Nuclear Oncology

By the end of this web based training, the attendee will be able to:   Describe the disease of cancer and how nuclear oncology imaging aids in diagnosis and treatment of the disease. Describe some of the oncology procedures that are available in general nuclear medicine imaging, such as neuroendocrine, lymphoma, prostate, thyroid cancer and sentinel node imaging. Describe the basics of PET/CT imaging. Describe some of imaging procedures for PET/CT oncology imaging such as lung cancer, melanoma, head and neck, and Sodium Fluoride bone imaging. You have now completed the course Introduction to Nuclear Oncology. You should now be able to: •   Describe the disease of cancer and how nuclear oncology imaging aids in diagnosis and treatment of the disease • Describe some of the oncology procedures that are available in general nuclear medicine imaging, such as neuroendocrine, lymphoma, prostate, thyroid cancer and sentinel node imaging • Describe the basics of PET/CT imaging •   Describe some of the imaging procedures for PET/CT oncology imaging for lung cancer, melanoma, head and neck, and Sodium Fluoride bone imaging Approximately 40% of US population will be diagnosed with cancer in their lifetime   20% will die of the disease   Early detection is critical   Nuclear medicine plays a key role in non-invasive, early detection of disease Data courtesy of Cancer.org Images courtesy of University Hospital Leipzig, Nuclear Medicine, Prof. Dr. O. Sabri Malignant or cancer cells multiply rapidly and use more resources.   Nuclear medicine uses radioactive tracers.   Radioactive tracers are formulated to target certain types of cancer cells PET Imaging Ring detectors LSO, LYSO, GSO, BGO, & Nal crystals Tracers emit two coincident photons per annihilation Patient remains still for the scan while table moves in and out of gantry Both SPECT and PET have versions of hybrid scanners SPECT/CT PET/CT MR/PET   Provides attenuation correction with anatomical and structural information.   Images are fused to aid in diagnosis. Image courtesy of Ludwig-Maximilians-University, Klinikum Grosshadern, Germany Images courtesy of University of Erlangen, Nuclear Medicine, Erlangen, Germany Preparation: No dietary restrictions Discontinue certain medications Lugol’s solution given to block thyroid uptake   Injection of MIBG  I131  MIBG – 72 hour uptake period  I123  MIBG – 24 hour uptake period Used to diagnose neuroendocrine tumors    Pheochromocytomas  Carcinoids  Paraganliumas  Neuroblastomas  Medullary thyroid cancer Uncommon tumors in adults   Neuroblastoma most commonly found in infants and children   131I MIBG and 123I MIBG Whole Body Scan for both I123 and I131 MIBG I123 MIBG – SPECT Scan in addition Used to detect neuroendocrine tumors   Neuroendocrine tumors have high density of somatostatin receptors   Pentetreotide is a somatostatin analog that is labeled with a radioactive tracer Indium 111 Data courtesy: Charite Campus Virchow-Klinikum, Universitätsmedizin Berlin, Geramny, Nuclear Medicine, Prof. Dr. W. Brenner No dietary restrictions   Discontinue octreotide treatment for 3 days prior to Octreotide injection.   Uptake time is 4-6 hours for whole body images   24 hour SPECT images are valuable Image courtesy of SIEMENS Healthcare Hodgkin's Disease  Lymphatic malignancy that starts in the lymph tissue  Reed-Sternberg cells   Non-Hodgkins Lymphoma  Also a lymphatic malignancy that starts in the lymph tissue  Affects T-cells and B-cells  Many different subcategories of the disease Gallium Citrate (Ga67) Highly useful in staging, detecting relapse or monitoring progression therapeutic response in HD and NHL   Gallium67 Citrate   Detects tumor and inflammation   Mimics an iron analog and is transferred by the blood bound to transferrin   Most lymphomas have transferrin receptors that bind gallium 24 hours after blood transfusion   24 hours after gadolinium –enhanced MRI scanning   