Rapid Review Tables
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Contents
Learning objectives and modules1 modules · about 30 min
Modules
The chapter is divided into study modules without changing the order of the text: read, watch the animations, then answer the questions linked to those headings.
Times are estimates: 130 words per minute, 3 min per animation, 1.5 min per question.
Rapid Review Tables
The scattered numerical information of the book gathered in one place for last-week revision. Values match the book chapters exactly; where US and EANM values differ, both are given.
Table 1: Diagnostic Radiopharmaceuticals – Adult Activity, Critical Organ, Effective Dose
Table 2: Radionuclides – Half-Life, Emission/Energy, Production
Table 3: Breastfeeding Interruption Times
Table 4: Radionuclide Therapies – Dose, Schedule and Patient Selection
Table 1: Diagnostic Radiopharmaceuticals – Adult Activity, Critical Organ, Effective Dose
| System | Radiopharmaceutical | Adult activity | Critical organ (highest dose) | Effective dose | Note (imaging time / key fact) |
|---|---|---|---|---|---|
| Bone | Tc-99m MDP/HDP | 300-740 MBq (8-10 MBq/kg) (EANM) / 740-925 MBq (20-25 mCi) (US) | Bladder | 4.9 µSv/MBq → 3-4 mSv | 2-4 h; plenty of fluids + frequent voiding; uptake determined by osteoblastic activity |
| Bone | F-18 NaF | 185-370 MBq (1.5-3.7 MBq/kg) | Bladder wall (150 µGy/MBq) | 17 µSv/MBq → 3.1-6.3 mSv | Axial 30-45 min, extremities 90-120 min; first-pass extraction 100% |
| Cardiac (amyloid) | Tc-99m PYP/DPD/HMDP | ~740 MBq (15-25 mCi) | – | 3.3-4.4 mSv | 1 h (and/or 3 h) planar + SPECT/CT; Perugini score, H/CL ratio; detects ATTR, usually not AL |
| Thyroid | Tc-99m pertechnetate | 74-111 MBq (EANM) / 37-185 MBq (1-5 mCi) | Colon wall (if thyroid blocked) | 13 µSv/MBq → ~1.0 mSv | Max. thyroid accumulation ~20 min, uptake 2-5% (EANM; classic normal ~0.4-4%); trapping only (no organification) |
| Thyroid | I-123 NaI (oral) | 7.4-14.8 MBq (EANM) / 3.7-14.8 MBq | Thyroid (2.7 mGy/MBq) | 150 µSv/MBq → ~1.2 mSv | 2-4 h (or 4-6 and/or 24 h); trapping + organification; perchlorate discharge test |
| Thyroid | I-131 NaI (diagnostic WBS) | 37-74 MBq (1-2 mCi) after hormone withdrawal, 110-148 MBq (3-4 mCi) with rhTSH (SNMMI/EANM 2022) / 0.37-3.7 MBq (uptake) | – | 0.28 mSv/MBq (thyroid blocked) – 14 mSv/MBq (low uptake) | 24-48 h; ≤3 mCi (111 MBq) to prevent stunning |
| Thyroid | Tc-99m MIBI (indeterminate nodule) | 370 MBq | – | ~3.3 mSv | Early 10 min + late 60 min; WOind threshold −19%; MIBI-negative nodule → high NPV |
| Parathyroid | Tc-99m MIBI | 400-900 MBq (with dual tracer + pertechnetate 74-150 MBq or I-123 7.4-14.8 MBq) | Gallbladder and kidneys | ~7 µSv/MBq → ~2.8-6.3 mSv (with dual tracer the pertechnetate or I-123 dose is added) | Early 10-15 min + late 1.5-2.5 h; MIBI-avid thyroid nodule is the main pitfall |
| Parathyroid | F-18 fluorocholine | 100-300 MBq (1.5-3.2 MBq/kg) | Kidney | 20 µSv/MBq → 2.0-6.0 mSv | 5 + 60 min or 20 min (+60-90 min); sensitivity 94%, PPV 97% |
| Adrenal cortex | I-131 NP-59 | 20 MBq (EANM) / 37 MBq (1 mCi) (US) | – (thyroid dose may be 29 mGy/MBq → blockade mandatory) | 1.8 mSv/MBq → ~36 mSv | Days 5 and 8; under dexamethasone, daily from day 2; spironolactone stopped ≥6 wk |
| Adrenal medulla / NET | I-123 MIBG | 185-370 MBq (EANM) / 370 MBq (10 mCi) | Liver | 13 µSv/MBq → 2.4-4.8 mSv | 24 h (± early); thyroid blockade 2-3 days; antipsychotics stopped longest |
| Adrenal medulla / NET | I-131 MIBG (diagnostic) | 40-80 MBq (EANM) / 18.5-37 MBq (0.5-1 mCi) | Liver | 140 µSv/MBq → 5.6-11.2 mSv | 24-48 h; thyroid blockade 5-10 days |
