Gamma Gazette Autumn Edition 2021 by The Australian and New Zealand Society of Nuclear Medicine by ANZSNM

SPECIAL FEATURE PREDICTIONS

Nuclear Medicine in this decade

TABLE OF CONTENTS

Cover Story 23 Predictions: Nuclear

Medicine in this decade

Views from experts and members

From the President

Introduction

Branch News

Special Interest Group/ Committee News

Articles

People in Nuclear Medicine

Education and Continuing Professional Development (CPD)

Industry News

Time to Relax

Calendar of Events

Office Bearers

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

FROM THE PRESIDENT

I’m thinking about standing in the doorway between the two rooms at the RAH so I can hear two talks at once! I look forward to seeing many of you over a glass at the Gala Dinner, although while you might not be in the same room as me, we can still be together through technology! Better get out my brush and give my favourite top hat a good clean!

Daniel

Daniel Badger - MANZSNM, President

reetings to everyone in our Nuclear Medicine family.

Here we are, reading the first Gamma Gazette for a new year, and we are all hoping that this year has to be better than last year!

I know you have all put your abstracts in and are looking forward to getting together for the ASM (May 21-23). The LOC, the federal council and the branch committees have been working furiously to get everything organised, and the draft program looks fantastic. Fortunately, all the content will be available online for some time after the ASM as there is no way you can watch everything live!

The Society continues to communicate with various levels of government and our overseas colleagues on many issues. The SNNMI have asked us to contribute to the Lu-177 Dosimetry challenge, a community science effort to improve standardisation of dosimetry methods in therapy. The EANM want us to help them in writing international guidelines on Immunotherapy. I know that the Cardiac MBS changes are a major issue for our members and many sites now have reduced numbers of scans because many patients will have to wait in a queue for a stress echo before they can have the Nuclear Medicine scan that is appropriate for their condition. On the plus side, calls are being made to improve funding for Nuclear Medicine, in particular for PET scans which are now completely essential, and I’m not just talking about FDG, but targeted cancer and brain agents. As an esteemed colleague of mine said recently “They need to realise that PET is no longer special. Every hospital needs PET”. There is also the huge explosion in radionuclide therapy and theranostics on the near horizon and the question of whether Australia should have our own medium energy cyclotron (I say yes!). We have a lot of work ahead of us, but together we can achieve what needs to be done. As always, do not hesitate to contact me or the Society if we can support you in your Nuclear Medicine journey.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

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

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Kevin London Vice-President ANZSNM

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Sarah Caplan Nuclear Medicine and Medical Imaging Technologist

Hamish Schumacher Nuclear Medicine & PET/CT Technologist

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Maddison Carroll Federal Council Member Nuclear Medicine Scientist

Paul Brayshaw Senior Medical Physicist Department of Nuclear Medicine and WA PET Service

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GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

INTRODUCTION TO THE AUTUMN EDITION Welcome everyone to the Autumn edition of the ANZSNM Gamma Gazette and the first edition for 2021. As we start 2021 we reflect on 2020 and the changing nature that the COVID-19 Pandemic presented. This issue focuses on the topic ‘Predictions: Nuclear Medicine in this Decade.' The ANZSNM branch meetings have embraced the use of technology and Zoom meetings. We will continue to use this and as restrictions ease, hopefully see the recommencement of face to face meetings to be able to network with our fellow Nuclear Medicine community. This year is the 51st Annual Scientific Meeting and will be held on 21st – 23rd May 2021, the topic is “ Key Collaborations, Key Impacts - Unlocking the potential of Nuclear Medicine”. Although the physical meeting could not be held in Western Australia due to the current restrictions, the annual meeting will go ahead with a unique and exciting structure combining face to face and virtual technology. Early bird Registrations will be opening soon – keep an eye on the website and emails for details. We hope you enjoy this Autumn edition of the Gamma Gazette and have had a healthy and happy start to 2021. Thank you to those who contributed to this edition and to the effort of the members who support the ANZSNM.

Tiffany Briggs — MANZSNM Branch Chair, Western Australia

We hope you like the new look of the Gamma Gazette. Following the theme of this edition's special feature, we thought it was time to bring in the new decade (let’s not mention 2020) to our official magazine with enthusiasm and positivity. We are conscious that our members, aside from seeking value for their fees, are time poor and have other media to consume. The Gamma Gazette since it’s inception around 40 years ago has had many iterations and remains a unique feature of the Society. It is published by and for the Society members and has a long storied history . Of course, we all need to keep moving and changing. This and future editions not only come with a fresh and clean new look, but also with new interactive features that will let you watch videos within the magazine, add events to your calendar, access educational content, links or emails from a single click and much more. Keep an eye on our website and social media channels where we will be sharing tips on how to use these features to get the most of your new digital reading experience. We hope you enjoy the content as much as we had putting this edition together. Don't hesitate to let us know your thoughts on secretariat@anzsnm.org.au Secretariat

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

BRANCH NEWS

QUEENSLAND BRANCH NEWS What a year 2020 was for everyone around the globe. The first branch report of the year is always a fantastic opportunity to sit down, get excited for the year ahead, reflect on what has worked in the past and area’s in which we can improve moving forward.

he last meeting of the ANZSNM Queensland Branch was the Annual State Radpharm Award followed by the QLD AGM. This event was hosted at the Princess Alexandra Hospital in the Russell Strong Auditorium on the 3rd of November 2020. The evening began with three Radpharm presentations; 1. Down the Rabbit Hole: 18F-Fluorodopa (FDOPA) imaging of Parkinson’s disease and parkinsonian syndromes by Catriona Stevenson from the Sunshine Coast University Hospital. 2. The utility of Ga68 PSMA expression in Adenoid Cystic Carcinomas of the Head and Neck by Anisa Kumari from the Princess Alexandra Hospital 3. The Benefit of Stress by Candice Nish from the Royal Brisbane and Women’s Hospital Whilst the judges deliberated on what was sure to be a very close competition owing to the fantastic quality and content of presentations given by all entrants for the Radpharm award, the evening continued with a presentation from Dr Nicole Maggacis from Princess Alexandra Hospital on FDG PET imaging in Large Vessel Vasculitis. The Annual General Meeting of the QLD ANZSNM Branch was held after the educational sessions (with the judges still deliberating) where the outgoing committee gave their final remarks for the year prior to the election of the new committee for 2021-2022.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

I would also like to welcome the new members of the Queensland committee co-secretaries, Christine Powell (IMED) and Anisa Kumari (Princess Alexandra Hospital) and treasurer Chris Anderson (Queensland Diagnostic Imaging), and I will be staying on for another two-year term as Chairperson. Maddison Carroll (Royal Brisbane and Women’s Hospital) is now our Queensland federal representative who will be instrumental in assisting with both the 2021 ASM hub in Brisbane and the 2022 Annual Scientific Meeting. I would like to take this opportunity on behalf of the Queensland branch to thank our outgoing committee members, Loren Katchel, Remi Hillary, James Turner and our outgoing QLD federal representative Judy Duong for their hard work and dedication over the past two years. The winner of the state Radpharm award for 2020 was announced at the conclusion of the meeting. Congratulations to Candice Nish (Royal Brisbane and Women’s Hospital) who will be going on to represent Queensland at the ASM for the national award in May. As always, I encourage all our members to get behind our local entrant by either attending her presentation at the local hub (Translational Research Institute) or viewing from the comfort of your home through the videoconferencing package. Stay safe and well,

Sarah Daniel — MANZSNM Branch Chair, Queensland

BRANCH NEWS

QUEENSLAND BRANCH NEWS

Radpharm Award Entrants (left to right) – Candice Nish, Catriona Stevenson and Anisa Kumari

Candice Nish - Radpharm Award Winner Queensland

ANZSNM QLD Branch Meeting Tuesday, 30th March 2021 Paediatric Imaging and Oncology FREE EVENT Face to Face & Virtual Event

Invited Speakers

In person: 6:15 pm Food & Beverages 6:45 pm Presentations Start Virtual: 6:45 pm Teleconference Starts Queensland Children's Hospital (QCH) Level 7 Auditorium 7C Parking available at venue

Live via Dr Bruce Goodwin Senior Nuclear Medicine Physician at Queensland Children Hospital (QCH)

Dr Steve Foresto Paediatric Oncologist at Queensland Children Hospital (QCH)

2 CPD HOURS

CERTIFICATE ATTENDANCE VIA ATTENDO PLUS

Registrations close Friday 26th March 2021

BRANCH NEWS

NEW ZEALAND BRANCH NEWS With a run of summery days in New Zealand, we are all feeling relaxed and rested after the Christmas break. Around the country the reports from the Nuclear Medicine and PET departments for the Autumn Gamma Gazette have all been very positive.

ongratulations to the students who have successfully completed their Postgraduate Diploma in Nuclear Medicine from the University of Auckland. A new round of students begin their studies in March, with Dunedin, Invercargill, Palmerston North and Wellington all having new recruits. Christchurch Hospital and Ascot (part of IDX in Auckland) are also looking for students. Vacancies for qualified NM Technologist positions are currently available at Palmerston North Hospital and SRG (part of IDX in Auckland) so keep an eye out for those advertisements. New Nuclear Medicine Radiologists Prue Lamerton, Unit Charge Hawkes Bay Hospital

Hawkes Bay Hospital are looking forward to NM Specialist, Dr Rachelle Steyn, coming from South Africa in April, starting early May. She is a great proponent for PET especially in the Public Health system, and also has a good deal of experience with Tc99m PSMA imaging and various therapies. Currently Rachelle is the Chair on the organising committee for the South African Nuclear Medicine Conference. From talking to her at length, Prue is confident NZ will benefit hugely from Rachelle’s expertise. This is an exciting opportunity for the team in the Hawkes Bay. Stefan Gabrielson

Shortly after joining the radiology service at Christchurch Hospital, I was honoured to be asked for this short presentation of my

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

background and initial experiences of work and life in New Zealand. I did my radiology and Nuclear Medicine training at Karolinska University Hospital, Stockholm, Sweden 2011-2018. In recent years I have mainly been working with oncological PET/CT, neurological PET and general Nuclear Medicine. I am interested in clinical research and teaching. In 2013 I enrolled in a postgraduate research programme at Karolinska Institutet and in 2019 I successfully defended my PhD thesis. My current area of research focuses on PET/CT evaluation of neoadjuvant treatment response in patients with oesophageal cancer and PSMAPET staging and re-staging of patients with prostate cancer. Since relocating with my wife and two sons to Christchurch, our experience of moving to New Zealand has been overwhelmingly positive. We have been met with great kindness by my new colleagues and community. Work in the Nuclear Medicine department in Christchurch is in many ways like my previous experiences. Protocols and imaging platforms are much the same. One major difference would be the high degree of self-reliance and clinical competence of NZ trained Nuclear Medicine technologists while still maintaining a multidisciplinary atmosphere. In my opinion, the service offers first class imaging and patient care. I am happy to be a part of the team and to make my contribution to our effort.

