Darlene Metter

Current controversies in the initial post-surgical radioactive iodine therapy for thyroid cancer: a narrative review

Differentiated thyroid cancer (DTC) is the most common endocrine malignancy and the fifth most common cancer in women. DTC therapy requires a multimodal approach, including surgery, which is beyond the scope of this paper. However, for over 50 years, the post-operative management of the DTC post-thyroidectomy patient has included radioactive iodine (RAI) ablation and/or therapy. Before 2000, a typical RAI post-operative dose recommendation was 100 mCi for remnant ablation, 150 mCi for locoregional nodal disease, and 175-200 mCi for distant metastases. Recent recommendations have been made to decrease the dose in order to limit the perceived adverse effects of RAI including salivary gland dysfunction and inducing secondary primary malignancies. A significant controversy has thus arisen regarding the use of RAI, particularly in the management of the low-risk DTC patient. This debate includes the definition of the low-risk patient, RAI dose selection, and whether or not RAI is needed in all patients. To allow the reader to form an opinion regarding post-operative RAI therapy in DTC, a literature review of the risks and benefits is presented.

Imaging of the Diabetic Foot Diagnostic Dilemmas

Multiple diagnostic imaging modalities are available and beneficial for the evaluation of the diabetic foot. There is not yet “one best test” for sorting out the diagnostic dilemmas commonly encountered. The differentiation of cellulitis alone from underlying osteomyelitis and the early detection of abscesses remain important diagnostic goals. Equally important, differentiation of osteomyelitis and neuroarthropathy remains a difficult job. This is often compounded by postoperative diabetic foot states status after reconstruction. Diagnostic evaluation often involves multiple studies that are complementary and that include conventional radiography, computed tomography, nuclear medicine scintigraphy, magnetic resonance imaging, ultrasonography, and positron emission tomography.

Are Nuclear Medicine Residents Prepared for Employment? A Survey-Informed Perspective

INTRODUCTION Nuclear medicine (NM) residency is a 3-year specialty program. However, previous accredited graduate medical education can satisfy up to 2 years of the 3-year requirement. There are 3NMresidency pathways available: (1) 3 years (after 1 year of graduate medical education), (2) 2 years (after 2 years of graduate medical education), and (3) 1 year (after completion of an accredited diagnostic radiology [DR] residency) [1]. The majority of NM residents are nonradiologists enrolled in 2-year or 3-year pathways; the 1-year pathway is populated by those already trained in DR. Thus, NM residents constitute a heterogeneous group. NM graduates from 2-year and 3-year programs are eligible for NM certification through the American Board of Nuclear Medicine (ABNM) only. Graduates from the 1-year program can pursue dual certification in DR and in NM through the ABR and the ABNM, respectively; these graduates are also eligible for ABR subspecialty certification in nuclear radiology. Radiology practices are experiencing an explosion in hybrid imaging (PET/CT, SPECT/CT). Coupled with manpower efficiencies forced by current economic constraints, there has been a clear demand for physicians with dual competency in radiology-based body imaging (especially CT) and NM. In recent years, many NM and DR educators have expressed their concerns regarding the employability of NM-only trainees who lack independent expertise in anatomic imaging. Relevant discussions have occurred within and among the

The Disruptive Professional: Case Scenarios

This article examines certain critical aspects relating to the clinical competency of professionalism. A discussion is presented which is centered on an analysis of two fictional scenarios explored from the standpoint of a current and a former program director, an associate dean, a department chair, and a lawyer. These cases are followed by a series of questions and a legal discussion which can then be used for either individual study or group discussion.

Career prospects for graduating nuclear medicine residents: survey of nuclear medicine program directors.

There has been much consternation in the nuclear medicine (NM) community in recent years regarding the difficulty many NM graduates experience in securing initial employment. A survey designed to determine the extent and root causes behind the paucity of career opportunities was sent to all 2010-2011 NM residency program directors. The results of that survey and its implications for NM trainees and the profession are presented and discussed in this article.