| NET | In-111 pentetreotide (OctreoScan) | 110-220 MBq (EANM) / 222 MBq (6 mCi) | – | 54 µSv/MBq → ~12 mSv | 4 and 24 h + at least one SPECT/CT (48 h if needed); spleen has the most intense physiological uptake |
| NET | Tc-99m HYNIC-TOC (Tektrotyd) | 370-740 MBq | – | 5 µSv/MBq → 1.8-3.7 mSv | 1-2 h and 4 h; first choice among gamma SSTR agents |
| NET | Ga-68 DOTATATE/DOTATOC/DOTANOC | 74-185 MBq (2-5 mCi); SNMMI/EANM 2023: DOTATATE 2 MBq/kg (max. 200), DOTATOC 148 MBq | Spleen | 23 µSv/MBq → 2.3-4.6 mSv (DOTATATE) | 60 min (EANM 40-90 min); short-acting SSA stopped 12 h before, scan just before the long-acting dose (SNMMI/EANM 2023); SUV not comparable between agents; sensitivity 93%, specificity 96% |
| NET / oncology | F-18 FDOPA | 4 MBq/kg (50-400 MBq) | – | 25 µSv/MBq | 4 h fasting; transported by LAT1/LAT2 |
| Cardiac | Tl-201 | 74-111 MBq stress-redistribution + 37 MBq reinjection (EANM) / 92-130 MBq (2.5-3.5 mCi; ASNC) | Bone surface/kidney | 140 µSv/MBq | Stress 10-15 min + 3-4 h redistribution (24 h if needed); first-pass extraction 85% |
| Cardiac | Tc-99m MIBI (MPI) | 1-day: stress 250-400 MBq + 3 times that for rest ≥3 h later; 2-day: 350-700 MBq/study | Gallbladder/kidney | Stress 7.9 / rest 9.0 µSv/MBq | Wait 15-30 min after stress, 45-60 min after rest; no redistribution; heating required |
| Cardiac | Tc-99m tetrofosmin | Similar to MIBI | Gallbladder/colon | Stress 6.9 / rest 8.0 µSv/MBq | Faster hepatic clearance (10-15 min after stress); labelling at room temperature |
| Cardiac (innervation) | I-123 MIBG | Planar 111-185 MBq; 370 MBq for SPECT / 185-370 MBq (5-10 mCi) | – | 0.013 mSv/MBq | Early 15 min + late 4 h; H/M ratio and washout; thyroid blockade ≥30 min before |
| Cardiac PET | Rb-82 | 1110-1480 MBq (analogue), 740-925 MBq (digital), 370-444 MBq (LAFOV) | – | 0.76 µSv/MBq | T½ 75 s; Sr-82/Rb-82 generator; vasodilator stress mandatory; daily Sr-82/Sr-85 breakthrough |
| Cardiac PET | N-13 ammonia | 370-925 MBq | – | 2.0 µSv/MBq | T½ 10 min; cyclotron; exercise stress possible |
| Cardiac | F-18 FDG (viability / sarcoidosis) | 185-400 MBq (2-4 MBq/kg in sarcoidosis) | – | 19 µSv/MBq → 3.5-7.6 mSv | Viability: glucose loading; sarcoidosis: 24 h high-fat, low-carbohydrate diet |
| Lung | Tc-99m MAA | 40-120 MBq (EANM) / 74-148 MBq (2-4 mCi) | – | 11 µSv/MBq → ~1.1 mSv for 100 MBq | Supine injection (~30 s); <100,000 particles → uneven distribution (SNMMI/EANM 2026); in pregnancy activity is reduced, particles not below 100,000 |
| Lung | Tc-99m DTPA aerosol | 900-1300 MBq in the nebuliser; ~20-40 MBq to the lungs (SNMMI/EANM 2026) | – | – | Particles 0.5-2 µm; central deposition in COPD (clumping) |
| Lung | Tc-99m Technegas | 20-30 MBq inhaled by the patient (EANM 2019) / 20-40 MBq; 400-900 MBq in the crucible (SNMMI/EANM 2026) | – | 15 µSv/MBq → ~0.45 mSv for 30 MBq | Particles ~0.1 µm; best ventilation agent in COPD |
| Lung | Kr-81m | ~6 GBq | Lung | 27 nSv/MBq → ~0.16 mSv | T½ 13 s; imaging simultaneous with perfusion (190 keV); lowest exposure |
| Renal | Tc-99m MAG3 | 75 MBq (EANM) / 185-370 MBq (5-10 mCi) (US) | Bladder (110 µGy/MBq) | 7.0 µSv/MBq → ~0.53 mSv | Tubular secretion; preferred in renal failure and paediatrics |
| Renal | Tc-99m DTPA | 37-185 MBq (EANM) / 185-370 MBq (5-10 mCi) (US) | – | 4.9 µSv/MBq | GFR measurement; extraction ~20% |
| Renal | Tc-99m DMSA | 70 MBq (EANM) / 111-185 MBq (3-5 mCi) (US) | Kidneys (180 µGy/MBq) | 8.8 µSv/MBq → ~0.62 mSv | 2-4 h static; acute pyelonephritis and scarring |
| Renal | I-123 OIH | 75 MBq (50-150 MBq for ERPF) | – | 12 µSv/MBq | ERPF; first-pass extraction ~80%; blood sample at 44 min |
| Renal | Direct radionuclide cystography (Tc-99m SC/DTPA/pertechnetate) | 20 MBq (not adjusted for weight) | – | ~0.048 mSv | VUR follow-up; dose 100 times lower than VCUG; does not assign grade I-V (rough 3 levels) |
