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Radiology oral boards review > nuclear > Flashcards

nuclear Flashcards

1
Q

Cardiac uptake on a scan - not PET

A

MIBG, sestamibi, thallium

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2
Q

MIBG vs. Octreotide

A

MIBG and octreotide can both localize to neuroendocrine tumors (pheochromocytoma, paraganglioma, **neuroblastoma, and carcinoid). In almost all cases, MIBG is the way to go. The exceptions are **carcinoids and extraadrenal pheochromocytomas, gastrinoma (according to Gainesville)

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3
Q

what nuclear scan to look for PCP pneumonia

A

Gallium 67

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4
Q

What is thyrogen and when is it used in nuc med?

A

a highly purified recombinant form of human thyroid stimulating hormone (TSH), given by injection prior to I-131 study as an alternative to going off thyroid hormone

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5
Q

normal distribution of octreoscan?

A

Liver, spleen, kidneys, thyroid, GB, bladder, Normal pituitary gland

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6
Q

What is MIBG structurally similar to?

A

Norepinephrine - thus scanning for Pheos, **neuroblastoma, and paragangliomas

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7
Q

half life of Tc-99m

A

6 hours

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8
Q

In-111 half life

A

2.8 (3) days

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9
Q

In-111 WBC scan normal distribution

A

liver, spleen, bone marrow (NO urinary or GI tract activity!)

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10
Q

I-123 half life

A

13h

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11
Q

Iodine scan normal distribution

A 
thyroid gland (target organ)
nasopharynx
salivary glands
stomach (target organ)
colon
bladder (target organ)
lactating breasts
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12
Q

I-131 half life

A

8 days

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13
Q

What’s the prep before I-131 scanning?

A

D/c thyroid hormone or us thyrogen

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14
Q

octreoscan - what radiopharmaceutical?

A

In-111

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15
Q

Octreoscan - what’s it used for?

A

Neuroendocrine tumors: carcinoid tumour, paraganglioma(s), glomus jugulare/tympanicum/vagale,
carotid body tumour, pheochromocytoma, small cell lung cancer, pituitary adenoma, neuroblastoma, medullary thyroid carcinoma, islet cell tumour of pancreas

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16
Q

octreotide is an analogue of what?

A

somatostatin (thus useful for neuroendocrine tumors)

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17
Q

MIBG - what radiopharmaceutical?

A

I-123

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18
Q

MIBG - used for what?

A

*phaeochromocytoma.
*neuroblastoma
esthesioneuroblastoma
carcinoid tumour
paraganglioma
phaeochromocytoma
medullary thyroid carcinoma
ganglioneuroma
ganglioneuroblastoma

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19
Q

MIBG normal distribution

A 
liver
spleen
heart(!)
salivary glands
urinary bladder 
gastrointestinal tract (faint)
lungs
brown fat
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20
Q

FDG - half life

A

109 minutes

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21
Q

Gallium-67 - half life

A

78 hours (think 67, 78)

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22
Q

Ga-67 normal distribution

A

lacrimal glands!
liver (site of highest uptake)
bone marrow
spleen
GI tract
salivary glands
nasopharynx
kidneys and bladder in the first 24 hours (only!)- faint uptake can still be normal for up to 72 hours
breast uptake (especially in pregnant and lactating women)
mild diffuse lung uptake at 24 hours or less

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23
Q

What’s a superscan in a bone scan? What are causes?

A

intense symmetric activity in the bones with diminished renal and soft tissue activity
diffuse metastatic disease (prostatic, breast cancer, TCC, lymphoma
metabolic bone diseases (renal osteodystrophy, hyperparathyroidism -often secondary hyperparathyroidism-, osteomalacia (will involve distal skeleton smoother uptake)
myelofibrosis / myelosclerosis
mastocytosis
widespread Paget’s disease

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24
Q

sestamibi - normal distribution

A

thyroid, parathyroid, heart

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25
Q

sestamibi radiopharmaceutical

A

Tc 99m

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26
Q

sestamibi - used for?

A 
parathyroid adenoma detection
cardiac imaging (MIBI)
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27
Q

sulpher colloid - what radiopharmaceutical?

A

Tc 99m

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28
Q

sulpher colloid normal distribution

A

spleen, Kupffer cells in the liver and a small proportion by bone marrow

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29
Q

Tc-99m pertechnetate - used for?

A

Meckel’s scan (also thyroid in pediatrics, parathyroid, testicle)

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30
Q

what’s a bone scan’s pharmaceutical?

A

Tc 99m MDP

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31
Q

What is lung perfusion imaging done with?

