Procedures and Quick Reference

Nuclear Medicine Technology:

Procedures and Quick Reference

Second Edition

Pete Shackett, BA, ARRT[N], CNMT

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Second Edition

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987654321

Library of Congress Cataloging-in-Publication Data

Shackett, Pete.

Nuclear medicine technology : procedures and quick reference / Pete Shackett.—2nd ed.

p. ; cm.

Includes bibliographical references and index.

ISBN-13: 978-0-7817-7450-5

ISBN-10: 0-7817-7450-0

1.Radioisotope scanning—Handbooks, manuals, etc.I.Title.

[DNLM:1.Radionuclide Imaging—methods—Handbooks.2.Radiopharmaceuticals—

Handbooks. WN 39 S524n 2009]

RC78.7.R4S48 2009

616.07'575—dc22

2007036323

Disclaimer

Care has been taken to confirm the accuracy of the information present and to describe generally accepted practices. However, the author, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be considered absolute and universal recommendations.

The author, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new or infrequently employed drug.

Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsibility of the health care provider to ascertain the FDA status of each drug or device planned for use in their clinical practice.

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About the Author

Pete Shackett was born and raised in Newport, New Hampshire. In 1970, Pete received a Bachelor of Arts degree in Biology from Plymouth State College of the University of New Hampshire in Plymouth, New Hampshire. While studying under Dr. Mary Bilheimer, he received a science essay award for a treatise entitled “The Sanitary Significance of Fecal Coliforms in the Environment.”

From 1970 to 1996, Pete pursued a career in music, publishing an album of all original music in 1988 entitled “Grouper Republic.”

In 1994, he resumed study at Hillsborough Community College, majoring in Nuclear Medicine under the direction and guidance of Dr. Max Lombardi. During his tenure as a student, he wrote a disquisition entitled “99mTc-tetrofosmin: The Efficacy and Significance of a New Myocardial Perfusion Radiopharmaceutical.” The paper and presentation won an award at the Florida Nuclear Medicine Technologist conference in 1996 and was accepted for publication in the Journal of Nuclear Medicine Technology. Pete graduated with high honors in 1996, earning the Award for Academic Excellence in Nuclear Medicine from Hillsborough Community College.

Lippincott Williams & Wilkins received a copy of the original manuscript for Nuclear Medicine Technology: Procedures and Quick Reference in 1998. The first edition of the book was published in 2000. Since then, Pete has continued to assimilate information, ideas, and experience in the field of nuclear medicine.

Pete Shackett presently resides, plays music, and practices nuclear medicine out of the Tampa Bay area in Florida.

Dedication

A true definition of devotion is when they weather the storm yet again. That said, I would like to dedicate the second edition to my lovely wife, Carolyn, and again to our canine gatekeeper and lifemate, Brandy. They bring the genuine meaning of happiness home.

In loving memory of my parents, Bertha and Wilfard Shackett

I would also like to extend a debt of gratitude and appreciation to my immediate family: Robert Shackett, Virginia Garrity, William Shackett, David Shackett, posthumously to Winifred (Dolly) Duhaime, to Carolyn’s brother, Donald Howe, and posthumously to her parents, Pauline and Viley Howe.

Acknowledgments

A special expression of gratitude and deepest respect to Dr. Max H. Lombardi, Director of Nuclear Medicine Technology (Retired), Hillsborough Community College, Tampa, Florida, for the opportunity of knowledge, encouragement, inspiration, and assistance. I would also like to thank Mr. Bud Rogers, CNMT, past Chief Technologist, Bayfront Medical Center, St. Petersburg, Florida, now owner and operator of the Advanced Nuclear Imaging mobile unit. Also, thank you to the many technologists, students, nurses, and physicians who contributed opinions and information during the development of the original manual and this second edition. I would also like to honor and thank posthumously Dr. Mary G. Bilheimer for her understanding and contributions to my education at the then-named Plymouth State College of the University of New Hampshire (now Plymouth State University).

Thanks to the following for donating their language translation expertise: Patrick DelMastro (Italian); Ania Lipska (Polish); Max Lombardi (Spanish, Portuguese, Italian); Joe Vuu (Mandarin Chinese); Victoria Russell, USF (Spanish); Shengrong Cai, USF (Mandarin Chinese); and Irshat Madyarov, USF (Russian).

Special thanks also go to the incredibly helpful radiologists of Pasadena Radiologist Associates, PA, St. Petersburg, Florida, for their many years of information (thinking out loud for me) and support (Drs. Greg Arterburn, Kit Clarke, Ronnie Pollack, and, despite his reluctance to discuss nuclear medicine, Brian Cornnell).

