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Nuclear Medicine

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Published: Mar 1, 2019

Words: 379 | Page: 1 | 2 min read

Works Cited

• International Atomic Energy Agency. (2019). Nuclear Medicine Resources Manual. Retrieved from https://www-pub.iaea.org/MTCD/Publications/PDF/Pub1777_web.pdf
• Ziessman, H. A., O'Malley, J. P., & Thrall, J. H. (2019). Nuclear Medicine: The Requisites. Elsevier.
• Fahey, F. H., & Zukotynski, K. (Eds.). (2016). Atlas of Nuclear Medicine. Springer.
• Henkin, R. E., Bova, D., Dillehay, G., & Jaszczak, R. (2019). Nuclear Medicine: A Core Review. Oxford University Press.
• Ell, P. J., Gambhir, S. S., & Hutton, B. F. (Eds.). (2019). Nuclear Medicine in Clinical Diagnosis and Treatment (4th ed.). Churchill Livingstone.
• O'Keefe, G. J., & Giammarile, F. (Eds.). (2016). Nuclear Medicine Therapy: Principles and Clinical Applications. Springer.
• Wong, K. K., Gould, M. K., & Wald, C. (Eds.). (2021). Nuclear Medicine: A Case-Based Approach. Springer.
• Saha, G. B. (2019). Fundamentals of Nuclear Pharmacy (7th ed.). Springer.
• Vallabhajosula, S. (Ed.). (2018). Molecular Imaging: Radiopharmaceuticals for PET and SPECT. Springer.
• Lin, E. C., & Buxbaum, S. G. (Eds.). (2020). Nuclear Medicine Physics: The Basics (9th ed.). Lippincott Williams & Wilkins.

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The role of nuclear medicine in modern society

Ag spoke to dr arturo chiti, president elect of the european association for nuclear medicine (eanm) about the role nuclear medicine plays in modern society, and its challenges..

In modern society there are a number of healthcare challenges that researchers are fighting against to find new prevention methods and treatments for. Diseases such as cancer can be treated more successfully if caught and diagnosis is made much earlier.

Nuclear medicine plays a pivotal role in this and can help give medical staff the early diagnosis for the patient, and a more localised point for treatment. The European Association of Nuclear Medicine (EANM) works to educate people in the method of nuclear medicine, and further advance methods to help with that all important early diagnosis. However, when people hear the word nuclear, it can generate a fear in some, and without the correct information patients don’t understand how nuclear medicine can help prevent and treat some of those major health challenges.

In order to help give patients more information about molecular imaging and nuclear medicine techniques, The EANM have put together information for patients to remove the fear regarding this form of treatment, and set their minds at ease. Editor Laura Evans spoke to Doctor Arturo Chiti, President Elect of the EANM about how nuclear medicine fits into modern society, and the challenges that come with such a complicated field.

“One of the advantages is that nuclear medicine is able to see molecular alterations – what we call functional alterations in cancer,” explains Doctor Chiti.

“From research we have learnt that these alterations normally proceed the multi-functional alterations that we see with a CT scan. This is important because when you suspect cancer is present it helps in giving a very early diagnosis compared to morphological imaging.”

The method of nuclear medicine can be quite complicated, but it can help a number of healthcare problems from cancer to thyroid problems. Doctor Chiti explained the process, and the advantages this has with diseases such as cancer.

“Nuclear medicine or molecular imaging uses small probes that are called tracers, and these probes are able to localise particular tissues within the human body.

“These probes help to visualise diseases like cancer, or even evaluate how the blood flow goes into the heart. With this principle we are able to treat diseases like cancer, because these probes have radio-nuclides imbedded into the molecule, and radio-nuclides help you to localise exactly where the problem may be in order to treat it,” he says.

“Nuclear medicine helps us to do what we call personalised or precise medicine, because we can visualise the target and we can treat accordingly to this.”

Over the years nuclear medicine has evolved to keep up with modern medicine, and the constant health challenges faced throughout Europe. There are a number of ways in which this has happened, as explained by Doctor Chiti.

“We have 2 main tracks, the most important is the research of radiopharmaceuticals. These are the probes that are used in the process of nuclear medicine,” he says.

