RADIO 250 [5]: ICC in Radiology and Nuclear Medicine

Lec 1: Introduction to Radiology/ Radio Protection

Johanna Caal, MD

TOPIC OUTLINE
PART ONE: INTRO TO RADIO
I.

Background

II.

Imaging Modalities
B. Angiography
C. Ultrasound
D. CT-Scan
E. MRI
F. Nuclear Medicine

III, Radiotherapy

I. BACKGROUND
A. HISTORY

February 9, 2015

Contrast is easily appreciated

Always correlate findings with history and PE findings
IMAGE RECALL (2016)

A. X-Ray

1. 1895: Wilhemlm Konrad Roentgen Discovered

X-rays
The very first x-ray was a film of the hand of Roentgens
wife (with her ring on it)
Did more to change the face of medicine than any
other single item in history B.G. Brogdon (Forensic
Radiologist)
The discovery of X-rays was also named the top
achievement by a British museum
X-ray of Adolf Hitlers oral cavity showed dental caries;
this was a testament to how dental care was very poor
during those times

2. 1896: Marie Curie Discovered Radioactivity

She died of leukemia due to exposure to radioactive
materials
B. USES OF RADIOLOGY

May be used for diagnostic or therapeutic purposes

Table 1. Uses of Radiology
DIAGNOSTIC
THERAPEUTIC/INTERVENTIO
NAL
General
Angiography
radiographs
Ultrasound
Contrast procedures
CT scan / MRI
Guided aspiration
Nuclear medicine
Guided biopsy
(RAI, bone
scan)**
Radiation oncology
Note: **Nuclear Medicine is under the Department of
Medicine in PGH because of historical reasons.
Endocrinologists founded the field for purposes of radioablation in thyroid disease. However, by principle and
for purposes of certification, it is under radiology.
C. OBJECTIVES

Select most appropriate imaging modality for a given

clinical situation
Give a diagnosis for a given chest x-ray
Give differential diagnoses
Explain how x-ray, ultrasound, CT scan, MRI and
nuclear medicine scans are done
Know some basics about radiotherapy
I. IMAGING MODALITIES
A. XRAYS

1. Conventional Radiographs / X-Rays

Utilizes radiation
Black/White/Gray
o Black (radiolucent): air (lungs, sinuses, bowel)
o White (radio-opaque): fluids, solids

Ahmad & Lorvin

X-ray film looking like pneumonia. But radiologist will be able

to tell obstructive pneumonia from squamous cell lung
carcinoma; the carcinoma has 1) a central location, 2) lobar
distribution due to bronchiole obstruction 3) metastaticlooking nodules
X-ray film showing distended diaphragm due to air beneath
the diaphragm or pneumoperitoneum. We need to look at
patient history for this. If patient is post-surgery, air in the
abdomen is not necessarily abnormal; the air may resorb in 3
days. But if it was an OPD consult, something must have
ruptured and hence must need exploratory laparotomy.

2. Mammography
Screening tool for breast cancer
Difficult to interpret
NOT
the
gold
standard
for
breast
evaluation/screening
o Breast MRI (or PET) remains to be the best imaging
modality
o BUT this cannot be used for screening

Problem with cost and accessibility

RIGHT AGE TO GET FIRST MAMMOGRAM?
o OLD GUIDELINES:
Initial screening at 40 years old unless with family
history of breast cancer (lowering it to age 35)
Every other year after initial screening until age 50
Every year beyond 50 years old
o NEW GUIDELINES (December 2009 January
2010):
First screening at age 50, then every other year
until 75
Were developed for cost-efficiency purposes
Problems with new guidelines:

Some people still get breast cancer before 50.

Theres a big part of the population that gets
breast cancer in their 40s.

Some people can also get breast cancer after

75.
o Old guidelines are still being used in clinical practice
especially in the US because incidence is high
o Beware of risk factors: obesity, high estrogen
storage
o Consider the maternal family history of breast
cancer and ovarian cancer. Age on which to start
screening is based on RISK.
IMAGE RECALL
Mammogram showing fibrocystic changes. In males this is not
really a problem. However, in females it normally causes
some degree of pain before an episode of menses.
Mammogram showing an angry looking ductal breast
carcinoma. Note lots of calcifications and lines.

