Blood flow measurements with radionuclide-labeled particles

When appropriately and correctly applied, the microsphere technique is relatively simple and extremely accurate. Distribution patterns, both of total systemic arterial blood flow or venous return as well as within specific organs, can be measured. Several techniques have been applied to quantitate flow using microspheres; the reference sample method is extremely simple and by far the most accurate of all. Collection of venous effluent is perhaps more accurate but requires extensive surgery and is almost certainly the least physiologic. Other methods used for quantitation, such as bolus injections of indocyanine green dye or in fusions of diffusable indicators, are considerably less accurate and therefore significantly reduce the reliability of the microsphere technique. Selection of the appropriate size microspheres allows for definition of arteriovenous anastomoses as well as the measurement of organ blood flows and distribution of blood flow within those organs. In most instances, smaller microspheres (15mu diameter or 8-10mu diameter) have significant advantages over larger ones. They are distributed more like red cells, obstruct less of the vascular bed, are less variable in size, and can be given in significantly greater numbers. This latter point is important, since the statistical criteria need to be satisfied and the use of small spheres allows for the more reliable measurement of blood flow to small organs or to small regions of organs.

A positron-emission transaxial tomograph for nuclear imaging (PETT)

An apparatus was developed for obtaining emission transaxial images of sections of organs containing positron-emitting radiopharmaceuticals. The detection system is a hexagonal array of 24 NaI(T1) detectors connected to coincidence circuits to achieve the "electronic" collimation of annihilation photons. The image is formed by a computer-applied algorithm which provides quantitative reconstruction of the distribution of activity. Computer simulations, phantom and animal studies show that this approach is capable of providing images of better contrast and resolution than are obtained with scintillation cameras. Advantages of positron vs. single photon reconstruction tomography are discussed.

Imaging transgene expression with radionuclide imaging technologies

A variety of imaging technologies are being investigated as tools for studying gene expression in living subjects. Noninvasive, repetitive and quantitative imaging of gene expression will help both to facilitate human gene therapy trials and to allow for the study of animal models of molecular and cellular therapy. Radionuclide approaches using single photon emission computed tomography (SPECT) and positron emission tomography (PET) are the most mature of the current imaging technologies and offer many advantages for imaging gene expression compared to optical and magnetic resonance imaging (MRI)-based approaches. These advantages include relatively high sensitivity, full quantitative capability (for PET), and the ability to extend small animal assays directly into clinical human applications. We describe a PET scanner (microPET) designed specifically for studies of small animals. We review "marker/reporter gene" imaging approaches using the herpes simplex type 1 virus thymidine kinase (HSV1-tk) and the dopamine type 2 receptor (D2R) genes. We describe and contrast several radiolabeled probes that can be used with the HSV1-tk reporter gene both for SPECT and for PET imaging. We also describe the advantages/disadvantages of each of the assays developed and discuss future animal and human applications.

Current use and future potential of organometallic radiopharmaceuticals

Contrary to common belief, organometallic compounds exhibit remarkable stability in aerobic and even diluted aqueous solutions. Technetium-sestamibi (Cardiolite) is one of the most prominent examples of this class of compounds routinely used in nuclear medicine. This review summarises the recent progress in labelling of biomolecules with organometallic complexes for diagnostic and therapeutic application in radiopharmacy and exemplifies in detail developments focussing on organometallic technetium- and rhenium-tricarbonyl technologies. The value of such technologies has been recognised and they have become a valuable alternative to common labelling methodologies. An increasing number of groups have started to employ an organometallic precursor for the purpose of radioactive labelling of various classes of biomolecules, and the advantages and limitations of this new technique are compared with those of other labelling methods. The synthetic access to appropriate precursors via double-ligand exchange or aqueous carbonyl kit preparation for routine application is described. Strategies and examples for the design of appropriate bifunctional chelating agents for the Tc/Re-tricarbonyl core are given. The functionalization of biomolecules such as tracers for the central nervous system (dopaminergic and serotonergic), tumour affine peptides (somatostatin receptors, neuroreceptors) and tumour binding single-chain antibody fragments is summarised. Where possible and appropriate, the in vitro and in vivo results in respect of these examples are compared with those obtained with classical (99m)Tc/(188)Re(V)- and (111)In-labelled analogues. The preclinical results show the in many ways superior characteristics of organometallic labelling techniques.