BRANCH NEWS

NEW ZEALAND BRANCH NEWS BARBARA OVENDEN RETIREMENT

Barb’s passion for Nuclear Medicine, along with her natural leadership, determination, professionalism and organisational skills came to the fore in several tenures as Charge Technologist of the Department. Barb has been integral to the development, training and mentoring of nuclear medicine students and technologists throughout the years. This includes being a member and examiner of the NZ training board, through to her role of Clinical Assessor for the current University of Auckland NM course. Throughout Barb’s time with Nuclear Medicine at Christchurch Public Hospital, she has seen the service evolve from working with New Zealand’s first gamma camera, then Australasia’s first gamma camera computer system, right through to the SPECT/CT hybrid systems of today.

The NZ NM community wish Barb a fond farewell as she retires in March this year after 49 years of dedication to this Department. Barb is an amazing friend and colleague, whose knowledge, wealth of experience and dedication will be missed more than she will know. Barb started as a trainee Nuclear Medicine Technologist at Christchurch Public Hospital Nuclear Medicine Department in December 1971. She gained qualifications in radioisotope and radioassay techniques from NZIMLT and a Diploma of Medical Nucleography via correspondence from RMIT Melbourne.

At every stage, Barb has embraced mastering the technology and systems required and her interest and intellect have contributed immeasurably to creating the excellent department we have here today. All her Nuclear Medicine colleagues thank her for her outstanding contribution and support throughout the years and wish her all the best for her well-earned retirement. MRTB CHANGES

In December 2020, the Medical Radiation Technologist Board gazetted some changes to prescribed qualifications for registration in the scopes of practice of Magnetic

Resonance (MRI) Technologist, Nuclear Medicine Technologist, and Sonographer. The changes give a pathway to registration for overseastrained practitioners who do not have a formal academic qualification in the relevant scope of practice. If they hold an underpinning degree in medical imaging and/or radiation therapy and meet the clinical experience requirement, they are eligible to sit the Board’s online registration examination. Once registered, they must work under supervision while they become familiar with the New Zealand health care system. USER LICENSES

From the NZ Branch of the ACPSEM, they are seeking clarification from the Office of Radiation Safety regarding User Licences and how they relate to the requirements of Radiation Practitioners under the ORS C1 and C2 Codes of Practice. Under C2 the main concern is regarding endocrinologists and other medical specialists performing therapy, although this could also be extended to radiologists wanting licences for PET imaging. The 51st Annual Scientific Meeting plans are moving forward with Auckland being our branch hub, keeping to the “Live and Local” theme for the upcoming ASM Virtual meeting in May. The concept is a great one, and we as a branch would like to thank the meeting LOC and the Society for pushing forward in these times where adapting to circumstances is becoming our mantra.

Pru Burns — MANZSNM Branch Chair, New Zealand

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BRANCH NEWS

VICTORIA/TASMANIA BRANCH NEWS The Victoria/Tasmania Branch enjoyed a nice break after their successful Day Seminar in November 2020, and took advantage of the relaxed COVID restrictions to go out and see people (a nice change from the previous six months!).

y the time you read this we would have completed our first virtual Master Class of 2021 : “ The Heart of the Problem - Nuclear Cardiology in 2021”, which was attended by over 100 participants and is now available to all members on EduTrace for viewing on-demand. We were most lucky to have Dr Kim Williams joining us for his 20th year presenting to the VIC/TAS branch. As with many recent events, we hosted him virtually live all the way from Chicago!

virtually with the rest of states across Australia and New Zealand through their ‘virtual hubs’ at our upcoming 51st Annual Scientific Meeting. We really look forward to the local format and to seeing all members and professional colleagues to experiece again the all-important social aspect of conferences; something we have sorely missed throughout 2020.

Kim Jasper — MANZSNM Branch Chair, Victoria/Tasmania

His US perspective on how COVID-19 has affected his hospital and its departments was very insightful and highly valuable for all attendees. Continuing with the COVID theme, we also had A/Prof Eddie Lau from Austin hospital, who presented on how COVID-19 has affected VQ scanning. His talk was complemented by Emma Harding (also from Austin), who gave us an NMT perspective on the changes required to scan COVID patients. Last but not least, we were also lucky to have Dr Nathan Better from The Royal Melbourne Hospital, who shared with us insights into the recent changes to the Medicare benefits for cardiac scanning and how these may impact our referrals and patients.

Dr Kim Williams’ presentation

Dr Nathan Better’s presentation

Emma Harding’s presentation

A/Prof Eddie Lau’s presentation

We are excited to soon join our colleagues from Metropolitan Melbourne, Rural Victoria and other states in person at our local hub at the Rydges in Geelong, and to connect

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

BRANCH NEWS

WESTERN AUSTRALIA BRANCH NEWS The WA Branch finished up last year managing to squeeze in our couple of meetings that we had postponed due to COVID disruptions throughout the year. Huge thanks go to our committee, our fantastic speakers who quickly put up their hands when we sent the call out for anybody able to present at short notice and of course, thank you to our ever supportive industry partners who are always generous in supporting our WA Branch both financially and in person at our meetings.

e got ourselves ready for the new year but the sudden and quick lockdown we had in February put us out again and we decided to reschedule. I know we aren’t the only state affected this way and I think it is time for WA to move in line with other parts of Australia and offer our meetings with an online option too. Our committee are working on this now and hopefully it will suit a lot of people who can’t attend in person either due to distance or their worklist. We have our usual meetings scheduled for the rest of the year but we are omitting the August workshop this year due to the ASM being held in May over two and a half days. We did rush to trial an online format to complement our face to face meetings last year but not everyone agreed to have the meeting recorded so we need to get better organised. A topic of conversation that has been on and off in some workplaces in WA has been members vs non-members at meetings and what is “fair/not fair”. As a branch committee we agreed long ago that we will always be delighted to have anyone attend our meetings. The committee volunteer their time as you all know and we consider that everyone is always welcome to attend anything we organise. We are lucky to be well supported at meetings in Perth, we have both members and non-members who present too and we do have great attendance time and again. While making meetings online will open up our meetings to more people, we will need to see how other states are managing this. On a closely related topic, I am really enjoying the ability to enjoy so many meetings from the privacy of my loungeroom. As residents of WA,

we are isolated from the rest of Australia. We can’t easily pop interstate for a meeting after work and just come back the next day. Even without hard borders going up and down and the ever-present threat of 2 weeks in home or hotel isolation, the travelling time required as well as the cost of flights and accommodation are all reasons that many of us just can’t go. It is really great to now be able to join in something that otherwise so many of us would never have contemplated attending, mostly due to our isolation over here. A trip to the East coast of Australia for a day seminar just isn’t a viable option for most of us but now we can attend online for free and enjoy them too. Just another benefit of being a member! A sincere thank you to anyone who has organised or hosted an online meeting that we West Australians (and other members elsewhere) can participate in and feel a connection that many of us never considered an option. Hopefully we can start to return the favour and run some of our own online! In the meantime, we are very excited over here for the ASM in May, our local organising committee have been working tirelessly for many months and the program is shaping up to be jam packed and absolutely fantastic! We are all looking forward to our Perth hub, to networking and catching up and an evening of socialising after a full day of learning will be fun too. See you there!

Georgina Santich — MANZSNM Branch Secretary, Western Australia

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

BRANCH NEWS

SOUTH AUSTRALIAN & NORTHERN TERRITORY BRANCH NEWS This year we welcome our new Branch Secretary, Katherine Guerrero and Branch Treasurer, Kimberly Nguyen on board. We say farewell and extend our gratitude to Tess Smith who has served in both roles for the past two years.

ess has contributed enormously to the ANZSNM South Australian Branch throughout this time. Her enthusiasm and commitment to the role saw us being the first branch to roll out online branch meetings in response to the Covid-19 pandemic - a huge achievement that has allowed our members to continue correspondence and gain CPD points. Tess has done an outstanding job and we thank her for her efforts.

quiz night had to be postponed. This event is looked forward to by all throughout the year, so it was important we were able to reschedule this as soon as possible in order to celebrate our team and their efforts throughout the tumultuous year that was. The quiz night took place on the 1st of February at the Belgian Beer Cafe, Adelaide. The formal part of this event was also streamed over Zoom so that our Northern Territory members could take part.

The SA&NT Technologist group Annual Dinner, Radpharm Awards & University Student Presentations was held at the Cathedral Hotel on the 15th of December 2020. This was the first opportunity for members of our extended community to come together and was very much enjoyed by all. We congratulate Jordan Zabolocki on winning the opportunity to represent South Australia for the Radpharm award at the next Annual Scientific Meeting. We wish Jordan the best of luck with his presentation '18F-FDG PET/CT in Cardiac Sarcoidosis diagnosis following appropriate diet preparation'.

Madeline Buttfield — MANZSNM Branch Chair, South Australia and Northern Territory

Unfortunately, the celebrations were short lived - due to COVID restrictions we were unable to host our branch Annual General Meeting and Quiz Night in person. The AGM was completed via ZOOM, in a similar format to our previous branch meetings, however the

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

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GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL INTEREST GROUP/COMMITTEE NEWS

TECHNOLOGY SPECIAL INTEREST GROUP NEWS Welcome to 2021- the year that couldn’t come quick enough! I have never felt so excited about the start to a year before. In the TSIG we went through a number of changes last year, with nearly every position within the Oversight Committee having someone new filling it. I thought that I would take this time to introduce you to your representatives. I am humbled to be leading such a great group, and am excited for what this year has in store! Please get in touch with them if you have any suggestions for how they can better serve your needs- or better yet to express your interest in contributing alongside us in improving our profession. Nicholas Daw — MANZSNM Chair, TSIG Committee

ick is a Nuclear Medicine Technologist at the Peter MacCallum Cancer Centre in Melbourne, and also the Chair of the Technologist Special Interest Group Oversight Committee. He is passionate about increasing the impact that Technologists can have on the communities that they serve, and enjoys connecting with others with this same passion. He is excited to be leading such a well credentialed group within the TSIG and its working groups this year, and always comes away from meetings with a renewed enthusiasm for what can be accomplished by a small but committed group of individuals. Originally getting involved within the TSIG due to his joy of developing others and his own ongoing learning and education, Nick has found the greatest benefit from his involvement has been in developing his own voice as an advocate for his fellow technologists, and in empowering others to do likewise.

