Radiopharmaceutical Tumor Localization (SPECT), Single Area - CAM 722

INDICATIONS FOR A BONE/JOINT SPECT/SPECT CT SCAN: 
When routine dynamic planar imaging is insufficient (ACR, 2017; Bartel, 2018; Donohoe, 2020; NCCN, 2020; O’Sullivan, 2017).

  • Screening evaluation of  patients with recent / active malignancy presenting with elevated alkaline phosphatase, or bone pain or new pathological fracture
  • Staging or Restaging evaluation for the following, when recent overlapping whole body imaging (CT or PETCT of the chest, abdomen and pelvis) has not been done.

Note: For known bone metastases, whole body planar bone scan for staging and restaging is typically sufficient.

    • Breast cancer≥ stage IIA 
    • Prostate cancer with PSA ≥ 10 or Gleason ≥7 or ≥T3 or before radionuclide bone therapy
    • Primary bone cancers (such as Ewings, Osteosarcoma)
    • Monitoring of exclusively or predominantly bone metastases
  • For all cancers, if other imaging (CT/MRI/ PETCT) could not be done or are inconclusive in evaluation of bone metastases
  • Staging and restaging for radionuclide bone therapy for predominant bone metastases

INFECTION

  • Osteomyelitis: a plain x-ray AND an MRI of the area have been performed, unless MRI is contraindicated, technically limited or inconclusive (ACR 2017, 2019)
  • Discitis: MRI is contraindicated, technically limited or inconclusive

BONE VIABILITY

  • Detection of early avascular necrosis, bone infarct, or bone graft viability when patient has had a plain x-ray; and MRI is contraindicated or inconclusive (ACR, 2016)

TRAUMA

  • Extremities: Detection of stress fractures and other occult skeletal trauma when there is persistent pain in the suspected area after negative or inconclusive x-ray and MRI (ACR, 2017)
  • Spine:
    • For indications such as spondylolysis or determination of age of fracture after CT/MRI is inconclusive (ACR, 2021).
    • Spondylolysis evaluation in a child, with persistent pain after MRI and conservative treatment, in determining further treatment plan (Cheung, 2018; Goetzinger, 2020)

INCONCLUSIVE

  • Inconclusive MR/CT
  • Identification of a primary etiology (via most reactive/ inflammatory changes) when multiple etiologies are identified by MRI/CT, AND intervention planning is needed (includes primary facet joint target localization) (ACR, 2021; Brusko, 2019; Cohen, 2020; Matar, 2013; Russo, 2017; Tender, 2019)

POSTOPERATIVE

  • Evaluation of persistent symptoms in postoperative spine/joints/bones, after X-ray and CT are negative/inconclusive (ACR, 2021; Backer, 2020; Choudhri, 2014; Gnanasegaran, 2018; Paycha, 2018; Peters, 2019; Van Der Bruggen, 2018)

EXTREMITIES

  • For evaluation of unexplained extremity pain when clinical criteria and other imaging (x-ray, AND MRI/ Ultrasound/ CT) evaluation is inconclusive (e.g., differentiating complex regional pain syndrome from other causes of pain) (Ha, 2015; Huellner, 2013; Kwon, 2011; Shin, 2017)

FOLLOW-UP

  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Note:  Inconclusive includes the scenario when imaging findings do not explain patient clinical symptoms or lack of treatment efficacy.

Descrition/Background
SPECT: Single-photon emission computed tomography (SPECT) is a nuclear medicine imaging technique used to localize data from gamma ray emitting injected radiopharmaceuticals to specific anatomical locations within the patient. The resulting 3D images can be reconstructed in multiple planes, much like a CT scan. The ability to manipulate the imaging data into distinct multiplanar slices improves the diagnostic capability and spatial resolution while using the same pharmaceutical as with traditional planar bone scan. Radiopharmaceuticals used vary based on the clinical indication. The technique is applied in brain, cardiac, pulmonary, abdominal, endocrine, and musculoskeletal imaging.

SPECTCT: SPECTCT (Single-photon emission computed tomography with Computed Tomography) is now available in many places. The CT portion helps to correct the attenuation (decrease) of photons from the target, as it gets absorbed/reflected through the soft tissues before it reaches the detector. It also helps with anatomic localization much like the CT of PETCT. The CT of SPECTCT may or may not be of diagnostic quality depending on the vendor. However, SPECTCT is now more common among newer gamma imaging scanners. SPECTCT leads to increased specificity and accuracy.

BONE SPECT/SPECTCT: Due to advances in cross-sectional imaging, the technique currently has limited indications for detecting bone pathology. It is most commonly used in patients who have been found to have an unexpected single area abnormality on a planar (screening) bone scan. It is also used in those who cannot undergo MRI or CT imaging, or to clarify the findings on MRI or CT. Although vast majority of bone scan indications have been replaced by MRI or CT over the decades, the recent advent of SPECT has shown comparable or complementary performance vs MRI for some indications as those listed above (Deidrichs, 2017; Ha, 2015; Huellner, 2013; Israel, 2019). For patients with impaired renal function who cannot receive iodinated or gadolinium-based contrast agents or undergo MRI for other reasons, SPECT/ SPECTCT imaging can improve the performance of conventional planar nuclear bone imaging.

TRACERS: Nuclear medicine bone imaging is commonly performed with Technicium-99m-MDP (methylene diphosphonate). For indications such as infection or inflammation, Indium-111/ Technetium 99m HMPAO (hexamethylpropyleneamine oxime) labelled white blood cells, or Gallium 67 (for spine/sternum) can be used. Gallium is typically used for discitis evaluation, and imaging can be carried out to 2-3 days post tracer injection for better target-to-background ratio. Technetium 99m sulfur colloid scan is typically used concordantly for marrow mapping, to distinguish bone marrow from infection site.

Although 18F-labelled sodium fluoride (NaF) PET scanning is highly sensitive for detecting bone lesions, its routine use has not replaced conventional bone scanning due to the latter’s "effectiveness, widespread availability, low cost and favorable dosimetry" (O’Sullivan, 2015). If a bone SPECT/SPECTCT is not sufficient, specific PET tracers that detect both soft tissue and bone metastases (e.g., F18- FDG, F18- Fluciclovine, Ga68-Dotatate) have replaced the need for a separate NaF PET.

CRPS: In the evaluation of complex regional pain syndrome (CRPS), formerly reflex sympathetic dystrophy, three phase bone scintigraphy (flow, blood pool and delayed images) and MRI imaging sensitivities reported in the medical literature, ranges widely (Shin, 2017). In general, scintigraphy is more specific than MRI. SPECT imaging, however, is not routinely used for this indication.

INDICATIONS FOR NON-BONE INFECTION / INFLAMMATION SPECT/SPECT CT:  
When primary standard modality of CT / CTA / MRI / Ultrasound are inconclusive, limited, or cannot be done (Sethi, 2019), including:

  • Fever of Unknown Origin when CT/MR are negative/inconclusive/limited
  • Non-bone infection/ inflammation when primary standard imaging is negative/ inconclusive, including infections related to
    • Transplant and vascular grafts when ultrasound / CTA are negative/inconclusive/limited (Lauri, 2020; Volkan-Salanci, 2021)
    • Prosthetic valves, when echocardiography AND Coronary CTA are inconclusive (Galea, 2020)
    • Cardiac implantable devices when echocardiography is inconclusive (Galea, 2020)

Description/Background
Infection-seeking tracers labeled with single-photon-emitting radionuclides include autologous leukocytes [white blood cells (WBC)] labelled with 99mTc-hexamethylpropyleneamine oxime (HMPAO) or 111In-diethylenetriaminepentaaceticacid (DTPA). Imaging is typically completed the same day (for Technetium-Tc labelled agents) or the 2nd  day (for Indium labelled agents). CT portion of SPECT CT localizes the infection agent accumulation to the anatomic site. The tracer activity is not affected by artifact from implants and devices. They are typically used when other modalities such as CT or MRI have not yielded conclusive results or have not explained clinical status.

For infections related to vascular grafts, nuclear medicine modalities are particularly useful to mapping the extent of the infection (focal uptake) for surgical planning. Primary imaging is first done with ultrasound for extracavitary graft and CTA for intracavitary graft (Lauri, 2020).

INDICATIONS FOR TUMOR SPECT/SPECT CT:  

  • Iodine imaging for subsequent post thyroidectomy staging of differentiated thyroid cancers, in the setting of (NCCN, 2020):
    • Post thyroidectomy neck CT/MR showing residual unresectable thyroid tissue/ disease in the neck
    • Distant metastases as seen on CT/MR
    • Post thyroidectomy unstimulated thyroglobulin > 5-10ng/ml
    • Radioactive iodine therapy is being considered for high risk or recurrent tumor
    • Post radioiodine treatment (post therapy scan)
    • During surveillance, with rising thyroglobulin or stable / rising antithyroglobulin antibodies or abnormal ultrasound neck

Note: Refer to neck SPECT/SPECTCT for thyroid nodules.

