~(99)Tc-MDP SPECT/CT扫描对骨转移瘤的诊断价值及所致辐射剂量的研究
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摘要
背景
放射性核素骨显像是目前核医学科使用率最高的检查项目,它不仅可显示骨骼形态,更能反映骨骼和病变的血流和代谢状况,常早于X线发现病变,并可进行全身扫描,对各种骨骼疾病的诊断和治疗效果的观察具有重要价值,在骨骼病变的诊断中具有早期诊断和探查范围广的显著优势。
显像仪器是诊断核医学重要工具,其研发过程经历了扫描机、γ照相机到计算机断层扫描仪。1979年Kuhl和Edwards成功研制了第一台SPECT(single photon emission computed tomography,单光子发射型计算机断层扫描仪),它是γ照相机与电子计算机技术相结合形成的一种核医学显像检查仪器,是在Y照相机平面显像的基础上,应用电子计算机技术增加断层显像功能,实现了断层显像。SPECT克服了平面显像组织、器官重叠造成的掩盖小病灶的缺陷,提高了对深部病灶的分辨率和定位准确性。但是与CT、MRI相比,SPECT对组织器官的解剖结构及比邻关系显示仍然不足。随着医学影像技术的飞速发展,图像融合技术已经广泛应用于临床,相继出现了SPECT/CT与PET/CT等融合仪器。PET/CT是目前最尖端的显像设备,18F-FDG PET/CT全身显像目前主要用于肿瘤的早期诊断、分级及分期、以及疗效评价方面,但由于价格昂贵,影响了其临床应用广度。
SPECT/CT是将核医学显像仪器SPECT和放射科断层显像仪器CT有机地融合,同时可利用X线CT扫描数据对SPECT图像进行衰减校正,实现了功能图像与解剖图像的同机融合。两种影像学技术的优势互补,相互印证,为临床提供了更多的诊断信息,显著提高了诊断的准确率。尽管有文献报道了同机CT对脊柱或肋骨的单发病灶的诊断价值,但是有关大样本量的对骨转移瘤诊断价值及相关因素的分析,特别是有关对低剂量CT的局部断层扫描及SPECT骨扫描对受检者所致的辐射剂量分析尚未见报道。
99mTc-亚甲基二磷酸盐(MDP)是最主要的骨显像剂,由于MDP特殊的物理化学性质,在骨组织高度浓聚,对骨组织病变具有重要诊断价值,但是放射性核素99mTc-,具有电离辐射效应,单光子发射型计算机断层扫描仪可对骨扫描受检者、医护人员及其周围的人员造成辐射,有一定的潜在危害,但是有关99mTc-亚甲基二磷酸盐(MDP)所造成的辐射剂量报道较少。因此本课题对以下问题进行了分析及研究：一是放射性核素显像/低剂量CT扫描对骨转移瘤的诊断价值及相关因素分析；二是SPECT/低剂量CT检查中99mTc-MDP及局部断层CT扫描所致辐射剂量的研究。
第一部分99mTc-MDP SPECT/CT扫描对骨转移瘤的诊断价值及相关因素分析
目的：
探讨99mTc-MDP SPECT/CT扫描对骨转移瘤的诊断价值及相关因素的分析,以指导临床对骨转移瘤早期诊断和治疗,减少患者骨相关事件(skeletal related events, SREs)的发生,提高患者的生存质量。
资料及方法：
回顾性分析聊城市人民医院核医学科(泰山医学院附属医院)2008年10月至2013年3月间,行全身骨扫描加局部99mTc-MDP SPECT/CT(德国西门子公司生产的SymbiaT2型双探头)扫描的患者451例,包含因骨外的恶性病变行手术、放射治疗或化学治疗的患者。所入选患者均先行全身骨扫描后,发现有难以确定性质的放射性浓聚灶,如少发(≦3)的放射性异常浓聚灶,或者没有明确原发肿瘤的多发(≧至4)放射性浓聚灶,随后加做SPECT/低剂量CT扫描以明确病变性质,记录患者的相关血液检测指标。图像分析由三名具有核医学及CT影像阅片经验的主治医师独立阅片,诊断意见不一致时,经相关医师共同阅片并讨论决定。采用统一的图像诊断评分标准1-4分,1分是评为良性病变,2分是评为可疑良性病变,3分是评为可疑恶性病变,4分是评为恶性病变。SPECT/低剂量CT图像的阅读方法是SPECT断层图像上放射性稀疏/缺损或放射性异常浓聚灶在融合图像上的定位是否准确,然后判断低剂量断层CT上病灶的结构及密度变化及SPECT图像特点。所有影像诊断均经临床电话随访、定期复查诊断CT、MRI或病理穿刺结果等,最终明确诊断。
应用SPSS16.0统计分析软件对资料进行统计学处理及分析,分别统计全身骨扫描、SPECT断层图像、CT断层图像及SPECT/CT融合图像诊断的灵敏度、特异性、阳性预测值、阴性预测值及准确性等指标,率的比较采用四格表x2检验,单样本的检验,医师阅图采用R0C曲线分析,比较AUC曲线下的面积。所有检验标准均设定为0.05,P<0.05为差异有统计学意义。
结果：
1.行骨扫描受检者的临床诊断分类
临床医师申请骨扫描检查以明确是否有骨转移瘤的临床诊断主要分为两大类,一类是患者有明确的恶性肿瘤病史380例(骨外原发的恶性肿瘤前5位是肺癌、乳腺癌、前列腺癌、食管癌、胃癌；治疗前67例,治疗后313例,其中有骨痛症状的108例,无骨痛症状的272例；恶性肿瘤的类型：肺癌135例,男98例,女37例；乳腺癌77例,男1例,女76例,肺癌与乳腺癌的男、女患病比例采用χ2检验,(χ2=6.98,4.58；P<0.05)男女患病的差别有统计学意义)。另一类是患者无明确的肿瘤病史但怀疑有骨转移瘤的98例(男41例,女57例,全身骨痛18例,胸锥或肋骨痛25例,腰锥痛23例,椎体骨折13例,肋骨骨折例8,肱骨骨折1例,上肢痛5例,髋部痛2例,下肢痛3例)。
2.99mTc-MDP SPECT/CT显像的定位、定性诊断价值
136例受检者均无明确的恶性肿瘤病史,其中1例甲状旁腺激素(PTH)异常高,99mTc-MIBI甲状旁腺早期-延迟显像及颈部局部SPECT/低剂量CT扫描,甲状腺右叶下极一甲状旁腺瘤。其中95例骨扫描显示肋骨多发的点状放射性浓聚灶及脊柱多发放射性浓聚灶,腰椎显著,女性骨质疏松的患病率高于男性,(χ2=6.98,4.58；P<0.05差异有统计学意义)；另外41例骨扫描显示中轴骨及肋骨放射性分布不均匀,未见异常的放射性浓聚灶,SPECT/CT扫描扫描后诊断为疑多发性骨髓瘤。
骨扫描显示有少发放射性浓聚灶的受检者342例,放射性核素异常浓聚灶共有657个,良性疾病156例,放射性浓聚灶302(46.1%)个,骨良性病变主要包括胸腰椎的退行性变、胸腰椎压缩性骨折、腰椎结核、关节退行性变、骨折、骨岛、骨血管瘤等。骨转移瘤286例,放射性浓聚灶354(53.9%)个,病变范围较小者,CT图像一般呈偏心性生长；病变范围较大者,骨质破坏呈大片状不规则溶骨性破坏,常伴有明显软组织肿块。其中成骨性转移灶216个,溶骨性骨转移瘤138个。
本研究39例(3.32%)骨显像中,显示骨外软组织异常摄取99mTc-MDP,其部位分别为肺10例、肝9例,乳腺7例,肌肉软组织及皮下4例,胸膜3例,腹膜2例,脾2例,胃癌术后残余灶、肺上沟癌及结肠癌各1例。其中4个定位于盆腔内,1个定位于右侧卵巢,穿刺病理为库肯伯格瘤；1个定位于右侧髂窝,术后病理为胃癌种植性转移灶,2例定位于右侧回盲部,6个月后随访的骨扫描病灶消失。股骨头坏死13例,尿液污染9例。
3.骨扫描SPECT、CT及SPECT/CT诊断价值。
SPECT/CT融合图像诊断的灵敏度、特异性、阳性预测值、阴性预测值及准确性分别为92.8%、100%、100%、97.5%和98.1%,明显高于骨扫描(χ2=4.29,4.20,7.56,4.51；P均<0.05)。骨扫描、SPECT、CT及SPECT/CT分别采取ROC分析,AUC (ROC曲线下的面积)分别是0.747、0.833、0.944、0.964,95%的可信区间分别是0.653-0.826.0.806-0.937、0.883-0.979、0.909-0.990。
4.少发骨转移瘤与相关临床因素的分析
本研究342例少发骨转移患者中,273例伴有骨外转移,其中131例伴前哨和(或)远处淋巴结转移,以骨转移为首发病变的69(20.2%)例。肺癌是最常见的骨外原发肿瘤,腺癌发生骨转移的几率最大,小细胞性肺癌次之。血清碱性磷酸酶ALP升高常见于溶骨性骨转移瘤,良性骨病变及成骨性骨转移瘤ALP升高不明显；结合相关肿瘤标志物CA125、CEA、CA153、NSE、AFP及PSA升高,提高了早期诊断骨转移瘤的准确率,特别是骨扫描及PET图像上病灶阳性,而CT图像上骨质没有明显变化者。
结论：
1、99mTc-MDP SPECT/CT扫描受检者的临床资料分析。本研究中以骨痛申请检查者多,女性患骨质疏松的人数多；胸部恶性病变中以转移瘤最多,多位于肋骨及胸骨；骨外恶性病变以乳腺癌、肺癌及前列腺癌较多；骨原发肿瘤发生在四肢骨较多,颅骨多为单发病灶；虽然前列腺癌较容易转移至骨盆,但是骨盆恶性肿瘤转移灶以肺癌最多,这与肺癌的发病率比前列腺癌高有关,骨盆的良性病灶多位于骶髂关节、及骶骨上缘；髋臼稍上方的髂骨是溶骨性骨转移的好发部位,放射性浓聚有时不太明显,因此髋臼处的放射性异常不可轻易诊断为退行性病变；当骨扫描发现盆腔内异常放射性浓聚灶,且前后位放射性浓聚程度差别较小时,病灶多位于盆腔内。回盲部的放射性浓聚的机制有待进一步研究。
2、99mTc-MDP SPECT/CT扫描的诊断价值。SPECT/低剂量CT扫描系统的应用,提高了对病灶解剖定位的准确性及骨显像特异性。不仅可对骨显像的阳性病灶进行准确定位,而且CT能显示骨质的结构改变,对常见的易与骨转移相混淆的退行性变病灶有较好的识别能力,提高了骨显像诊断骨转移的准确性；99mTc-MDPSPECT/低剂量CT显像减少了膀胱放射性滞留造成的影响,特别是对于骨扫描时意外发现的尿储留患者,提高了骶骨及耻骨病灶诊断的准确率,也减少了受检者进行导尿后重新扫描的麻烦。关于骨转移瘤诊断的标准,除了典型的影像学表现外,在不典型的病灶中,多种影像学方法相互借鉴加临床随访也可作为诊断骨转移瘤的“金标准”。低剂量CT图像所示的溶骨性病灶伴局部软组织肿块,直径大于2cm时,多表现为典型的“炸面圈征”,即病灶中心呈放射性分布稀疏缺损,病灶周边放射性浓聚。成骨改变的早期的病灶摄取MDP未见明显异常。
3、99mTc-MDP SPECT/CT扫描对治疗决策的影响：23例术前诊断骨转移,改变治疗方案；9例明确脊柱的放射性浓聚灶为转移瘤合并退行性病变,因此选择性进行了放疗；3例在病灶处穿刺为转移瘤,结合病理免疫组化及肿瘤标志位找到原发肿瘤,2例病灶穿刺结果为骨肉瘤。17例术前诊断骨转移,改变治疗方案；8例明确脊柱的放射性浓聚灶为转移瘤合并退行性病变,因此选择性的进行了放疗；3例在病灶处穿刺为转移瘤,结合病理免疫组化及肿瘤标志位找到原发肿瘤,1例病灶穿刺结果为髂骨炎性肉芽肿。
第二部分99mTc-MDP SPECT/CT扫描所致辐射剂量的研究
目的：
探讨在SPECT/CT检查中99mTc-MDP及局部断层CT扫描所致的辐射剂量,更好地贯彻医疗辐射防护最优化的原则。
资料及方法：
2013年4月一5月间在山东省聊城市人民医院核医学科做全身骨扫描并且行局部SPECT/CT检查的160人中单纯随机选取受检者40人,男性23人,女性17人,年龄56.6±13.1岁,体重72.0±13.9kg,核医学科工作人员共10人,医师4人,技师1人,护士5人,轮流负责淋洗和注射99mTc-MDP。分别记录40例受检者行同机CT扫描的长度,计算其均值,从而得出低剂量CT扫描对骨扫描检查者所造成的额外辐射剂量。
分别对99mTc-MDP所产生的医疗照射,职业照射及公众照射三方面进行研究。受检者在SPECT/CT检查中所受的99mTc-MDP内照射剂量加低剂量的CT断层所产生的额外的辐射剂量为医疗照射；核医学科的工作人员所接受的照射为职业照射,负责淋洗和注射99mTc-MDP的护士单独统计其所受到的辐射剂量；注射药物后的受检者作为辐射源对其他患者及家属所造成的辐射为公众照射。统计的结果与相应的国家标准及其他类似影像检查所致的辐射剂量进行分析、比较,从而衡量SPECT/CT检查中99mTc-MDP所导致的辐射危害或影响程度,为SPECT/CT扫描中的辐射防护提供更好的建议,更好地贯彻辐射防护最优化原则,促进SPECT/CT的更好应用。统计学处理是通过Microsoft Office Excel2003进行数据处理,SPSS进行单样本的检验和直线相关检验。
结果：
