INDICATIONS FOR ORDERING NUCLEAR MEDICINE STUDIES



Standard Operating Procedures for NUCLEAR MEDICINE STUDIES

1. Bone Scan:

( Order the following as: 78315 – 3 Phase Bone scan with option to do 78320 - Tomographic SPECT) RADO255 with RAD025

A. Procedure for evaluating bone disorders including:

• Skeletal Pain (bone or joint pain) / Fracture (For skeletal injuries/fractures it is preferable to image 48 hours or more after the injury)

• Inflammatory / Septic Arthritis

• Cellulitis / Osteomyelitis

• Renal Osteodystrophy

• Avascular Necrosis / Aseptic Necrosis

• Skeletal Lesions / Primary Bone Tumors

• Prosthetic Infection or Loosening or Painful Prosthesis

• Arthritis / Heterotopic Ossification

• Reflex Sympathetic Dystrophy

-- 3 Phase Bone scan includes imaging Single or Multiple regions or as a Whole Body exam.

-- Three Phase Bone Scans are done on most pediatric patients.

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

B. Skeletal Metasases: (78306 -Whole Body Bone) RAD0259

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

2. Bone Marrow Scan: (78104 – Whole Body) RADO252

Procedure for evaluation of regional bone marrow abnormalities.

• Diagnosis of osteomyelitis in conjunction with an 111In WBC scan.

• Diagnosis of prosthetic infection versus normal marrow accumulation at site of

prosthetic.

• Avascular Necrosis / Bone Infarction

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

3. Brain Tumor Imaging: (78607 – Tomographic SPECT) RAD0267

• Screening of patients suspected of having primary and/or metastatic brain tumors

• To determine the viable tumor burden in patients with known gliomas.

-- Baseline tumor burden prior to therapy

-- Follow residual tumor burden following treatment

-- Evaluation of patients suspected of having tumor versus infection (gallium utilized)

4. Cardiac Shunt Study: Right to Left (78428 – Cardiac Shunt Detection) RAD0271

• Detection, evaluation and quantitation of intra-cardiac shunts

• Follow-up from surgery for correction of intracardiac shunts

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

5. Gallium Inflamation and Infection Scan:

(Order the following as: 78806 – Whole Body) RAD0243

• To localize source of fever in patients with fever of unknown origin (FUO) or elevated WBC count.

• Diagnosis and follow-up of retroperitoneal fibrosis

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

(Order the following as: 78807—Tomographic SPECT RAD0338

• Detection of pulmonary and mediastinal inflammation/infection, especially in the immunocompromised patient.

• Evaluation and follow-up of active lymphocytic or granulomatous inflammatory processes, such as sarcoidosis or tuberculosis.

• Diagnosing osteomyelitis and/or disk space infection. (67 Ga is preferred over labeled leukocytes for disk space infection and vertebral osteomyelitis, and orthopedic hardware).

• Evaluation and follow-up of drug-induced pulmonary toxicity (e.g., bleomycin, amiodarone).

• Follow-up post surgery / transplant for infection / osteomyelitis.

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

6. Gallium Tumor Scan: (78804 – Whole Body Mult. Days with 778803-Tomographic SPECT) RAD0395 with RAD0445

• Lymphoma

-- Hodgin's Disease (HDL) Sarcoma

-- Non Hodgkin's Lymphoma (NHL) Testicular Tumors

-- Lung cancer Head and Neck Tumors

-- Melanoma Multiple Myeloma

-- Hepatocellular carcinoma Neuroblastoma

• Recurrence, Restaging, Management, and outcome of both HD and NHL

• Differentiation of brain tumor from infection

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

7. Gastric Empty Study: (78264 – Gastric Emptying Study) RAD0263

• Determination of possible delayed gastric emptying and quantitation of gastric emptying rate in patients with suspected gastroparesis of other motility problems.

• Evaluation of response to therapy in those patients who have proven delayed gastric

emptying.

• Evaluation of gastric motility in post-operative or post-radiotherapy patients.

