2021 WINTER EDITI ON I SSUE 33
The Lancet Oncology Commission on Medical Imaging and Nuclear Medicine What it is Report Findings Interview with co-author, Prof. Andrew Scott
Conference Highlights
2021 WINTER EDITION ISSUE 33
CONTENTS Cover 24 The Lancet Oncology Commission
on Medical Imaging and Nuclear Medicine
24
32 6 50
14
2
66 65
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
3
From the President
5
Introduction
6
Branch News
12
Special Interest Group/ Committee News
14
Submitted Articles & Papers
32
Highlights - 51 st Annual Scientific Meeting
50
Education and Continuing Professional Development
65
People in Nuclear Medicine
66
Calendar of Events
67 68 71
Time to Relax 2020 Financial Statements Office Bearers
FROM THE PRESIDENT parade of emails to respond to, documents to write/ review/edit/send off, meetings to attend and strategy to plan. Not to mention the work involved in making sure the Annual Scientific Meeting happens and things go OK! Don't get me wrong, I'm very pleased and proud to be a part of making a difference in nuclear medicine and supporting all of you, the members of the Society.
Daniel Badger - MANZSNM President
N
uclear Medicine is awesome! Nuclear Medicine is cool when you are part of a team!
[sung to the tune of song from The Lego Movie.]
I'm sure you all agree with me, because Nuclear Medicine is a wonderful profession to work in, but even more it is a true "team sport". It relies utterly on the skills and knowledge of a whole team of different professions, and without any one of the professions that we have in our membership, we just wouldn't be able to do what we do.
Writing this article in the Winter 2021 Gamma Gazette means it has been over one year since I took on the role as President of the Society, and so much has happened in that time! I didn't realise how much is done behind the scenes, with the society constantly dealing with enquiries and requests from members, nuclear medicine professionals from outside Australia, the public, organisations involved in nuclear medicine and research, and various government and other organisations. It is a never ending
You will all be familiar with the Lancet Oncology Commission on Medical Imaging and Nuclear Medicine, including the fantastic efforts of our own Andrew Scott. You won't be surprised to find that the quality and availability of imaging makes a huge difference in outcomes. Obviously the quality and access to appropriate and effective therapies are very important too. It is vitally important that we as the nuclear medicine community step up and make sure that we are part of the process of improving availability and the quality of nuclear medicine imaging and therapy, both in Australia and New Zealand, but also helping out our neighbours. The ANZSNM have recently made a submission to the IAEA's Regional Cooperative Agreement for Research, Development and Training Related to Nuclear Science and Technology for Asia and the Pacific (RCA), and in it we hope to contribute to better outcomes for patients both here and in our backyard. We also need to be on the forefront, providing our expertise to help develop standards and guidelines for theranostics - it is too important that it is done right not to allow it to grow in an uncontrolled way - we can't let it be like the cancers that we are imaging and treating! I was pleased to hear about Dr John Andrews being recognised with an AM in the latest Queen's Birthday Honours. John is a past president of the Society and you can find out more about his career and listen to interviews with him at www.thermh.org.au/profile/775752. According to John: "We did the first pulmonary embolism in Victoria at the Melbourne and I diagnosed it. And I hoped to God I was right..." Finally, while it seems like ages until May 2022 and the ASM in Brisbane, the time will fly by! You should already be thinking about your research projects and getting ready to send in abstracts. Stay safe and remember to keep supporting your colleagues and friends - they are your (and my) nuclear medicine family.
Daniel GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
3
OUR CONTRIBUTORS EDITORIAL COORDINATOR Rajeev Chandra General Manager PO Box 6178, Vermont South, VIC 3133 T 1300 330 402 F (03) 8677 2970 secretariat@anzsnm.org.au
EVENTS & ADVERTISING ENQUIRIES marketing@anzsnm.org.au
Prof Andrew Scott International Relations Committee
Sarah Daniel Branch Chair, QLD
SUBMISSIONS secretariat@anzsnm.org.au
DESIGN & PRODUCTION Enovate Studio www.enovatestudio.com
PUBLISHED IN Autumn, Winter & Spring/Summer
CONTENT SUBMISSIONS Jessica Fagan Branch Secretary, NZ
Lachlan Stranks Royal Adelaide Hospital, SA
SCIENTIFIC SUBMISSIONS ON ALL ASPECTS OF NUCLEAR MEDICINE ARE ENCOURAGED AND SHOULD BE FORWARDED TO THE SECRETARIAT (INSTRUCTIONS FOR AUTHORS PUBLISHED AT HTTPS://WWW.ANZSNM.ORG.AU/ACTIVITIES/ GAMMA-GAZETTE-CONTENT-SUBMISSION-ANDGUIDELINES/). LETTERS TO THE EDITOR OR POINTS OF VIEW FOR DISCUSSION ARE ALSO WELCOME. IF ORIGINAL OR PUBLIC DOMAIN ARTICLES ARE FOUND AND CONSIDERED TO BE OF GENERAL INTEREST TO THE MEMBERSHIP, THEN THEY SHOULD BE RECOMMENDED TO THE EDITOR WHO MAY SEEK PERMISSION TO REPRINT.
Benjamin-Minh Hoc Ly RMIT University, Melbourne
Mariana Elias University of South Australia, Adelaide
THE ANZSNM GAMMA GAZETTE IS PUBLISHED THREE TIMES A YEAR. DEADLINES FOR EACH ISSUE OF THE JOURNAL CAN BE FOUND ON OUR WEBSITE ANZSNM.ORG.AU
DISCLAIMER 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.
Isabel Barber University of South Australia, Adelaide
Ashleigh Hull University of South Australia, Adelaide
THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE © 2021 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).
WWW.ANZSNM.ORG.AU
4
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
INTRODUCTION TO THE WINTER EDITION
The ANZSNM 2021 Annual Scientific Meeting was recently held on the 21st – 23rd of May with great success. Members attended the event both online or in-person at one of the five ‘live and local’ sites organised across Australia and New Zealand. The ANZSNM Annual Scientific Meeting app was an excellent resource for attendees to access presentation information, contact other participants, and ask questions and provide live feedback throughout the event. Our secretary, Katherine Guerrero, reflected on the event – “The ANZSNM 2021 Conference brought together Nuclear Medicine professionals from across Australia and the globe. The scientific program was varied and engaging, and the high attendance reflected this. Importantly, the option for attendance in person allowed for enjoyable social networking with friends and colleagues.” Thank you to everyone involved with organising and running the Annual Scientific Meeting, and to all those who presented. It was a truly fantastic event. The theme for the ANZSNM 2021 conference was “Unlocking the Potential of Nuclear Medicine”. When reflecting on the past 12 or so months, I believe we as a branch have unlocked our potential by using the ZOOM platform to incorporate our Northern Territory peers into our regular branch meetings. The ability to collaborate with these members brings not only fresh faces, but an abundance of new knowledge and a wealth of opportunities. While we have returned to in-person meetings, we aim to incorporate a ZOOM link to facilitate their continued attendance. This link will also benefit local members unable to attend these meetings on the night, with attendance numbers having increased significantly since the introduction of this online platform. An added benefit of the online meetings is that all presentations are recorded. Our outgoing Treasurer/Secretary, Tess Smith, set up a system so that, with the presenters' permission, scientific meetings are now uploaded to the ANZSNM YouTube channel. This unlocks limitless potential for the valuable insights, research and advances of our esteemed members to be shared with the entire Nuclear Medicine community (while gaining CPD points, too!). I hope you enjoy this edition of the Gamma Gazette and that it inspires you to recognise the role you as an individual, your team, or your state branch can play in unlocking the Potential of Nuclear Medicine. Thank you to everyone who contributed to this edition – stay warm!
Madeline Buttfield — MANZSNM Branch Chair, South Australia and Northern Territory
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
5
BRANCH NEWS
NEW ZEALAND BRANCH NEWS It is hard to believe that we are already halfway through 2021! It has been business as usual for most Nuclear Medicine Departments in New Zealand so far this year. Many departments are still struggling with staff shortages, especially as patient numbers continue to rise.
T
here is some light at the end of the tunnel as some Auckland University students are due to graduate later this year.
Additionally, we welcomed the opening of the Trans-Tasman Bubble in early April. Hopefully, the bubble can be maintained safely, so that face to face contact with our Australian colleagues becomes the norm again. We have already had many engineers and service technicians brave the Tasman to attend sites for overdue maintenance to the relief of many departments across New Zealand. Thank you to those companies that have facilitated this!
hosted by Trish Mead, and her team. It was a great venue attended in person by over 25 delegates from all over New Zealand. It was wonderful to be able to catch up with everyone face to face as well as being able to attend the many outstanding virtual sessions. What an exciting event to be able to be a part of! The networking dinner was held at Gerome’s in Auckland, where we were buzzing with excitement to catch up with our NZ colleagues. Thank you to all the organising committees both locally and virtually for arranging such a successful event.
Stay safe, get vaccinated and keep warm this winter! As I write this brief update, we are a few weeks past attending the Live and Local Annual Scien- Jessica Fagan — MANZSNM tific Meeting. The New Zealand local event was Branch Secretary, New Zealand held at the Auckland City Hospital, wonderfully
2021 Upcoming NZ Branch Meetings 31 Aug
28 Sep
2 Nov
NZ Awards Night for Radpharm and Paul Orr Memorial Presentations
NZ Branch AGM
NZ Branch Inaugural Interesting Case Race
Online via Zoom
6
BOOK TODAY
Online via Zoom
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
Online via Zoom
BRANCH NEWS
SOUTH AUSTRALIA & NORTHERN TERRITORY BRANCH NEWS On the 1st of February, the South Australian and Northern Territory branch finally got together for the Annual Quiz night, which had previously been postponed due to COVID-19 restrictions.
T
he event took place at the Belgium Beer Café and participants embraced the opportunity to get together with their Nuclear Medicine peers and enjoy a night of fun activities. Northern Territory members joined us online via ZOOM.
The first branch meeting for the year took place on the 5th of May at the Women’s and Children’s Hospital. Members joined the meeting both in-person and online, with the combined format resulting in record numbers of attendance. Jack Anderson from the Royal Darwin Hospital presented ‘An overview of Royal Darwin Hospital PET activity for the last 2.5 years and into the future’ – an insightful presentation into the pearls and pitfalls of running a successful regional PET department. Members were then presented with a ‘Reflection of Learning during COVID-19 from the perspective of the Nuclear Medicine Student at University of South Australia’ by current 4th year University of South Australia students Isabel Barber, Joseph Gavini, Esra Laundy and Sunyu Cha. The next branch meeting will take place at Flinders Medical Centre, on the 22nd of September.
Madeline Buttfield — MANZSNM Branch Chair, South Australia and Northern Territory
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
7
BRANCH NEWS
PRESIDENT'S DARWIN MEET UP
T
he Society President who was on holiday in Darwin, contacted and caught up with our Northern Territory based members and enjoyed the famed Darwin sunsets along with a visit to the Royal Darwin Hospital's cyclotron. Below are some photos provided by Daniel. And for those of us down south, let’s not get too envious about the weather. Enjoy!
Left to right: Daniel Badger, Julio, Suzi McGavin, Mitch Andrews, Jack Anderson, Adrienne Little and Joshua Morigi. Daniel, Julio
and Suzi
ne and Adrien Jack, Joshua
Cyclotron
8
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
BRANCH NEWS
VICTORIA/TASMANIA BRANCH NEWS It was a busy time within the VIC/TAS branch the last few months as we put the finishing touches on our hub for the 51st Annual Scientific Meeting.
Kim Jasper — MANZSNM Branch Chair, Victoria/Tasmania
Saturday, 23 October 2021
E •
•
Radpharm and Student Oral Presentation Awards
SAV
VIC/TAS Branch AGM & Award Presentations
E • T
H
A big thank you to the committee members who travelled down to Geelong to help out as
Our next focus in the VIC/TAS branch will be our annual day seminar, as well as the local finals for the Radpharm and SOPA awards. Members are encouraged to keep their eyes open for further information, as well as any case studies that would make an interesting entrant.
D
We also had the chance to mingle and meet new people at the two social events – Friday night’s Welcome Reception and the Networking dinner on Saturday night. We thank the generous sponsors for their support in making sure these events went ahead and to all who attended for making both evenings enjoyable.
volunteers and assist with all of the little jobs that cropped up over the weekend. An extra special thanks to our Federal Council representative Christian, who was instrumental in securing this great venue and for making the weekend run smoothly.
ATE
O
ur “local” site at the Geelong Events Centre gave us a chance to catch up in person with many colleagues whom we had not seen face to face in over 15 months. We had up to 50 members of our nuclear medicine community rotate through the two rooms from Friday afternoon onwards.
Online via Zoom
submissions for the Student Inviting Oral Presentation Award and Radpharm Award
GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU SUBMISSION DEADLINEGAMMA 8 OCTOBER 2021
Enquiries: Vic-Tas.Secretary@anzsnm.org.au
9
BRANCH NEWS
WESTERN AUSTRALIA BRANCH NEWS The past few months have felt quite busy for the WA branch. After having our first meetings for the year cancelled due to surprise lockdowns, we did manage our April meeting, hosted by Perth Children’s Hospital, which was full of excellent presentations.
D
r Trenton Lee presented two recent cases of positive Meckel’s scans in his presentation “A Tale of Two Yolks”. Trent noted how interesting it was to go months (if not years) between positive scans, then to suddenly get two back to back, and actually a third after the presentation was complete. Cassandra Koudela presented in-depth on Horseshoe kidneys, and Dr Russel Troedson gave an interesting presentation on Alpha Therapy, reviewing much of the research, especially that coming out of Europe. Thank you to the lovely Jan from MIPS for sponsoring, Jan attends and sponsors many of our branch’s events!
Of course our big event this season was the Live and Local Annual Scientific Meeting held at the Harry Perkins Institute in Nedlands. Despite being a relatively small city, I was thrilled to see so many WA delegates attend in person. The content was very engaging and every day there was a great mix of topics. The 2021 ASM was originally meant to be held in Perth, so we were grateful to have 3 of the convenors be Perth based and attend the live and local event. Thank you Liesl, Tracey and Stephanie! The gala dinner at Little Way was a hit, even having a signature Nuclear Medicine cocktail… the “Berry Scintillation”. The Perth Nuclear Medicine community is quite tight-knit so it’s always fun to have a social event together. We can all agree that the weekend felt just like a real conference, keeping us very busy, and even a little tired after the 7am starts! We have our post-conference meeting coming up in July, hosted by Sir Charles Gairdner Hospital, and it will be a great opportunity to discuss our favourite talks. It was wonderful to hear at the AGM that WA is leading the way when it comes to events, with 9 held in the previous year despite COVID. We are thankful to have such an involved and active branch here in WA and we are looking forward to an even better year to come. Rosemary Dallen — MANZSNM Committee Member and Federal Representative, Western Australia
10
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
BRANCH NEWS
QUEENSLAND BRANCH NEWS On Tuesday the 11th of May 2021 the Queensland ANZSNM Branch held their first meeting of the year at the Queensland Children’s Hospital (QCH). I’m sure I speak for all states when I say that organising a branch meeting in the current climate is not so easy, but the event was nothing short of spectacular.
T
he auditorium at QCH provided ample space for social distancing and the videoconferencing facilities enabled us to broadcast the meeting far and wide.
The evening began with a presentation from Dr Bruce Goodwin from QCH who spoke about the importance of good quality imaging in paediatric Nuclear Medicine with a focus on gastrointestinal imaging. The second presentation of the evening was from Dr Steve Foresto “Paediatric Oncologist to the stars” who gave us a very interesting insight into the incidence of childhood cancers and treatment pathways currently available. The entire evening was recorded and is available to watch anytime by members through EduTrace, the ANZSNM’s online CPD platform. In other news, on behalf of the Queensland Branch and its members I would like to say a huge congratulations to Candice Nish from the Royal Brisbane and Women’s Hospital who took home the National RADPHARM award for her presentation at the ASM on “The Benefits of Stress”. A reminder to those looking to enter this year’s award that you must be a financial member of the ANZSNM 3 months prior to the state award, for Queensland that will be early November. Finally, the Local Organising Committee are hard at work preparing for the 2022 ASM in Brisbane, with the Brisbane Convention Centre booked for the conference and the Gallery of Modern Art (GOMA) booked for the pre-conference symposium and keynote speakers locked in. It’s full steam ahead in what we all hope to be the first face-to-face conference since the COVID-19 pandemic began. Keep Safe and Well. Sarah Daniel — MANZSNM Branch Chair, Queensland
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
11
SPECIAL INTEREST GROUP/COMMITTEE NEWS
TECHNOLOGISTS SPECIAL INTEREST GROUP
Pru Burns, Emma Brook and Karen Jones Chairs of TSIG Working Committees
W
e as technologists have much to celebrate.