3-4 weeks after chemotherapy   May be prescribed laxative for bowel clearanceCan eat, drink and take usual medications Patient receives intravenous injection of Gallium Citrate   Images are acquired 2-3 days after injection   Both whole body and SPECT images may be acquired   Delayed images may be necessary in 4-7 days post injection Image courtesy of MD Anderson Cancer Center In111 and Y90 Zevalin Activity in the blood pool areas (heart, abdomen, neck, and extremities) may be faintly visible    Moderately high to high uptake in normal liver and spleen   Moderately low or very low uptake in normal kidneys, urinary bladder, and normal (uninvolved) bowel   Non-fixed areas within the bowel lumen that change position with time; delayed imaging may be necessary to confirm gastrointestinal clearance   Focal fixed areas of uptake in the bowel wall (localization to lymphoid aggregates in bowel wall)   Tumor uptake may be visualized however tumor visualization on the In111 Zevalin scan is not required for Y90 Zevalin therapy Image courtesy of rad.kumc.edu Prostate cancer is the most frequently diagnosed cancer in men in the US. ProstaScint® (Cytogen) is used to determine if curative therapy is an option in men diagnosed with metastatic prostate CA.  Radical prostatectomy  Interstitial Implants  Radiation Therapy Bladder wall Opening of ureters from kidneys Normal prostate Seminal vesicle Urine No specific patient prep before the injection.  Patient may be given a bowel prep and/or catheterization before the imaging   Injection of In111 ProstaScint® (Capromab Pendetide)   Patient returns to the department 96 hours after injection for images   Planar images of the torso and SPECT images of the pelvis are acquired ProstaScint® Case: 53 year old male with a history of prostate CA and a Gleason score of 6. Scan: Increased radiopharmaceutical activity within the apex of the prostate consistent with prostatic carcinoma. Findings: Co registration of the ProstaScint scan with CT scan demonstrates a lesion located within the left apex and extending into the mid-prostate and base.           Siemens has a collaboration agreement with Cytogen & UHC regarding prostate cancer imaging & therapy.   Patients with papillary or follicular thyroid carcinoma have a 80-95% survival rate   Primary treatment is a thyroidectomy   The post surgical scan is used to determine of the radioiodine therapy is appropriate   Remnant thyroid and ablation dose   Thyroid cancer metastases Low iodine diet 1-2 weeks prior   No food 4 hours prior to administration of dose   No IV contrast studies performed 4-6 weeks prior to administration   Discontinue mineral supplements with iodine   Laxatives may be given before the scan to minimize bowel activity I131 Scan Patient swallows capsule and returns to the department 48-72 hours later for uptake measurement and whole body scan. I123 Scan Patient swallows capsule and returns to the department 24 hours later for uptake measurement and whole body scan. Image courtesy of University Hospital of Regensburg, Germany Image courtesy of SIEMENS Healthcare Breast and melanoma Ca metastasize to regional lymph nodes first.   Mapping lymphatic drainage improves staging in early cancer patients   SLN biopsy indicated in patients at risk for node metastasis   Early stage   No clinically evident metastatic disease Tc99m HSA   Tc99m  Dextran   Tc99m DTPA   Tc99m Ultrafilterd Sulfur Colloid (most commonly used in the United States)   Recommended to be filtered through a 0.22 micron millipore filter   Tilmanocept (Lymphoseek®) Millipore Filter Injection site prepared and draped to limit contamination Melanoma Patients Injections are divided into 4 to 6 doses Intradermal injections are given to create a wheal Injected within 1 cm of lesion or scar Breast Cancer Patients Injection types: Intradermal Subdermal Subcutaneous Peritumoral (performed using US) Periareolar Subarolar Imaging starts immediately after injection Recommended: Dynamic imaging: 30 frames for 30 seconds/frame Monitor closely for appearance of SLN When SLN is seen, image for longer time frame up to 30 mins Images courtesy of University Hospitals for Cleveland, Case Western Reserve. Images courtesy of University Hospitals for Cleveland, Case Western Reserve. Images courtesy of University Hospitals for Cleveland, Case Western Reserve. The radioactive tracer most widely used in PET is *FDG (Fluorine 18 fluorodeoxyglucose)   Produced from *18F (Fluorine) which is generated from a cyclotron.   