1、Hematopoietic and lymphatic imaging &Inflammation imagingChen JingDpt. Of Nuclear Medicine, Tongji Hospital, Tongji Medical College, HUSTBone marrow imagingSpleen imaginglymphoscintigraphy (FDG-PET/CT in lymphoma)Inflammation imagingMain contents Bone marrow is found in the hollow spaces in the inte

2、rior of bones, On average, bone marrow constitutes 4% of the total body mass of humans. . two types of bone marrow: red marrow and yellow marrow. The red marrow (active marrow) produces blood cells and clotting factors. The yellow marrow stores fat. At birth, all bone marrow is red. With age, more a

3、nd more of it is converted to the yellow type; only around half of adult bone marrow is red. Anatomy & PhysiologyIn adults, red marrow is found mainly in the axial skeleton (vertebral bodies, pelvis, sternum, ribs, scapulae), and in the proximal one third of the femurs and humeri.Yellow marrow is fo

4、und in the medullary cavity of the middle portion of long bones.In cases of severe blood loss, the body can convert yellow marrow back to red marrow to increase blood cell production.PrincipleRadionuclide bone marrow imaging is based on labeling one of the major components of bone marrow. ray can be

5、 detected from bone marrow by nuclear medicine imaging equipments, such as SPECT, camera.Radiopharmaceutics52Fe （ferrum）erythropoiesis in connection with iron metabolismmeasuring the extent of erythropoietic marrowproduced in a cyclotron with a half-life of 8.2hIts activity over the liver and the sp

6、leen is poor or absent, which makes it convenient to detect pathology in the bone marrow over the thoracic and lumbar areas.99mTc-labeled colloids (e.g. 99mTc-PHY) When injected into blood, rapidly cleared by the phagocytic cells in the blood, bone marrow and liver and by the reticuloendothelial cel

7、ls in the spleen.Bone marrow in the lower thoracic and upper lumbar spine cannot be properly visualized by 99mTc-colloids imaging due to overlapping radioactivity over the liver and spleen.l The lower thoracic and upper lumbar region of the spine are not well seen because of the intense activity in

8、the liver and spleen.99mTc-monoclonal antibodies (99mTc-MAB)directed against nonspecific iron-reacting antigen 95 (NCA-95), a differentiation antigen of granulopoiesis.clinically applied for the imaging of granulopoietic marrow.bone marrow scans of much-improved quality without significant superimpo

9、sition of liver and spleen the radioactivity over the bone marrow was found to be 2-3 times that with 99mTc-colloidsTechniquesHow is the procedure performedRemove jewelry, or other metals (because they may interfere with the image), and lie supine on the table.Anterior and posterior whole-body stati

10、c imagings were performed 30min after 10-15mCi (370-555MBq) radiotracers have been injected intravenously.*A pregnant or breast-feeding woman is not suggested to perform the examImaging AnalysisIn normal adults, radiocolloids are mainly taken up by the axial skeleton ( vertebral bodies, pelvis, ster

11、num, ribs, scapulae) the proximal one third of the femurs and humeri. In children, however, it is normal to see radioactivity in the axial skeleton and the whole long bone.Clinical application1、Indicate the best sites for obtaining bone marrow sampleBone marrow biopsy are usually accurate techniques

12、 for evaluating the bone marrow. But this evaluation is limited to a small part of bone marrow. Bone marrow imaging can provide information about the whole body distribution of functioning bone marrow in various clinical states. It is helpful to indicate the best sites for obtaining bone marrow samp

13、le and to reach the final diagnosis of the disease.2、Evaluate the amount of active marrow.Many tumor patients are treated with a combination of chemotherapy and radiation, both of which can have an adverse effect on bone marrow.In patients who have undergone these treatments and are being considered

14、 for additional therapy, bone marrow imaging can determine the amount of remaining functional tissue and show its distributionl the suppression of bone marrow activity in the axial skeleton and the long bone3、Aplastic anemia evaluating the amount of active marrow in the whole body and following up a

15、fter treatment荒蕪型荒蕪型（desolation）Few active marrow (remaining functional bone marrow) could be detected in the axial skeleton and long bone Aplastic anemia is a syndrome of bone marrow failure characterized by peripheral pancytopenia (deficiency of all three blood cell types ) and marrow hypoplasiaAc

16、cording to the amount of active marrow, aplastic anemia can be classified into three types:Aplastic anemia抑制型抑制型(suppression)Low active marrow in the axial skeleton and long bone Aplastic anemia正常型正常型 (normal)Radiotracers are taken up by the axial skeleton ( vertebral bodies, pelvis, sternum, ribs,

17、scapulae) and the proximal one third of the femurs and humeri. 4、Leukemia evaluating the amount of active marrow in the whole body, predicting prognosis and following up after treatment . . Low active marrow in the axial skeleton and expended peripheral bone marrow (PBM)*In literatures reported, rel

