PET Content Outline

NMTCB Specialty Exam
Positron Emission Tomography Examination
Content Outline
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DIAGNOSTIC PROCEDURES (~45%) [70 items]
1. Administration of Radiopharmaceuticals
  1. Routes
  2. Intravenous injection techniques
  3. Factors affecting biodistribution
    1. Cardiology
      1. Serum glucose level
      2. Serum insulin level
    2. Neurology
      1. Stimulation
      2. Surgical variants
      3. Radiation treatment
      4. Serum insulin/glucose levels
      5. Psychotropic drugs
      6. Ictal vs. inter-ictal state
    3. Oncology
      1. Serum insulin/glucose levels
      2. Exercise
      3. Chemotherapy
      4. Radiation therapy
      5. Surgery/biopsy
      6. Hemopoietins
      7. Muscle tension
      8. Hydration
      9. Inflammatory disease
      10. Infectious process
2. Administration of interventional pharmaceuticals, pharmaceuticals and contrast media
  1. Basic concepts
    1. Indications
    2. Contraindications
    3. Adverse reactions
    4. Medication interactions
    5. Dosing and route of administration
    6. Pediatric considerations
  2. Emergency Care
    1. CPR
    2. Emergency medications
    3. Diabetic complications
    4. Contrast reactions
    5. Hypoglycemia
  3. Pharmaceuticals
    1. Cardiology
      1. Dobutamine
      2. Adenosine
      3. Dipyridamole
      4. Glucose
      5. Insulin
      6. Hyperinsulinemic-euglycemic clamp
    2. Neurology
      1. Sedatives/Anxiolytics
      2. Antiseizure
    3. Oncology
      1. Diuretics
      2. IV/oral hydration
      3. Sedatives/ Anxiolytics
      4. Insulin
  4. Contrast media
    1. Types
      1. Oral
      2. Non-ionic
      3. Ionic
    2. Assessment & Monitoring
      1. H&P
      2. Vital Signs
      3. Lab Values
        
        BUN
        
        Creatine
        
        PT
        
        PTT
        
        Platelet
      4. Medications
    3. Special Considerations
      1. Allergy Perparation
      2. Pathologic Processes
      3. Contraindictions
      4. Indication?
    4. Adverse Reactions
      1. Recognition and assessment of symptoms
      2. Treatment (e.g. compresses, medications)
      3. Documentation
3. Gated Procedures (Cardiac and Respiratory)
  1. Equipment
  2. Lead placement
  3. Sources of error
    1. Patient
    2. Equipment
    3. User
4. Imaging Techniques:
  1. Cardiology:
    1. History and assessment
    2. Indications and contraindications
    3. Patient preparation/instructions
      1. pre-arrival
      2. pre-injection
      3. post-injection
      4. post-procedure– discharge instructions
    4. ECG’s
      1. Patient preparation, electrode placement
      2. Rate calculation
      3. Normal and abnormal rhythms
    5. Exercise
    6. Uptake period
    7. Patient positioning
      1. Low dose scout
      2. Transmission
      3. Anatomical markers
    8. Imaging techniques
    9. Anatomy/physiology/clinical indications
      1. Rest/Stress Perfusion
      2. Myocardial Viability
  2. Neurology:
    1. History and assessment
    2. Indications and contraindications
    3. Patient preparation/instructions
      1. pre-arrival
      2. pre-injection
      3. post-injection
      4. post-procedure– discharge instructions
    4. Uptake time
    5. EEG monitoring
      1. Patient preparation
      2. Seizure activity patterns
    6. Patient positioning
    7. Imaging techniques
    8. Anatomy/physiology/clinical indications
      1. Epileptic seizures
      2. Dementia
      3. Tumor
      4. Movement disorders
  3. Oncology:
    1. History and assessment
    2. Indications and contraindications
    3. Patient preparation/instructions
      1. pre-arrival
      2. pre-injection
      3. post-injection
      4. post-procedure – discharge instructions
    4. Uptake time
    5. Patient positioning
      1. Arms up/down
      2. Head first/feet first
    6. Imaging techniques
    7. Anatomy/physiology/clinical indications
      1. Colorectal cancer
      2. Head/Neck cancer
      3. Esophageal cancer
      4. Non-Small Cell Lung cancer
      5. Single Pulmonary Nodule (SPN) evaluation
      6. Breast cancer
      7. Melanoma
      8. Lymphoma
      9. Thyroid cancer
      10. Other indications
  4. Acquisition modes
    1. 2D
    2. 3D
    3. Emission
    4. Transmission
      1. Measured
      2. CT
    5. Single bed position
      1. Post-injection start time
      2. Scan duration
    6. Dynamic imaging
      1. Framing rates
      2. Injection sites/techniques
    7. Whole body imaging
      1. Post-injection start time
      2. Number of bed positions
      3. Scan duration/bed
      4. Slice overlap
INSTRUMENTATION/QUALITY CONTROL (~ 30%) [60 items]
1. Survey Meter
  1. Operating principles
  2. Quality control
  3. Source selection
  4. Interpretation of QC results
2. Dose calibrator
  1. Operating principles
  2. Quality control (accuracy, linearity, geometry, constancy)
  3. Frequency of quality checks
  4. Source selection
  5. Interpretation of results
3. Well Counter
  1. Operating principles
  2. Quality control (constancy, energy FWHM, chi-square)
  3. Frequency of quality checks
  4. Source selection
  5. Interpretation of results
4. Scintillation Detector Systems
  1. Principles of scintillation detection
  2. Detector materials
    1. BGO
    2. LSO
    3. GSO
    4. NaI
  3. System types
    1. Dedicated PET
      1. Full ring
      2. Partial ring
      3. Detector panels
    2. Integrated PET/CT
  4. Quality control
    1. Normalization
    2. Blank scan
    3. Gains (Singles)
    4. Calibration factors for quantification
    5. Scanner failure/recognition of instrumentation artifacts
      1. Detector failure
      2. High voltage drift
      3. Energy drift
      4. Gain drift
      5. Power supply drift/failure
      6. Temperature drift (cooling system failure)
      7. Coincidence timing malfunction
      8. Transmission source malfunction
      9. Septa mis-positioning/alignment
      10. Imaging table failure
  5. System performance
    1. Scatter fraction
    2. Randoms fraction
    3. Noise equivalent count rate (NEC)
    4. NEMA standards and testing
5. Theory of Operation
  1. PET
    1. Principles of Coincidence Detection
      1. Trues
      2. Randoms
      3. Scatter
      4. Lines of response (LORs)
      5. Delayed event
      6. Coincidence timing window
    2. Image Formation and Reconstruction
      1. Sinograms
        