  • For initial or restaging of Neuroendocrine tumors (typically In111-octreotide and Iodine-123 MIBG), for any part of the body (NCCN 2020),
    • When CT/MRI OR PET imaging is not available, cannot be done, has contraindications, or is inconclusive
    • I-131 MIBG: when I131 MIBG therapy is being considered
    • In 111- octreotide: Somatostatin analog therapy is being considered and Ga68 Dotatate PET is not available
  • Imaging during / post therapy with therapeutic agents such as 131 Iodine, 177Lu-Dotatate, 111In Zevalin, when it can change management
  • Lymphoscintigraphy with sentinel node localizations, for preoperative planning in melanoma, breast, head and neck, and gynecological cancers

Description/Background
Thyroid cancers are imaged by Iodine-123 or Iodine-131 tracers. Prior to treatment, sometimes a whole body I-123 imaging may be done if it is an aggressive cancer or if there is a suspicion of metastases. Whole body imaging with I-131 is acquired up to 10 days post therapeutic dosage with I-131 for thyroid cancers. Subsequent surveillance is done by monitoring thyroglobulin, thyroglobulin antibodies and ultrasound neck. If there is concern for recurrence, typically whole body I-123 or I-131 imaging is done after either stimulation (thyroid hormone withdrawal or thyrogen stimulation). SPECT/SPECTCT is frequently done of the neck; and of any other areas that need clarification on planar imaging.

Indium octreotide and Iodine MIBG (meta-iodobenzylguanidine) imaging are used to assess neuroendocrine tumors for somatostatin (SSTR) receptors to enable treatment with somatostatin analogs, such as octreotide acetate (Sandostatin). 

177Lu-Dotatate is a treatment for neuroendocrine cancers that have SSTR expression as seen on Gallium 68 PET or Indium 111 pentreotide/Octrotide imaging. 90Y- ibritumomab tiuxetan (or Zevalin®) is used as treatment for refractory non-Hodgkin’s lymphoma and may need initial biodistribution assessment with Indium111 ibritumomab tiuxetan. Therapeutic agents have some gamma or bremsstrahlung radiation that can be harnessed to image, to evaluate the biodistribution of the therapeutic tracer.

Lymphoscintigraphy with sentinel node mapping is often used in early stage breast, melanoma, and gynecological cancers immediately prior to surgical resection of primary lesion. This evaluates initial lymph nodes draining the target region. These lymph nodes are resected during surgery to see if involved, in which case the cancer is upstaged. For exact anatomic correlation, SPECT/SPECTCT is preferred, but may not be done due to time constraints before surgery. It is limited to newer systems with faster SPECTCT acquisition times or if planar imaging is inconclusive.

INDICATIONS FOR CARDIAC SPECT/SPECT CT
As addressed in MPI and MUGA guidelines. 

INDICATIONS FOR NECK SPECT/ SPECT CT (NON-CANCER):

  • Parathyroid adenoma: Clinically or laboratory proven hyperparathyroidism AND ultrasound of the neck completed. If CT is already completed, it should be inconclusive (Itani, 2020)
  • Thyroid: Abnormal thyroid tests and planar imaging is inconclusive for the location of a focal thyroid lesion.

Description/Background
Parathyroid adenomas are evaluated typically initially by cervical ultrasound. Parathryoid SPECT/SPECTCT with Tc99m sestamibi or Iodine and sestamibi tracer combo has similar diagnostic performance to 4D CT with less radiation dose.

Thyroid disorders that are diffuse typically do not need SPECT/SPECTCT imaging. However, it may be needed in cases of differentiation of a single cold nodule in the background of multinodular goiter to direct biopsy. Iodine -123 tracer is typically used for these.

INDICATIONS FOR LUNG SPECT/SPECTCT: 

  • Quantification of lung function prior to lung resection/ radiation and evaluation of congenital cardiac, thoracic or pulmonary disease, or lung transplants or bronchopleural fistulae (ACR, 2018).
  • Evaluation of congenital cardiac, thoracic, or pulmonary disease, or lung transplants or bronchopleural fistulae (ACR, 2018)
  • Chronic Thromboembolic pulmonary hypertension
  • Suspected acute pulmonary embolism with comorbidities (such as COPD, left heart failure, pneumonia, tumor) AND chest x-ray has been done, AND chest CTA cannot be done or limited. 
  • Calculation of lung shunt fraction prior to hepatic radioembolization.

Description/Background
Ventilation perfusion scans are typically done for pulmonary embolism (PE) assessment when chest CTA cannot be done; or for young patients, or in pregnancy when they have a normal chest x-ray (ATS 2011, due to lower radiation exposure). SPECT/ SPECTCT of the ventilation images is markedly limited in the US as the two ventilation tracers used in the US (Tc99m DTPA, Xenon) are not highly amenable to SPECT imaging. This and the overdiagnosis of small insignificant PE on SPECT/SPECTCT, like CTA, have enabled planar images to be the preferred method of evaluation of acute PE. However, for the purposes of lung surgery evaluation, congenital heart disease, and chronic pulmonary hypertension, the lung perfusion images have more significance, and these are amenable to SPECT/ SPECTCT with further increases in sensitivity and specificity.

INDICATIONS FOR A BRAIN SPECT/ SPECT CT (ACR, 2016):  

  • For preoperative localization of epileptic foci after EEG, Brain MRI and PET are done and insufficient (Duncan, 2016; Von Oertzen, 2018)
  • DAT scan (Buchert 2019; Hustad 2020; SNMMI, 2011)
    • To differentiate essential tremor and drug-induced parkinsonism from parkinsonian syndromes
    • For early/ inconclusive parkinsonian features
    • For dementia: differentiating Dementia with Lewy Bodies (DLB) from other dementia types. If FDG PET was completed for this indication, it was inconclusive.
  • For patient with history of stroke or trauma with recent Brain CT or MRI AND there are acute neurological changes or deficits not explained on the recent imaging study (ACR, 2016)
  • To evaluate cerebrovascular reserve in planning appropriate endovascular/vascular intervention or neurovascular surgical approach (ACR, 2016); can include:
    • Evaluation for vascular diseases such as Moyamoya
    • Carotid balloon occlusion
    • Hyperperfusion syndromes
    • Shunting for idiopathic normal pressure hydrocephalus (ACR, 2020)
  • Brain perfusion study for evaluation of brain death when CT or MRI already done and planar images are inconclusive (SNMMI, 2012)
  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Description/Background
Injected brain tracers used include 99mTc-bicisate (ECD; ethyl cysteinate dimer), 99mTc-exametazime (HMPAO; hexamethylpropylene amine oxime), and 99mTc-pentetate (DTPA; diethylenetriaminepentaacetic acid). I123 Ioflupane is used for DAT scan (Dopamine Transporter Scan). Brain studies are done as a default with SPECT/SPECTCT unless it is a brain death scintigraphy. These tracers cross the blood brain barrier where they emit gamma rays that are detected by the imaging system. A 3D image of the brain is created using computerized techniques with the degree of radionuclide activity corresponding to neuronal activity or cerebral blood flow.

Epilepsy: 15 – 30% of patients with refractory focal epilepsy do not have distinct lesions on MRI. The next investigation for a possible surgically resectable epileptogenic focus includes PET. If this is negative or inconclusive, ictal (during seizure) brain SPECT/SPECTCT can be obtained, which can reveal increased uptake at the epileptogenic area.  

Stroke/Trauma/Presurgical planning: These are usually evaluated with brain MRI (or brain CT if there is a contraindication to brain MRI). However, if these are inconclusive, or limited, or could not be done, or do not explain the clinical picture, or if additional information is needed for surgeries, Brain SPECT images are obtained, often to evaluate vascular reserve. Brain images are obtained at rest and after vasodilatory acetazolamide injection challenge. These may clarify inconclusive clinical or imaging abnormalities or assess vascular reserve for surgeries. This can also be done with other challenges as well, such as carotid balloon occlusion. In the assessment of transient ischemic disease, reduced perfusion can be seen earlier than changes on conventional imaging and may help plan appropriate therapeutic intervention. In traumatic brain injury (including whiplash, post-concussion syndromes), SPECT studies have shown areas of hypoperfusion without corresponding MRI or CT findings (ACR, 2015).