Half life is 110 minutes at 511 keV   Used as a tracer of glucose metabolism Image courtesy of University Hospital of Essen, Nuclear Medicine and Radiology, Germany *For indications & important safety information, see slides 81-83 at the end of this course.  Image courtesy: Institute de Medecine Nucleaire, Clinique Generale-Beaulieu, Geneva, Switzerland, Prof. Dr. D. Slosman Lung cancer attributes to more cancer deaths in US and western countries than any other cancer   Cigarette smoking is responsible for 90% of lung cancers   Often presents as a solitary pulmonary nodule (SPN) seen on a chest x-ray   1/3 of SPNs are malignant in patients >35 yrs old The radioactive tracer most widely used in PET oncology imaging is *FDG (Fluorine 18 fluorodeoxyglucose)   Produced from *18F (Fluorine) which is generated from a cyclotron   Half life is 110 minutes at 511 keV   Used as a tracer of glucose metabolism *For indications and important safety information, see slides 81-83 at the end of this course. Hydrated   No food 4-12 hours prior to injection   Avoid foods and beverages containing sugar for 12 hours prior to injection   Blood glucose level optimal at <150 mg/dl but should be below 200 mg/dl before injection Blood glucose levels checked and patient weight taken   Injection of *FDG   Uptake period of 45-90 minutes   Patient scanned whole body   Total time approximately 1.5 to 2 hours *For indications and important safety information, see slides 81-83 at the end of this course. Image courtesy of Vienna, General Hospital, Nuclear Medicine, Vienna, Austria Complicated anatomical situation   In US and western countries, oral cancer accounts for 2-5% of all cancers.   Occurs twice as often in males as females   75% of head and neck cancers are attributed to smoking and smokeless tobacco   Heavy alcohol consumption is another risk factor   Other risk factors are viral infections, poor nutrition, UV exposure and certain occupational exposures Data & image courtesy: University of Erlangen, Nuclear Medicine, Erlangen, Germany, Prof. Dr. T. Kuwert Hydrated   No food 4-12 hours prior to injection   Blood glucose level is optimal at <150 mg/dl   Uptake period should be 45 – 90 minutes post injection   Patient should lie in quiet, dimly lit room for 45 minutes   The scan is usually 1-2 bed positions at approximately 5 to 10 minutes per bed Image courtesy of SIEMENS Healthcare *For indications and important safety information, see slides 84-86 at the end of this course. Approved by FDA in 1972  to evaluate osteogenic changes. Indications include: Primary bone disease Metastatic bone disease Prior to therapy In response to therapy *For indications and important safety information, see slides 84-86 at the end of this course. Image courtesy of SIEMENS Healthcare Cancer spread Passive transport Extend from soft tissue to bone Intramedullary Lesions  90% of Bone Metastases  Active Red Marrow  Axial Skeleton of Adult (blue) Lesions grown in marrow Normal Bone Osteoclastic- resorptive Osteoblastic - productive Axial Skeleton (blue) Appendicular Skeleton (pink) Well hydrated and void immediately before scanning No NPO Usual medications Usual precaution for pregnant patients Breastfeeding precautions as of *FDG Diuretics or bladder catherization *For indications and important safety information, see slides 84-86 at the end of this