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Nucs Board Review > Seminars > Flashcards

Seminars Flashcards

1
Q

Extrapyramidal definition

A

corticospinal motor pathways (pyramidal projections) are not the primary site(s) of dysfunction

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2
Q

PSP

A

Bradykinesia/rigidity, supranuclear ocular palsy

FDG: Decrased striatum

DATSCAN: symmetric defects

No Lewy Body’s, TAU positive

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3
Q

MSA

A

Autonomic dysfunction

FDG: Decfreased striatum

DATSCAN: Symmetric defects

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4
Q

Corticobasilar degeneration

A

Dystonia, myoclonis, alien limb

FDG: Decreased precentral and post central gyri, decreased striatum, decreased thalamus

DATSCAN: assymetric reduction

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5
Q

Parkinson’s features

A

FDG: increased striatum (early stages)

I123-ioflupane (DATSCAN) - assymetric defect putamen > caudate

Lewy body deposition

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6
Q

Protein deposition in LBD

A

All have alpha-Syn protein deposition; subset have beta amyloid and tau (overlap with AD)

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7
Q

3 Pillars of drug survival

A

tissue exposure

target engagement

pharmacologic activity

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8
Q

NeuroPET targers

A

Dopamine:
- D1, D2/D3 (C11-raclopride), DAT (I123-Ioflupane), 5-L AA transporter (DOPA)

Seratonin:
- 5HT receptor agonists/antagonists

Opiod:
- u opiod receptor agonist - C11-carfentanyl

GABA
- GABA receptor antagonist (C11-flumazenil)

Beta amyloid -

  • C11PIB
  • F18-flurbetapir

Combined beta amyloid and neurofibrillary tangles:
- F18-FDDNP

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9
Q

Appropriate use amyloid PET

A
  1. Cognitive complaint with objectively confirmed impairment
  2. AD is a possible diagnosis, but diagnosis is uncertain after a comprehensive evaluation
  3. Knowledge of the presence or absence of Aβ pathology will aid diagnosis or management
  4. Persistent or progressive unexplained MCI
  5. Possible AD with an unclear clinical presentation (see text)
  6. Atypically early-age-onset progressive dementia (less than ~65 y in age)
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10
Q

PET tracers being used for gliomas

A

C11-MET
C11-AMT
F18-FET
F18-DOPA

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11
Q

PET findings in addiction

A

low striatal D2 receptors and dopamine transmission

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12
Q

Applications of beta amyloid imaging and tau

A

Noninvasive identification of Alzheimer disease pathology

Early diagnosis

Prediction of disease progression and response to disease-specific therapy

Subject selection for disease-specific trials

Monitor target engagement and effectiveness of disease-specific therapy

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13
Q

Tau tracers

A

F18-AV1451

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14
Q

Dosimetry before I131 therapy in children

A

Measure RAIU with < 10-15 MBq of I131 or I124 PET to avoid stunning

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15
Q

Two neurocutaneous syndromes with epilepsy ammendable to surgical treatment

A

TS

Sturge-Weber (angiomatosis, calcifictions, atrophy, gliosis)

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16
Q

Children - differences in MIBI and tetrofosmin biodistribution

A

Higher hepatic retention - do delayed at 90 min

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17
Q

Sp I123 and 131-MIBG

A

Specificity between 90-100%

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18
Q

PET tracers for NB

A

F18-FDG

F18-DOPA

Ga68-DOTATATE

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19
Q

BEIR statement on radiation carcinogenic risk in children

A

2-3 x higher than adults

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20
Q

ICRP Effective Dose Organ radiosensitivity weights

A
  1. 12 = Breast, Red Marrow, Lung, Colon, Stomach
  2. 08 = gonads

Lowest = 0.01 (brain, bone surface, salivary glands)

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21
Q

Rank effective dose (mSv) for the following studies: DMSA, MDP, MAG3, FDG

A

FDG (7.0) > MDP (4.2) > MAG3 (2.6) > DMSA (1.1)

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22
Q

Most common cause congenital hypothyroidism

A

Thyroid dysgenesis

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23
Q

ROME consensus for imaging in congenital hypothyroidismn

A

Knee radiographs (absent femoral and tibial epiphyses) reflect severity of hypothyroidism

