Nuclear Medicine

1. Radiopharmaceuticals are radioactive pharmaceutical agents or drugs used for either

diagnostic or therapeutic procedures. Describe the factors to be considered for a
radioactive compound before it can be used in the different protocols being done in a
Nuclear Medicine Department.
2. Radioiodine therapy has been frequently used to help treat malignancies in the thyroid
glands. Assume that a patient was administered 9 GBq of I-131, and 27 hours later the
patient suffered a cardiac arrest and died. If you were the medical physicist of the hospital,
what recommendations would you give to the people involved in the autopsy like the
embalmer?
3. Imaging with equipment that combines positron emission tomography and computed
tomography (PET/CT) provides the special benefits of both modalities in one procedure,
that is, a highly sensitive imaging technique used in oncology, cardiology, neurology and in
infectious and inflammatory diseases. The information from the PET scan and from the
CT scan is very different but complementary to each other. In this regard, how do
PET/CT doses compare with doses from other examinations?
4. It is not particularly difficult to derive meaningful and reproducible results from
radioactivity measurements, but careful attention to the details is rewarding. Discuss the
different factors that affect the efficiency of counting systems used in a Nuclear Medicine
Department.
5. The detection and subsequent count rate obtained from a radioactive source is
governed by many factors. These factors include operating voltage, resolving time,
geometry, efficiency of counting, and statistics among others. All of these depend on the
detector itself, the counter, the source of radiation, and the material surrounding the
source. If you were to be asked by your nuclear medicine practitioner as to what survey
instrument(s) will be procured for the department, what would you advise? Justify.
6. The dose calibrator is one of the necessary requirements in a Nuclear Medicine
laboratory. It is essential that one should be very familiar with the different
characteristics of this detector. Discuss in detail the description of this instrument, points
to consider during installation, routine use, and the quality assurance program dedicated to
it.
7. Imaging with equipment that combines positron emission tomography and computed
tomography (PET/CT) provides the special benefits of both in one procedure, that is, a
highly sensitive imaging technique used in oncology, cardiology, neurology, and infectious
and inflammatory diseases. The information from the PET scan and from the CT scan is
very different but complementary to each other. In this regard, how do PET/CT doses
compare with doses from other examinations?
8. Describe the relatively new field of theranostics. Being newly introduced in the
country, how do you think it can overcome its challenges?
9. After a PET scan, how long does a patient need to wait before using public
transportation without setting off radiation detectors?
1. The factors to be considered for a radioactive compound before it can be used in the
different protocols done in a Nuclear Medicine Department are the following:

• Radionuclide Purity
o Verifies that the amount of radionuclide contamination does not exceed the
standard limit.
o Confirms the radionuclidic identity (half-life determination)

• Radiochemical Purity
o Verifies that the amount of the radioactivity in the correct form meets the standard
requirement.

• Chemical Purity
o Verifies that the amount of chemical contamination does not exceed the standard
limit.

• pH
o Checks that the radiopharmaceutical is maintained at an appropriate ph (for stability
and integrity)

• Osmolality
o Checks that the radiopharmaceutical has proper osmolality to be acceptable for
human administration

• Filter Integrity
o Checks that the particulates in the radiopharmaceuticals have the proper size and
number of particles for a particular indication

• Sterility
o Checks that the risk of contamination by micro-organisms, particles and pyrogens is
eliminated
2. Since the radioactivity of the administered 9 GBq of I-131 is still high after 27 hours (around
8 GBq), radiation protection measures should be implemented. These procedures include:
• Autopsy should be suspended until a risk assessment has been undertaken by the
RPO

• The cadaver should have a label attached, identifying the radionuclide and the
corresponding radioactivity at the time of death

• Access to the room occupied by the deceased should be controlled until the room
has been decontaminated and surveyed

• Decontamination should be provided in consultation with the RHSO

• Nursing staff should be provided with instructions informing them that the normal
procedure of pressing down on the abdomen of a corpse must not be performed due
to the radiation and/or contamination levels that may result

• The RPO shall notify the morgue prior to the arrival of the body, and the RPO should
discuss radiation safety precautions with morgue personnel