Nicholas Daw, Chair of the Oversight Committee

Nick is well connected within the Nuclear Medicine scene, having previously worked at The Austin, The Alfred, and The Northern Hospitals, and been part of the organising committees for the TSIG Day Symposiums since 2017, as well as being a member of and then Chair of the TSIG CPD & Education Working group during that time. Away from work Nick is a passionate basketball player, who loves to regale anyone willing to listen of his exploits on court which get more impressive each time he shares. His lockdown hobby of distance running has started to transform into an obsession, he also finds a lot of meaning in mentoring young teens through his local church. Nick lives in Brunswick with his wife and cat, and are expecting a human addition to their family later this year.

GAMMA GAZETTE | ANZSNM.ORG.AU

SPECIAL INTEREST GROUP/COMMITTEE NEWS

Pru Burns, Chair of the Workforce Advocacy Working Group

Emma Brook, Chair of the Continuing Professional Development and Education Working Group

fell into Medical Imaging. An advert in the local paper mentioned a National Diploma in Radiography, and offered no student course fees AND you were paid to train – win, win. As a radiographer in the early 90’s, Nuclear Medicine was really a bit of a mystery. My early clinical experience with Nuclear Medicine was limited to a 3rd year MRT practical test - a VQ scan using Xenon-133 no less! Fast forward, and I completed my Post Graduate Diploma in Nuclear Medicine from Newcastle University in 1999. Moving to Melbourne, I did my PDY year in the eastern suburbs with a great team of NMT at Taft Diagnostic Imaging. Returning home in 2006, I was extremely fortunate to work at Pacific Radiology in the first PET/CT department in New Zealand. A career highlight was to be the first kiwi NMT to win the Radpharm Award at the 2013 Perth ASM. Sitting at the gala dinner, at a table with the only eight NZ attendees in a room full of the Australian NM elite, still feels very special. Currently I am the New Zealand branch chairperson of the ANZSNM. I enjoy this role for the opportunities it brings collaborating with my Australian colleagues via the Federal Council and as Chair of the Technologist Workforce Advocacy Working Group. I am also the Nuclear Medicine professional member on the NZ Medical Radiation Technologists Board (the NZ equivalent of the ARPHRA MRPB). I struggle with the concept of work/life balance – often one collides with the other! When organised, I enjoy time with my kids and partner mountain biking, skiing and constantly tricking the kids into eating alternative-meat meals!

mma Brook grew up in country South Australia before moving to Adelaide to study Psychology in 2004. With an interest in the human body and the mind but a near tragic accident in the family in 2007, she then decided to go on to study Nuclear Medicine. There she went on to graduate with first class honours in 2011, before moving to Western Australia to work at the Royal Perth Hospital. She completed her graduate year there, before going on to be one of the founding Technologists to work at the new Fiona Stanley hospital in 2014 and moving to Sir Charles Gardiner in 2017. As a relatively young Technologist, she believes in empowering individuals to further their education and supporting the Nuclear Medicine community where she is the current ANZSNM WA Treasurer, the incoming TSIG CPD & Education Chair and a committee member on the TSIG oversight committee. Continuing with her interests in psychology and human performance, Emma also works as a Psychological Examiner with the Australian Defence Forces where she was deployed to the Middle East in 2017. She is a proud advocate of Buddy Up Australia as well as Soldiers and Sirens which provides support for serving and ex serving military members and first responders where she regularly volunteers. Her personal interests when she isn’t working include renovating, gardening, trail running, red wine, stand up paddle boarding and pretending she can surf.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL INTEREST GROUP/COMMITTEE NEWS

Karen Jones, Federal Council Representative

rofessor Karen Jones trained as a nuclear medicine technologist and was awarded the prize for the top nuclear medicine student in 1991. She was the first nuclear medicine technologist in Australia to be awarded a PhD (1998) and, in 1999, the first technologist to be awarded the ANSTO Award for nuclear medicine scientists. She has subsequently established an internationally recognised career as a clinical researcher, while maintaining a strong interest in the nuclear medicine technologist profession. She has held two NHMRC Career Development Award (CDA) Fellowships and, in 2010, received an NHMRC Achievement Award as the highest ranked clinical NHMRC CDA-2 candidate. She currently holds the William T Southcott Senior Research Fellowship in Nuclear Medicine at the University of Adelaide where she has established a gamma camera suite and hot lab used exclusively for clinical research. Her research capitalises on the application of radioisotopic and ultrasound techniques to evaluate the relevance of upper gastrointestinal motor function to (i) postprandial hypotension (an abnormal fall in blood pressure after a meal), (ii) diabetes and

GAMMA GAZETTE | ANZSNM.ORG.AU

(iii) appetite regulation. She has been a CI on 17 NHMRC project grants and two NHMRC Centre of Research Excellence grants, as well as being responsible for numerous investigator-initiated clinical trials for international pharmaceutical companies. She has been an invited speaker at numerous international meetings, including the 7th World Congress of Nuclear Medicine and Biology (Germany 1998), American Gastroenterology Institute course on gastroparesis and functional dyspepsia (USA - 2008), 40th Nordic Meeting of Gastroenterology (Norway 2009), 80th American Diabetes Association meeting (USA 2020). She is a co-author of 281 publications, many in high impact journals e.g. J Nucl Med, Eur J Nucl Med, Diabetes Care, Gastroenterology, resulting in >14,000 citations; her h-index is 67. Karen is passionate about providing excellence in ‘teaching’, ‘research’ and ‘mentorship’, and is a strong advocate for nuclear medicine technologists wishing to pursue research. She continues to play a major role in supporting the training of clinician-scientists, from a variety of backgrounds including nuclear medicine, radiology, radiography,

endocrinology, gastroenterology, dietetics, nursing, pharmacy and intensive care. In addition to her full-time fellowship at the University of Adelaide, she holds an Adjunct Professorship at UniSA, where she teaches in the undergraduate nuclear medicine program and supervises Honours students. She has supervised 17 Honours and 11 PhD students to completion and has 7 current students. She also serves as a postgraduate coordinator in the Adelaide Medical School at the University of Adelaide, overseeing and supporting the PhD programs of ~15 other students. Karen has held a number of positions within the ANZSNM on both a state and national level. She currently serves on the TSIG Oversight Committee, TSIG CPD & Education Committee, TSIG Workforce Advocacy Committee, and is the TSIG representative on Federal Council. In her spare time she enjoys renovating her c1879 bluestone villa, cooking, watching AFL and, most importantly, spending time with her husband, 4 children, her exuberant spoodle (Maisie) and tabby cat (Dolly).

SPECIAL INTEREST GROUP/COMMITTEE NEWS

SCIENTIFIC ADVISORY PANEL UPDATE

By Dale L Bailey, MANZSNM Chair, Scientific Advisory Panel

he SAP is finalising the report to Federal Council on the case to be presented to the federal Department of Industry, Science, Energy and Resources (Minister the Hon. Karen Andrews) to implement a national cyclotron strategy towards a more reliable supply for the radionuclides that are currently imported from abroad (e.g., 67Ga, 123I, 201Tl, etc). Thanks to all who responded to the survey about current and future usage, and thanks to ANSTO Health and GMS for helping us with the distribution. Such a facility would

provide an almost total domestic source for all radionuclides required in nuclear medicine for the future. We will keep you updated on the progress of this proposal. The SAP is working closely with the Perth-based local organising committee (Co-convenors Dr Tracey Muir, Dr Liesl Celliers, Stephanie O'Donnell and Andrew Cluff) for this year’s Annual Scientific Meeting. While we are still unable to meet in one location, the situation does provide us with new opportunities to reimagine the meeting format and how we deliver content and

encourage participation. The distributed multi-hub model that is being developed in collaboration with our professional conference organisers (Event Studio) should allow more people to attend the meeting in their local hub than would normally be able to travel to the conference location. We encourage all members to get on board with this concept and strongly support the Annual Scientific Meeting – this model may be with us for some time to come.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

ARTICLES

IMPACT OF RECENT MEDICARE CHANGES TO MYOCARDIAL PERFUSION STUDIES IN A RURAL AND REMOTE CONTEXT By Pete Tually1,2, and Geoff Currie 2 1. TeleMed Health Services, Western Australia. 2. Rural Alliance in Nuclear Scintigraphy.

early half of all acute coronary syndromes (ACS) that present in the Australian population occur in patients with established coronary heart disease (CHD) [1]. In rural communities there is an over-representation of preventable CHD related death and dislocated healthcare systems, especially amongst the remote Aboriginal and Torres Strait Islander communities [2] where the coronary event rate for Indigenous Australians is 2.5 times greater than non-Indigenous Australians; and at a much earlier age [3]. Whilst the overall incidence of acute myocardial infarction (MI) for the entire population of Western Australia was reduced by 1.2% per year from 1993 to 2012, it was contrasted against an actual rise of 2.9% per year in the rural and regional communities [4]. Teng and colleagues have recently demonstrated that WA’s utilisation of Medicare funded specialist consultations is 43% lower in Indigenous people compared to non-Indigenous people in the 2 years preceding the first CHD related hospitalisation [5].

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

ARTICLES

Impact of recent Medicare changes to myocardial perfusion studies in a rural and remote context (Continued) Following percutaneous coronary interventions (PCI) or coronary artery bypass graft surgery (CABG), ongoing clinical management plays an important role [6]. Despite the advances in new techniques and drug eluting stents, restenosis (RS) and graft disease remain a clinical challenge. It is a particularly important issue in those considered high risk (e.g. multiple diseased vessels, those incompletely revascularised, history of silent ischaemia or diabetes). Consequently, various guidelines recommend regular non-invasive cardiac stress testing to identify in-stent RS, progression of known coronary lesions or de novo lesions [7-9]. The choice of test depends on availability, local expertise and patient

specific attributes (i.e. acoustic windows, age, radiation exposure, mobility), however, cardiac imaging techniques such as stress nuclear myocardial perfusion scans (MPS) or echocardiography (ECHO) are generally preferred. MPS and ECHO share comparable overall accuracy (>85%) for the detection of inducible ischaemia and can document the vascular territory, extent and severity of coronary flow restriction [10, 11]. Prognostically, numerous studies and meta-analyses have shown that MPS has a very high negative predictive value with excellent longer term outcomes associated with a normal result [12-14]. Access to these investigations, however, can be infrequent or unavailable in many regional communities.

Recent changes to the Medicare Benefit Schedule (MBS) for funding eligibility of MPS have the potential to negatively impact secondary prevention strategies for patients with CHD in remote Australia, further hindering efforts towards ensuring an equitable level of health care for rural communities. The following case illustrates new challenges for rural patients and their doctors. This MPS service is operated on a fly-in-fly-out basis at least three sessions per month. Travel expenses are partly funded by a commonwealth grant, which is administered by Rural Health West.