A

Tc 99m MAA

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32
Q

Tc brain scan radiopharmaceutical?

A

HMPAO

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33
Q

pertechnetate normal distribution

A

stomach, thyroid, salivary glands, (testicles)

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34
Q

Renal imaging agents:

What’s each for?

A

MAG3 - good for poor renal function pts (tubular excretion)
DTPA - generally used, need good renal fctn (glomerular filtration)
DMSA - cortical imaging (kids mostly)

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35
Q

What instructions to I-131

A 
drive home alone/sit in rear seat if ride
separate bedroom & bathroom
flush twice
don't share phone
store trash/laundry
flush tissues
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36
Q

What’s the allowed dose to the Public

A

5 mSv/year

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37
Q

Lung uptake on bone scan - what is it? Caused by?

A

Metastatic calcification or pulmonary microlithiasis
met calc: caused by same things as medullary calcinosis: hyperparathyroidism, renal tubular acidosis, milk-alkali, hyper vit. D, sarcoid, diffuse tumors (esp. myeloma)

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38
Q

Ddx for elevated I-123 uptake in thyroid

A

IF TSH is low (supressed): Graves

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39
Q

Ddx for low I-123 uptake in thyroid

A

IF TSH is low (supressed): Subacute or postpartum thyroiditis, exogenous (factitious),

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40
Q

WT@#$??: brain and heart, sharp images

A

FDG PET

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41
Q

WT@#$??: brain and heart, not so sharp

A

whole body HMPAO

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42
Q

WT@#$??: heart, no brain:

A

thallium, sestaMIBI, I-123 MIBG

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43
Q

WT@#$??: bone marrow, gut, lacrimal glands (no heart or brain)

A

Gallium

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44
Q

WT@#$??: liver, spleen, kidneys (no heart or brain)

A

octreotide

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45
Q

WT@#$??: spleen, liver, bone marrow (no heart or brain)

A

WBC

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46
Q

WT@#$??: shitty images, no heart or brain

A

I-131

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47
Q

What’s the full name of a Tc labelled WBC scan?

A

Tc-99m HMPAO WBC

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48
Q

How do you diagnose infected prosthesis in nucs?

A

Start with a bone scan - if normal, high negative predictive value
Do sulfur colloid
Do WBC scan - if WBCs go where there’s no marrow, it’s an infection

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49
Q

Dx for normal bone scan with known lytic lesions: in adult? in child?

A

Older: myeloma/plasmacytoma, RCC
Young: LCH

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50
Q

Abdominal tumor in a child visible (uptake) on bone scan

A

Neuroblastoma - look for mets
95% take up MDP
75% calcify

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51
Q

How long does radioactive material need to be stored before discarding?

A

10 half lives (I-131 would be 3 months)

then survey to ensure it’s not above background

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52
Q

What’s the generic (acronym) response to a radioactive spill?

A 
SWIM:
Secure the area
Warn others
Identify the spill/agent
Maintain the area (until help arrives)
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53
Q

Heart and liver uptake on bone scan

A

amyloidosis (also kidneys, but hard to tell since already hot on bone scan)

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54
Q

Radioactive spill categories - discuss

A

Major spill: >100 mCu or potential for airborne (any I-131), large area, uncontrollable, or catastrophic malfunction of radiation producing equipment
Minor spill: small quantity, not meet criteria for major, recognized and should not result in personnel contamination

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55
Q

What causes “ring artifact” in SPECT?

A

Center of rotation error

Non-uniform gamma camera

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56
Q

Steps to receive a radioactive package:

A

Survey, check for damage, wipe test

must be done w/in 3 hours during working hours, w/in 18 hours non-working

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57
Q

features of Lewy body dementia:

A

occipital abnormality (not seen in Alzheimer’s), visual hallucinations
2nd most common dementia
some think related to Parkinson’s

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58
Q

Absent perfusion to one lung on VQ

A

If vent is also abnormal: Swyer James, mass, mucus plug

If vent is normal: pulmonary mass, PA agenesis, PE, and fibrosing mediastinitis

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59
Q

unilateral focal spine uptake, young pt

A

pars fracture, ask for Hx, do SPECT

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60
Q

why would you see heterogeneous liver uptake on bone scan?

A

liver mets - acute cellular death or calcification in mucinous mets

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61
Q

How often do you have to do wipe tests on the patient waiting area?

A

Weekly. at least 5 spots per room.

Daily, you survey with the survey meter.

