Gallium-67 citrate scintigraphy is preferred over In-111 leukocyte scintigraphy for the detection of disk space infection. While both agents are sensitive for osteomyelitis, gallium-67 has been shown to be more sensitive for disc space infection compared to In-111 leukocyte imaging. This is due to potentially confusing normal bowel activity seen on gallium-67 scans that could obscure abdominal pathology. In-111 leukocyte imaging is generally preferred for evaluating other infectious/inflammatory conditions like abdominal abscesses and infected joint prostheses due to less potential for false positives from normal biodistribution.
The document provides rationales for questions on an interventional radiology exam. It includes descriptions of imaging findings and the correct answers for 7 multiple choice questions. For each question, it summarizes the key imaging findings and explains why the correct answer is right and the other options are wrong based on those findings and published references. The questions cover topics like cholangiocarcinoma, splenic artery occlusion, pneumothorax management, mesenteric ischemia, Eustachian valve, gonadal vein reflux, and popliteal artery entrapment syndrome.
A post-menopausal woman presented with an asymptomatic 3.0 cm simple ovarian cyst. Of the following statements, the one that is TRUE is that the cyst should be removed if the patient has an increased serum CA-125 level. A simple cyst under 5.0 cm in diameter in a post-menopausal woman has a very low risk of malignancy and can be followed with serial ultrasounds without surgery. The most common neoplasm found on surgical removal of these cysts is a serous cystadenoma, not a fibrothecoma.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to cardiac radiology. Question 102 asks which statement about cardiomyopathies is true. The correct answer is that cyclosporine immunosuppressive therapy can cause left ventricular hypertrophy. Cyclosporine is used after cardiac transplantation and can result in left ventricular hypertrophy as a side effect.
The document provides rationales for questions on a diagnostic radiology exam. Question 29 asks about an image showing changes in the small bowel. The most likely diagnosis is graft versus host disease based on the classic "ribbon bowel" appearance seen in the image. Graft versus host disease produces a total absence of mucosal folds in the small bowel, typically seen in the ileum rather than jejunum as seen in the image. This appearance is distinct from other potential diagnoses that may also cause small bowel abnormalities.
The document discusses rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to nuclear radiology. It provides details and images from various nuclear medicine studies, including thyroid scintigraphy, bone scintigraphy, renal scintigraphy, CNS shunt study, pulmonary perfusion scan, PET imaging, and radioimmunotherapy. For each question, it discusses the correct answer and explains why the other answer options are incorrect based on the findings and characteristics of the studies.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to breast radiology. The rationales discuss the correct answers and explain why the other answer options are incorrect based on imaging findings and characteristics of different breast diseases. Invasive lobular carcinoma is identified as the most likely diagnosis for one case based on its appearance on mammography of being seen best on one view only or at least.
This document contains rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to pediatric radiology. It provides the correct answer and an explanation for each question, referencing imaging findings and typical presentations of various pediatric conditions like congenital cystic adenomatoid malformation, hematometrocolpos, pulmonary sling, Hirschsprung's disease and more. Key anatomic and imaging features are discussed in the rationales to explain why each answer choice is right or wrong.
The document discusses rationales for exam questions related to chest radiology. Question 202 discusses a CT scan showing a smooth, round upper lobe mass with eccentric calcifications and air-trapping. The most likely diagnosis is a carcinoid tumor. Question 203 shows chest radiographs of a man with cough, demonstrating a classic right upper lobe collapse with a "Reverse S of Golden" suggestive of a central mass. Question 204 involves a CT scan showing post-intubation tracheal narrowing below the thoracic inlet.
The document provides rationales for questions on an interventional radiology exam. It includes descriptions of imaging findings and the correct answers for 7 multiple choice questions. For each question, it summarizes the key imaging findings and explains why the correct answer is right and the other options are wrong based on those findings and published references. The questions cover topics like cholangiocarcinoma, splenic artery occlusion, pneumothorax management, mesenteric ischemia, Eustachian valve, gonadal vein reflux, and popliteal artery entrapment syndrome.
A post-menopausal woman presented with an asymptomatic 3.0 cm simple ovarian cyst. Of the following statements, the one that is TRUE is that the cyst should be removed if the patient has an increased serum CA-125 level. A simple cyst under 5.0 cm in diameter in a post-menopausal woman has a very low risk of malignancy and can be followed with serial ultrasounds without surgery. The most common neoplasm found on surgical removal of these cysts is a serous cystadenoma, not a fibrothecoma.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to cardiac radiology. Question 102 asks which statement about cardiomyopathies is true. The correct answer is that cyclosporine immunosuppressive therapy can cause left ventricular hypertrophy. Cyclosporine is used after cardiac transplantation and can result in left ventricular hypertrophy as a side effect.
The document provides rationales for questions on a diagnostic radiology exam. Question 29 asks about an image showing changes in the small bowel. The most likely diagnosis is graft versus host disease based on the classic "ribbon bowel" appearance seen in the image. Graft versus host disease produces a total absence of mucosal folds in the small bowel, typically seen in the ileum rather than jejunum as seen in the image. This appearance is distinct from other potential diagnoses that may also cause small bowel abnormalities.
The document discusses rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to nuclear radiology. It provides details and images from various nuclear medicine studies, including thyroid scintigraphy, bone scintigraphy, renal scintigraphy, CNS shunt study, pulmonary perfusion scan, PET imaging, and radioimmunotherapy. For each question, it discusses the correct answer and explains why the other answer options are incorrect based on the findings and characteristics of the studies.
This document contains rationales for questions on the 2007 ACR Diagnostic Radiology In-Training Exam related to breast radiology. The rationales discuss the correct answers and explain why the other answer options are incorrect based on imaging findings and characteristics of different breast diseases. Invasive lobular carcinoma is identified as the most likely diagnosis for one case based on its appearance on mammography of being seen best on one view only or at least.
This document contains rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to pediatric radiology. It provides the correct answer and an explanation for each question, referencing imaging findings and typical presentations of various pediatric conditions like congenital cystic adenomatoid malformation, hematometrocolpos, pulmonary sling, Hirschsprung's disease and more. Key anatomic and imaging features are discussed in the rationales to explain why each answer choice is right or wrong.
The document discusses rationales for exam questions related to chest radiology. Question 202 discusses a CT scan showing a smooth, round upper lobe mass with eccentric calcifications and air-trapping. The most likely diagnosis is a carcinoid tumor. Question 203 shows chest radiographs of a man with cough, demonstrating a classic right upper lobe collapse with a "Reverse S of Golden" suggestive of a central mass. Question 204 involves a CT scan showing post-intubation tracheal narrowing below the thoracic inlet.
The document discusses several radiology cases involving the brain and spine. Question 291 presents CT scans of a woman with headaches and asks for the most likely diagnosis of a fat-containing extraconal orbital mass. Question 292 shows MR images of a woman with extremity weakness and asks for the most likely diagnosis of multiple brain and spine lesions. Question 293 presents MR images of a man with back pain and asks for the diagnosis of a posterior spinal mass seen on the images.
This document contains a multiple choice question and rationales from a pediatric radiology exam. The question shows MRI images of a 22-week fetus and asks for the most likely diagnosis. The rationales eliminate the other answer choices of posterior urethral valves, multicystic dysplastic kidneys, and bilateral ureteropelvic junction obstruction. The correct answer is Autosomal Recessive Polycystic Kidney Disease, as the images show enlarged, fluid-intensity kidneys without urine production, typical of this condition.
This document provides rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to ultrasound imaging. It discusses the correct answers and rationales for questions regarding various pathologies seen on ultrasound of the uterus, testes, kidneys, abdomen and fetal anatomy. Key details include identifying a cornual pregnancy based on its location, tubular ectasia of the rete testis in an older male, medullary nephrocalcinosis seen as echogenic renal pyramids, the left renal vein in the transverse abdominal image, and measuring fetal head circumference at the level of the thalami and cavum septi pellucidi.
This document contains 3 figures and associated questions from a diagnostic radiology in-training examination. Figure 1 shows images from an F-18 FDG PET study in a man with abdominal pain. Figure 2 shows a posterior Tc-99m bone scintigram in a man with back pain. Figure 3 shows an anterior whole body Tc-99m bone scan in a woman with head and neck pain and a history of thyroid cancer. The questions assess the examinee's ability to interpret the images and select the most likely diagnosis.
This document provides rationales for questions on the 28th Annual In-Training Examination for Diagnostic Radiology Residents. It includes explanations for answers to 5 multiple choice questions related to pediatric radiology cases. The questions cover topics such as autosomal recessive polycystic kidney disease, everting ureterocele, necrotizing enterocolitis, non-accidental trauma, and vein of Galen aneurysm. The rationales discuss the findings in the images and explain why each answer choice is right or wrong based on those findings and typical presentations of the diseases.
This document provides rationales for answers on a diagnostic radiology exam related to musculoskeletal radiology. The case presented involves radiographs and MRI images of various musculoskeletal injuries and conditions. The correct diagnosis for each case is provided along with explanations for why the other answer choices are incorrect. Key details that help distinguish between similar conditions are emphasized, such as findings that are more or less typical for a given diagnosis. A variety of musculoskeletal injuries, abnormalities, and diseases are discussed.
This document contains 5 clinical case scenarios involving interventional radiology procedures (questions 265-269). Each case is accompanied by an image and 4 possible answers. The correct answer is identified and a brief rationale is provided for each case. Question 270-279 continue testing knowledge of interventional radiology with additional multiple choice questions related to procedures, techniques, and disease processes.
The 48-hour whole body In-111 pentetreotide images showed multiple focal areas of increased tracer uptake in both lobes of the liver, consistent with neuroendocrine tumor hepatic metastases. There was also a large focal area of increased uptake in the epigastric region in the expected location of the pancreas body. The most likely diagnosis given these findings is islet cell carcinoma of the pancreas. Pheochromocytoma, carcinoid tumor, lymphoma, and colon adenocarcinoma are less likely given the imaging findings.
This document provides rationales for questions on the 2005 American College of Radiology Diagnostic In-Training Examination for interventional radiology residents. It includes the questions, images associated with some questions, findings for each image, and rationales for the correct answers. The questions cover topics such as locations of dialysis catheters, diagnoses for angiograms, standards for uterine artery embolization, and indications for percutaneous nephrostomy.
- Echogenic intracardiac focus is most commonly seen as a normal variant on prenatal ultrasound but should prompt careful examination for other abnormalities.
- While it represents a normal variant, echogenic intracardiac focus has been associated with trisomy 13 and 21 but not trisomy 18.
- The majority (90%) of echogenic intracardiac foci are located in the left ventricle, not the right ventricle as stated in one response option.
This document contains a radiology case study with 4 images (Figures 1-4) and accompanying questions. Figure 1 shows a lateral cervical spine x-ray. The diagnosis is ankylosing spondylitis based on diffuse bony ankylosis throughout the cervical spine. Figure 2 shows MRI images of the knee with a diagnosis of discoid meniscus due to excessive meniscal tissue. Figure 3 shows x-rays of the leg with a diagnosis of Brodie's abscess, seen as an elongated lytic lesion in the tibia. Figure 4 shows knee images of a 13-year-old boy with a diagnosis of chondroblastoma, seen as a well-defined lesion in the proximal tib
A 23-year-old woman presented with hearing loss. CT showed a soft tissue mass in the left middle ear cavity eroding the scutum and demineralizing the ossicles. The most likely diagnosis is cholesteatoma, a common middle ear soft tissue mass.