A 59-year-old gentleman suffered a non-ST elevated MI in a remote WA location during June 2020. Following a Royal Flying Doctor Service transfer to Perth he underwent cardiac catherisation (CA) where the main findings were a severe proximal to mid 90% long stenosis in the left anterior descending artery (LAD) and a moderate stenosis in the left circumflex system (LCx). Both lesions were stented with drug eluting stents and dual antiplatelet therapy recommend for 12 months. The patient complained of persistent exertional dyspnoea with mild LV dysfunction on resting echocardiography. Following a telehealth consultation the Perth based cardiologist sought a perfusion assessment to confirm myocardial viability status post MI and also a post exertional left ventricular ejection fraction (LVEF). The patient underwent an ergometer bicycle stress test reaching stage 3, limited by dyspnoea. There was neither chest pain nor ECG features of ischaemia. The MPS was negative for inducible ischaemia and LVEF was 45%. Radiotracer presence throughout the LAD and LCx territory was normal.

Three months later the patient developed atypical chest pain, unrelated to exertion, and presented to his regional hospital. There were no dynamic ECG changes and serial troponins were negative. Following consultation with his cardiologist in Perth, the hospital doctors referred him for an outpatient MPS appointment which was considered clinically appropriate at this location, which is greater than 600kms from a coronary catheterisation laboratory and deprived of any other diagnostic tests for the investigation of CAD.

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ARTICLES

Impact of recent Medicare changes to myocardial perfusion studies in a rural and remote context (Continued)

Following the new MBS regulations, Medicare denied the patient reimbursement for this repeat MPS. The patient’s local clinician was advised and arrangements into funding the study on a cost only basis via a community based grant was investigated. During the intervening period of 2 weeks, the patient’s chest pain episodes increased and he went to his GP. An ECG was obtained (the interpretation of which is no longer funded by Medicare for General Practitioners) and this initiated an urgent trip to Perth. Shortly after arrival into Perth a repeat CA was undertaken and this demonstrated severe stenosis at the proximal section of the LAD. A further drug eluting stent was inserted. The consensus was that a repeat MPS would have likely identified significant ischaemia which would have expedited this patient care and under better clinical circumstances. In this instance, the MBS changes further limited the specialist diagnostic options in managing the patient in a remote environment.

The substandard access to acute invasive coronary therapy and cardiac rehabilitation services in rural and remote centres will undoubtedly continue due to healthcare rationalisation and workforce shortages. Furthermore, despite the plethora of research publications explicating the persistent differences in mortality and morbidity rates between rural

and metropolitan sectors for patients with established CHD, scientificevidence based perspectives and strategies to address the problem rarely influence state and federal health policy interventions [15]. This underscores the necessity for early detection.

granted for locations in Modified Monash 3-7 areas and it is hoped there will also be further relaxation of the rules that prevent repeat MPS particularly for areas with very high levels of disadvantage.

Limited exemptions from the requirement of a ECHO (in suitable patients) prior to MPS have now been

References 1. 2. 3. 4. 5.

6. 7.

Briffa, T.G., et al., Population trends of recurrent coronary heart disease event rates remain high. Circ Cardiovasc Qual Outcomes, 2011. 4(1): p. 107-13. Statistics, A.B.o., Australian Aboriginal and Torres Strait Islander Health Survey: First Results, Australia, 2012-13 2013(4727.0.55.001). Health, A.I.o. and Welfare, Trends in cardiovascular deaths. 2017, AIHW: Canberra. Randall, S.M., et al., Western Australia population trends in the incidence of acute myocardial infarction between 1993 and 2012. Int J Cardiol, 2016. 222: p. 678-682. Teng, T.K., et al., Patterns of Medicare-funded primary health and specialist consultations in Aboriginal and non-Aboriginal Australians in the two years before hospitalisation for ischaemic heart disease. Int J Equity Health, 2018. 17(1): p. 111. Fihn, S.D., et al., ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. 2012. Gausia, K., et al., Evidence-based prescribing of drugs for secondary prevention of acute coronary syndrome in Aboriginal and nonAboriginal patients admitted to Western Australian hospitals. Intern Med J, 2014. 44(4): p. 353-61. Giedd, K.N. and S.R. Bergmann, Myocardial perfusion imaging following percutaneous coronary intervention: the importance of restenosis, disease progression, and directed reintervention. J Am Coll Cardiol, 2004. 43(3): p. 328-36. Harb, S.C. and T.H. Marwick, Prognostic value of stress imaging after

10.

11. 12. 13. 14. 15.

revascularization: a systematic review of stress echocardiography and stress nuclear imaging. Am Heart J, 2014. 167(1): p. 77-85. Hendel, R.C., et al., ACCF/ASNC/ACR/AHA/ASE/SCCT/SCMR/SNM 2009 appropriate use criteria for cardiac radionuclide imaging: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the American Society of Nuclear Cardiology, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the Society of Cardiovascular Computed Tomography, the Society for Cardiovascular Magnetic Resonance, and the Society of Nuclear Medicine. Circulation, 2009. 119(22): p. e561-87. Tweet, M.S., et al., Stress Echocardiography: What Is New and How Does It Compare with Myocardial Perfusion Imaging and Other Modalities? Current Cardiology Reports, 2015. 17(6): p.43. Iskander, S. and A.E. Iskandrian, Risk assessment using single-photon emission computed tomographic technetium-99m sestamibi imaging. J Am Coll Cardiol, 1998. 32(1): p. 57-62. Koh, A.S., et al., Long-Term Prognostic Value of Appropriate Myocardial Perfusion Imaging. Am J Cardiol, 2017. 119(12): p. 1957-1962. Matsuo, S., et al., Prognostic value of normal stress myocardial perfusion imaging in Japanese population. Circ J, 2008. 72(4): p. 611-7. tAlston, L., M. Nichols, and S. Allender, Policy makers' perceptions of the high burden of heart disease in rural Australia: Implications for the implementation of evidence-based rural health policy. PLoS One, 2019. 14(4): p. e0215358.

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© 2021 General Electric Company – All rights reserved. GE and the GE Monogram are trademarks of General Electric Company. GE Healthcare, a of General Electric Company. GE Medical Systems, Inc., doing business as GE Healthcare. JB00174AU 22division GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE PREDITIONS Nuclear Medicine in this Decade Einstein is quoted as having said ’the measure of intelligence is the ability to change’. No questions about those that work in the profession. We hear daily about change being the only constant. And, what a reminder we had last year with the pandemic. So, what does this decade mean for Nuclear Medicine itself? What would we like to see? In this the first edition of Gamma in 2021, we asked the luminaries, personalities and upcoming lights in our profession to peer into their professional crystal balls. Here are their responses and views.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"Therapy is the wave of the future. Seeing the cancer is vital, but being able to kill it even more so.” DB

Dr Daniel Badger

President, ANZSNM Medical Physicist, The Queen Elizabeth Hospital, Adelaide, South Australia Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why? DB — Therapy is the wave of the future baby! Seeing the cancer is vital, but being able to kill it even more so. Q — Why do you love working in Nuclear Medicine? DB — I love the people FAMILY I work with, and I love being able to make a difference in the lives of our patients. Question— What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Daniel Badger — Being a small group there is a danger that our profession, or parts of what we do, could get swallowed up by other groups or be pushed into insignificance. The challenge is to stay relevant and keep our focus. The opportunity is that PET scanning is now a normal, everyday imaging procedure that should be available at every major hospital, and there are going to be more and more applications for Radionuclide therapy.

Q — If you didn’t work in Nuclear Medicine, what would you be doing? DB — Maybe still working in Defence, or perhaps teaching? Or maybe I'd be writing self-help books... Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? DB — Therapy is getting bigger and bigger, and in therapy are bigger issues of radiation dose and potential harm to staff and patients.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"It is a very exciting time to be in nuclear medicine, and the future is bright – we just need to be strategic and take advantage of the opportunities we have available!” AS

Professor Andrew Scott

International Relations Committee MBBS (Hons), MD, MANZSNM FRACP, FAHMS, FAANMS, FAICD, DDU

involve strategic interaction with Government, and regulatory bodies, as well as industry. We also need to work together to have common objectives for our specialty and ensure these tremendous opportunities can be achieved through collective effort and vision for the future. Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why?

Question— What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Andrew Scott — The challenges in the next decade primarily will involve taking advantage of the tremendous opportunities in new diagnostic and therapeutic applications of nuclear medicine. We will need to build on our clinical trials network (ARTnet) to facilitate evidence-based studies to enable clinical and economic outcomes to be obtained – an area where we have world-class research and a network of investigators and sites that is setting the standard for trial activity. Supply and access to radiopharmaceuticals will be key – and this will

AS — Both are vital to allow nuclear medicine to have the greatest impact on patient outcomes and contribute to society. The majority of our studies will continue to be diagnostic, and new opportunities for neuroscience and dementia imaging, as well as SPECT/CT, and expanding PET indications in oncology, infection and cardiac imaging, will be key areas of progress. There is no question that therapeutic nuclear medicine, aligned with precision oncology, will transform the treatment of many patients. This will provide many challenges to ensure we have the workforce, training capability, facilities and access to novel therapeutic radiopharmaceuticals, as well as funding to support treatment applications. We will need to be strategic and focused on these major issues to take advantage of these new areas of nuclear medicine in the next decade.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

Professor Andrew Scott

Q — Why do you love working in Nuclear Medicine? AS — The field of nuclear medicine provides tremendous challenges and opportunities. It is not confined to one area of medicine – we are fortunate to be able to see the broad spectrum of patients and disease areas in our practices. Nuclear medicine has constant advances in technology, and innovation in radiopharmaceutical probes to interrogate precise clinical questions in patients, which has continued impact on clinical care. In addition, nuclear medicine provides a unique opportunity to combine research and clinical translation in patients and answer fundamental questions of biology and assist in drug development. These all combine to make nuclear medicine a wonderful specialty to work in, and I continue to enjoy working in all of these areas. Q — If you didn’t work in Nuclear Medicine, what would you be doing? AS — An interesting question! Most likely in an area of clinical medicine, as I have always wanted to be a doctor, although I suspect that engagement in research and health policy would be have been additional areas, I would have been involved in. Over the years I have also had extensive involvement with Pharmaceutical companies and Biotech, which has been quite productive, and this could perhaps also have been an area where I could have worked. Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? AS — Developments in technology, including digital connectivity and computational analysis (e.g. AI) will mean ongoing training in new advances in these areas will be vital. Theranostics will become highly important for clinical practice, and training and credentialling will be necessary for our profession to implement these new techniques and adjust to more direct patient care

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involvement. The field of medicine is undergoing major changes in quality system implementation, and we will all need to adopt these approaches for individual practice and for facility operations. Finally, to ensure we are able to implement the full potential of nuclear medicine diagnostic and therapeutic applications, we will all need to acquire knowledge and develop skills in regulatory and health policy / administration interaction, which will be essential at a local and national level. Q — Any other comments? AS — It is a very exciting time to be in nuclear medicine, and the future is bright – we just need to be strategic and take advantage of the opportunities we have available!

