POSITION PAPERS Procedure Guideline for : 1.0 KevinJ. Donohoe,Robert E. Henkin,Henry D. Royal,ManuelL. Brown,B. DavidCollier,RobertE. O'Mara and Robert F. Carretta Beth Israel Hospital, Boston, Massachusetts; Loyola University Medical Center, Mayville, Illinois; Mallinckrodt Institute of , St. Louis, Missouri; University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Medical College of Wisconsin, Milwaukee, Wisconsin; University of Rochester School of Medicine and Dentistry, Rochester, Minnesota; Roseville Community Hospital, Roseville, California

this point in the diagnostic work-up and (c) the effect of bone Key Words: ; procedure guidelines scintigraphywill have on patient management. Bone scintigraphy J NucíMed 1996; 37:1903-1906 is oftenhelpfulinthe managementof patientswithneoplasticdisease. In these patients, tumor histology and clinical stage should be PART I: PURPOSE consideredto determinethe likelihoodof metastasisto the skeleton. The purpose of this guideline is to assist The following is a partial list of common clinical settings for practitioners in recommending, performing, interpreting and which bone scintigraphy is indicated. This list is not all- reporting the results of bone scintigraphy. inclusive. The following indications are not listed in a specific order and bone scintigraphy is not necessarily the primary PART II: BACKGROUND INFORMATION AND diagnostic imaging study. DEFINITIONS A. Neoplastic disease A. Bone scintigraphy is a diagnostic imaging study which B. records the distribution of a in the C. Osteomyelitis skeletal system in planar (2-dimensional) and/or tomo- D. graphic (three-dimensional) images. E. Arthritides B. Whole-body bone scintigraphy produces planar images F. Reflex sympathetic dystrophy of the skeleton including anterior and posterior views G. Bone infarcts of the axial skeleton. Anterior and/or posterior views of H. Bone graft viability the appendicular skeleton are also obtained. Additional I. Otherwise unexplained bone pain views are obtained as needed. J. Distribution of osteoblastic activity prior to X9Srtherapy C. Limited bone scintigraphy records images of only a portion of the skeleton. PART IV: PROCEDURE D. Bone SPECT (single-photon emission computed to A. Patient Preparation mography) produces a tomographic image of a portion The rationale for performing the procedure and the of the skeleton. details of the procedure itself should be explained to the E. Multiphase bone scintigraphy usually consists of blood patient in advance. Unless contraindicated, patients flow images, immediate images and delayed images. should be well hydrated and instructed to drink two or The blood flow images consist of a dynamic sequence more 8-oz glasses of water between the time of injec of planar images of the area of greatest interest ob tion and the time of delayed imaging. The patient tained as the tracer is injected. The immediate (blood- should be asked to urinate immediately prior to delayed pool) images consist of one or more static planar imaging and to drink plenty of fluids for at least 24 hr images of the areas of interest, obtained within IOmin after administration. after injection of the tracer. Delayed images may be B. Information Pertinent to Performing the Procedure limited to the areas of interest or may include the whole 1. Question(s) to be answered by bone scintigraphy. body, may be planar or tomographic, and are usually 2. History of fractures, trauma, osteomyelitis, celluli- acquired 2 to 5 hr after injection. Further additional tis, edema, arthritis, , metabolic bone delayed images obtained up to 24 hr following tracer disease or limitation of function. injection may be obtained if necessary. 3. Current symptoms, physical findings. 4. History of recent scintigraphy, especially with ml, PART III: COMMON INDICATIONS 67GaandmIn. Because metabolic changes usually precede anatomic changes, 5. Results of prior bone scintigraphy. bone scintigraphy can often detect abnormalities before ana 6. Results of prior imaging studies such as conven tomic imaging studies such as routine radiographs. In addition, tional radiographs, CT and MRI. because the radiopharmaceutical is distributed throughout the 7. Historyof therapy that might affect the results of bone body, examination of the entire skeleton is facilitated. scintigraphy (e.g., antibiotics, steroids, chemotherapy, Bone scintigraphy may be indicated in a diverse patient popu , diphosphonates, iron therapy). lation (children, adults, symptomatic and asymptomatic). Before 8. History of orthopedic (e.g., presence and location of bone scintigraphy, several factors deserve consideration: (a) the prosthetic implants) and nonorthopedic surgery likelihood of the suspected condition in view of the clinical (e.g., ileal conduit) that might affect the results of presentation, (b) whether bone scintigraphyis the best modality at bone scintigraphy. 9. Relevant laboratory results (e.g., PSA in patients Received May 20, 1996; accepted May 27, 1996. For correspondence or reprints contact: Joanna Wilson, Society of Nuclear Medicine, with cancer). 1850 Samuel Morse Dr., Reston, VA 20190. 10. History of anatomic or functional renal abnormalities.

