MI Curriculum ACGME Format
Nuclear medicine is rapidly evolving. Molecular imaging, including non-radioactive tracers, is becoming an increasingly important part of our specialty. We need to educate both the current nuclear medicine physicians and scientists in molecular imaging and also need to educate the next generation. Although the ACGME training requirements for nuclear medicine residency training programs changed very recently, in July 2007, those changes were developed over the prior three years and do not fully reflect the shift towards molecular imaging that is occurring. The Molecular Imaging Center of Excellence of SNM established an Education Task Force to examine the educational needs for future physicians and scientists practicing molecular imaging. The initial result of that task force is the paper presented below. It is organized in the style of the central portion of the Nuclear Medicine residency training requirements and has been forwarded to the Residency Review Committee for their consideration. It is intended to be a recommendation for the optimal training that might be expected for a nuclear medicine resident in the near future. Program directors should not regard these recommendations as mandatory, but when feasible should consider incorporating these concepts into current training programs. This paper should be regarded as an initial proposal and will likely undergo considerable modification before the next version of the nuclear medicine training requirements is finalized. Comment is welcome and is encouraged.
a)Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents:
(1)will closely follow scientific progress in nuclear medicine and molecular imaging, and learn to incorporate it effectively for modifying and improving diagnostic and therapeutic procedures;
(2)will become familiar with and regularly read the major journals in nuclear medicine and molecular imaging. During residency this will involve regular participation in journal club;
(3)will use computer technology including internet web sites and CD-ROM teaching disks;
(4)will participate in the annual in-service examination;
(5)know and comply with radiation safety rules and regulations; including NRC and/or agreement state rules, local regulations, and the ALARA (as low as reasonably achievable) principles for personal radiation protection;
(6)will understand and use QC (quality control) procedures for imaging devices, laboratory instrumentation, radiopharmaceuticals and non-radioactive molecular imaging agents;
(7)must have didactic instruction in the following areas: (Those
residents who have completed an ACGME-accredited program in Diagnostic Radiology are exempted from instrumentation principles on MR, CT and ultrasound):
a.Physics and instrumentation
1.Physics: structure of matter, modes of radioactive decay, particle and photon emissions, and interactions of radiation with matter.
2. Instrumentation: principles of instrumentation used
in detection, measurement, and imaging of radioactivity with special emphasis on gamma cameras, SPECT and PET devices, and associated electronic instrumentation and computers employed in image production and display. Instruction must include the instrumentation principles involved in magnetic resonance imaging, spectroscopy, ultrasound, multi-slice computed tomography, optical imaging of bioluminescence and fluorescence and small animal imaging instrumentation.
3.Mathematics, statistics, and computer sciences as
applied to imaging: probability distributions; applications of mathematics to tracer kinetics, including compartmental modeling and quantification of physiologic processes; demonstrate a working knowledge of computational image-processing which may include interactive processing of images; quality control of image-acquisition and processing.
- Imaging science, contrast, signal to noise ratio,
spatial resolution
- Basic aspects of image processing with filtered backprojection and iterative algorithms used in both SPECT and PET reconstruction: projections, sinograms, backprojection algebraic and statistical iterative algorithms.
5.Medical decision-making with an emphasis on
efficacy of imaging;
b.Radiation biology
1.Biological effects of ionizing radiation at the organism, tissue and the cellular level;
2.means of reducing radiation exposure;
3.calculation of the radiation dose for the various ionizing radiation modalities, with specific treatment of dual modalities (e.g. dose from PET and dose from CT in PET-CT);
4.evaluation of radiation overexposure; and medical management of persons overexposed to ionizing radiation;
5.principles of dose assessment for internal emitters (based on MIRD and other models) for both diagnostic and therapeutic applications.
c.Radiation protection and regulatory issues
- Residents should be knowledgeable about the
regulations regarding the medical use of radionuclides as described in the 10 CFR Part 20 and 35.
- Instruction should include the training and experience as described in 10 CFR 35.190, 35.290 and 35.390. For example:
- the chemistry of unsealed radioactive materials for medical use;
- ordering, receiving and unpacking radioactive materials safely and performing the related radiation surveys;
- performing quality control procedures on instruments used to determine the activity of dosages and performing checks for proper operation of survey meters; calculating, measuring and safely preparing patient or human research subject dosages;
- using administrative controls to prevent a medical event involving the use of unsealed radioactive material;
- using procedures to contain spilled radioactive material safely and using proper decontamination procedures;
- administering dosages of radioactive drugs to patients or human subjects for uptake, dilution, excretion, and imaging and localization studies;
- eluting generator systems appropriate for preparation of radioactive drugs for imaging and localization studies, measuring and testing the eluate for radionuclide purity, and processing the eluate with reagent kits to prepare labeled radioactive drugs.
d.Molecular and cellular biology – the imaging of molecular targets, processes and events
1.Basic principles of molecular and cellular biology;
2.Examples of imaging molecular and cellular processes are not limited to but include:
i. Metabolism
ii. Proliferation
iii. Receptors
iv. Hypoxia
v. Reporter genes
vi. Apoptosis
vii. Angiogenesis
viii. Cell trafficking
e.Molecular imaging agents
1. Residents should be familiar with the established
radiopharmaceuticals, as well as emerging molecular imaging agents, including those that are non-radioactive. They should also understand how these agents are used for diagnosis, staging, therapy selection and monitoring therapeutic efficacy. The quantitative use of molecular imaging agents builds on an understanding of targeting and pharmacokinetic analysis (e.g. compartmental modeling).
