Nuclear Medicine

Nuclear medicine is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease.

In nuclear medicine procedures, radionuclides are combined with other elements to form chemical compounds, or else combined with existing pharmaceutical compounds, to form radiopharmaceuticals. These radiopharmaceuticals, once administered to the patient, can localize to specific organs or cellular receptors. This property of radiopharmaceuticals allows nuclear medicine the ability to image the extent of a disease-process in the body, based on the cellular function and physiology, rather than relying on physical changes in the tissue anatomy. In some diseases nuclear medicine studies can identify medical problems at an earlier stage than other diagnostic tests. It would not be wrong to call Nuclear Medicine as “Radiology done inside out” or “Endo-radiology” because it records radiation emitting from within the body rather than radiation that is generated by external sources like Xrays.

Treatment of diseased tissue, based on metabolism or uptake or binding of a particular ligand, may also be accomplished, similar to other areas of pharmacology. However, the treatment effects of radiopharmaceuticals rely on the tissue-destructive power of short-range ionizing radiation.
In the future, nuclear medicine may provide added impetus to the field known as molecular medicine. As our understanding of biological processes in the cells of living organism expands, specific probes can be developed to allow visualization, characterization, and quantification of biologic processes at the cellular and subcellular levels. Nuclear medicine is an ideal specialty to adapt to the new discipline of molecular medicine, because of its emphasis on function and its utilization of imaging agents that are specific for a particular disease process.

DiagnosticIn nuclear medicine imaging, radiopharmaceuticals are taken internally, for example intravenously or orally. Then, external detectors (gamma cameras) capture and form images from the radiation emitted by the radiopharmaceuticals. This process is unlike a diagnostic X-ray where external radiation is passed through the body to form an image.

There are several techniques of diagnostic nuclear medicine.
Nuclear medicine tests differ from most other imaging modalities in that diagnostic tests primarily show the physiological function of the system being investigated as opposed to traditional anatomical imaging such as CT or MRI. Nuclear medicine imaging studies are generally more organ or tissue specific (e.g.: lungs scan, heart scan, bone scan, brain scan, etc.) than those in conventional radiology imaging, which focus on a particular section of the body (e.g.: chest X-ray, abdomen/pelvis CT scan, head CT scan, etc.). In addition, there are nuclear medicine studies that allow imaging of the whole body based on certain cellular receptors or functions. Examples are whole body PET scanor PET/CT scans, gallium scans, indium white blood cell scans, MIBG and octreotide scans.
Iodine-123 whole body scan for thyroid cancer evaluation. The study above was performed after the total thyroidectomy and TSH stimulation with thyroid hormone medication withdrawal. The study shows a small residual thyroid tissue in the neck and a mediastinum lesion, consistent with the thyroid cancer metastatic disease. The uptakes in the stomach and bowel are normal physiologic findings.
While the ability of nuclear metabolism to image disease processes from differences in metabolism is unsurpassed, it is not unique. Certain techniques such as fMRI image tissues (particularly cerebral tissues) by blood flow, and thus show metabolism. Also, contrast-enhancement techniques in both CT and MRI show regions of tissue which are handling pharmaceuticals differently, due to an inflammatory process.

Diagnostic tests in nuclear medicine exploit the way that the body handles substances differently when there is disease or pathology present. The radionuclide introduced into the body is often chemically bound to a complex that acts characteristically within the body; this is commonly known as a tracer. In the presence of disease, a tracer will often be distributed around the body and/or processed differently. For example, the ligand methylene-diphosphonate (MDP) can be preferentially taken up by bone. By chemically attaching technetium-99m to MDP, radioactivity can be transported and attached to bone via the hydroxyapatite for imaging. Any increased physiological function, such as due to a fracture in the bone, will usually mean increased concentration of the tracer. This often results in the appearance of a ‘hot-spot’ which is a focal increase in radio-accumulation, or a general increase in radio-accumulation throughout the physiological system. Some disease processes result in the exclusion of a tracer, resulting in the appearance of a ‘cold-spot’. Many tracer complexes have been developed to image or treat many different organs, glands, and physiological processes.
Hybrid scanning techniquesIn some centers, the nuclear medicine scans can be superimposed, using software or hybrid cameras, on images from modalities such as CT or MRI to highlight the part of the body in which the radiopharmaceutical is concentrated. This practice is often referred to as image fusion or co-registration, for example SPECT/CT and PET/CT. The fusion imaging technique in nuclear medicine provides information about the anatomy and function, which would otherwise be unavailable, or would require a more invasive procedure or surgery.