| GI | Tc-99m pertechnetate (salivary gland) | 37 MBq (EANM) / 185-370 MBq (5-10 mCi) | – | 13 µSv/MBq → ~0.5 mSv | Max. uptake ~30 min; rapid washout after citric acid is normal |
| GI | Tc-99m pertechnetate (Meckel) | 200 MBq (EANM) / 185-370 MBq (5-10 mCi) | – | 13 µSv/MBq → ~2.6 mSv | Sensitivity increased by pentagastrin, cimetidine, glucagon |
| GI | Tc-99m-labelled red cells (bleeding / haemangioma) | 550-1110 MBq (EANM) / 740-1110 MBq (20-30 mCi) | – | 7 µSv/MBq → ~3.9-7.8 mSv | Dynamic for the first 60 min + 24 h if needed; usually positive in the first 4 h |
| GI | Tc-99m mebrofenin/DISIDA (HIDA) | 111-185 MBq (EANM) / 185-370 MBq (5-10 mCi) | – | 16 µSv/MBq → 1.8-3.0 mSv | Gallbladder 30-40 min (≤60 min normal); GBEF > 40%; bilirubin >5 mg/dL → mebrofenin |
| GI | Tc-99m sulphur colloid (gastric emptying) | 18-37 MBq (0.5-1 mCi) | – | 9.1 µSv/MBq → 0.16-0.34 mSv | Egg omelette + toast; 4-hour retention |
| Spleen / haematology | Tc-99m heat-damaged red cells | 74-185 MBq | Spleen | ~41 µSv/MBq → ~3.0-7.6 mSv | 49.5°C for 20 min; planar + SPECT/CT at 60-90 min; accessory spleen |
| Brain | Tc-99m HMPAO / ECD | 740 MBq (EANM) / 740-925 MBq (20-25 mCi) | – | ECD 7.7, HMPAO 9.3 µSv/MBq → 5.7-6.9 mSv | Imaging ECD 30-60 min, HMPAO 30-90 min; ictal SPECT; preferred in brain death |
| Brain | F-18 FDG (brain) | 150-250 MBq | Bladder wall | 19 µSv/MBq → 2.9-4.8 mSv | Psychosensory rest during the ~20 min uptake period |
| Brain | Amyloid PET (florbetapir / florbetaben / flutemetamol) | 370 / 300 / 185 MBq | – | 19 µSv/MBq → 3.5-7 mSv | Dichotomous reading; loss of grey-white matter contrast = positive |
| Brain | I-123 ioflupane (DaTscan) | 150-250 MBq (typically 185) (EANM) / 111-185 MBq (3-5 mCi) | – | – | SPECT at 3-6 h; thyroid blockade (perchlorate); cannot distinguish PD/MSA/PSP |
| Brain | F-18 FDOPA (neuro) | 150-250 MBq | Bladder wall | 25 µSv/MBq | ≥4 h fasting; antiparkinsonian drugs stopped ≥12 h; carbidopa increases striatal uptake ~2-fold |
| Brain | In-111 DTPA (cisternography) | 20 MBq (≤4 MBq/1 mL for a shunt) | – | ~2.4 mSv | MEAP collimator; 171 and 245 keV windows |
| Infection | Ga-67 citrate | 185-370 MBq (5-10 mCi) | – | ~10-18 mSv | 48-72 h; medium-energy collimator; 93/185/300 keV |
| Infection | In-111 oxine leucocytes | 10-18.5 MBq (0.3-0.5 mCi) | – | 3.6-6.5 mSv | 18-24 h; spleen most intense; preferred in abdominal infection |
| Infection | Tc-99m HMPAO leucocytes | 185-370 MBq (5-10 mCi) | – | 2.0-4.1 mSv | 1-4 h (+24 h); bowel activity on late images is normal |
| Infection | Tc-99m besilesomab / sulesomab | 400-800 MBq / 740-1110 MBq | – | ~6-6.9 mSv | Besilesomab HAMA → single administration in a lifetime (2-4 and 16-24 h); sulesomab can be repeated (1 and 4-6 h) |
| Infection | F-18 FDG (infection) | 175-350 MBq (2.5-5.0 MBq/kg) | – | 19 µSv/MBq → 3.3-6.7 mSv | EANM indications: sarcoidosis, osteomyelitis, spinal infection, FUO, endocarditis, vasculitis |
| Lymph / SLN | Tc-99m nanocolloid / sulphur colloid | 18.5-37 MBq (0.5-1.0 mCi) | – | ~1.2 µSv/MBq → 0.01-0.18 mSv | Same-day surgery 0.5 mCi, day before 1.0 mCi; intratumoral injection not recommended |
| Lymph / SLN | Tc-99m tilmanocept | 37-74 MBq (10-150 MBq) (EANM) / 18.5 MBq (0.5 mCi) (US) | – | – | ~7 nm, CD206 (mannose) receptor; single day with 10-15 MBq in pregnancy |
| Oncological PET | F-18 FDG | 185-370 MBq (5-10 mCi); EANM: 14 × kg / time per bed position (min) | Bladder wall (130 µGy/MBq) | 19 µSv/MBq | ≥4 h fasting; glucose <11 mmol/L (~200 mg/dL); 60 min uptake |
| Oncological PET | Ga-68 PSMA | 1.8-2.2 MBq/kg (100-200 MBq) | Kidneys | 20 µSv/MBq → ~2-4 mSv | Recurrence detection at PSA ≥0.2 ng/mL; false-positive ganglia |
