2020 SPRING/SUMMER EDITION ISSUE 28
A CONTINUING CELEBRATION OF 50 YEARS OF THE SOCIETY
2020 SPRING/SUMMER EDITION ISSUE 28
Contents
• • •
A glimpse of the Society's online archive A brief history of Nuclear Medicine and PET in Queensland Nuclear Medicine in a paediatric hospital over the years 1975-2017: a historical perspective with emphasis on administered patients' activities
• Role of 18F-FDG PET in the Management of Gestational Trophoblastic Neoplasia - A Case Study • Immunotherapy-Related Nephritis in a Melanoma Patient - A Case Study • Lymphangitis – A Suppurative Case Study • Rhenium-188 Cutaneous Brachytherapy for Non-Melanomatous Skin Cancer
Design & Production
Ester Gomez, Creative Director Enovate Studio ester@enovatestudio.com www.enovatestudio.com
Disclaimer
Editorial
Events & Advertising Enquiries
Rajeev Chandra, General Manager PO Box 6178, Vermont South, VIC 3133 1300 330 402 (03) 8677 2970 secretariat@anzsnm.org.au
marketing@anzsnm.org.au
Submissions secretariat@anzsnm.org.au
The views expressed in any signed article in the journal do not necessarily represent those of the Society. The individual rights of all authors are acknowledged. © 2019 The Australian and New Zealand Society of Nuclear Medicine. Copyright is transferred to the Australian and New Zealand Society of Nuclear Medicine once an article/paper has been published in the ANZSNM Gamma Gazette (except where it is reprinted from another publication).
From the President
I
t’s hard to believe that we are nearly at the end of another fast-paced year - I am sure we are all wondering where this year has gone! Since my last report in our Winter Edition, I have had the opportunity to attend a number of meetings both internationally and locally. I attended the EANM Congress in Barcelona in October, where we had a booth promoting the 2020 ASM Conference. Meetings in Barcelona included with EANM Executive, EANM Educational committee, SNMMI Executive and SNMMI Technologist group. Focus areas for ANZSNM continue to be educational initiatives/CPD opportunities and research activities, with ARTnet gaining a high international profile in clinical trials activities. There was also the opportunity for global discussions including on radioisotope supply, and also on future directions in Nuclear Medicine, in particular in therapy/theranostics. Preceding my trip to Barcelona I travelled to Rotorua, New Zealand where I had the chance to interact with the New Zealand Branch and to present at their conference which was, on this occasion, hosted jointly with the NZMIRT. I was able to attain insight into the challenges that our New Zealand members face, some of which are unique to New Zealand, and others which are common themes. Aside from the usual welcoming Kiwi hospitality, I was impressed by the energy of the NZ branch committee, and I look forward to their enthusiasm and ideas. Upon my return from Barcelona, I travelled to Canberra for the Capital Forum, where I provided an update on ANZSNM and ARTnet activities. Recently, I also attended and presented at the NSW Branch meeting in Sydney, which was co-hosted with the RAINS conference. Attending both the ACT branch and NSW branch meetings highlighted the educational strength of ANZSNM, and also provided a great opportunity for me to meet with branch members and industry/sponsors. Continuing the education theme, the TSIG symposium this year was held in Fremantle, and I was able to attend for part of this day. This was another excellent meeting with a varied program, and I enjoyed meeting and interacting with our technologist group. Education and networking are key activities for ANZSNM, and I would like to thank everyone who volunteers their time to ensure the success of these important activities for our profession. I cannot reflect on the last few months without discussing the issues of the Mo-99 production failure in ANSTO’s ANM facility, and its impact on our Nuclear Medicine community. The mechanical failure occurred in early September, and there has been a 2-month period of sourcing overseas Mo-99 in order to provide Tc-99m in Australia. As with the generator production issue last year, the focus has been on patient care and minimising patient impact, whilst trying to balance the complexity of supply needs/practice locations. The efforts of the members of ANZSNM, AANMS and RAINS who participated in the working group with representatives from ANSTO, GMS, NSW Health Ministry and TGA is greatly appreciated. ANZSNM particularly acknowledges Dale Bailey for his contribution to the working group, and for his leadership in ensuring communication to members. It is important that we continue active discussions regarding reliable radioisotope supply in Australia, and that we engage with Government on these critical issues. As I finish this last message for 2019, I encourage you to reflect again on our history over the last 50 years, which we have highlighted in each Gamma Gazette this year. In continuing the 50th anniversary celebrations, we celebrate our 50th ASM in Sydney from 24-26 April 2020. We look forward to this event with great anticipation. Abstracts and registrations are now open, so please visit the conference website and be amazed at the educational program! Lastly, I would like to wish you and your loved ones a wonderful festive season as we get ready to welcome the next decade! See you in the new year.
Roslyn Francis, President
Roslyn Francis 2020 Spring/Summer Edition gamma GAZETTE 3
Introduction to the Spring/Summer Edition
W
elcome to the 2020 Spring/Summer Issue of the Gamma Gazette. As the 2019 year is coming to a close, we look back and reflect on the year that has been our 50th year. All branches have had many successful meetings and workshops highlighting the community and knowledge that is involved throughout the Nuclear Medicine Society. Next year, the Commemorative 50th Annual Scientific Meeting will be held from April 24-26th 2020 in Sydney. “Local Innovation, Global Inspiration� is the theme and there are flexible registration options for one-day, two days or three days to suit travelling domestic and international colleagues. This has been designed after feedback from you. Calls for Registrations and Abstracts for posters and presentations are now open. Please get involved and try and find any interesting cases. Congratulations too to all the successful Radpharm applicants from each state who will make it there. Membership for the ANZSNM is now open for renewal also and it is great to be involved in such a supportive and educational community. The ANZSNM Early Career Community is also an initiative put forward this year to encourage professionals within their early career (first 8 years) to share experiences, leadership opportunities and network. The aim is to improve support, growth and collaboration within the nuclear medicine industry. We encourage all colleagues that are eligible to join if interested. Head to the Facebook page for more information. As a branch, Western Australia have been brainstorming and discussing the strong need for technologists in our state and ways in which we could go about promoting Nuclear medicine within WA to the rest of the community. Thank you to those who contributed to this edition and to the effort of all committee members involved in another successful year. A warm and festive season to you all. Tiffany Briggs - Branch Chair, Western Australia
CALLS FOR ABSTRACTS IS NOW OPEN Submissions close on 27 January 2020 4
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For all details and submissions, visit anzsnmconference.com/anzsnm2020
Branch News Western Australia Branch News
T
he WA Branch has had a busy time recently, starting with our Annual Workshop in early August. The theme for this year’s Workshop was “PET in Oncology – New Indications, New Opportunities” and we had a day of excellent presentations from a large number of invited speakers from across Perth. We had over 90 people join us throughout the day which is a new record attendance for our Annual Workshops. This included our brilliant speakers, our generous and supportive industry sponsors as well as a huge number of people from our local WA Nuclear Medicine Community. Thank you to everyone who joined us on the day, we hope you enjoyed it as much as we did. Thank you to everyone on the committee for all your hard work and support in once again producing a valuable educational day for the WA Nuclear Medicine Community. The TSIG also held its Annual Day Symposium in Perth this year in late August and it was a fantastic day. The speakers we heard from were engaging and generated plenty of conversation in the breaks. Everyone who attended the day thoroughly enjoyed themselves but I have to say it was a little bit disappointing from our WA branch committee’s point of view that more WA technologists did not attend. Many people didn’t take the opportunity to not only hear some fantastic presentations that we otherwise would have missed out on but the day was also a great opportunity to build relationships with people from interstate and also gain some substantial CPD hours. Most of us don’t often get to travel to interstate meetings and this really was a great experience to be a part of. Most recently the WA Branch held its Radpharm presentation night at Fiona Stanley Hospital. While we didn’t have any nominations this year the meeting was bursting with information about the upcoming PET Medicare rebate for breast cancer patients and an eye-opening first-hand account of what it is really like to be audited by AHPRA and with what speed and in what detail we will be required to act! We concluded the meeting with an open forum hosted by our President, A/Prof Ros Francis, about the current state of the Molybdenum shortage and how it is being handled, what we could potentially expect and how we can all play our part. We feel like WA is doing really well in this very unpredictable and difficult environment affecting all of us in Nuclear Medicine. It was a good opportunity for people to ask questions and talk about various options as a collective group. We will conclude our year with our AGM at the Perth Children’s Hospital in November and an unofficial social event was planned for Spring too. Georgina Santich – Branch Secretary, Western Australia
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Branch News Victorian/Tasmanian Branch News
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n Saturday 21st September, nearly 60 technologists gathered at the RACV Club in Melbourne for the VIC/TAS Branch Annual Day Seminar, this year more aptly titled as the Research Master Class. We had sent invitations for presentations from departments who are involved with current research. As such, we had a variety of speakers on different topics discussing all facets of the research process.
First up was Dr Jo Pinson, who was a technologist for to two weeks prior to surgery means it is less intrusive over 20 years before returning to studies to complete her for patients and there is less pressure on the day of the Honours (firstly) and then a PhD in Medicinal Chemistry. surgery to get a hookwire and a sentinel node localization She was able to discuss the trials and tribulations of performed prior to surgery. This was then followed research work and that “not getting the expected answer by a talk from Jason Bradley who is the Chief Nuclear Medicine Technologist at Monash, where these ROLLIS was not always a bad thing”. Her current role as the seeds are being used. He gave us an overview of how they Research Co-ordinator (Allied Health Transition Lead) has her overseeing allied health professionals set up the protocol for using these seeds, as well as and creating a research culture within some of the regulatory steps that needed to be departments. completed. Our second speaker was Lisa After a lovely lunch and a chance to MacFarlane from Peter MacCallum Not getting the expected catch up with colleagues, we snuck Cancer Centre, who gave us an the AGM in before we had Kate overview of “the village” it takes for answer was not always Francis from Austin Hospital talking clinical trials. She took us through about their soon to be installed MRI each of the stages of clinical trials, a bad thing. Linac machine for radiation therapy from the lab to translational research treatment. This cutting edge technology Dr Jo Pinson with the small animal scanner, and allows imaging of the treatment areas the cancer experience with patients in real time, meaning the treatment beam undergoing clinical trials. She also took us can be easily modified at each session. She through some examples of trials currently being also gave an overview of the technical issues that performed at the Peter MacCallum Cancer Centre and had to be overcome when introducing a magnetic field how different protocols can affect the day to day running to a machine that already uses many magnets to steer the of a busy PET department. electron beam. After morning tea, we had Dr Brett Paterson, who is a Last but not least, in the absence of any Radpharm synthetic inorganic/organic chemist, speaking about the presentations, we had Vivienne Interrigi speak to us about process of creating molecules in the lab and getting them her cancer journey with a breast cancer diagnosis in 2018. to the stage where they can be used for clinical imaging. After spending the day learning about all of the future He showed us through some of his work with Cu-64paths that Nuclear Medicine and PET may take, it was Sartate, as well as some of the advantages and pitfalls with nice to be reminded that at the end of the day, we are there using this isotope. for the patients. We then had Dr Chilton Chong, a Breast Surgeon, The VIC/TAS branch would like to thank all of the speaking about his experience with ROLLIS at Monash wonderful speakers who presented and the technologists Health. ROLLIS (Radioguided Occult Lesion Localisation that came along to hear them. I’d also like to say a big using Iodine Seeds) is where they use small I-125 markers thank-you to the branch committee members who worked or “seeds” to localise breast tumours prior to resection. so hard to ensure a well-run and interesting day. This procedure has replaced the need for a hookwire in their hospitals, and the fact that it can be performed up Kim Jasper - Branch Chair, Victoria/Tasmania
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Branch News
Lisa MacFarlane (left) and Jo Pinson (right) Dr Jo Pinson
Lisa MacFarlane
Dr Brett Paterson
From left to right, Christian Testa, Kim Jasper, My Linh Diep, Suzanne McGavin and Jessica Welch
Dr Chilton Chong
From left to right, Jo Pinson, Brett Patterson, Jason Bradley, Chilton Chong, Vivienne Interrigi and Kate Francis
Kate Francis
Jason Bradley
Vivienne Interrigi
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Branch News New South Wales Branch News
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he NSW Branch continues to remain relatively dormant due to a chronic decline in interest in mid-week evening meetings over the last few years. This probably has as much to do with Sydney traffic at 5-6pm as anything else. In place of the quarterly meetings that were previously held, there is a one day symposium held in Sydney each year in conjunction with the RAINS group. Saturday, the 2nd of November was the date for this year’s meeting, which was held at the Mercure Hotel on Broadway, near Central Station. The programme was developed by the NSW branch and RAINS to have a broader appeal to all members of the Society. The ANZSNM President, A/Prof Ros Francis, was a featured speaker. If any NSW members have any comment or feedback on the current situation or ideas for future symposia or mid-week meetings likely to generate significant interest please let the members of the branch committee know (Andrew Cluff (RNS): andrew.cluff@health.nsw.gov.au; James Player (POWH): james.player@hotmail.com; Dale Bailey (RNS): dale.bailey@sydney.edu.au. Dale L Bailey - Branch Chair, New South Wales
South Australia Branch News
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ur most recent meeting was hosted by Benson Radiology at their North Terrace department. It was a full house event, but we managed to fit everyone in. Rachel Watherston presented "Our experience with PSMA: From 68Gallium to 18Fluorine" and followed it with a tour of their new PET facilities.
My own role as Chairperson of the SA Branch is up for nomination for the 2020/2021 term. It has been a wonderful opportunity to host our regular branch meetings and learn more about the hard work the Society as a whole contributes to the nuclear medicine community both locally and nationally. I encourage any interested SA members to submit their nominations to the secretary (Tess Smith) prior to the branch AGM. The branch AGM and Quiz night is being held at the Belgium Beer Bar cafĂŠ once again on Wednesday 27th November. The SA technologist group AGM was held on Wednesday 20th November at the Coopers Alehouse. The
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state Radpharm award presentations will occur, as well as the opportunity for UNISA students to present their final presentations and Honours projects. RSVPs for this event is via the ANZNSM website under the calendar of upcoming events. We look forward to what is always a fun and educational couple of nights for the Adelaide nuclear medicine community to finish the year. Elyse Langeluddecke - Branch Chair, South Australia
Branch News
Queensland Branch News
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n the 27th of August the QLD branch held the third meeting of the year at the Translational Research Institute (TRI) in Brisbane. I’m very pleased to say that for each meeting we have held in 2019 the number of attendees has been growing in rapid increments. With the help of TRI and The University of Queensland we were able to again offer attendance via videoconference to members right across the state, with excellent feedback from those who joined us on the night.