The ANZSNM 2021 conference was a huge success for the Technologist community with 288 registered in the Scientist, Technologist, Nurse, and Registrar Category, that’s a whopping 52% of the total registrants. •
Two technologist driven sessions were held in addition to the Wellness Session. It is always inspiring to hear what our colleagues are up to around the two countries. All Local sites were supported by NMT helpers, including many technologist students, from assisting on registration desks, to starting the recorded presentations at Live sites, to co-ordinating venues for the Gala dinners. Thank you to all those involved in helping make this “Live and Local” iteration of our ASM a great success. Congratulations to the following Technologists: •
•
12
Brylee Thomson, Austin Health. Winner of the Curium Award. Her presentation entitled “16 vs 8 Bin Evaluation of Left Ventricle Ejection Fraction in Myocardial Perfusion Imaging” was interesting to all in the audience. Candice Nish, Royal Brisbane and
Women's Hospital / Queensland Children's Hospital. Winner of the Radpharm Technologist Case Presentation Award for her presentation entitled: “The Benefits of Stress: Acetazolamide versus exercise in PHACE Syndrome.”
Guidelines. Formal feedback has been forwarded to AHPRA for consideration. From the CPD & Education Group:
Given the postponement of the 2020 Technologist Symposium to March 2021, followed by the Live and Local Nicola Evans, recent UniSA grad- ASM in May 2021, the decision was uate. Winner of the Nuclear Medi- made to hold the next Technologist cine Undergraduate Student Symposium in 2022. CPD opportuniTechnologist Award for her ties, in the meantime, will be available presentation, based on the results by the way of webinars. A planning of her Honours year, entitled meeting, led by TSIG CPD Chair, “Effects of exenatide once week- Emma Brook, was held at the start of ly on intragastric distribution of June to brainstorm ideas for potential solids and liquids and perceptions TSIG webinars that will be held later of appetite, in healthy overweight this year and in 2022. A number of subjects.” great topics were proposed and we are currently in the process of organThe TSIG Oversight Committee (OC) ising speakers – watch this space! have recently been working on updating the Terms of Reference for the Coming up: Nick Daw’s term as TSIG TSIG OC and the two sub-committees. Chair comes to an end in September These were presented to the upcom- 2021. Nick will remain on the TSIG ing Technologist member consulta- OC as Immediate Past Chair, providtion via the AGM and approved. ing invaluable knowledge to the Committee. Nick will hand over the From the Workforce Advocacy role to Karen Jones who will hold the Group: combined positions of TSIG Chair and TSIG Federal Council Representative. Members of this sub-committee, led We thank Nick for his contributions by Pru Burns, have recently reviewed as outgoing Chair. consultation documents from APRHA on the Combined Code of Conduct and the MRPBA National Examination
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SPECIAL INTEREST GROUP/COMMITTEE NEWS
INTERNATIONAL RELATIONS COMMITTEE
Andrew Scott Chair, International Relations Committee
A
NZSNM has been a formal supporter of The Lancet Oncology Commission on Medical Imaging and Nuclear Medicine, which has described for the first time the health and economic impact of imaging and, in particular nuclear medicine in patients with cancer at a global level. The major findings of this project were published in Lancet Oncology in March 2021, with a number of commentaries: https://www.thelancet.com/commissions/medical-imaging-nuclear-medicine. The results of this project were presented at the European Society of Radiology conference in March, and will also be presented at the upcoming SNMMI conference. Prof. Andrew Scott was
a lead commissioner for this project, which has also resulted in a series of additional papers on global imaging impact in cancer in Lancet Oncology. This project has also involved all major international nuclear medicine and medical imaging societies in establishing global databases on imaging equipment and workforce, which will be utilised in plans for the inclusion of nuclear medicine and imaging in cancer policies for Governments.
Meetings with overseas nuclear medicine societies and associations have continued to be restricted by COVID-19 impact on meetings, but virtual contact has been maintained. It is anticipated that training programs with IAEA will not resume until 2022.
The IRC has also engaged with the SNMMI and the World Federation of Nuclear Medicine and Biology on Theranostic projects aimed at establishing frameworks for the guidance of training and implementation of Theranostic programs.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
13
SUBMITTED ARTICLES & PAPERS
REFLECTION OF LEARNING DURING COVID-19 FROM THE PERSPECTIVE OF NUCLEAR MEDICINE STUDENTS AT THE UNIVERSITY OF SOUTH AUSTRALIA
Barber I 1, Cha S 1, Gavini J 1, Laundy E 1 1
University Of South Australia, Adelaide
T
he emergence of the COVID-19 pandemic brought forth new approaches to controlling infectious diseases in Australia. The implementation of strict safety regulations saw rapid transitions of higher education teaching programs from face-to-face learning, to online formats. From March 18, 2020, the University of South Australia’s Nuclear Medicine program transitioned to an online format. Through reflecting on the student experience, university expectations, online learning, personal experiences and the consequences of reduced placement time were explored.
Student time management and independent learning was aided with the online delivery of lectures and tutorials. Reducing time (and money) spent on university transport led to more time which could be utilised for revision or assignment work. Despite most courses providing lecture recordings prior to the pandemic, the recorded tutorials allowed for self-paced learning. Moreover, the online format allowed for improved work – study balance, as many students struggled scheduling work around fulltime study. However, the absence of face-to-face lectures and tutorials made it increasingly difficult for some students to feel comfortable participating and communicating ideas during classes. Nevertheless, the accessibility of lectures and recorded tutorial classes was particularly beneficial in exam revision and overall learning, especially in the absence of clinical placement in comparison to previous years.
14
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SUBMITTED ARTICLES & PAPERS
Reflection of Learning during COVID-19 from the perspective of Nuclear Medicine students at the University of South Australia (Continued)
Z
oom tutorials became a fantastic way of building relationships between classmates, with break out rooms encouraging students to engage with peers outside of direct friendships.
Many students encountered interruptions and cancellations to their placements, filling many with great anxiety and uncertainty of when the placements will commence, whether placement time would need to be made up at a later date and if graduation dates would be shifted back to account for this. Additionally, with a lack of accessibility to processing software such as Xeleris, due to minimal face-to-face classes, students were worried about their regression in clinical skills and its impact on upcoming As students bonded over pets and house plants, the Zoom placements, as well as competence in being career-ready sessions encouraged collaborative work. Despite this, by graduation. Student anxiety was also heightened by online tutorials challenged students to take responsibility pressures to stay up to date with clinical competencies, for their own learning, ensuring they were current with as well as worries of supervisor expectations regarding content prior to the sessions or risk falling behind. clinical performance. However, students overall felt they Practicals are a crucial learning process for students as adjusted relatively quickly to the clinical environment, they provide an effective method for developing essential with supervisors and other technologists accommodating skills utilised in the medical field. The greatest asset of for interruptions and challenges to student learning and practicals is in engaging students, enhancing their moti- development due to COVID-19. vation to learn; hence why practicals are often included in the educational program. As all face-to-face classes had The educational limitations during the pandemic have ceased, due to the restrictions imposed by the pandemic, emphasised the importance of the development of a practicals were substituted by online learning such as support plan to compensate for the resulting educational video demonstrations and online activities. Notably, the gap. Numerous students have suggested the development siemens CT simulator practicals in our CT course provid- of a processing software that is accessible for students, ed a learning environment parallel to that on placement. providing opportunities to practice processing nuclear The use of the simulator improved the nuclear medicine medicine scans online and hence compensate for the student’s understanding of the CT workstation, which lack of placement days. Furthermore, online speeches was beneficial for upcoming nuclear medicine place- from current nuclear medicine technologists regarding ments. Nevertheless, online content was less engaging their work in the department were also suggested by than in-person practicals and student learning could not the students as part of the to-be-developed educational be gauged and corrected by lecturers as it could in face- support plan. Moreover, it would be pertinent to consider to-face sessions. Furthermore, as many practicals were an emotional support plan, as many students believe a self-led, and the main portal of contact with lecturers was deterioration in mentality had an impact on their studies via email; resulting in inefficiencies in requesting and during this period. Whilst such suggestions remain hypothetical, nevertheless, it is crucial that the improvements receiving support. made regarding online curriculum delivery consider the End of semester course exams were completed online students’ perspectives. and open-book. Students were required to demonstrate a deep understanding and comprehension of the content covered; thereby, the style of questions placed emphasis on applied knowledge and problem solving, rather than an ability to recite information. Student feedback suggests this style was beneficial as it was more reflective of the workplace environment; as the questions focused on applying skills more specific to the challenges involved in being a nuclear medicine technologist. However, feedback also suggested students feel they lack the ability to recite specific details, such as doses and parameters, for studies taught in these courses.
COVID-19 challenged students and educators to adapt to new methods of curriculum delivery. In the case of another pandemic, it is imperative to consider the student perspective when designing curriculum, developing new ways of delivering practical elements which still engage and motivate students.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
15
SUBMITTED ARTICLES & PAPERS
F-FDG PET IN SARCOIDOSIS TREATED WITH INFLIXIMAB
18
DOES RADIOLOGICAL RESPONSE CORRELATE TO CLINICAL RESPONSE? A POTENTIAL GUIDE TO THERAPY Lachlan D.G. Stranks1,2, Chong Ghee Chew1, Paul N. Reynolds1 1 2
Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, Australia The University of Adelaide, Adelaide, Australia
A
BSTRACT: Introduction/Aim: Sarcoidosis is a multiorgan disease with an unclear aetiology, and currently no standardised therapy. Infliximab is a novel therapeutic option, however long-term efficacy and treatment standardisation require ongoing evaluation. This study compares qualitative and quantitative change on 18F-FDG PET to subjective clinical response in patients treated with infliximab induction, to identify a potential role for radiological disease monitoring, and as an objective guide for ongoing therapeutic decision making. Method: 8 patients with refractory sarcoidosis were each treated with 6 cycles of infliximab. 18F-FDG PET scans were performed before and after therapy, with both qualitative and quantitative assessment performed, using visual inspection, as well as Maximum Standardised Uptake Value (SUVmax) and Metabolic Tumour Volume (MTV). A Pearson correlation coefficient (r) was calculated to demonstrate the strength of correlation between these values and subjective clinical improvement. Results: Symptoms improved in 6 of 8 patients, with an equivocal clinical response in the remaining 2 patients. There was a strong correlation between reduction in SUVmax and subjective clinical response (r = 0.86, p<0.006). The 2 patients with an equivocal clinical response had primarily cardiac involvement and only small reductions in SUVmax. Reduction in MTV similarly demonstrated a strong correlation with subjective clinical improvement. MTV declined in all 6 patients with definite clinical improvement, however disease activity was insufficient for measurement with this parameter in those with primarily cardiac disease. Conclusion: These results demonstrate that changes in 18F-FDG PET scans in patients treated with infliximab do correlate with clinical improvement, indicating 18F-FDG PET scans are likely to be a useful tool in guiding future therapy, particularly in patients with clinically significant pulmonary and extra-cardiac disease. INTRODUCTION: Sarcoidosis is a systemic disease characterised by the presence of non-caseating granulomas in affected organs [1]. Whilst multiple organs are often involved, the disease has a predilection for the lungs. The prevalence of sarcoidosis in Australia is estimated to be 4.4-6.3 per 100,000 population, with peak incidence in the 3rd and 4th decades of life [2].
16
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SUBMITTED ARTICLES & PAPERS
F-FDG PET in sarcoidosis treated with infliximab does radiological response correlate to clinical response? A potential guide to therapy. 18
(Continued)
The exact aetiology of sarcoidosis remains unclear. As such, the development of targeted therapy has been limited, with no standardised treatment regimen to date. Historically, those patients requiring treatment have relied on glucocorticoid therapy as first-line therapy, with methotrexate (MTX) typically used if this fails to adequately control disease activity [3]. Biological therapies, specifically those targeting TNF-α, have now emerged as a novel treatment option for patients with refractory sarcoidosis. This follows the rationale that TNF-α has been found to be a key component in the formulation of sarcoid granulomas, after it is secreted from macrophages in patients with active sarcoidosis [4]. Infliximab is one such anti-TNF agent that has been trialled for this indication, and whilst initial studies have demonstrated efficacy, ongoing evaluation is required [5]. Current induction therapy is generally 6 months (6 cycles), however longterm efficacy and treatment regimens remain unclear [5, 6]. Although clinical trials and international guidelines support the use of infliximab, this therapy comes at a high cost and is not subsidised by the Australian Pharmaceutical Benefits Scheme (PBS). Thus, objective evaluation in local health systems is important to justify its use.
utilised as a tool to assess disease activity in sarcoidosis and has a potential role in monitoring response to therapy [7]. This can be achieved both by visual assessment, and by assessing quantitative parameters, including Maximum Standardised Uptake Value (SUVmax) and Metabolic Tumour Volume (MTV) [7]. MTV has not previously been used in the assessment of disease activity for sarcoidosis, and its use in this study demonstrates a novel application for this parameter. MTV represents the ‘quantity’ of disease and so is a true reflection of disease activity. In the process of generating the MTV, a threshold of radiotracer avidity that defines active disease needs to be determined. To our knowledge, there is no defined threshold in current literature for classifying active sarcoidosis. 18 F-FDG PET has been shown to be a sensitive tool in quantifying inflammatory activity in both the lungs and extra-thoracic sites, however its relationship to subjective clinical response remains unclear. Similarly, its role in guiding ongoing clinical decision making is an area for further investigation, and there are currently no guidelines to instruct the ongoing use of infliximab. At this time, Medical Benefits Schedule funding does not cover 18F-FDG PET scanning for sarcoidosis, so further evaluation is necessary for resource allocation planning.
METHODS: This study was approved by the Human Research Ethics Committee of the Central Adelaide Local Health Network (ref no: 11993). Patient Selection - Patients treated with infliximab for the indication of sarcoidosis were identified by their responsible treating physician within the Department of Thoracic Medicine at the Royal Adelaide Hospital. The inclusion criteria comprised of: • • •
•
• •
Patients aged ≥ 18 years of age Diagnosis of sarcoidosis confirmed histologically Infliximab administered for the indication of sarcoidosis, for at least 6 months (6 cycles) duration 18 F-FDG PET performed prior to commencing infliximab demonstrating disease activity consistent with sarcoidosis Repeat 18F-FDG PET performed at least 6 months after initiation of therapy No clinical concern or evidence for infection, including infection with Mycobacterium tuberculosis
Ten patients were screened. Two of these did not have 18F-FDG PET scans performed at appropriate intervals, and so were excluded. Eight patients treated with infliximab between June 2017 and January 2020 were included Conventional computed tomography AIMS:This study aims to demon- in the audit – 5 males and 3 females, (CT) scanning, including high-resolu- strate that, in patients treated with with an average age of 52 years (age range from 34 to 66 years). All tion CT (HRCT) has long been used infliximab for sarcoidosis, disease patients had refractory sarcoidosis to assess patients with sarcoidosis, metabolic activity assessment using that had not responded to convenand whilst they can provide anatomic 18F-FDG PET scans correlates with tional therapy. detail, they are limited in their ability subjective clinical response and as to provide functional information such can be a valuable objective about active inflammatory disease monitor of therapeutic response to [7, 8]. 18F-FDG PET scanning can be guide ongoing management.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
17
SUBMITTED ARTICLES & PAPERS
F-FDG PET in sarcoidosis treated with infliximab does radiological response correlate to clinical response? A potential guide to therapy. 18
(Continued)
Audit Design - This was a retrospective observational study. Data Collection - Case notes and clinical letters were obtained for the patients who met inclusion criteria. The criteria for clinical improvement was based on the experienced treating physicians’ documentation of reported symptoms by the patients both pre and post infliximab therapy, and was categorised as yes, no, or equivocal. Data regarding adverse effects related to infliximab therapy was also collected, as were decisions regarding ongoing administration of infliximab following the 6-month induction period.