PROCEDUREGUIDELINEFORBONESCINTIGRAPHY•Donohoe et al. 1903 C. Precautions 1-2 sec per frame. If film is used, 3-5 sec per frame 1. Elective bone scintigraphy should be deferred in may be used. The acquisition should be started just as pregnant women. Bone scintigraphy is not contrain- the tracer is injected. Blood-pool images should be dicated in pregnancy when the expected benefits of the acquired within 10 min of tracer injection for approxi examination outweigh the very small radiation risk. mately 3-5 min per image. After 10 min, some activity 2. When possible, breastfeeding should be discontin may be apparent in the skeleton. ued for 24 hr after radiopharmaceutical injection. When digital images are acquired, blood flow images D. Radiopharmaceutical may be obtained in 64 X 64 X 16 or greater matrix at 1 to 3 sec per frame. Blood-pool images are usually Several 99mTc-labeled (e.g., diphos- obtained in 128 X 128 X 16 or greater matrix with count density of approximately 300,000 counts/image phonates or pyrophosphates) are available for bone scintigra (150,000-200,000 counts/image may be adequate for phy. The usual administered activity for adult patients is 740 to extremities). 1110 MBq (20 to 30 mCi) injected intravenously. For markedly Routine delayed images are usually obtained from 2 to obese adult patients, the administered activity may be increased 5 hr after injection. Additional delayed (6-24 hr) to 11-13 MBq/kg (300-350 ¿iCi/kg).For pediatrie patients, the images will result in a higher target-to-background ratio administered activity is 9-11 MBq/kg (250-300 juCi/kg), with and may permit better evaluation of the pelvis if it was a minimum of 40-90 MBq (1.0-2.5 mCi). The maximum obscured by bladder activity on the routine delayed administered activity for pediatrie patients should not exceed images. Six- to 24-hr delayed imaging may be particu the administered activity for an adult. larly helpful in patients with renal insufficiency and Bone radiopharmaceuticals are subject to oxidation. Care patients with urinary retention. should be taken to avoid introducing air into the multidose vial. Whole-body bone scintigraphy can be accomplished Quality control should be performed prior to administration of with multiple overlapping images (i.e., spot imaging) or the radiopharmaceutical (see the Society of Nuclear Medicine with continuous images (i.e., whole-body scan) ob Procedure Guideline for Imaging with Radiopharmaceuticals, tained in anterior and posterior views. When spot views J NucíMed 1996: in press). are used as the primary method of acquiring bone Radiation Dosimetry for Adults* images, the areas of bony skeleton covered by the spot views must overlap to avoid missing regions of the skeleton. the The first spot view of the axial skeleton, usually the largest chest, is acquired for approximately 500,000 to 1 radiation doseT dosetmSv activity million counts. The remaining spot views are then Radiopharmaceuticals"Tc (mCi)740-1MBq mGy(rad)0.063 (rem)0.008 acquired for the same time as the first view. Spot phosphates 110 i.v. images may be obtained using a 128 X 128 X 16 or a and phosphoratesAdministered(20-30)OrganreceivingBone (0.030) 256 X 256 X 16 matrix. Whole-body views are usually (0.23)Effective obtained in 256 X 1024 X 16 or greater matrix. Computer acquisition, processing and display of images "ICRP 53, normal bone uptake, normal renal function, page 215. may be particularly helpful in pediatrie populations fper MBq (per mCi) because of extreme ranges of normal uptake. Films of See also MIRD Committee Dose Estimate Report No. 13. Radiation scintigrams photographed with different intensities may absorbed dose for -99m-labeled bone imaging agents. J Nucí also be helpful if digital processing and review are not Medi 989:30:1117-1122. available. When whole-body scanning is used, the count rate (usually of the anterior chest) should be determined RadiationRadiopharmaceuticals""Tcold)Administeredfor Children* (5 year before image acquisition. The scanning speed should be adjusted so that routine (obtained 2-5 hr after injection) receiving the delayed anterior or posterior whole-body images con activity largest tain >1.5 million counts. If the scanner electronically MBq/kg radiation dose* Effective doseT joins multiple passes, care must be taken to avoid (mCi/kg)9-11 mGy(rem)0.22(rad) mSv having the "zipper" superimposed on the spine.