course. Acquisition Parameter Suggestions – CT Diagnostic CT recommended AC CT:  30 mAs or lower Acquisition Parameter Suggestions for PET 2-5 mins/bed 3D acquisition recommended Matrix size: 168 or 256 *For indications and important safety information, see slides 84-86 at the end of this course. *Sodium Fluoride Bone Study Patient information: 78-year-old male patient (73 kg) with bladder carcinoma and unknown bone metastases. Clinical finding: PETCT shows no bone metastases. All increased uptake areas, seen in the spine and pelvis, are due to degeneration. Scan protocol: CT: Low-dose CT for attenuation correction & anatomical localization. PET: 200MBq *F-18 NaF (2.7 MBq/kg), 30 min p. i., 2 min/bed, TrueV, HD•PET. Data courtesy of Diagnostisch Therapeutisches Zentrum AM Franfurter Tor, Berlin, Germany *For indications and important safety information, see slides 84-86 at the end of this course. *FDG *F18 NaF Image courtesy of SIEMENS Healthcare *For indications and important safety information, see slides 84-86 at the end of this course. First approved as radiolabeled monoclonal antibody therapy agent for Non-Hodgkin Lymphoma In111 Zevalin Imaging Used for initial biodistribution imaging Y90  Zevalin Therapy Pure beta emitter used for therapy Radiation dose is strong enough to kill targeted cells as well as some nearby cells Contraindicated for patients with: A known hypersensitivity reaction to murine proteins for HAMA Patients with greater than 25% tumor involvement of marrow and impaired marrow reserves Image courtesy of SIEMENS Healthcare Patient preparation for melanoma scanning is similar to the preparation of lung ca scanning   The uptake period is usually 45-90 minutes   Patients are scanned from head to toe instead of eyes to thighs with other PET/CT cancer screenings PET/CT Malignant Melanoma - ultraHD•PET Patient Information: 72-year-old patient (84 kg) with malignant melanoma near the left acromastium after resection for staging. Clinical Findings: The examination shows a lymph node metastasis in the left axilla, which is centrally necrotic. The focal *FDG uptake in the prostate is highly sugestive of a second malignant tumor. Scan Protocol: Biograph mCT-S(40); low-dose CT for attenuation correction and anatomical localization; PET: 267MBq (3.7MBq/kg) *18F-FDG, 50 minute uptake, 3 minutes per bed, TrueV,  ultraHD•PET. Data & images curtesy of Grone Hart Zuikenhuis, PET-CT Centrum West-Hederland, Gouda, Netherlands *For indications and important safety information, see slides 81-83 at the end of this course. PET/CT Malignant Melanoma - HD•PET Patient Information: 56-year-old patient (65 kg) with malignant melanoma for staging. Clinical Findings: The exam shows two hypermetabolic lesions located atthe left lower leg suggestive of tumor manifestation. In addition, one liver metastasis can be visualized. Diffuse elevated uptake in the left inguinal area caused by recent lymph node excision. Scan Protocol: Low-dose CT for attenuation correction and anatomical localization; PET: 297 MBq (4.6 MBq/kg) *18F-FDG, 60 minute uptake, 3 minutes per bed, HD•PET. Data & images curtesy of University Hospital of Manheim, Institute for Radiology and Nuclear Medicine, Germany *For indications and important safety information, see slides 81-83 at the end of this course. Planar & SPECT Imaging   Gamma Camera   Nal crystals in detectors   Tracers emit one photon per disintergration Camera may rotate around patient while the patient remains still Metastatic Lesions  Lytic – marrow    Sclerotic blastic  Mixed – lytic & sclerotic Lytic Lesions  Breast, Bladder, Kidney, Thyroid, Multiple Myeloma Sclerotic Lesions  Prostate, Breast  Sometimes Lung, Stomach, Cervical, Pancreas, Colon Many patients are asymptomatic Found incidentally through routine screenings   Image courtesy of SIEMENS Healthcare Melanoma is a deadly form of skin cancer that is increasing steadily in recent years   Malignant