Statistical Analysis - A Pearson correlation coefficient (r) was used to determine the strength of correlation between percentage change in average SUVmax and subjective clinical response. Statistical significance was set at a P value of 0.05. Given the nature of the data collected, this statistical analysis method could not be used to assess the correlation between percentage change in MTV and subjective clinical response. RESULTS:
Patients - Subjects’ baseline characteristics are summarised in table 1. All patients had refractory sarcoidosis that had failed to respond to previous courses of prednisolone and/or methotrexate. Two Other objective measures for disease activity and clin- patients had primarily cardiac involvement. Seven ical improvement were also collected where available, patients had pulmonary disease, and all eight had including pulmonary function tests, echocardiography, extrathoracic involvement. One patient was a former cardiac magnetic resonance imaging (MRI), and CT scans, smoker, and seven patients had never smoked. Three however these had not been performed universally in patients were being treated with prednisolone at the all patients, or in the appropriate timeframe around infliximab therapy, and so were not included in the study. time of infliximab initiation (doses ranging from 5mg to 50mg daily), three patients were on no active therapy, and concurrent treatment information was not avail18 The F-FDG PET scans were all performed through able for two patients. Two patients on prednisolone had the SA Medical Imaging Service at the Royal Adelaide reduction in their dose over the course of infliximab Hospital. A Nuclear Medicine Physician visually evaluated 18 therapy. All patients received 6 cycles (6 months) of all F-FDG PET scans, scoring sites as either positive (increased FDG activity consistent with sarcoidosis), or infliximab between 18F-FDG PET scans, with a dose negative (no or insufficient increased FDG activity). A of 5mg/kg. One patient (patient 4) received a dose at quantitative assessment was performed for all 18F-FDG monthly intervals. All other patients received doses at PET scans, with calculation of overall volume of active weeks 0, 2, 6, 12, 18, and 24. disease using the parameter of MTV. As there is no known acceptable radiotracer avidity threshold to define active 18F-FDG PET & Subjective Clinical Response - All patients sarcoidosis, the PET Response Criteria in Solid Tumours had improvement in SUVmax when comparing 18F-FDG PET (PERCIST) threshold, which is used in oncological scans, scans pre and post treatment with infliximab. Six of the was employed to determine active disease. SUVmax was eight patients had definite subjective clinical improvealso determined for each site of disease activity. The ment on completion of 6 cycles of infliximab therapy, average SUVmax was then calculated for each patient indicating there was a strong positive correlation between and each 18F-FDG PET scan. Percentage change in both reduction in SUVmax and subjective clinical response (r = average SUVmax and MTV were calculated for each patient. 0.86, p<0.006). Two patients, those with primarily cardiac Those patients whose 18F-FDG PET disease activity fell disease, reported equivocal change in symptoms (patient below the calculable MTV threshold were scored as a 4, patient 6). These two patients had a very low baseline -100% reduction. SUVmax prior to therapy, and had the smallest percentage reduction in SUVmax following infliximab induction. Simi18 F-FDG PET Protocol - The whole body 18F-FDG PET larly, these patients were those with baseline disease scans were performed using a Siemens Biograph mCT activity falling below the PERCIST threshold to determine Flow (Siemens Healthcare). The acquisition parameters: MTV, and so were excluded from assessment with this vertex to thigh, attenuation correction, scatter correction, parameter. All six eligible patients demonstrated reducresolution recovery (PSF), time of flight, 2 iterations, 21 tion in MTV, indicating complete correlation between subsets. The scans were reviewed qualitatively and quan- reduction in MTV and subjective clinical improvement. titatively to determine SUVmax and MTV using SyngoVia Version VB30A. 18
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SUBMITTED ARTICLES & PAPERS
F-FDG PET in sarcoidosis treated with infliximab does radiological response correlate to clinical response? A potential guide to therapy. 18
(Continued)
Therapeutic Decision Making - Table 3 summarises therapeutic decision making regarding ongoing infliximab administration following the 6-month induction period. Four of eight patients continued with further infliximab therapy. Of the four that did not continue, one patient was thought to have adequate radiological and clinical response not requiring any further therapy (patient 3), one patient demonstrated what was deemed an insufficient response to therapy (patient 4), and the reasoning was unclear in the remaining two patients. Adverse Effects - Six patients did not report any adverse effects. Patient 2 reported mild dizziness following the first dose of infliximab, that did not recur with subsequent doses. During their treatment with infliximab, patient 6 developed migratory arthralgias, and was found to have positive serum autoantibodies (ANA, anti-dsDNA) consistent with the development of drug-induced lupus, likely secondary to infliximab therapy. The patient completed the 6-month induction regimen, with subsequent cessation of infliximab after a further 2 doses (8 doses total). DISCUSSION: These results demonstrate that within this patient cohort, reduction in disease activity on 18F-FDG PET scans does correlate with improvement in clinical symptoms, in patients treated with infliximab induction for sarcoidosis. All patients who reported definite clinical improvement similarly demonstrated a reduction in both SUVmax and MTV.
n=8 Age (years)
52 (± 11)
M:F
5:3
Smoking Never Ex-smoker
7 1
Disease sites Pulmonary Extrathoracic Cardiac
7 8 4
Active therapy None (previous prednisolone) None (previous prednisolone & MTX) Prednisolone Prednisolone & MTX
3 1 3 1
Table 1: Subject characteristics at baseline
These results are overall consistent with similar studies that have evaluated the role of 18F-FDG PET scans in patients treated with infliximab, most of which had comparably small sample sizes [9]. These results also support the use of MTV as a parameter for assessing disease activity in sarcoidosis, which is a novel use for this quantitative assessment tool. Table 2: Changes in average SUVmax, MTV, clinical symptoms, and adverse effects following infliximab therapy
Patient
% Change average SUVmax
% Change MTV
Subjective clinical improvement
Adverse effects
1
-84.3
-100
Yes
Nil
2
-36.9
-70
Yes
Dizziness
3
-64.1
-100
Yes
Nil
4
-2.4
N/A
Equivocal
Nil
5
-55.9
-100
Yes
Nil
6
-16.8
N/A
Equivocal
7
-75.9
-91.5
Yes
Nil
8
-78.2
-100
Yes
Nil
Drug-induced lupus
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
19
SUBMITTED ARTICLES & PAPERS
F-FDG PET in sarcoidosis treated with infliximab does radiological response correlate to clinical response? A potential guide to therapy. 18
(Continued)
Table 3: Therapeutic decision making after 6 cycles of infliximab F-FDG PET improved
F-FDG PET not improved
18
Infliximab continued
Patients 1, 2, 6, 7
Infliximab ceased
Patients 3, 4, 5, 8
Figure 1: Change in average SUVmax by patient
Figure 2: Change in MTV (cm3) by patient Pre
Post
Post
1
2
3
4
5
6
7
1
8
Denotes those with definite subjective clinical response a)
2
3
5
643 7
0
55
0
109 0
1
129
2
196
428
3.1
3.2
2.7
2.5
2.4
2.5
2.6
3.5
650
8
7.7
6.9
10.1
11.4
11.7
17.4
2209
Pre
18
8
Denotes those with definite subjective clinical response. Patients 4 & 6 not included in MTV assessment. b)
Figure 3: Baseline 18F-FDG PET (a) of patient 1 demonstrating widespread disease, including extensive skeletal involvement. Post infliximab 18F-FDG PET (b) demonstrates significant improvement in disease activity in all sites. 20
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SUBMITTED ARTICLES & PAPERS
F-FDG PET in sarcoidosis treated with infliximab does radiological response correlate to clinical response? A potential guide to therapy. 18
(Continued)
a)
An acknowledged weakness of the study is the retrospective design and the subjective nature of defining a clinical response. However, the data provides support for the utility of 18 F-FDG PET scanning for the evaluation of an objective response to treatment. This could be investigated further with a formal prospective evaluation including a control group. Pragmatically, for patients who continue to report symptoms despite first- and second-line treatment, 18F-FDG PET scanning to exclude chronic irreversible scarring and confirm active disease may be an objective criterion before proceeding to expensive biological agents like infliximab.
b)
Figure 4: 18F-FDG PET of patient 7 before (a) and after (b) infliximab therapy, demonstrating significant improvement in disease activity, including pulmonary involvement. This patient reported a significant subjective clinical improvement in symptoms.
The two patients with primarily cardiac involvement (patient 4 & patient 6) demonstrated a considerably smaller reduction in SUVmax. These two patients were also those that reported equivocal change in subjective symptoms following treatment with infliximab. In addition, patient 6 was found to have developed drug-induced lupus as a consequence of infliximab therapy. This presented with non-specific symptoms similar to those of sarcoidosis, thus making assessment of subjective clinical response more difficult. MTV could not be calculated in the two patients with primarily cardiac involvement as disease activity was below the required PERCIST threshold. Given this study was a retrospective analysis using whole body 18F-FDG PET scans, assessment of cardiac disease was limited. To properly assess cardiac sarcoidosis and changes in disease activity, a dedicated cardiac PET scan with specific pre-scan dietary preparation is required.
Adverse effects were not common in this cohort, with one patient experiencing only transient mild symptoms at the time of their first infliximab dose. Patient 6 however did develop clinically significant drug-induced lupus secondary to infliximab therapy. This is a rare but recognised phenomenon, that eventually resulted in the cessation of therapy for this particular patient. Table 3 suggests that clinical decision making in regard to continuing infliximab therapy is relatively idiosyncratic, with variability between clinicians and between patients. Serial 18F-FDG PET, in conjunction with clinical assessment, may therefore be useful in determining ongoing therapy in patients with refractory sarcoidosis. This has been suggested in previous studies [10, 11]. 18F-FDG PET can provide both quantitative and qualitative data which may assist in producing more standardised protocols and guidelines regarding ongoing administration of infliximab beyond the standard induction period. The role of 18F-FDG PET scans in formally guiding ongoing therapy is a possible area of future assessment, and this may extend to potentially predicting future disease relapse. CONCLUSION: Changes in 18F-FDG PET on qualitative and quantitative assessment appear to very closely correlate with clinical response in patients with pulmonary and extra-cardiac sarcoidosis, treated with infliximab. It can thus be useful for disease monitoring and may have a significant role in guiding further therapy of sarcoidosis.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
21
SUBMITTED ARTICLES & PAPERS
F-FDG PET in sarcoidosis treated with infliximab does radiological response correlate to clinical response? A potential guide to therapy. 18
(Continued)
References 1. 2. 3.
4. 5. 6.
22
Kasper, D.L., et al., Harrison's principles of internal medicine. 19th Edition. ed. Principles of internal medicine. 2015: New York : McGraw Hill Education Medical. Ahmadzai, H., et al., Sarcoidosis: a state of the art review from the Thoracic Society of Australia and New Zealand. Medical Journal of Australia, 2018. 208(11): p. 499-504. Cremers, P.J., et al., Multinational evidence-based World Association of Sarcoidosis and Other Granulomatous Disorders recommendations for the use of methotrexate in sarcoidosis: integrating systematic literature research and expert opinion of sarcoidologists worldwide. Current Opinion in Pulmonary Medicine, 2013. 19(5): p. 545-561. Brito-Zerón, P., et al., Sarcoidosis: an update on current pharmacotherapy options and future directions. Expert Opinion on Pharmacotherapy, 2016. 17(18): p. 2431-2448. Vorselaars, A.D.M., et al., Effectiveness of infliximab in refractory FDG PET-positive sarcoidosis. European Respiratory Journal, 2015. 46(1): p. 175-185. Vorselaars, A.D.M., et al., Prediction of relapse after discontinuation of infliximab therapy in severe sarcoidosis. European Respiratory Journal, 2014. 43(2): p. 602-609.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
Treglia, G., et al., The Role of 18F-FDG-PET and PET/CT in Patients with Sarcoidosis: An Updated Evidence-based Review. Academic Radiology, 2014. 21(5): p. 675-684. 8. Mostard, R.L.M., et al., Severity of pulmonary involvement and 18F-FDG PET activity in sarcoidosis. Respiratory Medicine, 2013. 107(3): p. 439-447. 9. Keijsers, R., et al., 18F-FDG PET in sarcoidosis: An observational study in 12 patients treated with infliximab. Sarcoidosis, vasculitis, and diffuse lung diseases : official journal of WASOG / World Association of Sarcoidosis and Other Granulomatous Disorders, 2009. 25: p. 143-9. 10. Ambrosini, V., et al., 18F-FDG PET/CT for the Assessment of Disease Extension and Activity in Patients With Sarcoidosis: Results of a Preliminary Prospective Study. Clinical Nuclear Medicine, 2013. 38(4): p. e171-e177. 11. Sobic-Saranovic, D., et al., The Utility of 18F-FDG PET/CT for Diagnosis and Adjustment of Therapy in Patients with Active Chronic Sarcoidosis. Journal of Nuclear Medicine, 2012. 53(10): p. 1543-1549.
7.
Discovery MI Gen 2
Focus on what’s important... Specific sensitivity 1
Detect the smallest lesions with the highest sensitivity per cm (cps/kBq/cm) 2,3
PET/CT Digital Systems - NEMA Sensitivity/cm
GE Discovery MI Gen 2 Highest Sensitivity per cm
1 0.8 0.6 0.4 0.2 0 Vendor 1 Alternative ~24 cm AFOV
Vendor 2 Alternative ~20 cm AFOV
Vendor 1 Vendor 3 Alternative Alternative ~30 cm ~27 cm AFOV AFOV
GE Discovery Vendor 2 GE Discovery Vendor 2 GE Discovery GE Discovery MI Gen 2 MI Gen 2 Alternative MI Gen 2 MI Gen 2 Alternative 25 cm 20 cm ~106 cm 30 cm 15 cm ~26 cm AFOV AFOV
Discovery MI Gen 2 – Achieves the highest sensitivity per cm Discovery MI Gen 2 is the only PET/CT system that is engineered to reach an impressive 30 centimetres of coverage and has the potential to enable an exceptionally high sensitivity of 30 cps/kBq and high Peak 2 NECR of 450 kcps@24kBq/ml. This translates to a system designed to provide up to 75 percent improvement in scan times or dose. The goal of Discovery MI Gen 2 is clear: to provide your patients with access to the very best technology that is scalable and affordable.
Discovery MI Gen 2 Next generation. Even more in sight.
gehealthcare.com.au 1 Measured in cps/kBq/cm 2 Discovery MI Gen 2 has the highest NEMA sensitivity in the market, comparing with common PET/CT systems with same or similar AFOV, (based on IMV’s Medical Information Division’s 2019 report as the manufacturers representing more than 90% of the US Installed Base). 3 Table data gathered from public avaliable sources. © 2021 General Electric Company – All rights reserved. GE and the GE Monogram are trademarks of General Electric Company. GE Healthcare, a division of General GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU Electric Company. GE Medical Systems, Inc., doing business as GE Healthcare. JB00536AU
23
The Lancet Oncology Commission on Medical Imaging and Nuclear Medicine MARCH, 2021
The ANZSNM, alongside its peers such as the SNMMI and EANM made up 27 institutions worldwide who supported resourcing and the compilation of this landmark report. Andrew Scott was one of the four co-lead authors of this commission. The report will form the foundation of future research. In this section we distill some key aspects for you.
24
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - Summary
Summary The Commission was convened with the logistical support of the International Atomic Energy Agency (IAEA) to address three themes:
1
Evaluate status of equipment and workforce for cancer imaging in over 200 countries globally
2
This database is readily accessible to the public and for future researchers to use. For SPECT and PET, the number of equipment in high income countries was found to be mean 18.2 and 3.6 per million population respectively: in Australia/New Zealand it is 8.7 and 2.8 per million population.
In order to initially establish the health outcome improvement of enhancing access to medical Identifying barriers imaging and nuclear medicine in cancer patients, a to cancer imaging simulation modelling approach was conducted for particularly in low11 cancers, where country-specific mortality rates, income and middle impact of optimal imaging and treatment (based on income countries delphi analysis of opinion from international experts) on cancer outcomes, availability of treatment per country, and imaging equipment availability (from Determine the health IMAGINE database) was undertaken. This complex and economic benefits analysis was undertaken by the Commission with of scaling up cancer experts from Harvard University, USA. Expanding imaging globally by access to imaging (e.g. ultrasound) was found to have region and country greatest impact in low income countries, with MRI, income level PET and CT in middle-income countries, and PET, CT and SPECT in high income countries. It was found that combining improved access to imaging along with treatment and quality of care would improve 5 The initial Commission analysis found that there was year net survival by ten fold in low income countries, no available information on equipment or work- and five fold in middle income countries. This highly force for medical imaging and nuclear medicine on impactful data was published in Lancet Oncology a country level globally. Therefore, a major initial in 20201. project was to establish these parameters was undertaken with input from countries and regional soci- In a landmark analysis, the impact of improving eties. ANZSNM contributed equipment and workforce access to imaging on cancer patient survival for 11 information for this project. Co-ordinated by the common cancers at a global level, and financial beneIAEA, a database was established for equipment fits, was then evaluated. It was found that scale-up and workforce for over 200 countries. of imaging would prevent 2.46 million cancer deaths (3.2% of the projected total of 76 million worldwide IAEA Medical imAGIng and Nuclear deaths from 2020-2030) and save 54·92 million lifeyears. Even more strikingly, the analysis indicated mEdicine (IMAGINE) that imaging amplifies the benefits of other cancer services: the model estimated that while scale-up of treatment and quality of care alone would prevent 5.37 million deaths (7% of the worldwide total), adding imaging to achieve comprehensive scaleup would prevent 9·55 million deaths (12.5% of the worldwide total) and save 232·30 million life-years2. CLICK TO ACCESS Further analyses using this approach as part of the IMAGINE DATABASE Commission in cervical and breast cancer found simi-
3
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
25
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - Summary
breast cancer found similar high impact of access to imaging and treatment on overall survival3,4.
