级课件-核医学01绪论

核医学概论重庆医科大学附属第二医院核医学科袁耿彪

,636933392016年2月TheTrialofO.J.SimpsonTheIncriminatingEvidence

曾经，有一份真诚的爱情放在我面前，我没有珍惜，等到我失去的时候才后悔莫及，人世间最痛苦的事莫过于此……如果上天能够给我一个再来一次的机会，我会对那个女孩子说三个字：“我爱你。”如果非要在这份爱上加上一个期限，我希望是……一万年！

图像融合的新突破功能与分子显像，基因和药物相互渗透，将在21世纪对医疗卫生具有重大影响SPECT、PET显像：功能、代谢、分子显像、高特异、高灵敏解剖图像功能成像解剖图像功能成像解剖图像功能成像个性化医疗新纪元PersonalisedmedicinePredictDiagnoseInformTreatMonitor一核医学定义

研究核技术在医学的应用及其理论的学科，是用放射性核素诊断、治疗疾病和进行医学研究的医学学科。1、放射性示踪和靶向内照射是

核医学的基本原理年发现者/发明者发现/发明诺贝尔奖1895W.K.RoentgenΧ射线1896H.Becquerrel发现了铀的放射性1903,与Curie夫妇共享物理奖1898-1902P.Curil和M.Curie分离出放射性钋1911，M.Curie获化学奖1913-1924G.Hevesy用201Pb,210Pb,212Pb进行矿、植、动物体内Pb含量和转移等的示踪测定1925H.Blumgart用Ra测定人体血流速度1930E.Lowerence回旋加速器1939，物理奖1934I.Curie和F.JoliotG.Hevesy人工制备放射性核素30P用32P示踪研究P的生态循环1935，化学奖1943，化学奖1959，原子能和平利用奖1936J.Hamilton和J.Lowerence用32P治疗白血病1938G.SeaborgS.Hertz人工制成131I，发现了99mTc研究128I在兔甲状腺内的聚集1951，化学奖1942S.Hertz用131I治疗甲状腺功能亢进症1946E.Fermie核反应堆历届核医学诺贝尔奖获得者19031911193919351943195120072、放射性示踪技术与其他医学先进技术相结合，持续拓宽和深化核医学的内容核物理内分泌核医学更新的领域脑功能核医学心脏核医学放免分析放射性示踪剂和药物核医学仪器肿瘤核医学基因核医学医学先进理论技术核医学内容稀释原理血容量测定、血浆容量测定、红细胞容量测定血流动力学血流速度测定、心功能显像和测定跨膜肝肾功能显像，心肌、脑血流显像和测定代谢甲状腺显像和功能测定、葡萄糖代谢测定免疫理论、单抗技术放射免疫分析、放射免疫显像受体学说受体显像、神经递质显像、转运蛋白显像基因理论和基因工程技术基因显像、反义显像、转基因显像3、放射性药物和放射性仪器是诊断核医学发展的基石放射性药物报告者用途32PG.Hevesy(1935)P代谢研究和血液病治疗131IS.HERTZ(1938)碘代谢研究和甲状腺疾病诊治99mTc201Tl18FP.Harper(1963)Lebowitz(1975)M.Reivich(1979)肝显像心肌显像和肿瘤显像葡萄糖代谢显像131I(Anti-CEAAb)D.M.Gordenberg(1978)肿瘤放免显像和放免治疗11CH.N.Wagner(1983)神经受体PET显像99mTc(MIBI)J.Maddahi(1987)心肌显像和肿瘤显像99mTc(ECD)G.Demonccau(1988)脑血流显像123I(Octerotide)J.C.Reubi(1990)肿瘤受体研究和受体治疗111I(Octerotide)W.H.Bakker(1991)肿瘤受体显像111I(ASON)M.K.Dewanjee(1994)反义显像124I(FIAU)J.G.Tjuvajev(1996)转基因显像99mTc(TRODAY-1)H.F.Kung(1996)神经SPECT显像18F(FLT)Vesselle(2001)胸腺嘧啶显像18F(FDU)Buchmanna(2001)脱氧尿嘧啶核苷显像18F(FDDNP)Agdeppa(2001)组织病理学印迹显像124I(MBP-Ane5)Dekker(2002)细胞凋亡显像①放射性药物Radiopharmaceuticals

全球放射性核素供应和使用

全球共有54个反应堆在生产同位素，其中仅有6个反应堆生产钼-99及其他医用同位素。中国原子能研究院101堆（停堆）中国原子能研究院492堆（通量低）成都核动力院反应堆（半停堆）绵阳九院新堆（20MW明年运行）中国原子能研究院新堆（60MW明年运行）国内Mo-Tc每周需求量：<200Ci日本Mo-Tc每周需求量：1000Ci韩国Mo-Tc每周需求量：400CiSPECT+SPECT/CT70台PET+PET/CT12台费城人口:150万

