NM-GGC-PROC-006 Nuclear Medicine Referral Criteria. NHS Greater Glasgow and Clyde

Transcription

1 Referring Patients f Nuclear Medicine Procedures in Greater Glasgow and Clyde Introduction The Ionising Radiation (Medical Exposure) Regulations [IR(ME)R] 000 make it necessary f all investigations using ionising radiation to be justified on an individual patient basis. To meet this requirement, the Nuclear Medicine service have produced the following table of referral criteria which, if met, would justify a nuclear medicine procedure under most circumstances. These are taken from professional body guidelines including: British Nuclear Medicine Society European Association of Nuclear Medicine Society of Nuclear Medicine Royal College of Radiologists, in particular their Making the Best use of Clinical Radiology which can be accessed via staffnet at Referring Patients Referrals are accepted from any hospital doct who is, is acting on behalf of, a Consultant any General Practitioner. The name of the Consultant General Practitioner must be clearly stated on the request. Clinical Infmation Under the IRMER regulations it is essential that requests f nuclear medicine procedures contain sufficient clinical detail to allow the justification and authisation of the procedure by Nuclear Medicine staff. Part of the regulations clearly states the responsibility of the referrer "The referrer shall supply the practitioner with sufficient medical data (such as previous diagnostic infmation) relevant to the medical exposure requested by the referrer to enable the practitioner to decide whether there is sufficient benefit." Please note that the referrer remains responsible f the referral even if the task is delegated to another hospital doct acting on their behalf. The practitioner f a Nuclear Medicine procedure will always be a clinician holding an ARSAC certificate. AB MB 1 13/0/014 13/0/016 1 of 16

2 Patient Infmation on Request The following infmation about the patient is required as a minimum: Patient s surname Patient s fename Date of Birth Address CHI Number Hospital number (IP, if allocated) Examination requested Sufficient clinical infmation relevant to justify the medical exposure requested Indication of pregnancy, LMP and breast feeding as appropriate Indication of known potential medical complications associated with examination requested e.g. allergy, renal function (f CT contrast) Signature of referrer (this may be physical in terms of an electronically validated request) NAME of referrer Date of referral Name of consultant Hospital / Ward / Department / GP surgery Research projects should be clearly identified Please be patient if Nuclear Medicine staff contact you to ask f me infmation. Radiation Protection of Other People Nuclear Medicine investigations are different from other radiological investigations because the patients themselves become radioactive and may therefe pose a radiation risk to others. Please pay particular attention to any instruction sent back with the patient, with particular regard to whether urine and blood samples can be taken, bearing in mind these may both be radioactive. Occasionally, investigations treatments cannot be carried out because of the patient's family circumstances. Radiation to the Patient, Pregnancy and Breastfeeding The list of investigations following contains infmation about the radiation dose received (in msv) by the patient from the procedure and this must be bne in mind when considering the suitability of using a nuclear medicine procedure. As a guide, the natural background radiation dose received by any person is about.5 msv per annum. In the pregnant patient there is also a radiation dose to the foetus and this must be strictly limited. Furtherme, many radiopharmaceuticals appear in breast milk, so the breast-fed infant would receive a radiation dose. F these reasons the fact possibility of pregnancy breastfeeding must be clearly stated in the request f all females in the age range 1-55 years old. Supplementary Drugs In addition, some investigations require the administration of other, non-radioactive pharmaceuticals as an essential part of the test. These are specified in italics after the relevant referral criteria. Your request f an investigation will be taken as implying agreement to the administration of the specified supplementary drug (this AB MB 1 13/0/014 13/0/016 of 16

3 includes the administration of saline). If you are unhappy about your patient being given these drugs you feel they are contraindicated this must be clearly stated in the request. SPET-CT Nuclear medicine is a functional imaging modality it does however have poer resolution than many other types of imaging. Most nuclear medicine departments now have access to a low dose CT along with the nuclear medicine equipment and this can be used in SPET-CT to allow anatomical localisation and in some cases characterisation of lesions. Some investigations have this undertaken in all cases (the use of SPET-CT is indicated on the table), in others experienced staff within nuclear medicine will decided whether SPET-CT would be beneficial. Less Common Procedures Certain Investigations are not carried out by all Nuclear Medicine Departments. If necessary the request may be sent to another site. There may be other procedures which fall into the categy of research investigations and the ARSAC holder should be contacted. Contact Points General Nuclear Medicine Telephone Gartnavel General Hospital Glasgow Royal Infirmary Southern General Hospital Stobhill ACH Victia Infirmary Victia ACH Western Infirmary - see Gartnavel General Hospital Specialised Departments Nuclear Cardiology Nth Glasgow Institute of Neurological Sciences AB MB 1 13/0/014 13/0/016 3 of 16

