DNB Nuclear Medicine in India: Check out NBE released Curriculum

The National Board of Examinations (NBE) has released the Curriculum for DNB Nuclear Medicine. 

• Nuclear medicine is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease. In nuclear medicine procedures, radionuclides are combined with other elements to form chemical compounds, or else combined with existing pharmaceutical compounds, to form radiopharmaceuticals.

• These radiopharmaceuticals once administered to the patient, can localize to specific organs or cellular receptors. This property of radiopharmaceuticals allows nuclear medicine the ability to image the extent of a disease process in the body, based on cellular function and physiology, rather than relying on physical changes in the tissue anatomy.

• In some diseases, nuclear medicine studies can identify medical problems at an earlier stage than other diagnostic tests. Nuclear medicine, in a sense, is "radiology done inside out", or "endo-radiology", because it records radiation emitting from within the body rather than radiation that is generated by external sources like X-rays.

• Nuclear Medicine & Radiation Therapy is a medical specialty involving the application of radioactive substances in the diagnosis and treatment of disease.

• Nuclear medicine is the bridge between a particular clinical problem and a relevant test using radionuclides.

• It began as a minor technical tool used in a few branches of medicine, notably endocrinology and nephrology.

• However, throughout the world it has now become established as a clinical discipline in its own right, with specific training programs, special skills, and a particular approach to patient management.

• Although the practicing nuclear medicine physician must necessarily learn a great deal of basic science and technology, sound medical training and a clinical approach to the subject remains of fundamental importance.

• Nuclear medicine is the medical specialty that utilizes the nuclear properties of radioactive nuclides to make diagnostic evaluations of the anatomical and/or physiological conditions of the body and to provide therapy with unsealed radioactive sources.

I. OBJECTIVES OF THE PROGRAMME

1. PROGRAMME GOAL

Graduates from this training program will be equipped to function effectively within the current and emerging professional, medical, and societal contexts. It is expected that graduates of the program will have developed clinical skills and have acquired the theoretical knowledge for competent nuclear medicine practice. It is expected that a new nuclear medicine specialist will have:

• High-level skills in the technical processes and routine procedures undertaken in the specialty

• An approach to clinical judgment and to the practice of nuclear medicine that focuses on the clinical setting and the pathophysiological processes involved in each case

• The ability to apply a well-developed and appropriately structured knowledge base in internal and nuclear medicine and correlative imaging to the primary areas of professional practice of the specialty

• Research skills to support ongoing evidence-based practice in the specialty

• High-level communication skills, especially in the explanation and reporting of procedures and studies employed in the specialty. Graduates of the program will be able to employ these skills with referring doctors, other health professionals, and with patients and members of their families

• Well-developed educational skills to support a teaching role in areas related to the specialty, especially with medical students, junior staff, allied health professionals, and members of the public

• Quality assurance skills to enable the implementation and ongoing evaluation of nuclear medicine practice to a high technical and professional standard

• Organisational skills to support independent practice in nuclear medicine, as well as contributions to and leadership of hospital teams

• A high standard of ethical and professional behavior.

2. PROGRAMME OBJECTIVES

• After the Nuclear Medicine Advanced Training Program, trainees should be competent to provide, at the consultant level, unsupervised comprehensive medical care in nuclear medicine.

• Attaining competency in all aspects of this curriculum is expected to take two to three years of training. It is expected that all teaching, learning, and assessment associated with the Nuclear Medicine Curriculum will be undertaken within the context of the specialist's everyday clinical practice and will accommodate discipline-specific contexts and practices as required.

• As such it will need to be implemented within the reality of the current workplace and workforce issues and the need for health service provision.

II. TEACHING AND TRAINING ACTIVITIES

The fundamental components of the teaching program should include:

1. Case presentations & discussion- once a week

2. Seminar - Once a week

3. Journal club- Once a week

4. Grand round presentation (by rotation departments and subspecialties)- once a week

5. Faculty lecture teaching- once a month

6. Clinical Audit-Once a Month

7. A poster and one oral presentation at least once during their training period in a recognized conference.

The rounds should include bedside sessions, file rounds & documentation of case history and examination, progress notes, round discussions, investigations, and management plan) interesting and difficult case unit discussions.

The training program would focus on knowledge, skills, and attitudes (behavior), all essential components of education. It is divided into theoretical, clinical, and practical into all aspects of the delivery of rehabilitative care, including the methodology of research and teaching.

1. Theoretical: The theoretical knowledge would be imparted to the candidates through discussions, journal clubs, symposia, and seminars. The students are exposed to recent advances through discussions in journal clubs. These are considered necessary given inadequate exposure to the subject in the undergraduate curriculum.

2. Symposia: Trainees would be required to present a minimum of 20 topics based on the curriculum in three years to the combined class of teachers and students. A free discussion would be encouraged in these symposia. The topics of the symposia would be given to the trainees with the dates for presentation.

3. Clinical: The trainee would be attached to a faculty member to be able to pick up methods of history taking, examination, prescription writing,  and management in rehabilitation practice.

4. Bedside: The trainee would work up cases, and learn the management of cases by discussing them with the faculty of the department.

5. Journal Clubs: This would be a weekly academic exercise. A list of suggested Journals is given towards the end of this document. The candidate would summarize and discuss the scientific article critically. A faculty member will suggest the article and moderate the discussion, with participation from other faculty members and resident doctors. The contributions made by the article in furtherance of the scientific knowledge and limitations, if any, will be highlighted.

