Table Of ContentNuclear Medicine
and PET/CT
Technology and Techniques
Seventh Edition
Paul E. Christian, BS, CNMT, FSNMTS, PET
Associate Director, Molecular Imaging Program
Director, Cyclotron Radiochemistry Laboratory
Huntsman Cancer Institute
University of Utah
Salt Lake City, Utah
Kristen M. Waterstram-Rich, MS, CNMT, FSNMTS
Professor
Director, Premedical Studies
Biomedical Sciences Program Director
Rochester Institute of Technology
Rochester, New York
3251 Riverport Lane
St. Louis, Missouri 63043
NUCLEAR MEDICINE AND PET/CT TECHNOLOGY ISBN: 978-0-323-07192-5
AND TECHNIQUES, SEVENTH EDITION
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Notices
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C O N T R I B U T O R S
Carolyn J. Anderson, PhD Helen H. Drew, MT(ASCP), William Hubble, MA, CNMT,
Professor CNMT(NMTCB) RT(R)(N)(CT), FSNMTS
Radiology, Biochemistry & Technical Specialist, Core Special Academic Chair/NMT Program
Molecular Biophysics and Chemistry Laboratories Director
Chemistry Department Department of Pathology Associate Professor
Washington University Johns Hopkins Hospital Saint Louis University
St. Louis, Missouri Baltimore, Maryland Doisy College of Health Sciences
Department of Medical Imaging
Crystal Botkin, MPH, CNMT, PET Tracy L. Faber, PhD and Radiation Therapeutics
NMT Clinical Coordinator Professor of Radiology St. Louis, Missouri
Saint Louis University Emory University
Doisy College of Health Sciences Atlanta, Georgia Kathy Thompson Hunt, MS, CNMT
Department of Medical Imaging Program Chair, Nuclear Medicine
and Radiation Therapeutics James R. Galt, PhD Technology
St. Louis, Missouri Assistant Professor, Emory Baptist College of Health Sciences
University Memphis, Tennessee
Paul H. Brown, PhD Nuclear Medicine, Emory
Associate Professor of University Hospital Peter Jenkins, MS, CHP
Radiology Atlanta, Georgia Medical Physicist
Oregon Health Sciences University University of Utah Hospitals and
Portland, Oregon David Gilmore, MS, CNMT, NCT, Clinics
RT(R)(N) Salt Lake City, Utah
Paul E. Christian, BS, CNMT, Program Director, School of
FSNMTS, PET Nuclear Medicine Karen S. Langley, MS
Associate Director, Molecular Technology Radiation Safety Officer, Director
Imaging Program Beth Israel Deaconess Medical Radiological Health Department
Director, Cyclotron Radiochemistry Center, a Harvard Medical University of Utah
Laboratory School Affiliate Salt Lake City, Utah
Huntsman Cancer Institute Boston, Massachusetts
University of Utah Janice Leggett, RTNM
Salt Lake City, Utah Stanley J. Goldsmith, BA, MD Supervisor, Division of Nuclear
Director, Nuclear Medicine & Medicine
Gary L. Dillehay, MD, FACNP, Molecular Imaging British Columbia Children’s Hospital
FACR Professor of Radiology and Radiology Department
Professor of Radiology Medicine Vancouver, British Columbia
Department of Nuclear Medicine Weill Medical College of Cornell Canada
Northwestern Memorial Hospital University
Chicago, Illinois NewYork-Presbyterian Hospital/ Mark T. Madsen, PhD, FAAPM,
Weill Cornell Medical FACR
Kevin Donohoe, MD Center Professor of Radiology
Staff Physician, Division of Nuclear New York, New York University of Iowa
Medicine Iowa City, Iowa
Beth Israel Deaconess Medical Ravinder K. Grewal, MD
Center Assistant Attending Physician Leon S. Malmud, MD
Assistant Professor of Nuclear Medicine Service Dean Emeritus, Temple University
Radiology Memorial Sloan Kettering Cancer School of Medicine
Harvard Medical School Center Temple University Hospital
