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99mTc Sealed Sources for Localization in Biopsy Needles and Catheters, Lecture notes of Nuclear medicine

The construction and use of sealed 99mtc sources inserted into standard biopsy needles and catheters for anatomic localization by external radionuclide imaging. The technique facilitates proper placement and confirmation of position or direction of biopsy needles and catheters, especially for small targets deep in the body.

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FIG. 1. @mTc.filledprobeswere preparedfrom commonly
available needles and catheters. Variety of filling patterns are dem
onstrated.
For the purpose of anatomic localization, a
variety of sealed sources containing o9mTc were
constructed. These sources, when inserted into
biopsy needles and imaged with a portable scm
tillation camera, served to direct the proper
placement of those needles. Concomitant organ
imaging was used to identify the target site for
biopsy. indwelling CVP and Swan-Canz cathe
ters filled with sterile sodium pertechnetate were
localized against the mediastinal silhouette pro
vided by a flooded field transmission source
placed behind the patient. Larger diameter
catheters containing sealed sources within their
lumens were similarly imaged. These techniques
have proven to be clinically useful.
Successful percutaneous biopsy depends on a cli
nician's ability to direct a biopsy needle to its target.
Biopsy should be easy to perform provided the tar
get is large and its location certain. However, percu
taneous biopsy of a large organ, such as the liver,
is sometimes unsuccessful. Small targets deep in the
body present an even more difficult task. In addition
to the clinician's knowledge of anatomy and his abil
ity to palpate and percuss, several adjunctive meth
ods are available to guide him during needle biopsy.
These include conventional radiography, single and
biplane fluoroscopy, stereotatic devices, and ultra
sound.
Some clinicians use scintiphotography to localize
organs for subsequent percutaneous biopsy (1). Rou
tine radionuclide organ imaging is performed and
the anatomic location of the “target―organ is out
lined on the skin. The biopsy procedure is then per
formed in some other hospital location.
Similarly, verification of the proper placement of
indwelling catheters is usually accomplished with
conventional radiographs or fluoroscopy. Van Dyke,
Ct al have reported the added utility of a “radioac
tive―catheter in the cardiac catheterization labora
tory in which localization is accomplished by exter
nal imaging with a scintillation camera (2).
This report outlines our experience in constructing
and using sources of 9omTcsealed in short lengths of
sterile polyethylene tubing or standard hypodermic
needles. These are inserted into the lumen of a van
ety of biopsy needles and catheters to facilitate their
placement. Confirmation of proper alignment is by
imaging in the appropriate projections with a scm
tillation camera transported to the location where
the biopsy on catheterization procedure is to be per
formed.
MATERIALS AND METHODS
A variety of 9ftmTcsources have been constructed
and are shown in Fig. 1. In each case up to 1 mCi
Received Mar. 13, 1973; original accepted Apr. 23, 1973.
For reprints contact : Joseph P. Green, Div. of Nuclear
Medicine, Dept. of Radiology, University Hospital, 225 W.
Dickinson St., San Diego, Calif. 92103.
--
Volume 14, Number 10 743
SEALED SOURCES OF 99mTc INSERTED INTO
STANDARD BIOPSY NEEDLES AND CATHETERS:
USE IN ANATOMIC LOCALIZATION BY
EXTERNAL RADIONUCLIDE IMAGING
Joseph P. Green, William 1. Ashburn, Sheldon R. Hurwitz, and Samuel E. Halpern
University of California at San Diego, La Jolla, California
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FIG. 1. @mTc.filledprobeswere preparedfrom commonly available needles and catheters. Variety of filling patterns are dem onstrated.

For the purpose of anatomic localization, a variety of sealed sources containing o9mTc were constructed. These sources, when inserted into biopsy needles and imaged with a portable scm tillation camera, served to direct the proper placement of those needles. Concomitant organ imaging was used to identify the target site for biopsy. indwelling CVP and Swan-Canz cathe ters filled with sterile sodium pertechnetate were localized against the mediastinal silhouette pro vided by a flooded field transmission source placed behind the patient. Larger diameter catheters containing sealed sources within their lumens were similarly imaged. These techniques have proven to be clinically useful.