phosphates i.v. When the probability of disseminated disease is small, and phosphonatesDosimetry(0.25-0.30)Organ Bone (0.093) a limited study is reasonable. When disseminated dis (0.81)0.025 ease is more likely, spot views limited to the area of interest may be a source of error if distant disease is *ICRP 53, normal bone uptake, normal renal function, page 215. present. In some patients, SPECT imaging is helpful to better Tper MBq (per mCi) characterize the presence, location and extent of dis See also MIRD Committee Dose Estimate Report No. 13. Radiation absorbed dose for technetium-99m-labeled bone imaging agents. J Nucí ease. SPECT imaging should be performed as recom mended by the camera manufacturer. Typical acquisi Med 1989;30:1117-1122. tion and processing parameters are 360°circular orbit, E. Image Acquisition 60-120 stops, 64 X 64 X 16 or greater matrix, and If flow images are done, the camera should be posi 10-40 sec/stop. An equivalent total number of counts tioned over the region of interest prior to injecting the should be acquired if continuous acquisition is used. tracer. The acquisition computer should be programmed A pinhole collimator may be used if very high-resolu to acquire approximately 30 frames for approximately tion images of a specific area are necessary. Approxi-

1904 THEJOURNALOFNUCLEARMEDICINE•Vol. 37 •No. 11 •November 1996 mately 75,000-100,000 counts should be obtained for and (c) the shape of the abnormality (round, fusi pinhole collimator views. Zoom magnification or a form, linear, etc.) converging collimator may also be used to improve 5. The findings on blood flow, blood-pool and SPECT resolution, particularly when small structures or pediat studies should also be interpreted in accordance rie patients are being imaged. The physician interpret with Steps 1-4 (see above). ing the image should be notified when collimatore that For general reporting guidelines, see the Society of introduce distortion, such as a pinhole collimator, are Nuclear Medicine Procedure Guideline for General used. Imaging, J NucíMed 1996: in press. Other views, such as lateral, oblique or tangential, and special views such as frog-leg views of the hips or I. Quality Control sitting-on-detector (caudal) views of the pelvis are See the Society of Nuclear Medicine Procedure Guide obtained, when necessary. line for General Imaging, J NucíMed 1996: in press. F. Interventions J. Sources of Error The pelvis can be difficult to evaluate when there is 1. Urine contamination or a urinary diversion reser overlying bladder activity. In patients with pelvic symp voir. toms, one or more of the following additional views 2. Injection artifacts. may better evaluate the pelvis. 3. Prosthetic implants, radiographie contrast materials, 1. Repeat images immediately after voiding or other attenuating artifacts which might obscure 2. Sitting-on-detector (caudal) or oblique views normal structures. 4. Homogeneously increased bony activity (e.g., "su- 3. Lateral views perscan"). 4. 24-hr delayed images 5. SPECT acquisition. Single or multiple rapid (5-10 5. Patient motion. min per acquisition) SPECT acquisition(s) are pre 6. Greater than necessary collimator-to-patient dis ferred to avoid artifacts caused by changing activity tance. 7. Imaging too soon after injection, before the radio- in the bladder. Bladder artifacts are exaggerated in the plane where the SPECT acquisition begins and pharmaceutical has been optimally cleared from the ends. soft tissues. 8. Restraint artifacts caused by soft-tissue compres 6. Image immediately following catheterization of the bladder. (Note: Bladder catheterization should be sion. 9. Prior administration of a higher energy reserved for patients in whom visualization of the (13II, 67Ga, '"In), or of a %mTc radiopharmaceuti pelvis is essential) G. Processing cal that accumulates in an organ that could obscure or confound the skeletal activity. Generally no special processing of planar imaging is 10. Radioactivity extraneous to the patient. required. For general SPECT image processing guide lines, refer to the Society of Nuclear Medicine Proce 11. Significant findings outside the area of interest may be missed if a limited study is performed. dure Guideline for General Imaging, J NucíMed 1996: 12. Radiopharmaceutical degradation. in press. 