Nuclear Endocrinology

247 Pages·2012·8.274 MB·English

by  Doina Piciu (auth.)

Nuclear Endocrinology

Doina Piciu
Nuclear Endocrinology
Author Contributor
Doina Piciu, M.D., Ph.D. Alexandru Irimie, M.D., Ph.D.
Institute of Oncology Department of Oncological
Prof. Dr. Ion Chiricuţă and Gynecological Surgery
Nuclear Medicine and Endocrine Tumors University of Medicine and Pharmacy
Cluj-Napoca “Iuliu Hatieganu”
Romania Cluj-Napoca
Romania
ISBN 978-3-642-25013-2 e-ISBN 978-3-642-25014-9
DOI 10.1007/978-3-642-25014-9
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Foreword
“Nothing in life is to be feared; it is only to be understood”
Marie Curie
Two years ago, during an international medical congress I went to one of the
bookstores asking for a book of nuclear endocrinology. I was looking for a
brief, didactic, easy-to-use guide, dedicated to the daily practice of the endocri-
nologists. I was surprised not to fi nd this title and even more impressed when
the librarian asked me: “You want to buy or to write one?” At that moment I
noticed that there were several other books published dedicated to this special
connection of nuclear medicine procedures with other medical specialties:
nuclear cardiology, nuclear pneumology, nuclear neurology, nuclear hepatol-
ogy, nuclear medicine in psychiatry, nuclear medicine in nephrourology etc.
Even if the fi rst major contribution of radionuclide therapy in 1940 was the
application of radioactive iodine in therapy of Graves’ disease and nowadays a
special clinical interest of nuclear medicine continues to be devoted to endocri-
nology, I did not fi nd the book. Many scientists all over the world: endocrinolo-
gists, nuclear medicine physicians, oncologists, endocrine surgeons etc. devoted
their lives and their research to many of the issues related to both topics, endo-
crinology and nuclear medicine; their work inspired me and gave me the cour-
age to put them together in this book: N uclear Endocrinology .
Nuclear and molecular medicine is a rapidly changing fi eld, maybe with
the most impressive and challenging development in the last decade. The
concept of functional imaging, molecular and targeted nuclear diagnostic and
treatment of diseases is sometimes diffi cult to be assimilated by other medi-
cal specialties, so a dedicated update would be fi rstly in the benefi t of patient
care improvement. The purpose of the book was to give the endocrinologist a
nuclear medicine physician point of view. This book is designed to ensure an
update, to be an easy-to-use tool in clinical practice of endocrinologists and
to provide the most relevant information about nuclear medicine applicable to
endocrine pathology. The book is divided into two sections: fi rst part of gen-
eral nuclear medicine covering also general principles of nuclear physics; the
second part consists of nuclear endocrinology used in diagnosis and therapy,
organized by organ and by pathology.
This book expresses my work during the past 20 years in an important
nuclear medicine and endocrine tumors department, as nuclear medicine phy-
sician and endocrinologist, with thousands of patients being diagnosed and
more than 5,000 patients being treated by nuclear medicine procedures. All
the interesting clinical cases presented in this book are some of my patients.
v
vi Foreword
Behind the words and images are destinies and memories; I want to address
my gratitude to all of them for being steps in further knowledge for the read-
ers of this book.
Often, the endocrine diseases are fi eld of battles where the success of
treatment is ensured only if there is team work, if there is excellent collabora-
tion with other specialties: endocrinologists, nuclear medicine physicians,
surgeons, oncologists, radiologists, pathologists etc. To all my colleagues
who honored me as part of the team, I address special thanks and deep
consideration.
It is not possible to end this foreword without mentioning three names:
Ute Heilmann, Wilma McHugh and Corinna Schäfer from Springer. Only
because of their confi dence and their profi ciency my voice raised and is ready
to be heard.
At the end of this journey I would like to ask my husband, Radu, and my
precious daughter, Andra, to forget all the endless days when I was not able
to be with them, and thank them for all their support and their trust.
Cluj-Napoca, Romania Doina Piciu, M.D., Ph.D.
