Pediatric nuclear medicine, Part II: Common procedures and considerations

OBJECTIVE: This paper introduces technologists to pediatric nuclear medicine applications as well as serves as a review of the principles of pediatric imaging for more experienced technologists. After reading this article the nuclear medicine technologist should be able to: (a) identify pediatric populations commonly evaluated with nuclear medicine procedures; (b) state the indications for performing pediatric nuclear medicine procedures; and (c) discuss strategies and tips for performing nuclear medicine procedures on pediatric patients.     

Nuclear medicine and molecular imaging of the pediatric chest: current practical imaging assessment

In the chest, the indications for nuclear medicine studies are broader and more varied in children than in adults. In children, nuclear medicine studies are used to evaluate congenital and developmental disorders of the chest, as well as diseases more typical of adults. In the chest, pediatric nuclear medicine uses the same radiopharmaceuticals and imaging techniques as used in adults to evaluate cardiac and pulmonary disease, aerodigestive disorders, and pediatric malignancies. The introduction of PET (mostly using (18)F-FDG) has transformed pediatric nuclear oncology, particular for imaging malignancies in the chest.     

Where are we with nuclear medicine in pediatrics?

The practice of nuclear medicine in children is different from that in adults. Technical considerations including immobilization, dosing of radiopharmaceuticals, and instrumentation are of major importance. Image magnification and the capability to perform singlephoton emission tomography are essential to performing state of the art pediatric nuclear medicine. New advances in instrumentation with multiple detector imaging, the possibility of clinical positron emission tomography imaging in children, and new radiopharmaceuticals will further enhance pediatric scintigraphic imaging. This review highlights advances in pediatric nuclear medicine and discusses selected clinical problems.     

Investigation of the relation between administered dose and image quality for pediatric 99mTc-DMSA renal scintigraphy: clinical study applying the JSNM (Japanese Society of Nuclear Medicine) pediatric dosage card

Annals of Nuclear Medicine - In 2013, the Japanese Society of Nuclear Medicine (JSNM) announced consensus guidelines for pediatric nuclear medicine. These JSNM guidelines proposed use of lower...     

Minimizing and communicating radiation risk in pediatric nuclear medicine

The value of pediatric nuclear medicine is well established. Pediatric patients are referred to nuclear medicine from nearly all pediatric specialties including urology, oncology, cardiology, gastroenterology, and orthopedics. Radiation exposure is associated with a potential, small, risk of inducing cancer in the patient later in life and is higher in younger patients. Recently, there has been enhanced interest in exposure to radiation from medical imaging. Thus, it is incumbent on practitioners of pediatric nuclear medicine to have an understanding of dosimetry and radiation risk to communicate effectively with their patients and their families. This article reviews radiation dosimetry for radiopharmaceuticals and also CT given the recent proliferation of PET/CT and SPECT/CT. It also describes the scientific basis for radiation risk estimation in the context of pediatric nuclear medicine. Approaches for effective communication of risk to patients' families are discussed. Lastly, radiation dose reduction in pediatric nuclear medicine is explicated.     

Correlative pediatric imaging

Nuclear medicine, ultrasound, and magnetic resonance imaging (MRI) are considered ideal imaging modalities for pediatric patients. The future is even more promising for pediatric imaging with the development of newer and improved radiopharmaceuticals, instrumentation and diagnostic modalities such as positron emission tomography, labeled monoclonal antibodies, and faster dynamic and contrast enhanced MRI methods. However, correlation of more conventional imaging modalities with nuclear medicine, ultrasound and MRI remain essential for optimal patient care.     

Recent advances in pediatric nuclear medicine

The applications of nuclear medicine in pediatrics have grown parallel with the development of higher resolution complementary imaging modalities such as computed tomography, ultrasound, digital angiography, and magnetic resonance. The purpose of this article is to present clinically significant advances in pediatric nuclear imaging, with emphasis on newer techniques less often associated with pediatric patients.     

Pediatric applications of pinhole magnification imaging.