13. Changing bladder activity during SPECT of pelvic H. Interpretation/Reporting region. A brief history and physical exam are important for 14. Purely lytic lesions. proper interpretation of bone scintigraphy. In addition, 15. Pubic lesions obscured by underlying bladder activity. review of the medical record and discussion with the referring physician will help to assure the appropriate special views are obtained. When appropriate, abnor PART V: DISCLAIMER malities detected on bone scintigraphy should be cor The Society of Nuclear Medicine has written and approved related with the results of other imaging studies. guidelines to promote the cost-effective use of high quality 1. The technical quality of the image should be as nuclear medicine procedures. These generic recommendations sessed (inadequate, adequate but suboptimal, opti cannot be applied to all patients in all practice settings. The mal study). If the study is not interpreted as techni guidelines should not be deemed inclusive of all proper proce cally optimal, the reason for the suboptimal quality dures or exclusive of other procedures reasonably directed to should be specifically stated. obtaining the same results. The spectrum of patients seen in a 2. The target (bone)-to-background (soft tissues) ratio specialized practice setting may be quite different than the should be assessed. spectrum of patients seen in a more general practice setting. The 3. Soft tissues should be examined for abnormalities appropriateness of a procedure will depend in part on the (areas of increased or decreased tracer localization). prevalence of disease in the patient population. In addition, the a. Intensity of renal activity, renal morphology and resources available to care for patients may vary greatly from tracer distribution in urinary collecting systems, one medical facility to another. For these reasons, guidelines should be noted. cannot be rigidly applied. b. Residual tracer activity in the bladder following Advances in medicine occur at a rapid rate. The date of a voiding should be evaluated. guideline should always be considered in determining its 4. The skeletal localization of the radiopharmaceutical current applicability. should be surveyed and abnormalities reported (ar eas of increased or decreased tracer localization) including: (a) the anatomic location, (b) the distri PART VI: ISSUES REQUIRING FURTHER CLARIFICATION bution of abnormality (focal versus diffuse, etc.) None

PROCEDUREGUIDELINEFORBONESCINTIGRAPHY•Donohoe et al. 1905 PART VII: CONCISE BIBLIOGRAPHY strategies for imaging in the new health care climate. 1. Brown ML, O'Connor MK, Hung JC, et al. Technical Semin NucíMed 1994;24:188-207.

aspects of bone scintigraphy. Radial Clin North Am PART VIII: LAST HOUSE OF DELEGATES APPROVAL 1993;31:721-730. DATE 2. Brown ML, Collier BD Jr, Fogelman I. Bone scintigra June 11, 1995 phy: part 1. Oncology and . J NucíMed 1993; 34:2236-2240. PART IX: NEXT ANTICIPATED APPROVAL DATE 3. Collier BD Jr, Fogelman 1, Brown ML. Bone scintigra 1997 phy: part 2. Orthopedic bone scanning. J NucíMed 1993;34:2241-2246. ACKNOWLEDGMENTS 4. Fogelman I, Collier BD, Brown ML. Bone scintigraphy: Wendy Smith, MPH, Associate Director, Division of Health part 3. Bone scanning in metabolic bone disease. J Nucí Care Policy, Society of Nuclear Medicine, for project coordi Med 1993;34:2247-2252. nation, data collection, and editing; members of the Guideline 5. Holder LE. Bone scintigraphy in skeletal trauma. Radial Development Subcommittee David Becker, MD, David Brill, MD, Clin North Am 1993;31:739-781. Howard Dworkin, MD, Robert Hattner, MD, Roberta Locko, MD, 6. Pomeranz SJ, Pretorius HT, Ramsingh PS. Bone scintig and members of the Pediatrie Imaging Council who contributed raphy and multimodality imaging in bone neoplasia: their time and expertise to the development of this information.

