Nuclear medicine refers to the branch of medicine that involves administering radioactive substances in order to diagnose and treat a number of medical conditions, including some forms of cancer. Nuclear medicine is used for diagnosis and treatment of both oncological and non-oncological medical conditions. 

When used for monitoring or diagnosis of cancer, we use a number of radionuclides, administered through IV or oral routes. These radionuclides are derivatives of radioactive elements including gallium, technetium, thallium, iodine, etc.  

Basically, which radionuclide is suitable for the nuclear imaging or scan depends on the target organ and the type of diagnosis. In contrast to the traditional imaging techniques which focus on the primary structures only, nuclear medicine and imaging procedures can visualize body’s functioning at molecular and cellular level. This helps us to identify disease in its earliest stages. Also, it provides unique information that cannot be obtained using other imaging procedures.

The scans are also used to decide if the treatment is working and to devise more effective treatment for the patients.

How is Nuclear Medicine procedure performed?

During a nuclear medicine imaging procedure, small amounts of radioactive material is administered to diagnose, evaluate or treat a variety of diseases, including many types of cancers.

The patient is asked to swallow, or be injected with radioactive radiopharmaceuticals which accumulate in tumors or regions of inflammation. Sometimes they also bind to specific proteins in the body which can be seen on PET scans. This helps in identifying a disease before it is seen on other imaging tests.

In addition, these scans also determine the progression of disease or patient’s response to a prescribed treatment.

How can Nuclear Medicine help in diagnosis and management of cancer?

Nuclear medicine imaging is performed by using trace amount of radioactive material which is either swallowed or injected into the blood stream. These radiotracers travel through the infected area inside body and the energy beams/ rays released by these radiotracers are captured through a scanning device.

Nuclear imaging are functional imaging techniques which offer better diagnosis and treatment potential. These scans allow doctors to find the exact location of tumors and identify progression of the disease or stage of the cancer. These also provide detailed information about how a body organ is functioning.

Generally, nuclear imaging scans are noninvasive and painless procedures. 

   Nuclear medicine for cancer diagnosis helps in the following ways:

• Detect cancer recurrence

• Plan diagnosis and treatment

• Determine the stage of cancer type

• Determine if the cancer has spread to bones

• Detect atypical tumors of the adrenal and pancreas 

• Examine patient’s response to treatment

• Pinpoint location of sentinel lymph nodes for the surgical process for soft tissue or breast cancer tumors

NUCLEAR MEDICINE FOR TREATMENT OF CANCER

There are several types of nuclear medicine radionuclide therapies that treat various types of cancers. These include:

Radioactive Iodine Therapy:

Sometimes your thyroid gland absorbs almost all the iodine you take in. During this treatment, radioactive iodine collects in thyroid cells, where it destroys both the gland as well as the cancer cells. Unlike some other forms of radiation, radioactive iodine therapy does this without significant side effects in the rest of your body cells. It sometimes kills thyroid cancer cells that have spread to other parts of the body.

Lu-DOTATATE therapy for neuroendocrine tumors:

Neuroendocrine tumors that are extensive in nature and not responding to other forms of treatment can be treated by Nuclear Medicine therapies. 

Lu-PSMA therapy for prostate cancer: Extensive metastatic disease can be treated by Lu-PSMA therapy. Patients are symptomatically better with better quality of life after treatment. 

Y-90 Radioembolization:

This treatment therapy is generally performed to treat hepatocellular carcinoma.

Radioimmunotherapy:

If you have non-Hodgkin’s lymphoma that doesn’t respond to chemotherapy, your doctor may recommend this therapy. Also called RIT, the treatment option combines radiation therapy with immunotherapy.

Services

Nuclear Medicine in CMC

Department of Nuclear Medicine was set up in Chitwan medical college in December, 2020 under the direct supervision of Nuclear Physician Dr Jiwan Paudel from the initial phases of construction to a full-fledged functioning department. All this was possible because of constant support and guidance from Prof Dr Harish Chandra Neupane, Chairman and Managing director of CMC. 

The present activities in our department include different Nuclear Medicine Imaging, I-131 Uptake and Radionuclide Therapy.

Chitwan medical college, the top nuclear medicine hospital in Nepal has a well-equipped standard nuclear medicine department. The department is backed by a highly trained and experienced staff, ensuring global quality standards. At CMC, the best hospital for Nuclear medicine in Nepal, these scans are performed by trained technicians in our advanced imaging labs.