Pinhole magnification imaging is an important technique for practitioners of pediatric nuclear medicine. This article reviews basic principles of pinhole magnification imaging and ways for optimizing image acquisition with this technique. Applications to skeletal scintigraphy, scrotal scintigraphy and renal cortical scintigraphy are discussed and illustrated.     

The EANM practice guidelines for bone scintigraphy

Purpose

The radionuclide bone scan is the cornerstone of skeletal nuclear medicine imaging. Bone scintigraphy is a highly sensitive diagnostic nuclear medicine imaging technique that uses a radiotracer to evaluate the distribution of active bone formation in the skeleton related to malignant and benign disease, as well as physiological processes.

Methods

The European Association of Nuclear Medicine (EANM) has written and approved these guidelines to promote the use of nuclear medicine procedures of high quality.

Conclusion

The present guidelines offer assistance to nuclear medicine practitioners in optimizing the diagnostic procedure and interpreting bone scintigraphy. These guidelines describe the protocols that are currently accepted and used routinely, but do not include all existing procedures. They should therefore not be taken as exclusive of other nuclear medicine modalities that can be used to obtain comparable results. It is important to remember that the resources and facilities available for patient care may vary.

     

Guidelines for 18F-FDG PET and PET-CT imaging in paediatric oncology

OBJECTIVE: The purpose of these guidelines is to offer to the nuclear medicine team a framework that could prove helpful in daily practice. These guidelines contain information related to the indications, acquisition, processing and interpretation of (18)F-fluorodeoxyglucose positron emission tomography ((18)F-FDG PET) in paediatric oncology. The Oncology Committee of the European Association of Nuclear Medicine (EANM) has published excellent procedure guidelines on tumour imaging with (18)F-FDG PET (Bombardieri et al., Eur J Nucl Med Mol Imaging 30:BP115-24, 2003). These guidelines, published by the EANM Paediatric Committee, do not intend to compete with the existing guidelines, but rather aim at providing additional information on issues particularly relevant to PET imaging of children with cancer. CONCLUSION: The guidelines summarize the views of the Paediatric Committee of the European Association of Nuclear Medicine. They should be taken in the context of "good practice" of nuclear medicine and of any national rules, which may apply to nuclear medicine examinations. The recommendations of these guidelines cannot be applied to all patients in all practice settings. The guidelines should not be deemed inclusive of all proper procedures or exclusive of other procedures reasonably directed to obtaining the same results.     

Quo vadis pediatric nuclear medicine

What has happened to the nuclear medicine subspecialty since those earlier issues of the Seminars in Nuclear Medicine? The earliest issues in 1972 presented topics in vogue at the time that included brain "scanning," cisternography, whole body counting, and abdominal imaging with (99m)Tc pertechnetate. The second pediatric subspecialty issues in 1993 reflected a 21-year evolution of the subspecialty and included the topics of renal scintigraphy, labeled cells for abdominal imaging, metaiodobenzylguanidine imaging, single photon emission computed tomography, and bone scintigraphy for benign disorders. The current issues will address diverse topics that cover the spectrum of the current practice of pediatric nuclear medicine. They include radiation exposure and absorbed dose reduction, positron emission tomography/computed tomography in children, neuroblastoma and other neuroendocrine tumors, thyroid cancer and therapy, bone density studies and, of course, the most prevalent studies in children, renal and bone. Brain, heart, and lung studies complete the spectrum.     

Imaging prostate cancer

In the detection of prostate cancer, the most important role of imaging is ultrasound-guided prostatic biopsy. In the staging evaluation of prostate cancer, each presently used modality--transrectal US (TRUS), MR imaging, CT, nuclear medicine, and positron emission tomography--has advantages and disadvantages. Evidence-based guidelines on the use of CT and nuclear medicine bone scan, in assessing the risk of distant spread of prostate cancer, are available. There is no consensus and there are no guidelines, however, for the use of imaging in the evaluation of prostate cancer local tumor extent. Results on the value of TRUS vary widely, and prospective multicenter studies suggest that TRUS is no better than digital rectal examination in predicting extracapsular extension. MR imaging offers the most promise for local staging of prostate cancer, but it must resolve problems of reproducible image quality and interobserver variability, and it should prove its efficacy in multicenter trials before it can be recommended for general clinical use. The introduction of MR spectroscopic imaging further expands the value of MR imaging, offering anatomic and metabolic evaluation of prostate cancer.     