4 Nuclear Medicine Investigation Groups Nuclear Medicine Investigation Group 4 Bone Imaging. 5 Brain Imaging.6 Specialist Brain Imaging NeuroSPECT..6 Cardiac Imaging.9 Eye Imaging 9 Hepatobiliary Imaging.10 Gastro-Intestinal Imaging & Investigation 10 Haematological Imaging & Investigation.11 Infection, Inflammation Imaging & Investigation.1 Lung Imaging 13 Lymphatic Imaging & Investigation...13 Renal Imaging & Investigation...14 Salivary Imaging..14 Thyroid & Parathyroid Imaging & Investigation..15 Therapeutic Tumour Imaging...16 AB MB 1 13/0/014 13/0/016 4 of 16

5 Referral Criteria * dose received from ARSAC diagnostic reference level (DRL) 1. SNM Guidelines. BNMS Guidelines (including EANM) 3. RCR Guidelines Bone Imaging Isotope bone imaging with 99m Tc MDP is highly sensitive f osteoblastic activity but has po specificity. SPET-CT (low dose CT) is often used to increase specificity and provide accurate localisation. In lytic disease (e.g. myeloma) 99m Tc MDP imaging can give misleading infmation. Investigation of occult fracture 1 Investigation of osteomyelitis 1 Investigation of arthritides 1 Investigation of reflex sympathetic dystrophy 1 Investigation of bone infarcts 1 Investigation of bone graft viability 1 Distribution of osteoblastic activity pri to 89 Sr therapy 1 Investigation of low back pain Investigation of distribution of osteopotic fractures Investigation of neoplasia 1 Staging re-staging assessment of bone pain with known suspected malignancy increased tumour marker levels (e.g. PSA) moniting disease progression and response to chemo radiotherapy Investigation of X-ray abnmality Assessment of x-ray abnmality Investigation of bony pain post joint replacement which is otherwise unexplained 1 Investigation of hypercalcaemia Condylar disease Investigation of hypocalcaemia (osteomalacia) 3 Investigation of Paget's disease Investigation of osteoid osteoma Investigation of stress fracture, shin splints 3 Investigation of mandibular disders 99m Tc-MDP 5 Bone marrow imaging f the investigation of systemic haematological disders 99m Tc-colloid 4 AB MB 1.3 8/01/14 8/01/16 5 of 16

6 Brain Imaging The following procedures are undertaken within general nuclear medicine departments within GGC. Investigation of encephalitis 3 99m Tc-HMPAO 5 Investigation of dementia 1,3 99m Tc-HMPAO 5 Investigation of epilepsy (inter-ictal) 1,3 99m Tc-HMPAO 5 Investigation of regional cerebral blood flow 1,3 99m Tc-HMPAO 5 Evaluation of suspected brain trauma 1 99m Tc-HMPAO 5 Investigation of tumour viability 01 Tl -chlide 6 Movement disder imaging 13 I-DaTSCAN 4.4 Potassium Iodate Dementia with Lewy Bodies 13 I-DaTSCAN 4.4 Potassium Iodate Specialist Brain Imaging - NeuroSPECT The Institute of Neurological Sciences at Southern General Hospital has a specialist NeuroSPECT centre and as such has specific referral criteria please refer to this section f Specialist Brain Imaging. Brain SPET using HMPAO produces images of cerebral metabolic perfusion (usually reflecting brain function) and is used in: Evaluation of cerebrovascular disease, vasculitis and stroke Differential diagnosis of dementia Detection and evaluation of encephalitis (especially herpes encephalitis) Functional localisation of epileptic foci (only in presurgical context) Determination of brain death Brain SPET using HMPAO produces images of cerebral metabolic perfusion (usually reflecting brain function). When used in conjunction with acetazolamide the scan can indicate cerebrovascular reactivity and is used in: Evaluation of cerebrovascular reserve in TIA, completed stroke and/ vascular anomalies (e.g. arterial-venous malfmation) (Rarely) Helping in distinguishing vascular from neuronal causes of dementia 99m Tc-HMPAO 5 99m Tc-HMPAO Acetozolamide 5 AB MB 1.3 8/01/14 8/01/16 6 of 16