CMC is equipped with the latest state-of the-art technology, hybrid SPECT/CT with the latest hardware and software for all nuclear medicine imaging needs along with a complete hot laboratory facility including dose calibrator, fumehood, L Bench, SPECT cabinet and radiation monitoring equipments. SPECT/CT has revolutionized many fields of medical diagnosis, surgical planning and treatment. 

With an exclusive thyroid cancer ward, CMC is the only hospital with SPECT/CT facility as of 2021 in Nepal. It is also the one and only hospital to have a complete nuclear medicine imaging and therapeutic facilities under one roof.

Nuclear Imaging in CMC is thus performed on the Hybrid SPECT/CT equipped with Dual Head Gamma Cameras. Routine static imaging performed include Whole Body Skeletal, spot view skeletal scans, Thyroid, Liver, Renal cortical scans, I-131 whole body scans, etc.  Routine dynamic imaging performed include Renal Dynamic study,

Hepato-biliary, GI bleeding study, 3-phase skeletal imaging, etc. SPECT/CT studies of the skeletal system and thyroid cancers are also being performed regularly. Occasionally more sophisticated studies like Parathyroid Imaging, DRCG are also being carried out.

Iodine I-131 Uptake

Thyroidal Iodine -131 uptake studies for various diseases of the thyroid gland are being performed regularly.

Radionuclide Therapy

• Low dose I-131 therapy for Thyrotoxicosis (up to 30 mCi of I-131)  (on OPD basis) is being carried out regularly for Graves' disease, toxic nodule and toxic multinodular goiter.

• High Dose I-131 therapy for Thyroid Cancer patients is also being carried out regularly on in-patient basis for differentiated thyroid cancers.

SCANS AND THERAPIES PERFORMED IN NUCLEAR MEDICINE DEPARTMENT IN CMC

A. SCANS

1. DTPA scan: Functional assessment of kidneys and quantify renal function before and after surgical intervention of kidneys. It is routinely performed for donor and recipient evaluation during renal transplant surgeries. 

2. DTPA GFR scan: To find GFR of individual kidneys

3. Thyroid scans: To evaluate functional status of thyroid tissue and differential diagnosis of thyrotoxicosis

4. Whole body iodine scans: For differentiated thyroid cancers before and after treatments

5. DMSA scan: To evaluate cortical scars/pyelonephritic changes in recurrent UTI/VUR cases

6. Whole body bone scan: To assess bony metastases in different cancers and staging of the cancer

7. Three phase bone scan: To differentiate osteomyelitis versus cellulitis/ rule out osteomyelitis

8. Parathyroid scan: For pre-operative localization of parathyroid adenomas/ carcinoma

9. Meckel's scan: For diagnosis of meckel's diverticulum

10. GI bleed scan: To localize the site of bleeding and to find out if active bleeding is present

11. Gastroesophageal reflux scan: For evaluation of gastroesophageal reflux

12. DRCG scan:  For evaluating/diagnosing of VUR

13. Salivary scintigraphy: To assess functions of salivary glands specially after radiotherapy treatment for cancer

14. HIDA scan for assessment of biliary leaks, biliary stent patency, EHBA, gall bladder ejection fraction, sphincter of Oddi dysfunction

15. MUGA scan for assessment of cardiotoxicities of non-cardiac medications like cardiotoxic cancer chemotherapies and evaluation of DCM patients. 

B. THERAPIES

1. Graves' disease/Hyperthyroidism 

2. Toxic nodule 

3. Toxic MNG

4. Differentiated thyroid cancers

a. papillary thyroid cancer 

b. follicular thyroid cancer

 

Dr Jiwan Paudel

Consultant Sr. Lecturer

Mr Prabhat

Lecturer

Remix Maharjan

Imaging Technologist

Publications

Ongoing Research

  1. To evaluate the success rate of a single dose RAI in Graves’ disease and assess the factors determining the success rate.
  2. To standardize the normal uptake values of pertechnetate in Nepalese population. 
  3. Assessment of the safety of low dose radioiodine in Graves disease in Nepalese population.
  4. Assessment of the safety of high dose radioiodine in differentiated thyroid cancer in Nepalese population

Future Plan

• IMMEDIATE PLAN

Expand Nuclear medicine to include Nuclear Cardiology procedures.

• FUTURE PLAN

To start PET/CT with cyclotron facilities

• LONG TERM PLAN

1. Starting MSc Nuclear Medicine course for Nuclear Medicine technologists

2. Starting MD Nuclear Medicine course