Nuclear Medicine Resources Manual
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Nuclear Medicine
Resources
Manual
This manual provides comprehensive guidance, at the
international level, on many aspects of nuclear medicine
practice, including education, training, facilities and
equipment, quality systems, and radiopharmacy and
clinical practice. It will be of use to those working
in both new and more developed nuclear medicine
centres.
INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA
ISBN 92–0–107504–9
Nuclear Medicine Resources Manual
P1198_CovI-IV.indd 1 2006-01-30 15:57:38
NUCLEAR MEDICINE
RESOURCES MANUAL
The following States are Members of the International Atomic Energy Agency:
The Agency’s Statute was approved on 23 October 1956 by the Conference on the Statute of
the IAEA held at United Nations Headquarters, New York; it entered into force on 29 July 1957.
The Headquarters of the Agency are situated in Vienna. Its principal objective is “to accelerate and
enlarge the contribution of atomic energy to peace, health and prosperity throughout the world’’.
AFGHANISTAN
ALBANIA
ALGERIA
ANGOLA
ARGENTINA
ARMENIA
AUSTRALIA
AUSTRIA
AZERBAIJAN
BANGLADESH
BELARUS
BELGIUM
BENIN
BOLIVIA
BOSNIA AND HERZEGOVINA
BOTSWANA
BRAZIL
BULGARIA
BURKINA FASO
CAMEROON
CANADA
CENTRAL AFRICAN
REPUBLIC
CHAD
CHILE
CHINA
COLOMBIA
COSTA RICA
CÔTE D’IVOIRE
CROATIA
CUBA
CYPRUS
CZECH REPUBLIC
DEMOCRATIC REPUBLIC
OF THE CONGO
DENMARK
DOMINICAN REPUBLIC
ECUADOR
EGYPT
EL SALVADOR
ERITREA
ESTONIA
ETHIOPIA
FINLAND
FRANCE
GABON
GEORGIA
GERMANY
GHANA
GREECE
GUATEMALA
HAITI
HOLY SEE
HONDURAS
HUNGARY
ICELAND
INDIA
INDONESIA
IRAN, ISLAMIC REPUBLIC OF
IRAQ
IRELAND
ISRAEL
ITALY
JAMAICA
JAPAN
JORDAN
KAZAKHSTAN
KENYA
KOREA, REPUBLIC OF
KUWAIT
KYRGYZSTAN
LATVIA
LEBANON
LIBERIA
LIBYAN ARAB JAMAHIRIYA
LIECHTENSTEIN
LITHUANIA
LUXEMBOURG
MADAGASCAR
MALAYSIA
MALI
MALTA
MARSHALL ISLANDS
MAURITANIA
MAURITIUS
MEXICO
MONACO
MONGOLIA
MOROCCO
MYANMAR
NAMIBIA
NETHERLANDS
NEW ZEALAND
NICARAGUA
NIGER
NIGERIA
NORWAY
PA KI STA N
PANAMA
PARAG UAY
PERU
PHILIPPINES
POLAND
PORTUGAL
QATAR
REPUBLIC OF MOLDOVA
ROMANIA
RUSSIAN FEDERATION
SAUDI ARABIA
SENEGAL
SERBIA AND MONTENEGRO
SEYCHELLES
SIERRA LEONE
SINGAPORE
SLOVAKIA
SLOVENIA
SOUTH AFRICA
SPAIN
SRI LANKA
SUDAN
SWEDEN
SWITZERLAND
SYRIAN ARAB REPUBLIC
TAJIKISTAN
THAILAND
THE FORMER YUGOSLAV
REPUBLIC OF MACEDONIA
TUNISIA
TURKEY
UGANDA
UKRAINE
UNITED ARAB EMIRATES
UNITED KINGDOM OF
GREAT BRITAIN AND
NORTHERN IRELAND
UNITED REPUBLIC
OF TANZANIA
UNITED STATES OF AMERICA
URUGUAY
UZBEKISTAN
VENEZUELA
VIETNAM
YEMEN
ZAMBIA
ZIMBABWE
NUCLEAR MEDICINE
RESOURCES MANUAL
INTERNATIONAL ATOMIC ENERGY AGENCY
VIENNA, 2006
IAEA Library Cataloguing in Publication Data
Nuclear medicine resources manual. — Vienna : International Atomic
Energy Agency, 2006.
p. ; 24 cm.
STI/PUB/1198
ISBN 92–0–107504–9
Includes bibliographical references.
