(*) Profesor Titular, U de Chile numebook.cl

2. APORTES DEL SPECT-CT Dr Patricio González E 2012 (*) Profesor Titular, U de Chile www.numebook.cl

3. Temario • Osteoarticular • Cardiopatia Coronaria • Hiperparatiroidismo • Conclusiones

4. OSTEOARTICULAR

5. SAGITAL Mujer, 60 años. Cáncer rectal tratado (operación de Miles) en re-estadificación. A. SPECT óseo Tc99mMDP muestra actividad osteoblástica aumentada en L3 y persistencia de actividad extraósea en pelvis posterior, post micción. B. CT pelvis muestra alteraciones secundarias a cirugía. C. Fusión SPECT/CT localiza captación en vejiga posterior, la cual era neurogénica. La fusión SPECT- Tc99mMDP/CT comprobó que la actividad extraósea correspondía a eliminación urinaria normal del difosfonato. Carolina Aqueveque, Patricio González, Daniela Gutiérrez, Rodrigo Jaimovich, Juan Carlos Díaz, Paula Csendes, Patricia Orellana, Hugo Lavados, Isabel Alliende, Sandra Araya. Utilidad clínica de la fusión SPECT/CT con marcadores externos en patología oncológica Rev Méd Chile 2007; 135: 725-734.

6. Clinical History: Woman, aged 76. Pain at stress in the right knee after an accident. Diagnosis: Stress fracture in the medial part of the right tibial plate and mechanical stress or an enthesopathy at the tuberositas tibiae. Courtesy of Clinic St jean, Brussels, Belgium

7. Clinical History: 57 year old man. Right lower back pain. Diagnosis: Arthrosis L4-L5. A traumatic or malignant lesion was excluded.Further radiological workout was avoided. Courtesy of Clinic St jean, Brussels, Belgium In a study of 47 patients with 104 equivocal lesions on bone scintigraphy, with histological confirmation or longterm follow-up as the reference gold standard, SPECT/CT allowed correct diagnosis in 85% of the cases. The term “SPECT-guided CT” refers to the adaptation of the CT field of view to foci of increased bone metabolism. Using this method in 52 undetermined lesions in 44 patients, 92% of abnormal uptake foci visualized by SPECT were correctly classified, with distinct usefulness especially for lesions in the spine column, ribs and pelvis A review on the clinical uses of SPECT/CT Giuliano Mariani & Laura Bruselli & Torsten Kuwert & Edmund E. Kim & Albert Flotats & Ora Israel & Maurizio Dondi & Naoyuki Watanabe. Eur J Nucl Med Mol Imaging (2010) 37:1959–1985

8. 46 year-old male with a history of Hurthle cell thyroid carcinoma presented with back pain and elevated thyroglobulin Treatment: high dose 131I-iodine 157 mCi From Delbeke D & Israel O (eds): Hybrid PET/CT and SPECT/CT Imaging – A Teaching File. Springer 2009. 131I-iodide This has resulted in an overall increment in diagnostic accuracy, ranging between 21 and 73.9% on both post-treatment and diagnostic follow-up scans. In particular, SPECT/CT led to modification of therapeutic management in a fraction as high as 35–47% and avoided unnecessary treatment in about 20% of the patients. Stratification of risk was modified by the SPECT/CT findings in 25% of the patients A review on the clinical uses of SPECT/CT Giuliano Mariani & Laura Bruselli & Torsten Kuwert & Edmund E. Kim & Albert Flotats & Ora Israel & Maurizio Dondi & Naoyuki Watanabe. Eur J Nucl Med Mol Imaging (2010) 37:1959–1985

9. CARDIOPATIA CORONARIA

10. Cardiac Attenuation Correction with low-dose CT

12. Supine with AC 48 year-old female with atypical chest pain. Clin – ECG - Fixed anterior wall defect

13. Inferior wall attenuation AC No AC AC No AC AC No AC Images courtesy of Radiological Associates of Sacramento

14. SPECT/CT Attenuation Correction Improves Specificity and Normalcy Rate: A Multi-center Trial • 152 patients: • 83 with CAD (> 50% stenosis at angiography, • 32 with insignificant CAD (< 50% stenosis at angiography) • 37 Normal volunteers • Performance • Sensitivity: NC = 93%, AC = 94% • Specificity: NC = 56%, AC = 59% • Predictive accuracy: NC = 83%, AC = 84% • Normalcy rate: NC = 84%, AC = 97% . ASNC Sept 30-Oct 3, 2004, NY; Massod Y et al.