The first speaker of the night was Andrew Dixon from NSW Health who spoke to us about the logistics of performing 18F-PSMA imaging at Lismore Base Hospital. A very interesting insight, it was fantastic to learn that these types of imaging services are now available outside metropolitan cities. Following on from Andrew, Mark Couperthwaite spoke on behalf of our sponsor for the event, Cyclotek, about the cyclotron facility located on the Princess Alexandra Hospital (PAH) campus and its development over the past few years. A hot topic which shows no signs of cooling off any time soon, Cardiac Amyloid. Dr Dariusz Korczyk a Cardiologist from the PAH gave us an update on how Nuclear Medicine has moved its way up the flowchart as a diagnostic tool and how imaging performed contributes to overall patient management. Our last speaker of the evening was Renae McBrian a Radiographer from PAH who presented on recycling in the workplace. Renae has been making waves in the media most notably on ABC’s War on Waste. Thanks to projects launched by Renae and the team at PAH 600,000 tons of waste was diverted from landfill in 2018 alone. Her presentation got us all thinking about how we could be working more sustainably in everyday practice. The QLD branch committee is currently hard at work finalising the last meeting of the year, inclusive of the QLD Radpham award along with plans for our bi-annual symposium which will take place in 2020. I wish you all a very happy and safe end of 2019 and I look forward to seeing many of you at upcoming events within the new year. Sarah Daniel - Branch Chair, Queensland
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Branch News
Australian Capital Territory Branch News
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On the 19th of October, the ACT branch of the ANZSNM hosted its annual Capital Region Forum at The East Hotel. This is the second time this event has been run, with attendees travelling from as far as Wollongong. The day was held over five hours across the middle of the day, allowing time for those travelling from regional areas to attend. The Program covered a broad range of topics with presenters from a variety of specialties, there was something for everyone to learn. The morning opened with a welcome to country by Federal Council Representative Nick Ingold, who then started off the program by introducing A/Prof Roslyn Francis, ANZSNM President. A/Prof Ros Francis provided an update on ANZSNM business, including current CPD opportunities being offered through the Edutrace system, and an update on the current supply of Mo99/Tc99m generators from ANSTO. Ros also gave a brief introduction of ARTnet, the joint venture between ANZSNM and AANMS. Ros outlined the purpose of ARTnet and touched on some of the completed trials and current research projects that are ongoing as well as some new trials that have or will be commencing in 2019/20. Ross Bevan, Chief of NM from Canberra Health Service, stepped up to present the second item on the program, as Dr Sean Barrett had other commitments. An interesting case of the wandering spleen highlighted the broad variety of investigative imaging Nuclear Medicine offers from heat damaged Labelled Red Blood Cell Scans to PET/CT. A patient presenting with incidental findings of soft tissue masses on a chest x-ray, reported unexplained fatigue and weight loss, and with the help of Nuclear Medicine, was able to avoid an invasive and potentially high risk biopsy. Combined scanning and reporting by dual trained radiologists meant that Nuclear Medicine Imaging could verify what other modalities such as CT and MRI could not. It was proven through non-invasive NM Imaging that the masses found in the patient’s lung cavities were in fact thoracic splenosis from a motorbike accident around 30 years ago, and not metastatic lesions from an unknown primary source. Colin Mercer of Canberra Imaging Group lightened the mood with an entertaining presentation of some unusual PET cases performed at CIG and educated the room on understanding their PETential. Four cases were presented including “the case of the not so solitary pulmonary nodules”, and the kidney that had moved into a patients’ thorax cavity.
Helena Bush and Maia Bobrowski
Branch News Dr Iain Duncan from Garran Medical Imaging presented an informative talk about XSPECT/CT Bone and its impact on reporting and diagnosis. Dr Duncan presented substantiating evidence that using XSPECT/CT Bone increased the number of lesions identified by 2.4 on average and changed the diagnosis for 20% of reports completed when compared with SPECT/CT alone. As with most events, lunch was a major highlight in the program, with a wonderful spread put on by Agostinis Italian restaurant. Lunch on the day was sponsored by Bayer, the major sponsor of our event. Attendees enjoyed a well-earned brain break and some casual chat with colleagues before launching into the afternoon program. Matthew Cook, Professor of Medicine at the Australian National University, Director, Canberra Clinical Genomics and Centre for Personalised Immunology, started off our post lunch proceedings with an introduction to clinical genomics and precision medicine. Prof. Cook explained the technological advances being made in genome mapping and the benefits that have been seen by the 40% of patients who have shown genetic variants identifiable as the cause of clinical symptoms. Genomic mapping has allowed doctors to consider genetic variations rather than just environmental influences to be the cause of some pathophysiological processes. This is paving the way for the use of precision therapy options to treat the root cause, rather than applying conventional medications, which may only address symptoms. Hemant Verma, Validation Associate of Radpharm Scientific was kind enough to educate attendees on the extensive processes involved with good manufacturing practices. Radpharm was founded in 1986 and distributes products throughout Australia, New Zealand, South America, Asia and the Middle East. Radpharm was the first cold kits manufacturing company in the world to replace animal testing with HPLC. Kate Leary, Clinical Coordinator of Medical Imaging at the University of Canberra, provided insight into the role of clinical coordinator, and the challenges and responsibilities that come with the role. Valuable information was also provided on the assessment process for students, and the importance of providing feedback. Kate also provided examples of practical tools to help broach challenging or difficult conversations with a student, and discussed how those not meeting acceptable standards are put on “learning plans�. The Capital Region Forum was well received this year with a change in venue from last year, this year being held at East Hotel. The ACT Branch AGM saw a handover of some roles to new nominees while some positions were retained by those previously filling them. Discussions for organising the Capital Region Forum again next year have already begun, please keep an eye out for notifications to save the date for 2020. The program concluded on schedule, with afternoon tea and beverages enjoyed on Agostinis Terrace, sponsored by GMS. Canberra put on some impressive Spring weather and those who stayed certainly appreciated the sunshine and light atmosphere provided by our chosen venue. Rachael Prior - Branch Secretary, ACT 2020 Spring/Summer Edition gamma GAZETTE
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Branch News
New Zealand Branch News
M
erry Christmas from New Zealand to all our ANZSNM colleagues! It’s the time of the year when our department workloads start to increase, as the push to get scans performed and reported before Christmas goes a bit nuts. At the same time, daylight savings means we all want to be outside, making the work-life balance tip in the favour of life away from work. We would like to share our sympathy with those living in areas of Australia who have suffered through the recent bush fires. These fires are on such an enormous scale, such devastation to the landscape, wild life and the people living in these areas. Victoria Brooks is very well known to many ANZSNM members. Victoria has been the Charge NMT at Taranaki Base Hospital in New Plymouth for 34 years, and has contributed hugely to the NZ branch and Federal Council, most recently as our branch Chairperson. In January 2020, Victoria will leave Taranaki for a new adventure, detonating (sorry renovating!) a house on the Whangaparaoa Peninsula, north of Auckland. Always extremely passionate and supportive of the Nuclear Medicine community in NZ, Victoria has fought hard for her patients to have access to quality Nuclear Medicine examinations. Her drive to see a public PET department and better access to PET scans for public patients is inspiring and our branch and its members will miss Victoria’s enthusiasm. FOMO means Victoria will attend the social functions in Sydney next year, much to the enjoyment of her NZ peers - who are hoping she will design our costume for the Gala dinner! Congratulations to Prue Lamerton, Unit Charge Nuclear Medicine at Hastings Hospital, on winning the EANM’19 Best Regional e-Poster at the meeting recently in Barcelona. Prue’s poster, titled “Discovery, A New Zealand Nuclear Medicine Department voyage that has made a real difference” discussed the utilisation of hybrid SPECT/diagnostic CT scanners and the expanding role within Nuclear Medicine and Radiology departments in New Zealand. In public Radiology departments, rolling NMT/MIT 24-hour strikes have meant NM department waiting lists are ballooning out. Negotiations broke down in early November, and this week (25th November 2019) facilitation is taking place between the NMT/MIT union, APEX, and the MoH and DHB’s. From early 2020 the New Zealand MRTB (equivalent to AHPRA and the MRPBA) will offer an online examination as a pathway for registration for NMT’s wanting to work in New Zealand. The online exam will be offered to those overseas applicants with academic qualifications and clinical experience that have been assessed as not being equivalent to that of an entry-level practitioner in the scope of practice of NM. This will not apply to our Australian colleagues, who under the Trans-Tasman Mutual Recognition Act 1997 (TTMRA) are automatically eligible to register and work here as NMT’s. Finally, congratulations to the Department of Medical Imaging at the University of Auckland for having their application for a named nuclear medicine specialisation approved. All students now undertaking the Nuclear Medicine pathway of the Postgraduate Diploma in Health Sciences (Medical Imaging) will gain the qualification of PGDipHSc (Nuclear Medicine). From the NZ branch, Meri Kirihimete me te Hape Nū Ia” (e kī ana te Pākehā) ki ngā iwi me ngā hapū katoa. Pru Burns - Branch Chair, New Zealand 12
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Special Interest Group News
Technologists Special Interest Group
F
remantle, WA played host to 2019’s ANZSNM Technologist Special Interest Group Annual Day Symposium. The 40 technologists in attendance were treated to a fantastic day. The morning started with a focus on unique patients and Nuclear Medicine’s role in providing care to unique patients. Vicki Sigalis shared how a technologist can access the expertise of a multi-disciplinary team in dealing with a very complex patient, and Judy Duong shared a case study of a world Roslyn Francis (top); Chris Wood (bottom left) and Jack Meadows (right) first 3D printed tibial replacement. There are some very exciting developments being made in our industry. In the session sponsored by Siemens Healthineers, the President, A/ Prof Ros Francis updated us on the research being undertaken through ARTnet, and Simone Culleton reported on the fascinating history of PET in WA. The value of the TSIG symposium is that it can focus on what is highly relevant for Technologists. One such relevant issue arose from the MRPB’s recent communications regarding scope of practice which highlighted the need for health professionals to be able to identify and respond to deteriorating patients in their care, and to be able to identify when scans indicate an urgent response is required. Our response to this communication would be a theme of this symposium. Chris Wood, the lead CT radiographer at Fiona Stanley Hospital shared the ‘Must know CT Pathologies’, and nurse Tammy Hagen lead a discussion around identifying and responding to deteriorating patients. These topics sparked much discussion, and it was very exciting to hear technologists from all over Australia sharing their professional knowledge and experiences. We were also able to hear from technologists who work in unique settings. Dr Karen Jones shared what a career in research can be for a technologist, and the impact that she and her team are having in diabetes research through using gastric emptying scans. Jack Meadows and Pete Tually shared their passion for providing health care to rural Australia, and the unique challenges and rewards that this brings. In the final session for the day Tiffany Briggs, on behalf of MIPS, helped us to have a healthier response to mistakes and accidents that we might encounter, and how to create an environment where these can be dealt with compassionately and professionally. Congratulations to all the first-time speakers who all did a marvelous job and showed that they are experts in their field. Thank you to all the sponsors who made this event possible: Siemens Healthineers, MIPS, Imaxeon, Gamma Gurus, ANSTO, Landauer, and GMS. Thank you also to the WA state branch who helped connect us with speakers, and well done to the TSIG CPD&E committee members who were part of the organising committee. Nick Daw – Chair
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Special Interest Group News
Scientific Advisory Panel (SAP) Update
T
he Scientific Advisory Panel exists to assist the Society by providing advice of a scientific nature on a range of matters including: • Supporting the individual ANZSNM Annual Scientific Meeting (ASM) Local Organising Committee(s) (LOC) in determining the scientific content and invited speaker selection for the annual scientific meeting; • Ensure the format and quality of the ASMs is maintained at a consistent and high level; • Ensure the abstract review process for the ASM is fair and equitable; • To guide the LOC in selection of appropriate persons for named lectures at the ASM (e.g., Lowenthal, Pioneer, etc); • Oversee the ANZSNM ASM awards and Annual Research Grant process; • Advise Federal Council of ANZSNM on matters of a scientific nature; • Act as a liaison to Federal Council on scientific issues and content of the ASM to meet the needs of the participants and their disciplines (e.g., ANZSNM TechSIG, AANMS, ACPSEM, etc); • To make recommendations to the Federal Council on ANZSNM participation in other scientific and educational meetings.
There has recently been a number of founding SAP members who have stood down to allow for new members to join the panel. We would like to thank Prof Andrew Scott, Prof Vijay Kumar, A/Prof Paul Roach and Dr Liz Bailey for all of their efforts in guiding the SAP from its inception to the current day. Expressions of Interest from individuals to replace the vacancies created by these resignations have been received and the announcement of the successful applicants will be made after the November meeting of the Federal Council. Dale L Bailey - Chair
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Special
years of History
From the Archives
glimpse of the Society's online archive, currently holding approximaterly 200 files since the establishment of the Society over 50 years ago. What can you expect to see in the online archives to date? Currently the online archives include the following: • Branch reports • Committee reports • Conference Awards • Australia Day Honours List • Honorary Life Members • Members • Obituaries • History Book • Victorian Pioneers Meeting information • ANZSNM Nuclear Medicine News (1970 – 1978) • ANZSNM Nuclear Medicine Newsletters (1979 – 2010) • Papers • WFNMB 6th World Congress Communication and Publications • List of Past Presidents including a script about Dale Bailey (2016-2018) and 5 Past President Reports. What can you expect to see in the online archives in the future? Many of the categories listed above will continue to be expanded upon. However, the section that is still waiting to be developed will display all of the photos held by the Society. Many of these have been scanned and will start to be uploaded to the website in the coming months. The photos in this article are from conferences held in the 1980s and represent the earliest conference photos we have on record. The first three were taken at the 1985 conference in Manly and the last one at the 1989 conference in Melbourne. If you have conference photos from the 1980s or earlier that you would like to contribute to the Society’s Archive please send to archives@anzsnm.org.au Debra Huddleston - ANZSNM Historian/Archivist Photos left page: (Left) Mr. Chris McLaren, Royal Canberra Hospital receives the 1985 Mallinckrodt award from Mallinckrodt representative Mr G. Molk. (Middle) A flower tribute well and truly earned - presented by the president to the convenor, Dr Josephine Wiseman. (Right) Dr Hoschi, the retiring president with his successor, Dr I. Surveyor from Perth.