Brain Death: This is typically used in the ICU setting, when clinical assessment and electroencephalography are less reliable in diagnosing brain death because of conditions such as severe hypothermia, coma caused by barbiturates, electrolyte or acid–base imbalance, endocrine disturbances, drug intoxication, poisoning, and neuromuscular blockade. Brain death scintigraphy may also be helpful in patients who are being considered as possible organ donors or when family members require documentation of lack of blood flow.

Dementia: Brain SPECT imaging has been replaced by brain PET due to better resolution.

DAT scan (Dopamine transporter Imaging): I123 Ioflupane tracer demonstrates the location and concentration of dopamine transporters (DATs) in the synapses of striatal dopaminergic neurons. This is decreased in presynaptic parkinsonian syndromes (Parkinson's disease, multiple system atrophy, and progressive supranuclear palsy) but is not affected in mimicking conditions such as essential tremor, drug-induced parkinsonism or psychogenic parkinsonism. It is also useful in the differentiation of Alzheimer’s dementia from Dementia with Lewy Bodies. The latter is in the spectrum of parkinsonism, but may or may not have clinical symptoms of parkinsonism, such as bradykinesia, rigidity, or tremor at rest.  

INDICATIONS FOR A RADIONUCLIDE CISTERNOGRAPHY (CSF) SPECT/SPECT CT SCAN: 

  • CSF imaging (for evaluation of hydrocephalus, leak, shunt, normal pressure hydrocephalus, spontaneous intracranial hypotension) when
    • Brain/spine or respective site imaging already done with appropriate CT/ MRI / CT myelography, and deemed to be insufficient; AND
    • Planar images are insufficient for localization of abnormality.
  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested. 

Description/BACKGROUND
Cerebrospinal fluid (CSF) flow studies for the evaluation of obstructive or non-obstructive hydrocephalus of various etiologies or CSF leaks (CSF cisternography) are performed after the intrathecal administration of radionuclide. The radionuclides used for CSF flow studies are Indium-111 DTPA for cisternography and leaks (Ma, 2015). Persistence of activity in the lateral ventricles after 24 hours of imaging is diagnostic of normal pressure hydrocephalus. Cine phase contrast MRI is the preferred technique for evaluating CSF flow dynamics and helps determines which patients with NPH will benefit from treatment (Damasceno, 2015; Halperin, 2015).

To evaluate ventriculoperitoneal shunt patency, Tc-99m DTPA radionuclide is injected into the shunt reservoir. Normal shunt patency is confirmed by showing activity along the entire course of the shunt, ultimately spilling into the abdominal cavity.

CSF leaks are more commonly acquired either iatrogenic or post-traumatic (Lloyd, 2008) than congenital or spontaneous and can occur anywhere along the cranial spinal axis. Scintigraphy for detecting CSF leaks has been superseded by CT and MRI myelographic techniques or thin section skull base CT due to their better spatial resolution (Epstein, 2013; Lloyd, 2008). Diagnosis using scintigraphy requires intrathecal administration of radionuclide followed by imaging typically at 3,6, 24, and 48 hours. Pledgets can be placed in the nasal cavity or auditory canal in the setting of CSF rhinorrhea and otorrhea, respectively. CSF leak path is traced. Initial diagnostic imaging is typically done with high resolution CT, CT/MR cisternography (Eljazzar, 2019; Hiremath, 2019; Lipschitz, 2019).

Spontaneous idiopathic hypotension (SIH), also known as craniospinal hypotension, poses a diagnostic challenge due to its protean clinical symptoms, inconsistently demonstrated imaging findings on conventional MRI scanning, and lack of awareness of the diagnosis among clinicians. SIH often presents a variable mix of symptoms including orthostatic headaches, visual defects or blurred vision, limb paresthesia, transient 3rd cranial nerve palsy, numbness in the face or limbs, cognitive deficits, behavioral changes, neck pain and stiffness, taste alteration, or parkinsonism. In this condition a CSF leak anywhere along the neuraxis is not detected in nearly one-third of patients thought to be due to the slow or intermittent nature of these leaks (Lin, 2017). Radionuclide cisternography was found to be more sensitive than CT myelography in a few limited case series (Hashizume 2012; Wiesemann, 2006; Yoo, 2008). Imaging at multiple time points up to 48 hours, as well as direct and indirect signs, aid in the detection of intermittent or slow leaks, with lower radiation exposure than CT myelography (Martineau, 2020). SPECT-CT allows improved anatomical localization and characterization (Arai, 2012; Novotny, 2009).

INDICATIONS FOR RENAL SPECT/ SPECTCT (ACR, 2017; SNMMI, 2018)
Complex clinical scenarios involving the following indications wherein cross-sectional imaging and routine dynamic planar imaging alone is, or projected to be, insufficient:

  • Evaluation of renal collecting system for trauma, surgery, obstruction in ADULTS, or with signs, symptoms, and laboratory findings supporting the need for such an evaluation in adults; AND
    • CT has been performed and is inconclusive or contraindicated
  • For evaluation of renal collecting system for obstruction or vesicoureteral reflux in children and young females:
    • After ultrasound and VCUG (voiding cystourethrography) / VUS (voiding urosonography) are inconclusive or discordant with clinical picture (ACR, 2015, 2017)
  • For diagnosis of reno-vascular hypertension with signs, symptoms, laboratory findings, or other imaging supporting the need for such a diagnosis when
    • Duplex ultrasound is inconclusive; AND
    • MRA or CTA cannot be performed or is contraindicated; AND
    • The patient has adequate renal function (GFR >30) mL/min/1.73 m2) to undergo the study (ACR, 2017)
  • Further evaluation of renal perfusion and split function after completion of ultrasound, including in the setting of surgery, trauma, infection, congenital and mass abnormalities (ACR, 2017)
  • Diagnosis of renal transplant complications after ultrasound has been performed (ACR, 2017, Volkan-Salanci 2021)
  • Evaluation of renal infections and discrimination of pyelonephritis from cortical scarring (ACR, 2017)
  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.

Description/Background
Renal scintigraphy remains an important technique for evaluation of the renal circulation, parenchyma, and collecting system. Through the acquisition of serial images over time and graphic depiction of radionuclide activity, information about renal blood flow and function not typically afforded by cross-sectional imaging can be achieved through qualitative and quantitative means. Tailored studies utilizing the administration of diuretic or angiotensin-converting enzyme inhibitors, in conjunction with the radionuclide imaging agent, allows for evaluation of suspected hydronephrosis or renovascular hypertension, respectively. The ability to create 3D multiplanar images with the SPECT/SPECTCT technique greatly improves the diagnostic capability over traditional planar imaging. 

Tubular secretion agents, such as 99mTc-MAG3, are used for diuretic renography because tubular tracers are much more efficiently extracted by the kidney than 99mTc-DTPA, and washout is therefore easier to evaluate. 99mTc-DTPA (diethylene triamine pentaacetic acid) is filtered purely by the glomerulus and thus can be used both to image the kidney and to measure glomerular filtration rate. Tc 99m DMSA (Dimercaptosuccinic acid) is especially useful for pyelonephritis and scar evaluations.

OVERVIEW
Diuresis renography can evaluate severity of urinary tract obstruction and can differentiate an obstructed collecting system from a dilated, but non obstructing, system. It can also provide the differential function in each kidney. Multiple follow-up exams may be needed to detect gradual improvement or worsening.

Captopril Renography, is done by imaging before and after administration of acetylcholine esterase inhibitor in patients with high index of suspicion of renovascular hypertension. It is used to identify subgroup in whom hypertension caused by renal artery stenosis could potentially respond to revascularization (ACR, 2017).

Renal scintigraphy can be used to screen for postoperative complications in renal allograft dysfunction. These can include infarcts, acute tubular necrosis (ATN), collecting system obstruction, urine leaks, drug-induced nephrotoxicity, and rejection. ATN is differentiated from acute rejection as it usually occurs within the first few days after transplantation whereas acute rejection occurs from one week to months after transplantation. Baseline study may be for future comparison.

Renal scintigraphy can also be used to assess differential function in each kidney and in each segment of the kidney for further treatment implications in cases of surgery, trauma, infection, and congenital and mass abnormalities.