• An RPO or radiation safety staff should supervise the autopsy (if an autopsy is
unavoidable)

• Any residual activity in tissue samples should be evaluated prior to releasing the
samples to the pathology laboratory

• Embalming should be avoided if possible

• Staff (including the autopsy team and embalmers) handling the cadaver should wear
disposable gloves, and supplementary measures for radiation protection

• Cadavers containing more than 15 mCi of I-131 should be stored until the 15 mCi
has been reached.
3. Doses from PET/CT scans are dependent on the doses from both the PET scan component
and the CT scan component. The effective dose from the PET scan component is typically
8 mSv for adults using 400 MBq and is the same whether a part of the body or the whole
body is imaged. On the other hand, the effective doses from the CT scan component vary
widely depending on the type of the test, the area of the body scanned, and the purpose of
the test. For example, doses from the CT component can be low if the CT scan is aimed only
for the localization of abnormalities seen on a PET scan but can be high if the aim is to
produce high-resolution diagnostic scans. Because of this, the wide range of effective dose
values from PET/CT is mainly influenced by the CT component.

The approximate effective radiation dose received by an average-sized adult from CT scans
can be as low as 1.2 mSv (CT scan of the head and neck) and can be as high as 15.4 mSv (CT
scan of the abdomen and pelvis, repeated with and without contrast).

When compared to the approximate doses received from other examinations, the
approximate dose from PET/CT is relatively high. For example, screening using digital
mammography and chest X-rays only have approximate effective doses of 0.21 mSv and 0.1
mSv, respectively. These doses are significantly low when compared to the approximate
dose received from PET/CT whole body scans.
4. The main factors affecting the efficiency of counting systems used in a Nuclear Medicine
Department are the detection efficiency and the counting rate limitations.

The detection efficiency describes how well a radiation-measuring instrument converts

emission from the radiation source into useful signals from the detector. Typically, it is desired to
have a high detection efficiency since this enables the user of the counting system to extract
maximum information from a minimum amount of radioactivity.

The relationship between the detection efficiency, counting rate, and emission rate is given by
the equation below:

R (Eq. 1)
ÿ=
�㔉

Where:
ÿ [expressed in counts per radioactive emission] is the detection efficiency

�㕹 [expressed in counts per second] is the counting rate recorded from the source
�㕃 [expressed in radioactive emission per second (e.g., for a γ ray-emitting source,
γ rays/sec)] is the emission rate

Detection efficiency can also be described as a product of individual factors:

ÿ = ā × �㔀 × Ā × ā (Eq. 2)

Where:
ÿ is the detection efficiency
Ā is the geometric efficiency
�㔺 is the intrinsic efficiency
ÿ is the fraction of output signals from the detector that falls within the pulse-height analyzer
window
ā factor for absorption and scatter occurring within the source or between the source and
detector
The detection efficiency is affected by many factors which include:

• Geometric efficiency, g
o This is the efficiency describing how well the detector intercepts radiation
emitted from a radioactive source. This efficiency is affected by the size and shape
of the detector (i.e., how much radiation flux from the source is being intercepted
by the surface area of the detector) and by the distance of the detector from the
source (i.e., inverse-square law relationship).

• Intrinsic efficiency, �㔀
o This efficiency refers to the ability of the detector to convert the incident
radiation it absorbs into useful detector output signals. This efficiency is mainly
affected by the detector thickness, the detector composition (attenuation
coefficient), and the type of energy of the radiation to be detected.

The general equations for the intrinsic efficiency, �㔀, are the following:

ÿĀ. ĀĀ ÿ�㕎ÿ�㕎āÿĀÿĀ ÿÿāÿÿ�㕎ýāÿÿā ýÿā/ (Eq. 3)

�㔀þÿāÿýāĀÿ
=

ÿĀ.ĀĀ ÿ�㕎þÿ�㕎āÿĀÿĀ Āāÿÿýÿÿā þÿāÿýāĀÿ

�㔀 = 1 − ÿ−�㔇þ(Ā)þ (Eq. 4)
Where:
�㔺 is the intrinsic efficiency (value ranges between 0 and 1)

�㕁�㖍(Ā), typically measured in cm-1, is the linear attenuation coefficient of the

detector at the γ-ray energy of interest, E

�㖙 is the detector thickness (Note that the unit of �㖙 should be the reciprocal
of the unit of the �㕁�㖍(Ā) for example, if cm-1 is used for
�㕁�㖍(Ā), then �㖙 should be in cm)

Note that (Eq. 4) assumes that any interaction of the γ ray in the
detector produces a potentially useful signal from the detector.