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Brief History of Nuclear Medicine and PET in Queensland Authors: Sarah Daniel and Richard Boytar
Whilst we are currently celebrating the 50th year of the ANZSNM, it’s a great opportunity to reflect on our profession here at home. From where we started out with the use of rectilinear scanners and iodine therapy to today’s sophisticated hybrid imaging technology and the resurgence of therapy in Nuclear Medicine. We have much to celebrate here in Queensland and are very fortunate to house state of the art facilities across the state. In most recent years we have seen a rapid increase in the number of sites offering PET/CT. In 1999 the first PET scanner was installed at The Wesley Hospital and since then we now have 17 sites currently offering PET/CT services across the state of Queensland. We would like to thank A/Prof David Wong, Matthew Griffiths, Judy Duong, Sue Rattray and Jye Smith for their contributions to this article.
Special Feature - 50 years of history
1960s Royal Brisbane and Women’s Hospital Image 1 - Mr. Stratigos, Mrs. Greaves and Mr. Tooth observe a patient undergoing thyroid imaging on a rectilinear scanner
1969
The Australian and New Zealand Society of Nuclear Medicine is founded
1979 Princess Alexandra Hospital Image 2 – Toshiba advertisement of the Jumbo gamma camera The first gamma camera installed at Princess Alexandra Hospital (PAH) was a Toshiba Jumbo.
1981-87 Princess Alexandra Hospital
Image 3 – Michelle Jenkins at the Vax computer with WAM module in 1990 The first Nuclear Medicine Technologist in a Queensland Public Hospital was Julia Squires in 1981. The first senior position in Nuclear Medicine was Michelle Jenkins in 1987.
1980s ANZSNM Conference Image 4 - Queensland Nuclear Medicine staff enjoying the gala dinner at an ANZSNM conference held in Canberra.
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Special Feature - 50 years of history
1981-87 Image 5 – Matthew Griffiths, Carolyn Keith and Dr Ken Miles at the installation of Queensland’s first PET scanner
Princess Alexandra Hospital
On Monday the 8th of February 1999, Dr Ken Miles, Dr James Walters and Dr David Wong performed the first 18F-FDG PET scan at The Wesley Hospital in Queensland. The Wesley Hospital was not only home to Queensland's first PET scanner, but it was also the first to be installed into a private facility across the country. Fluorine-18 was flown in from Victoria and labelled to FDG inhouse prior to the first cyclotron installation (GE Minitrace) by Southern X-Ray in 2003 at Kelvin Grove.
2000 Princess Alexandra Hospital Image 6 – Dr John Anderson the first Director of Nuclear Medicine at PAH testing the Siemens E-cam after its installation in the new hospital In the late 1990s, construction began on the new Princess Alexandra Hospital; the new main hospital building was officially opened in 2001.
2005 Royal Brisbane and Women’s Hospital
Image 7 – Delivery of the Cyclotron In February 2005, excavation began for the installation of what would come to be Queensland Specialised PET Services inclusive of an in-house cyclotron and PET/CT scanner. The cyclotron vault required concrete walls that were 1.8 meters thick. Ice was used to chill the concrete to stop it setting to enable the walls and floor to be created from a single pour.
2005 Royal Brisbane and Women’s Hospital Image 8 - Dr Aravind Ravi Kumar, Dr William Fong, Louise Campbell, Cheree Morgan and Julia Squires with the first PET/CT patient On the 6th of December 2005, the first PET/CT scan was performed in Queensland on a Phillips Gemini GXL PET/CT using 18F-FDG manufactured on-site.
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2006 Princess Alexandra Hospital Image 9 – Richard Boytar with the decommissioned SIEMENS Symbia T6 SPECT/CT in 2017 A SIEMENS Symbia T6 SPECT/CT was installed, a first for the PAH. The installation of the SPECT/CT lead to the employment of the hospitals first PDY’s Nikki Wienert and Brad Hector in 2007.
2014 Princess Alexandra Hospital Image 10 – Matthew Gordon and Jye Smith at the commissioning of the PET/ MRI scanner In June 2014, the Herston Imaging Research Facility (HIRF) took delivery of the first PET/MRI machine in the southern hemisphere, a SIEMENS Biograph mMR 3T. The scanner was commissioned in HIRF and is devoted entirely to research along with a SIEMENS MRI 3T and PET/CT system.
2014 Wesley Medical Imaging, The Wesley Hospital Image 11 (left)– The first 68Ga-PSMA scan performed in Australia Image 12 (right) – Sarah Daniel NMS performing HPLC analysis prior to 68Ga-PSMA injection On the 16th of July 2014, the team lead by A/Prof Dr. David Wong at Wesley Medical Imaging performed the first 68Ga-PSMA PET/CT scan in Australia.
2014 Princess Alexandra Hospital Image 13 - PAH Molecular Imaging department staff - Gillian Jagger, Dr Phillip Law, George McGill, Dr Susanne Jeavons, Alison Brecknell, Amit Chacko, James Turner & Dr Stanley Ngai (left to right) with the SIEMENS PET/MRI scanner. A year of many firsts and a surge in new technology continued for Queensland with the PAH installing the first clinical PET/MRI machine a SIEMENS Biograph mMR 3T.
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2017
Centre for Advanced Imaging, The University of Queensland
Image 14 - A/Prof Kristofer Thurecht in the ACRF Facility at The University of Queensland A grant from the Australian Cancer Research Foundation (ACRF) enabled the purchase of a SIEMENS PET/CT scanner which lead to the first comparative oncology program and imaging (canine) to be performed in Australia.
2019
Unitingcare Medical Imaging, The Wesley Hospital Image 15 – Director of Nuclear Medicine and PET A/Prof David Wong outside the new facility In June this year, Unitingcare Medical Imaging (formerly Wesley Medical Imaging) opened the first dedicated Theranostics Centre in Queensland at The Wesley Hospital.
2019
Royal Brisbane & Women’s Hospital + Q-TRaCE Image 16 – Staff working within the new facility Department of Nuclear Medicine and Specialised PET Services, Royal Brisbane & Women’s Hospital + Q-TRaCE. Mid 2019 saw the completion of the expansion project within the Hot Lab at Royal Brisbane & Women’s Hospital. The expansion effectively doubles the compacity of the existing Hot Lab and features independent clinical and research work areas.
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Giovanni Bibbo, Nuclear Medicine, SA Medical Imaging, Women’s and Children’s Hospital, South Australia
ABSTRACT Since the establishment of nuclear medicine services at the hospital in later 1974, many changes with imaging equipment, radiopharmaceuticals and administered patients’ activities have occurred. Recording administered radiopharmaceutical activities and types of studies with patients’ demographic details from the first study performed has resulted in a database of more than 43 years of patients’ data. As part of the hospital’s best practice, the aim was to administer patients’ activities (dispensed minus residual) within 10% of the prescribed activities. The purpose of this work is to: (1) provide a brief history of the imaging equipment and radiopharmaceuticals used at the hospital, and (2) analyse retrospectively the whole data set to determine from an historical perspective the adherence of the patients’ administered activities to the prescribed protocols as they have been updated with time with the publication of key international and national documents. The means of the deviations of the administered activities from those of the prescribed protocols were found to be within 10% tolerance for all studies. However, the standard deviations of the means varied from 8.3% for bone to 16.1% for lung perfusion studies.
A quality assurance programme and adherence to it in administering radiopharmaceutical activities is essential in paediatric nuclear medicine. The quality assurance methodology described here is more appropriate than Diagnostic Reference Levels as the administered activities of paediatric patients are patients’ weights based. In addition, the current patients’ administered activities data set should be of great value for any future paediatric dosimetry and follow-up studies to determine possible radiation-induced cancers resulting from paediatric nuclear medicine studies. KEY WORDS Nuclear medicine, gamma camera, prescribed activities, radiopharmaceuticals, administered activities, paediatric activities. INTRODUCTION Nuclear medicine in Australia commenced in late 1960s with Picker Magnascanners in most departments (Walker (2007). The first two gamma cameras in Australia were the Nuclear Chicago Corporation Pho/Gamma III HP (Walker (2007) purchased by the Royal Adelaide Hospital (RAH) in 1967 (South Australian Medical Heritage Society). At the Women’s and Children’s Hospital (known then as the Adelaide Children’s Hospital),
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tertiary paediatric hospital, nuclear medicine was established in 1974. The first study on a 15-monthold male child was performed on 16 December 1974. He was administered 11.1 MBq (300 µCi) of 99mTc labelled human serum albumin (HAS) pharmaceutical for a lung study.
Over time, Nuclear Medicine has seen considerable changes, particularly in the 1970s and 1980s with the introduction of new radiopharmaceuticals (Drozdovitch et al. 2015) and computers to process and analyse images The development of alternate imaging modalities such as computed tomography (CT), ultrasound and magnetic resonance imaging (MRI) also impacted the scope of nuclear medicine studies. Initially, nuclear medicine studies at Women’s and Children’s Hospital (WCH) were performed on both children and adults. However, the establishment of a nearby private practice in November 1985 changed referral patterns with adults generally attending either the RAH or private practice and children under 18 attending WCH. With the establishment of nuclear medicine, a quality assurance program was also
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established. The three most important features of the quality assurance program were: (1) to measure not only the dispensed activities but also the residual activities so that the actual activities administered to patients were known; (2) to administer these activities with 10% of the prescribed activities; and (3) that the administered activities and details of these studies with the patients’ demographic details were to be kept as permanent records. As a result, a robust nuclear medicine patients’ database is available. The value of these historical data has provided the opportunity to review them over time and implement change in the pursuit of best practice. This work provides a brief history of nuclear medicine at WCH, coupled with a review of the commonly used radiopharmaceuticals and the administered activities over a 43year period. EQUIPMENT The gamma camera systems used at WCH since 1974 are shown in Table 1. The first gamma camera was a Searle Radiographic Pho Gamma IV with a half-inch crystal and 37 photomultiplier tubes. In April 1977, the camera was interfaced with a Digital Equipment Corporation (DEC) PDP 11/34 Gamma 11 mini computer system. This upgrade permitted the performance of studies that previously were not possible such as radionuclide angiograms, less invasive cardiac catheterizations and lung function studies. A second camera, General Electric Healthcare (GEH) MaxiCamera 400 was purchased in 1983 and interfaced also with the DEC computer. Each camera
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had an acquisition station for image acquisition. The acquired images were then transferred and processed on the DEC computer. The DEC computer system had 248 kB of memory and RK05 removable disks with a storage capacity of 10 MB. Often, two data disks per day had to be used because of the number of patients scanned with the two cameras and the limited capacity of the removable disks. Before the disks could be used again, the patient data had to be deleted. In addition, the DEC computer system was fitted with a floppy disk drive with floppy disks having a storage capacity of 487 kB. A Decwriter line printer was used for printouts and typing commands and an image display screen to view the images. A display terminal was added in 1990. RADIOPHARMACEUTICALS The imaging agents used over time for the common paediatric nuclear medicine studies performed at the hospital from 1/1/1975 to 31/12/2017 are summarized in Table 2. For the less frequently performed studies such as shunt, cerebrospinal fluid and gastrointestinal bleeding the pharmaceuticals are reported in the studies’ prescription activity protocols of Tables 3 and 4. Paediatric patients that required PET (Positron Emission Tomography) examinations were sent off-site as the hospital does not have a PET facility. ADMINISTERED ACTIVITIES Since the earlier applications of nuclear medicine in paediatrics, various empirical methods were used to determine the amount of radiopharmaceutical to be
Special Feature - 50 years of history
administered to paediatric patients (Goetz et al. 1983). The initial prescription activity protocols were based on age or body weight (Bell and McAfee 1974) or body surface area (Webster et al. 1974; NCRP 1983). However, there were no universally accepted adult administered radioactivities or minimum administered radioactivities for children. All suggested administered activities were based on experience gained over the years with the consequences that different institutions developed different standards. Over time, attempts have been made to standardize paediatric administered activities with the publication of the European Paediatric Task Group radiopharmaceuticals schedule (Piepsz et al. 1990), the European Association of Nuclear Medicine (EANM) Dosage Card (Lassmann et al. 2007) in 2007 and the North American Consensus Guidelines in 2011 and 2016 (Treves at al. 2011; Treves et al. 2016). With the formation of the Nuclear Medicine Global Initiative in 2012 [Fahey et al. 2015; Fahey et al. 2016), it is hoped that a single guideline of administered activities in paediatric nuclear medicine will eventually be universally accepted. At WCH, the prescription activity protocols were initially based on Webster et al. (NCRP 1983) adult fractions of administered activities computed on the basis of the two-thirds power of the patient’s body weight, assuming normal physiological clearance (Savage 1984). These fractions can be expressed as a best fit power-law function: 0.0564×W0.6778 where W is the body weight in kg. At that time, the minimum and maximum activities were determined from
published data for the different studies, and experienced based on image quality and count statistics. The body surface areas (BSA) of patients required for procedures such as for the determination of glomerular filtration rates were estimated from a nomogram based on the body surface area formula, BSA = 0.007184×W0.425×H0.725, of Du Bois and Du Bois (1916) where H(cm) is the height of the patients.