四川省人口：9000万SPECT+SPECT：18台PET+PET/CT：4台重庆地区人口：3000万PET/CT2台，PET1台SPECT10台（SPECT/CT3台）2011年核医学诊疗人数/千人/年--------------MettlerFAJr,etal.RadiologicandnuclearmedicinestudiesintheUnitedStatesandworldwide:frequency,radiationdose,andcomparisonwithotherradiationsources--1950-2007.Radiology.2009;253(2):520-31.影像+治疗SPECT+SPECT/CT台数/百万人SPECT或SPECT/CT年检查人数核医学仪器发明者盖革计数器H.Geiger(1929)闪烁扫描仪B.CassenERTZ(1951)γ相机横断层扫描仪PETH.O.Anger(1957)D.E.Kuhl(1963)

M.M.Ter-pogosium(1975)SPECTR.J.Jaszczak(1977)SPECT/PETG.Muehllehner(1995)microPETPET/CTS.R.Cherry(1997)D.W.Townsend(1999)②

核医学仪器Nuclearmedicineequipments

80年代90年代Γ照相机本世纪初PET/CTSPECT/CT70年代SPECT

X-1895

19711973美国伊利诺伊大学的PaulC.Lauterbur1974英国诺丁汉山大学的SirPeterMansfield20世纪80年代4、诊断核医学的发展方向和当今热点器官水平分子水平总体功能局部功能局部功能分子识别单光子核素灵敏度定向诊断正电子核素特异性

定量和定位诊断单纯诊断对治疗方案的影响单纯技术效益价格分析JNM2011-2012.1

分子显像：分子显像是对正常或异常的区域性分子水平活动进行的显像，并涉及到相关的基因型、组织病理和患者的临床表现（即表现型）。人体内所进行的数千个分子过程所带来的分子显像信息使我们不再依赖于医师的经验就可以对显像本身进行解读并根据其余的信息对其进行进一步的整理。核医学将在其他任何临床学科之前迎接这一革命所带来的挑战。

