PET/CT & Nuclear Medicine in Clinical Practice. Tuesday, February 21, The 8 th Snowmass 2017: Westin Snowmass Resort Snowmass Village, Colorado

Transcription

1 The 8 th Snowmass 2017: PET/CT & Nuclear Medicine in Clinical Practice Tuesday, February 21, 2017 Westin Snowmass Resort Snowmass Village, Colorado Educational Symposia

2 TABLE OF CONTENTS TUESDAY, FEBRUARY 21, 2017 Renal Scintigraphy (Andrew T. Trout, M.D.) State of the Art Hepatobiliary Nuclear Imaging (Pradeep G. Bhambhvani, M.D.) Communicating Risks of Radiation Exposure (Kevin J. Donohoe, M.D.) Standardized Solid Meal Gastric Emptying Study and Alternatives (Pradeep G. Bhambhvani, M.D.) Neuroendocrine Imaging (Arif Sheikh, M.D.) SAVE THE DATES Winter Symposia

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17 STATE OF ART NUCLEAR HEPATOBILIARY IMAGING (HIDA SCAN) Disclosures Honorarium from Educational Symposia PRADEEP BHAMBHVANI, MD Associate Professor Molecular Imaging & Therapeutics, Department of Radiology The University of Alabama at Birmingham February 21, 2017 Page 1 Page 2 Outline Introduction Indications Procedure CCK and other interventions Clinical scenarios and interpretation Cholecystitis (acute & chronic) Biliary obstruction Bile leak Biliary atresia Conclusion References Introduction Hepatobiliary scintigraphy (HIDA) is a diagnostic functional imaging test that evaluates hepatocellular function and the biliary system by tracing the production of bile from the liver, and its passage through the biliary system into the small bowel HIDA from hepatic IDA (iminodiacetic acid) Page 3 Page 4 Indications Right-upper-quadrant pain variants Acute cholecystitis Chronic cholecystitis & functional biliary pain syndrome Biliary obstruction Neonatal jaundice (biliary atresia/neonatal hepatitis) Sphincter of oddi dysfunction, choledochal cysts etc. Post operative biliary tract Bile leak Biliary stent patency Radiopharmaceuticals 99mTc-disofenin (DISIDA, 2,6-diisopropylacetanilido iminodiacetic acid) or 99mTc-mebrofenin (CHOLETEC, bromo-2, 4,6- trimethylacetanilido iminodiacetic acid) Dose: Adults: MBq (3-5 mci) (higher doses in jaundice) Infants & children: MBq/kg ( mci/ kg), minimum 18.5 MBq (0.5 mci) Page 5 Page 6 59

18 Preparation Fasting: Minimum 2 hours (preferably 6 hours) If fasting >24 hours pre-treat with CCK (to empty GB) Fatty meal prior evening ( 10g of fat, to empty GB) Hold narcotics for hours (4 half lives). Naloxone reversal an option Hold drugs affecting GB contractility: atropine, nifedipine, indomethacin, octreotide, theophylline, histamine blockers, progesterone, isoproterenol, benzodiazepines, ETOH, nicotine Gallbladder ejection fraction (GBEF) best done as an outpatient exam Procedure Radiopharmaceutical injected IV while patient lies supine on imaging table. NM camera placed anterior to the patient detects gamma rays emitted to form images. Include drains & catheters in field of view. Cine images are acquired initially for up to 60 minutes. Delayed images & interventions may be done to improve diagnostic certainty. Page 7 Page 8 Normal HIDA Scan Normal HIDA Scan (Alternative view) Page 9 RIGHT LATERAL Page In anterior view the activity in the duodenum often interferes with activity in the gallbladder region! Slide Courtesy of Dr. Mark Tulchinsky Slide Courtesy of Dr. Mark Tulchinsky Anterior View Page 11 Anterior View Page 12 60