Radiation protection for paediatric patients at WCH has always been very important (Savage 1984). It was recognized that the incidence of ionizing radiation-induced cancer for children is higher than adults (ICRP 1969), so the nuclear medicine quality assurance program aimed for patients’ activities to be administered within a tolerance of ±10% of the prescribed activities With the employment of a medical physicist at the hospital in October 1989, a process was setup in 1991 to review patients’ administered activities and prescribed activity protocols to ensure that the administered activities were minimal, but consistent with
obtaining diagnostic images and hence the requested clinical information. Prior to 1/9/1991, the technologists meticulously recorded in log books the dates and types of examinations, names and age of patients, name of radiopharmaceuticals and administered activities. Patients’ weights were not recorded as clinicians traditionally prescribe according to the individual’s age. Even patients’ radiation doses were (Cristy 1980) and still are (Stabin et al. 2005; ICRP 2015) presented in terms of patients’ ages. From 1/9/991, patients’ weights were recorded to ensure compliance with the administered activity prescription protocols which were based on individual mass (Sutherland et al. 1980; Savage 1984; Savage et al. 1984). From 1/8/2011, the data have been entered in a Microsoft Access (Microsoft Corporation, Redmond, Washington, USA) database. In 1993, the adult fractions of administered activities and the minimum and maximum activities were reviewed, comparing them with those published by the European Paediatric Task Group (Piepsz et al. 1990) and the United Kingdom Administration of Radioactive Substances Advisory Committee (ARSAC) (ARSAC 1993). However, these fractions were not changed as they were numerically between those published by the European Paediatric Task Group and the ARSAC. However, the minimum and maximum activities for different studies were adjusted to the latest published data. Minimum and maximum activities since then have been regularly reviewed (Stanton et al. 2014; Bibbo et al. 2018) with the publication of key
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international (Lassmann et al. 2007; Gelfand et al. 2011; Treves et al. 2016) and national (Smart and Towson 2000; Botros et al. 2009) documents. The fractions of administered activities were again reviewed in 2005 and at that time it was considered still to be a best practice, basing the administered activities on the patient body surface area for the purpose of image quality and counting statistics for the younger children even though the administered activities for these patients were slightly higher than if the linear patient’s weight relationship was used. However, with this revision, the BSA was calculated using Haycock et al. (1978) formula and the relationship between BSA and weights of patients was derived from a data set of heights and weights of patients presenting in nuclear medicine at the hospital. A least square fit of the patients’ weights as a function of the calculated BSA of these data produced the following power law relationship: AF70 = 0.0502×W0.7041 where AF70 is the adult fractions normalized to a standard adult of 70 kg. The AF70 of the administered activities were reviewed again in 2016 by comparing them with the European Association of Nuclear Medicine (EANM) paediatric dosage card power law fraction-weight relationship (Lassmann et al. 2007) but no changes were made. PRESCRIBED RADIOPHARMACEUTICAL ACTIVITY PROTOCOLS Major revisions of the prescribed protocols were made in 1992, 2001-2005, 2011 and 2015. Minor changes have been made between these dates and in 2017 for some studies. The protocols for the prescribed minimum and maximum administered activities for the period 19751992 are reported in Table 3 and for major changes in the protocols over the period 1992-2017 reported in Table 4.
RESULTS
As an example of the value of the database, the complete diagnostic nuclear medicine patients’ administered activities (dispensed minus residual activities) data set from 1/1/1975 to 31/12/2017, except for the missing data from 1/8/1994 to 31/12/1998, have been retrospectively analysed for compliance with prescription protocols. The analysis and publication of the current data was approved by the hospital’s Human Research Ethics Committee. As part of this work, only results from the four most commonly performed studies (studies with sufficient statistics) - bone, renal using the radiopharmaceuticals 99mTc-DMSA and 99mTc-
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MAG3 and thyroid uptake - have been analysed in detail and presented in graphic form in Figures 1 to 7 and, numerically, deviations of the administered activities from the prescribed protocols, in Table 5. Less common studies such as Meckel’s diverticulum, lung perfusion, biliary and cardiac have also been analysed in detail but the results are only reported numerically in Table 5. The minimum and maximum deviations in Table 5 represent outliers in the data. 99mTc-MAG3 data include both transplant and non-transplant studies. As part of the radiopharmaceutical administered activities best practice program, deviations of the administered activities from the prescribed protocols (minimum, maximum and mean activities and standard deviations from the means) have been calculated regularly over time for the most common studies. But, prior to 1/9/1991, patients’ ages were recorded instead of the patients’ weights and, thus, the data could only be analysed as a function of patients’ ages, the results of which are of limited value as there is a large variation of patients’ weights with age and hence patients’ administered activities. An example of the patients’ data from 1/1/1975 to 31/12/1991 for the administered activities of bone studies as a function of age is shown in Fig. 1. For many studies, the age was rounded to the whole number as shown in Fig. 1. In graphic form, the administered activities as a function of patient’s weights from 1/1/1992 to 30/6/2013 and from 1/7/2013 to 21/6/2017 for bone studies are shown in Figures 2 and 3 respectively. The prescribed protocols for these studies with the deviations of the administered activities from the protocols are indicated on the respective figures. The data from 22/6/2017 to 31/12/2017 are not presented here in graphic form but for these studies the maximum and minimum prescribed activities guidelines were reduced to 500 MBq and 50 MBq respectively on 22/6/2017. Similar results are shown in figures 4 and 5 for 99mTcDMSA and in Fig. 6 for 99mTc-MAG3 studies. In Fig. 6, both renal transplant and non-transplant studies are shown. 99mTc-DTPA was used for renal studies from 1/1/1975 to 2007. However, the majority of the studies with 99mTc-DTPA were performed prior to 1992 when the patients’ weights were not recorded. Thus, the analysis of the administered activities as a function of the patients’ weights could not be performed for this radiopharmaceutical. Administered activities data of 99mTc-HDP/MDP, 99mTc-DMSA and 99mTc-MAG3 from August 2011 to January 2017 have been previously analysed and published (Bibbo et al. 2018). Thyroid uptake data from 1/1/1994 to 31/12/2017 are shown in
Special Feature - 50 years of history
Fig. 7. The number of brain studies per year performed from 1975 to 2017 is shown in Fig. 8. The means of the administered activities from the prescribed activities with corresponding standard deviations for these studies are reported in Table 5. The negative value for the mean of the administered activities indicates that on average the administered activities were less than the prescribed ones. The means varied from -0.2% for bone to 6.1% for lung perfusion and the standard deviations varied from 8.3% for bone to 16.1% for lung perfusion studies. The increased value of the standard deviation for lung perfusion studies is due to low prescribed activities for studies on patients with weight less than 20 kg. This is because with low prescribed activities it is difficult for the technologists to dispense small activities and predict the residual activities before injection (Bibbo et al. 2018). For 99mTcHDP/MDP, 99mTc-DMSA, 99mTcMAG3, thyroid uptake, Meckel’s Diverticulum and biliary studies, the standard deviations were below or just above 10%.
B
ONE STUDIES Bone studies have been the most common studies performed on children at the hospital, as shown in Figures 1 to 3, with a number of bone seeking radiopharmaceutical agents used over time as they became available (99mTc labelled polyphosphate, Skeltec I and Skeltec II, 99mTcMDP, 99mTc-IDP for 32 patients between 31/1/1979 and 27/2/1980 and then finally 99mTc-HDP). Skeltec I and Skeltec II were 99mTcstannous-polyphosphate complexes (Murray et al. 1972) developed at the Australian Atomic Energy
Commission (currently Australian Nuclear Science and Technology Organization). They were one of the first 99mTc labelled bone scanning agents accepted worldwide as the agent of choice for bone scanning at that time. The prescribed protocol has been revised several times (see Tables 3 and 4). The initial maximum and minimum activities were 750 MBq and 80 MBq respectively. The minimum activity was reduced to 70 MBq on 1/6/2005 and then both the maximum and minimum activities were reduced to 600 MBq and 50 MBq respectively on 1/7/2013. The protocol was revised in June 2017 and from 1/7/2017 the maximum activity was reduced to 500 MBq while maintaining the minimum activity at 50 MBq. The overall mean of the administered activities from the prescribed activities (Table 5) was -2% with a standard deviation of 8.3% indicating that for the bone studies data set from 1992 there was compliance with the prescribed protocols and the imposed tolerance of Âą10%.
R
ENAL 99MTC-DMSA STUDIES Most of the 99mTc-DMSA studies were performed on patients weighing less than 35 kg (see Fig. 4), and, in particular, less than about 15 kg. For these younger patients the prescribed activities were low, being the minimum protocol activity or just above it. The minimum activities for the prescribed protocols were 40 MBq initially, reduced to 25 MBq on 1/10/2015 and then to 18.5 MBq on 1/7/2017. With these minimum activities it becomes difficult to dispense low activities and predict the residual activities before injection. Since the administered activity to
patients is the dispensed minus the residual activity, it required a high level of expertise both in dispensing and in administering the radiopharmaceutical to patients (Bibbo et al. 2018). The maximum protocol activity has only been slightly reduced from 120 MBq to 100 MBq on 1/10/2015. The mean of the deviations of the administered activities from the prescribed activities was calculated to be -4.9% (Table 5) for the whole 99mTc-DMSA data set from 1/1/1999 to 31/12/2017, i.e., the administered activities to patients were almost 5% less than the prescribed activities. The mean value of -4.9% indicates that considering the difficulties in determining accurately the prescribed activities for patients of low weights, they conformed well with the protocol prescribed activities (Figures 4 and 5 and Table 5).
R
ENAL 99MTC-MAG3 AND 99MTC-DTPA STUDIES 99mTc-MAG3 was first used on 29/11/1988 for a renal transplant study but was not routinely used until July 1991. By 1999, 99mTc-MAG3 was the principal radiopharmaceutical for renal studies and 99mTc-DTPA was only used for studies requiring either renal and glomerular filtration rates or the use of captopril. After 2007, 99mTc-DTPA was no longer being used for renal studies. 99mTcDTPA studies peaked in 1991 with 604 studies and then decreased rapidly from 1993 with the use of 99mTc-MAG 3. The 99mTc-MAG3 prescribed activities protocol has been reviewed over time but not changed since the initial maximum and minimum activities of 70 MBq and 15 MBq for non-transplant
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studies and a maximum and minimum activities of 200 MBq and 15 MBq respectively for transplant patients (Tables 3 and 4). The overall mean of the deviations of the administered activities from the prescribed activities for the combined non-transplant and transplant studies was 1.5% with a standard deviation 9.8% (Table 5) which is within the 10% tolerance. The separate values for the mean deviations and standard deviation for the nontransplant and transplant studies are shown in Fig. 6.
T
HYROID UPTAKE STUDIES The initial prescribed protocol with a maximum activity of 80 MBq and a minimum of 20 MBq has been changed only once on 1/8/2011 with the reduction of the minimum activity to 10 MBq. The mean of the administered activities was 5% above the prescribed activities whereas the standard deviation was 12.8% (Table 5 and Fig. 7). The large value of the standard deviation is mainly due to the difficulties in dispensing low prescribed activities (minimum activities: 20 MBq before 1/8/2011 and 10 MBq after) to the very young patients of age less than 5 years (Fig. 7). The number of studies over the years has been reasonably consistent with an average 15.4 studies per year with a maximum of 26 and minimum of 7.
B
RAIN STUDIES For brain studies 99mTc labelled sodium pertechnetate was used from 1975 to 1988 for both cerebral radionuclide angiography and static scintigraphy. 99mTc-DTPA was also used in parallel to 99mTc labelled sodium pertechnetate but the numbers of studies using 99mTc-DTPA were few per year. With the introduction of 99mTc-HMPAO, trade name Ceretec, in 1989, the use of 99mTc labelled sodium pertechnetate and 99mTc-DTPA were discontinued. 201Tl was used only for tumour scintigraphy from 1993 till 2006 but only for a few studies per year. 99mTc-ECD was first used in 2006 but only for epilepsy studies. The number of brain examinations peaked in 1976 with 378 studies (Fig. 8). With the introduction of ultrasound on site in July 1976 and CT service offsite in a private radiological practice in 1977, the number of brain studies dropped to 250 studies in 1977. In 1978, the number of studies dropped even further to 115. The first CT scanner was installed on site in October 1984 and by this time the average number of brain studies per year was reduced on average to 2.5 mainly for brain death studies. About 20% of the brain studies were performed on children less than one year old. In the age group 1 to 13 years, the number of studies was evenly distributed at 7% per year. Few examinations were performed on children older than 13 years.
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B
ILIARY STUDIES For biliary studies, a number of radiopharmaceuticals have been used over the years: 99mTc-Pyg from 1975 to 1980 for a total of 18 examinations, 99mTc-HIDA in 1980 for two examinations, 99mTc-EHIDA for one examination in 1985, 99mTc-DIDA for 73 examinations from 1980 to 1986, and 99mTc-DISIDA from 1986 to present. The number of studies per year from 1975 to 2017 was from a minimum of one per year to a maximum of 35 per year with an average of 14.5 per year. The highest number of studies per year was performed between 1986 and 2003 with an average of 26.4 studies per year. The prescribed protocol has been reviewed a number of times since 1975. The initial maximum and minimum prescribed activities were 200 and 40 MBq respectively which were reduced to 150 and 40 MBq respectively on 1/8/2006 and then to 130 and 18.5 MBq respectively on 1/8/2015.
M
ECKEL’S DIVERTICULUM STUDIES The prescribed protocols for Meckel’s diverticulum studies have been updated twice since 1975, as indicated in Tables 3 and 4: 1/12/1993 and 1/8/2011. The mean of the administered activities of 2% above the prescribed activities with a standard deviation of 10.7% (Table 5) was within the 10% accepted tolerance.
L
UNG PERFUSION STUDIES Perfusion studies have been performed on both paediatric and obstetric patients; either as ventilation and perfusion studies on the same day, perfusion only or as a two-day protocol. The data presented here were for paediatric patients only. The protocols differ for perfusion only or combination studies (see Tables 3 and 4). The perfusion only protocol has not changed over time and remains at minimum 10 MBq and maximum 80 MBq. With the appointment of a new Clinical Head of Nuclear medicine in 1995, the minimum protocol activity for a perfusion study performed immediately subsequent to a ventilation study was changed from 60 MBq to 80 MBq and currently remains that value. The maximum protocol activity remained unchanged over time to 150 MBq.
L
UNG VENTILATION STUDIES 133Xe was used for lung ventilation studies until 1988 when a change was made to 99mTc-DTPA. The protocol for ventilation was and still is 1,000 to 1,400 counts/second for paediatric patients, adjusted for weight, and 700 to 800 counts/second for pregnant patients.
Special Feature - 50 years of history
C
ARDIAC STUDIES Cardiac studies were mainly first pass gated studies performed with 99mTc pertechnetate stannous colloid. The initial maximum prescribed protocol activity was 925 MBq (Savage et al. 1984). The protocol was revised in 1992 with a maximum of 500 MBq and a minimum of 80 MBq. In 2005, it was revised again and the minimum administered activity was reduced to 60 MBq. The number of cardiac studies performed increased dramatically in the late 1970s from two studies in 1975, nine in 1976 to a peak of 82 in 1977. Between 1978 and 1983, the number of cardiac studies remained steady at an average of 54.2 studies per year. Since 1984, the number of studies per year declined steadily until the year 2000. Very few first pass gated studies have been performed since the year 2000.
L
IVER/SPLEEN STUDIES Both 99mTc-calcium-phytate and 99mTc-sulphur colloid have been used for liver/spleen studies. The number of studies per year peaked in 1976 with 141 studies and then decreased. Between 1977 and 1993 the average number of studies per year was 37 and after 1993 to 2008 only one or two studies per year have been performed. No liver/spleen studies have been performed since 2008.