Imagesacquiredina54-year-oldpatientwithisletcelltumor:CT;(B)octreotidescintigraphy;(C)18F-DOPAPET;(D)11C-5-hydroxytryptophanPETFIGURE3.Imagingapoptosisinvivoinmouse2dafterocclusionofleftanteriordescendingartery(allimagescoronalview).(Left)18FFDGscanshowsmassivelydecreaseduptakeinanteriorwall,whereas18F-FDGuptakeinremainingmyocardialareasispreserved.(Middle)Sumimageoflast30minof90-min68Ga-annexinVscaninsameanimal,showingspecificuptakeinareaofdecreasedmetabolism,indicatingpresentapoptosis.(Right)Fusionof18F-FDGand68Ga-annexinVscans.FIGURE2.Smallmesentericlymphnodemetastasis(arrows)ofpancreaticNETin71-y-oldman:portal-venousCT(A),68Ga-DOTATOCPET(B),andfusedPET/CT(C).NotmeetingCTmalignancycriteria,withdiameterof0.55cmperpendiculartolongestaxisandroundconfiguration,thislesionwasdetectedonlybecauseofincreaseduptakeonPETSPECT/CToftumor-bearingratinjectedwith40MBq111In-octreotide(top).Inthebottomimage,exvivoautoradiography(toprow)iscomparedwithinvivoSPECTimages(bottomrow).TheauthorsconcludedthattheirsmallanimalSPECT/CTdevicewasahighlyaccuratetoolforfollowingphysiologicprocessesinthesameanimalovertimewithdifferenttracers.Ratimage(topright)acquiredwiththeU-SPECTIIclearlyshowstherightandleftventricles.Collimatorimages(left)andmouseimage(bottomright)indicatetheincreasedspatialresolutionpossiblewiththisdevice.动物显像TriisotopeSPECTwithCTimageacquiredwithaminiaturized,stationary,multiringCZTSPECTsystemthatprovides24uniqueangularsamplesandhascomponentsthatarefunctionalinMRfieldsupto7T.Intheimage,orange=99mTctargetingofbone;blue=123Itargetingofthyroid;andgreen=201Tlcardiactargeting.FIGURE3.SPECT/CTimagesoffemalemicebearinghumanovarianIGROV-1tumorxenografts(arrows),4hafterinjectionof111In-DTPA-folatealone(A)andincombinationwithpredosedpemetrexed(B)(28).Vol.52•No.1•January2011FIGURE3.Representativewhole-bodySPECT/CTimageofB16/F1melanoma–bearingmouse(10daftercellinoculation)2hafterinjectionof14.8MBqof111In-DOTA-GGNle-CycMSHhexEffectsoftheAminoAcidLinkersontheMelanoma-TargetingandPharmacokineticPropertiesof111In-LabeledLactamBridge–Cyclizeda-MSHPeptidesStressandrestimagesacquiredwithadualdetectorAngercamera(top)andanewsystemforhigh-speedmyocardialperfusionimaging(bottom)ina66-year-oldmalewithleftcircumflexarteryischemia.StressandrestimageswiththeAngercamerawereacquiredover19and11minutes,respectively，thesefigureswere4and2minutesforthehighspeedsystemResultswithintegratedsoftwarefusionof64-sliceCTangiographyandSPECT.Stress(left);rest(right)FIGURE2.Inpatient13,positiveosteomyelitisresultsconcordantbetweenWBCscintigraphy(T/Bratio.2.0andincreasingovertime)and18F-FDGPET/CT(SUVmax.2.0andCT-confirmedlocalizationinbone):clinicalimageofdiabeticfoot(A);anteriorandposteriorWBCscintigraphyimagesafter30min,3h,and20h(B);transaxial18F-FDGPET/CTimagesafter1h(C).Ant5anterior;Post5posterior.FIGURE1.Inpatient3,negativeresultsconcordantbetweenWBCscintigraphy(T/Bratio,2.0anddecreasingovertime)and18F-FDGPET/CT(SUVmax,2.0):clinicalimageofdiabeticfoot(A);anteriorandposteriorWBCscintigraphyimagesafter30min,3h,and20h(B);transaxial18F-FDGPET/CTimagesafter1h(C).Ant5anterior;Post5posterior.核医学科常用设备和项目1、常规体外检测设备：化学发光仪，放免仪2、显像设备：GE符合线路SPECT/CT3、功能测定设备：甲功仪，肾图仪4、131I治疗甲亢和甲癌、89Sr,153Sm治疗转移性骨肿瘤5、双能X线骨密度仪X线显像系统按装在旋转的γ相机上X线球管正对CT探头18F-FDG，其他正电子核素显像PET/CTCardiovascularSystemSkeletalSystemEndocrineSystemCentralNervousSystemPulmonarySystemGenitourinarySystemGastrointestinalSystemHepatobiliarySystemSPECT,SPECT/CT成像Cardiovascular

System

心肌灌注显像

statusofmyocardiumandcoronaryperfusion.

心室造影（心功能测定）

statusofheartfunction.Stress-inducedischemiainthelateralwall心肌缺血后侧壁MI下壁MI心室造影（心功能测定）门控心肌断层显像患者男性，36岁，广泛前壁心梗后，PET显像见前壁和心尖FDG代谢缺损，提示该处心肌活力缺乏。HSA

VLA

HLA

心脏显像发展灌注成像—99mTc-MIBI,201Tl心肌核素显像代谢成像—18F-FDG,11C-PA,11C-AC,3N-GA,99mTc-HL91显像

评价血流供应,血管储备功能和细胞活性评价心肌细胞活性分子成像—18F-FDG,125I-MCP-1,99mTc-Annexinⅴ,125I-MIBG显像巨噬细胞的能量底物受体激动剂凋亡剂神经受体干细胞移植和基因治疗H.WillanStrauss,NuclMed,2004,Vol骨显像的优势:高敏感性

(Highsensitivityindetectingearlydiseaseofmanytypes).Sensitivefordetectingthechangedlocalmetablism.Ontheotherhand,a30%to50%changeinbonedensityisrequiredbeforelesionscanbedetectedradiographically.显示全身骨骼

(Abilitytosurveytheentireskeletonquicklyatreasonableexpense).SkeletalSystemNormaladultbonescintigramBonescanofachild(4y9m).Feelpaininleftshoulder.Diffusemets.41yfemale,7yafteroperationofbreastCa.feelpaininshoulderandpelvisBonepainwithunknowncause.13ygirlwitha

甲状腺显像

甲状腺吸碘功能测定

(RadioactiveIodineuptake,RAIU)