1. Nuclear medicine physicians — Handbooks, manuals, etc.
2. Nuclear medicine — Equipment and supplies — Handbooks,
manuals, etc. 3. Nuclear medicine — Instruments — Handbooks,
manuals, etc. 4. Nuclear medicine — Safety measures — Handbooks,
manuals, etc. 5. Radiotherapy — Handbooks, manuals, etc.
I. International Atomic Energy Agency.
IAEAL 05–00421
COPYRIGHT NOTICE
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of the Universal Copyright Convention as adopted in 1952 (Berne) and as
revised in 1972 (Paris). The copyright has since been extended by the World
Intellectual Property Organization (Geneva) to include electronic and virtual
intellectual property. Permission to use whole or parts of texts contained in
IAEA publications in printed or electronic form must be obtained and is
usually subject to royalty agreements. Proposals for non-commercial
reproductions and translations are welcomed and will be considered on a
case by case basis. Enquiries should be addressed by email to the Publishing
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© IAEA, 2006
Printed by the IAEA in Austria
February 2006
STI/PUB/1198
FOREWORD
Over the past decade many IAEA programmes have significantly
enhanced the capabilities of numerous Member States in the field of nuclear
medicine. Functional imaging using nuclear medicine procedures has become
an indispensable tool for the diagnosis, treatment planning and management of
patients. However, due to the heterogeneous growth and development of
nuclear medicine in the IAEA’s Member States, the operating standards of
practice vary considerably from country to country and region to region. This
publication is the result of the work of over 30 international professionals who
have assisted the IAEA in the process of standardization and harmonization.
This manual sets out the prerequisites for the establishment of a nuclear
medicine service, including basic infrastructure, suitable premises, reliable
supply of electricity, maintenance of a steady temperature, dust exclusion for
gamma cameras and radiopharmacy dispensaries. It offers clear guidance on
human resources and training needs for medical doctors, technologists,
radiopharmaceutical scientists, physicists and specialist nurses in the practice of
nuclear medicine. The manual describes the requirements for safe preparation
and quality control of radiopharmaceuticals. In addition, it contains essential
requirements for maintenance of facilities and instruments, for radiation
hygiene and for optimization of nuclear medicine operational performance
with the use of working clinical protocols. The result is a comprehensive guide
at an international level that contains practical suggestions based on the
experience of professionals around the globe.
This publication will be of interest to nuclear medicine physicians,
radiologists, medical educationalists, diagnostic centre managers, medical
physicists, medical technologists, radiopharmacists, specialist nurses, clinical
scientists and those engaged in quality assurance and control systems in public
health in both developed and developing countries.
The IAEA is grateful to all those who have contributed to and reviewed
this manual.
The IAEA officers responsible for this publication were A.K. Padhy and
K.K. Solanki of the Division of Human Health.
EDITORIAL NOTE
Although great care has been taken to maintain the accuracy of information
contained in this publication, neither the IAEA nor its Member States assume any
responsibility for consequences which may arise from its use.
The use of particular designations of countries or territories does not imply any
judgement by the publisher, the IAEA, as to the legal status of such countries or territories,
of their authorities and institutions or of the delimitation of their boundaries.
The mention of names of specific companies or products (whether or not indicated
as registered) does not imply any intention to infringe proprietary rights, nor should it be
construed as an endorsement or recommendation on the part of the IAEA.