INDICATIONS FOR ABDOMEN / PELVIS SPECT/ SPECT CT SCAN

  • Hepatic radioembolization (ACR-ABR-ASTRO-SIR-SNMMI 2019)
    • For evaluation of pulmonary and gastrointestinal shunts or dosimetry calculations prior to procedure
    • Post-procedure imaging in lieu of PET to determine dose effect/dose toxicity
  • For evaluation of the following:
    • Intermittent/occult gastrointestinal bleeding after initial workup is indeterminate/contraindicated (scopes, CTA) (ACR, 2016)
    • Indeterminate or vascular hepatic lesions or bleed, when CT/MRI are contraindicated/inconclusive (ACR, 2017)
    • Indeterminate accessory splenic tissue/asplenia when CT/MRI are contraindicated/inconclusive (ACR, 2015)
  • Liver transplant (and other hepatic surgery/radiation) preoperative and postoperative function and complications when ultrasound/CT/MR are indeterminate or contraindicated (ACR, 2017)
  •  Localization of:
    • Suspected ectopic/residual gastric tissue (e.g., Meckel’s diverticulum) (ACR, 2015)
    • Abnormalities in hepatobiliary scintigraphy (e.g., biliary abnormalities/leaks) when ultrasound (in infants) or CT is inconclusive/contraindicated (ACR, 2017)
  • Peritoneal imaging for evaluation of complications of shunts, dialysis, or peritoneal integrity, when CT is inconclusive/ contraindicated (ACR, 2015)
  • A follow-up study may be needed to help evaluate a patient’s progress after treatment, procedure, intervention, or surgery. Documentation requires a medical reason that clearly indicates why additional imaging is needed for the type and area(s) requested.  

Description/BACKGROUND
Most indications utilize a series of standard planar images over time to determine the progression of the radionuclide through the respective system. However, SPECT / SPECTCT improves anatomic localization, increases diagnostic certainty and accuracy, and decreases the need for delayed imaging.

99mTc-labeled autologous red blood cells (99mTc-RBCs) are injected in intermittent gastrointestinal bleeds and imaged intermittently up to 24 hours to localize bleeds. It can detect bleeding rates as low as 0.1 cc/min to 0.5 cc/min (vs CTA-0.3-1ml/min and angiography 0.5-1ml/min). SPECT/SPECTCT increases the sensitivity and specificity of bleeding-site localization. It has lower radiation exposure than CTA, particularly relevant in children (e.g., Meckel diverticulum studies) (Grady, 2016).

Tc99m sulfur colloid (and sometimes Tc99m RBC) ARE used to identify indeterminate vascular hepatic lesions, such as hemangiomas and hemangioendotheliomas. Denatured Tc99m RBC is useful for identifying indeterminate accessory splenic tissue.

Hepatic radioembolization is used for liver dominant malignancy or metastases that are unresectable. It involves intraarterial injection of yttrium 90 glass or resin microspheres. Tc99m MAA arterial injection before the procedure is needed to ensure that an excessive uncorrectable shunt of the treatment agent to the lungs or the GI tract is not present. Post-procedure bremsstrahlung planar imaging (using the Y90 embolization agent), SPECT, SPECT/CT, is recommended within 24 hours of the conclusion of the procedure for documentation of placement of devices, assessment of significant extrahepatic shunting, evaluation for suboptimal/excessive tumor radiation exposure, and establishing dose-effect and dose-toxicity via quantitative data when planning subsequent treatments. Quantitative assessments would be better with Y90 PET.

Peritoneal imaging includes evaluation of patency of peritoneovenous shunts, diaphragmatic perforations or peritoneal loculations, especially prior to intraperitoneal chemotherapy. This is done by injection of Tc99m MAA into the peritoneal cavity.

SPECT/SPECTCT in hepatobiliary imaging can help localize abnormalities in hepatobiliary imaging by distinguishing superimposed bowel activity and clarifying biliary abnormalities and bile leaks. It may obviate the need for delayed imaging and increase diagnostic certainty. Imaging is done utilizing the IV administration of Tc99m-labeled iminodiacetic acid which is excreted by hepatocytes like bile.

Liver transplant complications are best evaluated by ultrasound, CT, and MR; however, limited applications in pediatric patients may exist when radiation doses or sedation considerations exist.

REFERENCES

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  11. Donohoe KJ, Cohen EJ, Giammarile F, et al. Appropriate use criteria for bone scintigraphy in prostate and breast cancer. August 2020. http://s3.amazonaws.com/rdcms-snmmi/files/production/public/Quality/jnm191429_v8.pdf.
  12. Donohoe KJ, Cohen EJ, Giammarile F, et al. Appropriate use criteria for bone scintigraphy in prostate and breast cancer: Summary and excerpts.J Nucl Med. 2017; 58(4):14N-17N.
  13. Dyrberg E, Hendel HW, Løgager VB, et al. A prospective study determining and comparing the diagnostic accuracy of fluoride-PET/CT, choline-PET/CT, whole-body bone SPECT/CT and whole-body MRI for the detection of bone metastases in patients with prostate cancer.Eur J Hybrid Imaging. 2018; 2(19). https://doi.org/10.1186/s41824-018-0038-y.
  14. Fontaine J, Bhavan K, Lam K, et al. Comparison between Tc-99m WBC SPECT/CT and MRI for the diagnosis of biopsy-proven diabetic foot osteomyelitis. Wounds. 2016; 28(8):271-278.
  15. Gnanasegaran G, Paycha F, Strobel K, et al. Bone SPECT/CT in post operative spine. Semin Nucl Med. 2018 Sep; 48:410–424.
  16. Goetzinger S, Courtney S, Yee K, et al. Spondylolysis in young athletes: An overview emphasizing nonoperative management. J Sports Med (Hindawi Publ Corp). 2020 Jan 21; 2020:9235958. Epub 2020. 
  17. Ha S, Hong SH, Paeng JC, et al. Comparison of SPECT/CT and MRI in diagnosing symptomatic lesions in ankle and foot pain patients: Diagnostic performance and relation to lesion type. PLoS One. 2015 Feb 10; 10(2):e0117583.
  18. Horger M, Eschmann SM, Pfannenberg C, et al. Added value of SPECT/CT in patients suspected of having bone infection: Preliminary results. Arch Orthop Trauma Surg. 2007; 127:211–221.
  19. Huellner MW, Bürkert A, Strobel K, et al. Imaging non-specific wrist pain: Interobserver agreement and diagnostic accuracy of SPECT/CT, MRI, CT, bone scan and plain radiographs. PLoS One. 2013; 8:e85359.
  20. Israel O, Pellet O, Biassoni L, et al. Two decades of SPECT/CT - the coming of age of a technology: An updated review of literature evidence. Eur J Nucl Med Mol Imaging. 2019; 46(10):1990‐2012.  
  21. Kwon HW, Paeng JC, Nahm FS, et al. Diagnostic performance of three-phase bone scan for complex regional pain syndrome type 1 with optimally modified image criteria. Nucl Med Mol Imaging. December 2011; 45(4):261-267.
  22. Matar HE, Navalkissoor S, Berovic M, et al. Is hybrid imaging (SPECT/CT) a useful adjunct in the management of suspected facet joints arthropathy? Int Orthop. 2013; 37(5):865-870. doi:10.1007/s00264-013-1811-y.  
  23. Mavriopoulou E, Zampakis P, Smpiliri E, et al. Whole body bone SPECT/CT can successfully replace the conventional bone scan in breast cancer patients. A prospective study of 257 patients. Hell J Nucl Med. 2018 May-Aug; 21(2):125-33.
  24. Murphey MD, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria Osteonecrosis of the Hip. J Am Coll Radiol. 2016; 13(2):147-155.
  25. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Breast Cancer. 2020. https://www.nccn.org/professionals/physician_gls/pdf/breast_blocks.pdf. 
  26. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology - Prostate Cancer. 2020. https://www.nccn.org/professionals/physician_gls/pdf/prostate_blocks.pdf. 
  27. National Comprehensive Cancer Network (NCCN). NCCN Guidelines. Various cancers. 2020. 
  28. O’Sullivan GJ, Carty FL, Cronin CG. Imaging of bone metastasis: An update. World J Radiol. August 28, 2015; 7(8):202-211.  
  29. Paycha F, Gnanasgaran G, Van den Wyngaert. Post-operative SPECT/CT in Orthopedics. 2018 Sep; 48(5):393-482.
  30. Peters MJM, Bastiaenen CHG, Brans BT, et al. The diagnostic accuracy of imaging modalities to detect pseudarthrosis after spinal fusion-a systematic review and meta-analysis of the literature. Skeletal Radiol. 2019; 48(10):1499-1510. doi:10.1007/s00256-019-03181-5.
  31. Ravaioli A, Pasini G, Polselli A, et al. Staging of breast cancer: New recommended standard procedure. Breast Cancer Res Treat. 2002; 72:53–60.
  32. Russo VM, Dhawan RT, Baudracco I, et al. Hybrid bone SPECT/CT imaging in evaluation of chronic low back pain: Correlation with facet joint arthropathy. World Neurosurg. 2017 Nov; 107:732-738.
  33. Shin SH, Kim SJ. Bone scintigraphy in patients with pain. Korean J Pain. July 2017; 30(3):165-175.
  34. Silberstein EB, Buscombe JR, McEwan A, et al. Society of Nuclear Medicine Procedure Guideline for Palliative Treatment of Painful Bone Metastases. Version 3.0. http://snmmi.files.cms-plus.com/docs/pg_ch25_0403.pdf. Approved January 25, 2003. 
  35. Tamm AS, Abele JT. Bone and gallium single-photon emission computed tomography-computed tomography is equivalent to magnetic resonance imaging in the diagnosis of infectious spondylodiscitis: A retrospective study. Can Assoc Radiol J. 2017 Feb; 68(1):41-46.
  36. Tender GC, Davidson C, et al. Primary pain generator identification by CT-SPECT in patients with degenerative spinal disease. Neurosurg Focus. 2019 Dec 1; 47(6):E18.
  37. Van der Bruggen W, Hirschmann MT, Strobel K, et al. SPECT/CT in the postoperative painful knee. Semin Nucl Med. 2018 Sep; 48(5):439-453. doi: 10.1053/j.semnuclmed.2018.05.003. Epub 2018 Jun 21.
  38. Walker EA, Beaman FD, Wessell DE, et al. ACR Appropriateness Criteria® Suspected Osteomyelitis of the Foot in Patients with Diabetes Mellitus. J Am Coll Radiol. 2019; 16(11S):S440-S450.