tumor of the melanocytes   PET/CT is useful in detecting malignant disease Neuroblastoma: 131I-MIGB and CT   Case: 7-year-old male - Status post surgery and radio-chemotherapy for Neuroblastoma IV: Therapy with 131I-MIBG for disseminated recurrence. Findings: Abdominal tracer accumulation in the left abdomen with localization in the left liver (red arrow) is demonstrateed with SPECT. Physiological uptake in right adrenal gland (blue arrow). Data courtesy of University Erlangen, Nuremberg, Germany Neroblastoma: 123I-MIBG and CT     Case: 9-year-old female - status post RChTx (Radiation and chemotherapy treatment) for Neuroblastoma IV with complete remission. Follow-up scan to monitor patient's status. Findings: In the planar image faint intracranial MIBG uptake. SPECT and correlated CT revealed recurrent tumour in the right ptrous bone with signs of osteolysis. Data courtesy of University of Erlangen Nuremberg, Germany   Paraganglioma: I-123-MIBG, Tc-99m-DPD and CT     Case: Male patient, 40-years-old with hormone secretion. Evaluation of MIBG uptake before therapy and clinical suspicion of bone metastases. Scan: I-123-MIBG-SPECT 4 h p.i., Tc-99m-DPD-SPECT 4 h p.i. and CT-Scan, Findings: Multiple MIBG-positive lesions (white arrows), intra-abdominal and in the spine and pre sacral. The bone scan revealed multiple skeletal metastases. Data courtesy of University Erlangen Nuernberg, Germany   Meuroblastoma: I-123-MIBG and CT    pre-surgery   post-surgery   Case: Neuroblastoma VI, S/P chemotherapy, surger and I-131-MIBG-therapy. MIBG positive lymph nodes abdominal Scan: I-123-MIBG-SPECT. 24 h p.i. and CT-scan. Planar images pre and post radio guided surgery Findings: MIBG avid lumph nodes intrabdominal. After surgery (guided with gamma probe) planoar no evidence of remaining tumour tissue Data courtesy of University Erlangen Nuernberg, Germany   Pancreatic Gastrinoma: In-111-Octreotide and CT Case: Female patient, 9-years-old, with pancreatic gastrinoms. Octreotide scan ordered to confirm liver metastases. Scan: 6.3 mCi In-111 Octreotide SPECT, 24 h p.i. and CT scan Findings: Metastases in left lobe of liver, corresponding to hyper-vascular lesions seen on CT Data courtesy of University of Iowa   Thymic Carcinoid: In-111-Octreotide and CT Case: Female patient, 23-years-old with thymic carcinoid having baseline evaluation before thereapy Scan: 6.3 mCi In-111 Octreotide SPECT 24 h p.i. and CT Findings: Mild uptake in anterior and mid-mediastinum on SPECT corresponding to lesions on CT Date courtesy of University of Iowa    Carcinoid     70-year-old male, 75.7 kg (167 lbs) - Metastatic carcinoid-type tumor presents today for continuation of care 2 metastatic lesions to the right lobe of the liver, larger node is in segment 6/7 and the smaller node that was not expected is in segment 5, not seen in CT. Data courtesy of University of Michigan, Ann Arbor, MI, Dr. M. Piert   99mTc-Octreotide SPECT•CT      Patient Information: 33-year-old male patient with neuroendocrine tumore of the left adrenal gland. Clinical FIndings: The examination shows multiple focal tracer accumulations in the mediastinal and hilar lymph nodes, imtrapulmonary, intra-heatic as well as multiple bone metastases. Significant focal lesions in the area of the increased left adrenal gland. Scan Protocol: 936 MBq 99mTc-Octreotide (TektrotydTM), 4 h p.i., Whole body: 10cm/min, SPECT Thorax and Abdomen: 7.5 min acquisition time, Flash3D, low-dose CT for attenuation correction and anatomical localization Data curtesy: Charite Campus Virchow-Klinikum, University Berlin, Germany, Nuclear Medicine, Prof. Dr. W. Brenner     Lymphoma: Ga-67-Citrate and CT Case: Male patient, age 31-years-old with Cerebral lymphoma Scan: Ga-67-Citrate-SPECT 24 h p.i. and CT-Scan Findings: Intense Gallium uptake in the right thorax with localization in the right pulmonary hilus. Since the primary tulour presented no tracer uptake, further