| Oncological PET | F-18 PSMA (DCFPyL / PSMA-1007) | – | – | – | No fasting needed; PSMA-1007 has hepatobiliary excretion (little urine in the pelvis), benign bone uptake more frequent |
| Oncological PET | F-18 fluorocholine (FCH) | 4 MBq/kg (50-400 MBq) | Kidney | 20 µSv/MBq | Biochemical recurrence; well-differentiated HCC |
| Oncological PET | C-11 choline | 400-600 MBq (prostate) / 370 MBq (parathyroid) | – | 4.4 µSv/MBq (~1.6 mSv) | T½ 20 min → on-site cyclotron |
| Oncological PET | F-18 fluciclovine (FACBC) | 370 MBq (not adjusted for weight/age) | – | – | Imaging after 3-5 min; ≥4 h fasting; bladder not emptied 30-60 min before |
| Oncological PET | F-18 FES | 111-280 MBq | – | – | 60 min; tamoxifen stopped ≥6 wk, fulvestrant ~28 wk; SUVmax <1.5 → no response to hormone therapy |
| Oncological PET | Ga-68/F-18 FAPI | – | – | ~1.4-1.6 mSv/100 MBq | No fasting needed; imaging possible after 10 min; fibrosis/wounds false positive |
| Oncological PET | F-18 FET | 185-200 MBq | – | – | Static 20-40 min, dynamic 0-40/50 min; recurrence vs radionecrosis specificity 85-95% |
Try it in the calculator: Effective dose →
Source: Chapters 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25
Table 2: Radionuclides – Half-Life, Emission/Energy, Production
| Radionuclide | Physical T½ | Decay / emission | Main photon energy (keV) | Production | Use |
|---|---|---|---|---|---|
| Tc-99m | 6.01 hours | IT (88.5-89% γ, 11.5% IC) | 140 | Generator (Mo-99/Tc-99m) | Most SPECT agents (MDP, MAG3, MIBI, MAA, etc.) |
| I-123 | 13.2 hours | EC (~100%) | 159 | Cyclotron: ¹²⁴Xe(p,2n)→¹²³Xe→¹²³I or ¹²⁴Te(p,2n) | Thyroid, MIBG, DaTscan; no stunning |
| I-124 | 4.18 days | β⁺ 22.8% (Emax 2.14 MeV) | 511 | Cyclotron | Thyroid lesion dosimetry (PET) |
| I-125 | 59.4 days | Pure EC (X + Auger) | 27-35 (X-rays) | – | RSL seed; I-125 albumin (plasma volume) |
| I-131 | 8.02 days | β⁻ (Emax 606 keV, mean 192 keV) | 364 | Reactor: ¹³⁰Te(n,γ) (most common) or U-235 fission | Thyroid diagnosis/therapy, MIBG therapy |
| In-111 | 2.80 days (67.3 hours) | EC | 171, 245 | Cyclotron: ¹¹²Cd(p,2n) | Leucocytes, OctreoScan |
| Ga-67 | 3.26 days (78.3 hours) | EC | 93, 185, 300, 394 | Cyclotron: ⁶⁸Zn(p,2n) | Infection, lymphoma |
| Tl-201 | 3.04 days (73 hours) | Pure EC | 69-83 (Hg X) + 167 | Cyclotron: ²⁰³Tl(p,3n)²⁰¹Pb →²⁰¹Tl | Myocardial perfusion (older) |
| Xe-133 | 5.24 days | β⁻ | 81 | Reactor (fission) | Ventilation (washout); ventilation first in V/Q |
| Kr-81m | 13 s | IT | 190 | Generator (Rb-81/Kr-81m; Rb-81 T½ 4.6 hours) | Ventilation; simultaneous with perfusion, lowest dose |
| Cr-51 | 27.7 days | EC | 320 | Reactor: ⁵⁰Cr(n,γ) | Red cell survival/blood volume, GFR |
| Co-57 | 271.8 days | EC | 122 | Cyclotron | Flood source, dose calibrator/probe QC |
| Cs-137 | 30.2 years | γ emitter | 662 | Reactor (fission) | Dose calibrator constancy reference |
| F-18 | 109.8 min | β⁺ 96.7% (Emax 0.634 MeV), 3% EC | 511 | Cyclotron: ¹⁸O(p,n) | FDG, NaF, PSMA, FAPI; shortest range (~0.6 mm) |
| C-11 | 20.4 min | β⁺ 99.8% (Emax 0.960 MeV) | 511 | Cyclotron: ¹⁴N(p,α) | Choline, methionine, acetate, raclopride |
| N-13 | 9.97 min | β⁺ 99.8% (Emax 1.199 MeV) | 511 | Cyclotron: ¹⁶O(p,α) | N-13 ammonia (cardiac) |
| O-15 | 2.04 min | β⁺ 99.9% (Emax 1.732 MeV) | 511 | Cyclotron: ¹⁴N(d,n) or ¹⁵N(p,n) | O-15 water (blood flow, gold standard) |
| Ga-68 | 67.71 min | β⁺ 88.9% (Emax 1.899 MeV), 11.1% EC | 511 | Generator (Ge-68/Ga-68) | DOTATATE, PSMA, FAPI |
| Rb-82 | 75 s | β⁺ 95.4% (Emax 3.35 MeV), 4.6% EC | 511 | Generator (Sr-82/Rb-82) | Cardiac perfusion PET, MBF; longest range (~5.9 mm) |