• Evaluation of gastric outlet obstruction

8. Hepatobiliary (HIDA) Scan: (78223 – Hepatobiliary Ductal System Imaging w or w/o Pharm. Intervnt.) RAD0299

• Functional assessment of the hepatobiliary system / Or asses the integrity of the hepatobiliary tree.

These broad categories include:

-- Suspected acute cholecystitis -- Evaluate for choledochal cyst

-- Suspected chronic biliary tract disorders -- Jaundice

-- Common bile duct obstruction / Extravasation / Leak -- Gallstone/lithotripsy patients

-- Evaluation of congenital abnormalities of the biliary tree -- Evaluation of right upper quadrant pain

-- Evaluation of route of biliary drainage in post-op biliary diversion -- Evaluation of biliary atresia vs. neonatal hepatitis

9. Liver and Spleen Scan: (78205 – Liver Imaging SPECT) RAD0324

• This study can be used for determining the size and shape of the liver and spleen.

• For suspected focal nodular hyperplasia of the liver. These lesions often have normal or

increased uptake on sulfur colloid imaging.

10. Lymphoscintigraphy: Breast and Melanoma:

(78195 -- Lymphatic / Lymph Nodes w/Imaging with option for 77803 --Tomographic SPECT) RAD0330 RAD0445

(38792 – Sentinel Node I.D. w/out Imaging) RAD0330

• Lymphoscintigraphy for Intra-operative Identification of Sentinel Lymph Nodes in conjunction with Breast Carcinoma and Malignant Melanoma with the aid of the intra-operative gamma probe.

• Visualization of lymphatic drainage and assisting in imaging Sentinel Lymph Node position(s) prior to surgery.

• Malignant melanomas may be performed with SPECT imaging to assist in localization.

• Lymphatic Transport Mapping (Used to plan patient’s therapy) / Lymphedema evaluation

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

11. Mammoscintigraphy: (78800 – Localization of Tumor, Limited Area) RAD0394

• Evaluate breast cancer in patients in whom mammography is nondiagnostic, equivocal, or difficult to interpret:

-- Presence of scar tissue -- Implants

-- Dense breast tissue -- Severe dysplastic disease

• Assist in identifying multicentric and multifocal carcinomas in patients with tissue

diagnosis of breast cancer.

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

12. Meckles Diverticulum: (78261 – Gastric Mucosa Imaging) RAD0331

• The indication for a Meckel’s scintiscan is to localize ctopic gastric mucosa in a Meckel’s diverticulum as

the source of unexplained gastrointestinal bleeding. Bleeding Meckel’s diverticula usually occur in

young children. The Meckel’s scintiscan should be used when the patient is not actively bleeding.

13. Myocardial Perfusion Scan: Adensosine/Lexiscan (78452 – Myocard. Perfusion Imaging, SPECT – Multiple) RAD0335

• For the detection of coronary artery disease (CAD) and assessing prognosis in patients with symptoms suggestive of CAD.

• For risk stratification of post myocardial infarction patients and in patients with unstable angina or chronic CAD.

• For cardiac risk stratification prior to non-cardiac surgery in patients with known CAD or those with risk factors for CAD.

• For the evaluation of the efficacy of therapeutic interventions in patients with known CAD

• Risk stratification of clinically stable patients into low and high-risk groups very early after acute myocardial infarction (>1 day) or early after angioplasty or stenting (less than 2 weeks).

• Inability to perform adequate exercise.

-- Degenerative joint disease (DJD) -- Obesity

-- Arthritis -- SOB

-- Gait Disturbance -- Vertigo

-- Peripheral Vascular Disease (PVD) -- Weakness

-- Advanced age -- Stroke

• Patients with Left Bundle Branch Block (LBBB), or Pacemaker.

• Concomitant treatment with medications which blunt the heart rate response (beta blockers, calcium channel blockers).