6. Research: The student would carry out the research project and write a thesis/ dissertation by NBE guidelines. He/ she would also be given exposure to partake in the research projects going on in the departments to learn their planning, methodology, and execution to learn various aspects of research.

III. SYLLABUS

1. SCIENTIFIC BASIS OF NUCLEAR MEDICINE

a. Radio Biology, Radiation safety Quality Assurance in Nuclear Medicine

i. Knowledge

• Outline the basic principles of radioactive decay, nuclear reactions, and production of radionuclides, detection, and measurement of ionizing radiation

• Discuss the effects of ionizing radiation on humans

• Describe the legislative control of radiation in India and the world

• Describe the principles and procedures of radiation protection as applied to nuclear medicine, including the as low as reasonably achievable (ALARA) principle

• Describe the principles of operation of SPECT, PET, CT, and hybrid SPECT/CT and PET/CT cameras, including:

• performance characteristics, and differences between cameras

• quality control

• equipment specification and selection

• computer acquisition

• image processing and display

ii. Skills

• Outline the basic principles of radioactive decay, nuclear reactions, and production of radionuclides, detection and measurement of ionizing radiation

• Discuss the effects of ionizing radiation on humans

• Describe the legislative control of radiation in India and the world

• Describe the principles and procedures of radiation protection as applied to nuclear medicine, including the as low as reasonably achievable (ALARA) principle

• Describe the principles of operation of SPECT, PET, CT, and hybrid SPECT/CT and PET/CT cameras, including:

• performance characteristics, and differences between cameras

• quality control

• equipment specification and selection

• computer acquisition

• image processing and display

• Explain and apply principles of radiation safety to:

• adult patients, including pregnant or breastfeeding patients

• pediatric patients

• practice staff

• Advise referring doctors, medical students, nuclear medicine technologists, and junior medical staff about the principles of:

• radiation safety, including legislative requirements

• operation of SPECT, PET, CT, and hybrid cameras

• principles of radiopharmaceutical chemistry

• recent developments and trends in nuclear medicine instrumentation and diagnostic and therapeutic radiopharmaceuticals.

b. Biostatistics

i. Knowledge

• The trainee shall have the basic skills to be able to understand the following parameters used in assessing the research and apply them critically to any relevant scientific paper:

• Ethical basis of research

• Prospective or retrospective

• Sample size

• Appropriate methodology

• How the data is assessed

• Appropriate use of statistics and their meaning

• The use of the terms phase 1, phase 2, and phase 3 trials

• Understanding the requirements and limitations of randomized controlled trials

• How results may affect practice or determine the need for further research

• The importance of looking at levels of evidence such as the Cochrane method

ii. Skills

• The trainee will be able to critically assess the research in the field of nuclear medicine and radiology

• Be able to understand both strengths and weaknesses of research

• Understand the particular limitations which occur in research in imaging

2. DIAGNOSTIC NUCLEAR MEDICINE

a. Cardiovascular Nuclear Medicine

i. Knowledge

• Basic Anatomy of the heart

• Understand the pathophysiology of coronary artery disease, exercise testing, heart failure

• Discuss the appropriateness of using various PET and SPECT techniques to determine myocardial perfusion and viability

ii. Skills

• Supervise and interpret resting and exercise ECGs

• Supervise and interpret stress testing using pharmacological agents

• Assess coronary artery disease using SPECT radiopharmaceuticals

• Assess ventricular function using radionuclide ventriculography

• Assess congenital heart disease using radiolabelled shunt studies

• Perform I-123 MIBG adrenergic cardiac imaging studies

• Discuss the role of complementary imaging techniques for cardiac disease

• Discuss the role of CTCA in the management of coronary artery disease

• Assess myocardial perfusion using SPECT and PET techniques

• Assess myocardial viability using SPECT and PET techniques

• Cardiac transplant evaluation

b. Endocrine Nuclear Medicine

i. Knowledge

• Identify anatomy and common variants of the thyroid and parathyroid glands and explain their anatomical relations in the neck

• Identify the surface anatomy of the thyroid and parathyroid glands

• Understand the pathophysiology of parathyroid disease and its clinical importance.

• Discuss the physiology of the thyroid gland concerning control by TRH/TSH and thyroid hormone synthesis and storage

• Describe thyroid function tests and the results in hyper- and hypothyroidism Describe iodine handling by the thyroid

• Pathophysiology of different causes of hyperthyroidism

• Different treatment options for patients with hyperthyroidism

• Appropriate selection of patients with hyperthyroidism for I-131

• Pathophysiology of thyroid cancer

• Understand both the dosimetric and empirical methods method used in treating hyperthyroidism and thyroid cancer with I-131

• Identify the anatomy of the adrenal glands

• Discuss hormone production and secretion by the adrenal glands

• Understand the pathophysiology of medullary and cortical adrenal tumors. Know the probability of bilateral disease or malignant spread

ii. Skills

• Perform and interpret radioisotope scans for the thyroid gland using both technetium and radioactive iodine

• Assess thyrotoxicosis and thyroid nodules

• Reading pre-therapy radioisotope studies to determine if treatment is appropriate with I-131

• Performing and interpreting parathyroid scintigraphy including both planar and SPECT imaging

• Interpret adrenal cortical imaging

• Perform and interpret I-131 MIBG imaging for detection and staging of pheochromocytomas