19 Slide Courtesy of Dr. Mark Tulchinsky 40 o Anterior View Left Anterior Oblique view separates GB from duodenal activity makes good anatomical sense! Slide Courtesy of Dr. Mark Tulchinsky Page 13 Page 14 Slide Courtesy of Dr. Mark Tulchinsky 40 o LAO Projection Anterior View LAO view separates GB from duodenal activity makes good functional imaging sense! Slide Courtesy of Dr. Mark Tulchinsky Post CCK 2 min/frame Page 15 Page 16 Interventions Normal GBEF Suspected acute cholecystitis: GB not seen in the first hour IV Morphine Sulfate (preferred): 0.04 mg/kg or fixed 2 mg dose over 2-3 min or Delayed images at 3-4 hours Assessment of GBEF Fatty Meal: Inconsistent CCK (Gold standard) Page 17 Page 18 61

20 GBEF Formula GBEF(%) = (NetGBcountsmax NetGBcountsmin) 100 NetGBcountsmax Cholecystokinin (CCK, Sincalide, Kinevac ) 33 amino acid polypeptide made in the proximal small bowel. Active component is the C-terminal octapeptide Can be safely used with gallstones Boluses cause abdominal pain and nausea (50%) Sincalide: Synthetic analog of the terminal octapeptide Dose: 0.02 µg/kg IV infusion in ml NS Pretreatment (over min) if: Prolonged fasting (>24h) Hyperalimentation GBEF (over 60 min) Page 19 Page 20 CCK Protocols, SNM practice guidelines for hepatobiliary scintigraphy. J Nucl Med Tech 2010;38: a. 0.04, 3, 43±26%, 15-88%, 12. b. 0.02, 3, 35±17%, 17-59%, 6. c. 0.02, 3, 56±27, 0-100%, 23. Format: sincalide dose (μg/kg), d. 0.01, 3, 46±20, 12-74%, 20. time of infusion (min), GBEF e. 0.01, 10, 76±16, 37-96%, 13. (mean±sd), GBEF range, and number of normals studied f. 0.02, 15, 76±22, 32-98%, 15. g. 0.02, 15, 57±29, -2-98, 60. h. 0.01, 30, 64±20, 26-95%, 14. i. 0.02, 30, 70±22, 17-97%, 23 j. 0.02, 30, 71±25, 8-99%, 60. k , 45, 75±12, >40% (95% confidence limits), 40. l. 0.01, 60, 68±16, 15-88%, 20. m. 0.02, 60, 84±16, %, 60. Bhambhvani P et al. Variability in cholescintigraphy protocols in hospitals across the state of Alabama. J Nucl Med 2010; 51 (Supplement 2):597. Hours NPO 2-4 hrs 4 or more hrs Screening for No Yes Opiate Use CCK Pretreatment if No Yes NPO > 24hrs 58 5 GBEF Determination CCK Fatty Meal Variable Method CCK Dose µcg/kg > than 0.02 µcg/kg 53 4 Duration of CCK <3 min 3-5 min >5 but <30 30 min infusion (5 sites used a Fatty Meal) 12 3 min Normal GBEF ( ) 30% 35% 40% 50% Evaluation if GB not 2 hr delay 3-4 hr Morphine Variable seen at 1 hr delay use Page 21 Page 22 J Nucl Med 2010; 51: J Nucl Med 2010; 51: volunteers (32-F, 28-M); Ages Institutions, 15 subjects each All got CCK 0.02 µg/kg over 15, 30 and 60 min Coefficient of variation: 52%, 35% & 19% for the 15, 30 & 60 min infusion (p<0.0007) Normal GBEF (lower end of normal) : 15 & 30 min: 15% & 13% 60 min: 38% (least variation & highest EF s) Page 23 Page 24 62

21 J Nucl Med Technol Dec;38(4): Clinical Gastroenterology and Hepatology 2011;9: Page 25 Page 26 Unavailability of Sincalide: Options Generic Sincalide (QC concerns) Acute Cholecystitis Most common indication for HIDA Fatty meals (Normal GBEF) Whole milk, 300 ml ( 51%) Ensure Plus, 237 ml ( 33%) Lipomul: Soybean oil emulsion 30 ml ( 20%) Ziessman H, Petry NA. J Nucl Med Aug;54(8):17N. US is the initial test of choice (sufficient in 80% patients) HIDA is more accurate Sensitivity 95-98%, specificity 90% (HIDA) versus 70% & 86% (US) Detects the pathophysiologic event (GB/CD obstruction) seen as persistent non-visualization of the GB Page 27 Page 28 Acute Cholecystitis Acute Cholecystitis: GB Non-visualization Calculous (90-95%) Acalculous (5-10%) Elderly Critically ill (burns, sepsis, immunosuppressed, DM) Postpartum Vasculopathy Page 29 Page 30 63

