weighing risks against benefits ALARA principle appropriate activities (radiopharmaceutical doses)

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2 weighing risks against benefits ALARA principle appropriate activities (radiopharmaceutical doses) based on EANM references adequate appointment method (patient booking system)

3 Appropriate activities (doses) for children are based on EANM recommendations, calculated by bodyweight

4 radiopharmaceuticals are generally administered intravenously- if it is possible through a cannula examinations are usually performed in lying position, infants can be placed on the detector appropriate fixation e.g. vacuum mattress or general anesthesia is used if it is necessary

5 Vesevizsgálatok Csontszcintigráfia 123I-MIBG szcintigráfia Speciális vizsgálatok (Meckel- diverticulum kimutatása, epeút atresia kimutatása, pajzsmirigy szcintigráfia, agyi vizsgálatok focalis epilepsziában )

6 sufficient hydration decreases radioactivity affecting the patient (and the staff) obtaines good image quality (e.g. bone or kidney scintigraphy, better organbackground ratio) providing undisturbed conditions for the child during waiting is important

7 Renal Imaging Bone Scintigraphy 123I-MIBG Scintigraphy Meckel Diverticulum Scintigraphy Other Examinations

8 Static: Renal scintigraphy + ratio (geometric mean) calculation Dinamic: Camera-renography + Furosemid-diuresis

9 Radiopharmaceutical: MBq 99mTc-DMSA (dimercaptosuccinic acid, taken up by the proximal tubular cells cortical imaging ) Acquisition: 120 minutes after the injection Planar imaging from 4 different directions: - anterior, posterior - RPO (right posterior oblique) - LPO (left posterior oblique) Evaluation: morphology, focal parenchymal defect ( 1.5 cm), relative function

10 Indications: congenital diseases: agenesia, hypo,- dysplasia, horseshoe kidney, poly- or multicystic kidney pyelonephritis, reflux disease : focal parenchymal defect, scarring

11 Solo Kidney on the Left Side in a Newborn

12 Multicystic Disease on the Left Side

13 Focal parenchymal defect on the right side

14 Determining relative renal function (geometric mean) of the left and the right kidney from the DMSA imaging: Posterior view ROI of the left and the right kidney Anterior view ROI of the left and the right kidney Calculating parameters by computer (counts; geometric mean) It is very important in children with kidney failure and malformations

15 Posterior view: left kidney: 48.4% right kidney: 51.6% Anterior view: left kidney: 50.7% right kidney: 49.3% Geometric mean: left kidney: 49.5% right kidney: 50.5%

16 Relative ratio of the kidney function: Posterior view: left kidney: 83.8% right kidney: 16.2% Anterior view: left kidney: 88.5% right kidney: 11.5% Geometric mean: left kidney: 86.3% right kidney: 13.7% Nephrectomy is recommended under 10%

17 Glomerular or tubular function of the kidneys, excretion is investigated (99mTc-DTPA, 99mTc-EC, 99mTc-MAG3) Very sensitive method, which should be performed in the early stages of kidney disorders Time-activity curve = renogram Phase I = perfusion Phase II = filtration or secretion function Phase III = excretion function

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19 Before examination: Extra fluid consumption (up to 500ml)- sufficient hydration status Inserting bladder catheter if necessary Fixation (usually vacuum mattress, sometimes sedation or narcosis) may be necessary Radiopharmaceutical: 99mTc-DTPA (glomerular secretion) or 99mTc-MAG3 (tubular secretion) i.v. Dynamic frame series from posterior view, 75 frames, frame-duration: 20 seconds; duration of the study: 25 minutes

20 functional or organic obstructions (with iv. Furosemid) (vesico-ureteral) reflux disease with mictio examination(during urination) juvenile hypertension (renovascular hypertension; with captopril) kidney transplantation

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22 Pyelo-ureteric stenosis /functional (right side) and organic (left side)/ and organic vesico-ureteric stenosis on both sides Organic pyelo-ureteric stenosis on the left side, functional pyeloureteric and organic vesicoureteric stenosis on the right side

23 Method: Camera-Renography + Micturition Evaluation: during micturition activity in the ureter(s) is rising while bladder activity is decreasing reflux

24 before micturition during micturition

25 MAG3 Renography Micturition

26 Radiopharmaceutical: 99mTc-MDP i.v. acquisition can be started 2 hours later planar whole body examination (a-p, p-a) 3-phase bone scintigraphy if necessary supplementary planar images, SPECT, SPECT-CT if necessary Evaluation can be difficult due to physiologically high activity of the epiphyseal plates, therefore symmetrical position is very important

27 inflammations: osteomyelitis, arthritis bone tumors: benign, malignant, metastases osteonecrosis (aseptic): Perthes disease (Pinhole-collimator) fractures (e.g. stress fracture) Sudeck-atrophy (reflex dystrophy)

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32 Regression in all phases

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34 This radiopharmaceutical accumulates in neuroendocrine tumors which contain ADRENERG RECEPTORS Physiological activity: salivary glands, heart, liver, spleen, bowels, urinary tract

35 Thyroid blockade: pretreatment with Lugol solution (in order to protect the thyroid from unnecessary irradiation, to reduce the physiological accumulation in the thyroid gland) Image acquisition: 4 and 24h after the injection anterior and posterior whole body scan imaging complemented by SPECT examination in the 4th hour and SPECT/CT examination in the 24th hour

36 1. Neuroblastoma (one of the most common solid malignant tumours of childhood) Confirmation of diagnosis of neuroblastoma Staging; detection of distant metastases Detection of local recurrence Follow-up under therapy (2. Pheochromocytoma) (3. Some other kind of tumours)

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40 Meckel diverticulum: Incidence is 2%, causes symptoms in 10%, first of all in childhood occlusion abnormality of omphaloenteric duct (in the foetus the small intestine is connected to the umbilicus with a little duct, which in normal cases closes at birth) it may contain stomach mucous membrane cells Ulceration, bleeding, other complications! Symptoms: melena, pain around the navel Therapy: surgical removal

41 Radiopharmaceutical: 99mTc-pertechnetate i.v. 99m Tc-pertechnetate is taken up by the mucin-producing cells of gastric mucosa - even if it is ectopic Static images from ant. view 5, 10, 20, 30 minutes after the injection Pathologically increased activity in the region of bowels

42 Diagnosing Bile Duct Atresia: Cholescintigraphy with 99mTc-trimetil-bromo-IDA The gallbladder and the bile ducts are not visible 24 hours after the administration of the radiopharmaceutical, little activity appears in the urinary tract

43 Thyroid scintigraphy Lung scintigraphy Lymphoscintigraphy Brain perfusion scintigraphy PET-CT examinations

44 Thank You For Your Attention!