3. Contrast X-Rays
Utilizes
IV contrast: iodine or barium-based
(reconstituted powder, chalk-like)
Used especially for visualizing the GI system because
it will be excreted
Different kinds:
o Esophagogram
o IntravenousPyelogram
o Upper GI series

Distended bladder is
o Barium enema
normal. If post void,
abnormal.
o Distal colonogram
o Fistulogram
o Cholangiogram
o Hysterosalpingogram
o Sinugram
HYSTEROSALPINGOGRAM

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LEC 1: Intro to Radio + Radioprotection

First imaging modality used for infertility studies
to rule out organic causes
White triangle = uterine cavity
Normal hysterosalpingogram: there is spill of
contrast material in the peritoneum which
indicates patency of the Fallopian tubes
B. ANGIOGRAPHY

Used to visualize vasculature (contrast within

vascular structures)
Distally subtracted/reversed contrast is black
Gold standard for diagnosis of stroke
o BUT because it is time-consuming and stroke
is an emergency, CT scan is preferred
Very few doctors do interventional radiology
o Radiation exposure very high may lead to
cancer, dryness of skin andwrinkles
Femoral artery is usually used
o Easier to find and thread the needle
o Basic skill needed in performing this is ABG
Two types of contrast used:
o Ionic contrast more allergenic
o Non-ionic contrast hypoallergenic

The standard contrast in CT scans today

3-4 times more expensive than ionic

contrast
Two types of contrast used:
Standard angiography: vessels appear white
with structures in the background
Digitally subtracted angiography: all noncontrast images are removed; vessels appear
black
Gel-foam or alcohol embolization: for brain
aneurysms; therapeutic
Pig-tail catheter:
o In renal angiography; indicated for highvolume contrast procedures
o Most often used in kidney transplant surgery
(pre-operative assessment for donors)
o Uses large volume of contrast to see if the
uptake of both kidneys are the same

Radio 250

Innovations nowadays include 2D, 3D, 4D,

Doppler and color
o 4D: usually for fetus, c/o OB, the fourth
dimension is time so this is a video
General Features
High-frequency sound
o Frequency of sound above the range of
hearing (>20 Hz to 20 KHz)
o Medical ultrasound uses values within the
range of 1 to 20 MHz
No electromagnetic radiation: instead uses sound
waves
The probe comes in different shapes and sizes
since UTZ has different uses; not just for
studying the unborn child, but also for
abdomen, pelvis, thyroid, breast and testes
Can characterize lesions (solid, cystic, calcific)
May be used as guide for interventional
procedures (thoracocentesis, biopsy)
Real-time: both an advantage and disadvantage;
you cannot blame someone who did it before if
current findings are different
Operator-dependent
Can assess vasculature
o Turn ON the Doppler to differentiate areas of
turbulent flow for dilated vessels and ducts
Viewing UTZ results: look at the WHOLE
picture
and
analyze
the
surrounding
structures
Reading Ultrasound Findings
Fluid [or densely fluid]: hypoechoic (black)
Varying densities: hyperechoic; pus is GRAY
Gallbladder stones: hyperechoic with posterior
sonic shadowing (sound hits the stone and
echoes back thus no image is formed beyond
the stone)
IMAGE RECALL

UTZ of gallbladder showing stones. Gallstones must have sonic

shadowing to be identified as such.
UTZ of liver; take note of its characteristic structure. Hepatic
IMAGE RECALL
artery and common bile duct were shown. Turn ON the
Angiograms showing cerebral distribution of blood vessels in
Doppler to show flow and differentiate arterial from venous
vessels. Common bile duct has sluggish flow of fluid which
the early arterial and capillary phases. An outpouching can
cant be picked up by the Doppler.
be observed in the region of the parietal lobe; this is an
aneurysm.
UTZ of kidney, showing a dilated collecting system. This is not
Kidney angiogram used to assess which kidney is easier to
necessarily a problem since the patients are usually asked to
hold their voiding before the ultrasound is done. Post-void,
harvest. A pig-tail catheter can be seen. The right kidney has
this should normalize. Laterality of kidney? Distinguish by
only one artery connecting to the aorta, as opposed to the
looking at adjacent structure. In this case, liver is nearby so
one at the left which has 2-3 vessels connected to the aorta.
right kidney. USE THE ENTIRE IMAGE, not just the kidney.
Therefore, the left kidney is harder to extract because there
are more vessels that will need to be ligated.
C. ULTRASOUND

History
Began as SONAR used by the military
Medically became popular in the 1970s
Ahmad and Lorvin

Ultrasound in Pregnancy
Generally used to study the fetus
However, may not be entirely safe
o A British study found that children undergoing
several ultrasounds as fetuses ended up with
hearing problems