• Perform and interpret newer agents for the detection of Pheochromocytoma like FDG PET imaging, Somatostatin receptor PET among others

• Be able to assess and treat a patient with hyperthyroidism with radioactive iodine

• Discuss the appropriate assessment, risk stratification, and management of thyroid cancer

• Discuss the role of complementary imaging techniques for endocrine disease

c. Gastrointestinal Nuclear Medicine

i. Knowledge

• Describe the pathophysiology of GI motility disorders

• Describe the pathology of primary and secondary hepatic tumors

• Describe the pathophysiology of acute and chronic cholecystitis, biliary dyskinesia, sphincter of Oddi dysfunction, cystic duct syndrome, and post cholecystectomy syndrome

• Describe the pathology relating to GI hemorrhage

• Describe the pathology of IBD

• Describe the pathology of intra-abdominal sepsis

ii. Skills

• To assess the diseases of GI motility

• Assess gallbladder and biliary function using hepatobiliary scans

• Assess GI hemorrhage

• Assess inflammatory bowel disease (IBD) and intra-abdominal sepsis

• Assess abnormal splenic function using Tc-99m labeled tracers

• Assess hepatic artery catheters and peritoneal-venous shunts using Tc- 99m labeled tracers

• Describe the use of salivary and lacrimal gland imaging

• Assess GI disease using complementary GI imaging techniques

d. Genitourinary Nuclear Medicine

i. Knowledge

Describe the pathophysiology of:

• renovascular hypertension (RVH)

• types of urinary tract obstruction and the effects of diuretics on these mechanisms

• acute pyelonephritis and renal scarring

• transplant rejection

• vesicoureteric reflux

• renal failure

• acute tubular necrosis (ATN)

• acute epididymitis and testicular torsion

ii. Skill

• Perform and interpret a renal dynamic study with emphasis on obstruction, renovascular hypertension, and renal malformation

• Perform and interpret renal cortical imaging

• Perform and interpret DRCG scans for VUR

• Perform and interpret imaging for renal infection and inflammation

• Assess a renal transplant patient

• Assess renal failure

• Discuss the role of complementary imaging techniques for genitourinary disease

e. Infection and Inflammation Nuclear Medicine

i. Knowledge

• Describe the fundamentals of humoral inflammation and cellular inflammation

• Describe the general characteristics of neutrophils, lymphocytes, monocytes, and macrophages, and their role in the body's resistance to infection

• Skills

• Assess infection and inflammation using nuclear medicine techniques

• Recognise the emerging role of PET in the assessment of inflammation or infection

f. In Vitro Nuclear Medicine Techniques

• Assess patients using C-14 urea breath tests to evaluate Helicobacter pylori infection

• Assess patients using C-13/14 breath tests to evaluate intestinal absorption

• Assess patients using Cr-51 EDTA, Tc-99m DTPA to evaluate renal function

• Discuss the role and use of Cr-51 RBCs to evaluate GI bleeding

• Discuss radioiodine uptake or the assessment of thyroid function

• Perform and interpret GFR calculation using the Plasma Clearance method of Tc- 99mDTPA and Cr51 EDTA

g. Musculoskeletal Nuclear Medicine

i. Knowledge

• Describe the pathogenesis and pathological features of osteoporosis, Paget's disease, osteomalacia, hyperparathyroidism, and renal osteodystrophy

• Describe the clinicopathological features of regional migratory osteoporosis

• Describe the effects on bone metabolism of the various physical and pharmacological treatments that are employed in the treatment and prevention of osteoporosis.

• Describe the pathogenesis and pathological features of acute and chronic osteomyelitis (including vertebral osteomyelitis), septic arthritis, and discitis.

• Describe the natural history of periprosthetic bone changes in cemented and non-cemented prosthetic joint replacements Arthritis and Related Conditions:

• List the causes of inflammatory arthritis and describe the basic clinicopathological features of these conditions, including reference to the distribution of joint involvement

• Describe the basic clinicopathological features of osteoarthritis and degenerative disease of the spine

• Describe the etiology of osteonecrosis, including radiation osteonecrosis, and bone infarction

• Describe the clinicopathological features of complex regional pain syndrome/reflex sympathetic dystrophy (CRPS/RSD)

ii. Skills

• Describe techniques of bone scintigraphy and PET imaging

• Assess musculoskeletal trauma

• Assess metabolic bone disease

• Assess skeletal infection

• Assess prosthetic joint replacements

• Assess patients following spinal surgery

• Assess arthritis and related conditions

• Discuss the role of complementary musculoskeletal imaging modalities

h. Neurological Nuclear Medicine

i. Knowledge

• Discuss the anatomy of the brain and spinal cord with particular emphasis on cross-sectional anatomy

• Identify the surface markings of the cerebral lobes

• Identify the intracerebral structures of the brain in transverse, sagittal, and coronal planes

• Identify the cerebral arteries, the territories that they perfuse, and their relations to other cerebral structures

• Identify the cerebral veins and sinuses and their relations to other cerebral structures

• Identify the cerebral ventricles and their relations to other cerebral structures, including the spinal cord

• Discuss the physiology of the brain in normal and abnormal states, with particular attention to regional cerebral perfusion

• Explain the fundamentals of cerebral perfusion and autoregulation

• Describe the relationship between cerebral perfusion and cerebral metabolism in health and disease