Boston, Massachusetts New York, New York Philadelphia, Pennsylvania
v
vi Contributors
Donna C. Mars, MEd, CNMT, Sally Schwarz, RPh, MS Jean-Luc Urbain, MD
NCT Washington University School of St. Joseph Hospital
Assistant Professor, Allied Health Medicine London, Ontario
Division Department of Radiology/Division Canada
Baptist College of Health Sciences of Nuclear Medicine
Memphis, Tennessee St. Louis, Missouri Mark Wallenmeyer, MBA, CNMT,
FSNMTS
Derek McGuire, RTNM, CDT Akash Sharma, MD Assistant Professor of Nuclear
Nuclear Medicine Technologist Instructor in Radiology Medicine Imaging Sciences
British Columbia Children’s Division of Nuclear Medicine University of Arkansas for Medical
Hospital Mallinckrodt Institute of Radiology Sciences
Radiology Department Washington University School of Little Rock, Arkansas
Vancouver, British Columbia Medicine
Canada St. Louis, Missouri Kristen M. Waterstram-Rich, MS,
CNMT, FSNMTS
Denise A. Merlino, CPC, CNMT, H. William Strauss, MD Professor
MBA Attending Physician Director, Premedical Studies
President, Merlino Healthcare Nuclear Medicine Service Biomedical Sciences Program
Consulting Corp. Memorial Sloan Kettering Cancer Director
Magnolia, Massachusetts Center Rochester Institute of Technology
New York, New York Rochester, New York
Frances L. Neagley, CNMT,
FSNMTS Nancy M. Swanston, CNMT, PET, Katherine Zukotynski, BASc, MD,
Editor, Journal of Nuclear Medicine RT(N) FRCP(C)
Technology Manager, Diagnostic Imaging Staff Radiologist, Dana-Farber
Society of Nuclear Medicine Section of Positron Emission Cancer Institute
Reston, Virginia Tomography Associate Radiologist, Brigham and
Division of Diagnostic Imaging Women’s Hospital
Neeta Pandit-Taskar, MD The University of Texas MD Instructor in Radiology, Harvard
Associate Attending Physician Anderson Cancer Center Medical School
Nuclear Medicine Service Houston, Texas Boston, Massachusetts
Memorial Sloan Kettering Cancer
Center Kathy Thomas, MHA, CNMT,
New York, New York PET
Applications/Technical Support
Henry Royal, MD Capintec, Inc.
Professor, Radiology Battle Ground, Washington
Associate Director, Division of
Nuclear Medicine
Mallinckrodt Institute of Radiology
Washington University School of
Medicine
St. Louis, Missouri
F O R E W O R D
The production of a textbook is a labor of love. To have The chapter on computer science has undergone a
reached the status of a seventh edition shows a level of major revision with the focus shifting more to computer
dedication amongst the authors and editors that is applications and practical digital imaging. The reader of
unusual. For almost three decades, this book has pro- this chapter will also be introduced to basics of PACS,
vided a mainstay in the education of nuclear medicine networking, and image co-registration (fusion) of digital
technologists. When one looks back, nuclear medicine images. The chapter on radiochemistry and radiophar-
was much simpler when the first edition of this book was macology has been updated with increased focus on the
published. Without significant change from either the operation of the 99Mo-99mTc generator and more infor-
first or the sixth edition, this book would not be of much mation on PET radiopharmaceuticals. Further, the reader
use. A look at the book today, now in its seventh edition, is introduced to some of the new regulatory changes,
shows it to be current and demonstrates a blending of including USP Chapter <797>. Other chapters have had
old and new while also addressing future developments. facelifts as appropriate to keep them current.