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

outside of our community with a hook to hang their hat on and say “Ahh. So that is what nuclear medicine is.” The important issue for our future is to open the doors wide allowing ideas for new radiopharmaceuticals to be developed and applied in the clinical setting, and to facilitate people with the ability and ambition to help patients along their path to success. Funding is important for this endeavor but also is moving egos aside, being open to new ideas, and having the courage to chart an uncertain course. Q — Why do you love working in Nuclear Medicine?

Dr Kevin London

KL — Cross fertilisation - the meaningful sharing of knowledge and experience across medical and nonmedical domains. Having a technologist, physicist, radiopharmacist, nurse, and doctor all looking at each other to come up with a solution to a tough clinical problem is simultaneously terrifying and exhilarating.

Vice-President, ANZSNM MBChB, PhD, FRACP, FAANMS, MANZSNM Medical Co-Head, Senior Staff Specialist Clinical Senior Lecturer, The University of Sydney Department of Nuclear Medicine The Children’s Hospital at Westmead

Q — If you didn’t work in Nuclear Medicine, what would you be doing? KL — Pursuing a career in quiz shows with specialist subjects of heavyweight boxing greats of the 20th century or esoteric movie quotes from the 1990s; or working as a Paediatrician.

"In healthcare, the way we will work in the future will require the integration of data, skill, knowledge from humans and AI systems.” KL Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Kevin London — Reliable, high-quality radiopharmaceutical supply is the lifeblood of what we all do. For us as a society and a professional body charged with the responsibility of helping our patients, without this supply line our world and that of our patients becomes significantly more difficult. Major opportunities lie within this space to improve our supply chain, challenging as they may be. Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why? KL — We have to stop thinking this way. There is no distinction between imaging and therapeutics “Theranostics” is an invented word to provide those

Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? KL — No idea, but it probably will not involve a traditional “skill” but more likely a character trait like flexibility, openness, or empathy. In healthcare, the way we will work in the future will require the integration of data, skill, knowledge from humans and AI systems. The groups that succeed will be those that identify and cast aside the useless baggage of outdated thinking (I wish I knew what these outdated ideas are!). Q — Any other comments KL — Nuclear medicine is known for adapting with rapid change, so expect this to accelerate and brace yourself for an uncomfortable and rewarding path ahead.

GAMMA GAZETTE ATUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"Undoubtedly, in the next decade, we need to engage more deeply and develop our understanding of the language of molecular biology and genetics.” DB

Professor Dale Bailey

Past President, ANZSNM Principal Physicist, Royal North Shore Hospital, Sydney & Director, Sydney Vital Translational Cancer Research Centre, Sydney

treatment. This explains some of the slow uptake of the Alzheimer’s Disease imaging agents, which mainly reside in the reseach domain at present for lack of an effective treatment. Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why?

Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Dale Bailey — The challenge at present for nuclear medicine lies mainly in being able to generate the required level of evidence to transition promising new molecular imaging and treatment strategies into funded, cost-effective therapies. Any new imaging probe that is introduced will need to be matched with a treatment. Many new effective targeted therapies for mutations or rearranged genes are very expensive. Nuclear medicine probes can be used to select the most appropriate patients for these expensive treatments as well as to monitor response. If no response is seen within a specified timeframe there is likely little point in continuing with the expensive treatment. I believe we are now beyond the days of simply generating a novel radiopharmaceutical that can diagnose a disease or condition - it needs to be matched to a potential

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

DB — This is not an either/or situation, but rather we need to develop both imaging and therapeutic radiopharmaceuticals which are matched to a treatment or biomarker (which could be imaging). The biomarkers or treatments do not need to be radiopharmaceuticals, however, they need to be part of a “matched pair” aimed at ameliorating the disease or disorder. Q — Why do you love working in Nuclear Medicine? DB — One of the most attractive features about the field of nuclear medicine is its multidisciplinary nature. Where else do you get medical specialists, physicists, chemists, nurses and allied health staff in the same discipline? And further to this, I am very aware that nuclear medicine is not just stuck in a “single organ” discipline, but bridges across many areas of medicine such as cancer, cardiovascular, neurosciences, musculoskeletal, infection, endocrine and so on. It includes diagnostic/staging as well as therapies. It is increasingly being driven by molecularly targeted approaches. Outside of the medical disciplines it incorporates widely varying fields from nuclear physics and chemistry to molecular profiling and mathematics. I

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

published the figure on the right (Fig. 1) in 2014 to try to capture the richness of this multidisciplinary area. The future for this field is extremely attractive if you want an interesting and varied working life. Q — If you didn’t work in Nuclear Medicine, what would you be doing? DB — Professional tennis player, except I do not have the talent.

Figure 1. Nuclear Medicine – “Molecular Imaging” – is at the core of many diverse fields with which it interacts. (From Bailey, D. L. (2014). "Thirty years from now: future physics contributions in nuclear medicine." Eur J Nucl Med Mol Imag Physics 1(4): 1-8)

Q —What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? DB — Undoubtedly, we need to engage more deeply and develop our understanding of the language of molecular biology and genetics. We need this to be able to collaborate effectively with colleagues in other areas. That is why I strongly believe that the scientists in the field of nuclear medicine need to understand the physiological and functional pathways and targets to further interrogate the disease process or disordered metabolism. Q —Any other comments DB — The next 10 years are going to be very interesting for nuclear medicine and will reward anyone who is willing to engage with the new developments – especially in Australia where we are entering a “Golden Age” for new agents and procedures.

The author in a nuclear bunker under the city of Prague in the pre-COVID era when we could still travel.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"I see the next generation of NMT’s needing to continue to be innovative and creative, pushing boundaries and encouraging growth in our profession.” PJB Q — Why do you love working in Nuclear Medicine? PJB — In a recent interview with a prospective trainee NMT, they actually asked us this exact question. Honestly, I could not stop talking! I love the patients, I love the technology, I love the collaboration, I love the hot lab. At the top of the list is being part of a “special or select” group within Medical Imaging. From a quote by Liam Neeson “What I do have are a very particular set of skills; skills I have acquired over a very long career.” Q — If you didn’t work in Nuclear Medicine, what would you be doing?

Pru Burns

Federal Council Member Unit Charge Nuclear Medicine Wellington Regional Hospital

Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Pru Burns — In New Zealand challenge and opportunity are a double edged sword. The connection of both is around the access for all patients to imaging and therapeutic applications that are available elsewhere in the world. Being on an island should allow us the opportunity to be at the forefront of Molecular Imaging, without the hindrance of big government and corporate influence. The challenge of being a small nation, is we don’t seem to allocate the funds to turn the opportunities into a reality.

PJB — If I had a do-over it would be an Emergency Medicine doctor on a Life Flight helicopter, or a council gardener spending all day outside designing and planting botanical gardens. EM Doctor – for the impact they have at a crucial part in a person's life, and I am never happier at work than when juggling 20 things at once. A gardener for the complete opposite – for the serenity and peace that being in a garden brings me. Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? PJB — In NZ, critical skills focusing on leadership will be important to the ongoing success of our modality to stand out in departments where Radiology constantly competes with us for resources, staff, equipment and budget. I see the next generation of NMT’s needing to continue to be innovative and creative, pushing boundaries and encouraging growth in our profession. Flexibility is key - in the era of hybrid imaging, having some fluidity in the way we are educating our trainees will be important.

Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why? PJB — I see this as a 50/50 split, with imaging and therapy complementing each other. I think therapeutic applications will lead the way, and running parallel will be the development of imaging techniques to support and measure the successes of the Nuclear Medicine targeted therapies.

GAMMA GAZETTE | ANZSNM.ORG.AU

Career highlight, performing a PET/ CT scan on a tiger in 2013. Photo courtesy of Dr Trevor Fitzjohn and Pacific Radiology Wellington.

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

to start but as the education and responsibility of the technologist has evolved over the years, the value of the role has not kept pace. Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why? VS — In terms of imaging, we’ve been doing things the same way for a very long time. That just means that there is scope to innovate. There’s been a lot of excitement building around therapeutic applications of Nuclear Medicine over the past few years and it would be wise to capitalise on this new-found popularity whether that be in the diagnostic or the therapeutic arena. Q — Why do you love working in Nuclear Medicine?

Federal Council Member Chief Nuclear Medicine Paediatric Specialist Technologist Women’s and Children’s Hospital ANZSNM Federal Council Member

VS — I love the versatility required to work in paediatric Nuclear Medicine. I enjoy the technical challenges presented by small patients with complex cases but I also enjoy tapping into the side of my brain needed to keep kids distracted and entertained through difficult processes. I don’t think there are many jobs where you need a strong working knowledge of anatomy, physiology, pathology and radio-pharmacy alongside an instant recall for all the songs from Frozen!

"In terms of imaging, we’ve been doing things

Q — If you didn’t work in Nuclear Medicine, what would you be doing?

Victoria Sigalas

the same way for a very long time. That just means that there is scope to innovate.” VS Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Vicky Sigalas — Speaking from a technologist’s perspective, I see a potential workforce issue in the future. Particularly with the new breed of highly intelligent, highly educated technologists graduating through our universities, there is scope for discontent to breed amongst a professional group that may rightfully be seeking greater responsibility, greater recognition and greater remuneration from their career. Of course there is also the issue of job satisfaction. Will a modern technologist be satisfied in a role that traditionally has little room for career development? How will the profession retain great technologists as they move into other fields where their diverse skills are better acknowledged? It may not be a popular conversation

VS — I’d be a concert pianist. In my twenties I was a disciplined musician; studying, practicing and performing regularly. It was a real tug of war between the two careers for many years. I find playing piano incredibly satisfying and the juxtaposition of exacting technique versus creative expression really speaks to me. Again, it’s the versatility that I enjoy. Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? VS —I think one thing Covid has taught us is the value of flexibility. When I studied Nuclear Medicine there was a lot of focus on memorising standards. Now I see more value in critical thinking. I believe an essential skill moving forward will be the ability to pivot from an existing position in response to varying situations. Nuclear Medicine professionals in the future will need an evolving mindset to truly stay relevant.