SUMMARY Many changes have occurred in the last 43 years - new imaging equipment, modalities and radiopharmaceuticals. The original nuclear medicine personnel are no longer here, but the inherited best practice and patient care of paediatric nuclear medicine patients at WCH have not changed. Patients’ radioactivities are still measured and administered within the ±10% tolerance. The ±10% methodology described here is more appropriate than Diagnostic Reference Levels as the administered activities of paediatric patients are patients’ weights based. Concerns regarding radiation protection for paediatric patients have resulted in a continuously evolving range of nuclear medicine studies being requested over time. However, nuclear medicine still remains an essential imaging and physiological functional modality in research, diagnosis and treatment of patients. The historical data presented in this work should be of great value for future retrospective paediatric studies to determine possible radiationinduced cancers resulting from paediatric nuclear medicine studies.
Table 1 Camera systems used at WCH since 1974 Period
Gamma Camera
1974 - 1986
Searle Radiographic Pho Gamma IV GEH MaxiCamera 400 Siemens Healthineers Orbiter GEH STARCAM XC/T
1983 - 1992 1986 - 2000
1992 - 2000
Computing System DEC PDP 11/34 Gamma 11 mini computer
Camera Head single
SPECT Collimators Capability no LEGP, LEHR, Convergent, Divergent, MEGP, Pin Hole
interfaced to DEC computer
single
yes
Interfaced to DEC computer
single
yes
GEH STAR 4000 computer system. Startport Data Station interfaced to the Orbiter camera
single
yes
LEGP, LEHR, HRC, MEGP, HEGP, Pin Hole, Fan Beam LEGP, LEHR, MEGP, HEGP, Pin Hole LEGP, LEHR, EEGP, MEGP, HEGP, Pin Hole, Fan Beam
2000- 2012
ADAC Forte
double
yes
2012 current
GEH Discovery NM/CT 670
double
yes
LEGP, LEHR, MEGP, HEGP, Pin Hole LEGP, LEHR, HRC, MEGP
SPECT = Single Photon Emission Computer Tomography - EEGP = Extend Energy General Purpose - HEGP = High Energy General Purpose - HRC = High Resolution Converging - LEGP = Low Energy General Purpose - LEHR = Low Energy High Resolution MEGP = Medium Energy General Purpose
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Table 2 Radiopharmaceuticals used from 1975 to 2017 Study Bone
Radiopharmaceutical
1/1/1975 -27/4/1975 14/2/1976 – 16/2/1977 99m Tc-stannous-polyphosphate complex (Skeltec I) 21/1/1975 -3/4/1975
Tc labelled polyphosphate
21/1/1975 - 11/2/1977
Tc-MDP (methylene diphosphonate) Tc-IDP (imido diphosphate)
7/12/1976 to current 17/1/1980 - 27/2/1980
99m
Tc-HDP (hydroxyl diphosphonate)
28/8/1992 - current
Tc-glucoheptonate Tc-DTPA (diethylene-triamine-penta-acetic acid) 99m Tc-DMSA (dimercaptosuccinic acid)
1/1/1975 – 24/5/1978 31/1/1975 - current
99m 99m
99m 99m
10/7/1980 - current
Tc-MAG3 (mercaptoacetyltriglycine)
12/7/1991 - current
Tc-DTPA
1/1/1975-30/10/1990
Tc-pertechnetate
1/1/1975-7/4/1988
99m
Brain
Comment
99m
Skeltec II
Renal
Period of Use
99m 99m
developed at the Australian Atomic Energy Commission# Occasional use only after 14/2/1976 few studies up to 12/2/1977 replaced 99mTc-MDP for paediatric patients Few studies after 15/6/77 few studies pre 15/6/77 occasionally used before 2/5/1983
Tc-HMPAO (hexamethylpropyleneamineoxime) 20/4/1989-current
99m
Tc-ECD (ethyl cysteine dimer) Tc-sulphur colloid
29/1/2006-current 1/1/1975-18/2/1980
primarily for epileptic studies
Tc-calcium phytate
24/3/79-current
only occasionally used pre 18/2/80
99m
Tc-PyG (pyridoxylideneglutamate)
1/1/1975-31/3/1980
Tc-HIDA (hydroxy iminodiacetic acid) 99m Tc-DIDA ((diisopropyl-iminodiacetic acid)
1/4/1980-31/7/1980 1/8/1980-24/2/1986
99m
Liver/Spleen
99m 99m
Biliary
99m
Tc-DISIDA (diisopropyl-iminodiacetic acid)
25/12/86- present
99m
Tc-HSA (human serum albumin)
1/1/1975-
Tc-MAFH (macroaggregated ferrous hydroxide)
13/5/1975-30/30/1979
99m
Lung Perfusion
99m
Tc-MAA (macroaggregated albumin)
Lung Ventilation
99m
30/3/1978-present
Xe Tc-aerosol DTPA 99m Tc-pertechnetate
1/1/1975-15/2/1988 9/2/1987-present 1/1/1975-present
133
99m
Meckel’s Diverticulum Thyroid Uptake
Tc-pertechnetate
for a period of time both imaging agents were used
1/1/1975-present
I-sodium iodide Tc-pertechnetate 99m Tc-pertechnetate sulphur colloid
19/9/1975 and 9/2/1987 for only 2 studies 1/1/1975-present first pass 1/1/1975-present
99m
# Currently Australian Nuclear Science and Technology Organization
30
from 1/10/1977-30/9/1979 both 99mTc-MAFH and 99mTcMAA were used
99m 123
Cardiac studies Gastric oesophageal reflux
2 studies only
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Special Feature - 50 years of history
Table 3 Minimum and maximum administered activities for the various studies for the period 1975-1992
Study
Radiopharmaceutical
Prescribed Activities (MBq) Pre 1992 1992 Max Min Max Min
Tc- PyG/ HIDA/DIDA/DISIDA
225
60
200
40
Tc-Skeltec/MDP/IDP/HDP
750
80
750
80
Tc- pertechnetate/ HMPAO
740
100
740
100
Tc-pertechnetate
700
200
500
80
Tc- pertechnetate
925
200
800
80
250
100
150
60
40
20
40
20
Tc-HAS/ MAFH/ MAA with aerosol no aerosol
150 80
60 10
150 80
60 10
Tc-S colloid/Ca phytate
150
50
100
40
Tc-pertechnetate
650
60
200
40
320 100 140
100 15 40
200 70 120
60 15 40
80
20
80
20
Biliary
99m
Bone
99m
Brain
99m
First pass
99m
Gated cardiac
99m
Gallium
67
Gastric Esophageal Reflux
99m
Lung perfusion
99m
Liver/spleen
99m
Meckel’s
99m
Renal
99m
Tc-DTPA Tc-MAG3 99m Tc-DMSA
Thyroid uptake
99m
Ga-citrate Tc sulphur colloid
99m
Tc-pertechnetate
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Special Feature - 50 years of history
Table 4 Minimum and maximum administered radioactivities for the various studies for the period 1992-2017 Study Biliary Bone Brain Cardiac
Prescribed Activities (MBq) 1992 2001-2003 2017 Max/Min Max/Min Max/Min 200/40 150/40 130/18.5 750/80 750/80 500/50 740/100 740/100 740/100
Radiopharmaceutical Tc DISIDA Tc HDP/MDP 99m Tc HMPAO 99m Tc-MIBI 99m 99m
perfusion (2 days)
Tc-MIBI
stress (1 day)
99m
Rest (1 day)
99m
300/40
350/40
300/40
350/40
Tc-MIBI
800/110
Ga-Citrate
Colonic transit
67
CSF leak
99m
Direct cystogram First pass Gallium infection lymphoma
99m
5
7/2
60/40
60/40
3x3** 500/80 150/60
25 500/60 100/20
300/120
200/40
11/8
7/2
40
20
800/80 550/80
800/80 550/80
400/40
400/40
20 30 40/20
20 30 40/15
400/100
400/100
5/eye
5/eye
Tc DTPA
Tc DTPA, MAG3 or pertechnetate Tc pertechnetate 67 Ga citrate 67 Ga citrate 99m
Gastric emptying solid
99m
gated blood pool GI bleeding heat damaged
99m
under 3 years over 3 years Gastric Esophageal Reflux Labelled White Cell
99m
Lacrimal
99m
GFR only
Tc Ca phytate
Tc RBC Tc RBC 99m Tc RBC
800/80 550/80
Tc DTPA Tc DTPA 99m Tc sulphur colloid 99m Tc stannous colloid
30 50 40/20
99m
99m
Tc pertechnetate
Tc Ca phytate ventilation Tc DTPA (aerosol)* Perfusion 99mTc MAA (with aerosol)# perfusion only 99mTc MAA (no aerosol) 99m Lymphoscintigraphy Tc Antimony colloid
Liver/spleen Lung
99m
Meckel’s 123 I MIBG
99m
Parathyroid
99m
PET (tumor)
18
Renal
99m
99m
123
Tc pertechnetate I MIBG
transplant
Shunt Testicular Thyroid uptake
100/40 2.000/1,500 150/60 80/10
100/20 2,000/1,500 150/80 80/10 2x28
80/15 2,000/1,500 150/80 80/10 2x28
200/40
200/40 200/40
130/18.5 300/40
Tc MIBI
FDG
700/80
Tc DMSA Tc DTPA
120/40 200/60
120/40 200/60
200/14 360/14 260/14 100/18.5 200/30
99m
Tc MAG3
70/15
70/15
70/15
Tc MAG3 Tc DTPA 99m Tc Sulphur colloid
200/15 300/60
200/15
200/15
2x5
2x5
Tc pertechnetate Tc pertechnetate 99m Tc pertechnetate
20 500/80 80/20
20 200/40 80/20
20 200/40 80/10
99m
Salivagram
30/20 500/80 150/60
Ga Citrate
gastric emptying liquid
67
RBC
-
99m 99m
99m 99m
Torso brain
*Vent to 1,000 – 1,400 counts/second and 700-800 counts/second for pregnant patients - #Max 80 MBq for pregnant patient
Special Feature - 50 years of history
Table 5 Percentage deviations of the administered activities from prescribed activities for a number of common nuclear medicine studies from 1992 to 2017
Deviation
Studies Bone Tc-HDP/ MDP
99m
Mean
Renal 99m Tc-DMSA
Renal (NT+T)# 99m Tc-MAG3
Thyroid Uptake
Meckel’s Diverticulum
Lung Perfusion
Biliary
-0.2%
-4.9%
1.5%
5.0%
2.0%
6.1%
-3.2%
8.3%
11.1%
9.8%
12.8%
10.7%
16.1%
12.0%
Min
-54.7%
-55.3%
-42.9%
-29.4%
-33.1%
-59.0%
-41.3%
Max
47.4%
46.9%
46.6%
48.6%
33.3%
52.2%
47.6%
Standard Deviation
#For 99mTc-MAG3, NT = non-transplant, T = transplant studies
Fig 1 Administered activities of bone studies data from 1/1/1975 to 31/12/1991 as a function of patients’ ages
Fig 2 Administered activities of bone studies data from 1/1/1992 to 30/6/2013 as a function of patients’ weight
Fig 3 Administered activities of bone studies data from 1/7/2013 to 21/6/2017as a function of patients’ weight
Fig 4 Administered activities of 99mTc-DMSA studies from 1/1/1999 to 30/9/2015 as a function of patients’ weight
2020 Spring/Summer Edition gamma GAZETTE 33
Special Feature - 50 years of history
Fig 5 Administered activities of 99mTc-DMSA studies data from 1/10/2015 to 30/6/2017 as a function of patients’ weight
Fig 6 Administered activities of 99mTc-MAG3 studies from 1/1/1999 to 31/12/2017 as a function of patients’ weight showing both transplant and non-transplant studies
Fig 7 Administered activities of thyroid uptake studies from 1/1/1994 to 31/12/2017 as a function of patients’ weight
Fig 8 Number of brain studies from 1975 to 2017
Acknowledgement
I wish to acknowledge Victoria Sigalas, Tracy Benger and Catherine Munn for their valuable critique and proof reading of the manuscript. References •
• •
• •
•
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Administration of Radioactive Substances Advisory Committee. Notes for guidance on the administration of radioactive substances to persons for purposes of diagnosis, treatment or research. U K: ARSAC; 1993. Bell EG, McAfee JG, Subramanian G. Radiopharmaceuticals in Paediatrics. In: James AE, Wagner HN, Cooke RE (eds). Paediatric nuclear medicine. W B Saunders. London; 1974. Bibbo G, Sigalas V, Kirkwood I. A review of paediatric administered radiopharmaceutical activities to determine compliance with prescription guidelines. Nuclear Medicine Communications 39:205–212; 2018. DOI: 10.1097/MNM.0000000000000800 Botros GM, Smart RC, Towson JE (2009) Diagnostic reference activities procedures in Australia and New Zealand derived from the 2008 survey. ANZ Nuclear Medicine. 40:2-11 Cristy M. Mathematical phantoms representing children of various ages for use in estimates of internal dose. NUREG/CR-1159 ORNL/ NUREG/TM-367, Oak Ridge National Laboratory. Oak Ridge, Tennessee; 1980. Drozdovitch V, Brill AB, Callahan RJ, Clanton JA, DePietro A, Goldsmith SJ, Greenspan BS, Gross MD, Hays MT, Moore SC, Ponto JA, Shreeve WW, Melo DR, Linet MS, Simon SL. Use of radiopharmaceuticals in diagnostic nuclear medicine in the United
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• •
•
• • •
States: 1960–2010. Health Phys. 108:520–537; 2015. DOI: 10.1097/ HP.0000000000000261. DuBois D, DuBois EF. A formula to estimate the approximate surface area if height and weight be known. Arch Int Med 17:863-871; 1916. Fahey FH, Bom HH-S, Chiti A, Choi YY, Huang G, Lassmann M, Laurin N , Mut F, Nunez-Miller R, O’Keeffe D, Pradhan P, Scott AM, Song S, Soni N, Uchiyama M, Vargas L. Standardization of administered activities in paediatric nuclear medicine: A report of the first Nuclear Medicine Global Initiative Project, Part 1-Statement of the issue and a review of available resources. J Nucl Med. 56:646651; 2015. Doi: 10.2967/jnumed.114.152249. Fahey FH, Bom HH-S, Chiti A, Choi YY, Huang G, Lassmann M, Laurin N , Mut F, Nunez-Miller R, O’Keeffe D, Pradhan P, Scott AM, Song S, Soni N, Uchiyama M, Vargas L. Standardization of administered activities in paediatric nuclear medicine: a report of the first Nuclear Medicine Global Initiative Project, Part 2-current standards and the path toward global standardization. J Nucl Med 57:1148–1157; 2016. DOI: 10.2967/jnumed.115.169714. Gelfand MJ, Parisi MT, Treves ST. Paediatric radiopharmaceutical administered doses: 2010 North American Consensus Guidelines. J Nucl Med 52:318-322; 2011. Goetz WA, Hendee WR, Gilday DL. In vivo diagnostic nuclear medicine paediatric experience. Clin Nucl Med. 8:434-439; 1983. Haycock GB, Chir B, Schwartz GJ, Wisotsky DH. Geometric method for measuring body surface area: a height-weight formula validated
Extract from the past
Special Feature - 50 years of history
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•
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• •
•
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•
•
•
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in infants, children and adults. J Pediat 93: 62-66; 1978. International Commission on Radiological Protection. Radiosensitivity and spatial distribution of dose. ICRP; Publication 14; 1969. Pergamon Press, Oxford. International Commission on Radiological Protection. Radiation dose to patients from radiopharmaceuticals: a compendium of current Information related to frequently used substances. ICRP; Publication 128; Ann ICRP 44(2S); 2015. Lassmann M, Biassoni L, Monsieurs M, Franzius C, Jacobs F, Dosimetry E. EANM Dosimetry and Paediatrics Committees. The new EANM paediatric dosage card. Eur J Nucl Med Mol Imaging. 34:796–798; 2007. Murray IPC, McKay WJ, Robson J, Sorby PJ, Boyd RE. Skeltec, a thermo-stable 99mTc agent for skeletal scintigraphy. J Nucl Med 13:455-456; 1972. National Council on Radiation Protection and Measurements. Protection in Nuclear Medicine and Ultrasound Diagnostic Procedures in Children. Bethesda, MD: NCRP; Report 73; 1983. Piepsz A, Hahn K. Roca I, Ciofetta G, Toth G, Gordon I, Kolinska J, Gwidlet J. A radiopharmaceuticals schedule for imaging in paediatrics. Eur J Nucl Med 17:127–129; 1990. Savage JP. Minimising radiation hazards in paediatric nuclear medicine. Australas Radiol 28:362-367; 1984. [Journal of Medical Imaging and Radiation Oncology]. DOI: https://doi. org/10.1111/j.1440-1673.1984.tb02366.x. Savage JP, Esterman AJ, Clapp R, Toogood IRG, Adams APS, Goldblatt E. Chelation therapy does reverse myocardial deterioration in patients with thalassaemia major. Eur Paediatr Haematol Oncol 1:125-133; 1984. DOI: 10.3109/08880018409141721 Smart RC, Towson JE (2000) Diagnostic reference activities for nuclear medicine procedures in Australia and New Zealand. Radiation protection in Australia. 17:2-14 South Australian Medical Heritage Society Inc. Nuclear medicine in South Australia 1960-1975 and now. Available at http://samhs.org.au/Virtual%20Museum/xrays/Nuclear%20 Medicine/Nuclear%20Medicine.html. Accessed 18 June 2018 Stabin MG, Sparks RB, Crowe E. OLINDA/EXM: the secondgeneration personal computer software for internal dose assessment in nuclear medicine. J Nucl Med 46:1023-1027; 2005. Stanton K, Bibbo G, Kirkwood I. Paediatric radiopharmaceutical dose optimisation at the Women’s and Children’s Hospital, Adelaide. Intern Med J 44 (Suppl 1):1–18; 2014. Sutherland AD, Savage JP, Paterson DC, Foster BK. The nuclide bone-scan in the diagnosis and management of perthes’ disease. The Journal of Bone and Joint Surgery 62-B:300-306; 1980. [The Bone & Joint Journal]. https://doi. org/10.1302/0301-620X.62B3.7410461. Treves ST, Paris MT, Gelfand MJ. Paediatric radiopharmaceutical doses: New guidelines. Radiology 261:347-349; 2011. Treves ST, Gelfand MJ, Fahey FH, Parisi MT. Update of the North American consensus guidelines for paediatric administered radiopharmaceutical activities. J Nucl Med 57:15N-18N; 2016. Walker BM. Thirty year celebration of the contribution of nuclear medicine physicists in Australia. Australas Phys Eng Sci Med 30:239-251; 2007. Webster EW, Alpert NM, Brownell GL. Radiation doses in paediatric nuclear medicine and diagnostic x-ray procedures. In: James AE, Wagner HN, Cooke RE (eds). Paediatric nuclear medicine. W B Saunders. London, pp 34–58; 1974.