1.医疗照射(受检者)。骨扫描受检者行局部SPECT/CT扫描时受到99mTc-MDP医疗照射的有效剂量为8.23±0.99mSv,应用统计学方法与职业照射的年剂量限值(20mSv)进行单个样本的t检验,t=65,P<0.001,有统计学意义；与公众照射的年剂量限值(5mSv)进行单个样本的t检验,t=17.9,P<0.001,有统计学意义。
2.受检者外照射的辐射剂量。由曲线公式分别计算出9mTc-亚甲基二膦酸盐(MDP)剂量率为2.5μSv/h时的时间点和距离点,距离骨扫描检查者1.0米和1.5米处剂量率为2.5μSv/h的时间分别是245min和212min；注射9mTc-亚甲基二膦酸盐(MDP)后120分钟和240分钟剂量率为2.5μSv/h的距离分别是2.9米和1.6米。
3.工作人员的辐射剂量。医师胸部佩戴1年TLD所受的辐射剂量为0.972mSv；淋洗和注射99mTc-MDP的护士佩戴1个月TLD的累积值是0.384mSv,一年所受的辐射剂量为1.534mSv,其左右手食指的辐射剂量是0.215mSv和0.374mSv,铅眼镜内的辐射剂量是0.195mSv。
4.受检者的附加辐射剂量。局部低剂量CT扫描对受检者所造成的附加的辐射剂量亦较小(2.3±1.7mSv),受检者所获得的诊断价值远大于他们所受到的辐射危害,符合医疗辐射实践正当性原则；另一方面从距离防护和时间防护对他们的活动稍加约束,减少对其它人员的辐射及做到辐射防护最优化也是是切实可行的。
结论：
工作人员所受职业照射在有关规定的约束限值内,患者接受的医疗照射略高于公众照射剂量限值,99mTc-MDP SPECT/CT扫描的诊断价值远远大于医疗辐射危害,符合医疗照射实践正当性,防护最优化的原则。
[关键词]9mTc-亚甲基二膦酸盐(MDP)；辐射剂量；辐射防护
全文创新点：
1.全身骨扫描阳性结合肿瘤标志物检测水平升高,对骨转移瘤的早期诊断具有较高的诊断价值。
2.99mTc-MDP SPECT/CT扫描同机融合图像在少发骨转移瘤定位诊断和鉴别诊断中具有较高的诊断价值,有助于临床治疗决策的选择。
3.研究了99mTc-MDP SPECT/CT扫描所致的辐射剂量,包括医疗照射和职业照射。验证了工作人员所受职业照射在有关规定的约束限值内,患者接受的医疗照射略高于公众照射剂量限值,99mTc-MDP SPECT/CT扫描的诊断价值远远大于医疗辐射危害,符合医疗照射实践正当性,防护最优化的原则。
Background
Nuclide imaging (diagnostic nuclear medicine) belongs to the category of clinical nuclear medicine, the radionuclide is introduced into the body of patients, nuclear medicine instruments detect gamma rays from radionuclide, mainly display function and metabolism of tissues and organs and achieve the purpose of diagnosis of disease. Nuclear medical imaging instrument has experienced scanner, gamma camera to computed tomography scanning, however, which is different from the X-ray tomography instrument (traditional type of scanner transmission computed tomography(CT), nuclear medicine tomography instrument called emission computed tomography(ECT), ECT is divided into single photon emission computed tomography(SPECT) and positron emission computed tomography(PET).
Kuhl and Edwards successfully developed the first SPECT in1979, SPECT is a more advanced imaging modality combined with computer technology which was developed on the basis of the gamma camera planar imaging, Application of electronic computer technology increased the function of the tomography imaging, overcome the faults of overview small lesions due to tissue and organ overlapping, improve the positioning accuracy of deep lesions in the planar imaging. However SPECT anatomical structures of tissues and organs and distance relationship shows that still is inferior to CT and MRI. With the rapid development of medical imaging technology, image fusion technology has been widely used in clinical. SPECT/CT is the excellent integrations of functional and metabolic imaging of SPECT with morphologic imaging of CT, realizes the complementary advantages of the two imaging technology, provide more diagnostic information for clinical, also can use X-ray attenuation correction for a CT scan data of SPECT images.
Except for diagnosis of nuclear medicine, nuclear medical imaging equipment, radionuclide is another important part of nuclear medicine diagnosis,99mTc-methylene bisphosphonate (MDP) is one of the main bone imaging agent, due to its special physical and chemical properties, although it has the important value of imaging, but as a radionuclide99mT-MDP and it can also be on bone scan client, medical staff and the surrounding radiation, has certain potential hazards, but99mT-methylene bisphosphonate (MDP) caused by the radiation dose size, domestic no research about this aspect of the system, so this subject to the following two parts were retrospectively analyzed and research:
1. The diagnostic value of SPECT/CT scanning for bone metastases
2. Study on Radiation dose Caused by99mT-MDP and CT in SPECT/CT scanning.
PART I
The diagnostic value of SPECT/CT scanning for bone metastases Objective:
Investigate diagnostic value of radionuclide imaging/low dose CT imaging in the suspected bone metastases and analysis of related factors for early diagnosis and early reasonable treatment of bone metastases, reduce bone related events (skeletal related events, SREs), improve the quality of life of patients.
Materials and methods:
This was a retrospective study, from October2008to March2013, There were451patients underwent the whole body bone scan and99mTc-MDP SPECT/CT (German Siemens SymbiaT2type dual probe) scanning of in the nuclear medicine department of Liaocheng people's hospital (affiliated taishan medical universityl), containing the patients underwent the surgery, radiotherapy or chemotherapy of malignant tumors, it is difficult to determine the nature of the radioactive lesions in the whole body bone scan, such as the number of radioactive lesions≤3, or there is no clear of the multiple primary tumors but radioactive lesions≥4, then SPECT/low dose CT scans was performed in order to make clear nature of the lesions, meanwhile record the patient's blood tests associated indicators. Image analysis:three nuclear medicine and CT image doctors independently read the imagings, when they did not agree on diagnosis, the other physician need to read the image and discuss the decision. SPECT/low dose CT image:the position of radioactive defection or radioactive lesions in the fusion image is accurate on SPECT CT images, and then determine the structure and density of lesions on low dose CT image characteristic. The final diagnosis was confirmed by the clinical follow-up included telephone and review of diagnostic CT, MRI and biopsy results, etc.