• Energy-Selective Counting, f
o When a pulse-height analyzer is used, only the output signals within the pulse-
height analyzer window are counted. An example is when counting is limited
only to the photopeak. γ rays interacting with the detector via Compton
scattering are not counted.
 • Absorption and scatter of radiation within the source itself or by material between the
source and the radiation detector, F
o There are instances when absorption and scatter of radiation happens before the
radiation reaches the detector. An example of this instance is when the radiation
source is inserted at a depth within an absorbing and scattering medium. Absorption
typically results in a decrease in the recorded counting rate while scattered
radiation may result in either a decrease or an increase in the counting rate
depending on whether there is more scattering away from or toward the
detector.

• Complicating Factors

o Nonuniform Detection Efficiency

▪ In some cases, radiation is not detected by the detector uniformly across
the entire surface of the detector. An example of such an event is when
there are differences in the possible trajectories of radiations striking a
detector from a point source. One trajectory may encounter a different
detector thickness than the other trajectories. This results in a nonuniform
intrinsic efficiency since the intrinsic efficiency is affected by the detector
thickness the radiation interacts with (see Eq. 4).

o Detection of Simultaneously Emitted Radiations in Coincidence

▪ There are instances when some radionuclides emit multiple γ rays in
sequence, say within a few nanoseconds from one γ ray to the next γ ray,
from a single nuclear disintegration. Since the period between the
emission of the two γ rays is well within the resolving time of most
detectors, these two emissions are recorded as a single event with an
energy equal to the sum of the energies deposited by the individual γ rays
in the detector.

The other main factor affecting the efficiency of a counting system used in a Nuclear Medicine
Department is its corresponding counting rate limitation. Any instrument has a finite counting limit.
When the actual number of radiation interactions exceeds the counting rate limit of a counting
system, inaccurate measurements are produced due to data losses and data distortions.

Counting rate limitations include the following:

• Dead Time
o This is related to the time required to process the individual detected events by the
detector. The system cannot process other radiation interactions during the dead
time. This results to signal loss. When another interaction occurs immediately after the
first interaction, signal distortion is experienced. For the same dead time, counts lost
increase as the interaction increases within the dead time.

• Detections involving low energy β-particle emitters

o Low-energy β-particle emitters pose problems in detection and measurement due
to the relatively short ranges of β-particles in solid materials. For low-energy β-
particles to be efficiently detected, a very thin entrance window, preferably designed
from a low-density material is required.
5. For detecting radionuclides with γ-ray emissions in the range of 80-300 keV, I would recommend
procuring a sodium iodide [NaI(Tl)] scintillation detector due to the following reasons:
a. A NaI(Tl) scintillation detector is a good absorber and an efficient detector of
penetrating radiations (e.g., x-rays and γ rays in the 50- to 250-keV energy range) due to
it being relatively dense and having an element of relatively high atomic number (i.e,
iodine with an atomic number of 53).
b. This detector is efficient as it yields one visible light photon per ~30 eV of radiation
energy absorbed.
c. Loss of scintillation light due to self-absorption is low since this detector is transparent
to its own scintillation emissions.
d. The scintillation light is well-matched in wavelength to the peak response of the
photomultiplier tube photocathode.
e. The decay time (the time necessary for the intensity of the light pulse to return to 1/e of
its maximum value) of NaI is fast.