Cardiac function at rest and during exercise in normals and in patients with coronary heart disease: evaluation by radionuclide angiocardiography

This study demonstrates that radionuclide angiocardiography provides a simple and noninvasive approach for evaluation of myocardial function. Previous work concerning myocardial performance has been generally conducted with the patient in the supine position. Radionuclide angiocardiograms were performed in the present study at rest and during exercise in 30 normal subjects and in 30 patients with ischemic coronary artery disease. There were 30 normal controls (Group I), ten with single coronary artery disease (Group II), and 20 patients with multiple vessel coronary disease (Group III). All subjects were studied in the erect posture on a bicycle ergometer. In the normal controls, the mean heart rate doubled and the cardiac output tripled during exercise. Intensive training can lead to extraordinary levels of cardiac performance as shown in a world-class athlete who during peak exercise attained a heart rate of 210, an ejection fraction of 97%, and a cardiac output of 56 litres per minute. In the patients with coronary artery disease, both groups, were able to increase cardiac output to approximately twice the resting value. The magnitude of increase in blood pressure during exercise was not significantly different in the three groups. However, definite changes were present in the end-diastolic volume at rest was 116 and rose to 128 ml in Group I, 93 rising to 132 ml in Group II, and 138 increasing to 216 ml in Group III. The stroke volume increased comparably in all three groups, but the ejection fraction from rest to exercise showed a marked contrast in the controls compared to those with multivessel coronary disease. The ejection fraction rose in Group I from 66 to 80% during exercise, while in Group II it fell from 69 to 67%, and in Group III from 60 to 46%. These findings indicate that patients with ischemic myocardial disease respond to the stress of exercise by cardiac dilatation to maintain of increase stroke volume at increased heart rates. Moreover, the magnitude of this response appears to be greatest in patients with left main coronary artery stenosis. This approach for evaluating myocardial function during exercise provides useful data of importance in selecting medical versus surgical management of patients with ischemic coronary artery disease.

Inorganic scintillators in medical imaging

A review of medical diagnostic imaging methods utilizing x-rays or gamma rays and the application and development of inorganic scintillators is presented.

The role of the striatal dopamine transporter in cognitive aging

We examined the relationship of age-related losses of striatal dopamine transporter (DAT) density to age-related deficits in episodic memory and executive functioning in a group of subjects (n = 12) ranging from 34 to 81 years of age. The radioligand [(11)C]beta-CIT-FE was used to determine DAT binding in caudate and putamen. Results showed clear age-related losses of striatal DAT binding from early to late adulthood, and a marked deterioration in episodic memory (word and figure recall, face recognition) and executive functioning (visual working memory, verbal fluency) with advancing age. Most importantly, the age-related cognitive deficits were mediated by reductions in DAT binding, whereas DAT binding added systematic cognitive variance after controlling for age. Further, interindividual differences in DAT binding were related to performance in a test of crystallized intelligence (the Information subtest from the Wechsler Adult Intelligence Scale-Revised) that showed no reliable age variation. These results suggest that DAT binding is a powerful mediator of age-related cognitive changes as well as of cognitive functioning in general. The findings were discussed relative to the view that the frontostriatal network is critically involved in multiple cognitive functions.

In vivo quantitation of lesion radioactivity using external counting methods

Quantitative external counting methods for the in vivo determination of the activity uniformly distributed in an area of interest (lesion) have been developed. The theoretical work has been extended to include the effects of regions of differing attenuation coefficient and of non-target organ activity in the tissue surrounding the lesion. A clinical quantitative procedure utilizing a "calibrated" gamma camera and associated computer system is described. Studies including a bone substitute material in a water phantom confirmed the basic theoretical work.

