Molecular Imaging

Description:

Molecular Imaging encompasses all diagnostic and therapeutic in vivo procedures using unsealed radioactive materials. Most of these procedures are imaging procedures.  The clinical rotations take place at UC Irvine Medical Center, at the VA Long Beach Medical Center and at Long Beach Memorial Medical Center. At UC Irvine Medical Center, the day usually begins around 8 a.m. The resident is responsible for obtaining relevant patient data prior to or at the time of dosing a patient. This data may be from the referring physician, the chart, the patient or from our radiology files. This data may modify the requested study. The resident must understand the clinical indication for the study and what it is expected to demonstrate. The resident is responsible for ensuring studies are complete prior to the patient leaving the department and that all possible information has been obtained from the study. The resident on the service is responsible for formulating a preliminary interpretation on all of the studies reviewed during the day. The resident dictates the cases after review with the attending physician. This need not happen at a fixed time; optimally each scan is dictated as the patient is leaving the department. Dictation might be delayed to obtain correlation with prior studies or additional information from the referring physician. After the attending has reviewed the cases with you, remain in the nuclear medicine reading room to dictate the cases and to serve as a consultant to the referring physicians as they review their films. The resident in nuclear medicine is often asked to present cases at Tumor Boards, Morbidity and Mortality Conferences and Clinical Pathologic Conferences, even when these cases do not involve nuclear medicine studies.

General Goals:

• Describe the most common indications for nuclear medicine studies and discuss the advantages and limitations in these and other clinical presentations. Discuss alternative imaging modalities when the role of nuclear medicine is limited.
• Prescribe a method of performing an examination given a specific clinical indication. Aim to maximize information and minimize time and cost.
• Develop a viewing pattern and a dictating style that answers the clinical question posed and that presents the relevant findings in a cogent, logical and easily understandable fashion.
• Recognize common pathologic entities and provide a diagnosis or a differential diagnosis, as appropriate.
• Know the physical and biological characteristics of common radiopharmaceuticals used in clinical nuclear medicine studies.
• List the quality control procedures involved in the preparation and administration of radiopharmaceuticals.
• Describe the quality control procedures employed and the frequency with which they must be done to ensure optimal performance of the equipment and compliance with government regulations.

Specific Goals:

At the end of their rotations, each resident should be familiar with the indications for the following sorts of studies, the diagnostic criteria and the radiopharmaceuticals used in each:

• First Year
  1. Skeletal scintigraphy: Use of 2 and 3-phase scans, diagnosis of osteomyelitis, patterns of metastatic involvement, RSD, stress injuries, and arthritides.  Therapy for metastatic bone pain using Sr-89 or Sm-153.
  2. Lung scintigraphy: Criteria for pulmonary embolus, different ventilatory agents, differential diagnosis of abnormal scans.
  3. Gastrointestinal scintigraphy: Hepatobiliary scans and the pharmacological interventions possible, liver spleen scanning, GI bleeding studies, Meckel’s scan, functional studies.
• Second Year
  1. Genitourinary scintigraphy: Various renal radiopharmaceuticals, the pharmacological interventions used, renal transplant evaluation, testicular scans, GU functional studies.
  2. Tumor and Inflammatory scintigraphy: Gallium-67, labeled WBC’s, MIBG, Octreoscan and some familiarity with monoclonal antibodies and 18-FDG.
• Third Year
  1. CNS scintigraphy: Brain perfusion scans and the indications, brain death studies, cisternography.
  2. Endocrine scintigraphy: Thyroid and parathyroid scans, hyperthyroid therapy, management of thyroid carcinoma.
• Fourth Year
  1. Cardiovascular scintigraphy: myocardial perfusion scans, the stress agents used, gated SPECT, parametric images (bullseye), use of attenuation correlation. Gated blood pool scans, including phase analysis and other quantitation and some familiarity with infarct scans.
  2. Quality Control and Artifacts: radiopharmaceutical preparation, camera QC and processing to include SPECT and its artifacts (especially in cardiac scans).

Reading List:

For Nuclear Medicine Physics:

• Chandra, R. Introductory Physics of Nuclear Medicine
• 2. Saha, G. Physics and Radiobiology of Nuclear Medicine

For Radiation Biology:

• Hall, Eric Radiobiology for the Radiologist

For Clinical Nuclear Medicine:

• Thrall JH and Ziessman HA. Nuclear Medicine: The Requisites
• As a lesser choice:
• Mettler F and Guiberteau M. Essentials of Nuclear Medicine Imaging

As References:

• Wagner H, Szabo Z and Buchanan J. Principles of Nuclear Medicine
• Herbert JG, Eckelman WC and Neuman RD. Nuclear Medicine: Diagnosis and Therapy
• Fogelman I and Maisey M. An Atlas of Clinical Nuclear Medicine
• Journal of Nuclear Medicine
• Seminars in Nuclear Medicine