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62
Q

Causes of soft-tissue uptake on bone scan:

A

Calcification: metastatic calc (hyper Ca2+), calciphylaxis, NSF (nephrogenic systemic fibrosis), actively calcifying tumors (mucinous GI/ovary)
Acute/subacute cellular death: tumors under treatment, infarcts (cerebral, myocardial), polymyositis/dermatomyositis, thermal injury
Ossification: osteosarc mets, myositis ossificans

63
Q

concerned for spine infxn/discovert osteo: what nuclear study? What could you add to this?

A

Gallium. If it’s discordant with MDP bone scan, very powerful sign of osteomyelitis

64
Q

Pt with met prostate ca - what are the odds that FDG will be positive?

A

30-40% (so it’s not zero!)

65
Q

what tumors take up gallium?

A

the -omas:

Lymphoma, melanoma, hepatoma (HCC), sarcoma and primary bone, lung ca

66
Q

distal limb pain - decreased uptake on bone scan - what could it be?

A

Reflex Sympathetic Dystrophy, chronic

aka Chronic Regional Pain Syndrome

67
Q

Diffuse muscle uptake on FDG-PET

A

hyperglycemia, given insulin

reduces sensitivity of the exam

68
Q

Pt has been given multiple doses of I-131 for metastatic thyroid ca. What dose do you start worrying about lung fibrosis?

A

600 mCi cumulative

69
Q

CSF leak study - agent?

A

In-111 DTPA injected into CSF

70
Q

FDG in brain used to differentiate what?

A

recurrent tumor (hot) from radiation necrosis (cold)

71
Q

What are the legal criteria for brain death?

A

There are none - dx by doctors, hospital may have criteria

72
Q

Agents used in a “Brain death” scan

A

ECD, HMPAO, (DTPA would be flow only - not for static images)

73
Q

Sagittal sinus is visualized on a “brain death” scan - is this brain death?

A

No

74
Q

Study shows blood being pumped through heart - what is it? Who gets one? What do you want to find out?

A

MUGA scan (Multi Gated Acquisition Scan)
usually using Tc-99m pertechnetate
Pts on Doxorubicin, herceptin
10% drop or <45% EF means stop Rx

75
Q

big tubular defect over scan

A

Cracked crystal

76
Q

What’s plummer’s disease? How treated?

A

Single, autonomously functioning thyroid disease

Rx high dose I-131

77
Q

Ddx of lytic bone lesion without uptake on bone scan:

A

cold osteomyelitis in kids (Surg emergency
aggressive tumor (lung and breast)
AVN
plasmacytoma/myeloma, LCH, radiation

78
Q

What studies can be used to diagnose pulmonary Kaposi’s sarcoma?

A

Gallium (which is negative), thallium (which is positive)

79
Q

What’s the pt prep before MIBG scan?

A

oral potassium iodide starting day of injection (protect thyroid)
stop sympathomimetic drugs (blood pressure medicines, anti-depressants, antipsychotics, diet pills, and most over-the-counter nasal sprays)

80
Q

Nuclear study to differentiate FNH from HCC - what is it? What does a hot defect mean? Cold?

A

Hot: FNH (2/3 are iso to bright)
Cold: not helpful, could be either cancer or FNH

81
Q

Brain scan for seizures - what agent(s) for ictal and for interictal

A

Ictal: HMPAO (FDG is too much trouble)
Interictal: FDG is more sensitive

82
Q

When do you image in a sestamibi scan for parathyroid adenoma?

A

10 minutes, 2 hours

83
Q

Causes of false negative sestamibi parathyroid scans

A

cystic lesion, small, just hyperplasia not adenoma

84
Q

Uptake in aortic wall on FDG

A

Aortitis, most likely Takayasu

85
Q

Captopril renal scan - explain

A

Looking for stenosis proximal to kidney

Renal scan looks worse after Captopril (relaxes efferent arterioles) than without it

86
Q

How to distinguish CNS toxo from lymphoma?

A

Both ring-enhance in immunocompromized patients

Thallium - cold in toxo, hot in lymphoma

87
Q

decreased uptake (symmetric or asymmetric) in frontal lobes on brain scan

A

Frontal or frontotemporal dementia

88
Q

Bone scan appearance of Hypertrophic Pulmonary Osteoarthropathy
Causes:

A

Linear uptake along tibias and femurs (periosteal)

Lung: NSCLC, pulm lymphoma, abscess

89
Q

Cause of brain visualization in lung perfusion study

A

R to L shunt

90
Q

Ddx cold nodule in thyroid

A

Cancer (15-20% chance), colloid cyst, abscess, hematoma, lymph node

91
Q

Odds that a hot thryoid nodule on FDG-PET will be cancer?

