Download MBBS Radiodiagnosis and Radiationtherapy Mnemonic Short Book

I.
IMAGING TECHNIQUES

X- RAYS
? Are electromagnetic radiation

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? Have penetrating power less than gamma rays but more than alpha and beta rays
? Can pass through human body, Cannot be absorbed completely
? Produced by Coolidge tube when fast moving stream of electrons produced by a cathode(Tungsten
filament) strikes the anode(tungsten/ molybdenum containing copper plate)
? X-rays are most scattered by H+ ions.

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? Causes ionization in 3 ways: Photoelectric effect, Compton effect & Pair production
? Contrast can be increased by increasing the current (mA)
? Penetration can be increased by increasing the voltage (mV)
? Machine is kept at 6 feet distance form photographic plate to prevent magnification.
? Optimum distance of target film: 90-100cm

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? Best chest X ray is done at: 120-150 kilovolt peak.
? Gunson method: X- ray of soft tissues of neck
? Cyclotron produces Gamma rays
ULTRASOUND (USG)
? Based on piezoelectric effect of crystals made up of lead zirconate titanate.

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? Ian Donald - father of obstetric ultrasound. Also invented the B-mode scanner.
? Dr. John Wild and John Reid: invented an A-mode scanner for the detection of ovarian cancer.
? John Wild ("father of medical ultrasound") first used ultrasound to assess the thickness of bowel tissue.
? Contains waves with frequencies>20,000 Hz.
? In medical USG frequencies commonly used are 2-10 MHz

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? Frequencies used:
? Trans abdominal ultrasound: 3-5 MHz,
o
Trans-vaginal: 5-7.5MHz,
o

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Breast: 15 MHz,
o
Gut wall: 7.5-20 MHz
o
Vessels: 20 MHz

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? Types of image display
o
A ?Mode
one dimensional picture, used only in eye scan
o

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B- Mode-
two dimensional picture, commonly used
o
Real time scan
gives moving picture

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o
M-Mode
motion display (e.g. in ECHO)
? USG causes delirious effect on small micro-organisms by acoustic cavitation.
? Investigation of choice for obstetric conditions

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DOPPLER
? Based on Doppler Effect (change in the perceived frequency of sound emitted by a moving source measures
blood flow). It provides both audio and video signals.
? Types: Continuous waves & Pulsed waves
? In Doppler imaging colour displays direction of blood flow. It is

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Red --- when direction of flow is towards the transducer.
Blue --- if flow is away from transducer.
CT- scan or CAT scan
? Invented by God Frey Hounsfield in 1963, awarded Nobel Prize.
? Basic principle of CT is linear attenuation of x-rays.

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? Incident x-rays are linearly attenuated by their interaction with orbital electrons of tissues.
? Measurement of attenuation of emerging / detected beam gives density of intervening tissues and this
density forms basis of signal intensity variation obtained in x-ray tomograms.
? Electron density of tissues in numbered as Hounsfield number (H.N.) or Hounsfield units.
o

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Air have a value of -1000 HU
o
Fat of -120 to -200 HU
o
Water ? 0 HU

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o
Soft tissue of 20-60 HU
o
Blood of 50-60 HU
o

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Bone of +1000 HU
? Two type of contrast agents are used
o
Ionic ? water soluble iodide dyes (e.g. Na- diatrizoate, megliumine, conray, urograffin, angiografin) ?
may cause anaphylaxis

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o
Non ionic- Safer but expensive e.g. iohexol (Omnipaque), lopamiro
? Uses of various contrast agents:
Contrast
Procedure

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Contrast
Procedure
Dionosil (Tantalum)
Bronchography
Hypaque, sodium

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IVP
diatrizoate
Myodil
DSA, Myelography
Methylene blue

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Lymphangiography
lopanoic acid
Oral
Conray 280
Aortography, cerebral

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(Telepaque)
cholecystography
angiography
(OCG)
Biligrafin

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IV cholecystography
Conray 280/420
HSG
Metrizamide, lohexol
Ventriculography

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Conray 420
CT scan, coronary
(Omnipaque)
angiography
Gastrografin (Dionosil)

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Oesophagoscopy
Gadolinium
MRI
? Spiral CT, also known as helical or volumetric-acquisition CT: Technique by which the volume area is
scanned as the patient continuously travels through the scan field, while data is acquired along the spiral

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path.
? Advantages:
o
Spiral CT will produce a clearer, more defined image and provides better details.
o

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Spiral CT is 8 to 10 times faster than a traditional CT scanner. This saves time and reduces radiation
exposure by eliminating the need for multiple scans.
o
Spiral CT can digitally reconstruct more than one image from a single slice and allows for multiplaner
reformatting (overlapping structure).

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o
Spiral CT has the ability to scan an entire region in a single breath hold, averaging about 30 seconds or
less. Shorter scan time allows coordination of peak contrast enhancement, which results in clearer
images and about 1/3 less dye load.
MRI

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? Based on gyromagnetic property of protons (or hydrogen nucleus, H+)
? Described first by Bloch & Purchell, applied as human tool by Damadian & Lauterbeur (1972)
? It can be plain MRI or contrast MRI.
? Most common contrast agent used is i.v. Gadolinium.
? Proton density and relaxation time are assessed by radiofrequency pulse and the computer generates a gray

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scale image from this data.
? Magnetic field used in the range of 0.15-3 tesla
? MRI spectroscopy provides in vivo characterization of chemical composition and metabolic activity of brain.

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? Relaxation time:
o

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T1time taken to return to original axis (T1 images are used to find out normal anatomical details)lt has
got high soft tissue discrimination (CSF looks black)
o
T2: Time taken by proton to displace. Used to assess pathological processes (fluid looks white).
The induction (transmitter/receiver coil) used in MRI are Maxwell coils.

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? Water (CSF) looks white (hyperintense) on T2.
? CSF looks hyperintense on T2 weighted image and hypointense on T1 weighed image.
MRI EVALUATION OF HEMORRHAGES

Biochemical form

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Stage of
Time
T1
T2
haemorrhage

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Oxyhemoglobin in
Hyperacute
Immediate to
Isointense
Hyperintense

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RBCs
first few hours
Deoxyhemoglobin in
Acute
Hours to days

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Isointense to
Hypointense
RBCs
hypointense
Methoxyhemoglobin

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Early subacute
First several
hyperintense
Hypointense
in RBCs

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days
Extracellular metHb
Late subacute
Days to
Hyperintense

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Hypointense
months
Ferritin and
Chronic
Days to infinite

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!so to
Hypointense
hemosedrin
time
hypointense

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Substance
T1 weighted
T2 weighted
Water/vitreous/CSF
Black

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Light grey or white
Fat
White
Light grey
Muscle

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Grey
Grey
Air
Black
Black

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Fatty bone marrow
White
Light grey
Brain: white matter
Light grey

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Grey
Brain: grey matter
Grey
Very light grey
Common Contraindications to MR Imaging

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? Cardiac pacemaker or permanent pacemaker leads, Internal defibrillatory device
? Cochlear prostheses, Bone growth stimulators, Spinal cord stimulators
? Electronic infusion devices
? Intracranial aneurysm clips (some but not all)
? Ocular implants (some) or ocular metallic foreign body

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? McGee stapedectomy piston prosthesis
? Duraphase penile implant
? Swan-Ganz catheter
? Magnetic stoma plugs, Magnetic dental implants
? Magnetic sphincters

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? Ferromagnetic IVC filters, coils, stents--safe 6 weeks after implantation
? Tattooed eyeliner (contains ferromagnetic material and may irritate eyes)
PET

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? PET produces tomographic images.
? A cyclotron is required to generate positron-emitting isotopes that can be made from compounds, such as F,

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C, N and O.
? Radiopharmaceuticals for PET imaging: FDG, C methionine and [18] F-methyl tyrosine.
? Disadvantages of PET: limited availability and high cost due to the necessity of a cyclotron
? Positron emitting radio nuclides are used:- O2- informs 02 uptake, CO2 - informs blood flow, 18 FDG --
informs glucose utilization and is most frequently used moiety,

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? Indications:
o
To distinguish radiation necrosis from recurrent glioblastoma
o
To evaluate transformation of brain tumor from low grade to high grade

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o
To evaluate the potential for recurrence of meningioma
o
To assess tumor viability and monitor treatment response
o

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For diagnosing occult metastasis & recurrent cancers
o
To differentiate benign from malignant pulmonary nodules
o
To evaluate staging, restaging, and response to therapy; local and distant metastasis; and response to

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treatment in patients with breast cancer
o
For the diagnosis, staging, and restaging of colorectal, esophageal, head and neck, breast and lung
cancers and lymphoma and melanoma.
o

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For restaging of recurrent or residual thyroid cancers, of follicular cell origin,
o
In stroke PET is useful to differentiate viable from non -- viable tissue
SINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY
? Detection of emitted gamma rays by a gamma camera.

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? Requires radiopharmaceuticals that cross the blood?brain barrier.
? Radiopharmaceuticals used are133Xe, 123I isopropyl iodoamphetamine (IMP), 99mTc ethyl cysteinate dimer
(ECD) or 99mTc hexamethylpropylene amine oxide (HMPAO).
? Clinical applications include dementia, cerebrovascular disease, epilepsy, encephalitis, head injury, and other
less common disorders that result in abnormal cerebral perfusion.

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? SPECT can also be used to image uptake at neurotransmitter receptors using various radiopharmaceuticals
usually labeled with 123I.
? Many different SPECT radiopharmaceuticals are taken up into intracranial tumours, including 201TI chloride,
99mTc MIBI, 123I-methyl tyrosine and 111 In octreotide.
? Because of the requirement for lead collimation, SPECT has inherently poorer resolution than PET and

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absolute quantitation is not possible.
? SPECT is relatively inexpensive and has good patient acceptability.
CT and MRI Imaging Characteristics of Various Tissues:
Tissue
CT Gray Scale

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MRI T1 Signal
MRI T2 Signal
Brain
Gray
Gray

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Gray
Air
Black
Black
Black

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CSF
Black
Black
White
Fat

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Black
White
Black
Calcium
White

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Black
Black
Bone
Very white
Black

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Black
Extravasated blood
White
White
Black

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Inflammation
Contrast enhancing
Gray, gadolinium enhancing
White
Edema

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Dark gray
Gray
White
Tumor
Gray or white and contrast

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Gray or white and gadolinium
White
enhancing
enhancing

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? FLAIR (fluid-attenuated inversion recovery) imaging is a technique that gives a high signal for parenchymal

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lesions and a low signal for CSF.
? It is sensitive to calcium and iron within brain tissue, shows early stages of infarction, and accentuates
inflammatory demyelinating lesions.
EFFECTS OF RADIATION
? Maximal permissible radiation dose: The dose of radiation which if received each year for a 50 yrs working

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life time would not be expected to produce any harmful effect.
? The LD50/30 (i.e., a dose that causes a 50% mortality rate at 30 days) is approximately 4 Gy[1 Gy=100 rad]
for whole-body exposure without medical support.
? For most of the conditions, a min. dose of about 1000 cGy is required for whole body irradiation.
? Whole- body exposure to doses >9-10 Gy is almost always fatal.

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? In addition to the GI syndrome associated with very large exposures, patients may develop a neurovascular
syndrome; the latter dominates with whole- body doses >20 Gy.
? With medical support, the LO50/30 ranges between 8 and 10 Gy.
? The recommended occupational limit of maternal exposure to radiation from all sources is 500 mill Rads
for entire 40 weeks of gestation

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? 10 days rule advices that any x ray examination involving the abdomen of a women of child bearing age
should be carried out within 10 days of menstruation.
? Deterministic effects: develop due to cell killing by high dose radiation.
? Stochastic effects: develop due to mutation effect of low dose radiation.
? Fetus is most sensitive to the effects of radiation during 8 ? 15 weeks of gestation.

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? Amount of radiation received from out space = 0.1 rad/year. Additional permissible dose = < 5 rads/ year.
? Radiation exposure: CT scan> Bone scan> X ray
? No radiation hazard: MRI & USG.

Latest ICRP recommendations for maximum permissible dose for various groups are:

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? Occupational exposure(radiation workers)
50 mSv/year
? Public (in general)
20 mSv/year
? Pregnancy

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40.5 mSv for declared term

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II.
NORMAL FEATURES

View (Chest- X-ray)

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Structure seen
RAO (Right Anterior Oblique)
Rt lung, Lt. atrium, Gall bladder ,Mitral valve
Left Anterior Oblique
Tracheal bifurcation

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Right Posterior Oblique
Right retro cardiac space
Right decubitus view
Right middle lobe of the lung
Lardotic view

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Apex, Lingual lobe
Reverse lardotic view
Interlobar effusions

View

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Structure seen
Cald well (Occipito-Frontal)
? Superior orbital fissure ,foramen rotundum & superior margin of
view
? orbit

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? Lamina papyracea, Maxillary sinus, ethmoid sinus, frontal sinus
Water (O-M: Occipito mental)
? Maxillary sinus, sphenoid sinus,-frontal sinus
view
? Intra Temporal fossa, zygoma & zygomatic arch

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Basal submentovertical view
? Sphenoid, posterior ethmoid , maxillary sinus, Zygoma & zygomatic
arch
? Mandible along with coronoid & condyloid process

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Holman Miller sign (Antral sign): anterior bowing of the posterior wall of the maxillary antrum seen on lateral skull
films.

