Atlas of Clinical Nuclear Medicine PDF
Preview Atlas of Clinical Nuclear Medicine
AN ATLAS OF CLINICAL NUCLEAR MEDICINE THIRD EDITION IGNAC FOGELMAN BSc, MD, FRCP Professor of Nuclear Medicine, King’s College, London, UK and Honorary Consultant, Guy’s and St Thomas’, NHS Foundation Trust, London, UK SUSAN E. M. CLARKE MB, BS, MSc, FRCP, FRCR, FBIR Senior Lecturer, Division of Imaging Sciences and Biomedical Engineering, King’s College, London, UK and Honorary Consultant, Guy’s and St Thomas’, NHS Foundation Trust, London, UK GARY COOK MB, BS, MSc, MD, FRCR, FRCP Professor of Clinical PET Imaging, Division of Imaging Sciences and Biomedical Engineering, King’s College, London, UK and Honorary Consultant, Guy’s and St Thomas’, NHS Foundation Trust, London, UK GOPINATH GNANASEGARAN MB, BS, MSc, MD, FRCP Consultant Physician, Department of Nuclear Medicine, Guy’s and St Thomas’, NHS Foundation Trust, London, UK Boca Raton London New York CRC Press is an imprint of the Taylor & Francis Group, an informa business CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2014 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Version Date: 20131028 International Standard Book Number-13: 978-1-84184-752-8 (eBook - PDF) This book contains information obtained from authentic and highly regarded sources. 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Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com CONTENTS Foreword _______________________________ vii Preface __________________________________ix Acknowledgements _______________________xi 1 Bone ____________________________________ 1 2 Endocrinology __________________________307 3 Renal _________________________________443 4 Oncology ______________________________593 5 Brain __________________________________879 6 Nuclear cardiology______________________941 7 Lung _________________________________1075 8 Liver and spleen _______________________1175 9 Gastrointestinal tract ___________________1245 10 Paediatrics ____________________________1297 11 Infection _____________________________1389 12 Radionuclide therapy ___________________1507 13 Miscellaneous _________________________1547 Index ________________________________1585 An appendix listing of Common SPECT and PET Radionuclides and Radiopharmaceuticals used in Nuclear Medicine can be found on http://www.crcpress .com/product/isbn/9781841846538. FOREWORD The experienced interpreter of diagnostic medical images is ease of the readers’ comprehension of the subject matter. well versed in the concept of pattern recognition. This is of I, in particular, enjoyed the beautiful, colourful anatomic casts particular importance in Nuclear Medicine because of the of the bronchopulmonary segments in the lung chapter and non-specifi city of many of the fi ndings we may encounter on coronary arterial tree in the cardiology chapter. The explana- a radionuclide image. Over the past several decades, many tory “bullets” following a great number of the fi gure legends Nuclear Medicine atlases have appeared either devoted to a provide valuable additional commentary on the particular specifi c area of organ imaging, or more generally, attempting fi nding being discussed. The inclusion of SPECT and PET/CT to encompass a broader overview of radionuclide imaging in this similar teaching format signifi cantly adds to the unique- methodology. The fi rst two editions of this current work fall ness of the Atlas. into this latter category. All of these publications have served I have long known and admired Dr. Ignac Fogelman’s great their timely purpose in the overall history of our specialty. talents as a clinical investigator, teacher and author of innu- In the 1600 pages that follow, Drs. Fogelman, Clarke, Cook merable articles and texts; primarily dealing with osseous dis- and Gnanasegaran have created a classic work that should ease. With the invaluable assistance of his colleagues in Great stand for many years as the standard of what a comprehensive Britain, he has created this third masterful edition of an Atlas atlas should be. In their preface, the authors indicate that they of Clinical Nuclear Medicine, which will stand as a greatly “have made a valiant attempt to include most of what one appreciated invaluable contribution to both Nuclear Medicine would expect to observe routinely and to contend with issues physicians and clinicians interested in learning how radionu- that we personally have found interesting and challenging.” clide methodology can enhance their patient care. They have succeeded. The net result of their “valiant attempt” is Our great thanks to Dr. Fogelman and his associates for their a