**4. Cases studies and future trends of nuclear imaging**

Current clinical applications of nuclear medicine include the ability to:


The use of nuclear hybrid imaging, particularly PET-CT, is expanding rapidly. More recently, positron emission tomography (PET) has increased its applications in total body imaging to include the postoperative orthopedic patient. PET and PET-CT scanning for postoperative infection has also been investigated in the spine, also showing good results, with increased specificity for infection in contrast to routine three-phase bone scan or combination radiotrac‐ ers [35]. The increasing specificity of nuclear medicine agents continues to broaden nuclear medicine applications in the postoperative musculoskeletal imaging setting.

The development of SPECT and SPECT-CT is a logical consequence of the previous success of PET-CT, the first of these hybrid imaging techniques. The introduction of this technique, about 10 years ago, meant a final advanced nuclear medicine in the field of oncology. Pushed forward by the scientific and commercial success of these PET-CT, the industry developed the SPECT-

Rest (a) Effort Rest (b) Effort

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**Figure 13.** A SPECT slice of a patient's heart. SPECT is generally indicated for evaluation of coronary perfusion and myocardial viability. (a): showing anterior ischemia, (b): demonstration of a myocardial infarction. Source: CEM, Ren‐

CT PET

**Figure 14.** Larynx cancer demonstration and imaging with PET and CT images combination. Source: CEM, Rennes.

**Figure 15.** Bone SPECT Scan (Phosphonates -99m-Tc), (a): depicting bone metabolism in whole body: abnormal osteo‐ genesis zones screening and surveillance (bone lesions carcinoma and other primary or metastatic bone lesions (Pa‐ get's disease, Osteomyelitis and fractures)), (b): SPECT bone scan showing left femoral neck fracture. Source: CEM,

(a) (b)

PET/CT

nes.

Rennes.

CT, a technology similar to the exams conventional (= non-PET) nuclear medicine. Here too, the SPECT functional information is supplemented by information from CT coupled thereto. Within a single examination, SPECT-CT is able give the correct diagnosis of bone lesion corresponded to metastatic disease. In a general hospital, the SPECT-CT is also used in the development of pain syndromes of orthopedic or rheumatic origin, for example at the lumbar level ("back pain") or a knee. The success of SPECT-CT is that the bone scan shows osteoblastic lesions selectively cause pain and coupling with the CT image interpretation makes-SPECT abnormalities more accurately [36]. SPECT-CT is also successively used for the detection of sentinel lymph node scintigraphy. It allows the visualization of the effect or lymph vessels in which they lead and are thus likely to be the site of métastastiques cells. In principle (and in practice), if such individual nodes called "sentinel" are not found with the tumor cells, while cleaning, any additional node excision is unnecessary [36]. Among other undesirable side effects, thus avoiding impairment of lymphatic drainage of the upper limb and the onset postoperative thugs. SPECT-CT allows more accurate localization by this or these nodes but also give information on their volume, shape and density, all useful information for surgeons in their quest intraoperative these nodes. SPECT-CT in this area still has other potential applications, such as cancers of the prostate, cervix of the uterus and of the head and neck. Patients with thyroid cancer who develop recurrent disease is suspected are often subjected to whole body scintigraphic imaging after administration of a small activity of an isotope of iodine (iodine-123 or iodine-131). With SPECT-CT, better diagnosis of pulmonary embolism is also possible. Pulmonary embolism (PE) is indeed a common problem in cancer. Planar scintigraphic imaging of the normal, the diagnosis of PE is typically established by the demonstration of a mismatch, a defect of pulmonary perfusion with preserved ventilation, normal in the same territory. Here SPECT acquisitions of pulmonary ventilation (after inhalation aerosol technetium) and pulmonary perfusion (after injection of macro-aggregates of albumin technetium) will be combined with a CT scan of the lungs. The classically observed mismatches between ventilation (preserved) and perfusion (altered) will be confronted with anomalies of the CT scan in the corresponding regions [36]".

