to reduce pain
    of injections.
  • Flow 30-60sec/frame, 10-15 minutes
  • Statics every 5 minutes for up to 30 minutes,
    300 second counts.

Lymphoscintigraphy / SLN node
  • Normal results
  • Radiotracer enters the lymphatic system through
    normal channels and proceeds through the system
    into the major lymphatic beds
  • Visualization of the sentinel node or nodes is
    normal within the first 30 minutes
  • Biopsy of these nodes will yield the results

Lymphoscintigraphy / SLN node
  • Abnormal results
  • None or only some of the expected nodes
    visualizing indicates malignant blockage.
    Surgical or trauma scars can block the normal
    progression of the lymph
  • Continuity of chain interrupted
  • Enlargement of chain width because of lymphoma,
    congestion or lyphadenitis
  • Displacement of expected location by metastasis
    or collateral circulation

Tumor PET
  • Indications
  • Evaluation of grade of glioma and true extent of
    brain tumor
  • Differentiation of recurrent tumor from scar and
    radiation necrosis
  • Evaluation of chemotherapy effect on metabolism
  • Contraindications
  • Patient too agitated, uncooperative or
    claustrophobic to remain still for acquisition
  • Specific consideration of drug and food
    ingestion, or lack thereof for each study

Tumor PET
  • Radiopharmaceutical F-18-FDG, the most widely
    used. 5-15 mCi (Shackett)
  • Method of administration IV injection, done
    quickly because of radiation exposure

Tumor PET
  • Patient Prep
  • Patient is NPO after midnight
  • No caffeine or tobacco 12 hours before exam
  • Discontinue all meds on morning of exam
  • Diabetic patients half their dosage
  • Patient should be fully hydrated
  • Patient must remain calm with no movement during

Tumor PET
  • Procedure
  • Patient is placed in a reclining chair or bed for
    10 minutes and asked to relax and refrain from
    talking. Room should be quiet and dark.
  • Inject the F-18-FDG, followed by 20 to 30 mL
    saline flush
  • Patient should continue to rest for 45 to 90 more

Tumor PET
  • Procedure (cont)
  • Patient is placed supine on the imaging table and
    reminded to stay still
  • Image per protocols at facility.

  • Sources I stole from
  • Nuclear Medicine and PET. Christian, Bernier,
  • Nuclear Medicine Technology. Shackett.
  • Principles and Practice of Nuclear Medicine.
    Early and Sodee.
  • The package insert for NeoTect.

Good Luck on the Boards!
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