Contents
Part I General Nuclear Medicine
1 Principles of Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Principles of Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . 3
1.2 Basics of Nuclear Physics . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.1 Atomic Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.2.2 Radioactivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.2.3 Interaction of Radiation with Matter . . . . . . . . . . . . 7
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 Specifi c Measurements, Units and Terms . . . . . . . . . . . . . . . . 9
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
3 Dosimetry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
3.1 Decays of Radionuclides and Doses Calculation . . . . . . . . 13
3.1.1 Fluorine F-18 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.1.2 Gallium Ga-68 and Gallium Ga-67 . . . . . . . . . . . . 14
3.1.3 Radioiodine I-123 . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.1.4 Radioiodine I-124 . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.1.5 Radioiodine I-125 . . . . . . . . . . . . . . . . . . . . . . . . . . 14
3.1.6 Radioiodine I-131 . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1.7 Indium In-111 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1.8 Lutetium Lu-177 . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1.9 Techentium-99m (Tc-99m) . . . . . . . . . . . . . . . . . . . 16
3.1.10 Thallium Tl-201 . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.1.11 Yttrium Y-90 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
3.2 Dose Rates to Target and Critical Organ . . . . . . . . . . . . . . . 17
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
4 The Radiation Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
4.1 Basic Factors in Radiation Protection . . . . . . . . . . . . . . . . . 19
4.2 Staff Protection in Nuclear Medicine Units . . . . . . . . . . . . 21
4.3 General Measures to Reduce the Irradiation
of Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
4.4 Physical Factors in Radiation Protection . . . . . . . . . . . . . . . 22
4.4.1 Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.4.2 Distance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
4.4.3 Shielding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
vii
viii Contents
4.5 Special Recommendations for Patients
Undergoing Nuclear Medicine Procedures . . . . . . . . . . . . . 23
4.5.1 For Female Patients of Childbearing
Age and Breastfeeding . . . . . . . . . . . . . . . . . . . . . . . 23
4.5.2 Procedures in Case of Nuclear Events . . . . . . . . . . . 24
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
5 Equipments in Nuclear Medicine . . . . . . . . . . . . . . . . . . . . . . . 27
5.1 Gamma Camera . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.1.1 Collimators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
5.1.2 Crystals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
5.1.3 The Photomultiplier Tubes . . . . . . . . . . . . . . . . . . . 30
5.1.4 Imaging and Processing . . . . . . . . . . . . . . . . . . . . . . 30
5.2 Instruments for Thyroid Uptake Evaluation . . . . . . . . . . . . 33
5.3 Positron Emission Tomography (PET)
and Fusion Images Equipments (PET/CT) . . . . . . . . . . . . . 34
5.4 Whole Body Counting Systems . . . . . . . . . . . . . . . . . . . . . 35
5.5 Gamma Probe Equipments . . . . . . . . . . . . . . . . . . . . . . . . . 35
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
6 Radiopharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
6.2 Radiopharmaceuticals in Endocrinology. . . . . . . . . . . . . . . 39
6.2.1 Fluorine-18 Fluorodeoxyglucose
(18F-FDG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
6.2.2 Radiopharmaceuticals with Gallium-68
and Gallium-67 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.2.3 Radiopharmaceuticals with
Radioiodine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
6.2.4 Indium-111 Pentetreotide
(In-111 Pentetreotide) . . . . . . . . . . . . . . . . . . . . . . . 43
6.2.5 Technetium-99m . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
6.2.6 Thallium-201 Chloride
(Tl-201 Chloride) . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
6.2.7 Radiopharmaceuticals for Targeted
Radionuclide Therapy . . . . . . . . . . . . . . . . . . . . . . . 50
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Part II Nuclear Endocrinology
7 The Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
7.1 Anatomy of the Thyroid Gland . . . . . . . . . . . . . . . . . . . . . . 53
7.2 Physiology of the Thyroid Gland . . . . . . . . . . . . . . . . . . . . 55
7.3 Diagnosis of the Thyroid Gland . . . . . . . . . . . . . . . . . . . . . 57
7.3.1 Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . 57
7.3.2 Laboratory Serum Testing . . . . . . . . . . . . . . . . . . . . 58
