M. Elizabeth Oates

Endocrine neoplasm scintigraphy: added value of fusing SPECT/CT images compared with traditional side-by-side analysis.

Purpose: Positron emission tomography (PET)/computed tomography (CT) imaging integrates physiology and anatomy, providing a powerful dual-modality approach. Analogously, fusing independently acquired single photon emission computed tomography (SPECT) and CT images can overcome interpretive challenges in characterizing and localizing abnormalities by either modality alone, potentially enhancing diagnostic confidence. This study explores the added value of SPECT/CT image fusion compared with traditional “side-by-side” SPECT/CT image review for a variety of endocrine neoplasms. Methods and Materials: We identified 11 abnormal endocrine neoplasm SPECT scans in 10 patients with contemporary relevant CT scans. These cases included: 4 I-131 (posttherapy thyroid cancer), 2 I-123 (pretherapy thyroid cancer), 2 In-111 OctreoScan (neuroendocrine neoplasm), one Tc-99m sestamibi (thyroid cancer), one Tc-99m tetrofosmin (parathyroid adenoma), and one I-123 MIBG (adrenergic neoplasm). SPECT and CT images were uploaded onto side-by-side workstations, one with fusion software. Two experienced nuclear radiologists first reviewed “side-by-side” SPECT/CT images followed by fused SPECT/CT images. They scored 2 parameters—anatomic localization and diagnostic confidence—using a 4-point scale (1 “not helpful” to 4 “very helpful”). Score differences ≥1 indicated “added value”; ≤0 indicated “lack of added value.” Results: Compared with “side-by-side” SPECT/CT images, fused SPECT/CT images yielded “added value” for anatomic localization and diagnostic confidence in two thirds of cases. Fusion led to altered diagnoses in 4 of 11 examinations. Greater confidence was also achieved in 3 of 4 when the interpretation was changed and in 4 of 7 cases when it was not. Conclusions: CT correlation can be helpful in interpreting endocrine neoplasm SPECT imaging. SPECT/CT image fusion outperformed “side-by-side” SPECT/CT analysis for neoplasm anatomic localization and diagnostic confidence. Therefore, SPECT/CT fusion should be performed routinely because it potentially influences clinical decision-making and patient management.

Imaging techniques for infections in the surgical patient

Gallium-67 citrate is easy to use and readily available, but the need to delay imaging for 2 to 4 days after injection hinders rapid diagnosis. Moreover, normal gastrointestinal activity limits its usefulness in evaluating the abdomen. Labeling leukocytes with Indium-111 oxine is a time-consuming, technically involved process, yet the images obtained at 24 hours will usually reveal sites of inflammation or infection. Although the techniques have similar sensitivities, the higher specificity of In-111 makes it the superior agent for many clinical situations. When there are localizing signs or symptoms or a reason to suspect a specific body region, CT or ultrasonography is the imaging modality of choice. Guided needle aspiration can then be performed and is usually diagnostic. Radionuclide imaging with either Ga-67 or In-111 is available as an adjunct if needle aspiration cannot be performed or is inconclusive. Since it provides total-body surveillance, radionuclide imaging is particularly useful for screening when there are no localizing signs and in cases of occult sepsis or fever of unknown origin. If positive, it can direct further imaging with CT or ultrasound.

Initial Staging of Differentiated Thyroid Carcinoma: Continued Utility of Posttherapy 131I Whole-Body Scintigraphy