GAMMA GAZETTE ATUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"The future of identifying new imaging, will lead to the development of further therapies.” SMG

Suzanne McGavin

Federal Council Treasurer Industry Fellow, Nuclear Medicine RMIT University, Melbourne

Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Suzanne McGavin — I believe the current challenges of the NM industry is increasing visibility. Although we have and are slowly making our profession known in the wider health profession community, I think we have developed some amazing new radiopharmaceuticals and therapies in which patients are not accessing as frontline treatment when feasible. I believe we need to continue to expand our exposure in other health communities and become engaged and integrated in their conferences and professional development education, to increase awareness of our role in patient diagnosis and treatment. Participating in wider interprofessional collaborations would diversify our profession and hope to increase our exposure of the amazing diagnosis and treatment options we have available or are currently developing. I believe the opportunities for Nuclear Medicine stem from the same thought as the challenges. With our increased research and successful discoveries, we

have opportunities to further expand and become involved in frontline medical care. Our professionals can diversify in their roles as Nuclear Medicine professionals and become involved in various career paths working with a range of health professionals, making a career in Nuclear Medicine one of diversity and opportunity. Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why? SMG — I feel this is a very personal preference. For me, I am and always have been extremely excited about the development of Nuclear Medicine therapies. The field excites me about how we can change patient outcomes and also the mindset of patients diagnosed with cancer. I have always said, from the start of my career, it would be a dream that a cancer diagnosis is not a negative experience, that a trip to a Nuclear Medicine department, some simple personalised treatment, will blast the cancer away and life continues. In the same breath, without our developing imaging applications, the identification of new ways to treat various cancers is limited, so we cannot have one without the other. The future of identifying new imaging, will lead to the development of further therapies.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

Suzanne McGavin Q — Why do you love working in Nuclear Medicine? SMG — I love that we are a unique profession that is still in its infancy of what we can achieve. This makes being part of Nuclear Medicine exciting as we are evolving at a fast pace so you can never get bored of what we can do. The profession allows so much variation in our daily activities that I find it continues to peak my interest, even when you think you have seen everything, each day something new will pop up. Q — If you didn’t work in Nuclear Medicine, what would you be doing? SMG — I was thinking about this the other day. When I was younger, I wanted to become a teacher, as I am currently kind of doing that, my other profession would be a Lawyer. I was thinking how different my personality may have evolved if I worked in corporate law instead of healthcare. I am very happy that I chose healthcare as I believe we become well-rounded humans by default with an intrinsic need to help and care for others.

to initiate, accept and implement, but with an evolving profession, I think we need to develop the skill to embrace it and make it our responsibility to be part of the process. Q — Other comments? SMG — It is to be noted that these answers are just my personal thoughts. When thinking about the answers, it was somewhat confronting to put these down to be so exposed to the wider community. I hope they are viewed as more ‘food for thought’ and if nothing else, provide conversation and thought of what others may also think in response to the questions.

Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? SMG — With my tertiary education hat on, I think the critical area is patient communication skills and interpersonal skills. With the changes COVID-19 has brought to social restrictions and delivery of education and healthcare, along with differences in generational upbringings, the inherent understanding of social interactions is limited. I think we need to accept and appreciate this and assist with the development of these skills for prospective professionals. For current professionals, I think being change champions and seeking opportunities to improve our current practices is a skill which can be challenging. Change is difficult

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"As a newly qualified technologist I find myself continuing to be amazed at new discoveries, learnings, and developments, the learning most definitely does not stop when you become qualified!.” SC

Sarah Caplan

Nuclear Medicine and Medical Imaging Technologist New Zealand

Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Sarah Caplan — As a Nuclear Medicine Technologist working at a regional District Health Board in New Zealand (NZ) I believe we face several challenges which are shared on a national level also. Staff shortages and retention issues, not only with regards to technologists but also in terms of Nuclear Medicine Physicians, are still present nationally. With the current COVID-19 environment we are living in, I believe this has impacted international technologists coming into the country and therefore over the next decade it is essential that we continue to train technologists and work hard to keep them in the NZ workforce. Another potential challenge may

Q — What is more important for the future, new imaging

or therapeutic applications of Nuclear Medicine? Why? SC — A very interesting question! Fittingly with my

answer to the question above from my perspective I believe therapeutic applications are going to be a fundamental turning point in the development of Nuclear Medicine. As research and clinical trials continue we will be able to better understand the clinical utility of targeted radionuclide therapies which can be personalised to a specific individual depending on the characteristics their tumour or malignancy demonstrates. This has the ability to maximise the effectiveness of therapy and can result in a better quality of life for the patient. These kinds of advances are a very exciting prospect for the future of Nuclear Medicine and has the potential to be life changing for our patients. Q — Why do you love working in Nuclear Medicine? SC — Nuclear Medicine is a dynamic and continually

evolving modality which makes it very exciting to be a part of. I love the fact that no two days in the Nuclear Medicine department are ever the same. As a newly qualified technologist I find myself continuing to be amazed at new discoveries, learnings, and developments, the learning most definitely does not stop when you become qualified! Learning will only continue as research continues and technology carries on advancing, resulting in new imaging and therapeutic applications being discovered and developed over the next decade.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

Sarah Caplan Q — If you didn’t work in Nuclear Medicine, what would

you be doing?

SC — Up until undertaking my Bachelor of Applied

Science (Medical Imaging Technology) Degree, in all honesty I didn’t actually know Nuclear Medicine existed. It wasn’t until I had to get clinical hours in Nuclear Medicine as part of the clinical requirements of the course that I realised my passion for the modality. After qualifying as a Medical Imaging Technologist I was then lucky enough to get a training position in Nuclear Medicine and the rest is history. However, I did have a couple of backup plans if I wasn’t successful in getting into the Medical Imaging course. If I wasn’t working in Nuclear Medicine, a Degree in Midwifery was on the cards to enable me to still work in the field of healthcare which I’m interested and passionate about. Q — What do you think will be critical skill areas for

skill development in the next decade for current and prospective professionals?

SC — Over the next decade I think it will only become

more important that technologists are able to perform fusion imaging accurately as this form of imaging becomes used more and more frequently. I believe quantitation will also become common practice. With the hope of PET/CT becoming more easily accessible, as well as the development of new softwares, being able to quantify radionuclide uptake in diseased tissues to evaluate response to treatment will also become a critical skill technologists will have to develop.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SPECIAL FEATURE Predictions: Nuclear Medicine in this decade

"In terms of imaging, we’ve been doing things the same way for a very long time. That just means that there is scope to innovate. ” MC

MC — I think diagnostics will always be at the core of our work. We’ve seen more efficient and effective diagnostic imaging leads to earlier detection of disease which results in better patient outcomes. I am excited by the progression of therapeutic Nuclear Medicine, currently it is not accessible for many departments, so I believe imaging will remain central to our advancing practice.

Maddison Carroll

Federal Council Member Nuclear Medicine Scientist Royal Brisbane and Women’s Hospital

Question — What do you see are the upcoming challenges and opportunities for Nuclear Medicine? Maddison Carroll — Isotope supply has proven to be the main challenge I have faced as a young technologist. With this being a continuing issue, I imagine it will be an ongoing problem for the profession. What I have seen result from the shortage is admirable resilience and adaptability from the profession. We were innovative in the face of adversity and reacted in ways that improved practice. For example, I experienced rapid protocol changes to meet the department workload through patient dose reduction and adjusting scanning parameters. I think finding mechanisms to decentralise the production of radiopharmaceuticals would greatly improve how Nuclear Medicine and Molecular Imaging is delivered in both metro and rural Australia. Q — What is more important for the future, new imaging or therapeutic applications of Nuclear Medicine? Why?

GAMMA GAZETTE | ANZSNM.ORG.AU

Q — Why do you love working in Nuclear Medicine? MC — I love being part of such an innovative profession. I am constantly learning and adapting my practice to meet the changes occurring in all aspects of Nuclear Medicine. I also love providing quality care to patients in this setting. I value applying my learning and seeing how this improves the quality in images I can attain whilst prioritising my patients’ wellbeing. Q — If you didn’t work in Nuclear Medicine, what would you be doing? MC — Very recently, I commenced a Bachelor of Laws. My long-term goal is to be in a role to advocate for change to benefit the lives of our patients. Q — What do you think will be critical skill areas for skill development in the next decade for current and prospective professionals? MC — Technology is a key aspect of the day-to-day function of a Nuclear Medicine department and professionals need to be ready to adapt their practice with technological advancements. We see this clearly with new imaging applications but also with changes in patient record keeping and using dose dispensing software in hot labs. These developments will continue to happen as technology becomes more accessible and all professionals need to be open and willing to adapt to it.

It will certainly be an interesting look back at these predictions in the coming years and reflect on them. We would like to thank all contributors.

PEOPLE IN NUCLEAR MEDICINE

VALE

Nabil Morcos

he ANZSNM community was saddened to hear of the passing of Nabil Morcos. Nabil was known to many in our community from his radiochemistry and scientific leadership roles at ANSTO and at Cyclomedica. He will be remembered as an innovator and inveterate inventor, and co-discoverer of several radioisotopes and isomeric states. Nabil was born in Cairo, Egypt in 1944. He held a doctorate in Nuclear and Radiochemistry from the University of Arkansas and was a research professor in the Physics and Environmental Engineering Departments at Vanderbilt University (Nashville TN, USA 1997-2003). He had several stints at Brookhaven National Laboratory in the Chemistry and Radioactive Waste Management Divisions in support of the US Nuclear Regulatory Commission. He spent over 20 years in the radiopharmaceutical research industry where he developed several products from concept to market including the Squibb Mo-99/Tc-99m generator. He held 17 patents in radiopharmaceutical and related medical areas. He also spent ten years prior to joining ANSTO at the US DOE at INEEL and Hanford working on Plutonium Production Legacy Waste as a radiochemistry and safety advisor to the DOE. After moving to Australia, Nabil held the positions of R&D leader at ANSTO ARI (now ANSTO Life Sciences) and COO at Cyclomedica in a local career spanning over 20 years. Nabil and his wife, Micki, took up residence in Cronulla where Nabil was a keen photographer of splendid sunrises and nature. He will be sorely missed.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