Thanks also to Carol Bonanno and Andrew Friden, Cytogen Prostascint; George Gonzales, West Coast Imaging of Clearwater, Florida, for PET information; Victoria Russell, USF Language Department, Tampa, Florida, for assistance and enlisting assistance at the University for language updates; Denise Merlino of the SNM for assistance with coding; Barbara J. Ossias, Reimbursement Revenue Solutions, LLC; Dale Walkey Partners Imaging Center of Sarasota, Sarasota, Florida, for PET information; Skip Watkins of Shared PET Imaging of Florida; the program directors that contributed ideas and opinions during the development of the second edition, including Nancy Clifton, Larry Gibson, Lorenzo Harrison, Max Lombardi, and Jasmin Trunzo. And thanks to the many students of Nuclear Medicine Technology that contributed ideas to the first and second editions of this book.

Considerations and thanks are given to the many physicians, technologists, and nursing staff too numerous to mention at the various institutions for their continuing assistance, instruction, suggestions, observations, and insight. None were forgotten and all very much appreciated. Sincere appreciation is extended to those who made it obvious that they had little or no interest or enthusiasm for this project. Because of or despite their criticism, they challenged me to be stronger, more focused and determined, and to find better sources and solutions. Everyone, it seems, can serve a useful purpose.

Disclaimer

This manual is intended to be the clinician’s book. It is an amalgamation of protocols from many institutions, technologists’ experiences, physicians’ input, and written resources. It is to serve only as a guide in the performance of the procedures listed. Specific department protocols should always be followed as written when available. The manual is not intended to be the consummate and quintessential encyclopedia of nuclear medicine. The scope of the manual covers the basic data needed for most routine imaging and includes a reference section of peripheral material utilized on a daily basis by many personnel (not only nuclear medicine) within the hospital and clinic settings. Tables, charts, and data are incorporated that are usually difficult to find quickly or in any one source. These may be of use to departments, students, physicians’ reading rooms, various diagnostic technicians, and nursing stations. A list of references is included that were used in the collation of this material in hopes that the readers will pursue them for more specific information. If there is ever a question, without question, discuss it with your radiologist or nuclear physician.

