Clinical Nuclear Medicine

This is likely the most controversial volume in the entire series, because of the national changes in thyroid cancer management and thyroid therapy, much of which is driven by the American Thyroid Association (not an organization embraced by all nuclear physicians). The controversy symbol is all through this volume

For thyroidology, the available imaging agents, imaging techniques, and differential diagnoses of scan patterns are reviewed. The treatment variables of Graves Disease and thyroid cancer are reviewed and many case-examples are presented. The controversies that are discussed would require 30-40 years of controlled trials to answer (and as such, will likely never be performed or clarified; certainly not in my lifetime). You need to know both sides of the arguments.

Parathyroid imaging is reviewed in detail.

A much larger section is neuroendocrine imaging.  MIBG imaging is covered.  In the old days, MIBG was the dominant imaging technique for pheochromocytomas and paragangliomas.  Much of this has been replaced by DOTATATE (reviewed in the DOTATATE chapter).  It still has a dominant role in neuroblastoma that is reviewed, including therapy.

This volume is actually edition 1.1, which was updated after the clinical approval and availability of ⁶⁸Ga-DOTATATE. In the original volume, octreotide imaging was “king”.  I have left the octreotide section in place, if only to show important teaching examples, and to provide the overall history.  Octreotide imaging revolutionized our knowledge of gastrinomas, as well as many other neuroendocrine diseases, and this allows one to see its place in history.  Then comes the new section on DOTATATE, including therapy / Theranostics. DOTATATE has essentially replaced octreotide, where available.  It’s strengths and weaknesses are reviewed.  DOTATATE has achieved a particularly important role in paraganglioma imaging;  The knowledge of genetics of paragangliomas has exploded over the past 6 -8 years, and this rapidly changing area is a challenge to the average practitioner.  The current status of this knowledge base is reviewed.

A few representative images:

Congential Organification Defect with perchlorate washout test:

Graphic representation of thyroid hormone production:

Whole body radio-iodine scan showing widespread pulmonary and mediastinal metastases:

⁶⁸Ga DOTATATE IN PARAGANGLIOMA