Successful percutaneous biopsy depends on a cli nician's ability to direct a biopsy needle to its target. Biopsy should be easy to perform provided the tar get is large and its location certain. However, percu taneous biopsy of a large organ, such as the liver, is sometimes unsuccessful. Small targets deep in the body present an even more difficult task. In addition to the clinician's knowledge of anatomy and his abil ity to palpate and percuss, several adjunctive meth ods are available to guide him during needle biopsy.

These include conventional radiography, single and

biplane fluoroscopy, stereotatic devices, and ultra sound. Some clinicians use scintiphotography to localize organs for subsequent percutaneous biopsy (1). Rou tine radionuclide organ imaging is performed and the anatomic location of the “target―organ is out lined on the skin. The biopsy procedure is then per

formed in some other hospital location.

Similarly, verification of the proper placement of

indwelling catheters is usually accomplished with conventional radiographs or fluoroscopy. Van Dyke, Ct al have reported the added utility of a “radioac tive―catheter in the cardiac catheterization labora

tory in which localization is accomplished by exter

nal imaging with a scintillation camera (2).

This report outlines our experience in constructing

and using sources of 9omTcsealed in short lengths of

sterile polyethylene tubing or standard hypodermic

needles. These are inserted into the lumen of a van

ety of biopsy needles and catheters to facilitate their

placement. Confirmation of proper alignment is by

imaging in the appropriate projections with a scm tillation camera transported to the location where the biopsy on catheterization procedure is to be per formed.

MATERIALS AND METHODS

A variety of 9ftmTcsources have been constructed

and are shown in Fig. 1. In each case up to 1 mCi

Received Mar. 13, 1973; original accepted Apr. 23, 1973. For reprints contact : Joseph P. Green, Div. of Nuclear Medicine, Dept. of Radiology, University Hospital, 225 W. Dickinson St., San Diego, Calif. 92103.

--

Volume 14, Number 10 743

SEALED SOURCES OF 99mTc INSERTED INTO

STANDARD BIOPSY NEEDLES AND CATHETERS:

USE IN ANATOMIC LOCALIZATION BY

EXTERNAL RADIONUCLIDE IMAGING

Joseph P. Green, William 1. Ashburn, Sheldon R. Hurwitz, and Samuel E. Halpern

University of California at San Diego, La Jolla, California

GREEN, ASHBURN, HURWITZ, AND HALPERN

of o9mTcas sterile sodium pertechnetate was placed

either into lengths of sterile polyethylene tubing, ap

propniate-sized hypodermic or spinal needles, or

short indwelling plastic catheters. The tips of the

metal needles and short plastic catheters were sealed

with an epoxy glue while the tip of polyethylene tub

ing was sealed by pinching the distal end with a hot

hemostat (3). Polyethylene tubing was filled and

then heat-sealed. A previously sealed needle or cath

eter was filled by inserting a smaller diameter needle

through the hub end to the tip and injecting as the

inner needle was withdrawn. Continuous (linear)

sources were made by filling the entire length with

the radioactive solution, and interrupted (calibrated)

sources were formed by interposing air bubbles at

1-cm intervals during the filling process. The short

plastic catheters and metal needles were autoclaved

before filling, and the entire operation was carried

out under sterile conditions.

The selection of appropriate length and source

arrangement depended on the diameter and length

of the biopsy needle or catheter into which the source

was to be placed as well as the intended purpose, i.e.,

simple confirmation of position or insertion and positioning (re-positioning) under continuous “scm tigraphic― control.

In the case of small-diameter vascular catheters,

such as central venous (CVP) or Swan-Ganz pul

monary arterial catheters, external visualization was

accomplished by filling the entire length of the cath

eter with sterile ODmTc_sodium pertechnetate after

the catheter had been inserted in the conventional

manner. None or very little of the radioactive solu

tion was injected into the patient since only the vol

ume necessary to fill the dead space of the catheter

was used.