Technical issues in performing PET studies in pediatric patients

The purpose of this review is to familiarize the reader with aspects of PET that are important to its performance in pediatric patients. Recognition of differences in applying PET technology to children than to adults should result in higher quality scans in pediatric patients. The reader should be able to recognize key differences in performing PET scans in pediatric patients and to recall basic indications for PET scanning in children. High-quality PET imaging of pediatric patients is challenging and requires consideration of issues common to pediatric nuclear medicine but uncommon to imaging of adult patients. These include intravenous access, sedation, fasting, consent, and clearance of activity from the urinary tract. This article focuses on technical differences involved in pediatric PET compared with adult PET and serves as a guide to enhance the quality of scans and to ensure the safety and comfort of pediatric patients. Upon reading this article, the reader will be familiar with the aspects of PET that pertain to pediatric patients, know how to apply PET imaging techniques to pediatric patients, and know the indications for PET scanning in children.     

Nuclear medicine procedures in cardiovascular diseases. An evidence based approach.

The aim of evidence-based medicine is to integrate individual clinical expertise with the best available external clinical evidence from systematic research. The aim of this article is to introduce the concept of evidence based medicine and to review the evidence for applying cardiovascular nuclear medicine in various clinical settings. A systematic review is defined as a scientific technique to identify and summarize evidence on effectiveness of interventions and to allow the consistency of research. Different clinical applications of nuclear medicine procedures in cardiology have been reviewed. Radionuclide imaging techniques appear to be appropriate in risk assessment, prognosis and evaluation of therapy in patients after acute myocardial infarction. In patients with unstable angina, radionuclide testing is indicated in the identification of ischemia within the distribution of the "culprit" lesion or in remote areas. Exercise and pharmacological cardiac perfusion imaging are appropriate and useful in the diagnosis and prognosis of chronic coronary artery disease. Nuclear medicine procedures are also useful in the assessment of myocardial viability in patients with left ventricular dysfunction, in the assessment of interventions for the evaluation of patients after percutaneous transluminal coronary angioplasty and coronary artery bypass grafting. There has been rapid evolution in radionuclide imaging technologies and both the number and the complexity of choices for the clinician have increased. Further progress in technology and clinical applications of nuclear cardiology may be expected. The development of new instrumentation and of new agents will allow consistent progress and improve the state-of-art of nuclear cardiology. Thus, guidelines for the use of cardiac radionuclide imaging have been difficult to develop and apply. An evidence-based approach may be useful for the best use of nuclear medicine procedures in cardiovascular diseases.     

Simultane Ganzkörper-PET-MRT in der pädiatrischen Onkologie

Diagnostic imaging plays an essential role in pediatric oncology with regard to diagnosis, therapy-planning, and the follow-up of solid tumors. The current imaging standard in pediatric oncology includes a variety of radiological and nuclear medicine imaging modalities depending on the specific tumor entity. The introduction of combined simultaneous positron emission tomography (PET) and magnetic resonance imaging (MRI) has opened up new diagnostic options in pediatric oncology. This novel modality combines the excellent anatomical accuracy of MRI with the metabolic information of PET. In initial clinical studies, the technical feasibility and possible diagnostic advantages of combined PET-MRI have been in comparison with alternative imaging techniques. It was shown that a reduction in radiation exposure of up to 70?% is achievable compared with PET-CT. Furthermore, it has been shown that the number of imaging studies necessary can be markedly reduced using combined PET-MRI. Owing to its limited availability, combined PET-MRI is currently not used as a routine procedure. However, this new modality has the potential to become the imaging reference standard in pediatric oncology in the future. This review article summarizes the central aspects of pediatric oncological PET-MRI based on existing literature. Typical pediatric oncological PET-MRI cases are also presented.     

