1. VCU NMT Program Adrenal Scintigraphy Aldosteronism Addison’s Cushing’s Virilizing Adenomas Pheochormocytomas Neuroblastomas Adrenal Cortical Pathologies: Adrenal Medulla Pathologies: Adrenal Cortex Adrenal Medulla

2. VCU NMT Program Adrenal Scintigraphy NP59 is one component of imaging that has already been covered in class via a previous lecture. Therefore we will continue with 131 I mIBG

3. Adrenal Medulla imaging for determination of Medullar metastatic lesions is performed with I131 labeled mIBG, or I123 labeled mIBG which is not commercially available at this time. Detection of adrenal medulla activity is primarily used in the evaluation of neuroblastoma and pheochromocytoma. VCU NMT Program Adrenal Scintigraphy

4. Neuroblastoma is a form of cancer that usually occurs in infancy and childhood. The term neuro indicates "nerves," while blastoma refers to a cancer that affects immature or developing cells. Nearly 90% of cases are diagnosed by age 6. When detected early, neuroblastomas can usually be treated effectively. However, in as many as seven out of 10 cases, the disease is not diagnosed until it has already metastasized (spread). Overall, about 40% of children with neuroblastomas can be cured with a combination of surgery, followed by chemotherapy and/or radiation therapy.

5. VCU NMT Program Adrenal Scintigraphy Pheochromocytomas are vascular tumors of adrenal medulla tissue characterized by hypersecretion of epinephrine and norepinephrine. This condition puts the patient in a prolonged version of flight or flight and ultimately wears the body down. Pheochromocytomas may be found in the adrenal medulla or as metastatic tumors along the sympathetic ganglia (throughout the thorax and abdomen, but commonly along the vertebra and aorta).

6. VCU NMT Program Adrenal Scintigraphy Specific points which you should remember: Before administering mIBG the patient should be treated with Lugol’s solution which blocks thyroid uptake of free I131. Lugol’s administration should continue for 6 -7 days. Administration of NP-59 I131 should be slow to prevent reactions. mIBG should only be used for Adrenal Medulla pathologies. Normal areas of uptake include salivary glands, liver, spleen, heart, GI tract, and bladder. Many drugs interfere with uptake of mIBG in medulla tissue. Sequential imaging should be performed to help identify normal vs. abnormal uptake. Empty bladder before imaging. 1. antidepressants 2. antihypertensives 3. sympathomimetic: decongestants cocaine speed Obtain a complete list of medications and check with radiologist.

7. VCU NMT Program Adrenal Scintigraphy Aldosteronism Addison’s Cushing’s Virilizing Adenomas Adrenal Cortical Pathologies: Pheochormocytomas Neuroblastomas Adrenal Medulla Pathologies: mIBG NP-59 Review

8. VCU NMT Program Adrenal Scintigraphy 24 hour mIBG I131 for Pheochromocytoma

9. VCU NMT Program Adrenal Scintigraphy 48 hour mIBG for Pheochromocytoma

10. VCU NMT Program Adrenal Scintigraphy 48 hour I131 mIBG for Neuroblastoma

11. VCU NMT Program 72 hour I131 mIBG 4 year old. E.

12. VCU NMT Program Adrenal Scintigraphy 48 hour I131 mIBG for Neuroblastoma

13. VCU NMT Program Adrenal Scintigraphy Neuroblastoma in 4 yo. Wide spread metastatic evolvement of bone marrow.

14. VCU NMT Program Adrenal Scintigraphy Metastatic Pheochromocytoma in liver

15. VCU NMT Program Adrenal Scintigraphy 48 hour I131 mIBG for Pheochromocytoma

16. VCU NMT Program Adrenal Scintigraphy Generally, Neuroblastomas are imaged at 48 and 72 hours with I131 mIBG. Pheochormocytomas are generally imaged at 24 and 48 hours. The timing difference is largely due to Pheochromocytomas being much more vascular; therefore, they demonstrate more rapid accumulation of the radiopharmaceutical. Sequential imaging (subsequent days days) helps to distinguish normal vs abnormal uptake. How?