SPECIFIC VIEWS IN RADIOLOGY:
Features

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View
Features
View
Supraorbital fissure
Cald well view

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Patella
Skyline view
Recurrent shoulder
Strikers view
Minimal pleural effusion

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Lateral Decubitus
dislocation
Sella turcica
Lateral skull view Pneumothorax
PA view in full

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expiration
Scaphoid
Oblique view
Internal auditory meatus
Periorbital view

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CARDIAC BORDERS
THE BASE OF HEART: forms the posterior surface. It is formed mainly by the left atrium and by small part of right
atrium.
MEDIASTINAL/ HEART BORDER ON X-RAY:

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Right Border: Formed by superior vena cava, Rt atrium, Inferior vena cava
Left Border: Formed by Aortic arch, Left ventricle, Main pulmonary artery, Left atrial appendages.
? The left heart is formed by the main pulmonary artery and heart (left atrial appendage and left ventricle)
? The knob-like shadow of the aortic arch in superior mediastinum is formed by the posterior part of arch,
which is absent or deformed in coarctation of aorta.

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? A small "nipple" may occasionally be seen projecting laterally from aortic knuckle or knob due to the
presence of left superior intercostal vein and this normal nipple should not be misinterpreted as adenopathy
(aortopulmonary window). Below the aortic knuckle or knob is a concavity, the pulmonary bay, the floor of
which is formed by the main pulmonary artery beyond the pulmonary valve.
? The pulmonary bay may be filled in by PDA.

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? Below the pulmonary bay, the left ventricle forms the left heart border.

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? Just below pulmonary bay is the left bronchus, below which is the left atrial appendage, not forming a
discrete shadow unless enlarged, and below that is the level of right ventricular infundibulum, azygous vein
lesion on right side and does not contribute to left heart border.
? However, a coronary artery aneurysm can cause abnormal bulging of left heart border.

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RADIOLOGICAL FEATURES OF INTESTINE
Useful differentiating features B/W SI & LI includes Size & distribution of loops
? Dilated small bowel loops are numerous & arranged centrally in the abdomen
? Loops show small radius of curvature & the presence of solid feces is the only reliable sign that the loop is

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large bowel.
? The other signs can be misleading.

Features
Small bowel

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Large bowel
Haustra
Absent
Present
Valvulae conniventes

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Present in jejunum
Absent
Number of loops
Many
Few

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Distribution of loops
Central
Peripheral
Diameter of loops
Small

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Large
Radius of curvature of loop
30-50mm
50mm
Solid feces (only reliable sign)

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Absent
May be +

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III.
SIGNS IN RADIOLOGY

RADIOLOGICAL SIGNS OF THORAX
SIGN/ SPECIFIC FEATURE

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SEEN IN
Meniscus/moon/air crescent/double arch
Hydatid cyst of lung
sign/combo sign/water lilly/camalotte
sign/serpent sign/ rising sun sign/ empty cyst

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sign
Popcorn calcification
Hamartoma, Mediastinal nodes of histoplasmosis
Westermark sign, Hapton's hump, Palla sing
Pulmonary thrombo-embolism

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Fleishner lines, Felson's sign
Sail sign, Mulvay wave sign, Notch sign
Thymic enlargement
Comet tail sign
Rounded atelectasis

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Golden S sign
Right Upper Lobe collapse secondary to a central
Luftsichel sign, Broncholobar sign
m
L a

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efs
t s
Upper Lobe collapse
Ring around artery sign
Pneumo-mediastinum

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Continuous diaphragm sign
Tubular artery sign, Double bronchial wall
sign
V sign of Naclerio, Spinnaker sail sign
Deep sulcus sign, Visceral pleural line

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Pneumothorax
Thumb sign
Epiglottitis
Steeple sign
Croup

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Air crescent sign, Monod sign
Aspergilloma
Bulging fissure sign
Klebsiella pneumonia
Batwing sign

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Pulmonary edema on CXR
Collar sign, Dependant viscera sign
Diaphragmatic rupture
Feeding vessel sign
Pulmonary septic emboli

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Finger in glove sign
ABPA
Halo sing
Aspergillosis
Head cheese sign

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Subacute hypersensitivity pneumonitis
Juxtaphrenic peak sign
Right Upper Lobe atelectasis
Reversed halo sign
Cryptogenic organized pneumonia

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Saber sheath sign
COPD
Sandstorm lungs
Alveolar microlithiasis
Signet ring sign

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Bronchiectasis
Superior triangle sign
Right Lower Lobe atelectasis
Split pleura sign
Empyema

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Tree in bud sign on HRCT
Endo bronchial spread in TB
CHEST X-RAY OF ECHINOCOCCUS
? Oval mass
? Meniscus/ moon/ crescent / double arch sign

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? Rising sun sign/empty cyst sign
? Water Lilly / camalotte sign
? Serpent sign/ Cumbo sign

Superior rib notching

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Inferior rib notching

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? Poliomyelitis, Osteogenesis imperfect
? Coarctation of Aorta [M/C cause]
? Restrictive lung disease
? Pulmonary- oligemia/ A-V malformation

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? Neurofibromatosis, Marfan's syndrome
? Aortic thrombosis
? Connective tissue disease- RA, SLE,
? Subclavian obstruction
Scleroderma

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? Tausig Blalock operation
? Sjogren's syndrome, Hyper parathyroidism
RADIOLOGICAL SIGNS OF CARDIOVASCULAR SYSTEM

Radiological feature

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Disorder
Four bump heart
MS/ MR due to left atrial appendage
enlargement
Glassy heart on ECHO

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Amyloidosis
Double cardiac shadow, Double density sign, Bedford
Left atrial enlargement
sign
Dock's sign, E-sign , figure of 3 sign, reversed E sign,

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Coarctation of aorta
inverted 3 sign
Double aortic knuckle
Aortic dissection
Jug handle appearance

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Primary pulmonary hypertension
Maladie de roger effect
Small VSD
Hilar dance (pulmonary plethora)
ASD

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Box shaped heart
Tricuspid Atresia
Water bottle/ flask shaped heart/ leather bottle/pear
Pericardial effusion
shaped/money bag heart/ purse like heart/ Epicardial

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fat pad sign
Coeur en sabot i.e. boot shaped heart
Tetralogy of Fallot
Spade like deformity on ECHO
Atypical HOCM

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Egg in cup appearance, square root sign
Constrictive pericarditis
Inverted moustache sign
Mitral stenosis
Egg on side appearance ,Egg shaped heart, Egg in string

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D- Transposition of great arteries (D- TGA)
Convex left heart border
L-TGA
Ground glass ventricular septum
Hypertrophic Obstructive Cardiomyopathy

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(HOCM)
Straight left upper cardiac border
Ebstein's Anomaly
Concave main pulmonary segment & right aortic arch
Persistent Truncus arteriosus

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Snowman sign, Figure of 8 sign, Cottage loaf sign
Total Anomalous Pulmonary Venous
Connection (TAPVC) -- supra cardiac variety
Goose neck sign
Atrioventricular septal defect

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Tubular heart
Emphysema
Stag antler / hands up sign
CCF
Schimitar sign / Turkish sword appearance

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Congenital venolobar syndrome
Sitting duck heart
Persistent truncus arteriosus
Yin yang sign
Pseudo aneurysms

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Small heart sign
Tension pneumopericardium
High attenuating crescent sign
Impending rupture of abdominal aortic
aneurysm

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Draped aorta sign
Contained rupture of abdominal aortic
aneurysm

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RADIOLOGICAL SIGNS OF ALIMENTARY TRACT

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Sign
Disease
Single Air Bubble sign
Pyloric stenosis/ obstruction
Double bubble sign

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Ladd band / Malrotation, Annular
pancreas
Duodenal atresia/ stenosis/ web/
duplication cyst
Multiple air fluid level

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Ileal obstruction
Triple bubble sign
Jejunal obstruction
String of beads sign, Stepladder appearance, Concertina effect,
Small bowel obstruction

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Candy-cone appearance, Snake head appearance on barium study
Gas under diaphragm, Liver edge sign, Falciform ligament sign, Gall
Pneumoperitoneum
bladder sign, Diaphragmatic muscle slip sign/ leaping dolphin sign,
Luscent liver sign, Anterosuperior bubble sign

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Doge's cap sign, Riglers double wall sign, American footballs sign,
Cupola's sign, Triangle sign, Visible transverse mesocolon sign,
Visible small bowel mesentery sign, Pneumo-omentum/ pneumo-
mesocolon, Urachus sign, Medial/ lateral umbilical fold sign,
Inverted V sign, pneumoscrotum

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Birds beak appearance (barium meal), hurst phenomenon
Oesophageal Achalasia
Cork screw appearance (barium meal)
Diffuse oesophageal spasm
Beak sign, Double track or Tram track sign, Shoulder sign, string

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Hypertrophic pyloric stenosis
sign, diamond sign, Twinning recess, pyloric test, test sign,
mushroom sign, caterpillar sign
Seagull / Mercedes Benz/ Crow feet sign
Radiolucent gall stone with gas

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Multiple gas fluid level (step ladder pattern)
Intestinal obstruction
Cigar bundle appearance on X- ray, Winding highway railway tract
Round worm
on USG & Medusa Head colonies on CT scan

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Whirlpool sign in USG, corkscrew sign
Midgut volvulus
Coffee Bean sign, Bent tyre tube sign, Liver overlap sign, Pelvis
Sigmoid volvulus
overlap sign, Left flank overlap sign

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Shark mouth appearance
Ileocecal valve
Lead pipe appearance/ Stippled appearance/ Pipe stem appearance Ulcerative colitis
String of Kantor, Bull's eye or Target lesion
Crohn's disease (regional Ileitis)

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Thumb printing sign
Ischemic colitis (Also in amoebic &
ulcerative colitis)
Saw tooth appearance (on barium enema)/ Champagne glass sign,
Diverticulitis of colon

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Bowlers hat sign
Apple core lesion & Napkins sign (on barium enema)
Ca-colon
Pincer sign, Claw sign, Coiled spring appearance, target sign,
Intussusception

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Meniscus sign, crescent in Doughnut Sign, Pseudokidney sign,
Sandwich sign, Hay fork sign
Hamburger sign, Signa de dance, Dance sign
Bubbly / frothy/ soap bubble/apple sauce appearance
Meconium ileus

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Pulled up caecum/ obtuse ileo caecal angle/ filling defect/
Ileocaecal TB
incompetent ileocaecal valve Fleishner sign, Inverted umbrella
defect, Steirlin sign, Amputed cecum, Goose neck deformity

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Hamptons line

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Benign gastic ulcer
Carmens meniscus sign;Kirkland complex
Malignant gastric ulcer
Apple peal appearance
Ileal atresia

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Moulage sign
Coeliac sprue
Arrowhead sign, Rovsings sign
Acute appendicitis
Straight line sign

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HCC
Comet-tail sign on USG
Adenomyomatosis of gall bladder
Central dot sign
Caroli's disease

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Triangular cord sign
Biliary Atresia
Shaggy esophagus
Esophageal candidiasis
Accordion sign

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Pseudomembranous colitis
Champagne sign
Emphysematous cholecystitis
Cluster of grapes sign
Pneumatoses cystoides coli

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Corkscrew sign
Midgut volvulus
Dependant viscera sign
Diaphragmatic rupture
Fat ring sign

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Mesenteric panniculitis
Molar tooth sign
Extraperitoneal bladder rupture
Ribbon bowel appearance on barium
Graft versus host disease

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Spokewheel sign
Small bowel volvulus
Straight line sign on PET
Peritoneal carcinomatosis
RADIOLOGICAL SIGNS IN PANCREATIC DISORDERS

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? In chronic pancreatitis, cholangio pancreatography (ERCP) is the most sensitive imaging modality.
? The positive findings are: Chain of lakes appearance, String of pearls appearance, Beading appearance.
? On x-ray numerous irregular calcification are pathognomic of chronic pancreatitis.
? String of beads sign -small bowel obstruction.
? Double bubble sign - in annular pancreas.

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Disease
Pathognomic sign
Chronic pancreatitis
Beaded appearance, Sting of pearls appearance, Rat tail stricture of CBD,
(On ERCP)

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Chain of lakes appearance
Acute Pancreatitis
Renal Halo sign, Gasless abdomen, Colon cut off ,Sentinel loop
(Abdominal X-Ray)
Carcinoma pancreas

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Double contour of medial border of duodenal C loop, Double duct
sign(ERCP) dilated/ widened Duodenal-C loop, mucosal irregularity,
Rose
thorning of medial wall of 2nd part of duodenum, Scramble Egg
appearance, Inverted/ Reverse-3 sign of frost berg

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BLUNT TRAUMA
? Spleen is the most commonly injured organ in blunt injury abdomen.
? Contrast- enhanced CT is the investigation of choice for detecting splenic injuries.
? Kehr sign (after elevating foot end, referred pain over left shoulder d/t irritation of under surface of
diaphragm by blood) is seen in splenic ruptures.

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? On X- ray:
Fracture of left lower ribs,
Obliteration of splenic & psoas shadows
Elevation of left diaphragm
Indentation of stomach & presence of free fluid between coils of intestine.

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PHEOCHROMOCYTOMA
? Arises from para ganglion cells of ANS.
? Most common site of origin ?adrenal medulla
? Most common extra-adrenal site: organ of zuckerkandl
? Investigation of choice for: is CT scan followed by MRI.