2. Radiopharmaceuticals: reactor, cyclotron, and
generator production of radionuclides; radiochemistry; pharmacokinetics; and formulation of radiopharmaceuticals. Basic strategies for
radiolabeling small molecules, peptides, antibodies,
aptamers and biomolecules with radionuclides for
SPECT and PET imaging with emphasis on chelation strategies appropriate for each radionuclide-molecule pair, as well as labeling with radiohalogens (fluorine, bromine and iodine radionuclides). Overview of radionuclides relative to molecular therapies and strategies employed to increase radiotherapeutic targeting including multi-step targeting approaches.
3.Non-radioactive agents (e.g. optical, ultrasound, MR, CT): fluorescent dyes and proteins (including near-infrared), microbubbles, nanoparticles, contrast agents. Applications of certain classes of molecular agents for therapeutic purposes (e.g. photodynamic therapy (PDT).
(8)should have continuing instruction in the relevant
basic sciences. This should include formal lectures and formal labs, with an appropriate balance of time allocated to the major subject areas, which must include physical science and instrumentation; radiation biology; radiation protection and regulatory issues; molecular and cellular biology; and molecular imaging agents. Instruction in the basic sciences should not be limited to only didactic sessions. The resident’s activities also should include laboratory experience and regular contact with basic scientists in their clinical adjunctive roles;
(9)must have clinical didactic instruction and clinical experience in both diagnostic imaging and non-imaging nuclear medicine procedures and therapeutic applications. The clinical didactic instruction must be well organized, thoughtfully integrated, and carried out on a regularly scheduled basis. The clinical didactic instruction and clinical experience must include the following areas:
a.Diagnostic use of radiopharmaceuticals for non-tumor and tumor diagnostic nuclear medicine, cardiovascular nuclear medicine, and nuclear medicine/molecular imaging of the brain: biological mechanisms of localization and targeting, clinical indications, technical performance, and interpretation of in vivo imaging of the body organs and systems, using external detectors and scintillation cameras, including SPECT and PET and correlation of nuclear medicine procedures with other pertinent imaging modalities such as plain film radiography, angiography, computed tomography, bone densitometry, ultrasonography, and magnetic resonance imaging. Training should include the specific study types that are outlined below. New radiopharmaceuticals, single photon emitters and positron emitters, are always being investigated. It is important that instruction include diagnostic use of new radiopharmaceuticals as they become available and established in clinical practice.
b.Non-tumor Diagnostic Nuclear Medicine
1.Musculoskeletal studies, including bone imaging for
benign disease and bone densitometry;
2.Endocrinologic studies, including thyroid,
and parathyroid imaging studies. Thyroid studies should include measurement of iodine uptake and dosimetry calculations for radio-iodine therapy;
3.Gastrointestinal studies of the salivary glands,
esophagus, stomach, small and large bowel, and liver, both reticuloendothelial function and the biliary system. This also includes studies of
gastrointestinal bleeding, Meckel diverticulum;
4.Pulmonary studies of perfusion and ventilation performed with radiolabeled macroaggregates and radioactive gas or aerosols used in the diagnosis of pulmonary embolus, as well as for quantitative assessment of perfusion and ventilation;
5.Genitourinary tract imaging: renal perfusion and
function procedures, clearance methods, renal
scintigraphy with pharmacologic interventions,
renal transplant evaluation, and vesicoureteral
reflux;
6.Hematologic imaging studies: splenic
sequestration, hemangioma studies, labeled
granulocytes for infection, thrombus imaging,
bone marrow imaging, and
7.Non-imaging studies: training and experience in
the application of a variety of non-imaging
procedures, including in-vitro studies including
Schilling test/ B12 absorption studies,
glomerular filtration rate, and red blood cell mass
and plasma volume.
c.Cardiovascular Nuclear Medicine
1.Exercise and pharmacologic stress testing: the pharmacology of cardioactive drugs; physiologic gating techniques; patient monitoring during interventional procedures; management of cardiac emergencies, including electrocardiographic interpretation and cardiopulmonary life support; and correlation of nuclear medicine procedures with other pertinent imaging modalities such as angiography, computed tomography, ultrasonography, and magnetic resonance imaging;
2.Myocardial perfusion imaging procedures performed with radioactive and non-radioactive perfusion agents in association with treadmill and pharmacologic stress (planar and tomographic, including gated tomographic imaging). Specific applications should include patient monitoring, with special emphasis on electrocardiographic interpretation, cardiopulmonary resuscitation during interventional pharmacologic or exercise stress tests, pharmacology of cardioactive drugs, and hands-on experience with performance of the stress procedure (exercise and pharmacologic agents) for a minimum of 50 patients. Program directors must be able to document the experience of residents in this area, e.g., with logbooks;
3.Ventriculography performed with ECG gating for evaluation of ventricular performance. The experience should include first pass and equilibrium studies and calculation of ventricular performance parameters, e.g., ejection fraction and regional wall motion assessment;
4.PET imaging of the heart, including studies of myocardial perfusion and myocardial viability, and metabolic studies.
