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Curriculum standards

Knowledge guides

LG16: Oncological nuclear medicine

Key presentations and conditions

Trainees will have a comprehensive depth of knowledge of these presentations and conditions.

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Less common or more complex presentations and conditions

Trainees will understand these presentations and conditions.

Trainees will understand the resources that should be used to help manage patients with these presentations and conditions.

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Epidemiology, pathophysiology, and clinical sciences

Trainees will have a comprehensive depth of knowledge of the principles of the foundational sciences.

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Investigations, procedures, and clinical assessment tools

Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.

Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.

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Important specific issues

Trainees will identify important specialty-specific issues and the impact of these on diagnosis and management and integrate these into care.

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Presentations
  • Evaluate response to oncological treatment
  • Known cancer diagnosis for staging
  • Preoperative sentinel node mapping
  • Suspected recurrence of malignancy for restaging
Conditions
  • Breast cancer
  • Cancer of unknown primary
  • Gynaecologic oncology
  • Haematologic malignancies
  • Head and neck cancer
  • Lung cancer
  • Melanoma and non-melanoma skin cancers
  • Neuro-oncology
  • Neuroendocrine tumours
  • Primary and secondary osseous disease
  • Prostate cancer
  • Sarcoma
  • Thyroid cancer
  • Upper and lower gastrointestinal (GI) cancer
  • Urological and testicular malignancies

PCH

  • Central nervous system (CNS) malignancies
  • Lymphoma
  • Neuroblastoma
  • Sarcoma – bone and soft tissue
  • Thyroid cance

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Presentations
  • Known rare or uncommon cancer diagnosis for initial staging Conditions
Conditions
  • Other rare and uncommon cancers, including but not limited to:
    • gallbladder and extrahepatic bile ducts
    • GI stromal tumours (GIST)
    • Kaposi sarcoma
    • Merkel cell cancer
    • mesothelioma
    • multiple myeloma
    • pancreatic cancer
    • penile cancer
    • peritoneal cancer
    • primary liver cancer

PCH

  • Role of nuclear medicine, including PET, in the assessment of less common paediatric malignancies

For each presentation and condition, Advanced Trainees will know how to:

Synthesise
  • recognise the clinical presentation
  • identify relevant epidemiology, prevalence, pathophysiology, and clinical science
  • take a comprehensive clinical history
  • conduct an appropriate examination
  • establish a differential diagnosis
  • plan and arrange appropriate investigations
  • consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
  • provide evidence-based management
  • prescribe therapies tailored to patients’ needs and conditions
  • recognise potential complications of disease and its management, and initiate preventative strategies
  • involve multidisciplinary teams
Consider other factors
  • identify individual and social factors and the impact of these on diagnosis and management
Fundamentals of cancer biology relevant to nuclear medicine
  • Cancer genetics (e.g. hereditary cancer syndromes, relevant cancer gene mutations)
  • Tumorigenesis (e.g. clonal differentiation)
Basic principles of chemotherapy, targeted therapy and immunotherapy
Fundamentals of radiobiology, radiotherapy and radionuclide therapy
The clinical science, epidemiology, pathophysiology, and staging of key and less common cancer types
Assessment of oncological disorders with PET
  • Mechanism and kinetics of PET isotope uptake for common radiopharmaceuticals, including but not limited to F-18 FDG, Ga-68-DOTA-Octreotate and F-18 and/or Ga-68 PSMA:
    • difference in radioisotope uptake between normal and malignant cells
    • malignancies are suited for various PET radiopharmaceuticals
    • optimal timing of image acquisition for different PET radiotracers following injection, including dual time point imaging (where applicable)
    • patterns of normal physiologic tracer distribution for the different PET radiopharmaceuticals
  • Methods of quantitation, such as standardised uptake values, including SUVmax, SUVmean, and SUVpeak, metabolic tumour volume (MTV), and total glycolytic volume (TGV), and their use and limitations
  • Partial volume effect and its influence of quantitative parameters
Assessment of oncological disorders with SPECT
  • Cell biology of bone tracer uptake in skeletal metastasis
  • Flare response in skeletal scintigraphy – timing and management strategies
Treatment of oncological disorders with radionuclide therapies or Theranostics
  • Suitable conditions for radionuclide therapies (Theranostics), such as hepatic and osseous metastases, neuroendocrine tumours, prostate cancer, and thyroid cancer

PCH

  • Understanding of common genetic associations with childhood cancers
Investigations
  • Liver and lung SPECT / CT for SIRT dosimetry work-up
  • Lymphoscintigraphy for sentinel node mapping
  • PET / CT staging of tumours using appropriate cancer staging guidelines
  • Single photon studies for assessment of bone metastatic disease
  • Single photon studies for assessment of eligibility for and effects of cancer treatment (e.g. cardiac and renal studies)
  • The role of diagnostic CT, MRI and ultrasound in cancer diagnoses and management
Procedures
  • Injection techniques for sentinel node mapping, including pain minimisation strategies

PCH

  • I-123 MIBG for neuroblastoma (including thyroid blockade) and role of other PET agents
  • PET / CT staging of tumours using appropriate cancer staging guidelines
  • Diagnostic study reporting:
    • correlating various imaging modalities for correct interpretation of nuclear medicine investigations
    • good working knowledge of diagnostic CT and cross-sectional anatomy (minimum standard)
    • interpretation of images to distinguish non-malignant findings, such as:
      • benign mimics, such as Warthin tumour
      • infection / inflammation
      • normal physiologic uptake
      • reactive findings
      • treatment-related adverse effects
    • knowledge of appropriate use of PET scoring systems, such as Deauville 5-point scale and modified Krenning score
    • local software for reporting and providing clear and accurate reports for investigations
    • provide timely, clear, and accurate reports which address the clinical question
Assessment of oncological disorders with PET
  • Acquisition protocols for PET and CT components, including use of contrast CT
  • Methods of response assessment for clinical trials, such as the Deauville score in lymphoma, PET response evaluation criteria in solid tumours (PERCIST), and response criteria in solid tumours (RECIST), and the limitations of these criteria
  • Optimum time for scanning in relation to chemotherapy, immunotherapy, radiotherapy, and surgery
  • PET protocols for management of abnormal blood glucose levels in patients undergoing FDG PET / CT studies
  • PET protocols for optimising tumour visualisation, such as brown fat suppression and sedation (where appropriate)
Assessment of oncological disorders with SPECT
  • Application of lymphoscintigraphy for staging in breast carcinoma, genitourinary cancers (penile, vulval), and melanoma:
    • common lymphatic drainage patterns
    • influence of intra-tumoral, peri-tumoral, and peri-areolar injection in breast cancer
  • Knowledge of guidelines and recommendations for tumour absorbed dose, normal liver dose, and lung dose during SIRT for various liver cancers
  • Knowledge of the principles of palliative care
  • Management of physical interventions, such as hydration of patients undergoing bone scans
  • Performance of bone scintigraphy for staging and response assessment in different cancer types
  • Quantification of tumour:
    • background ratio in liver MAA SPECT / CT scans performed for SIRT work-up
    • calculation of tumour absorbed radiation dose
    • predicted dose to normal liver and lung
  • The role and limitations of bone scintigraphy in assessing skeletal metastatic disease
  • The role of CT in assessing response in skeletal metastases
  • The role of pre- and post-therapy cardiac and kidney surveillance with serial gated blood pool studies and nuclear GFR studies in patients receiving potentially toxic treatments, such as anti-HER2 therapies in breast cancer (heart) and carboplatin chemotherapy for ovarian cancer (kidneys)