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? IOC for locally recurrent, metastatic, Ectopic & Extra ? adrenal pheochromocytoma is MIBG scan (Using I123
or I131)
? Sensitivity: MIBG > MRI > CT > USG
RADIOLOGICAL SIGNS OF EXCRETORY SYSTEM

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Radiological feature
Disease
Rim/ crescent sign & Soap bubble appearance
Hydronephrosis
Flower vase appearance of ureter

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Horse shoe kidney
Yo yo phenomenon
Duplex ureter of kidney
Putty kidney, autonephrectomy, moth eaten appearance,
TB kidney

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Kerr's kink, irregular cavity, phantom calyx
Corkscrew ureter, beaded ureter, pipe stem ureter
TB ureter
Golf hole ureter
TB bladder

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Drooping flower appearance
Ectopic ureter
Cobra head appearance/ adder head/ Spring onion
Ureterocele
appearance

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Egg in cup appearance, Signet ring sign on IVU
Analgesic nephropathy causing papillary
Lobster claw sign on IVU, Ball on tee sign on IVU
necrosis
Thimble bladder

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Tubercular/ chronic cystitis
Fir tree appearance/pine cone bladder or christmas tree
Neurogenic bladder
bladder
Sandy patches

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Schistosomiasis of bladder
Chalice/ Bergman sign
Ureteric dilatation distal to neoplasm
Fish hook bladder
BPH

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B/L spider leg appearance, Swiss- cheese/ black
Autosomal dominant Polycystic kidney
nephrogram,
Sun burst nephrogram/ Patchy chaotic nephrogram
Autosomal recessive Polycystic kidney

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Renal fascia sign
Acute renal artery occlusion
Bunch of flowers appearance, Paintbrush appearance
Medullary sponge kidney
Edling sign

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Pseudoureterocle
Wind in the sail appearance, Keyhole appearance
Posterior urethral valves
Sunburst appearance, Bladder in bladder appearance,
Extra peritoneal bladder rupture

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Molar tooth sign
Nubbin sign
Reflux nephropathy involving the lower
pole of a duplicated collecting system
Goblet sign, Bergmans coiled catheter sign

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Ureteral transitional cell carcinoma
? Pseudo ureterocele: malignant stricture of distal ureter.
INVESTIGATIONS IN RENAL TUBERCULOSIS

PLAIN FILM

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? Focus on calcification, which is seen in 25-45%, at various stages of disease.
o
triangular in papillary necrosis
o
focal or amorphous : putty kidney (endstage)

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? Fluoroscopy - IVP
? Traditional plain film IVP is quite sensitive to renal tuberculosis with only 10% of affected patients having
normal imaging. Features include:
o
Parenchymal scars 50%

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o
Moth eaten calyces: early finding
o
Irregular caliectasis
o

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Phantom calyx
o
Hydronephrosis
? Other lower urinary tract signs include:
o

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Kerr kink 3
o
Saw-tooth ureter
o
Pipe-stem ureter

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o
Beaded or corkscrew ureter
o
Thimble bladder
ULTRASOUND

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Sonographic appearances are non-specific and variable, depending on the stage of disease.
Early
? Normal kidney or small focal cortical lesions with poorly defined border + / - calcification.
? Progressive papillary destruction with echogenic masses near calyces.
? Distorted renal parenchyma.

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? Irregular hypoechoic masses connecting to collecting system; no renal pelvic dilatation.
? Mucosal thickening + / - ureteric and bladder involvement.
? Small, fibrotic thick-walled bladder.
? Echogenic foci or calcification (granulomas) in bladder wall near ureteric orifice.
? Localised or generalised pyonephrosis.

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End stage
? Small, shrunken kidney, "paper-thin" cortex and dense dystrophic calcification in collecting system.
? May resemble chronic renal disease.
Ultrasound is less sensitive than CT in detection of:
? Calyceal, pelvic or ureteral abnormalities.

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? lsoechoic parenchymal masses.
? Small calcifications.
? Small cavities that communicate with collecting system.
CT
? CT is the most sensitive modality for visualizing renal calcifications.

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? CT IVP is more sensitive at identifying all manifestations of renal tuberculosis.
Early
? Papillary necrosis (single or multiple) resulting in uneven caliectasis
? Progressive multifocal strictures can affect any part of the collecting system
? Generalised or focal hydro nephrosis.

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? Mural thickening and enhancement
? Poorly enhancing renal parenchyma, either due to direct involvement or due to hydronephrosis

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End stage
? Progressive hydronephrosis results in very thin parenchyma, mimicking multiple thin walled cysts.
? Amorphous dystrophic calcification eventually involves the entire kidney (known as putty kidney).

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RADIOLOGICAL SIGNS IN ORTHOPEDICS
Classical radiological feature
Condition
Sunray appearance, Codman's triangle
Osteosarcoma

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Onion peel appearance
Ewing's sarcoma
Soap bubble appearance
Osteoclastoma
Speckled/ Mottled/ Patchy calcification

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Chondrosarcoma
Wormian bones
Osteogenesis imperfect
Trethowan's sign
Slipped capital femoral epiphysis

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Aneurysmal sign
TB Spine
Honey comb appearance
Adamantinoma
Moth-eaten appearance in bone (permeative

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? Multiple myeloma
process of bone)
? Primary lymphoma of bone (reticulum cell
sarcoma)
? Ewing sarcoma

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? Infection
? Eosinophilic granuloma
? Malignant fibrous histiocytoma
? Metastases, especially Burkitt lymphoma
? Mycosis fungoides

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Driven snow appearance
Pindborg tumor
IMPORTANT FEATURES:

Sutural diastasis, copper beaten skull

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Raised intracranial tension
Bracket calcification
Lipoma of corpus callosum
Dawson fingers on brain MRI
Multiple sclerosis

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Tram track/ rail road track gyriform cortical calcifications
Sturge weber syndrome
Hyperdense MCA sign, Insular ribbon loss sign
Acute stroke
Light bulb sign on MR diffusion

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Pseudo delta sign, Cortical vein sign
SAH
Sugar icing appearance , Zuckerguss appearance
Medulloblastoma
Dural tail sign, Mother-in-law sign, Sunburst/ spoke wheel

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Meningioma
tumour vascularity
Geographic lytic skull, Vertebra plana
Eosinophilic Granuloma
Multiple punched out lesion in skull vault

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Multiple myeloma
Hair-on-end skull vault
Thalassemia
Picture frame vertebra
Pagets disease

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Fish mouth vertebra
Sickle cell anemia, Homocystienuria
Bat wing 4th ventricle
Joubert syndrome
Boxcar ventricles

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Huntington's disease
Clover leaf skull
Thanatophoric dysplasia
Cord sign, Empty delta sign
Intravertebraldural sinus thrombosis

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Corduroy appearance, Polka dot appearance
Intravertebral hemangioma

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Eye of the tiger sign
Hollaverden spatz syndrome
Flat tyre sign, Umbrella sign

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Ruptured globe
Figure of 8 appearance
Pachygyria
Fish vertebrae
Sickle cell disease

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Hot cross bun sign
Multisystem atrophy
Inverted napoleon hat sign
Spondylolisthesis
Scottie-terrier dog sign

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Spondylolysis
Mount fuji sign
Tension pneumocephalus
Reversal sign
Anoxic brain injury

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Salt and pepper pattern
Vascularity in glomus tumours
Sandwich vertebra
Osteopetrosis
Strawberry skull on antenatal USG

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Trisomy 18
Tau sign
Persistent trigeminal artery

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X-ray features of Osteosarcoma:
? Area of irregular destruction of metaphyses
? Erosion of the overlying cortex
? New bone formation in the matrix of the tumor
? Irregular periosteal reaction

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? Codman's triangle
? Sun-ray appearance
Disease
Radiological feature

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Osteosarcoma
Variable mixture of radio opacities & radiolucency (hall mark)
Sun burst/ sun ray appearance (11nd). Codman's triangle (non specific)
Osteoclastoma Ewing's
Soap bubble appearance

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sarcoma
Onion peel appearance
Paget's disease
In osteo lytic hot phase: Advancing wedge/ Blade of grass/ candle flame appearance
In mixed phase: cotton ball skull, picture frame vertebrae

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In cool phase: bowing, bone density increased
Features
Disorders
Geographic lytic skull /Vertebrae
Eosinophilic granuloma/ Hans- Schuller Christian disease/Histiocytosis

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plana
Multiple punched out lesions
Multiple myeloma
Chicken wire calcification
Chondroblastoma (CODMAN'S TUMOR)

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Hair on end skull vault
Thalassemia, sickle cell anemia
Erosion of dorsum Sella
Raised ICT (earliest & most common)
Salt peeper skull

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Hyperparathyroidism
Silver beaten app. Of vault
Raised ICT
Sunray calcification with spicules
Meningioma

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Epiphyseal dysgenesis, Punctate/ fragmented epiphysis
Hypothyroidism
Epiphyseal enlargement with squaring and angulation
Juvenile chronic arthritis

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? Small epiphysis marginated by sclerotic rim (Wimberger sign)

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Scurvy
? Radiodense calcification at growing metaphyseal end (Frankel's
line),
? Radiolucent zone due to lack of mineralization of osteoid
(Trumerfeld zone),

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? Pelkan's spur & Subperiosteal hemorrhage
Epiphyseal widening, Cupped & frayed metaphysic
Rickets
PUNCHED OUT LESIONS OF SKULL
? Infectious Disorders

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o
Fungal osteomyelitis
o
Blastomycosis
o

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Coccidioidomycosis
? Granulomatous, Inflammatory Disorders
o
Sarcoidosis
o

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Hand-Schuller-Christian syndrome
? Neoplastic Disorders
o
Metastatic bone disease
o

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Adenocarcinoma of prostate
o
Multiple myeloma
? Metabolic, Storage Disorders
o

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Gout
o
Histiocytosis X
? Congenital, Developmental Disorders
o

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Bony cystic angiomatosis
? Hereditary, Familial, Genetic Disorders
o
Ollier's enchondromatosis
? Vegetative, Autonomic, Endocrine Disorders

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o
Primary Hyperparathyroidism
? Reference to Organ System
o
Systemic mastocytosis

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HAIR ON END SKULL
(HINEST)
? Hereditary spherocytosis
? Iron deficiency anemia
? Neuroblastoma

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? Enzyme (G-6PD) deficiency
? Sickle cell disease
? Thalassemia major
Radiological signs of vertebral diseases:
Vertebra piano

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Eosinophilic Granuloma
Rugger jersey spine
Osteopetrosis, osteodystrophy due to CRF
Fish mouth vertebra
Homocystinuria, Sickle cell anemia

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Cod mouth vertebra
Osteoporosis, osteomalacia &
Hyperparathyroidism
Picture frame vertebra, "cotton wool," or osteoporosis
Paget's disease

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circumscripta
Calcification of intervertebral disc
Alkaptonuria

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CAUSE OF HAIR ON END SKULL VAULT
Hemolytic anemias: Thalassemia major/ Cooley's anemia (most common) & Sickle cell anemia, Neoplastic:
Hemangioma: Meningioma; Metastasis
Others: Cyanotic heart disease; Iron deficiency anemia; Ewing's sarcoma, syphilis, infantile cortical hyperostosis
(Caffey's disease).

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RADIOGRAPHIC FINDINGS IN ARTHRITIS
Disease State
Findings in Hip or Knee
Osteoarthritis
Joint space narrowing, subchondral sclerosis, osteophytes,

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subchondral cysts
Hip: Superior or medial narrowing
Knee: Early narrowing on Rosenberg views; flattening of femoral
condyles
Rheumatoid arthritis or SLE

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Uniform joint narrowing, erosion near joint capsule
Ankylosing spondylitis
Osteopenia, Osteophytes, ankylosis of sacroiliac joints
Gout
Tophi, erosions

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Calcium pyrophosphate
Calcification of menisci and hyaline cartilage
deposition disease
Osteonecrosis
Crescent sign, spotty calcification

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Gaucher disease
Erlenmeyer flask appearance, distal femora
Neuropathic joint
Four Ds: destruction, debris, dislocation, densification (sclerosis,
hypertrophy)

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Hemophilic arthropathy
Epiphyseal widening, sclerosis, cysts, joint space narrowing
?
Erosive osteoarthritis: gull's wing/ angel wing appearance.