PURPOSE To retrospectively compare pretherapy iodine 123 ((123)I) and posttherapy iodine 131 ((131)I) sodium iodide whole-body scintigraphy of patients with newly diagnosed differentiated thyroid cancer to determine if there is significant and clinically relevant discordance of nonphysiologic iodide-avid foci (IAFs) between the two examinations. MATERIALS AND METHODS This study was approved by the Institutional Review Board, the requirement for informed consent was waived, and the study complied with HIPAA. The authors identified 108 patients (88 women, 20 men; age range, 16-86 years; mean, 47.5 years; 45 patients younger than 45 years, 63 patients 45 years and older) who previously had undergone total or near-total thyroidectomy for differentiated thyroid carcinoma. Each patient had undergone a pretherapy ( 123)I whole-body scan followed by a posttherapy ( 131)I whole-body scan. The number and location of IAFs were recorded on both scans. Data were compared by using a Wilcoxon signed rank test for paired data and assessed clinical relevance based on changes in tumor staging. RESULTS Posttherapy ( 131)I whole-body scans revealed additional IAFs outside the thyroid bed not detected on pretherapy ( 123)I scans in 21 (19%, P < .001) of 108 patients. Nineteen (90%) of these 21 had IAFs in new locations (P < .001), with tumor upstaging of 11 (59%, 10% of total) of those 19 patients; six (55%, 6% of total) of those 11 had scintigraphic patterns consistent with unsuspected metastatic disease. Concordant scintigraphic patterns were observed in 87 (81%) of 108. CONCLUSION In patients with newly diagnosed differentiated thyroid cancer who had undergone thyroidectomy and ( 131)I ablation, posttherapy ( 131)I whole-body scintigraphy revealed new IAFs in 18% and clinical upstaging occurred in 10% of patients compared with pretherapy ( 123)I whole-body scintigraphy. Therefore, posttherapy ( 131)I whole-body scintigraphy provides incremental clinically relevant information as it helps to establish the true extent of IAFs and may contribute to altering of staging.

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

American College of Radiology and Society of Nuclear Medicine and Molecular Imaging Joint Credentialing Statement for PET/MR Imaging: Brain

Founded in 1951, the Joint Commission, formerly known as the Joint Commission on Accreditation of Healthcare Organizations and, previous to that, the Joint Commission on Accreditation of Hospitals, is a United States–based nonprofit organization that accredits more than 20,000 health care organizations and programs in the United States. The Joint Commission requires that there be a credentialing system for delineating and granting privileges for every hospital physician. The Joint Commission does not specify those qualifications. Privileges are generally practice-specific and are not usually transferable from hospital to hospital. The granting of clinical privileges cannot and should not depend on a single criterion such as board certification or membership in a particular specialty society; other options, such as documented evidence of requisite training, relevant experience, judgment skills, and demonstrated current competence, should be available. It is the final responsibility of the hospital medical staff and hospital governing board to ensure that a physician meets a reasonable standard of competency. PET/MR imaging is an emerging complex hybrid imaging modality recently introduced into clinical practice (1–3). In June 2013, the American College of Radiology (ACR) and the Society of Nuclear Medicine and Molecular Imaging (SNMMI) charged a joint task force with developing a credentialing statement for physicians responsible for the oversight and interpretation of PET/MR imaging examinations. The task force has prepared this joint statement related to brain PET/MR imaging as the first in a planned series of credentialing statements covering all organ systems and clinical applications. This joint statement is intended to guide credentialing bodies that privilege physicians to oversee, supervise, and interpret brain PET/MR imaging for patient care in the United States.

Adoption of the 16-Month American Board of Radiology Pathway to Dual Board Certifications in Nuclear Radiology and/or Nuclear Medicine for Diagnostic Radiology Residents

RATIONALE AND OBJECTIVES In 2010, the American Board of Radiology (ABR) approved a new 16-month nuclear subspecialty training pathway within a standard 48-month Accreditation Council for Graduate Medical Education (ACGME)-accredited diagnostic radiology (DR) residency available to institutions sponsoring ACGME-accredited nuclear radiology (NR) and/or nuclear medicine (NM) program(s). This accelerated pathway leads to eligibility for dual ABR certifications in DR and NR or in NM by the American Board of Nuclear Medicine (ABNM). The American College of Radiology, in conjunction with the ABR, aimed to understand adoption of this new pathway, barriers to implementation, preferences for subspecialty certification, and competing alternative combined DR/NR/NM training pathways. MATERIALS AND METHODS During 2013-2014, there were 20 ACGME-accredited NR fellowship and 43 ACGME-accredited NM residency programs eligible to adopt this new 16-month pathway. They were surveyed by e-mail correspondence regarding implementation and barriers to implementation, board certification (ABR-NR and ABNM) preferences, and local alternative training pathways. RESULTS With 100% of the surveys completed, a small cadre of qualifying DR programs (14, 22%) has adopted (9, 14%) or is seriously considering adopting (5, 8%) the 16-month ABR pathway. For most, implementation is problematic with numerous barriers in common. Five (8%) institutions are developing 60-month nontraditional models as alternative routes to ABR-DR/ABR-NR certifications and/or dual ABR/ABNM board certifications. CONCLUSIONS In spite of strategies to promote a shortened training pathway in NR/NM, traditional subspecialty fellowships outside the DR residency remain the dominant pathway leading to ABR subspecialty certification in NR and/or ABNM certification for diagnostic radiologists.