22 Acute Cholecystitis: GB Non-visualization Pitfalls False Positives Chronic cholecystitis Prolonged or no fasting Poor liver function Congenital/surgical absence of GB False Negatives GB mimics (bowel, diverticulum, cystic duct & rim signs) Intermittent GB obstruction Acalulous cholecystitis (sensitivity 70-80%) Cystic duct is less often obstructed CCK challenge & WBC scan Page 31 Page 32 Cystic Duct Sign Rim Sign Page 33 Page 34 Chronic Calculous Cholecystitis (CCC) Recurrent biliary colic with gallstones seen on US & relieved with cholecystectomy If symptoms atypical, HIDA with CCK GBEF very useful. Abnormal suggests CCC. Refer for cholecystectomy Normal consider other etiologies Chronic Cholecystitis: HIDA findings 1) Delayed GB filling (after 1 hour) with normal biliary to bowel transit 2) Delayed/disparate GB filling relative to small bowel in the 1st hour 3) Delayed biliary to bowel transit with normal GB filling 4) Unusually slow GB filling 5) Irregular or eccentric GB filling 6) Faint or very small contracted GB 7) Band or septa across GB 8) Photopenic defects in GB 9) GB non-visualization 10) Poor response to sincalide (Low GB ejection fraction) 11) Combinations of the above 12) Normal hepatobiliary scan with prompt GB and small bowel activity Chamarthy M, Freeman LM. Hepatobiliary Scan Findings in Chronic Cholecystitis Clin Nucl Med 2010;35: Page 35 Page 36 64

23 Chronic Cholecystitis: Low GBEF GB non-visualization in an outpatient without acute symptoms: Chronic Cholecystitis Page 37 Page 38 Chronic Acalculous Cholecystitis (CAC) 5-10% of chronic cholecystitis CT/US not useful as no gallstones. HIDA has a role Synonyms Gallbladder/biliary dyskinesia Functional gallbladder disorder Chronic acalculous gallbladder disease Acalculous gallbladder dysfunction Gallbladder spasm Chronic Acalculous Cholecystitis Recurrent biliary colic No gallstones Low GBEF Symptoms improve with cholecystectomy Pathology reveals chronic inflammation Page 39 Page 40 Chronic Acalculous Cholecystitis Enterogastric Reflux CCK 0.02 mcg/kg over 45 min (EF measured at 60 min) 103 patients, 21 with GBEF <40% 11 randomized to cholecystectomy 10 became asymptomatic 1 improved No surgery group (10) remained symptomatic, 2 had cholecystectomy with symptom resolution 12/13 GB had chronic inflammation on histopathology Yap L et al. Acalculous biliary pain: cholecystectomy alleviates symptoms in patients with abnormal cholescintigraphy. Gastroenterology 1991;101: Page 41 Page 42 65

24 High Grade Biliary Obstruction (Persistent Liver Scan) Partial Obstruction & Sphincter of Oddi Dysfunction Good hepatic uptake, prompt secretion into the biliary ducts, and gallbladder filling; however, clearance from the biliary ducts is delayed Biliary to bowel transit does not exclude partial obstruction. Poor clearance from biliary ducts is characteristic CCK infusion can help differentiate from functional delays (prompt transit after CCK) Page 43 Page 44 Bile Leak: Post MVA Liver Laceration Bile Leak-Post Cholecystectomy: SPECT-CT Page 45 Page 46 Biliary Atresia Biliary Atresia (Absent Bowel Activity) Progressive, idiopathic, fibro-obliterative disease of the extrahepatic biliary tree. Presents as neonatal jaundice Early diagnosis is critical to prevent irreversible liver failure HIDA: Persistent hepatogram and no biliary-to-bowel transit over 24 hours Preparation to prime liver enzymes: Phenobarbital: 5mg/kg/d for 3-5d or Ursodeoxycholic Acid: 20 mg/kg/d for 2-3d prior Treatment: Palliative hepatoportoenterostomy (Kasai procedure) Often, ultimately, liver transplantation Page 47 Page 48 66