• Explain the concepts of cerebral blood volume and luxury perfusion • explain the effect of seizures on cerebral blood flow

• Describe the pathophysiology of atherosclerosis, cerebral ischemia, cerebral infarction, cerebral atrophy, intracranial hemorrhage, intracranial aneurysms, intracranial vascular malformations, cerebral tumors, cerebral vasculitis, drug-induced cerebral injury, cerebral HIV/AIDS, and encephalitis

• Describe the pathophysiology and classification of seizures

• Describe the pathophysiology and classification of dementia

• Describe the physiology of CSF production and flow

• Describe the pathophysiology of normal pressure hydrocephalus, obstructed hydrocephalus, non-obstructed hydrocephalus, and CSF leaks

• Describe the pathophysiology of brain death

ii. Skills

• Perform and interpret cerebral perfusion studies using SPECT and PET

• Assess disorders of CSF flow and suspected CSF leaks using scintigraphic techniques

• Perform and interpret FDG PET /SPECT studies for the classification of Dementias

• Perform and interpret ictal and interictal studies for localizing the epileptogenic focus

• Identify emerging brain SPECT and PET techniques

• Assess impaired neurological function using a complementary imaging technique

i. Evaluation of Osteoporosis

• Describe techniques used to evaluate osteoporosis

• Assess quality assurance procedures in bone mineral density (BMD) estimation

• Interpret and report lumbar spine BMD scans

• interpret and report proximal femur BMD scans

• Assess BMD in the appendicular skeleton

• Assess total body bone mineral and body composition

• Outline absolute fracture risk

j. Oncological Nuclear Medicine

i. Knowledge

• Understand the pathophysiology of cancer

• Be able to take an appropriate history from the patient (or their parents) and examine the patient as required

• Understand how F-18 FDG may be used to diagnose lung cancer in a patient with a single pulmonary nodule or stage a patient which CT suggests is operable

• Understand the role of FDG imaging in a range of cancers

• Know the health economic arguments concerning the use of PET-CT in diagnosing and staging cancer

• Know the causes of a false negative or false positive result

• Be able to identify other unsuspected pathology on the PET or CT study

ii. Skills

• Be able to run a glucose clamp in a diabetic patient if required

• Be able to decide if a study is positive for cancer and also be able to determine if a patient with known cancer is operable

• Recognise issues related to the misregistration of fusion images and be able to determine how the effect of this may be reduced

• Be able to recognize the causes of false positive uptake of F-18 FDG

• and if possible how to differentiate this uptake from cancer

• Know when additional images/tests may be required

• Keep up to date with the latest research findings and recommendations on the use of F-18 FDG PET in cancer

• Be able to confidently present the results in an MDT

• Assess patients with lung cancer

• Assess patients with GI malignancies

• Assess patients with breast cancer

• Assess patients with head and neck malignancies

• Assess patients with melanoma

• Assess patients with neuroendocrine tumors

• Assess patients with lymphoma and other hematological malignancies

• Assess patients with gynecological malignancies

• Assess patients with sarcoma

• Assess primary bone tumors

• Assess skeletal metastatic disease

• Assess patients with brain malignancy

• Assess patients using lymphoscintigraphy

• Explain the use of radiological imaging to assist in the interpretation of oncological nuclear medicine studies

k. Newer Advances in PET

• Understand PET can be used in a variety of different diseases using a variety of PET pharmaceuticals to look at different types of diseases including:

• F-18 skeletal disease

• F-18 FLT cancer cell turnover

• F-18 choline Renal cell cancer/ Prostate cancer

• F-18 DOPA pancreatic neuroendocrine tumors

• Parkinson's syndrome

• F-18 FMISO Hypoxia

• C-11 or F-18 beta-amyloid for Alzheimer's disease

• C-11 /F18 agents for Brain primary tumors

• Ga-68/ Somatostatins Neuroendocrine tumors

• Understand the mechanism of uptake of each agent and what may lead to a false negative or false positive study

• Understand the imaging protocol for each agent and each indication

• Be aware of the legal framework in place when using novel tracers

l. Pulmonary Nuclear Medicine

i. Knowledge

• Identify the lobes and fissures of the lungs and their anatomical relations in the thorax

• Identify the bronchopulmonary segments of both lung and their projections in both two-dimensional and three-dimensional imaging

• Describe the physiologic features of ventilatory function, measurement of ventilatory function, and patterns of abnormal function

• Describe the physiologic features of pulmonary circulation, measurement of pulmonary circulation, and patterns of abnormal function

• Describe the physiologic features of gas exchange, measurement of gas exchange, and mechanisms of abnormal function • describe the relationship between pulmonary blood flow and pulmonary ventilation under normal conditions and in PE

• Describe the metabolic functions of the lung and its effects on lung physiology

ii. Skills

• Describe the assessment, management, and outcomes of pulmonary embolism (PE) and deep venous thrombosis (DVT)

• Assess PE using ventilation and perfusion imaging

• Discuss the role of ancillary tests and complementary imaging techniques for PE

• Assess patients by quantitation of lung ventilation and perfusion

• Assess inflammatory lung disease

m. Paediatric Nuclear Medicine Diagnostic

• Describe the basic principles of pediatric nuclear medicine

• Assess musculoskeletal disorders

• Assess genitourinary disorders

• Assess GI disorders

• Assess infection and inflammation

• Assess thyroid disease

• Assess pulmonary disease

• Assess malignancy

• Assess neurological disease

• Assess congenital cardiac disease

n. Sentinel Node imaging

i. Knowledge

• Understand the pathophysiology of malignant disease know how it spreads and in which cancers sentinel node localization is both possible and useful