“In an effort to get more specific molecules to visualise or treat specific targets, we are carrying out research of radiopharmaceuticals for diagnosis, biological characterisation, and therapy. We can also design molecules which are exactly the same or similar to drugs which are used – non radioactive drugs.

“So the key aim is to be able to visualise the targets of drugs, which are used in oncology. This means you can select those patients that are going to benefit from a particular treatment.”

Technology also plays a vital role in molecular imaging, and one of the main challenges that Doctor Chiti pointed out was keeping up to date with sophisticated technology, as it evolves.

“We are using big hardware in order to track the radiopharmaceuticals which are injected into the patient, and this means that from that point of view we are aiming at having more and more sophisticated technology in order to visualise very small alterations in the human body,” says Doctor Chiti.

“Of course the imaging we use is always multi-modality imaging, that means that you have the molecular imaging, but you always have a CT scan or an MR scan as a companion in order to be able to have morphological and functional imaging in the patient at the same time. This increases the accuracy of the diagnoses we can do.”

Radiopharmaceuticals are the core of Doctor Chiti’s discipline, and it is the regulations relating to this area that he believes are one of the main challenges that faces the nuclear medicine field, as he explains.

“Regulatory issues are challenging because every radiopharmaceutical has to be approved at a European level, and then at a national level. Sometimes this is cumbersome and quite slow.

“Another issue is that radiopharmaceuticals are not developed at the same level throughout Europe. There are some countries where they are further developed than others. So, for example, there might be in country A, radiopharmaceutical for diagnosis or therapy available, but in neighbouring country B it is not. What we are aiming for is harmonised regulations throughout Europe – at least for radiopharmaceuticals.”

Looking ahead, Doctor Chiti would like to see nuclear medicine integrated with other clinical departments, in order to gain the best possible outcomes for patients.

“It will mean integrating nuclear medicine procedures with the other diagnostic imaging procedures – multi-modality imaging, and be more integrated in the oncological tracts, cardiological and neurological and also in those clinical tracts which are related to infection imaging,” he concludes.

“In my mind there will be more clinical speciality within this field of medicine, with more technology specialists working with the medical doctors.”

Doctor Arturo Chiti

President Elect

European Association of Nuclear Medicine (EANM)

Tel: +43 (0)1 212 80 30

[email protected]

www.eanm.org

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What is Nuclear Medicine?

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Nuclear medicine is the branch of medicine that involves the administration of radioactive substances in order to diagnose and treat disease. The scans performed in nuclear medicine are carried out by a radiographer. This speciality of nuclear medicine is sometimes referred to as endoradiology because the radiation emitted from inside the body is detected rather than being applied externally, as with an X-ray procedure, for example.

For nuclear medicine scans, radionuclides are combined with other chemical compounds to form the radiopharmaceuticals that are widely used in this field. When administered to the patient, these radiopharmaceuticals target specific organs or cellular receptors and bind to them selectively. External detectors are used to capture the radiation emitted from the radiopharmaceutical as it moves through the body and this is used to generate an image. Diagnosis is based on the way the body is known to handle substances in the health state and disease state.

The radionuclide used is usually bound to a specific complex (tracer) that is known to act in a particular way in the body. When disease is present, the tracer may be distributed or processed in a different way to when no disease is present. Increased physiological function that may occur as a result of disease or injury usually results in an increased concentration of the tracer, which can often be detected as a “hot spot.” Sometimes, the disease process leads to exclusion of the tracer and a “cold spot” is detected instead.  A large variety of tracer complexes are used in nuclear medicine to visualize and treat the different organs, tissues and physiological systems in the body.

The main difference between nuclear medicine diagnostic tests and other imaging modalities is that nuclear imaging techniques show the physiological function of the tissue or organ being investigated, while traditional imaging systems such as computed tomography (CT scan) and magnetic resonance imaging (MRI scans) show only the anatomy or structure.

Nuclear medicine imaging techniques are also organ- or tissue-specific. While a CT or MRI scan can be used to visualize the whole of the chest cavity or abdominal cavity, for example, nuclear imaging techniques are used to view specific organs such as the lungs, heart or brain. Nuclear medicine studies can also be whole-body based, if the agent used targets specific cellular receptors or functions. Examples of these techniques include the whole-body PET scan or PET/CT scan, the meta iodobenzylguanidine (MIBG) scan, the octreotide scans, the indium white blood cell scan, and the gallium scan.