The changes to the current edition make it ideal for the A feature that I particularly like is the outline at the
education of the nuclear medicine technologist. (It is also beginning of chapters and the list of learning objectives
a great source of information for anyone in the first who and key terms for the chapter. Preceding the objectives
wants an eminently readable text.) is a standard outline of the chapter that is directed at
Today’s seventh edition is as up-to-date as a book can those looking for a quick reference on a given topic. For
be. A completely new chapter on instrumentation by educators, this structure is particularly useful. The
Mark Madsen brings into focus all of the current devices quality of illustrations is excellent, and they have
and is filled with excellent illustrations and descriptive been chosen to drive home or illustrate principles in
material that is current and understandable. In the sixth the text. The illustrations and captions are clear and
edition, a new chapter was added on CT physics. Now understandable.
a new addition to this text is a chapter on the physics One of the interesting features of this text is its inte-
and principles of MRI. At first glance, this would seem gration with the Evolve website. This integration allows
to be a somewhat unusual addition to a nuclear medicine the instructor to enrich their own materials with images
text; however, it shows how the editors and authors are from the textbook. Downloadable examination ques-
preparing the reader to deal with future clinical develop- tions permit the use of the most current thinking
ments in imaging. A completely new chapter on brain to assess the student’s comprehension of the presented
imaging from the Boston group with so much experience material. Although this text is directed primarily at the
in this area is another example of the forward-looking nuclear medicine technology student, its organization
nature of this text. In the group of new and updated and quality make it a text useable by radiology and
chapters is a complete revision of the chapter on cardiac nuclear medicine residents as well an absolute necessity
imaging that incorporates imaging guidelines for clinical on everyone’s reference shelf.
appropriateness. The nuclear medicine technologist is
going to find himself/herself right in the middle of imple- Robert E Henkin, MD, FACNM, FACR
mentation of appropriateness criteria, and this is a won- Professor Emeritus of Radiology
derful starting place to get accustomed to the terminology Loyola University Stritch School of Medicine
and implementation of such guidelines. Maywood, Illinois
vii
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P R E F A C E
CONTENT
into changes and advancements that are under investiga-
Writing a book is definitely a labor of love and a testa- tion. The many expert contributors of the chapters have
ment to patience. The process takes over two years, and reviewed and updated the information in this edition to
the work waxes and wanes throughout the time period; bring the materials and figures to the current level of
but it is not until the very end that one gets a glimpse of clinical practice. There are several chapters that have
how the book will look in print. undergone notable revisions. Chapter 3, “Instrumenta-
This book, now in its seventh edition, has stood the tion,” has been replaced with a new chapter by a
test of time. It continues to keep pace with the changes new contributing author in an effort to make this topic
in the field of nuclear medicine and healthcare as it more easily understood and comprehensive and to
expands and evolves to meet the needs of the profession- provide an uptake to changes in this expanding area
als facing the challenges of changing technology and and new device configurations. Chapter 12, “Principles
medical practice. Through all of the revisions, it has of Magnetic Resonance Imaging,” is a completely new
stayed true to its focus of providing information that chapter. Chapter 12 has been added to provide the reader
covers all aspects of nuclear medicine, thereby serving as with a familiarity of magnetic resonance and magnetic
a comprehensive introductory text for nuclear medicine resonance imaging, and it is not intended to be a com-
professionals to enter practice in this field. This book is prehensive study of MRI. Chapter 14, “Central Nervous
intended for use by technologists and student technolo- System,” was revised by a new group of contributing
gists, and it is also intended as a reference guide for authors from Boston who have provided a major revi-
physicians and scientists entering nuclear medicine. It is sion to the chapter. There are also new co-authors in
used by many nuclear medicine technologist educational Chapters 15, 19, 21, and 23. Chapter 22 has a new title
programs and as a resource in many nuclear medicine “Inflammatory/Tumor/Oncology Imaging and Therapy.”
