1. Which of the following is the best test to determine the response of by linxiaoqin

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									1. Which of the following is the best test to determine the response of
chronic osteomyelitis to antibiotics?

     a.   Gallium-67 scan
     b.   sulfur colloid scan
     c.   Indium-111 WBC scan
     d.   Tc-99m MDP scan

Type- Nucs
Answers- a
Notes-

Mettler p.392, gallium accumulation in osteo decreases with ABX therapy,
will remain positive with Tc-99 MDP scanning due to residual remodeling
1993 Single Best Answer Question
by AE

2. Which of the following is true regarding Tc-99m HMPAO brain
scintigraphy?

      a. The effects of acetazolimide leads to increased regional blood
flow in areas of potential ischemia
      b. Better extraction than Tc-99m ECD
      c. Decrease activity during the luxury perfusion phase of a stroke
      d. 90% of Alzheimers patients demonstrate bilateral temporal-
parietal defects
      e. Focal decrease seen with HSV infection

Type- Nucs
Answers- d
Notes-

Tc-99m ECD and Tc-99m HMPaO have similar extraction rates.
Bilateral perfusion defects in the temporal-parietal region has a 80% PPV
for Alzheimers.
There is relative decrease in regional blood flow in areas of ischemia
with acetazolimide.
Increase perfusion during the luxury phase of a stroke.
1999 Board Question
by AE

3. Delayed tubular binding agents include:

     a.   Tc-99m glucoheptanate
     b.   I-131 Orthohippuran
     c.   Tc-99m DMSA
     d.   Tc-99m DTPA

Type- Nucs
Answers- a,c
Notes-

by AE
1997 Question
4. Tc-99m DTPA used in aerosol ventilation scintigraphy is primarily
cleared from the lungs by which of the following mechanisms?

     a.   fixes to brohchiole/alveolar epithelium and decays over time
     b.   expectoration
     c.   alveolar-capillary exchange
     d.   transpiration
     e.   ciliary transport

Type- Nucs
Answers- c
Notes-

by AE
1997 Question

5. Which is the least likely cause of non-skeletal uptake on bone scan?

     a.   Malignant effusion
     b.   Severe cirrhosis
     c.   Urinoma
     d.   Colon carcinoma

Type- Nucs
Answers- b
Notes-

by AE
1997 Question

6. Which of the following is true regarding the appearance of shin
splints on Tc-99 bone scan?

     a.   Normal
     b.   Hot on   first and   second phases, fades on third phase
     c.   Hot on   first and   second phases, normal third phase
     d.   Hot on   all three   phases
     e.   Normal   first and   second phases, hot on third

Type- Nucs
Answers- e
Notes-

by KW
Verified Dahnert p130
The term shin splint has been used as a general term for any exercise-
induced dull pain in the lower leg. The term is often overused as there
are various entities including stress fractures, myositis, periostitis,
tendinitis, and compartment syndrome that can cause leg pain. In the
nuclear medicine literature, however, the term has been applied to a
distinct clinical and scintigraphic entity. The symptoms include pain,
usually along the medial edge of the tibia, which is enhanced by running
but usually not of significant severity to cause complete cessation of
the offending activity. This is a somewhat different symptom complex from
that seen in more advanced stages of stress fracture where the
abnormality causes sufficient pain to completely preclude performance of
the particular activity. The characteristic scintigraphic finding is an
elongated region of moderate to intense radiotracer up-take along the
posteromedial or anterolateral tibial cortex on the delayed bone scan.
The abnormal activity is best visualized on the lateral view. In contrast
to the acute stress fracture, the arterial and blood pool phases are
normal. Also, shin splints are always associated with negative
radiographs. (TF)
1999 Board Question

7. Nuclear imaging is most sensitive for metastitic disease from what
subtype of thyroid cancer?

        a.   medullary
        b.   anaplastic
        c.   follicular
        d.   papillary

Type- Nucs
Answers- c
Notes-

by KH
1995 Question
not verified

8. Regarding nuclear scans for brain death:

      a. the hot nose sign is diagnostic
      b. delayed activity on HMPAO scan is suggestive
      c. study positive for brain death is invalidated if the patient is
on barbiturates

Type- Nucs
Answers- b
Notes-

by KH
1995 Question
not verified

9. Mechanism of sestamibi localization:

        a. binding to nonspecific cytoplasmic receptors
        b. active transport
        c. passive transport

Type- Nucs
Answers- a
Notes-

by KH
1995 Question
not verified

10. Which of the following items can be used to evaluate uniformity in
nuclear medicine Gamma cameras?

     a.    Technetium 99m and bar phantom
     b.    Cesium 137
     c.    Cobalt 57
     d.    point source of technetium 99m
     e.    Cobalt 60

Type- Nucs
Answers- c,d
Notes-

mettler40, to test for spatial resolution, several phantoms have been
developed. In general, they are either Lucite sheets embedded with lead
bars or a sheet of lead with holes in it.
1993 True/False Question
Cobalt-57 is used for extrinsic field uniformity (with collimator).
A point source of 200-400 microCi Tc-99m is used for intrinsic field
uniformity (without collimator). Uniformity tests are done daily.
Reference: Dahnert 1993, p. 652 For extrinsic field uniformity testing,
most labs use a phantom filled with uniform solution of Tc-99m or
permanent disk source of uniformly distributed Cobalt-57.
ref; Req. p 26 The girl who cant dance says the band cant play. Yiddish
Proverb.
by KH

11. Which of the following statements are true with regards to hot
nodules on thyroid scintigraphy?

      a.   A hot nodule with suppression of the remainder of the thyroid
gland is   diagnostic of an autonomous nodule
      b.   May represent well differentiated thyroid CA
      c.   Multiple hot nodules are diagnostic of Plummers syndrome

Type- Nucs
Answers- a,c
Notes-

mettler122, D324.
Per Ian Weissman.
Plummers is toxic nodular goiter.
In toxic multinodular goiter, there may be multiple small regions of
hyperactive thyroid tissue. Occasionally, several clearly defined hot
nodules are present. Even in the presence of hyperfunctioning nodules,
the remainder of the thyroid may not be suppressed because of autonomy
present within it. This is unlike the findings with a solitary
hyperfunctioning nodule, when virtually no extranodular tissue may be
visible. Assuming that an abnormality on scan corresponds to a
functioning nodule, and not to a region of normal thyroid surrounded by
nonfunctioning tissue (e.g., focal thyroiditis), the hot nodule may
represent either a TSH-independent, autonomous lesion or a TSH-dependent
lesion. Neither autonomy of the nodule nor the presence of a hot nodule
in general indicates hyperfunction of the thyroid. In fact,
hyperthyroidism secondary to a functioning nodule is usually seen only
with rather large nodules. Establishing the functional status of a nodule
is extremely important, since a true hot nodule is virtually never
malignant. Although there have been reports of cancer coexisting with a
hot nodule, these appear frequently to be incidentally noted occult
carcinomas that happen to be located adjacent to a benign lesion. For all
practical purposes, a hot nodule is a benign lesion, generally an
adenoma.
1999 Board Question
by KH

12. Which of the following steps is blocked by captopril?

     a.   Angiotensin I to angiotensin II
     b.   Renin to angiotensinogen
     c.   Effect of renin on efferent glomerulus
     d.   Angiotensinogen to angiotensin I
     e.   Effect of renin on afferent glomerulus

Type- Nucs
Answers- a
Notes-

Captopril is an ACE(angiotensin converting enzyme) inhibitor.
Blocks Angiotensin I to angiotensin II
1999 Board Question
by CM

13. Which of the following will not show increased uptake on all three
phases of a bone scan?

     a.   Healing fracture
     b.   Soft tissue necrosis distal great toe
     c.   Osteoblastoma
     d.   Osteomyelitis treated with antibiotics for one week

Type- Nucs
Answers- b
Notes-

d. Osteoblastoma 100% on bone scan. (D106) Osteomyelitis 100% on 3-
phase bone scan. (D109-111) Healing fracture abnormal in 95%. Soft
tissue necrosis only if it has dystrophic calcification.
1998 Board Question
by CM

14. Which of these have decreased uptake of thallium:

      a. An 85% stenosis of the left coronary artery at rest
      b. The uptake of thallium given the history of a previous
myocardial infarction
      c. An 85% stenosis of the left coronary artery immediately post
exercise

Type- Nucs
Answers- b,c
Notes-

Mettler p131
Stenosis up to 90% may not have abnormal Thallium uptake
85% stenosis at rest probably wrong
by KW
Verified Dahnert p918
Stenosis >75% yields abnormal uptake with 86% sensitivity
1989 Board Question

15. Which relationships are true regarding bone scanning?

      a. Increased activity only on delayed imaging is seen with
Osteoblastoma
      b. Hot on all three phases is seen with Osteoblastoma
      c. Mixed hot and cold areas are seen with Neuroblastoma mets

Type- Nucs
Answers- b,c
Notes-

Osteoblastomas, osteoid osteomas, chondroblastomas, and giant cell tumors
usually have intense activity on delayed images. mettler299
overall sensitivity of detection better than radiography, purely lytic
lesions may present as photopenic areas, soft-tissue uptake of Tc-99m
phosphate in 60% D258
a,c
1998 Board Question
by KH

16. With regards to a thyroid lesion, which of the following is most
suggestive of malignancy?

     a.   Cystic changes
     b.   Increased doppler flow around the periphery of the lesion
     c.   Hyperechoic matrix
     d.   Peripheral rim of calcification
     e.   Punctate calcifications

Type- Nucs
Answers- e
Notes-

(Primer p581) Thyroid cancer is typically hypoechoic and has poorly
defined margins. One feature that should prompt particular concern is
microcalcifications. (RUS 451)
1999 Board Question
by CM
17. With regards to Tc-99m labelled RBCs for a GI bleeding study, which
of the following is false?

      a. Can be used for an upper GI bleed
      b. 24 hour imaging adds little information with regards to
localization
      c. More sensitive than sulfur colloid for intermittent bleeding
      d. Movement of counts within the abdomen is necessary for
localization

Type- Nucs
Answers- b
Notes-

Dahnert p.927--Two agents have been used historically, Tc-99m labeled
RBCs and Tc-99m sulfur colloid.
Tc-99m SC is not very sensitive for intermittent bleeding b/c it is
rapidly cleared from blood by the RES system, it also cannot be used for
upper GI bleed due to uptake in the liver and spleen.
Tc-99m labeled RBCs can be used for active and intermittent bleeding, as
well as upper GI bleed.
1999 Board Question
by AE

18. 3 mCi Tc MAA for a lung scan is given to a nursing mother:

      a.   give 200 mg Kcl to the baby for one day
      b.   give lugol to the mother for 3 days
      c.   bottle feed the baby for 24 hours, then return to the breast
feeding
      d.   bottle feed the baby for a week, then return to the breast
feeding
      e.   give lugol to the baby for 3 days

Type- Nucs
Answers- c
Notes-

according to table in Mettler, p.449
1988 Board Question
by AE

19. A 30 y/o woman who is otherwise healthy presents with a 1 day history
of shortness of breath and chest pain. Chest radiograph and EKG are
normal. Ventilation-perfusion scan reveals 5 small peripheral segmental
perfusion defects with a normal ventilation component. Which of the
following is most appropriate?

      a. admit the patient and schedule elective pulmonary angiography on
the following day
      b. perform emergent pulmonary angiography
      c. repeat the ventilation-perfusion scan in 48 hours
      d. begin the patient on anticoagulant medication with no further
studies needed
      e. no need for further imaging, do not begin patient on
anticoagulant medication

Type- Nucs
Answers- b
Notes-

1995 Single Best Answer Question
by MH

20. A 31 yr old woman presents with a tender thyroid and sore throat.
She appears nervous and T4 level are markedly elevated. Radio-iodine
uptake was less than 1%. Most likely diagnosis:

     a.   Subacute thyroiditis
     b.   Hashimotos thyroiditis
     c.   Factitious thyroiditis
     d.   Graves disease
     e.   Acute suppurative bacterial thyroiditis

Type- Nucs
Answers- a
Notes-

Subacute thyroiditis usually presents as a pinful swollen gland with
elevated circulating thyroid hormone levels but with markedly depressed
radioiodine uptake. Attempts at imaging with radioiodine or Tc99m
pertechnetate usually show little or no localization of
radiopharmaceutical in the gland. Mettler117.
C.Acute suppurative thyroiditis is caused by bacterial or fungal
infection of the thyroid and is extremely uncommon. The diagnosis of this
entity is usually not difficult, and thyroid scanning would generally not
be performed. A much more common abnormality is subacute (De Quervian)
thyroiditis, which is thought to be caused by viral infection. These
patients generally present with a painful, tender, and enlarged thyroid,
and signs of hyperthyroidism are frequently present secondary to an
outpouring of thyroid hormone into the blood from the inflammed thyroid.
The natural history is variable, but over the subsequent weeks to months,
the hyperthyroid phase is succeeded by euthyroid and sometimes
hypothyroid stages, before the gland recovers and function returns to
normal. The scan appearance changes significantly during the course of
the disease. Initially, the gland is inflammed and functions poorly, with
very low radioiodine uptake. Although the scan may not allow any
evaluation of morphology, the low uptake is an important piece of
information in diagnosing the cause of the patients hyperthyroidism,
particularly if the clinical presentation is not typical. As the patient
progresses through the hypothyroid and recovery phases, the radioiodine
uptake gradually increases to the normal range, in some patients
transiently rising above normal. Occasionally, subacute thyroiditis can
present with a focal pattern of involvement. The scan in these patients
will demonstrate localized zones of decreased tracer uptake rather than
the diffuse abnormality that is usually seen. (TF)
INCREASED UPTAKE
Graves disease
Toxic multinodular goiter
Toxic solitary nodule
Hashimotos thyroiditis (usually early)
Iodine deficiency
Dyshormonogenesis
Following recovery from subacute thyroiditis or antithyroid drug therapy
DECREASED UPTAKE
Hypothyroidism, primary or secondary
Exogenous thyroid hormone
Iodine load
Hashimotos thyroiditis
Subacute thyroiditis
Painless thyroiditis (TF) mettler109
1998 Board Question
by KH

21. A 40 y/o woman with a family history of thyroid disease has had a
sore throat, neck pain, tremulousness, and restlessness for 4 weeks. Her
T3 and T4 are both elevated. She undergoes I-123 scan 8 weeks after a
contrast-enhanced CT study. Her uptake is <1%. She has:

     a.   acute suppurative thyroiditis
     b.   thyroiodine intoxication
     c.   Hashimoto thyroiditis
     d.   Graves disease
     e.   subacute thyroiditis (also called Dequervain thyroiditis)

Type- Nucs
Answers- e
Notes-

(D p335)
1994, 1992 Single Best Answer Question
Subacute thyroiditis typically presents with symptoms of hyperthyroidism
and
increased T3 and T4 but very low thyroid uptake. It usually follows a
viral illness - typically measles, mumps, rubella, coxsackie, or
influenza. It presents with a tender gland, adenopathy, hyperthyroidism,
thyromegaly, and can be painful. None of the other choices listed are
painful.
Hashimoto thyroiditis is characterized by autoantibodies to thyroid
tissue and
thyromegaly. It may be accompanied by hyperthyroidism, hypothyroidism,
or normal thyroid function. A thyroid scan may reveal uniform increase
uptake, a multinodular goiter, or diffusely poor uptake. Occasionally it
may be difficult to distinguish from Graves disease.
Suppurative thyroiditis results from bacterial infection and is rare.
While iodinated contrast may lower subsequent levels of thyroid uptake,
by 8
weeks after the CT scan it should not be <1%. We typically wait about 3
months after contrast-enhanced CT before doing an uptake measurement to
assure that there is no effect from iodinated contrast.
by CM
22. A 54-year-old man with history of coronary artery disease and
previous MI undergoes cardiac PET imaging evaluation. An area of
myocardium is identified in the LAD distribution with demonstrates
decreased activity following N-13 ammonia infusion. The same area
demonstrates increased uptake following administration of FDg. The most
likely explanation for these findings is?

     a.   Scar with collateral circulation
     b.   Scar
     c.   Normal myocardium
     d.   Hibernating myocardium
     e.   Stunned myocardium

Type- Nucs
Answers- d
Notes-

according to Mettler, the best answer would be myocardial ischemia( FDG
ia a marker for glucose which the heart uses during anaerobic metabolism)
Stunned - hypokinetic with normal perfusion/fdg
Hibernating - hypokinetic with decreased perfusion/normal fdg
According to Dr. Kim and Bidani.
The advantages of 13-N ammonia for myocardial blood flow include rapid
clearance from blood and high myocardial extraction (80% to 90%) and
retention (82%), which results in high contrast myocardial images. A
linear relationship was observed between microspheres and 13-N ammonia
for myocardial blood flow. Potential disadvantages of 13-N ammonia are
that it is probably retained in the myocardium by metabolic trapping
mainly by the glutamic acid-glutamine pathway. Therefore, 13-N ammonia
may not accurately reflect blood flow during conditions such as extremely
low pH or reduced intracellular ATP. In addition, a recent study
indicates that after intravenous injection 13-N ammonia is rapidly
converted to metabolic intermediates, making quantitation problematic.
In patients with recent infarction two patterns were observed: (1) a
concordant decrease in 13-N ammonia and FDG up-take, and (2) a relative
increase in FDG uptake compared with blood flow. This latter pattern was
predominantly observed in patients with persistent symptoms and signs of
ischemia and is thought to represent viable myocardium that is still able
to metabolize glucose anaerobically. This pattern of relatively increased
FDG uptake compared with blood flow was also observed in patients with
acute myocardial infarction and predicted patients in whom wall motion
improved over time.
Infarcted myocardium is characterized by decreased myocardial blood flow
and concordantly decreased uptake of a metabolic tracer.
Just as for glucose, the glucose analog FDG, is taken up by the myocyte
using facilitated transport and undergoes phosphorylation, but it does
not then undergo further glycolysis or glycogenolysis and does not
readily diffuse out of the myocyte; therefore it is effectively trapped.
FDG is an excellent tracer of exogenous glucose uptake and
phosphorylation.
1999 Board Question
by AE
23. A 57 year old male is undergoing a dipyridamole stress Thallium
examination. During dypyridamole administration the patient begins to
complain of severe chest pain radiating to the left arm. The most
appropriate next step should be?