For detecting α particles and β particles, I would recommend a Geiger-Müller (GM) with thin
mica or aluminum entrance windows for the following reasons:

f. GM-type survey meters are most useful for detecting small amounts of
radioactivity (e.g., minor spills and surface contamination).
g. GM-type survey meters are portable and battery-operated.
h. This type of survey meter is more sensitive than ionization chamber survey meters.
6. The dose calibrator is one of the necessary requirements in a Nuclear Medicine laboratory. It is
essential that one should be very familiar with the different characteristics of this detector. Discuss
in detail the description of this instrument, points to consider during installation, routine use, and the
quality assurance program dedicated to it.

Answer:

A dose calibrator is a special purpose ionization detector used to measure radioactivity in the
μCi to Ci range. A simplified schematic of a dose calibrator is shown on Figure 1. As can be seen
from Figure 1, the radioactive sample of interest is inserted close to the center of the chamber via
the hole along the axis of the <well=.

The general structure of this special ionization chamber is as follows:

• Typically, the chamber is cylindrical in shape (increases the dose calibrator9s
overall sensitivity)
• The chamber is sealed and filled with a rare gas such as argon at high pressures to avoid
fluctuations in response with ambient barometric pressure
• Outside chamber walls are appropriately shielded to minimize interference from
radioactive sources outside the chamber

Figure 1. A simplified schematic of a dose calibrator from Chandra, R. et al. Nuclear Medicine Physics: The Basics.
8th ed.
The principle and operation of a dose calibrator is as follows:
• The radioactive sample of interest is inserted close to the center of the
chamber via the hole along the axis of the <well=
• The applied voltage across the electrodes in the chamber is high enough for each
electrode to attract all the corresponding primary ion pairs produced in the ionization
chamber (positive ion to the negative electrode and negative ion to the positive
electrode)
• The applied voltage is, at the same time, relatively low so that the energy provided to
the primary ion pairs is not enough to produce secondary ion pairs
• The corresponding current produced in the ionization chamber by the radioactive
sample of interest in a given geometric arrangement is directly proportional to the
amount of the radioactivity of the sample of interest
• Note that different radionuclides with the same amount of radioactivity produce
different amounts of current (this requires the dose calibrator to first be calibrated for the
desired radionuclides individually before actual use)

Some of the typical uses of a dose calibrator are listed below:

• for assaying relatively large quantities (i.e., MBq range) of γ-ray emitting radioactivity
• for measuring or verifying the activity of generator eluates, patient
preparations, shipments of radioactivity received from suppliers
• for measurement of radiation exposure

Limitations and disadvantages of this type of ionization chamber are listed below:
• cannot be used as a counter since the amount of current produced in response to a single
ray or particle is small
• no inherent ability for energy discrimination
Points to consider during installation and routine use based on PNRI A.O. 03 series of 2020
AMENDMENT TO THE CPR PART 13, <LICENSES FOR MEDICAL USE OF UNSEALED
RADIOACTIVE MATERIAL, Rev. 2” (will be elaborated on in the Quality Assurance Section):
• Test each dose calibrator for constancy with a dedicated check source upon
installation and daily before use. Testing shall be done on a frequently used setting with
a sealed source, a long-lived radionuclide with an activity of at least 2 MBq;
• Test each dose calibrator for accuracy upon installation and at least annually
thereafter by assaying at least two sealed sources of different energies, one low and one
high energy, whose activities the manufacturer has determined to be within 5 percent of
its stated activity; these sealed sources shall have an activity of at least 2 MBq;
• Test each dose calibrator for linearity upon installation and at least quarterly
thereafter over the range of its use between 0.4 MBq and the highest dose that will be
dispensed;
• Test each dose calibrator for geometry dependence upon installation over the range of
volumes and volume configurations for which it will be used. The licensee shall keep a
record of this test for the duration of use of the dose calibrator.
Quality assurance program dedicated for dose calibrators based on NRLSD BULLETIN 93-04 <DOSE
CALIBRATOR QUALITY CONTROL= from PNRI:
• The following test and check procedures for the use of dose calibrators should be done
at frequencies stated on the previous section (Points to consider during installation and
routine use)
• Constancy Checks
o This procedure checks the reproducibility (the ability of a tool to produce
consistent results given a set of test conditions) of the measurements obtained
when using a dose calibrator to measure the activity of a known source over a
long period of time.
o The performance should be such that all individual measured activities are within
+/- 5% of the mean measured activity.
o A long-lived sealed medium-energy gamma radiation source such as Co-60 is
suitable for this procedure.
• Accuracy Test
o This test ensures that the activity is within 10% of a given calculated reference
source whose activity has been determined by the manufacturer to be within +/-
5% of the activity stated in the standards set in the country where the source was
purchased
o At least one sealed source with a principal energy between 100 keV and 500
keV, must be used for this test.
o If the error exceeds 10%, the dose calibrator must be repaired or replaced.
• Linearity Tests
o This test ensures that the dose calibrator can indicate the correct activity
over the range for which it is to be used.
o Technetium-99m can be used for this test because of its availability and short
half-life.
o Dosage readings must be mathematically corrected if the percent deviation
exceeds 10%.
• Geometry Independence
o This test ensures that the indicated activity does not change with volume or
configuration.
o This test must be done over the range of volumes and volume configurations
for which it will be used, and should be done using a syringe that is normally used
for injections.
• It is required to perform appropriate checks and tests after adjustments or repairs of
the dose calibrator. This ensures that the dose calibrator satisfies all the requirements for
each test.
7. PET produces functional images but with relatively poor resolution, while CT provides high-
resolution anatomic images but not functional or metabolic information. Integrating these two
systems enables a highly sensitive imaging technique used in oncology, cardiology, neurology, and
infectious and inflammatory diseases