Dr John T Andrews Nuclear Medicine Physician My interest in radio-isotopes in medicine goes back to the early 60s at the Peter MacCallum Clinic, later the Cancer Institute, when a radio-therapist. Thanks to the clinic staff, I participated in nuclear medicine procedures, spending much time in that area. Appointed in 1966 to the Royal Melbourne Hospital as the first full-time medical specialist in nuclear medicine in Victoria, I became Director of the new Department of Nuclear Medicine. Early on, I was involved in the formation of the Society and with the technologist's course development, writing a book on the subject with Ms Jean Milne. For some years served on the Society executive including as President and as Chairman of the Accreditation Board and took part also in the formation of what is now the Australian Association of Medical Specialists in Nuclear Medicine. It has been a rewarding and happy period of my life. Relevant publications:
Nuclear Medicine Clinical and Technological Bases J. T. Andrews & M. Jean Milne John Wiley & Sons, New York 1977 John T Andrews The Formative Years of Nuclear Medicine in Victoria. Health & History. 2008. 10/2. pp 109-129. 2020 Spring/Summer Photograph in ANZ Edition Nucleargamma Medicine GAZETTE 35 December 1993. p 8.
Introducing Post-Nominals A number of you may be wondering what the fuss is about the newly member-only benefit, the use of the MANZSNM post nominal. In this article, we answer some of the questions and why we think that this is important.
What is the MANZSNM?
It is a post nominal that full members who meet the requirements of being a paid member of the ANZSNM can use after their name. For instance, Jane Smith, who is a voting member (having satisfied the requirements of the Society’s rules) is able to use it in addition to any other qualifications she may have achieved after their name - e.g. Jane Smith B.Sc, MMedRadSc, MANZSNM.
Why have it?
There are many ways to answer this. For those of you who choose to use the post nominals, it invites a question to those who are curious enough about what it might mean. It helps get into the community who we serve minds that we are part of everyday healthcare. A nuclear procedure is something an average Australian will face twice in their lifetime (See our Youtube video from Geoff Currie). It therefore, helps us differentiate too from a very curious and empowered healthcare consumer as to how we are different from radiographers or sonographers say - who also do vital work. For the sake of brevity, the primary reason is that of being another way to promote Nuclear Medicine. The profession is not large in number and outnumbered by other professions. The NM profession is represented by Physicians who number less than 400 in A/NZ and have their own post nominals and largely “others” that we, the ANZSNM and some others representing a few thousand. Yet, and increasingly, Nuclear Medicine is having a bigger impact on healthcare outcomes and research with over 600,000 NM procedures undertaken in Australia alone. Some recent reimbursement approvals confirm in part the growing impact. Put another way, how many of you are familiar with the CPA, AHRI, Registered Master Builders or LMVD or other some such related organisations and their acronyms? What
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gamma GAZETTE 2020 Spring/Summer Edition
about in health imaging? How many of you get asked - “so what is Nuclear Medicine”?. A mere post nominal is not going to answer those questions. Perhaps it doesn’t need the sort of name recognition as car dealers but certainly, there is more good than harm of using the post nominals especially if it builds a value and brand - to use marketing jargon. The latter two concepts are important when we are trying to encourage new people into the profession and of course catch the attention of the funding authorities as new therapies are developed. For you personally, it indicates to your current and prospective employers that you have a belief in your own ongoing professional development and contribution to your profession. Of course, this might be already known to your employer and you may already have this in your Resume, but in a world where some sort of differentiation is key, saying you are a member of something might just sway the employer.
Why Now?
Here again there are many reasons. To keep it short; to ensure that the profession is further promoted by those who are in it to those outside of it. Secondly, and importantly, as a Society after being in existence for 50 years surely it is about time that we have the maturity to promote membership within it?
Is it compulsory to use the Post Nominals?
Of course not. It is up to you to use it, but we would hope that at least, you feel encouraged to do so, after reading some of the reasons outlined above.
When does it commence?
For those who have signed up as full members in the 2020 financial year you are eligible to use this.
EXPIRES 15th DEC 19
RENEW AND SECURE YOUR MEMBERSHIP FOR 2020 AT THE EARLY BIRD PRICE OF $198 Continue to enjoy member-only benefits including post-nominals*, full access to EduTrace and the Society’s archive, networking opportunities, advocacy and representation, event registration discounts and much more.
Don’t miss this special price! R E N E W
T O D A Y
w w w. a n z s n m . o rg. a u *Post nominals is available to full members
ARTnet Trials Update October 2019 ARTnet CLINICAL TRIALS UPDATE ProPSMA Study: a prospective randomised multi-centre study of the impact of Ga-68 PSMA-PET/CT imaging for staging high risk prostate cancer prior to curativeintent surgery or radiotherapy (funded by the Prostate Cancer Foundation of Australia and Movember) Principal Investigator: Prof Michael Hofman (Peter MacCallum Cancer Centre, Melbourne) ProPSMA study involved 10 sites across Australia. Prior to patient enrolment, study sites were certified by ARTnet for camera validation for Gallium-68 (see publication below) and for radiopharmaceutical synthesis of Ga-68 PSMA-11. Randomisation of 300 patients for ProPSMA was completed in November 2018, well ahead of schedule, as seen in the accrual chart. This landmark phase 3 randomised trial may lead to global practice changing data by comparing Ga-68 PSMA-11 directly to conventional imaging. All patients have now reached the 6 month follow-up primary endpoint. Sites are now working actively to finalise their data and the analysis of the primary endpoint will be performed shortly. We look forward to the results being presented in the first quarter of 2020.
TheraP Study:Â A randomised phase 2 trial of 177Lu-PSMA617 theranostic versus cabazitaxel in progressive metastatic castration resistant prostate cancer (ANZUP / PCFA / Endocyte / ANSTO / Movember) Principal Investigator: Prof Michael Hofman (Peter MacCallum Cancer Centre, Melbourne) TheraP trial involves 11 sites across Australia. ARTnet provided oversite of the Nuclear Medicine manual, and site accreditation for PET camera validation and for radiopharmaceutical synthesis of Ga-68 PSMA and Lu-177 PSMA-617. Recruitment also has progressed extremely well in the TheraP trial, with recent notification that the accrual target of 200 randomised patients has been
Ga68 PSMA PET
Lu177 PSMA
2020 Spring/Summer Edition gamma GAZETTE 39
Articles
The Australian Radiation Protection and Nuclear Safety Agency (ARPANSA) published new national Diagnostic Reference Levels (DRLs) for nuclear medicine in 2017. The DRLs were based on data collected via a national survey which ran in 2014 – 2015 and from two earlier surveys that were conducted in 1998 and 2008 by the Australian and New Zealand Society of Nuclear Medicine (ANZSNM). The Australian nuclear medicine DRLs cover general nuclear medicine, SPECT/CT and PET/CT for adult patients. A Technical Report has now been published describing the methodology of data collection as well as the overall results. ARPANSA is planning to carry out other survey of nuclear medicine facilities and procedures in 2020. Further emphasis will be placed on CT imaging in hybrid scanning along with issues relating to paediatric imaging. As in the previous survey ARPANSA will be establishing a liaison panel to provide technical and clinical guidance and to oversee the methodologies employed in data collection. Representation will be sought from the special interest groups of the ANZSNM as well as the AANMS and ACPSEM to assist ARPANSA in this project. The Australian Government Department of Health Diagnostic Imaging Accreditation Scheme (DIAS) was developed to ensure safety and quality standards for diagnostic imaging practices and was established in June 2007 through the Health Insurance Act 1973. DIAS links mandatory accreditation to the payment of Medicare benefits for diagnostic imaging services listed in the Diagnostic Imaging Services Table (DIST). DIAS released advisory statement, A17/01 – Introduction of Adult Diagnostic Reference Levels for Nuclear Medicine to provide information about the introduction of adult DRLs and to clarify the requirements for annually comparing facility reference levels (FRLs) to the nationally established DRLs. The following standard relates directly to nuclear medicine facilities in Australia that claim Medicare benefits for diagnostic imaging services listed in the DIST.
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Standard 3.2, Optimised Radiation Technique Charts Standard of the DIAS requires a practice providing services which use ionising radiation to establish a program to ensure that radiation doses administered to patients are • annually compared with diagnostic reference levels (DRLs) for diagnostic imaging procedures for which DRLs have been established in Australia; and • if DRLs are consistently exceeded, a review is undertaken to determine whether radiation protection has been optimised. The introduction of new adult DRLs for nuclear medicine will require practices providing Medicare funded nuclear medicine imaging services, including PET and SPECT services, to undertake an annual comparison of their facility reference levels against the newly established Australian DRLs. The ARPANSA’s Technical Report (180) is available at https://www.arpansa.gov.au/sites/default/files/tr180. pdf, and further information about the national nuclear medicine DRLs can be found at https://www.arpansa.gov. au/research-and-expertise/surveys/national-diagnosticreference-level-service/current-australian-drls-update/nm General material concerning the National DRL service is located at https://www.arpansa.gov.au/research-andexpertise/surveys/national-diagnostic-reference-levelservice and any enquires can be made by contacting ARPANSA on 1800 033 972 (9am – 4pm weekdays) or ndrld@arpansa.gov.au Paul Marks ARPANSA
Education & CPD Case Study Role of 18F-FDG PET in the Management of Gestational Trophoblastic Neoplasia Author: Rosemary Dallen, WA PET Service, Sir Charles Gairdner Hospital
BACKGROUND/AIMS Gestational Trophoblastic Disease (GTD) is a spectrum of rare pregnancy related conditions that arise from the cells that would normally become the placenta. It occurs due to abnormal fertilisation of the ovum; either due to the egg not containing DNA or the mixing of foetal and trophoblastic (placental) tissue. They can be benign or malignant (neoplastic). GTD usually occurs in women <20 years or >45 years. There are five types of GTD. The first, Hydatidiform mole, is usually benign and accounts for 80-90% cases. It is made up of villi swollen with fluid. Next, Invasive mole, a malignant tumour that develops from a Hydatidiform mole and invades the myometrium, 4% metastasise usually to lungs and brain. Third, Choriocarcinoma is a fast growing malignant form that commonly metastasises, half develop from Hydatidiform mole but they can also occur after miscarriage, termination or live birth. And finally, Placental-site & Epithelioid tumours are both very rare, both resistant to chemotherapy and have a poor prognosis. Most GTD tumours present in 1st trimester with vaginal bleeding and abnormally high serum βHCG. Diagnosed with trans-vaginal ultrasound and staged with CT chest and brain, and occasionally MRI. Benign Hydatidiform mole is removed via suction D&C. Malignant forms are treated with methotrexate chemotherapy, and if unsuccessful, treated with multi-agent chemotherapy. A suction D&C may also be performed for nonmetastatic tumours. The aim of the journal was to evaluate role of FDG PET in both the primary staging of gestational Trophoblastic Neoplasia, and in monitoring treatment efficacy and influence of management.