With respect to economic impact, the analysis showed that a global scaleup of imaging from 2020— 2030 would cost $6.84 billion, and this would lead to productivity gains of $1.23 trillion for the cancer cases diagnosed in 2020— 2030 and a net benefit of $1.22 trillion, yielding a remarkable return of $179 for every dollar invested. Combining imaging with improvement in access to treatment and quality of care would double the returns gained by investing in treatment and quality of care alone. This highly impactful data was published earlier this year in Lancet Oncology2,5, and the major Commission report was included in a dedicated edition of Lancet Oncology with 7 commentaries6. This information will be used for major policy initiatives for enhancing access to imaging in low, middle and high income countries, with nuclear medicine (SPECT and PET) being shown to have an essential role in this approach to improving outcomes for cancer patients. As the final Commission report states..”the investment in population based health can be a tool towards a nation’s development, rather than a mere byproduct of it.’
26
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
Nuclear medicine often doesn’t get the profile it deserves within the healthcare spectrum. And, if you ever needed reminding about what effect your profession can or is making to global healthcare then this report is an objective reminder. Importantly there is a bright future for Nuclear Medicine in which we all can all play a part. References 1.
Z.J. Ward, A.M. Scott, H. Hricak, M. Abdel-Wahab, D. Paez, M.M. Lette, H.A. Vargas, T.P. Kingham, R. Atun. Estimating the impact of treatment and imaging modalities on 5-year net survival of 11 cancers in 200 countries – a simulation-based analysis. Lancet Oncology 21:1077-1088, 2020.
2. Z.J. Ward, A.M. Scott, H. Hricak, R. Atun. Global costs, health, and economic benefits of scaling up treatment and imaging modalities for survival of 11 cancers: a simulation-based analysis. Lancet Oncol 22:341-350, 2021. 3. Z.J. Ward, A.M. Scott, H. Hricak, M. Abdel-Wahab, D. Paez, M.M. Lette, H.A. Vargas, T.P. Kingham, R. Atun. Estimating the impact of treatment and imaging modalities on 5-year net survival of 11 cancers in 200 countries – a simulation-based analysis. Lancet Oncology 21:1077-1088, 2020. 4. Z.J. Ward, R. Atun, H. Hricak, K. Asante, G. McGinty, E.J. Sutton, L. Norton, A.M. Scott, L.N. Shulman. The impact of scaling up access to treatment and imaging modalities on global disparities in breast cancer survival: a simulation-based analysis. Lancet Oncology (in press) 5.
H. Hricak, M. Abdel-Wahab, R. Atun, M. Mikhail Lette, D. Paez, J.A. Brink, L. Donoso-Bach, G. Frija, M. Hierath, O. Holmberg, P-L Khong, J.S. Lewis, G. McGinty, W.J.G. Oyen, L.N. Shulman, Z.J. Ward, A.M. Scott. Lancet Oncology Commission on Medical Imaging and Nuclear Medicine. Lancet Oncol 22:e136-72, 2021.
6. https://www.thelancet.com/commissions/medical-imagingnuclear-medicine
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - At a Glance
At a Glance WHAT ARE SOME OF THE REPORT FINDINGS? •
Global cancer incidence by 2040 is expected to rise by 62%. Between 2020 and 2030, 76 million deaths are being modelled for cancer
•
Worldwide the overall survival rates for cancer are improving but less so in low and middle income countries https://humanhealth.iaea.org/HHW/DBStatistics/IMAGINE.html
•
Global inequities exist given the upfront capital • costs with trained human resources
•
The cost of investment is a barrier to adoption creating of cancer imaging including for older imaging technologies such as x-rays
•
For $1 spent globally bridging the gap in availability of imaging there is a return of $179
•
1 CT scanner serves 25,000 people in high income countries. In low income countries it serves 1,700,000 — a factor of 68 times.
•
•
•
•
1 PET scanner serves around 300,000 people in high income countries. In low income countries, it is an astounding 1 PET scanner for 167 million 1 SPECT scanner is available per 50,000 people in high income countries, whereas in low income countries it serves 10 million people As a lead up to the report, a microsimulation model by Lancet Oncology showed for 11 cancers (which represent 60% of all diagnosed cancers) that simultaneous expansion of treatment, imaging and quality of care “could improve 5-year net survival rates by >10 times in low income countries.”1
Further modelling showed that combined improved access to imaging and treatment and quality of care could save 9.5 million lives in a decade (the entire population of New Zealand nearly twice over)2. Radiopharmaceutical supply and supply chains, especially with the challenges of half lives remain a problem3.
WHAT ARE THE FINDINGS FOR AUSTRALIA AND NEW ZEALAND? •
Australia and New Zealand ranks similar to mean numbers for high-income countries globally for the number of PET (2.8) scanners per million population
•
In terms of SPECT (8.7) scanners per million population Australia and New Zealand had slightly lower numbers compared to mean of high-income countries which is (18.2) scanners per million population
•
Australia has 14 nuclear medicine specialists per million inhabitants, similar to the mean for high-income countries
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
27
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - At a Glance
W
hat are the solutions proposed?
1. Aim to incorporate imaging for cancer patients into health policy and cancer control plans for countries globally 2. Investment in equipment and workforce to allow low and middle income countries to have infrastructure and human resources similar to next higher income group 3. The use of digital tools and innovations including artificial intelligence and telemedicine to improve access to imaging resources. Whilst a presence would be required to undertake scans for instance the use of telemedicine for ‘downstream’ data processing 4. Investment in training, research and innovation, including clinical trial capability 5. A need for collaboration across multiple stakeholders to address a scale up is required. Money alone simply will not achieve the outcomesand a comprehensive regional and country plan that combines workforce alongside dollars spent on equipment has to be considered 6. Imaging should be included as part of the comprehensive approaches to treatment of cancer alongside clinical decision making. This is especially the case in low and middle income countries in matching technologies with the treatments available locally as well as the resources
28
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - Interview
Interview
WITH PROFESSOR ANDREW SCOTT one of the lead co-authors
E
ver wondered how a report such as this is put together? One of the authors of the Lancet Commission for Oncology was our own, Professor Andrew Scott, AM.
Andrew is well known to us in the profession and serves as the Director of the Department of Molecular Imaging and Therapy at Austin Health, as well as a Professor at Melbourne University and La Trobe University, and Head of the Tumour Targeting Program at the Olivia Newton-John Cancer Research Institute. Andrew also sits on the ANZSNM Council and is chair of the International Relations Committee of the Society. Given our close proximity to Andrew, we thought to ask some ‘behind the scenes’ questions. We focussed on the machinations ofhow a landmark and large scale report is put together. Here is what he told us. GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
29
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - Interview
G
amma Gazette (GG): Andrew, Congratulations on our behalf to you and your colleagues on the report. An outstanding achievement and of course more so given the challenges and distraction with the onset of COVID-19 last year. How did you come to be involved in the project?
like a Lancet Oncology Commission is what is expected at the end of the project, which in this case was a large paper with policy-changing data that would inform national governments and international organisations. We brought together a larger Commission group, consisting of 16 experts in imaging, nuclear medicine, radiology, oncology and public health, and defined an outline of the Andrew Scott(AS): I was approached final paper and sections, and alloto be a lead Commissioner for this cated leadership of sections to one project in late 2018, principally of the Commissioners. As each part because of my previous role as of the project came together, we President of the World Federation enlisted input from an additional of Nuclear Medicine and Biology, but 21 "commissioners-at-large" for also as I have had numerous interac- key input. Consultations occurred tions with the IAEA and other major with all major nuclear medicine, societies such as SNMMI, EANM and radiology and oncology societies AOFNMB. I also knew two of the in Europe, North America, Latin other lead Commissioners quite America, Middle East, Africa, and well – Prof Hedi Hricak (New York) Asia-Oceania. The results were far and Prof May Abdel-Wahab (IAEA). more impactful than we initially When I was asked to be a part of anticipated, hence there were 4 the Commission, I readily agreed. I additional papers published apart thought it would be very interesting from the main Lancet Oncology as any Lancet Oncology Commis- Commission paper. sion is a major global initiative, and I also felt it was important to have (GG): The Report had many someone with a Nuclear Medicine moving parts, the IMAGINE databackground involved in a senior role base, a financial model, and the in such a major project. report recommendations divided into eight sections. How is it all (GG): With a project as large as ultimately synthesised, and who this, incorporating the globe, how ensures there is coherence to the does one start? Is it you sitting different aspects? down scoping out what you think it should include? People being (AS): It was not straightforward! assigned areas? What is the The collection of equipment and approach even to what should go workforce information for medical into a report? imaging and nuclear medicine was the initial biggest challenge, as we (AS): The approach to a large had to liase with the nuclear mediproject like this is not dissimilar to cine and radiology societies and any project – you must have a clear key contacts in 200 countries indiplan before starting as to what you vidually, as well as databases and propose to do, how it should be done, industry connections – this took and who should be involved. Of almost 9 months. The IAEA Division course, there are surprises along the of Human Health was an essential way, but this is not unexpected! A key part of this process. Then, to develop component of a major endeavour the financial model, key incidence
30
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
and survival data from global cancer databases (GLOBOCAN, SEER and CONCORD-3) was obtained, and a delphi analysis of appropriate use of imaging and therapeutics in 11 main cancers types was elicited from panels of imaging (34 experts) and therapy (21 experts) participants we assembled from around the globe. Other sections were brought together by our expert groups. The final manuscript was written by the lead Commissioners, working closely together and ensuring consistency of language and messaging. (GG): Could you please talk a little about the data analysis work in terms of the microsimulations done on the 11 cancers in 200 countries? Who and what was the process including compiling, interrogating and checking the data output? (AS): This was a very interesting process, as it involved complex modelling undertaken by experts in the TH Chan School of Public Health at Harvard University (Zach Ward and Rifat Atun). This type of analysis is used for major public health analyses, such as used by WHO and governments to justify policy changes and health care expediture. It requires accurate input data on disease incidence, country-based statistics on health outcomes, justification for health care use, and expert opinion on clinically relevant practice. There may be 1,000 simulations performed for every variable, and this process requires major computing resources (such as at Harvard University). Checks of accuracy are built into the models, so that independent verification on results are made to ensure the validity of results. It is very technical, but a proven methodology for population-based analyses.
A REVIEW OF THE LANCET ONCOLOGY COMMISSION on Medical Imaging and Nuclear Medicine - Interview
(GG): Related to the previous question the report makes compelling arguments for quality of life and lives saved. For instance $6.84 Billion would yield $1.23 trillion. A counter though perhaps fatuous argument to make given the high returns that are derived but, for low income countries (who are financially constrained), wouldn't investing in primary healthcare save more lives? (AS): The implementation of screening for early detection of cancer is clearly justified, and in our Commission we made clear that this was a very important public health initiative that should be implemented particularly in low and middle income countries. Our Commission focused principally on patients once they were diagnosed with cancer, and how to improve outcomes based on current rates and stage of cancer at diagnosis. We were surprised at what financial returns could be achieved over 10 years just with improving access to imaging. For this reason we will be taking these results to international groups (eg WHO, UICC) to argue for policy changes that will be adopted by Governments. The results also highlighted where improvements in access to imaging (including nuclear medicine) even in high-income countries could be achieved, including Australia and New Zealand. (GG): Coming back to the report, if you are assigned tasks within the plan for which there are deadlines (alongside your ‘normal’ work) how did you manage to complete your tasks? Tips for those of us less adept in managing our time Andrew? (AS): We all lead busy lives, and for myself I do have a range of clinical
commitments and administrative responsibilities that occupy most of my time during normal work hours. What I try to do is each day set a plan for what I aim to achieve, and be as efficient as I can be to complete these tasks. I always spend at least an hour (or two) early each morning and again every evening completing my emails and major tasks, and making calls to key collaborators. I rarely have time to write reports or papers in normal hours, and this is done in the evenings and weekends. With time I have found that I can multi-task quite effectively, and achieve deadlines. What is also quite important is to think "big picture" as least once a week – where are the main projects heading, what key issues need to be addressed and analyses performed, what deadlines have to be met, who do I need to speak to. Fitting all this into the week with home and family commitments can be a challenge, but it can be achieved!
straightforward. Having a structure of lead Commissioners did allow decisions to be made quickly, a small group of us wrote all the papers, and the other experts involved in the Commission were happy to give comments on final drafts. (GG):In terms of your contributions and of course aside from your professional knowledge, experience and insights what do you think were the critical perspectives you could provide from being located in Australasia?
(AS): Australia and New Zealand have always had a reputation for quality academic outputs and health policy initiatives in Nuclear Medicine. This has been recognised by all major International societies, and key opinion leaders. We are also far away from the politics of health care in the US and Europe, but known to have strong engagement with Asia and Oceania in our field of medicine. In this context, I was able to (GG): In focussing on the organisa- be seen as an independent expert tion and conclusions of the report but also representing Nuclear Mediand given that you probably didn’t cine in this project (and the only have face to face meetings due lead Commisioner with this backto COVID how did you overcome ground). I hope that my involvement issues? For instance, academic in the Commission will give further disagreements and debate as to credence to Australasia being a the items that should be made in leader globally in nuclear medicine, the conclusion? and having a major impact in health outcomes for patients. (AS): A lot of online webinar meetings, and phone calls! At the beginning of the project (pre-COVID) I was fortunate to be able to spend a month in Vienna, New York and Boston (as part of Sabbatical leave) with the lead Commissioners planning the project, and spending some time with the Harvard group understanding the health outcome and financial modelling process. Once the results started to come through the outcomes were reasonably CLICK TO ACCESS
THE FULL REPORT
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
31
51
st
ANNUAL SCIENTIFIC MEETING HIGHLIGHTS
32
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
T
he 51st Annual Scientific Meeting of the ANZSNM was the Society’s first “live and local” event, with virtual presentations by guest speakers from Australia, New Zealand and around the world projected simultaneously to hubs in Auckland, Sydney, Geelong, Adelaide and Perth. It was a mammoth undertaking and perhaps a little over ambitious? But in the end it was a great success, with a record number of live and virtual attendees, more international guest speakers than ever before and
an interactive platform where delegates could communicate directly with the speakers during and after the talks, view their favourite session again and catch up on sessions that they had missed. The theme of our conference was Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine. This provided us with the potential to include a broad range of presentations covering clinical aspects of PET and nuclear medicine as well as therapy, preclinical imaging and research, teaching and impact of COVID19 to name just a few. We were honoured to have presentations by Dr Fabian Kiessling - RWTH Aachen University; Dr Rudi Dierckx - University Medical Center Groningen; Dr Fabien Hyafil Bichat Hospital - Paris; Dr Pek Lan Khong - The University of Hong Kong; Dr Arthur Braat - University Medical Centre, Utrecht; Dr Hossein Jadvar University of Southern California; Dr Patrick Veit-Haibach - Joint Depart-
ment Medical Imaging, Toronto; Dr. Tim van de Wyngaert - Antwerp University Hospital; Dr Alan Packard - Boston Children's Hospital/Harvard Medical School; Dr John Buscombe British - Nuclear Medicine Society; Dr Jun Hatazawa - Osaka, Japan; Dr Michael Van Dam - University of California; Dr Carlo Romano - Policlinico di Monza Healthcare Group and the Villa Maria Healthcare Group, Italy; Dr Alberto Signore and Dr Chiara Lauri - University of Rome; Dr Abass Alavi - University of Pennsylvania; Dr Elena Zamagni Bologna - University School of Medicine; Dr Phillip Kuo University of Arizona, and Dr Irene Buvant - Institut Curie, France. The Pioneer Lecture was provided by Dr Andrew McLauglin - Burwood Nuclear Medicine and the Lowenthal Lecture by Dr Darin O’keefe - Christchurch Hospital, New Zealand.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
33
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
As well as this we had a full complement of high quality local speakers including; Dr Kate Moodie, Dr Bill Macdonald, Dr Sherene Loi and Dr Hillary Martin for the interactive breast cancer expert panel discussion, Dr Judith Trotman, Dr Nathan Better, Dr Richard Gauci, Dr Michael Mond, Dr Grace Kong, Dr Chris Rowe, Dr Dale Bailey and Dr Kathy Willowson and concurrent sessions jam-packed with submitted abstracts and award presentations. The semi-virtual format allowed us to have a more intimate, relaxed gala dinner on the Saturday evening with colleagues and friends within our state. Dinners were held at the Rockford in Adelaide, Rydges Geelong, Germone Restaurant in Auckland and Little Way in Perth.
volunteers at each hub, the chairpeople and moderators without whom this ambitious project would not have been possible. See you all in Brisbane in 2022! Tracey Muir, Liesl Celliers, Stephanie O'Donnell and Andrew Cluff 2021 ASM Convenors Take a peek at what you can expect by visiting our YouTube channel or clicking on the screen below.