7.3.3 Fine Needle Aspiration Biopsy
(FNAB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
7.3.4 Imagistic Diagnostic . . . . . . . . . . . . . . . . . . . . . . . . 63
7.3.5 Nuclear Imaging Tests . . . . . . . . . . . . . . . . . . . . . . . 64
Contents ix
7.4 Radioiodine Therapy in Benign Thyroid
Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
7.5 Radioiodine Therapy in Malignant Thyroid
Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
7.5.1 Classifi cation of Thyroid Tumors . . . . . . . . . . . . . . 128
7.5.2 The TNM Staging System . . . . . . . . . . . . . . . . . . . . 131
7.5.3 Thyroid Cancer Staging . . . . . . . . . . . . . . . . . . . . . . 132
7.5.4 Treatment Recommendations . . . . . . . . . . . . . . . . . 133
7.5.5 European Thyroid Association (ETA)
and American Thyroid Association
(ATA): Indications for Postsurgical
Radioiodine Thyroid Ablation,
Procedure and Follow-up . . . . . . . . . . . . . . . . . . . . . 135
7.5.6 Radioactive Iodine Therapy . . . . . . . . . . . . . . . . . . . 136
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
8 The Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
8.1 Anatomy of the Parathyroid Glands . . . . . . . . . . . . . . . . . . 165
8.1.1 Embryology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
8.1.2 Parathyroid Vascularity . . . . . . . . . . . . . . . . . . . . . . 165
8.2 Physiology and Pathophysiology of the
Parathyroid Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8.2.1 Pathophysiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 166
8.2.2 The Ten Parathyroid Rules of Norman . . . . . . . . . . . . . 167
8.3 Diagnosis of the Parathyroid Glands . . . . . . . . . . . . . . . . . . 167
8.3.1 Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . 167
8.3.2 Laboratory Serum Testing . . . . . . . . . . . . . . . . . . . . 168
8.3.3 Imaging Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
8.4 Radio-Guided Surgery of the Parathyroid
Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
8.4.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186
8.4.2 Minimally Invasive Parathyroidectomy . . . . . . . . . . 186
8.4.3 The Radio-Guided Minimally Invasive
Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . 186
8.4.4 Gamma Probe–Guided Operation Technique . . . . . 188
8.4.5 Radiation Safety Considerations . . . . . . . . . . . . . . . 189
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
9 The Adrenal Glands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
9.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
9.2 Pathophysiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
9.2.1 Pathologies of the Adrenal Cortex . . . . . . . . . . . . . . 192
9.2.2 Pathologies of Adrenal Medulla:
The Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . 193
9.3 Adrenal Cortical Scintigraphy . . . . . . . . . . . . . . . . . . . . . . . 193
9.3.1 Cushing’s Syndrome . . . . . . . . . . . . . . . . . . . . . . . . 194
9.3.2 Primary Aldosteronism . . . . . . . . . . . . . . . . . . . . . . 194
9.3.3 Hyperandrogenism . . . . . . . . . . . . . . . . . . . . . . . . . . 194
9.4 Adrenal Medullary Scintigraphy . . . . . . . . . . . . . . . . . . . . . 195
9.4.1 Clinical Applications . . . . . . . . . . . . . . . . . . . . . . . . 195
x Contents
9.5 Nuclear Therapy of Malignant
Pheochromocytoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198
10 Neuroendocrine Tumors (NET) . . . . . . . . . . . . . . . . . . . . . . . . . 201
10.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
10.1.1 Systems of Nomenclature and Grading
System for Neuroendocrine Tumors . . . . . . . . . . . . 201
10.2 Nuclear Imaging of Neuroendocrine Tumors (NET) . . . . . 202
10.2.1 NET Imaging with In-111 Octreoscan . . . . . . . . . . 203
10.3 Nuclear Therapy of Neuroendocrine Tumors . . . . . . . . . . . 204
10.3.1 Treatment Proposed Plan . . . . . . . . . . . . . . . . . . . . . 205
10.3.2 Radiometabolic Therapeutic
Approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
10.3.3 Combination Treatments . . . . . . . . . . . . . . . . . . . . . 206
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
11 PET/CT in Endocrinology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
11.1 Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
11.2 PET/CT in Thyroid Pathology . . . . . . . . . . . . . . . . . . . . . . 211
11.2.1 PET/CT in the Differential Diagnosis
of Benign Thyroid Nodules and
Malignant Thyroid Nodules . . . . . . . . . . . . . . . . . . . 212
11.2.2 PET/CT in the Follow-up of Thyroid
Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 212
11.2.3 The Role of PET/CT in Other
Malignancies Associated with Thyroid
Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214
11.2.4 PET/CT F-18 FDG . . . . . . . . . . . . . . . . . . . . . . . . . 214
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229