     a.   Stop dipyridamole and administer nitroglycerine
     b.   Stop dipyridamole and administer B-Blockers
     c.   Stop dipyridamole and administer aminophylline
     d.   Titrate down the dipyridamole drip until symptoms resolve
     e.   Titrate down the dipyridamole drip and increase IV fluids

Type- Nucs
Answers- c
Notes-

Mettler155
1999 Board Question
by MH

24. A 65 yr old female is s/p total thyroidectomy 2 days prior for
papillary cell Ca. Which should be done?

     a. Begin immediate thyroid hormone replacement
     b. Undergo total I-131 scanning with ablation in 4-6 weeks
     c. Have serum calcium and phosphate levels drawn

Type- Nucs
Answers- b,c
Notes-

anaplastic and medullary CA do not concentrate I-131 and are not detected
by iodine scanning
Serum calcium and phosphate need to be checked because parathyroids may
have been removed also.
1998 Board Question
by AE

25. A 71-year-old man has a MUGA test. His resting ejection fraction is
52%. With exercise his ejection fraction is 51%. Which of the following
are true?

     a.   the resting EF is normal
     b.   the exercise EF is normal
     c.   normal resting EF should be at least 55%
     d.   the decrease of EF exercise is expected

Type- Nucs
Answers- c
Notes-

In most laboratories, a normal left ventricular ejection fraction is at
least 50% and usually is greater than 55%. A normal right ventricular
ejection fraction is greater than 40%. mettler169. In normal subjects,
the left ventricular ejection fraction increases during maximal exercise,
usually by more than 5 percentage points (ejection fraction units) above
resting levels. Failure of the left ventricular ejection fraction to
rise by 5%, or a decrease during peak exercise, is considered abnormal.
However, particularly young women, the elderly (older than 60years), and
patients with high resting ejection fractions (more than 70%), a
signigicant incrase in ejection fraction with exercise may not occur.
mettler176-177.
1989, 1988 True/False Question
Normal resting ejection fraction should be greater than or equal to 55%
and should rise by at least 5% with exercise (except in young females and
in patients with high baseline ejection fractions - in this case the EF
should increase by at least 3%).
by KH

26. A hot area on MAA lung scan could be due to:

     a.   Abscess
     b.   Clot in the syringe before injection
     c.   AVM
     d.   Bronchogenic CA
     e.   old PE

Type- Nucs
Answers- b
Notes-

by KW
Requisites p134
1988 Board Question

27. A LEAP collimator:

     a.   none of the above
     b.   is more sensitive to lateral decentering
     c.   pinhole is more sensitive
     d.   is designed to operate similar to an I-131 collimator

Type- Nucs
Answers- a
Notes-

1992 True/False Question
A Low Energy All Purpose collimator is a parallel hole collimator, so it
is not
sensitive to lateral decentering.
The pinhole collimator is less sensitive to tracer activity but has
better resolution
and therefore has greater sensitivity for detecting disease.
I-131 is high energy so needs a high energy collimator with thick septa.
A low energy collimator is designed to be used with radionuclides whose
emissions are up to 150 keV; it is used for technetium-99m and thallium-
201. A
medium-energy collimator is designed for radionuclides with emissions of
up to 400 keV;
it is used for I-131 and indium-111.
by AE

28. A lung scan which shows decreased perfusion in lower lobes may be
seen in:

     a.   Pericardial effusion
     b.   Alpha-1-antitrypsin disease
     c.   Mitral disease
     d.   CHF

Type- Nucs
Answers- b,c,d
Notes-

D378
1988 Board Question
by MH

29. A nonfunctioning thyroid nodule in a child:

     a. is more likely to be malignant than in an adult
     b. is less likely to be malignant than in an adult

Type- Nucs
Answers- a
Notes-

Not Verified
1993 Board Question

30. A patient is found to have low arterial oxygen saturation which does
not improve with the administration of 100% O2. Venous oxygenation is
normal. The most likely explanation for these findings is?

     a.   Diffusion abnormality
     b.   Ventilation-Perfusion mismatch.
     c.   Right-to-left shunt
     d.   Left-to-right shunt

Type- Nucs
Answers- c
Notes-

the blood passing through the shunt is not exposed to the lungs,
therefore not affected by 100% O2.
1999 Board Question
by AE

31. A patient receives 5000 rads to the L3 vertebral body over 4 weeks.
Which of thefollowing radionuclide uptake patterns is seen on a bone scan
6 months later?

     a. increased activity in the entire lumbar spine
     b. increased activity at L3
     c. decreased activity at L3
     d. decreased activity in the entire lumbar spine

Type- Nucs
Answers- c
Notes-

1993 Single Best Answer Question
Following XRT, there is an initial (first few weeks) increase in activity
in the
portal. If >2000 rads have been given, there is a subsequent decrease in
activity within 2-
3 months. This persists for at least 12 months.
The answer to the above question assumed that the entire L-spine was not
in the
radiation portal.
Reference: Gottschalk, p. 1058
by MH

32. A patient who had an MI three years ago is shown to have and 80%
stenosis on cardiac catheterization. Heart examination with
radioactivity labeled ammonia shows decreased activity and evaluation
with F18-labeled FDG shows increased activity. The most likely cause is:

     a.   infarct
     b.   scar
     c.   hibernating myocardium
     d.   stunned myocardium
     e.   ischemia and scar

Type- Nucs
Answers- c
Notes-

1994 Single Best Answer Question
Hibernating myocardium refers to severe, chronically ischemic tissue that
is
viable but appears cold on thallium imaging and nonfunctional on
echocardiography.
PET imaging will demonstrate increased F18-labeled-FDG uptake (over dead
myocardium, over ischemic myocardium, or above normal ????). (Thrall, p.
60).
Stunned myocardium is myocardium in the distribution of an acutely
ischemic
area -- this may not survive. Stunned myocardium usually will take up
thallium.
by AE

33. A pregnant woman is 7 months pregnant, has a history of breast
carcinoma, and has new onset right hip pain. Tc-99m-MDP bone scan
should:

     a. not be performed because the Tc-99m interferes with therapy
      b. not be performed because the patient is known to have breast
carcinoma so the examination is therefore unnecessary.
      c. be performed
      d. not be performed because of the uptake of Tc-99m by the fetus

Type- Nucs
Answers- c
Notes-

1994, 1989 Single Best Answer Question
by CM

34. A rim sign and non-visualization of the gallbladder after 4 hours on
a DISIDA scan is associated with:

     a. gangrenous cholecystitis
     b. acalculus cholecystitis
     c. hepatic abscesses

Type- Nucs
Answers- a
Notes-

1993, 1989 Single Best Answer Question
The rim sign is seen in 20% of patients whose gallbladders are not
visualized on hepatobiliary scans. - 40% of these patients have gangrene
or perforation. The sign is not associated with chronic cholecystitis or
ascending cholangitis. 70-85% have acute cholecystitis. mettler265.
by KH

35. A single lesion within the right lobe of the liver is initially cold
on technetium-99m RBC imaging. It shows slow increase in intensity with
centripetal fill in. Which of the following is the most likely
diagnosis?

     a.   focal nodular hyperplasia
     b.   hemangioma
     c.   metastasis
     d.   hepatocellular carcinoma
     e.   adenoma

Type- Nucs
Answers- b
Notes-

1995 Single Best Answer Question
by AE

36. A technetium thyroid scan and I-131 scan were shown. The technetium
scan showed a hot lesion in the inferior pole of the right lobe which was
cold on the I-131 scan. Differential diagnosis:

     a. papillary carcinoma
     b. colloid cyst
     c. adenoma
     d. infarct

Type- Nucs
Answers- a,c
Notes-

Dahnert p304
Adenoma produces rapid turnover of Iodine, such that little remains at
24hour imaging
1988 Board Question
by KH

37. A young woman presents with sore throat, neck pain, restlessness, T4
is elevated and her thyroid uptake is low. The most like etiology is:

     a.   acute suppurative thyroiditis
     b.   graves disease
     c.   Hashimoto thyroiditis
     d.   factitious thyoiditis
     e.   sub acute thryroiditis

Type- Nucs
Answers- e
Notes-

by KW
De Quervain = Subacute thyroiditis
2-3 weeks after upper respiritory infection, viral, with painful/tender
gland with fever
Destruction of thyroid gland causes increase T4 and decreased uptake
2000 Board Question

38. According to the Nuclear Regulations Committee (NRC) the administered
dose of a radiopharmaceutical should be within what percentage of the
presribed dose?

     a.   10
     b.   25
     c.   15
     d.   30
     e.   5

Type- Nucs
Answers- a
Notes-

by KW
Verified Requisites p49
Administered dose must be +/- 10% of prescribed dose
It is important that the dose of radioactivity for any given patient is
dispensed accurately. A gross error in calculation of the volume of
solution required will mean a similar gross error in the dose received by
the patient. It is therefore essential that each dose be measured in a
dose calibrator before administration. Such measurement is now mandatory
under the regulations of the NRC; errors of administration greater than +
50% are reportable to the NRc. Moreover the sensitivity of a calibrator
must be checked daily. Various other performance factors such as energy
dependence and linearity must be checked at longer time intervals.
1999 Board Question

39. Advantages of SPECT thallium over planar imaging are:

     a.   better detection of specific vessel disease
     b.   increased specificity
     c.   faster imaging time
     d.   increased sensitivity for subendocardial infarction
     e.   more sensitive for ischemic changes

Type- Nucs
Answers- a,b,d,e
Notes-

(Mettler p134 + Lipman)a.F(about the same amount of time generally but
many variables come into play such as single vs dual head camera and
gating)
1994 True/False Question
One of the advantages of SPECT is that the volume of image data is
collected simultaneously. Planar radionuclide imaging suffers a
limitation in the loss of object contrast from background activity-- the
radioactivity underlying and overlying an object is superimposed on the
object. For thalium-201 it is desirable to keep total imaging time below
10 minutes because of internal redistribution. So a 180 degree arc is
used for single head cameras. Multihead cameras get info in a shorter
time. For planar imaging, get three views for ten minutes each. p 57.
Two artifacts in imaging the ventricle are overlying soft tissue from the
breast in women and the interposition of the diaphragm between the gamma
camera and the heart on the left lateral view with the pt supine.
ref: Req p 32, 57-8
there is a higher extraction fraction with thallium than with sestamibi
there is greater cardiac activity with thallium than with sestamibi
time to imaging is less important with sestamibi than with thallium
sestamibi does not redistribute
The technetium agents = Sestamibi or Teboroxime
At rest, the extraction fraction of Sestamibi in the coronary circulation
is about that of thallium (Thrall, p. 72).
Sestamibi does not redistribute (myocardial clearance half-life of Tl-201
is
approximately 5-10 minutes while that of Sestamibi is greater than 5
hours) therefore image Tl-201 5 minutes after injection and image
Sestamibi 30-90 minutes after injection (Thrall, p. 70).
Sestamibi has only a slight redistribution (Thrall, p. 70). (Teboroxime
does not redistribute at all.) The lack of redistribution of Sestamibi
means that 2 injections must be done - one at rest and one at stress.
Since thallium redistributes, in theory, you only need one injection for
both stress and rest. However, two injections are routinely employed to
improve detection of reversible defects (Thrall, p. 68).
by CM
40. After 45 minutes in a DISIDA scan, activity is present in the liver,
biliary tree, and bowel. The next step should be:

        a.   fatty meal
        b.   reinject DISIDA and scan for 4 hours
        c.   inject Tc-sulfur colloid and scan
        d.   nothing - diagnosis of acute cholecystitis is made
        e.   morphine

Type- Nucs
Answers- e
Notes-

1994, 1992, 1989 Single Best Answer Question
When you dont see the gallbladder after 30-45 minutes, morphine is given
to
cause contraction of sphincter of Oddi which refluxes DISIDA into the
patent (normal)
cystic duct and into the normal gall bladder. This raises the
sensitivity to 95% for
detecting acute cholecystitis.
Often, by the time you give morphine (dose is 0.04 mg/kg up to 4 mg),
most of the
DISIDA is gone, so you may need to reinject the patient.
by MH

41. Agent of choice for:

        a. salivary gland imaging - Tc99m pertechnetate
        b. bone marrow imaging - Tc99m labelled Sulfur Colloid
        c. meckles diverticulum imaging - Tc99m pertechnatate

Type- Nucs
Answers- a,b,c
Notes-

Mettler p127,326
by KW
Verified Dahnert + Atlas of Nuclear Imaging, p1
1988 Board Question

42. AIDS patient with a negative gallium lung scan most likely has:

        a.   Kaposis
        b.   CMV
        c.   TB
        d.   PCP

Type- Nucs
Answers- a
Notes-

by KW
Dahnert p896
PCP has increased uptake at time when physical signs and symptoms
unimpressive
Tuberculosis has intense uptake in active lesions, 97%
CMV reveals diffuse uptake as well
Primary lung CA + lymphoma have variable uptake
No mention of Kaposis
1997 Old Board Question

43. All of the following conditions demonstrate increased activity in the
lungs with Gallium-67 except:

     a.   PCP
     b.   MAI
     c.   Kaposis
     d.   Lymphoma

Type- Nucs
Answers- c
Notes-

(D p896-7) Kaposis sarcoma does not accumulate gallium (Mettler p389).
During the prodrome period of ARDS secondary to Pneumocystis carinii
pneumonia in the acquired immune deficiency syndrome (AIDS), gallium
scanning may be valuable in detecting radiographically occult lung
disease. Gallium scanning can show markedly increased activity in diffuse
lung infections prior to the development of radiographic abnormality
(TF).
Patients with large cell lymphoma do not frequently have a second chance
if they fail treatment initially. Kaplan and colleagues looked at Ga67
scanning in large cell lymphoma and have found that gallium avidity
halfway through a chemotherapeutic protocol is a poor prognostic
indicator and recommend consideration of change in treatment. Their data
agree with those of Armitage and co-workers; and they state that if
patients do not respond rapidly to treatment, they are unlikely to do
well. Therefore, in following patients with large cell lymphoma after
treatment begins, besides routine chest radiography to evaluate for
initial response to treatment as well as to look for complications, Ga67
scanning is recommended at the midway point of the chemotherapeutic
protocol. If this is positive, correlative chest films and CT are
recommended. (TF)
1999 Board Question
by CM

44. All of the following demonstrate uptake on MIBG nuclear scan except:

     a.   Carcinoid
     b.   Pheochromocytoma
     c.   Aldosteronoma
     d.   Paraganglioma
     e.   Neuroblastoma

Type- Nucs
Answers- c
Notes-

Think medulla
MIBG (Metaiodobenzylguanidine is a guant=ethidine analog similar to
norepinephrine. It is taken up by chromaffin cells and is therefore
useful for imaging normal and abnormal sympathetic adrenergic tissue,
especially pheochromocytomas, whether located in the adrenal medulla or
ectopically, and neuroblastomas. MIBG is localized in other
neuroendocrine tumors to lesser degree, including carcinoid, medullary
thyroid carcinoma, and paraganglioma. In the setting of pheochromocytoma
and neuroblastoma, the sensitivity and specificity of MIBG are high,
approaching 90%. mettler365.
Aldosternoma
1999 Board Question
by KH

45. All of the following statements are true regarding cardiac perfusion
imaging with Thallium and Tc-99 Sestamibi except?

      a.   Redistribution is less of a problem with Sestamibi than with
Thallium
      b.   Uptake of Sestamibi is by passive diffusion
      c.   Timing is less important with Thallium than with Sestamibi
      d.   First pass uptake is greater with Thallium

Type- Nucs
Answers- c
Notes-

Thallium undergoes constant recirculation and redistribution so timing is
more critical. First pass not feasible with Tl-201. Approximately 88%
of thallium is extracted in the first pass. Thallium is a potassium
analog involved in the NA-K-ATPase pump. At resting flow, the extraction
of sestamibi is approximately half that of Tl-201. There is minimal
recirculation or redistribution with sestamibi. Sestamibi diffuses
passively out of the blood and localizes in the mitochondria (Requisites-
Nuc p70,56,72)
1999 Board Question
by CM

46. Appearance of cavernous hemangioma on sulfur colloid imaging?

     a.    Demostrate gradual filling in on delayed imaging
     b.    Cold defect
     c.    Most lesions are hot compared to normal liver
     d.    Increased flow is noted during the early angiographic phase

Type- Nucs
Answers- b
Notes-

Most hepatic masses will be cold defects, however FNH may have normal
uptake because it contains Kuppfer cells.
D.95% accuracy with SPECT. Lesions > 2cm are detectable in 70-90%. SC
shows a cold defect. Tc-99m RBC shows delayed filling and increased
activity on delayed scan at 1-2 hours.
Hemangioma is hyperechoic 60-70%, hypoechoic 20%, and mixed 20%. No
doppler signal.
Dynamic CT shows a well-circumscribed spherical to ovoid low density mass
that then has peripheral enhancement, and then complete fill-in on
delayed images 3-30 min after bolus.
MRI has a 90-95% accuracy. Shows spherical to ovoid mass (87%) with
smooth well-defined margins (87%) and no capsule. Hypo- to isointense on
T1, hyperintense light bulb on T2, peripheral enhancement with late fill-
in.
Complications: spontaneous rupture 4.5%, abscess formation, Kasabach-
Meritt syndrome of platelet sequestration. (D444)
1998 Board Question
by AE

