Nuclear medicine

Question	Answer
1. TRUE/FALSE - bone scintigraphy is useful in the diagnosis of: a. Acute osteomyelitis	True. Acute osteomyelitis causes bone destruction and increased osteoblastic reaction leading to focal increased tracer on blood pool and delayed images.
1. TRUE/FALSE - bone scintigraphy is useful in the diagnosis of: b. Inflammatory arthritis	True. Inflammatory arthritis shows diffuse increase in vascularity on the blood pool in the joint space and this leads to a mild diffuse increase in sub-chrondral bone in the joint.
1. TRUE/FALSE - bone scintigraphy is useful in the diagnosis of: c. Stress injuries	True. Stress fractures maybe normal on plain x-ray but on bone scan are focally “hot” due to bone repair and increased osteoblastic reaction.
1. TRUE/FALSE - bone scintigraphy is useful in the diagnosis of: d. Avascular necrosis	True. Avascular necrosis of bone may be ‘cold’ or photopenic due to absent blood flow but later may show increased osteoblastic reaction around the AVN site during bone repair.
2. TRUE/FALSE - SPECT/CT allows a better visualisation and determination of bone vascularity and destruction in osteomyelitis, avascular necrosis of the femoral head in slipped capital epiphysis.	True. SPECT allow tomography and has a higher sensitivity and specificity for the various aetiologies.
3. TRUE/FALSE - bone scintigraphy adds little to plain skeletal radiology in evaluating infants and children at risk for non accidental injury.	False. Skeletal injury particularly fractures undergo bone repair and have increased osteoblastic reaction. The bone scan is more sensitive than plain x-ray for the diagnosis of microfractures and stress fractures. There are particular patterns which are highly sensitive and specific for NAI.
4. Preterm US shows moderate dilatation of the right pelvicalyceal system. Postnatal US at 3 weeks confirms this finding. TRUE/FALSE - to confirm obstruction of the urinary system, proceed with: a) CT scan	False. CT scan is not necessary and has increased radiation exposure in a newborn. Low specificity for obstruction.
4. Preterm US shows moderate dilatation of the right pelvicalyceal system. Postnatal US at 3 weeks confirms this finding. TRUE/FALSE - to confirm obstruction of the urinary system, b) Micturating cystourethrogram	False. Micturating cystourethrogram. The patient may have reflux, which causes a dilated pelvi-calyceal system however the question is to diagnose obstruction.
4. Preterm US shows moderate dilatation of the right pelvicalyceal system. Postnatal US at 3 weeks confirms this finding. TRUE/FALSE - to confirm obstruction of the urinary system, c) Diuretic radionuclide renal MAG3 scan	True
4. Preterm US shows moderate dilatation of the right pelvicalyceal system. Postnatal US at 3 weeks confirms this finding. TRUE/FALSE - to confirm obstruction of the urinary system, d) Renal radionuclide DMSA scan	False. Renal DMSA scan shows renal parenchyma and not excretion of tracer and does not diagnose obstruction.
4. Preterm US shows moderate dilatation of the right pelvicalyceal system. Postnatal US at 3 weeks confirms this finding. TRUE/FALSE - to confirm obstruction of the urinary system, e) Referral to a urologist	False. There is no need to refer to an urologist as it depends on the result of the diuretic MAG3 scan. If this shows significant obstruction to urine flow then a referral to an urologist is necessary.
5. An infant of 6 weeks has prolonged jaundice (conjugated hyperbilirubinemia). US of the liver shows a small gallbladder but was otherwise normal. TRUE/FALSE - to determine the cause, proceed with: a) CT scan of the liver	False. CT scan is unnecessary as it does not show biliary excretion and also has a high radiation exposure. USS is preferred as the anatomical modality, not invasive and gives information on whether the gallbladder is present or not visualised and the portal plate, which if present, the diagnosis is more likely BA.
5. An infant of 6 weeks has prolonged jaundice (conjugated hyperbilirubinemia). US of the liver shows a small gallbladder but was otherwise normal. TRUE/FALSE - to determine the cause, proceed with: b) Liver biopsy	False. Liver biopsy is not required at this stage as it is invasive and in the majority biliary atresia is excluded by hepatobiliary scintigraphy. If excretion is not found on scintigraphy liver biopsy is probably indicated. This would be performed at the time of operative cholangiogram.