25 Neonatal Hepatitis (+ Bowel Activity). No Biliary Atresia Conclusions HIDA is a valuable time tested imaging modality of the hepatobiliary tract Its main advantage over other modalities is that it permits physiologic imaging of liver function and biliary patency Morphine augmented HIDA allows for rapid diagnosis of acute cholecystitis CCK (0.02 µg/kg infusion over 60 min) has the least variability & may be considered the GBEF method of choice Page 49 Page 50 References Thank You Ziessman HA. Hepatobiliary Scintigraphy in J Nucl Med 2014; 55:1 9 Ziessman HA. Nuclear Medicine Hepatobiliary Imaging. Clinical Gastroenterology and Hepatology 2010;8: Tulchinsky M et al. SNM practice guidelines for hepatobiliary scintigraphy. J Nucl Med Tech 2010;38: Ziessman HA. Sincalide Cholescintigraphy-32 Years Later: Evidence-Based Data on Its Clinical Utility and Infusion Methodology. Semin Nucl Med 42:79-83 Ziessman HA et al. Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement. J Nucl Med. 2003; 44: Covington MF et al. Classification Schema of Symptomatic Enterogastric Reflux Utilizing Sincalide Augmentation on Hepatobiliary Scintigraphy. J Nucl Med Technol 2014; 42: Tulchinsky M et al. Hepatobiliary Scintigraphy in Acute Cholecystitis. Semin Nucl Med 42: Chamarthy M, Freeman LM. Hepatobiliary Scan Findings in Chronic Cholecystitis. Clin Nucl Med 2010;35: Page 51 Page 52 67

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29 Disclosures/Disclaimers I have no conflicts of interest. Three Things to Learn Communication includes listening. You must be trustworthy. Don t expect to win many people to your side, no matter how good your evidence. Why Think About Radiation Risk? 71

30 What do people fear? Unknown Can t see Can t smell Can t taste Can t touch Risk Communication Who you will communicate with Medical colleagues Patients Research subjects Hostile groups Intentional exposures Unintentional exposure Fear vs. Risk Rank hazard mortality Rank fear of hazard Correlation between fear and risk is ~.2 How to Communicate Risk Know your audience Educational level Study subject? What are their concerns? Health Property Financial Your Audience Who is More Fearful? Listen to your audience before you speak What is their concern? Health effects? Economic concerns? Family? Assess understanding as you go along. Summarize Ask them what they think about what you have told them 72

31 Assess Level of Education and Understanding Listening helps Know what vocabulary to use Chest X-ray or.? Background Have they already made up their mind? Where do they get their information? What is worrying them? Speaking to Specific Groups Anti-nuclear Regulators General Public Medical Professionals Disaster drills Consumers of radiological services Educating Medical Professionals Intentional vs Unintentional Exposures Besides Speaking Intentional Medical Radiation worker Unintentional Accidents Terrorist attacks Power Plants Written communication Web-based Blogs Social media Wiki articles Newspapers Editorials Letters 73