18、apse rate within 10 months in expanded PBM patients (74.4 %) was significant higher than that in non-expanded PBM patients (13.6 %).5、bone marrow infarcts in Sickle Cell Anemia(SCA) . . Bone marrow infarcts are common in patients with SCA. Plain films are usually normal in acute bone marrow infarcts

19、. The bone marrow scan, however, is a sensitive means of confirming bone marrow infarct. In normal individuals, active bone marrow is confined to the proximal portions of the humeri and femurs, but in patients with SCA the marrow expands peripherally to the distal end of the long bones, especially a

20、round the knees. Areas of infarction appear as cold areas surrounded by increased uptake in the surrounding active marrow. (A) Small defect in distal humerus (B) Defects in both femora(D) Distal tibial infarct.(E) Infarcts in proximal right tibia and distal left femura6、avascular necrosis of the hip

21、s It is important to make an early diagnosis of avascular necrosis of the hip, especially after trauma, so that appropriate therapy can be instituted. Radiocolloid scan in a trauma patient show decreased activity in the right femoral head. Surgery confirmed avascular necrosis.7、Multiple myeloma expl

22、oring the lesion areas involved and following up after treatmentBone marrow metastasis from tumors :diffuse asymmetric increased radiotracer uptake in the axial skeleton and expanded PBM8、Others真性紅細胞增多癥(polycythemia vera), 骨髓增生異常綜合征(myelodysplastic syndrome), 慢性溶血性貧血(chronic hemolytic anemia), 慢性失血性

23、貧血(chronic hemorrhagic anemia), 缺鐵性貧血(iron-deficiency anemia)Low active marrow in the partial axial skeleton ( ribs and scapulaes) and expanded PBM (femurs and humeri)Iron-deficiency anemiaAdvantage of bone marrow scintigraphy Compared with other Techniques （biopsy and MRI） Bone marrow biopsy is an

24、excellent techniques for evaluating bone marrow and can provide a specific clinical diagnosis. But this evaluation is limited to a small part of bone marrow. Radionuclide bone marrow imaging is a simple noninvasive technique that provides information about the whole body distribution of functioning

25、bone marrow in various clinical states. Magnetic resonance imaging (MRI) is a highly sensitive technique for evaluating bone marrow and can predict differences between fatty, cellular, and fibrotic marrow. However bone marrow scintigraphy is preferred when whole body screening is desired, since the

26、cost of MRI limits its use for this purpose. Radiotracer and Principleu99mTc sulfur colloid (99mTc-SC) is the most commonly used radiopharmaceutical for spleen imaging. Following intravenous administration, it is rapidly removed from the blood by the reticuloendothelia system of the liver, spleen. u

27、The spleen can be adequately visualized and separated from the adjacent liver in patients with normal upper abdominal anatomy. uIn certain disease states, whenever there is reasonable double about the ability to establish the presence or absence of splenic, 99mTc labeled heat-denatured RBCs imaging

28、is recommended as an imaging method complementary to the SC scanNormal imageClinical applicationestablish the presence or absence of splenic tissue and evaluate its functiondiagnose accessory spleenDiagnose auxiliarily spleen infarction and spleen trauma Detect the planted spleenDistinguish tumors i

29、n the spleen from those on the left abdomenl a network of small channels similar to blood vessels that circulate the lymph fluid and lymphocytes of the immune system throughout the body.l Lymph nodes, which act like a filter for foreign bodies such as germs, viruses, are located along this network.R

30、adiotracer and PrincipleRadiocolloid is physiologically transported from an appropriate interstitial injection site to the drainage lymph nodes. And the image can provide functional, as well as anatomic and morphological data of lymph system.45nm 顆粒直徑 100nmMethodsThe type of study you are having wil

31、l determine the location of your injection and the number of scans performed.Breast cancer The radiotracer may be injected in multiple sites near the tumor and/or around the nipple. The breast, chest and underarm regions will be imaged. Imaging usually is completed within 30 minutes to one hour, but

32、 may take up to two or more hours.Arm or leg edema The radiotracer is injected between the first and second fingers or toes of each hand or foot. Both the swollen and healthy arm or leg will be imaged so that the two sides can be compared. Depending on the degree of lymphatic obstruction and the cau

33、se, imaging may take 30 minutes to several hours.Image analysisWe include the internal mammary lymphoscintigraphy as an example of how toanalyze the image data A B C DA, normaldiscrete lymphatic aggregated with good bilateral radiocolloid uptakeB, suspicious of abnormality diminished radiocolloid up