• http://unm.lf1.cuni.cz/vyuka/nuclear_medicine_jwfrank.pdf
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• https://www.snmmi.org/
• http://www.nupecc.org/pub/npmed2014.pdf

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Dr. Ananya Mandal is a doctor by profession, lecturer by vocation and a medical writer by passion. She specialized in Clinical Pharmacology after her bachelor's (MBBS). For her, health communication is not just writing complicated reviews for professionals but making medical knowledge understandable and available to the general public as well.

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Nuclear Medicine and Molecular Imaging Essay

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In current healthcare settings, nuclear medicine has become an important tool for aiding patients. Despite the dangers associated with the use of radioactive elements, through their application in diagnostics and treatment, it is possible to limit their harm and enhance their benefits. In particular, these types of tools are invaluable when working on treating various types of cancer. For example, lymphoma, as the type of cancer that affects the body’s blood system, usually requires the use of nuclear medicine. Before any treatment is administered, molecular imaging is used to determine the diagnosis and the severity of the disease. Compared to other types of imaging, it enables doctors and physicians to examine patients on the deepest of levels and detect the presence of cancer and other disturbances (“Fact sheet: Molecular imaging and lymphoma,” n.d.). From that point onward, nuclear medicine serves as a tool for healing or managing the patient’s condition. Both chemotherapy and radiation therapy are widely used. These methods utilize either medicine or energy beams that are capable of attacking the cancer cells or managing their spread. Naturally, even these types of treatment are not always effective, and the ability of doctors to use them hinges on the patient’s response. However, it is undeniable that the application of radioactive and nuclear elements gives individuals more opportunities to live fulfilling lives.

Throughout this course, I was able to learn about a number of different treatment and diagnostics methods, as well as understand the development of the medical sphere in the past decades. I think that this knowledge gave me a newfound appreciation for researchers and doctors that strove to improve the tools at their disposal and create approaches capable of fighting even chronic diseases. In terms of my own everyday life, this knowledge helps me understand that concepts like harm or benefit are not always black and white, and many things that are inherently dangerous can be used responsibly. This applies to both medicine and all other kinds of human activity.

Fact sheet: Molecular imaging and lymphoma . (n.d.). Society of Nuclear Medicine and Molecular Imaging (SNMMI). Web.

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Nuclear medicine: a global perspective

• Published: 25 March 2020
• Volume 8 , pages 51–53, ( 2020 )

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• Diana Paez 1 ,
• Francesco Giammarile 1 &
• Pilar Orellana 1  

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In this era of globalization, health systems, primarily in low- and middle-income countries (LMICs) [ 1 ] are required to accommodate the care and management of the increasing burden of non-communicable diseases (NCDs). Vast regions of the world also must contend with the double burden of disease, including facing outbreaks of novel viruses. Health systems need to address the epidemiological transition from communicable to NCDs with strengthened capacity. Nuclear Medicine has become an integral part of an efficient health system that acknowledges this shift with the management of various NCDs, in particular cardiovascular, oncological, and neurodegenerative diseases.

Without a doubt, innovation in research and development is a driving force in nuclear medicine. New devices, radiopharmaceuticals, clinical applications, and evidence-based medicine are produced at a fast pace and need to be propagated. New standards of best practices should be emphasized not only as part of training programmes, but also all efforts should be made to keep the medical community abreast with developments to provide optimal patient care and professional growth.

Global health realities show large inequities in access to nuclear medicine services. These are now showcased in an unprecedented, comprehensive manner in the NUclear mEdicine DAtaBase (NUMDAB) [ 2 ], as well as in the IAEA Medical imAGIng and Nuclear mEdicine global resources database (IMAGINE) [ 3 ].