7 Specialist Brain Imaging NeuroSPECT cont d Brain SPECT using HMPAO is used to assess regional perfusion during a WADA (intracarotid sodium amytal test) procedure in presurgical wkup f epilepsy. Brain SPET using FPCIT produces images of the pre-synaptic dopamine transpters (density is highest in the striatum). Used in patients with symptoms of Parkinsonism a trem disder and the scan will provide an accurate differential diagnosis of degenerative parkinsonism (Parkinson s Disease, Progressive Supranuclear Palsy, Multiple System Atrophy, Cticobasal Degeneration, Lewy Body Dementia) versus non-degenerative conditions, such as essential trem, drug-induced pseudoparkinsonism and vascular parkinsonism. Differential diagnosis between Lewy Body Dementia and Alzheimer s Disease. 99m Tc-HMPAO sodium amytal 13 I-FPCIT Datscan Brain SPET using IBZM produces images of the post-synaptic dopamine D recepts (density is highest in the striatum). It is used in patients with symptoms of Parkinsonism and provides infmation on: The potential response of the patient to antiparkinsonian medication (non-responders are me likely to have low recept density) Differential diagnosis of parkinsonism (patients with parkinsonism plus syndromes are me likely to have low recept density, patients with early idiopathic Parkinson s Disease are me likely to have nmal slightly raised recept density). However, its low sensitivity requires judicious use of this indication. The extent of D recept blockade under treatment with neuroleptics similar drugs. The assessment of conditions which result in post-synaptic striatal deficit such as Wilson s Disease and Huntington s Disease. 13 I-IBZM 5.0 AB MB 1.3 8/01/14 8/01/16 7 of 16

8 Specialist Brain Imaging NeuroSPECT cont d Brain SPET using Thallium (a potassium analogue) produces images of ATP-ase activity in brain regions where there is some disruption of the blood-brain-barrier. It is indicated in: Differential diagnosis of brain tumours Determination of malignancy grade of gliomas Differential diagnosis of recurrent brain tumour and radiation necrosis Selection of biopsy site Tumour delineation f therapy planning Follow-up of primary brain tumours and malignant transfmation Differential diagnosis of Toxoplasmosis and Lymphoma in AIDS Brain SPET using alpha-methyl-tyrosine produces images of amino-acid transpt within the brain. It is used in: Differential diagnosis of brain tumours and non-neoplastic lesions Follow-up of primary brain tumours Detection of residual and recurrent glioma Selection of biopsy site Tumour delineation f therapy planning Brain SPET using Octreoscan produces images of somatostatin recepts. The density of somatostatin recepts is characteristically high in most meningiomas. The scan is used in: Differential diagnosis of meningioma vs other brain masses Localisation of brain tumours (usually meningioma) Follow-up of meningiomas. 01Tl-chlide 6 13I-alphamethyl-tyrosine In-octreotide 8 AB MB 1.3 8/01/14 8/01/16 8 of 16

9 Cardiac Imaging Diagnosis of conary artery disease 1, presence 1, location (conary territy) 1, Extent(number of vascular territies) 1, Assessment of the degree of conary stenosis and impact on regional perfusion 1 Myocardial viability assessment 1, Ischaemia vs. scar 1 predict improvement in function following revascularization 1, Risk assessment (prognosis) in patients 1, post myocardial infarction 1 pre-operative f maj surgery who may be at risk f conary events 1 Moniting treatment effect 1 after conary revascularization 1, Medical therapy f congestive failure angina 1 Lifestyle modification 1 Pre cardiac transplant assessment Post cardiac transplant assessment Assessment of congenital cardiac abnmalities Assessment of arrythmias Assessment of right ventricular dysplasia Assessment of patients with Syndrome X Assessment of cardiac ejection fraction Regional wall motion, ventricular volumes and stroke volume ratios Moniting cardiac ejection fraction following administration of cardiotoxic drugs 99m Tctetrofosmin 01 Tl-chlide Dipyridamole Adenosine Dobutamine Regadenoson 99m Tc-nmal erythrocytes Pyrophosphate 99m Tc-nmal erythrocytes Pyrophosphate 6 (stress) 6 (rest) Eye Imaging Investigation of lacrimal drainage 99m Tcpertechnetate 99m Tc-colloid AB MB 1.3 8/01/14 8/01/16 9 of 16