18-year-old with gestational choriocarcinoma. PET/ CT performed to complete the staging. Transaxial PET/CT image shows uterine FDG uptake (a) and lung uptake at multiple sites (b). After chemotherapy, the patient underwent another PET/CT scan that showed persistent uptake in the uterus (c). No significant sites of uptake were detected in the lungs (d). Based on PET/CT results, the patient was treated with hysterectomy and adjuvant chemotherapy with subsequent reduction of the serum βHCG to undetectable levels.
Choriocarcinoma in a 23-year-old patient two years after normal pregnancy, presenting with abdominal distension and raised beta-hCG levels. CT Pelvis reveals extra uterine tumour deposits later proven to be choriocarcinoma. Uterus is marked with black arrows.
2020 Spring/Summer Edition gamma GAZETTE 41
Education & CPD Case Study Role of 18F-FDG PET in the Management of Gestational Trophoblastic Neoplasia (Continued)
“In patients with chemotherapy resistance, PET/CT performed after treatment was more useful than conventional examinations in identifying sites of resistance and in guiding patient management.”
METHODS This was a Retrospective study of 41 patients between 2002-2010 at San Raffaele Hospital, Heidelberg. The mean age was 35 (17-56 years). 38 patients were from point of primary staging, and three included post first line chemotherapy due to resistance. All 38 referred for primary staging received conventional evaluations, including gynaecological examination, βHCG serum measurement, chest x-ray, TV-US, abdominal and chest CT scan, before treatment. If lung metastases were present, CT brain also performed. An FDG PET scan was performed for staging (PET in 6 patient, PET/CT in 35 patients). Low risk patients were treated with methotrexate and folic acid. High risk patients were treated with multiagent chemotherapy (EMA-CO regimen). Monitoring during treatment consisted of weekly βHCG measurements. Monitoring post treatment included one year of monthly βHCG measurements in low-risk patients and two years in high-risk patients. An FDG PET scan was repeated at end of chemotherapy if staging scan was positive for extra-uterine disease. Patients with persistent disease were treated again with chemotherapy or with surgical removal of tissue showing persistent disease. RESULTS For staging, PET was concordant with TV-US in 91% patients, (3 false negatives), and CT in 81% patients (7 false negatives). PET did not provide any additional information during staging. For treatment response: 12 patients received a PET/CT on completion of chemotherapy. Eight high-risk patients also received PET/CT after the first line chemotherapy when βHCG became undetectable. Of these eight, PET/ CT showed a complete metabolic response in all; however CT demonstrated remaining lung and liver metastases in two of these patients (false positives). Of seven chemotherapy-resistant patients, conventional imaging plus a second PET/CT scan were performed to identify site of resistance. In one of these patients, PET/CT detected an FDG-avid lung nodule not found on CT. In two patients, the CT scan showed disease in multiple organs including the lung and liver, while PET/CT revealed the persistence of GTN at a single disease site in the lung of one patient, and uterus of the other. In one chemotherapy resistant patient, PET/CT identified uptake in an axillary lymph node, not identified by CT. CONCLUSION FDG PET is not useful for staging, but is useful for treatment monitoring, or in patients with chemo-resistant disease. For Stage 1, TV-US is still the best for diagnosis. However, FDG PET can benefit high-risk patients due to precise mapping of active metastases, and also assists in reducing false-positive found on CT post-treatment. 42
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References for this article can be found on page 58
Education & CPD Case Study Immunotherapy-Related Nephritis in a Melanoma Patient: A Case Study Author: Rosemary Dallen, WA PET Service, Sir Charles Gairdner Hospital
CASE DESCRIPTION
A 52-year-old female with BRAF mutant metastatic melanoma was referred to our department for staging, and then surveillance PET scans. After the staging scan demonstrated multiple sites of disease, the patient began treatment with Novartis PDR001 (spartalizumab) immunotherapy combined with dabrafenib and trametinib. During her treatment, the patient developed drug-induced nephritis, which was diagnosed on FDG PET. TECHNIQUE Whole body planar imaging and SPECT/CT of the spine and pelvis (low dose CT for attenuation-correction and localisation) were performed three hours post injection of 800MBq 99mTc-HDP.
PROCEDURES PERFORMED
Four wholebody 18F-FDG PET/CT scans were performed, each approximately 10 weeks apart. Uptake time ranged from 63-79 minutes, and imaging was performed on a Siemens Biograph TruePoint16 and a Siemens Biograph64 mCT.
FINDINGS
The first PET scan demonstrated multiple FDG-avid metastases in the liver, skeleton, lung, right hilum, left deltoid, and subcutaneously in the lateral left hip. Immunotherapy was then commenced. On the second PET scan, 10 weeks later, there was a complete metabolic response of hepatic and pulmonary metastases, and partial metabolic response at all other sites. Twelve weeks later, a third PET scan demonstrated a complete metabolic response however, there was new diffuse renal parenchymal uptake and minimal urinary excretion, in keeping with immunotherapy-related nephritis. This finding was highlighted in the report to alert the patientâ&#x20AC;&#x2122;s clinician. Six days after this scan, the patient presented to the emergency department, reporting fevers, shortness of breath, and tachycardia. The final PET scan, nine weeks from the 4th, demonstrated no metabolic evidence of recurrent melanoma, in addition to resolution of the nephritis.
OUTCOME
Due to the PET scan findings, immunotherapy was ceased and the patient continued with dabrafenib and trametinib only. The patient was treated with prednisolone which led to resolution of her nephritis, confirmed on the final PET scan. The four PET scan MIPs are displayed consecutively in figure 1.
Figure 1 2020 Spring/Summer Edition gamma GAZETTE 43
Education & CPD Case Study Immunotherapy-Related Nephritis in a Melanoma Patient: A Case Study (Continued)
DISCUSSION
Novartis PDR001 (spartalizumab) is a PD-1 (programmed death-1 receptor) immune checkpoint inhibitor. Other common anti-PD-1 include pembrolizumab and nivolumab, while atezolizumab (anti-PD-L1) and ipilimumab and tremelimumab (anti-CTLA4) immunotherapies are also in widespread use. Immunotherapy with drugs such as this has become first-line treatment for metastatic melanoma. The use of immune-checkpoint inhibitors has revealed a group of immune-related adverse events (irAEs), many of which are a result of the same immunologic mechanisms responsible for the therapeutic effects. These drugs block the inhibitory mechanisms that suppress the immune system and protect the body from an acute or chronic immune response. irAEs are observed in up to 90% of patients on anti-CTLA-4 antibody treatment, and 70% in patients on anti- PD-1/PD-L1 antibody treatment. A 2017 article in the Journal of immunotherapy of Cancer stated that â&#x20AC;&#x153;Skin, gut, endocrine, lung and musculoskeletal irAEs are relatively common, whereas cardiovascular, hematologic, renal, neurologic and ophthalmologic irAEs occur much less frequently.â&#x20AC;? Severe side effects are relatively uncommon, but can be life-threatening, with deaths occurring in up to 2% of patients. Early recognition is imperative, and it should be noted that immunotherapy related irAEs typically have a delayed onset and longer duration than those resulting from chemotherapy. The condition may need to be managed with prompt cessation of therapy and immunosuppression. Considering the increasing numbers of PET patients receiving immunotherapy, it is important to be aware of these side effects (not simply nephritis, but colitis, pancreatitis, hepatitis etc), and to alert referring clinicians to their findings. These adverse effects may require temporary suspension or permanent discontinuation of therapy, and may be treated with corticosteroids and/or immunosuppression, depending on the grade. Some other examples from our department include a 66 year old woman with metastatic melanoma, treated with Nivolumab, who developed colitis that was demonstrated on her PET scan (figure 2). Another was a 74-year-old woman with metastatic melanoma on Pembrolizumab, who also developed nephritis that was evident on her PET scan (figure 3).
Figure 2
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Figure 3
Education & CPD Case Study Lymphangitis â&#x20AC;&#x201C; A Suppurative Case Study Author: Ying Xiao, Fiona Stanley Hospital
BACKGROUND
Lymphangitis refers to the inflammation of lymphatic channels1. The acute form of lymphangitis occurs due to bacterial origin, while the chronic process is of mycotic, mycobacterial or filarial cause2. The leading cause of lymphangitis is by the infection of S.pyogenes and Group A streptococci2, while infrequently by S.aureus or pasteurella multocida after an animal bite1.
CASE STUDY
Figure 1 Whole-body blood pool image
Figure 2 Whole-body bone scan
A 75-year-old male presented to nuclear medicine department for a Bone/Gallium protocol querying osteomyelitis. He had acute back pain and amoxycilin-resistant E.Coli bacteraemia of unclear source. Clinically the patient had tenderness in mid to lower lumbar region radiating to both sides, and non-specific abdominal tenderness. The patient was already on Tazocin. The patient was administered 920MBq of 99mTc-HDP, immediately followed by whole-body blood pool imaging. After a delay of three hours, whole-body images were acquired. The whole-body blood pool images of the bone scan indicated no abnormal hyperaemia to indicate a site of active infection, as shown in Figure 1. The whole-body bone scan showed mild degenerative uptake, as demonstrated in Figure 2. A Gallium scan followed two days after the bone scan, the patient was administered 150MBq of 67Gallium-Citrate at the end of the bone scan. The 67Gallium scan found diffuse intense activity in the left supraclavicular fossa extending postero-inferiorly along the paratracheal and para-oesophageal regions (T2-8), as shown in Figure 3. There is also apparent loss of contiguity, then activity was seen again in the right retrocrural space as well as in the retroperitoneum in the close proximity to the second and third part of the duodenum (Figure 4), indicating further sites of soft tissue infection. One week later, this patient was referred for a FDG-PET scan in evaluation of vascular stent infection to determine the final duration of antibiotics therapy. At the time of referral, the patient had already commenced on long-term Ceftriaxone. The FDG-PET scan demonstrated concordant findings with the 67Gallium scan. There was diffuse and intense activity involving the thoracic duct (Figure.5), which tracked superiorly from the level of L2 vertebra along the course of the thoracic duct and continuing superiorly to the thoracic inlet on the left, posterior to the left subclavian vessels. This
Figure 3 Whole-body Gallium scan 2020 Spring/Summer Edition gamma GAZETTE 45
Education & CPD Case Study Lymphangitis – A Suppurative Case Study (Continued) likely reflected the route of spread of E.Coli from a duodenal rupture, as shown in Figure.6. The findings were suggestive of suppuratives lymphangitis. The persistent activity at the site suggested that antibiotic therapy to date had not sterilised the infection, and a follow-up PET scan in another 1-2 months as a guide to antibiotic therapy was advised.
CONCLUSION
This patient continued intravenous Ceftriaxone for another two weeks, and oral Augmentin Duo Forte for two weeks after discharge. In this case, the PET scan was helpful in determining deep seated sites of infection which guided the clinicians to decide the duration of treatment in this case. In addition, the PET scan findings that the patient had suppurative lymphangitis than an infected stent spared the patient the burden of being on long-term antibiotics therapy. Although the patient never returned for a follow-up PET scan, it would have been beneficial for clinicians to be confident in the eradication of infection.
Figure 4 Activity in paratracheal and paraoesophageal regions
Figure 5 Intense uptake of FDG in the thoracic duct
References: •
Myers, A. (2017). Localised Lymphadenitis, lymphadenopathy, and lymphangitis. In: Loong, Sarah S., Prober, Charles G., Fischer, Marc. Principles and Practice of Paediatric Infectious Diseases. 5th ed. Philidephia: Elsevier. pp158-163.
•
Bennett, J. Dolin, R. Blaser, M. (2015). Lymphadentitis and Lymphangitis. In: Pasternack, M. Swartz, M. Mandell, Douglas, and Bennet’s Principles and Practice of Infectious Diseases. 8th ed. Philidephia: Elsevier. pp1226-1237.
Figure 6 Primary source of E.Coli bacteraemia
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gamma GAZETTE 2020 Spring/Summer Edition
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Education & CPD Case Study Rhenium-188 Cutaneous Brachytherapy for NonMelanomatous Skin Cancer Author: Dr Joe Cardaci, Diagnostic Nuclear Imaging, Hollywood Private Hospital, Nedlands, Western Australia
BACKGROUND
Australia has one of the highest incidences of skin cancer in the world, with more skin cancers diagnosed in Australia each year than all of Western Europe. There are a variety of treatment options available, with treatment tailored to the lesion, and the individual’s personal circumstances. External beam radiotherapy is one option but generally requires fractionation with multiple attendances required over a period of weeks. Rhenium-188 SCT (Skin Cancer Therapy) is a novel topical brachytherapy technique which allows for direct application of Re-188, suspended in an acrylic matrix, to the lesion to deliver a predetermined radiation dose to the lesion. Re-188 has a half life of 17 hours and releases a beta particle (EMax 2.12 MeV) with average penetration in soft tissue of about 3mm. It allows for predictable dosimetry with deposition of 92% of the radiation dose within 2mm of the epidermal surface, thereby protecting the underlying stroma and adjacent anatomical structures. Over 1,300 lesions have been treated in Europe. The reported remission rate is 98.5% at 12-78 month follow up, with 89% remitting after a single treatment session1. For lesions less than 4.5cm2 in area and with a depth of <2mm, the cure rate is over 98% with a single treatment session. The cosmetic results of treatment are
generally excellent. The lesion is marked (preferably by the referring dermatologist) allowing a 5mm margin. A clear plastic film is applied over the lesion, and the surface area is measured. The Re-188 resin paste is delivered to the Nuclear Medicine department in a prefilled cartridge called a carpoule. Using a hand-held applicator, the Re-188 resin is painted evenly onto the plastic film directly over the lesion. The dose to the lesion can be determined from the amount of radioactivity applied (determined by measurement of the carpoule pre and post application), the measured surface area of the lesion, and the depth of tumour infiltration which has been previously determined on punch biopsy of the lesion. A dose of 50 Gray absorbed dose radiation generally is delivered in 15-120 mins, with an average of about an hour. When the calculated time has elapsed, the plastic film and adherent resin matrix is peeled off the lesion and the patient can be discharged. The technique requires no local anaesthesia, is painless, non-invasive, personalised, and is generally completed in a single treatment session.