PEOPLE IN NUCLEAR MEDICINE

VALE

Michael Quinlan

rofessor Michael Quinlan was a pioneer of Nuclear Medicine. He was the first Nuclear Medicine Physician in Western Australia, having trained in Nuclear Medicine at Johns Hopkins University, Baltimore under the guidance of Dr Henry Wagner. He worked initially at Royal Perth Hospital in the Department of Medical Physics and he then established the Nuclear Medicine Department at Sir Charles Gairdner Hospital in 1970. He later also established Nuclear Medicine at St John of God Hospital. He was committed to education and training, and he established the first Nuclear Medicine registrar training program in WA. He was a foundation member and committee member of the Australian and New Zealand Society of Nuclear Medicine (formed in 1969). In addition to his commitment to Nuclear Medicine, he made significant contributions to many WA health organisations and universities including Notre Dame (Foundation Dean of College of Health 1999, and Chancellor 2008-2011), Adjunct Professor at the University of Western Australia, Fellow of Royal Australian College of Physicians (awarded College medal 1998), Director of Medical Teaching Unit St John of God Hospital, Emeritus Consultant Sir Charles Gairdner Hospital. In 2018 he was awarded Order of Australia for his work in medicine and clinical services. Professor Quinlan had a lifelong commitment to medicine, particularly in teaching and education, however those that worked with him reflect on his genuine care and compassion for patients. Professor Quinlan passed away after a brief illness in October 2020. The Society wishes to extend and record our condolences to Professor Quinlan’s family, friends and colleagues.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

EDUCATION AND CPD | Case Study

IMPLEMENTATION OF FDG PET IN THE MANAGEMENT OF ERDHEIM CHESTER DISEASE

Authors: Hamish Schumacher, Kunthi Pathmaraj and Sze Ting Lee Austin Health

rdheim Chester Disease (ECD) is a non-Langerhans dendritic form of histiocytosis. Prevalence of ECD is extremely rare with approximately 500 known cases in the medical literature with no known aetiology.1 Histiocytic disorders such as ECD occur when the body begins to overproduce and accumulate white blood cells called histiocytes.2 Typically ECD occurs in advanced ages with patients generally above the age of 50 years old when diagnosed.1 ECD can manifest itself with a variety of clinical presentations differing from asymptomatic to severe skeletal pain and neurological issues. The typical presentation of ECD involves the patient experiencing weight loss, night sweats, and fevers, whilst 50% of cases also experience bone pain throughout the appendicular skeleton. ECD is a multi-systemic disorder with skeletal involvement being the most common indication with 96% of cases showing bilateral

osteosclerotic lesions throughout the long bones. Lesser affected systems involve the skin, pulmonary, cardiovascular, renal and, central nervous system (CNS).1,3,4 CNS involvement is a major indicator for prognosis and is seen in approximately 50% of cases and symptoms of CNS infiltration manifest as diabetes insipidus.3 Other radiographic findings that are indicative but non-specific for ECD include extra-axial masses that mimic meningiomas, as well as peri-renal rinds of soft tissue or “hairy kidney” that is seen in 29% of cases.5 The prognosis of ECD is directly proportional to its’ extent and distribution and it has a 5-year survival rate of 68%.1

CASE REPORT A 30-year-old male suffering from extreme jaw pain, generalized teeth mobility and loss of teeth, visited his dentist to investigate the aforementioned symptoms.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

An orthopantomogram (OPG) was performed and showed advanced periodontal disease, mostly affecting the teeth apices. Periapical lucencies throughout both the mandible and maxilla were also observed that indicated an infective or inflammatory bone loss disorder. One week later, tissue samples from the patient’s right posterior mandible marrow were taken to investigate for possible Langerhans cell histiocytosis (LCH). Findings showed extensive xanthogranulomatous infiltrate with numerous foamy histiocyticlike cells within the infiltrate. The results were non-conclusive for LCH but based on the mandibular bone loss and pathological findings, a histiocytic disease such as ECD could not be excluded. A Computed Tomography (CT) scan of the chest, abdomen, and pelvis post intravenous contrast (CAP+) was performed a month later, to investigate extra-cranial histiocytic deposits. The findings showed small sclerotic foci in the proximal femora,

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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

bilateral perinephric rinds, excessive soft tissue in the mediastinum, and a bulky pancreas (Image 2,3,4). It was concluded that the scan findings were non-specific for a histiocytic process. The differential diagnosis was IgG4 disease, isolated perinephric retroperitoneal fibrosis, ECD, and lymphoma. The patient presented to the Department of Molecular Imaging and Therapy two months later for an 18F-Fluorodeoxyglucose (FDG) Positron Emission Tomography (PET) scan following a multi-disciplinary deliberation that felt a FDG PET scan could lead to a more definitive diagnosis. The patient was intravenously administered with 219 MBq of FDG followed by an uptake time of 76 minutes. A 21-bed scan from vertex to toes was then performed in conjunction with a low dose modulated CT (120kv, 14-63 mAs) for the purposes of attenuation correction and anatomical localization.

SCAN FINDINGS The total body PET scan demonstrated multiple areas of intense FDG uptake bilaterally in the distal humeri, the proximal ulna and radius, the mid to distal femora, the tibiae, fibulae, and patellae that are consistent findings of ECD. Intense uptake was also identified bilaterally in soft tissue lying adjacent to the mastoid process and the masseters that was most likely physiological. Moderate uptake was visualized in the maxilla and mandible, the clavicles, the head of both humeri, the midshaft of both the ulna and radius bilaterally, the greater trochanter of the right femur, bilaterally in the calcaneum and navicular, and the left medial cuneiform. There were no FDG avid soft tissue lesions within the whole body. The perinephric soft tissue seen on the CT CAP+ did not accumulate FDG (Image 1).

DISCUSSION This case demonstrates the effectiveness of functional imaging over conventional anatomical imaging which can have limitations in detecting specific pathological processes. The non-specific nature of FDG is advantageous

when investigating histiocytic pathologies. Additional benefits of PET imaging include the possibility to perform a whole-body scan compared to limited fields of views that are typically performed with CT scans. Moreover, functional imaging allows potential biopsy sites to be targeted as it provides identification of metabolically active pathological sites.

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

EDUCATION AND CPD | Case Study

Current literature illustrates the effectiveness of FDG imaging in the more common LCH. However, these scan findings prove that FDG PET has a role also in the diagnosis of ECD.6 Following discussions with international experts regarding management pathways for ECD, it had been decided that the patient would initially be treated with a chemotherapeutic agent known as a MEK inhibitor. Studies have shown that this drug has high efficacy in treating ECD and these responses have been proven by visualising metabolic response on FDG PET scans.7 It is clear from the above findings that the use of FDG PET imaging in the management of ECD is highly valuable and can be implemented throughout the entirety of the patients’ management from the initial diagnosis to treatment response.

References 1. Mazor, R., Manevich-Mazor, M. and Shoenfeld, Y., 2013. Erdheim-Chester Disease: a comprehensive review of the literature. Orphanet Journal of Rare Diseases, [online] 8(1), p.137. Available at https://link.springer.com/ article/10.1186/1750-1172-8-137 2. Histio.org. 2021. Histiocytic Disorders. [online] Available at https:// www.histio.org/page.aspx?pid=378#. YBiJex1S-fV 3.Haroche, J., Arnaud, L., CohenAubart, F., Hervier, B., Charlotte, F., Emile, J. and Amoura, Z., 2014. Erdheim–Chester Disease. Current Rheumatology Reports, [online] 16(4). Available at https://link.springer.com/ article/10.1007/s11926-014-0412-0 4. Arnaud, L., Malek, Z., Archambaud, F., Kas, A., Toledano, D., Drier, A., Zeitoun, D., Cluzel, P., Grenier, P., Chiras, J., Piette, J., Amoura, Z. and Haroche, J., 2009. 18F-fluorodeoxyglucose-positron emission tomography scanning is more useful in followup than in the initial assessment of patients with Erdheim-Chester disease. Arthritis & Rheumatism, [online] 60(10), pp.31283138. Available at https://onlinelibrary. wiley.com/doi/full/10.1002/art.24848

5. Zaveri, J., La, Q., Yarmish, G. and Neuman, J., 2014. More than Just Langerhans Cell Histiocytosis: A Radiologic Review of Histiocytic Disorders. RadioGraphics, [online] 34(7), pp.2008-2024. Available at https://pubs.rsna.org/doi/full/10.1148/ rg.347130132 6. Albano, D., Bosio, G., Giubbini, R. and Bertagna, F., 2017. Role of 18F-FDG PET/ CT in patients affected by Langerhans cell histiocytosis. Japanese Journal of Radiology, [online] 35(10), pp.574-583. Available at https://link.springer.com/ article/10.1007/s11604-017-0668-1 7. Cohen Aubart, F., Emile, J., Maksud, P., Galanaud, D., Cluzel, P., Benameur, N., Aumaitre, O., Amoura, Z. and Haroche, J., 2016. Efficacy of the MEK inhibitor cobimetinib for wild-type BRAF Erdheim-Chester disease. British Journal of Haematology, [online] 180(1), pp.150-153. Available at https:// onlinelibrary.wiley.com/doi/full/10.1111/ bjh.14284

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

On behalf of the Local Organising Committee (pictured below), we would like to invite you to attend the 51st Annual Scientific Meeting, the only and most long-lived conference for the Nuclear Medicine Community in Australia and New Zealand, which will be held from the 21-23 May 2021. The 2021 edition will be delivered by a unique and exciting new hybrid model, combining the best of face to face and the latest virtual technology.

2021 Annual Scientific Meeting Local Organising Committee

he theme of the meeting is Key Collaborations, Key Impacts - Unlocking the Potential of Nuclear Medicine. The two and a half day semi-virtual program will offer the same rich content and broad range of presentation platforms as the traditional face-to-face conference. Featuring international keynote speakers, selected live sessions, pre-recorded presentations with live Q&A, interactive panel sessions, poster sessions, a virtual exhibit hall, and on demand access of selected content for registered attendees following the conclusion of the Conference. With a focus on both Live and Local, the ANZSNM 2021 conference program will be delivered via a live virtual platform with an option to meet face to face at multiple local sites (subject to restrictions) or from your home or office. Major cities and other popular areas will host local sites to enable you to be an active participant in the meeting. You may even be able to host your own smaller local site in your town or department. The ANZSNM is committed to hosting an annual conference for the Nuclear Medicine community and we are excited for 2021! With plenty of opportunities for delegates to participate and contribute in a GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU 45 variety of different ways, this will be a “must attend” event for all in the Nuclear Medicine community.

CONFERENCE PACKAGES LIVE & LOCAL NETWORKING PACKAGE Our Live and Local Networking Package is the total experience. Over 3 days, this package provides you the opportunity to gather together and engage face to face with colleagues whilst enjoying the virtual platform streaming all sessions to the Live and Local Site of your choice.

The Live and Local Networking Package includes: • • • • • •

Attendance at your nominated Live and Local Site Watch presentations together with your colleagues Engage in Live Q & A via conference app Network with the nuclear medicine community Meet with Sponsors and Industry Partners in person Catering (breaks scheduled within the official program) • Attendance at the Networking Event/Dinner on Saturday 22 May in close proximity to your nominated local site (food included, beverages at your own expense)

The added benefit of this package is attendance at the Networking Event/ Dinner located in close proximity to your selected Live and Local Site on the evening of Saturday 22 May.