The geometric transfer function component for scintillation camera collimators with straight parallel holes

A theoretical approach has been developed that allows the geometric transfer function component for conventional scintillation camera collimators to be predicted in closed form. If transfer function analysis is to be useful in describing imaging system performance, the image of a point source must not depend on source position in a plane parallel to the detection plane. This shift invariance can be achieved by analysis of system response in terms of an effective point spread function, defined as the normalised image of a point source that would be obtained if the camera collimator were uniformly translated (but not rotated) during image formation. The geometric component of the corresponding effective transfer function is shown to be expressed simply by the absolute square of the two-dimensional Fourier transform of a collimator hole aperture, with the spatial frequency plane scaled by a factor which depends on collimator length, source-to-collimator distance, and collimator-to-detection plane distance. Closed form algebraic expressions of the geometric transfer function have been obtained for all four common hold shapes (circular, hexagonal, square and triangular). Monte Carlo simulations and experimental measurements have shown these theoretical expressions to be highly accurate.

Drug targeting of a peptide radiopharmaceutical through the primate blood-brain barrier in vivo with a monoclonal antibody to the human insulin receptor

Peptide radiopharmaceuticals are potential imaging agents for brain disorders, should these agents be enabled to undergo transport through the blood-brain barrier (BBB) in vivo. Radiolabeled Abeta1-40 images brain amyloid in tissue sections of Alzheimer's disease autopsy brain, but this peptide radiopharmaceutical cannot be used to image brain amyloid in vivo owing to negligible transport through the BBB. In these studies, 125I-Abeta1-40 was monobiotinylated (bio) and conjugated to a BBB drug delivery and brain targeting system comprised of a complex of the 83-14 monoclonal antibody (mAb) to the human insulin receptor, which is tagged with streptavidin (SA). A marked increase in rhesus monkey brain uptake of the 125I-bio-Abeta1-40 was observed after conjugation to the 8314-SA delivery system at 3 h after intravenous injection. In contrast, no measurable brain uptake of 125I-bio-Abeta1-40 was observed in the absence of a BBB drug delivery system. The peptide radiopharmaceutical was degraded in brain with export of the iodide radioactivity, and by 48 h after intravenous injection, 90% of the radioactivity was cleared from the brain. In conclusion, these studies describe a methodology for BBB drug delivery and brain targeting of peptide radiopharmaceuticals that could be used for imaging amyloid or other brain disorders.

Lymphoscintigraphy, the sentinel node concept, and the intraoperative gamma probe in melanoma, breast cancer, and other potential cancers

There is a resurgence of interest in lymphoscintigraphy because of attention to the sentinel node concept and the availability of the surgical gamma probe that can be used in the operating room to localize radiolabeled sentinel nodes. Conventional surgical management of melanoma has been altered for intermediate thickness tumors such that lymph node dissection is performed for a lymph node bed only if the sentinel node is tumor positive on histological exam after gamma probe-guided excision. This approach is cost effective, saving about 80% of these patients (sentinel node tumor negative) the cost and morbidity of unnecessary "elective lymph node dissection." In addition, a biopsy can be performed on all lymph node beds that receive lymphatic drainage from the tumor site thereby improving staging and perhaps survival by providing the most appropriate therapy. Substantial work has been done to develop optimum imaging techniques and the best radiopharmaceutical preparation to achieve accurate, reproducible lymphatic drainage images. Our methodology includes the following intradermal injections of a technetium 99m sulfur colloid (modified preparation) are followed by dynamic imaging (10 seconds per frame); static imaging up to 30 minutes and late imaging at 1 to 2 hours. Images show lymphatic channels that lead to sentinel nodes in 1, 2, 3, or more anatomic locations. Surgical management is altered to include sampling sentinel nodes of nodal beds, many of which would not have been sampled by previous conventional surgical estimates of lymphatic drainage. While clinical success of lymphoscintigraphy and intraoperative probe localization of the sentinel node in melanoma is evident, use of lymphoscintigraphy and the sentinel node concept in breast cancer is investigative, but promising. The radiopharmaceutical is injected around the tumor in the breast followed by imaging to delineate lymphatic drainage to the sentinel node(s). Optimum methodologies for radiopharmaceutical, volume and/or activity of injectate, and imaging have yet to be determined. Breast lymphatic drainage can be to axilla, internal mammary, and/or supraclavicular nodes in any combination.