A 68-year-old woman presented with left eye pain and proptosis. Angiography showed early filling of both cavernous sinuses and ophthalmic veins, indicating a carotid-cavernous fistula.
MR of a 6-month-old boy with vomiting showed a large enhancing mass in the left lateral ventricle with flow voids. The most likely diagnosis is a choroid plexus
The document describes 3 radiology case studies involving the gastrointestinal system:
1) A case of scleroderma diagnosed based on an x-ray showing dilation of the small bowel with closely spaced folds.
2) A case of appendicitis diagnosed on CT showing an enlarged appendix with periappendiceal inflammation and an appendicolith.
3) A case of a gastric leiomyoma diagnosed on barium study and CT showing a rounded filling defect in the stomach with central ulceration arising from the gastric wall.
A 15-year-old female volleyball player presented with low back pain without trauma. Bone scan showed increased uptake in the left L5 lamina. SPECT localized this to the pars interarticularis. Radiographs were normal. This is most consistent with a stress fracture of the left L5 pars interarticularis, a common injury in young athletes.
This document appears to be a series of questions and answers from a diagnostic radiology in-training examination. The questions cover topics in genitourinary tract radiology and ask examinees to identify diagnoses, classifications, or characteristics based on provided radiographic images and clinical scenarios. Rationales are given for each answer that provide additional radiologic and clinical details.
The document discusses images from radiology exams of the pelvis and genitourinary system. Figure 1 shows a sagittal MRI of the pelvis showing diffuse thickening of the junctional zone, consistent with adenomyosis. Figures 2A and 2B show an intratesticular mass on ultrasound, indicating seminoma. Figures 3A-C show an ovarian teratoma on ultrasound and MRI of the pelvis in a pregnant patient. Figure 4 shows a bladder tumor on CT scan in a patient with hematuria. Figure 5 shows a hysterosalpingogram indicating Asherman's syndrome. Figures 6A-C show renal cell carcinoma extending into the renal vein, stage IIIA by
Previous year question on bone cyst based on neet pg, usmle, plab and fmge or...Medico Apps
- Aneurysmal bone cyst cannot be diagnosed using fine needle aspiration cytology (FNAC) according to the document.
- FNAC of aneurysmal bone cyst shows only red blood cells and is inconclusive for diagnosis.
- Cystic lesions such as aneurysmal bone cyst, unicameral bone cyst, and some telangiectatic osteosarcomas yield specimens containing predominantly blood or fluid with little diagnostic cellular content making diagnosis via FNAC difficult.
This document contains a question bank covering various topics related to radiology of the cardiovascular system, bones, central nervous system, and other areas. Major questions cover topics like development of atrial and ventricular septum, techniques for angiography and its complications, etiology and imaging features of mitral stenosis, investigating cardiomegaly, pericardial effusion, pulmonary embolism, calcium metabolism and hyperparathyroidism, imaging bone tumors, spinal trauma, subarachnoid hemorrhage, and more. Short notes cover additional focused topics within each specialty.
Presentation2, radiological imaging of gastrointestinal schwannoma.Abdellah Nazeer
This document discusses radiological imaging findings of gastrointestinal schwannomas. Some key points:
- Gastrointestinal schwannomas most commonly occur in the stomach (60-70% of cases). On CT and MRI, they often appear as well-defined, hypodense masses that demonstrate homogeneous enhancement with contrast.
- While radiological imaging findings are nonspecific, gastrointestinal schwannomas typically have the appearance of a solitary mass, and immunohistochemical staining can aid in diagnosis.
- Schwannomas can also occur in rare locations like the pancreas, adrenal gland, retroperitoneum, abdominal wall, pelvis and liver. Imaging characteristics vary depending on the location but may include cystic degeneration
Presentation1, pet ct, functional mri and ct angiography in bone tumour.Abdellah Nazeer
This document discusses the use of PET/CT, functional MRI, and CT angiography in evaluating bone tumors. It provides the following key points:
1) PET/CT uses radioactive tracers like FDG to detect cancer cells through their increased glucose metabolism, allowing detection of tumors at early stages. The degree of FDG uptake does not necessarily correlate with a bone tumor's malignant potential.
2) Functional MRI techniques like diffusion weighted imaging and magnetic resonance spectroscopy provide additional tumor characterization by revealing water mobility and choline metabolites related to cellularity.
3) CT angiography is useful for determining a tumor's relationship to major blood vessels, though its role is now limited due to the capabilities of other modalities
Nuclear imaging techniques can evaluate renal function and detect abnormalities. Radiotracers that are filtered, secreted, or retained by the kidneys provide information. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) are measured to assess kidney function. Obstructions are identified by delayed tracer excretion. Diuretic renography distinguishes dilated but unobstructed systems from true stenoses. Techniques require specialized cameras but provide functional details and separate evaluation of each kidney without invasive procedures.
This document discusses musculoskeletal trauma, focusing on osseous trauma. It describes different types of fractures including complete, incomplete, and radiologically occult fractures. It provides details on imaging modalities used to identify occult injuries, including limitations of conventional radiography and benefits of MRI. Specific acute osseous trauma injuries like contusions, avulsion fractures, and their appearances on imaging are examined. The document also reviews chronic osseous trauma conditions, fracture description terminology, common fracture eponyms, and the stages of fracture healing.
The document discusses several radiology cases involving the brain and spine. Question 291 presents CT scans of a woman with headaches and asks for the most likely diagnosis of a fat-containing extraconal orbital mass. Question 292 shows MR images of a woman with extremity weakness and asks for the most likely diagnosis of multiple brain and spine lesions. Question 293 presents MR images of a man with back pain and asks for the diagnosis of a posterior spinal mass seen on the images.
This document contains a multiple choice question and rationales from a pediatric radiology exam. The question shows MRI images of a 22-week fetus and asks for the most likely diagnosis. The rationales eliminate the other answer choices of posterior urethral valves, multicystic dysplastic kidneys, and bilateral ureteropelvic junction obstruction. The correct answer is Autosomal Recessive Polycystic Kidney Disease, as the images show enlarged, fluid-intensity kidneys without urine production, typical of this condition.
This document provides rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam related to ultrasound imaging. It discusses the correct answers and rationales for questions regarding various pathologies seen on ultrasound of the uterus, testes, kidneys, abdomen and fetal anatomy. Key details include identifying a cornual pregnancy based on its location, tubular ectasia of the rete testis in an older male, medullary nephrocalcinosis seen as echogenic renal pyramids, the left renal vein in the transverse abdominal image, and measuring fetal head circumference at the level of the thalami and cavum septi pellucidi.
This document contains 3 figures and associated questions from a diagnostic radiology in-training examination. Figure 1 shows images from an F-18 FDG PET study in a man with abdominal pain. Figure 2 shows a posterior Tc-99m bone scintigram in a man with back pain. Figure 3 shows an anterior whole body Tc-99m bone scan in a woman with head and neck pain and a history of thyroid cancer. The questions assess the examinee's ability to interpret the images and select the most likely diagnosis.
This document provides rationales for questions on the 28th Annual In-Training Examination for Diagnostic Radiology Residents. It includes explanations for answers to 5 multiple choice questions related to pediatric radiology cases. The questions cover topics such as autosomal recessive polycystic kidney disease, everting ureterocele, necrotizing enterocolitis, non-accidental trauma, and vein of Galen aneurysm. The rationales discuss the findings in the images and explain why each answer choice is right or wrong based on those findings and typical presentations of the diseases.
This document provides rationales for answers on a diagnostic radiology exam related to musculoskeletal radiology. The case presented involves radiographs and MRI images of various musculoskeletal injuries and conditions. The correct diagnosis for each case is provided along with explanations for why the other answer choices are incorrect. Key details that help distinguish between similar conditions are emphasized, such as findings that are more or less typical for a given diagnosis. A variety of musculoskeletal injuries, abnormalities, and diseases are discussed.
This document contains 5 clinical case scenarios involving interventional radiology procedures (questions 265-269). Each case is accompanied by an image and 4 possible answers. The correct answer is identified and a brief rationale is provided for each case. Question 270-279 continue testing knowledge of interventional radiology with additional multiple choice questions related to procedures, techniques, and disease processes.
The 48-hour whole body In-111 pentetreotide images showed multiple focal areas of increased tracer uptake in both lobes of the liver, consistent with neuroendocrine tumor hepatic metastases. There was also a large focal area of increased uptake in the epigastric region in the expected location of the pancreas body. The most likely diagnosis given these findings is islet cell carcinoma of the pancreas. Pheochromocytoma, carcinoid tumor, lymphoma, and colon adenocarcinoma are less likely given the imaging findings.
This document provides rationales for questions on the 2005 American College of Radiology Diagnostic In-Training Examination for interventional radiology residents. It includes the questions, images associated with some questions, findings for each image, and rationales for the correct answers. The questions cover topics such as locations of dialysis catheters, diagnoses for angiograms, standards for uterine artery embolization, and indications for percutaneous nephrostomy.
- Echogenic intracardiac focus is most commonly seen as a normal variant on prenatal ultrasound but should prompt careful examination for other abnormalities.
- While it represents a normal variant, echogenic intracardiac focus has been associated with trisomy 13 and 21 but not trisomy 18.
- The majority (90%) of echogenic intracardiac foci are located in the left ventricle, not the right ventricle as stated in one response option.
This document contains a radiology case study with 4 images (Figures 1-4) and accompanying questions. Figure 1 shows a lateral cervical spine x-ray. The diagnosis is ankylosing spondylitis based on diffuse bony ankylosis throughout the cervical spine. Figure 2 shows MRI images of the knee with a diagnosis of discoid meniscus due to excessive meniscal tissue. Figure 3 shows x-rays of the leg with a diagnosis of Brodie's abscess, seen as an elongated lytic lesion in the tibia. Figure 4 shows knee images of a 13-year-old boy with a diagnosis of chondroblastoma, seen as a well-defined lesion in the proximal tib
A 23-year-old woman presented with hearing loss. CT showed a soft tissue mass in the left middle ear cavity eroding the scutum and demineralizing the ossicles. The most likely diagnosis is cholesteatoma, a common middle ear soft tissue mass.
A 68-year-old woman presented with left eye pain and proptosis. Angiography showed early filling of both cavernous sinuses and ophthalmic veins, indicating a carotid-cavernous fistula.
MR of a 6-month-old boy with vomiting showed a large enhancing mass in the left lateral ventricle with flow voids. The most likely diagnosis is a choroid plexus
The document describes 3 radiology case studies involving the gastrointestinal system:
1) A case of scleroderma diagnosed based on an x-ray showing dilation of the small bowel with closely spaced folds.