• Identify and discuss the different techniques available for sentinel node localization

• Know when and if SPET/CT may be of use

• Understand how the images analyzed and are displayed for reading, including the use of a "shadow gram"

ii. Skills

• Inject radiotracers for sentinel node localization

• Use an intra-operative hand-held probe for sentinel lymph node localization

o. Radionuclide Therapy

Basic Knowledge

• Describe the mechanisms of radiation-induced cell damage

• Describe tissue characteristics that modify the response to radiation-induced injury

• Describe the general characteristics of the relationship between cell cycle and radiation-induced injury

• Describe the effects of toxic doses of radiation on normal organs

p. Treatment of Hyperthyroidism with I-131

i. Knowledge

• Pathophysiology of different causes of hyperthyroidism

• Different treatment options for patients with hyperthyroidism

• Appropriate selection of patients with hyperthyroidism for I-131

• Understand appropriate follow-up required for patients having been treated with I-131

• Reading pre-therapy radioisotope studies to determine if treatment is appropriate with I-131

• Understand both the dosimetric and empirical methods method used in treating hyperthyroidism with I-131

• Understand the legislation concerning the safe delivery of I-131 including radiation protection for self, other staff, and the patient's caregivers

ii. Skills

• Be able to take relevant history and perform relevant clinical examination within the thyroid clinic

• Recognise those complications that would be a contra-indication to treatment with I-131

• Be able to explain the treatment and obtain consent for treatment with special reference to female patient's concerns about fertility and contraception

• Be able to advise on the management of thyroid eye disease

• Advise on termination and re-commencement of anti-thyroid medication

• Arrange appropriate follow-up and further management of the patient

q. I -131 therapy for the treatment of patients with thyroid cancer

i. Knowledge

• Pathophysiology of thyroid cancer

• Different treatment options for patients with thyroid cancer

• Appropriate selection of patients with hyperthyroidism for I-131. Understand the need for ablation of thyroid remnant

• Understand the long-term prognosis of the disease in patients treated or not with I-131

• Understand appropriate follow-up required for patients having been treated with I-131 for thyroid cancer

• Reading pre-therapy radioisotope studies to determine if treatment is appropriate with I-131 including I-123 and F-18 FDG PET imaging

• Understand both the dosimetric and empirical methods method used in treating thyroid cancer with I-131

• Understand the advantages and disadvantages and methodology of use of withdrawal of thyroid hormone supplementation and/or TSH stimulation in preparation for therapy

• Understand the role of thyroglobulin in the long-term follow-up of patients with thyroid cancer

• Understand the legislation concerning the safe delivery of I-131 including radiation protection for self, other staff, and the patient's caregivers

• Understand special requirements for the treatment of patients under the age of 18

• Work with the thyroid cancer MDT to determine the best management of the patient

• Recognise those complications that would be a contra-indication to treatment with I-131

ii. Skills

• Be able to prepare the patient for therapy with I-131 including the use of low-iodine diets and side effects of thyroid hormone supplement withdrawal

• Be able to explain the treatment and obtain consent for treatment with special reference to female patient's concerns about fertility and contraception

• Advise on termination and re-commencement of thyroxine replacement therapy

• Arrange appropriate follow-up and further management of the patient

• Be responsive to the concerns of the patient and their carers concerning the treatment in particular reference to concerns the patient may have about cancer

• Communicate essential information in an appropriate and timely way

• Be aware of issues concerning fertility and contraception in different ethnic cultures and how that impacts patient carer. Radionuclide Synovectomy

i. Knowledge

• Pathophysiology of different causes of inflammatory joint disease Different treatment options with inflammatory joint disease Appropriate selection of patients for treatment with radionuclides

• Understand appropriate follow-up required for patients having been treated with radiation synovectomy including awareness of complications including infection and radionecrosis

• Know the European Association of Nuclear Medicine guidelines on appropriate radio-isotope and activity to be given depending on joint and the number of joints that can be treated at any given time

• Understand the need for immobilization of the joint for 24 hours after treatment

• Understand the legislation concerning the safe delivery of Y-90, Re- 186 and Eu-169 including radiation protection for self, other staff, and the patient's caregiver

ii. Skill

• Be able to take relevant history and perform a relevant clinical examination of patients with joint disease

• Be able to explain the procedure to the patient and obtain consent

• Be able to ensure the correct activity of radiopharmaceutical has been drawn up

• Be able to have skills to inject joints using a sterile technique or use other clinicians such as radiologists and rheumatologists to obtain access to the joint

• Be able to withdraw an appropriate amount of fluid from the joint and

• give corticosteroids if indicated

• Able to give radioisotopes without contamination of patient, self, or colleagues

• Give advice on post-therapy complications and suggest appropriate actions

• Ensure the patient's joint is appropriately immobilized for at least 24 hours Arrange appropriate follow-up and further management of the patient

s. Radiolabelled antibodies in hematological malignancy

i. Knowledge

• Pathophysiology of lymphoma, leukemia, and myeloma and when to use radiolabelled antibodies in the treatment of these diseases

• Be aware of the probable success of treatment compared to alternative therapies. In addition, possible side effects compared to alternative treatments and long-term prognosis including the risk of myelofibrosis and acute leukemia