| Cu-64 | 12.7 hours | β⁺ 17.6%, β⁻ 38.5%, EC 43.9% | 511 | Cyclotron: ⁶⁴Ni(p,n) | Theranostics; Cu-64 DOTATATE (delayed imaging) |
| Zr-89 | 3.27 days (78.4 hours) | β⁺ 22.7% (Emax 0.902 MeV) | 511 | Cyclotron: ⁸⁹Y(p,n) | Immuno-PET (antibodies) |
| Mo-99 | 65.92 hours (~66 hours) | β⁻ | 740, 780 | Reactor: U-235 fission (yield ~6.1%); alternatively ⁹⁸Mo(n,γ) | Parent of the Tc-99m generator (transient equilibrium) |
| Ge-68 | 270.8 days (~271 days) | EC | – (daughter Ga-68: 511) | Cyclotron | Parent of the Ga-68 generator (secular equilibrium); PET QC phantom |
| Sr-82 | 25.36 days | EC | – (daughter Rb-82: 511) | Cyclotron | Parent of the Rb-82 generator (secular equilibrium); breakthrough → bone dose |
| Y-90 | 64.1 hours (2.67 days) | Pure β⁻ (Emax 2.28 MeV, mean 0.94 MeV) | None (bremsstrahlung SPECT; PET via internal pair production) | Reactor / Sr-90/Y-90 generator | Radioembolisation, Zevalin, DOTATOC, RSV (knee) |
| Lu-177 | 6.65 days | β⁻ (Emax 497 keV, range ~2 mm) | 113, 208 | Reactor | PRRT (DOTATATE), PSMA-617 |
| Ho-166 | 26.8 hours | β⁻ (Emax 1.85 MeV) | 81 | Reactor: ¹⁶⁵Ho(n,γ) | Liver microspheres (imageable with SPECT + MR) |
| Sm-153 | 46.3 hours (1.93 days) | β⁻ (Emax 808 keV) | 103 | Reactor | EDTMP: bone pain palliation |
| Sr-89 | 50.5 days | Almost pure β⁻ (Emax 1.46 MeV) | 909 (0.01%; practically not imageable) | Reactor | Bone pain palliation (Ca analogue) |
| P-32 | 14.3 days | Pure β⁻ (Emax 1.71 MeV) | None | Reactor: ³²S(n,p) | Polycythaemia vera |
| Re-186 | 3.72 days | β⁻ (Emax 1.07 MeV) | 137 | Reactor | RSV (medium joints), HEDP bone palliation |
| Re-188 | 17.0 hours | β⁻ | – | Generator (W-188/Re-188; W-188 T½ 69.4 days, transient equilibrium) | HEDP bone palliation, RSV, liver tumours |
| Er-169 | 9.40 days | β⁻ (Emax 351 keV) | – | Reactor | RSV (small joints) |
| Ra-223 | 11.4 days | α (5.78 MeV; 4 α in the chain; ~95% of the energy as α) | Low abundance, no routine imaging | Reactor | Bone met. mCRPC (Xofigo) |
| Ac-225 | 9.9-10.0 days | α (4 α in the cascade; range 47-85 µm) | Low photon yield | Reactor / generator | PSMA and DOTATATE alpha therapy (research) |
| At-211 | 7.21 hours | α (5.87 MeV) | – | Cyclotron | Alpha therapy (research) |
| Bi-213 | 46 min | α | – | – | Alpha therapy/RIT (experimental) |
| Pb-212 | – | α-emitter therapy | – | – | Pb-212 DOTAMTATE (Phase 1) |
| Tb-161 | 6.9 days | β⁻ + Auger (range ~0.3 mm) | – | – | Experimental (alternative to Lu-177) |
Source: Chapters 1, 2, 5, 6, 11, 12, 13, 17, 20, 22, 26, 27, 28
Table 3: Breastfeeding Interruption Times
| Radiopharmaceutical | Interruption time | Note |
|---|---|---|
| Tc-99m pertechnetate (thyroid, salivary gland, Meckel) | 12 h | Expressed milk is discarded; the salivary gland study is ideally postponed |
| Tc-99m MAA | 12 h | – |
| Tc-99m-labelled red cells (in vivo labelling; ERNA/GI bleeding) | 12 h | Free pertechnetate concentrates in the breast; milk can be expressed beforehand |
| Tc-99m HMPAO leucocytes | 12 h | No interruption needed with In-111 leucocytes |
| Tc-99m MDP/HDP | Not needed (EANM: ≥4 h / one feed) | – |
| Tc-99m MIBI / tetrofosmin (MPI) | Not needed (4 h / one feed for safety) | Parathyroid MIBI: not mandatory; 24 h interruption → infant dose ~0 |
| Tc-99m DTPA, MAG3, EC, DMSA | Not needed (≥4 h / one feed for safety) | DTPA preferred for renal studies in breastfeeding women |
| Tc-99m sulphur colloid | Not needed (EANM: ≥4 h) | – |
| Tc-99m PYP/DPD/HMDP (cardiac amyloid) | Not needed | – |
| Tc-99m HMPAO/ECD (brain perfusion) | Not needed | – |
| I-123 OIH | 12 h | – |
| I-123 NaI | 3-4 days | Former recommendation ≥3 wk; Chapter 13 recommends stopping, ≥3 wk if I-123 is used for parathyroid |
| I-123 MIBG | ≥24 h (EANM) | 48 h in Chapter 23 |