Adopts unified image diagnostic criteria of1to4points,1point is chosen as benign,2points is chosen as suspicious benign,3points is chosen as suspicious malignant and four points is rated as malignant, statistics of the whole body bone scan, SPECT CT images, CT, CT image and SPECT/CT fusion image diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Application SPSS16.0statistical analysis software for statistical data processing and analysis, the rate of compares the four table chi-square test, ROC curve analysis, one sample t test, All inspection standards are set to0.05, P<0.05for the difference was statistically significant.
Results:
1. The clinical classification of the patients underwent bone scan.Clinicians for bony metastases of bone scan in order to make clear whether the clinical diagnosis of basically has two kinds, some patients with clear history of malignant tumor,380cases of patients with primary malignant tumor of the top5are lung cancer, breast cancer, prostate cancer, esophageal cancer, gastric cancer; Before67cases,313cases after treatment, including bone pain symptoms in108cases,272cases with no symptoms of bone pain; The type of malignant tumor,135cases of lung cancer,98cases of male and female37cases;177cases of breast cancer, male and female,76cases of lung cancer and breast cancer in male and female ratio is used chi-square test,(chi-square-6.98,6.98; P<0.05, the differences between men's and women's disease was statistically significant, other patients without malignant tumor but suspected patients in98cases of bone metastases,41cases were male,57cases were female, the whole body bony pain were18cases, thoracic vertebra or ribs were25cases, lumbar vertebra were23cases, vertebral fractures were13cases, fractured ribs were8cases, humerus fracture wasl case, upper limb pain were5cases, hip pain were2cases, lower limb pain were3cases.
2.The localization and qualitative value on99mTc-MDP SPECT/CT imaging136cases were no clear malignant tumour history, including1case of parathyroid hormone (PTH) abnormally high levels, early-delay99mTc-MIBI parathyroid imaging and partial SPECT imaging/low dose CT scanning revealed a parathyroid adenoma in the right thyroid lobe under extremely. Among them,95cases of bone scan revealed multiple rib focal radioactive concentration and spine multiple radioactive strong gathering lesions, lumbar significantly, women, the prevalence of osteoporosis is higher than men (chi-square=6.98,6.98; P<0.05difference was statistically significant); And41cases of bone scan showed the axial skeleton and ribs, uneven distribution of radioactive werenot seen abnormal radioactive strong lesios, SPECT/CT scans revealed multiple myeloma was confirmed by clinical materials.
Bone scan showed have less radioactive strong subjects,342cases of the oven, radionuclide extremely strong fusion focal a total of657,156cases of benign disease, radioactive thick polyethylene oven302(46.1%), bone benign lesions mainly includes the degeneration of thoracolumbar; Thoracolumbar compression fractures; Lumbar spinal tuberculosis; Joint degeneration. Fracture, bone island; Along they like located.286cases of bone metastases, radioactive strong focal354(53.9%), smaller scope of lesions in CT images generally show partial mind growth, a large patch of irregular bone destruction with strong disease extent in soluble bony destruction, often accompanied by obvious mass lesion. Among them into osseous metastases,216,138dissolved osseous bone metastases.
In this study,39cases (3.32%) abnormal bone imaging showed bone soft tissue outside the absorb99mTc-MDP, its parts, respectively, for10cases,9cases of liver and lung7cases, breast muscle tissue and subcutaneous4cases, pleura in3patients, peritoneal in2cases, splenic in2cases, gastric cancer postoperative residual focal sulcus carcinoma, lung and colon cancer in1case. Four of them located in pelvic cavity, a position on the right side of the ovary, biopsy for library kinberg tumor; A location in the right iliac fossa, postoperative pathology for metastases of gastric cancer in2cases located in the right side of the back blind department, after6months follow-up bone scan lesions disappeared.9cases, including13cases of femoral head necrosis, urine pollution.
3. Bone scan, SPECT, CT and SPECT/CT diagnostic value.SPECT/CT fusion image diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy were92.8%,100%,100%,97.5%and98.1%, significantly higher than bone scan (chi-square=4.29,4.29,4.20,4.51; P<0.05). Bone scan, SPECT, CT and SPECT/CT using ROC analysis respectively, AUC (area under the ROC curve) are respectively0.747,0.833,0.944,0.833,95%ci respectively is0.653-0.826.0.806-0.937,0.883,0.979,0.909,0.909.
4. The analysis of bone metastases and the related clinical factors.In this study,342cases of patients with bone metastases,273casesof which had outside the bone metastasis,131patients of which had sentinel lymph node metastasis and (or) the distance, the pathological changes of bone metastases as the starting69(20.2%) cases. Lung cancer is the most common primary tumor bone, adenocarcinoma of the chance of bone metastases is the largest, small cell lung cancer. Elevated serum alkaline phosphatase (ALP in osseous bone metastases, benign bone lesions and osseous bone metastases increased ALP is not obvious; Combined with the related tumor marker CA125, CEA, CA153, NSE, AFP and elevated PSA, and improves the accuracy of early diagnosis of bone metastases, especially bone scan images were positive, and bone have no obvious change on CT images.
Conclusion:
1.The characteristics of radionuclide imaging/CT scans and applicants. In this study with bone pain number of applicants for inspectors more women suffer from osteoporosis than man. Malignant breast lesions with metastases, the ribs and sternum were most seen, prostate cancer is more easily transferred to the pelvis, but pelvic malignant tumor metastases, lung cancer was most seen, it is associated with the incidence of lung cancer is higher than prostate cancer, bone malignant lesions in the breast cancer, lung cancer and prostate cancer is more, primary bone tumors occurred in four limbs which is more, the skull more for single lesion, pelvic benign lesions located in the sacroiliac joint, and the superior border of sacral; Acetabulum slightly above the iliac crest is a usual location to osseous bone metastases, radioactive lesions (sometimes less obvious, thus cotyle of radioactive anomalies in don't easily diagnosed with degenerative diseases; When bone scans found abnormal pelvic cavity radioactive strong stove, and a radioactive concentration degree of poly (before and after the difference is small, lesions located in the pelvic cavity, the mechanism of radioactive concentration needs further research.
2. The diagnostic value of low dose CT scans in SPECT/CT. SPECT/low dose CT scanning improved the accuracy of the anatomical location of lesions and bone imaging specificity, not only can be positive lesions of bone imaging for accurate positioning, and CT can show the structure of the bone change, easily confused with bone metastases of common degeneration lesions have better recognition ability, improve the accuracy of bone metastases of bone imaging diagnosis;99mTc-MDP SPECT/low dose CT imaging to reduce the impact of bladder radioactive retention, especially for the bone scan unexpectedly found that patients with urinary retention, improve the accuracy of the diagnosis of sacral and pubic bone lesions, also reduced the client for urethral catheterization after rescanning trouble. About bone metastases tumor diagnosis standard, in addition to the typical imaging findings, in atypical lesions, a variety of clinical follow-up imaging methods from each other and also can be used as the "gold standard" diagnosis of bone metastases. Low dose CT image shown in dissolving the bony lesions with local soft tissue mass, diameter greater than2cm, more show the typical "donut", namely the lesion center sparse defect distribution is radioactive, perifocal radioactive concentration. Osteogenesis change early lesions absorb MDP saw no obvious abnormalities.
3. Radionuclide imaging/low dose CT scan influenced treatment decisions:23cases of preoperative diagnosis of bone metastases, change treatment;9cases with clear spine of radioactive concentration stove for metastases with degenerative diseases, and selective radiotherapy;3cases in puncture for metastatic lesions, combined with immunohistochemical and tumor marker to find the primary tumor,2cases were obtained the results of osteosarcoma.17cases of preoperative diagnosis of bone metastases, change cure;8cases of clear spine of radioactive concentration stove for metastases with degenerative diseases, so the selective of the radiation;3cases in puncture for metastatic lesions, combined with immunohistochemical and tumor marker to find the primary tumor,1case of targeted biopsy results of ilium inflammatory granuloma. PET/CT scan can find more, more early bone metastases, the discovery of more effective for bone metastases starting symptoms of primary lesions, and can further clarify the diagnosis of multiple myeloma.
part Ⅱ
Study on Radiation dose Caused by99mTc-MDP in SPECT/CT scanning
Objective:
In recent years, SPECT/CT has gained increasing clinical acceptance as a important hybrid anatomical-functional imaging modality, SPECT/CT allow the acquisition of anatomic(CT) and functional(SPET) information of a patient within a single examination and provides intrinsically coregistered images of the two modalities.99mTc-MDP is the most important bone imaging agent.99mTc-MDP is also grouped to the radioactive drug, in one hand, it conduce to clinical diagnose as a functional imaging-agent, on the other hand,99mTc-MDP can bring about radiation to the patients,the staff and the public, however, a few of documents is about the radiation dose of99mTc-MDP, so that, It is necessary for the health of the staff and the public to study the radiation dose caused by99mTc-MDP in SPET/CT examinations and to implement preferably the theory of radiation optimization.
Methods:
1. There are160patients who undergoing whole body bone imaging,40of that were selected randomly and the activity of injected99mTc-MDP were recorded,23patients was male,17patients was female, the purity of99mTc-MDP is93%, the activity of99mTc-MDP is23±1.4mCi (870±51.8MBq) according to patients injected99mTc-MDP.Between April to May2013in liaocheng city in shandong province people's hospital nuclear medicine, the whole body bone scan and locally aged56.6±13.1, weigh72.0±13.9kg t, the nuclear medicine personnel10people,4people, engineer1person, the nurse is responsible for the elution and5people injected with99MTC-MDP1person
2. Effective dose of the patients were estimated by dose coefficients and intravenous administration of an activity99mTc-MDP; the doserate from patients was surveyed with the451P-DE-SI Ion Chamber Survey Meter, The time were lOmin, 60min,120min and240min after the patients were injected99mTc-MDP, the distance were0.5m、1.0m and1.5m from the patients. the staffs dose was recorded with TLD and FJ-377thermoluminescence dose reader.