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A
B
C

FIG: BAMBOO SPINE APPEARANCE OF ANKYLOSING SPONDYLITIS

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Figure: The characteristic differences between osteoporosis, osteomalacia, and hyperparathyroidism in the spine.
(A) Osteoporosis manifests as a biconcave vertebral body with prominent vertical trabeculae.
(B) Osteomalacia manifests as uniform deossification with a loss of trabecular detail and anterior wedge-shaped
compression fractures.
(C) The "rugger jersey" spine of secondary hyperparathyroidism manifests as increased density adjacent to the

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vertebral end plates.
Shiny corner sign
Ankylosing spondylitis
Pseudo shiny corner sign
Degenerative spondylosis

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Waldenstrom sign
Osteoarthritis hip
Patellar tooth sign
Patella-femoral joint OA
Movie sign

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Chondromalacia patellae

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Licked candy stick appearance, Jigsaw vertebra
Atrophic neuropathic arthritis
Tumbling building block spine
Migrating mouse sign

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Synovio-chondro-metaplasia
Apple core deformity of hip
Cocktail sausage digit, spindle digit, ivory phalanx, Pencil in cup/
Psoriatic arthropathy
pestle and mortar/ mushroom and stem/ balancing pagoda/ cup in

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saucer appearance, opera glass hand, whittling effect, mouse ears
sign
Bone in bone appearance, Sandwich vertebra, Rugger-jersey spine
Osteopetrosis
Erlenmeyer flask deformity

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Flowing candlewax appearance
Melorrhosteosis
Hot cross bun skull
Cliedo-cranial dysplasia
Paired posterior iliac horns

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nail patella syndrome
Elephant ears, Mickey mouse ears, Clinodactyly
Downs syndrome
Bare orbit, Empty orbit sign
Neurofibromatosis-1

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Hook shaped vertebral bodies, Cut corner sign
MPS l/ hurler syndrome
Central beaking of vertebrae, Ape like pelvis
MPS IV/ morquio syndrome
Gull wing sign

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Erosive OA
Steinberg sign
Marfan syndrome
Pelkan spur/ Pencil thin cortex/ Corner sign of Parke
Scurvy

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Trummerfield zone of rarefaction/ White line of Frankel/ Wimberger
sign
Looser zone/ lines, Milkmans fracture, Osteoid seams
Osteomalacia
Increment fracture, Umbau zones

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Rugger jersey spine/ Brown tumours/ Pepper pot skull/ Subperiosteal
Hyperparathyroidism
resorption of phalanges
Cotton wool appearance, Candle flame/ blade of grass lysis
Pagets disease

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Picture frame vertebra
Penumbra sign
Brodies abscess
Inverted napoleon hat sign, Gendarme's cap sign
Spondylolisthesis

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Bowline of Brailsford, Broken collar/ neck of scotty dog, Scottish
terrier sign
Button sequestrum, Floating teeth sign, Hole with hole appearance
Histiocytosis-X
Swan neck deformity, Boutonniere deformity, Hitch hiker thumb

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RA
Hammer toes
Trident hand, Tomb stone iliac bone, Cheuron sign
Achondroplasia
Intervertebral disc calcification

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Alkaptonuria
Pear shaped vertebra
Spondylo-epiphyseal dysplasia
congenita
Hump shaped vertebra, Heaped up vertebra

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Spondylo-epiphyseal dysplasia
tarda
Inferiorly beaked vertebra
MPS l/ hurler syndrome
Centrally beaked vertebra

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MPS IV/ hunter syndrome
Biconcave lens vertebra
Osteogenesis imperfecta
Spool shaped vertebra
Pyknodysostosis

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Bullet nose vertebra
Achondroplasia
Vertebra with central anterior tongues
Pseudochondroplasia
H shaped vertebra

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Thanatophoric dwarfism

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FEATURES OF BRAIN HEMATOMA ON CT SCAN

Extradural
Subdural

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Subarachnoid: (SAH)
? Biconvex (Lens
? Crescent
? Non- contrast CT is investigation of choice for diagnosing
shaped/

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(Concavo-
the hematoma.
lenticular)
Convex)
? Four vessels (both carotids & both vertebra's) Digital

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? Hyper dense
? Hyper dense
subtraction angiography (DSA) is the investigation of
in acute cases.
(<2 weeks)

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choice for determining etiology.
? Hypo dense in
? Isodense (2-4
? The hallmark of SAH is blood in CSF detected by lumbar
Chronic cases

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wks)
puncture.
? Hypo dense (> 4
? Lysis of blood in CSF causes Xanthochromia which is peak
wks)

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at 48 hours.

? Most common intracranial lesion after head injury is subdural hematoma.
? Most common cause of SAH is head trauma.
? Investigation of choice for SAH is Non- contrast CT

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? M.C. cause of spontaneous SAH is ruptured saccular aneurysm.
Diffuse axonal injury (DAI)
? It is caused by shearing of the white matter, often at the gray-white junction.
? May be due to the differing tissue density or fixation between two structures in differing response to
rotation, acceleration, and deceleration.

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? Detection is often associated with changes in the lobar white matter, brainstem, and corpus callosum with
ovoid or elongated regions of decreased density.
? Patients usually present with severe impairment of consciousness from the moment of impact.
? MRI (FLAIR or T2 weighted) - most useful in defining the extent of axonal shearing and non-hemorrhagic
injury.

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? CT results -often negative, but acute areas of petechial hemorrhage & cerebral edema have been seen in
early stages.
IMPORTANT SIGNS IN RADIOLOGY
? Puff of smoke sign: Moyamoya disease
? Polka dot sign: vertebral hemangioma

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? Dripping candle wax sign: melorheostosis
? Accordion sign: pseudomembranous colitis
? Air crescent sign: aspergilloma
? Angelwing sign: pulmonary edema [bat wing sign]
? Air bronchogram sign: pneumonia

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? Anteater's nose sign: tarsal coalition
? Apple core appearance: Ca Colon
? Blade of grass sign [Flame sign]: Paget's disease
? Bevelled edge appearance: eosinophilic granuloma
? Bowler hat sign, Mexican hat sign: colonic polyp

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? Black pleura sign: alveolar microlithiasis
? Bird of prey sign: sigmoid volvulus
? Bone within bone appearance: osteopetrosis
? Breast within breast appearance: hamartoma of breast
? Bear paw sign: xanthogranulomatous Pyelonephritis

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? Pelvic brim sign: Paget's disease
? Bite sign, crescent sign: avascular necrosis of femur

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? Bulging fissure sign: Klebsiella pneumonia
? Banana sign/ lemon sign: neural tube defect
? Carman meniscus sign: Ca stomach

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? Cotton wool appearance: Paget disease
? Cobra head appearance: Ureterocele
? Coblestone appearance: Crohn's disease
? C sign: tarsal coalition
? Coffee bean sign: sigmoid volvulus

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? Colon cut off sign: acute pancreatitis
? Comb sign: Crohn's disease
? Comet tail sign: round atelectasis
? Comet sign: pelvic phlebolith
? Continuous diaphragm sign: pneumomediastinum

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? Corduroy sign: vertebral hemangioma
? Corkscrew oesophagus: diffuse esophageal spasm
? Crazy paving sign: pulmonary alveolar proteinosis
? Champagne glass pelvis: Achondroplasia
? Celary stalk sign: rubella, osteopathia striata, anterior cruciate ligament degeneration

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? Corkscrew sign: midgut volvulus
? Cottage loaf sign: diaphragmatic rupture
? Codfish vertebra: sickle cell disease
? Jerry Thomas sign: scapho lunate dislocation
? Dense MCA sign: hyperacute stroke(CT sign)

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? Double bubble sign: duodenal atresia, annular pancreas
? Double density sign: enlarged left atrium (mitral stenosis)
? Doughnut sign: testicular torsion(nuclear scan)
? Draping aorta sign: leaking abdominal aortic aneurysm
? Deep sulcus sign: pneumothorax

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? Double duct sign: periampullary, pancreatic Ca
? Erlenmeyer flask deformity: Gaucher's disease, thalassemia, osteopetrosis, pyle's disease
? Fat pad sign: pericardial effusion
? Foot ball/ falciform ligament sign: Pneumoperitoneum (infant)
? Fallen lung sign: fracture bronchus

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? Fishhook ureter: BPH
? Flat waist sign: left lower lobe collapse
? Gloved finger sign: allergic bronchopulmonary aspergillosis
? Gull wing sign: erosive osteoarthritis
? Goose neck sign: endocardial cushion defect

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? Hampton line: benign gastric ulcer
? Hampton hump: pulmonary infarction
? Honda sign: sacral insufficiency fracture
? Hide bound appearance: scleroderma
? Hair on end appearance: hemolytic anemia

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? Hot nose sign: brain death
? Holly leaf appearance: asbestosis
? Hot cross bun sign: multi system atrophy-C
? Half moon/ light bulb sign: posterior shoulder dislocation
? Head cheese sign: hypersensitivity pneumonitis

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? Ivory vertebra: osteoblastic vertebral metastasis
? Insular ribbon sign: acute cerebral infarct

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? Ivory phalanx: psoriasis
? Molar tooth sign: extra peritoneal bladder rupture
? Mercedes Benz sign: gall stone

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? Micky mouse sign: Paget's disease
? Napoleon hat sign: spondylolisthesis
? 1-2-3 sign: Sarcoidosis
? Pie in the sky sign: urethral injury
? Pyloric teat, pyloric beak, caterpillar sign, double triple track sign, string sign: hypertrophic pyloric stenosis

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? Rugger Jersey spine: secondary hyperparathyroidism
? Rigler sign: Pneumoperitoneum
? Rice grain calcification: cysticercosis
? Ring sign: renal papillary necrosis
? Sandwich sign: lymphoma

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? Spine sign: lower lobe pneumonia
? String of beads sign: mechanical small bowel obstruction
? Stack of coins: scleroderma
? Trough sign: posterior shoulder dislocation
? Westermark sign: pulmonary embolism

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? Yin yang sign: partly thrombosed aneurysm
? Wimberger's sign: congenital syphilis
IMPORTANT FACTS
? FARADAY CAGE: prevent the passage of electromagnetic waves. Contain Mu-copper foils which can be
applied as wall papers.

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? Contrast used in CT: lohexol (non ionic),Metrizamide- not used now
? Dye of choice for myelography: lopamidol
? Pindborg tumor: calcifying Epithelial Odontogenic Tumor (CEOT)
? M/C cause of intra cranial calcification: Pineal body calcification
? M/c endocrine abnormality following intracranial radiotherapy: Growth hormone deficiency

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? M/C calcifying brain tumor in child: Craniopharyngioma followed by oligodendroglioma
? Suprasellar calcification with cystic appearance: Craniopharyngioma
? M/C solid renal neoplasm in neonates: Mesoblastic nephroma
? M/C malignant abdominal neoplasm in children: Wilm's tumor (nephroblastoma)
? M/C malignancy in children: Leukemia > Brain tumors > Nephroblastoma

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? M/C renal mass in childhood: Hydronephrosis > multicystic dysplastic kidney> Nephroblastoma
? Hyperparathyroidism: Brown's tumor (m/c in mandible), Subperiosteal erosion (Hallmark), Salt pepper
appearance & basket work appearance.
? Williams syndrome/ Idiopathic hypercalcemia of malignancy: Supravalvular aortic stenosis, Mental
retardation & Elfin facies(round faces with full cheeks & lips)

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? Emergency radiotherapy given in:
o
Neoplastic cardiac tamponade
o
Acute epidural spinal cord compression

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o
Tumor lysis syndrome
o
Severe hypercalcemia
o

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SVC syndrome.
? M/C radiation induced secondary cancer: Leukemia
? M/C radiation induced secondary cancer following treatment for head & neck cancers: Thyroid cancer
? Neutron beams are more effective in treating salivary gland tumors.
? Soap bubble appearance in abdominal x-ray -Meconium ileus

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? Soap bubble appearance in head CT-Cryptococcal meningitis

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? Soap bubble calcification in x-ray-Osteoclastoma
? Puffed rice appearance on CT-Scan head-neurocysticercosis
? Soap bubble cerebral calcification in head CT-Toxoplasmosis (Congenital)
COMMON CAUSES OF EGG SHELL CALCIFICATION OF NODES

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? Egg shell calcification means peripheral rim calcification of lymph nodes.
? Pneumoconiosis (M.C): Silicosis (M.C), Coal workers pneumoconiosis: not seen in Asbestosis, berylliosis,
baritosis, talcosis.
? Sarcoidosis & Lymphoma following radiotherapy
? Rare causes are: Fibrosing mediastinitis, Fungal + Bacterial infections: histoplasmosis, Coccidiodomycosis,

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Blastomycosis, Tuberculosis, Amyloidosis
TYPES OF CALCIFICATIONS:
Popcorn calcification
Pulmonary hamartoma, Mediastinal nodes in acute histoplasmosis,
fibroadenoma

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Pericardial calcification
Constrictive pericarditis
Cardiac calcification
Carcinoid syndrome
Basal ganglia calcification

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Idiopathic(M/C), Hypoparathyroidism
Egg shell calcification
Silicosis, Sarcoidosis, TB, lymphoma after radiation
Rice grain calcification
Cysticercosis

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Tram track(rail road)calcification
Sturge Weber syndrome
Calcification of menisci
Pseudogout
Adrenal & ear pinna calcification

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Addison's disease
Cardiac wall calcification
Endomyocardial fibrosis
Most common primary CNS neoplasm
Glioblastoma multiforme

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2nd most common primary CNS neoplasm
Meningioma
Most common intracranial germ cell tomour
Germinoma
Most common mixed glioma

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Oligo-astrocytoma
Most common site of schwannoma
Vestibular division on 8th nerve
Most common intracranial tumour in neonates
Teratoma

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M/C primary intracranial neoplasm in sellar/ parasellar
Pituitary adenoma
region
Most common intraaxial posterior fossa tumor in adults
Metastasis from extracranial sites

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Most common of all primary intracranial neoplasms
Glioblastomamultiforme
Most common supretentorial neoplasm in adults
Glioblastomamultiforme
Most common intracranial tumour to calcify

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Oligodendroglioma
Most common site of cellular ependymoma in brain
4th ventricle
Most common nonglial primary brain tumour
Meningioma

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Most common intracranial extraaxial tumour
Meningioma
most common spinal extradural neoplasm
Metastasis
Most common benign spinal neoplasm

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Vertebral hemangioma
Most common malignant extradural neoplasm
Metastasis
Most common spinal intramedullary tumour in adults
Ependymoma

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Most common spinal intramedullary tumour in children
Astrocytoma
CEREBRAL RING ENHANCING LESIONS
DR MAGIC LNT
? Demyelinating disease

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? Radiation
? Metastasis (2nd m/c)
? Abscess
? Glioblastoma multiforme (m/c cause)
? Infarct

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? Contusion
? Lymphoma
? Neurocysticercosis
? Tuberculoma
? Toxoplasmosis

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? Syphilis
? Behcet disease
A

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B

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Cysticercosis; contrast-enhanced CT. Sections at the levels of the third ventricle (A) and the lateral ventricles (B).
Lesions are at different stages of development: homogeneously enhancing ring with calcified scolex; some are
associated with vasogenic oedema.
A

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B

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Tuberculoma: CT. Axial sections before (A) and after (B) IV contrast medium: a superficial mass slightly denser than
brain is surrounded by vasogenic oedema in the frontal and temporal lobes; it shows marked contrast enhancement.

