Barnard Institute of Radiology & Oncology, Madras Medical College & Government General Hospital,

and Advanced Nuclear Medicine Research Institute, Chennai. E. Mail – dreprabhu@gmail.com

Medical Imaging in Future – Physician’s Perspectives

Dr. E. Prabhu, M.D.(Gen. Medicine), D.R.M., FIMSANuclear Medicine Physician, E.C. member, SNM (India) &

NABH Assessor for Medical Imaging

15th August, 2010

Internal Medicine has always attracted the best students, has prestige, poses intellectual challenge and promises full patient care.

There fore we need periodic up-dates in

Technical advances in genetics and molecular biology

Medical Imaging, Computers and their role in Clinical Decision Making

Political, Economic & Life- style challenges in modern society

Currently, we do not focus only on the causes of our patient’s problems. Instead, we search for modifiable molecular manifestations of the problems in terms of location, structure, function & biochemistry.

K ShellK Shell

L ShellL Shell

M ShellM Shell

DNA Strand

Options in Medical Imaging includes the Digital Radiography, Ultrasound, the Computed Tomography, Optical Imaging, Magnetic Resonance & Functional MR, the SPECT / PET and the PACS for Image Archiving and Communication

Clerca. J et al; Scintigraphic Imaging of Paediatric Thyroid Dysfunction, Horm Res (2008);70:1-13

There are about 20,000 different types of molecules in the body. Either these molecules send wrong messages are don’t receive right messages. Recognition of the molecules is the basic for diseases.

…functions are fast processes of short duration, while structures are slow processes of long duration …

Technological Advances in Medicine for Diagnosis and Treatment are Less Invasive, Precise and

Objective

Modern Medical Imaging helps in Integration and Weighing of Complex Clinical information

This helps us to take Leadership position in Medicine by interpreting bewildering array of information and making wise Clinical decisions

Thyroid Scan & Thyroid SPECT Scan

Parathyroid & Adrenal glands Scan

Spinal Metastasis & Metastatic Disease to the Spine & Related Structures

Approximately 94-98% of these patients present with epidural and/or vertebral involvement. Intradural extramedullary and intramedullary seeding of systemic cancer is unusual; they account for 5-6% and 0.5-1% of spinal metastases, respectively. Patil et al. National inpatient complications and outcomes after surgery for spinal metastasis from 1993-2002. Cancer. Aug 1 2007;110(3):625-30.

99mTc – DTPA 51Cr – EDTA

99mTc – DTPA 51Cr – EDTA

99mTc – MAG3 99mTc – EC131I – OIH

99mTc – MAG3 99mTc – EC131I – OIH

99mTc – DMSA 99mTc – GHA

99mTc – DMSA 99mTc – GHA

Radiopharmaceuticals in Kidney imaging

99mTc-DTPA Dynamic Renal Scan – Left Kidney Outflow Obstruction

11C – Acetate 18F-FDG (Glucose Metabolism)

11C – Acetate 18F-FDG (Glucose Metabolism)

55Co/68Ga – EDTA GFR= 58 – 30ml/min/100g

55Co/68Ga – EDTA GFR= 58 – 30ml/min/100g

15O – H2O Normal 340ml/min/100gC.K.D.

210+110 ml/min/100g

15O – H2O Normal 340ml/min/100gC.K.D.

210+110 ml/min/100g

15C– CO gas (Renal Blood

Volume) Young – 19ml/100g Old – 12

ml/100g

15C– CO gas (Renal Blood

Volume) Young – 19ml/100g Old – 12

ml/100g

11C – Gly-Sar (Drug Metabolism)

11C – Gly-Sar (Drug Metabolism)

11C –Zofenopril Calcium ACE binding

11C –Zofenopril Calcium ACE binding

18F –FHBG18F –FHBG

13N –NH313N –NH3

62Cu– PTSM

62Cu– PTSM

(Renal Blood Flow) 300 –

550 ml/min/100g

(Renal Blood Flow) 300 –

550 ml/min/100g

(Monitoring HSV1-tk reporter gene

therapy)

(Monitoring HSV1-tk reporter gene

therapy)11C(R)–PK1119511C(R)–PK11195

(Ischaemia in RAS, Tumour Hypoxia &

Angiogenesis)

