Nuclear Medicine Technology:
Procedures and Quick Reference
Second Edition
Pete Shackett, BA, ARRT[N], CNMT
Acquisitions Editor: Peter Sabatini
Managing Editor: Andrea M. Klingler
Marketing Manager: Allison Noplock
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Second Edition
Copyright © 2009, 2000 Pete Shackett.
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9 8 7 6 5 4 3 2 1
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
51
Angiocardiography)
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
238
Cell Survival, and Splenic Sequestration
42. Renal: Cortical Imaging (99mTc-DMSA)
244
43. Renal: Renogram, Diuretic, and Captopril: Tubular Function, ERPF, and
249
GFR
44. Salivary Gland Imaging
259
45. Schilling Test
263
46. Scintimammography
268
47. SPECT (Single Photon Emission Computed Tomography) Imaging and
274
Hybrid Imaging Overview
48. Testicular Scan
283
49. Therapy: BEXXAR® (Radioimmunotherapy: RIT for B-cell non-Hodgkin’s
287
Lymphoma)
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
313
Lymphoma)
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.
B.
Conversion Tables
362
Lbs/Kgs
363
In/Cm
364
Target Heart Rates (Cardiac Studies)
365
mCi/MBq
366
Radiopharmaceuticals
367
Standard Adult Dose Ranges
368
Medical Radionuclides
370
C.
Common Math Equations for Nuclear Medicine
373
Kit Preparations (An Overview)
374
Pediatric Dosing in Nuclear Medicine
379
Radioactive Isotopes
386
Decay Tables of Common Radionuclides
410
137
Cs
411
57
Co
412
18
F
413
67
Ga
414
111
In
415
123
I
416
131
I
417
Mo
418
99
D.
99m
Tc
419
201
Tl
420
133
Xe
421
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.
F.
G.
H.
Laboratory Tests
439
Normal Ranges
440
Enzymes and Hormones
446
Language Barrier Buster™ / Interpretech™
451
Chinese
452
French
454
German
457
Italian
459
Portuguese
462
Russian
464
Spanish
467
Japanese
470
Polish
471
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
Patient Release Methods and Information for Thyroid Therapies
491
Methods of Patient Release
492
Inpatient Information
495
I.
Outpatient Information
495
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
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
L.
References
559
Acknowledgment of Trademarks
563
Index
567