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IV.
INVESTIGATION OF CHOICE

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RADIO NUCLIDE IMAGING
? 99Tc is the most commonly used radiopharmaceutical, for imaging in nuclear medicine; it is used with
different ligands for imaging of different sites.
Radio nuclide

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Uses
Tc 99m labeled serum albumin
Detection of pulmonary embolism
Tc 99m labeled RBC's
Spleen imaging

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Tc 99m labeled DMSA
Renal morphology
Tc 99m labeled DTPA
Measures GFR
Tc 99m labeled HIDA/ PIPIDA

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Functions of hepato biliary tree
Tc 99m labeled MAG-3
Diagnostic of transplant rejection
Thallium 201 chloride
Cardiac imaging (cold spots in myocardial studies)

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Ga-67 nitrate
To detect tumours, inflammation, abscess cavities
COLD NODULE
? Area of decreased radio isotope intake.
? 15 -- 20 % of cold nodules may be malignant.

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? Multiple cold nodules with interfering regions of increased uptake indicates a multi nodular gland with low
incidence of associated malignancy.
HOT NODULE
? Area of increased radio-isotope uptake
? Almost never harbors malignancy, represent a benign condition

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? Represents either autonomous or hypertrophic area
Exception: Warthin's tumor & oncocytoma- malignant tumour showing hot nodule on radionuclide scan

TECHNETIUM-99M BONE SCAN
? The bone scan labels the osteoblast activity with the radioactive tracer, technetium-99.

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? An increase in osteoblastic activity results in the incorporation of more of the diphosphonate molecule into
the mineral matrix of bone, causing it to appear "hot" or "dark";
? Absence of osteoblastic activity produces a "cold" or photopenic ("photon poor") area, due to decreased
radiotracer localization and photon emission.
INDICATIONS:

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? Malignant Tumors : Primary and Metastatic
? Benign Bone Tumors: Osteoid Osteoma
? Trauma: Occult Fractures, Domestic Violence/Abuse
? Infection: Osteomyelitis, Arthritis
? Metabolic diseases: Paget's , Bone (Avascular) Necrosis

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? Soft Tissue diseases: Myositis Ossificans
? Unexplained bone Pain
"HOT" BONE SCAN:
? Seen in any disorder that results in increased bone formation.
? Areas of active bone metabolism, such as the epiphyseal growth plate, most metastatic bone lesions,

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osteoarthritis and osteomyelitis.

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? In normal cases, the "hottest" areas are those undergoing the most rapid growth, including the distal
femur, the proximal tibia, and the proximal humerus. In the adult, greater activity is seen in the axial
skeleton than in the appendicular skeleton
? Regional Hyperactivity may be due to:

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o
Normal bone growth and remodeling
o
Increased blood flow(trauma, heterotopic ossification)
o

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Reactive osteoblastic activity (active infections, tumors)
o
Reparative bone process(healing fractures, tumors, infections)
o
Hyper-metabolic activity(metabolic disorders)

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? Lesions that appear hot on bone scan include healing fractures and osteoblastic tumors, such as osteogenic
sarcoma.
COLD BONE SCAN:
? A loss of blood flow to the bone, or a bone infarction, can cause this type of spot.
? When a person suffers a bone infarction, the part of the bone that no longer receives blood can die, leading

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it to collapse.
? Multiple myeloma may not show up on a bone scan because only osteoclastic activity is involved in the
majority of lesions.
? Malignant Tumors
o

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Lung (2-4%)
o
Breast (5%)
o
Renal (10%)

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o
Neuroblastomas (bone marrow metastasis)
o
Thyroid (most cases)
o

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Multiple Myeloma (most cases)
? Bone Abscesses (they are surrounded by activity)
? Bone ischemia (AVN, sickle cell, etc.)
? Hemangiomas(normal or decreased activity)
BONE SCAN IN METASTATIC LESIONS:

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? Most sensitive routine imaging modality to try and identify both sclerotic and lytic lesions.
? In most cases they demonstrate increased uptake (hot spot) although occasionally (in very aggressive purely
lytic lesions) a photopaenic defect (cold spot) may be visible.
SUPERSCAN:
? Greater than normal activity in the kidneys is most commonly due to urinary tract obstruction, and bilaterally

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decreased activity most often reflects renal failure.
? An important exception to the latter is the absence of renal activity in the so-called superscan, in which
diffuse skeletal uptake is so avid that renal uptake is undercut.
? A common condition producing a superscan is diffusely metastatic prostate carcinoma.
INVESTIGATION OF CHOICE

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USG
CT-Scan
HRCT
MRI
PET/SPECT

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Cystic lesions,
Adrenals, pancreas,
Lung pathology like
Posterior fossa,
Occult

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fluid
mediastinum,
bronchiectasis,
spine CNS,
metastasis

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accumulation
calcification, cerebral
interstitial lung
muscle, soft
hemorrhage

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disease
tissue, joints,
etc.,
INVESTIGATION OF CHOICE IN CARDIAC CONDITIONS

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Cardiac conditions
Investigation of choice
Aortic dissection: Stable patient
MRI
Unstable patient

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Trans esophageal Echo with CT scan
Pericardial effusion
Echo (Investigation of choice), CT/MRI (second choice)
Valvular disease
Trans esophageal echo cardiogram

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Constrictive pericarditis
MRI
Coarctation of aorta
Gadolinium-enhanced 3D MRA
Myocardial function

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Tc-Albumin scan
Cardiac tamponade/ Cardiomyopathy
Echo cardiogram
? Gold standard test for ventricular function in heart: MRI.
INVESTIGATION OF CHOICE IN RESPIRATORY CONDITIONS

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? Pleural effusion- lateral decubitus
? Pneumothorax - CXR PA view on full expiration.
? Bronchiectasis in ILD: HRCT
INVESTIGATION OF CHOICE FOR OTHER CONDITIONS
? Single Bone Metastasis -- CT

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? Multiple Bone Metastasis -- Bone scan
? Spine Metastasis -- MRI
? Avascular necrosis- MRI
? Bone Density/Osteoporosis- DEXA (Dual energy x ray absorptiometry)
? Aneurysm/ AV Fistula- Angiography

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? Dissecting Aneurysm (Stable) - MRI (Unstable)-Trans oesophageal USG
? Pericardial Effusion- Echocardiography
? Lobulated pericardial effusion- MRI > CT
? Minimum Pericardial Effusion- Echocardiography
? Ventricular Function- Echocardiography

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? Radiotherapy/Chemotherapy induced cardiotoxicity- Endomyocardial Biopsy
? Pulmonary Embolism- CECT> Pulmonary Angiography > V/Q Scan
? Interstitial lung disease(Sarcoidosis)- HRCT
? Bronchiectasis- HRCT scan
? Solitary Pulmonary Nodule- High resolution CT (HRCT)

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? Posterior Mediastinal Tumor- MRI
? Pancoast Tumor (Superior Sulcus Tumor) -- MRI
? Minimum Ascites/Pericardial effusion/Pleural effusion -- USG
? Traumatic Paraplegia- MRI
? Posterior Cranial Fossa -- MRI

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? Acute Haemorrhage- CT
? Chronic Haemorrhage- MRI
? Intracranial Space Occupying Lesion- MRI
? Primary brain tumour- contrast MRI (Gold standard however remains to be biopsy)
? Metastatic brain tumor- (Gadolinium) contrast enhanced MRI

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? Temporal Bone-CT
? SAH Diagnosis- unenhanced CT
? SAH aetiology- 4 vessel MR Angiography > CT Angiography > DSA
? Nasopharyngeal angiofibroma- CECT scan
? Acoustic neuroma- Gadolinium DTPA enhanced MRI

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? Obstetrics- USG

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? Calcifications- CT
? Blunt abdominal Trauma- CT
? Acute Pancreatitis- CT
? GERD- pH manometer > endoscopy

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? Dysphagia- Endoscopy
? Congenital hypertrophic pyloric stenosis- USG
? Extrahepatic biliary atresia- perioperative cholangiogram
? Obstructive Jaundice/GB Stones- USG
? Diverticulosis -- barium enema

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? Diverticulitis -- CT scan
? Renal TB (early) --IVP (Late)- CT
? Posterior Urethral Valve- MCU
? Ureteric stone- non contrast CT
? Renal Artery Stenosis- Percutaneous Angiography

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? Extraintestinal Amoebiasis- ELISA
? Discrete swelling(solitary nodule) of thyroid- FNAC
? MRI is the investigation of choice for imaging traumatic spine (ex paraplegia). CT is second best investigation.
? The most important imaging modality in suspected or known acute head trauma is the noncontrast CT. CT is
superior to MRI for the detection of acute blood and fractures,

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Small intestinal tumor
CT contrast
Early renal TB
IVP
Advanced renal TB

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CT> IVP> USG
Pregnant lady with abdominal mass
MRI
Dental & TM joint pathology
Ortho pantomography [OPG]

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Meckel's diverticulum
? Most common type of omphalomesenteric duct remnant.
? Results from failure of the yolk sac to close during fetal life
? Present in 0.5-3% of the population.

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? Occur 30-90 cm from the ileocaecal valve and range in size from 0.5 to 13 cm in diameter.
? About 20-40% cause symptoms.
? Complications: ulceration, bleeding, perforation, inflammation, intussusception, internal hernia, volvulus,
and adhesions.
? Ectopic gastric mucosa is present in the diverticulum in about 20% of all patients who present with bleeding

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and in 95% of children who bleed.
? Radionuclide imaging with 99mtechnetium pertechnetate is more accurate (sensitivity-85%) in the
paediatric age group than in adults.
? Meckel's diverticula which haemorrhage contain ectopic gastric mucosa in 95% of cases and 99mTc
scintigraphy is useful in this subset of patients.

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? A characteristic angiographic feature: demonstration of a persistent vitellointestinal artery in who present
with chronic gastrointestinal bleeding.
FOREIGN BODIES
? IOC: conventional film-screen radiography
? Glass objects: plain radiography, xeroradiography, CT and MRI.

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? Gravel: all methods except MRI where ferromagnetic streak artefacts may obscure visualization. Plastic:
easily detected by MRI.
? Wooden foreign bodies, especially when wet, are only seen by CT and MRI.
? Xeroradiography does not have any benefit over plain radiography in identifying foreign bodies.

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? FB in children: USG

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GOLD STANDARD METHODS
For diagnosis of breast cancer
Mammography
For staging of breast cancer
Axillary lymph node dissection

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For evaluation of a stable patient with suspected
Angiography
vascular injury
For diagnosis of GERD
Ambulatory 24 hr pH monitoring

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For the diagnosis of GI perforation
Finding pneumoperitoneum
For diagnosis of Zollinger-Ellison syndrome
Serum gastrin levels( most patients have
serum gastrin levels above 1000pennl)

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For diagnosis of colonic mucosal disease
Colonoscopy
For diagnosis of steatorrhoea
Timed quantitative stool fat determination
For treatment of incontinence with an isolated

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Overlapping sphincteroplasty
sphincter defect
For diagnosis and method of management of acute
Laparotomy
arterial occlusion

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For confirmation of mesentric arterial occlusion
Mesentric angiography
For diagnosis of celiac disease
Small intestine biopsy
For identifying choledocholithiasis

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ERCP
For diagnosis of primary sclerosing cholangitis
ERCP
For diagnosis of hepatitis C
HCV RNA assay

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For diagnosis of invasive amoebiasis
ELISA
Of diagnosis of Klatskin tumor
Cholangiography
For assessment of function of sphincter of Oddi

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Manometry
For assessing degree of liver injury and fibrosis
Liver biopsy
For diagnosis of intraluminal bile duct abnormalities
ERCP

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For estimating resting energy expenditure
Indirect calorimetry
For diagnosis of iron deficiency anemia
Estimation of serum ferritin
For proving that the life span of red cell is decreased (

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Red cell survival study
useful in hemolytic anemia)
For evaluation of stem cell transplantation therapy
Hemopoietic stem cell transplantation
For diagnosis of acute pharyngitis

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Throat culture
For diagnosis of pertussis
Culture of nasopharyngeal secretions
For diagnosis of DVT
Contrast venography

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For differentiating allograft rejection and reactivation
Endo-myocardial biopsy
of disease after heart transplantation
For diagnosis of otitis externa caused by p. Aeruginosa
Technetium99 bone scan

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For diagnosis of acoustic neuroma
Gadolinium MRI
Investigation for diagnosis of shigella infection
Isolation and identification of pathogen from
fecal material

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For diagnosis of tuberculous meningitis
Culture of CSF
For diagnosis of HSV encephalitis
Brain biopsy (CSF PCR largely replaced brain
biopsy in recent times)

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For diagnosis of histoplasmosis
Fungal culture
For diagnosis of hypertrophic cardiomypathy and atrial
Echocardiogram
myxoma

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For imaging heart valves and valve motion
2D echocardiography
abnormalities
For assessment of myocardial viability (identification of
PET

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ischemic or hibernating myocardium)
For assessment of LV mass and volume
MRI
For evaluation of renal arteries and identification of
Contrast arteriography

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renal artery lesions
For evaluation of respiratory gas exchange
ABG
For assessment of albuminuria
24 hr urine collection

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For diagnosis of PNH
Flow cytometry
For diagnosis of ATTR and other AF mutations
DNA sequencing
For identifying and quantifying atherosclerosis in

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X-ray cerebral angiography
cerebral arteries
For evaluating anatomy of arterio-venous
X-ray angiography
malformation

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For diagnosis and classification of ataxia
Genotype
For diagnosis of lung infection (radiotherapy induced)
Open-lung biopsy
in a cancer patient