We would like to particularly thank Daniel Badger and the Council along with Rachael Rogers from Event Studio who helped to make this event such a success. We also want to thank and acknowledge the important contribution of the branch representatives in each state, the many
https://https://bit.ly/2022ASMVideo
T
he virtual platform allowed delegates from all parts of
the world to attend the event remotely, access all presentations, live Q&A sessions, network
with peers and engage with industry partners.
34
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
35
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
Live Q&A with Prof John Buscombe - Moderated by Prof Dale Bailey
Live Q&A with Prof Michael van Dam - Moderated by Dr Giancarlo Pascali
Live Q&A with Prof Fabian Kiessling - Moderated by Dr Giancarlo Pascali
Live Q&A with Dr Patrick Veit-Haibach - Moderated by Dr Geoffrey Schembri
L
ive Q&A sessions
were held after most
presentations. Delegates had the chance to submit
their questions on the
Live Q&A with Prof Pek Lan Khong - Moderated by A/Prof Eddie Lau
virtual chat and had the presenters answer them and provide their views on hot topics. Live Q&A Physics Symposium with Prof Steven Meikle, Dr Irene Buvat, Dr Chong Chew, Mansour Alqahtani and Benjamin Crouch - Moderated by Dr Kevin Hickson
Live Q&A Session ARTNet with Prof Michael Hofman, and A/Prof Louise Emmett - Moderated by A/Prof Roslyn Francis 36
Telix Pre-Conference Symposium Live Q & A with A/Prof Nat Lenzo, Dr Hossein Jadvar and Dr Kathy Willowson - Moderated by Dr Danielle Meyrick
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
Live Keynote Q&A with Dr Fabien Hyafil - Moderated by Dr Abdul Ihdayhid
Live Radiopharmacy Symposium Q&A with Dr Laurence Morandeau, Prof Christopher Rowe and Dr Stephen Taylor Live Keynote Q&A with Prof Phillip Kuo Moderated by Prof Christopher Rowe
Live Cardiology and Vascular Q&A with Dr Barry Elison and A/Prof Nathan Better - Moderated by Prof Dale Bailey
Live National Imaging Facility Q&A with Prof Graham Galloway, Dr Giancarlo Pascali and Dr Tien Pahm
L
ive event sites were a success and a hub
for our delegates to get together in person, see each other and network after months of non-face-to-face events. We acknowledge Siemens for
their sponsorship of the National Network dinner events.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
37
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
t was great to be around everyone and have the community feeling.
I
t was the BEST! So fantastic to talk and gather with colleagues!
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
Click here for more photos
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
SHIMAZDU AWARD IN VITRO AND IN VIVO CHARACTERIZATION OF ZR-DF-RADIOLABELED BISPECIFIC ANTI-PD-L1/TGF-βRII FUSION PROTEIN BINTRAFUSP ALFA
89
Ingrid Burvenich Shimazdu Award Winner
B
By I Burvenich1,2, Y Goh1, N Guo1, H Gan1,2, A Rigopoulos1,2, D Cao1,2, Z Liu1,2, U Ackermann2,3,4, C Wichmann1,2, A McDonald1,2, N Huynh1, G O'Keefe3,4, S Gong3,5, F Scott1,2, L Li6, W Geng6, A Zutshi6, Y Lan6, A Scott1,2,3,4,5 1 Olivia Newton-John Cancer Research Institute, Melbourne, Australia, 2School of Cancer Medicine, La Trobe University, Melbourne, Australia, 3Department of Molecular Imaging and Therapy, Austin Health, Melbourne, Australia, 4 Department of Medicine, University of Melbourne, Melbourne, Australia, 5School of Engineering and Mathematical Sciences, La Trobe University, Melbourne, Australia, 6EMD Serono Research & Development Institute, Billerica, USA
positive murine breast cancer model ACKGROUND: Bintra- (EMT-6). The presence of PD-L1 and fusp alfa (M7824) is a TGF-ß targets in different tissues was next-generation type of confirmed via immunohistochemistry. PD-L1 targeting molecule allowing simultaneous targeting of RESULTS: Conditions for the Df-conPD-L1 and trapping of transforming jugation and 89Zr-radiolabeling of bintrafusp alfa and controls were growth factor beta (TGF-ß). established. PD-L1 binding and trapAIMS: In preparation of a clinical ping of TGF-ß ligands of constructs bioimaging trial, this study aimed was maintained after radiolabelling. to generate 89Zr-labeled bintrafusp A combined PET imaging/biodistribualfa investigational drug product tion study clearly showed the effect of and controls, and to perform the in protein dose on the amount of 89Zr-lavitro and in vivo characterization of beled bintrafusp alfa that can reach 89 Zr-Df-bintrafusp alfa and 89Zr-Df-con- the tumor: by increasing the amount of unlabeled protein, uptake in lung trol radioconjugates. and spleen can be reduced, and as a METHODS: Bintrafusp alfa (anti- result, the blood pool activity as well PD-L1 human IgG1 antibody fused to TGF-ß receptor II (TGF-ßRII)), avelumab (anti-PD-L1 human IgG1 control antibody), isotype control (mutated inactive anti-PD-L1 IgG1 control antibody), and trap control (mutated inactive anti-PD-L1 human IgG1 fused to active TGF-ßRII) were chelated with p-isothiocyanatobenzyl-desferrioxamine(Df). Invivo biodistribution studies were performed at different dose levels to identify tissue distribution and 89Zr-Df-bintrafusp alfa tumor uptake in a PD-L1/TGF-ß
40
GAMMA GAZETTE | ANZSNM.ORG.AU
as the tumor uptake of 89Zr-labeled bintrafusp alfa was increased. Results of PET/CT imaging of 35ßg 89Zr-labeled bintrafusp alfa are shown in the figure below. CONCLUSION: Our results demonstrate that 89Zr-labeled bintrafusp alfa is now suitable for use in the bioimaging clinical trial study of 89Zr-bintrafusp alfa PET scans in patients with advanced or metastatic NSCLC receiving M7824 alone or in combination with chemotherapy.
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
CURIUM AWARD
16 VS 8 BIN EVALUATION OF LEFT VENTRICLE EJECTION FRACTION IN MYOCARDIAL PERFUSION IMAGING
Brylee Thomson Curium Award Winner
By Thomson B1, NG W1, Pathmaraj K1,2, Lee ST1,2,3, Rowe, C1,4, Boktor R1,2,3 1 Department of Molecular Imaging and Therapy, Austin Health; 2Olivia Newton-John Cancer Research Institute, Austin Health; 3School of Cancer Medicine, La Trobe University, 4Department of Medicine, The University of Melbourne
B
ACKGROUND: Myocardial Perfusion Imaging (MPI) is a reliable diagnostic tool used for assessing ischemic heart disease. Accurate left ventricular ejection fraction is important for optimal management of patients with cardiac disease, which is routinely performed during myocardial perfusion imaging. A previous internal study in our institution comparing the left ventricular ejection fraction (LVEF) on MPI using 8 bin data compared to gated blood pool scans (GBPS) showed a 4% underestimation of LVEF in MPI (20 seconds per step for 60 steps). Hence, we routinely added 4% to the LVEF generated from MPI. The new generation GE Discovery SPECT scanners offer advances in gamma camera crystal sensitivity and reconstruction parameters, which initiated a review of this practice.
AIMS: To assess the difference and accuracy of LVEF calculation using 16 versus 8 bin gated data when performing MPI SPECT scans and to determine if the routine addition of 4% to the LVEF could be avoided.
difference (P<0.0001) between the 8 bin and 16 bin acquisition. The 16 bin acquisition protocol had an average 4% greater LVEF compared to the 8 bin, as shown in the table below. The 16 bin acquisition improves temporal sampling, which coupled with resoMETHODS: Using the GE Discovery lution recovery, more accurately DR, a new protocol involving MPI computes the LVEF compared to 8 acquisition using 16 bins was imple- bin gate acquisition. mented, which increased the acquisition time by 5 seconds per step and CONCLUSION: The results demonoverall scanning time by 5 minutes. strate that a more accurate LVEF is The data was converted to 8 bins by generated by contemporary SPECT/ combining every two consecutive CT scanners using 16 bin gated acquibins into one. Both sets of data were sition. This has obviated the need to processed using standard recon- routinely add 4% to the MPI generated struction algorithms by a single LVEF. This project has resulted in a technologist. LVEF was recorded and change of practice for MPI processing compared by two experienced nuclear and reporting in our department and medicine physicians. has restored the confidence of our referring doctors in our MPI generRESULTS: 105 patients, with 165 data- ated LVEF. combination with chemosets were evaluated. Matched pair therapy. t-test shows a statistically significant
Number of Scans
16 bins Range of EF(%)
16 bins Average EF(%)
8 bins Range EF(%)
8 bins Average EF(%)
Average difference in EF(%)
All
165
23-96
61
26-94
57
4.4
Stress
105
26-96
64
34-94
59
4.2
Rest
60
23-85
57
26-84
53
4.6
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
41
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
AANMS AWARD
CLINICAL INSIGNIFICANCE OF [ 18 F]PSMA-1007 AVID NONSPECIFIC BONE LESIONS: A RETROSPECTIVE EVALUATION
Evyn Arnfield AANMS Award Winner
Evyn Arnfield Royal Brisbane and Women's Hospital, Queensland
P
URPOSE:[ F]PSMA-1007 offers advantages of low urinary tracer excretion and theoretical improved spatial resolution for imaging prostate cancer. However, non-specific bone lesions (NSBLs), defined as mild to moderate focal bone uptake without a typical morphological correlate on CT, are a common finding on [188F] PSMA-1007 PET/CT. The purpose of this study was to investigate the clinical outcomes of patients with [18F] PSMA-1007 avid NSBLs, to determine whether patients with NSBLs represent a higher risk clinical cohort, and to determine whether SUVmax can be used as a classifier of bone metastasis. 18
1007 avid bone lesions. Finally, we analysed an SUVmax threshold to identify bone metastases using ROC curve analysis.
RESULTS: Ninety-four of 214 patients (43.9%) demonstrated at least one NSBL. No [18F]PSMA-1007 avid NSBLs met criteria for a likely malignant or definitely malignant lesion after a median 15.8-month follow-up interval (11.9% definitely benign, 50.3% likely benign, and 37.7% equivocal). There were no statistically significant differences in serum PSA, Gleason score and uptake time between patients with [18F]PSMA-1007 avid NSBLs and those without [18F]PSMA-1007 avid bone lesions. All NSBLs with adequate follow-up had SUVmax ≤11.1. The value of the highest SUVmax distinguished METHODS: A retrospective audit of between NSBLs and definite prostate 214 men with prostate cancer was performed to investigate the clinical cancer bone metastases, whereby an outcomes of [18F]PSMA-1007 avid SUVmax threshold of ≥7.2 maximised NSBLs according to defined criteria. the Youden’s index. We also compared the serum PSA, Gleason score and uptake time of CONCLUSION:[18F]PSMA-1007 avid NSBLs rarely represent prostate cancer patients with [18F]PSMA-1007 avid 18 NSBLs to patients without [ F]PSMA- bone metastases. When identified in
42
GAMMA GAZETTE | ANZSNM.ORG.AU
the absence of definite metastatic disease elsewhere, it is appropriate to classify those with SUVmax <7.2 as likely benign. NSBLs with SUVmax 7.2-11.1 may be classified as equivocal or metastatic, with patient clinical risk factors, scan appearance, and potential management implications used to guide interpretation.
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
GMS POSTER AWARD NO THEATRE TIME REQUIRED – THE USE OF LYMPHOSCINTIGRAPHY WITH SPECT/CT AND ULTRASOUND TO GUIDE PERCUTANEOUS FNA OF THE SENTINEL NODE IN A MELANOMA PATIENT
Danielle Nuske GMS Poster Award Winner In the photo, Danielle visiting Madame Curie's laboratory in Paris' Museum in 2018
B
Danielle Nuske1 & C. Ghee Chew1 Department of Nuclear Medicine, Radiology SA, Calvary North Adelaide Hospital, South Australia
1
guided nodal biopsy. Radioactivity of A C K G R O U N D : A the aspirate slides noted at >10X back75-year-old female patient ground indicated radioactive sentinel with right upper arm nodal sampling. Lymphocytes in melanoma was referred cytopathological analysis further for lymphoscintigraphy and ultra- confirmed lymph node sampling. No sound-guided fine needle aspiration malignant cells were found. (FNA) of the sentinel node. OUTCOME: The patient avoided a PR O C E D U R E : 9 9 m Tc- N a n o S c a n more invasive surgical sentinel lymph (54MBq / 0.4mL) was administered node biopsy (SLNB). Subsequent intradermally at the melanoma management remained unchanged site. Before acquiring planar images for a negative sentinel node biopsy. the patient performed upper body exercises. The surface locations of DISCUSSION: While SLNB with the visualised axillary sentinel node pre-operative lymphoscintigraphy were marked anteriorly and laterally. and blue dye is standard in earlyMetallic ECG buttons were placed at stage melanoma, it has potential the marks prior to SPECT/CT. Ultra- complications and contraindications. sound then guided the percutaneous Ultrasound-guided percutaneous sentinel node FNA biopsy. The aspi- FNA of the sentinel node following rate slides were examined for radio- lymphoscintigraphy is a viable, miniactivity using a hand-held radiation mally invasive alternative which has monitor. Cytopathological analysis been reported in the literature. The success of both techniques depends followed. on prompt and accurate sentinel FINDINGS: The planar images node identification. To improve showed prompt radiotracer uptake biopsy yield our protocol includes: by a single right axillary lymph node. 1. routine post injection exercise to SPECT/CT localised the node depth expedite and enhance nodal idenat 1.5cm. Metallic landmarks on CT tification; 2. metallic button placeassisted ultrasound evaluation which ment as CT landmarks; 3. radioactivity
evaluation with a monitor to confirm sentinel nodal sampling. CONCLUSION: Percutaneous FNA biopsy of sentinel node with lymphoscintigraphy SPECT/CT can be confidently performed and is less invasive than nodal resection.
CLICK TO VIEW THE POSTER
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
43
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
RADPHARM AWARD THE BENEFITS OF STRESS: ACETAZOLAMIDE VERSUS EXERCISE IN PHACE SYNDROME
Candice Nish Radpharm Award Winner
Candice Nish Royal Brisbane and Women's Hospital, Queensland
C
8 minutes. At this point exercise ASE DESCRIPTION:A induced symptoms became present 13-year-old male patient and the patient was injected with with a complex history 99mTc-ECD. The exercise stress was of left trigeminal nerve discontinued 1 minute later. A SPECT/ neuralgia, secondary to Posterior fossa CT was performed for approximately brain malformations, Haemangioma, 45 minutes to assess the vascular distriArterial anomalies, Coarctation of bution of the radiotracer. General aorta and Eye abnormalities (PHACE) anaesthetic was used for all imaging syndrome, was investigated using as requested. cerebral perfusion SPECT/CT imaging. FINDINGS: Comparing the 99mTcPROCEDURES PERFORMED: A ECD exercise stress to the 99mTc-ECD 99m Technetium Ethylcysteniate Dimer baseline, a 10%-20% exercise induced (99mTc-ECD) baseline and 99mTc- decrease in perfusion to the right cereECD Acetazolamide challenge were bral hemisphere was shown. acquired separately under normal parameters followed by a Single OUTCOME:Due to the results indiPhoton Emission Computed Tomog- cated by the nuclear medicine scan, raphy (SPECT/CT). A 99mTc-ECD Acet- the patient went on to have surgery azolamide exercise stress, using a which lead to significant improvement treadmill, was also performed using in the patient’s trigeminal neuralgia the Bruce Protocol for approximately and quality of life.
44
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
DISCUSSION:This case study indicates how, in nuclear medicine, functional imaging and the adaptability of scanning techniques to a patient’s needs, can aid in the diagnosis and treatment pathway of patients.