departments worldwide. As described by its title, the chapter has expanded to
The textbook remains divided into two main sections: include the growing area of nuclear medicine therapy in
the basic science chapters and the clinical applications. oncology. Lastly, each chapter has protocols separated
The knowledge base formed from the basic science chap- from the text for easy reference.
ters (e.g., mathematics, physics, instrumentation, patient
care, and radiation safety) provide the foundation on
LEARNING ENHANCEMENTS
which the clinical chapters build. In the clinical chapters,
the science is expanded to include anatomy and physiol- Each chapter begins with an outline, learning objectives,
ogy, and it is in the clinical chapters where you can see and key terms. The key terms appear in the front of
the complexity of the field of nuclear medicine and how each chapter to aid students in identifying terms with
the interconnectedness of physics, chemistry, anatomy, which they should become familiar. Each term will
and physiology result in diagnostic images, or are used appear in boldface the first time that it used in the
in clinical and therapeutic applications. The clinical chapter. The key terms are also defined in the Glossary
chapters essentially start at the head and work their way at the end of the book. There are also summaries
down the body. The last two chapters, “Inflammatory/ at the end of each chapter to highlight a few of the
Tumor/Oncology Imaging and Therapy” and “Pediatric important concepts in each chapter. The full-color
Imaging,” include topics that span all body systems. This PET/CT and cardiac scan insert has been expanded to
coherent framework for the knowledge base of the book provide additional examples of realistic scans found in
provides an efficient and logical approach to studying practice.
the field of nuclear medicine that allows for students to Chapter 1, “Mathematics and Statistics,” gives the
see a unifying theme or connectedness of the infor- reader opportunities to practice the basic math skills
mation. An appendix of radiopharmaceuticals, which necessary to function as a nuclear medicine technologist.
summarizes many of the radionuclide properties, radio- The answers for these questions are provided at the end
pharmaceutical names, and clinical applications, is also of the book so that the reader can assess their knowledge
included as an easy reference. before proceeding to the next chapter.
Boxes and tables are used throughout the book to call
attention to important information. The information
NEW TO THIS EDITION
and writing style are targeted toward readers new to
Each revised edition captures the changes that have nuclear medicine. The fundamentals are addressed first,
occurred since the previous edition and gives a glimpse and then topics build to become more complex.
ix
x Preface
• An electronic image collection with all of the images
INSTRUCTOR ANCILLARIES
from the textbook in .jpeg and PowerPoint formats
The Evolve website is a secure and interactive learning
environment designed to work in coordination with Instructors may use Evolve to provide an Internet-
Nuclear Medicine and PET/CT Technology and Tech- based course component that reinforces and expands
niques, seventh edition. The instructor materials avail- the concepts presented in class. Evolve may be used to
able on Evolve will assist the educator in preparing publish the class syllabus, outlines, and lecture notes;
exams and pre senting material. The following assets are set up “virtual office hours” and email communication;
included on Evolve: share important dates and information through the
online class calendar; and encourage student participa-
tion through chat rooms and discussion boards. Evolve
• A test bank with multiple choice questions in Exam- also allows instructors to post exams and manage their
View and Word formats, including rationales for grade books online. For more information, visit http://
correct answers and references to the coordinating evolve.elsevier.com/Christian/nuclear/ or contact an Else-
page number in the textbook vier sales representative.
A C K N O W L E D G M E N T S
We would like to thank the hard work and extraordinary endured the time commitment made by the authors to
efforts of the contributing authors of this text. Without ensure the delivery of quality material.
their dedication and commitment to the project, it would Lastly, we would like to thank and extend our appre-
not have been possible. It is also their talent in presenting ciation to our editors at Elsevier/Mosby, as well as the
information that allows the reader to transform this production and design team, whose support, guidance,
information into a knowledge base through which they patience, and diligent work have made this project a
can practice nuclear medicine. success.
We would also like to thank and recognize the co-
workers, families, and loved ones of all of those involved Paul E. Christian
in the book whose names do not appear in writing but Kristen M. Waterstram-Rich
xi