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LEC 1: Intro to Radio + Radioprotection

o
o
o

This is possible due to high frequency

affecting the formation of the inner ear
Study difficult to replicate
As a precaution, do not do too much
ultrasound during the first trimester (when
organogenesis is still in full swing) wait until
the second trimester
D. COMPUTED TOMOGRAPHY (CT) SCAN

360 X-rays in an arch

o A lot of X-rays: 360 circumferential x-rays
reorganized and interpreted by computer, thus
called glorified X-ray
o Thats 360 X-rays PER SLICE! So if 50 slices: 360 xrays TIMES 50
More radiation but perceives more information
o Make sure that the patient needs it. Ensure
judicious use!
o Get a CT scan if doing PE and UTZ will hurt the
patient and if you suspect an abdominal aortic
aneurysm (pulsatile abdomen)
Evolution: conventional spiral multi-slice
o The slice value is the number of cross-sections
the CT can produce in one second. PGH has 2-slice
while St. Lukes has 64-slice.

Radio 250

sticking out of the bone, need prosthesis adjustment. Patient

is obliquely positioned and cant lie straight.

Higher Resolution CT Scan Machines

CT angiography, CT venography, CT colonoscopy,
3D reconstruction
PET-CT scan
o Fusion with PET is the best kind out there
o PET shows function while CT shows
structure/anatomy
Reading CT Scan Findings
Black: air/fat (hypodense)
White: fluid/solid organs (hyperdense)

Uses of CT Scan

For further evaluation of an x-ray lesion

Used for screening for sinus disease (because

there is no way that you can see the sinus
from the outside) and certain lung diseases

Best for studying bones; also used for

aneurysms, brain masses and metastasis,
strokes, hemorrhages, staging of neoplasms,
aspiration of cysts, or biopsy of masses (CTguided biopsy)

Assessment of malignancy or metastasis (see

explanation in Image Recall section below)

E. MAGNETIC RESONANCE IMAGING (MRI)

DOES NOT involve radiation, BUT use of a strong

magnet causes molecular realignment
o Makes use of the realignment of the spin of
hydrogen nuclei under a strong magnetic
field and usesradiofrequency radiation to
generate an image of soft tissues, which
contain the most water (andhydrogen atoms)
Best for soft tissue visualization,especially spine,
brain and musculature
Bone detail is not great in MRI so for bone, CT
scan is still the preferred modality
Metastasis: still the most common brain tumor
IMAGE RECALL
Brain MRI showing septations, capsulations, and necrotic foci.
This is glioblastoma multiforme, the worst CNS tumor.
Very bad prognosis: without treatment, patient is dead within
6 months; with treatment, it becomes 9 months.
Brain MRI showing a pituitary tumor with intratumoral
bleeding, where the areas inside the tumor show a whiter
register.
Knee MRI showing an ACL tear, common in sports injuries.
Spinal cord MRI: you can see everything!
F. NUCLER MEDICINE

IMAGE RECALL

Use of radioactive isotopes to measure function

Abdominal CT image showing the transverse colon, spleen Not
clear pictures; HOWEVER these are
and liver.
physiologic images
Brain CT image showing multiple lesions. When presented
with such: metastasis vs. parasitic infection
o Metastases are usually accompanied by brain edema; the
process is faster, and edema is a quick reaction to a
sudden insult
o Parasitic infection DOES NOT result in edema because this
is a slow process and the brain is able to adapt
CT image of a laterally-placed well-defined encapsulated
cystic mass in the neck area. This is most likely benign, a
branchial cleft cyst. Remove entire capsule.
o Midline cysts on the neck = thyroglossalduct cyst

o Lateral cysts = branchial cleft cyst (congenital)

3D CT image showing a very large abdominal aortic
aneurysm, pan-renal in nature, already affecting the common
iliacs. What can you do? Nothing. There is no other vessel
that can serve to by-pass the aneurysm. Also, placing a stent
will not work; the mesh around it will just fold on itself so that
it fits on the stent, thus obstructing flow.
Bone window of CT to show prosthesis. Problem: portions are

Ahmad and Lorvin

Types of Scans Used in Nuclear Medicine

Bone scan
o Most commonly used
o Black portions represent highly metabolized
areas
o Picks up ANYTHING: it is very sensitive but not
specific.
o Specially used to find metastasis
Thyroid scan: functional scan (there should be
homogenous distribution)
PET scan
o Uses glucose which is absorbed by actively
metabolizing areas, thus not used for brain
because the brain is ALWAYS metabolizing

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LEC 1: Intro to Radio + Radioprotection