wonderful, comprehensive, compendium of everything you tireless efforts over several years to provide us with this ulti- want to know about interpreting radionuclide images and more. mate reference on how to interpret radionuclide images. Each of the 13 chapters has introductory sections structured as a mini-test dealing with basic anatomy, physiology and Leonard M. Freeman, M.D. pathophysiology stressing the normal and its variants. Superb Bronx, New York line drawings, photographs and numerous tables add to the June, 2013 PREFACE It is some 18 years since the last edition of this Atlas was issues that we p ersonally have found interesting and challeng- p ublished. That is a long time to keep you waiting, and we are ing. Many s imple, easy-to-remember teaching points have truly sorry. However, it seemed a daunting task to produce a been included throughout this text, and our hope is that the new Atlas of Clinical Nuclear Medicine; to include all the new end product will be clinically useful and of practical value. radiopharmaceuticals, advances with SPECT/CT; and to cover Thus, our success depends on you, dear reader, as it is upon the revolution in imaging, that is PET/CT. Fortunately, help your opinion as to how close we have come to achieving our was to hand with our younger colleagues (Dr. Gnanasegaren goal that we will ultimately be judged. and Dr. Cook) who injected knowledge, dynamism, and stamina into the project. Nevertheless, this remains a hugely Ignac Fogelman ambitious task with an aim to provide a truly comprehensive Susan E. M. Clarke Atlas. We have made a valiant attempt to include most of what Gary Cook one would expect to observe routinely and to contend with Gopinath Gnanasegaran ACKNOWLEDGEMENTS We would like to thank all of the contributors to the Atlas, who (Brain chapter), Dr. Lorenzo Biassoni (Paediatrics chapter), and are identifi ed by their contributions. We would also like to Dr. Parthiban Arumugam (Nuclear Cardiology chapter). They thank the staff of the Department of Nuclear Medicine at Guy’s have collated all the new material and assisted in the reconstruc- and St Thomas’ Hospital who have assisted in obtaining the tion of these chapters. Finally, our thanks go to the staff of CRC new material for this third edition. In particular, we acknowl- Press for their constructive help throughout the preparation of edge the valuable contribution made by Dr. Petra Lewis this new edition. Prof. Adil Al-Nahhas, UK Prof. Gynter Moedder, Germany Dr. Parthiban Arumugam, UK (Nuclear Cardiology chapter) Dr. Hosahalli Mohan, UK Prof. Dale Bailey, Australia Dr. Nicola Mulholland, UK Stacey Baker, UK Dr. Malavika Nathan, UK Dr. K. K. Balan, UK Dr. Shaunak Navalkissoor, UK Dr. James Ballinger, UK Dr. Alp Notghi, UK Dr. Sally Barrington, UK Dr. Ewa Nowosinska, UK Dr. Tara Barwick, UK Dr. Tom Nunan, UK Nynke S. van den Berg, the Netherlands Prof. Michael O’Doherty, UK Dr. Lorenzo Biassoni (Paediatrics chapter), UK Dr. Saabry Osmany, Singapore Dr. Shankar Kumar Biswas, Bangladesh Howmedica Osteonics Corp (Stryker), USA Dr. Jamshed Bomanji, UK Dr. Ann-Marie Quigley, UK Prof. S. E. Bouyoucef, Algeria Dr. Venkat Ratnam, India Dr. John R. Buscombe, UK Dr. Paul J. Roach, Australia, UK Dr. Sugama Chicklore, UK Dr. Stephen M. Schlicht, Australia Dr. Dhruba Dasgupta, UK Dr. Gregory Shabo, UK Dr. Indirani Elangovan, India Dr. Shelly Simon, India Dr. Rashika Fernando, UK Dr. Natasha Singh, India Dr. Mohamed Halim, UK Dr. Ajay Sreedasyam, UK GE Healthcare, UK Dr. Shanmuga Sundaram, India Robin Karugaba, UK Dr. Teresa Szyszko, UK Dr. Gilbert Keng, Singapore Dr. Muriel-Buxton Thomas, UK Dr. Sujeeth Konan, UK Deborah Tout, UK Dr. B. A. Krishna, India Dr. Fahim Ul-Hassan, UK Dr. Rakesh Kumar, India Dr. Renato A. Valdés Olmos, the Netherlands Dr. Werner Langsteger, Austria Dr. Sanjay Vijayanathan, UK Prof. Richard Lawson, UK Dr. Zaid Viney, London, UK Prof. Valerie Lewington, UK Dr. Sobhan Vinjamuri, UK Dr. Petra Lewis, UK Dr. Hans Van der Wall, Australia Dr. Chen Low, UK Dr. Vikki Warbey, UK Dr. Shahid Mahmood, Singapore Rob Williams, Australia Julie Martin, Hermes Medical Solutions Ltd, UK CHAPTER 1 BONE CHAPTER CONTENTS INTRODUCTION Investigation of benign bone disease ANATOMY/PHYSIOLOGY Benign bone lesions Mechanism of diphosphonate uptake on bone Benign bone tumour RADIOPHARMACEUTICALS Trauma Chemical structures of diphosphonates Bilateral stress fractures NORMAL SCANS Knee trauma: meniscal tears Normal whole-body scan Trauma: non-accidental injury (NAI) Three-phase bone scan Surgical trauma Blood pool scans Arthritis Bone scan quantitation Sacroiliitis Miscellaneous Metabolic bone disease Artefacts