CT training of nuclear medicine residents in the united states, 2013-2014

PURPOSE In 2011, the ACGME Nuclear Medicine (NM) Residency Review Committee revised the NM program requirements, which increased CT training for NM residents. This article examines the effect of this revision. METHODS Requests were e-mailed to all NM program directors asking that their residents be given the opportunity to complete an online survey regarding their CT training. Subsequently, an identical online survey regarding CT training was e-mailed directly to all members of the NM Residents Organization of the American College of NM asking that they complete the survey regarding their CT training if they had not already done so. RESULTS Resident responses, compared with those from a similar 2011 survey, indicate a perception that CT training and CT expertise gained in ACGME-accredited NM programs have improved. However, some NM residents are not provided with the opportunity to develop critical skills in interpreting and dictating CT scans during their time on dedicated CT services. The survey indicates that experience gained during NM residency in head and neck/neuroradiology, emergency, and musculoskeletal CT is marginal at best. A slight majority felt that CT training should be further increased. CONCLUSIONS Compared with a 2011 survey of NM residents and the 2011 implementation of expanded CT training requirements, a follow-up survey seems to indicate improvement in CT training for most NM residents. Nevertheless, an opportunity clearly remains to further improve the breadth and depth of CT skills during NM residency. However, whether such an improvement will result in a reversal of multiyear downward trends in the number of NM residents and training programs in the United States is not clear.

Current Status of Ventilation-Perfusion Scintigraphy for Suspected Pulmonary Embolism

OBJECTIVE The purpose of this article is to outline recent progress made in ventilation-perfusion (V/Q) scintigraphy imaging techniques and the interpretation systems used for the diagnosis of pulmonary embolism (PE). Various state-of-the-art approaches that can be selected according to the needs dictated by the medical practice environment and specific patient groups are presented. CONCLUSION Although advances in tomographic imaging have certainly improved the sensitivity of V/Q scans for the diagnosis of PE, they may lead to overdiagnosis by revealing small and clinically insignificant PEs.

Abnormal radionuclide uptake in pseudomyxoma peritonei

A case of pseudomyxoma peritonei with increased radionuclide uptake in the abdomen is described. The uptake of the radionuclide was confined to the omentum as confirmed by the CT study of the abdomen and pelvis. The mechanism of uptake and differential diagnosis are discussed.

ACR 2016 Open-Microphone Session: ACR Membership 3.0-Moving From Member Volume to Value

This report of the 2016 ACR Council Open Microphone session reviews the discussion around interests and concerns of council members and state chapter leaders as to the perceived and real value of their ACR membership, and how the ACR might further enhance membership value and meaningful engagement with members.

Adult Gamma Camera Myocardial Perfusion Imaging: Diagnostic Reference Levels and Achievable Administered Activities Derived From ACR Accreditation Data

PURPOSE The aim of this study was to glean from accreditation surveys of US nuclear medicine facilities the in-practice radiopharmaceutical diagnostic reference levels (DRLs) and achievable administered activities (AAAs) for adult gamma camera myocardial perfusion imaging (MPI). METHODS Data were collected from the ACR Nuclear Medicine Accreditation Program during one three-year accreditation cycle from May 1, 2012, to April 30, 2015. Data elements included radiopharmaceutical, administered activity, examination protocol, interpreting physician specialty, practice type, and facility annual examination volume. Facility demographics, DRLs, and AAAs were tabulated for analysis. RESULTS The calculated DRLs and AAAs are consistent with previously published surveys, and they adhere to national societal guidelines. Facilities seeking ACR accreditation are nearly evenly split between hospital based with multiple gamma cameras and office based with single gamma cameras. The majority of facilities use single-day, low-dosage/high-dosage (99m)Tc-based protocols; a small minority use (201)TlCl protocols. Administered activities show a consistency across facilities, likely reflecting adoption of standard MPI protocols. CONCLUSIONS This practice-based analysis provides DRL and AAA benchmarks that nuclear medicine facilities may use to refine gamma camera MPI protocols. In general, the protocols submitted for ACR accreditation are consistent with national societal guidelines. The results suggest that there may be opportunities to further reduce patient radiation exposure by using modified examination protocols and newer gamma camera software and hardware technologies.