32 What if you Don t Know? Say: I don t know Do not lose credibility with your audience. You need to remain a trusted source. Ultimate Goal In speaking to patients You are an advocate for the patient We are adding risk to their lives, we are damaging their tissues What is the risk of NOT doing the scan? In speaking to Physicians You are an advocate for the patient AND physician In speaking to regulators You are an advocate for the patient Is something not working well? Radiation Doses and Dose Limits Dose Examples Source Dose msv (mrad) Torso CT (w/wo) 40 (4,000) PET/CT 8 25 (800 2,500) Myocardial perfusion (R/S) 7 (700) Chest CT ( ) Natural background (per 3.5 (350) year) Chest x-ray 0.1 (10) Dental X-rays (0.5) Flying (0.3) /hr Radiologyinfo.org Examples of Radioactive Materials Physical Radionuclide Half-Life Activity Use Cesium yrs 1.5x10 6 Ci Food Irradiator Cobalt-60 5 yrs 15,000 Ci Cancer Therapy Plutonium ,000 yrs 600 Ci Nuclear Weapon Iridium days 100 Ci Industrial Radiography Hydrogen-3 12 yrs 12 Ci Exit Signs Strontium yrs 0.1 Ci Eye Therapy Device Iodine-131 Therapy 8 days Ci Nuclear Medicine Technetium-99m 6 hrs Ci Diagnostic Imaging Americium yrs Ci Smoke Detectors Radon days 1 pci/l Environmental Level Communication in Radiation Disaster The worried well are going to require a large amount of resources. Emphasize medical care over radiation exposure concerns. Communication of reliable and accurate information is very important and very unlikely. 74

33 Decontamination Max Mussel Tammy Tech References 75

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37 RADIONUCLIDE GASTRIC EMPTYING STUDY Standard Solid-Meal & Alternatives Honorarium from Educational Symposia Disclosures PRADEEP BHAMBHVANI, MD Associate Professor Molecular Imaging & Therapeutics, Department of Radiology The University of Alabama at Birmingham February 21, 2017 Page 2 Introduction Consensus Guideline and Standardized Meal Patient Preparation Interpretation Rapid Emptying Alternative Meal Shortened Protocol Liquid Emptying Conclusions Outline Radionuclide Gastric Emptying GOLD STANDARD Page 3 Page 4 Radionuclide Gastric Emptying Scintigraphy Alternatives Most comprehensive & physiologic studies of gastric motor function Widely available Simple, noninvasive & quantitative Uses a physiologic meal (solids with or without liquids) Can determine therapy effectiveness Not routinely done as more studies needed 13 C Octanoic acid breath testing Wireless motility capsule Page 5 Page 6 79

38 Normal Stomach Physiology Fundus: - Tonic reservoir which undergoes receptive relaxation - Constant pressure gradient Controls Liquid Emptying Gastric Emptying: Time Activity Curves Lag Phase Antrum: - Phasic contractions, grind solid food particles Controls Solid Emptying Page 7 Liquid Emptying: Exponential Solid Emptying: Linear Page 8 Introduction Gastroparesis is a syndrome of objectively delayed gastric emptying in the absence of mechanical obstruction and with symptoms of nausea, vomiting, early satiety, bloating and/or upper abdominal pain The radionuclide study cannot differentiate functional delay from anatomic obstruction (e.g. tumor or ulcer). EGD or CT or barium study can aid with that More symptoms with delays in solid emptying versus liquid emptying Idiopathic (50%) Diabetes Mellitus Etiology of Gastroparesis Post-surgical (vagus injury): Bilroth II, heart & lung transplants, fundoplication Medications Viral Dysautonomia CNS: MS, Brainstem CVA/tumor, PD, SCI Infiltrative disorders: Scleroderma, Amyloid etc. Page 9 Page 10 Factors Affecting Gastric Emptying Effect of increasing liquid calorie content on liquid (a) and solid (b) emptying Meal related (fat, protein, acid, osmolality, volume, weight, caloric density, particle size) Patient position (standing, sitting, supine) Incomplete meal or emesis Stress, Exercise Medications Tobacco smoking Hyperglycemia Menstrual cycle Collins PJ et al., Gut, 1983, Dec;24(12): Page 11 Page 12 80