Used to monitor treatment, NOT before
diagnosing
o The only indication for using PET-CT Scan
before treatment is if you dont know what to
treat
o PET costs P80,000, PET-CT costs P120,000
that is why biopsy is cheaper
Myocardial scan
V/Q scan: gold standard for pulmonary
thromboembolism before, but now CT scan is
used
Thallium scan
Renal function scan (DMSA, DTPA)
Liver scan
o

Normal thyroid scan. Not really that clear in terms of

visualization. However, the concern here is that of iodine
uptake: it must be distributed homogenously.
Bone scan: look for hot areas (hypermetabolic areas such
as lumbar and cervical spine)
PET-CT. This is used to see the functioning mass relative to
where it is anatomically located. Do not do for an untreated
lesion. Get a CT, then biopsy, then treat. Use PET-CT to check
for any residual cancer cells.
III. RADIOTHERAPY

Used in radiation oncology

o External beam radiation therapy (EBRT):
conventional, 3D conformal, intensity-radiated
o Stereotactic radiosurgery
- source is
outside the body but its concentrated into
laser-like beams
o Brachytherapy - source is place inside the
body

usually done for cases of cervical, thyroid

and prostate cancers

3D conformal is better than brachytherapy

for nasopharyngeal CA
For treatment of malignancies and benign
conditions (warts, hypertrophic scars) but
usually the last resort
Uses high-energy gamma rays
EBRT or brachytherapy
o Cobalt

Uses gamma rays

Less protective because even if you turned

off the machine, the rod will still emit
radiation

Head has to be lined with 6-8 inch lead slab

as counter weight
o Linear accelerator

Uses electricity, so it is safer than cobalt

No need for counter weight

ONLY RADIOLOGIC EMERGENCIES (* - mentioned
SVC syndrome*
Brain herniation
Ahmad and Lorvin

Spinal cord compression*

Very bad (non-stoppable) vaginal and intranasal
bleeding*
PART TWO: RADIOPROTECTION
OUTLINE
included in the exam
I. General Information
II. Risks of Radiation Exposure
III.
Radiation Values
IV.
Radiation in Medicine
V. Final Words

*not

I. GENERAL INFORMATION
A. USES OF RADIATION

IMAGE RECALL

by Maam)

Radio 250

Table 1. Uses of Radiation

MILITARY /
Radiation as weapon (i.e. atomic
bomb)
PARAMILITA
Weapons of mass destruction (WMD)
RY USE

Dirty bombs (bombs with radioactive

material)
- environment becomes radioactive
- also affect the first responders
(doctors, police, politicians, etc.)
INDUSTRIAL Civil engineering (check integrity of
infrastructures)
USE
Sterilization (canned goods to prolong
shelf life: radiation slows down the
aging process of fruits)
MEDICAL
Diagnostic and therapeutic
USE
B. IS RADIATION SAFE

It can be safe
There is no such thing as safe dose of
radiation
There is no threshold dose wherein values
below which radiation is said to be safe
BUT it may be very beneficial to patients
C. RADIATION-CANCER LINK

Only proven cancers are:

o Melanoma (due to UV and
radiation)
o Thyroid cancer (gamma rays)
o Leukemia

not

ionizing

D. RADIATION POISONING

Radiation will affect actively dividing cells

Recall KGB member who defected to Great
Britain and became victim of polonium
poisoning in 2002
o Polonium in tea ended up in his GIT
Because Po is an -emitter (which are weaker
than -emitters that can easily pierce the body),
the radiation hit the wall of the esophagus,
bounces off the GI tract, and keep going until

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LEC 1: Intro to Radio + Radioprotection

radiation levels are so high that death becomes
inevitable
o Postmortem investigation: Caf was still
radioactive, as well as the bus/taxi/ambulance
that he rode
II. RISK OF RADIATION EXPOSURE
A. IS IT SAFE TO STAY IN THE DEPT OF RADIOLOGY?

YES, it is safe in the lecture room and the

reading room
BUT NOT inside the X-ray room, and NOT inside
the cobalt room
o You run the risk of being exposed to scatter
radiation so avoid lingering on these areas
B RADIOLOGIST MANTRA

TIME: the shorter the time of exposure, the

better
DISTANCE: the farther you are from the source,
the better
SHIELDING: basically to protect yourself from
scatter radiation
**The reason for the lack of signal in the Radio
department is that walls were created with certain
thickness to work as a shield from the radiation. The
doors are lead-lined to serve as protection from the
radiation as well.
C. WHAT HAPPENS WHEN HUMANS ARE EXPOSED TO
RADIATION?