NON-BONE INFECTION/INFLAMMATION

  1. Erba PA, Israel O. SPECT/CT in infection and inflammation. Clin Transl Imaging. 2014; 2:519–535.
  2. Erba PA, Leo G, Sollini M, et al. Radiolabelled leucocyte scintigraphy versus conventional radiological imaging for the management of late, low-grade vascular prosthesis infections. Eur J Nucl Med Mol Imaging. 2014; 41:357–368.
  3. Galea N, Bandera F, et al. multimodality imaging in the diagnostic work-up of endocarditis and Cardiac Implantable Electronic Device (CIED) infection. J Clin Med. 2020; 9(7):2237.
  4. Lauri C, Iezzi R, Rossi M, et al. Imaging modalities for the diagnosis of vascular graft infections: a consensus paper amongst different specialists. J Clin Med. 2020; 9(5):1510.
  5. Sethi I, Baum YS, et al. Current status of molecular imaging of infection: A primer. Am J Roentgenol. 2019; 213(2):300-308.
  6. Volkan-Salanci B, Erbas B. Imaging in renal transplants: An update. Semin Nucl Med. 2021 Jan 20:S0001-2998(20)30134-3.  

TUMOR

  1. Bluemel C, Herrmann K, Giammarile F, et al. EANM practice guidelines for lymphoscintigraphy and sentinel lymph node biopsy in melanoma. Eur J Nucl Med Mol Imaging. 2015; 42:1750–1766.  
  2. Francis GL, Waguespack SG, Bauer AJ, et al. Management guidelines for children with thyroid nodules and differentiated thyroid cancer. Thyroid. 2015 Jul; 25(7):716-59.
  3. Giammarile F, Alazraki N, Aarsvold JN, et al. The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer. Eur J Nucl Med Mol Imaging. 2013 Dec; 40(12):1932-47. doi: 10.1007/s00259-013-2544-2. Epub 2013 Oct 2.
  4. Giammarile F, Bozkurt M, Cibula D, et al. The EANM clinical and technical guidelines for lymphoscintigraphy and sentinel node localization in gynaecological cancers. Eur J Nuc Med Mol Imaging. 2014 Jul; 41(7):1463-77. doi: 10.1007/s00259-014-2732-8. Epub 2014 Mar 8.
  5. Haugen BR, Alexander EK, Bible KC, et al. 2015 American Thyroid Association management guidelines for adult patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2016 Jan; 26(1):1-133.
  6. Hope TA, Abbott A, Colucci K, et al. NANETS/SNMMI procedure standard for somatostatin receptor–based peptide receptor radionuclide therapy with 177Lu-DOTATATE. J Nucl Med. 2019 Jul; 60(7):937-43.
  7. National Comprehensive Cancer Network (NCCN). NCCN Guidelines for Neuroendocrine Cancer. Feb 2020.
  8. National Comprehensive Cancer Network (NCCN). NCCN Guidelines for Thyroid Cancer. Feb 2020.
  9. Skanjeti A, Dhomps A, Paschetta C, et al. Lymphoscintigraphy for sentinel node mapping in head and neck cancer. Semin Nucl Med. 2021 Jan; 51(1):39-49.
  10. Taïeb D, Hicks RJ, Hindie E, et al. European Association of Nuclear Medicine Practice Guideline/Society of Nuclear Medicine and Molecular Imaging Procedure Standard 2019 for radionuclide imaging of phaeochromocytoma and paraganglioma. Eur J Nucl Med Mol Imaging. 2019 Sep; 46(10):2112-2137. doi: 10.1007/s00259-019-04398-1. Epub 2019 Jun 29.
  11. Tennvall J, Fischer M, Delaloye AB, et al. EANM procedure guideline of radio-immunotherapy for B-cell lymphoma with 90Y-radiolabeled ibritumomab tiuxetan (Zevalin®). Eur J Nucl Mol Imaging. 2007 Apr; 34(4):616-22.

NECK (NON-CANCER)

  1. Giovanella L, Avram AM, Iakovou I, et al. EANM practice guideline/SNMMI procedure standard for RAIU and thyroid scintigraphy. Eur J Nucl Med Mol Imaging. 2019; 46:2514–2525. https://doi.org/10.1007/s00259-019-04472-8.  
  2. Itani M, Middleton WD. Parathyroid Imaging. Radiol Clin North Am. 2020 Nov; 58(6):1071-1083. doi: 10.1016/j.rcl.2020.07.006.
  3. Treglia G, Trimboli P, Huellner M, et al. Imaging in primary hyperparathyroidism: Focus on the evidence-based diagnostic performance of different methods. Minerva Endocrinol. 2018 Jun; 43(2):133-143. doi: 10.23736/S0391-1977.17.02685-2. Epub 2017 Jun 23.
  4. Wan QC, Li JF et al. Comparing the diagnostic accuracy of 4D CT and 99mTc-MIBI SPECT/CT for localizing hyperfunctioning parathyroid glands: a systematic review and meta-analysis. Nucl Med Commun. 2020 Dec 9.
  5. Zafereo M, Yu J, Angelos P, et al. American Head and Neck Society Endocrine Surgery Section update on parathyroid imaging for surgical candidates with primary hyperparathyroidism. Head Neck. 2019 Apr 19. https://onlinelibrary.wiley.com/doi/abs/10.1002/hed.25781.