39 Medications and Gastric Emptying Study to Establish Normal Values ACCELERATE Metoclopramide Erythromycin Domperidone Cisapride DELAY Narcotics (Morphine, Percocet, Vicodin) Alpha-2-adrenergic agonists (Clonidine), Atropine Tricyclic antidepressants, Benzodiazepines & Phenothiazines Calcium channel blockers, Progesterone, Theophylline Anticholinergics (Bentyl, Levsin, Donnatal) Octreotide Page 13 Page 14 Tougas G et al. Am J Gastroenterol. 2000;95: sites in 4 countries (US, Canada, Italy, Netherlands) 123 volunteers (60-F, 63-M); ages No GI illness/surgery, no ongoing medical condition & no medications All had a 99m Tc-labeled low fat egg meal. 20 patients also had the 99m Tc-labeled liver meal 1 min images and gastric retention at 60, 120 and 240 minutes Tougas G et al. Am J Gastroenterol. 2000;95: Results N=123 Percent Retention Median 95 th Percentile 1 hour hour hour T-50 (min) Lag phase (min) Page 15 Page 16 Tougas G et al. Am J Gastroenterol. 2000;95: Consensus Recommendations Other Results No significant difference in emptying between meals, except 3h retention was higher with the liver meal Gender: There was more gastric retention in women at 1 and 2h but no difference from men at 4h Age: Greater retention in younger patients BMI: No relationship with gastric emptying Page 17 Page 18 81

40 SNMMI Guideline Minimum 4 hour fasting Patient Preparation Fasting blood sugar less than 200 mg% Insulin & oral medications OK with standardized meal J Nucl Med Technol Sep;37(3): Stop Narcotics, Prokinetics, Anticholinergics for 2 days If nausea or vomiting, Zofran use is safe Women are ideally studied on days 1-10 of menstrual cycle Page 19 Avoid smoking on day of test Page 20 Standardized Meal: Egg Whites Sandwich (255 kcal) EGG-BEATERS (118 ml/4 oz. 60 kcal), mci 99m Tc sulfur colloid mixed with egg whites, scrambled or omelet Imaging Anterior & posterior 1 minute images after meal & hourly up to 4 hours 2 toasted white bread slices (120 kcal) 30g strawberry jam (75 kcal) 120 ml water Meal eaten separately or as sandwich in <10 minutes At least 50% of the meal should be consumed Calculate gastric retention from geometric mean after region of interest (ROI) drawn around stomach Geometric mean = anterior counts x posterior counts ROI should avoid small bowel Higher sensitivity at 4 hours Page 21 Page 22 Interpretation Interpretation Time Point Lower Normal Limit for Gastric Retention 0 min A lower value suggests rapid emptying Upper Normal Limit for Gastric Retention A greater value suggests delayed emptying 1 hour 30% 90% 2 hour 60% 3 hour 30% 4 hour 10% Delayed Emptying 2 hour retention >60% and/or 4 hour retention of 10% Rapid Emptying 1 hour retention <30% Normal Values for Low Fat Egg-Whites Gastric Emptying Study Am J Gastroenterol. 2007;102:1 11 Page 23 Page 24 82

41 4 HOUR NORMAL EMPTYING GASTRIC RETENTION 1 HOUR: 69% 2 HOUR: 25% 3 HOUR: 17% 4 HOUR: 2% SEVERE DELAYED EMPTYING GASTRIC RETENTION 1 HOUR: 76% 2 HOUR: 64% 3 HOUR: 47% 4 HOUR: 40% Page 25 Page 26 Severity of Gastroparesis Rapid Gastric Emptying No correlation between severity and symptoms Severity scale (% gastric retention) 11-15%: Mild 16-35%: Moderate >35%: Severe Camilleri M. N Engl J Med 2007;356: Usually seen After peptic ulcer surgery (pyloroplasty) In early type 2 DM Zollinger-Ellison syndrome Hyperthyroidism Symptoms: Diarrhea, abdominal pain, bloating, nausea (early dumping syndrome), diaphoresis, palpitations, weakness, fainting (late dumping syndrome) Symptoms often similar to gastroparesis Page 27 Page 28 Rapid Gastric Emptying Alternative Meal (Ensure Plus ) Use of a High Caloric Liquid Meal (Ensure Plus ) as an Alternative to a Solid Meal for Gastric Emptying Scintigraphy 20 healthy volunteers Egg-whites sandwich (EWS) and Liquid Nutrient Meal (LNM) GE exams on separate days Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, Page 29 Page 30 83