3. Statistical analysis. All data were processed and analyzed statistically with Excel2003and SPSS13.0.
Results:
1. Effective dose of99mTc-MDP is5.23±0.76mSv, compared to the effective dose of the other radionuclide such as18F-FDG, the difference of them was little, however, the effective of125I was evidently higher, It was not evidence of the difference between the radiation dose caused by X-ray scanning and the effective dose of99mTc-MDP, the dose limits of occupational exposure is20mSv and that of public exposure is5mSv, there is statistical significance compared to the dose limits.
2. The correlation coefficients of the doserate-distance and doserate-time are-0.994and-0.988respectively, as it can be seen, the influence of the dance is greater than that of the time,2.5μSv/h can be calculated from the basic standards for protection against ionizing radiation and for the safety of radiation sources.
3. The overall radiation dose per year received by the staffs was0.873mSv, the overall radiation dose per year received by the injector and the technologist is respectively1.572mSv and1.558mSv, the data were lower than the corresponding dose limit. Total radiation dose per year received by the fingers of the technologist were also lower than the corresponding dose limit.
4. Additional radiation dose are smaller (2.3±1.7mSv), diagnostic value are important for patients, conform to the practice of medical radiation legitimacy principle; On the other hand,distance protection and time protection may be reduced the radiation and radiation protection optimization is feasible on SPECT/CT imaging.
Conclusions:
It is little for patients that dose commitment is caused by99mTc-MDP in SPECT/CT examinations, but the clinician should consider the overall radiation dose received by patients. It is practicable to limit patients' moving region properly to decrease public radiation from the patients who were injected99mTc-MDP.
放射性核素骨显像是目前核医学科使用率最高的检查项目,它不仅可显示骨骼形态,更能反映骨骼和病变的血流和代谢状况,常早于X线发现病变,并可进行全身扫描,对各种骨骼疾病的诊断和治疗效果的观察具有重要价值,在骨骼病变的诊断中具有早期诊断和探查范围广的显著优势。
显像仪器是诊断核医学重要工具,其研发过程经历了扫描机、γ照相机到计算机断层扫描仪。1979年Kuhl和Edwards成功研制了第一台SPECT(single photon emission computed tomography,单光子发射型计算机断层扫描仪),它是γ照相机与电子计算机技术相结合形成的一种核医学显像检查仪器,是在Y照相机平面显像的基础上,应用电子计算机技术增加断层显像功能,实现了断层显像。SPECT克服了平面显像组织、器官重叠造成的掩盖小病灶的缺陷,提高了对深部病灶的分辨率和定位准确性。但是与CT、MRI相比,SPECT对组织器官的解剖结构及比邻关系显示仍然不足。随着医学影像技术的飞速发展,图像融合技术已经广泛应用于临床,相继出现了SPECT/CT与PET/CT等融合仪器。PET/CT是目前最尖端的显像设备,18F-FDG PET/CT全身显像目前主要用于肿瘤的早期诊断、分级及分期、以及疗效评价方面,但由于价格昂贵,影响了其临床应用广度。
SPECT/CT是将核医学显像仪器SPECT和放射科断层显像仪器CT有机地融合,同时可利用X线CT扫描数据对SPECT图像进行衰减校正,实现了功能图像与解剖图像的同机融合。两种影像学技术的优势互补,相互印证,为临床提供了更多的诊断信息,显著提高了诊断的准确率。尽管有文献报道了同机CT对脊柱或肋骨的单发病灶的诊断价值,但是有关大样本量的对骨转移瘤诊断价值及相关因素的分析,特别是有关对低剂量CT的局部断层扫描及SPECT骨扫描对受检者所致的辐射剂量分析尚未见报道。
99mTc-亚甲基二磷酸盐(MDP)是最主要的骨显像剂,由于MDP特殊的物理化学性质,在骨组织高度浓聚,对骨组织病变具有重要诊断价值,但是放射性核素99mTc-,具有电离辐射效应,单光子发射型计算机断层扫描仪可对骨扫描受检者、医护人员及其周围的人员造成辐射,有一定的潜在危害,但是有关99mTc-亚甲基二磷酸盐(MDP)所造成的辐射剂量报道较少。因此本课题对以下问题进行了分析及研究：一是放射性核素显像/低剂量CT扫描对骨转移瘤的诊断价值及相关因素分析；二是SPECT/低剂量CT检查中99mTc-MDP及局部断层CT扫描所致辐射剂量的研究。
第一部分99mTc-MDP SPECT/CT扫描对骨转移瘤的诊断价值及相关因素分析
目的：
探讨99mTc-MDP SPECT/CT扫描对骨转移瘤的诊断价值及相关因素的分析,以指导临床对骨转移瘤早期诊断和治疗,减少患者骨相关事件(skeletal related events, SREs)的发生,提高患者的生存质量。
资料及方法：
回顾性分析聊城市人民医院核医学科(泰山医学院附属医院)2008年10月至2013年3月间,行全身骨扫描加局部99mTc-MDP SPECT/CT(德国西门子公司生产的SymbiaT2型双探头)扫描的患者451例,包含因骨外的恶性病变行手术、放射治疗或化学治疗的患者。所入选患者均先行全身骨扫描后,发现有难以确定性质的放射性浓聚灶,如少发(≦3)的放射性异常浓聚灶,或者没有明确原发肿瘤的多发(≧至4)放射性浓聚灶,随后加做SPECT/低剂量CT扫描以明确病变性质,记录患者的相关血液检测指标。图像分析由三名具有核医学及CT影像阅片经验的主治医师独立阅片,诊断意见不一致时,经相关医师共同阅片并讨论决定。采用统一的图像诊断评分标准1-4分,1分是评为良性病变,2分是评为可疑良性病变,3分是评为可疑恶性病变,4分是评为恶性病变。SPECT/低剂量CT图像的阅读方法是SPECT断层图像上放射性稀疏/缺损或放射性异常浓聚灶在融合图像上的定位是否准确,然后判断低剂量断层CT上病灶的结构及密度变化及SPECT图像特点。所有影像诊断均经临床电话随访、定期复查诊断CT、MRI或病理穿刺结果等,最终明确诊断。
应用SPSS16.0统计分析软件对资料进行统计学处理及分析,分别统计全身骨扫描、SPECT断层图像、CT断层图像及SPECT/CT融合图像诊断的灵敏度、特异性、阳性预测值、阴性预测值及准确性等指标,率的比较采用四格表x2检验,单样本的检验,医师阅图采用R0C曲线分析,比较AUC曲线下的面积。所有检验标准均设定为0.05,P<0.05为差异有统计学意义。
结果：
1.行骨扫描受检者的临床诊断分类
临床医师申请骨扫描检查以明确是否有骨转移瘤的临床诊断主要分为两大类,一类是患者有明确的恶性肿瘤病史380例(骨外原发的恶性肿瘤前5位是肺癌、乳腺癌、前列腺癌、食管癌、胃癌；治疗前67例,治疗后313例,其中有骨痛症状的108例,无骨痛症状的272例；恶性肿瘤的类型：肺癌135例,男98例,女37例；乳腺癌77例,男1例,女76例,肺癌与乳腺癌的男、女患病比例采用χ2检验,(χ2=6.98,4.58；P<0.05)男女患病的差别有统计学意义)。另一类是患者无明确的肿瘤病史但怀疑有骨转移瘤的98例(男41例,女57例,全身骨痛18例,胸锥或肋骨痛25例,腰锥痛23例,椎体骨折13例,肋骨骨折例8,肱骨骨折1例,上肢痛5例,髋部痛2例,下肢痛3例)。
2.99mTc-MDP SPECT/CT显像的定位、定性诊断价值
136例受检者均无明确的恶性肿瘤病史,其中1例甲状旁腺激素(PTH)异常高,99mTc-MIBI甲状旁腺早期-延迟显像及颈部局部SPECT/低剂量CT扫描,甲状腺右叶下极一甲状旁腺瘤。其中95例骨扫描显示肋骨多发的点状放射性浓聚灶及脊柱多发放射性浓聚灶,腰椎显著,女性骨质疏松的患病率高于男性,(χ2=6.98,4.58；P<0.05差异有统计学意义)；另外41例骨扫描显示中轴骨及肋骨放射性分布不均匀,未见异常的放射性浓聚灶,SPECT/CT扫描扫描后诊断为疑多发性骨髓瘤。
骨扫描显示有少发放射性浓聚灶的受检者342例,放射性核素异常浓聚灶共有657个,良性疾病156例,放射性浓聚灶302(46.1%)个,骨良性病变主要包括胸腰椎的退行性变、胸腰椎压缩性骨折、腰椎结核、关节退行性变、骨折、骨岛、骨血管瘤等。骨转移瘤286例,放射性浓聚灶354(53.9%)个,病变范围较小者,CT图像一般呈偏心性生长；病变范围较大者,骨质破坏呈大片状不规则溶骨性破坏,常伴有明显软组织肿块。其中成骨性转移灶216个,溶骨性骨转移瘤138个。
本研究39例(3.32%)骨显像中,显示骨外软组织异常摄取99mTc-MDP,其部位分别为肺10例、肝9例,乳腺7例,肌肉软组织及皮下4例,胸膜3例,腹膜2例,脾2例,胃癌术后残余灶、肺上沟癌及结肠癌各1例。其中4个定位于盆腔内,1个定位于右侧卵巢,穿刺病理为库肯伯格瘤；1个定位于右侧髂窝,术后病理为胃癌种植性转移灶,2例定位于右侧回盲部,6个月后随访的骨扫描病灶消失。股骨头坏死13例,尿液污染9例。
3.骨扫描SPECT、CT及SPECT/CT诊断价值。