2) A case of appendicitis diagnosed on CT showing an enlarged appendix with periappendiceal inflammation and an appendicolith.
3) A case of a gastric leiomyoma diagnosed on barium study and CT showing a rounded filling defect in the stomach with central ulceration arising from the gastric wall.
A 15-year-old female volleyball player presented with low back pain without trauma. Bone scan showed increased uptake in the left L5 lamina. SPECT localized this to the pars interarticularis. Radiographs were normal. This is most consistent with a stress fracture of the left L5 pars interarticularis, a common injury in young athletes.
This document appears to be a series of questions and answers from a diagnostic radiology in-training examination. The questions cover topics in genitourinary tract radiology and ask examinees to identify diagnoses, classifications, or characteristics based on provided radiographic images and clinical scenarios. Rationales are given for each answer that provide additional radiologic and clinical details.
The document discusses images from radiology exams of the pelvis and genitourinary system. Figure 1 shows a sagittal MRI of the pelvis showing diffuse thickening of the junctional zone, consistent with adenomyosis. Figures 2A and 2B show an intratesticular mass on ultrasound, indicating seminoma. Figures 3A-C show an ovarian teratoma on ultrasound and MRI of the pelvis in a pregnant patient. Figure 4 shows a bladder tumor on CT scan in a patient with hematuria. Figure 5 shows a hysterosalpingogram indicating Asherman's syndrome. Figures 6A-C show renal cell carcinoma extending into the renal vein, stage IIIA by
Previous year question on bone cyst based on neet pg, usmle, plab and fmge or...Medico Apps
- Aneurysmal bone cyst cannot be diagnosed using fine needle aspiration cytology (FNAC) according to the document.
- FNAC of aneurysmal bone cyst shows only red blood cells and is inconclusive for diagnosis.
- Cystic lesions such as aneurysmal bone cyst, unicameral bone cyst, and some telangiectatic osteosarcomas yield specimens containing predominantly blood or fluid with little diagnostic cellular content making diagnosis via FNAC difficult.
This document contains a question bank covering various topics related to radiology of the cardiovascular system, bones, central nervous system, and other areas. Major questions cover topics like development of atrial and ventricular septum, techniques for angiography and its complications, etiology and imaging features of mitral stenosis, investigating cardiomegaly, pericardial effusion, pulmonary embolism, calcium metabolism and hyperparathyroidism, imaging bone tumors, spinal trauma, subarachnoid hemorrhage, and more. Short notes cover additional focused topics within each specialty.
Presentation2, radiological imaging of gastrointestinal schwannoma.Abdellah Nazeer
This document discusses radiological imaging findings of gastrointestinal schwannomas. Some key points:
- Gastrointestinal schwannomas most commonly occur in the stomach (60-70% of cases). On CT and MRI, they often appear as well-defined, hypodense masses that demonstrate homogeneous enhancement with contrast.
- While radiological imaging findings are nonspecific, gastrointestinal schwannomas typically have the appearance of a solitary mass, and immunohistochemical staining can aid in diagnosis.
- Schwannomas can also occur in rare locations like the pancreas, adrenal gland, retroperitoneum, abdominal wall, pelvis and liver. Imaging characteristics vary depending on the location but may include cystic degeneration
Presentation1, pet ct, functional mri and ct angiography in bone tumour.Abdellah Nazeer
This document discusses the use of PET/CT, functional MRI, and CT angiography in evaluating bone tumors. It provides the following key points:
1) PET/CT uses radioactive tracers like FDG to detect cancer cells through their increased glucose metabolism, allowing detection of tumors at early stages. The degree of FDG uptake does not necessarily correlate with a bone tumor's malignant potential.
2) Functional MRI techniques like diffusion weighted imaging and magnetic resonance spectroscopy provide additional tumor characterization by revealing water mobility and choline metabolites related to cellularity.
3) CT angiography is useful for determining a tumor's relationship to major blood vessels, though its role is now limited due to the capabilities of other modalities
Nuclear imaging techniques can evaluate renal function and detect abnormalities. Radiotracers that are filtered, secreted, or retained by the kidneys provide information. Glomerular filtration rate (GFR) and effective renal plasma flow (ERPF) are measured to assess kidney function. Obstructions are identified by delayed tracer excretion. Diuretic renography distinguishes dilated but unobstructed systems from true stenoses. Techniques require specialized cameras but provide functional details and separate evaluation of each kidney without invasive procedures.
This document discusses musculoskeletal trauma, focusing on osseous trauma. It describes different types of fractures including complete, incomplete, and radiologically occult fractures. It provides details on imaging modalities used to identify occult injuries, including limitations of conventional radiography and benefits of MRI. Specific acute osseous trauma injuries like contusions, avulsion fractures, and their appearances on imaging are examined. The document also reviews chronic osseous trauma conditions, fracture description terminology, common fracture eponyms, and the stages of fracture healing.
A nuclear renogram is a nuclear medicine scan that uses radioactive tracers injected intravenously to evaluate kidney function and detect obstructions over time. It provides information on perfusion, filtration, drainage and detects abnormalities. There are three main types of radiotracers - filtered agents show perfusion and drainage, excreted agents show tubular function, and cortical agents show scarring. A normal renogram will have uniform perfusion and prompt drainage curves for each kidney, while abnormalities like hydronephrosis or multicystic dysplastic kidney can be identified.
Through the eyes of young observers: Geographers Imagine, Image and Create Fu...becnicholas
How many times have we paused to consider what it is that goes on in the online worlds of young people? Should we just see their behaviour (and ours) as being that other world – be it Facebook, twitter, digital games or ‘research’ – or should we be aligning our teaching approaches with the realities of ever on networked spaces? If we take the latter approach and get networked in our teaching then what of the other world of real world spaces, real time and real people living their everyday lives. In truth geographers are in the ‘box seat’ to blend the new with the old. We can use the ever changing and expanding array of ‘apps’ and explore understandings of the world around us in ways that are dynamic and with opportunities to model alternative futures – all within the constructs of geography, its standards and its traditions. It’s the best time to be a geographer and we have a new curriculum that reflects the challenges of our times. Remember to look out the window!
Fuengirola Ayer y Hoy es un documento que describe cómo ha cambiado la ciudad de Fuengirola a través del tiempo, desde sus orígenes como pequeño pueblo pesquero hasta convertirse en un importante destino turístico en la actualidad, atraído por sus playas y clima cálido.
Working with the Australian Curriculum: Geography, Malcolm McInerney, AGTAbecnicholas
The document discusses the development of the Australian curriculum for geography. It presents an opportunity to evaluate geography courses, develop a 21st century curriculum, and promote geography as a dynamic subject. The long process of developing the curriculum involved many drafts, feedback periods, and revisions over several years. The document argues the curriculum should reflect new developments in geography and teach students to think geographically using key concepts. It also outlines the proposed structure and content of the new geography curriculum.
RememberItNow Presentation to U.S. Office of eHealth InitiativesMobile PRM
RememberItNow! recently presented their eHealth service to the U.S. Office of eHealth Initiatives in response to their request for information on new medication management technology.
Learn how RememberItNow! can improve medication compliance with SMS, Push and eMail medication reminders, an easy-to-use PHR, and a private care community.
Discover the future of eHealth and how it starts with the patient’s perspective. To learn more about RememberItNow! please visit:
http://www.rememberitnow.com
The document provides step-by-step instructions for creating an account and purchasing mobile currency through an app. It describes downloading the app, signing in, selecting the "Create Account" option, accepting terms, entering a control code to verify a purchase, and checking that the new account has been updated correctly.
This document summarizes the results of a message gap analysis conducted on 158 messages from 16 global companies. It found that about half of mainstream media messages did not reflect the companies' intended messages, and bloggers' messages had an even greater gap of 69%. Key insights include that aspirational language needs concrete facts to be picked up, companies should provide full context to avoid others shaping the narrative, industry jargon should be avoided, and bloggers are more likely than media to speculate and make competitor comparisons.
Legacies Old Media New Media Nahf Conf March 09Graham Richards
The document discusses traditional legacy marketing strategies and how charities can incorporate new media approaches. It emphasizes that both traditional and new media can be used complementarily to appeal to wider audiences. Some new media opportunities discussed include creating legacy microsites, using videos and social media, providing online memorial pages, publishing obituaries online, and treating all supporters as potential donors. The key message is that charities should make their online presence accessible, interactive, and focused on sharing real stories in order to engage more supporters and get results with legacy marketing.
NewStar is a recruitment agency that has been in business for over 5 years. They provide permanent and temporary staffing solutions as well as special project staffing. They understand organizations and industries to focus on delivering customized service. NewStar sources candidates effectively through online job boards and proactive searching. They conduct structured behavioral interviews, skills testing, and reference checks to find the best personality fits for unique job profiles. NewStar works with businesses of all sizes from small to large corporations and has offices in Canada, the United States and India.
Where We Are Today – The Current Landscape of Identity ManagementDuane Blackburn
This document summarizes a presentation by Duane Blackburn from MITRE Corporation on the current landscape of identity management. Some common themes from Blackburn's research and discussions with stakeholders are: the importance of identity management for collaboration and trust but challenges in managing identities across interconnected systems; the need for improved technologies, standards, privacy protections and governance; and that despite progress, governments still lack comprehensive identity management strategies. Blackburn also provided conceptual models of identity management and discussed depictions in Hollywood.
Keynote address at Innovation in Tertiary Education Services 2014 conference, Auckland, New Zealand, 5th May 2014.
Discusses how MOOCs are stimulating a climate of innovation and change in education online, shows case studies of innovative teaching formats in a range of Universities and Community Colleges.
Argues that MOOCs are performing at plateau of stable expectations, and that their greatest impact is a set of invigorated conversations around cost, access, quality and delivery of education.
Compares two interdisciplinary courses, one a blended/hybrid course at Harrisburg Community Colleges, and one offered later as a MOOC at UC Irvine, both using topic of Zombies as a vehicle.
Concludes that MOOCs have unleashed an innovative set of approaches across HE (rather than being in them selves innovative). Schools focussed on classroom delivery have an opportunity to re-invent what they do. Elite institutions can use the MOOC as an intermediary format for delivering their content across multiple formats
The document discusses gastrointestinal radiology and contains questions and answers about various gastrointestinal conditions and imaging findings. Question 226 asks which finding on helical CT with dynamic bolus contrast enhancement is the best prognostic indicator of acute pancreatitis. The correct answer is the presence of pancreatic necrosis.
The document discusses several radiology cases involving the genitourinary system. Case 1 involves color and Doppler ultrasound images of a transplant patient with elevated creatinine, showing an arteriovenous fistula is most likely. Case 2 shows a contrast-enhanced CT of a motor vehicle accident patient with bilateral non-enhancing kidneys, indicating bilateral renal arterial injury. Case 3 involves a contrast-enhanced CT pelvis image of a prostate cancer patient showing a bulbous contrast-filled structure at the uretero-vesical junction, consistent with a simple ureterocele.