A

30%

92
Q

Pt with treated thryoid cancer. Thyroglubulin is increasing but I-123 is negative, what do you do?

A

FDG-PET

93
Q

Absent caudate and putamen on nuclear brain scan

A

Huntington’s chorea

94
Q

Gastric radiotracer accumulation in bleeding scan - ddx. how do you determine which it is?

A

Gastric bleed vs free pertechnetate.

Look for thyroid activity to indicate free pertechnetate.

95
Q

Tc WBC scan - what’s normal GI activity?

In-111 WBC scan - what’s normal GI activity?

A

Tc HMPAO: under 4 hours is abnormal (later can be okay)

In-111: NO GI activity is normal

96
Q

What renal imaging agent in renal transplant?

A

Mag-3

97
Q

octreotide study - focal uptake in head

A

meningioma

98
Q

Nucs study has low resolution: why?

A

pt too far from camera, wrong photopeak (eg set for Cobalt at 122, not 140 for Tc)

99
Q

What is star artifact?

A

septal penetration by eg I-131 with the wrong collimator (needs high energy)

100
Q

What is the photopeak for I-131?

A

364keV (high energy collimator)

101
Q

Nucs: Linear cold defect +/- branching

A

cracked NaI crystal

102
Q

Nucs: cold roundish defect

A

defective photomultiplier tube - ask for a flood image

103
Q

Nucs: Bright thin line artifact

A

bent collimator

104
Q

Reasons for increased blood flow/pool to a limb on bone scan

A

RSD, cellulitis, tumor in that limb (anything that causes increased blood flow)

105
Q

Increased bone marrow uptake on PET ddx:

A

Homogeneous: response to chemo or granulocyte stimulating factor
Heterogeneous: tumor/mets

106
Q

Nucs study in a baby looking for aspiration

A

Salivagram - drop of sulfer colloid under the tongue, see if it goes into trachea

107
Q

Ddx poor liver function in infant on hepatobiliary scan

A

Poor clearance = poor function
Neonatal hepatitis, TPN cholestasis
(usually functions fine with atresia, just won’t go into bowel)

108
Q

How to check for residual spleen?

A

heat damaged RBCs

109
Q

How do you diagnose NPH on nucs scan?

A

Cisternogram with In-111 DTPA, should go into lat ventricles (heart or Valentine’s sign) then leave them by 24 hours (Trident sign). If there’s still tracer in lat ventricles at 24 h, it’s NPH

110
Q

How do Dx hibernating myocardium? What is it?

A

Area of low/nonperfusion on standard cardiac perfusion study (or PET NH3 study)
Mismached by high uptake on FDG-PET scan
Area of ischemia and low contractility that is amenable to reperfusion

111
Q

Spleen seen on bone scan

A

Splenic autoinfaction from sickle cell anemia

112
Q

What’s the panda sign in nucs? What does it mean?

A

Increased uptake of Ga-67 in lacrimal and and parotid glands in sarcoid (ddx Sjogren’s)

113
Q

What’s the lamda sign in nuclear medicine?

A

Bilateral hilar and right paratracheal lymph-nodes on Ga-67 in sarcoid

114
Q

What’s the scan that looks for reversible ischemia in the brain?

A

Diamox scan - works by challenge using vasodilator Diamox just like on cardiac perfusion studies

115
Q

abnormal uptake in the axilla on nuclear study (e.g. bone scan)

A

Nodal uptake from infiltration - ask about injection site

116
Q

What’s the Alzheimer’s specific neuroimaging agent?

A

Amyvid

117
Q

Ddx cardiac uptake on bone scan

A

MI, Amyloid (look for liver), calcified aneurysm or pericardium

118
Q

How many MAA particles are used in a normal perfusion (Q) scan?

A

250K (below ~70-100K begins looking mottled

119
Q

What are reasons for reducing the number of particles used in a nuclear perfusion scan?

A

Shunt, pulmonary HTN, pregnancy, pediatric patient

120
Q

What’s a normal T1/2 for renal clearance of MAG3? What’s abnormal?

A

Nl T1/2: 10 min
Abnl: 20 min
between: indeterminate

121
Q

Uptake seen on a corrected PET that’s not seen on the uncorrected images =

A

Barium/oral contrast artifact from the CT

122
Q

Ddx for no thyroid even seen on an I-123 thyroid scan

A

acute thyroiditis, factitious hyperthyroidism, s/p resection (should have been known)

123
Q

What does a 4 quadrant bar phantom evaluate?

A

Resolution & linearity

124
Q

What’s stunned myocardium?