Table of Contents

About the Author / iii
Dedication / iv
Acknowledgments / v
Disclaimer / vi
Section One SCANS
1. / Adrenocortical Scan / 2
2. / Adrenal Medulla: Pheochromocytoma Scan (mIBG) / 7
3. / Angiography / 13
4. / Bone Density (Densitometry) / 17
5. / Bone Marrow Study / 23
6. / Bone Scan (Skeletal Imaging) / 28
7. / Brain Scan/Death (Brain Flow) / 36
8. / Brain SPECT (Single Photon Emission Computed Tomography) / 41
9. / Breath Test for H. pylori: PYtest® C-14 Urea Breath Test (UBT) / 47
10. / Cardiac: Gated First-Pass Study (First-Transit Radionuclide Angiocardiography) / 51
11. / Cardiac: MUGA and MUGA-X (Stress MUGA) / 56
12. / Cardiac: Myocardial Infarction (MI) Scan / 62
13. / Cardiac: Resting Study (Perfusion) / 66
14. / Cardiac: Stress Test (Perfusion) / 71
15. / Cisternography / 79
16. / Cystography (Voiding Cystourethrogram): Direct and Indirect / 84
17. / Dacryoscintigraphy (Lacrimal Study) / 89
18. / DVT (Deep Venous Thrombosis): Venography / 94
19. / Esophageal Transit Time / 100
20. / Gallium Scan / 104
21. / Gastric Emptying (Solid and Liquid) / 110
22. / Gastroesophageal Reflux / 116
23. / Gastrointestinal Bleed / 120
24. / HIDA (Hepatobiliary or Gallbladder) Scan / 125
25. / LeVeen or Denver Shunt Patency / 134
26. / Liver SPECT (Hepatic Hemangioma) / 138
27. / Liver/Spleen Scan / 142
28. / Lung Perfusion and Quantitation / 148
29. / Lung Transmission (and Transmission Imaging) / 156
30. / Lung Ventilation: Gas and Aerosol / 160
31. / Lymphoscintigraphy (Lymphangiogram) / 166
32. / Meckel’s Diverticulum / 173
33. / NeutroSpec®: Radioimmunoscintigraphy (RIS) for Infection / 178
34. / OctreoScan® / 182
35. / Parathyroid Scan / 188
36. / Positron Emission Tomography (PET): An Overview / 196
37. / PET: Brain Imaging 18F-FDG / 205
38. / PET: Cardiac Perfusion and Viability / 212
39. / PET: Whole Body (Tumor) Imaging 18F-FDG and PET/CT / 222
40. / ProstaScint® Scan (Radioimmunoscintigraphy [RIS]) / 231
41. / Red Blood Cell Studies: Plasma Volume, Red Blood Cell Volume, Red Blood Cell Survival, and Splenic Sequestration / 238
42. / Renal: Cortical Imaging (99mTc-DMSA) / 244
43. / Renal: Renogram, Diuretic, and Captopril: Tubular Function, ERPF, and GFR / 249
44. / Salivary Gland Imaging / 259
45. / Schilling Test / 263
46. / Scintimammography / 268
47. / SPECT (Single Photon Emission Computed Tomography) Imaging and Hybrid Imaging Overview / 274
48. / Testicular Scan / 283
49. / Therapy: BEXXAR® (Radioimmunotherapy: RIT for B-cell non-Hodgkin’s Lymphoma) / 287
50. / Therapy: Bone Pain (Palliation) / 293
51. / Therapy: Intra-articular (Joint); Synovectomy / 299
52. / Therapy: Intracavitary (Serosal) / 304
53. / Therapy: Polycythemia Vera / 309
54. / Therapy: Zevalin® (Radioimmunotherapy for B-cell non-Hodgkin’s Lymphoma) / 313
55. / Thyroid: Ablation / 318
56. / Thyroid: Ectopic Tissue Scan (Substernal) / 325
57. / Thyroid: Hyperthyroid Therapy (<30 mCi) / 330
58. / Thyroid: Scan / 335
59. / Thyroid: Uptake / 341
60. / Thyroid: Whole Body 131I Cancer Study and rTSH Augmentation / 349
61. / White Blood Cell Scan (111In-oxime and 99mTc-HMPAO) / 354
Section Two QUICK REFERENCE
A. / Conversion Tables / 362
Lbs/Kgs / 363
In/Cm / 364
Target Heart Rates (Cardiac Studies) / 365
mCi/MBq / 366
B. / Radiopharmaceuticals / 367
Standard Adult Dose Ranges / 368
Medical Radionuclides / 370
Common Math Equations for Nuclear Medicine / 373
Kit Preparations (An Overview) / 374
Pediatric Dosing in Nuclear Medicine / 379
Radioactive Isotopes / 386
C. / Decay Tables of Common Radionuclides / 410
137Cs / 411
57Co / 412
18F / 413
67Ga / 414
111In / 415
123I / 416
131I / 417
99Mo / 418
99mTc / 419
201Tl / 420
133Xe / 421
D. / Standard Drug Interventions / 422
Calculations, Preparations, and Administration / 423
Infusion Rate Tables / 428
Side Effects Of Common Drugs / 433
Drugs And Studies Affecting 123I and 131I Uptake / 435
Drug Lists: Anticoagulants and Ace Inhibitors / 437
E. / Laboratory Tests / 439
Normal Ranges / 440
Enzymes and Hormones / 446
F. / Language Barrier Buster™ / Interpretech™ / 451
Chinese / 452
French / 454
German / 457
Italian / 459
Portuguese / 462
Russian / 464
Spanish / 467
Japanese / 470
Polish / 471
G. / Regulations / 474
Misadministration / 475
Radiation Safety / 476
State Inspections (self-assessment) / 483
Example: Patient End-of-Day Report / 489
Example: RP Rec-Disp Daily Report / 490
H. / Patient Release Methods and Information for Thyroid Therapies / 491
Methods of Patient Release / 492
Inpatient Information / 495
Outpatient Information / 495
I. / Patient History Sheets / 496
Adrenal Scans / 497
Bexxar®/Zevalin® / 498
Bone Scans / 499
Brain Scan (SPECT) / 500
Cardiac/MUGA / 501
Gallium/Indium/Ceretec® / 502
Gastric Emptying Scan (liquid/solid) / 503
GI Bleeding Scan/Meckel’s / 504
HIDA (gallbladder study) / 505
Lung Scan (Aerosol) / 506
Lung Scan (Gas) / 507
Liver/Spleen Scan / 508
Miscellaneous Worksheet / 509
NeutroSpec® / 510
Octreoscan® / 511
PET Scans / 512
ProstaScint® Scan / 513
Renal/Renogram/Captopril Scan / 514
Scintimammography / 515
Thyroid Uptake and Scan / 516
J. / Abbreviations Commonly Used in Nuclear Medicine / 518
K. / Coding / 529
Exams (CPT) / 530
Radiopharmaceuticals (HCPCS) / 533
L. / Anatomical Images / 535
Brain (and Brain CSF) / 536
Cardiac System / 540
Endocrine System and Thyroid / 542
Gastrointestinal System (Esophagus, GI Tract, Stomach) / 543
Hepatobiliary System / 545
Lungs / 547
Lymphatic System / 548
Miscellaneous Systems (Catecholamine Sites, Lacrimal, Salivaries, Testicular) / 549
Renal System / 552
Skeletal System / 553
Vascular System (Arteries, Veins) / 557
References / 559
Acknowledgment of Trademarks / 563
Index / 567