肾上腺显像甲状旁腺显像EndocrineSystem

甲状腺显像

Ultrasonographyandfineneedleaspiration(FNA)biopsyhavepartiallysupplantedthyroidscintigraphyintheevaluationofpatientswithclinicallypalpablethyroidnodules.在判断甲状腺结节的功能状态上具有不可替代的独特优势(Uniquelysuitedtodeterminethefunctionalstatusofthyroidnodules).NormalthyroidimagewithI-123PinholecollimatorA:diffusegoiterB:coldnoduleC:autonomousnoduleD:substernalthyroidDiffuseenlargement(Grave’sdisease)ColdnoduleofleftlobeEctopicthyroid—lingualthyroid肾上腺髓质显像嗜铬细胞瘤(pheochromacytomas)甲状旁腺显像ParathyroidadenomaTc-99mMIBIA:earlyimageB:2hrdelayedimage唾液腺显像和功能检查普通脑显像(ConventionalBrainImaging(Blood-BrainBarrierScintigraphy)

脑血流灌注断层显像(SPECTCerebralPerfusionImaging)

PET脑代谢显像(PositronEmissionTomography)

脑池显像(Cisternography)CentralNervousSystemCerebralinfarctionofleftfrontallobe(Tc-99mHMPAO)Upper:MRI.Middle:perfusion.Lower:DiamoxinterventionIctalidentificationofepilepticfocus:Hypermetabolismandhyperperfusionareaisseenintherightparietallobe多巴胺功能显像

在帕金森病中的应用多巴胺受体和转运体在神经末梢突触前和突触后的显像示踪剂多巴胺能示踪剂1、突触前的标记物：18F-FDOPA;18F-FPCIT(分别与DA和DAT结合)2、突触后的标记物：

11C-Raclopride，spiperone（螺哌隆）的衍生物（分别为D2和D1受体的配体）用于脑功能大体评估的示踪剂1、葡萄糖代谢类：18F-FDG2、脑血流：15O-H2O

轻度中度重度18F－FPCITFDOPAPET评价胎儿细胞移植方法的疗效在帕金森患者的双侧壳核中植入经培养的中脑组织应用FDOPAPET评估其疗效术前术后1年术后2年术后4年62岁PD患者FDOPA/PET壳核的FDOPA摄取肺通气显像肺灌注显像PulmonarySystem临床应用:肺栓塞的诊断肺气肿下肢深静脉显像GenitourinarySystem99mTc-DTPA肾动态显像+肾小球滤过率的测定

131I-Hippor99mTc-MAG3肾动态显像+有效肾血浆流量测定Normaldynamicrenography:corticalfunctionphaseandclearancephaseSmallleftkidney(cause?)HydronephrosisofrightkidneyNormaltransplantkidneyAbnormaltransplantkidney:slowclearance胃排空功能Gastricmotility(Gastricemptying)幽门螺杆菌检测

Helicobacterpyloriinfection胃肠道出血定位Gastrointestinalbleeding异位胃黏膜显像EctopicgastricmucosaGastrointestinalSystem胃肠道出血定位灵敏度85%-90%出血率0.1ml/min9y/omale异位胃黏膜显像肝胶体显像Technetium-99mSulfurColloidLiver-SpleenImaging肝血池显像Technetium-99mRedBloodCellLiver