SPECT/CT融合图像诊断的灵敏度、特异性、阳性预测值、阴性预测值及准确性分别为92.8%、100%、100%、97.5%和98.1%,明显高于骨扫描(χ2=4.29,4.20,7.56,4.51；P均<0.05)。骨扫描、SPECT、CT及SPECT/CT分别采取ROC分析,AUC (ROC曲线下的面积)分别是0.747、0.833、0.944、0.964,95%的可信区间分别是0.653-0.826.0.806-0.937、0.883-0.979、0.909-0.990。
4.少发骨转移瘤与相关临床因素的分析
本研究342例少发骨转移患者中,273例伴有骨外转移,其中131例伴前哨和(或)远处淋巴结转移,以骨转移为首发病变的69(20.2%)例。肺癌是最常见的骨外原发肿瘤,腺癌发生骨转移的几率最大,小细胞性肺癌次之。血清碱性磷酸酶ALP升高常见于溶骨性骨转移瘤,良性骨病变及成骨性骨转移瘤ALP升高不明显；结合相关肿瘤标志物CA125、CEA、CA153、NSE、AFP及PSA升高,提高了早期诊断骨转移瘤的准确率,特别是骨扫描及PET图像上病灶阳性,而CT图像上骨质没有明显变化者。
结论：
1、99mTc-MDP SPECT/CT扫描受检者的临床资料分析。本研究中以骨痛申请检查者多,女性患骨质疏松的人数多；胸部恶性病变中以转移瘤最多,多位于肋骨及胸骨；骨外恶性病变以乳腺癌、肺癌及前列腺癌较多；骨原发肿瘤发生在四肢骨较多,颅骨多为单发病灶；虽然前列腺癌较容易转移至骨盆,但是骨盆恶性肿瘤转移灶以肺癌最多,这与肺癌的发病率比前列腺癌高有关,骨盆的良性病灶多位于骶髂关节、及骶骨上缘；髋臼稍上方的髂骨是溶骨性骨转移的好发部位,放射性浓聚有时不太明显,因此髋臼处的放射性异常不可轻易诊断为退行性病变；当骨扫描发现盆腔内异常放射性浓聚灶,且前后位放射性浓聚程度差别较小时,病灶多位于盆腔内。回盲部的放射性浓聚的机制有待进一步研究。
2、99mTc-MDP SPECT/CT扫描的诊断价值。SPECT/低剂量CT扫描系统的应用,提高了对病灶解剖定位的准确性及骨显像特异性。不仅可对骨显像的阳性病灶进行准确定位,而且CT能显示骨质的结构改变,对常见的易与骨转移相混淆的退行性变病灶有较好的识别能力,提高了骨显像诊断骨转移的准确性；99mTc-MDPSPECT/低剂量CT显像减少了膀胱放射性滞留造成的影响,特别是对于骨扫描时意外发现的尿储留患者,提高了骶骨及耻骨病灶诊断的准确率,也减少了受检者进行导尿后重新扫描的麻烦。关于骨转移瘤诊断的标准,除了典型的影像学表现外,在不典型的病灶中,多种影像学方法相互借鉴加临床随访也可作为诊断骨转移瘤的“金标准”。低剂量CT图像所示的溶骨性病灶伴局部软组织肿块,直径大于2cm时,多表现为典型的“炸面圈征”,即病灶中心呈放射性分布稀疏缺损,病灶周边放射性浓聚。成骨改变的早期的病灶摄取MDP未见明显异常。
3、99mTc-MDP SPECT/CT扫描对治疗决策的影响：23例术前诊断骨转移,改变治疗方案；9例明确脊柱的放射性浓聚灶为转移瘤合并退行性病变,因此选择性进行了放疗；3例在病灶处穿刺为转移瘤,结合病理免疫组化及肿瘤标志位找到原发肿瘤,2例病灶穿刺结果为骨肉瘤。17例术前诊断骨转移,改变治疗方案；8例明确脊柱的放射性浓聚灶为转移瘤合并退行性病变,因此选择性的进行了放疗；3例在病灶处穿刺为转移瘤,结合病理免疫组化及肿瘤标志位找到原发肿瘤,1例病灶穿刺结果为髂骨炎性肉芽肿。
第二部分99mTc-MDP SPECT/CT扫描所致辐射剂量的研究
目的：
探讨在SPECT/CT检查中99mTc-MDP及局部断层CT扫描所致的辐射剂量,更好地贯彻医疗辐射防护最优化的原则。
资料及方法：
2013年4月一5月间在山东省聊城市人民医院核医学科做全身骨扫描并且行局部SPECT/CT检查的160人中单纯随机选取受检者40人,男性23人,女性17人,年龄56.6±13.1岁,体重72.0±13.9kg,核医学科工作人员共10人,医师4人,技师1人,护士5人,轮流负责淋洗和注射99mTc-MDP。分别记录40例受检者行同机CT扫描的长度,计算其均值,从而得出低剂量CT扫描对骨扫描检查者所造成的额外辐射剂量。
分别对99mTc-MDP所产生的医疗照射,职业照射及公众照射三方面进行研究。受检者在SPECT/CT检查中所受的99mTc-MDP内照射剂量加低剂量的CT断层所产生的额外的辐射剂量为医疗照射；核医学科的工作人员所接受的照射为职业照射,负责淋洗和注射99mTc-MDP的护士单独统计其所受到的辐射剂量；注射药物后的受检者作为辐射源对其他患者及家属所造成的辐射为公众照射。统计的结果与相应的国家标准及其他类似影像检查所致的辐射剂量进行分析、比较,从而衡量SPECT/CT检查中99mTc-MDP所导致的辐射危害或影响程度,为SPECT/CT扫描中的辐射防护提供更好的建议,更好地贯彻辐射防护最优化原则,促进SPECT/CT的更好应用。统计学处理是通过Microsoft Office Excel2003进行数据处理,SPSS进行单样本的检验和直线相关检验。
结果：
1.医疗照射(受检者)。骨扫描受检者行局部SPECT/CT扫描时受到99mTc-MDP医疗照射的有效剂量为8.23±0.99mSv,应用统计学方法与职业照射的年剂量限值(20mSv)进行单个样本的t检验,t=65,P<0.001,有统计学意义；与公众照射的年剂量限值(5mSv)进行单个样本的t检验,t=17.9,P<0.001,有统计学意义。
2.受检者外照射的辐射剂量。由曲线公式分别计算出9mTc-亚甲基二膦酸盐(MDP)剂量率为2.5μSv/h时的时间点和距离点,距离骨扫描检查者1.0米和1.5米处剂量率为2.5μSv/h的时间分别是245min和212min；注射9mTc-亚甲基二膦酸盐(MDP)后120分钟和240分钟剂量率为2.5μSv/h的距离分别是2.9米和1.6米。
3.工作人员的辐射剂量。医师胸部佩戴1年TLD所受的辐射剂量为0.972mSv；淋洗和注射99mTc-MDP的护士佩戴1个月TLD的累积值是0.384mSv,一年所受的辐射剂量为1.534mSv,其左右手食指的辐射剂量是0.215mSv和0.374mSv,铅眼镜内的辐射剂量是0.195mSv。
4.受检者的附加辐射剂量。局部低剂量CT扫描对受检者所造成的附加的辐射剂量亦较小(2.3±1.7mSv),受检者所获得的诊断价值远大于他们所受到的辐射危害,符合医疗辐射实践正当性原则；另一方面从距离防护和时间防护对他们的活动稍加约束,减少对其它人员的辐射及做到辐射防护最优化也是是切实可行的。
结论：
工作人员所受职业照射在有关规定的约束限值内,患者接受的医疗照射略高于公众照射剂量限值,99mTc-MDP SPECT/CT扫描的诊断价值远远大于医疗辐射危害,符合医疗照射实践正当性,防护最优化的原则。
[关键词]9mTc-亚甲基二膦酸盐(MDP)；辐射剂量；辐射防护
全文创新点：
1.全身骨扫描阳性结合肿瘤标志物检测水平升高,对骨转移瘤的早期诊断具有较高的诊断价值。
2.99mTc-MDP SPECT/CT扫描同机融合图像在少发骨转移瘤定位诊断和鉴别诊断中具有较高的诊断价值,有助于临床治疗决策的选择。
3.研究了99mTc-MDP SPECT/CT扫描所致的辐射剂量,包括医疗照射和职业照射。验证了工作人员所受职业照射在有关规定的约束限值内,患者接受的医疗照射略高于公众照射剂量限值,99mTc-MDP SPECT/CT扫描的诊断价值远远大于医疗辐射危害,符合医疗照射实践正当性,防护最优化的原则。
Background
Nuclide imaging (diagnostic nuclear medicine) belongs to the category of clinical nuclear medicine, the radionuclide is introduced into the body of patients, nuclear medicine instruments detect gamma rays from radionuclide, mainly display function and metabolism of tissues and organs and achieve the purpose of diagnosis of disease. Nuclear medical imaging instrument has experienced scanner, gamma camera to computed tomography scanning, however, which is different from the X-ray tomography instrument (traditional type of scanner transmission computed tomography(CT), nuclear medicine tomography instrument called emission computed tomography(ECT), ECT is divided into single photon emission computed tomography(SPECT) and positron emission computed tomography(PET).
Kuhl and Edwards successfully developed the first SPECT in1979, SPECT is a more advanced imaging modality combined with computer technology which was developed on the basis of the gamma camera planar imaging, Application of electronic computer technology increased the function of the tomography imaging, overcome the faults of overview small lesions due to tissue and organ overlapping, improve the positioning accuracy of deep lesions in the planar imaging. However SPECT anatomical structures of tissues and organs and distance relationship shows that still is inferior to CT and MRI. With the rapid development of medical imaging technology, image fusion technology has been widely used in clinical. SPECT/CT is the excellent integrations of functional and metabolic imaging of SPECT with morphologic imaging of CT, realizes the complementary advantages of the two imaging technology, provide more diagnostic information for clinical, also can use X-ray attenuation correction for a CT scan data of SPECT images.