42 EWS versus Ensure Plus Alternative Meal (Ensure Plus ) Egg Whites Sandwich (EWS) Liquid Nutrient Meal (LMN) Ensure Plus Ensure Plus gastric emptying is overall similar to EWS Calories (kcal) Fat % 2 28 Protein % Carbohydrate % Fiber % 2 0 Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, Ensure Plus meal empties without a lag phase and takes slightly longer to empty from the distal stomach, likely due to its higher fat content Reasonable alternative to the EWS meal Sachdeva et al: Dig Dis Sci July 2013, Volume 58, Issue 7, Page 31 Page 32 Shortened Protocol Shortened Protocol 174 patients (123-F, 51-M) Abnormal Emptying: >65% retention at 2 hours Normal Emptying: <45% retention at 2 hours Very accurate <25% patients needed 4 hour imaging J Nucl Med 2015; 56: Bonta V et al: Clin Nucl Med; Vol 36(4), Apr 2011, p Page 33 Page 34 4 academic institutions; 431 patients Shortened Protocol At 2 hours: 261 (60.6%) had gastric retention <45%, i.e. normal 62 (14.4%) had gastric retention >65%, i.e. delayed emptying; and 108 (25.1%) had intermediate values requiring imaging through 4 hours Bonta criteria had a sensitivity, specificity, and accuracy of 92.4%, 96.9%, and 95.8%. False negative results seen in 8 patients (1.9%). Bonta criteria shortened the study duration in most patients, resulting in an effective compromise between reduced resource use, improved patient convenience, and preserved accuracy. J Nucl Med 2015; 56: Sources of Error Vomiting after meal or Incomplete meal or prolonged meal ingestion time Non-standard meal Poor labeling Slow meal passage from the mouth/esophagus into the stomach Gastroesophageal reflux Overlap of small-bowel activity with the stomach ROI Lack of decay correction etc. Page 35 Page 36 84

43 Issues Requiring Clarification Pediatric GES (no standards yet) Post-surgical (Bariatric, Billroth-no normal values) Value of other emptying metrics: Fundal antral and antral-pyloric coordination Gastric accommodation Regional muscular contraction patterns Antral motility Fundal accommodation response Separate fundal and antral emptying curves Effect of varying meal composition on emptying etc. Liquid Gastric Emptying Conventional belief: There is good correlation between solid & liquid emptying, so the latter is not done routinely Alternative to solid meal or part of a solid-liquid study Post-operative states Solid meal intolerance Dumping syndrome or Research study Page 37 Page 38 Liquid Gastric Emptying Ziessman HA et al. J Nucl Med : Solid gastric emptying is more sensitive than liquid emptying for detection of Gastroparesis liquid emptying is preserved until the disorder is advanced Tadataka Yamada, Textbook of Gastroenterology 4 th edition Liquid emptying is always normal when solid emptying is normal and A liquid only study should be reserved for those who cannot tolerate solids The Requisites: Nuclear Medicine 3 rd Edition. Harvey Ziessman, Janis P O Malley & James H Thrall Liquid GE studies are by themselves of limited clinical value because liquid emptying usually is not abnormal until gastroparesis is far advanced Update on GI Scintigraphy, Seminars in Nuclear Medicine, 2006, 36, , Alan H Maurer, Henry P Parkman 101 symptomatic patients (24-M 77-F) had sequential liquid solid GES 7 patients were diabetic Liquid GES with 111 In DTPA and solid GES with EWS Normal liquid GES: <19 min (mean ± 2SD) or <22 min (mean ± 3 SD) Page 39 Page 40 Ziessman HA et al. J Nucl Med : Ziessman HA et al. J Nucl Med : Normal liquid GES T1/2 <19 min Normal liquid GES T1/2 <22 min A Normal liquid GES Normal solid GES Delayed solid GES Delayed liquid GES Total Total B Normal liquid GES Normal solid GES Delayed solid GES Delayed liquid GES Total Total Liquid gastroparesis seen in 30% of patients with normal solid emptying Gastroparesis diagnosis increased from 16% with only abnormal solid study to an additional 28-32% with normal solid but abnormal liquid study Page 41 Page 42 85