10 Hepatobiliary Imaging Evaluation of suspected acute cholecystitis 1 Evaluation of chronic biliary tract disders 1 Evaluation of common bile duct obstruction 1 Detection of bile extravasation 1 Evaluation of abnmalities of biliary tree 1 Investigation of pain post cholecystectomy Investigation of pain in suspected biliary hypertension 99m Tc-IDA 99m Tc-IDA 99m Tc-IDA 99m Tc-IDA 99m Tc-IDA 99m Tc-IDA 99m Tc-IDA 99m Tc-IDA Investigation of gall bladder kinetics Fatty meal stimulated (Calogen) 99m Tc-IDA Investigation of bile duct kinetics Investigation of hepatic hemangioma 1,3 Evaluation of liver trauma Buscopan (GRI Only) 99m Tc-nmal erythrocytes Pyrophosphate 8 99m Tc-colloid 0.8 Gastro-Intestinal Imaging & Investigation Investigation of gastric emptying 1 Patients with suspected gastroparesis, nausea, vomiting, upper abdominal bloating chronic aspiration Investigation of gastric emptying (solid phase) Investigation of gastric emptying (liquid phase) Investigation of oesophageal transit and reflux 1 Investigation of Meckel s diverticulum as a source of unexplained GI bleeding 1,3 Investigation of acute GI bleeding 1,3 H Pyli infection detection 1 Investigation of dyspepsia H Pyli eradication post therapy 99m Tc-solid meal In-DTPA 3 99m Tc-solid meal m Tcpertechnetate 5 Losec (GRI only) Cimetidine (RHSC) 99m Tc-nmal erythrocytes Pyrophosphate 3 14 C-urea C-urea C-urea 0.0 AB MB 1.3 8/01/14 8/01/16 10 of 16

11 Haematological Imaging & Investigation Measurement of blood volume (e.g. in polycythaemia) Red cell turnover and sites of sequestration Investigation of splenic function in patients with thrombocytopenia 1 To check if mass is functioning splenic tissue and / assess localisation of spleen tissue 1 15I-HSA and 51 Cr-nmal erythrocyes 51 Cr-nmal erythrocyes 99m Tc-denatured red cells 99m Tc-denatured red cells 99m Tc-colloid AB MB 1.3 8/01/14 8/01/16 11 of 16

12 Infection, Inflammation Imaging & Investigation To detect sites of infection/inflammation in patients with fever of unknown igin 1 To localize an unknown source of sepsis and to detect additional site(s) of infection in patients with persistent recurrent fever and a known infection site 1(any renal bone any chronic infection) To survey f site(s) of abscess infection in a febrile post-op patient without localizing signs symptoms. Fluid collections, ileus, bowel gas and/ fluid, and healing wounds reduce the specificity of CT and ultrasound 1 To detect and follow-up osteomyelitis primarily when there is existing bone pathology such as infected joint prostheses, non-united fractures sites of metallic hardware from pri bone surgery 1 To detect osteomyelitis in diabetic patients when degenerative traumatic changes, neuropathic osteoarthropathy pri osteomyelitis have caused increased bone remodeling 1 To detect osteomyelitis involving the skull in postoperative patients and f follow-up of therapy 1 Labelled leucocytes are preferred Labelling can be achieved with: 111 In-leucocytes 99m Tcexametazime leucocytes When labelling is unavailable inappropriate: 9 To detect mycotic aneurysms, vascular graft and shunt / fistula infections 1 In cases of osteomyelitis when there has been thopaedic intervention such as infected joint prostheses, sites of metallic hardware from pri bone surgery 1 To detect site(s) and extent of inflammaty bowel disease 1 To detect site(s) and extent of Crohn s disease 1 Evaluation and follow-up of active lymphocytic granulomatous inflammaty processes such as sarcoidosis tuberculosis (Ga) 1 Diagnosing osteomyelitis and/ disk space infection. Ga-67 is preferred over labeled leukocytes f disk space infection 1 AB MB 1.3 8/01/14 8/01/16 1 of 16 99m Tc- Leucoscan (osteomyelitis) 67 Ga Laxative ( may be used) 111 In- Leucocytes 99m Tcexametazime leucocytes ± 99m Tc-colloid (f marrow delineation) 99m Tcexametazime leucocytes 99m Tcexametazime leucocytes 67 Ga Laxative 67 Ga Laxative ±

13 Lung Imaging Investigation of acute PTE 1, Perfusion : Monit changes in perfusion after PTE 99m Tc-MAA Preoperative ventilation-perfusion assessment Investigation and follow up of chronic PTE Ventilation : Investigation of intracardiac shunts 81m 1 Kr Investigation of chronic lung disease 99m Tc- Technegas Post pneumonectomy assessment 99m Tc-Aerosol Lymphatic Imaging & Investigation Sentinel node investigation f some cancers require specialist ARSAC approval and the individual departments should be contacted directly about such investigations, e.g. head and neck, penile, vulval Sentinel node localisation melanoma patients 99m Tc-colloid 0.05 Investigation of po lymph drainage 99m Tc-colloid 0.05 Sentinel node localisation breast patients 99m Tc-colloid 0.05 Sentinel node localisation penile cancer 99m Tc-colloid 0.05 Sentinel node localisation head and neck 99m Tc-colloid 0.05 AB MB 1.3 8/01/14 8/01/16 13 of 16