| I-123 ioflupane (DaTscan) | 4 days | – |
| I-131 NaI (diagnostic or therapeutic, any dose) | Stopped PERMANENTLY | Stopped completely for that infant; can resume in a later pregnancy; must be stopped before RAI (breast NIS); avoid pregnancy for 6-12 months after treatment |
| I-131 MIBG | Stopped (permanently) | – |
| I-131 NP-59 | Stopped (permanently) | Pregnancy an absolute contraindication |
| I-131 lipiodol | Contraindicated | Pregnancy/breastfeeding an absolute exclusion criterion |
| Radioiodinated HSA (I-125) | Not recommended | Cr-51 does not pass into milk |
| Ga-67 citrate | ≥3-4 wk (stopped in practice) | The diagnostic agent requiring the longest interruption apart from I-131 |
| Tl-201 | 48 h | – |
| In-111 (pentetreotide, leucocytes) | Not needed | – |
| F-18 FDG | 3-6 h (EANM) | Close contact with the infant is also limited during this time; Chapter 14 does not recommend interruption for sarcoidosis |
| F-18 fluorocholine | 12 h | – |
| Amyloid PET (florbetapir, florbetaben, flutemetamol) | 12 h | Pregnancy a relative contraindication |
| F-18 FDOPA | 12 h | – |
| Short-lived positron emitters (cardiac PET perfusion) | Not needed | – |
| Y-90 ibritumomab (Zevalin) | Contraindicated | Pregnancy and breastfeeding contraindications |
Source: Chapters 10, 13, 14, 15, 16, 17, 18, 19, 20, 23, 24, 25, 26, 29
Table 4: Radionuclide Therapies – Dose, Schedule and Patient Selection
| Therapy | Indication | Dose / schedule | Patient selection and prerequisites | Main toxicity / contraindication |
|---|---|---|---|---|
| I-131 – Graves | Graves hyperthyroidism (RAIU 40-80%) | Fixed 370-555 MBq (10-15 mCi) (US) / 370-740 MBq or 3.7-11.1 MBq/mL tissue (EANM); calculated 80-200 µCi/g (usually 150) × gland (g) / RAIU24 | Stop methimazole 2-5 days, PTU 2-8 wk with fixed activity (4-7 days with the dosimetric approach) before (EANM); continue beta-blocker; low-iodine diet 1-2 wk; wait 6-8 wk after iodinated contrast; pregnancy test | Hypothyroidism 50-80% (2-6 months); transient thyroiditis; worsening ophthalmopathy 15-20% (prednisolone 0.3-0.5 mg/kg, 3 months); CI: pregnancy, breastfeeding, non-cooperation; relative: goitre >80 g, active moderate-severe ophthalmopathy |
| I-131 – TMNG | Toxic multinodular goitre (RAIU 15-50%); volume reduction of selected non-toxic MNG | Fixed 555-1110 MBq (15-30 mCi); calculated 150-300 µCi/g; EANM target >150 Gy | Same preparation as Graves | Same CI as Graves; response in 3-6 months |
| I-131 – Toxic adenoma | Plummer (hot nodule + suppressed surroundings) | 370-740 MBq (10-20 mCi); EANM target 300-400 Gy | Same preparation as Graves; suppressed tissue does not take up iodine → spared | Same CI as Graves |
| I-131 – DTC remnant ablation | DTC (papillary/follicular) after total thyroidectomy | Low risk 1.1 GBq (30 mCi; ATA 2015); intermediate 1.1-5.5 GBq (30-150 mCi); high 3.7-7.4 GBq (100-200 mCi); EANM fixed 1.11-7.4 GBq | THW 3-4 wk (T3 bridge) or rhTSH 0.9 mg IM ×2 days; TSH >30 mIU/L; iodine <50 µg/day for 1-2 wk; diagnostic I-131 ≤111 MBq (stunning); pregnancy test | Sialadenitis (most common), nausea, radiation thyroiditis, taste change; CI: pregnancy, breastfeeding (stop permanently); avoid pregnancy 6-12 months; MTC/anaplastic → ineffective |
| I-131 – DTC adjuvant | Known/suspected microscopic residual disease | ≤5.5 GBq (≤150 mCi) (ATA 2015) | Same preparation as ablation | Same as ablation |
| I-131 – DTC metastases | Local recurrence, LN, distant met. (lung, bone) | 5.5-11.1 GBq (150-300 mCi), repeatable; dosimetric MTA: BM ≤2 Gy, lung retention at 48 h ≤80 mCi (3 GBq), lesion ≥80 Gy | THW may be preferred (prolonged TSH elevation); RAI-refractory → TKI (lenvatinib, sorafenib) | Pulmonary fibrosis (diffuse lung met.), BM suppression, AML/bladder ca (cumulative >600 mCi), permanent male infertility >400 mCi (sperm banking), xerostomia, nasolacrimal obstruction |