Procedure Guideline for Lung Scintigraphy: 1.0

J. Anthony Parker, R. Edward Coleman, Barry A. Siegel, H. Dirk Sostman, Kenneth A. McKusick and Henry D. Royal Beth Israel Hospital, Boston, Massachusetts; Duke University Medical Center, Durham, North Carolina; Mallinckrodt Institute of Radiology, St. Louis, Missouri; New York Hospital-Cornell Medical Center, New York, New York; Massachusetts General Hospital, Boston, Massachusetts

PART IV: PROCEDURE Key Words: lung scintigraphy; ; practice A. Patient Preparation guidelines 1. A should be obtained before lung J NucíMed 1996; 37:1906-1910 scintigraphy for pulmonary embolism. A routine chest radiograph obtained in both the posterior- PART I: PURPOSE anterior and lateral projections is preferred. A por The purpose of this guideline is to assist nuclear medicine table anterior-posterior chest radiograph is accept practitioners in recommending, performing, interpreting and re able only if the patient cannot tolerate a routine porting the results of lung scintigraphy for pulmonary embolism. chest radiographie examination. In patients who have no changes in signs or symptoms, a chest PART II: BACKGROUND INFORMATION AND radiograph within 1 day of scintigraphy is adequate. DEFINITIONS A. Aerosol Ventilation Scintigraphy A more recent chest radiograph (preferably within 1 A diagnostic imaging test that records the bronchopul- hr) is necessary in patients whose signs and symp monary distribution of an inhaled radioactive aerosol toms are changing. within the lungs. 2. Before intravenous administration of the pulmonary B. Gas Ventilation Scintigraphy radiopharmaceutical, the patient should A diagnostic imaging test that records the pulmonary be instructed to cough and to take several deep distribution of a radioactive gas during breathing ma breaths. The patient should be in the supine position neuvers. during injection, or in the case of a patient with C. Pulmonary Perfusion Scintigraphy orthopnea, as close to supine as possible. A diagnostic imaging test that records the distribution B. Information Pertinent to Performing the Procedure of pulmonary arterial blood flow. 1. In women of childbearing age, pregnancy and lac D. Lung Scintigraphy for Pulmonary Embolism tation status should be noted and the procedure A diagnostic imaging test that assesses pulmonary performed in a manner to minimize radiation expo perfusion and often includes ventilation scintigraphy. sure. 2. Pertinent clinical history includes, but is not limited PART III: COMMON INDICATIONS to: (a) right-to-left shunt, (b) severe pulmonary A. The most common indication for lung scintigraphy is to hypertension, (c) chest pain, (d) dyspnea, (e) he determine the likelihood of pulmonary embolism. moptysis, (f) syncope, (g) symptoms of deep venous B. Less common indications (e.g., evaluation of lung transplan thrombosis, (h) oral contraceptive use, (i) recent tation, preoperative evaluation, right-to-left shunt evalua surgery, (j) prior pulmonary embolism, (k) cancer, tion) will be included in future versions of this guideline. (1) congestive failure, (m) antecedent illness, (n) smoking and (o) intravenous drug abuse. Received May 20, 1996; accepted May 27, 1996. For correspondence or reprints contact: Joanna Wilson. Society of Nuclear Medicine, 3. Pertinent findings on physical examination include, 1850 Samuel Morse Dr., Reston, VA 20190. but are not limited to: (a) vital signs, (b) chest

1906 THEJOURNALOFNUCLEARMEDICINE•Vol. 37 •No. 11 •November 1996