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
Nicola Evans Nuclear Medicine Undergraduate Student Award Winner
NUCLEAR MEDICINE UNDERGRADUATE STUDENT AWARD EFFECTS OF EXENATIDE ONCE WEEKLY ON INTRAGASTRIC DISTRIBUTION OF SOLIDS AND LIQUIDS AND PERCEPTIONS OF APPETITE, IN HEALTHY OVERWEIGHT SUBJECTS Nicola Evans University of South Australia
B
receive either exenatide QW (6M, 10F; age: 59.9±0.9 years; BMI: 29.6±0.6kg/m 2 ) or placebo (6M, 10F; age: 60.6±1.2 years; BMI: 29.5±1.0kg/m 2 ) for eight weeks. At baseline and post-intervention, body weight was recorded, and GE and perceptions of appetite were measured for 120 minutes after a solid/ liquid meal, comprising 100g minced beef (radiolabelled with 20MBq 99m Tc-sulphur colloid) and 150mL 10% glucose (radiolabelled with 7MBq 67 Ga-EDTA). Regions-of-interest were drawn to generate intragastric meal distribution curves of the total, proximal and distal regions. Data are mean values ± the standard error of the mean, with P&lt;0.05 considered statistically significant. AIM: To evaluate the effects of exenatide QW, on solid and liquid intragastric distribution and perceptions RESULTS: Exenatide QW induced of appetite, in healthy overweight a mean weight loss of 2.1±0.5kg (P=0.001). Exenatide QW also delayed volunteers. total stomach solid (P=0.04) and METHODS: Thirty-two overweight liquid (P=0.02) GE, compared to participants were randomised to placebo, with no significant changes ACKGROUND: Obesity and type 2 diabetes are associated with increased morbidity and mortality; however, weight loss decreases complications. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) induce weight loss, although the mechanisms are poorly understood. Postprandial fullness is directly related to distal meal retention, and although the long-acting GLP-1RA, exenatide once weekly (QW), slows gastric emptying (GE), its effects on intragastric meal distribution and appetite sensations have not previously been evaluated.
to intragastric distribution. Post-intervention, there were no significant changes to perceptions of fullness (P=0.32), hunger (P=0.32), or desire to eat (P=0.54). Weight loss induced by exenatide QW appears unrelated to intragastric distribution, indicating that other mechanisms are involved. CONCLUSION: In healthy overweight participants, eight weeks of treatment with exenatide QW slows solid and liquid GE with no significant changes in intragastric distribution and no effect on sensations of appetite, despite significant weight loss.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
45
SPECIAL FEATURE 51st Annual Scientific Meeting Highlights: Key Collaborations, Key Impacts: Unlocking the Potential of Nuclear Medicine
Society Recognition We congratulate all of the award winners on their excellence and success. There are also two plenary lectures given by individuals that the Society wishes to honour by invitation to present — the Pioneer Lecture and the Lowenthal Lecture. The Pioneer Lecture is given to an individual who has made a considerable contribution to the Society of Nuclear Medicine in Australia or New Zealand. The Lowenthal Lecture, is awarded to an individual who has made a significant contribution over the years to the local nuclear medicine community. This year’s lecturers did not disappoint. The two honorees for 2021 are well known to the ANZSNM community and need minimal introduction. Their presentations can be found on the ANZSNM site with the links below.
PIONEER LECTURER Dr Andrew McLaughlin
CLICK TO WATCH
LOWENTHAL LECTURER
Dr Darin O'Keeffe
CLICK TO WATCH
46
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
Ashleigh Hull Research Award recipient
PRE-CLINICAL STUDIES OF MUC1 TARGETED ALPHA THERAPY FOR PANCREATIC CANCER Ashleigh Hull 1,2*, Yanrui Li 1, Dylan Bartholomeusz 2,3, William Hsieh 1,2 and Eva Bezak 1,4
Cancer Research Institute and Allied Health and Human Performance Academic Unit, University of South Australia Department of PET, Nuclear Medicine & Bone Densitometry, Royal Adelaide Hospital, South Australia Medical Imaging 3 Adelaide Medical School, The University of Adelaide, South Australia 4 School of Physical Sciences, The University of Adelaide, South Australia 1
2
P
ancreatic ductal adenocarcinoma (PDAC) is a highly aggressive malignancy with an unmet clinical demand. Despite advances in conventional therapies, surgery remains the only curative treatment option for PDAC, however its application is restricted to patients with locally advanced disease only (10 – 20% of cases). Several anatomical and physiological factors attribute to a lack of curative treatments for PDAC including the unfavourable location of the pancreatic vasculature which complicates surgical resections; the cellular heterogeneity of the pancreas which limits the effectiveness of a single treatment type; the stromal barrier that restricts the entry of intravenous substances including chemotherapy; and the hypoxic nature of PDAC which reduces the efficacy of external beam radiation therapy.
48
GAMMA GAZETTE | ANZSNM.ORG.AU
Targeted alpha therapy (TAT) has ideal radiobiological properties to overcome these barriers however there have been few applications of TAT to PDAC. The aim of this project is to investigate the safety and feasibility of TAT for PDAC by developing and testing a novel alpha-immunoconjugate (AIC), 225Actinium-DOTA-C595. This AIC is designed to target cancer-specific mucin 1 epitopes (MUC1-CE) overexpressed on PDAC. A series of controlled in vitro experiments will be performed to assess the pharmacokinetics and cytotoxicity of 225Actinium-DOTA-C595 in MUC1-CE positive and negative PDAC cells. Complementary diagnostic and therapeutic radioimmunoconjugates, 64Copper-DOTA-C595, 99mTechnetium-DOTA-C595 and 177Lutetium-DOTA-C595, will also be prepared and tested for comparison purposes and for future use in biodistribution/beta therapy studies.
More than 60 years’ experience making lifesaving and lifechanging procedures possible
Partnering with nuclear medicine professionals to enable ~700,000 patient procedures each year* * These include diagnostic imaging scans (SPECT and PET) to aid in patient management, and a growing range of therapies. Stats are based on published Medicare statistics combined with non-MBS data sourced from the nuclear medicine community.
www.ansto.gov.au
EDUCATION AND CPD | Case Study
THE EFFICACY OF NUCLEAR MEDICINE SCINTIGRAPHY IN THE DETECTION OF CARDIAC AMYLOIDOSIS: A CASE-BASED APPROACH
Marianna Elias, University of South Australia
A
& Judge 2020). The Nuclear Medicine BSTRACT: Cardiac bone scintigraphy was acquired to Amyloidosis (CA) is char- evaluate for cardiac amyloidosis and acterised as insoluble consolidate previous findings. amyloid plaque depositions within the myocardium and is INTRODUCTION: An 86-year-old often associated with several clinical male inpatient presented into the manifestations (Wong & Judge 2020) department with increasing shortness The two common subtypes involving of breath and known atrial fibrillation the myocardium are Immunoglobin with a referral to evaluate for possible light chain (AL) and Transthyretin CA. A CMR image acquisition to eval(ATTR) amyloid plaques (Wong & uate for infiltrative heart disease and Judge 2020). ATTR and AL cardiac monitor left ventricular hypertrophy amyloidosis can be distinguished preceded the nuclear medicine examthrough using nuclear medicine scin- ination. tigraphy utilising the Technetium 99m Hydroxy-methylene-diphosphonate Amyloidosis refers to the deposition (99m Tc-HDP) bone-seeking radio- of extracellular insoluble and atyppharmaceutical. This tracer, like other ical extracellular fibrils that transpire 99m Tc phosphonate derivatives, from the accumulation of misfolded, accumulates in ATTR amyloid deposi- usually soluble proteins sourced by tions, with the cause for this phenom- the liver (Sun et al. 2018). CA is the enon remaining unknown (Treglia et deposition and aggregation of fibril al. 2018; Khor et al. 2020). We present plaques into the myocardium (Wong a case of an 86-year-old male patient & Judge 2020). Systemic amyloidosis who presented to the department in the form of Immunoglobulin light following a cardiac Magnetic Reso- chains (AL) and Transthyretin (ATTR) nance (CMR) Imaging investigation are the most common plaque types to evaluate for newly diagnosed atrial that aggregate in the myocardium fibrillation and increasing shortness and manifest from genetic predispoof breath. These clinical manifesta- sitions or are classified as tions being typical of that of cardiac amyloidosis (Wong
50
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
senile (Wong & Judge 2020). CA can be a clinical indicator of congestive heart failure with preserved ejection fraction and rapidly progressive, restrictive cardiomyopathy (Kuria, Gitau & Makhdomi 2019). Diastolic and systolic dysfunctions may also ensue (Sun et al. 2018). Nuclear medicine bone scintigraphy is utilised to assess and differentiate between AL and ATTR CA and monitor disease progression (Bokhari et al. 2013). Differentiation between these subtypes, is pertinent for an improved patient prognosis, in that ATTR and AL CA each require separate treatment pathways and clinical management (Bokhari et al. 2013; Khor et al. 2020). NUCLEAR MEDICINE PROCEDURE & FINDINGS PATIENT PREPARATION: The departmental nuclear medicine bone scintigraphy protocol was utilised. Initially the procedure and a bone questionnaire were discussed with the patient, and at which time it was established that the patient had nil bone pain, with no oncological history. Verbal and written consent was also obtained.
We’ve got you covered
SPEED Order, Map & Treat in Days FLEXIBILITY Activity & Coverage Optimization KNOWLEDGE Rapid Post-Op Dosimetry From planning to treatment, we’ve got you covered with clinical flexibility, speed and confidence in delivery. The is The SIR-Spheres Advantage. To learn more, visit our website: www.sirtex.com
Available for download until July 26th on the ANZSNM 2021 Live and Local Website:
Developments in SIRT dosimetry: recommendations and clinical implementation - ANZSNM 2021 symposium* *The presentation is available for those registered for ANZSNM Live and Local 2021 until July 26th
Kathy Willowson, Ph.D.
Senior Medical Physicist Department of Nuclear Medicine, Royal North Shore Hospital Sydney SIR Spheres ® is a registered trademark of Sirtex SIR-Spheres Pty Ltd. www.sirtex.com © 2021 Sirtex Medical Inc APM-ANZ-001-05-21
EDUCATION AND CPD | Case Study
The efficacy of nuclear medicine scintigraphy in the detection of cardiac amyloidosis: a case-based approach (Continued)
PROTOCOL: 850 mega Becquerels (MBq) of Tc-99m HDP was administered to the patient intravenously. The patient was then sent away and returned 3 hours post injection for their image acquisition. The patient was positioned supine on the scanning bed, pillow underneath knees and head, arms strapped to sides and feet strapped together with his toes together and heels apart. Left and right lateral skull static images were acquired preceding the whole body, departmental routine of these patient presentations. Following this, the patient was asked to place their arms up above their head for anterior and posterior thoracic static images, to further investigate the heart and rib cage. These were acquired for 3 minutes each utilising a Low Energy All Purpose collimator and a Siemens SYMBIA dual-headed hybrid imaging system. This is typical of a cardiac amyloidosis investigation. These images were then assessed and processed whilst the patient remained on the scanning bed. The resultant images were then processed for quantitative analysis and scrutinised by the reporting doctor. It was at their discretion that a thoracic SPECT/CT was also acquired to formulate a 3D image of the thoracic region. This involves the gamma camera rotating around the patient for approximately 8 minutes followed by a low dose CT image acquisition. The CT image enables for anatomical localisation and attenuation correction. The imaging parameters involved a 128x128 matrix, using a step and shoot acquisition at 13 seconds per view and a total of 96 views (48 views per head).
0= no cardiac uptake
1= cardiac uptake < bone
VARTIATION TO PROTOCOL: In the department, standard bone scintigraphy is usually completed approximately 2 hours post injection. However, with cardiac amyloidosis indications, patients are asked to return 3 hours post injection. This is to ensure that bone-to-cardiac uptake ratio is at its optimum level. Imaging at 3 hours post injection increases specificity and sensitivity to the disease process, in that bone and amyloid accumulation is at its peak with a corresponding reduction in blood pooling of radiotracer (Singh et al. 2019). FINDINGS: The Perugini visual scoring system is employed in clinical practices globally as a means of analysing radiopharmaceutical cardiac uptake and was utilised for this case (Figure 1) (Giorgetti et al. 2019; Kuria, Gitau, Makhdomi 2019). The resultant images demonstrated diffuse low-grade cardiac activity in the same intensity of that of bone uptake in both static and fused SPECT/CT coronal images (red arrows) (Figures 2 & 3). There is also evidence of increased focal high-grade uptake of left sternoclavicular joint. This is consistent with that of normal variant and is typical of degenerative changes in elderly patients. In this study, the anterior static localised view of the thorax was processed for image evaluation by the reporting doctor. The processing involved identical ROIs drawn of cardiac uptake and of the contralateral side for count differentiation (Figure 4). This is to validate any stark differences in counts between other soft tissue structures within the same vicinity. This finding is consistent with that of grade II on the Perugini visual grading system.
2= cardiac uptake = bone
3= cardiac uptake > bone
Figure 1: A visual representation of the Perugini visual grading system (Giorgetti et al. 2019, pg. 26).
52
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
EDUTRACE
YOUR CPD E-LEARNING PORTAL * Exclusive to ANZSNM members
EDUTRACE PROVIDES ACCESS TO A WIDE RANGE OF COURSES ON-DEMAND TO ADD TO YOUR CPD CONTINUING EDUCATION The content includes proprietary programs as well as others shared by international imaging and therapy organisations with which the ANZSNM has developed excellent relationships over the past 50 years.
Resources including webinars, case studies and online seminars Contributions from local and world experts National and overseas industry conference presentations and webinars Access from any device, anywhere at any time. Integration of CPD points with Attendo Plus mobile app
VISIT anzsnm.org.au/edutrace to get started
EDUCATION AND CPD | Case Study
The efficacy of nuclear medicine scintigraphy in the detection of cardiac amyloidosis: a case-based approach (Continued)
Figure 2: The resultant static coronal thorax image.
Figure 3: The resultant image of a coronal thoracic SPECT/CT.
Figure 4: An anterior projection of the thorax. Two identical region of Interests (ROIs) were placed in adjacent positions relative to the sternum, without bone impedence. ROI B counts (cardiac): 6.16, ROI A counts (mediastinum): 5.21.
CARDIAC MRI PROTOCOL AND FINDINGS: CMR was specifically utilised to evaluate cardiac functions and morphology (Wong & Judge 2020). Cardiac morphological MRI image acquisitions are quite complex and involve intricate patient preparation. It requires accurate placement of electrocardiogram (ECG) electrodes to ensure an acceptable ECG waveform external to the magnet (McRobbie et al. 2017).
Data acquisition most commonly occurs in diastole, where cardiac and respiratory motion is minimised (McRobbie et al. 2017). ECG triggering enables this, where data is consistently acquired at the same point of the cardiac cycle (McRobbie et al. 2017).
tricular septal thickness is substantial and is demonstrated in figure 5 (c) whereby length 3, is approximately double the thickness of that of the septum, length 4.
Initially an MRI questionnaire is completed, and any contraindications are recognised. These include, but are not limited to, identifying pacemakers, metal implants (e.g. stents) and any renal impairment if contrast is deemed necessary. Patients are then linked up to an electrocardiogram that triggers the turbo spin echo image acquisition with a double inversion recovery sequence (McRobbie et al. 2017). This is acquired in a single breath hold and involves the use of a 1.5T magnet.
54
It can characterise diffuse myocardial enhancement and right ventricular enhancement, both are pathophysiological of ATTR CA (Aljaroudi et al. 2014). It is also able to determine the cause of left ventricular hypertrophy, distinguishing between cardiac amyloid origin or other disease processes (Wong & Judge 2020). CMR images revealed cardiomegaly and bilateral pleural effusion (blue arrows) with right side greater than left, and interventricular septal thickening (red arrow) (Figure 5). Interventricular septal thickening is typical in that of amyloid plaque deposits in the myocardium (red arrow) (Treglia et al. 2018) The increase in interven-
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
The image investigation proved clinically relevant in the patient management pathway, in that the CMR was suggestive of cardiac amyloidosis, however the subtype remained unclear. As such, it was pertinent to the patient’s clinical journey that these imaging investigations preceded that of the nuclear medicine imaging to validate its utility of the scan to the patient and to justify radiation exposure. DISCUSSION: CA is often under diagnosed within clinical practice as it poses as several clinical manifestations and can cultivate a myriad of disease processes, one of which is atrial fibrillation (Glaudermans et al. 2014). As the plaques deposit typically into left ventricular myocardium,
EDUCATION AND CPD | Case Study
The efficacy of nuclear medicine scintigraphy in the detection of cardiac amyloidosis: a case-based approach (Continued)
left ventricular hypertrophy and associated cardiomyopathy develops (Wong & Judge 2020). The plaques prohibit stroke volume augmentation in response to vasodilation and thus causes severe atrial dilation (Wong & Judge 2020). Cardiomegaly, interventricular septal thickening, pleural effusion and known atrial fibrillation, are typical clinical manifestations that generate of that of CA (Kuria, Gitau & Makhdomi 2019). Nuclear medicine bone scintigraphy is the only imaging modality that can distinguish between ATTR vs AL CA (Sun et al. 2018). Cardiac uptake of 99mTc-HDP indicates the clinical diagnosis of ATTR CA (Glaudermans et al. 2014; Khor et al. 2020). The degree of cardiac uptake reflects the extent of plaque deposition (Glaudermans et al. 2014).