• Appropriate selection of patients for patients with hyperthyroidism with these agents

• Be aware of the use of immunohistochemistry in identifying patients appropriate for treatment

• Know in which clinical situations pre-scanning with a tracer dose is needed for dosimetric assessment or to determine suitability for treatment

• Be aware of the indications for use of Y-90 tiuxetan ibritumomab and other available agents

• Be aware of the dosing regimes for use of Y-90 tiuxetan ibritumomab (or other agents)

• Be aware of the need for conditioning with un-radiolabelled antibodies such as Rituximab and the required timings for these treatments

• Be aware if the treatment will be performed in isolation or combination with other anti-cancer drugs or bone marrow transplant

• Understand the legislation concerning the safe delivery of Y-90 and I- 131 products including radiation protection for self, other staff, and the patient's careers

• Be able to discuss the appropriate use of Y-90 tiuxetan ibritumomab or alternate agents with hematological colleagues including within an MDT

• Recognise those complications that would be a contra-indication to treatment with these agents

ii. Skills

• Be happy to administer these drugs via a central line catheter using an aseptic technique

• Be able to explain the treatment and obtain consent for treatment with special reference to female patient's concerns about fertility and contraception

• Communicate to the patient a realistic view of the outcomes of these treatments

• Understand the experimental nature of some of these treatments

• Be prepared to treat acute anaphylaxis or other less acute immune reactions

• Arrange appropriate follow-up and further management of the patient

t. Radionuclide treatment for bone metastases

i. Knowledge

• Pathophysiology of bone metastases and the methods used to treat bone pain

• Understand the relevance and use of diagnostic imaging with Tc- 99m MDP/HDP in selecting patients for therapy

• Be aware of the probable success of treatment compared to alternative therapies. In addition, possible side effects compared to alternate treatments and long-term prognosis including the risk of bone marrow suppression

• Appropriate selection of patients for treatment via site-specific MDT

• Understand the appropriate preparation of the patient for the treatment of painful bone metastases including whether or not it will be given in combination with chemotherapy drugs and/or bisphosphonates

• Be aware of recommendations for activities to be given for both the beta emitters Sr-89, Sm-153 EDTMP, Re-186/Re-188 HEDP, and the alpha emitter Ra-233

• Understand the appropriate dosing regimes including standard dose and weight-related dosing including minimum time intervals for repeat treatments

• Understand the legislation concerning the safe delivery of these products and the different requirements for radiation protection for self, other staff, and the patient's carers with each agent

ii. Skills

• Be able to discuss the appropriate use of agents used to treat painful bone metastases with colleagues including within an MDT

• Recognise those complications that would be a contra-indication to treatment with each agent with particular reference to possible hematological toxicity

• Understand that some contra-indications such as the risk of long bone and vertebral fracture may be treated and then the patient presented for therapy

• Be able to explain the treatment and obtain consent for treatment with special reference to female patient's concerns about fertility and contraception (where relevant)

• Communicate to the patient a realist view of outcomes in this palliative treatment

• Be able to explain the possibility of a flare reaction, the best methods to treat and the expected duration

• Explain how success in treatment is determined including the use of pain diaries the expected duration of treatment and the time when a repeat treatment may be given

• Arrange appropriate follow-up and further management of the patient

u. I -131 mg therapy

i. Knowledge

• Pathophysiology of those tumors including neuroblastoma, phaeochromocytoma, paraganglioma, and neuroendocrine tumors in which I-131 mIBG may be useful

• Understand the relevance and useful of diagnostic imaging with I- 123/I-131 mIBG in selecting patients for therapy

• Be aware of probable success of treatment compared to alternative therapies. In addition, possible side effects compared to alternative treatments and long-term prognosis include risk of bone marrow suppression and effects on the thyroid

• Appropriate selection of patients for treatment with I-131 mIBG

• Understand appropriate follow-up required for patients having been treated with I-131 mIBG with appropriate referring clinician

• In particular, be aware of the dosimetric and empirical approaches to treatment

• Understand the legislation concerning the safe delivery of I-131 mIBG including radiation protection for self, other staff, and the patient's carers

ii. Skills

• Be able to discuss the appropriate use of I-131 mIBG with oncological colleagues including within an MDT

• Know how patients should be prepared for therapy for example the stopping or reduction of drugs that interfere with uptake and the need to give appropriate cover with potassium iodide

• Recognise those complications that would be a contra-indication to treatment with I-131 mIBG for example when and where cardiovascular monitoring is required

• Be able to deal with any resultant cardiovascular side effect

• Be able to explain the treatment and obtain consent for treatment with special reference to female patient's concerns about fertility and contraception

• Communicate to the patient a realist view of outcomes in this palliative treatment

• Arrange appropriate follow-up and further management of the patient

• Be able to deal with the special concerns in treating children including the fears and hopes of the patient's family/guardians

• Be responsive to the concerns of the patient (and parent/guardian) and their carers concerning the treatment and an understanding of expectations and long-term effects of treatment

• When treating children be able to communicate in a manner appropriate for the child's age and development

v. Radiolabelled Peptide/Radioligand therapy

• Pathophysiology of those tumors including phaeochromocytoma, paraganglioma, prostate cancer, and neuroendocrine tumours among others in which radiolabeled peptides/ligands may be useful

