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ENDONCRINE GLANDSRADIOISOTOPE IMAGING AND THERAPY
THYROID GLAND TRAPPING MECHANISM : 99mTc-04Na (γ)IODINATION: 123I (γ), 131I (β), 125I (Auger e-)METABOLISM: 18FDG, 201TI (x), 99mTcMIBI (γ)
PARATHYROIDS METABOLISM (K): 201TI(x), 99mTc-MIBI (γ)
ADRENAL CORTEX STEROIDOGENESIS: 131I(123I) CHOLESTEROL
ADRENAL MEDULLA NORADRENALIN SYNTHESIS: 131I(123I) MIBG
PITUITARY GLAND RECEPTORS: 18F-BROMOCTYPTINE111In- 99mTc-OCTREOTIDE
RVH (RENIN) ACE-INHIBITORS 99mTc-MAG3/LASIX
SOMATOSTATIN RECEPTOR IMAGING: 111In-OCTREOTIDE
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EMBRYOLOGY OF THE ADRENAL GLANDS
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ADRENAL IMAGINGCORTEX: 131I(123I) CHOLESTEROL or NP-59
(On/Off Dexamethasone Suppression)
Carcinomas Do Not Visualize
MEDULLA: 131I (123I) META-IODO-BENZYL-GUANIDINE or MIBG
Carcinomas Visualize with MIBG
MEDULLA also:111In-SOMATOSTATIN ANALOGUE
or Octreotide
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ADRENAL GLANDS
Normalglands
lesionresponseto DXM
suppressionNP-59imaging
CORTEX: 1) Hydrocortisone: (Cushing’s)
a) Hypertrophy (bilateral).….. hypertrophic + +b) Tumor (benign)…………… suppressed - +
2) Aldosterone: Aldosteronoma (Cohn’s).. suppressed - +3) Androgens: ……....Congenital Adrenal Hypertrophy - +4) Carcinomas ………………………… NL - -
2) Carcinomas (Neuroblastoma)…………… NL - +
Octreo orMIBG
imagingMEDULLA:1) Norepinephrine: Pheochromocytoma….. NL - +
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HYPOTHALAMIC PITUITARY ADRENAL AXIS
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ADRENOCORTICAL SCINTIGRAPHY PROTOCOL
PATIENT PREPARATIONDEXAMETHASONE 8 mg/day from day -5 to day +3LUGOL’S SOLUTION 5 drops/day from day -2 to day + 8
INJECTIONDay 1: 0.5-1.0 mCi 131I(123I) CHOLESTEROL (NP-59)
IMAGING Days +2 (+3) : Scan on dexamethasone suppressionDays +5 (+7) : Scan off dexamethasone suppression
FOR BETTER LOCALIZATIONa) MAG3 Renal Scanb) SPECT/CT
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CORTICAL SCINTIGRAPHY NP-59
48 hours24 hours
On Dexamethasone
Normal Adrenals
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CORTICAL SCINTIGRAPHY NP-59
Off Dexamethasone
Normal Adrenals
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ADRENOCORTICAL IMAGINGUSE OF RENAL SCAN TO LOCALISE LESIONS
MAG3 RENAL SCAN
Appropriate localization
Normal Adrenals
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ADRENOCORTICAL ADENOMA NP59 FUSION
Adrenal Scan Renal Scan Fusion Image+
+ =
=
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Children with virulism131I-NP59 studies
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CONGENITAL ADRENAL HYPERTROPHY
NP-59 scans from 3 children with Congenital Adrenal Hypertrophy
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ECTOPIC ADRENAL TISSUEIN TESTES OR OVARIES
NP-59 scans from 3 children with suspected Ectopic Adrenal tissue in the testes
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Patient hypertensiver/o aldosterone producing tumor (s)
131I-NP59 study
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Aldosteronoma of the left adrenal gland(Cohn’s)
Tumor left adrenal gland
RADIO-CHOLESTEROL 131I-NP59 SCANS
liver
bowel
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A patient with Cushing’s Syndrome131I-NP59 study
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CUSHING’S ADENOMA LEFT ADRENALSUPPRESSION OF THE RIGHT ADRENAL
bowel
bowel
liverliver
Left adrenal cortical tumor. What about the right adrenal?
