Technetium (99mTc) sestamibi

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Technetium (99mTc) sestamibi (INN) (commonly sestamibi; USP: technetium Tc 99m sestamibi; trade name Cardiolite) is a pharmaceutical agent used in nuclear medicine imaging. The drug is a coordination complex consisting of the radioisotope technetium-99m bound to six (sesta=6) methoxyisobutylisonitrile (MIBI) ligands. The anion is not defined. The generic drug became available late September 2008. A scan of a patient using MIBI is commonly known as a "MIBI scan."

Sestamibi is mainly used to image the myocardium (heart muscle). It is also used in the work-up of primary hyperparathyroidism to identify parathyroid adenomas, for radioguided surgery of the parathyroid and in the work-up of possible breast cancer.

Technetium (99mTc) sestamibi
Tc CNCH2CMe2(OMe) 6Cation.png
Clinical data
Trade names Cardiolite
License data
Pregnancy
category
  • US: C (Risk not ruled out)
Routes of
administration
Intravenous
ATC code
Legal status
Legal status
Pharmacokinetic data
Bioavailability NA
Protein binding 1%
Metabolism Nil
Biological half-life Variable
Excretion Fecal (33%) and renal (27%)
Identifiers
CAS Number
PubChem CID
Chemical and physical data
Formula C36H66N6O6Tc
Molar mass 777.852 g/mol
  (verify)

Cardiac imaging (MIBI scan)

A MIBI scan or sestamibi scan is now a common method of cardiac imaging. Technetium (99mTc) sestamibi is a lipophilic cation which, when injected intravenously into a patient, distributes in the myocardium proportionally to the myocardial blood flow. Single photon emission computed tomography (SPECT) imaging of the heart is performed using a gamma camera to detect the gamma rays emitted by the technetium-99m as it decays. Two sets of images are acquired. For one set, 99mTc MIBI is injected while the patient is at rest and then the myocardium is imaged. In the second set, the patient is stressed either by exercising on a treadmill or pharmacologically. The drug is injected at peak stress and then imaging is performed. The resulting two sets of images are compared with each other to distinguish ischemic from infarcted areas of the myocardium. This imaging technique has a sensitivity of around 90%.[1] Resting images are useful only for detecting tissue damage, while stress images provide evidence of coronary artery (ischemia) disease.[2][3] Consequently, comparing these two images has led to many errors in disease detection and to results which fail to match results seen when the arteries of the heart are looked at using coronary angiography. Recent (2003-2014) studies taking 10 years to complete have demonstrated (infra) that comparing stress-stress images can accurately detect ischemia while rest-rest images can accurately differentiate between dead (infarcted) heart (myocardium) tissue and stunned or hibernating myocardium.

Sestamibi was previously thought to not redistribute because earlier studies looked at individuals with no ischemia.[4] The Fleming-Harrington Redistribution Wash-in Washout (FHRWW) or redistribution rate for such individuals without heart disease was approximately 15–20%, with half of this (10%) the result of technetium-99m decay over 55 minutes. It is now known that sestamibi redistributes more under conditions of ischemia with the most critical disease only detectable by "wash-in" where the Black Hole effect of cardiology is detected by a delay in uptake by the tracer (both sestamibi and myoview) during the first few minutes. Failure to image the heart at 5 minutes after stress leads to these individuals being missed. Specifically, the count activity increases at 60 minutes compared with 5-minute images when critical narrowing of coronary arteries is present.[4]

With dipyridamole (Persantine MIBI scan)

When combined with the drug dipyridamole, a brand name of which is Persantine, a MIBI scan is often referred to as a Persantine MIBI scan.

Parathyroid imaging

In primary hyperparathyroidism, one or more of the four parathyroid glands either develops a benign tumor called an adenoma or undergoes hyperplasia as a result of homeostatic dysregulation. The parathyroid gland takes up 99mTc MIBI following an intravenous injection, and the patient's neck is imaged with a gamma camera to show the location of all glands. A second image is obtained after a washout time (approximately 2 hours), and mitochondria in the oxyphil cells of the abnormal glands retaining the 99mTc are seen with the gamma camera. This imaging method will detect 75 to 90 percent of abnormal parathyroid glands in primary hyperparathyroidism. An endocrine surgeon can then perform a focused parathyroidectomy (less invasive than traditional surgery) to remove the abnormal gland.