investigation in order to rule out secondary malingnancy or inflammations like Sarcoidosis was recommended. Data curtesy of University of Erlangen Nuernberg, Germany Increased Diagnostic Value of Diagnostic Contrast CT with PET  Patient Information: 81-year-old male with squamous cell carcinoma of right lung for restaging. Clinical Findings: Increased *18F-FDG uptake in the antero-medial aspect of the right lung adjacent to the mediastinum extending posteriorly corresponding to a zone of fibrosis suggestive of inflammatory changes following radiation. There is a marked scarring of the right upper lobe, as well as the superior segment of the right lowe lobe along the oblique fissure with airspace opacity and air brinchograms. The calcified posterior pleural mass involving the 6th costovertebral junction without hypermentabolism appears to be post radioation residual mass. Scan Protocol: 592 MBq (16.0) mCi0 *18F-FDG, 90 minute uptake, 3 minutes per bed, 7 bed positions, CT Thorax (120kV, 140 eff. mAs, 1 mm slice thickness), CT WB (120 kV, 140 mAs, 1 mm slice thickness) Data curtesy of the University of Minnesota, Minneapolis, Minnesota, U.S.A. *For indications and important safety information, see slides 81-83 at the end of this course. Lung Cancer TruePoint PET•CT Indication: 62-year-old patient with lung cancer System Biograph 64 TrueV CT: i.v. contrast, 120kV, 160 ref. mAs, CAREDose4D, 64 X 0.6 mm slice collimation, 2mm slice width, 1.0 mm Increment: PET: 289 MBq *F-18 FDG, 58 kg (5.0 MBq/kg), 1 h p.i., 4 beds, 3 min / bed, 12 min total acquisition time, iterative reconstruction (4 iterations, 8 subsets, 6 mm Gaussian) Findings: High *FDG uptake in the known tumor of the right lung. Nor further metastasis. Data curtesy : Karolinska University Hospital Solna, Stockholm, Sweden, Prof. Stig A. Larson *For indications and important safety information, see slides 81-83 at the end of this course. Lung Cancer - ultraHD•PET Image Quality   Patient Information: 67-year-old patient (77 kg) with lung cancer for staging Clinical Findings: The examination shows hig *FDG uptake in the known lung tumor, centrally necrotic, as well as metastases in the adrenal glands, a lymph node metastasis para-aortal and a bone metastases in the thoracic spine Scan Protocol: Biograph mCT-S(40); low-dose CT for attenuation correction and anatomical localization; PET: 284 MBq (3.7 MBq/kg) *18F-FDG, 60 minute uptake, 3 minutes per bed, TrueV, ultraHD•PET Data curtesy of Grone Hart Zuikenhuis, PET-CT Centrum West-Hederland, Gouda, Netherlands *For indications and important safety information, see slides 81-83 at the end of this course. Hypoharynx Carcinoma     Indication 57-year-old patient with hypopharynx carcinoma on the left side. Status after radiation and chemotherapy. Suspicion of recurrent tumor and lung metastases. Method Biograph 64 CT: i.v. contrast enhanced, 120kV, 170 ref. mAs, 3 mm slice thickness, 1.2 mm increment PET: 221 MBq *F-18 FDG, 57 kg, 3.9 MBq/kg, 60 min p. i., 3 min / bed, iterative reconstruction (2 iterations, 8 subsets, 7 mm Gaussian) Findings Recurrent tumor supraclavicular on the left. Multiple lung metastases on both sides. Data courtesy: University of Erlangen, Nuclear Medicine, Erlangen, Germany, Prof. Dr. T. Kuwert. *For indications and important safety information, see slides 81-83 at the end of this course. Tonsil Carcinoma - HD•PET Delineation of Small Lymph Nodes Patient information: 74-year-old patient (66 kg) with tonsil carcinoma for staging before surgery Clinical finding: The examination shows the known tonsil carcinoma on the right side as well as multiple cervical lymph node metastases ipsi- and contra-lateral Scan protocol: CT: contrast enhanced CT, 230 ref. mAs, 3 mm slice thickness; PET:319 MBq *18F-FDG (4.3 MBq/kg), 60 min uptake, 3 inutes per bed, TrueV, HD•PET Data courtesy of University of Vienns, General Hospital, Nuclear Medicine, Vienna, Austria *For indications and important safety information, see slides 81-83 at the end of this course.   