The Mark IV system for radionuclide computed tomography of the brain

The Mark IV scanning system is a simple four-sided arrangement of 32 independent detectors which rotate continously as a unit, detecting, processing, and displaying the reconstructed data while the study progresses. Detection is by single photon counting and is compatible with commercially available radionuclides. An empirical correction is applied for attenuation, difference in detector response, and scatter. It is a high-sensitivity device with approximately uniform resolution throughout the section plane. There is good reproducibility and accuracy for absolute quantification of radionuclide concentration in the brain. Clinical applications include scans of 99mTcO4, 99mTc-RBC, 123I-iodoantipyrine, 99mTc-diphosphonate, and 111In-DTPA.

Computerized x-ray scanning of the brain

✓ Computerized scanning of the brain is a new diagnostic x-ray method that utilizes modern electronic and computer technology for the measurement of the transmission of x-ray photons through tissue. The cranium is scanned in successive layers by a narrow beam of x-rays in such a way that the transmission of x-ray photons across a particular slice can be measured, and by means of a computer and a suitable algorithm used to construct a detailed differential picture of the internal structure and tissues of the brain.

Intraoperative probes and imaging probes

Intraoperative probes have been employed to assist in the detection and removal of tumors for more than 50 years. For a period of about 40 years, essentially every detector type that could be miniaturized had been tested or at least suggested for use as an intraoperative probe. These detectors included basic Geiger-Müller (GM) tubes, scintillation detectors, and even state-of-the-art solid state detectors. The radiopharmaceuticals have progressed from (32)PO(4)(-) injections for brain tumors to sophisticated monoclonal antibodies labeled with iodine-125 for colorectal cancers. The early work was mostly anecdotal, primarily interdisciplinary collaborations between surgeons and physical scientists. These collaborations produced a few publications, but never seemed to result in an ongoing clinical practice. In the mid 1980s, several companies offered basic gamma-detecting intraoperative probes as products. This led to the rapid development of radioimmunoguided surgery (RIGS) and sentinel node detection as regularly practiced procedures to assist in the diagnosis and treatment of cancer. In recent years intraoperative imaging probes have been developed. These devices add the ability to see the details of the detected activity, giving the potential of using the technique in a low-contrast environment. Intraoperative probes are now established as clinical devices, they have a commercial infrastructure to support their continued use, and there is ongoing research, both commercial and academic, that would seem to ensure continued progress and renewed interest in this slowly developing field.

111In-pentetreotide scintigraphy: procedure guidelines for tumour imaging

This document provides general information about somatostatin receptor scintigraphy with (111)In-pentetreotide. This guideline should not be regarded as the only approach to visualise tumours expressing somatostatin receptors or as exclusive of other nuclear medicine procedures useful to obtain comparable results. The aim of this guideline is to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of (111)In-pentetreotide scintigraphy.

Review article-Bone scanning

The discovery of a number of phosphate complexes labelled with 99-Tc-m that localize in bone has aroused wide-spread interest in bone scanning. The physiological properties of these and other clinically useful bone-seeking radiopharmaceuticals are compared, and their physical properties assessed in relation to the characteristics and limitations of avilable detector systems. A hypothesis is put forward to explain the behaviour of the technetium-labelled agents. It is concluded that although there are differences in biochemical behaviour between these agents, strontium and fluorine, all three may, under suitable conditions, give similar clinical information. The radiation dose received by the patients is least with the usual dose of 99-Tc-m and the blood clearance of the diphosphonate and pyrophosphate preparations is faster than that of strontium, although slower than fluorine. The psi-ray energy of technetium permits a much greater efficiency of detection than of fluorine. These factors, toghether with the general availability of 99-Tc-m and its relatively low cost make the technetium diphosphonate or pyrophosphate preparations the agents of choice for most skeletal radioisotope imaging. However, there are as yet insufficient follow-up studies to be able to assess the incidence of either false-negative or false-positive findings with these agents.