Thyroid US

Thyroid scintigraphy

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24
Q

Timing of scintigraphy for CH and initiation of L-thyroxine

A

Imaging must be done within a week of beginning therapy

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25
Q

Protocol for congenital hypo

A

Prep: ensure < 1 week since starting therapy

Tracer: I123 - 0.03 mCi, image after 1 hour; Tc99m - 0.11-0.22 mCi, image after 15 minutes

Dose: I123 - 3.6 mSv; Tc99m - 1.2 mSv

Collimator: LEHR

Matrix: 128 x 128

FOV: anterior acquisition of trunk

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26
Q

Milk scan protocol

A

Prep - 4-6 hr fast

Tracer: 0.25 mCi Tc99m-SC

Position: Supine; posterior images

Matrix: 128 x 128, 5-10s vs 30s frames x 60 minutes, then static chest with 256 x 256 matrix

FOV: mouth to upper abdomen

Critical organ - lower large bowel

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27
Q

Salivagram protocol

A

Prep: None

Tracer: 0.3 mCi Tc99m-SC

LEHR collimator, 128 x 128, dynamic 60min 30s frames, then static A and P chest at 256 x 256 for 3-5 min

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28
Q

Dose reduction strategies pediatric PET/CT

A
  1. Eliminate unnecessary tests
  2. Reduce dose of tracer
  3. Reduce CT imaging params - decrase mAs, kvp; Incrase pitch; use dose modulation
  4. Reduce area imaged
  5. Choose appropriate CT - diagnostic vs non-diagnostic
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29
Q

Pediatric MDP dose and timing

A

0.25 mCi/kg, image at 2-4 hrs

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30
Q

Main advantage of direct RNC vs indirect

A

Both the filling and micturition phases assessed, increasing sensitivity of study

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31
Q

Expected bladder capacity for age

A

30 + (30*age in yrs)

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32
Q

International Reflux grading system

A

1 = Contrast refluxes into normal sized ureter

2 = Contrast reflues into non-dilated ureter and pelvicalyceal system

3 = Mild hydronephrosis, sharp angle of fornices blunted

4 = Moderate dilatation with distortion of fornices

5 = severe dilatation, tortuosity of ureter, clubbing of calyces

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33
Q

Techniques for Crohn’s imaging

A
  1. WBC scintigraphy - extent of active disease; differentiates inflammatory from fibrotic strictures
  2. FDG-PET - Non-specific pan-inflammatory marker; high radiation dose
  3. FDG PET-MRI -
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34
Q

Nuc medicine tracers for type 1 diabetes

A

F18-DOPA - quantifying functional beta cell mass

Radiolabeled IL-2 - Uptake correlates with duration of disease

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35
Q

Classic Hodgkin’s lymphoma classification

A
  1. Nodular sclerosing
  2. Mixed cellularity
  3. Lymphocyte rich
  4. Lymphocyte depleted
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36
Q

PET tracers for imaging bone marrow

A
  1. F18-FDG (glucose metabolism)

2. F18-FLT (DNA proliferation)

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37
Q

SPECT tracers for imaging bone marrow

A
  1. Tc-SC (RES)
  2. Tc-nannocolloid (RES)
  3. Tc/In111-WBCs - RES/neutrophils
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38
Q

Dual time point imaging (DTPI)

A

Malignant lesions tend to accumulate FDG more than normal tissues, therefore higher target to background on delayed

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39
Q

Benign bone/soft tissues lesions with high FDG uptake (false positives)

A 
Hibernoma
Sarcoid
Myosotis ossificans
Infection
\+ Bone lesions (osteoid osteoma, GCT, enchondroma)
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40
Q

Malignant bone/soft tissue lesions with low FDG uptake (false negative)

A

well diff liposarc
myxoid liposarc
chondrosarcoma
chordoma

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41
Q

PET findings relapsing polychondritis

A

Auricular, nasal, larynx, tracheal chondritis

Bronchial chondritis

Relapsing polychondritis

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42
Q

3 major types of aggregated amyloid proteins

A
  1. beta amyloid
  2. Tau
  3. alpha-synuclein (alpha-syn)
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43
Q

Desired amyloid PET properties

A
  1. Selectively binds amyloid
  2. Crosses BBB
  3. No radiolabeled metabolites in brain
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44
Q