This document discusses a case of a 46-year-old male who presented with abdominal pain after a laparoscopic cholecystectomy and was found to have a bile leak. An ERCP revealed a leak from the cystic duct stump that was treated with stent placement. Bile duct injuries are a risk of cholecystectomy and can be classified in various ways. Diagnosis involves imaging studies and treatment aims to redirect bile flow away from leak sites.
(FULL) CME Glass (of milk) Half Full copy.pdfgdbnqj7b9v
Dr. Firhan Bin Hassan presented a case of a 33-year-old woman with progressive dyspnea and pleural effusions. Investigation of her pleural fluid found high triglyceride levels consistent with a diagnosis of chylothorax. Further testing found the woman to be positive for ANA and have elevated IgG, supporting an underlying connective tissue disease as the cause of her chylothorax. Management involved treating the underlying condition medically while draining the pleural effusions. The case highlights the importance of a thorough diagnostic workup to identify the etiology of chylothorax to guide appropriate management.
The 9-year-old cat presented with a progressive hind limb mass, weight loss, pyrexia, heart murmur, and harsh lung sounds. Diagnostic testing revealed abnormalities consistent with disseminated mycobacterial infection involving the lungs, liver, kidneys, and bones. Acid-fast bacilli were identified on cytology of an aspirated kidney lesion, and subsequent PCR and culture confirmed Mycobacterium bovis infection. The cat responded well to antimicrobial therapy but later developed oral squamous cell carcinoma requiring euthanasia.
This document contains 5 radiology case studies with images and descriptions of findings. It tests the ability to diagnose common genitourinary conditions based on imaging features. The cases include:
1) A CT showing infundibular strictures in the kidney collecting system, most consistent with renal tuberculosis.
2) A non-contrast CT of a right adrenal hemorrhage seen as a mixed attenuation mass with surrounding stranding.
3) A renal arteriogram showing early venous filling, consistent with a congenital renal arteriovenous fistula.
4) A CT of a renal abscess seen as a fluid attenuation mass with a single air bubble.
5) An excretory
This document reviews various causes of bile duct strictures, including:
1. Benign conditions such as iatrogenic strictures, pancreatitis, gallstones, primary sclerosing cholangitis, and liver transplantation.
2. Malignant conditions like cholangiocarcinoma, pancreatic cancer, and ampullary carcinomas.
3. Miscellaneous rare causes including inflammatory pseudotumors, gallbladder cancer, and metastatic disease involving the bile ducts.
The document provides images from ERCP and MRCP procedures demonstrating examples of strictures from many of these conditions. It aims to help radiologists recognize the imaging appearances of different etiologies of bile duct strictures.
The document describes a case involving a chest x-ray and pulmonary angiogram findings in a 57-year-old female patient who presented with chest pain two weeks following a hemorrhagic stroke. The pulmonary angiogram shows multiple filling defects in the left main pulmonary artery and its branches, consistent with pulmonary embolism. While anticoagulation is usually the standard therapy for pulmonary embolism, it is contraindicated in this patient due to her recent stroke. Therefore, the best management option is placement of an inferior vena cava filter to prevent further pulmonary emboli while existing clots dissolve, as anticoagulation cannot be used due to her recent hemorrhagic stroke.
The document describes an ultrasound examination of a 25-year-old female with a palpable right adnexal mass. Longitudinal and transverse endovaginal images show a 4 cm predominantly cystic mass with a heterogeneous echotexture arising from the right ovary. This is most consistent with a dermoid cyst, as dermoids can appear cystic with an echogenic mural nodule or "dermoid plug".
This document discusses a case study of a cynomolgus monkey that underwent MRI imaging as part of a diagnostic evaluation. The MRI revealed an enlarged stomach and liver, and a narrowed opening from the stomach to the duodenum. Necropsy found the stomach filled with food, an empty intestine, and thickening of the pancreas around the opening of the pancreatic and biliary ducts. Histopathology determined the cause of death was obstructive pancreatic necrosis and pyloric stenosis, due to a primary blockage of the pancreatic duct that caused acute pancreatic death, narrowing of the opening from the stomach, malabsorption, and liver damage. This case demonstrates how enhanced imaging like MRI can improve diagnostics and
This document provides an overview of imaging diseases of the spleen. It begins with an introduction to the spleen's anatomy and function. Common imaging modalities for evaluating the spleen include CT, US, and MR. Patterns of splenic enhancement on imaging are described. Splenomegaly is defined on imaging as the spleen measuring greater than 13 cm or extending below certain anatomical landmarks. Causes of splenomegaly discussed include liver cirrhosis. Both cystic and solid splenic lesions are reviewed in detail, including simple cysts, abscesses, hemangiomas, and infections such as tuberculosis. Specific imaging findings that help characterize each splenic pathology are emphasized.
The CT scan of the liver showed no abnormalities. The liver appeared normal in size and density without any focal lesions, cysts, or signs of cirrhosis. The visualized intra- and extra-hepatic biliary ducts were also normal in caliber with no evidence of dilatation or obstruction.
This document provides background information and summarizes key principles regarding acute appendicitis. It begins by discussing the appendix's role in the digestive system and risk factors for appendicitis. The anatomy and pathophysiology of appendicitis are then described, noting that obstruction of the appendix is the underlying cause. Common presenting symptoms are reviewed, emphasizing that the classic presentation is seen in less than 50% of cases, making diagnosis challenging. Differential diagnoses and the role of laboratory tests, imaging, and clinical assessment in evaluation are also summarized. Throughout, it is stressed that diagnosis relies on integrating multiple factors rather than any single finding.
Squamous Cell Carcinoma in the Native Kidney of a Renal Transplant Recipient ...Apollo Hospitals
We are reporting a case of squamous cell carcinoma of the native kidney in a renal transplant recipient. A 54-year-old gentleman, a renal transplant recipient for three years, presented with flank pain. On evaluation he was found to have a mass in the upper pole of the left native kidney. Renal angiogram was done which showed a functioning trans-
planted kidney with a large mass arising from the upper pole of the left native kidney. He underwent nephrectomy. The histopathology reported a squamous cell carcinoma. He was given adjuvant radiotherapy to the tumor bed using image guided radiotherapy thereby delivering a differential dose to the high risk areas and preserving the surrounding normal structures. He developed a urethral nodule which was found to be a squamous cell carcinoma. The lesion was excised with clear margins. We present this case because it is rare and to discuss adjuvant management.
- A patient underwent right lung surgery for metastasis excision and later developed a pleural effusion suspected to be a chylothorax from damage to the thoracic duct
- Anterior lymphoscintigraphy image showed abnormal accumulation of radiopharmaceutical throughout the right side of the thorax, confirming a lymphatic leak
- Appropriate uptake was seen in abdominal and superior mediastinal lymphatics and within the liver and spleen
- The document discusses a chest radiograph and CT images of a 51-year-old man with shortness of breath. It shows bilateral perihilar opacities on chest radiograph and thin-walled cysts, ground glass opacities, and reticular opacities on CT.
- The most likely diagnosis is Pneumocystis carinii pneumonia. Findings are consistent with PCP including bilateral often perihilar reticular and ground glass opacification that may become confluent and cysts that are commonly multiple and have predilection for upper lobes.
- Other choices such as pulmonary alveolar proteinosis, cardiogenic pulmonary edema, idiopathic pulmonary fibrosis are
A 33-year-old woman presented with recurrent abdominal pain and jaundice. Imaging revealed a duodenal intussusception caused by a duodenal duplication cyst. Magnetic resonance imaging clearly depicted the cyst as the lead point for the intussusception and showed biliary dilatation. At surgery, a 4 cm cyst was removed from the duodenum. Histopathology confirmed it was a duodenal duplication cyst, a rare congenital anomaly usually diagnosed in childhood that can remain asymptomatic into adulthood.
The document describes an endoscopic retrograde cholangiogram (ERC) image from a 24-year-old female with jaundice. The ERC shows obstruction and dilation of the intrahepatic and extrahepatic biliary tree down to the cystic duct junction, where there is thinning of contrast and an apparent filling defect in the cystic duct. The findings are consistent with Mirizzi syndrome, which is partial or complete obstruction of the common hepatic duct caused by a stone lodged in the distal cystic duct.
Primary Small Cell Neuroendocrine Carcinoma of the Petrous Apex: A Report of ...IJBNT Journal
Small cell neuroendocrine carcinomas (SCNEC) are extremely rare in the head and neck region, known to be highly aggressive with poor prognosis. We report the second case in the literature of a poorly differentiated SCNEC involving the petrous apex of the temporal bone, and we present its management.
This document contains rationales for exam questions related to neuroradiology. Question 70 describes images showing increased T2 signal in the dorsal columns of the cervical spinal cord. The most likely diagnosis is subacute combined degeneration, which is caused by vitamin B12 deficiency and commonly presents with numbness in the hands. Question 71 concerns images of a child with seizures and developmental delay, showing features of holoprosencephaly. Question 72 discusses images of a man with seizures, showing a punctate calcification with ring enhancement, most consistent with cysticercosis given the patient's Hispanic ethnicity.
This document contains rationales for questions from the 2007 ACR Diagnostic Radiology In-Training Exam. The rationales provide explanations for the correct answers to multiple choice questions related to diagnostic radiology topics including test sensitivity and predictive values, medical ethics, and radiation safety. Specifically, one rationale discusses how the positive predictive value of a diagnostic test increases as the prevalence of a disease increases in a population. Another rationale examines the ethical requirement for physicians to be honest with patients about medical errors or complications. A third rationale identifies radon exposure as contributing the most to background radiation levels in the US.
The document discusses randomized controlled trials and which statements about them are true. It states that option C, "Randomization reduces the risk of an imbalance in factors which could influence the clinical course of the patients," is true. Randomization helps balance both known and unknown prognostic factors between treatment groups in a randomized controlled trial.
This document contains a series of chest radiograph and CT images along with questions about cardiac findings.
Image 1 shows calcification of the aortic valve on a lateral chest x-ray, consistent with aortic stenosis.
Image 2 shows calcifications in the wall of the left atrium on a non-contrast CT, related to prior endocarditis from rheumatic heart disease.
Image 3 demonstrates enlargement of the central pulmonary arteries and diminished peripheral vasculature on chest x-ray, characteristic of pulmonary hypertension due to emphysema (cor pulmonale).
Image 4 shows a defect in the superolateral aspect of the atrial septum on CT, consistent with a sinus
The document discusses breast radiology questions from an exam. Question 188 describes a case where a fibroadenoma was found on biopsy initially and a follow up mammogram 6 months later. The most likely diagnosis is a phyllodes tumor based on the description of phyllodes tumors typically appearing mammographically. Question 189 describes mammogram images and the most likely clinical presentation is peau d'orange skin in the left breast, indicative of inflammatory breast cancer. Question 190 involves calcifications on a mammogram and ductal carcinoma in situ is considered the most likely diagnosis.
The document is the rationales section from an in-training examination for diagnostic radiology residents sponsored by the American College of Radiology. It contains multiple choice questions in physics related to topics like radiation dose, CT, MRI, fluoroscopy, and radiography. For each question, the correct answer is identified and supported by a short explanation citing relevant references.