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For assessment of visual impairment
Snellen's chart
For bacterial stain analysis
Pulse-field gel electrophoresis
For resection of anterior and middle mediastinal

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Median or lateral thoracotomy
masses
Of treatment of coarctation of aorta
Surgical repair
For evaluation of coronary artery disease

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Cardiac catheterization
For culture of v. Cholerae o139
Conventional culture method
To determine cut-off titer of widal test for diagnosis of
Nested PCR

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typhoid fever
For diagnosis of chronic arterial mesentric ischemia
Angiography
For evaluation of imaging modalities for liver tumors
Intraoperative ultrasonography

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For diagnosis of common bile duct stones
Endoscopic cholangiography
For measurement of GFR
lnulin clearance
For diagnosis and treatment of ventilator associated

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Broncho alveolar lavage
pneumonia (VAP)
To differentiate follicular and papillary carcinoma of
Histology
thyroid gland

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Radiopharmaceuticals currently used and their common clinical applications

Organ system
Clinical
Radiopharmaceuti

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Biological behaviour
application
cal
Cardiovascular system
Myocardial

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Detection of
201TI (thallous
K+ analogue extracted in proportion to
perfusion
ischaemia,

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chloride)
bloodflow
infarction, and
99mTc isonitriles
Cationic complexes taken up by myocytes

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viability
in
assessment
99m
proportion to blood flow

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Tc teboroxime
Lipophilic compound which accumulates by
diffusion

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99mTc phosphines
Uptake proportional to blood flow

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Myocardial
Viability
123I fatty acids
Enters primary metabolic pathway in viable
metabolism

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assessment
cells: limited catabolism
18F-deoxyglucose
Enter metabolic pathway in viable cells
demonstrates secondary shift to anaerobic

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glycolysis
Cardiac
Quantification of
99mTc-red blood
Characterization of cardiac chambers

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ventriculograph
right and left
cells
motion, localization of red cells within
y

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ventricular
cardiac chambers
function at rest
and with
exercise

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Detection of wall
99mTc-albumin
motion
abnormalities
Quantification

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and detection of
shunts (and
valvar
regurgitation)
Cellular blood components

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Red blood cells
Detection of
99mTc-labelled red
Red cell pooling
haemangioma

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blood cells
Cardiac
ventriculography
Gastrointestinal
Red cell extravasation

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bleeding
Red cell survival
51Cr (sodium
Red cell disappearance from the blood
chromate)

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White blood
Localization of
99mTc-mln-labelled
Cellular diapedesis
cells

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sites of infection
cells
or inflammation
99mTc-labelled
antigranulocyte

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antibody
Platelets
Platelet survival
111In-labelled
Platelet sequestration and degradation

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platelets
Localization of
sites of active
thrombosis
Central nervous system

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Cerebral blood
Blood flow
99mTc-HMPAO
Diffusion through the blood?brain barrier
flow

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distribution
(BBB) and brain extraction
Tumours
99mTc-ECD
seizure

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disorders
Dementia

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brain death
studies
Regional blood

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H215O
BBB diffusible flow tracer
flow at rest and
upon activation
Cerebral

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Functional and
18F-deoxyglucose
Enter metabolic pathway in viable cells
metabolism
regional

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mapping of
neuronal activity
at rest
at rest
upon activation

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during seizure
in the interictal
state
Staging of brain
18F-deoxyglucose

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tumour
Follow-up of
201TI
therapy
Cerebrospinal

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CSF shunt
111ln-DTPA
Follows cerebral spinal fluid (CSF) flow
fluid
patency

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dynamics
Localization of
CSF leaks
Differentiation
of normal

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pressure
hydrocephaly
from atrophy
Gastrointestinal system
Liver--spleen

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Space-occupying
99mTc-sulphur
Phagocytosis by reticulo-endothelial cells
imaging
lesions, organ

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colloid
sizing, RES
function
Spleen imaging
Detection of

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Heat-damaged
Splenic trapping of damaged cells
ectopic splenic
99mTc-
tissue

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labelled red blood
c
9 e
9 ll
m s

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Hepatobiliary
Assessment of
Tc-iminodiacetic
Active uptake--follows bilirubin
imaging

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biliary ducts
acid derivatives
conjugation
patency
and excretion pathway

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Evaluation of
gallbladder
contractility
Diagnosis of
acute vs chronic

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cholecystitis

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Differentiation
between biliary
atresia and
neonatal

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hepatitis
Bowel transit
Oesophageal
99mTc-sulphur
Transit of labelled material

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studies
transit and reflux
colloid
Gastric emptying
99mTc-sulphur

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Compartmental localization of labelled
and antral
colloid
material
motility

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111ln-DTPA
Gastric emptying
13or14TC-labelled
Detection in breath of exhaled 13?'14CO2
substrates

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metabolite
Duodenogastric
99mTc-iminodiacetic Bile detection and localization
reflux
acid derivatives

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Small bowel and
111ln-DTPA
Transit of labelled material
colon transit
13 or 14C-labelled

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Detection in breath of exhaled 13 or 14CO2
substrates
metabolite
Helicobacter
Detection of HP

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13 or 14C-labelled
Detection in breath of exhaled 13 or 14CO2
pylori (HP)
Urease
urea

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metabolite
infection
production
Gastrointestinal
Acute and

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99mTc-sulphur
Extravasation in the bowel
bleeding
chronic bleeding
c

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9 o
9 l
mlo
T i
cd

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-l abelled
RBC's
Peritoneovenou
Determination
99mTc-sulphur

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Compartmental localization
s
of shunt patency
colloid
shunts

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Salivary glands
Evaluation of
99mTc-
Active uptake and secretion
salivary function

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pertechnetate
and ducts
patency
Gastric mucosa
Detection and

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99mTc-
Active uptake by gastric mucosa
localization of a
pertechnetate
Meckel's

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diverticulurn
containing
gastric mucosa
Genitourinary system
Renal perfusion

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Evaluation of
99mTc-DTPA
Early intravascular localization
arterial blood
flow

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Diagnosis of
99mTc-MAG3
transplant
99mTc-DTPA
rejection

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Renal function
GFR
51Cr-EDTA
Clearance by glomerular filtration
measurement

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Measurement of
Tubular uptake
effective renal
99mTc-MAG3
plasma flow;

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tubular function
Renal
Detection of
99mTc-DMSA
Retention in renal cortex

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morphology
renal infarct
Global renal
morphology
Bladder

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Quantitation of
99mTc-DTPA
Compartmental localization
bladder residual
vesicoureteral

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reflux
Scrotum
Differentiation
99mTc-
Early intravascular localization

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between acute
pertechnetate
testicular torsion
Pulmonary system
Ventilation scan

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Evaluation of
133Xe gas
Distributes in lungs in proportion to
regional
regional

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ventilation
81Krm gas
v
entilation
99mTc aerosols

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Perfusion scan
Detection of
99mTc albumin
Pulmonary capillary blockade
pulmonary

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macroaggregates
emboli, right to
left shunts;
preoperative
and transplant

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evaluation of
relative lung
perfusion
Parenchymal
Interstitial lung

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67Ga
Binds to transferrin in the intravascular
tissue
disease staging
compartment,

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and therapeutic
evaluation
Musculoskeletal
Detection of soft
99mTc-

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Intravascular and early soft tissue
system
tissue vs primary
polyphosphate
distribution (Phase I and II)

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bone disorders
compounds
during Phases I
and II of study
Detection of

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Fixed to hydroxyapatite crystals (Phase Ill)
benign, alignant,
and
infectious bone
lesions

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Thyroid-parathyroid

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Thyroid
Evaluation of
Iodine-123
Active uptake (123I and 99mTc) followed by

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gland size,
organification (123I)
morphology and
function
(uptake).

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99mTc- ertechnetate
Determination
of functional
status of nodules
Detection of

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Iodine-131
Active uptake and organification
thyroid cancer
and metastases,
thyroid cancer

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treatment
Parathyroid
Localization of
99mTc-M IBI
Cationic complexes taken up in proportion

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parathyroid
to
adenoma and
blood flow and trapped in mitochondria
carcinoma

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Tumour markers
Neuroendocrine
Somatostatin
111In-pentetreotide Binds to somatostatin receptors
tissue

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receptor positive
(Octecotide?)
tumours
Lymphopoietic
Staging and

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67Ga (gallium
Binds to transferrin in the intra-vascular
tissue
localization of
citrate)

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compartment, taken up by cancer cells,
lymphoma
binds to lactoferrin and ferritin, and
concentrates in lysosomes
Brain neoplasia

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Brain tumour
201TI (thallous
Concentrates in tumour cells following BBB
staging and
chloride)

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damage
therapeutic
follow up
Adenocarcinom
Tumour

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111In-Satumomab
Antigen-antibody recognition
a
detection and
pendetide

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staging
Miscellaneous
Tumour
18F-deoxyglucose
Uptake proportional to tumour

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neoplasia
detection and
staging
GOLD STANDARD METHODS
? Gold standard for treatment of organ confined, muscle invasive, bladder cancer is ? Radical

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cystoprostatectomy in men and anterior pelvic exenteration in woman
? Gold standard method for management of hydatid disease ? Surgery
? Gold standard method for management of blunt hepatic trauma ? Non-operative management
? Gold standard for treatment of femoral shaft fractures ? Reamed locked intramedullary nailing
? Gold standard method in case of difficult intubation ? Flexible fibreoptic intubation scope

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? Gold standard treatment of hyperparathyroidism ? Surgery
? Gold standard procedure for thymectomy ? Trans cervical mediastinoscopy and surgery
? Gold standard for treatment of adrenal tumors ? Laparoscopic adrenalectomy
? Gold standard method for treatment of GERD ? Laparoscopic Nissens fundoplication

---

? Gold standard for evaluating cure rate in duodenal ulcer patients ? Vagotomy

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? Gold standard method of treatment of Symptomatic cholelitiasis ? Lap cholecystectomy
MAMMOGRAPHY
? Diagnostic accuracy ? 90 ? 95 %
? 45% of breast cancers can be seen on mammography before they are palpable.
Indications:

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? Coarse nodular breast, Fibro adenosis, Woman, aged 40yrs with family H/o cancer
FEATURES
BENIGN
MALIGNANT
Opacity

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-Smooth margin
Ill defined margin(Spiculated)
-Low Density, Homogenous
High density, Wide halo
-Thin Halo

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Calcification
-macro calcification (>0.5mm in diameter)
Micro calcification (<0.5mm in
-egg shell curvilinear, -Popcorn(Fibro adenoma), -
diameter)

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Floating calcification, -Tramline/ tortuous
calcification, -Rod like Wide spread calcification
Skin
Normal
Thickened

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Nipple/ Areola
+retracted
+retracted
Duct
_

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Normal
_
F ocal dilatation
Subcutaneous retro
Normal

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Obliterated
mammary space
Surrounding
Normal
Disrupted

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parenchyma
BARIUM STUDIES
Study of GIT by instillation/ ingestion of barium suspension made from pure barium sulphate.

Procedure

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Organ studied
Barium swallow
Oesophagus
Barium meal
From stomach to proximal jejunum

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Barium follow through
From stomach to ileocaecal junction
Barium enema
Large intestine (administration of contrast via rectum)
Small bowel enema (Enteroclysis)

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From jejunum to ileocaecal junction
DTPA (Reno gram)
DMSA (Isotope scanning)
? DTPA is useful for evaluating perfusion and
? Tc 99 DMSA is used for Renal morphological

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function
imaging
? of each kidney
? This compound gets fixed in renal tubules &
? Indications:

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images may be obtained after 1-2 hours of
1.
Measurement of relative renal function in
injection- Lesions such as tumors & benign
each kidney.

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lesions as show filling defect
2.
Urinary tract obstruction
? Used to assess cortical function of kidney
3.

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Diagnosis of renovascular cause of
hypertension
4.
Investigation of renal transplant

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? MCU is the most accurate method of demonstrating vesicoureteric reflux, and as this is important in children

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with urinary tract infection and reflux nephropathy.
? The ascending urethrogram gives excellent anatomical information concerning the distal urethra as far as the
distal sphincter mechanism.
? Ultrasound and CT are the investigations of choice in the diagnosis and staging of renal tumours.
? Dynamic CT is more accurate than angiography in detecting a small neoplasm.

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? Antegrade pyelography is an accurate method of demonstrating precisely the site of an obstruction to the
upper urinary tract.

---

V.
RADIOTHERAPY

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? Radioactivity was discovered by Henry Becquerel in 1896.
? J.J. Thompson- discovered electrons
? W.K.Roentgen- discovered X Rays in 1895.
? Madam Marie Curie- discovered radioactive substances radium, uranium etc.
? Rutherford- discovered nucleus, alpha & beta rays

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? Chadwick- discovered neutrons
? Maxwell- discovered electromagnetic waves
Radiotherapy is treatment of malignant tumor with ionizing radiation, most commonly by using y rays; which causes
excitation or ionization of electron (ejection of electron from orbit) and kills tumor cells by producing double strand
breaks in DNA (direct) or free radicals (indirect).

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? The DNA molecules present along the chromosomes are the critical targets for radiation damage.
? Chromosomal abnormalities occur in cells irradiated in G1 phase before doubling of genetic material.
? Chromatid aberration occurs in cells irradiated in G2 phase.
? Most sensitive phase to radiation is M> G2M interphase
? Most resistant phase is end of S phase.

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? Lymphocyte analysis provides evidence of recent total body exposure.
? A typical course of radiation therapy should be described as 4500 cGy delivered to a particular target (e.g.,
mediastinum) over 5 weeks in 180-cGy fractions.
? Most curative radiation treatment programs are delivered once a day, 5 days a week in 150- to 200cGy
fractions.