CASE STUDIES
Case Study 1 A 65-year-old female with a 2 x 2cm in situ Squamous Cell Carcinoma of the nose present for over 10 years. Prior treatments included multiple
previous surgeries, serial curettage and cautery, topical Efudex, topical Aldara, topical Picato gel, and recurrent cryotherapy. A single session Re-188 treament was applied. At clinical follow up 6 months post treatment there was complete clinical remission of the SCC.
Case Study 2 A 46-year-old male. Biopsy confirmed BCC left cheek. Present for almost four years. Patient very needlephobic, declined excision and failed to reattend. Would need General Anaesthesia for excision. Agreed to single treatment session Re-188 SCT. Complete remission at clinical follow up.
Re-188 SCT has CE Mark approval but is not yet approved by the Australian Therapeutic Goods Administration (currently under review by TGA). The technique is available in Italy, Germany, South Africa and, more recently, Australia. The first Australian patients were treated in Perth earlier this year, via the TGA Special Access Scheme.
References: •
1. Cipriani, C and Sedda, A.F. “Epidermal Radionuclide Therapy – Dermatological High-Dose-Rate Brachytherapy for the Treatment of Basal and Squamous Cell Carcinoma.” In Therapeutic Nuclear Medicine, edited by Baum, R.P. New York, Springer. 2014. ISBN 978-3-540-36719-2.
2020 Spring/Summer Edition gamma GAZETTE 49
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ANSTO/ANZSNM Research Grant 2020
Grant value up to $20,000 Awards & Grants Applications open now
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Inviting applications for ANSTO/ANZSNM Research Grant 2020 Closing date: 20th December 2019 For further information on Research Grant Conditions & Applications visit www.anzsnm.org.au/membership/awards-grants/anstoanzsnm-research-grant/ ANSTO and the ANZSNM (“the Society”) are pleased to offer a competitive grant aimed at encouraging research in nuclear medicine in Australia and New Zealand. The grant is up to the value of $20,000 and is expected to run for approximately one year. ANSTO is Australia’s government-funded nuclear science organisation. Its vision is to deliver excellence in innovation, insight, and discovery through its people, partnerships, nuclear expertise and landmark infrastructure. In assessing applications for the grant, preference will be given to early career researchers in order to provide seed funding for pilot investigations that could lead on to further grant applications. The grant will be offered yearly but the evaluating committee reserves the right to not award the grant if there is no suitable application. All aspects of nuclear medicine will be considered for this grant including, but not restricted to: • novel developments in radiopharmaceuticals; • hardware and software innovation; • epidemiology and audit activities; • pilot clinical trials; • retrospective studies on outcomes in diagnostic and therapeutic procedures in nuclear medicine; • education, training and professional development activities. The ANSTO/ANZSNM Research Grant is intended to achieve one or more of the following: 1. 2. 3. 4. 5.
Approach a meaningful conclusion in one year; Assist investigators striving to establish new programs or new directions; Fund initial exploratory research for which external funding will be sought subsequently; Address circumscribed clinical problems of a sort unlikely to attract industry funding; Survey groups of patients to assess the success rate, sequelae, safety or any other aspect of diagnostic or radionuclide therapy protocols; 6. Bridge the gap of a year between completion of one external grant and the commencement of another. The evaluating committee will consist of one representative from ANSTO, one member of the Society's Scientific Advisory Panel and the ANZSNM President or their delegate. The successful applicant/team is expected to acknowledge ANSTO’s and the Society’s support in any publications and provide a report to be published in the Gamma Gazette upon completion. The applicant will ideally present the outcome(s) of the research at the next ANZSNM ASM. Prof Vijay Kumar Member, Scientific Advisory Panel AZNSNM
2020 Spring/Summer Edition gamma GAZETTE 51
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EVENTS CALENDAR NSW Health/HETI Workshop: Nuclear Medicine Quantification For Planning And Verification In Theranostics 30 November — 1 December 2019 Kerry Packer Education Centre, Royal Prince Alfred Hospital, Camperdown NSW 2000
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A summer dose of fun GAMMA GAZETTE CRYPTIC CROSSWORD Hello all! It’s about that time of year again when we can all kick off our feet and put our shoes up. Perhaps you’d like to try this cryptic with all that time to spare? The style is most similar to the Times and Guardian cryptics (e.g. as reprinted in The Australian here in Oz). Flummoxed? There should be a solution grid hidden somewhere in the Gazette, ideally upside-down and in font size 0.002, but those soft-hearted Editors may show more mercy. If you hate my setting, you can always abuse me at Paul.Brayshaw@health. wa.gov.au. I will be happy to explain my reasoning behind any of the clues. Spoiler alert! There may be a few words we all know… Happy solving! Paul Brayshaw
ACROSS 1, 16d & 14d Old sonographer positions Timmy for operation - a useful technique for oncological staging (8,8,10) 5 Spirit held back within can go crazy (6) 10 Film director shown by soldier maybe to eat mixed ration? Quite the reverse! (9) 11 Image transfer standard in send I complete (5) 12 Mundane to cut off the tip of one's rear end (4) 13 After notification initially, no rail rebuilt around north-east without constant gradient (3-6) 15 Exaggerated, as where a woman would wear the jacket? (4,3,3) 17 Endlessly dirty 23 (4) 19 Taboos said to protect bones (4) 20 Uninhabited area more overgrown beside notorious loch (10) 22 Again swears test resat drunk (9) 24 Initially good looking in bed, full of insincere talk (4) 26 Worked away softly at German song (4) 27 Surgical procedure on old pirate botched first (9) 28 Cowardly yowler cut short, left shattered (6) 29 Hate a man dreadfully, someone loathed (8)
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gamma GAZETTE 2020 Spring/Summer Edition
DOWN 1 Shame to take gratuity back in front of Yankee (4) 2 Sore at first, nipple earrings adjusted for huntsman's best friend? (8,7) 3 Tiny alto mishap, possibly major? (8) 4 The first person to take on both sides - this makes some cry (5) 6 Anoint old diocesan's head in downpour (6) 7 Decline manicure for working in our profession? (7,8) 8 After state of oblivion cut short, pledge to meet halfway (10) 9 Data retrieved from mixed woodland (8) 14 See 1 ac. 16 See 1 ac. 18 In extremes of pain, fury returns at beginning of trial - a possible contraindication for 7? (8) 21 Bookish American goes off to artist's room (6) 23 Behind vessel beheaded 17 (5) 25 Member of ancient race Cain destroyed (4)
WORD SEARCH
MAKE YOUR OWN WORKSHEETS ONLINE @ WWW.ATOZTEACHERSTUFF.COM
NAME:_______________________________ DATE:_____________
by Cassandra Koudela, Sir Charles Gairdner Hospital, WA
M A L I G N A N T U H Y P E R T E N S I O N S G M
E O N R A D I O I S O T O P E H I S O M E R I C N
V P K U C O R O N A R Y G O J T E C H N E T I U M
C L D S C O L I O S I S A A R R H Y T H M I A V P
S U U T H O R A C I C B M B A Y J B B C O L O N A
N C R N G W Y Q X L O T M C I S S O E H B C O E R
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ALZHEIMER ARRHYTHMIA BECQUERELS BETA BIOCHEMISTRY BONE BRAIN CALCANEUS CARDIOVASCULAR COBALT COLON CORONARY CURIE EMBOLISM ENDOCRINE
C W K R E N E P H R E C T O M Y C E Q A H E T D T
R U O J D B G A S T R I C F I Y P H U R Y E Z O H
O S S I F I C A T I O N Q F J H Q A E T R Y X C Y
S N L S L G O L G L O M E R U L A R R M O Y K R R
I W S J C L E V H L U M B A R F R L E B I B C I O
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FLUORINE GAMMA GASTRIC GLOMERULAR GOITER HEART HEPATOBILIARY HYPERTENSION HYPOTHYROIDISM INFLAMMATION ISOMERIC LUMBAR LUNG LYMPHOMA MALIGNANT
Y M U C O S A O B S P N D A C N C G S K I B T E D
T H Y R O I D L I O C O P V A R O R L K T R U R K
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T O S T E O C L A S T R A M R R T L N E U T R O N
METABOLISM MUCOSA NECROSIS NEPHRECTOMY NEUTRON OSSIFICATION OSTEOBLAST OSTEOCLAST OSTEOMYELITIS OSTEOPOROSIS PARATHYROID PHALANGES RADIOISOTOPE REACTOR SARCOIDOSIS
G E X P H A L A N G E S O S T E O P O R O S I S X
K L S P F E T R A N S P L A N T T I P G O I T E R
I N F L A M M A T I O N S A R C O I D O S I S K B
N O M E T A B O L I S M O S A L Z H E I M E R W F
M T S V A H E P A T O B I L I A R Y M V S V E T L
U R A N I U M Z S H O S T E O B L A S T Y M O Z G
SCOLIOSIS TECHNETIUM THORACIC THYROID THYROIDITIS TRANSPLANT URANIUM
CROSSWORD by Cassandra Koudela, Sir Charles Gairdner Hospital, WA
ACROSS 1. Unit of absorbed radiation dose 5. A substance that absorbs charged particle radiation and then releases this energy through fluorescence 7. What is the oxidation state of Gallium? 8. Time frame at the end of which a cell or tissue has eliminated half the quantity of a molecule present ( Half-life) DOWN 1. What does the G in MAG-3 stand for? 2. Charged particle accelerator 3. Tc-99m decays by transition 4. The strongest reducing agent commonly used in Nuclear Medicine ( Chloride) 5. DOTATATE is an analogue of which peptide hormone? 6. An ion or molecule that binds to a central metal atom Answers can be found on page number 58 2020 Spring/Summer Edition gamma GAZETTE 55
OFFICE BEARERS President Vice President Past President Treasurer Committee
A/Prof Roslyn Francis (WA) Dr Daniel Badger (SA) Prof Dale Bailey (NSW) Ms Suzanne McGavin (VIC) Prof Karen Jones (TSIG) Dr Rajiv Bhalla (RPS) Mr Nicholas Ingold (ACT) Ms Judy Duong (QLD) Ms Prudence Burns (NZ) Mr Christian Testa (VIC/TAS) Mrs Victoria Sigalas (SA) Dr Geoff Schembri (AANMS Representative) Prof Andrew Scott (IRC)
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Now Available in Print & Digital KEY CONTENT • Case studies • Papers & Abstracts • Industry Specific Reports • Industry News • Events and Awards • Community Members Profiles Gamma Gazette is the official publication of the Australian and New Zealand Society of Nuclear Medicine. Founded in 1969, the ANZSNM is the major professional Society for those practising Nuclear Medicine in Australia and New Zealand.
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AIMS AND OBJECTIVES OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE 1. Promote: • The advancement of clinical practice of nuclear medicine in Australia and New Zealand; • Research in nuclear medicine; • Public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; • Co-operation between organisations and individuals interested in nuclear medicine; and • The training of persons in all facets of nuclear medicine. 2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine through standing committees and special groups: • The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand. • The TSIG Committee is the group overseeing the Technologist Special Interest Group (TSIG) and ensures that all projects, committees and activities of the TSIG align with the values and strategic plan of the ANZSNM. It reports directly to the ANZSNM Federal Council and oversees the two TSIG working groups: CPD & Education Working Group and Technologist Workforce Advocacy Working Group. The committee is able to form working groups to perform specific tasks as required to provide opportunities for the benefit of Technologist members of the ANZSNM after consultation with the ANZSNM Federal Council. • The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality and provide a forum for development in Australia and New Zealand.
Content References References for case study: ”Role of 18F-FDG PET in the Management of Gestational Trophoblastic Neoplasia” on page 42: •
American Cancer Society (2017, November 27). Gestational trophoblastic Disease. Retrieved from https://www.cancer.org/cancer/gestational-trophoblastic-disease/about/what-is-gtd. html
•
Chang, T., Yen, T., Li, Y., Wu, Y., Chang, Y., & Ng, K. et al. (2005). The role of 18F-fluorodeoxyglucose positron emission tomography in gestational trophoblastic tumours: a pilot study. European Journal Of Nuclear Medicine And Molecular Imaging, 33(2), 156-163. doi: 10.1007/s00259-005-1873-1
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Cohn, D., Ramaswamy, B., and Blum, K. (2014). Malignancy and Pregnancy. (7th ed.). Creasy and Resnik’s Maternal-Fetal Medicine: Principles and Practice, pp 932-948). Elsevier, Saunders
•
Dhanda, S., Ramani, S., & Thakur, M. (2014). Gestational Trophoblastic Disease: A Multimodality Imaging Approach with Impact on Diagnosis and Management. Radiology Research And Practice, 2014, 1-12. doi: 10.1155/2014/842751
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Goldstein, D., and Berkowitz, R (2014). Gestational Trophoblastic Disease. (5th ed). Abeloff's Clinical Oncology (pp 1614-1629). Churchill Livingstone, Elsevier Inc
•
Mapelli, P., Mangeili, G., Gentile, C., Radaiotti, E., Giorgione, V., Spinapolice, E., Gionolli, L., Messa, C., and Candiani, C. (2013) Role of 18F-FDG PET in the management of gestational trophoblastic neoplasia: European Journal of Nuclear Medicine and Molecular Imaging, 40:505–513. DOI 10.1007/s00259-012-2324-4
•
Sharma, P. (2017). 18F-FDG PET/CT Demonstrating Chorioadenoma Destruens After Evacuation of Complete Hydatidiform Mole. Clinical Nuclear Medicine, 42(10), 766-767. doi: 10.1097/rlu.0000000000001770
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Cryptic Crossword Answers
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Nuclear Medicine Physics and Chemistry Crossword Answers Across: 1. GRAY 2. SCINTILLATOR 3. THREE 4. BIOLOGICAL
Down: 1. GLYCINE 2. CYCLOTRON 3. ISOMERIC 4. STANNOUS 5. SOMATOSTATIN 6. LIGAND
2020 Spring/Summer Edition gamma GAZETTE 58