A

acute injury - still has normal perfusion but abnormal wall motion

125
Q

How often do you have to check constancy of the dose callibrator? What do you use?

A

Constantly! Daily

Cesium 137

126
Q

premedication for Meckel’s scan?

A

cimetidine

127
Q

premed for hepatobiliary scan in an infant

A

phenobarbital x 5 days

128
Q

Octreotide uptake other than neuroendocrine tumors

A

parathyroid, medullary thyroid, SCLC, lymphoma, meningioma

129
Q

You just gave the radiopharmaceutical to the wrong patient - what is that called? What do you do now?

A

Medical event (not misadmin)
at least 20% of intended dose, exposure of >5Rem to whole body, or >50Rem to any organ
Report to NRC (or DoH in agreement state) by the next day, in writing in 15 days
Any I-131 over 30microCi gets reported
Inform patient, referring MD, do root cause analysis to prevent future errors

130
Q

contraindications to exercise cardiac stress testing:

What do you do instead?

A 
pt cannot exercise, LBBB, severe HTN, recent MI, unstable angina, recent PE
Use regadenoson (Lexiscan)
131
Q

Dose callibrator QC - what needs to be done?

A

Geometry once (or after major move)
Accuracy annually
Linearity quarterly
Constancy daily (constantly)

132
Q

Occupational dose limit to a declared pregnant worker?

A

5mSv per pregnancy (the general public)

133
Q

Radiopharmaceutical for bone pain

A

Strontium or samarium

134
Q

Maximal amount of aluminum permitted in Tc99m? how do you check for this?

A

10ug/mL

Turns indicator paper red

135
Q

Little uptake of Mag3 in a renal transplant (not recent)

A

rejection, cyclosporine toxicity, renal artery stenosis, renal vein thrombosis

136
Q 
What are the radiation dose limits to:
Whole body (worker):
Fetus of worker:
General Public:
Family of an I-131 patient:
A

Whole body (worker): 50 mSv
Fetus of worker: 5mSv
General Public: 1mSv
Family of an I-131 patient: 5mSv

137
Q

T1/2 of Cobalt 57

A

270 days

138
Q

T1/2 of Cesium (Cs 137)

A

30 years

139
Q

Radioactive packages - three types and acceptable radiation at surface and 30cm

A

White 1: 0.5mrem/hr, 0mrem/hr
Yellow 2: 50mrem/hr, 1 mrem/hr
Yellow 3: 200mrem/hr, 10 mrem/hr

140
Q

Procedure for accepting a radioactive package

A

wear protective equipment
Check for damage, monitor with survey
meter, wipe tests. If any of these fail, call the shipper.
Check the slip, open and inspect contents.
Log it in.
Report any anomalies to RSO

141
Q

What do you do in the nuc med department at the end of the day?

A

Daily survey - with GM survey meter (must be done after all procedures are finished
<5mrem/hr restricted

142
Q

QC for gamma cameras

A

Daily flood

Weekly bar phantom

143
Q

How do you perform an intrinsic flood on a gamma camera? An extrinsic flood?

A

Intrinsic: point source (between heads, curvature corrected)
Extrinsic: uniform source (Cobalt)

144
Q

Nuc med artifact: freckling / small spots

A

water got into NaI crystal and is dissolving spots

145
Q

Which radionuclides are beta emitters?

A

I-131, Xe133, Mo99

146
Q

Which radionuclides are positron emitters?

A

F18 (others C11, N13, O15 not used much)

147
Q

How does Tc99m produce radiation?

A

Isomeric transition

148
Q

What radionuclides use electron capture?

A

I123, Ga67, In111, Tl201 (guess electron capture if you don’t know)

149
Q

What’s the maximum amount of Mo contamination allowed in Tc99m?
how do you check for it?

A

0.15uCi/1mCi Tc (that’s micro per milli!)

Use the dose calibrator

150
Q

What are the rules for nursing after various radiopharmaceuticals?

A

FDG: 1 day
all Tc99m: 1 day
I123, In111: 2-3 days
I131, Ga: cease completely

151
Q

What is flare phenomenon?

A

healing from chemotherapy, occurs 3 weeks - 3 months after initiation of therapy.
If unsure, repeat bone or PET scan at 6 months after start of therapy.

152
Q

Difference between shin splints and stress fracture on bone scan?

A

Shin splints are diffuse - linear

Stress fracture is focal

153
Q

What’s used for radionuclide cystography?

What are indications for this study?

A

pertechnetate

Initial diagnosis of reflux, post-op, screening siblings

Radiology oral boards review (10 decks)

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