Verification of the position of biopsy needles and

catheters was accomplished with a “portable―Anger

Nuclear Data scintillation camera. As previously de

scribed, this device is fitted with oversized wheels to facilitate transportation to any location in the hos pital, e.g., patient's room, intensive care unit, open ating room, etc (4). Before insertion of the biopsy needle or catheter,

an appropriate radiopharmaceutfèal was adminis

tered intravenously to permit visualization of the

desired organ or tissue. Insertion of the biopsy needle

was then performed in the usual manner up to the time when confirmation of position or direction of

the needle was desired. The stylus of the needle was

then withdrawn and replaced with the previously

prepared sterile “°“Tcsealed source, followed by

standard imaging in two or more right angle pro

jections. Technetium-labeled radiopharmaceuticals were selected for organ imaging. The activity of the source was adjusted to facilitate a single image which demonstrates both the position of the needle and the

anatomic features of interest. Similarly, localization

of larger diameter indwelling catheters was accom pushed by inserting the appropriate length sealed source to the full length of the catheter followed by

appropriate imaging.

The location of vascular catheters within the heart

or great vessels was facilitated by placing a trans

F1G.2. Routnebrainscanshows

large occipital lesion on left. Operating room study demonstrates proper position ing of biopsy needle which contains sealed tIomTcsource.

(^744) JOURNAL OF NUCLEAR MEDICINE

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GREEN, ASHBURN, HURWITZ, AND HALPERN

optic bronchoscope has been followed during bron choscopy.

The anatomic localization of any larger diameter

tube or catheter can be determined, provided that a

sealed source can be inserted the length of its lumen.

Concomitant organ imaging and/or the use of a flooded-field transmission source provides additional

anatomic landmarks to help in determining the loca

tion of the radioactive sealed source. Numerous addi

tional possible uses of this technique are suggested,

for example, to follow the movement of a Miller

Abbott or similar indwelling tube from the stomach

into the small bowel.

ACKNOWLEDGMENT This work was supported in part by Grant No. 74- from the American Heart Association.

REFERENCES

1. TULLY Ri, STARKVJ, HOFFERPB, et al: Renal scan prior to renal biopsy—A method of renal localization. I _Nuci Med 13: 544—547,

  1. VAN DYKE D, ANGERH. DUFFIE FiR, et a): Cardiac_ catheterization using a radioactive catheter and the scm tillation camera. Radiology 91: 749—752, 1972 3. NELIS A, EGE G: Simple technique for recording an tenor landmarks on a prone patient in dual-crystal scan ning. I Nuci Med 13: 281, 1972 4. HURWITZ SR. ASHBURNWL, GREENJP, et al: Clini cal applications of a “portable―scintillation camera. I Nuc! _Med 14:585—587, 1973
  2. WEBERPM, nos REMEDIOSLV, JASKOIA: Quantita_ tive radioisotopic angiocardiography. I Nuci Med 13 : 815— 822, 1972

FIG. 5. (A)Anteriorchestimagewith@°mTcflooded-fieldtrans.

mission source behind patient. (B) Composite image with transmis. sion source and linear @@mTcsource in tracheal suction catheter, showing catheter tip to be located in right main stem bronchus.

eter is manipulated into a desired location. Although

routine CVP and Swan-Ganz catheter visualization by scintiphotography would not appear to be a rou

tine procedure, it may prove to be valuable in those

cases where catheter placement is difficult or the final position is uncertain. The movement of tracheal suction catheters has been monitored during tracheal aspiration, an exam ple of which is shown in Fig. 5. Since this is nor

mally a “blind―procedure, it has become a valuable

teaching aid in our experience for the therapist doing

the suctioning to be able to follow the movement

of the catheter as it is manipulated. It is clinically

valuable to assure that both the right and left bronchi are suctioned during tracheal toilet, and it is sur prising how frequently the left main bronchus is never entered. Similarly, the movement of a fiber

First Annual Winter Meeting

January 4—6,1974 Fairmont-Roosevelt^ Hotel^ New Orleans, La.

Announcement

Threedays of teachingsessionsand workshopsare plannedcoveringthe areasof:

Imaging Radioimmunoassay Adminisfration

Attendees will register for the series of workshops in the topic of their choice. Continuing educa tion certificates will be awarded.

For further informationand registrationforms contact:

TECHNOLOGISTSECTION Society of Nuclear Medicine

305 East 45th Street

New York, New York 10017

746 JOURNAL OF NUCLEAR MEDICINE

TECHNOLOGISTSECTION

SOCIETY OF NUCLEAR MEDICINE