Radiation Sickness
Nausea and vomiting: usually the first sign,
esp. with low doses
Weakness
Blood changes
o Immediate whole blood replacement must be
done (pancytopenia)
In PGH, whole blood is scarce because most
of the time, it is divided into different blood
products
o Problem: marrow may have died out, may
need bone marrow transplant
Hair loss: highly suggestive of radiation
sickness when all of the above mentioned
symptoms are also present; very close to death
at this point
Death: usually with very high dose
After symptoms occur, good supportive care is
necessary
Radiation Effects
Works best in actively-dividing cells
Gum hemorrhage, petechiae, alopecia, skin
blisters
D. WHAT HAPPENS WHEN FETUSES ARE EXPOSED TO
HIGH DOSES OF RADIATION?

Ahmad and Lorvin

Radio 250

Table 2. Consequences of High Dose

Radiation Exposure to Fetuses

PRE Low chances of congenital anomalies

IMPLANTATION
because the baby dies
STAGE
High doses are lethal to the blastomere
just before implantation
ORGANOGENE Higher frequency of congenital
SIS
anomalies
Most dangerous because a lot of
women dont know theyre pregnant
FETAL STAGE Fetuses can tolerate radiation, lesser
instances of lethality and congenital
anomalies reported
Anomalies may not be present during
birth but appear only after several
years (e.g. papillary thyroid cancer
(benign) after 20 years)
E. WHAT HAPPENS WHEN YOU ARE EXPOSED TO SMALL
AMOUNTS OF RADIATION?

Sleepiness: protective function of the body

Hunger: GI changes, mucosa sloughs off (also
explains nausea/vomiting)
Change in menstrual cycle: a little radiation
can stimulate the follicle to erupt and help
induce pregnancy
F. HOW MUCH RADIATION IS TOO MUCH

IAEA / NCRP Recommendation of

Allowable Radiation Exposure
Lay person: 5 mSv (milliSieverts) /yr
Occupational worker: annual average of 20 mSv
over 5 years, should not exceed 50 mSv
Patient: no limit set; weigh the risks vs.
benefits
III. RADIATION VALUES
A. NATURAL RADIATION

2.93 mSv/year average

External source like cosmic (0.26 mSv) and
gamma rays (0.28 msV)
o Space radiation
Ozone layer (but now it has holes)
o Deposits of radioactive matter
Eastern Europe, South America, North Korea
o Land
Soil has radiation but in minute amounts
Mountainous areas contain higher amounts
of naturally occurring radioactive materials
as compared to flatlands
Some land areas do contain naturally higher
radioactive materials, best to avoid these
areas
Internal source through ingestion (carbon and
potassium containing food) and inhalation

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LEC 1: Intro to Radio + Radioprotection

B MEDICAL RADIATION

C WILL I GET STERILE IF I HANG AROUND RADIO DEPT?

0.53 mSv/year average

It depends on how high a dose one was exposed

to but most likely no, but try to stay out of
cobalt room!

IV. RADIATION IN MEDICINE

We cannot control exposure to natural radiation

but we can control exposure to medical
radiation.
A. HOW MUCH RADIATION DO I GET?

1 chest X-ray
1 abdominal X-ray
1 pelvic X-ray
1 extremity X-ray
MEANING:
Permissible doses (lay
persons)
Natural radiation
Medical radiation

0.06
0.55
0.65
0.01

mSv
mSv
mSv
mSv

Lots of air
Lots of organs
Organs + bone
Small bone

Up to 5 mSv/yr
3 mSv/yr
No more than 2 mSv per
year

WHAT IS EQUIVALENT TO 2 mSv? (either of the

following):
33 chest X-rays (dont need much radiation
because a lot of air)
3 abdominal X-rays
3 pelvic X-rays
200 extremity X-rays (by virtue of smallness)

Ahmad and Lorvin

Radio 250

D. RADIOSENSITIVITY

MOST
Lens (can opacify
to form cataracts)

LESS
Spinal
cord

Ovaries

Solid
organs
Lymph
nodes

Testis (better
chance of not
getting sterile)*

LEAST
Skin (very
slowly
dividing)
Bones
muscles

*In females all eggs are present at birth, while males

undergo cycles.
V. FINAL WORDS

Always remember ALARA: As Low As

Reasonably Achievable
Radiology is always about PERSPECTIVE: What
you see is not always how it appear to be
Learn to see 2D things in a 3D construction in
your worlds
END OF TRANSCRIPTION

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