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? Therapeutic radiation is delivered in three ways:
o
Teletherapy, with beams of radiation generated at a distance and aimed at the tumor within the patient
o
Brachytherapy, with encapsulated sources of radiation implanted directly into/adjacent to tumor

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tissues
o
Systemic therapy, with radionuclides targeted in some fashion to a site of tumor.
? Teletherapy is the most commonly used form of radiation therapy.

---

? X-rays and gamma rays are the forms of radiation most commonly used to treat cancer.

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Radiation
Content
Penetrating
Ionizing
Damaging power

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Sources
power
power
- Particle Helium nuclei
Poorest

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Maximum
Most damaging
Uranium,
(i.e. 2 protons
Plutonium

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& 2 neutrons
-Particle
Either high
Greater than -
Lesser than

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< particle
Phosphorous-
energy
particle (100)
particle

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32,strontium-
electron or
89,samarium-
antimatter
132,1-131

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counterpart
positron
X-Ray
Low energy
More than -

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Lesser than
< Particle
photons
particles
particle

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Y-
Very high
More than X-
Minimum
Least damaging

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Co-60, radium -
Radiation
Energy
Rays 10000 i.e.,
ionizing

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126.
photons
Most penetrating
Penetration power: y- ray > x ray > particle > particle
Ionizing & Damaging Power: - particle> -particle> x-ray > y ray

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? Gamma rays are produced by decay of atomic nuclei in radioisotopes like cobalt & caesium.
? For deep seated tumors, X rays & Gamma rays are used, as high energy penetrating beam deliver a less
intense superficial dose & causes less skin damage.
? Electron beams have very low penetrance & used to treat mycosis fungoides.
? I-131: emits both beta & gamma rays.

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? Californium: emits neutron.
? Heating of tungsten filament by battery produces electron beam which is targeted towards positive charged
tungsten or molybdenum containing copper block; this produces X-rays
? Linear accelerator and betatron are used to produce x-ray by accelerating electrons.
Neutrons

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? Uncharged particulate radiation.
? Present in nuclear reactors and at high altitudes.
? Have highest penetrating power.
? Water and paraffin wax are effective in absorbing it.
? Predominant neutron emitter: californium.

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BRACHYTHERAPY
? First proposed by Forssell in 1931.
? Delivered by two methods:
o
Intra cavitatory therapy: Eg: Manchester system for Rx of Ca. cervix

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o
Interstitial implantation: Eg. HDR therapy for Ca. Bronchus & ca. Oesophagus.
? Radionuclides used in brachytherapy:
o
Caesium 137, Cobalt 60, Iridium 192, Iodine 125, Radium 226, Radon 222, Strontium 90, Samarium 145,

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Palladium 103, Gold 198, Yetrium 169.
? The characteristic features of Brachytherapy are:
o
Maximum radiation effect can be obtained in diseased tissue.
o

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Minimum risk of to the normal tissue.
o
It requires trained personnel & Invasive

---

o
It is often used in brain tumours & cervical cancers.

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UNITS OF RADIATION
Feature
S.I. Unit
Non S.I. Unit
Radioactivity

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Becquerel (Bq)
Curie
Absorbed dose
Gray (Gy)
Rad

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Dose equivalent
Sievert (Sv)
Rem
Exposure
Coulombs/ kg

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Roentgen


ISOTOPES USED IN MEDICINE
Reactor Radioisotopes (half-life indicated in brackets):

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? Molybdenum-99 (66 h): Used as the 'parent' in a generator to produce technetium-99m.
? Technetium-99m (6 h): Used in to image the skeleton and heart muscle in particular, but also for brain,
thyroid, lungs (perfusion and ventilation), liver, spleen, kidney (structure and filtration rate), gall bladder,
bone marrow, salivary and lacrimal glands, heart blood pool, infection and numerous specialized medical
studies.

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? Uses of Technetium 99 tagged RBC's:
o
Commonly indicated in Acute Lower Gastrointestinal Bleeding.
o
Relatively sensitive & very specific imaging method for noninvasive diagnosis of liver hemangioma.

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o
Measurement of left ventricular ejection fraction. Assessment of regional wall motion (left and right
ventricles).
? Chromium-51 (28 d): Used to label RBC's and quantify gastro-intestinal protein loss.
? Cobalt-60 (10.5 months): Formerly used for external beam radiotherapy.

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? Copper-64 (13 h): To study genetic diseases affecting copper metabolism. Eg: Wilson's and Menke's diseases.
? Dysprosium-165 (2 h): Used as an aggregated hydroxide for synovectomy treatment of arthritis.
? Erbium-169 (9.4 d): Use for relieving arthritis pain in synovial joints.
? Holmium-166 (26 h): Being developed for diagnosis and treatment of liver tumours.
? Iodine-125 (60 d): Used in brachytherapy (prostate and brain), to evaluate the filtration rate of kidneys and

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to diagnose DVT in the leg. It is also used in radioimmuno-assays to show the presence of hormones in tiny
quantities.
? Iodine-131 (8 d): Used in treating thyroid cancer, imaging the thyroid; in diagnosis of abnormal liver
function, renal (kidney) blood flow and urinary tract obstruction. A strong gamma emitter, but used for beta
therapy.

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? Iridium-192 (74 d): Supplied in wire form for use as an internal radiotherapy source for cancer treatment
? Iron-59 (46 d): Used in studies of iron metabolism in the spleen.
? Lutetium-177 (6.7 d): emits just enough gammas for imaging while the beta radiation does the therapy on
small (eg endocrine) tumours. Its half-life is long enough to allow sophisticated preparation for use.
? Palladium-103 (17 d): Used to make brachytherapy permanent implant seeds for early stage prostate cancer.

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? Phosphorus-32 (14 d): Used in the treatment of polycythemia vera (excess red blood cells). Beta emitter.
? Potassium-42 (12 h): Used for the determination of exchangeable potassium in coronary blood flow.
? Rhenium-186 (3.8 d): Used for pain relief in bone cancer. Beta emitter with weak gamma for imaging.
? Rhenium-188 (17 h): Used to beta irradiate coronary arteries from an angioplasty balloon.
? Samarium-153 (47 h): Sm-153 is very effective in relieving the pain of secondary cancers lodged in

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the bone, sold as Quadramet. Also very effective for prostate and breast cancer. Beta emitter.
? Selenium-75 (120 d): Used as seleno-methionine to study the production of digestive enzymes.
? Sodium-24 (15 h): For studies of electrolytes within the body.
? Strontium-89 (50 d): Very effective in reducing the pain of prostate & bone cancer. Beta emitter.
? Xenon-133 (5 d): Used for pulmonary (lung) ventilation studies.

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? Ytterbium-169 (32 d): Used for cerebrospinal fluid studies in the brain.

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? Ytterbium-177 (1.9 h): Progenitor of Lu-177.
? Yttrium-90 (64 h): for brachytherapy and as silicate colloid for relieving pain of arthritis. Pure beta emitter.
? Radioisotopes of caesium, gold and ruthenium are also used in brachytherapy.
Cyclotron Radioisotopes:

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? Carbon-11, Nitrogen-13, Oxygen-15, Fluorine-18: positron emitters used in PET.
? F-18 in FDG in detection of cancers and the monitoring of progress in their treatment, using PET.
? Cobalt-57 (272 d): Used as a marker to estimate organ size and for in-vitro diagnostic kits.
? Gallium-67 (78 h): For tumour imaging & localization of inflammatory lesions (infections).
? Indium-111 (2.8 d): Used for specialist diagnostic studies, eg brain studies, infection and colon transit

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studies.
? Iodine-123 (13 h): Used for diagnosis of thyroid function, a gamma emitter without the beta radiation of 1-
131.
? Krypton-81m (13 sec) from Rubidium-81 (4.6 h): Kr-81m gas can yield functional images of pulmonary
ventilation, e.g. in asthmatic patients, and for the early diagnosis of lung diseases and function.

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? Rubidium-82 (65 h): Convenient PET agent in myocardial perfusion imaging.
? Strontium-92 (25 d): Used as the 'parent' in a generator to produce Rb-82.
? Thallium-201 (73 h): for diagnosis of coronary artery disease, other heart conditions such as heart muscle
death and for location of low-grade lymphomas.
T1/2 in hours

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T1/2 in days
T1/2 in years
I132-2.3 hours
I131- 8 days; Gold- 2.7 days
Co60- 5.2 years

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Tc99-6 hours
Thallium-3.2 days; Radon-3.8 days
Tritium- 12 years
I123-13 hours
Xenon-5.2 days; P32- 14 days

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St 90- 28 years ; Cs132- 30 years
I125- 60 days
Ra- 1622 years; U? 701 x 108 yrs
Co- 60 has the following features:
? Naturally occurring isotope

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? Atomic. No. 27
? Atomic. Wt. 58.93
? Half- life 5.3 years
? Emits and y- rays
? Used in both brachy & Teletherapy

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Internal Contaminant Radionuclides: Properties and Treatment

Isotope
Symbol
Common

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Radiation
Exposure
Focal
Treatment
Name

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Usage
Type, t%
Type
Accumulation
Radiologic

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in Body
t1/2
Biologic,
days
Manganese

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Mn-56
Reactors,
, y, 2.6 h
External,
Liver

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N/A
research
5.7
internal
laboratories

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Cobalt
Co-60
Medical
, y, 5.26 y
External,

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Liver
Gastric lavage,
radiotherapy
9.5
internal

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purgatives;
devices,
penicillamine in
commercial
severe cases

--- Content provided by FirstRanker.com ---

food
irradiators
Strontium
Sr-90
Fission

--- Content provided by FirstRanker.com ---

, 28 y
Internal
Bones--
Strontium, calcium,
product of

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18,000
similar to
Ammonium chloride
uranium
calcium

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Molybdenum
Mo-99
Hospitals--
, y, 66.7
External,

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Kidneys
N/A
scans
h 3
internal

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Technetium
Tc-99m
Hospitals--
, y, 6.049
External,

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Kidneys, total
Potassium
scans
h 1
internal

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body
perchlorate to
reduce thyroid dose
Cesium
Cs-137

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Medical
, y,, 30 y
External,
Renal
Ion-exchange

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radiotherapy
70
internal
excretion
resins, Prussian

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devices
blue
Gadolinium
Gd-153
Hospitals

--- Content provided by FirstRanker.com ---

, y, 242 d
External,
N/A
N/A
1000

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internal
Iridium
Ir-192
Commercial
0, y, 74 d

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External,
Spleen
N/A
radiography
50

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internal
Radium
Ra-226
Instrument
, , y,

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External,
Bones
MgSO4 lavage,
illumination,
1602 y

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internal
ammonium
industrial
16,400
chloride, calcium

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applications,
alginates
old medical
equipment,
former Soviet

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Union
military
equipment
Tritium
H-3

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Luminescent
, 12.5 y
Internal
Total body
Dilution with

--- Content provided by FirstRanker.com ---

gun sights,
12
controlled water
muzzle-
intake, diuretics

--- Content provided by FirstRanker.com ---

velocity
detectors,
nuclear
weapons
Iodine-131

--- Content provided by FirstRanker.com ---

131I
Reactor
, y, 8.1 d
Internal
Thyroid

--- Content provided by FirstRanker.com ---

Potassium/sodium
accidents,
138
iodide,
thyroid

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propylthiouracil,
ablators
methimazole
Uranium
U-235

--- Content provided by FirstRanker.com ---

Depleted
, , y,
Internal
Kidneys,
NaHCO3, chelation

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uranium,
108 y 15
bones
with EDTA
natural

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uranium, fuel
rods,
weapons-
grade material

---

Plutonium

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Pu-239
Produced
, 2.2 x
Internal
Lungs, bones,

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Chelating with
from uranium
104y
bone marrow,
DTPA or EDTA

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in reactors,
73,000
liver, gonads
nuclear
weapons

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Americium
Am-
Smoke
, 458 y
Internal

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Lungs, liver,
Chelating with
241
detectors,
73,000

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bones, bone
DTPA or EDTA
nuclear
marrow
weapon

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detonation
fallout
Polonium
Po-210
Calibration

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, 138.4 d
Internal
Spleen,
Lavage,
source

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60
kidneys
dimercaprol
Thorium
Th-232

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Calibration
, 1.41 x
Internal
N/A
N/A

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source
1010y
73,000
Phosphorus
P-32

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Research
B,14.3 d
Internal
Bones, bone
Lavage, aluminum

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laboratories,
1155
marrow,
hydroxide
medical

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rapidly
facilities
replicating
cells
CRANIOSPINAL IRRADIATION

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Craniospinal irradiation is used for patients who have, or are at risk for, disseminated disease throughout the CNS
that is not sufficiently responsive to chemotherapy (typically methotrexate).
Aim is to irradiate the entire sub arachnoid space,
Indications:
? Medulloblastoma

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? PNET (pineoblastoma, ependymoblastomas, unclassified).
? Germ Cell tumour with CSF and/or MRI positive for malignant cells.
? Pure germinoma.
? Non Hodgkins Lymphoma with CSF positive for malignant cells.
Total Body Irradiation (TBI)

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? Used as a systemic treatment since 1900 for palliating symptoms or obtaining short term remissions.
? Done for: acute leukemia in adult, high grade lymphomas (intensive cytoreductive chemo radiotherapy
followed by Bone Marrow Transplant)
? Prophylactic Craniospinal irradiation is useful in CNS malignancy which disseminates via CSF or any
malignancy with high risk of CNS spread.

