**16. References**

130 12 Chapters on Nuclear Medicine

radionuclides have been exploited by nuclear medicine and, as well as treating several forms of neoplasia, this method can also be used to treat a number of benign articular pathologies in the field of rheumatology. Carry out a 'radiosynovectomy' procedure is possible after intra-articular administration of suitable radiopharmaceuticals. The direct irradiation of the synovial membrane can produce a therapeutic effect on persistent synovitis that is resistant to traditional drug treatment. The radiopharmaceuticals that have been used to date for radiosynovectomy are made up of small colloidal particles labelled to β-emitting isotopes (yttrium-90, rhenium-186, erbium-169, samarium-153). These compounds release their radiation energy within a radius of a few millimetres from the uptake sites. These substances are phagocytized by synoviocytes localised in relation to the synovia and it creates a radiation source that can act locally and reduce inflammatory and proliferative elements (Colamussi et al., 2004; as cited in Gumpel et al., 1975). The availability of new radiopharmaceuticals, created by replacing the colloid vector with hydroxyapatite crystals, has allowed the main undesired effect of these substances (radiation to other organs such as drainage lymph nodes, liver, spleen and bone marrow, due to the passage of the radio compound from the articular cavity to the lymphatic and then to the blood flow systems) to be avoided (Clunie et al., 1996). In the absence of side effect, this technique of low cost may be useful, not only in the treatment of advanced stage and drug-resistant arthropathies, but also to manage pain and improve articular function in the first stages of rheumatoid arthritis (Colamussi et al., 2004; as cited in Uyeo et al., 1978). A fundamental element to the success of radiosynovectomy therapy is that treatment is started early in the disease's history. This is because while radiation therapy can successfully control proliferation of the inflamed synovial membrane, it is not effective in joints that have suffered advanced osteo-cartilage damage and where the synovitic component is virtually non-existent (Franssen et al., 1989). Cases reported would further suggest its use in a wider spectrum of rheumatic disorders ranging from spondylitis to Paget's disease and from hæmophiliac synovitis to pigmented villonodular synovitis. Nevertheless, despite abundant anecdotal evidence of its efficacy, there is a paucity of controlled trials and those that have been done have produced conflicting results (Dos Santos et al., 2009, 2011) and/or have been of insufficient sample size. Two meta-analyses have been published. The first one (Jones, 1993) was made in order to assess the evidence on yttrium-90 therapy for chronic synovitis of the knee. It found out that Yttrium was superior to placebo (OR 2.42, 95% CI 1.02-5.73), although possible publication bias limited the interpretation of this result. Yttrium was not superior to triamcinolone (OR 1.89, 95% CI 0.81-10.55) or other active modalities (OR 1.04, 95% CI 0.72-1.52). The second one and most recent (Van der Zant et al., 2009) has been published with the objective to perform a systemic review and meta-analysis on the effectiveness of radiosynoviorthesis. It has shown high success rates of radiosynoviorthesis, but differences in effect with glucocorticoid injection are less evident, although there is marked heterogeneity in study design of a small number of comparative studies. Therefore the efficacy of radiosynovectomy alone or in combination with steroid therapy must be assessed by other sufficiently powered randomised controlled studies.

Nuclear medicine techniques supply physiological information that is complementary to that provided by radiological techniques and can play a fundamental role not only for the examination and treatment of articular disorders but also in overall patient evaluation.

**15. Conclusion** 


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**6** 

**Role of the Radionuclide Metrology** 

Nuclear medicine practices rely on the use of radiopharmaceuticals, for diagnosis and therapy purposes. Their use is based on the incorporation in the human body through a medical procedure: intravenous injection, ingestion, or inhalation. The quality of the administration procedure is tightly influenced by the following determining factors: the administration of the right activity to the patient, such as prescribed by the medical doctor, and the quality of the radiopharmaceutical product. The full control of these parameters is obtained by using high quality measurement equipment and following well established

The radiopharmacy units, the measurement equipment providers and the nuclear medicine units can fulfill these requirements only by using calibrated instrumentation and following validated measurement methods. The technical support is offered by the Radionuclide Metrology Laboratories (RML) which can assure the continuity of the metrological traceability chain of measurement up to the highest, primary radioactivity standards. The metrological traceability and its chain are defined by the document: *"BIPM, JCGM 200:2008 – International vocabulary of metrology – Basic and general concepts and associated terms (VIM)",*



From these definitions one can deduce the role of the RMLs: to develop activity standards, to validate them in relation with the International System of Units (SI) and to disseminate them as radioactive standard sources and solutions, or calibration services to the implied



procedures for the measurement and application of the radiopharmaceutical.

**1. Introduction** 

as:

entities.

*measurement uncertainty"* 

these requirements

*used to relate a measurement result to a reference"* 

This chapter of the book presents the following aspects:

process, and in nuclear medicine units;

*Horia Hulubei National Institute for R&D in Physics and* 

**in Nuclear Medicine** 

*Nuclear Engineering, IFIN-HH,* 

Sahagia Maria

*Romania* 