According to the data available at International Atomic Energy Agency (IAEA) [ 2 , 3 ], 134 out of 195 countries have nuclear medicine facilities. There are over 25,000 SPECT cameras. The heterogenous global distribution of SPECT systems range between 0.036 cameras/million inhabitants in low-income countries (LIC) to 17.9 cameras/million in high-income countries (HIC). It should also be noted that the difference between upper middle-income countries (UMIC) and lower middle-income (LMIC) countries is sixfold (1.33 cameras/million vs 0.20 cameras/million, respectively) (Table 1 ). The regional distribution is also heterogenous. In the Americas, the USA has the highest rate of SPECT cameras/million inhabitants (45.3), whereas Canada has 16 cameras/million. There are 1456 cameras, with a rate of 3.73 cameras/million in Latin America and the Caribbean (LAC). Ranging from Argentina with 8.74 cameras/million, Brazil with 6.36, Colombia with 2.8 cameras/million inhabitants, Ecuador with 0.7 scanners/million to countries such as Aruba or Barbados with no availability of SPECT scanners.

Inequities in access to PET-CT are more striking. In high-income countries, there are 3.2 scanners/million inhabitants and in low-income settings, 0.007 scanners/million (Table 1 ).

Regionally, using the African continent as an example, only 9 out of 54 countries have PET scanners.

Stimulating market projections to inject investment and research and development is key to maintaining and growing nuclear medicine access. Currently, the discipline of diagnostic nuclear medicine (SPECT and PET) has the smallest share of the global medical imaging market (including CT, MRI, US, and X-ray) at 6.5%. It is expected to be the fastest growing segment due to the rising prevalence of NCDs, increased needs for early and accurate diagnoses, new technological developments both in hardware and software, the availability of new tracers, and its welcomed reception in emerging markets.

The LAC region serves to illustrate the global nuclear medicine growth. The practice of nuclear medicine in the region has experienced an important development in the last decades. However, there is great heterogeneity among countries regarding the availability of technology and human resources. According to data collected by the IAEA throughout the years, PET scanners in the LAC region had a Compound Annual Growth Rate of approximately 21% and grew from 22 systems in 6 countries (out of the 33 countries in the region) in 2005, to 144 systems in 11 countries in 2015, and 301 systems in 17 countries in 2019. Although the growth was higher than the global nuclear medicine imaging devices market, the number of PET scanners per million inhabitants is around 0.47. In the Middle East (ME), the number of PET scanners in 2016 was 194 [ 4 ] and grew to 220 scanners in 2019, the number of PET scanners per million inhabitants in the ME is 0.66 [ 3 ]. In both cases LAC and the ME, the number of PET scanners/million inhabitants is still far below the recommended 2.0 to 2.5 scanners per million in an optimal health setting [ 5 ]. As for the SPECT market, there existed 1200 systems in 2015 [ 6 ] in 20 out of the 33 LAC countries to 1456 systems in 2019, distributed in 23 countries [ 3 ].

In this era of unprecedented scientific and technological developments there is an increasing demand for “a personalized medicine approach” which is the development of better strategies for detecting and treating diseases based on an individual’s unique profile. The growth of personalized medicine is propelled by several factors that include the advances in molecular biology, genetics and proteomics, the better understanding of normal and pathological processes, the greater knowledge of the mechanism of individual diseases, the superior identification of disease subtypes and the better prediction of individual patient’s responses to treatment.

Expanded use of nuclear medicine techniques has the potential to accelerate, simplify, and reduce the costs of developing and delivering improved health care, reduce the healthcare expenditure and could facilitate the implementation of personalized medicine. Its applications can go far beyond diagnostics, allowing support in the selection of the appropriate therapy, evaluating the therapy response and follow-up; and driving the journey to personalized medicine.

Nuclear medicine has come to a fork in the road, with the choice being whether to remain a diagnostic lesion-detection technique, or whether to join the revolution in precision medicine, characterizing tumour biology and directing treatment through highly specific tracers that guide us to the world of theragnostic with translation molecular imaging being the central focus (Fig.  1 ).

Nuclear medicine in disease management

To reach the full potential of nuclear medicine, including theragnostic, it is essential to train nuclear medicine professionals, not only newcomers but also experienced professionals trained in the field; to work with regulatory bodies to ensure and comply with safety requirements; to cooperate alongside policy makers, to include reimbursements for established and emerging applications, and to implement quality management systems in clinical practice to ensure the safety and quality of services provided.

Nuclear medicine and medical imaging should be included in the main global public policy guidelines for management of patients. Multisectoral coordination amongst key stakeholders (World Health Organization, IAEA, and other United Nations organizations; governmental bodies, professional organizations, non-governmental organizations, and private sector) is crucial to be able to deliver the best care possible. Unfortunately, this multisectoral coordination is currently unclear.