47. Bone marrow scan with technetium sulfur colloid.   Uptake is by:

     a.   diffusion
     b.   compartmentalization
     c.   active uptake
     d.   phagocytosis

Type- Nucs
Answers- d
Notes-

particles are phagocytosed by RES cells in bone marrow, Mettler p.326.
1988 Board Question
by AE

48. Bone scan:

      a. in patient with multiple bony metastases and no renal uptake,
may simulate chronic renal failure
      b. Shows increaed uptake with increased blood flow
      c. Best imaged one day after injection
      d. May be normal with widespread bony involvement

Type- Nucs
Answers- a,b
Notes-

by KW
Dahnert 899-902
Abnormal with widespread bony involvement (aka superscan - no renal
activity)
Best imaged 2-3 hours after injection
in patient with multiple bony metastases and no renal uptake, may
simulate chronic renal failure.
1988 Board Question
49. Can a hot cranial suture on bone scan which is normal on plain film
represents benign disease?

     a. False
     b. True

Type- Nucs
Answers- b
Notes-

1991 True/False Question
by AE

50. Concerned the criteria for evaluating whether or not exercise is
adequate for a Thallium Stress study and what are acceptable reasons to
terminate the study:

      a. Chest pain relieved by aspirin was a legitimate reason to stop
the study
      b. 5 mm of ST depression on EKG
      c. Claudication is a legitimate reason to terminate the study
      d. Increase in Systolic BP > 200

Type- Nucs
Answers- a,b,c
Notes-

by KW
Verified Dahnert p919, Requisites p62
Requisites says to stop with just 3mm of ST depression.
Other good reasons:
Inability to continue due to fatigue, dyspnea, or faintness
Pallor or diaphoresis
Syncope, blurred vision
VTach, ATach, AFib
Increase in Systolic BP > 240
Decrease in Systolic BP
1989 Board Question

51. Concerning a MUGA in a 70 y/o gentleman whose resting ejection
fraction began at 50%, and rose to 53% after stress:

     a.   Pyrophosphate imaging is indicated
     b.   Coronary arteriography is indicated
     c.   A normal response to exercise
     d.   The first pass study must be repeated

Type- Nucs
Answers- b
Notes-

by KW
Verified Requisites p81,85-86
Normal baseline EF is greater than 50%.
Normal response to excercise is an increase in EF by 5%.
Any failure to increase or any decrease in EF following stress is
abnormal.
Tc99m Pyrophosphonate show increased uptake in infarcts immediately
following cell death, with optimal time for scan at 24-48 hours. As this
patient has no symptoms in the history, this does not seem appropriate.
1996 Question

52. Concerning Alzheimers disease and nuclear medicine scintigraphy:

     a.   none of the above
     b.   has preference for the sensory motor strip
     c.   can mimic multiinfarct dementia
     d.   has preference for frontal and temporal lobes
     e.   findings do not correlate with clinical findings

Type- Nucs
Answers- c
Notes-

1993 True/False Question
In patients with Alzheimer disease, brain scans typically reveal
bitemporoparietal defects(c.F,? but see below). This pattern corresponds
to the pathologic finding of abnormal tangles of nerve fibers and
degenerative neuritic plaques, which occur in the same distribution. The
patients degree of dysfunction is related to the number of these abnormal
cortical structures(a.F). This scintigraphic pattern has a predictive
value of over 80%(b.?F,see below); however, it can sometimes be seen in
other diseases; including Parkinsons disease. The occipital lobes,
sensory motor cortex(d.F), and cerebellum are generally spared. Less
frequent and less specific patterns seen with Alzheimers disease include
unilateral temporal-parietal and anterior(??frontal) perfusion
defects(c.??T)(Req-Nuc p271-2).
The scintigraphic pattern of multi-infarct dementia is that of multiple
assymmetric perfusion degects, often involving the primary cortex and
deep structures (Requisites-Nuc p272). However, Dahnert(p904) lists
multi-infarct dementia in the DDX of Alzheimers(b.??T).
Sensitivities of 80-90% have been reported using either
hexamethylpropylene amine oxime (HMPAO) or iodoamphetamine (IMP).
Alzheimers disease may be differentiated from other causes of senile
dementia by the characteristic bilateral decrease in regional cerebral
blood flow in the parietotemporal cortex with preservation of uptake in
the sensory-motor cortex, basal ganglia, visual cortex, and cerebellum.
(Mettler, p. 67)
Pick disease is a form of dementia which is clinically similar to
Alzheimer
disease. The hallmark is severe atrophy of the anterior portion of both
frontal lobes. With SPECT imaging, bifrontal defects are seen,
accompanied by volume loss.
Progressive supranuclear palsy may also demonstrate similar findings.
AIDS encephalopathy is due to infection of the brain by the HIV virus,
and does
not indicate an opportunistic infection. Multiple, small cortical
defects are seen using SPECT imaging with either IMP or HMPAO. The
pattern is not distinguishable from multiinfarct dementia.
Reference: Mettler 1991, p. 67
When choosing between two evils, I always like to pick the one I never
tried before. Mae West(1892-1980), U.S. screen actor. As Frisco Doll,
in the film Klondike Annie(1936).
Mae West (18921980), U.S. screen actor. As Frisco Doll, in the film
Klondike Annie
by CM

53. Concerning Iodine-131 therapy for postoperative treatment of thyroid
carcinoma. The appropriate dose for treating lymph node metastases is:

     a.   250-500 mCi
     b.   500 mCi and above
     c.   100-200 mCi
     d.   25-50 mCi
     e.   15-30 mCi

Type- Nucs
Answers- c
Notes-

Mettler p.124
1993 Single Best Answer Question
Doses are 100 mCi for thyroid only, 150 mCi for lymph node metastases,
and 200
mCi for diffuse metastases. Repeated doses upto 1 Ci may be required. p
337 Req.
by AE

54. Concerning pseudohypoparathyroidism and pseudohypoparathyroidism:

     a.   both have hypocalcemia
     b.   both are sex-linked dominance
     c.   both may be complicated by hyperparathyroidism
     d.   both have frequent soft tissue calcification
     e.   teeth tend to be normal in pseudo HPT and abnormal in pseudo HPT

Type- Nucs
Answers- b,d
Notes-

Dahnert p119-120
1988 Board Question
by KH

55. Concerning radionuclide imaging of the thyroid:

      a. Iodine 125 is helpful in imaging substernal thyroid
      b. the dose to the thyroid is lowest with Iodine 123
      c. photopeaks of technetium and Iodine 123 are approximately
similar
     d. Iodine 123 obviates the problem of discordant nodules
     e. the dose per mCi of Iodine 131 is approximately 1.5 rads

Type- Nucs
Answers- c,d
Notes-

D906-907
1993, 1991 True/False Question
Well-differentiated papillary, follicular, and mixed carcinomas represent
about
75% of all primary thyroid malignancies. Well-differentiated papillary
carcinoma tends
to metastasize to local neck lymph nodes, whereas follicular lesions tend
to
hematogenously metastasize with a predilection for the lungs and
skeleton. Medullary
and anaplastic carcinomas are less common and rarely concentrate I-131;
therefore,
iodine imaging is not useful for following these patients or in a
therapeutic capacity.
I-131, not I-125 is used for imaging thyroid tissue or metastases
anywhere but the
anterior neck, including the substernal region.
The photopeak of I-123 is 159 keV and the photopeak of Tc-99m is 140 keV.
Discordant nodules are hot on Tc-99m but cold on iodine imaging. Some of
these
prove to be cancer so hot nodules on Tc-99m should be further evaluated
with iodine
imaging. Imaging with iodine would obviate the problem of discordant
nodules.
The dose to the thyroid is lowest with Tc-99m pertechnetate (2 rad =
0.12-0.20
rad/mCi X 5-10 mCi per exam) vs. I-123 (8 rad = 11-20 rad/mCi X 100-400
microCi per
exam) and I-131 (80 rad = 1100-1600 rad/mCi X 30-50 microCi per exam).
Therefore,
the dose of I-131 is around 80 rads.
Chances of malignancy:
- patient with a cold nodule and prior head and neck radiation = 40%
- patient with a cold nodule with no history of head and neck radiation =
20%
- hot nodule = <1%
- discordant nodule = 78%
Other Factors Tending toward Malignant:
- young patients
- males
- hard lesion
- no shrinkage on thyroid hormone
- family history of thyroid carcinoma
Reference: Mettler 1991, pp. 83-90
by MH
56. Concerning radionuclide ventriculography evaluation of a left-to-
right shunt, which of the following is false?

     a.   can determine the magnitude of pulmonic stenosis
     b.   accurately determines the anatomic size of the shunt
     c.   the uptake in the lungs is useful information for evaluation
     d.   examination is suboptimal if a high bolus is not given
     e.   accurately detemines the hematologic size of the shunt

Type- Nucs
Answers- a,b
Notes-

Dahnert p923
1995 Single Best Answer Question
It is possible to detect shunts and calculate shunt index ratios for both
L-R and R-L shunts. It is possible to detect shunts as small as 20%. A
mathematical function called the gamma variate is used.           (fig 4-
38, p 84) Activity is measured over the lungs including recirculation.
R-L shunts may be detected using Tc-99m labeled MAA. The ratio of tracer
in the lung to the tracer gaining access to the systemic circulation
provides a measure of severe shunting.
Ref: p 83-4 Req.
by KH

57. Concerning Tc-99m MDP:

     a. 40-50% excreted in urine by 4 hours
     b. 50-60% taken up in the skeleton
     c. Uptake in bone is by chemisorption

Type- Nucs
Answers- a,b,c
Notes-

Not Verified
1993 Board Question

58. Concerning Technetium HIDA scans:

      a. Critical organ is the liver
      b. a normal shows activity in the common bile duct in 15 minutes.
      c. In the proper clinical setting, can be a very sensitive
indicator for cholecystitis
      d. Can visualize with bilirubin greater than 5 mgs%
      e. With hepatic dysfunction can have delayed visualization of the
bile duct

Type- Nucs
Answers- b,c,d,e
Notes-

Dahnert p924
1988 Board Question
by AE

59. Concerning Thallium 201 imaging:

      a.   simple diffusion
      b.   10% of injected dose is taken up by the myocardium
      c.   right ventricle is seen on exercise images
      d.   comparing immediate to delayed images may help differentiate
ischemia   from scarring
      e.   uptake is related to perfusion even at blood flow rates 2-3 x
normal

Type- Nucs
Answers- b,c,d,e
Notes-

a.In normal subjects approximately 5% of the administered dose localizes
in the myocardium (Req-Nuc p56). 4% of total dose localizes in
myocardium at rest (D p917). These are close enough to 10% for me to
answer a. True. c.Over a wide range of flow rates the extraction of Tl-
201 is proportional to relative regional perfusion (Req-Nuc p56).
d.Thallium is a potassium analog. Sodium-potassium homeostasis is
maintained as an energy-dependent process involving the Na-K-ATPase pump
(Req-Nuc p56). Post-exercise right ventricular activity is frequently
seen and routinely visualized on SPECT studies (Req-Nuc p63).
1988 Board Question
by CM

60. Concerning thallium heart scan:

      a.   ischemic disease can be distinguished from infarcts by comparing
rest and   exercise scans
      b.   need greater than 50% occlusion to show ischemia
      c.   sodium-ATPase pump involved in uptake
      d.   best visualized after one hour

Type- Nucs
Answers- a,b,c
Notes-

M131-133
1988 Board Question
Image Thallium immediately!
by MH

61. Concerning the radionuclide evaluation of CSF leak:

        a. patient should be positioned supine for imaging
        b. pledget activity greater than 1.5x plasma activity indicates
leak
        c. agent of choice is Tc-99m DTPA
        d. imaging should begin 6-12 hours after lumbar injection

Type- Nucs
Answers- b
Notes-

D905
Image 4-6hours
1993 True/False Question
Pledget activity/serum activity ratio >1.5 indicates CSF rhinorrhea
(leak). Imaging should be done at 1-3 hours initially because most leaks
occur near
basilar cisterns and this is usually when radioactivity arrives there.
This also lets you
check the adequacy of injection into the subarachnoid space. According to
Req, measure
approximately 4hrs later.
The agent of choice is Indium-111 labeled DTPA. Tc-99m compounds are of
little use in adult CSF imaging because of their short half life.
Patients should be imaged in whatever position provokes the rhinorrhea.
ref: Req p 278-9
by MH

62. Contraindications to the administration of morphine during a DISIDA
scan include:

     a.   pancreatitis
     b.   chronic cholecystitis
     c.   visualization of activity in the small bowel
     d.   gallbladder filling
     e.   dilated common bile duct

Type- Nucs
Answers- a,d,e
Notes-

by KW
Diagnostic Nuclear Imaging, p766
Morphine in a patient with a dilated duct may dislodge a cystic duct
stone.
Pancreatitis is a soft contraindication.
1995 True/False Question
Morphine is used as an alternative to delayed imaging which is used to
ensure the
dx of cholecystitis and non filling of the gallbladder. Morphine is used
when there has
been excretion into the bowel but no visualization of the gallbladder.
Morphine increases
the intraluminal pressure at the sphincter of Oddi. This results in
preferntial biliary flow
via the cystic duct if it is patent.
Scintigraphic examination of pt with chronic chole is usually normal.
Delayed
gallbladder filling is seen in <5%.
Pancreatitis is thought to create a false positive examination.
ref: Requisites p 196-7
63. Description was given about an area of increased radiotracer
accumulation in a 30 y/o female by sulfur colloid administration.   You
are asked to find the least likely diagnosis:

     a.   Focal nodular hyperplasia
     b.   Superior vena cava obstruction
     c.   Metastases
     d.   Budd-Chiari syndrome

Type- Nucs
Answers- c
Notes-

Decrease uptake; Metastasis (especially colon); cyst; hepatoma (
especially in cirrhosis); adenoma; hematoma; hemagioma; abscess;
pseudotumor (cirrhosis);
Increased uptake; FNH; Cirrhosis with regenerating nodule; Budd-Chiari
syndrome (caudate lobe); SVC obstruction (arm injection; quadrate lobe)
Mettler241
1989 Board Question
by KH

64. Diffuse pulmonary activity is noted during a sulfur-colloid scan.
Which of the following is the least likely cause?

     a.   patient on estrogen therapy
     b.   collagen vascular disease
     c.   cirrhosis
     d.   sarcoid
     e.   widespread pulmonary metastases

Type- Nucs
Answers- d
Notes-

1993 c PreTest Single Best Answer Question
Diffuse pulmonary activity during a sulfur-colloid liver-spleen scan
occurs with
patients receiving estrogen therapy. This may be caused by a release of
totipotential cells
from the bone marrow, which travel to the lungs and assume the role of
phagocytes,
which trap the radiopharmaceutical. The differential diagnosis of
increased lung activity
on a sulfur-colloid scan includes cirrhosis, aluminum breakthrough,
collagen vascular
disease, Hunter syndrome, histiocytosis X, and widespread pulmonary
metastases.
Obtained from Notebook, Question number 82
by AE

65. Each of the following are cold nodules on imaging with Iodine 123:

     a. Autonomous adenoma
     b.   Discordant nodule
     c.   Papillary cell carcinoma
     d.   Non-toxic multinodular goiter
     e.   Follicular cell carcinoma

Type- Nucs
Answers- b,c,d,e
Notes-

by KW
Verified Dahnert p304, Requisites p327-329
1989 Board Question

66. For a ventilation scan performed with aerosolized Tc-99m DTPA after a
Tc-99m MAA perfusion scan, what statement best describes the desired
image counts?

     a.   At least 10 times greater than the counts for the perfusion scan
     b.   At least equal to the counts for the perfusion scan
     c.   3-5 times the counts for the perfusion scan
     d.   Enough to get a good diagnostic image

Type- Nucs
Answers- c
Notes-

Because lung perfusion imaging is also performed using a Tc99m agent, a
3-4 fold count rate differential must be used when using Tc99m DTPA
aerosol to prevent interference of the 2 radiopharmaceutical. The order
in which the procedures are preformed dictates the relative administered
doses. Performing the aerosol study after perfusion imaging has the
advantage of allowing the ventilation scan to be avoided if perfusion is
normal. In practice, however, aerosol imaging is usually performed
before perfusion imaging because it is more difficult to deliver a larger
activity of the Tc99m DTPA aerosol than of the Tc99m MAA(Mettler p197).
1999 Board Question
by CM

67. For gastric emptying study, which is true?

      a. The half time for solids is 30 minutes
      b. For proper calculation of the half-life. The geometric mean of
the anterior and posterior projection is taken
      c. It cannot be used to follow patients with gastroparesis because
of poor reproducibility
      d. Liquids have a linear curve

Type- Nucs
Answers- b
Notes-

Solid 50% at 90min - linear
Liquid 50% at 30min - exponential
by KW
2000 Board Question
Calculation of the Geometric Mean
The geometric mean is the square root of the product of the anterior and
posterior counts.
Geometric Mean = square root (anterior counts x posterior counts)
For example, assume the anterior counts collected for an image taken one
minute after the patient finished consuming the standard meal were 102
764 cpm while the corresponding posterior counts collected were 128 842
cpm. The geometric mean is calculated as:
Geometric Mean = sqrt (102 764 x 128 842)
= sqrt (1.32403 x 1010)
= 115 067 cpm

68. For pharmacological augmentation for detection of meckels
diverticulum. Which drugs act by inhibition of secretion of pertechnate
from the gastric mucosa in the meckels?

     a. Cimetidine
     b. Viagra
     c. Pentagastrin

Type- Nucs
Answers- a
Notes-

by KW
Dahnert p703
Cimetidine inhibits secretion
Pentagastrin stimulates uptake
2000 Board Question

69. Gallium can be used in the chest to detect:

     a.   lymphoma
     b.   TB
     c.   PCP
     d.   nocardia
     e.   Kaposi sarcoma