Osteomalacia Contamination Fibrous dysplasia CLINICAL APPLICATIONS Paget’s disease Investigation of malignancy Miscellaneous Staging Bone SPECT/CT Assessment of extent of disease Malignant bone disease Localisation problems Spine Superscan of malignancy Benign bone disease Signifi cance of SPECT Thorax Assessment of disease progression and response Osteitis pubis Resolution Femoroacetabular impingement syndrome Flare phenomenon Ankle: impingement syndromes Osteogenic sarcoma Stress fractures Chondrosarcoma Miscellaneous Histiocytosis X INTRODUCTION which often suggest a specifi c diagnosis. The mechanism of tracer Bone imaging encompasses a wide spectrum of pathologies uptake in bone is not fully understood, but it is believed that diphos- from benign conditions such as trauma and infection to pri- phonate is adsorbed onto the surface of the bone, with particular mary and secondary malignant lesions. Despite advances in affi nity for sites of new bone formation. It is thought that diphos- anatomical imaging, including magnetic resonance imaging phonate uptake on bone primarily refl ects osteoblastic activity but (MRI) and multi detector computed tomography (MDCT), is also dependent on skeletal vascularity. Thus, bone scan images bone scintigraphy continues to play a major role in the diag- provide a functional display of skeletal activity. As functional change nosis of bone pathology. in bone occurs earlier than structural change in most pathologies, Bone scintigraphy is commonly used as a screening test for the bone scan will often detect abnormalities before they are seen suspected bone metastases because of its high sensitivity, avail- on an X-ray. Any diphosphonate, which is not taken up by bone, is ability, low cost, and ability to scan the entire skeleton. Historical excreted via the urinary tract, and in a normal study the kidneys are data and clinical experience have established bone scintigraphy clearly visualised on the bone scan; indeed, there are many exam- as the reference standard in the search for skeletal metastatic dis- ples of renal pathology which have been detected for the fi rst time ease, and, in the same way, many indications have been estab- on a bone scan. Improvements in gamma camera design, including lished for benign skeletal disorders. For many years 99mTc-labelled the increased availability of tomographic scintigraphy [single pho- diphosphonates, particularly 99mTc-methylene diphosphonate ton emission computed tomography (SPECT)], have also helped in (MDP), have been the most widely used radiopharmaceuticals. bone imaging by increasing sensitivity and specifi city. In recent A 99mTc-MDP bone scan shows exquisite sensitivity for skel- years, there has been increasing interest in the use of positron emis- etal pathology, but this technique has the limitation that scan sion tomography (PET) tracers, such as 18F-FDG and 18F-fl uoride, appearances may be non-specifi c. However, in many clinical in the investigation of various aspects of skeletal disease especially situations recognisable patterns of scan abnormality are seen, bone metastases (Table 1.1). BONE ANATOMY/PHYSIOLOGY Mechanism of diphosphonate uptake on bone Figure 1.1 Mechanism of diphosphonate uptake on bone. MDP O H BONE O C P O H O P O O Adsorbs onto bone surface BONE Mineralized bone Marrow cavity Osteoblasts Osteoid Mineralized bone Marrow cavity Figure 1.2 Microautoradiography of rabbit bone showing adsorption of 3H-hydroxyethylidene diphosphonate on bone surfaces. The heavy concentration of silver grains is at the interface between osteoid and bone, that is, at the site where mineralisation occurs. Source: Courtesy of Dr. M.D. Francis, Cincinnati, USA. 2 BONE RADIOPHARMACEUTICALS Table 1.1 Specifi c and Non-specifi c SPECT and PET Radiopharmaceuticals for Bone Imaging SPECT tracers PET tracers Specifi c Specifi c 99mTc-methylene diphosphonate (MDP) 18F-Fluoride Non-specifi c Non-specifi c 67Gallium 18F-fl uorodeoxyglucose (FDG) 201Thallium 11C-Choline 99mTc-Sestamibi (MIBI) 11C-Acetate 99mTc-Tetrofosmin 68Ga-DOTATOC/DOTANOC 123/131I-meta iodobenzylguanidine (MIBG) 123/131I-Iodine 111In-Octreotide Chemical structures of diphosphonates OH CH OH OH H OH 3 HO P C P OH HO P C P OH OH OH OH OH H OH HEDP MDP HOOC CH COOH 2 OH H OH OH CH OH HO P C P OH HO P C P OH OH OH OH OH H OH HMDP DPD Figure 1.3 Chemical structures of bone tracers. At the present time MDP is the most widely used agent. Abbreviations: HEDP, hydroxyethylidene diphosphonate; MDP, methylene diphosphonate; HMDP, hydroxymethylene diphosphonate; DPD, dicarboxy- propane diphosphonate. 3
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