There are some ongoing efforts by the international community to deal with the burden of diseases. In 2015, the United Nations established the Sustainable Development Goals, a set of 17 specific goals aimed at transforming our world by 2030 and achieving a better and more sustainable future for all [ 7 ]. Goal 3 focuses on ensuring healthy lives and promoting well-being for all at all ages. It is important to highlight two targets: target 3.4 addresses the challenges of reducing NCD premature mortality by 30% by 2030 and target 3.9 aims at strengthening the capacity of all countries, particularly developing countries, for early warning, risk reduction and management of national and global health risks.

To support national efforts to address the burden on NCDs, the 66th World Health Assembly endorsed the WHO Global Action Plan (GAP) for prevention and control of NCDs 2013–2020 (resolution WHA66.10) [ 8 ]. The GAP offers a paradigm shift by providing a roadmap and policy options menu for Member States, the WHO, other UN organizations, intergovernmental organizations, NGOs and the private sector. The hypothesis is that, if implemented collectively between 2013 and 2020, we will achieve nine voluntary global targets, including a relative 25% reduction in premature NCDs mortality by 2025. Target 8 is of pivotal importance to the medical imaging community. Its objective is to achieve 80% availability of affordable basic technologies and essential medicines, including generics required to treat NCDs in both public and private facilities. The problem is that medical imaging and nuclear medicine are not defined under target 8. Nevertheless, there is an opportunity to include medical images as affordable or basic technologies, for which the professional community must participate in decision-making processes.

It is fundamental to advice the health authorities of the importance of including medical imaging and nuclear medicine as part of the policies, strategies, and action plans for health technologies and the national health plan.

World Bank Group. New Country Classifications by Income Level: 2019–2020. https://blogs.worldbank.org/opendata/new-country-classifications-income-level-2019-2020

NUMDAB, NUclear Medicine DAtaBase. https://humanhealth.iaea.org/HHW/NuclearMedicine/NUMDAB/index.html

IMAGINE, the new IAEA Medical imAGIng and Nuclear mEdicine global resources database. https://humanhealth.iaea.org/HHW/DBStatistics/IMAGINE.html

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Paez, D., Giammarile, F. & Orellana, P. Nuclear medicine: a global perspective. Clin Transl Imaging 8 , 51–53 (2020). https://doi.org/10.1007/s40336-020-00359-z

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DOI : https://doi.org/10.1007/s40336-020-00359-z

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H. Jadvar and P.M. Colletti

Wolters Kluwer, 2021, 310 pages, $110.99

In contrast to the discipline of conventional radiology, to which medical school students, trainees, and many practitioners of medicine are heavily exposed, the field of nuclear medicine is somewhat specialized and requires special training for optimal understanding of its role in various domains in medicine. Therefore, there is a dire need for a simplified exposure to the specialty that provides some practical knowledge about the field and its unique role in the day-to-day practice of medicine. “The Essentials” series is a collection of radiology textbooks that follow such a standardized format. The series is designed to provide a practical tool for those who wish to gain a broad base of knowledge on various specialties in medical imaging. The content is confined to the essentials of the specialty and can be understood by the novice. However, enough details are included to be useful for those who teach the specialty and to provide a reference for health-care providers practicing the specialty of imaging. “The Essentials” books are compact in size and allow for residents and other interested groups to grasp practical knowledge about the various procedures that are offered by this specialty. Furthermore, the self-assessment sections provide multiple-choice questions at the end of each chapter. As such, this additional training is of particular benefit for those who are preparing for an image-rich computer-based examination for professional and maintenance certifications.

Currently, the field of nuclear medicine is the fastest-growing discipline in medical imaging. The recent introduction of novel radiopharmaceuticals for imaging and targeted therapy is revolutionary; therefore, educating trainees and the community at large about their applications in many disciplines is essential at this time. These include innovations in high-technology instruments related to digital and time-of-flight cameras, total-body PET instruments, PET/CT, PET/MRI, and SPECT/CT. This textbook provides a concise yet comprehensive overview of the field of molecular imaging that fits the criteria intended for “The Essentials” series. Each chapter describes the basics of physics, instrumentation, quality control, radiochemistry, radiation safety, and other essential information about each procedure.