        2D
        
        3D
        
        Fourier rebinning
        
        Filtered back projection (FBP)
        
        Iterative reconstruction
        
        Ordered subset expectation maximization (OSEM)
        
        Maximum likelihood expectation maximization (MLEM)
      2. Image filters/cutoff frequencies
    3. Data processing/corrections
      1. Normalization
      2. Decay correction
      3. Attenuation correction
        
        Calculated
        
        Measured
        
        Segmented
        
        No attenuation correction
      4. Random correction
      5. Scatter correction
  2. CT
    1. Principles, Operations and Components
      1. Tube
        
        kVp
        
        mA
        
        warm-up
      2. Detectors (single and multi-row)
      3. Collimation
    2. Image Processing and Display
      1. Filtered back projection and reconstruction
      2. Reconstruction filters (algorithms)
      3. Effective slice thickness
      4. Reconstruction interval
      5. CT Number
      6. Topogram
6. Data Analysis
  1. Quantitative analysis
    1. Region of interest
    2. Time activity curves
    3. Standardized Uptake Value (SUV)
      1. Methods of calculation
      2. Sources of error
    4. Metabolic flow rate measurement and analysis
    5. R to L count profiles and histogram
    6. Cardiac polar mapping
    7. Other
  2. Image reconstruction variants
7. Basic Principles of Image Fusion/Image Registration
  1. Manual
  2. Mechanical
  3. Automated
    1. Rigid
    2. Deformable
8. Image Artifacts
  1. Pre-procedure
    1. Medications
    2. Prosthetics
    3. Therapeutic effects
    4. Exercise
  2. Injection/uptake
    1. Muscle tension
    2. Injection sites/tubing
    3. Radioactive contamination
    4. Environment (temperature, noise)
  3. Scanning Procedure
    1. Patient motion
    2. Transmission/emission (misalignment)
    3. Bed position overlap
    4. Urinary catheter lines
    5. IV lines
    6. High Z material
    7. Filter/cutoff selection
    8. Partial volume effect
    9. Attenuation correction
    10. CT
      1. Contrast
      2. Metallic/Attenuation correction
      3. Beam Hardening
      4. Partial Volume Averaging
      5. Truncation
      6. Respiration
RADIATION PROTECTION (~ 10%) [20 items]
1. Personal protection/monitoring
  1. Basic concepts (ALARA)
  2. Personnel protection
    1. Time
    2. Distance
    3. Shielding
      1. Patient dose
      2. Dose calibrator
      3. Scanning room
      4. Waiting room
      5. Control room
      6. Patient holding room
      7. Waste
      8. Scatter radiation (CT)
  3. Personnel monitoring devices (body/extremity)
  4. Regulatory requirements including appropriate signage
  5. Signage
    1. Radioactive Materials Areas (PET)
    2. Radiation Area (CT)
    3. Cyclotron Area
2. Patient Radiation Dose Considerations
  1. Technical Factors Affecting Patient Dose
    1. kVp
    2. mAs
    3. pitch
    4. collimation
  2. CT Dose Index (CTDI)/Multiple Scan Average Dose (MSAD)
  3. Pediatric Dose Reduction
3. Area/facilities monitoring
  1. Basic concepts
  2. Survey equipment
  3. Radiation surveys
  4. Regulatory requirements
4. Packaging and storage of radioactive materials
  1. Inspection of incoming/outgoing materials
  2. Storage of radiopharmaceuticals
5. Records
  1. Shipping of radioactive materials
  2. Receipt of radioactive materials
  3. Administration of radioactive materials
  4. Storage of radioactive materials
  5. Disposal of radioactive materials
  6. Radiation surveys
6. Radioactive decontamination
  1. Area
  2. Personnel
7. Disposal of Radioactive Waste
  1. Release to environment
  2. Decay to storage
  3. Incineration
  4. Transfer to authorized recipient
8. Medical Events
  1. Definitions
  2. Reporting and notification