44 Sachdeva P et al. Dig Dis Sci (2011) 56: Retrospective study; 449 patients (346-F & 103-M) 62 diabetics (15%) 27% (60/228) had delayed liquid & normal solid emptying Normal solid GES Delayed solid GES Rapid solid GES Total Normal liquid GES Delayed liquid GES (>50% retention at 1h) Total Page 43 Page 44 Added Value of Liquid Emptying Prior publications have found poor correlation between symptoms and GES One reason may be that only antral function has been studied Therapies specific for fundal dysfunction are needed Solid-meal gastric emptying is standardized! Ensure Plus is a viable alternative meal Conclusions Shortened protocol maintains accuracy while improving clinic workflow Liquid emptying has added diagnostic value Page 45 Page 46 References Abell TL, Camilleri M, Donohoe K, et al. Consensus recommendations for gastric emptying scintigraphy: a joint report of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. Am J Gastroenterol. 2008;103: Tougas G, Eaker EY, Abell TL, et al. Assessment of gastric emptying using a low fat meal: establishment of international control values. Am J Gastroenterol. 2000;95: Ziessman HA. Goetze S, Bonta D, Ravich W. Experience with a new standardized 4-hr gastric emptying protocol. J Nucl Med. 2007;48: Sachdeva P, Malhotra N, Pathikonda M, et al. Gastric emptying of solids and liquids for evaluation for gastroparesis. Dig Dis Sci Apr;56(4): Ziessman HA, et al. The added diagnostic value of liquid gastric emptying compared with solid Emptying alone. J Nucl Med : Bonta D, Lee H, Ziessman H. Shortening the 4 hour gastric emptying protocol. Clin Nucl Med. 36(4), April 2011, pp Donohoe KJ et al. Procedure Guideline for Adult Solid-Meal Gastric-Emptying Study 3.0. J. Nucl. Med. Technol Sep;37(3): Collins PJ, Horowitz M, Cook DJ et al. Gastric emptying in normal subjects-a reproducible technique using a single scintillation camera and computer system. Gut Dec;24(12): Sachdeva P, Kantor S, Knight LC, et al. Use of a high caloric liquid meal as an alternative to a solid meal for gastric emptying scintigraphy. Dig Dis Sci Jul;58(7): Pelletier-Galarneau M, Sogbein OO, Pham X et al. Multicenter validation of a shortened gastric-emptying protocol. J Nucl Med Jun;56(6): Page 47 Thank You Page 48 86

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49 Neuroendocrine Imaging Neuroendocrine Imaging has been one of the first receptor based imaging modalities in Nuclear Medicine. It is now becoming increasingly important as the involvement of Nuclear Medicine in this field is growing. The talk will review the basic indications of imaging with Pentetreotide and mibg imaging with SPECT, and discuss options that have been used clinically in PET, including the newly approved tracers. 1) Review of pathologies within Neuroendocrine Imaging 2) Review of SPECT tracers used for clinical imaging 3) Review of PET tracers used for clinical imaging in Neuroendocrine Diseases 4) Comparison of PET vs. SPECT tracers 5) Implications of prognosis and therapy with Nuclear Medicine References: 1) Pfannenberg AC, et al. Benefit of Anatomical-functional Image Fusion in the Diagnostic Work-up of Neuroendocrine Neoplasms Eur J Nucl Med Mol Imaging. 2003;30: ) Buchmann I, et al. Comparison of 68 Ga-DOTATOC PET and 111 In-DTPAOC (Octreoscan) SPECT in Patients with Neuroendocrine Tumours Eur J Nucl Med Mol Imaging (2007) 91

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51 Educational Symposia SAVE THE DATES 5620 West Sligh Avenue Tampa, Florida WINTER 2018 SYMPOSIA Vail Snowmass *Snowmass February 4-9, 2018 February 11-16, 2018 February 18-23, 2018 Vail Marriott Mountain Resort & Spa The Westin Snowmass Resort The Westin Snowmass Resort Vail, CO Snowmass Village, CO Snowmass Village, CO *Dates and Location Subject to Change. ONE If you enjoyed this meeting and would like to share it with your colleagues, these lectures and thousands more are available for streaming on-demand at FREE HOUR edusymp.com docmeded.com (800) (Toll-Free, U.S. & Canada) (813) (Direct) Table of Contents