Venn diagram aggregated amyloid proteins

A
  1. Pure beta amyloid = cerebral amyloid angiopathy
  2. Pure tau = Frontotemporal dementia, CBD, PSP
  3. Pure alpha-syn = PD, DLB, MSA
  4. Beta amyloid + tau = AD
  5. All 3 = Lewy Body variant AD
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45
Q

Radiolabeled peptide definition

A

Between small molecules and large biologics

Eg. SSTRs, PSMA

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46
Q

C11 production

A

N14(p,alpha)C11

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47
Q

Y90

A

From Sr90->Y90

T1/2 64h

100% beta

mean energy 935 keV; mean path 2.5 mm

48
Q

Lu177

A

From neutron activation of Lu176(n,gamma)Lu177

T/1/2 6.7d; 79% beta; mean free path 0.7 mm; mean free energy 130 kev

49
Q

Perfusion changes following surgery for CHD

A
  1. Fontan - preferential drainage to one lung if only upper limb injected -> need to do upper and lower limb injection
  2. Unidirectional Glenn - same

3.

50
Q

Tc99m-tilmanocept

A

Used for lymphscintigraphy

targets CD206 receptor on macrophages and dendritic cells

Sustained uptake in first order lymph nodes

51
Q

When to not do lymphoscintigraphy for breast CA

A

Invasive cancer T3/T4

Inflammatory breast cancer

DCIS with plan for conservative surgery

Pregnancy

52
Q

Most important prognostic factors in a patient with GI cancer?

A
  1. Tumor depth

2. Metastatic lymph node spread

53
Q

Normal HIDA scan time reference poitns

A

Peak liver by 10 min
CBD by 20min in most
GB and small bowel by 30 min in most
SB by 60 min in 80%

54
Q

Pros Radiation planning based on PET/CT derived volumes

A
  1. Less risk of missing disease, small nodes

2. Incidental synchronous tumours

55
Q

Cons Radiation planning based on PET/CT derived volumes

A
  1. FDG uptake in non-malignant tissues
  2. Non-FDG avid lesions could be overlooked
  3. PET does not detect microscopic disease
56
Q

Lymphoma histologies not well evaluated by PET due to variable uptake

A
  1. CLL
  2. Marginal zone lymphoma
  3. Lymphoplasmacytic lymphoma
  4. Cutaneous T cell lymphoma including mycosis fungoidfes
57
Q

Lymphoma staging according to Lugano classification

A

Limited = Stage I and II
I - one node or group of adjacent nodes; single extranodal lesion without nodal involvement

II - Two or more nodal groups on either side of the diaphgragm; Stage I or II with limited contiguous extranodal involvement

Advanced = III and IV
III = Nodes on both side of diaphgram; nodes above the diaghragm with spleen involvement

IV = Additonal non-contiguous extralymphatic invovlement

58
Q

Nodal tissues according to Lugano

A

Tonsils, weldeyer ring, and spleen are considered nodal tissues not extranodal sites of disease

59
Q

FDG avid lymphomas

A 
HL
DLBC lymphoma
Follicular 
Mantle cell
Burkitt
Marginal zone
60
Q

SUVpeak

A

Maximum tumor activity within a 1-cm3 VOI in the hottest part of the tumor volume

Does not require definition of tumour boundaries

Slightly affected by noise (better than SUVmax)

61
Q

SUVmean

A

Depends on segmention method

Moderately affected by noise

62
Q

MTV

A

Metabolic tumour volume

MTV represents the total volume of the metabolically active tumor in a VOI, expressed in cubic centimeters or millili- ters, and is slightly affected by noise

63
Q

TLG

A

Total lesion glycolysis

= semented tumour volume SUVmean x MTV

64
Q

PET image segmentation techniques

A
  1. Manual
  2. Fixed - fixed threshold of SUV
  3. Adaptive - adapted to tumour to background ratio
  4. Gradient - Edge detection methods
65
Q

Purpose of DEXA images

A
  1. Confirm ROIs
  2. Detect motion
  3. Identify overlying structures, hardware, calc
  4. Incidental disease
66
Q

Risk factors for osteoporotic fractures

A
  1. Prior fragility fracture
  2. Age
  3. Sex
  4. Low BMI
  5. Race (white > black)
  6. Alcohol/smoking
  7. FH hip fracture
  8. Glucocorticoid use
67
Q