Type- Nucs
Answers- a,b,c,d
Notes-

Notes
Mettler p372, 390
Also Bronchogenic carcinoma, sarcoid, Idiopathic pulmonary fivrosis;
diffuse pneumonitis; pulmonary sarcoid; lymphangitic metastases; PCP;
miliary tuberculosis; vleomycin toxicity; radiation pneumonitis (early
edxudative phase) mettler375
1994 True/False Question
by KH

70. Gallium:
     a. effect of chemotherapy on liver uptake
     b. lactoferrin attachment in WBC
     c. ferric ion analog

Type- Nucs
Answers- b,c
Notes-

Gallium binds to transferrin in plasma.
1988 Board Question
by AE

71. Gallium-67 is preferred to Indium-111 for the following:

     a.   fever of unknown origin
     b.   intraabdominal abscess
     c.   suspected pulmonary inflammation
     d.   vertebral osteomyelitis
     e.   acute osteomyelitis

Type- Nucs
Answers- a,c,d
Notes-

by KW
Verified Requisites p159,161,155
Note that Ga67 is preferred for disk space disease
1995 True/False Question

72. Gamma camera resolution is improved by:

     a.   increased collimator length
     b.   increased hole diameter of the collimator
     c.   thinner septae
     d.   pinhole collimator

Type- Nucs
Answers- a,d
Notes-

1993 True/False Question
Discordant answer.... Thicker septa = less scatter, Thinner septa =
smaller pixel size
Resolution of a scintillation camera is comprised of intrinsic resolution
of the
camera (Ri) and resolution of the collimator (Rc). Overall resolution is
the square root of Ri squared + Rc squared.
Resolution of the collimator is inversely proportional to d(F + L + c)/L
where:
d = hole diameter
F = distance of the source from the collimator face
L = length of the collimator
c = thickness of the crystal
The intrinsic resolution of the camera cannot be changed by the operator.
Note that in general resolution and sensitivity are inversely
proportional -
increasing the sensitivity will decrease the resolution and vice versa.
Pinhole collimators have extremely high resolution at the expense of
sensitivity
(very few photons get through) and distortion of images arising from
photons arising from different planes.
References: Mettler 1991, pp. 15-16; Chandra 1992, p.162
Thinner septae gives a larger hole diameter, and possibly greater septal
penetration.
c.(Primer p920) d.T(Mettler p20)
by CM

73. Given a 2 ml vial of Tc-99m with 1 mCi of activity at 8 a.m., what
amount, in milliliters, is needed at 2 p.m. for a dose of 1 mCi?

     a.   2.0
     b.   2.82
     c.   2.3
     d.   3.6
     e.   2.6

Type- Nucs
Answers- d
Notes-

1993 Single Best Answer Question
T of Tc99m is 6 hours, so there will be a half the activity remaining, so
you will need a little less than twice the volume. 2ml x 2 = 4ml (close
to 3.6ml)
Examinations: As long as learning is connected with earning, as long as
certain jobs can only be reached through exams, so long must we take this
examination system seriously. If another ladder to employment was
contrived, much so-called education would disappear, and no one would be
a penny the stupider.
E.M. Forster (1879-1970), British novelist, essayist. New York Times (24
Nov. 1963).
by CM

74. HIDA scan:

     a. can diagnose gallstones
     b. can diagnose acalculous cholecystitis
     c. must fast 8 hours prior to exam

Type- Nucs
Answers- b
Notes-

Fasting 2-4 hours
1988 Board Question
by MH
75. In a bone scan with diffuse increased activity in the bones and
decreased activity in the kidneys as well as increased activity in the
stomach and lungs. What is the most likely cause?

     a.   mucinous producing carcinoma
     b.   breast carcinoma with hypocalcemia
     c.   hyperthyroidism with free Technetium
     d.   chronic renal failure with renal osteodystrophy
     e.   metastatic disease

Type- Nucs
Answers- c
Notes-

1994 Single Best Answer Question
Hyperparathyroidism or renal failure may cause localized activity in the
GI tract (particularly the stomach) as well as the lungs. Both may also
cause a superscan. Causes of a superscan include: metastatic disease
from breast or prostate carcinoma and metabolic bone disease
(osteomalacia, hyperparathyroidism, and renal osteodystrophy).
by KH

76. In a child with missed torsion of the testicle, the nuclear medicine
finding is:

     a.   photopenic defect
     b.   hyperemic
     c.   donut sign
     d.   cut-off sign
     e.   normal

Type- Nucs
Answers- c
Notes-

1993 Single Best Answer Question
Scrotal imaging is usually performed with 10-20 mCi of technetium-99m-
pertechnetate. Dynamic (2 second) images will reveal increased perfusion
in cases of
infection or tumor. The donut sign is due to absent flow within the
testicle with
surrounding dartos hyperemia giving a bulls eye or donut sign. This sign
is not
pathognomonic and can be seen with abscess, hematoma, reactive hydrocele,
and
occasionally a necrotic tumor. Other signs would include normal nuclear
medicine
angiogram or nubbin sign which is a bump of activity extending medially
from the iliac
artery due to reactive flow in the spermatic cord and abrupt termination.
In acute torsion, there should be normal or decreased activity during the
flow
phase, and a photon-deficient area on the delayed scans.
by MH
77. In a cirrhotic patient being evaluated, colloid shift on liver-spleen
scan is due to:

     a.   hepatocellular dysfunction
     b.   intrahepatic shunting
     c.   varices
     d.   altered or activation of the extrahepatic RES function
     e.   portal hypertension

Type- Nucs
Answers- a,b,d,e
Notes-

varices are a result of portal HTN, but are not a cause of colloid shift.
1994 Single Best Answer Question
In a liver-spleen scan with Tc-99m sulfur colloid, increased sulfur
colloid
concentration by the spleen and bone marrow compared with the liver
(colloid shift)
may be found in patients with diseases that cause derangement of hepatic
function and/or
portal hypertension. Among diffuse hepatocellular diseases, hepatic
cirrhosis is the most
common abnormality presenting in this fashion.
The mechanisms governing colloid shift have variously bee attributed to:
1) the consequences of portal hypertension with shunting of colloid-laden
blood away
from the liver to the spleen and bone marrow and/or
2) a decrease in the number or functional capability of hepatic Kupffer
cells, thereby
decreasing liver clearance of sulfur colloid.
In various liver diseases, either or both of these principles may play a
role.
However, the observation that alleviation of portal hypertension does not
necessarily
result in a return to normal radiocolloid distribution has led some
investigators to
postulate that intrahepatic shunting, not portal hypertension per se,
plays the major role in
producing the phenomenon of colloid shift, especially in cirrhotic
patients. Such shunting
would allow portal blood to bypass hepatic sinusoids, making more colloid
available to
the spleen and bone marrow.
Reference: Mettler 1991, pp. 181-183
by AE

78. In a pateint undergoing a diapyridamol stress test becomes
hypotensive. Which of the following is the best treatment?

     a. Give atenolol
     b. Give theophyline
     c. Give epinephrine
     d. Give atropine

Type- Nucs
Answers- b
Notes-

by KW
Dahnert p920 - Persantine is reversed with aminophylline
1997 Old Board Question

79. In a patient who is being evaluated with In-111-labeled WBCs that
were damaged during the labeling process, where would increased activity
be noted?

     a.   liver
     b.   bone marrow
     c.   lung
     d.   kidneys
     e.   salivary glands

Type- Nucs
Answers- c
Notes-

by KW
Requisites p158
Cell damage yields increased uptake in the lungs
1994 Single Best Answer Question
Reference: Thrall

80. In a patient with a segmental CXR abnormality:

     a. V/Q can still be useful to rule out a PE

Type- Nucs
Answers- a
Notes-

1992 True/False Question
A CXR abnormality doesnt preclude doing a V/Q scan. One can have V/Q
mismatches in areas where there is no CXR abnormality, thus giving
intermediate or high
probability depending on the number and size of the defects.
by MH

81. In a V/Q scan in a patient in CHF:

     a.   the exam may cause RV failure
     b.   the examination should be postponed
     c.   microspheres should be used instead of tagged albumin
     d.   patient should be pretreated with lidocaine

Type- Nucs
Answers- a
Notes-

Tc99m MAA = macroaggregated albumin. Tc99m human albumin
microspheres(HAM) are not commercially available in the U.S.
Patients with pulmonary HTN may have significantly fewer remaining
pulmonary capillaries than normal, a relative contraindication (Req-Nuc
p132-3). Answer d?
1988 Board Question
by CM

82. In a V/Q scan with matched   defects and the same sized defect on CXR,
what is the probability of PE?

     a.   low probability
     b.   high probability
     c.   intermediate probability
     d.   very low probability

Type- Nucs
Answers- c
Notes-

by KW
Requisites p137, Dahnert 913
Very Low probability is not an option under modified PIOPED.
Dahnert lists the triple match as intermediate probability
1992 Single Best Answer Question

83. In brain scanning, which of the following features is most helpful in
making a diagnosis:

     a.   benign lesions are smooth
     b.   tumors have finger like projections
     c.   certain lesions have certain preferred locations
     d.   abscess with cold centers

Type- Nucs
Answers- c
Notes-

Primer p.854, Alzheimers--bilateral perfusion defects in temporal-
parietal regions
Mettler p.94 Parkinsons--increased perfusion in basal ganglia
AIDS dementia--multifocal cortical and subcortical perfusion defects
1988 Board Question
by AE

84. In Gallium Scans:

     a.   if positive they indicate septicemia
     b.   there is decreased activity with leukopenia
     c.   there is decreased activity with antibiotics
     d.   there is increased activity in abscesses if the are 28 days old
     e.   greatest intensity is at 4 hours
Type- Nucs
Answers- c,?d
Notes-

Mettler p388
1988 Board Question
by MH

85. In gated blood pool ventriculography:

     a.   the left ventricular ejections fraction can be determined
     b.   a region of acute myocardial necrosis can be seen.
     c.   cardiac wall contractility is evaluated
     d.   the regurgitant index can be calculated
     e.   the aortic valve leaflets are identified

Type- Nucs
Answers- a,b,c,d
Notes-

d.(Mettler p179) e.Akinesis of a wall segment suggests MI.
1988 Board Question
by CM

86. In regards to thyroid:

     a. failure of the duct to atrophy causes a thyroglossal duct cyst
     b. foramen cecum is the origin of the thyroglossal duct
     c. normal free T-4 is 0.5 to 1.0 micrograms per DL

Type- Nucs
Answers- a,b
Notes-

Dahnert p332
0.8-2.2ng/dL
1988 Board Question
by KH

87. In thyroid imaging:

     a.   TC04-99m, a low energy collimator is best for imaging resolution
     b.   I-125 is better than Tc04 99m for imaging
     c.   TC-04 99m is trapped by the thyroid, but not organified
     d.   The main disadvantage of I-125 is the low photon energy

Type- Nucs
Answers- c,d
Notes-

1988 Board Question
by KH
88. Increased FDG-18 activity is seen in all of the following tumors
EXCEPT?

     a.   Lymphoma
     b.   Bronchogenic
     c.   Melanoma
     d.   Prostate
     e.   Breast

Type- Nucs
Answers- d
Notes-

FDG imaging has been used in the evaluation of a number of malignancies.
Metastases from melanoma show great avidity for FDG, with sensitivity and
specificity approaching 100%. FDG is concentrated by malignant gliomas,
so that the degree of uptake is directly related to the histologic grade
of the tumor. Lung Cancer, also. FDG may occasionally be useful in
evaluating potential malignancy of suspicious neck, breast, abdominal,
and pelvic masses. It is also sensitive for the detection of metastases,
either regional nodal or distant. mettler384.
Mettler p383
1999 Board Question
by KH

89. Increased lung uptake on a Thallium-201 cardiac scan is associated
with:

     a.   Multivessel coronary disease
     b.   Right heart failure
     c.   Increased pulmonary capillary pressure
     d.   Left heart failure
     e.   Increased risk of mortality

Type- Nucs
Answers- a,c,d,e
Notes-

Not Verified
1996 Question

90. Increased uptake on Gallium-67 imaging is least likely to be seen in
an AIDS patientwith which one of the following diseases?

     a.   Cryptococcus
     b.   Lymphoma
     c.   PCP
     d.   Nocardia
     e.   CMV

Type- Nucs
Answers- d
Notes-
Kaposis sarcoma does not accumulate gallium--Mettler 389-391, agree with
below.
1994 Single Best Answer Question
Thrall and Mettler list PCP, CMV, and lymphoma as taking up Gallium-67 in
the
lungs. Thrall lists granulomatous processes like miliary TB and
histoplasmosis; therefore
one would assume that Cryptococcus would also be positive, but I dont
have a specific
reference. Given that Nocardia can be acute and suppurative, it is
probably the right
answer.
by AE

91. Indium labeled leukocytes are preferred over Gallium for which of the
following?

     a.   Splenic abscess
     b.   Chronic osteomyelitis
     c.   Inflammatory bowel disease
     d.   Vertebral osteomyelitis

Type- Nucs
Answers- b,c
Notes-

a.T(Req-Nuc p167,Mettler p397) b.F(Mettler p397-8) c.?F(both taken up by
spleen but Gallium to a lesser degree???) d.T(Ga is secreted in colon)
Ga-67 citrate, In-111 WBC and Tc-99m WBC are used as agents for
inflammation.
Ga-67 citrate is indicated in chronic and nonpyogenic inflammation,
pulmonary infection and lymphadenitis with HIV, and granulomatous disease
such as sarcoid. Uptake is seen in acute pyogenic abscess, phlegmon,
acute cholecystitis, acute pancreatitis, acute gastritis, diverticulitis,
IBD, surgical wounds, pyelonephritis, and perinephric abscess. Diffuse
uptake in peritonitis.
In-111 WBC used for occult sepsis, acute pyogenic infection, abdominal
and renal abscess, IBD, non-pulmonary infection with HIV, prosthetic
(bone, cardiovascular) graft infection, acute and chronic or complicated
bone or joint infection.
Tc-99m WBC advantages over In-111 include improved photon flux and
earlier imaging, disadvantages include biliary excretion leading to bowel
activity which may obscure abdominal findings, and heart and blood pool
which may also obscure findings. Dahnert
1998 Board Question
by CM

92. Match the etiology of the false positive on the cardiac nucs scan:

     a. Diaphragm creep - Inferior wall defect
     b. Left bundle branch block - Fixed Septal Defect
     c. Left bundle branch block - Reversible septal defect

Type- Nucs
Answers- a,c
Notes-

by KW
Mettler p163
1997 Old Board Question

93. Matching regarding the thyroid:

     a. Hashimotos - Subacute thyroiditis
     b. Dequervains - Chronic thyroiditis
     c. Plumbers syndrome - Thyroid adenoma

Type- Nucs
Answers- c
Notes-

by KW
Robbins 1220-2
DeQuervains = Subacute thyroiditis = non-suppurative granulomatous
inflammatory process, may be viral
Hashimotos = Chronic Lymphocytic thyroiditis = chronic inflammatory
glandular autoimmune disease
Plumbers syndrome = overproduction of thyroid hormone due to thyroid
nodules/adenoma
1997 Old Board Question

94. MIBG cannot be used to scan:

     a.   adrenal aldosteronoma
     b.   paraganglioma
     c.   medullary carcinoma of the thyroid
     d.   neuroblastoma
     e.   pheochromocytoma

Type- Nucs
Answers- a
Notes-

agree with below, Mettler p.363-367
1994, 1993, 1992, 1991 Single Best Answer Question
MIBG is used to scan adrenal medullary hyperplasia or tumors or other
neuroendocrine tumors (APUDomas). These include adrenergic tumors
(pheochromocytomas, neuroblastoma, ganglioneuromas, ganglioneuroblastoma,
and
paragangliomas), carcinoids, islet cell tumors, and medullary carcinoma
of the thyroid.
MIBG is structurally similar to norepinephrine and is taken up into
presynaptic receptors.
The senstivity for detection of pheochromocytoma is between 79% and 89%.
I131-NP-59 (iodocholesterol) is used to image adrenal cortical tumors,
like aldosteronoma.
by AE
95. Octreotide scanning is useful for all the listed tumors except:

     a.   gastrinoma
     b.   renal cell carcinoma
     c.   medullary carcinoma of the thyroid
     d.   Meningioma
     e.   carcinoid

Type- Nucs
Answers- b
Notes-

Octreotide = Somatostatin
by KW
2000 Board Question

96. On a MAG-3 renal examination, a continuously rising renogram curve is
least likely to be seen in which of the following conditions?

     a.   Cyclophosphamide toxicity
     b.   Renal artery stenosis with captopril
     c.   Pyelonephritis
     d.   Obstruction
     e.   ATN

Type- Nucs
Answers- c
Notes-

by KW
Requisites p309,p305, Dahnert p798,799
According to Dahnert, Cyclosporine nephrotoxity causes tubular damage
(?ATN) and microthrombosis.
Also, ATN causes a delay in excretion.
Pyelonephritis usually shows focal areas of decreased uptake, no mention
of delayed excretion.
Pyonephrosis can cause obstruction from pus within the collecting
systems.
I am not sure if the anwer given refers to Pyelonephritis or
Pyonephrosis.
1999 Board Question

97. On a thallium-201 treadmill test, the patient is unable to reach
maximum exercise secondary to leg pain. Thallium-201 gives a reversing
lesion in the septum. Which of the following are true?

     a.   the results   are definitely normal
     b.   only angina   or ST segment depression should stop the test
     c.   leg pain is   an OK reason to stop the test
     d.   the patient   should repeat the test with dipyridamole
     e.   the results   are definitely abnormal

Type- Nucs
Answers- c
Notes-

1989, 1988 True/False Question
by CM

98. On dynamic brain scan shows rapid intense activity in the right
lateral area which quickly clears. Static uptake in that area:

     a.   normal
     b.   subdural hematoma
     c.   glioblastoma
     d.   meningioma
     e.   arterial-venous malformation

Type- Nucs
Answers- c,?d,e
Notes-

1988 Board Question
by MH

99. On renal scintigraphy, what would be the response to captopril in a
patient with right renal artery stenosis?

     a.   decreased activity on the left side
     b.   increased initial uptake on the right side
     c.   decreased initial uptake on the right side
     d.   no change

Type- Nucs
Answers- c
Notes-

by KW
Dahnert p931
You would expect excretion of radionuclide to decrease after
administration of captopril -- increasing T1/2
2000 Board Question

100. One would prefer In 111 WBC to Gallium scanning in:

     a. lung fungal infection
     b. vertebral osteomyelitis
     c. inflammatory bowel disease

Type- Nucs
Answers- c
Notes-

Lung is Gallium
by KW
2000 Board Question
101. Perfusion defect out of proportion to ventilation defect is seen
with all of the following except?

     a.   Fibrosing mediastinitis
     b.   Hypoplasia of the left pulmonary artery
     c.   Interstitial pneumonia
     d.   Hilar lymph nodes

Type- Nucs
Answers- c
Notes-

(Req-Nuc p142)
1998 Board Question
by CM

102. Persistently increasing activity on a MAG 3 curve would not be seen
in which one ofthe following diseases?

     a.   cyclosporin toxicity
     b.   pyelonephritis
     c.   renal artery stenosis following captopril administration
     d.   ATN
     e.   obstruction

Type- Nucs
Answers- b
Notes-

by KW
Requisites p309,p305, Dahnert p798,799
1994 Single Best Answer Question
ATN and cyclosporin toxicity typically present with preservation of renal
perfusion but poor excretion of radiotracer. However, cyclosporin
toxicity, hyperacute
and chronic rejection, and ureteral or renal artery occlusion may all
have diminished
perfusion and function.
ATN, cyclosporin toxicity (similar scintigraphic appearance to ATN),
obstruction,
and renal artery stenosis S/P captopril will all show increasing MAG-3
activity.
Pyelonephritis results in defects of MAG-3 uptake. These can be wedge-
shaped.