Except for diagnosis of nuclear medicine, nuclear medical imaging equipment, radionuclide is another important part of nuclear medicine diagnosis,99mTc-methylene bisphosphonate (MDP) is one of the main bone imaging agent, due to its special physical and chemical properties, although it has the important value of imaging, but as a radionuclide99mT-MDP and it can also be on bone scan client, medical staff and the surrounding radiation, has certain potential hazards, but99mT-methylene bisphosphonate (MDP) caused by the radiation dose size, domestic no research about this aspect of the system, so this subject to the following two parts were retrospectively analyzed and research:
1. The diagnostic value of SPECT/CT scanning for bone metastases
2. Study on Radiation dose Caused by99mT-MDP and CT in SPECT/CT scanning.
PART I
The diagnostic value of SPECT/CT scanning for bone metastases Objective:
Investigate diagnostic value of radionuclide imaging/low dose CT imaging in the suspected bone metastases and analysis of related factors for early diagnosis and early reasonable treatment of bone metastases, reduce bone related events (skeletal related events, SREs), improve the quality of life of patients.
Materials and methods:
This was a retrospective study, from October2008to March2013, There were451patients underwent the whole body bone scan and99mTc-MDP SPECT/CT (German Siemens SymbiaT2type dual probe) scanning of in the nuclear medicine department of Liaocheng people's hospital (affiliated taishan medical universityl), containing the patients underwent the surgery, radiotherapy or chemotherapy of malignant tumors, it is difficult to determine the nature of the radioactive lesions in the whole body bone scan, such as the number of radioactive lesions≤3, or there is no clear of the multiple primary tumors but radioactive lesions≥4, then SPECT/low dose CT scans was performed in order to make clear nature of the lesions, meanwhile record the patient's blood tests associated indicators. Image analysis:three nuclear medicine and CT image doctors independently read the imagings, when they did not agree on diagnosis, the other physician need to read the image and discuss the decision. SPECT/low dose CT image:the position of radioactive defection or radioactive lesions in the fusion image is accurate on SPECT CT images, and then determine the structure and density of lesions on low dose CT image characteristic. The final diagnosis was confirmed by the clinical follow-up included telephone and review of diagnostic CT, MRI and biopsy results, etc.
Adopts unified image diagnostic criteria of1to4points,1point is chosen as benign,2points is chosen as suspicious benign,3points is chosen as suspicious malignant and four points is rated as malignant, statistics of the whole body bone scan, SPECT CT images, CT, CT image and SPECT/CT fusion image diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy. Application SPSS16.0statistical analysis software for statistical data processing and analysis, the rate of compares the four table chi-square test, ROC curve analysis, one sample t test, All inspection standards are set to0.05, P<0.05for the difference was statistically significant.
Results:
1. The clinical classification of the patients underwent bone scan.Clinicians for bony metastases of bone scan in order to make clear whether the clinical diagnosis of basically has two kinds, some patients with clear history of malignant tumor,380cases of patients with primary malignant tumor of the top5are lung cancer, breast cancer, prostate cancer, esophageal cancer, gastric cancer; Before67cases,313cases after treatment, including bone pain symptoms in108cases,272cases with no symptoms of bone pain; The type of malignant tumor,135cases of lung cancer,98cases of male and female37cases;177cases of breast cancer, male and female,76cases of lung cancer and breast cancer in male and female ratio is used chi-square test,(chi-square-6.98,6.98; P<0.05, the differences between men's and women's disease was statistically significant, other patients without malignant tumor but suspected patients in98cases of bone metastases,41cases were male,57cases were female, the whole body bony pain were18cases, thoracic vertebra or ribs were25cases, lumbar vertebra were23cases, vertebral fractures were13cases, fractured ribs were8cases, humerus fracture wasl case, upper limb pain were5cases, hip pain were2cases, lower limb pain were3cases.
2.The localization and qualitative value on99mTc-MDP SPECT/CT imaging136cases were no clear malignant tumour history, including1case of parathyroid hormone (PTH) abnormally high levels, early-delay99mTc-MIBI parathyroid imaging and partial SPECT imaging/low dose CT scanning revealed a parathyroid adenoma in the right thyroid lobe under extremely. Among them,95cases of bone scan revealed multiple rib focal radioactive concentration and spine multiple radioactive strong gathering lesions, lumbar significantly, women, the prevalence of osteoporosis is higher than men (chi-square=6.98,6.98; P<0.05difference was statistically significant); And41cases of bone scan showed the axial skeleton and ribs, uneven distribution of radioactive werenot seen abnormal radioactive strong lesios, SPECT/CT scans revealed multiple myeloma was confirmed by clinical materials.
Bone scan showed have less radioactive strong subjects,342cases of the oven, radionuclide extremely strong fusion focal a total of657,156cases of benign disease, radioactive thick polyethylene oven302(46.1%), bone benign lesions mainly includes the degeneration of thoracolumbar; Thoracolumbar compression fractures; Lumbar spinal tuberculosis; Joint degeneration. Fracture, bone island; Along they like located.286cases of bone metastases, radioactive strong focal354(53.9%), smaller scope of lesions in CT images generally show partial mind growth, a large patch of irregular bone destruction with strong disease extent in soluble bony destruction, often accompanied by obvious mass lesion. Among them into osseous metastases,216,138dissolved osseous bone metastases.
In this study,39cases (3.32%) abnormal bone imaging showed bone soft tissue outside the absorb99mTc-MDP, its parts, respectively, for10cases,9cases of liver and lung7cases, breast muscle tissue and subcutaneous4cases, pleura in3patients, peritoneal in2cases, splenic in2cases, gastric cancer postoperative residual focal sulcus carcinoma, lung and colon cancer in1case. Four of them located in pelvic cavity, a position on the right side of the ovary, biopsy for library kinberg tumor; A location in the right iliac fossa, postoperative pathology for metastases of gastric cancer in2cases located in the right side of the back blind department, after6months follow-up bone scan lesions disappeared.9cases, including13cases of femoral head necrosis, urine pollution.
3. Bone scan, SPECT, CT and SPECT/CT diagnostic value.SPECT/CT fusion image diagnostic sensitivity, specificity, positive predictive value, negative predictive value and accuracy were92.8%,100%,100%,97.5%and98.1%, significantly higher than bone scan (chi-square=4.29,4.29,4.20,4.51; P<0.05). Bone scan, SPECT, CT and SPECT/CT using ROC analysis respectively, AUC (area under the ROC curve) are respectively0.747,0.833,0.944,0.833,95%ci respectively is0.653-0.826.0.806-0.937,0.883,0.979,0.909,0.909.
4. The analysis of bone metastases and the related clinical factors.In this study,342cases of patients with bone metastases,273casesof which had outside the bone metastasis,131patients of which had sentinel lymph node metastasis and (or) the distance, the pathological changes of bone metastases as the starting69(20.2%) cases. Lung cancer is the most common primary tumor bone, adenocarcinoma of the chance of bone metastases is the largest, small cell lung cancer. Elevated serum alkaline phosphatase (ALP in osseous bone metastases, benign bone lesions and osseous bone metastases increased ALP is not obvious; Combined with the related tumor marker CA125, CEA, CA153, NSE, AFP and elevated PSA, and improves the accuracy of early diagnosis of bone metastases, especially bone scan images were positive, and bone have no obvious change on CT images.
Conclusion:
1.The characteristics of radionuclide imaging/CT scans and applicants. In this study with bone pain number of applicants for inspectors more women suffer from osteoporosis than man. Malignant breast lesions with metastases, the ribs and sternum were most seen, prostate cancer is more easily transferred to the pelvis, but pelvic malignant tumor metastases, lung cancer was most seen, it is associated with the incidence of lung cancer is higher than prostate cancer, bone malignant lesions in the breast cancer, lung cancer and prostate cancer is more, primary bone tumors occurred in four limbs which is more, the skull more for single lesion, pelvic benign lesions located in the sacroiliac joint, and the superior border of sacral; Acetabulum slightly above the iliac crest is a usual location to osseous bone metastases, radioactive lesions (sometimes less obvious, thus cotyle of radioactive anomalies in don't easily diagnosed with degenerative diseases; When bone scans found abnormal pelvic cavity radioactive strong stove, and a radioactive concentration degree of poly (before and after the difference is small, lesions located in the pelvic cavity, the mechanism of radioactive concentration needs further research.
2. The diagnostic value of low dose CT scans in SPECT/CT. SPECT/low dose CT scanning improved the accuracy of the anatomical location of lesions and bone imaging specificity, not only can be positive lesions of bone imaging for accurate positioning, and CT can show the structure of the bone change, easily confused with bone metastases of common degeneration lesions have better recognition ability, improve the accuracy of bone metastases of bone imaging diagnosis;99mTc-MDP SPECT/low dose CT imaging to reduce the impact of bladder radioactive retention, especially for the bone scan unexpectedly found that patients with urinary retention, improve the accuracy of the diagnosis of sacral and pubic bone lesions, also reduced the client for urethral catheterization after rescanning trouble. About bone metastases tumor diagnosis standard, in addition to the typical imaging findings, in atypical lesions, a variety of clinical follow-up imaging methods from each other and also can be used as the "gold standard" diagnosis of bone metastases. Low dose CT image shown in dissolving the bony lesions with local soft tissue mass, diameter greater than2cm, more show the typical "donut", namely the lesion center sparse defect distribution is radioactive, perifocal radioactive concentration. Osteogenesis change early lesions absorb MDP saw no obvious abnormalities.
3. Radionuclide imaging/low dose CT scan influenced treatment decisions:23cases of preoperative diagnosis of bone metastases, change treatment;9cases with clear spine of radioactive concentration stove for metastases with degenerative diseases, and selective radiotherapy;3cases in puncture for metastatic lesions, combined with immunohistochemical and tumor marker to find the primary tumor,2cases were obtained the results of osteosarcoma.17cases of preoperative diagnosis of bone metastases, change cure;8cases of clear spine of radioactive concentration stove for metastases with degenerative diseases, so the selective of the radiation;3cases in puncture for metastatic lesions, combined with immunohistochemical and tumor marker to find the primary tumor,1case of targeted biopsy results of ilium inflammatory granuloma. PET/CT scan can find more, more early bone metastases, the discovery of more effective for bone metastases starting symptoms of primary lesions, and can further clarify the diagnosis of multiple myeloma.
part Ⅱ
Study on Radiation dose Caused by99mTc-MDP in SPECT/CT scanning
Objective:
In recent years, SPECT/CT has gained increasing clinical acceptance as a important hybrid anatomical-functional imaging modality, SPECT/CT allow the acquisition of anatomic(CT) and functional(SPET) information of a patient within a single examination and provides intrinsically coregistered images of the two modalities.99mTc-MDP is the most important bone imaging agent.99mTc-MDP is also grouped to the radioactive drug, in one hand, it conduce to clinical diagnose as a functional imaging-agent, on the other hand,99mTc-MDP can bring about radiation to the patients,the staff and the public, however, a few of documents is about the radiation dose of99mTc-MDP, so that, It is necessary for the health of the staff and the public to study the radiation dose caused by99mTc-MDP in SPET/CT examinations and to implement preferably the theory of radiation optimization.