34、take in the upper left parasternal nodesC, abnormalthe left parasternal lymphatics have been disrupted with ill-defined aggregates of radiocolloid along the parasternal border and substernallyD, abnormalcomplete obliteration of the right parasternal nodes Clinical applicationIdentify the sentinel ly

35、mph node（SLN）, or the first node to receive the lymph drainage from a tumor lSentinel node scanning has become widely accepted in breast cancer, malignant melanoma，head and neck cancer, thyroid cancer, non-small cell lung cancer, gastric cancer, penile cancer, and vulvar cancers. lThe Relevance rati

36、o of SLN in breast cancer is 92%98%, and its coincidence ratio is 90%100%. Over 50% patients avoid axillary lymph node dissection after SLN scanninglThe Relevance ratio of SLN in melanoma is 80%98%ContraindicationslAbsolute contraindications include clinically positive (N1) axilla and allergy to com

37、ponent used.lRelative contraindications include the following ： Prior biopsy (especially excisional biopsy) Previous breast and axillary surgery Advanced disease (associated with fatty degeneration of nodes with reduced function) Neoadjuvant chemotherapy Multicentric and multifocal disease Ductal ca

38、rcinoma in situ35y, left breast carcinomaLymphoscintigraphy at different points in time after radiocolloid injection in four sites near the tumor. SLN didnt appear till 1h postinjectionPlan a biopsy or surgery that will help assess the stage of cancer and create a treatment plan.Identify points of b

39、lockage in the lymphatic systemLymphedemaIll-defined expanded lymphatic vessel and diminished radiocolloid uptake in the right leglymphatic fistulademonstrating the site and the number of the fistulous communicationsLymphangitislymphatic vessel expanded with increased radiotracer uptakelymph fluid s

40、ped uplymph nodes enlargedAvailable to assist in radiation field designFDG-PET/CT in lymphomaFDG-PET/CT is now the cornerstone of staging procedures in the state-of-the-art management of HD and aggressive NHL.It plays an important role in staging, restaging, prognostication, planning appropriate tre

41、atment strategies, monitoring therapy, and detecting recurrence.The role of 18F-FDG PET/CT in indolent lymphomas is still unclear and calls for further investigational trialsn PET/CT in initial stagingPET/CT can detect more lesions than CT and may lead to a change in the stage of up to 8-20% of pati

42、ents.NHL (DLBCL)n PET/CT in Evaluation of Treatment Response18 F-FDG PET has been shown to be able to distinguish between post-treatment fibrosis and viable tumor 18 F-FDG PET has a higher specificity (92% vs. 17%), accuracy (96% vs. 63%), and positive predictive value (94% vs. 60%) than does CT.A c

43、ase of HL (lymphocyte predominant type): Pre-therapy scan shows a large FDG-avid left axillary lymph node mass as seen on the MIP (A) Cornonal (B), and transaxial (C) PET/CT images. The interim scan performed after 3 cycles of chemotherapy is negative as seen on the corresponding PET/CT images (D-F)

44、67Ga-citrate imagingLabeled leukocyte imagingLabeled antimicrobial imaging 18F-FDG PETInflammation imaging67GalactoferrinWBCtransferrinmicrobia67Ga compound67Ga-citrate is bound to plasma protein mainly transferrin after intravenous injection. And it entry into inflamed tissues by endocytosis, diffu

45、sion, or exchange of transferrin-bound gallium with lactoferrin.Inflamed tissue67Ga枸櫞酸鹽顯像枸櫞酸鹽顯像67Ga-citrate imagingNormal imageANTPOST48h48h72h72h About 10-15% (up to 25%) of the injected activity is excreted by the kidneys during the first 24 hours following injection. Subsequently, the main route

46、of excretion is via the bowel. By 48 hours after injection about 75% of the dose remains in the body and is distributed among the liver, bone, bone marrow, and other organs / tissues, including nasopharynx, lacrimal grand, salivary glands, breast, thymus and spleen.Leukocyte labeled in vitro with 11

47、1In or 99mTcChemotactic factor attract and guide the movement of cellsWBCIV.Chemotactic factorWBCInflamed tissueWBC*currently the radionuclide gold standard for diagnosing most infection in the immunocompetent population放射性核素標記白細胞顯像labeled leukocyte imaging99mTc-HMPAO WBCnormal image1h4hANTPOSTANTPO

48、STThe radiotracer seen in the spleen, liver, bone marrow, kidneys, bowel and bladder.（1）skeleton disease節段性回腸炎（Crohns disease）patient following biopsy-proven Osteomyelitis caused by staphylococcus aureus after hormone therapyA & B shows intense radiouptake in the left distal femur and left proximal tibia.D shows osteonecrosis in the involved bone111In-WBC imaging 99mTc-MDP bone scanX-rayMRIClinical application（2）Abdominal and pelvic infectionSubphrenic abscess（膈下膿腫）Limi