• Understand the relevance and useful of diagnostic imaging with In-

• 111 pentapeptide/Ga-68 DOTATATE/NOC/TOC/PSMA and another agent PET in selecting patients for therapy and how this helps the patient selection

• Understand the relationship between the diagnostic and therapeutic peptides used

• Be aware of the legislation required to perform radiolabelled somatostatin therapy

• Be aware of the different peptides available and the characteristics of Y-90 and Lu-177 and how selections are made on the combination used for therapy

• Be aware of probable success of treatment compared to alternative therapies. In addition, possible side effects compared to alternative treatments and long-term prognosis include risk of bone marrow suppression and renal failure and the need for co-administration of anionic amino acids

• Understand appropriate follow-up required for patients having been treated with radiolabelled somatostatins with the appropriate referring clinician

• In particular be aware of published dosing regimes

• Understand the legislation concerning the safe delivery of both Y-90 and Lu-177 labeled agents including radiation protection for self, other staff, and the patient's carers

• Be aware of newer advances in radiopeptide therapy including the use of alpha emitters

• Skills

• Be able to discuss the appropriate use of radiolabelled somatostatins with oncological colleagues including within an MDT

• Know how patients should be prepared for therapy for example the stopping or reduction of short-acting or long-acting somatostatins and starting amino acid infusions at least 1 hour prior to therapy and providing anti-emetics

• Be able to explain the treatment and obtain consent for treatment with special reference to female patients' concerns about fertility and contraception. Also, explain the dosing regime (normally 3-4 cycles every 6-12 weeks)

• Communicate to the patient a realist view of outcomes in this palliative treatment

• Arrange appropriate follow-up and further management of the patient

• Be able to deal with the special concerns in treating children including the fears and hopes of the patient's family/guardians

w. Intra-arterial therapy of liver primary cancer/metastatic disease

i. Knowledge

• Pathophysiology of primary and secondary cancers within the liver

• Understand the relevance and use of diagnostic imaging with CT/MRI and PET in selecting patients for therapy

• Be aware of probable success of treatment compared to alternative therapies. In addition, possible side effects compared to alternate treatments and long-term prognosis including risk of bone marrow suppression and effects on the thyroid

• Appropriate selection of patients for treatment including size and site of the tumor(s) and the presence or absence of portal vein thrombosis

• Understand appropriate follow-up required for patients having been treated with these agents with appropriate referring clinician

• Be aware of guidelines for treatment with Y-90 particulates

• In particular, be aware of the dosimetric and empirical approaches to treatment

• Understand that TARE with Y-90 labeled or other agents particulates a pre-dosing intra- arterial Tc-99m MAA scan should be performed to determine both the possibility of shunting to the lungs (must be less than 20%) and the effect on the administered activity

• Understand the legislation concerning the safe delivery of Y-90 labeled products including radiation protection for self, other staff and the patient's caregivers

ii. Skills

• Be able to discuss the appropriate use of Y-90 particulates and other agents with colleagues including within an MDT

• Know how patients should be prepared for therapy for example the

• requirements for intra-arterial cannulation including clotting screen and platelet count

• Be able to give product safely within the sterile facilities of the X-ray special suite

• Be able to explain the treatment and obtain consent for treatment with special reference to female patient's concerns about fertility and contraception

• Communicate to the patient a realistic view of outcomes in this palliative treatment

• Be able to deal with the special concerns in treating children including the fears and hopes of the patient's family/guardians Topics to be included in all subjects:

• Biostatistics, Research Methodology and Clinical Epidemiology

• Ethics

• Medico-legal aspects relevant to the discipline

• Health Policy issues as may be applicable to the discipline

V. LOG BOOK

A candidate shall maintain a log book of operations (assisted/performed) during the training period, certified by the concerned postgraduate teacher / Head of the department / senior consultant.

This log book shall be made available to the board of examiners for their perusal at the time of the final examination.

The logbook should show evidence that the before-mentioned subjects were covered (with dates and the name of the teacher(s) The candidate will maintain a record of all academic activities undertaken by him/her in the logbook.

1. Personal profile of the candidate

2. Educational qualification/Professional data

3. Record of case histories

4. Procedures learned

5. Record of case Demonstration/Presentations

6. Every candidate, at the time of the practical examination, will be required to produce a performance record (log book) containing details of the work done by him/her during the entire period of training as per the requirements of the log book. It should be duly certified by the supervisor as work done by the candidate and countersigned by the administrative Head of the Institution.

7. In the absence of the production of a log book, the result will not be declared.

VI. RECOMMENDED TEXT BOOKS AND JOURNALS

1. Text books

• Conventional Nuclear medicine in Pediatrics (A Clinical based atlas) by Garganese, Maria Carmen, D'Errico, Giovanni Francesco Livio (Eds.)

• Principles and Practice of Nuclear Medicine by Paul J.Early

• Essentials of Nuclear Medicine Imaging by Fred A.Mettler

• Reconstruction Tomography in Diagnostic Radiology and nuclear medicine by Michel M.Ter-Pogossian.