LUNG

  1. American College of Radiology (ACR). ACR–SPR–STR practice parameter for the performance of pulmonary scintigraphy. 2018. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/Pulmonary_Scintigraphy.pdf.
  2. Bucknell NW, Hardcastle N, Bressel M, et al. Functional lung imaging in radiation therapy for lung cancer: A systematic review and meta-analysis. Radiother Oncol. 2018 Nov; 129(2):196-208.
  3. Chirindel A, Cachovan M, Vija AH, et al. 3D-Quantitated lung perfusion 99mTc-MAA SPECT/CT: Impact on intended management in comparison to planar (2D) lung perfusion scan in lung cancer patients. J Nucl Med. 2019 May 1; 60(Suppl 1):299.
  4. Elojeimy S, Cruite I, Bowen S, et al. Overview of the novel and improved pulmonary ventilation-perfusion imaging applications in the era of SPECT/CT. Am J Roentgenol. 2016; 207(6):1307-1315.
  5. Elsayed M, Cheng B, Xing M, et al. Comparison of Tc-99m MAA planar versus SPECT/CT imaging for lung shunt fraction evaluation prior to Y-90 radioembolization: Are we overestimating lung shunt fraction? Cardiovasc Intervent Radiol. 2021 Feb; 44(2):254-260.
  6. Genseke P, Wetz C, Wallbaum T, et al. Pre-operative quantification of pulmonary function using hybrid-SPECT/low-dose-CT: A pilot study. Lung Cancer. 2018 Apr; 118:155-160.
  7. Gopalan D, Blanchard D, Auger WR. Diagnostic evaluation of chronic thromboembolic pulmonary hypertension. Ann Am Thorac Soc. 2016 Jul; 13(Suppl 3):S222–S239.
  8. Gopalan D, Delcroix M, Held M. Diagnosis of chronic thromboembolic pulmonary hypertension. Eur Resp Rev. 2017 Mar; 26(143):160108.
  9. Kappadath SC, Lopez BP, Salem R, et al. Review of lung shunt and lung dose calculation methods for radioembolization treatment planning. Q J Nucl Med Mol Imaging. 2021 Mar; 65(1):32-42.
  10. Kristiansen J, Perch M, Iversen M, et al. Lobar quantification by ventilation/perfusion SPECT/CT in patients with severe emphysema undergoing lung volume reduction with endobronchial valves. Respiration. 2019; 98:1-9. 10.1159/000500407.
  11. Le Roux PY, Robin P, Tromeur C, et al. Ventilation/perfusion SPECT for the diagnosis of pulmonary embolism: A systematic review. J Thromb Haemost. 2020 Nov; 18(11):2910-2920.
  12. Metter D, Tulchinsky M, Freeman LM. Current status of ventilation-perfusion scintigraphy for suspected pulmonary embolism. Am J Roentgenol. 2017; 208(3):489-494.
  13. Moradi F, Morris TA, Hoh CK, et al. Perfusion scintigraphy in diagnosis and management of thromboembolic pulmonary hypertension. Radiographics. 2019 Jan-Feb; 39(1):169-185. doi: 10.1148/rg.2019180074.
  14. Mortensen J, Berg RM. Lung scintigraphy in COPD. Sem Nuc Med. 2019 Jan; 49():16-21.
  15. Toney L, Wanner M, Miyaoka R, et al. Improved prediction of lobar perfusion contribution using technetium-99m-labeled macroaggregate of albumin single photon emission computed tomography/computed tomography with attenuation correction. J Thorac Cardiovasc Surg. 2014 Nov; 148(5):2345-52. doi: 10.1016/j.jtcvs.2014.04.036.
  16. Wang M, Wu D, Ma R, et al. Comparison of V/Q SPECT and CT Angiography for the diagnosis of chronic thromboembolic pulmonary hypertension. Radiology. 2020 Aug; 296(2):420-429.
  17. Waxman AD, Bajc M, Brown M, et al. Appropriate use criteria for ventilation-perfusion imaging in pulmonary embolism: Summary and excerpts. J Nucl Med. 2017 May; 58(5):13N-15N.

BRAIN

  1. Acker G, Lange C, Schatka I, et al. Brain perfusion imaging under acetazolamide challenge for detection of impaired cerebrovascular reserve capacity: Positive findings with O-15-water PET in patients with negative Tc-99m-HMPAO SPECT. [Published online ahead of print July 20 2017]. J Nucl Med. 2018. doi: 10.2967/jnmed.117.195818.
  2. Amen DG, Trujillo M, Newberg A, et al. Brain SPECT imaging in complex psychiatric cases: An evidence-based, underutilized tool. Open Neuroimag J. 2011; 5:40-48. doi: 10.2174/1874440001105010040.
  3. American College of Radiology (ACR). ACR Appropriateness Criteria® Head Trauma. Published 2020. Accessed August 6, 2021. https://acsearch.acr.org/docs/69481/Narrative/.
  4. American College of Radiology (ACR). ACR Appropriateness Criteria® Dementia and Movement Disorders. https://acsearch.acr.org/docs/69360/Narrative/. Published 2015. Retrieved January 28, 2018.
  5. American College of Radiology-Society for Pediatric Radiology (ACR-SPR). ACR–SPR practice parameter for the performance of single photon emission computed tomography (spect) brain perfusion imaging, including brain death examinations. 2016. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/brainperf-spect.pdf?la=en.
  6. Banks KP, Peacock JG, Clemenshaw MN, et al. Optimizing the diagnosis of Parkinsonian syndromes with 123I-Ioflupane brain SPECT. Am J Roentgenol. 2019 213(2):243-253.
  7. Baumgartner C, Koren JP, Britto-Arias M, et al. Presurgical epilepsy evaluation and epilepsy surgery. F1000Res. 2019; 8:F1000 Faculty Rev-1818. Published 2019 Oct 29. doi:10.12688/f1000research.17714.1.
  8. Buchert R, Buhmann C,Apostolova I, et al. Nuclear imaging in the diagnosis of clinically uncertain Parkinsonian Syndromes. Dtsch Arztebl Int. 2019; 116(44):747-754. doi:10.3238/arztebl.2019.0747.
  9. Chandra S, Vaghani G, Bal CS, et al. Role of concordance between ictal-subtracted SPECT and PET in predicting long-term outcomes after epilepsy surgery. Epilepsy Res. 2014 Dec; 108(10):1782-9. doi: 10.1016/j.eplepsyres.2014.09.024. Epub 2014 Sep 28.
  10. Desai A, Bekelis K, Thadani VM, et al. Interictal PET and ictal subtraction SPECT: sensitivity in the detection of seizure foci in patients with medically intractable epilepsy. Epilepsia. 2013 Feb; 54(2):341-50. doi: 10.1111/j.1528-1167.2012.03686.x. Epub 2012 Oct 2.
  11. Djang DSW, Janssen MJR, Bohnen N, et al. SNM Practice Guideline for Dopamine Transporter Imaging with 123I-Ioflupane SPECT 1.0*. J Nuc Med. 2012 Jan; 53(1). Epub 2011 Dec 8.
  12. Donohoe KJ, Agrawal G, Frey KA, et al. SNM Practice Guideline for Brain Death Scintigraphy 2.0. J Nuc Med Tech. 2012 Sep; 40(3). Epub 2012 Jun 28.
  13. Duncan JS, Winston GP, Koepp MJ, et al. Brain imaging in the assessment for epilepsy surgery. Lancet Neurol. 2016 April 1; 15(4): 420–433.
  14. Falk N, Cole A. Evaluation of suspected dementia. Am Fam Physician. 2018 Mar; 97(6):398-405.
  15. Frankle WG, Slifstein M, Talbot PS, et al. Neuroreceptor imaging in psychiatry: Theory and applications. Int Rev Neurobiol. 2005; 67:385-440. doi: 10.1016/S0074-7742(05)67011-0.
  16. Graebner AK, Tarsy D, Shih LC, et al. Clinical impact of 123I-Ioflupane SPECT (DaTscan) in a movement disorder center. Neurodegener Dis. 2017; 17:38-43. doi: 10.1159/000447561. Epub 2016 Sep 10.
  17. Hort J, O’Brien JT, Gainotti G, et al. EFNS guidelines for the diagnosis and management of Alzheimer’s disease. Eur J Neurol. 2010 Oct; 17(10):1236-48.
  18. Hustad E, Aasly JO. Clinical and Imaging Markers of Prodromal Parkinson's Disease. Front Neurol. 2020; 11:395. Published 2020 May 8. doi:10.3389/fneur.2020.00395. 
  19. Isaacson SH, Fisher S, Gupta F, et al. Clinical utility of DaTscan™ imaging in the evaluation of patients with parkinsonism: A US perspective. Expert Rev Neurother. 2017; 17(3): 219-225.
  20. Juhász C, John F. Utility of MRI, PET, and ictal SPECT in presurgical evaluation of non-lesional pediatric epilepsy. Seizure. 2020 Apr; 77:15-28. doi: 10.1016/j.seizure.2019.05.008. Epub 2019 May 11. 
  21. Juni JE, Waxman AD, Devous MD, et al. Procedure guideline for brain perfusion SPECT using 99mTc radiopharmaceuticals 3.0. J Nucl Med Technol. 2009; 37(3):191-195. doi: 10.2967/jnmt.109.067850.
  22. Kim S, Mountz JM. SPECT imaging of epilepsy: An overview and comparison with F-18 FDG PET. Int J Mol Imaging. 2011 May; 813028. https://www.hindawi.com/journals/ijmi/2011/813028/. Retrieved January 28, 2018.
  23. Kupsch AR, Bajaj N, Weiland F, et al. Impact of DaTscan SPECT imaging on clinical management, diagnosis, confidence of diagnosis, quality of life, health resource use and safety in patients with clinically uncertain parkinsonian syndromes: A prospective 1-year follow-up of an open-label controlled study. J Neurol Neurosurg Psych. 2012; 83:620-628.
  24. Kupsch AR, Kupsch A, Bajaj N, et al. Changes in clinical management and diagnosis following Datscan™ spect imaging in patients with clinically uncertain parkinsonian syndromes: A 12-week follow-up study. Neurodegener Dis. 2013; 11:22-32. doi: 10.1159/000337351.
  25. Moonis G, Subramaniam RM, Trofimova A, et al. ACR Appropriateness Criteria® Dementia. J Am Coll Radiol. 2020 May;17(5S):S100-S112. doi: 10.1016/j.jacr.2020.01.040.
  26. Rathore C, Kesavadas C, Ajith J, et al. Cost-effective utilization of single photon emission computed tomography (SPECT) in decision making for epilepsy surgery. Seizure. 2011 Mar; 20(2):107-14.
  27. Seifert KD, Wiener JI. The impact of DaTscan on the diagnosis and management of movement disorders: A retrospective study. Am J Neurodegener Dis. 2013; 2(1):29-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601468/. Retrieved January 30, 2017.
  28. Sidhu MK, Duncan JS, Sander JW, et al. Neuroimaging in epilepsy. Curr Opin Neurol. 2018 Aug; 31(4):371-378.
  29. Tsougos I, Kousi E, Georgoulias P, et al. Neuroimaging methods in epilepsy of temporal origin. Curr Med Imaging Rev. 2019; 15(1):39-51.
  30. Vagal AS, Leach JL, Fernandez M, et al. The Acetazolamide Challenge: Techniques and Applications in the Evaluation of Chronic Cerebral Ischemia. Am J Neuroradiol. 2009 May; 30(5):876-884.
  31. Von Oertzen TJ. PET and ictal SPECT can be helpful for localizing epileptic foci. Curr Opin Neurol. 2018; 31:184–191.
  32. Yu J, Zhang J, et al. Cerebral Hyperperfusion Syndrome after revascularization surgery in patients with Moyamoya Disease: Systematic review and meta-analysis. World Neurosurg. 2020 Mar; 135:357-366.e4.