The document appears to be excerpts from an examination for diagnostic radiology residents, including four multiple choice questions and associated images regarding musculoskeletal diagnoses. Question #202 asks about a lateral tibial lesion in a child and provides images. The most likely diagnosis is osteofibrous dysplasia, characterized by a lobulated lucency in the anterior cortex associated with anterior bowing of the tibia.
This document contains information about the 28th Annual In-Training Examination for Diagnostic Radiology Residents, including sample test questions and rationales. The test is sponsored by the Commission on Education and Committee on Residency Training in Diagnostic Radiology of the American College of Radiology. Sample multiple choice questions are provided about various neuroradiology topics, such as diagnoses for different brain and spine imaging findings. Rationales are given for each answer choice.
One health condition that is becoming more common day by day is diabetes.
According to research conducted by the National Family Health Survey of India, diabetic cases show a projection which might increase to 10.4% by 2030.
8 Surprising Reasons To Meditate 40 Minutes A Day That Can Change Your Life.pptxHolistified Wellness
We’re talking about Vedic Meditation, a form of meditation that has been around for at least 5,000 years. Back then, the people who lived in the Indus Valley, now known as India and Pakistan, practised meditation as a fundamental part of daily life. This knowledge that has given us yoga and Ayurveda, was known as Veda, hence the name Vedic. And though there are some written records, the practice has been passed down verbally from generation to generation.
These lecture slides, by Dr Sidra Arshad, offer a simplified look into the mechanisms involved in the regulation of respiration:
Learning objectives:
1. Describe the organisation of respiratory center
2. Describe the nervous control of inspiration and respiratory rhythm
3. Describe the functions of the dorsal and respiratory groups of neurons
4. Describe the influences of the Pneumotaxic and Apneustic centers
5. Explain the role of Hering-Breur inflation reflex in regulation of inspiration
6. Explain the role of central chemoreceptors in regulation of respiration
7. Explain the role of peripheral chemoreceptors in regulation of respiration
8. Explain the regulation of respiration during exercise
9. Integrate the respiratory regulatory mechanisms
10. Describe the Cheyne-Stokes breathing
Study Resources:
1. Chapter 42, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 36, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 13, Human Physiology by Lauralee Sherwood, 9th edition
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
Cell Therapy Expansion and Challenges in Autoimmune DiseaseHealth Advances
There is increasing confidence that cell therapies will soon play a role in the treatment of autoimmune disorders, but the extent of this impact remains to be seen. Early readouts on autologous CAR-Ts in lupus are encouraging, but manufacturing and cost limitations are likely to restrict access to highly refractory patients. Allogeneic CAR-Ts have the potential to broaden access to earlier lines of treatment due to their inherent cost benefits, however they will need to demonstrate comparable or improved efficacy to established modalities.
In addition to infrastructure and capacity constraints, CAR-Ts face a very different risk-benefit dynamic in autoimmune compared to oncology, highlighting the need for tolerable therapies with low adverse event risk. CAR-NK and Treg-based therapies are also being developed in certain autoimmune disorders and may demonstrate favorable safety profiles. Several novel non-cell therapies such as bispecific antibodies, nanobodies, and RNAi drugs, may also offer future alternative competitive solutions with variable value propositions.
Widespread adoption of cell therapies will not only require strong efficacy and safety data, but also adapted pricing and access strategies. At oncology-based price points, CAR-Ts are unlikely to achieve broad market access in autoimmune disorders, with eligible patient populations that are potentially orders of magnitude greater than the number of currently addressable cancer patients. Developers have made strides towards reducing cell therapy COGS while improving manufacturing efficiency, but payors will inevitably restrict access until more sustainable pricing is achieved.
Despite these headwinds, industry leaders and investors remain confident that cell therapies are poised to address significant unmet need in patients suffering from autoimmune disorders. However, the extent of this impact on the treatment landscape remains to be seen, as the industry rapidly approaches an inflection point.
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
1. Section III – Nuclear Radiology
Figure 1A
Figure 1B
58. You are shown whole body images and selected spot images from a Tc-99m methylene
diphosphonate bone scintigram obtained in an adult male patient presenting with joint pain
(Figures 1A and 1B). What is the MOST LIKELY diagnosis?
A. Multiple cortical skeletal metastases
B. Osteomyelitis
C. Shin splints
D. Hypertrophic osteoarthropathy
1
Diagnostic In-Training Exam 2006
2. Section III – Nuclear Radiology
Question 58
Rationales:
A. Incorrect. Focal cortical metastases are uncommon, but do occur. However, the symmetrical metadi-
aphyseal distribution of the lesions and involvement of both the proximal and distal appendicular
skeleton are highly atypical for metastases. The clinical history of joint pain also points to other
more likely etiologies for the findings present.
B. Incorrect. Osteomyelitis may produce areas of increased cortical tracer uptake, secondary to perios-
titis associated with the active infectious process. Abnormality is not usually limited to cortical
areas alone, and is often more intense than the findings in this case. Furthermore, the bilaterally
symmetrical distribution of the findings is highly atypical for osteomyelitis.
C. Incorrect. Shin splints may also produce areas of increased uptake along the cortical surfaces of
long bones, as seen in this case. However, the findings in shin splints are usually confined to the tib-
iae, and most often involve primarily the diaphyseal regions, often with only low-level increased
uptake. Furthermore, involvement of the upper extremities would not be expected with shin splints.
D. Correct. The findings in this case are characteristic in appearance and location for secondary hyper-
trophic osteoarthropathy (formerly known as hypertrophic pulmonary osteoarthropathy or HPO).
This disorder is most often associated with intrathoracic lesions, such as primary lung neoplasms or
mesothelioma. It can also occur in association with other intrathoracic lesions, including bronchiec-
tasis, emphysema, lung infections, metastatic disease, etc. It may be seen in patients with congenital
heart disease, inflammatory bowel disease and lymphoma. Patients may present with joint pain,
clubbing and periosteal new bone formation on radiographs. The differential diagnosis also includes
pachydermoperiostosis and thyroid acropachy.
2 American College of Radiology
3. Section III – Nuclear Radiology
Figure 2A
59. You are shown serial 5-minute anterior images and final right anterior oblique and right lateral
images from a Tc-99m DISIDA hepatobiliary scan performed on a 55-year-old man with
abdominal pain, fever and ascites, s/p paracentesis (Figures 2A and 2B). What is the MOST
LIKELY diagnosis?
A. Acute cholecystitis
B. Bile leak
C. Common bile duct obstruction
D. Normal study
3 American College of Radiology
5. Section III – Nuclear Radiology
Question 59
Findings: There is prompt hepatic uptake, with early visualization of activity in the region of the gall-
bladder fossa. Faint, amorphous activity is noted inferior to the liver on the right, beginning at 10 min-
utes and better seen thereafter. In addition, there is accumulation of activity throughout the peritoneal
cavity, beginning at 15 minutes post-injection, and progressively increasing throughout the study. There
is also the appearance of abnormal linear activity along the inferior margin of the left lobe of the liver,
beginning at 25-30 minutes into the study and progressively increasing in intensity. The right lateral
image demonstrates activity spreading anterior to the liver, also consistent with intraperitoneal biliary
leakage. Hepatic clearance is also moderately prolonged.
Rationales:
A. Incorrect. The findings are not consistent with acute cholecystitis. There is prompt visualization of
the gallbladder as early as 5-10 minute post-injection, which essentially excludes acute cholecysti-
tis. Furthermore, acute cholecystitis does not explain the presence of biliary leakage present in this
case. Perforation of the gallbladder may occur in gangrenous cholecystitis, but that entity is virtual-
ly always associated with cystic duct obstruction, which would result in non-visualization of the
gallbladder as well.
B. Correct. The findings in this case described above are consistent with a relatively large bile leak,
most likely arising in the region of the gallbladder fossa. In this case, the findings may be secondary
to trauma from paracentesis.
C. Incorrect. There is prolonged hepatic clearance and non-visualization of the small bowel, both find-
ings that occur in the presence of common bile duct obstruction. However, in common duct obstruc-
tion, there is often complete non-visualization of the biliary tree, including the gallbladder, even in
the absence of cholecystitis. In addition, common duct obstruction is not usually associated with bil-
iary leakage, which is present in this case.
D. Incorrect. This study is not normal. A significant degree of biliary leakage is demonstrated, as
described above. Furthermore, the images also demonstrate prolonged hepatic clearance and non-
visualization of the small bowel, both of which are also abnormal findings.
5 American College of Radiology
6. Section III – Nuclear Radiology
Figure 3
60. A 2-month-old male with marked hypertension is referred for captopril renography. You are
shown serial 1-minute posterior pre- and post-captopril images (Figure 3). What is the MOST
LIKELY diagnosis?
A. Normal study
B. Right renal artery stenosis
C. Left renal artery stenosis
D. Bilateral renal artery stenosis
6 American College of Radiology
7. Section III – Nuclear Radiology
Question 60
Findings: The baseline pre-captopril study demonstrates mildly decreased tracer uptake bilaterally, with
normal excretion. The post-captopril images demonstrate significant bilateral deterioration in excretion,
with marked cortical retention noted bilaterally.
Rationales:
A. Incorrect. Although initial (left) study appears symmetrically normal, there is clearly a bilateral
delay in cortical clearance and excretion on the post-captopril study.
B. Incorrect. In unilateral right renal artery stenosis, ACE-inhibitor should create an asymmetric delay
in right renal washout, not the bilaterally delayed washout present in this case.
C. Incorrect. In unilateral left renal artery stenosis, ACE-inhibitor should create an asymmetric delay in
left renal washout, not the bilaterally delayed washout present in this case.
D. Correct. The post-captopril study fails to demonstrate sequential right and left renal pelvis and
bladder activity seen at midpoint of the baseline pre-captopril study. Administration of the ACE
inhibitor has produced a symmetric delay in renal cortical clearance, manifested by marked bilateral
cortical retention and non-visualization of the renal pelves and bladder. These findings are typical
for bilateral ACE-inhibition of compensatory post-glomerular vascular constriction, with resultant
delay in transcortical clearance, in this child with bilateral congenital renal artery stenosis.
7
Diagnostic In-Training Exam 2006
8. Section III – Nuclear Radiology
Figure 4
61. You are shown representative coronal, transaxial and sagittal images from an F-18 FDG
(fluorodeoxyglucose) PET scan (Figure 4). What is the MOST LIKELY diagnosis?
A. Lymphoma
B. Bronchogenic carcinoma
C. Esophageal carcinoma
D. Normal variant
8 American College of Radiology
9. Section III – Nuclear Radiology
Question 61
Rationales:
A. Incorrect. The abnormal uptake in this case is located in the posterior mediastinum, where adenopa-
thy due to lymphoma may occur. However, the linear configuration of the activity is characteristic
of esophageal activity, rather than the typical focal rounded appearance of adenopathy. Furthermore,
no other sites of adenopathy are present. The findings are characteristic of an esophageal neoplasm,
making squamous cell carcinoma or adenocarcinoma far more likely than lymphoma.