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? They are: Medulloblastoma, Glioblastoma, Germinoma, Small cell lung Carcinoma, ALL, Non Hodgkin's
lymphoma & Leptomeningeal rhabdomyosarcoma.
INDICATIONS FOR TOTAL BODY IRRADIATION
MALIGNANT
NON MALIGNANT

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Leukemias: ALL, AML, CML, hairy cell leukemia
Immune disorders- aplastic anemia
Lymphoma's: NHL, refractory Hodgkin's lymphoma,
Genetic disorders- osteopetrosis,
myelodysplasia, multiple myeloma, mycosis fungoides

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Fanconi's anemia, wiskott-aldrich
syndrome
Pediatric solid tumors: Ewing sarcoma, Neuroblastoma
Adult solid tumors: testicular Ca, Small cell Ca of lung

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? The standard treatment for brain metastases has been whole-brain radiotherapy (WBRT) usually

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administered to a total dose of 3000 cGy in 10 fractions.
? This affords rapid palliation; approximately 80% of patients improve with glucocorticoids and radiation
therapy.
STEREOTACTIC RADIOSURGERY (SRS)
? Introduced by Lekshell in 1951.

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? Treats brain disorders with a precise delivery of a single, high dose of radiation in a one-day session.
? Ideally confined to a lesion of 3-5cm size.
? Stereotactic radiosurgery (SRS) delivered through a variety of techniques including the gamma knife, linear
accelerator, proton beam and CyberKnife can deliver highly focused doses of RT, in a single fraction.
? Focused radiation beams are delivered to a specific area of the brain.

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? It does not remove the tumor or lesion, but it distorts the DNA of the tumor cells.
? The cells then lose their ability to reproduce and retain fluids.
? Most of the beams used today are 4MV or 6MV beams.
? The three basic forms of stereotactic radiosurgery are:
o

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Particle beam (proton)
o
Cobalt-60 based (photon), most well-known machine is the Gamma Knife.
o
Linear accelerator based (linac)

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Indications

? Arteriovenous Malformations
? Metastatic Brain Tumors
? Acoustic

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? Trigeminal Neuralgia
? Neuromas
? Essential Tremor
? Meningiomas
? Parkinson's Tremor/Rigidity

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? Pineal and Pituitary Tumors
? Current research areas include epilepsy,
? Glial Tumors and Astrocytomas
headaches and neuro-psycho conditions.
? Low grade tumors

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INTENSITY MODULATED RADIATION THERAPY (IMRT)
? High precision radiotherapy by computer controlled X-ray accelerator to deliver precise radiation doses to a
malignant tumor or specific areas within the tumor.
? IMRT used in treatment of tumours of:

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o
Breast, Thyroid, lung, Prostate & Gynecological cancers
o
Head & neck cancers
o

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Liver & brain cancers
o
Lymphoma, sarcoma
INTRA OPERATIVE RADIOTHERAPY
? Applied with ortho voltage X --ray

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? Specialized radiation technique for treating deeply located cancers with large single dose, avoiding damage
to the normal tissues.
? Intra operative electron beam followed by photons via X- rays & Gamma rays is the recent regimen.
? Used in pancreatic, gastric & rectal cancers; head & neck cancers, genitor urinary & gynecological cancers,
retroperitoneal sarcomas.

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FAST NEUTRON RADIOTHERAPY (FNRT)
? Uses neutrons of megaelectron volts (MeV) energy.

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? Generated by accelerating either protons or deuterons with cyclotrons or particle accelerators and then
delivering them to appropriate target (mostly beryllium).
? Fission neutrons (1-2MeV) from nuclear reactors can also be used to treat patients.

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? For neutrons of energies used in RT, about 85% of deposited energy is via a knock on reaction (billard ball
type collision) involving the hydrogen nucleus ('H).
? Kinetic energy release in matter (KERMA) is larger in high hydrogen content tissue such as fat or myelin.
? It is the higher energy transfer that gives rise to the different radiobiological properties of FNRT.
? Fast neutrons have RBEs 3 to 3.5 in terms of most normal tissue late effects, RBEs 4 to 4.5 in terms of

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damage to CNS and RBEs 8 for salivary gland malignant tumors.
? Neutron therapy is best used in the treatment of certain tumor that exhibit a resistance to standard low
LET radiotherapy -- a small niche, but it remains a very important treatment option for small number of
patients for whom it appears to be better than tradition forms of treatment.
? Examples.

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o Patients with inoperable or recurrent salivary gland malignant tumors or in high risk situations where
there has been an incomplete surgical extirpation or
o Where inoperable or incompletely resected sarcomas of bone, cartilage and soft tissue or locally
advanced prostate cancers particularly those that are not hormonally responsive have been found.
o May also be beneficial in metastases from melanoma & renal cell carcinoma.

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Boron Neutron Capture Therapy (BNCT)
? Pure beams of very low energy neutrons do not directly deposit much energy in tissue. The basic idea is to
selectively attach a nuclide with a large cross section for capturing thermal neutrons [eg boron 40(10B) or
gadolinium ? 157 (157Gd)] to the cancer cells.
? The nucleide then undergoes a nuclear reaction with the localized release of substantial amount of energy

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and kills the tagged cancer cells but does not damage the surrounding untagged normal cells.
? At present moderated neutron beams from nuclear reactors are used but there is ongoing work in
developing high current particle accelerator to produce low energy thermal or epithermal beams for BNCT.
Californium ? 252 (252CF) Neutron Brachytherapy
? Beneficial for tumors in which hypoxia is thought to be a factor in limiting tumor control with standard

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treatment.
METHODS FOR ORGAN PRESERVATION
QUART Technique
Breast
Intra operative Brachytherapy

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Soft tissue sarcomas
Stereotactic radiosurgery
Small brain tumors
Chemo irradiation
Bladder cancer

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Concurrent chemotherapy
Anal cancer
Plaque therapy
Uveal melanoma
External radiotherapy

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Retinoblastoma & laryngeal cancers
External radiotherapy/ brachytherapy
Prostate, head & neck, gynecological cancers
RADIOSENSITIVITY
Very high

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High
Intermediate
Low
Bone marrow (most),
Skin, growing muscles, bones, Brain,

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Adult bone, Adult
Pancreas,
Testes & ovary,
spinal cord, Pituitary, thyroid ,
cartilage, Oral

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Uterus
Growing cartilage/
salivary gland, Stomach, small
mucosa,
Vagina,

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growth plate/
intestine, intestine, colon, rectum,
Oesophagus Urinary
Adrenals
epiphysis, Breast, Lens

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Liver, lung, heart, kidney, cornea
bladder

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M/C affected ? skin (more commonly moist areas)
Most common skin manifestation- Erythema

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Most sensitive blood cell ? lymphocyte
Most resistant blood tissue- platelets
Most sensitive body tissue- bone marrow
Most resistant body tissue- CNS
Most sensitive cell in CNS- neuron

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Most sensitive CNS part ? mid brain, medulla, spinal cord
Most sensitive abdominal organ- kidney
Most sensitive hormone: growth hormone
Most sensitive mucosa ? intestinal mucosa

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RADOSENSITIVITY OF TUMOURS:
High
Moderate
Relatively Resistant
Highly resistant

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Ewing's sarcoma
Nasopharyngeal Ca
Renal cell Ca
Hepatoma
Seminoma

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Dysgerminoma, Teratoma &
Rectal / colon Ca
Pancreatic Ca
Lymphoma
Ovarian Ca

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Ca Cervix
Osteosarcoma
Wilm's tumor
Medulloblastoma
Melanoma

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Multiple myeloma
Small cell Ca lung
Ca. breast
Basal cell Ca
MOST RADIOSENSITIVE TUMORS

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? Ovarian tumor: Dysgerminoma > Teratoma
? Brain tumor: Medulloblastoma
? Testicular tumor: Seminoma
? Lung tumor: small cell CA
? Kidney tumor: Wilm's tumor

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? Bone tumor: Ewing's Sarcoma & multiple myeloma
RADIOSENSITIZERS
RADIOPROTECTIVE
RADIATION
AGENTS

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POTENTIATOR
? Anti-cancer drugs: Cisplatin , 5-FU, Hydroxyurea
? Amifostine
? Doxorubicin
Vincristine, Bleomycin

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? Sodium butyrate
? Dactinomycin
? Metronidazole, Misonidazole, Etanidazole,
? IL-1
Pimonidazole

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? GM-CSF
? Hyperbaric O2 (Most potent) (not -
cyclophosphamide)
? Amifostine reduces cisplatin-induced nephrotoxicity & also reduces xerostomia in patient with head & neck
Ca.

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? Sodium butyrate when given topically improves the symptoms of radiation proctitis.
RADIO IODINE THERAPY IN THYROID CANCER
? Well differentiated thyroid cancer still incorporates radio iodine, but less efficiently than normal tissue.
? Indication- For tumor that takes up iodine, I131 treatment can reduce or eliminate residual disease.
? Thyroid ablation + I133-Treatment in:

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o
Large papillary tumor
o
Lymph node involvement

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o

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FCT
o
Evidence of metastasis
WILM'S TUMOUR
? The postoperative radiotherapy in Wilm's tumour should be started within 10 days of surgery.

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? Delay in starting RT beyond 10 days leads to tumour cell repopulation and increase in relapse rate.
? Recommended dose: 1.2 to 1.5 Gy per fraction
? Indications of RT in Wilm's tumour are:
Stage II, Ill, IV with unfavorable histology (UH)
Stage III & IV with favorable histology (FH)

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Metastatic disease
Clear cell sarcoma of kidney in all stages.
MEDULLOBLASTOMAS
? Most common malignant brain tumor of childhood, approximately 20% of all primary CNS tumors among
children.

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? Arise from granule cell progenitors or from multipotent progenitors from the ventricular zone.
? Associated syndromes: Gorlin syndrome, Turcot's syndrome and familial adenomatous polyposis.
? Histology: highly cellular tumors with abundant dark staining, round nuclei, and rosette formation (Homer-
Wright rosettes).
? Features: headache, ataxia, and signs of brainstem involvement.

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? MRI: densely enhancing tumors in the posterior fossa, sometimes associated with hydrocephalus.
? Seeding of the CSF is common.
? Treatment: maximal surgical resection, craniospinal irradiation, and chemotherapy with agents such as
cisplatin, lomustine, cyclophosphamide, and vincristine.
BONE SECONDARIES

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Ca. Prostate produce mainly osteoblastic (Osteosclerotic) secondaries.
? Mostly blastic: Bladder, bowel, breast, bronchial, Carcinoid, lymphoma & Prostate [4 Bees Can lick Pollen
? Usually lytic but frequently blastic: Breast
Invariably lytic: Kidney/Thyroid
WEDGE ANGLE

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"The angle which the 50 per cent isodose curve makes with the normal to the axis or "the angle through which the
50 per cent isodose curve has been turned at the central axis"
Internal Contaminant Radionuclides: Properties and Treatment
Isotope
Common Usage

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Exposure
Mode of
Focal
Treatment
Type

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Contamination Accumulation in
Manganese
Reactors, research External,
N/A
Liver

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N/A
laboratories
internal
Cobalt
Medical

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External,
Lungs
Liver
Gastric lavage,
radiotherapy

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internal
purgatives;
devices,
penicillamine in
commercial food

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severe cases
irradiators
Strontium
Fission product of
Internal

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Moderate GI
Bones--similar
Strontium, calcium,
uranium
tract

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to calcium
ammonium chloride
Molybdenum Hospitals--scans
External,
N/A

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Kidneys
N/A
internal

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Technetium
Hospitals--scans

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External,
IV
Kidneys, total
Potassium perchlorate
internal

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administration
body
to reduce thyroid dose
Cesium
Medical

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External,
Lungs, GI tract,
Renal excretion
Ion-exchange resins,
radiotherapy

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internal
wounds,
Prussian blue
devices
follows

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potassium
Gadolinium
Hospitals
External,
N/A

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N/A
N/A
internal
Iridium
Commercial

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External,
N/A
Spleen
N/A
radiography

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internal
Radium
Instrument
External,
GI tract

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Bones
MgSO4 lavage,
illumination,
internal
ammonium chloride,

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industrial
calcium alginates
applications, old
medical
equipment,

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former Soviet
Union military
equipment
Tritium
Luminescent gun

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Internal
Inhalation, GI
Total body
Dilution with
sights, muzzle-

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tract, wounds
controlled water
velocity detectors,
intake, diuretics
nuclear weapons

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Iodine-131
Reactor accidents, Internal
Inhalation, GI
Thyroid
Potassium/sodium

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thyroid ablators
tract, wounds
iodide,
propylthiouracil,
methimazole

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Uranium
Depleted
Internal
GI tract
Kidneys, bones

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NaHCO3, chelation
uranium, natural
with EDTA
uranium, fuel
rods, weapons-

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grade material
Plutonium
Produced from
Internal
Limited lung

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Lungs, bones,
Chelating with DTPA
uranium in
absorption,
bone marrow,

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or EDTA
reactors, nuclear
high retention
liver, gonads
weapons

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Americium
Smoke detectors,
Internal
Inhalation, skin Lungs, liver,
Chelating with DTPA

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nuclear weapon
wounds
bones, bone
or EDTA
detonation fallout

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marrow
Polonium
Calibration source
Internal
Inhalation,

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Spleen, kidneys
Lavage, dimercaprol
wounds
Thorium
Calibration source

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Internal
N/A
N/A
N/A
Phosphorus

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Research
Internal
Inhalation, GI
Bones, bone
Lavage, aluminum

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laboratories,
tract, wounds
marrow, rapidly
hydroxide, phosphate
medical facilities

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replicating cells
Abbreviations : DTPA, diethylenetriamine pentaacetic acid; EDTA, ethylenediamine tetraacetic acid

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MANAGEMENT PROTOCOL OF RADIATION INJURY

*****END*****

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