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Ovid: Baum's Textbook of Pulmonary Disease

Editors: Crapo, James D.; Glassroth, Jeffrey; Karlinsky, Joel B.; King, Talmadge E. Title: Baum's Textbook of Pulmonary D isease, 7th Edition Copyright 2004 Lippincott Williams & Wilkins
> Table of Contents > Section I - Diagnostic Methods > Chapter 1 - Imaging of Lung Disease > NUCLEAR MEDICINE TECHNIQUES

NUCLEAR MEDICINE TECHNIQUES

Part of "Chapter 1 - Imaging of Lung Disease"

Ventilation Agents
A variety of agents is available for the scintigraphic evaluation of emphysema. They include gases such as 133Xe and 81mKr, as well as the radioaerosols 99mTc pentetate (99mTc-DTPA) and Technegas (Daiichi Radioisotope, Tokyo, Japan) (9). The choice of ventilation agent often depends on availability. Gaseous
81mKr

is the ideal ventilation agent, providing near instant regional ventilatory mapping with ability to

perform single photon emission CT (SPECT) imaging. However, 81mKr must be obtained from a 81Rb generator, which has a clinical lifespan of about one working day. Also, its 13-second P.4 half-life means that imaging must be performed during steady state and that washout imaging cannot be performed. Because of its availability, 133Xe is the most widely used gaseous ventilation agent, with a half-life of 5.1 days. It allows imaging of wash-in, equilibrium, and washout phases. Images taken at equilibrium correspond to regional lung volume. Delayed washout is a sensitive indicator of air trapping. Limitations of 133Xe include the fact that the photon that it emits has relatively low energy, resulting in greater attenuation in the chest wall and lower-resolution images. Also, if dynamic imaging is performed, scanning is limited to one projection only, a disadvantage in ventilation/perfusion imaging for pulmonary embolism. 127Xe has a higher photon energy (203 keV) but has a longer half-life of 36 days and is less widely available. M odern radioaerosols provide excellent images of ventilation in patients without airway disease (Fig. 1.3), but are deposited in the airways to a variable extent in patients with chronic obstructive pulmonary disease, with resultant nonuniform demonstration of the distal airspaces. The most commonly used aerosol in clinical practice is 99mTc-DTPA. The clearance of this aerosol has also been used as an index of the severity of ILD; patients with ILD have faster clearance of this agent. However, the value of this washout index is limited by the fact that washout is also increased in cigarette smokers, and the technique is not widely used in clinical practice.

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Ovid: Baum's Textbook of Pulmonary Disease

FIGURE 1.3. Ventilation-perfusion imaging in diagnosis of pulmonary embolism. A: Ventilation image, obtained with 99mTc pentetate aerosol, shows homogenous ventilation on posterior view. B: M atched perfusion image shows large (segmental) perfusion defects in the left mid lung, and in the lateral segment of the left lower lobe. There is also decreased perfusion in the right upper lobe. The presence of unmatched segmental abnormalities indicates a high probability for pulmonary embolism.

Technegas (Daiichi Radioisotope, Tokyo, Japan), is a 99mTc-labeled ultrafine carbon particle radioaerosol (9). These particles are small enough to reach the lung periphery but probably do not reach the alveoli, as movement of gas in the smallest airways, beyond the 16th-order division, is largely by molecular diffusion (9). Central airway deposition is less with Technegas than with 99mTc-DTPA, and Technegas appears to provide an effective measure of ventilation in patients with obstructive lung disease (10).

Perfusion Agents
Perfusion imaging is almost always performed with 99mTc-labeled human albumin microparticles, the most common of which is macroaggregated human serum albumin (99mTc-M AA), with a particle size of 10 to 100 microns, allowing these particles to be trapped in pulmonary capillaries. 99mTc-albumin microspheres have more uniform size (2045 microns), but are more expensive and less widely available. Usually 200,000 to 400,000 particles are injected intravenously, and about 95% of them are trapped in the lung on the first pass, occluding less than 1 in 1,000 capillaries (11). Distribution within the lungs via microembolization is proportional to regional pulmonary arterial flow. In patients with right-to-left shunts, the agents can bypass the lungs and be trapped in capillaries in brain and kidneys. Images obtained over the kidneys and brain may help diagnose the presence of such a shunt.

Ventilation and Perfusion Imaging

Perfusion imaging with microparticles is an excellent method for identifying perfusion defects due to pulmonary embolism (Fig. 1.3). However, the excellent matching of ventilation and perfusion means that patients with pneumonia or airway obstruction will have perfusion defects that must be distinguished from pulmonary embolism by ventilation imaging. Use of radioaerosols is preferred for this P.5 purpose because matching images of ventilation and perfusion can be obtained in eight projections. Unmatched segmental or large subsegmental perfusion defects are usually (>90%) due to pulmonary embolism. Smaller unmatched defects are less specific and must be regarded as indeterminate or intermediate probability for pulmonary embolism. Small perfusion defects (<25% of a segment) are usually associated with a low (<10%) probability of pulmonary embolism. A normal perfusion scan is
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Ovid: Baum's Textbook of Pulmonary Disease

associated with a very low probability of pulmonary embolism. Unilateral absence of perfusion on perfusion scanning is usually not due to pulmonary embolism. Differential diagnosis of this finding includes obstruction of the pulmonary artery or main bronchus by a mass, unilateral small-airway disease (Swyer-James syndrome), and pulmonary artery agenesis.

Positron Emission Tomography

Positron emission tomography (PET) with 18fluoro-deoxyglucose (18-FDG) has revolutionized the evaluation of thoracic malignancy by its ability to depict metabolically active tumor within and outside the thorax. FDG is a glucose analog that is avidly imbibed by metabolically active cells and is phosphorylated into FDG-6-phosphate, which cannot be further metabolized in the glycolytic pathway. It therefore accumulates in metabolically active cells. The positrons emitted simultaneously when the
18F

isotope decays can be detected and localized with a coincidence-detecting tomographic camera. Images obtained by PET can be reconstructed in any plane (sagittal, axial, coronal). To precisely localize the abnormality, PET images must be correlated with corresponding axial CT images. PET-CT fusion scanners can perform PET and CT almost simultaneously, allowing direct mapping of the site of PET activity to the corresponding axial CT image. However, experienced cross-sectional imagers can usually perform the same correlation without the need for synchronous acquisition of PET and CT. 18FDG PET is widely used for discriminating between benign and malignant lung nodules and for staging of lung cancer. The most important role of PET is in staging of established lung cancer. PET may also show increased uptake in the pleura in patients with malignant effusions. In patients with malignant pleural mesothelioma, PET may be useful in showing occult mediastinal nodal metastases (12).

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