14 Renal Imaging & Investigation Assessment of split renal function function of one me moieties 99m Tc-MAG3 99m Tc-DMSA Assessment of obstruction Dilation of collecting system 99m Tc-MAG3 0.7 Suspected PUJ obstruction Post surgical evaluation of a previously obstructed system Indirect micturating cystogram f vesico-ureteric reflux Frusemide Tc-MAG3 0.7 Assessment of kidney and scarring In acute UTI 99m Tc-DMSA 0.7 Post UTI infection Assessment of hseshoe ectopic kidney 99m Tc-DMSA 0.7 Localisation of poly functioning kidney 99m Tc-DMSA 0.7 Assessment of kidney function in presence of an abdominal mass 99m Tc-DMSA 0.7 Assessment of perfusion of renal transplants Assessment of kidney perfusion Assessment of urine leak post surgery Assessment of patients with nephrotic syndrome Measurement of Glomerular Filtration Rate (GFR) Assessment of live kidney don 99m Tc pertechnetate 99m Tcpertechnetate m Tc-MAG m Tc-MAG Cr-EDTA m Tc-MAG m Tc-DMSA Cr-EDTA Salivary Imaging Investigation of dry mouth 3 99m Tcpertechnetate 1.0 AB MB 1.3 8/01/14 8/01/16 14 of 16

15 Thyroid & Parathyroid Imaging & Investigation Assessment of functionality and structure of thyroid nodules 1, Assessment of goitre including hyperthyroid goitre Assessment of uptake function pri to radio-iodine therapy 1, 13 I 99m Tcpertechnetate 13 I 99m Tcpertechnetate 13 I 99m Tcpertechnetate I To locate ectopic thyroid tissue (i.e. lingual) determine whether a suspected thyroglossal duct cyst is the only functioning thyroid tissue present 1, To assist in evaluation of congenital hypothyroidism 1 To evaluate a neck mass. Radionuclide scintigraphy may be helpful to confirm that the mass is functioning thyroid tissue 1 To investigate retro-sternal goiter sub-sternal mass To differentiate thyroiditis (i.e. subacute silent) and factitious hyperthyroidism from Graves disease and other fms of hyperthyroidism 1, To investigate the suspected misuse of thyroxine / triiodothyronine Thyroid uptake studies in the investigation of thyroid disease (uptake counter) 1 Whole-body 13-I / 131-I imaging f thyroid metastases 1 Whole-body 01-Tl imaging f thyroid metastases 13 I 99m Tcpertechnetate I 99m Tcpertechnetate I 99m Tcpertechnetate I 4 13 I 99m Tcpertechnetate 13 I 99m Tcpertechnetate 13 I 99m Tcpertechnetate I13 I Tl 13 I Investigation of thyroid binding defects Investigation of medulary carcinoma of the thyroid (potassium iodate) Investigation of thyroid cancers 1 Investigation of hyperparathyroidism 1 To localize tissue pri to surgery in patients with persistent recurrent disease Perchlate (f discharge) 99m Tc-DMSAV 13 I 131 I 01 Tl 99m Tc-sestamibi + 13 I + SPET-CT AB MB 1.3 8/01/14 8/01/16 15 of 16

16 Therapeutic Please note these therapies have very specific radiation protection needs and therefe are only perfmed on a limited number of specific sites. Thyrotoxicosis 131 I Toxic diffuse goitre 131 I Uni-nodular toxic goitre (toxic adenoma) 131 I Multi-nodular toxic goitre (multifocal autonomy) 131 I Nodular goitre non-toxic 131 I Thyroid cancer 131 I 131 I mibg Neuroendocrine tumours Bone metastases (palliative pain relief) 1, Treatment of Polycythemia rubra vera and essential thrombocythaemia Treatment of arthritic conditions / synovitis Treatment of cystic brain tumours Treatment f bone pain in prostate cancer Treatment f lymphoma Treatment f carcinoid Treatment f carcinoid Potassium iodate 89 Sr 186 Re-HEDP 3 P 90 Y 90 Y 3 Ra-chlide 90 Y-Zevalin 90 Y-peptides 177 Lu-peptides Tumour Imaging Investigations of neuroendocrine tumours Investigation of somatostatin producing tumours Thyroid cancers see Thyroid Investigations Investigation of lymphoma (recurrence, restaging and management) 1 Investigation of active tumour (brain) 13 I-mIBG Potassium iodate 111 Inpentetreotide 67 Ga 01 Tl AB MB 1.3 8/01/14 8/01/16 16 of 16