Cardiac sympathetic NS tracer for PET

A

C11-HED

68
Q

Clinical uses for PET myocardial blood flow

A
  1. Identification/characterization subclinical CAD
  2. Extent and severity of multivessel CAD
  3. Detecting balanced ischemia
69
Q

Indications for viability imaging with PET

A
  1. EF<40% and known or suspected CAD

2. NYHA class >= 2

70
Q

Who does not need viability imaging

A

Angina CCS >=2
Normal or mild LV dysfunction
Critical L main disease
Good targets

71
Q

Rank resolution for cardiac PET perfusion tracers

A

F18 flurpiridaz > N13 ammonia > O15 water > Rb 82

Also same rank of positron range

72
Q

Rank extraction fraction for cardiac PET perfusion tracers

A

O18 H20 (100%) > Flurpiridaz (94%) > N13 ammonia (80) > Rb82 (65)

73
Q

i131 gamma and beta energies

A

356kev gamma

606 kev beta

74
Q

Which is better for retrosternal evaluation: Tc99m-pertechnetate or I123

A

123

75
Q

Normal distribution FDOPA

A

Basal ganglia, pancreas, liver, duodenum, gallbladder, biliary tracts, kidneys, ureter

76
Q

CrCl formula

A

[(140-age) x weight]/(72xsCr); multiple by 0.85 if female

77
Q

Broad classification of artifacts

A 
Instrumental
Technical
Radiopharmaceutical 
Patient
Treatment related
78
Q

C11-flumazenil

A

GABA

Delineates seizure focus better than FDG

Sensitiive in mesial temp sclerosis

79
Q

Hypoxia imaging agent

A

F18-FMISO, can be used for gliomas

80
Q

Scintomammography indications

A
  1. Equivocal findings on mammo, US, MRI
  2. Non-diagnostic mammo and contraindication to MR
  3. Nipple discharge, no abnormality on other modalities
  4. Suspected recurrence
  5. Response to neoadjuvant chemo
81
Q

ATA pediatric intermediate risk thyroid cancer

A
  1. Extensive N1a (level VI) or minimal N1b (I-V) nodes
  2. Low risk for distant mets but increased risk for incomplete nodal dissection

Should have I131

82
Q

ATA pediatric high risk group

A
  1. Extensive N1b nodes
  2. Locally invasive disease (T4)

Should have I131

83
Q

Advantages Ga68-EDTA PET/CT compared with gamma camera renal imaging

A
  1. Better SR
  2. Better temporal resolution
  3. Quantification more accurate and quantitiave
84
Q

Advantages Ga68 V/Q imaging

A
  1. Better SR
  2. Improved sensitiivity
  3. Quantification
  4. Respiratory gating of the PET
85
Q

Potential PET tracers for protate CA and targets

A
  1. FDG
  2. C11/F18 acetate (lipid metabolism)
  3. Choline (lipid metabolism)
  4. C11-methionine (AA transport)
  5. Ga68-PSMA (PSMA antibodies)
  6. F18-FDHT (androgen receptor)
  7. F18-FLT (DNA/Cell proliferation)
  8. F18-NaF - Calcium analog (binds to hydroxy group, incorporated into hydroxyappetite)
86
Q

CT truncation artifact

A

when anatomy extends beyond the axial field of view of the scanner (typically 50 cm) and is common in CT whole-body imaging

CT truncation effects can propagate to PET by causing regions of overcorrection and undercorrection of attenuation in the arms.

87
Q

Physiologic distribution of Choline

A

Low level brain
SG
Liver and pancreas most intense
Excretion via GU so kidneys, ureters, bladder hot

Abnormal focal brain = meningioma or high grade glioma

88
Q

Suspect peripheral osteomyelitis - correct tracer choice?

A

If no ORIF hardware or surgery > 6 months -> FDG

If ORIF and hardware < 2 years old -> WBC

if ORIF and hardware > 2 years old -> bone scan +/- WBC

89
Q

Suspect hip prosthesis infection, - correct tracer choice?

A

If placement < 2 years WBC

If > 2 years, bone scan +/- WBC

90
Q

Suspect knee prosthesis infection, - correct tracer choice?