A review of applications of PET, PET-CT, SEPCT and SPECT-CT and their clinical benefits with an emphasis on oncologic applications is given below (Figures 12-18).

**Figure 12.** Thyroid scan with planar scintigraphy (99mTc04). Source: CEM, Rennes.

Principles and Applications of Nuclear Medical Imaging: A Survey on Recent Developments http://dx.doi.org/10.5772/54884 23

CT, a technology similar to the exams conventional (= non-PET) nuclear medicine. Here too, the SPECT functional information is supplemented by information from CT coupled thereto. Within a single examination, SPECT-CT is able give the correct diagnosis of bone lesion corresponded to metastatic disease. In a general hospital, the SPECT-CT is also used in the development of pain syndromes of orthopedic or rheumatic origin, for example at the lumbar level ("back pain") or a knee. The success of SPECT-CT is that the bone scan shows osteoblastic lesions selectively cause pain and coupling with the CT image interpretation makes-SPECT abnormalities more accurately [36]. SPECT-CT is also successively used for the detection of sentinel lymph node scintigraphy. It allows the visualization of the effect or lymph vessels in which they lead and are thus likely to be the site of métastastiques cells. In principle (and in practice), if such individual nodes called "sentinel" are not found with the tumor cells, while cleaning, any additional node excision is unnecessary [36]. Among other undesirable side effects, thus avoiding impairment of lymphatic drainage of the upper limb and the onset postoperative thugs. SPECT-CT allows more accurate localization by this or these nodes but also give information on their volume, shape and density, all useful information for surgeons in their quest intraoperative these nodes. SPECT-CT in this area still has other potential applications, such as cancers of the prostate, cervix of the uterus and of the head and neck. Patients with thyroid cancer who develop recurrent disease is suspected are often subjected to whole body scintigraphic imaging after administration of a small activity of an isotope of iodine (iodine-123 or iodine-131). With SPECT-CT, better diagnosis of pulmonary embolism is also possible. Pulmonary embolism (PE) is indeed a common problem in cancer. Planar scintigraphic imaging of the normal, the diagnosis of PE is typically established by the demonstration of a mismatch, a defect of pulmonary perfusion with preserved ventilation, normal in the same territory. Here SPECT acquisitions of pulmonary ventilation (after inhalation aerosol technetium) and pulmonary perfusion (after injection of macro-aggregates of albumin technetium) will be combined with a CT scan of the lungs. The classically observed mismatches between ventilation (preserved) and perfusion (altered) will be confronted with

22 Imaging and Radioanalytical Techniques in Interdisciplinary Research - Fundamentals and Cutting Edge Applications

anomalies of the CT scan in the corresponding regions [36]".

**Figure 12.** Thyroid scan with planar scintigraphy (99mTc04). Source: CEM, Rennes.

with an emphasis on oncologic applications is given below (Figures 12-18).

A review of applications of PET, PET-CT, SEPCT and SPECT-CT and their clinical benefits

**Figure 13.** A SPECT slice of a patient's heart. SPECT is generally indicated for evaluation of coronary perfusion and myocardial viability. (a): showing anterior ischemia, (b): demonstration of a myocardial infarction. Source: CEM, Ren‐ nes.

**Figure 14.** Larynx cancer demonstration and imaging with PET and CT images combination. Source: CEM, Rennes.

**Figure 15.** Bone SPECT Scan (Phosphonates -99m-Tc), (a): depicting bone metabolism in whole body: abnormal osteo‐ genesis zones screening and surveillance (bone lesions carcinoma and other primary or metastatic bone lesions (Pa‐ get's disease, Osteomyelitis and fractures)), (b): SPECT bone scan showing left femoral neck fracture. Source: CEM, Rennes.

(a)

Smoking Non-

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**Figure 17.** PET and SPECT neuro-receptors and neuro-transporters imaging with specific radio-marker molecules. (a): dopamine transporter, (b): dopamine receptor, (c): Nicotine receptor, and (d): Opioid receptor. Source: CEM, Rennes.