CEREBROSPINAL FLUID (CSF)

  1. Arai H, Yamamoto Y, Maeda Y, et al. SPET/CT imaging in radionuclide cisternography to detect cerebrospinal fluid leakage in spontaneous intracranial hypotension associated with SLE. Eur J Nucl Med Mol Imaging. 2012 Jul; 39(7):1225-6.
  2. Bowser B, Hunt C, Johnson G, et al. Utility of SPECT and SPECT/CT for localization of spontaneous cerebrospinal fluid leaks. J Nucl Med. May 1, 2015; 56(suppl 3):1612. http://jnm.snmjournals.org/content/56/supplement_3/1612.
  3. Chiewvit S, Nuntaaree S, Kanchaanapiboon P, et al. Assessment lumboperitoneal or ventriculoperitoneal shunt patency by radionuclide technique: A review experience cases. World J Nucl Med. 2014 May-Aug; 13(2):75–84. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4150163/.
  4. Damasceno BP. Neuroimaging in normal pressure hydrocephalus. Dement Neuropsychol. 2015 Oct-Dec; 9(4):350–55. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5619317/.  
  5. Eljazzar R, Loewenstern J, Dai JB, et al. Detection of Cerebrospinal Fluid Leaks: Is There a Radiologic Standard of Care? A Systematic Review. World Neurosurg. 2019 Jul; 127:307-315. doi: 10.1016/j.wneu.2019.01.299. Epub 2019 Feb 22.
  6. Epstein NE. A review article on the diagnosis and treatment of cerebrospinal fluid fistulas and dural tears occurring during spinal surgery. Surg Neurol Int. 2013; 4 Suppl 5:S301-S317. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3801173/. Retrieved January 21, 2018.
  7. Garg AK, Suri AM, Sharma BS, et al. Changes in cerebral perfusion hormone profile and cerebrospinal fluid flow across the third ventriculostomy after endoscopic third ventriculostomy in patients with aqueductal stenosis: A prospective study. J Neurosurg Pediatr. January 2009; 3(1):29-36. doi: 10.3171/2008.10.PEDS08148.
  8. Halperin JJ, Kurlan R, Schwalb JM, et al. Practice guideline: Idiopathic normal pressure hydrocephalus: Response to shunting and predictors of response: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2015 Dec 8; 85(23):2063–71. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4676757/#.
  9. Hashizume K, Watanabe K, Kawaguchi M, et al. Comparison between computed tomography-myelography and radioisotope-cisternography findings in whiplash-associated disorders suspected to be caused by traumatic cerebrospinal fluid leak. Spine. 2012 May 20; 37(12):E721-E726.
  10. Hiremath SB, Gautam AA, Sasindran V, et al. Cerebrospinal fluid rhinorrhea and otorrhea: A multimodality imaging approach. Diag Interven Imaging. 2019 Jan; 100(1):3-15. DOI: 10.1016/j.diii.2018.05.003.
  11. Kranz P, Luetmer PH, Diehn Fe, et al. Myelographic techniques for the detection of spinal CSF leaks in spontaneous intracranial hypotension. AJR Am J Roentgenol. January 2016; 206(1):8-19. https://www.ajronline.org/doi/full/10.2214/AJR.15.14884. Retrieved December 31, 2017.
  12. Lin J, Zhang S, He F, et al. The status of diagnosis and treatment to intracranial hypotension, including SIH. J Headache Pain. 2017; 18(1):4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5236046/. Retrieved December 31, 2017.
  13. Lipschitz N, Hazenfield JM, Breen JT, et al. Laboratory testing and imaging in the evaluation of cranial cerebrospinal fluid leaks and encephaloceles. Curr Opin Otolaryngol Head Neck Surg. 2019 Oct; 27(5):339-343.
  14. Lloyd KM, DelGaudio JM, Hudgins PA. Imaging of skull base cerebrospinal fluid leaks in adults. Radiology. September 2008; 248(3):725-736. http://pubs.rsna.org/doi/full/10.1148/radiol.2483070362. Retrieved January 21, 2018.
  15. Ma HY, Chun K, Milstein D, et al. Clinical utilities of radionuclide dynamic cerebrospinal fluid studies. J Nucl Med. 2015 May 1; 56(Suppl 3):1893. http://jnm.snmjournals.org/content/56/supplement_3/1893.short. Retrieved December 29, 2017.
  16. MacDonald A, Burrell S. Infrequently performed studies in nuclear medicine: Part 2. J Nucl Med Technol. 2009; 37(1):1-13. http://tech.snmjournals.org/content/37/1/1.
  17. Martineau P, Chakraborty S, Faiz K, et al. Imaging of the spontaneous low cerebrospinal fluid pressure headache: A review. Can Assoc Radiol J. 2020; 71(2):174–185.
  18. Moonis G, Subramaniam RM, et al. ACR Appropriateness Criteria® Dementia. J Am Coll Radiol. 2020 May; 17(5S):S100-S112. doi: 10.1016/j.jacr.2020.01.040. PMID: 32370954.
  19. Novotny C, Pötzi C, Asenbaum S, et al. SPECT/CT fusion imaging in radionuclide cisternography for localization of liquor leakage sites. J Neuroimaging. 2009 Jul; 19(3):227-34.
  20. Thut DP, Kreychman A, Obando JA. 111In-DTPA cisternography with SPECT/CT for the evaluation of normal pressure hydrocephalus. J Nucl Med Technol. March 1, 2014; 42(1):70-74. http://tech.snmjournals.org/content/42/1/70.full#ref-15. Retrieved January 27, 2017.
  21. Tsai, SY, Wang SY, Shiau Y, et al. Clinical value of radionuclide shuntography by qualitative methods in hydrocephalic adult patients with suspected ventriculoperitoneal shunt malfunction. Medicine. April 2017; 96(17): doi: 10.1097/MD.0000000000006767.
  22. Wiesemann E, Berding G, Goetz F, et al. Spontaneous intracranial hypotension: Correlation of imaging findings with clinical features. Eur Neurol. 2006; 56:204-210.
  23. Yoo H-M, Kim SJ, Choi CG, et al. Detection of CSF leak in spinal CSF leak syndrome using MR myelography: Correlation with radioisotope cisternography. AJNR Am J Neuroradiol. 2008 Apr; 29(4):649-654. doi: 10.3174/ajnr.A0920. Epub 2008 Jan 17.