B. Incorrect. As discussed above, the linear uptake located in the posterior mediastinum is characteris-
tic in appearance for an esophageal neoplasm. There are no focal pulmonary nodules or foci of
mediastinal or hilar adenopathy, as would be anticipated in the presence of bronchogenic carcinoma.
C. Correct. The linear pattern of increased FDG uptake in the posterior mediastinum, in the expected
location of the esophagus, is characteristic in appearance for an esophageal neoplasm, most likely
representing squamous cell carcinoma of the esophagus.
D. Incorrect. Mildly increased uptake near the gastroesophageal junction may be seen as a normal vari-
ant, or in patients with gastroesophageal reflux. Mild diffuse esophageal uptake may also occur in
esophagitis. The uptake in this case is far more intense than would be anticipated as a normal vari-
ant, and the location of the activity remote from the gastroesophageal junction is not consistent with
a normal variant.
9
Diagnostic In-Training Exam 2006
10. Section III – Nuclear Radiology
Figure 5
62. A 28 year-old HIV positive woman presents with headache, papilledema, and a ring-enhancing
right thalamic mass on CT (not shown). You are shown a transaxial Tl-201 chloride image of the
brain (Figure 5). What is the MOST LIKELY diagnosis?
A. Lymphoma
B. Cytomegalovirus infection
C. Toxoplasmosis infection
D. Normal study
10 American College of Radiology
11. Section III – Nuclear Radiology
Question 62
Findings: Transaxial Tl-201 chloride SPECT images of the brain demonstrate a focal area of increased
tracer uptake near the midline, in the region of the CT lesion in the basal ganglia.
Rationales:
A. Correct. CNS lymphoma may produce a ring-enhancing lesion on CT and is thallium-avid. These
findings are most consistent with CNS lymphoma arising in an immunocompromised host.
B. Incorrect. CMV is not thallium-avid, as is the lesion in this case.
C. Incorrect. Toxoplasmosis can produce cerebral ring-enhancing CT lesion, but it is not thallium-avid,
as is the lesion in this case.
D. Incorrect. The focal area of increased tracer uptake in the midline basal ganglia region represents a
striking abnormality, which is not attributable to any normal finding. This is not a normal study.
11
Diagnostic In-Training Exam 2006
12. Section III – Nuclear Radiology
Figure 6
63. You are shown representative coronal, transaxial and sagittal tomographic radionuclide images
(Figure 6). Which one of the following radiotracers was MOST LIKELY utilized for
this study?
A. Tc-99m methylene diphosphonate
B. Tc-99m sulfur colloid
C. F-18 fluorodeoxyglucose
D. F-18 sodium fluoride
12 American College of Radiology
13. Section III – Nuclear Radiology
Question 63
Rationales:
A. Incorrect. The normal biodistribution of Tc-99m methylene diphosphonate (MDP) includes the axial
and appendicular skeleton, kidneys and bladder. The liver, spleen, mediastinum, and brain, which
are visualized in this case, are not seen on a normal bone scintigram.
B. Incorrect. The normal biodistribution of Tc-99m sulfur colloid includes intense liver and spleen
activity. Less intense activity is identified in the central bone marrow (skull, ribs, sternum, vertebral
bodies, pelvis, proximal humeri and femora). The most intense activity in this study is osseous.
Moderate activity is seen within the spleen and low level activity in the liver, mediastinum and
brain. This biodistribution is not typical for sulfur colloid.
C. Correct. The normal biodistribution of F-18 fluorodeoxyglucose (FDG) is accumulation in the
brain, myocardium, blood vessels, pharynx, liver, spleen, bone marrow, kidneys, ureters, urinary
bladder, and GI tract. Intense marrow uptake is seen in this patient with lymphoma after administra-
tion of granulocyte colony stimulating factor (G-CSF), which is given to support bone marrow func-
tion following therapy. Normal marrow uptake is usually less intense than hepatic uptake. While this
distribution is not normal, it is more characteristic of FDG than any of the other tracers listed.
D. Incorrect. The normal biodistribution of F-18 sodium fluoride is osseous, with uptake dependent on
regional blood flow and osteoblastic activity by chemisorption. Hydroxyl groups are exchanged to
form fluoroapatite in the hydroxyapatite crystals. Because of the superior spatial resolution and
three-dimensional localization afforded by PET imaging, there is a high sensitivity for the detection
of metabolically active skeletal lesions using F-18 sodium fluoride.
13
Diagnostic In-Training Exam 2006
14. Section III – Nuclear Radiology
64. Concerning subacute thyroiditis, serum thyroid hormone levels are elevated as the result of
which one of the following?
A. Increased thyroid hormone production
B. Increased TSH secretion by the pituitary gland
C. Release of pre-formed thyroid hormone into the circulation
D. Iodine excess in the thyroid gland
Question 64
Rationales:
A. Incorrect. Thyroid hormone production is reduced in subacute thyroiditis. The elevated thyroid
function tests and signs and symptoms of hyperthyroidism that occur early in the disorder are relat-
ed to release of pre-formed thyroid hormone into the circulation from the inflamed thyroid gland.
B. Incorrect. The increased thyroid hormone levels produced by the release of pre-formed hormone
into the circulation results in a feedback inhibition of TSH secretion by the pituitary, resulting in
decreased serum TSH levels.
C. Correct. Subacute thyroiditis is a viral disorder, often following a recent upper respiratory infec-
tion. The inflammatory response in the gland results in increased permeability and increased release
of pre-formed thyroid hormone into the circulation from the colloid. The increased serum thyroid
hormone levels, in turn, result in clinical evidence of hyperthyroidism, despite a low thyroid uptake.
D. Incorrect. The pathophysiology of subacute thyroiditis does not involve abnormalties in iodine
metabolism per se. The acute inflammatory response in this disorder is associated with decreased
iodide uptake and organification during the early stage of the disease.
14 American College of Radiology
15. Section III – Nuclear Radiology
Gallium-67 citrate scintigraphy is preferred over In-111 leukocyte scintigraphy in which one of
65.
the following entities?
A. Abdominal abscess
B. Infected joint prosthesis
C. Disk space infection
D. Inflammatory bowel disease
Question 65
Rationales:
A. Incorrect. While both radiopharmaceuticals are efficacious for the detection of abdominal abscesses,
Indium-111 leukocyte imaging is often preferred, as the result of the absence of potentially confus-
ing normal bowel activity, as occurs in Gallium-67 scintigraphy. This normal bowel uptake may
lead to false positive gallium studies.
B. Incorrect. Indium-111 leukocyte imaging is superior to gallium-67 scintigraphy in the evaluation of
suspected infected joint prostheses, in part related to the bone seeking properties of gallium, leading
to potential false positive gallium studies due to increased tracer localization secondary to increased
bone turnover in the absence of infection.
C. Correct. While sensitive for osteomyelitis, Indium-111 leukocyte scintigraphy has been found to be
less sensitive than gallium-67 scintigraphy for the detection of disc space infection.
D. Incorrect. Again, the absence of normal bowel localization makes In-111 leukocyte scintigraphy
better suited to the assessment of active inflammatory bowel disease. In gallium-67 scintigraphy,
normal bowel uptake, especially in the colon, can be incorrectly attributed to inflammatory bowel
disease.
15
Diagnostic In-Training Exam 2006
16. Section III – Nuclear Radiology
66. Concerning the presence of multiple focal “hot spots” on a Tc-99m macroaggregated albumin
(MAA) scan, which one of the following is CORRECT?
A. The study may need to be repeated on another day.
B. The patient is at risk for the development of acute hypoxemia.
C. A false positive study will result.
D. The patient has multiple arteriovenous malformations (AVMs).
Question 66
Rationales:
A. Correct. The finding of focal “hot spots” on a Tc-99m MAA scan indicates the aggregation of the
radiopharmaceutical into larger particles, which lodge in the pulmonary vascular bed. This artifact
may be produced by drawing blood back into the syringe during injection or by failing to resuspend
the particles prior to injection, in the event the dose is left sitting for a prolonged time after being
drawn up. While it is not associated with any adverse effects in the patient, these foci of increased
activity may obscure portions of the underlying lungs, resulting in the need to repeat the study after
significant radioactive decay has occurred.
B. Incorrect. While technically these foci do represent small, iatrogenic pulmonary emboli, they are
virtually never associated with any clinically demonstrable adverse effects. In general, pulmonary
perfusion imaging with Tc-99m MAA is associated with transient occlusion of less the 0.1% of the
pulmonary capillary bed. Thus, this occurrence is unlikely to produce acute hypoxemia.
C. Incorrect. While these “hot spots” may obscure underlying detail in evaluating pulmonary perfu-
sion, they are not associated with artifactual perfusion defects that would produce a false positive
study.
D. Incorrect. Pulmonary AVMs are associated with right to left shunting, permitting Tc-99m MAA par-
ticles to bypass the pulmonary capillary bed. Thus, AVMs would tend to produce focal perfusion
defects, rather than focal areas of increased tracer localization.
16 American College of Radiology
17. Section III – Nuclear Radiology
Concerning the analysis of radionuclide gated blood pool (MUGA) studies, which one of the
67.
following will result in an UNDERESTIMATION of the left ventricular ejection fraction?
A. Placement of the background region of interest over the splenic blood pool activity
B. Assignment of too small a systolic region of interest
C. Use of a single region of interest for both the systolic and diastolic frames
D. Inclusion of a portion of the left atrium in the diastolic region of interest
Question 67
Distractors: SCORE ALL CHOICES AS CORRECT
A. Placement of the background region of interest over the splenic blood pool activity
B. Assignment of too small a systolic region of interest
C. Use of a single region of interest for both the systolic and diastolic frames
D. Inclusion of a portion of the left atrium in the diastolic region of interest
Rationales:
A. Placement of the background ROI over the spleen will result in excessive background subtraction.
The relative effect of the extra background subtraction will be greater on the systolic ROI, which
has fewer counts, and therefore will not “cancel out”. Thus, the denominator of the ejection fraction
equation will be relatively reduced, resulting in an artifactually elevated, rather than reduced.
B. Too small of a systolic region will result in exclusion of value counts from the systolic region, mak-
ing the percentage change between systolic and diastolic counts appear to be larger than it actually
is. Again, this error would result in an artifactually elevated calculated ejection fraction.
C. This technique was initially used when the procedure was originally introduced. However, by using
the same region for both measurements, the systolic region extends beyond the actual margins of
the ventricle in end-systole, thus including background counts from adjacent structures, making the
apparent ejection fraction artifactually too low. For this reason, the standard method of analysis at
present requires assignment of separate diastolic and systolic regions of interest, in order to improve
the accuracy of the measurement.
D. Inclusion of a portion of the left atrium in the diastolic region of interest will have the effect of
introducing additional counts into the region that are not valid ventricular counts. Thus, the apparent
total end-diastolic counts will be inappropriately high, resulting in an apparent higher percentage of
ventricular emptying and a falsely elevated ejection fraction calculation.
17
Diagnostic In-Training Exam 2006
18. Section III – Nuclear Radiology
Concerning radionuclide myocardial perfusion imaging, which one of the following is NOT
68.
associated with an inferior wall perfusion defect on a stress Tc-99m sestamibi SPECT study?