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.

CT Bismuth Breast Shielding: Is It Time to Make Your Own Decision?

C M A d s f The advent of CT revolutionized the practice of radiology. Since its introduction 40 years ago, CT has evolved into an essential diagnostic imaging modality capable of providing detailed images of organs and tissues quickly, safely, and accurately. It has been estimated that about 68 million CT procedures were performed in 2007 in the United States [1]. The clinical applications of CT have continued to expand. With this additional utilization, there is ever-increasing radiation dose to the patient population. Consequently, CT has been thought of as an increasing source of radiation exposure [2,3]. In 2006, a National Council on Radiation Protection and Measurements [4] report on population exposure showed that Americans were exposed to 7 times s much ionizing radiation from edical procedures as had been the ase in the early 1980s. The increase as due primarily to the growth in he use of medical imaging proceures, mostly the higher utilization of T (24% of the total radiation expoure per capita). With the increasing number of T examinations, public concerns bout radiation dose as well as awareess of the potential risk keep growng. These concerns are not limited o overall body radiation exposure ut also include specific organ doses. he breast is one of the tissues that is ost sensitive to radiation exposure. ccordingly, breast shielding techiques during CT examinations have een introduced. However, the use of reast shielding has triggered a debate ver its benefit in reducing breast raiation exposure compared with its mpact on diagnostic accuracy (notaly image quality). [ We conducted a Google literaure search and found 27 scientific apers published since 1997 releant to the use of breast shielding in T. Among those, 13 studies invesigated the use of breast shielding n radiation dose reduction and mage quality [5-17]. An average eduction of radiation dose up to pproximately 57% was reported ithout affecting diagnostic accuracy although the use of bismuth breast hielding generated beam hardening nd streak artifacts). Therefore, the se of bismuth breast shielding was ecommended in routine CT examiations. Nine studies or reviews indiectly supported the use of breast hielding [18-26], while 5 studies recmmended using alternative techiques to reduce radiation to the reast or discouraged the use of breast hielding altogether [27-31]. There is no question regarding the ffectiveness of bismuth shields to reuce radiation to the breast. Concerns egarding breast shielding include an dverse effect on image quality and aborption of photons exiting the patient n their way to the detectors. The deate focuses on the impact on image uality, especially CT Hounsfield unit hanges, increasing noise as well as eam hardening and streak artifacts, ossibly compromising diagnostic acuracy. Figure 1 provides a demonstraion of the use of bismuth breast shieldng and its impact on image quality. owever, most of the published literaure shows that the effect of breast hields on image quality is unremarkble. Thus, there is an overall benefit to he use of breast shielding. Some roups have even successfully impleented policies of using bismuth reast shielding intheir routinepractice 32]. Strategies have also been develb

Recruitment Into a Combined Radiology/Nuclear Medicine Subspecialty

Between the 2009-2010 and 20152016 academic years the number of nuclear medicine (NM) residency programs accredited by the ACGME has dropped 23%, from 56 to 43, and NM residents 48%, from 166 to 86. During the 20152016 year only 86 of 158 (54%) NM residency slots and 13 of 37 (35%) nuclear radiology (NR) fellowship slots were filled [1-3]. Unfilled slots place residency and fellowship programs at risk for closure. At a time when combined skills in diagnostic radiology (DR) and NM or NR are highly soughtafter by private and academic practices, these unfilled positions are lost opportunities for diagnostic radiologists to receive marketable advanced training. Therefore, it is timely to establish a robust recruitment program to encourage more DR residents to pursue advanced training in NM or NR and to attract medical students into combined DR and NM or NR residency programs. Marketability of NM graduates is far better for diagnostic radiologists than for those without certification in DR for many reasons, including that NM physicians cannot cross-cover other radiological disciplines; some even have difficulty providing independent interpretations of hybrid imaging