103. Photopeak testing and saline chromatography:

     a.   detection of aluminum contamination
     b.   sterility testing
     c.   pyrogen testing
     d.   detection of breakthrough molybdenum

Type- Nucs
Answers- a
Notes-

Instant thin-layer chromatography is usually performed to assess
radiochemical purity, using silica gell impregnated in glass fiber sheets
or strips. Using various solvents, impurities can be identified by their
different migrations in the particular solvent used. mettler45. The
amount of 99Mo contamination, or breakthrough, during elutionis normally
determined by placing the eluate from the generator in a lead shield and
measuring the penetraion of any 99Mo photos. mettler43.
1994, 1988 Single Best Answer Question
technetium-99m photons are attenuated by the shield, but the higher-
energy molybdenum-99 photons penetrate the shield and are counted.
(Thrall, p. 44)
Saline chromatography is used to detect other reduction states of Tc-99m
in the eluate besides the desired +7 valence state (TcO4-).   (Thrall, p.
44)
Aluminum breakthrough is caused by leaching of aluminum from the
generators elution column. When excess aluminum accumulates, it results
in the formation of large particles, or colloid, which are then taken up
by the liver. If used in the preparation of sulfur colloid, the
particles that form may be large enough to be deposited in the lungs.
Testing is done with colorimetric spot testing with Aurin tricarboxylic
acid (rosolic acid paper). The limit is 10 micrograms per ml of eluate.
incompletely remembered matching question.
by KH

104. Possible causes of increased activity in the kidney region on bone
imaging include:

     a.   radiation therapy
     b.   antibiotic therapy
     c.   Wilms tumor
     d.   neuroblastoma
     e.   chemotherapy

Type- Nucs
Answers- a,b,d,e
Notes-

mettler 306 & 299 &73, d821
Chemotherapy antibiotics, and a number of other etiologies can cause
increased uptake of bone agent in the kidneys.
1994 True/False Question
Neuroblastomas do and Wilms dont take up bone scan agents.
Chemotherapeutic agents which may cause increased uptake in the kidney on
bone scan: doxorubicin, vincristine, cyclophosphamide.
References: Mettler and Thrall
by KH

105. Preoperative lung scans are useful for evaluating lung cancer
because:

     a. none of the above
        b. a defect indicates decrease blood supply because of invasion of
tumor
        c. shows extent of tumor
        d. may show lesion not seen on x-ray

Type- Nucs
Answers- a
Notes-

1988 Board Question
by MH

106. Primary hyperparathyroidism:

        a.   decreased vitamin d causes increasing bone symptoms
        b.   decreased serum calcium
        c.   not responsive to parathormone stimulation
        d.   decreased serum phosphorus
        e.   serum calcium may be normal on repeated exams

Type- Nucs
Answers- c,d,e
Notes-

Cecils p541
hypercalcemia due to uncontrolled secretion of parathormone by one/more
hyperfunctioning parathyroid glands featuring 1.brown tumor 2
chondrocalcinosis.
REquires surgical Treatment D81
1988 Board Question
by KH

107. Radiation-induced defect on liver scan with technetium sulfur
colloid is due to damage of:

        a.   Portal system
        b.   hexagonal cells
        c.   Kuppfer cells
        d.   biliary system

Type- Nucs
Answers- c
Notes-

(Req-Nuc p210)
1988 Board Question
by CM

108. Regarding cardiac imaging with Sestamibi, which is most accurate?

        a.   There is rapid redistribution
        b.   The colon is the critical organ
        c.   Uptake is by active transport
        d.   First pass uptake is greater than Thallium
Type- Nucs
Answers- b
Notes-

by KW
Verified Dahnert p 918, Requisites 71-72
90% of thallium is taken up in 90 seconds, 40% of Sestamibi first pass
extraction.
Sestamibi passively diffuses into cells, and is retained in the
mitochondria.
Little redistribution is present compared to Thallium.
Technetium-99m Sestamibi is a highly lipophilic cationic complex that
consists of 6 methoxyisobutyl isonitrile molecules attached to a single
99mTc that is taken up in the myocardium in direct proportion to blood
flow. Once it enters the myocytes it remains trapped, similar to a
microsphere, and does not redistribute to any significant degree. Thus,
the initial uptake represents blood flow at the time of injection and
remains fixed over time. The majority of the compound is cleared by the
liver, concentrated in the biliary system, and excreted into the
intestine that receives the highest radiation dose. Usually patients are
imaged 1 hour following a rest or exercise study to allow sufficient
background clearance and optimize heart to background ratios. However,
newer protocols are being developed that allow imaging 15 minutes
following an exercise study.
The lack of redistribution of 99mTc sestamibi offers 2 distinct
advantages: post-stress studies can be repeated without loss of
sensitivity and use of this agent in acute situations to measure blood
flow. Since one of the limitations of 201Tl is that it redistributes
immediately after uptake, post-stress imaging needs to be started
immediately or areas of ischemia may be missed with a loss of
sensitivity. If the patient moves during acquisition, repeat imaging is
not advisable, but with 99mTc sestamibi, patients can be imaged again
without loss of sensitivity. Patients presenting with acute ischemic
events such as unstable angina or myocardial infarction, can be injected
with 99mTc sestamibi and imaging performed several hours later when they
are stable. The 99mTc sestamibi uptake seen at the time of imaging will
represent the uptake at the time of injection and provides useful
diagnostic and prognostic information.
1998 Board Question

109. Regarding causes for a perfusion scan defect:

     a. Pulmonary artery aneurysm
     b. Hilar Lymphadenopathy
     c. Bronchial adenomas

Type- Nucs
Answers- b,c
Notes-

by KW
Requisites p142
lists bronchogenic CA as a cause of mismatch, but doesnt say why
Original answer provided was Bronchial adenoma, secondary to reflux
vascoconstriction secondary to hypoxia
I added Pulmonary artery aneurysm as a wrong choice.
1988 True/False Question

110. Regarding diuretic renal scintigraphy.   Which is essential?

     a.   normal renal function
     b.   absence of history of previous obstruction
     c.   increase creatinine
     d.   absence of renal calculi

Type- Nucs
Answers- a
Notes-

by KW
2000 Board Question

111. Regarding equilibrium gated radionuclide ventriculography:

     a.   In vivo labeling of RBCs is adequate
     b.   EF may be overestimated if background counts are subtracted
     c.   EF is calculated using images obtained at 8 frames per cycle
     d.   Averaging of 5-8 cycles is adequate

Type- Nucs
Answers- b
Notes-

by KW
Verified Requisites p73,75,79
Cycle is devided into 16-24 frames per cycle.
100 to 300 cycles are averaged for optimal statistics.
According to formula on p79, if you subtract from each of the numbers for
background correction, the EF will go up.
Modified in vitro or in vitro is needed for gated exams.
This basic approach has been called equilibrium gated blood pool imaging,
MUGA (the name of an early computer software processing package), or
radionuclide angiography. All of these names refer to the technique
whereby 99m Tc-RBCs are injected into the patient where they equilibrate
within the intra-vascular space and define the great vessels and the four
chambers of the heart. Acquisition requires that the images be gated
using the ECG signal to identify the beginning of each cardiac cycle to
accumulate a sufficient number of beats and identify discrete time
intervals or frames in the heart cycle to assess global parameters such
as ejection fraction, filling, and emptying rates or regional contraction
analysis.
Acquisition is performed using a small or a large field of view gamma
camera equipped with a general all-purpose parallel-hole coilimator that
is interfaced to a dedicated computer system. Routine views include a
best septal view left anterior oblique, usually a 35-45 degree, and then
the camera is rotated 45 degree on each side of this best septal view to
acquire anterior and left lateral images. For some patients a steeper
left lateral, almost a left posterior oblique, is required in order to
see the true inferior wall. optimal positioning requires that the camera
head be as close as possible to the chest wall and a 10 degree caudal
tilt is frequently required.
A typical frame mode study is acquired for a minimum of 16 frames and
usually requires that there be a total of 4-6 million counts for the
entire study, or 250,000 counts in each frame or a preset number of
counts in the left ventricular region of interest. Alternatively studies
can be acquired for a fixed time interval, usually 5-10 minutes, or a
fixed number of accepted beats, usually 250-500. Ideally, all of these
methods will result in sufficient counts within the left ventricular
region of interest to allow clear separation of the blood pool edges from
the other ventricular chambers and surrounding background activity. This
process usually requires filtering and either visual or automated edge
detection algorithms to define the contours.
1998 Board Question

112. Regarding evaluation of brain death with nuclear scintigraphy:

      a. delayed activity in the brain following Tc-99m-HMPAO
administration is suggestive of the diagnosis
      b. it has no role in the determination of brain death
      c. barbiturate intoxication invalidates the results
      d. a hot nose sign is diagnostic of brain death

Type- Nucs
Answers- a
Notes-

hot nose is non-specific   M83
1995 Single Best Answer Question
deep coma with total abscence of brain stem reflexes or spontaneous
respiration,
reversible causes such as drug intoxicaiton, metabolic problems,
hypothermia must be
excluded. The dause of brain dysfuction must be diagnosed and the
clinical findign of
brain death must be present for a defined period of time ( 6-24hr).
Confirmatory tests can increased the certainty, but the dx is primarily
clinical.
EEG, and radionuclide studies just evaluate the cortex not the brain
stem. In sth setting
of barbituate tox, hypothermia, the EEG may be flat even though recovery
is possible.
Scintigraphy is not affected by drug intoxication, hypothermia. Abnormal
radinuclide angiogram is more specific than EEG for brain death.
Dx findings of brain death include the lack of intraarterial flow and no
visualization of major venous sinuses. Often the hot nose sign is seen
in dx of brain
death. Can occasionally see faint visualization fo sagittal or
transverse sinus in abscence
of cranial perfusion.
Tc-99m HMPAO is used for cerebral perfusion imaging. In brain death,
HMPAO
shows no cerebral perfusion. It is advatageous because can evaluate on
bolus flow
images or on delayed images. therefore, it is not dependent on a good
bolus needed for
flow imaging. The distribution of HMPAO is porportional to the regional
cerebral blood
flow. By 10 minutes there is raped 15% washout of brain activity.
p 268, 263-4
by MH

113. Regarding Gallium-67 imaging in a patient with AIDS:

        a. is more sensitive than CXR for opportunistic infection of the
lungs
        b. uptake in the abdominal nodes is specific for MAI
        c. uptake in hila is suggestive of PCP
        d. reverts to normal after 5 days of therapy for PCP

Type- Nucs
Answers- a
Notes-

1992, 1988 True/False Question
Gallium is more sensitive than CXR for evaluation of PCP. Gallium often
shows
diffuse activity bilaterally when the CXR is normal. However, Gallium-67
is nonspecific
and there are numerous other causes of increased lung activity (bleomycin
toxicity,
miliary TB, XRT, ....). The Gallium scan will return to normal only
after the PCP has
been completely treated.
Uptake in the hila in a patient with AIDS is more suggestive of MAI or
TB. In a
patient who does not have AIDS, this pattern can be seen with sarcoid,
lymphoma, etc.
Similarly, uptake in abdominal lymph nodes can be seen with MAI, but also
with many
other entities, especially lymphoma.
With Indium-111 scanning, diffuse lung activity corresponds to disease in
only
10% of cases. One in six normal patients have increased pulmonary
localization of
Indium-111-labeled WBCs, for reasons which are not clear.
by MH

114. Regarding gastric emptying examination by nuclear medicine:

        a.   lipids will increase rate of emptying
        b.   300 mCi of Tc-99m-SC in 30 cc water
        c.   fluids show linear emptying curve
        d.   there is exponential emptying with solids
        e.   demonstrate 50% emptying at 30 minutes for fluids in a normal
study
Type- Nucs
Answers- e
Notes-

1995, 1991, 1988 True/False Question
- The dose of Tc-99m-SC is usually 0.5-3 mCi.
- fluids exhibit exponential emptying with a half-life of 30 minutes
- solids exhibit a linear curve with a half-life of 90 minutes. Solids
are more sensitive for detecting abnormality.
- Caloric content and meal size affect the emptying time - lipids reduce
the rate of emptying of both solids and liquids
The half-time for emptying of the liquid phase is 40 (12-65) minutes.
mettler277.
by KH

115. Regarding gastric emptying studies:

      a. 50% emptying at 30 minutes is considered normal
      b. Lipids incease the rate of gastric emptying
      c. Solids empty in an exponential fashion
      d. Liquids empty in a linear fashion
      e. Imaging should begin 30 minutes after ingestion of the
radiotracer

Type- Nucs
Answers- a
Notes-

Mettler p.277, liquids empty in a exponential fashion, solids in a linear
fashion
Normal emtying times: Solids= 50% at 90 min., Liquids= 50% at 40 min.
Imaging should begin immediately after eating.
Delayed gastric emptying can be classified as mechanical or functional.
Mechanical obstruction can result from duodenal or pyloric channel ulcer,
stomach cancer, and hypertrophic pyloric stenosis. Functional delay in
emptying results from abnormal gastric motility due to vagotomy,
diabetes, hypothyroidism, trauma, anticholinergic drugs, and opiates.
Osmolality, pH, volume, caloric content, fat content, and protein all
affect the gastric emptying rate. Distention of the stomach is thought to
accelerate emptying while fat inhibits. The solid and liquid contents of
the stomach empty at different rates (linear and exponential,
respectively). Most Nuclear Medicine departments label the solid phase.
Whole eggs or egg whites are usually labeled.
Note that the initial work-up in a patient with symptoms of gastric
outlet obstruction should include a contrast examination rather than a
scintigraphic study. A gastric emptying study is performed using 0.5-3
mCi of Tc-99m sulfur colloid is mixed with scrambled eggs during cooking.
The normal T1/2 for activity leaving the stomach is 90 minutes (45-110
minutes). 99mTc DTPA, 125 uCi, in water (or juice) can be used to monitor
liquid phase emptying. Note that the position of stomach contents changes
with time. Anterior and posterior counts from selected regions of
interest need to be averaged. If 111 In DTPA is used, liquid and solid
phases can be monitored simultaneously. The half time for liquids is
typically 30 (12-65 minutes) minutes. (TF)
1998 Board Question
by AE

116. Regarding I-131 total body imaging:

      a. has a high sensitivity for detection of well differentiated
medullary carcinoma
      b. is rarely performed beyond 24 hours
      c. evaluation of abdominal metastases is limited because of GI
uptake
      d. patient must be off T4 for one or two weeks
      e. limited to 3-5 mCi because of total body dose

Type- Nucs
Answers- c
Notes-

1994 True/False Question
Dahnert p906 - renal + GI excretion
Mettler says off 4-6weeks for T4
Total body imaging is usually done to find metastases - the dose is 2-5
mCi I-131.
Scanning is frequently performed beyond 24 hours (usually 48-72 hours)
because it
demonstrates more lesions. The long half-life (8.1 days) allows this.
Medullary and
anaplastic carcinomas do not take up iodine. Guidelines:
- off of T4 for 4-6 weeks
- off of T3 for 2 weeks
- not have had water soluble iodinated contrast for 6 weeks
Reference: Thrall
by MH

117. Regarding liver scintigraphy?

      a. bowel transit in HIDA scan can differentiate between neonatal
hepatitis and biliary atresia
      b. Sulfur Colloid is taken up by hepatocytes
      c. HIDA is taken up by kupfer cells

Type- Nucs
Answers- a
Notes-

by KW
HIDA extracted by hepatocytes
Sulfur Colloid taken up by RES/Kupffer cells
2000 Board Question

118. Regarding MUGA:
       a. first pass study is more accurate for RVEF than conventional
MUGA
       b. inappropriately small systolic ROI causes artifactually low EF
       c. atrial fibrillation degrades the quality of the scan