A. Inferior wall exercise-induced ischemia
B. Prior inferior wall myocardial infarction
C. Left bundle branch block
D. Diaphragmatic attenuation artifact
Question 68
Rationales:
A. Incorrect. Inferior wall ischemia characteristically produces a perfusion defect in this region on
stress myocardial perfusion images. In the case of reversible ischemia, the defect would be expected
to resolve on a resting study.
B. Incorrect. An area of prior myocardial infarction typically produces a “fixed” perfusion defect,
which would be visible both on stress and resting images. Thus, from evaluation of stress images
alone, it cannot be differentiated from a defect due to exercise-induced ischemia, as in item A.
C. Correct. Left bundle branch block may be the result of myocardial ischemia or infarction, or may
be an incidental finding. It may produce perfusion abnormalities on myocardial perfusion scintigra-
phy in the absence of coronary artery disease. When it produces abnormalities, the most common
finding is a reversible perfusion defect in the interventricular septum, not in the inferior wall. In
patients with known left bundle branch block, it is preferable to perform a pharmacologic stress test,
using dipyridamole or adenosine, rather than treadmill exercise in conjunction with the imaging,
since this artifact is more commonly associated with the latter procedure.
D. Incorrect. Diaphragmatic attenuation artifact commonly produces apparent defects in the inferior
wall. These defects may or may not be present both on stress and resting images, and may be sus-
pected by inspection of planar rotating images from the raw data set. This artifact most often occurs
in male patients, and is more common in obese patients as well.
18 American College of Radiology
19. Section III – Nuclear Radiology
69. Which is an appropriate use of F-18 fluorodeoxyglucose (FDG) PET imaging in breast
carcinoma?
A. Screening
B. Initial staging
C. Differentiating between a pulmonary metastasis and a primary lung carcinoma
D. Treatment monitoring
Question 69
Rationales:
A. Incorrect. FDG PET imaging is not an appropriate or approved study for breast cancer screening.
Screening is best done by self-examination and periodic mammography, which are more sensitive
and cost-effective approaches to breast cancer screening.
B. Incorrect. FDG PET imaging is less sensitive for the initial staging of breast cancer than lym-
phoscintigraphy with sentinel lymph node biopsy. Very high sensitivity is provided by the latter
approach, particularly when immunohistochemistry techniques are utilized. This approach to staging
is rapidly becoming the standard of care for these patients.
C. Incorrect. FDG PET imaging is not capable of differentiating between a solitary pulmonary metas-
tasis and a primary lung tumor. In most cases, both lesions are associated with increased glucose
metabolism and thus, increased FDG uptake.
D. Correct. As is true for a number of neoplasms, FDG PET imaging is very sensitive and specific for
assessing the response to therapy in breast carcinoma, whether performed after the completion of
therapy (re-staging) or during the course of therapy (treatment monitoring).
19
Diagnostic In-Training Exam 2006
20. Section III – Nuclear Radiology
70. A post-menopausal woman with osteoporosis undergoes dual-energy x-ray absorptiometry
(DEXA) scanning, demonstrating marked osteopenia of the lumbar spine and hip, but normal
bone density of the distal forearm. What is the BEST explanation for these findings?
A. Inappropriate scanning of the dominant forearm rather than the non-dominant
B. Insensitivity of forearm bone density measurement secondary to preponderance of cortical bone
C. Underestimation of the bone density in the spine and hip secondary to arthritic changes
D. Scan performed too distally in the forearm
Question 70
Rationales:
A. Incorrect. While it is true that it is preferable to scan the non-dominant forearm or hip in DEXA
scanning, and scanning the dominant side could produce a higher bone density value, the differ-
ences between the dominant and non-dominant sides are often minimal, and this is therefore not the
best explanation for the findings.
B. Correct. The bones of the extremities, such as the radius and ulna, are composed primarily of corti-
cal bone, and contain relatively less trabecular bone than either the spine or hip. Quantitatively, the
extremities account for the majority of the whole body bone mineral content. Thus, bone density
measurements of the forearm are most valuable in patients with metabolic bone disease, or other
conditions associated with decreases in total skeletal calcium content. Post-menapausal osteoporosis
preferentially involves the trabecular bone initially, which is present in higher percentages in the
vertebral bodies and femoral neck regions. Therefore, forearm measurements tend to be relatively
insensitive for the early detection of post-menopausal osteoporosis.
C. Incorrect. In fact, the opposite is true. The presence of arthritic changes is most often associated
with falsely elevated bone density measurements, especially in the spine, secondary to increased
bone density at sites of spurring or sclerosis associated with arthritic involvement.
D. Incorrect. Again, the opposite is true. Moving from proximal to distal in the forearm, there is a pro-
gressive increase in the relative trabecular bone content. Typically, bone density measurements of
the forearm are performed in the distal third of the radius and ulna, in order to maximize the contri-
bution of trabecular bone in the measurement. Scanning more distally may also be performed, to
further increase the percentage of trabecular bone being evaluated. Thus, scanning more distally
would tend to decrease the measured bone mineral density of the forearm.
20 American College of Radiology
21. Section III – Nuclear Radiology
71. What is the most commonly cited threshold for the diagnosis of malignancy using standardized
uptake value (SUV) on PET imaging for a solitary pulmonary nodule?
A. 1.0
B. 1.5
C. 2.5
D. 3.0
Question 71
Rationales:
A. Incorrect. The correct value is 2.5.
B. Incorrect. The correct value is 2.5.
C. Correct. Many malignant lesions will greatly exceed this value, and some lesions with SUV values
< 2.5 are malignant, but 2.5 is the most commonly cited threshold for the diagnosis of malignancy
using SUV analysis.
D. Incorrect. The correct value is 2.5.
21
Diagnostic In-Training Exam 2006
22. Section III – Nuclear Radiology
Concerning infection imaging with In-111 labeled leukocytes, which one is CORRECT?
72.
A. Uptake is dependent on regional blood flow.
B. It is insensitive for the detection of inflammatory bowel disease.
C. Transient pulmonary uptake clears within 15 minutes post-injection.
D. It is more sensitive than Ga-67 citrate imaging for detection of Pneumocystis carinii pneumonia
(PCP).
Question 72
Rationales:
A. Correct. While not the sole determinant of uptake, the uptake of In-111 labeled leukocytes is
dependent upon regional blood flow. For example, a walled-off abscess without a direct blood sup-
ply will not accumulate In-111 labeled leukocytes, and may appear as a photopenic defect.
B. Incorrect. In-111 WBC imaging is very sensitive for active inflammatory bowel disease. It has
advantages over Ga-67 citrate imaging in this clinical setting, as a result of the absence of normal
bowel uptake of the tracer.
C. Incorrect. Transient lung uptake can be seen 4 hours after injection or even longer, sometimes mak-
ing the diagnosis of pulmonary infection difficult.
D. Incorrect. In-111 WBC’s are less sensitive than Ga-67 citrate for detecting chest infections, such as
PCP. As a result, Ga-67 citrate imaging is preferred in the clinical settings of suspected chest infec-
tion or in immunocompromised patients presenting with fever of unknown origin.
22 American College of Radiology
23. Section III – Nuclear Radiology
73. The Nuclear Regulatory Commission (NRC) mandates daily performance testing of the ioniza-
tion chamber radioisotope dose calibrator for which one of the following?
A. Geometry
B. Constancy
C. Linearity
D. Accuracy
Question 73
Rationales:
A. Incorrect. Assessment of the effects of geometry is required at time of initial setup or after alter-
ation/repair of well calibrator only. This insures that variations in radioactive dose volume or posi-
tion in counting chamber will not produce aberrant dose determination.
B. Correct. This daily mandated test measures instrument precision and is designed to show repro-
ducible readings day after day on all clinical energy settings. This is essentially a mini-accuracy test
that does not account for half-life of long-lived low, medium, and high energy sealed standards.
More or less rigor is applied, depending on whether a single 137Cs source is counted in all standard
energy settings (Tc99m, 201TI, 123I, 131I, etc.) and the same reading is compared day to day or a more
elaborate daily count of multiple sealed sources (57Co, 133Ba, 137Cs) is obtained. No more than a 5%
daily count rate variation is allowable.
C. Incorrect. Sequential assay of count rates of the same radioisotope from low to high activity, usually
by counting an initially high activity Tc-99m source as it decays over 48 hours. This multi-day
study can’t be performed daily, and is usually performed at installation, quarterly thereafter and
whenever the device undergoes repair.
D. Incorrect. Designed to insure correct readings throughout the entire energy spectrum clinically
encountered, this rigorous test requires reproduction of count rates with low, medium, and high
energy sealed standard sources 57Ba, 137Cs. This elaborate test is performed at installation of the
device, annually thereafter and whenever the device undergoes repair.
23
Diagnostic In-Training Exam 2006
24. Section III – Nuclear Radiology
74. For the man-made radiation contributions to the background radiation in the United States, which
of the following represents the MOST significant source of exposure to the U.S. population?
A. Medical x-rays
B. Radon
C. High-altitude air travel
D. Nuclear medicine
Question 74
Rationales:
A. Correct. Medical x-rays are the most significant source of man-made radiation sources. They con-
tribute an annual effective dose of 0.39 mSv or 39 mrem to the U.S. population.
B. Incorrect. Radon is a naturally occurring source of radiation.
C. Incorrect. High-altitude air travel adds to an individual’s cosmic ray exposure, and is of very small
quantity.
D. Incorrect. Nuclear does not contribute as much as medical x-rays as a source of exposure to the U.S.
population. They contribute an annual effective dose of 0.14 mSv or 14 mrem to the U.S. popula-
tion.
24 American College of Radiology
25. Section III – Nuclear Radiology
Which one of the following sets of I-123 thyroid scintigraphy findings and history of radiation
75.
exposure is associated with the LOWEST relative risk for thyroid carcinoma?
A. Multiple cold nodules with previous head and neck irradiation
B. Multiple cold nodules without prior head and neck irradiation
C. Solitary cold nodule without prior head and neck irradiation
D. Solitary cold nodule with previous head and neck irradiation
Question 75
Rationales:
A. Incorrect. This combination of scan findings and history is associated with the highest relative like-
lihood of malignancy of all those listed, in the range of 40%.
B. Correct. The finding of multiple cold nodules without prior radiation exposure is consistent with a
non-specific multinodular goiter, and carries a risk of underlying malignancy of only ~ 5%.
C. Incorrect. While the absence of prior head and neck irradiation reduces the likelihood of malignan-
cy, the prevalence of malignancy in patients presenting with solitary cold thyroid nodules is still in
the range of about 15-20% overall.
D. Incorrect. The history of prior head and neck irradiation significantly increases the likelihood of
malignancy in a patient with a solitary cold nodule, with the likelihood being somewhere in the
range of 30-40%, slightly lower than for option A.
25
Diagnostic In-Training Exam 2006
26. Section III – Nuclear Radiology
Which one of the following is NOT a normal site of F-18 fluorodeoxyglucose (FDG) localization?