The right adrenal is suppressed
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A patient with Cushing’s Syndrome131I-NP59 study
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ADRENOCORTICAL HYPERPLASIA
liver
Both adrenal glands large/prominent off Dexamethasone
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Patient hypertensiver/o aldosterone producing tumor (s)
131I-NP59 study
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R/O ALDOSTERONOMA:
Bilateral Adrenal Hyperplasia
Tc-99m-MAG3 I-131-NP59
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RADIO-CHOLESTEROL 131I-NP59 SCANS INTERPRETATION DEPENDS ON PATIENT PREPARATION
IF NO DEXAMETHASONE WAS GIVEN = THE STUDY IS NORMAL ON LOW DOSE DEXAMETHASONE = BILAT. ADRENAL HYPERPLASIA
ON HIGH DOSE DEXAMETHASONE = BILATERAL ADENOMAS
Tc-99m-MAG3 I-131-NP59
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A patient with Cushing’s Syndrome131I-NP59 study
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ADRENOCORTICAL ADENOMA NP59
bowel
liver
Left adrenal gland large/prominent Right adrenal suppressed
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EMBRYOLOGY OF THE ADRENAL MEDULLA
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IMAGING ADRENAL MEDULARY LESIONS 131/123I meta-iodo-benzyl guanidine (MIBG)
It is associated with the neurosecretory granules of the cytoplasmic portion of the adrenal medulla
INDICATIONS• Pheochromocytomas: sensitivity 85%, specificity > 99%
• Neuroblastomas: Sensitivity is greater than 90%
for soft tissue, bone, or bone marrow involvement
METHOD
Patient preparation: Stop medications with sympathetic action
Inject 500µCi (5-10mCi) 131I (123I)-MIBG and scan at 48hr (+72hr)
LESION LOCALIZATION
MAG3 Renal Scan or SPECT/CT
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A patient with hypertension is studied to exclude Pheochromocytoma
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MIBG NORMAL STUDIES
Total body studiesbecause
pheochromocytomas may involve
the adrenal glands,sympathetic ganglia,
or other sites
Normal Adrenal
visualization
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MIBG NORMAL STUDY
PHYSIOLOGIC ADRENAL VISUALIZATION
24Hr (low count image) 48Hr 48Hr Repeat Study
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SENSITIVITY OF MIBG FOR PHEOCHROMOCYTOMA
15yo boy with Pheo (k=autotransplanted kidney) 75yo man with recurrentmalignant metast Pheo
Cancer 1984; 34(2):86
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A patient with clinical and laboratory findingssuggesting Pheo
and a CT showing lesion in the left adrenal
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PHEOCHROMOCYTOMA
Anterior
Posterior
MIBG study
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PHEOCHROMOCYTOMA
MIBG study
48hr post 0.750mCi 131I-MIBG
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ADRENAL MEDULLARY PHEOCHROMOCYTOMA
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PHEOCHROMOCYTOMA“Ectopic”
MIBG studyRenal Scan
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57yo man s/p L adrenalectomy for Pheochromocytoma
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MALIGNANT METASTATIC PHEOCHROMOCYTOMA
Ant
Ant Ant Ant
Post Post
MIBG study
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MALIGNANT PHEOCHROMOCYTOMA METASTATIC TO LUNGS
45yo woman s/p resection of pheochromocytoma
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123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA
10yo boy with laboratory presentation raising the question of Pheochromocytoma.
MRI is negative. Patient allergic to iodine.