Radioguided surgery of the parathyroids

Following administration, 99mTc MIBI collects in overactive parathyroid glands. During surgery, the surgeon can use a probe sensitive to gamma rays to locate the overactive parathyroid before removing it.[5]

Breast imaging

The drug is also used in the evaluation of breast nodules. Malignant breast tissues concentrate 99mTc MIBI to a much greater extent and more frequently than benign disease. As such, limited characterization of breast anomalies is possible. Scintimammography has a high sensitivity and specificity for breast cancer, both more than 85%.[6]

More recently, breast radiologists administer lower doses of 99mTc sestamibi (approximately 150–300 MBq or 4–8 mCi) for Molecular Breast Imaging (MBI) scans which results in a high sensitivity (91%) and high specificity (93%) for breast cancer detection.[7] It however carries a greater risk of causing cancer making it not appropriate for general breast cancer screening in patients.[8]

The last reference listed is in reference to a 740-megabecquerel (20-millicurie) dose, which is given with the Dilon single-head system, which requires a higher dose since only one camera is utilized (meaning the camera needs to be able to see through more tissue). A 150–300 MBq (4–8 mCi) dose, which is used in the other two commercially available MBI systems is essentially equivalent to a mammogram (150 MBq or 4 mCi) or a tomosynthesis exam (300 MBq or 8 mCi).[9]

Since even small doses of ionizing radiation are believed to carry some risk of causing cancer, MBI is usually limited to women with dense breast tissue, which often results in inconclusive mammograms. Researchers continue to devote their time to improving the technology, changing scan parameters, and reducing dose to patients."[10]

References

  1. ^ Underwood, S. R.; Anagnostopoulos, C.; Cerqueira, M.; Ell, P. J.; Flint, E. J.; Harbinson, M.; Kelion, A. D.; Al-Mohammad, A.; Prvulovich, E. M.; Shaw, L. J.; Tweddel, A. C. (1 February 2004). "Myocardial perfusion scintigraphy: the evidence". European Journal of Nuclear Medicine and Molecular Imaging. 31 (2): 261–291. doi:10.1007/s00259-003-1344-5. PMC 2562441Freely accessible.
  2. ^ GORLIN, R; BRACHFELD, N; MACLEOD, C; BOPP, P (May 1959). "Effect of nitroglycerin on the coronary circulation in patients with coronary artery disease or increased left ventricular work". Circulation. 19 (5): 705–18. doi:10.1161/01.CIR.19.5.705. PMID 13652363.
  3. ^ Ignatavicius, Donna D.; Workman, M. Linda (2015). Medical-surgical Nursing: Patient-centered Collaborative Care. 646: Elsevier Health Sciences. ISBN 9781455772551.
  4. ^ a b Fleming, Richard M, ed. (2011). "Fleming-Harrington Redistribution Wash-in Washout (FHRWW): The Platinum Standard for Nuclear Cardiology". Establishing better standards of care in Doppler echocardiography, computed tomography and nuclear cardiology. Rijeka, Croatia: InTech. doi:10.5772/22369. ISBN 978-953-307-366-8.
  5. ^ Untch, B. R.; Barfield, M. E.; Bason, J.; Olson Jr, J. A. (2007). "Minimally Invasive Radio-guided Surgery for Primary Hyperparathyroidism". Annals of Surgical Oncology. 14 (12): 3401–3402. doi:10.1245/s10434-007-9519-0. PMID 17899291.
  6. ^ Liberman, Moishe; Sampalis, Fotini; Mulder, David S.; Sampalis, John S. (July 2003). "Breast Cancer Diagnosis by Scintimammography: A Meta-analysis and Review of the Literature". Breast Cancer Research and Treatment. 80 (1): 115–126. doi:10.1023/A:1024417331304. PMID 12889605.
  7. ^ Rhodes DJ, Hruska CB, Phillips SW, Whaley DH, O'Connor MK (January 2011). "Dedicated dual-head gamma imaging for breast cancer screening in women with mammographically dense breasts". Radiology. 258 (1): 106–18. doi:10.1148/radiol.10100625. PMID 21045179.
  8. ^ Moadel, RM (May 2011). "Breast cancer imaging devices". Seminars in nuclear medicine. 41 (3): 229–41. doi:10.1053/j.semnuclmed.2010.12.005. PMID 21440698.
  9. ^ O'Connor MK, Li H, Rhodes DJ, Hruska CB, Clancy CB, Vetter RJ (December 2010). "Comparison of radiation exposure and associated radiation-induced cancer risks from mammography and molecular imaging of the breast". Medical Physics. 37 (12): 6187–98. doi:10.1118/1.3512759. PMC 2997811Freely accessible. PMID 21302775.
  10. ^ "Development of radiation dose reduction techniques for cadmium zinc telluride detectors in molecular breast imaging". Proc SPIE. Retrieved 10 December 2013.

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