14. Myocardial Perfusion Scan: Exercise (78452 – Myocard. Perfusion Imaging, SPECT – Multiple) RAD0335

• To evaluate the functional capacity of selected patients with valvular heart disease

• To evaluate the blood pressure response of patients being treated for systemic arterial hypertension who wish to engage in vigorous dynamic or static exercise

• To evaluate asymptomatic males over the age of 40 with two or more risk factors for CAD

• To evaluate sedentary male patients >40 years who plan to enter a vigorous exercise program

• To evaluate stress induced cardiac arrhythmia

15. Myocardial Infarct Study w/PYP: (78469 – Myoc. Imaging, Infact Tomographic SPECT) RAD0295

• Detection of Acute Myocardial Infarction

• Patients with pre-existing ECG abnormalities

• Patients with atypical symptoms

• Patients who are post-op open heart surgery

Note: Myocardial scanning is not indicated in evaluating a patient with a typical MI.

16. Neuroendocrine Tumor Imaging: (78804 – Whole Body Mult. Days with 778803-Tomographic SPECT) RAD0395 with RAD0445

• Detecting primary and metastic pheochromocytoma in adults.

• Improving the diagnosis of neuroblastomas in pediatric patients.

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

17. Octreoscan: (78804 – Whole Body Mult. Days with 778803-Tomographic SPECT) RAD0395 with RAD0445

A. Detection and localization of a variety of suspected neuroendocrine and some non-neuroendocrine

tumors and their metastases

B. Staging patients with neuroendocrine tumors.

C. Determination of somatostatin-receptor status (patients with somatostatin receptor-positive tumors

may be more likely to respond to octreotide therapy).

D. Follow-up of patients with known disease to evaluate potential recurrence.

E. Staging patients with Neuroendocrine tumors.

• Adrenal medullary tumors ( pheochromocytoma, neuroblastoma, ganglioneuroma)

• GEP (gastroenteropancreatic) tumors, e.g., gastrinoma, insulinoma, glucagonoma,

VIPoma (vasoactive intestinal polypeptide secreting tumor) and non-functioning GEP tumors

• Carcinoid tumors (The following is a partial list as other entities may also demonstrate somatostatin positive receptor uptake.)

-- merkel Cell tumor of the skin -- Paraganglioma

-- Small-Cell Lung Carcinoma -- Benign and malignant bone tumors

-- Lymphoma (Hodgkin’s and non-Hodgkin’s -- Differentiated thyroid carcinoma (Papillary, follicular, Hürthle cell)

-- Medullary Thyroid Carcinoma -- Melanoma

-- Pituitary Adenomas -- Astrocytomas / Meningioma

-- Breast Carcinoma -- Non-small cell lung carcinoma

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

18. Parathyroid Imaging: (78070 – Parathyroid Imaging) RAD0342

Parathyroid Planar w SPECT w CT: (78072) RAD1660

• To localize hyperfunctioning parathyroid tissue in primary hyperparathyroidism in patients with newly diagnosed hypercalcemia

and elevated PTH levels.

• To localize hyperfunctioning parathyroid tissue (usually adenomas) in patients

with persistent or recurrent disease.

• To provide localization information prior to parathyroid surgery.

19. Pulmonary Aspiration: Pediatric and Adult (78262 – Gastroesophageal Reflux Study) RAD0285

• Suspected aspiration into the lungs due to gastroesophageal reflux.

Pulmonary Aspiration with Gastric Empty Study (78264 – G. E. Study & 78262 – Reflux Study) RAD0263 and RAD0285

• Suspected aspiration into the lungs due to gastroesophageal reflux.

• Determination of possible delayed gastric emptying and quantitation of gastric emptying rate in patients with suspected gastroparesis of other motility problems.

-- Diabetics -- Peptic Ulceration

-- Cancer of the Stomach -- Tauma

• Evaluation of response to therapy in those patients who have proven delayed gastric

emptying.

• Evaluation of gastric motility in post-operative or post-radiotherapy patients.