(Ischaemia in RAS, Tumour Hypoxia &

Angiogenesis)

11C(L)–753,03711C(L)–753,037

PET Radiopharmaceuticals in Kidney Imaging

99mTc – MIBI Myocardial Perfusion Study

99mTc – MAA Lung Perfusion Scan – Before & After Treatment

PET imaging of the Immune System in Small animals

99mTc- Sulphur Colloid (Normal & Cirrhosis of Liver)

Women Imaging in Nuclear Medicine

Scintimamography and Hysterosalphingoscintigraphy

18F- FDG

99mTc- ECD, HMPAO

18F Carfentanyl (Opoid receptor)

99mTc - RBCs (Blood Volume)

Cerebral Perfusion SPECT with 99mTc-ECD

Acetylcholinesterase & vesicular acetylcholine transporter radiotracers (+)-4- 18F]fluorobenzyltrozamicol

-Amyloid radiotracers N-11C]methylamino-4’-hydroxy-stilbene

2-fluorine-18 fluorodeoxyglucose (18F)FDG

Muscarinic – cholinergic system 11C] scopalamine, 11C]topanyl benzilate

Apoptosis 99mTc] Annexin 4-18F]fluoro benzyl-annexin V

Nicotinic – cholinergic receptors 18F] fluoroNIDA52189

Brain Serotonin system5-HT1A receptor ligands - agonists 11C] carbonyl-WAY-1006355-HT1A receptor ligands - antagonists 11C] O - methyl-WAY-1006355-HT2A receptor ligands 11C]N-methylspiroperidol (NMSP)

Brain Dopamine system

D1 Striatum to s. nigra N-18F] fluropropyl SCH 24518 D2 Striatum to g. pallidus N-18F]fluroalkylspiropiradol D3 N. Accumbens & islands of Calleja 11C raclopride D4 Several

limbic & cortical regions 11C nafadotride D5 Limbic

areas 11C N-2-4-(4-chlorophenyl)- piperazin-1-yl]ethyl]-3-methoxybenzamide (PB-12)

Hypoxia 18F]fluoromisonidazole, 60/62Cu]ATSM

Metabolic Images of the Brain

In modern medicine, orientation towards organs has become old fashion!

MRI / MRS

PET

ANATOMY, ATROPHY, CONNECTIVITY, DIFFUSION, RELAXOMERTY,MAGNETIZAATION

TRANSFER, PERMEABILITY PERFUSION & BLOOD FLOW

GLUCOSE CONSUMPTION

BLOOD / TISSUE OXYGENATION

CELL LABELLING

NEUROTRANSMITTORS

RECEPTOR DENSITY

METABOLITE CONCENTRATIONTISSUE pH

AMINO / NUCLEIC ACID METABOLISM

Structure + Function

Integration

Then Dawn of Fusion & Multidisciplinary Medical Imaging

PET MRI CT PET-MRI PET-CT PET-CT-MRI

Receptors, enzymes, membrane transporters and Signal transduction proteins in renal diseases, Tissue Hypoxia and Apoptosis in renovascular disease and in obstruction

Endothelial dysfunction and assessment of molecular response to drugs and atherosclerosis; Drug delivery systems based on anion, cation, glucose and peptide transporters

Reporter gene therapy and monitoring rejection, Targeting receptors, oncoproteins, growth factors and cytokines

Anatomical and Functional Renal Images PET+CT+MRI

Current trends in Molecular Imaging

131I Whole Body Scan

124I Whole Body PET Scan

18F - FDG Whole Body PET Scan

Funding in Nuclear Medicine

Political and Economic Challenges of Modern Society

Projected Mid-year Population in 2010

26%

17%

96 %

Population Structure by Age & Sex in 2005

SEA Countries

USAMales Females

Burden of Diseases in the USA and Third World

Countries

Public Health Expenditure in Developed Countries

Public Expenditure on Health in SEA Region

Current Research in Medicine and Medical Imaging

‘....in future, diagnoses will be molecular, treatment will be molecular, and monitoring the response to treatment will be molecular...’ .

1970 2010

Personalized Medicine