5. Metabolic imaging of the heart, including MIBG and fatty acids.
d.Nuclear Medicine/Molecular Imaging of the Brain
1.Neurologic studies, including cerebral perfusion
with both single photon emission computed tomography (SPECT) and positron emission tomography (PET), cerebral metabolism with FDG, and cisternography. This experience should include studies of stroke, dementia, epilepsy, brain death, and cerebrospinal fluid dynamics.
2.PET imaging of the brain, including studies of
dementia, epilepsy, and brain tumors.
e.Tumor Imaging
1.Musculoskeletal studies, including bone imaging for malignant disease;
2. Endocrinologic studies, including whole-body scanning
for thyroid metastases, adrenal imaging, and octreotide and other receptor-based imaging studies. Thyroid studies should include dosimetry calculations for radio-iodine therapy as clinically indicated;
3. PET imaging in oncology, including studies of tumors
of the lung, head and neck, esophagus, colon, thyroid,
and breast, as well as melanoma, lymphoma, and other
tumors as the indications become established;
4.Single Photon Oncology studies: gallium, thallium, sestamibi, antibody-based, peptide-based, and other agents as they become available;
5. Oncology experience should include all the common
malignancies of the brain, head and neck, thyroid,
breast, lung, liver, colon, kidney, bladder and prostate.
It should also involve lymphoma, leukemia, melanoma,
and musculoskeletal tumors;
6. Hands-on experience with lymphoscintigraphy,
including sentinel node mapping, is very important.
f.Therapeutic uses of unsealed radiopharmaceuticals and molecular targeted pharmaceuticals:
1.Patient selection and management, including dose calculation, dosimetry, administration, drug and radiation toxicity, post-therapy hematologic monitoring, radiation protection considerations in the treatment of metastatic cancer and bone pain, primary neoplasms, solid tumors, malignant effusions; and the treatment of hematologic, endocrine, and metabolic disorders;
2. Instruction should include the mechanisms of targeting
and action of the therapeutic agents (including a discussion of the generation and labeling of antibodies, antibody fragments, and peptides);
3. Specific clinical experience should include
radioiodine in hyperthyroidism (minimum of 10 cases) and thyroid carcinoma (minimum of 5 cases), radiolabeled antibodies (minimum of 3 cases) and radionuclides for painful bone disease. Instruction should include therapy with small molecules and other radiolabeled molecular therapeutics as they become available and established. Program directors must be able to document the experience of residents in this area, including patient follow-up, e.g., with logbooks.
h.Additional areas of experience
1.Co-registration and image fusion of SPECT and PET
images with computed tomography (CT) and magnetic
resonance imaging (MRI) studies.
2. Anatomic imaging of brain, head and neck, thorax,
abdomen, and pelvis, with CT to be able to understand the correlation between anatomic and functional imaging. This training should include a minimum of 4 months of CT experience that may be combined with a rotation that includes PET-CT or SPECT-CT, although rotation on a CT service is desirable for part of the training. The experience must emphasize correlation of CT images associated with PET-CT or SPECT-CT. The resident must acquire sufficient experience with such studies under the supervision of qualified faculty to be able to supervise the performance and accurately correlate the CTs associated with PET-CT or SPECT-CT studies. This requirement does not apply to residents who have completed training in an ACGME-approved diagnostic radiology program.
3. Diagnostic use of molecular imaging agents and
techniques (e.g., MR contrast agents, spectroscopy, optical imaging probes for bioluminescence and fluorescence, ultrasonography): biology/mechanisms of targeting, clinical indications, technical performance, and interpretation of in vivo imaging of body organs and systems, using pertinent imaging modalities such as scintillation cameras, optical imaging devices, computed tomography, ultrasonography, and MR imaging as they pertain to molecular imaging. New molecular imaging agents and techniques are always being investigated. It is important that instruction include diagnostic use of new molecular imaging agents and techniques as they become available and established in clinical practice.
4. Experience in radiation oncology and medical oncology.
This is essential because of the increasing close interaction with these specialties. The experience can consist of one month rotations or an equivalent experience through participation in patient management conferences and clinics. Instruction should include the use of PET and PET/CT images for radiation treatment planning if available.
Suggest to the Residency Review Committee to Move the Following Paragraphs:
Move from under medical knowledge competency to under practice-based learning competency
g.Quality management and improvement: principles of quality management and performance improvement, efficacy assessment, and compliance with pertinent regulations of the Nuclear Regulatory Commission and the Joint Commission on the Accreditation of Healthcare Organizations.
Move from under medical knowledge competency to under systems-based practice competency
5. Fundamentals of the operation of a positron emission tomography (PET) imaging center, including medical cyclotron operation for production of PET radionuclides such as fluorodeoxyglucose (FDG), experience in PET radiopharmaceutical synthesis, and image acquisition and processing.