The table of contents includes radiochemistry, instrumentation, physics, and radiation safety as introductions to technical bases for performing various procedures. The clinical section deals with assessment of diseases and disorders of various organs and anatomic structures (thyroid, parathyroid, and neuroendocrine glands; central nervous system; skeleton; lungs; gastrointestinal tract; kidneys; and lymph nodes). Also, chapters are devoted to radiotheranostics, the essentials of pediatric nuclear medicine, quality assurance, and procedures on pregnant and lactating patients. Overall, the book includes 19 chapters.

The chapters are organized in a logical manner and describe in some detail the imaging techniques that practitioners of the discipline follow. Therefore, readers who may not be familiar with the role of nuclear medicine procedures will be able to comprehend the scope of this discipline in clinical settings. No critically important topics are missing from this comprehensive book.

The chapters are written by highly qualified and expert contributing authors with longstanding experience in their respective disciplines. The main authors, Drs. Jadvar and Colletti, have substantially contributed by writing several chapters of this book.

Overall, this book provides a well-balanced view of current applications of conventional nuclear medicine and PET. Therefore, the book is a strong medium for introducing physicians and scientists to ongoing activities in the field and their relevance to the day-to-day practice of medicine. There are no serious weaknesses to the overall content of the book. Additionally, the figures and tables are of high quality. Most of the figures in the book are selected from the authors’ own clinical files and are of high quality.

In conclusion, Nuclear Medicine: The Essentials provides a comprehensive and excellent review of the current practice of the field. Therefore, this book will be of great interest to trainees, technologists, and scientists, as well as to practitioners of this rapidly evolving specialty. As such, the book is highly recommended for those who wish to refresh their understanding of the field and its various applications in medicine.

Published online Sep. 8, 2022.

• © 2023 by the Society of Nuclear Medicine and Molecular Imaging.

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Dacryoscintigraphy: A Pictorial Essay

Shefali madhur gokhale.

Department of Nuclear Medicine, Inlaks and Budhrani Hospital, Pune, Maharashtra, India

Dacryoscintigraphy is a noninvasive, simple, easy to perform imaging modality used in the evaluation of epiphora. However, it is an infrequently done study in nuclear medicine departments. A standardized protocol and a systematic interpretation of the scans help in answering the queries of the clinicians in cases of epiphora. We have attempted to build a pictorial essay of the various findings detected on dacryoscintigraphy.

Introduction

Imaging the nasolacrimal system with use of radiopharmaceuticals, in other words, dacryoscintigraphy is an underutilized tool in the present-day nuclear medicine department.

Of the few nuclear medicine departments that perform the procedure, there are differences in the protocol followed, the use of collimators, and the use of radiopharmaceuticals. The indications for the procedure are evaluation of epiphora,[ 1 ] detection of subclinical lacrimal duct obstruction, appropriate patient selection for surgery,[ 2 ] and evaluating the success of dacryocystorhinostomy.[ 2 ] It is contraindicated in acute infective and allergic conditions of the eye. The small size of the structures of the nasolacrimal system is a major limitation. As compared to dacryocystography, the radiation exposure involved is about 100 times lower.[ 3 , 4 ] It has a distinct advantage over the syringing/saccharin test[ 5 ] in being noninvasive.[ 3 ] As there is no instrumentation of canaliculi or administration of contrast/saline under high pressure, false-negative and false-positive[ 3 , 5 ] results are avoided.

The standard protocol that we followed involved the use of Tc-99 m sulfur colloid in a dose of 50–100 microCi/10 μl[ 3 , 5 ] with the use of low-energy high-resolution collimator and images acquired immediately, postinstillation of normal saline drops and postblowing of the nose.[ 6 ]

A systematic interpretation of the various sequences helps arrive at the etiology of epiphora.

Dacryoscintigraphy interpretation in patients presenting with epiphora

To demonstrate normal flow through the nasolacrimal system.

A case of dacryocystorhinostomy on the left side in a 26-year-old male patient.

Drainage of tracer into the nasal cavity within the first 15-min postinstillation of radiopharmaceutical is considered normal.

The left eye reveals flow of tracer to the medial canthus region with accumulation of tracer there. There is no drainage of tracer into the nasal cavity.