Type- Nucs
Answers- a,c
Notes-

mettler173. Arthythmia filtering.
Unlike first-transit studies, right ventricular ejection fractions are
not reliably calculated from the equilibrium study because the right
ventricle is not easily separated from the right atrium or left
ventricle.mettler176
1992 True/False Question
Atrial fibrillation does degrade the quality of the scan.   Each R-R
interval is divided into 16-32 segments and data is sorted into these
segments. An irregular rhythm can severely degrade images.
A first pass study is more accurate for RVEF than MUGA. The right
ventricle is not reliably separated from the right atrium and left
ventricle on equilibrium studies. An inappropriately small systolic ROI
does not cause an artifactually low EF, actually it causes and
artifactually high EF. Reference: Mettler 1991, pp. 132-134
by KH

119. Regarding nuclear medicine ventriculography:

      a. images are obtained in 32 separate segments of equal time with
cycling thorugh the
      b. the normal image is obtained by subtracting the end-systolic
frame from the end-diastolic frame
      c. both paradoxical and normal imaging are performed in the
anterior projection
      d. the paradox image is obtained by subtracting the end-diastolic
frame from the end-systolic frame
      e. the atria and ventricles are out of phase by 90 degrees

Type- Nucs
Answers- b,d
Notes-

M166
1995 True/False Question
segments based on the position in the cardiac cycle
Typically both the ejection fraction and stroke volume images are
obtained in the
45 degree LAO projection.
Dyskinetic segments of ventricle can be identified employing the paradox
image.
The paradox image is essentially an inverse stroke volume image in that
the diastolic
frame of the ventriculogram is subtracted from the systolic frame. With
normal left
ventricular activity, no areas of activity (positive values) should be
identified in the region
of the left ventricular wall.
In a normal phase analysis, the contraction pattern is expected to follow
a standard
sequence: atrial contraction fills the ventricular chambers followed by
contraction of the
ventricles. Since the atria are filling when the ventricles are emptying
and vice versa,
they can be thought of as contracting with the phase difference of 180
degrees.
Reference: Mettler 1991, pp. 125-126
by MH

120. Regarding nuclear renal scan:

     a. DMSA binds to sulfhydryl goups
     b. Iodohippurate acts by tubular secretion

Type- Nucs
Answers- a,b
Notes-

Not Verified
1993 Board Question

121. Regarding persantine stress thallium:

     a.   chest pain indicates ischemia
     b.   its IV half-life is longer than that of adenosine
     c.   dilatation is reversed by aminophylline
     d.   direct dilatory effect on the coronary arteries

Type- Nucs
Answers- b,c
Notes-

Persantine is an inhibitor of adenosine deaminase. It allows
accumulation of adenosine in the coronary bed. This allows detection of
ischemia through creation of steal phenomenon, increasing coronary blood
flow 3-5 times above resting levels.
Chest pain during persantine thallium is a non-specific symptom. Other
side effects include: headache, dizziness, flushing, and nausea. Side
effects may be treated with aminophylline.
The half-life of adenosine is measured in seconds.
Reference: Mettler 1991, pp. 111-112
1992 Question

122. Regarding PET and SPECT:

     a.   imaging in longitudinal plane for SPECT
     b.   PET uses nuclides have longer half-life
     c.   axis of rotation more important for SPECT
     d.   imaging in axial plane in PET
Type- Nucs
Answers- a,c,d
Notes-

1993 True/False Question
Data on SPECT is obtained volumetrically which permits multiple
tomographic slices to
be obtained simultaneously with registration of the data between planes.
Image
reconstruction for PET is the same principle as SPECT> p 34 Thrall
by MH

123. Regarding radionuclide myocardial imaging:

      a. thallium stress imaging is more sensitive for detecting disease
of the LAD artery than exercise EKG
      b. stress thallium is more sensitive for mapping regions of
ischemia than exercise EKG demonstrating 2-3 mm of ST depression
      c. thallium stress imaging is sensitive for detecting ischemia in
regions of abnormal wall motion
      d. thallium stress imaging is sensitive for detecting myocardial
ischemia when an EKG is uninterpretable secondary to arrhythmia

Type- Nucs
Answers- a,b,c,d
Notes-

1995 True/False Question
With the traditional treadmill test, ischemia is detected by alterations
in the
electrolyte flux across ischemic membrane which result in ST depression.
On
scintigrams, there is decreased regional blood flow which is seen as a
cold area. Failure to achieve adequate exercise is the single most
common reason for false negative results. Included in the reasons for
failure to achieve adequate exercise is dysarrhythmia. p. 61
Actual anatomy of coronary circulation is variable in its details. The
districution of the major vessels is reasonably predictable. The LAD
serves the septum and anterior left ventricular wall. The left
circumflex serves the lateral and posterior walls. The RCA serves the
RV, inferior wall, inferior septum. p 63-4
Joe Viggiano, the nucs fellow, said that poor perfusion happens first and
then
results in ischemia which leads to EKG changes. So, scintigraphy is more
sensitive than EKG in identifying ischemic changes.   In arrthymia,
although there are greater false positives in scintigraphy, it is still
more sensitive than EKG especially in cases like A. fib. In LBBB, the
septum contracts while the rest of the ventricle is in diastole, so
decreased uptake in seen in this region and classically gives a false
positive reading.
With EKG abnormalities, if there is ST depression in certain leads,
identifying the area of ischemia is less reliable than on scintigraphy.
ref: Requisites p 61-4 (D p916)
by CM

124. Regarding reflux studies:

      a. anterior views are more sensitive than posterior views
      b. should be done 2 hours after ingestion
      c. the patient drinks in an erect position and is scanned while
supine or prone
      d. sulfur colloid or indium should be used

Type- Nucs
Answers- a,c,d
Notes-

Mettler p.277
1991, 1988 True/False Question
Imaging is done immediately after ingestion.
HUP and CHOP use sulfur colloid but indium may also be used.
Calculations are done with a geometric mean of the anterior and posterior
counts
to correct for attenuation; however, if this choice is not given,
anterior scanning is better
than posterior scanning.
by AE

125. Regarding shin splints on bone scan:

        a.   normal first and second phases, hot on third
        b.   hot first and second phases, fades on third
        c.   hot on all three phases.
        d.   normal
        e.   hot first and second phases, normal third

Type- Nucs
Answers- a
Notes-

mettler314-315.
1992 Single Best Answer Question
Shin splints represent a chronic traction periostitis at the posterior
tibial muscle insertion. They usually present as a flat/linear area of
increased activity in the posteromedial and anterolateral cortex of the
tibia. Perfusion and blood pool images are normal. Treatment is rest
and antiinflammatories. Stress fracture presents as a fusiform focus of
increased activity. A bone scan is more sensitive than a radiograph for
the diagnosis of both shin splints and stress fractures, and often
becomes positive earlier in the course of disease.
by KH

126. Regarding SPECT imaging for the evaluation of seizure disorders:

      a. For ictal imaging, tracer can be injected 20 minutes after the
start of a seizure
      b. Interictal imaging is more sensitive for detecting abnormalities
than ictal imaging
      c. Ictal imaging can be delayed for 2-3 hours following seizure
      d. Imaging most often demonstrates abnormalities in the frontal
lobes
      e. Interictal SPECT demonstrates increased tracer uptake

Type- Nucs
Answers- c
Notes-

(Req-Nuc p272)
E as long as the patient was injected during the seizure.
1998 Board Question
by CM

127. Regarding SPECT with myocardial perfusion imaging, which of the
following statements is false?

      a.   Increased sensitivity for small ischemic areas
      b.   Performed at rest
      c.   Can differentiate between perfusion defect and attenuation
artifact
      d.   Can measure ejection fraction

Type- Nucs
Answers- c
Notes-

1999 Board Question
by MH

128. Regarding Tc-99m prep kit:

     a. Technetium dioxide prevents hydroxylation
     b. EDTA scavenges free metal impurities
     c. Stannous is the reducing agent

Type- Nucs
Answers- a,b,c
Notes-

Not Verified
1993 Board Question

129. Regarding technetium-99m MDP radionuclide bone scan:

     a. the agent causes temporary cessation in bone metabolic activity
     b. the agent localizes to bone in 3 hours
     c. MDP chemiabsorbs to osteoclasts

Type- Nucs
Answers- b
Notes-
by KW
Verified Requisites p95
Tc99m MDP localizes to bone in 2-6 hours.
MDP chemiabsorbs to hydroxyapetite?
1995 True/False Question
Uptake in bone by Tc-99m MDP is rapid and uptake by 2-6hrs after the
injection
represents approximately 50% of injected dose. In practice, most imaging
begins by 2-
3hrs post adminstration.
Mechanism of tracer localization is less well understood for phosphate
substances.
It is felt that adsorption is primarily to the mineral phase of bone with
little binding to the
organic phase. Uptake is higher in amorphous calcium phosphate than
mature
hydorxyapatite. This helps explain the avidity of tracer for areas of
increase osteogenesis.
In Resnick, the mechanism if MDP is also not well understood. But it
suggests
that MDP may be able to diffuse accross the bone capillary wall. The
phosphate
compound may chemiabsorb at kink and dislocation sites on the surface of
the HA
crystal. Sites of rapid bone turnover, are associated with large mineral
surface that is
available for exchange and chemisorption. It has also been proposed that
such binding
predominates at the organic matrix, particularly in the immature
collagen.
ref: Requisites p 95, Resnick p 186

130. Regarding technetium-99m sulfur colloid for detection of GI bleed:

     a.   has greater sensitivity than angiography
     b.   is best for upper GI bleeds
     c.   is good for detecting intermittent bleeds
     d.   requires labelling of red blood cells

Type- Nucs
Answers- a
Notes-

1995, 1989, 1988 Single Best Answer Question
Nuclear medicine scintigraphy with sulfur colloid for GI bleeding can
detect
bleeding at rates 0.1 ml/minute which approximately 1/10th the rate at
which angiography (1 ml/min) can reliably detect bleeding. There is too
much background activity from accumulating activity in the liver and
spleen to allow sulfur colloid imaging to be useful in the upper GI
tract. Sulfur colloid scanning is a one-shot deal with useful images
being obtained for approximately 30-45 minutes after the injection.
Labelled red blood cells can be used to image the patient in a delayed
fashion for intermittent bleeds. (Req-Nuc p241-248)
by CM

131. Regarding technetium-99m-labeled red blood cells, technetium
pertechnetate binds to which of the following sites?

     a.   beta chain of hemoglobin molecule
     b.   iron component of the hemoglobin
     c.   red cell membrane
     d.   alpha chain of hemoglobin molecule

Type- Nucs
Answers- a
Notes-

1995 Single Best Answer Question
In the in vivo rbc labelling, the pertechnetate diffuses across the rbc
membrane
where it is reduced by the stannous ion. The Tc-99m label binds to the
beta chain of the
hemoglobin.
ref: Req p 73
by MH

132. Regarding technetium-99m-labeling of red blood cells:

      a. other answers not remembered
      b. in order to do in vivo labeling, 0.5-1.0 mg of stannous ion is
injected intravenously

Type- Nucs
Answers- b
Notes-

RBC labeling -- In vivo method has a labeling efficiency of 75-80%.
Stannous pyrophosphate is injected. Wait 10-20minutes. Inject Na
pertechnatate.
Modified in vivo labeling has an efficacy of 85-90%. Inject stannous
pyrophosphate, wait 10-20 min, withdraw 5-8ml into a shielded syringe
containing Tc-99m Na pertechnatate, gently mix syringe contents for
10minutes at room temperature and reinject.
In vitro has two forms both with 98% labelling efficiency. The
Brookhaven method, mix heparainized whole blood with Sn 2+, Na citrate,
dextrose, NaCl. Incubate 10minutes, add EDTA, centrifuge. Withdraw
1.25ml of packed rbc and transfer to sterile vial containing 1-3ml Tc 99m
pertechnatate. Incubate at room temp for 10 minutes.
The in vitro commercial labeling kit, add heparanized whole blood to
stannous chloride and mix. Add Na hypochlorite and mix. Add Citric
acid, Na citrate, dextrose andmix. Add Tc pertechnatate to reaction vial
and mix. Allow to react for 20 minutes.
ref: Requisites p 244 table 10-9
1995 Question
133. Regarding technetium-99m-Sestamibi cardiac imaging:

     a. the uptake in the myocardium is by passive diffusion
     b. the first pass uptake is less than that of thallium-201
     c. Sestamibi typically rapidly redistributes within the myocardium

Type- Nucs
Answers- a,b
Notes-

Tc sestamibi is a member of the isonitriles. Tc 99m sestamibi diffuses
passively out of the blood and localizes in the mitochodria on the basis
of their negative electrical potentials. The extraction fraction in the
coronary circulation is less than teboroxime or Tl-201. At rest flows,
the extraction is 1/2 of Tl-201. The maximum extraction decreases with
increasing flow. Sestamibi underestimates flow at very high flows and
overestimates at low flows.
Uptake in the myocardium is rapid but is somewhat obscured by activity in
the lung and liver in the time immediately after injection. Clearance t
1/2 of tc-sestamibi is excess of 5 hours. Progressive clearance by lung
and liver over 60-120 minutes improves imaging of heart. There is
minimal recirculation or redistributions after initial uptake.
Diagnostic criteria for sestamibi are the same as with thallium. In
normal, there should be no defects at rest or exercise. Prior MIs will
demonstrate abnormalities. Areas of exercise induced ischemia will
appear as defects of post stress studies and will normalize when tracer
is reinjected at rest.
ref: Requisites p 72-3
1995 Question

134. Regarding Thallium-201 imaging:

      a. intracellular distribution
      b. The energy of the imaged photons are 65 to 80 keV
      c. Flow rate must differ by 2 to 1 to be positive
      d. First pass extraction equal to 50%
      e. with exercise there is increased activity in the liver which can
obscure the left heart border

Type- Nucs
Answers- a,b,c,e
Notes-

Mettler p.132, agree with below.
1993 True/False Question
Thallium is an analog of the potassium ion - it is delivered to capillary
beds by
regional blood flow and is actively pumped into viable cells by the Na/K
adenosine
triphosphate pump.
The first pass extraction of Thallium is about 90% and the plasma half-
life is 10
minutes. Only 3-5% of thallium activity localizes in the heart.
The flow rate for normal/abnormal is about 2:1. Animal studies have
shown that
at maximum exercise, 50% stenosis is generally sufficient to consistently
present as a
defect.
Photopeaks of Tl-201 are 69 keV and 81 keV (98%).
Activity in the RV is best visualized on a 30-45 degree LAO view. It is
often seen
normally during the stress portion of the exam. Its absence, or a defect
that later
redistributes, should be regarded as suspicious for ischemia. During the
redistribution
study phase, RV activity is usually too minimal to be visualized in
normal individuals.
When there is RV activity on a rest-only study, it suggests RV
hypertrophy or an
increased RV workload, such as pulmonary hypertension.
The right and left chamber sizes are roughly equal by scintigraphy. The
ratio of
lung to heart activity is usually 30%. A value of 50% or greater is
abnormal, and suggests
left ventricular dysfunction on the basis of coronary artery disease.
Liver or spleen activity overlying the inferior wall of the left
ventricle, especially
on the redistribution images, may produce a relative increase in activity
in the inferior
wall, with the resultant appearance of reversible redistribution on
exercise studies and the
reverse effect noted on dipyridamole studies suggesting inferior wall
myocardial
ischemia, Mettler 1991, p. 121
by AE

135. Regarding thallium-201 myocardial imaging:

      a. thallium-201 myocardial imaging uses a low energy high
sensitivity collimator
      b. patients are imaged with their left arm above the head
      c. the detectors move from a right anterior oblique position to a
left posterolateral position
      d. uses a 256 x 256 matrix for imaging
      e. 36 stations are used with 20 to 40 second intervals at each
stations

Type- Nucs
Answers- a,b,c
Notes-

1995 True/False Question
60 Stations....64X64Matrix
Thallium 201 planar imaging uses a low-energy,high resolution or general
purpose, parallel hole collimator and a 20-25% window centered at 80 KeV.
This 80 keV window encompasses the K-beta series of mercury-201 x-rays.
Pt are imaged in the supine position. Obtain 35 degree LAO, 70 degree
LAO, left lateral views for 10 minutes each. For rest redistribution
studies, repeat the same views 2-4 hr later. Use a standard or large
field of view camera. The larger the matrix size, the better the
potential spatial resolution, but the longer the time to acheive adequate
counting statistics. Most use 64x64 or 128x128,
For spect imaging, use general all purpose collimator and 10%window
centered at 80 KeV. The matrix is 64x64 byte mode. the framing is 60
views/180 degree arc length from 45 degree RAO to 135 degree LPO for a
single head camera. Spatial resolution is degraded the farther the
camera head is from the organ of interest. So noncircular orbits or
body-contoured arc paths are desirable to keep the camera head as close
to the body surface as possible. Among low energy collimators, designs
are optimized for either sensitivity or resolution. The thicker the
collimator, the higher the spatial resolution and the lower the
sensitivity. ref: Requistes. p 57-58, 22, 29
by KH

136. Regarding the stripe sign in ventilation-perfusion imaging of the
lungs:

      a. commonly seen in patients with COPD
      b. indicates evidence of perfusion in the periphery of the pleura
      c. cannot be interpreted in the presence of small bilateral pleural
effusions
      d. indicates a peripheral perfusion defect

Type- Nucs
Answers- b
Notes-

indicates low probability for PE
1995 Single Best Answer Question
The stripe sign refers to a margin of radioactivity between a perfusion
defect and
the pleural surface. PE should extend all the way to the pleura. If
stripe sign, suggest
parenchymal abnormality such as pulmonary hemmorhage or other fluid
accumulation
other than PE.
Pleural effusions attenuate the signal. If the pt is upright, can get
fluid in the
fissure causing a curvilinear perfusion defect. If subpulmonic effusion,
can potentially
miss it.
p 143-4 Thrall
by AE

137. Regarding the thallium-technetium subtraction technique; a focus of
activity could represent:

     a. parathyroid adenoma
     b. thyroid nodule

Type- Nucs
Answers- a,b
Notes-

by KW
Verified Requisites p342
Thallium - uptake in thyroid + Parathyroid.
Technetium - uptake in thyroid only.
1988 True/False Question
Parathyroid scintigraphy is usually a combination of pertechnetate and
thallium
imaging. A pertechnetate (thyroid) scan is subtracted from a thallium
(both thyroid and
parathyroid) scan to reveal parathyroid activity alone, although the
pathology is evident in
most cases without subtraction. False positives in parathyroid
scintigraphy include
thyroid carcinoma, goiter, and lymphoma (all accumulate thallium but not
pertechnetate).
In subraction imaging, the thallium is avidly taken up in the thyroid and
parathyroid tissue, while Tc-99m is only accumulated in thyroid tissue.
Pitfalls of this
techniqe include, inhomogenous uptake in a multinodular goiter, or
follicular adenoma.
Primary mets can take up Thallium and give a false positive. Pt motion
can also give
misregistration. p 342 Req.