Methods:
1. There are160patients who undergoing whole body bone imaging,40of that were selected randomly and the activity of injected99mTc-MDP were recorded,23patients was male,17patients was female, the purity of99mTc-MDP is93%, the activity of99mTc-MDP is23±1.4mCi (870±51.8MBq) according to patients injected99mTc-MDP.Between April to May2013in liaocheng city in shandong province people's hospital nuclear medicine, the whole body bone scan and locally aged56.6±13.1, weigh72.0±13.9kg t, the nuclear medicine personnel10people,4people, engineer1person, the nurse is responsible for the elution and5people injected with99MTC-MDP1person
2. Effective dose of the patients were estimated by dose coefficients and intravenous administration of an activity99mTc-MDP; the doserate from patients was surveyed with the451P-DE-SI Ion Chamber Survey Meter, The time were lOmin, 60min,120min and240min after the patients were injected99mTc-MDP, the distance were0.5m、1.0m and1.5m from the patients. the staffs dose was recorded with TLD and FJ-377thermoluminescence dose reader.
3. Statistical analysis. All data were processed and analyzed statistically with Excel2003and SPSS13.0.
Results:
1. Effective dose of99mTc-MDP is5.23±0.76mSv, compared to the effective dose of the other radionuclide such as18F-FDG, the difference of them was little, however, the effective of125I was evidently higher, It was not evidence of the difference between the radiation dose caused by X-ray scanning and the effective dose of99mTc-MDP, the dose limits of occupational exposure is20mSv and that of public exposure is5mSv, there is statistical significance compared to the dose limits.
2. The correlation coefficients of the doserate-distance and doserate-time are-0.994and-0.988respectively, as it can be seen, the influence of the dance is greater than that of the time,2.5μSv/h can be calculated from the basic standards for protection against ionizing radiation and for the safety of radiation sources.
3. The overall radiation dose per year received by the staffs was0.873mSv, the overall radiation dose per year received by the injector and the technologist is respectively1.572mSv and1.558mSv, the data were lower than the corresponding dose limit. Total radiation dose per year received by the fingers of the technologist were also lower than the corresponding dose limit.
4. Additional radiation dose are smaller (2.3±1.7mSv), diagnostic value are important for patients, conform to the practice of medical radiation legitimacy principle; On the other hand,distance protection and time protection may be reduced the radiation and radiation protection optimization is feasible on SPECT/CT imaging.
Conclusions:
It is little for patients that dose commitment is caused by99mTc-MDP in SPECT/CT examinations, but the clinician should consider the overall radiation dose received by patients. It is practicable to limit patients' moving region properly to decrease public radiation from the patients who were injected99mTc-MDP.
引文
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3. Wells R, Farncombe T, Chang E, et al.Reducing bladder artifacts in clinical pelvic SPECT images. J Nucl Med.2004;45:1309-1314.
4. Allenbach G, Prior JO, Theumann N, et al.Suppressing bladder artifacts in bone SPECT of the pelvis. Ann Nucl Med.2007;21:339-344.
5. Thientunyakit T, Taerakul T, Chaudakshetrin P, et al.A comparison of the diagnostic performance of half-time SPECT and multiplanar pelvic bone scan in patients with significant bladder artifacts. Nucl Med Commun. 2013;34:233-239.
6. 韩丽君,屈婉莹,潘纪戍,等.正电子发射计算机体层摄影-CT诊断骨转移瘤的临床价值[J].中华放射学杂志,2005,39(11)：1157-1161.
7. 孟悛非,徐文坚,徐爱德,等.骨骼肌肉系统[A].见：吴恩惠.医学影像诊断学.北京：人民卫生出版社,2001.390-392.
8. Romer W, Nomayr A, Uder M, et al. SPECT-guided CT for evaluating foci of increased bone metabolism classified as indeterminate on SPECT in cancer patients. J Nucl Med.2006 Jul; 47(7):1102-1106.
9. Utsunomiya D, Shiraishi S, Imuta M, et al. Added value of SPECT/CT fusion in assessing suspected bone metastasis:comparison with scintigraphy alone and nonfused scintigraphy and CT. Radiology 2006;238:264-271.
10. Franc B, Myers R, Pounds T, et al. Clinical utility of SPECT-(low-dose) CT versus SPECT alone in patients presenting for bone scintigraphy. Clin Nucl Med. 2012;37:26-34.
11.尚玉琨,李舰南,蔡良,等.病理证实的130例脊柱疾病核素骨显像研究[J].中国医学影像学杂志,2004,12(6)：424-426.
12.李伟,屈婉莹,李威,等.SPECT/CT骨显像鉴别诊断脊柱良恶性病变的价 值[J].中华核医学杂志,2002,22：343-345.
13.马全福,匡安仁.SPECT/CT骨显像对脊柱单发病灶的诊断价值.中国临床医学影像杂志2008年第19卷第2期
14. Zhang Y, Shi H, Cheng D, et al. Added value of SPECT/spiral CT versus SPECT in diagnosing solitary spinal lesions in patients with extraskeletal malignancies. Nucl Med Commun.2013;34:451-458.
15. Gayed I, Kim E, Awad J, et al.The value of fused SPECT/CT in the evaluation of solitary skull lesion. Clin Nucl Med.2011;36:538-541.
16. Hassan F, Mohan H, Gnanasegaran G, et al. Beware of the focal uptake at the ischium on the bone scan in prostate cancer. Nucl Med Commun. 2011;32:320-323.
17. Sharma P, Singh H, Kumar R,et al. Bone scintigraphy in breast cancer:added value of hybrid SPECT-CT and its impact on patient management. Nucl Med Commun.2012;33:139-147.
18. Helyar V, Mohan H, Barwick T, et al.The added value of multislice SPECT/CT in patients with equivocal bony metastasis from carcinoma of the prostate. Eur J Nucl Med Mol Imaging.2010; 37:706-713.
19. Gemmel F, Coningh A, Collins J, et al. SPECT/CT of osteitis condensans ilii: one-stop shop imaging. Clin Nucl Med.2011;36:59-61.
20. Ivan Z, David C, James S, et al. Soft-Tissue Uptake of Technetium-99m-MDP After prostate Cryoablation. J Nucl Med.1997; 38:525-528.
21. Pirayesh E, Rakhshan A, Amoui M, et al. Metastasis of femoral osteosarcoma to the abdominal wall detected on 99m Tc-MDP skeletal scintigraphy. Ann Nucl Med.2013;27:478-480.
22. Oppenheimer A, Onyedika C, Freeman L. MDP uptake in peritoneal carcinomatosis and Krukenberg tumors from mucinous adenocarcinoma. Clin Nucl Med.2011;36:235-236.
23. Timothy M, Ibrahim A, Miguel H. Incidental Detection of Gastrointestinal Stromal Tumor by Tc-99m MDP Bone Scan. Clin Nucl Med.2012;37:198-199.
24. Hung Y, Yeh L, Chang W, et al. Prospective Study of Decreased Bone Mineral Density in Patients with Cervical Cancer without Bone Metastases:a Preliminary Report. Jpn J Clin Oncol.2002; 32:422-424
25. Thanapprapasr D, Nartthanarung A, Likittanasombut P, et al. Bone metastasis in cervical cancer patients over a 10-year period. Int J Gynecol Cancer.2010; 20: 373-378.
26. Even-Sapir E, Metser U, Mishani E, et al. The detection of bone metastases in patients with high-risk prostate cancer:Tc99m-MDP planar bone scintigraphy, single and multi-field-of-view SPECT, F18-fluoride PET and F18-fluoride PET/CT. J Nucl Med.2006;47:287-297.
27. Chakraborty D, Bhattacharya A, Mete U, et al. Comparison of 18F Fluoride PET/CT and 99mTc-MDP Bone Scan in the Detection of Skeletal Metastases in Urinary Bladder Carcinoma. Clin Nucl Med.2013;00:00-00
1.GBZ120-2006,1临床核医学放射卫生防护标准[S].
2.程晓莉,王海荣.核医学人员所受外照射水平[J].中华放射医学与防护杂志,1999,19(1)：55-56.
3. ICRP. Radiation Dose to Patients From Radiopharmaceutical. Publication 80. New York. NY:International Commission on Radiological Protectio:1998
4.中华人民共和国国家标准.电离辐射防护与辐射源安全基本标准.GB18871—2002.北京：中国标准出版社出版.
5.李德平等译.国际放射防护委员会1990年建议书[M].北京：原子能出版社,1993.
6.郑钧正.放射防护与放射学的发展[J].中华放射学杂志,2003,37(纪念特刊)：100-105.
7.GBZ128-2002,职业性外照射个人监测规范[S].
8. UNSCEAR. Sources and efftcts of ionizing radiation Vol. I:Sources[M]. New Youk,UN,2000.
9. ICRP. Radiological Protection and Safety in Medicine, ICRP Publication 73 [M]. Oxford:Pergam on Press, 1996.中文译本：季明烁译.医学中的放射防护和安全.北京：原子能出版社,1999.
10. IAEA. Radiological Protection for Medical Exposure to Ionizing Radiation [M]. Safety Guide,Safety standards series No. RSG1.5.Vienna,2002.
11.唐文祥,朱志贤,郑钧正,等.X射线CT所致受检者辐射剂量探讨.中华放射医学与防护杂志,2000.20(增刊)：79
12.鲍世宽等译.国际放射防护委员会第53号出版物[M].北京：原子能出版社,1991.