Scintigraphy胆道显像CholescintigraphyHepatobiliarySystemPlanarstudy.Left,immediatepostinjectionimageshowscolddefectinsuperolateralportionoftherightlobe.Smallareahasincreaseduptake.Right,delayedimage(60min.)showscompletefilling.SPECTofTc-99mSC.Well-definedcolddefect.SPECTofTc-99mRBC.正常胆囊显像萎缩性胆囊SPECT/CT显像FIGURE1.Lymphoscintigraphyofpatientwithnonpalpableleftbreastcancer2hafterperiareolarinjectionof99mTc-colloidalrheniumsulfide,withthe2detectorspositionedatrightangles.(A)Anteriorviewshows2axillarysentinelnodes.(B)Onleftlateralview,only1axillaryfocusisseen;the2sentinelnodesaresuperimposed.FIGURE2.Lymphoscintigraphyofpatientwith25-mminvasivelobularcarcinomaofleftbreast.(A)Anteriorplanarviewshows2axillarysentinelnodesplusinternalmammarydrainage.Medium-energycollimatorwasusedtoreducestarartifacts.(B)SPECT,CT,andSPECT/CTfusionimagesofaxillashowuppersentinelnodeatBerglevelII(beneathpectoralisminor)andothersentinelnodeatBerglevelI.(C)Internalmammarynodeisinsecondintercostalspaceanddidnotundergobiopsy.Axillarysentinelnodeswerenegative.FIGURE1.(A)Planaranteriorimageshowingdrainageof99mTcnanocolloidfrominjectionsiteinrighttesticleto2abdominallymphnodesandradioactivityalonglymphaticchannel,whichdecreasedintime,indicatinglymphatictractvisualization.(B)CoronalSPECT/CTimagefusionshowingbothsentinellymphnodes(yellow)alongsideinferiorvenacava.(C)LaparoscopicSNprocedureusingportableg-cameraandlaparoscopicg-raydetectionprobe.(D)Preexcisionimage(leftscreen)acquiredwithportableg-camerashowingbothSNsinoperationroom.Afterexcision(rightscreen),nosignificantremainingactivityisseen.FIGURE2.(A)Planaranteriorimageshowingdrainagefromrighttesticleto2adjacentlymphnodesinmedialareaofabdomen.Someuptakeisalsoseeninmorelaterallylocatedlymphnode(arrows).(B)CoronalfusedSPECT/CTimageshowingbothmediallymphnodesbetweenaortaandvenacavaandlateralnodeintrajectoryofrighttesticularvessels.(C)TransverseSPECT/CTimageshowing2SNsdisplayedinyellow.(D)CTimageshowingthatmedialSNcorrespondstosmalllymphnodeventraltoareabetweenaortaandcava,whereaslateralnodeisinareaventraltopsoasmuscle(circles).InthisfunicularSN,micrometastaseswerefoundathistopathologyPET,PET/CT成像回旋加速器合成、热室PETESTABLISHEDVALUESOFFDGPETEvaluationofpulmonarynodulesStagingmalignanciesPredictingprognosisFollowuptreatmenteDetectingrecurrencesNatureofunknownprimaryGuidingtreatments:surgery,RT,Chemotherapy,orimmunotherapyConformalRTwithrespirationgatingSpectacularresultsinmultiplemyeloma,lymphoma,tyrosinekinaseinhibitortherapy(STI-571,Gleevec)inGIST(gastrointestinalstromaltumor)到2000年美国HCFA（HealthCareFinancingAdministration

）批准保险的PET项目已有11项乳腺癌淋巴瘤结直肠癌孤立性肺结节非小细胞性肺癌阿尔茨海默病黑色素细胞瘤头颈部肿瘤肿瘤全身广泛转移心肌灌注心肌存活患者，男性。CT：示左、右上肺均有占位病变。

PET：右上肺FDG高代谢灶。女，39岁，CT示“右下肺占位”性质不明5个月。PET：示右下肺高代谢病灶。术后病理女，72岁，CT示“右下肺占位”2年。无症状体征。注射FDG60分钟后PET显像：CT所示右下肺病灶处SUV最大值0.98注射FDG180分钟后PET显像：CT所示右下肺病灶处SUV最大值1.16注射FDG210分钟后PET显像：CT所示右下肺病灶处SUV最大值1.44鼻咽癌放疗、化疗后3年；近期CT示纵隔淋巴结肿大；PET示纵隔内异常高代谢灶。纵隔穿刺活检证实为泡状核细胞癌。肺癌广泛转移食管癌卵巢癌晚期2例黑色素瘤一例男73岁，晚期肺癌患者;经化疗、放疗2个月后复查。卵巢癌化疗前后对比X刀肺门、纵隔放疗2周后患者男性，34岁，鼻咽癌手术及放疗后3月余，MRI见脑干及左侧海绵窦异常信号，欲鉴别放射性坏死或复发。肺鳞癌化疗后6年乳腺癌

术后10年

女，50岁，既往有子宫肌瘤子宫全切术及右侧卵巢囊肿切除术史。

PET体检。TherapyresponseFIGURE2.Baseline(top)andweek3(bottom)scansofpatientwitharesponseonallmodalities:CT(A),18F-FDG(B),H215OPET(C),andDCEMRI(D).MonitoringResponsetoAntiangiogenicTherapyin

Non–SmallCellLungCancer……bevacizumab;erlotinibJNuclMed2011;52:48–55FIGURE1.(A)HypervasculartumorsarenotedonpretreatmentMRimageof68-y-oldmandiagnosedwithHCC.(C)SPECT/CTimage(74MBqof99mTc-MAAwasadministeredviamicrocatheterplacedinlefthepaticartery)showsincreasedactivitydepositioninsuperiorlaterallefthepaticartery.(B)One-monthposttreatmentMRimagedemonstratesabsenceoftissueenhancement,suggestingcompletetumornecrosis,andnormalparenchymaradiationeffectinsuperiorlaterallefthepaticartery.(D)Immediateposttreatment(1.29GBqof90Yadministeredviacatheterplacedinsuperiorlaterallefthepaticartery)PET/CTactivitydistributionmatchesthe1-moposttreatmentMRimageregionwiththeradiationeffect.FIGURE2.(A)Middlehepaticlobehypervasculartumornotedonpre