138. Regarding thin layer chromatography for Tc-99m-MAA preparation:

     a.   free technetium stays   at the origin
     b.   Tc-99m-MAA moves with   the solvent front
     c.   Tc-99m-MAA must first   be hydrolyzed
     d.   none of the above
     e.   sterile saline is the   solvent of choice

Type- Nucs
Answers- d
Notes-

None of the above
mettler45-47
1992 True/False Question
Thin layer chromatography is used to check for radiochemical impurity.
To check for free TcO4-, the agent is typically acetone, since this will
cause free technetium to migrate and most labeled compounds with remain
stationary (including Tc-99m-MAA, colloid, and microspheres).
Macroaggregated albumin particle size may be evaluated by using a
hemocytometer slide.
USP limit for radiochemical purity is 95% for TcO4-, 92% for TcSC and 92%
for all other Technetium-labeled compounds. With the standard 5 mCi dose
of technetium-99m-MAA (200,000-500,000 particles) approximately 0.1% of
pulmonary arterioles are embolized. In the infant, the number of
arterioles is not as great and the number of particles is therefore
reduced to 100,000. In patients with pulmonary hypertension, who have
thickening of the arterial walls and pruning of the vascular tree, the
number of particles must also be reduced.
by KH

139. Regarding treatment for thyroid cancer post op. which of the
following is false:

     a. A dose of 200 mCi for lung mass can cause pulmonary fibrosis
     b. Two doses of 100 mCi is contraindicated because of leukemia

Type- Nucs
Answers- b
Notes-

by KW
2000 Board Question
Dahnert p334
Greater risk above 200mCi for pulmonary fibrosis
Guidelines for maximum dose administration
The guidelines regarding the maximum activity which can safely be
administered are: [11]
1- Blood dose should be no more than 200 rads
This limit is set to reduce marrow toxicity. Frequently (90%) doses of
this level are associated with mild, transient decreases in blood cell
counts, but no instances of permanent suppression have been reported.
2- Retained whole body activity of no more than 120 mCi at 48 hours (or
80 mCi in patients with lung metastases to avoid potential pulmonary
fibrosis)
A- Leukemia
The risk for AML is only minimally increased above the general population
with a peak incidence 2 to 10 years post therapy (0.5% increased risk).
Patients at risk are generally above the age of 50 and have received a
dose of approximately 900 mCi. The risk is greatest when this large dose
has been given over a short period of time (6 to 12 weeks). These
patients have usually received a blood dose greater than 200 rads. It may
also be possible that patients with thyroid cancer are at an increased
risk for this type of malignancy regardless of the type of therapy they
receive.
To minimize the risk for leukemia Beierwaltes recommends a 1 year
interval between therapies and a total cumulative dose of administered
activity not to exceed 800 mCi [19] It is important to note that the
mortality from recurrence exceeds that from leukemia by 4 to 40 fold.

140. Regarding V/Q examination:

      a. stripe sign is seen with pleural effusion
      b. low probability cannot be given in a patient with diffuse
alveolar infiltrates
      c. frequently patients with COPD have a fissure sign
      d. high probability study cannot be given in a patient with COPD
involving >50% of the lung

Type- Nucs
Answers- c,d
Notes-

In fact, in patients with matched ventilation-perfusion defects
accompanied by extensive ventilation abnormalities involving greater than
50% of the lung field, interpretation may be so difficult as to warrant
an intermediate probability or even and indeterminate reading, especially
when matched defects of a segmental nature are present. mettler217.
The stripe sign consists of a thin line or stripe of activity
representing perfused lung tissue between a perfusion defect and the
adjacent pleural surface. The sign is postulated to be due to decreased
attenuation of alveolar airspace activity because of decreased blood in
the surrounding capillaries. The fissure sign refers to linear perfusion
deficits corresponding to the interlobar pulmonary fissures, both major
and minor. This sign is commonly seen in the presence of pleural fluid
in the fissures but may also be seen in the presence of fissural pleural
thickening and is frequently observed in patients with COPD. mettler215-
216.
1994 True/False Question
If there are no perfusion defects or if perfusion defects are
substantially smaller than radiographic abnormality then the scan is low
probability. If there are large unmatched V/Q abnormalities, a scan can
be called high probability in a patient with COPD. The fissure sign
represents pleural fluid in fissures - it is unrelated to COPD. The
stripe sign refers to a margin of radioactivity between a perfusion
defect and the pleural surface of the lung. The significance of this
finding is that this indicates that the perfusion defect is likely due to
parenchymal abnormality rather than PE.
Revised PIOPED criteria:
- intermediate prob. ------> 1 large + 1 segmental defect
- high probability ---------> greater than or equal to 2 large or 1 large
and greater than or
equal to 2 moderate or greater than or equal to 4 moderate segmental
defects
by KH

141. Regarding V/Q scans:

      a. high probability scan in a patient with prior PE is less likely
to be PE than a high probability scan in a patient who has never had a PE
      b. the probability of PE does not depend on clinical suspicion in a
patient with a low probability scan
      c. intermediate probability scan is not useful
      d. Xe-127 can be used after Tc-99m perfusion scan
      e. greater than half of patients with PE have a high probability
scan

Type- Nucs
Answers- a,d
Notes-

Mettler p.212--High prob has sensitivity of 40%, misses 60% of patients
with PE
1992 True/False Question
It is more difficult to interpret a high probability scan in a patient
with prior PE.
This is assuming that there are no prior studies or that the prior study
was abnormal.
Only about 50% of patients less than 40 y/o revert to a normal V/Q scan
after a PE. A
normal scan is unlikely after a PE in a patient older than 60 y/o,
underlying lung disease,
or a PE-caused infarct. PIOPED is designed to look at patients who have
not had a prior
PE but can still extrapolate findings to patients with prior PE (i.e., 2
new large defects is
high probability).   A high probability scan in a patient with prior PE
has a 74% positive
predictive value - in patients without prior PE the positive predictive
value is 91%.
More than 80% of patients with high probability V/Q scan have a PE.
(20-79%
of patients with intermediate probability and <20% of patients with low
probability)
Therefore, an intermediate probability scan is not worthless, especially
if there is a very
high or very low clinical suspicion. PIOPED data varied the probability
based on clinical
suspicion.
Xe-127 has a photopeak of 203 keV, and therefore can be used after Tc-
99m-
MAA. Xe-133 must be performed before the perfusion scan, Mettler p.194.
by AE

142. Regulations state that the dose calibrator is required to measure
radionuclide doses with the maximum error being +/-%?

     a.   5
     b.   50
     c.   25
     d.   10
     e.   20

Type- Nucs
Answers- d
Notes-

Mettler 1998 p.39
1995 Single Best Answer Question
Reference: Mettler 1991, p. 27
by AE

143. Small matched V/Q defects makes the likelihood of PE:

     a.   >90%
     b.   50%
     c.   5-10%
     d.   60-80%
     e. <1%

Type- Nucs
Answers- c
Notes-

by KW
Requisites p141 states that 12% have PE with low probability scan
Dahnert lists 16% have PE with low probability scan
1992 Single Best Answer Question
This corresponds to a low probability V/Q scan, making the likelihood of
PE<20%. High prob is >80% chance PE, Intermediate is 20-80%. p 137
Thrall

144. T/F regarding the purity of Technicium-99m:

     a. Unremembered

Type- Nucs
Answers- a
Notes-

Radionuclide purity: The most common radionuclidic contaminant in the
generator eluate is the parent radionuclide, Mo-99. Technetium-99, the
daughter product of the isomeric transition of Tc99m is also present but
is not considered an impurity or contaminant. Although Tc99 can be a
problem from a chemical standpoint in radiolabeling procedures. The
amount of Mo99 in the eluate is subject to limits set by the Nuclear
Regulatory Commission(NRC) and must be tested on each elution. By taking
advantage of the energetic 740 and 780 keV gamma rays of Mo99 an estimate
of the number of microcuries of Mo99 in a sample may be determined using
lead shielding to absorb 140 keV Tc99m photons. The unshielded sample is
then measured on the Tc99m setting and a ratio of Mo99 to Tc99m activity
can be calculated. The NRC limit is 0.15 microcuries of Mo99 activity
per 1.0 mCi of Tc99m activity in the administered dose. Because the half
life of Mo99 is longer than that of Tc99m, the ratio of Mo99 is longer
than that of Tc99m, the ratio actually increases with time.
Chemical purity: Another routine QA step is to measure the generator
eluate for the presence of the column packing material, Al2O3. For
fission generators the maximum alumina concentration is 10 micrograms/ml.
Colorimetric spot testing is used to compare to a standard to check this.
Radiochemical purity: The expected valence state of Tc99m, as eluated
from the generator, is +7 in the chemical form of pertechnetate(TcO4-).
The US Pharmacopeia standard for the generator eluate is that 95% or more
of Tc99m activity be in this +7 state.(Req-Nuc p43-44)
1998 Board Question
by CM

145. Thallium imaging:

     a.   10% taken up by myocardium
     b.   The RV is better seen in stress study than during rest
     c.   The localization occurs because thallium is an analogy of CA++
     d.   It is easier to detect single vessel disease vs 3 vessel disease
      e. Ischemia is differentiated from scar tissue by differences in
stress vs rest images

Type- Nucs
Answers- b,d,e
Notes-

1988 Board Question
Per Dr. Buchignani
by MH

146. The best indicator of prognosis at 8 hours status post myocardial
infarction is:

     a.   ejection fraction of 25% on MUGA scan
     b.   positive antimyosin scan (Indium 111 antimyosin)
     c.   increased uptake in the lung on thallium scan
     d.   positive pyrophosphate scan
     e.   negative pyrophosphate scan

Type- Nucs
Answers- a
Notes-

1993 Single Best Answer Question
In general, Tc-99m-pyrophosphate imaging appears to predict morbidity and
mortality by confirming the direct relationship between infarct size and
the likelihood of acute complications. Extensive local infarcts
(doughnut pattern) or an enlarging infarct give poor prognosis. If the
scan is positive for more than three months this indicates increased risk
of future ischemic event. However, to obtain maximum predictive benefit,
the pyrophosphate imaging should be done at 24-72 hours after the
symptoms. Abnormally increased thallium uptake in the lungs correlates
anatomically with multiple vessel coronary artery disease or single
vessel disease involving either a dominant left circumflex artery of
high-grade proximal LAD lesion - and clinically with increased morbidity
and mortality.
Reference: Mettler 1991, pp. 103, 111
The prognosis of patients following an acute MI is directly linked to the
degree of functional impairment(Req-Nuc). The resting LVEF as determined
by gated radionuclide ventriculography has proven to be a reliable
measure of the impact of coronary occlusion on left ventricular function
in early myocardial infarction and, as such, has shown to be an important
predictor of prognosis. (Mettler p177)
by CM

147. The best time to image an infarct with Tc-99m-pyrophosphate is:

     a.   5-7 days
     b.   > 8 days
     c.   1-3 days
     d.   12-24 hours
     e.   <12 hours
Type- Nucs
Answers- c
Notes-

by KW
Verified Requisites p86
The best time to study the patient is 24-48 hours after the infarct.
Of note, the best time to image is 3 to 4 hours after injection.
1992, 1989v Single Best Answer Question
A positive scan may occur within 10-12 hours, but scans become
increasingly
positive until approximately 72 hours. they may revert to negative
within 10 days to 2
weeks. A negative scan between 12 and 24 hours does not exclude acute MI
and should
be repeated.
Reference: Mettler 1991, pp. 98-99

148. The dose of I-131 for hyperthyroidism needs to be increased in which
of the following:

     a.   patient is being treated with PTU
     b.   large gland size
     c.   patient is on beta blockers
     d.   previous radiation to the neck
     e.   toxic multinodular goiter

Type- Nucs
Answers- a,b,e
Notes-

M122-123
1995, 1994 True/False Question
Since PTU blocks the organification of iodine, patients on PTU cannot be
treated
with I-131. A patient should be off PTU for at least 2 weeks prior to I-
131
administration. If patient is off PTU, increased dose of I-131 is
needed.
Beta-blockers (Inderal) are often used for control of hyperthyroid
symptoms.
There is no interference with I-131 therapy.
Multinodular goiter is only treated if it is toxic. Toxic nodular goiter
is called
Plummers disease. It is particularly resistant to radioactive iodine
therapy and frequently
requires doses 2 to 3 times larger than those applicable in diffuse toxic
goiter (Graves
disease).
I-131 is only for treatment of functioning thyroid carcinoma, toxic
nodular goiter
(Plummer disease - dose = 20-30 mCi), or in a patient who is toxic from
Graves disease
(dose = 8-15 mCi). Mettler says Administered doses are frequently
selected at the
higher end of the dose range if the patients are severely hyperthyroid or
have large glands
or significant cardiac disease aggravated by their thyrotoxic state.
Note that he does not
indicate a requirement to increase the dose, so answer the question as
you see fit.
Patients can become transiently hyperthyroid following I-131 therapy
(thyroid
storm). However, this is rare and cardiac symptoms can be treated with
beta-blockers,
etc.
Reference: Mettler 1991, p. 91
Pt with toxic nudules are generally thought to be more difficult to treat
with
radioiodine than pt with goiter because the tissue is relatively
radioresistant. Req p 337
by MH

149. The fractional dose in a gamma agent uniformly distributed in an
organ is related to:

     a.   bacquerels per milliliter
     b.   organ shape
     c.   organ size (mass)
     d.   gamma energy

Type- Nucs
Answers- c,d
Notes-

1993 True/False Question
by KH

150. The most likely condition to show cold nodules on technetium-99m
sulfur colloid liver-spleen scan in a 40 y/o female:

     a.   Budd-Chiari
     b.   metastatic breast cancer
     c.   adenoma
     d.   metastatic colon cancer
     e.   FNH

Type- Nucs
Answers- b
Notes-

1995v, 1992, 1989 Single Best Answer Question
Most metastases are space-occupying (therefore, decreased activity)
lesions on
liver-spleen scan. In a 40 y/o female breast cancer is more likely than
colon cancer.
Focal nodular hyperplasia frequently is indistinguishable from liver on
L-S scan
but also can have increased uptake.
Adenomas are usually photopenic but can have normal activity - also, this
is not a common lesion - breast metastases are more likely.
Budd-Chiari syndrome (hepatic vein thromboses) may occur secondary to
tumor
invasion or hypercoagulation syndromes, but frequently the etiology is
undetermined. It
presents as an enlarged, tender liver accompanied by ascites. It causes
increased activity
in the caudate lobe (or decreased activity everywhere) secondary to its
direct IVC
drainage.
SVC obstruction can caused increase activity in the quadrate lobe if
injection is
done in either arm.
Aluminum clumps cause focal increased activity.
by MH

151. The probability of PE in a scan in which a few small scattered
subsegmental mismatches are seen is:

     a.   low
     b.   high
     c.   moderately high
     d.   intermediate

Type- Nucs
Answers- a
Notes-

by KW
Requisites p137
Low -
non segmental or small subsegmental perfusion defects
matched perfusion and ventilation defects with normal chest xray
perfusion defect with larger area of chest xray abnormality
Intermediate -
One moderate or one moderate and one large segmental defect with normal
chest
High -
Two or more large mismatched segmental defects
The equivalent (two moderate, one large, four moderate) mismatched
segmental defects
1991 Single Best Answer Question

152. The time activity curve from a patient undergoing a gated blood pool
study is shown. The most likely explanation for the findings is?

     a.   Mitral regurgitation
     b.   Patient motion
     c.   Mitral stenosis
     d.   Aortic regurgitation
     e. Left-to-right shunt

Type- Nucs
Answers-
Notes-

??
1999 Board Question
by MH

153. There was a question on oriental cholangiohepatitis, advantage of
tc99m DTPA as a ventilation agent, how to determine field uniformity in
nucs camera, technical question regarding dedicated pet scanner vs. dual
head SPECT camera (with coincidence counting software)?

     a. not remembered

Type- Nucs
Answers- a
Notes-

Mettler p194
by KW
2000 Board Question

154. Thyroid scan.    Hot spot with technetium. Cold spot with I-131 in
the same location.    What is nuclear medicine diagnosis:

     a.   synthesis defect
     b.   transport defect
     c.   papillary carcinoma
     d.   organification defect
     e.   nodular goiter

Type- Nucs
Answers- d
Notes-

Dahnert p304
Theoretically, the discordant images are produced by the preservation of
technetium trapping, but not of organification of iodine within the
nodules. Using iodine imaging, a small number of cases of hot nodules on
99mTc pertechnetate imaging have suvsequenty proved to be cold, and some
of those lesions have been shown to be thyroid carcinoma. mettler115-116.
If the lesion proves to be discordant, further investigation is
warranted, depending on the clinical status of the patient.
1988 Board Question
by KH