The right eye reveals flow of tracer into the lacrimal sac, nasolacrimal duct (NLD), and drainage into the inferior meatus of the nose, all within the first 15-min postinstillation of Tc-99 m sulfur colloid, which is considered as normal [ Figure 1 ].[ 5 , 7 ]

Dacryoscintigraphy reveals drainage of tracer into the lacrimal sac (bold black arrow), nasolacrimal duct (hyphenated arrow), and inferior meatus of nose (black arrow) from the right eye. There is no drainage of tracer into the nasal cavity from the left eye

Interpretation

• Failed dacryocystorhinostomy on the left side
• Normal tear flow in the right eye.

To evaluate cause of epiphora in spite of a bilaterally normal syringing test

A 61-year-old female patient had a history of trauma to eyes approximately 2 months back. She had complaints of watering from the right eye for 2 months. Syringing revealed the passage of saline downward into the nasal cavity bilaterally.

The right eye reveals flow of tracer into the proximal NLD in immediate images. However, there is drainage into the inferior meatus of nose noted only in the images acquired postblowing of the nose.

The left eye reveals partial flow of tracer into the inferior meatus of the nose in the immediate images. There is persistent partial tracer stasis in the region of medical canthus noted in the delayed images [Figure ​ [Figure2a 2a - ​ -c c ].

(a) Immediate dynamic images of dacryoscintigraphy reveal drainage of tracer into the proximal nasolacrimal duct on the right side (bold black arrow). Partial drainage of tracer from the left eye into inferior meatus of the nose is noted (black arrow), (b and c) Dacryoscintigraphy images acquired postblowing of nose reveal flow of tracer from the right eye into inferior meatus of nose (bold black arrow). Persistent partial tracer stasis noted in the region of medial canthus of the left eye (black arrow)

Intraductal delay right eye with some inflammation at the lower end of NLD, which is relieved by nose blowing.

Partial functional impedance left eye.

The word “functional impedance” is used as an anatomic obstruction which is ruled out by the syringing test.[ 8 ] Hence, the finding of syringing test forms an important history in the interpretation of dacryoscintigraphy.

Epiphora since childhood

A 4.5-year-old female patient, a case of right-sided dacryocystitis. She has had complaints of right-sided epiphora since childhood.

Findings and Interpretation

The right eye reveals drainage of tracer into the NLD only in the image acquired postblowing of nose. This could be due to two reasons, either local inflammation at the NLD or resistance offered by the valves of the nasolacrimal system. Since this patient has had complaints since childhood, the symptoms are likely to be secondary to resistance offered by valves.

The left eye reveals drainage of tracer into the left NLD in immediate images. However, there is drainage into the inferior meatus of nose noted in the image acquired postblowing of nose. As the patient is asymptomatic on the left side, scan features are likely to represent local inflammation at the lower end of the left NLD [Figure ​ [Figure3a 3a - ​ -c c ]

(a) Immediate dynamic images of dacryoscintigraphy reveal flow of tracer into left nasolacrimal duct (black arrow), (b) there is no significant change in drainage observed after administration of normal saline drop, (c) images acquired after blowing of nose reveal flow of tracer into the nasolacrimal duct on the right (bold black arrow) and into the inferior nasal meatus on left (hyphenated arrow)

Bilateral epiphora, abnormal syringing test

A 64-year-old male patient with complaints of bilateral epiphora for 6–8 months.

There was no passage of saline detected on the syringing test bilaterally.

As there has been no passage of saline on the syringing test, there is likely to be an anatomic obstruction; however, the level of obstruction is to be detected.[ 5 ]

In the right eye, there is flow of tracer to the medial canthus region. However, the delayed images indicate that there is no flow of tracer into the lacrimal sac.

In the left eye, there is flow of tracer to the medial canthus region and lacrimal sac. However, there is no drainage into the NLD [Figure ​ [Figure4a 4a - ​ -c c ].

(a) Immediate dynamic images of dacryoscintigraphy reveal flow of tracer to the region of medial canthus bilaterally (arrows), (b) after administration of normal saline drops, no significant change in drainage of tracer is noted bilaterally, (c) delayed images reveal flow of tracer into the left lacrimal sac (arrowhead)

• PRESAC delay right eye
• PREDUCTAL delay left eye.