• Evaluation of gastric outlet obstruction

20. Renal Hypertension Study with Captopril: Pediatric and Adult

(78708 – Kidney Imaging w/ Vascular Flow and Function, single study with

Pharmacologic intervention) RAD0414

• Renovascular hypertension caused by renal hypoperfusion from stenosis.

• Renal artery thrombosis in infants / Coarctation of the aorta in infants.

• Abrupt or severe hypertension / Hypertension resistant to 3-drug therapy

• Bruits in the abdomen or flank

• Recurrent pulmonary edema in an elderly hypertensive patient

• Worsening renal function during therapy with angiotensin-converting enzyme inhibitors.

• Grade 3 or 4 hypertensive retinopathy / Unexplained azotemia

• Onset of hypertension under age 30 years or over 55 years.

• Hypertension in children / Hypertension in infants with an umbilical artery catheter.

21. Renal With or Without Lasix: Pediatric and Adult

(78709 – Kidney imaging with vascular flow and function, multiple studies

With and without pharmacological intervention) RAD0319

• To differentiate a true obstruction from a dilated nonobstructed system (stasis)

• Ureteropelvic or ureterovesical obstruction as a cause of hydronephrosis

• Post-surgical evaluation of a previously obstructed system

• Distension of pelvicalyceal system as an etiology of back pain

• Assess vascular compromise

• Assess differential function

22. Renal / DMSA: (78710 – Tomographic SPECT) RAD0411

• Acute pyelonephritis / Renal Scarring

• Evaluate function of renal mass

• Solitary or ectopic renal tissue (e.g., pelvic kidney)

• Horseshoe and pseudohorseshoe kidneys

23. Renal Transplant Study:

(78709 – Kidney imaging with vascular flow and function, multiple studies

With and without pharmacological intervention) RAD0319

• To visualize and evaluate renal artery flow (perfusion) and excretion

• To aid in the diagnosis of rejection and/or leak

24. Thyroid Scan and Uptake: (78007 – Thyroid imaging, w/ uptake; multiple determinations) RAD0435

• Evaluate for Hyperthyroidism or Hypothyroidism

• Evaluate function of a thyroid nodule

• Document the existence , the size and location of the thyroid gland or location of ectopic thyroid tissue.

• Demonstrate heterogeneity of function within a hyperthyroid gland (Toxic Nodular Goiter)

• Post-operative evaluation of the thyroid gland

25. Voiding Cysternogram: (78470 & 78730 – Ureteral reflux study, with bladder residual study) RAD0457 and RAD0448

• Initial evaluation of females with urinary tract infection for reflux

• Diagnosis of familial reflux

• Evaluation of vesicoureteral reflux after medical management or assessment of the results of antireflux surgery

• Serial evaluation of bladder dysfunction (e.g., neurogenic bladder) for reflux

26. White Blood Cell Study: (78806 – Whole Body, with option to do 78807 – Tomographic SPECT) RAD0243 with RAD0338

• To evaluate febrile postoperative patient without localizing signs or symptoms. Fluid collections, ileus, bowel gas, fluid, and/or healing wounds may reduce the specificity of CT and ultrasound to detect site(s) and extent of inflammatory bowel disease. 99mTc-labeled leukocytes may be preferable for this indication.

• To detect acute osteomyelitis (less than one week duration) in conjunction with bone imaging. Gallium imaging is preferred performed in conjunction with bone imaging for chronic infection greater than one week, in the presence of prior surgery or hardware, spine or disc infections and in diabetic patients when degenerative or traumatic changes, neuropathic osteoarthropathy, or prior osteomyelitis have caused increased bone remodeling.

• To detect mycotic aneurysms, vascular graft infections, and shunt infections.

-- We may perform SPECT, or SPECT/CT for the following indications without additional authorization if warranted:

• Attenuation Correction

• Improved Specificity and Sensitivity

• Improved localization

• Better definition for surgical approach

• Improved correlation with other anatomic imaging and fusion

Note: The 99mTc Ceretec WBC study is performed instead of the 111In WBC study when acute appendicitis is suspected, a STAT study is needed, in pediatric population or

if 111Indium is not available.

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