155. True statements regarding the use of bone scan in patients with
malignancy include:

      a. it is more sensitive than plain X-ray to detect metastases in
patients with renal cell cancer
      b. it should be performed only in symptomatic individuals with
prostate cancer
      c. it does not change prognosis in non small cell cancer of the
lung
      d. flare effect in patients with breast cancer indicates
progression of the disease
      e. prostate metastases rarely display decreased activity

Type- Nucs
Answers- e
Notes-

Follow-up bone scans in patients undergoing treatment for advanced breast
and prostate cancer should be interpreted with caution. Within the first
3 months of chemotherapy, a favorable response by focal bone metastases
may result in healing that causes increased uptake at involved sties.
This flare phenomenon can give the false impression of new lesions or
extension of existing metastatic sites. Bone lesions that appear 6
months or later after treatment almost always indicate disease
progression. mettler293.
1992 True/False Question
In a patient with a known malignancy, a single bone lesion on bone scan
has a 54% chance of being a metastasis . Pain at the site of a bone
lesion increases the likelihood of tumor being present. Half of the
solitary metastases discovered by bone scan will not be evident on plain
film. At least in 1995, bone scan is frequently used in preoperative
staging of patients with prostate cancer, looking for occult metastases
(MR may eventually take over this role). It is more sensitive than plain
films for detecting nearly all metastases. There
needs to be 50% cortical loss to seen metastases on plain film versus 2%
for some tumors on bone scan. Renal cell carcinoma is one tumor that may
give photopenic metastases, reflecting the low metabolic activity and
bone turnover, but they can show areas of increased
activity. Bone scanning is relatively insensitive for bone metastases in
metastatic renal cell carcinoma, with a true positive rate of 50% or
less. However, the metastases usually are clinically apparent.
Prostate metastases always show increased activity reflecting their
osteoblastic nature. A positive bone scan in any patient with previously
unsuspected diffuse metastases will obviously change prognosis. Flare
refers to worsening of a patients bone scan in the period immediately
following chemotherapy reflecting healing of metastases. This can be
seen as early as 3 weeks following treatment and as late as 6 months
after treatment, so dont recommend a
bone scan during this period because you cant tell the difference between
better and worse!
by KH

156. True/False regarding nuclear medicine:

      a.   None of the above
      b.   In a patient with a MEN syndrome that has a thyroid CA resected,
the best   way to detect for metastatic disease is with I-131
      c.   8mCi of Tc99m-MAA gives a radition dose ot the lungs of 2 rads
      d. In-111 labeled WBCs have increased sensivity for detection of
infection with the patient on antibiotics

Type- Nucs
Answers- a
Notes-

by KW
Dahnert p888, Mettler p396,124
Medullary carcinoma is with MEN, doesnt always take up I-131--- Image
with Thallium
Antibiotics..... do not appear to diminish labeled leukocyte sensitivity
for infection
So it doesnt diminish it, but does it increase??? By mettler it seems
not.
.4 rad/mCi of 8mCi or Tc99m-MAA = 3.2 rads
1997 Old Board Question

157. Ulcer disease associated with hyperparathyroidism is due to:

     a.   hypercalcemia stimulating antral cells
     b.   hypercalcemia affecting parietal cell
     c.   hypercalcemia affecting chief cell
     d.   direct stimulating effect of parathormone on parietal cells

Type- Nucs
Answers- b
Notes-

parietal cells produce acid, increased by calcium
1988 Board Question
by AE

158. Using Tc-99m-DTPA for a V/Q scan:

      a. about 90% of DTPA comes out in the sputum
      b. may be done in a positive pressure room
      c. must collect urine for 6 hours and give it to the radiation
safety officer
      d. the patient must remain 12 feet away from other patients
      e. nurses can only have 15 minutes contact every 6 hours

Type- Nucs
Answers- b
Notes-

1991 True/False Question
For 135., any room is OK, Xenon needs a special room. Xenon requires
collection of exhaled gas and outside ventilation (under strict
regulation) or trapping in
charcoal until counts decay to background.
Tc-99m DTPA ventilation scans are done with aerosol.
Reference: Mettler 1991, pp. 146-148
by MH
159. V/Q scan:

     a. half-life and breakdown usually less than 12 hours for MAA
     b. 250-300,000 particles injected
     c. particle size is 5-80 microns

Type- Nucs
Answers- a,b,c
Notes-

MAA particles range in size from a few microns to 90-100 microns. The
majority (60-80%) of MAA particles in commercial preparations are in the
10-30 micron range. 60,000min-400,000max particles. The biological T1/2
of Tc99m MAA preparations in the lung is 2-3 hours. (Req-Nuc p132)
1988 Board Question
by CM

160. What dissociation will decrease the atomic number by one?

     a.   alpha decay
     b.   positron decay
     c.   internal conversion
     d.   electron capture
     e.   negatron decay (I assume this is beta minus decay)

Type- Nucs
Answers- b,d
Notes-

1993 True/False Question
Atomic number = Z, Mass number = A (Primer p908, Req-Nuc Ch1).
In beta minus decay, a neutron is converted into a proton with release of
an electron and antineutrino. Atomic number increases by one.
In positron decay, a proton is converted into a neutron and excess energy
is released as a positron (positively charged electron) and a neutrino.
Atomic number decreases by one.
In electron capture, a proton inside the nucleus is converted into a
neutron by capturing an electron from one of the atomic shells. There is
subsequent emission of characteristic x-ray or Auger electron. Atomic
number decreases by one.
In internal conversion an excited nucleus transfers its energy directly
to an orbital electron. Atomic number does not change.
Alpha decay gets rid of a helium atom, so atomic number decreases by two.
Reference: Chandra 1992, pp. 13-18
by CM

161. What is the advantage of sulphur colloid nucs scanning over Tc rbc
scanning for GI bleed?

     a.   More sensitive
     b.   Can be prepared quickly and hence the study can be done quickly
     c.   Better for bleed in the splenic flexure
     d.   Better for UGI bleeds
Type- Nucs
Answers- b
Notes-

by KW
Dahnert p927
2000 Board Question

162. What is the appearance of torsion of the appendix of the testicle on
technetium-99m pertechnetate imaging?

     a.   cut off sign
     b.   hyperemic
     c.   normal
     d.   donut sign

Type- Nucs
Answers- c
Notes-

Vestiges of developmental remnants (testicular appendages) attached to
the testes may also undergo torsion. Scrotal imaging is frequently
normal; occasionally, delayed images show a focus of increased activity
adjacent to the testes. mettler362
1989 Single Best Answer Question
There are no nuclear medicine findings with torsion of the appendix of
the testicle. The clinical symptom is acute pain.
Reference: Journal of Nuc. Med. 24:735-742, 1983
by KH

163. What is the most important reason for limiting the amount of
molybdenum breakthrough with Tc-99m examinations?

     a.   Interferes with radiopharmaceutical labeling
     b.   Beta emitter
     c.   Interferes with biologic distribution
     d.   Half-life of 60 days

Type- Nucs
Answers- b
Notes-

67 Hour half life of Moly-99
Beta-emitter, Bad
1999 Board Question
by MH

164. What is the probability of PE in a patient who has a normal CXR with
one large and one moderate defect on perfusion and a normal ventilation
component?

     a. intermediate probability
     b. low probability
     c. indeterminate
     d. high probability

Type- Nucs
Answers- a
Notes-

Mettler p.212
1994 Single Best Answer Question
by AE

165. What would be the expected finding in a captopril renal scan in a
patient with right renal artery stenosis?

     a.   equal activity bilaterally
     b.   no uptake in the right kidney
     c.   increased uptake in the right kidney
     d.   delayed, decreased uptake in the right kidney
     e.   early uptake in the right kidney

Type- Nucs
Answers- d
Notes-

by KW
Verified Requisites p310-311
1995, 1992 Single Best Answer Question
Captopril prevents the effect of angiotensin II on efferent arteriole
vasoconstrictors. This results in decreased glomerular flow, decreased
urine output, and
decreased renal function. Renal blood flow may increase after captopril
and may be one
reason why there is slow uptake (and therefore slow increase in activity)
- the glomerulus
has less time to see the tracer on each pass. There is also decrease in
peak activity and
retention of activity by the kidney.

166. Which are true regarding Indium labeled white blood cell scan in
osteomyelitis:

     a.   useful   for   detecting   spinal osteomyelitis
     b.   useful   for   detecting   osteomyelitis in a fracture
     c.   useful   for   following   antibiotic treated osteomyelitis
     d.   useful   for   detecting   osteomyelitis in sickle cell anemia
     e.   useful   for   detecting   acute superimposed on chronic osteomyelitis

Type- Nucs
Answers- b,c,d,e
Notes-

1993 Single Best Answer Question
Requisites p169
by KH
167. Which is is best for COPD?

     a. DTPA
     b. Xenon
     c. Krypton-81m

Type- Nucs
Answers- b
Notes-

Because they do not permit washout imaging, short-lived agents do not
permit washout imaging, short-lived isotopes, such as Kr81 are of less
value that Xe133 in assessing subtle obstructive changes. mettler221;
1991 True/False Question
You cant do equilibrium or washout with Krypton (because of short half-
life of 13 seconds) to measure air trapping. The photopeak is 191 keV.
by KH

168. Which is the least likely to be hot in the liver on sulfur colloid?

     a.   FNH
     b.   Budd Chiari
     c.   adenoma
     d.   Mets

Type- Nucs
Answers- d
Notes-

by KW
Dahnert p925
Mets are likely to be cold, as they contain no Kupffer cells to uptake SC
FNH has variable quantity of Kupffer cells
Budd Chiari - causes decreased flow in most of liver, with increased flow
in quadrate lobe (collateral via umbilical vein)
Regenerating nodules show increased uptake as well
1997 Old Board Question

169. Which is the most common cause of hepatic uptake during Tc99m MDP
study:

     a.   massive hepatic necrosis
     b.   metastatic disease
     c.   abscess
     d.   active hepatitis

Type- Nucs
Answers- b
Notes-

by KW
Dahnert p901
2000 Board Question
170. Which is true regarding the imaging of gastrointestinal bleeding?

      a. Sulfur colloid requires less preparation by the technologist
than labeled RBCs
      b. Imaging with sulfur colloid can be performed at 24 hours without
re-injection
      c. A focus of increased activity that moves with peristalsis allows
precise localization of the bleeding site
      d. Sulfur colloid is less sensitive than angiography for slow
bleeds

Type- Nucs
Answers- a
Notes-

Mettler p257
1998 Board Question
by MH

171. Which of the following agents can be used to treat diffuse bony
metastases?

     a.   Strontium-89
     b.   Strontium-90
     c.   Strontium-85m
     d.   P-32

Type- Nucs
Answers- a,d
Notes-

by KW
Reference Nuclear Oncology, p106
Samariam 153 is also used for treatment.
Strontium 85m is used for imaging.
1995 Single Best Answer Question

172. Which of the following are causes of falsely low EF on radionuclide
cine angio (MUGAscan):

     a.   30% asymmetric energy window (technetium peak)
     b.   overlap of left atrium and left ventricle
     c.   impaired diastolic function
     d.   systolic region of interest is too small
     e.   incorrect background subtraction

Type- Nucs
Answers- b,e
Notes-

M169-170
1994, 1992 True/False Question
Ejection Fraction (EF) = (end diastolic - end systolic)/(end diastolic -
background)
Normal EF is >55%.
If the left atrium or ascending aorta is inappropriately included in
measurement of
end systolic counts, EF will be falsely lowered (ED will measure
inaccurately high). If
end systolic counts are undermeasured, this will falsely elevate EF.
Undermeasurement
or failure to include background counts in the denominator will increase
it, thus falsely
lowering the EF.
References: Mettler 1991, pp. 128-135; Gottshalk, pp. 221-222
by MH

173. Which of the following are checked daily as part of quality
assurance?

     a.   accuracy
     b.   constancy
     c.   linearity
     d.   geometric efficiency

Type- Nucs
Answers- b
Notes-

Dahnert p889
1988 True/False Question
Daily: peaking, constancy or uniformity (before first clinical case using
point source)
Weekly: spatial resolution and linearity; SPECT - center of rotation
shift test, uniformity
Monthly: collimator uniformity
Yearly: accuracy (+/- 5%)
Upon installation and after every repair: geometric efficiency
by MH

174. Which of the following are reasons for using technetium
pertechnetate for thyroid scanning?

      a. exam needs to be completed in two hours
      b. patient unable to take oral medications
      c. patient on PTU
      d. evaluation of uptake for I-131 therapy for hyperthyroidism
      e. previous evaluation demonstrates hot nodule on pertechnetate
examination

Type- Nucs
Answers- a,b,c
Notes-

by KW
Verified Mettler p76
These are the three indications listed.
Imaging with tech in 20 minutes, as apposed to 6 hours for I123.
1994, 1988 True/False Question
Iodine scans require approximately 2 weeks off of PTU. PTU blocks Iodine
organification in the gland, but will not affect the Tc-99m-pertechnetate
scan. Although a
technetium pertechnetate scan can be completely done in 2 hours, an
iodine uptake can be
done in 2 hours (???). Technetium pertechnetate is given IV and iodine
is given po.
If there is a hot nodule on the pertechnetate examination, then an iodine
scan
should be done ----> 2-3% will be cold (i.e., carcinoma).   If the lesion
was hot on a
previous iodine scan, technetium pertechnetate will not add any
information.
I-131 treatment should only be based on I-123 or I-131 uptakes.
References: Thrall; A. Scheff

175. Which of the following best describes the stripe sign utilized in
ventilation-perfusion lung scintigraphy?

      a. Indicates evidence of perfusion in the periphery of the lung
      b. Indicates the presents of a pleural effusion
      c. Commonly seen in patients with COPD
      d. Cannot be interpreted in the presence of small bilateral pleural
effusions
      e. Indicates a peripheral perfusion defect

Type- Nucs
Answers- a
Notes-

by KW
Verified Dahnert p913
This Question originally offered the choice Indicates evidence of
perfusion in the periphery of the pleura.
I assume this actually ment periphery of the lung.
1999 Board Question

176. Which of the following causes the greatest v/q mismatch?

     a. hilar bronchogenic carcinoma
     b. radiation changes
     c. fibrosing mediastinitis

Type- Nucs
Answers- c
Notes-

by KW
Dahnert p912
2000 Board Question
177. Which of the following findings on SPECT imaging of a Tc-99m MDP
study is most specific for a metastatic deposit to the vertebral body?

     a.   Increased   activity   bridging two adjacent vertebral bodies
     b.   Increased   activity   in an expanded vertebral body
     c.   Increased   activity   in the vertebral body only
     d.   Increased   activity   in the vertebral body and pedicle

Type- Nucs
Answers- d
Notes-

by KW
Verified Dahnert p96
Disks are relatively resistant to invasion.
Usually non-expansile.
Vertebral pedicles often involved.
1999 Board Question

178. Which of the following is a relative contraindication to Sr-89
therapy for bony metastases?

     a.   Primary CA other than breast or prostate
     b.   Thrombocytopenia less than 100,000
     c.   Previous radiation therapy
     d.   Life expectancy less than 3 months
     e.   Previous chemotherapy

Type- Nucs
Answers- d
Notes-

Mettler p.330, also should not be used if platelets< 60,000 or WBC count<
2400
Used for pain relief for bony mets, not for cure.
Cannot cremate and must have a special funeral if Strontium given prior
to death
1999 Board Question
by AE

179. Which of the following is least likely to cause uptake in the liver
on Tc-99m-MDP bone scan?

     a.   metastatic colon cancer
     b.   osteosarcoma metastasis
     c.   contamination of the agent with aluminum
     d.   metastatic breast cancer
     e.   contamination of the mixing vial by air

Type- Nucs
Answers- e
Notes-

Tc99m Aluminum particles have uptake in lung and liver
Mixture of air yields Free Technetium - Mettler p47
Dahnert p113
mettler302,44,
1995, 1992 Single Best Answer Question
Metastatic colon cancer and osteosarcoma may contain Ca++ and thus may
show increased activity on Tc-99m-MDP. Aluminum and air can cause
clumping and focal areas of increased activity. Metastatic breast cancer
is more likely to cause a photopenic defect because its metastases rarely
calcify. (However, this may not be true for treated breast mets!)
According to Mettler (ed. 3, p. 226) breast carcinoma metastases may pick
up bone tracer, and widespread cholangiocarcinoma is another cause of
this scintigraphic appearance.
by KH

180. Which of the following is least likely to produce renal uptake on
Technetium MDPbone scan?

     a.   aluminum contamination
     b.   nephrocalcinosis
     c.   dehydration
     d.   chemotherapy
     e.   radiation therapy

Type- Nucs
Answers- a
Notes-

M306
1993 Single Best Answer Question
Reference: Mettler 1991, p. 226.
by MH

181. Which of the following is not a cause of diffuse uptake of
technetium-99m MDP in the bones with no appreciable uptake in the
kidneys?

     a.   chronic renal disease
     b.   aggressive osteoporosis
     c.   hyperparathyroidism
     d.   hyperthyroidism
     e.   diffuse osteoblastic bony metastases

Type- Nucs
Answers- b
Notes-

Dahnert p.900
1995 Single Best Answer Question
Causes of a superscan with decreased renal uptake include metastatic
disease,
metabolic bone disease(hyperthyroidism, primary hyperpara, renal
osteodystrophy,
osteomalacia, hypervit D), myelofibrosis. Box 5-2 ,p 97
Scintigraphy doesnt have a role in osteoporosis.   Can ID insufficiency
fxs.
ref: thrall, p 97, 120
by AE

								
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