The advantages of the PET/CT hybrid imaging system include the following:
• helps in accurately identifying the anatomic location of <hotspots= seen in 18F-fluorodeoxyglucose
(FDG) whole-body cancer studies
• allows the possibility of using the CT scan for the computation of the corrections for photon
attenuation and scatter of the corresponding PET study since data from the CT scan can be
considered to be in fairly good spatial and temporal registration with the corresponding PET study

Regarding radiation doses, doses from PET/CT scans are dependent on the doses from both the PET
scan component and the CT scan component. The effective dose from the PET scan component is
typically 8 mSv for adults using 400 MBq and is the same whether a part of the body or the whole
body is imaged. On the other hand, the effective doses from the CT scan component vary widely
depending on the type of the test, the area of the body scanned, and the purpose of the test. For
example, doses from the CT component can be low if the CT scan is aimed only for the localization
of abnormalities seen on a PET scan but can be high if the aim is to produce high resolution diagnostic
scans. Because of this, the wide range of effective dose values from PET/CT is mainly influenced by
the CT component.
8. Theranostics is a combinatorial term for therapy and diagnostics that enables accurate imaging
and subsequent targeted radionuclide treatment. It is geared towards a personalized treatment
approach to the patient. In nuclear medicine clinical practice, theranostics is performed by using
the same molecule labeled with two different radionuclides (one radionuclide for imaging and
another for therapy).

Since theranostics is a relatively new field, the pieces of materials and equipment needed for this
type of treatment must be procured. Hospitals must be convinced to invest in this field. The
administrative staff of the hospitals must be guided on how to procure equipment from suppliers
and must be trained to check what specifications should be given importance for the procurement
to be cost-effective.

Extensive training should also be provided to the personnel that will be assigned to be involved
in the theranostics department of the hospital. Additions and revisions on the existing policies
being implanted on the hospital should be done to include procedures involving theranostics.

Local regulatory bodies involved such as the Food and Drug Administration of the Philippines
should also take time to prepare the necessary guidelines in regulating equipment and materials
involved in theranostics.

By proper training of the personnel, cooperation between agencies responsible for the regulation
of equipment involving theranostics, and proper information dissemination to the public, patients
in the Philippines will be able to access quality procedures involving theranostics.

9. Since isotopes used for PET imaging decay so rapidly, there is no danger of activating a
radiation detector once 24 hours have elapsed from the time when the patient has undergone a
PET scan procedure. There is also no danger to other travelers on public transportation following
a PET scan.
It is recommended for the patient to obtain a document from the PET Center indicating that
he/she has undergone a PET/CT scan, in case that the patient is questioned.