15. Anatómico

16. Cortes coronales SPECT/CT en estrés A review on the clinical uses of SPECT/CT Giuliano Mariani & Laura Bruselli & Torsten Kuwert & Edmund E. Kim & Albert Flotats & Ora Israel & Maurizio Dondi & Naoyuki Watanabe. Eur J Nucl Med Mol Imaging (2010) 37:1959–1985 The addition of CTCA to MPI SPECT may avoid falsenegative scintigraphic findings in advanced three-vessel disease, showing a balanced impairment of blood flow in all cardiac segments.

17. FIGURE 3. Kaplan–Meier survival curves for MACE-free and event-free survival. Figure 3 illustrates the survival free of MACEs (A) and free of any event (B) for the low-, intermediate-, and high-risk groups (i.e., CT-AC SSS 0, 1–8, and .8). Direct comparison of CT-AC and FBP of an SSS of 1–3 by a x2 test reached a P value of 0.05 for MACEs and a P value less than 0.01 for any cardiac events. Improved Outcome Prediction by SPECT Myocardial Perfusion Imaging After CT Attenuation Correction Aju P. azhenkottil*, Jelena-Rima Ghadri*, Rene N. Nkoulou, Mathias Wolfrum, Ronny R. Buechel, Silke M. Ku¨est, Lars Husmann, Bernhard A. Herzog, Oliver Gaemperli, and Philipp A. Kaufmann. J Nucl Med 2011; 52:196–200

18. HIPERPARATIROIDISMO

19. MIBI.Coronal 99mTc-pertecnetate Parathyroid adenoma Technetium 99m-MIBI-SPECT 58y/o female with elevated PTH levels (293pg/ml) and neck ultrasound that only showed two nodules in the right thyroid lobule* The Tc 99m-MIBI parathyroid SPECT scintigraphy shows a focus of increased MIBI uptake at 10 min, inferior to the left thyroid lobule and retroesternal, compatible with a parathyroid adenoma. In the 99mTc pertecnetate image it is seen an homogenuos uptake in the thyroid gland Tc 99m-MIBI parathyroid scintigraphy is a sensitive and specific tool for topographic localization even of small parathyroid adenomas, sensitivity is increase to 95% by supplementary use of the SPECT. (1) Preoperative SPECT in patients with primary hyperparathyroidism is essential for accurate localization of parathyroid adenomas and for the selection of patients who are candidates for minimally invasive radioguided surgery (2).

20. SPECT/CT correctly localized 100% of the scintigraphy-positive lesions versus 61% for SPECT alone. Hybrid imaging had a significant surgical impact in 39% of the cases (retrotracheal parathyroid adenomas). In an additional report, SPECT/CT had an 89% diagnostic accuracy for single adenomas and predicted the intraoperative location of a lesion within 19 mm with 95% confidence. Nevertheless, accurate detection of multigland disease was still difficult A review on the clinical uses of SPECT/CT Giuliano Mariani & Laura Bruselli & Torsten Kuwert & Edmund E. Kim & Albert Flotats & Ora Israel & Maurizio Dondi & Naoyuki Watanabe. Eur J Nucl Med Mol Imaging (2010) 37:1959–1985

21. CONCLUSIONES Valor agregado del SPECT/CT Mejora la calidad de imagen Localización exacta de lesiones y tejidos adyacentes. Diferencia áreas fisiológicas de procesos patológicos. El CT detecta alteraciones relevantes para el diagnóstico definitivo. Aumento en la especificidad. Mejora el manejo del paciente: Identificación de lesiones de alto riesgo. Mejora el estudio de las lesiones. Caracterización de lesiones no diagnosticas. En terapia diferencia áreas activas de proceso secuelares

22. Gracias Por Su Atenciòn  preguntas o comentarios…..