Bilateral Pleural effusion
Although the mechanism of uptake responsible for HDP binding to the ATTR cardiac amyloid plaques remains unknown, it has been theorised that the higher calcium content of ATTR CA is responsible for its avidity to HDP (Treglia et al. 2018). The grade II Perugini visual grade for this study is indicative of ATTR CA (Figures 2, 3 & 4). The utility of SPECT/CT imaging in the evaluation for ATTR CA is far reaching. Planar images are limited as it is difficult to differentiate between myocardial uptake and that of overlying rib uptake and may add to ROI myocardial counts (Singh et al. 2019). SPECT/CT overcomes these challenges, enables attenuation correction and anatomical localisation (Singh et al. 2019). Similar case studies conducted by Davies et al. (2017) & Sun et al. (2018) opted for transthoracic echocardiography or CMR as a non-invasive mode of diagnosis and evaluation for CA prior to nuclear medicine scintigraphy. Serial endomyocardial biopsies remain utilised as the gold standard procedure in diagnosis of CA subtypes (Khor et al. 2020). However, given the invasive nature and associated risks of perforation and bleeding, nuclear medicine is currently the preferred method for clinical diagnosis, with approximately a 100% specificity to ATTR CA (Singh et al. 2019; Khor et al. 2020).
Figure 5: Resultant images from MRI image acquisitions. (a) Transverse 1.5T cardiac MRI image with gadolinium contrast (TR = 266.43ms, TE = 1.25ms). (b) Sagittal 1.5T cardiac MRI image with gadolinium contrast and recorded septal thickness values (TR = 32.23ms, TE = 1.23ms). 1: Length - 5.72cm 2: Length - 5.27cm 3: Length - 1.90cm 4: Length - 0.94cm
The patient’s disease management pathway coincided with that of relevant literature as other imaging investigations need to be completed prior to nuclear medicine bone scintigraphy. Although optimal at distinguishing between cardiac amyloid subtypes, nuclear medicine is limited in the anatomical information that can be pertained from the images. The CA plaque differentiation is pertinent in
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
55
EDUCATION AND CPD | Case Study
The efficacy of nuclear medicine scintigraphy in the detection of cardiac amyloidosis: a case-based approach (Continued)
disease management as ATTR, and AL require different courses of treatment (Kuria, Gitau & Makhdomi 2019). Nuclear Medicine assisted in patient treatment planning as it was able to provide a diagnosis of ATTR CA. It provides value as part of disease management and treatment planning (Bokhari et al. 2013). It is widely used as a monitoring tool, pre and post treatment (Bokhari et al. 2013). ATTR CA in the myocardium inhibits stroke volume regulation (Yamamoto & Yokochi 2019; Wong & Judge 2020). As such, heart failure therapy, for example ACE inhibitors can potentially further deteriorate the patient’s condition through increasing hypotension (Wong & Judge 2020). Therapeutic agents have recently developed directed at treating the underlying causes of ATTR (Wong & Judge 2020). These are TTR tetramer stabilisers. These cannot eradicate the disease process, however, can reduce the production and in turn deposition of amyloid proteins in the myocardium (Wong & Judge 2020).
CONCLUSION: It is evident through literature that nuclear medicine scintigraphy particularly SPECT/CT is the only imaging modality that can definitively distinguish between ATTR and AL CA. Several of the patient’s clinical manifestations can be directly correlated with that of CA (Wong & Judge 2020). Nuclear medicine in conjunction with CMR addressed the disease processes and thus contributed to improving the patient’s quality of life, through CA subtype identification allowing for catered treatment accordingly. Had the two imaging modalities not corroborated their findings, the patient’s condition could have further deteriorated their health before identification. As such, the efficacy of nuclear medicine in evaluating for cardiac amyloidosis is substantiated.
Heart or liver transplantation has also been explored as a treatment option for genetically predisposed ATTR (Wong & Judge 2020). ATTR CA cultivated without genetic mutations, i.e., senile CA are often diagnosed at an older age at which point transplantation procedures are contraindicated (Wong & Judge 2020).
References Aljaroudi, WA, Desai, MY, Tang, W, Phelan, D, Cerqueia, MD & Jaber, WA 2014, ‘Role of imaging in the diagnosis and management of patients with cardiac amyloidosis: State of the art review and focus on emerging nuclear techniques’, Journal of Nuclear Cardiology, vol. 21, no. 2, pp. 271-283. Bokhari, S, Shahzad, R, Castano, A & Maurer, MS 2013, ‘Nuclear imaging modalities for cardiac amyloidosis’, Journal of Nuclear Cardiology, vol. 21, no. 2014, pp. 175184. Davies, T, Saleh, A, Coghlan, G, Whelan, C & Agarwal, B 2017, ‘A case study of likely wild-type cardiac transthyretin amyloidosis causing rapid deterioration’, Journal of the Intensive Care Society, vol. 18, no. 2, pp. 138-142. Giorgetti, A, Genoveesi, D, Milan, E, Acampa, W, Giubbini, R, Cuocolo, A & Marzullo, P 2019, ‘Cardiac amyloidosis’, Clinical and Translational Imaging, vol. 7, no. 1, pp. 21-32. Glaudermans, AWJM, van Rheenen, RVJ, van der Berg, MP, Noordzij, W, Koole, M, Blokzijl, H, Dierckx, RAJO, Slart, RHJA & Hazenberg, BPC 2014, ‘Bone scintigraphy with 99m-technetium-hydroxymethylene diphosphate allows early diagnosis of cardiac involvement in patients with transthyretin-derived systemic amyloidosis’, The Journal of Protein Folding Disorders, vol. 21, no. 1, pp. 35-44. Khor, YM, Cuddy, S, Falk, RH & Dorbala, S 2020, ‘Multimodality Imaging in the Evaluation and Management of Cardiac Amyloidosis’, Seminars in Nuclear Medicine, vol. 50, no. 4, pp. 295-310. Kuria, IM, Gitau, SN & Makhdomi, KB 2019, ‘Bone scintigraphy imaging of cardiac amyloidosis’, World Journal of Nuclear Medicine, vol. 18, no. 3, pp. 314-316. McRobbie, DW, Moore, EA, Graves, MJ 2017 & Prince, MR 2017, ‘Chapter 16: A Heart to Heart Discussion: Cardiac MRI’ in MRI from Picture to Proton, 3rd edn, Cambridge Medicine, Cambridge, UK, pp. 269-287. Ramsay, SC, Lindsay, K, Fong, W, Patford, S, Younger, J & Atherton, J 2018, ‘Tc-HDP quantitative SPECT/CT in transthyretin cardiac amyloid and the development of a reference interval for myocardial uptake in the nonaffected population’, European Journal of Hybrid Imaging, vol. 2, no. 17, pp. 1-13. Singh, V, Falk, R, Carli, MFD, Kijewski, M, Rapezzi, C & Dorbala, S 2019, ‘State-of-the-art radionuclide imaging in cardiac transthyretin amyloidosis’, Journal of Nuclear Cardiology, vol. 26, no. 1, pp. 156-173. Sun, JP, Yang, XS, Yan, BP & Wong, K 2018, ‘Cardiac Amyloidosis’, in JP Sun, XS Yang & BP Yan (eds.), Comparative Cardiac Imaging: A Case-based Guide, John Wiley & Sons Ltd., Oxford, United Kingdom, pp. 267-279. Treglia, G, Glaudemans, AQJM, Bertagna, F, Hazenberg, BPC, Erba, PA, Giubbini, R, Ceriani, L, Prior, JO, Giovanella, L & Slart, RHJA 2018, ‘Diagnostic accuracy of bone scintigraphy In the assessment of cardiac transthyretinrelated amyloidosis: a bivariate meta-analysis’, European Journal of Nuclear Medicine and Molecular Imaging, vol. 45, no. 11, pp. 1945-1955. Wong, LSM & Judge, DP 2020, ‘Cardiac Amyloidosis’, in HF Baars, PAFM Doevendans, AC Houweling & P van Tintelen (eds.), Clinical Cardiogenetics, Springer, Cham, pp. 167177. Yamamoto, H & Yokochi, T 2019, ‘Transthyretin cardiac amyloidosis: an update on diagnosis and treatment’, ESC Heart Fail, vol. 6, no. 6, pp.1128-1139.
56
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
EDUCATION AND CPD | Case Study
EVALUATION OF RENAL FUNCTION PRIOR TO CHEMOTHERAPY - A CASE STUDY REVIEW
Benjamin-Minh Hoc Ly (Second Year Student), RMIT University, Melbourne
A
BSTRACT: This article intends to provide insight into how Nuclear Medicine (NM) can be utilised to diagnose renal pathologies. It will summarise the process of glomerular filtration, known properties of 99mTc-DTPA and recommended protocols for dynamic renal scintigraphy. A case of a 72-year-old who presented to the department for evaluation will be used to explain the rationale and importance of NM to her prognostic pathway. The patient was determined to have poor renal function, determined by the glomerular filtration rate (GFR) study and a renal impairment demonstrated on imaging. NM combines the efficiency of dual-use tracers and functional imaging to provide an extensive amount of clinical information for patient care. BACKGROUND: A 72-year-old female patient presented to the Nuclear
Medicine department for a dynamic renal study.
affected. If the kidneys cannot discard wastes and excess fluids, renal failure can occur.
Information stated the patient was diagnosed with renal cell carcinoma from a prior biopsy. This scan serves to determine whether the patient is suitable for undergoing radiation therapy, as it can further deteriorate kidney function (Santos et al., 2020). It was requested to assess the patient’s GFR, which is a widely accepted indicator of renal function (Schaeffner, 2017).
It was also confirmed the patient had moderate hydronephrosis in the left kidney and a para-aortic nodal mass, which was confirmed through MRI and CT imaging. While a paraaortic nodal mass is rare, it can be presented within the renal pelvis or kidney (Yamada et al., 1998). It can lead to upper urinary tract obstruction (Caiafa et al., 2013), which blocks urinary drainage (Hong et al., 2020). The patient was visibly tired and This could cause deterioration to the mentioned feeling more tired than renal parenchyma and dilation of usual, which is a common symptom the ureters, renal pelvis and calyces. associated with cancer (Larkin et al., Furthermore, anuria (non-passage of 2010). In addition, her clinical history urine through the ureters) and retrostated she suffered from hypertension. grade flow (back up of urine into the High blood pressure can damage and kidneys) can happen. narrow the renal arteries, decreasing the amount of blood flow (Bidani & IMAGING PROCEDURE: The patient Griffin, 2004). With damage to the was positioned supine on the scankidney’s vessels, renal function will ning bed (FOV near the L1 - L3 vertebe detrimentally brae), with the collimator positioned posteriorly (Ziessman et al., 2014). GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
57
Biograph Vision Quadra
Bigger perspective. Better answers.
The power of a proven platform. The perspective of a large axial field of view. Biograph Vision Quadra™ takes the potential of PET/CT even further. Dynamically see vertex to thighs in a single position and deepen the dimension of your investigations. Whether you are exploring new research questions or identifying the best clinical approach with Biograph Vision Quadra, the answers are yours to find.
Engineered for new research dimensions With 106 cm axial PET field of view, Biograph Vision Quadra offers a whole-body (vertex to thighs) perspective so you can scan more in one position to dynamically follow tracer kinetics throughout the body. And with best-in-class time-offlight performance and PET effective sensitivity1, you can see with outstanding clarity. Developed to reshape clinical outcomes The accuracy, performance, and reproducibility of Biograph Vision are the gold standard in PET/CT imaging. With Biograph Vision Quadra, you achieve the same outstanding detail and definition that you have come to expect— increased detectability of smaller lesions, reduced scan time and effective dose, and faster evaluation of treatment impact2
Data courtesy of Inselspital, Bern, Switzerland
1. Measured value, based on phantom studies performed on a single system. Biograph Vision Quadra has ≤249ps time of flight performance based on acceptance values. Data on file. 2. Compared to Biograph mCT
58
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
Published by Siemens Healthineers · © Siemens Healthcare Pty Ltd, 2021
Designed for your realities With a 106 cm axial PET field of view, you can perform a whole-body scan in one position on a machine built for the same space as a traditional PET/CT scanner. Our innovative architecture is designed for easy serviceability, efficient data management, and enhanced workflows. With Biograph Vision Quadra, you have a research and clinical solution designed for your realities.
EDUCATION AND CPD | Case Study
Evaluation of Renal Function Prior to Chemotherapy - A Case Study Review (Continued)
Tc-DTPA was chosen as the radiopharmaceutical to evaluate renal blood flow, parenchymal function and elimination of the tracer through the renal collecting system. 99m
Wang et al. (2020) note that 99mTc-DTPA can be used for addressing a diagnosis of suspected urinary tract obstruction. Despite its low extraction fraction of approximately 20% (Taylor et al., 2018), 99mTc-DTPA is the only renal tracer that can calculate the patient’s eGFR as it is predominately cleared via glomerular filtration. The patient was intravenously administered 209 MBq of 99mTc-DTPA in the right antecubital fossa whilst lying on the scanning bed. The perfusion phase consists of 1 sec/frame for 60 frames. The subsequent dynamic phase is composed of 1 min/frame for 20 frames. A zoom factor of 1.23 was employed to allow for an optimal magnification of the kidneys (EANM, 2016).
Figure 1: Initial perfusion images. RESULTS: Renal Blood Flow - From the initial time of 99mTc-DTPA being intravenously administered, the tracer is shown to first pass from the bloodstream into the abdominal aorta (Figure 1). From T0 + 3 seconds, we see gradually increased activity within the kidneys. This means the tracer has moved from the afferent arterioles into the glomerulus of the nephrons (Burke et al., 2014).
Figure 2: Time-activity curve (TAC) that demonstrates renal perfusion.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
59
EDUCATION AND CPD | Case Study
Evaluation of Renal Function Prior to Chemotherapy - A Case Study Review (Continued)
The TAC (Figure 2) demonstrates the tracer entering the abdominal aorta, crossing the bloodstream to enter the renal arteries (Bounous et al., 1960). A rising slope is visualised alongside rapidly accumulating counts within T0 + 1 - 5 seconds for the aorta, left and right kidney respectively. Around 15 seconds, we see the slope decreasing as the tracer is moving to the renal parenchyma, meaning counts are steadily reducing. This graph demonstrates normal renal perfusion of both kidneys and stable tracer flow into the abdominal aorta from around T0 + 15 seconds - 60 seconds. Renal Dynamic - During T0 + 120 seconds, we see gradual uptake of the tracer in the left kidney. At T0 + 180 seconds,
Figure 3: Renal accumulation and excretion dynamic. the renal pelvis of the right kidney has demonstrated 99mTc-DTPA uptake. At T0 + 19 minutes, profound retention of the tracer is seen within the renal pelvis of both kidneys. This is more evident in the left kidney in comparison to the right one. There is no exhibited tracer clearance into the ureters or the bladder for either kidney, strongly suggesting the presence of a potential urinary tract obstruction.
Figure 4: TAC that visualises both renal accumulation and excretion.
60
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
EDUCATION AND CPD | Case Study
Evaluation of Renal Function Prior to Chemotherapy - A Case Study Review (Continued)
At around the T0 + 3 minutes (Figure 4), counts in the right kidney have begun to gradually decrease. At around T0 + 5 minutes, counts in the left kidney have begun to increase. In a normal TAC, peak cortical uptake is usually seen during T0 + 3 - 4 minutes and accumulation of activity in the bladder at T0 + 10 - 15 minutes. As this is not seen, this graph indicates functional impairment of both kidneys. HOW IS THE eGFR CALCULATED? The weight of four empty syringes was recorded before the patient’s arrival. 4 x 10 mL blood samples are taken. The first one serves as a baseline, which checks for radiation contamination from such things as prior imaging or therapy. The remaining three were used to acquire blood samples after administration of 99mTc- DTPA at 2, 3 and 4 hours after injection (Murray et al., 2013). The patient was also asked to continue their drinking and food consumption habits, allowing the GFR obtained to be truly reflective of the patient’s daily life. This also meant not engaging in heavy exercise or having a large meal, as high protein consumption can affect the eGFR to perform any heavy exercise. Samples intervals should be greater than 45 minutes and the exact time of all blood samples recorded for quality assurance. After centrifuging, 2 mL of plasma were pipette into individual counting tubes. These counting tubes are then placed into a gamma counter, forming a linear graph. Information was then derived to be inputted into the following equation. Formula (Piepsz et al., 2001): Part 1 Part 2
• • • •
V = Volume of distribution (mL). Reference counts = Average reference counts per minute/mL. Injection weight of 99mTc-DTPA (grams). T0 = Counts at start of injection.
REPORT: The derived eGFR was 40 mL/minute, which is normally 75 mL/minute for individuals over 70 years of age (National Kidney Function, 2013). This indicates moderate impairment of kidney function. Both kidneys demonstrated renal perfusion and progressive tracer accumulation. The study showed progressive tracer accumulation in the left kidney without spontaneous net clearance or drainage. A functionally significant obstruction in the right kidney cannot be excluded either.