Management of malignant melanoma of the head and neck using dynamic lymphoscintigraphy and gamma probe-guided sentinel lymph node biopsy

BACKGROUND

The sentinel lymph node (SLN) biopsy is revolutionizing the surgical management of primary malignant melanoma. It allows accurate nodal staging, and targets patients who may benefit from regional lymphadenectomy and systemic therapy; however, its use in the management of head and neck melanoma has not been widely accepted.

METHODS

A retrospective review of patients treated for clinical stages I and II malignant melanoma of the head and neck with dynamic lymphoscintigraphy and gamma probe-guided SLN biopsy.

RESULTS

Fifty-eight patients (47 male and 11 female) were identified. Primary melanoma sites included the scalp (21), ear (8), face (13), neck (15), and eyelid (1). Primary tumor staging was T2 (11), T3 (24), and T4 (23). Dynamic lymphoscintigraphy visualized SLNs in 57 patients (98.3%). In 43 cases (75%) a single draining nodal basin was identified, and in 14 cases there were multiple draining nodal basins. Sentinel lymph nodes were successfully identified in 72 (96%) of 75 nodal basins. Positive SLNs were identified in 10 patients (17.5%). Sentinal lymph node positivity by tumor staging was T3, 16.7% and T4, 27.3%. Completion lymphadenectomy revealed residual disease in 3 patients (30%). Relapse occurred in 10 (21.3%) of the 47 patients with negative SLN biopsy results and 7 (70%) of those with positive results.

CONCLUSIONS

Gamma probe-guided SLN localization in the head and neck region was successful in 96% of draining nodal basins. It can target regional lymphadenectomy in patients who may benefit from regional nodal dissection.

A Wiener filter for nuclear medicine images

To improve the quality of digital nuclear medicine images, we have developed a new implementation of the Wiener restoration filter. The Wiener filter uses as its optimality criterion the minimization of the mean-square error between the undistorted image of the object and the filtered image. In order to form this filter, the object and noise power spectrums are needed. The noise power spectrum for the count-dependent Poisson noise of nuclear medicine images is shown to have a constant average magnitude equal to the total count in the image. The object power spectrum is taken to be the image power spectrum minus the total count, except in the noise dominated region of the image power spectrum where a least-squares-fitted exponential is used. Processing time is kept to a clinically acceptable time frame through use of an array processor. Pronounced noise suppression and detail enhancement are noted with use of this filter with clinical images.

Influence of collimator choice and simulated clinical conditions on 123I-MIBG heart/mediastinum ratios: a phantom study

PURPOSE

(123)I presents imaging problems owing to high-energy photon emission. We investigated the influence of collimators on (123)I-MIBG heart/mediastinum ratios (H/M ratios). Secondly, we assessed the influence on H/M ratios of different activity concentrations, simulating clinical conditions. Thirdly, the value of scatter correction was assessed.

METHODS

The AGATE cardiac phantom was filled with (123)I in three sequential conditions: A, heart and mediastinal activity; B, adding lung activity; and C, adding liver activity (protocol I). In protocol II, myocardium and liver were filled with different activities ranging from low to high. For each condition, static anterior planar and single-photon emission computed tomography studies were acquired on a Siemens e.cam (SI) and a General Electric Millennium VG (GE) system, using low-energy high-resolution and medium-energy (ME) collimators for protocol I and only ME collimators for protocol II . For the SI camera, a triple energy window (TEW) scatter correction was applied.

RESULTS

Planar H/M ratios were influenced by scatter and septal penetration from increasing amounts of liver activity. These effects were less pronounced for ME collimators. Although the TEW scatter correction increased ratios overall, TEW correction did not improve the relative differences between the ratios. TEW correction therefore does not add any benefit to obtain an accurate reflection of myocardial activity concentrations.

CONCLUSION

For straightforward implementation of semi-quantitative (123)I-MIBG myocardial studies, we recommend the use of ME collimators without scatter correction.