Indications, Important Safety Information, Dosage Forms, and Strenths for *Fludeoxyglucose F18 Injection and *Sodium Fluoride F18 Injection   *Important safety information is available on the next few slides. Please see accompanying full prescribing information.   Indications & Usage Fludeoxyglucose F 18 injection (18F FDG) is indicated for positron emission tomography (PET) imaging in the following settings: Oncology: For assessment of abnormal glucose metabolism to assist in the evaluation of malignancy in patients with known or suspected abnormalities found by other testing modalities, or in patients with an existing diagnosis of cancer.   Cardiology: For the identification of left ventricular myocardium with residual glucose metabolism and reversible loss of systolic function in patients with coronary artery disease and left ventricular dysfunction, when used together with myocardial perfusion imaging.   Neurology: For the identification of regions of abnormal glucose metabolism associated with foci of epileptic seizures.   *Please see accompanying full prescribing information.   Important Safety Information Radiation Risk: Radiation-emitting products, including Fludeoxyglucose F 18 Injection, may increase the risk for cancer, especially in pediatric patients. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and health care worker.   Blood Glucose Abnormalities: In the oncology and neurology setting, suboptimal imaging may occur in patients with inadequately regulated blood glucose levels. In these patients, consider medical therapy and laboratory testing to assure at least two days of normoglycemia prior to Fludeoxyglucose F 18 Injection administration.   Adverse Reactions: Hypersensitivity reactions with pruritus, edema and rash have been reported; have emergency resuscitation equipment and personnel immediately available.   *Please see accompanying full prescribing information.   Dosage Forms and Strengths Multiple-dose 30 mL and 50 mL glass vial containing 0.74 to 7.40 GBq/mL (20 to 200 mCi/mL) of Fludeoxyglucose F 18 injection and 4.5 mg of sodium chloride with 0.1 to 0.5% w/w ethanol as a stabilizer (approximately 15 to 50 mL volume) for intravenous administration.   Fludeoxyglucose F 18 injection is manufactured by Siemens’ PETNET Solutions, 810 Innovation Drive, Knoxville, TN 39732   *Please see accompanying full prescribing information.   Indications & Usage Sodium fluoride F 18 injection is a radioactive diagnostic agent for positron emission tomography (PET) indicated for imaging bone to define areas of altered osteogenic activity.   *Please see accompanying full prescribing information.   Important Safety Information Allergic Reactions As with any injectable drug, allergic reactions and anaphylaxis may occur. Emergency resuscitation equipment and personnel should be immediately available.   Cancer Risk Sodium fluoride F 18 injection may increase the risk of cancer. Use the smallest dose necessary for imaging and ensure safe handling to protect the patient and healthcare worker.   Adverse Reactions No adverse reactions have been reported based on a review of the published literature, publicly available reference sources and adverse drug reaction reporting systems. The completeness of the sources is not known.   *Please see accompanying full prescribing information.   Dosage Forms and Strengths Multiple-dose vial containing 370–7,400 MBq/mL (10–200 mCi/mL) at EOS reference time of no-carrier-added sodium fluoride F18 in aqueous 0.9% sodium chloride solution. Sodium Fluoride F 18 Injection is a clear, colorless, sterile, pyrogen-free and preservative-free solution for intravenous administration.   Sodium Fluoride injection is manufactured by Siemens’ PETNET Solutions, 810 Innovation Drive, Knoxville, TN 39732   *Please see accompanying full prescribing information.