5. An infant of 6 weeks has prolonged jaundice (conjugated hyperbilirubinemia). US of the liver shows a small gallbladder but was otherwise normal. TRUE/FALSE - to determine the cause, proceed with: c) MRI abdomen	False. MRI is unnecessary as does not show biliary excretion.
5. An infant of 6 weeks has prolonged jaundice (conjugated hyperbilirubinemia). US of the liver shows a small gallbladder but was otherwise normal. TRUE/FALSE - to determine the cause, proceed with: d) Hepatobiliary radionuclide scan after preparation with URSO	True. The main cause for conjugated hyperbilirubinemia in this age of patient is neonatal hepatitis or biliary atresia. Obstruction to bile flow separates these 2 conditions. Also in neonatal hepatitis the hepatocyte function is usually reduced whereas in biliary atresia there is normal uptake in the early weeks up to 6-8 weeks.
6. TRUE/FALSE - PET/CT imaging is used in a 13F adolescent with biopsy proven Hodgkins lymphoma of mediastinum and neck for: a) Initial staging	True. PET/CT is now diagnostic test of choice for initial staging. This is done in conjunction with anatomical imaging eg. CT or MRI. Accurate staging is essential so the appropriate protocols are undertaken.
6. TRUE/FALSE - PET/CT imaging is used in a 13F adolescent with biopsy proven Hodgkins lymphoma of mediastinum and neck for: b) Response to treatment	True. The PET/CT is the most accurate way to assess response to treatment. If the patient is an early rapid responder this indicates a better prognosis and may indicate that radiotherapy is not necessary. For slow/poor responders more aggressive protocols will be undertaken including radiotherapy.
6. TRUE/FALSE - PET/CT imaging is used in a 13F adolescent with biopsy proven Hodgkins lymphoma of mediastinum and neck for: c) Surveillance after completion of chemotherapy and radiotherapy	True. Surveillance is necessary post therapy and the length of time depends on the initial stage of disease and response to therapy eg. stage 4 usually would have 3 monthly PET/CT up to 2 years post completion of therapy. Recurrence is most likely in the first 12 months post completion of therapy.
6. TRUE/FALSE - PET/CT imaging is used in a 13F adolescent with biopsy proven Hodgkins lymphoma of mediastinum and neck for: d) As guidance for biopsy of lymph nodes which appear metabolically active	True. False positive uptake in lymph nodes particularly in the neck in children and adolescents may occur due to URTI or other inflammatory processes. If these nodes remain metabolically active after repeat studies biopsy of the most metabolically active maybe undertaken to exclude recurrence.
6. TRUE/FALSE - PET/CT imaging is used in a 13F adolescent with biopsy proven Hodgkins lymphoma of mediastinum and neck for: e) A mass appears in the axilla	True. If a mass occurs in the axilla or elsewhere recurrence is considered likely. The PET scan will help determine recurrence and also if there is disease elsewhere. The PET also assists in US controlled biopsy of the most metabolic area in the mass.
7. TRUE/FALSE - PET/CT is used in these scenarios. a) Pyrexia of unknown origin	True. Used in patients with PUO where there is a high sensitivity for finding an inflammatory site and there are particular patterns of a metabolically active process or lymphadenopathy eg. autoimmune vasculitis, auto-inflammatory diseases, EBV driven lymphadenopathy.
7. TRUE/FALSE - PET/CT is used in these scenarios. b) Known osteomyelitis treated for staph aureus but has ongoing fevers	True. Multifocal osteomyelitis may have major consequences and often there is poor response to surgery and antibiotic therapy. The PET scan is a very good test for screening of undiagnosed sites of infection, which may require further surgery and drainage of abscess.
7. TRUE/FALSE - PET/CT is used in these scenarios. c) Refractory epilepsy for surgical assessment	True. Refractory epilepsy may be treated with resection of the epileptic focus. It is very difficult to localise these foci and the techniques include MRI co-registered with interictal PET/CT and ictal SPECT blood flow studies.
7. TRUE/FALSE - PET/CT is used in these scenarios. d) Assessment of lympho-proliferative disease post transplant	True. Lympho-proliferative disease may occur in post solid organ transplant patients. This condition may be a non-specific inflammatory reaction and lymphadenopathy through to aggressive malignancy in particular aggressive non-Hodgkins lymphoma. PET/CT is useful to determine the metabolic activity in any mass, which assists in whether biopsy should be undertaken. PET/CT can also be used to assess response after change of medications.

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	Created by Averil Tam over 6 years ago