| I-131 MIBG – neuroblastoma | High-risk MIBG(+) neuroblastoma (90-95% positive) | 444-666 MBq/kg (12-18 mCi/kg), single or repeated | Thyroid blockade (KI/SSKI) started 24-48 h before, continued 10-15 days; stop drugs that reduce MIBG uptake | BM suppression (dose-limiting; BM 2 Gy limit), nausea, sialadenitis, hypothyroidism (inadequate blockade) |
| I-131 MIBG – phaeo/PGL | Unresectable/metastatic MIBG(+) phaeochromocytoma/paraganglioma | 3.7-11.1 GBq (100-300 mCi), repeatable | Drug withdrawal: antipsychotics ~3-4 wk, labetalol 10 days, TCA 1-3 days; alpha-blocker preparation; thyroid blockade | BM suppression (thrombocytopenia, neutropenia), hypertensive crisis (catecholamine release), nausea, hypothyroidism |
| Lu-177 DOTATATE (PRRT) | SSTR(+) well-differentiated GEP-NET (G1-2, Ki-67 ≤20%); advanced midgut NET (NETTER-1) | 7.4 GBq (200 mCi) × 4 cycles, 8 wk apart (total 29.6 GBq); AA: 25 g lysine + 25 g arginine, started 30-60 min before, 4-6 h | Ga-68 DOTATATE PET/Octreoscan: Krenning ≥2 (≥ liver); contraindications (2026): pregnancy, severe acute illness, aplastic marrow; with eGFR <40 activity reduction is considered, safety <30 not established; not given if Hb <8, WBC <3000, neutrophils <1000, platelets <75,000 | Lymphopenia (most common), thrombocytopenia; AA-related nausea; nephrotoxicity (cumulative kidney ≤23 Gy, BED ≤40 Gy; BM ≤2 Gy); hormonal/carcinoid crisis ~1%; MDS/AML 2-3% |
| Y-90 DOTATOC | SSTR(+) NET, bulky disease | Fixed or 1.85-3.7 GBq/m² BSA | Nephroprotective AA essential | Toxicity higher than Lu-177; kidney critical (1.2-5.1 Gy/GBq; ~37-40 Gy BED); bremsstrahlung imaging only; clinical research |
| Alpha PRRT (Ac-225 DOTATATE, Pb-212 DOTAMTATE) | NET refractory to Lu-177 (Ac-225); Phase 1 (Pb-212) | Activity much lower than with beta emitters | – | Not yet formally approved |
| Lu-177 PSMA-617 | PSMA(+) mCRPC: after ARPI + taxane (VISION) or after ARPI, taxane-naive (PSMAfore) | 7.4 GBq (200 mCi) × 6 cycles, 6 wk apart (total 44.4 GBq); EANM/SNMMI 2023: 6-9.3 GBq, 4-10 wk in practice (EANM 2019: 3.7-9.3 GBq, 6-8 wk, 2-6 cycles) | PSMA PET (Ga-68 PSMA-11/F-18 DCFPyL): met. uptake > liver; no PSMA(-)/FDG(+) lesions; adequate BM, renal, liver function | Fatigue, xerostomia, nausea (most common); BM suppression (most common G≥3); mild renal toxicity; MDS/AML rare; Gy/GBq: kidney 0.4-0.8, salivary 0.5-1.9, lacrimal 0.4-3.8 |
| Ac-225 PSMA-617 | High PSMA(+) mCRPC that has exhausted, or is unsuitable for, approved options (research) | ~100 kBq/kg/cycle, 6-8 wk apart | Exclusion: unmanageable urinary obstruction, GFR <30 mL/min, marked organ dysfunction, severe myelosuppression | Xerostomia (most common); dose-limiting: salivary glands, kidney, BM; post-therapy imaging/dosimetry difficult |
| Ra-223 dichloride | mCRPC with symptomatic bone met., no known visceral met. (ALSYMPCA) | 55 kBq/kg (1.49 µCi/kg) IV × 6 cycles, 4 wk apart | ≥2 bone met. (bone scan/NaF PET); first dose: Hb ≥10 g/dL, PLT ≥100×10⁹/L, ANC ≥1.5×10⁹/L; subsequent: ANC ≥1.0, PLT ≥50×10⁹/L | Thrombocytopenia (most common dose-limiting), anaemia, neutropenia; nausea/diarrhoea (faecal excretion); flare; CI: visceral met., Crohn's/UC, BM failure, abiraterone+prednisolone (ERA-223 fracture ↑) |