CONTENTS
CHAPTER 1. GENERAL INTRODUCTION. . . . . . . . . . . . . . . . . . . . . . 1
CHAPTER 2. HUMAN RESOURCE DEVELOPMENT . . . . . . . . . . . . 5
2.1. Training of medical doctors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
2.2. Training of nuclear medicine technologists. . . . . . . . . . . . . . . . . 37
2.3. Training in radiopharmacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
2.4. Training in medical physics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
2.5. Training in nuclear instrumentation. . . . . . . . . . . . . . . . . . . . . . . 49
2.6. Training in radiation safety and radiation protection . . . . . . . . 50
Bibliography to Section 2.6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.7. Training in molecular biology using radionuclide methods . . . 53
2.8. Training in radioimmunoassay . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
2.9. Training of nurses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
CHAPTER 3. ESTABLISHING NUCLEAR MEDICINE
SERVICES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.1. Introduction and categorization . . . . . . . . . . . . . . . . . . . . . . . . . . 67
3.2. In vivo diagnostic procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
3.3. In vitro and radioimmunoassay laboratories. . . . . . . . . . . . . . . . 76
3.4. Radiopharmacies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
3.5. Medical physics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
3.6. Positron emission tomography . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
3.7. Cyclotrons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
3.8. Establishment of a molecular biology laboratory. . . . . . . . . . . . 97
3.9. Radiation safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Bibliography to Chapter 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
CHAPTER 4. INSTRUMENTATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
4.2. Purchase of imaging equipment . . . . . . . . . . . . . . . . . . . . . . . . . . 108
4.3. Single photon imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
4.4. Dual photon imaging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
4.5. Other instrumentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
4.6. Computers and networking. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
4.7. Glossary of technical terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Bibliography to Chapter 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
CHAPTER 5. GUIDELINES FOR GENERAL IMAGING. . . . . . . . . . 167
5.1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
5.2. Nuclear cardiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.3. Central nervous system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201
5.4. Nephrology and urology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
5.5. Respiratory system. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 260
Bibliography to Section 5.5 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
5.6. Liver and gastrointestinal system . . . . . . . . . . . . . . . . . . . . . . . . . 267
5.7. Nuclear medicine imaging studies in endocrinology . . . . . . . . . 299
5.8. Musculoskeletal system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318
Bibliography to Section 5.8 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 335
5.9. Special procedures in oncology. . . . . . . . . . . . . . . . . . . . . . . . . . . 336
5.10. Haematology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 359
Bibliography to Section 5.10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 376
5.11. Inflammation and infection. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377
Bibliography to Section 5.11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
5.12. Radioimmunoassay protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
5.13. Molecular methods — Use of radionuclides in
molecular biology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 410
Bibliography to Section 5.13 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 430
CHAPTER 6. RADIONUCLIDE THERAPY. . . . . . . . . . . . . . . . . . . . . . 433
6.1. Setting up a unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 433
6.2. Radionuclide therapy — Safety principles . . . . . . . . . . . . . . . . . 435
Bibliography to Section 6.2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 448
6.3. Dosimetry and mathematical models in
radiopharmaceutical therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . 449
6.4. Radioiodine therapy for thyrotoxicosis . . . . . . . . . . . . . . . . . . . . 451
6.5. Iodine-131 therapy in thyroid cancer . . . . . . . . . . . . . . . . . . . . . . 455
6.6. Palliative treatment of metastatic bone pain. . . . . . . . . . . . . . . . 461
6.7. Iodine-131 meta iodobenzylguanidine therapy. . . . . . . . . . . . . . 464
Bibliography to Section 6.7 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 468
6.8. Phosphorus-32 therapy in polycythemia rubra vera. . . . . . . . . . 469
6.9. Radiosynovectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
Bibliography to Section 6.9 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 476
6.10. Iodine-131 Lipiodol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 477
Bibliography to Section 6.10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
6.11. Intracoronary radionuclide therapy using the
Re-188 DTPA balloon system . . . . . . . . . . . . . . . . . . . . . . . . . . . 487
6.12. Radiopeptide therapy for cancer . . . . . . . . . . . . . . . . . . . . . . . . . 491
Bibliography to Section 6.12 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
6.13. Radioimmunotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 494
CHAPTER 7. QUALITY ASSURANCE AND QUALITY CONTROL
PROTOCOLS FOR RADIOPHARMACEUTICALS . . 499
7.1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 499
7.2. Requirements for documentation. . . . . . . . . . . . . . . . . . . . . . . . . 499
7.3. Control of starting materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 500
7.4. Radionuclidic activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
7.5. Radionuclidic purity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501
7.6. Radiochemical purity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 502
7.7. Chemical purity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 503
7.8. Determination of particle size. . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
7.9. Particulate contamination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 504
7.10. Control of pH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
7.11. Sterility and apyrogenicity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 505
7.12. Ongoing evaluation of product performance . . . . . . . . . . . . . . . 506
7.13. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 507
Bibliography to Chapter 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 508
CHAPTER 8. RADIATION SAFETY PRACTICE IN NUCLEAR
MEDICINE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
8.1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
8.2. Local rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 509
8.3. Radiation safety aspects of radiopharmaceutical
preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
8.4. Safety precautions: Ward and other non-nuclear
medical staff . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
8.5. Disposal of radioactive waste . . . . . . . . . . . . . . . . . . . . . . . . . . . . 514
8.6. Administration of radionuclides to women of
child bearing age or pregnant patients. . . . . . . . . . . . . . . . . . . . . 515
8.7. Breast feeding patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 515
8.8. Typical radiation doses from diagnostic studies . . . . . . . . . . . . . 517
8.9. Monitoring. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 518
8.10. Radiation safety infrastructure . . . . . . . . . . . . . . . . . . . . . . . . . . . 520