13. ICRP. Radiation and Your Patient:A Guide for Medical Procedures [M]. ICRP Supporting Guidance, Oxford:Pergam on Press,2002.
14. IAEA Proceedings on radiological protection of patients in diagnostic and interventional radiology, nuclear medicine and radiotherapy[M].Vienna, IAEA. 2001.
15. Suleiman OH, Fejka R, et al. The radioactive drug research committee:a 2005 update[J]. J Nucl Med,2005,46(S2):28P-29P.
16.国际放射防护委员会.放射诊断中患者的防护.国际放射防护委员会第34号出版物.郑钧正,卢正福,译.北京：原子能出版社,1987
17.朱志贤,郑钧正,陈峰等.放射诊断医疗照射指导水平的确定方法[J].中国辐射卫生,2004,13(2)：83-87.
18. Gunnar Brix, Ursula Lechel, Gerhard Glatting, et al Radiation Exposure of Patients Undergoing Whole-Body Dual-Modality 18F-FDG PET/CT [J]. Nucl Med.2005;46:608-613.
19. Benjamin Guillet, Pierre Quentin, Serge Waultier, et al.Technologist Radiation Exposure in Routine Clinical Practice with 18F-FDG PET. Journal of Nuclear Medicine Technology,2005;33:175-179.
20. Monsieurs M, Thierens H, Dierckx R.A, et al.(1998) Real-life radiation burden to relatives of patients treated with iodine-131:a study in 8 centers in Flanders (Belgium). Eur. J. Nucl. Med.25; 1368-1376.
2. 李亚明.骨、关节系统[A].见：李少林.核医学.第6版.北京：人民卫生出版社,2004.124-143.
3. Wells R, Farncombe T, Chang E, et al.Reducing bladder artifacts in clinical pelvic SPECT images. J Nucl Med.2004;45:1309-1314.
4. Allenbach G, Prior JO, Theumann N, et al.Suppressing bladder artifacts in bone SPECT of the pelvis. Ann Nucl Med.2007;21:339-344.
5. Thientunyakit T, Taerakul T, Chaudakshetrin P, et al.A comparison of the diagnostic performance of half-time SPECT and multiplanar pelvic bone scan in patients with significant bladder artifacts. Nucl Med Commun. 2013;34:233-239.
6. 韩丽君,屈婉莹,潘纪戍,等.正电子发射计算机体层摄影-CT诊断骨转移瘤的临床价值[J].中华放射学杂志,2005,39(11)：1157-1161.
7. 孟悛非,徐文坚,徐爱德,等.骨骼肌肉系统[A].见：吴恩惠.医学影像诊断学.北京：人民卫生出版社,2001.390-392.
8. Romer W, Nomayr A, Uder M, et al. SPECT-guided CT for evaluating foci of increased bone metabolism classified as indeterminate on SPECT in cancer patients. J Nucl Med.2006 Jul; 47(7):1102-1106.
9. Utsunomiya D, Shiraishi S, Imuta M, et al. Added value of SPECT/CT fusion in assessing suspected bone metastasis:comparison with scintigraphy alone and nonfused scintigraphy and CT. Radiology 2006;238:264-271.
10. Franc B, Myers R, Pounds T, et al. Clinical utility of SPECT-(low-dose) CT versus SPECT alone in patients presenting for bone scintigraphy. Clin Nucl Med. 2012;37:26-34.
11.尚玉琨,李舰南,蔡良,等.病理证实的130例脊柱疾病核素骨显像研究[J].中国医学影像学杂志,2004,12(6)：424-426.
12.李伟,屈婉莹,李威,等.SPECT/CT骨显像鉴别诊断脊柱良恶性病变的价 值[J].中华核医学杂志,2002,22：343-345.
13.马全福,匡安仁.SPECT/CT骨显像对脊柱单发病灶的诊断价值.中国临床医学影像杂志2008年第19卷第2期
14. Zhang Y, Shi H, Cheng D, et al. Added value of SPECT/spiral CT versus SPECT in diagnosing solitary spinal lesions in patients with extraskeletal malignancies. Nucl Med Commun.2013;34:451-458.
15. Gayed I, Kim E, Awad J, et al.The value of fused SPECT/CT in the evaluation of solitary skull lesion. Clin Nucl Med.2011;36:538-541.
16. Hassan F, Mohan H, Gnanasegaran G, et al. Beware of the focal uptake at the ischium on the bone scan in prostate cancer. Nucl Med Commun. 2011;32:320-323.
17. Sharma P, Singh H, Kumar R,et al. Bone scintigraphy in breast cancer:added value of hybrid SPECT-CT and its impact on patient management. Nucl Med Commun.2012;33:139-147.
18. Helyar V, Mohan H, Barwick T, et al.The added value of multislice SPECT/CT in patients with equivocal bony metastasis from carcinoma of the prostate. Eur J Nucl Med Mol Imaging.2010; 37:706-713.
19. Gemmel F, Coningh A, Collins J, et al. SPECT/CT of osteitis condensans ilii: one-stop shop imaging. Clin Nucl Med.2011;36:59-61.
20. Ivan Z, David C, James S, et al. Soft-Tissue Uptake of Technetium-99m-MDP After prostate Cryoablation. J Nucl Med.1997; 38:525-528.
21. Pirayesh E, Rakhshan A, Amoui M, et al. Metastasis of femoral osteosarcoma to the abdominal wall detected on 99m Tc-MDP skeletal scintigraphy. Ann Nucl Med.2013;27:478-480.
22. Oppenheimer A, Onyedika C, Freeman L. MDP uptake in peritoneal carcinomatosis and Krukenberg tumors from mucinous adenocarcinoma. Clin Nucl Med.2011;36:235-236.
23. Timothy M, Ibrahim A, Miguel H. Incidental Detection of Gastrointestinal Stromal Tumor by Tc-99m MDP Bone Scan. Clin Nucl Med.2012;37:198-199.
24. Hung Y, Yeh L, Chang W, et al. Prospective Study of Decreased Bone Mineral Density in Patients with Cervical Cancer without Bone Metastases:a Preliminary Report. Jpn J Clin Oncol.2002; 32:422-424
25. Thanapprapasr D, Nartthanarung A, Likittanasombut P, et al. Bone metastasis in cervical cancer patients over a 10-year period. Int J Gynecol Cancer.2010; 20: 373-378.
26. Even-Sapir E, Metser U, Mishani E, et al. The detection of bone metastases in patients with high-risk prostate cancer:Tc99m-MDP planar bone scintigraphy, single and multi-field-of-view SPECT, F18-fluoride PET and F18-fluoride PET/CT. J Nucl Med.2006;47:287-297.
27. Chakraborty D, Bhattacharya A, Mete U, et al. Comparison of 18F Fluoride PET/CT and 99mTc-MDP Bone Scan in the Detection of Skeletal Metastases in Urinary Bladder Carcinoma. Clin Nucl Med.2013;00:00-00
1.GBZ120-2006,1临床核医学放射卫生防护标准[S].
2.程晓莉,王海荣.核医学人员所受外照射水平[J].中华放射医学与防护杂志,1999,19(1)：55-56.
3. ICRP. Radiation Dose to Patients From Radiopharmaceutical. Publication 80. New York. NY:International Commission on Radiological Protectio:1998
4.中华人民共和国国家标准.电离辐射防护与辐射源安全基本标准.GB18871—2002.北京：中国标准出版社出版.
5.李德平等译.国际放射防护委员会1990年建议书[M].北京：原子能出版社,1993.
6.郑钧正.放射防护与放射学的发展[J].中华放射学杂志,2003,37(纪念特刊)：100-105.
7.GBZ128-2002,职业性外照射个人监测规范[S].
8. UNSCEAR. Sources and efftcts of ionizing radiation Vol. I:Sources[M]. New Youk,UN,2000.
9. ICRP. Radiological Protection and Safety in Medicine, ICRP Publication 73 [M]. Oxford:Pergam on Press, 1996.中文译本：季明烁译.医学中的放射防护和安全.北京：原子能出版社,1999.
10. IAEA. Radiological Protection for Medical Exposure to Ionizing Radiation [M]. Safety Guide,Safety standards series No. RSG1.5.Vienna,2002.
11.唐文祥,朱志贤,郑钧正,等.X射线CT所致受检者辐射剂量探讨.中华放射医学与防护杂志,2000.20(增刊)：79
12.鲍世宽等译.国际放射防护委员会第53号出版物[M].北京：原子能出版社,1991.
13. ICRP. Radiation and Your Patient:A Guide for Medical Procedures [M]. ICRP Supporting Guidance, Oxford:Pergam on Press,2002.
14. IAEA Proceedings on radiological protection of patients in diagnostic and interventional radiology, nuclear medicine and radiotherapy[M].Vienna, IAEA. 2001.
15. Suleiman OH, Fejka R, et al. The radioactive drug research committee:a 2005 update[J]. J Nucl Med,2005,46(S2):28P-29P.
16.国际放射防护委员会.放射诊断中患者的防护.国际放射防护委员会第34号出版物.郑钧正,卢正福,译.北京：原子能出版社,1987
17.朱志贤,郑钧正,陈峰等.放射诊断医疗照射指导水平的确定方法[J].中国辐射卫生,2004,13(2)：83-87.
18. Gunnar Brix, Ursula Lechel, Gerhard Glatting, et al Radiation Exposure of Patients Undergoing Whole-Body Dual-Modality 18F-FDG PET/CT [J]. Nucl Med.2005;46:608-613.
19. Benjamin Guillet, Pierre Quentin, Serge Waultier, et al.Technologist Radiation Exposure in Routine Clinical Practice with 18F-FDG PET. Journal of Nuclear Medicine Technology,2005;33:175-179.
20. Monsieurs M, Thierens H, Dierckx R.A, et al.(1998) Real-life radiation burden to relatives of patients treated with iodine-131:a study in 8 centers in Flanders (Belgium). Eur. J. Nucl. Med.25; 1368-1376.
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