Standardisation of imaging in neuroendocrine tumours: results of a European delphi process

In 1998 and 1999, a delphi consensus procedure was performed to establish guidelines for standardised diagnostic imaging of neuroendocrine tumours. The procedure included four consecutive workshops of a European group of experts in neuroendocrine tumours as well as feedback given by specialists from the departments of radiology, nuclear medicine, surgery and internal medicine of the according home institutions. Diverging approaches among the centres, which became apparent during the discussion, reflect a lack of controlled studies specifically for rare subgroups of neuroendocrine tumours. This paper summarises the standards for diagnostic imaging as developed during the delphi process. In particular, the diagnostic workflows as well as the technical properties of different imaging modalities are described in detail.     

Procedure guidelines for PET/CT tumour imaging with 68Ga-DOTA-conjugated peptides: 68Ga-DOTA-TOC, 68Ga-DOTA-NOC, 68Ga-DOTA-TATE

The aim of these guidelines is to assist nuclear medicine physicians in recommending, performing, reporting and interpreting the results of somatostatin (SST) receptor PET/CT imaging using ⁶⁸Ga-DOTA-conjugated peptides, analogues of octreotide, that bind to SST receptors. This imaging modality should not be regarded as the only approach to visualizing tumours expressing SST receptors or as excluding other imaging modalities useful for obtaining comparable results. The corresponding guidelines of ¹¹¹In-pentetreotide scintigraphy imaging have been considered and partially integrated with this text. The same has been done with the relevant and recent literature in this field and the final result has been discussed by distinguished experts.     

Pediatric nuclear medicine, Part I: Developmental cues

OBJECTIVE: Children provide a continuous challenge for the nuclear medicine technologist. The task of successfully completing a nuclear medicine procedure varies little among a 20-y-old, a 40-y-old and a 60-y-old patient. Successful completion of a procedure varies much more among a 2-y-old, a 4-y-old and a 6-y-old. Successfully completing a pediatric nuclear medicine procedure includes quick acquisitions, technically acceptable images or calculations, and satisfied patients and parents. Understanding your patient is crucial, and it provides the parents with a greater sense of comfort and confidence about the nuclear medicine technologist and the procedure. After reading this article the nuclear medicine technologist should be able to: (a) discuss the developmental stages of children according to several major theories; (b) identify the physical and mental expectations for each age group; (c) explain applications for incorporating this information into common pediatric nuclear medicine practice; and (d) discuss the common realities surrounding the behavior of children and their parents. A second article will feature tips, indications and populations for common pediatric procedures.     

Evaluating the fundamental qualities of a nuclear medicine radiographer for the provision of an optimal clinical service

The developing nature of nuclear medicine practice highlights the need for an evaluation of the fundamental qualities of a Radiographer working within this discipline. Existing guidelines appear to be in place for clinical technologists working within nuclear medicine. However, limited guidance has been provided for Radiographers practicing within this discipline. This article aims to discuss the fundamental qualities that are considered essential for optimal service delivery, following consultation with various stakeholders. Areas such as technical expertise and knowledge, appropriate use of imaging equipment and current models of safe working practice will be discussed. Patient care and ethical considerations will also be evaluated, along with some core recommendations for future advanced practice.     

新型冠状病毒肺炎疫情防控期核医学诊疗工作的防护建议

2019年12月以来,新型冠状病毒肺炎（COVID-19）被发现并迅速蔓延。疫情防控期核医学诊疗工作中如何进行防护显得尤为重要。核医学诊疗工作涉及门诊、影像检查、检验和放射性核素病房治疗等,环节较多,流程相对复杂。因此,对核医学诊疗过程中各个环节工作人员和患者的管理、防护以及工作场所的环境消毒等的要求应更为严格。笔者根据国家相关指南和实际工作状况,提出了COVID-19疫情防控期核医学诊疗工作的防护建议,旨在加强核医学诊疗工作中的防控,并保障医患安全。