RENAL

  1. American College of Radiology (ACR). ACR–SPR practice parameter for the performance of radionuclide cystography. 2015. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RadionuclideCystog.pdf?la=en. 
  2. American College of Radiology (ACR). ACR–SPR practice parameter for the performance of renal scintigraphy. 2017. https://acsearch.acr.org/list. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/RenalScint.pdf?la=en.
  3. Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: Detection, evaluation, and management: A scientific statement from the American Heart Association. Hypertension. 2018; 72(5):e53–e90. doi:10.1161/HYP.0000000000000084.
  4. De Palma D. Radionuclide tools in clinical management of febrile UTI in children. Semin Nucl Med. 2020 Jan; 50(1):50-55.
  5. Lao D, Parasher PS, Cho KC, et al. Atherosclerotic renal artery stenosis—Diagnosis and treatment. Mayo Clin Proc. 2011 Jul; 86(7):649-57. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127560/.
  6. Mettler FA, Guiberteau MJ. Essentials of Nuclear Medicine Imaging. 6th ed. Philadelphia, PA. Elsevier Inc. 2012.
  7. Osterman M, Joannidis M. Acute kidney injury 2016: Diagnosis and diagnostic workup. Crit Care. 2016; 20:299. Epub 2016 Sep 27. https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1478-z.
  8. Rahman M, Shad F, Smith MC. Acute kidney injury: A guide to diagnosis and management. Am Fam Physician. 2012 Oct 1; 86(7):631-39. https://www.aafp.org/afp/2012/1001/p631.html.
  9. Silay MS, Spinoit AF, Bogaert G, et al Imaging for vesicoureteral reflux and ureteropelvic junction obstruction. Eur Urol Focus. 2016 Jun; 2(2):130-138. doi: 10.1016/j.euf.2016.03.015. Epub 2016 Apr 13.
  10. Society of Nuclear Medicine and Molecular Imaging (SNMMI). The SNMMI and EANM practice guideline for renal scintigraphy in adults. 2018 Mar. http://s3.amazonaws.com/rdcms-snmmi/files/production/public/FileDownloads/ProcedureStandards/Renal%20Scintigraphy_Blaufox_0318.pdf.
  11. Taylor AT, Brandon DC, de Palma D, et al. SNMMI Procedure Standard/EANM practice guideline for diuretic renal scintigraphy in adults with suspected upper urinary tract obstruction 1.0. Semin Nucl Med. 2018; 48(4):377–390. doi:10.1053/j.semnuclmed.2018.02.010.
  12. Uliel L, Mellnick VM, Menias CO, et al. Nuclear medicine in the acute clinical setting: indications, imaging findings, and potential pitfalls. Radiographics. March-April 2013; 33(2):375-396. http://pubs.rsna.org/doi/full/10.1148/rg.332125098. Retrieved January 27, 2017.
  13. Volkan-Salanci, Erbas et al. Imaging in renal transplants: An update. Semin Nucl Med. 2021 Jan 20:S0001-2998(20)30134-3.   

ABDOMEN/ PELVIS

  1. American College of Radiology (ACR). ACR–ABS–ACNM–ASTRO–SIR–SNMMI practice parameter for selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. Revised 2019.
  2. American College of Radiology (ACR). ACR Appropriateness Criteria® - Liver lesion, Initial Characterization. https://acsearch.acr.org/docs/69472/Narrative/. Published 2020.
  3. American College of Radiology (ACR). ACR–SPR practice parameter for the performance of gastrointestinal scintigraphy. 2015.
  4. American College of Radiology (ACR). ACR–SPR practice parameter for the performance of hepatobiliary scintigraphy. 2017.
  5. American College of Radiology (ACR). ACR–SPR practice parameter for the performance of liver and spleen scintigraphy. 2015.
  6. Chung M, Dubel GJ, Noto RB, et al. Acute lower gastrointestinal bleeding: Temporal factors associated with positive findings on catheter angiography after 99mTc-labeled RBC scanning. AJR Am J Roentgenol. 2016 Jul; 207(1):170-176. doi: 10.2214/AJR.15.15380. Epub 2016 Apr 21. 
  7. Dittmann H, Kopp D, Kupferschlaeger J, et al. A prospective study of quantitative SPECT/CT for evaluation of lung shunt fraction before SIRT of liver tumors. J Nucl Med. 2018 Sep; 59(9):1366-1372. doi: 10.2967/jnumed.117.205203.
  8. Ekmekci S, Diz-Kucukkaya R, Turkmen C, et al. Selective spleen scintigraphy in the evaluation of accessory spleen/splenosis in splenectomized/nonsplenectomized patients and the contribution of SPECT imaging. Mol Imaging Radionucl Ther. 2015 Feb; 24(1):1–7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4372766/.
  9. Feuerstein JD, Ketwaroo G, Tewani SK, et al. Localizing acute lower gastrointestinal hemorrhage: CT angiography versus tagged RBC scintigraphy. 2016 Sep; 207(3):578-584. doi: 10.2214/AJR.15.15714. Epub 2016 Jun 15. 
  10. Furukawa Y, Long DE, Ellsworth SG. Functional liver-image guided hepatic therapy (FLIGHT): A technique to maximize hepatic functional reserve. Med Dosim. 2020 Jun 1; 45(2):117-120.
  11. Grady E. Gastrointestinal bleeding scintigraphy in the early 21st century. J Nucl Med. 2016 Feb; 57(2):252-259. doi: 10.2967/jnumed.115.157289. Epub 2015 Dec 17. 
  12. Horvat N, Marcelino AS, Horvat JV, et al. Pediatric liver transplant: Techniques and complications. RadioGraphics. 2017 Oct; 37(6):1612-1631. 
  13. Labeur TA, Cieslak KP, Van Gulik TM, et al. The utility of 99mTc-mebrofenin hepatobiliary scintigraphy with SPECT/CT for selective internal radiation therapy in hepatocellular carcinoma. Nucl Med Commun. 2020 Aug; 41(8):740-749.
  14. Lake S, Johnson PT, Kawamoto S, et al. CT of splenosis: Patterns and pitfalls. Am J Roentgenol. 2012 Dec; 199(6):W686-W693. https://www.ajronline.org/doi/full/10.2214/AJR.11.7896.
  15. Mettler FA, Guiberteau MJ. Essentials of Nuclear Medicine Imaging. 6th ed. Philadelphia, PA. Elsevier Inc. 2012.
  16. Mikell JK, Dewaraja YK, Owen D. Transarterial radioembolization for hepatocellular carcinoma and hepatic metastases: Clinical aspects and dosimetry models. Semin Radiat Oncol. 2020 Jan; 30(1):68-76. doi: 10.1016/j.semradonc.2019.08.005.
  17. Morsbach F, Sah BR, Spring L, et al. Perfusion CT best predicts outcome after radioembolization of liver metastases: A comparison of radionuclide and CT imaging techniques. Eur Radiol. July 2014; 24(7):1455-1465. https://link.springer.com/article/10.1007%2Fs00330-014-3180-3. Retrieved January 25, 2018.
  18. Otomi Y, Otsuka H, Terazawa K, et al. The diagnostic ability of SPECT/CT fusion imaging for gastrointestinal bleeding: A retrospective study. BMC Gastroenterol. 2018 Dec 10; 18(1):183. https://doi.org/10.1186/s12876-018-0915-7.
  19. Serenari M, Bonatti C, Zanoni L, et al. The role of hepatobiliary scintigraphy combined with spect/ct in predicting severity of liver failure before major hepatectomy: A single-center pilot study. Updates Surg. 2021 Feb; 73(1):197-208. Epub 2020 Nov 2.
  20. Society of Nuclear Medicine and Molecular Imaging (SNMMI). Procedure Standards. http://www.snmmi.org/ClinicalPractice/content.aspx?ItemNumber=6414.
  21. Tafti BA, Padia SA. Dosimetry of Y-90 Microspheres Utilizing Tc-99m SPECT and Y-90 PET. Semin Nucl Med. 2019 May;49(3):211-217. doi: 10.1053/j.semnuclmed.2019.01.005.
  22. Tomassini F, D'Asseler Y, Linecker M, et al. Hepatobiliary scintigraphy and kinetic growth rate predict liver failure after ALPPS: A multi-institutional study. HPB (Oxford). 2020 Oct; 22(10):1420-1428.
  23. Tong AK, Tham WY, Too CW, et al. Molecular imaging and therapy of liver tumors. Semin Nucl Med. 2020 Sep; 50(5):419-433.
  24. Truant S, Baillet C, Gnemmi V, et al. The impact of modern chemotherapy and chemotherapy-associated liver injuries (cali) on liver function: value of 99mtc-labelled-mebrofenin spect-hepatobiliary scintigraphy. Ann Surg Oncol. 2021 Apr; 28(4):1959-69.
  25. Uliel L, Mellnick VM, Menias CO, et al. Nuclear medicine in the acute clinical setting: indications, imaging findings, and potential pitfalls. Radiographics. 2013 Mar-Apr; 33(2):375-96.
  26. Zink SI, Ohki SK, Stein B, et al. Noninvasive evaluation of active lower gastrointestinal bleeding: Comparison between contrast-enhanced MDCT and 99mTc-labeled RBC scintigraphy. AJR Am J Roentgenol. 2008 Oct; 191(4):1107-1114. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association.  All Rights Reserved" 

History From 2020 Forward     

11/01/2021 

Annual review, adding multiple new medical necessity criteria. Updating descrption, rationale and references.

11/04/2020

New Policy

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