| Sr-89 chloride (Metastron) | Pain palliation of osteoblastic bone met. (prostate, breast) | 148 MBq (4 mCi) or 1.5-2.2 MBq/kg (US) / 150 MBq (EANM); slow IV over 4 min; repeat ≥90 days | Bone scan(+) lesion; stop Ca therapy ≥2 wk before; can be combined with bisphosphonates; contraception 4 months; life expectancy >3 months | Marked BM suppression (nadir 12-16 wk US; EANM 4-6 wk, recovery 3-6 months); flare 10% (48-72 h); CI: PLT <60,000, WBC <2400 (US) / Hb <90 g/L, leucocytes <3.5, PLT <100×10⁹/L (EANM); GFR <30 or creatinine >180 µmol/L; DIC; spinal cord compression |
| Sm-153 EDTMP (Quadramet) | Pain palliation of osteoblastic bone met. | 37 MBq/kg (1 mCi/kg) IV bolus; repeat ≥8 wk | Bone scan(+) lesion; good hydration; response in 1 wk (faster than Sr-89) | Mild BM suppression (nadir 3-5 wk; EANM ~wk 4, recovery 6-8 wk); flare; CI shared with Sr-89 |
| Re-186 / Re-188 HEDP | Pain palliation of bone met. (EANM) | Repeat ≥6-8 wk | Rapid urinary excretion (first 12-24 h) → beware of urinary contamination | Nadir at wk 3-5; flare ~10% |
| Y-90 resin microspheres (SIR-Spheres) | HCC (unsuitable for surgery/TX/TACE; also with PVT; bridging/downstaging), liver met. (CRC, NET, breast), ICC | BSA: A(GBq) = (BSA − 0.2) + T/(T+N) or partition model; HCC tumour dose ≥120 Gy | Tc-99m MAA shunt: <10% full dose, 10-15% ↓20%, 15-20% ↓40%, >20% CI; GI shunt → coil embolisation; prophylactic PPI 6 wk | Post-embolisation syndrome (most common, 20-70%); radiation pneumonitis (lung ≤30 Gy single session, ≤50 Gy cumulative); GI ulcer; REILD (normal liver ≤70 Gy, cirrhotic ≤40 Gy); biliary complications |
| Y-90 glass microspheres (TheraSphere) | Same as resin | MIRD: A(GBq) = D(Gy) × M(kg) / 50; D 80-150 Gy (lobe); HCC tumour dose ≥205 Gy | Same MAA shunt assessment as resin | Same as resin; less embolic effect |
| Ho-166 microspheres (QuiremSpheres) | Same as Y-90 (HCC, liver met.) | ~250 MBq scout → treatment 1-2 wk later from the same catheter position; tumour ≥60 Gy | Scout with the same microspheres (instead of MAA); SPECT + MR dosimetry | Similar to Y-90 (post-embolisation syndrome, REILD, GI ulcer) |
| I-131 lipiodol | Inoperable, histologically confirmed primary HCC | 2.22 GBq (60 mCi) into the hepatic artery, slowly under fluoroscopy | Whole-body imaging/dosimetry after ~1 wk | Fever, hepatic pain during injection, rare acute pneumonitis; absolute CI: pregnancy/breastfeeding, life expectancy <1 month, hepatic encephalopathy, Okuda III, contrast allergy |
| Y-90 ibritumomab (Zevalin) | CD20(+) relapsed/refractory low-grade/follicular B-NHL; FL consolidation | Rituximab 250 mg/m² on day 1 and day 7-9 (EANM day 8) → Y-90 within 4 h: PLT ≥150,000 14.8 MBq/kg (0.4 mCi/kg), PLT 100-149,000 11.1 MBq/kg (0.3 mCi/kg); max 1184 MBq (32 mCi) (US) / 11 or 14 MBq/kg, max 1200 MBq (EANM) | PLT ≥100,000; BM involvement ≤25%; In-111 pre-imaging no longer mandatory; no routine dosimetry | Delayed myelosuppression (PLT nadir 7-9 wk, neutropenia 5-7 wk; EANM 4-6 wk; recovery 3-4 months); infection; MDS/AML 2-5%; CI: PLT <100,000, BM involvement >25%; EU authorisation expired in 2024 |
| RSV – Y-90 silicate/citrate | Large joint (knee); refractory synovitis: RA, haemophilic arthropathy, PVNS, OA, PsA | Single intra-articular injection (max range 11 mm); repeat after 6-12 months | Fluoroscopic/US guidance; arthrogram beforehand, aspiration of effusion; particles ≥5-10 µm; immobilisation 48-72 h (EANM 48 h) | Transient flare (24-48 h); extra-articular leakage → skin radiation necrosis, lymphatic spread; infection (rare) |
| RSV – Re-186 sulphide | Medium joint (shoulder, hip, elbow, wrist/ankle) | Single intra-articular injection (max range 3.6 mm) | Same as Y-90 RSV | Same as Y-90 RSV |
| RSV – Er-169 citrate | Small joint (MCP, MTP, PIP) | Single intra-articular injection (max range 1 mm) | Same as Y-90 RSV | Same as Y-90 RSV; lower success in small joints |
Source: Chapters 12, 13, 20, 23, 26
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