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123I-MIBG SPECT/CT Pheochromocytoma
10 yo child with hypertension + lab work suggesting Pheochromocytoma
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123I-MIBG SPECT/CT for PHEOCHROMOCYTOMA
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MULTI-ENDOCRINE NEOPLASIA
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MULTIPLE ENDOCRINE ADENOMATOSIS (MEA)
Familial SyndromesCommon: Neuroectodermal origin of glands involved
(informational coding)
1 Multiple Endocrine Neoplasia type I (MEN-I)Parathyroid AdenomaPancreatic Islets (Zollinger-Ellison Syndrome)Pituitary (Hypo or Hyper Function)
2 Multiple Endocrine Neoplasia type II (MEN-II)Parathyroid Adenoma
PheochromocytomaMedullary Thyroid Carcinoma
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A Child with a history of resected Medullary thyroid carcinoma
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BILATERAL PHEOCHROMOCYTOMASMEN-II
MIBG study
24hr 48hr 96hr
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A Child with a history of resected Medullary thyroid carcinoma and Pheochromocytoma
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RECURRENT PHEOCHROMOCYTOMAMEN-IIMIBG study
11/17 off medication7/14 while taking Labetalol
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27yo man s/p thyroidectomy at age 15y for Medullary carcinomaand bilateral adrenalectomy at age 20y for pheochromocytomas
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RECURRENT PHEOCHROMOCYTOMAMEN-IIb
MIBG study
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NM studies in NEUROBLASTOMA
Bone Scan/(Liver-Renal scans)
MIBG Total Body Imaging/Therapy
Antibody Imaging/Therapy
Somatostatin-analogue (Octreotide)
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NEUROBLASTOMAPrimary Tumor calcified
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A 10 mo old child with proptosis
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NEUROBLASTOMA PRIMARY TUMOR
Tc-99m MDP Bone scan
AND METASTASIS TO BONES
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A child with Neuroblastoma. Evaluate for metastases
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NEUROBLASTOMA Primary
VISCERAL METASTASIS
131I-MIBG
Anterior Posterior
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NEUROBLASTOMA WITH VISCERAL METASTASIS
131I-MIBG STUDYAND TcSC, TcDTPA
SC+DTPA
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A child with Neuroblastomaand positive bone marrow biopsy
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NEUROBLASTOMA WITH BONE MARROW METASTASIS
131I-MIBG
Posterior total body images to better show the bone marrow
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111In-OCTREOTIDE SCINTIGRAPHY
Somatostatin(14AA) Octreotide=Oligopeptide analogue(8AA)
CarcinoidGastrinomaInsulinomaGlucagonomaParaganglioma
Non-Small Cell Lung cancerMeningiomas PheochromocytomaApudomas non specifiedMedullary thyroid carcinoma
Tumors with membrane somatostatin receptors Granulomatous Autoimmune
SarcoidosisWegener’s TuberculosisGraves’ Thyroid Exophthalmos
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111In-OCTREOTIDE SCINTIGRAPHY
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A child with Neuroblastoma
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111In-OCTREOTIDE SCINTIGRAPHYNEUROBLASTOMA
Bone metastases of neuroblastoma
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FDG-PET INNEUROBLASTOMA
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FDG-PET IN NEUROBLASTOMA
FDG accumulates within most neuroblastomas
It also accumulates within neuroblastomaswhich are MIBG negative
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A child with Neuroblastoma
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MIBG and FDG-PET in NEUROBLASTOMA
tumor tumor
tumortumor
Skull metastasisPrimary Tumor
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Recurrent Neuroblastoma in a 6 month old boy
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FDG-PET INNEUROBLASTOMA
Recurrent Tumor
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Neuroblastoma at diagnosis and 6mos after chemotherapy
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FDG-PET IN NEUROBLASTOMAEFFECT OF THERAPY
FDG-PET CT-Scan MIBG
Baseline
After Chemotherapy
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A 17 year old girl with right shoulder pain
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FDG-PET INHEPATOBLASTOMA
CT Scan FDG - PET
necrotictumor
necrotictumor
Active viable tumor
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PITUITARY GLAND TUMORS
PET: 11C-BROMOCRYPTINESPECT: SOMATOSTATIN analogue
(111I-OCTREOTIDE)