76.
A. Salivary glands
B. Gallbladder
C. Colon
D. Kidneys
Question 76
Rationales:
A. Incorrect. Symmetrical salivary gland uptake is a normal finding on FDG PET imaging.
B. Correct. The gallbladder is not a normal site of FDG localization. Increased uptake in the gallblad-
der suggests the presence of cholecystitis or a neoplastic process within the gallbladder.
C. Incorrect. While variable in intensity and extent, colonic uptake of FDG is normal.
D. Incorrect. Renal uptake is almost always visualized on FDG PET studies. Renal excretion into the
collecting systems and bladder is also seen in the majority of cases.
26 American College of Radiology
27. Section III – Nuclear Radiology
77. What is the basic principle underlying the C-14 urea breath test for Helicobacter pylori
infection in patients with peptic ulcer disease?
A. Absence of urease in mammalian cells
B. Chemical breakdown of C-14 urea by gastric acid
C. Formation of C-14 labeled glucose
D. Renal excretion of C-14 urea absorbed from the stomach
Question 77
Rationales:
A. Correct. The basis of this study is that the Helicobacter pylori bacteria present in the stomach in
patients with this infection contain the enzyme urease, necessary for the breakdown of urea. This
metabolism of C-14 labeled urea results in the formation of C-14 labeled CO2 gas, which is then
detected using a liquid scintillation counter. In the absence of the bacterial infection, the cells of the
gastric mucosa, which lack the enzyme urease (like all mammalian tissue), are unable to break
down the urea, and thus no C-14 labeled CO2 gas is formed, resulting in a negative study.
B. Incorrect. The study has nothing to do with the presence or absence of gastric acid. Only the pres-
ence of the enzyme urease, found in the Helicobacter pylori organisms, but not in the gastric cells,
can break down the C-14 urea to form C-14 labeled CO2 gas.
C. Incorrect. The physiology of the study is as described above. In no way is the formation of glucose
or other aspects of carbohydrate metabolism involved.
D. Incorrect. Again, the metabolism of C-14 labeled urea by bacterial urease is the basis of the study.
Renal excretion is not involved, and no urine collections are performed. The study is performed by
having the patient ingest the radiopharmaceutical, followed by collection of two breath samples,
which are analyzed in a liquid scintillation counter for the presence of C-14 labeled CO2 gas.
27
Diagnostic In-Training Exam 2006
28. Section III – Nuclear Radiology
A patient with pernicious anemia had a normal Stage 1 Schilling Test. Which one of the
78.
following could explain the result?
A. Prior radioisotope study
B. Incomplete urine collection
C. Prior resection of terminal ileum
D. Concurrent vitamin B-12 therapy
Question 78
Rationales:
A. Correct. The situation described is one where the test yields a false-negative result in a patient with
pernicious anemia (as indicated in the history). Measurement of the excreted Cobalt-57 labeled vita-
min B-12 is performed by counting the urine. Typical window settings used for counting are 50-200
keV for the 122 and 136-keV photons of Cobalt-57. The presence of other radioactive material in
the urine that emits photons within the acceptance window will increase the measured counts, and
can result in an inaccurate determination of the excretion of the radiolabeled vitamin B-12.
B. Incorrect. The situation described is one where the test result is a false-negative. Incomplete urine
collection could result in a low measured excretion, and a false positive (not a false negative) result
C. Incorrect. The situation described is one where the test result is a false-negative. Prior resection of
terminal ileum could result in a reduced absorption of the orally administered vitamin B-12, and
thereby a low excretion
D. Incorrect. The situation described is one where the test result is a false-negative. Prior vitamin B-12
therapy may result in a low measured excretion, and a false positive study. The patient should not
receive parental vitamin B-12 for at least 3 days prior to the study. Biliary excretion of the previous-
ly administered vitamin B-12 may decrease the fractional absorption of the test dose. If it does not
get absorbed, it cannot get excreted into the urine, so measured excretion will be low.
28 American College of Radiology
29. Section III – Nuclear Radiology
79. In nuclear medicine, what is the main difference between an intrinsic uniformity and extrinsic
uniformity quality control test?
A. The intrinsic test is performed without the collimator, and the extrinsic test is performed with the
collimator.
B. The intrinsic test uses Co-57, while the extrinsic test uses Tc-99m.
C. The intrinsic test utilizes an internal electronic test mode of the gamma camera, while the extrin-
sic test utilizes an external flood source.
D. The intrinsic mode uses an internal calibration source within the gamma camera, while the
extrinsic test utilizes an external flood source.
Question 79
Rationales:
A. Correct. The intrinsic uniformity or flood test is performed without the collimator and is an indica-
tion of the uniformity of the camera itself. The extrinsic test is performed with the collimator on
using a large flood source.
B. Incorrect. Either source material may be used. Typically a syringe of Tc-99m at a distance several
time larger than the camera crystal is used for the intrinsic test, and the extrinsic test is performed
with a large water and Tc-99m filled flood source, or a solid Co-57 flood source.
C. Incorrect. Internal electronic checks are different from the measured uniformity tests.
D. Incorrect. There are no internal radiation sources to a gamma camera used for uniformity testing.
29
Diagnostic In-Training Exam 2006
30. Section III – Nuclear Radiology
80. Concerning the presence of hydrolyzed reduced Tc-99m in a dose of Tc-99m MDP (methylene
diphosphonate) administered intravenously for a bone scan, which is CORRECT?
A. It results in thyroid visualization.
B. It can be identified using a dose calibrator.
C. It is more likely to occur in the presence of excess stannous ion.
D. It occurs more commonly when multidose vials are used.
Question 80
Rationales:
A. Incorrect. Hydrolyzed reduced technetium-99m is a colloidal impurity that results in hepatic and
reticuloendothelial visualization, not thyroid visualization, which is typical of the presence of free
pertechnetate as an impurity.
B. Incorrect. Only chromatography pre-imaging will detect this radiopharmaceutical impurity.
C. Incorrect. On the contrary, Sn(II)ion is a reducing agent protecting MDP from hydrolysis.
D. Correct. The introduction of air into a multidose MDP vial is the most frequent cause of this
hydrolyzed technetium-99m contaminant. The more violations of the vial, the more likely air will
be introduced.
30 American College of Radiology
31. Section III – Nuclear Radiology
81. Concerning treatment of intractable pain from widespread metastatic bone lesions with
Metastron® (Sr-89) and Quadramet® (Sm-153), which one is CORRECT?
A. Both can be imaged using a gamma camera to assess the biodistribution of the therapeutic dose.
B. The longer half-life of Metastron (50 days) versus Quadramet (1.9 days) provides a superior
therapeutic effect.
C. Because of the highly energetic beta particles produced by both agents, a lead syringe shield is
employed during dose administration.
D. Recovery from bone marrow toxicity is faster following Quadramet administration.
Question 81
Rationales:
A. Incorrect. Metastron is a pure beta emitter. The absence of an imagable gamma photon precludes
verification of bone lesion uptake. By contrast, Sm-153 has an imagable gamma photon energy of
103 keV, permitting bone scintigraphy to be performed in conjunction with the therapeutic proce-
dure.
B. Incorrect. While it is true that the half-life of Metastron is significantly longer, resulting in more
prolonged lesion irradiation, the clinical efficacy of both treatments are quite similar.
C. Incorrect. Due to bremsstrahlung production of high energy photons when high atomic number
material (eg. lead) is used for shielding, acrylics are the preferred material for handling of these
materials. Materials with lower atomic numbers, such as plastic or acrylics make ideal shields. In
addition, bremsstrahlung production is proportional to the atomic number, which is lower for these
materials.
D. Correct. The major limitation of both therapies is myelosuppression. Metastron causes 15-30%
drops in the platelet and WBC counts from pre-injection values, and Quadramet, 40-50%. However,
8-12 weeks are required for full bone marrow recovery from Metastron, versus only 6-8 weeks for
Quadramet.
31
Diagnostic In-Training Exam 2006
32. Section III – Nuclear Radiology
82. Reduced occipital lobe glucose metabolism on F-18 FDG (fluorodeoxyglucose) cerebral PET
imaging is MOST common in which one of the following progressive dementias?
A. Alzheimer’s
B. Pick’s
C. Parkinson’s
D. Lewy body
Question 82
Rationales:
A. Incorrect. Alzheimer’s dementia at the earliest stages is associated with temporoparietal and later
frontal lobe FDG hypometabolism, with typical sparing of sensorimotor and visual cortex (occipital
lobe).
B. Incorrect. Pick’s disease is a degenerative dementia predominately involving frontal and temporal
lobes. Frontal hypometabolism precedes development of temporal hypometabolism. The visual cor-
tex is generally uninvolved.
C. Incorrect. Parkinson’s dementia is a late manifestation of a neurodegenerative disease, primarily
affecting the basal ganglia. There is occasional involvement of the occipital cortex, although tem-
poroparietal hypometabolism pattern similar to that of Alzheimer’s, but with additional striatal
hypometabolism, is a more common FDG pattern.
D. Correct. Decreasing cognitive function accompanied by visual disturbance including hallucinations
is common presentation in diffuse Lewy body disease (DLBD) which is becoming more widely rec-
ognized and accounts for up to 20% of all autopsy confirmed dementias. Medical and lateral occipi-
tal lobe FDG metabolism is more severely reduced in DLBD than other dementias. When identified
on FDG PET images, cholinergic therapy has been useful in controlling the disease.
32 American College of Radiology
33. Section III – Nuclear Radiology
83. Concerning the biodistribution of Indium-111 ibritumomab tiuxetan (Zevalin®) 48 hours
following intravenous administration, which one is CORRECT?
A. Persistent blood pool activity indicates the presence of a human anti-mouse antibody (HAMA)
response.
B. Absence of bone marrow activity indicates > 25% marrow infiltration by lymphoma.
C. Renal activity less intense than hepatic is indicative of altered biodistribution.
D. Hepatic activity more intense than bowel uptake is normal.
Question 83
Rationales:
A. Incorrect. The cardiac blood pool activity gradually decreases with time as Zevalin is distributed to
the other organs and a small component is excreted. Persistent but decreased blood pool activity is
normal at 48 hours. The development of a HAMA response occurs in < 2% of patients. More rapid
clearance of the Zevalin antibody can occur with the development of a HAMA response, and hence,
a shorter circulation time.
B. Incorrect. The Zevalin therapeutic regime should not be given to patient’s with greater than or equal
to 25% lymphoma marrow involvement. Altered biodistribution is suggested with rapid blood pool
clearance and increased marrow uptake.
C. Incorrect. Normal renal activity with Indium-111 Zevalin is generally manifested as faint activity
(moderately low to very low activity), which is much less intense than hepatic uptake. Altered renal
biodistribution is present if renal activity greater than liver is demonstrated on the posterior images.
D. Correct. Bowel activity is common and normal. However, normal gastrointestinal biodistribution is
activity that is less intense than liver and decreases over time (moderately low to very low intensi-
ty). Bowel activity more intense than hepatic uptake is indicative of altered biodistribution.
33
Diagnostic In-Training Exam 2006