(a)

(b)

(c)

(d)

Smoking

**Figure 16.** SPECT and PET applications in Neurology. These techniques are indicated in the diagnosis of Regional brain abnormalities (Cerebral perfusion) in and in vitro leukocyte marking (99mTc). (a) Epilepsy: SPECT can be very helpful in the localization of the epileptogenic zone and for mapping functional areas of the brain, such as those for language and motor function, (b) Parkinson: image from of a normal healthy case (left) and abnormal image in the case of early Parkinson's disease untreated, and (c) Alzheimer: PET scan of a normal volunteer (left) and a patient with Alzheimer's disease (right). Nuclear imaging devices help doctors diagnose such diseases in their initial stages. Sources: CEM, Ren‐ nes and Daniel Silverman, UCLA.

Principles and Applications of Nuclear Medical Imaging: A Survey on Recent Developments http://dx.doi.org/10.5772/54884 25

**CT Ictal SPECT Inter-ictal SPECT**

24 Imaging and Radioanalytical Techniques in Interdisciplinary Research - Fundamentals and Cutting Edge Applications

**Figure 16.** SPECT and PET applications in Neurology. These techniques are indicated in the diagnosis of Regional brain abnormalities (Cerebral perfusion) in and in vitro leukocyte marking (99mTc). (a) Epilepsy: SPECT can be very helpful in the localization of the epileptogenic zone and for mapping functional areas of the brain, such as those for language and motor function, (b) Parkinson: image from of a normal healthy case (left) and abnormal image in the case of early Parkinson's disease untreated, and (c) Alzheimer: PET scan of a normal volunteer (left) and a patient with Alzheimer's disease (right). Nuclear imaging devices help doctors diagnose such diseases in their initial stages. Sources: CEM, Ren‐

(a)

(b)

(c)

nes and Daniel Silverman, UCLA.

**Figure 17.** PET and SPECT neuro-receptors and neuro-transporters imaging with specific radio-marker molecules. (a): dopamine transporter, (b): dopamine receptor, (c): Nicotine receptor, and (d): Opioid receptor. Source: CEM, Rennes.

Finally, the development of new iterative algorithms and high-speed/high-capacity compu‐ tational systems for rapid image reconstruction; would allow image data to be converted to quantitative parametric images pertaining to biological and pharmacological processes in

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27

I would like to thank Prof. Patrick Bourguet from the Department of Nuclear Imaging and Medicine, Centre Eugène Marquis (CEM), Rennes, France, for his support in the realization of this work and particularly for giving me the permission to use some examples of nuclear

Data and statements expressed in this paper are those from the author and published bibliog‐ raphy cited in this work, and do not necessarily reflect organizations, laboratories and the firms which the author has mentioned as examples. The author does not endorse any equipment or

imaging applications and illustrations developed at his nuclear imaging laboratory.

Department of Physics, Faculty of Science, University of Ferhat Abbas-Sétif, Algeria

[1] Anger, H. O. Scintillation Camera. The Review of Scientific Instruments, 29(1);

[2] Anger, H. O. Scintillation camera with multichannel collimators. J Nucl Med, 5;

[3] Jonasson, T. Revival of a Gamma Camera, Master of Science Thesis (2003). Nuclear Physics Group, Physics Department, Royal Institute of Technology, Stockholm, TRI‐

disease.

**Disclaimer**

material cited herein.

**Author details**

Faycal Kharfi\*

**References**

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(1964). , 515-531.

TA-FYS 2003:40, 0028-0316X., 0280-316.

**Acknowledgements**

**Figure 18.** During radiotherapy planning FDG-PET-CT has been shown to be useful to better delineate the biologically active tumor volume and to distinguish between viable tumor tissue and non-specific changes due to previous surgi‐ cal and/or radio therapeutic treatments. The figure present a planning for radiotherapy fields based on images from PET-CT in a patient with advanced stage lung carcinoma. Source: www.IAEA.org/.../gc54inf-3-att1\_en.pdf.