A

If placement < 5 years WBC

If > 5 years bone scan +/- WBC

91
Q

Suspect spondylodisciitis

A

FDG

92
Q

Absorbed dose

A

energy imparted by ionizing radiation per unit mass of irradiated material (Gy)

93
Q

Collective dose

A

The sum of the individual doses received in a given period by a specified population from exposure
to a specified source of radiation.

94
Q

Annual limit on intake

A

The derived limit for the amount of radioactive material allowed to be taken into the body of an adult
worker by inhalation or ingestion in a year.

95
Q

Unrestricted area

A

Dose rate does not exceed 0.02 mSv/hr

96
Q

Activity limit for Classification of a Major Spill

A 
Tc = 100 mCi
TI201 = 100mCi
I123 = 10 mCi
Ga67 = 10mCi
In111 = 10 mCi
I131 = 1 mCi
97
Q

Law of Bergonie Tribondeau

A

Radiosensitivity of living cells proportional to rate of division and inversely proportional to their degree of specialization

98
Q

Stage of gestation, possible effect of radiation

A

3-4 weeks = death
4-8 weeks = death, growth retardation, anatomic malformations
8-15 - weeks = growth retardation, microcephaly, MR, anatomic malformations
16-40 weeks = growth retardation, decreased brian size, MR

99
Q

Hypoxia imaging agents

A

FAZA

FMISO

100
Q

Two radioimmunoconjugates in clinical use

A 
Y90-Zevalin; 
Pure beta
2.29 MeV
Path length = 5 mm
Half life = 64 hrs
No isolation required
Dosimetry not requred
I131-Bexar
Gamma (364) + beta 606 kev
Path length 0.8 mm
Half life 8 days
Isolation required
Dosimetry required
101
Q

Tumours expressing somatostatin receptors

A 
SCLC
GI and pancreatic tumours
CNS malignancies
Breast
Prostate
102
Q

Goals for MAA study prior to radiomicrosphere therapy

A
  1. Identify/quantify intrahepatic shunting to lungs
  2. Extrahepatic GI uptake due to vascular connection
  3. Blood flow ratio to tumour vs normal parenchyma
103
Q

CANMEDS ROLES

A
  1. Medical Expert - central role
  2. Communicator - relationships with physicians and patients
  3. Collaborator - work effectively with other health care providers to provide patient centred care
  4. Leader - Contribute to a high quality health system
  5. Health Advocate - use their influence to improve health
  6. Scholar - lifelong commitment to continuous learning and teaching
  7. Professional - ethical practice, high personal standards of behaviour
104
Q

Accuracy

A

Degree to which a variable represents what it is suppose to represent; affected by systematic error/bias

105
Q

Precision

A

Degree to which a variable can be repeated (affected by random error - variance)

106
Q

ROC curve

A

True positive rate vs false positive rate (sn vs 1-sp) for a binary classifier system as the disrimination threshold is changed

107
Q

Odds ratio

A

= (EE/EN)/(CE/CN)

EE = experimental events
EN = Experimental non events

C = control

108
Q

Observational study designs

A

No intervention

Cross sectional, cohort, case control, case series

109
Q

Cross sectional

A

Determines prevalence; all measures made at one point in time

No distinction between cause and effect

110
Q

Selection bias

A

“patients who participate in screening may have more indolent cancers”. Systematic error due to a non-random sample of a population causing some members of the population to be less likely to be included than others resulting in a biased sample

111
Q

Length time bias

A

Periodic screening finds slower growing cancers

Therefore patients with tumors detected by means of screening will have better prognosis.

112
Q

Lead time bias

A

Lead time bias – “cancer may be found earlier, but the time of death is unchanged”.

113
Q

Recall bias

A

Recall bias - type of systematic bias which occurs when the way a survey respondent answers a question is affected not just by the correct answer, but also by the respondent’s memory

114
Q

Dose Length Product

A

CTDI x scan length (cm); approximates the total energy imparted to the patient (mGy cm)

CT Dose Index (CTDI) - mean absorbed radiation dose over total volume scanned (Gy); obtained by phantom measurements

115
Q

Heterogeneous flood field causes

A
  1. Inadequate mixing of radiopharmaceutical
  2. Loss of coupling between crystal and PMT
  3. Incorrect PMT voltate correction

Nucs Board Review (21 decks)

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