**Northern Lincolnshire and Goole NHS Foundation Trust - Nuclear Medicine** 

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SELECT sop AS "SOP Code",title AS "Title",reviewdate AS "Review Date" FROM sops WHERE sop='REF018'|0]] 
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^  Authorised By  ^  Authorising Role  ^  Authorisation Signature \\  (only on master paper copy)  ^  Date Authorised  |
|  Prof G Avery  |  ARSAC Licence Holder  |    |  2025-01-15  |

====== REF018 - MIBG Tumour Imaging ======
See [[referral_criteria:ref000-how_to_refer_to_nlagnm|REF000 - Referring to Nuclear Medicine (NLAG)]] for details on how to refer. 

=====  Description =====
Iodine-123 labelled metaiodobenzylguanidine (MIBG) is a radiopharmaceutical of similar structure to noradrenaline and is used in the diagnosis and localisation of active catecholamine secreting tumours, such as phaeochromocytomas, and their metastases. 

Appropriate biochemical markers and cross sectional imaging e.g. CT should have been performed prior to requesting MIBG. If biochemical markers are negative but a clinical suspicion remains then the request must be discussed with the ARSAC licence holder. 


[[sqlite:unused:unused:unused:/home/heynmorg/public_html/wikifarm/nlag/data/meta/arsac/database2019.db|SELECT fullname AS "ARSAC Licence Holders" FROM practitionerlicences INNER JOIN practitioners,procedurecodes,praclicproc,nuclides,chemicalforms ON practitionerlicences.practitioner=practitioners.id AND praclicproc.plicid=practitionerlicences.id AND praclicproc.procid=procedurecodes.id AND procedurecodes.nuclide_id=nuclides.id AND procedurecodes.chemicalform_id=chemicalforms.id AND practitionerlicences.certificateactive='Y' WHERE procedure_code='123I-117-167'  AND date('now')<=expirydate  ORDER BY expirydate|0]]

[[sqlite:unused:unused:unused:/home/heynmorg/public_html/wikifarm/nlag/data/meta/employers_procedures/drl_database.db|
SELECT nuclide AS Nuclide, pharmaceutical_form AS "Pharmaceutical Form",  
local_drl AS "Local DRL (MBq)" FROM drls INNER JOIN nuclides ON drls.nuclide_id=nuclides.id 
WHERE drls.id=17|0]]

^                              ^ Radiopharmaceutical  ^  CT Component of SPECT/CT  |
^Typical Radiation Dose (mSv)  |  5.2 (with thyroid blocked)  |  3.2 - 6.4 mSv  |

===== Staff Entitled to Refer =====
  * The referrer may be any clinician holding a current valid medical qualification and currently employed in Secondary Care. 

===== Supplementary Drugs  =====
  * Sodium chloride for parenteral use (0.9% w/v).
  * Potassium iodide tablets or Lugol's solution or potassium perchlorate for oral use. 

===== Contraindications =====
^ Patient Demographics  | • Pregnancy \\ • Breast-Feeding Patients  \\  •  Renal Insufficiency[([[http://www.eanm.org/publications/guidelines/2012_published_OC_GL_Radionuclide_Imaging_of_Phaeochromocytoma_and_Paraganglioma.pdf|EANM 2012 guidelines for radionuclide imaging of phaeochromocytoma and paraganglioma. Eur J Nucl Med Mol Imaging (2012) 39:1977–1995]])]|
^ Drugs |Many classes of drugs are known (or may be expected) to interfere with the uptake and/or vesicular storage of mIBG. A table including some of the most important medications that may affect the results of MIBG scintigraphy[([[http://www.eanm.org/publications/guidelines/gl_onco_mibg_1.pdf|Bombardieri et al. 131I/123I-Metaiodobenzylguanidine (mIBG) Scintigraphy – Procedure Guidelines For Tumour Imaging. Eur J Nucl Med Mol Imaging (2010) 37:2436–2446]])] is available from [[http://www.heynm.org.uk/pdfs/mibg_drug_stop_list.pdf]] |

===== Patient Preparation =====
==== Thyroid Blockade ====
130mg potassium iodide tablets per day for a total of 3 days, starting the day before the injection of I-123 MIBG and continuing for 2 further days (i.e. the night before the injection, the night of the injection and the following night)[(#1)][(#2)]
     * If potassium iodide is unavailable, alternatives such as Lugol's solution can be used (0.8ml contains 104mg of iodine). Can be given with milk or water/cordial.
     * See the ARSAC Notes for Guidance (section 8) for further details and alternatives[(https://www.gov.uk/government/publications/arsac-notes-for-guidance|ARSAC Notes for Guidance]])]. 

When thyroid blocking agents are administered to children, consideration should be given to reducing the dosage[(#3)]. i.e. 
  * children of 3 to 12 years 50% of adult dose 
  * children of 1 month to 3 years 25% of adult dose 
  * neonates (birth to under 1 month) 12.5% of adult dose 

If iodine is contraindicated, thyroid blockade can be carried out with potassium perchlorate (200 mg adult dose). If used, this should be administered 1 hour[(#3)] prior to the administration of I-123 MIBG and repeated at 8 hour intervals[(#3)] for 2 days[(#1)].

**It should be noted that currently potassium perchlorate is not licensed in the UK.**

==== Drug Interactions ====
Care must be taken to ensure that drugs which interfere with MIBG uptake are discontinued (if possible) for an adequate time prior imaging. See [[http://www.heynm.org.uk/pdfs/mibg_drug_stop_list.pdf]].  Patients with metabolically active catecholamine secreting tumours (i.e. phaechromocytoma, paraganglioma) often receive alpha- or beta-blocking treatment. Therefore, drug interruption should be decided by consultation between the referring physician and the ARSAC licence holder, to enable evaluation of the patient’s condition. If it is decided to proceed  without changing the medication, it should be noted that this could impair diagnostic accuracy[(#1)][(#2)]

===== Clinical Indications =====
| Investigation and localisation of suspected phaeochromocytoma  |
| Investigation and localisation of suspected extra-adrenal phaeochromocytoma |
| Investigation and localisation of suspected phaeochromocytoma metastases  |
| Assessment of the unilateral or bilateral nature of the disease  |
| Assessment of the possible therapeutic use of iodine-131 MIBG  |
| Investigation and localisation of suspected neuroblastoma  |
| Investigation and localisation of suspected neuroblastoma metastases  |
| Investigation and localisation of suspected carcinoid tumour  |
| Assessment of suspected post-operative recurrence of disease  |