ROLE OF NM IN PATIENT MANAGEMENT: This study demonstrates the use of 99mTc-DTPA for the dual use of imaging renal function and assessing a patient's eGFR, which are both important aspects in the lead up to either chemotherapy or radiation therapy evaluation. Another benefit provided via Nuclear Medicine to the patient was the fairly short duration of gaining multiple results from one examination. The patient only requires two cannulas to perform imaging and eGFR assessment, making this a non-invasive procedure.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
61
EDUCATION AND CPD | Case Study
Evaluation of Renal Function Prior to Chemotherapy - A Case Study Review (Continued)
The results obtained provide information about the physiological function of the patient’s kidneys and can complement the anatomical information derived from CT and MRI images. Given the low radiation dose and swift effective half clearance time of 99mTc-DTPA, the patient was able to promptly undergo ultrasound imaging afterwards to
detect potential ureteric masses. Overall, the site of renal obstruction is localised for future intervention, especially for targeted therapy. In addition, a comprehensive assessment of the patient’s eGFR and renal impairment was achieved.
References •
Bidani, A., & Griffin, K. (2004). Pathophysiology of Hypertensive Renal Damage. Hypertension, 44(5), 595 – 601. https://doi.org/10.1161/01. HYP.0000145180.38707.84
•
Bounous, G., Shumacker, H., & King, H. (1960). Studies in Renal Blood Flow: Some General Considerations. Annals of Surgery, 151(1), 47 – 58.
•
Burke, M., Pabbidi, M., Farley, J., & Roman, R. (2014). Molecular Mechanism of Renal Blood Flow Autoregulation. Current Vascular Pharmacology, 12(6), 845 – 858. https://doi.org/10.2174/157016111131166 60149 Page !4 Part 1 Part 2
National Kidney Foundation. (2013). GFR (Glomerular Filtration Rate): A Key To Understanding How Well Your Kidneys Are Working. https:// www.kidney.org/sites/default/files/docs/11-101813_abe_patbro_gfr_b.pdfv
•
Nuraj, P., & Hyseni, N. (2017). The diagnosis of obstructive hydronephrosis with colour doppler ultrasound. ACTA Informatica Medica, 25(3), 178 – 181. https://doi.org/10.5455/aim. 2017.25.178-181
•
Piepsz, A., Colarinha, P., Gordon, I., Hahn, K., Olivier, P., Sixt, R., Velzen, J., & Paediatric Committee of the European Association of Nuclear Medicine (2001). Guidelines for glomerular filtration rate determination in children. European Journal of Nuclear Medicine, 28(3), 31 - 36. Santos, M., Brito, B., Silva, F., Botelho, A., & Melo, F. (2020). Nephrotoxicity in cancer treatment: An overview. World Journal of Clinical Oncology, 11(4), 190 - 204. https://doi. org/10.5306/wjco.v11.i4.190
•
Schaeffner, E. (2017). Determining The Glomerular Filtration Rate - An Overview. Journal of Renal Nutrition, 27(6), 375 - 380. https://doi.org/10.1053/j. jrn.2017.07.005
•
Taylor, A., Brandon, D., Palma, D., Blaufox, M., Durand, E., Erbas, B., Grant, S., Hilson, A., & Morsing, A. (2018). SNMMI Procedure Standard Guideline for Diuretic Renal Scintigraphy in Adults With Suspected Upper Urinary Tract Obstruction 1.0. Seminars in Nuclear Medicine, 48(4), 377 – 390. https://doi.org/10.1053/j.semnuclmed.2018.02.010
•
•
Caiafa, R., Vinuesa, A., Izquierdo, R., Brufau, B., Colella, J., & Molina, C. (2013). Retroperitoneal Fibrosis: Role of Imaging in Diagnosis and Follow-up. RNSA Radiographics, 33(2), 535 – 552. https://doi.org/10.1148/rg.332125085
•
European Association of Nuclear Medicine (2016). Dynamic renal imaging in obstructive renal pathology: A technologist's guide. https:// www.enam.org/content-eanm/uploads/2016/11/ tech_dynamic.pdf
•
Hong, J., Suh, S., & Shin, J. (2020). Clinical significance of urinary obstruction in critically ill patients with urinary tract infections. Medicine, 99(1), 1 – 7. https://doi.org/10.1097/MD.0000000000018519
•
•
Larkin, J. M., Pyle, L. M., & Gore, M. E. (2010). Fatigue in renal cell carcinoma: The hidden burden of current targeted therapies. The Oncologist, 15(11), 1135 - 1146. https://doi.org/10.1634/theoncologist.2010-0078 McQuillan, B., Zelasko, S., & Wolin, E. (2016). Nuclear Medicine Genitourinary Imaging in Native Kidneys. Journal of the American Osteopathic College of Radiology, 5(3), 14 - 20. https://www. jaocr.org/articles/nuclear-medicine-genitouri-
nary-imaging-in-native-kidneys Murray, A., Barnfield, M., Waller, M., Telford, T., & Peters, A. (2013). Assessment of Glomerular Filtration Rate Measurement with Plasma Sampling: A Technical Review. Journal of Nuclear Medicine Technology, 41(2), 67 - 75. https://doi.org/10.2967/jnmt.113.121004
•
Wang, Y., Li, M., Dai, S., & Li, Y. (2020). The role of Tc-99m DTPA renal dynamic scintigraphy in retroperitoneal liposarcoma. BioMed Research International, 2020, 1 – 5. https://doi. org/10.1155/2020/9765162
•
Yamada, H., Komatsu, R., Nagae, H., Fujioka, Y., & Fujita, M. (1998). Idiopathic retroperitoneal fibrosis with duodenal obstruction successfully treated with corticosteroids. Internal Medicine, 37(7), 592 – 598. https://doi.org/10.2169/internalmedicine.37.592
•
Ziessman, H., O’Malley, J., Thrall, J., & Fahey, F. (2014). The Requisites: Nuclear Medicine (4th ed.). Elsevier Roberts.
Acknowledgements: I want to express my deepest thanks to Suzanne McGavin for providing feedback and advice during the drafting of this article. My appreciation is also to the Nuclear Medicine department at Peter MacCallum Cancer Centre and the individual patient for allowing permission to use the acquired images.
62
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
EDUCATION AND CPD | Case Study
A total digital PET-CT transformation
Air cooling technology. A first of its kind for digital PET-CT. As the world’s first 100% air-cooled digital PET-CT system, the Cartesion Prime alleviates many costs, risks, and complexities associated with water coolers. With the industry’s smallest digital PET-CT footprint, it’s easier and more cost effective to install into tighter, existing spaces.
Personalised Care
Made possible. anz.medical.canon
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
63
INSTANTLY get your ATTENDANCE CERTIFICATE with Attendo Plus Receive your digital certificate via email right after attending an event just in a few clicks.
Attendance Certificate
3 EASY STEPS Register your interest for an event Scan the event QR code at check-in to register your attendance A digital certificate is sent to you by email within 24 hours after the event
DOWNLOAD Download it from the iTunes Store
LEARN MORE HERE www.attendoplus.com/guests
Attendo Plus is the mobile app that helps you manage your events, track CPD points, avoid filling out forms, skip the queues at check-in and much more just 64 clicks! GAMMA EDITION 2021attended | ANZSNM.ORG.AU with a few Save GAZETTE time, keepWINTER digital records of your events, get digital certificates of attendance and keep informed of what events yours and other organisations are running with Attendo Plus.
Download it from Google Play
Visit attendoplus.com today to learn more.
PEOPLE IN NUCLEAR MEDICINE
Order of Australia Honours ohn Andrews, AM The Society is pleased to congratulate Dr John Andrews, a past President and Life Member of the Society, who has been recognised in the 2021 Queen's Birthday Honours. His citation was ‘For significant service to nuclear medicine, and to professional societies'. John has been created a Member in the Order of Australia (AM). In responding to the Society's congratulations John replied, "It is a great privilege to receive an AM. So good to see Nuclear Medicine as the principal reason. ANZSNM has always been very important to me and a large part of my professional life as well as a source of great friendships and pleasure. It is marvellous to see how nuclear medicine has advanced over the years and the recent program of the last meeting was so interesting." In a great indication of John's belief in his passions, John requested the following : "If you thought appropriate, would my recently published book on the History of the Foundation Years of the Medical Association for the Prevention of War entitled "Preserving Life by Preventing War" with co-author Vicki Standish be of interest? This is available as an eBook for all members who wish to read it and there is also available a hard copy if needed." For members of the Society, this e-Pub can be read here.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
65
2021 ANZSNM UPCOMING EVENTS
AUG
31 SEP
22 OCT
23 NOV
16
NZ Branch Awards Night for Radpharm and Paul Orr Memorial Presentations 6:00 - 8:00 pm Virtual Event via Zoom SA & NT Branch Meeting and Scientific Presentation 5:30 pm Refreshments 6:00 pm Presentation Flinders Medical Centre
VIC/TAS Branch AGM and Presentations Awards Virtual Event via Zoom
WA Branch Meeting - AGM 5:30 pm Refreshments 6:00 pm Meeting & Presentation Perth Radiological Clinic
SEP
21 SEP
28 NOV
2 NOV
24
WA Branch Meeting Radpharm Presentation Night 5:30 pm Refreshments 6:00 pm Meeting & Presentation QScan
NZ Branch AGM 6:00 - 7:00 pm Virtual Event via Zoom
NZ Branch Inaugural Interesting Case Race 6:00 - 7:00 pm Virtual Event via Zoom
SA & NT Branch AGM & Quiz Night 5:30 pm Refreshments 6:00 pm Presentation Venue to be confirmed
OTHER EVENTS SEP
27 OCT
28
27-29 September British Nuclear Medicine Society (BNMS) Annual Meeting 2021 Virtual Event 28 October Neuroendocrine Cancer Australia National Theranostics Round Table Parliament House Canberra
OCT
20 OCT
29
20-23 October 34 th Annual Congress of the European Association of Nuclear Medicine Virtual Event 29 October CHILI - Conference on Hybrid Imaging Virtual Event
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
For more details and registeration details visit
anzsnm.org.au
Attendo Plus mobile App
66
ime to relax Submitted by SA Branch
3 LETTERS CPD RAY 4 LETTERS BONE MIBI PEAK PSMA
5 LETTERS ANSTO DECAY DELAY FACET GAMMA SPECT
6 LETTERS NODULE PHOTON UPTAKE
7 LETTERS CARDIAC CONTROL FASTING GALLIUM GLUCOSE NUCLEAR QUALITY SCATTER THERAPY THYROID
8 LETTERS CONTRAST EMISSION LYMPHOMA POSITRON PROSTATE RESEARCH 9 LETTERS GENERATOR INFECTION
9 LETTERS INJECTION PERFUSION PULMONARY RADIATION THYROXINE
10 LETTERS MOLYBDENUM MYOCARDIAL TECHNETIUM TOMOGRAPHY 11 LETTERS ARTHROPATHY
Solutions to crosswords
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
67
2020 FINANCIAL STATEMENTS These statements were presented to members at the recent General Annual Meeting
STATEMENT OF PROFIT OR LOSS AND OTHER COMPREHENSIVE INCOME FOR THE YEARZealand ENDED 31ST DECEMBER 2020 Australian and New Society of Nuclear Medicine Limited
ABN 35 133 630 029 STATEMENT OF PROFIT OR LOSS AND OTHER COMPREHENSIVE INCOME FOR THE YEAR ENDED 31ST DECEMBER, 2020 Note
2020
2019
$
$
284,634
359,680
(131,364)
(90,832)
Journal expenses
(13,267)
(11,704)
Research grant
(19,454)
(21,999)
(152,325)
(154,564)
(41,618)
(49,398)
-
(252)
(6,276)
(14,866)
-
(1,533)
(79,670)
14,532
-
-
(79,670)
14,532
Other comprehensive income
-
-
Total other comprehensive income for the year
-
-
Total comprehensive income for the year
(79,670)
14,532
Total comprehensive income attributable to the members of the entity
(79,670)
14,532
REVENUE
2(a)
EXPENSES Conference, meeting and committee expenses
Management costs Administration & ARTnet expenses Depreciation expenses Website Development and maintenance costs Write off of equipment Surplus/ (Loss) before income tax for the year Income tax expense Net profit / (loss) for the year
3
To read the full Financial Report, visit www.anzsnm.org.au Under the members section including the Annual General Meeting proceedings.
68
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
2020 FINANCIAL STATEMENTS These statements were presented to members at the recent General Annual Meeting
STATEMENT OF FINANCIAL POSITION AS AT 31ST DECEMBER, 2020
Australian and New Zealand Society of Nuclear Medicine Limited ABN 35 133 630 029 STATEMENT OF FINANCIAL POSITION AS AT 31ST DECEMBER, 2020 Note
2020
2019
$
$
ASSETS CURRENT ASSETS Cash and cash equivalents
4(a)
702,229
737,461
Trade and other receivables
5
26,924
3,128
Other assets
6
52,469
80,510
781,622
821,099
-
-
-
-
781,622
821,099
8
91,064
85,817
2(b)
131,591
96,645
TOTAL CURRENT LIABILITIES
222,655
182,462
TOTAL LIABILITIES
222,655
182,462
NET ASSETS
558,967
638,637
Retained earnings
558,967
638,637
TOTAL EQUITY
558,967
638,637
TOTAL CURRENT ASSETS NON-CURRENT ASSETS Property, plant and equipment
7
TOTAL NON-CURRENT ASSETS TOTAL ASSETS LIABILITIES CURRENT LIABILITIES Trade and other payables Revenue in advance
EQUITY
To read the full Financial Report, visit www.anzsnm.org.au Under the members section including the Annual General Meeting proceedings.
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
69
2020 FINANCIAL STATEMENTS These statements were presented to members at the recent General Annual Meeting
Australian and New Zealand Society of Nuclear Medicine Limited ABN 35 133 630 029 STATEMENT OF CHANGES IN EQUITY STATEMENT OF CHANGES IN EQUITY FOR THE YEAR ENDED 31ST DECEMBER, 2020 FOR THE YEAR ENDED 31ST DECEMBER, 2020
Retained Earnings
Total
$
$
Balance at 1 January, 2019
624,105
624,105
Profit attributable to the entity
14,532
14,532
638,637
638,637
Profit attributable to the entity
(79,670)
(79,670)
Balance at 31st December, 2020
558,967
558,967
Balance at
31st
December, 2019
Australian and New Zealand Society of Nuclear Medicine Limited ABN 35 133 630 029
STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31ST DECEMBER 2020 STATEMENT OF CASH FLOWS FOR THE YEAR ENDED 31ST DECEMBER 2020 Note
2020
2019
$
$
193,646
369,324
3,074
3,799
-
50,000
CASH FLOW FROM OPERATING ACTIVITIES Receipts from members & other operating activities Interest received Receipts on behalf of ARTnet Payments to suppliers and contractors Net cash provided by operating activities
4(b)
(231,952)
(338,308)
(35,232)
84,815
CASH FLOW FROM INVESTING ACTIVITIES Payment for property, plant and equipment
-
-
Payment for intangible asset
-
-
Net cash used in investing activities
-
-
Net Increase in cash held
(35,232)
84,815
Cash at the beginning of the financial year
737,461
652,646
702,229
737,461
Cash at the end of the financial year
4(a)
To read the full Financial Report, visit www.anzsnm.org.au Under the members section including the Annual General Meeting proceedings.
70
GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU The accompanying notes form part of these financial statements.
PRESIDENT Dr Daniel Badger (SA) Vice President Dr Kevin London (NSW) Immediate Past President A/Prof Roslyn Francis (WA) Treasurer Ms Suzanne McGavin (VIC)
GENERAL MANAGER & SECRETARIAT All Correspondence Mr Rajeev Chandra, General Manager ANZSNM Secretariat, PO Box 6178, Vermont South, Victoria 3133 Tel: 1300 330 402 | Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au
COMMITTEE Mr Nicholas Ingold (ACT) Ms Maddison Carroll (QLD) Ms Prudence Burns (NZ) Mr Christian Testa (VIC/TAS) Mrs Victoria Sigalas (SA) Ms Rosemary Dallen (WA) Prof Karen Jones (TSIG) A/Prof Giancarlo Pascali (RPS) Dr Samuel McArthur (AANMS) Prof Andrew Scott (IRC)
AIMS AND OBJECTIVES OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE
SPECIAL INTEREST GROUPS/COMMITTEES Technologists Chair: Mr Nicholas Daw Radiopharmaceutical Science Chair: A/Prof Giancarlo Pascali Physics Chair: Mr Andrew Chicco (Acting) Quality and Technical Standards Committee Chair: Dr Darin O’Keeffe Scientific Advisory Panel Chair: Prof Dale Bailey International Relations Committee Chair: Prof Andrew Scott
BRANCH SECRETARIES New South Wales/Australian Capital Territory Dr Kevin London (Chair) Queensland Ms Anisa Kumari and Ms Christine Powell South Australia/Northern Territory Ms Katherine Guerrero Victoria/Tasmania Ms My Linh Diep Western Australia Ms Georgina Santich New Zealand Ms Jessica Fagan
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.
Archivist Ms Debra Huddleston GAMMA GAZETTE WINTER EDITION 2021 | ANZSNM.ORG.AU
71