Practical concerns in nuclear imagingThe amount of radiation from diagnostic nuclear medicine procedures is kept within a safe limit relative to the established “ALARA” (As Low As Reasonably Achievable) principle. The radiation dose from nuclear medicine imaging varies greatly depending on the type of study. The effective radiation dose can be lower than, or comparable to, or can far exceed the general day-to-day environmental annual background radiation dose. It can also be in the range or higher than the radiation dose from an abdomen/pelvis CT scan.

Some nuclear medicine procedures require special patient preparation before the study to obtain the most accurate result. Pre-imaging preparations may include dietary preparation or the withholding of certain medications. Patients are encouraged to consult with the nuclear medicine department prior to a scan.

AnalysisThe end result of the nuclear medicine imaging process is a “dataset” comprising one or more images. In multi-image datasets the array of images may represent a time sequence (i.e. cine or movie) often called a “dynamic” dataset, acardiac gated time sequence, or a spatial sequence where the gamma-camera is moved relative to the patient. SPECT(single photon emission computed tomography) is the process by which images acquired from a rotating gamma-camera are reconstructed to produce an image of a “slice” through the patient at a particular position. A collection of parallel slices form a slice-stack, a three-dimensional representation of the distribution of radionuclide in the patient.

The nuclear medicine computer may require millions of lines of source code to provide quantitative analysis packages for each of the specific imaging techniques available in nuclear medicine.
Time sequences can be further analysed using kinetic models such as multi-compartment models or a Patlak plot.

Interventional nuclear medicineRadionuclide therapy can be used to treat conditions such as hyperthyroidism, thyroid cancer, and blood disorders.

In nuclear medicine therapy, the radiation treatment dose is administered internally (e.g. intravenous or oral routes) rather from an external radiation source.

The radiopharmaceuticals used in nuclear medicine therapy emit ionizing radiation that travels only a short distance, thereby minimizing unwanted side effects and damage to noninvolved organs or nearby structures. Most nuclear medicine therapies can be performed as outpatient procedures since there are few side effects from the treatment and the radiation exposure to the general public can be kept within a safe limit.

Radiation doseA patient undergoing a nuclear medicine procedure will receive a radiation dose. Under present international guidelines it is assumed that any radiation dose, however small, presents a risk. The radiation doses delivered to a patient in a nuclear medicine investigation, though unproven, is generally accepted to present a very small risk of inducing cancer. In this respect it is similar to the risk from X-ray investigations except that the dose is delivered internally rather than from an external source such as an X-ray machine, and dosage amounts are typically significantly higher than those of X-rays.

The radiation dose from a nuclear medicine investigation is expressed as an effective dose with units of sieverts(usually given in millisieverts, mSv). The effective dose resulting from an investigation is influenced by the amount of radioactivity administered in mega becquerels (MBq), the physical properties of the radiopharmaceutical used, its distribution in the body and its rate of clearance from the body.

Effective doses can range from 6 μSv (0.006 mSv) for a 3 MBq chromium-51 EDTA measurement of glomerular filtration rate to 37 mSv (37,000 μSv) for a 150 MBq thallium-201 non-specific tumour imaging procedure. The common bone scan with 600 MBq of technetium-99m-MDP has an effective dose of approximately 3.5 mSv (3,500 μSv) (1).

Formerly, units of measurement were the curie (Ci), being 3.7E10 Bq, and also 1.0 grams of Radium (Ra-226); therad (radiation absorbed dose), now replaced by the gray; and the rem (Röntgen equivalent man), now replaced with the sievert. The rad and rem are essentially equivalent for almost all nuclear medicine procedures, and only alpha radiation will produce a higher Rem or Sv value, due to its much higher Relative Biological Effectiveness (RBE). Alpha emitters are nowadays rarely used in nuclear medicine, but were used extensively before the advent of nuclear reactor and accelerator produced radionuclides. The concepts involved in radiation exposure to humans is covered by the field of Health Physics.