Epiphora in old age

A 59-year-old female diabetic and hypertensive patient presented with bilateral epiphora for 3–4 years.

There is pooling of tracer noted in the orbits bilaterally [Figure ​ [Figure5a 5a and ​ andb b ].

(a and b) Dacryoscintigraphy images reveal pooling of tracer in the orbits bilaterally (arrows)

This could be due to either failure of tear flow mechanism in the eyes or laxity of eyelids.

In this case, in view of the age of the patient and comorbidities, scan features are likely to be secondary to eyelid laxity.

To evaluate dacryocystorhinostomy on one side and epiphora on the other side

A 61-year-old male patient had presented with left lacrimal fossa abscess with dacryocystitis. At that time, syringing test had allowed passage of saline in the right eye. He underwent dacryocystorhinostomy on left side.

Findings and interpretation

The left eye reveals flow of tracer to the medial canthus region. However, there is no drainage of tracer into the left NLD. Hence, we conclude that the dacryocystorhinostomy on the left side has failed.

On the right side, we have an important clinical history of the syringing test allowing passage of saline. Hence, there is no anatomical obstruction noted on the right side.

Flow of tracer is noted to the right lacrimal sac. However, there is no drainage of tracer noted into the right NLD. This is a case of preductal delay. In view of the finding of syringing test, it is secondary to functional impedance on the right side [Figure ​ [Figure6a 6a - ​ -c c ].

(a) Dacryoscintigraphy images reveal drainage of tracer into the lacrimal sac bilaterally; however, there is no drainage of tracer into the nasolacrimal duct bilaterally. There is a minor difference in the radioactivity administered in both eyes, causing a minor difference in intensity of tracer to start with. As scan progresses, the difference in intensity of radiotracer in the two eyes increases as more tracer is flowing out of left eye and soaked out with tissue paper, (b) dacryoscintigraphy images reveal drainage of tracer into the lacrimal sac bilaterally; however there is no drainage of tracer into the nasolacrimal duct bilaterally, (c) dacryoscintigraphy images reveal no drainage of tracer into the nasolacrimal duct bilaterally

The word “impedance” is preferred by the ophthalmologists instead of “obstruction,” when the syringing test has allowed passage of saline.[ 8 ]

It is important to note that there is no transit of tracer into the NLDs bilaterally in patient V and patient VI. However, patient VI differs in having the flow of tracer to the medial canthus region on right side, hence changing the interpretation of the scans.

Dacryoscintigraphy is a simple noninvasive and physiological assessment of the nasolacrimal system. A standardized protocol and systematic interpretation would help us identify the cause of epiphora and ascertain the success of surgical procedures performed if any.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Dacryoscintigraphy: A Pictorial Essay

Affiliation.

• 1 Department of Nuclear Medicine, Inlaks and Budhrani Hospital, Pune, Maharashtra, India.
• PMID: 29962717
• PMCID: PMC6011558
• DOI: 10.4103/ijnm.IJNM_18_18

Dacryoscintigraphy is a noninvasive, simple, easy to perform imaging modality used in the evaluation of epiphora. However, it is an infrequently done study in nuclear medicine departments. A standardized protocol and a systematic interpretation of the scans help in answering the queries of the clinicians in cases of epiphora. We have attempted to build a pictorial essay of the various findings detected on dacryoscintigraphy.

Keywords: Dacryoscintigraphy; epiphora; nasolacrimal duct.

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Conflict of interest statement

There are no conflicts of interest.

Dacryoscintigraphy reveals drainage of tracer…

Dacryoscintigraphy reveals drainage of tracer into the lacrimal sac (bold black arrow), nasolacrimal…

(a) Immediate dynamic images of…

(a) Immediate dynamic images of dacryoscintigraphy reveal drainage of tracer into the proximal…

(a) Immediate dynamic images of dacryoscintigraphy reveal flow of tracer into left nasolacrimal…

(a) Immediate dynamic images of dacryoscintigraphy reveal flow of tracer to the region…

(a and b) Dacryoscintigraphy images…

(a and b) Dacryoscintigraphy images reveal pooling of tracer in the orbits bilaterally…

(a) Dacryoscintigraphy images reveal drainage…

(a) Dacryoscintigraphy images reveal drainage of tracer into the lacrimal sac bilaterally; however,…

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