• Internal Radiation Dosimentry:1994 Health physics summer school by Otto G.Raabe

• Mird Primer for Absorbed Dose Calculations by Robert Loevinger

• Mird: Radionuclide Data and Decay schemes by Keith F. Eckerman

• Mird Cellular S.Values: self-absorbed dose per unit cumulated activity for selected radionuclides and monoenergetic electron and alpha particle emitters incorporated into different cell compartments by S.Murty Goddu

• PET: Molecular Imaging and its biological applications by Michael E.Phelps

• Positron Emission Tomography: Basic Sciences by Dale L.Bailey

• Single-Photon Emission Computed Tomography by Barbara Y.Croft

• Monte Carlo Calculations in Nuclear Medicine: Applications in Diagnostic Imaging by Ljungberg Ljungberg

• Therapeutic Applications of Monte Carlo Calculations in Nuclear Medicine by Habib Zaidi

• Dictionary and Handbook of Nuclear Medicine and Clinical Imaging by Mario P. Iturralde

• Handbook of Nuclear medicine by Mark T.Madsen

• Nuclear Medicine Board Review: Questions and answers for self-assessment by Richard Goldfarb

• Practical Nuclear Medicine by Edwin L.Palmer

• Handbook of Nuclear Medicine: handbooks in radiology series by Frederick L.Datz

• Nuclear Medicine: Case Review series by Harvey A.Ziessman

• Nuclear Medicine: The Requisites by Harvey A.Ziessman

• Nuclear medicine Imaging: A Teaching File by M.Reza Habibian

• Nuclear Radiology (Fifth series) test and syllabus by Barry A.Siegel

• Clinical Atlas of Pet: With Imaging Correlation by Michael S.Kipper

• Atlas of Clinical Nuclear medicine by Ignac Fogelman

• Nuclear Medicine: A Teaching File by Frederick L.Datz

• Radiopharmaceuticals for Therapy 2016 by FF.Knapp, Ashutosh Dash

• Nuclear Medicine in Clinical Diagnosis and Treatment by Peter Josef ELL, Sam Gambhir

• PET Imaging of Thoracic Disease, an issue of PET Clinics by Drew A.Torigian, Abass Alavi

• Radiation Safety in Nuclear Medicine by Max H.Lombardi

• Diagnostic Nuclear Medicine: A Physics Perspective by Dr.David Hamilton

• Frontiers in Nuclear Medicine (Nuclear Medicine in Clinical Oncology

• Current status and future aspects by Cuno Winkler, Contributions by J.Adelstein

• Clinical Nuclear Medicine: Edited by Hans-Jurgen Biersack, Leonard M.Freeman

• Essentials of Nuclear Medicine by M.V Merrick

• Basic sciences of Nuclear Medicine by Magdy M.Khalil

• Radiation physics for nuclear medicine by Marie Claire Cantone, Christroph Hoeschen

• Progress in Radiopharmacy by P.H.Cox, edited by Steven J.Mather,

• C.B Sampson, C.R Lazarus

• Nuclear Medicine in Tropical and Infectious Diseases by Francisco Jose H.N Braga

• Radioguided Surgery edited by Giuliano Mariani, Armando

E.Giuliano, H.William Strauss.

• Exercises in Clinical Nuclear medicine by Gary Cook, Jane Dutton

• Herbal Radiomodulators: Applications in medicine, Homeland defense and space edited by R.Arora

• Radiotherapy and Brachytherapy by Yves Lemoigne, Alessandra Caner

• Safety and Efficacy of Radiopharmaceuticals edited by Knud Kristensen, Elisabeth Norbygaard

• Radioprotectors: Chemical, Biological, and clinical Perspective by Edward A.Bump, Kamal Malaker

• Diagnostic Nuclear Medicine: A Physics Perspective by David I.Hamilton, P.J Riley

2. List of Major Journals on Nuclear Medicine

• Radiotherapy and Oncology.

• Medical Physics ('The International Journal of Medical Physics)

• Physics in medicine and biology.

• Medical Dosimetry.

• Radiation Oncology.

• The British Journal of Radiology.

• Medical & Biological Engineering & Computing.

• Biological Engineering, IFMBE.

• Applied Radiation and Isotopes

• Nuclear Instruments and Methods in Physics Research

• The Journal of Applied Clinical Medical Physics

• Physica Medica

• Australian Physics & Engineering Science in Medicine

• Acta Oncologica

• International Journal of Radiation Research (IJRR)

• Journal of Medical Physics

• Technology in Cancer Research and Treatment

• Reports of Practical Oncology and Radiotherapy

• BMC Medical Physics

• Journal of Medical Imaging and Radiation Oncology

• Journal of Medical Imaging and Radiation Sciences

• Medical Image Analysis

• Radiological Physics and Technology

• Radiation Physics and Chemistry

• The Journal for Radiation Physics, Radiation Chemistry , and Radiation Processing

• Polish Journal of Medical Physics and Engineering

• Practical Radiation Oncology

• Journal of Radiation Research

• Japanese Journal of Radiology

• Clinical Oncology

• Radiation Research

• Nuclear Instruments and Methods in Physics Research

• Radiation Measurements

• The Journal of Radiotherapy in Practice

• Journal of Cancer

• European Journal of Cancer

• South Asian Journal of Cancer

• Blood Cancer Journal

• Journal of Radiology & Radiation Therapy

• International Journal of Radiation Oncology

• ASRT Journals and Magazines

• Radiation Oncology and Cancer

• Journal of Medical Radiation Sciences

• Frontiers in Oncology

• American Society for Radiation Oncology (ASTRO)

• Frontiers of Radiation Therapy and Oncology

• Journal of Cancer Research and Therapeutics

• Global Journal of Advanced Radiation Research

• International Journal of Cancer Therapy and Oncology