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 socialbehavioral 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 imageacquisition and processing.
4.
Imaging science, contrast, signal to noise ratio,
spatial resolution

5.
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.
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
1.
Residents should be knowledgeable about the
regulations regarding the medical use of
radionuclides as described in the 10 CFR Part 20
and 35.
2.
Instruction should include the training and
experience as described in 10 CFR 35.190, 35.290
and 35.390. For example:
i. the chemistry of unsealed radioactive materials
for medical use;
ii. ordering, receiving and unpacking radioactive
materials safely and performing the related
radiation surveys;
iii. 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;
iv. using administrative controls to prevent a
medical event involving the use of unsealed
radioactive material;
v. using procedures to contain spilled radioactive
material safely and using proper
decontamination procedures;
vi. administering dosages of radioactive drugs to
patients or human subjects for uptake, dilution,
excretion, and imaging and localization studies;
vii. 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.
2.
Basic principles of molecular and cellular biology;
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
(8)
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 multistep 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).
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 radioiodine 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 SPECTCT studies. This requirement does not apply to
residents who have completed training in an ACGMEapproved 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.