RADIOPHARMACEUTICALS (~15%) [50 items]
1. Radiopharmaceutical Characteristics
  1. Method of localization
    1. Radiopharmaceutical kinetics
    2. Target organs
    3. Radiopharmaceutical biodistribution and normal variants
  2. Dose considerations
2. Physical properties of radioactive materials
  1. Types of emissions
  2. Energies
  3. Decay rate and half-life
  4. Radiopharmaceutical quality control
3. Dosage determination
  1. Calculation of pediatric dose
  2. Calculation of radiopharmaceuticals/pharmaceutical dose
  3. Volume determination
  4. Units - calculations and conversion
  5. Dose determination according to scan mode and equipment type
4. Dose preparation and administration
  1. Verify correct radiopharmaceutical for exam
  2. Preparation for administration
  3. Assay in dose calibrator
  4. Radiopharmaceutical labeling
  5. Administration technique
  6. Residual dose measurement
5. Positron radiopharmaceutical principles
  1. Positron decay
  2. Positron energy
  3. Annihilation reaction
  4. Bremsstrahlung radiation
  5. Decay factors
  6. Exposure rates
  7. Half value layer
6. Radionuclide production
  1. Cyclotron
    1. Principles of operation
    2. Targetry
    3. Chemical Synthesis devices (manual or automated Chemisty Box)
  2. Generators
    1. Principles of operation
    2. Elution
    3. Quality control
7. Synthesis of radiopharmaceuticals
  1. Basic chemistry
  2. Synthesis modules
8. Quality control of radiopharmaceuticals/radiochemicals/chemicals
  1. Purity
  2. Identity
  3. Sterility
  4. Apyrogenicity
  5. pH
  6. Stability
PROCEDURES LIST
1. Cardiology
  1. CMS approved indications:
    1. Rest/stress perfusion
    2. Viability
2. Neurology
  1. CMS approved indications
    1. Alzheimer
    2. Epileptic seizures
  2. Other indications
    1. Dementias
    2. Brain tumors
    3. Movement disorders
    4. Cerebral Blood Flow / Brain Mapping
3. Oncology
  1. CMS approved indications
    1. Colon cancer
    2. Cervical cancer
    3. Head/Neck cancer
    4. Non-small cell lung cancer
    5. Solitary pulmonary nodule (SPN) evaluation
    6. Breast cancer
    7. Melanoma
    8. Lymphoma
    9. Thyroid cancer
  2. Other indications:
    1. Ovarian cancer
    2. Pancreatic cancer
    3. Sarcomas
    4. Prostate cancer
    5. Renal carcinoma
    6. Gastric cancer
    7. Endometrial cancer
    8. Testicular cancer
    9. Hepatocellular cancer
    10. Small cell lung cancer
    11. Mesothelioma
    12. Unknown primary
4. Miscellaneous Imaging
  1. F-18 FDG inflammation/infection imaging
  2. F-18 sodium fluoride - skeletal imaging
DIAGNOSTIC RADIOPHARMACEUTICALS
1. C-11 acetate
2. C-11 Choline
3. C-11 Palmitate
4. F-18 fluorodeoxyglucose (FDG)
5. F-18 fluorodopa (F-Dopa)
6. F-18 sodium fluoride
7. F-18 fluorothymidine (FLT)
8. F-18 fluoromisonidazole (FMISO)
9. N-13 ammonia
10. O-15 O₂
11. O-15 water
12. Rb-82 chloride
MISCELLANEOUS PHARMACEUTICALS
1. Acetylsalicylic acid
2. Anticoagulants
3. Antiarrhythmics
4. Calcium channel blockers
5. ACE inhibitors
6. Cholesterol-lowering drugs
7. Digoxin
8. Nitrates
9. Beta blockers
10. Caffeine
11. Growth stimulation hormone factor
12. Hematopoetins
13. Diabetic medications
14. Steroids
15. Glucose
16. Nicotinic Acid Derivatives
INTERVENTIONAL PHARMACEUTICALS
1. Adenosine
2. Dipyridamole
3. Diuretics
4. Aminophylline
5. Dobutamine
6. Theophylline
7. Furosemide
8. Insulin
9. Glucose
10. Sedatives/Anxiolytics
CONTRAST MEDIA
1. Oral
2. Non-ionic
3. Ionic
EQUIPMENT LIST
1. Dedicated PET scanner and integrated PET/CT scanner
2. Dose calibrator
3. Well counter
4. Survey meter
5. Glucose meter
6. ECG monitor
7. Gate box/trigger
8. Defibrillator, emergency cart access
9. O₂saturation monitor
10. Intravenous infusion pump
11. EEG monitor
12. Radiopharmaceutical generator
13. Dose delivery system