LIVE & LOCAL PACKAGE Live and Local Package provides you access a site near you to gather together and engage face to face with colleagues whilst enjoying the live virtual platform streaming all conference sessions. This package includes 3 day access to your Live and Local Site. The Live and Local Package below includes: • • • • • •

Attendance at your nominated Live and Local Site Watch presentations together with your colleagues Network with the nuclear medicine community Engage in Live Q & A via conference app Meet with Sponsors and Industry Partners in person Catering (breaks scheduled within the official program)

VIRTUAL PACKAGE The upcoming ANZSNM 2021 Conference will be available to watch live via a virtual platform to all registered delegates. Going virtual means you can experience and engage with the nuclear medicine community from anywhere, your office or at home at your own convenience! The live virtual platform will allow delegates to participate by connecting and networking, engaging in live Q & A and interact with sponsors. Going virtual means you can experience and engage with the nuclear medicine community from anywhere, your office or at home at your own convenience! The Virtual Package includes:

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

• Access to online presentations • Participate in Live Q & A • Access to the Meeting Hub and Virtual Exhibitions

Meet and network with colleagues while enjoying the 2021 program delivered via a virtual platform streaming all the online sessions to nominated local site. Register and attend this year's event at a Live and Local Site near you!

GAMMA GAZETTE | ANZSNM.ORG.AU

Where will you be on 21st - 23rd May 2021?

The 2021 Annual Scientific Meeting is proudly sponsored by

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

Discover the recently published international recommendations for the use of SIR-Spheres® Y-90 resin microspheres This publication reports the state-of -the art recommendations for optimization of selective internal radiation therapy (SIRT) with yttrium-90 (90Y) resin microspheres and supports best practices to treat patients collaboratively in a program-based system to improve patient outcomes.

Join Sirtex for a online discussion with guest speakers Dr Kathy Willowson and Dr Sanjay Baijal Tuesday, 23rd March 2021 Session 1: 6pm - 7pm AEST | Session 2: 7:30 - 8:30pm AEST* * Both sessions are the same to account for different regions; please only register for one session

Pr esent er Dr K at hy Willo wso n Nuclear Medicine Physicist Australia

NEW

Pr esent er Dr S anj ay Baij al Interventional Radiologist India

International recommendations for personalized SIRT with SIR-Spheres® Y-90 resin microspheres

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SIR Spheres ® is a registered trademark of Sirtex SIR-Spheres Pty Ltd. www.sirtex.com

INTERNATIONAL RECOMMENDATIONS FOR PERSONALISED SELECTIVE INTERNAL RADIATION THERAPY OF PRIMARY AND METASTATIC LIVER DISEASES WITH YTTRIUM-90 MICROSPHERES Article Provided by Sirtex Medical

GAMMA GAZETTE | ANZSNM.ORG.AU

INDUSTRY NEWS European Journal of Nuclear Medicine and Molecular Imaging https://doi.org/10.1007/s00259-020-05163-5

GUIDELINES

International recommendations for personalised selective internal radiation therapy of primary and metastatic liver diseases with yttrium-90 resin microspheres Hugo Levillain 1 & Oreste Bagni 2 & Christophe M. Deroose 3 & Arnaud Dieudonné 4 & Silvano Gnesin 5 & Oliver S. Grosser 6 & S. Cheenu Kappadath 7 & Andrew Kennedy 8 & Nima Kokabi 9 & David M. Liu 10 & David C. Madoff 11 & Armeen Mahvash 12 & Antonio Martinez de la Cuesta 13 & David C. E. Ng 14 & Philipp M. Paprottka 15 & Cinzia Pettinato 16 & Macarena Rodríguez-Fraile 13 & Riad Salem 17 & Bruno Sangro 13 & Lidia Strigari 18 & Daniel Y. Sze 19 & Berlinda J. de Wit van der veen 20 & Patrick Flamen 1 Received: 11 September 2020 / Accepted: 8 December 2020 # The Author(s) 2021

Abstract Purpose A multidisciplinary expert panel convened to formulate state-of-the-art recommendations for optimisation of selective internal radiation therapy (SIRT) with yttrium-90 (90Y)-resin microspheres. Methods A steering committee of 23 international experts representing all participating specialties formulated recommendations for SIRT with 90Y-resin microspheres activity prescription and post-treatment dosimetry, based on literature searches and the responses to a 61-question survey that was completed by 43 leading experts (including the steering committee members). The survey was validated by the steering committee and completed anonymously. In a face-to-face meeting, the results of the survey were presented and discussed. Recommendations were derived and level of agreement defined (strong agreement ≥ 80%, moderate agreement 50%–79%, no agreement ≤ 49%). Results Forty-seven recommendations were established, including guidance such as a multidisciplinary team should define treatment strategy and therapeutic intent (strong agreement); 3D imaging with CT and an angiography with cone-beam-CT, if available, and 99mTc-MAA SPECT/CT are recommended for extrahepatic/intrahepatic deposition assessment, treatment field definition and calculation of the 90Y-resin microspheres activity needed (moderate/strong agreement). A personalised approach, using dosimetry (partition model and/or voxel-based) is recommended for activity prescription, when either whole liver or selective, non-ablative or ablative SIRT is planned (strong agreement). A mean absorbed dose to non-tumoural liver of 40 Gy or less is considered safe (strong agreement). A minimum mean targetabsorbed dose to tumour of 100–120 Gy is recommended for hepatocellular carcinoma, liver metastatic colorectal cancer and cholangiocarcinoma (moderate/strong agreement). Post-SIRT imaging for treatment verification with 90Y-PET/CT is recommended (strong agreement). Post-SIRT dosimetry is also recommended (strong agreement). Conclusion Practitioners are encouraged to work towards adoption of these recommendations. Keywords SIRT . Dosimetry . Recommendations . Liver tumours

Introduction

This article is part of the Topical Collection on Dosimetry * Hugo Levillain hugo.levillain@bordet.be Extended author information available on the last page of the article

Selective internal radiation therapy (SIRT) with yttrium-90 (90Y)-loaded microspheres has been broadly adopted as a locoregional therapy for advanced hepatocellular carcinoma (HCC) [1–3], intrahepatic cholangiocarcinoma (ICC) [4, 5], and liver metastases of malignancies including neuroendocrine tumours (NETs) and colorectal cancer (mCRC) [6]. Although SIRT is a well-established therapy, efforts to personalise and refine the planning and administration of therapy

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

INDUSTRY NEWS Eur J Nucl Med Mol Imaging

are ongoing. The ability to accurately predict, plan and deliver optimal doses to the tumour and non-tumoural tissues, including a final validation of the dose distribution, is a first principle of radiotherapy. Knowing the true absorbed dose to tissue compartments is the primary way to safely individualise therapy for maximal response while respecting normal tissue tolerances. Recent progress in positron emission tomography (PET) imaging has improved the ability to estimate absorbed 90 Y doses [7–11] and a more accurate dosimetric approach to activity calculation in SIRT is now possible. Published randomised trials of SIRT were initiated before the widespread introduction of personalised dosimetry approaches, and therefore, expert guidance on how best to perform personalised dosimetry is needed. Recommendations on dosimetry for 90Y-glass microspheres for HCC have been published [12], but because of differences in the size and specific activity of 90Y-glass microspheres and 90Y-resin microspheres, separate recommendations are needed for 90Y-resin microspheres. In addition, recommendations should be developed for other tumour types. Our aim was to provide recommendations to assist practitioners in optimising individualised activity prescription for SIRT with 90Y-resin microspheres in primary and metastatic liver tumours. It is anticipated that this manuscript will be the

first in a series on this topic that will provide essential guidance for practitioners and future research.

Methods The method used to reach agreement was based upon Delphi methods (Fig. 1). The steering committee (SC) consisted of 23 experts in nuclear medicine (n = 7), medical physics (n = 7), interventional radiology (n = 7), radiation/surgical/medical oncology (n = 1) and hepatology (n = 1) from Europe, North America and Asia. Experts were included based on their recognised clinical expertise, experience with SIRT and academic contributions to the field. Generally, and based on information provided by Sirtex Medical, experts were selected from centres that had conducted over 100 SIRT procedures with 90Y-resin microspheres, and if they had published on SIRT and personally been involved in the management of more than 50 patients receiving 90Y-resin microspheres. A questionnaire to collect opinion on pre-SIRT simulation, interventional strategy, individual activity prescription methods and treatment evaluation, was tested and refined by the SC. The finalised questionnaire consisting of 61 questions (Supplementary File 1) was administered anonymously to a

Fig. 1 Overview of methodology

Experts recruited to steering committee Questionnaire developed Steering committee meeting 1 Questionnaire 1 circulated to expert panel

Questionnaire approval and identification of wider expert panel members

61 questions via online survey

Analysis of responses to questionnaire Steering committee meeting 2 Working groups develop recommendations Recommendations consolidated and reviewed Finalise recommendations and summary text

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

Discussion of questionnaire responses, development of statements and working group assignment

INDUSTRY NEWS Eur J Nucl Med Mol Imaging

broader expert panel of 41 members (including the SC; of the additional 18 included in the expert panel, specialties were nuclear medicine (n = 11), medical physics (n = 2), interventional radiology (n = 4) and radiation/surgical/medical oncology (n = 1)). Upload of the questionnaire, collection and collation of the responses was managed by a third-party agency. Questionnaire responses were refined into a series of statements and the level of agreement of responders was rated (‘strong agreement’ when ≥ 80% of responders agreed with a statement; ‘moderate agreement’ when 50–79% of responders agreed with a statement; these definitions were developed by the SC based on the range of definitions of consensus used in Delphi studies [13]). Responses were not assessed/compared by responder specialty. Working groups from the SC summarised the evidence to support sub-groups of these statements. Published data on SIRT dosimetry from blinded or prospective randomised controlled trials are limited, and most evidence cited in this recommendation would be considered weak. Using an evidence grading system such as the GRADE system [14] is therefore unlikely to add value to these recommendations.

radiation oncologist and surgeon) and any other specialty that may provide useful information (e.g. diagnostic radiologist or pathologist). SIRT may be useful for liver-only disease and may also be recommended in selected cases when extrahepatic disease is present and not deemed prognostically relevant. Therefore, whole body imaging to detect extrahepatic disease is important to exclude patients from SIRT or guide their management plan [15] (R2, Table 1). Additional essential pre-SIRT steps for all tumour types (whether or not the liver is (pre)cirrhotic) include assessment of the arterial liver anatomy, underlying liver function and portal hypertension (R3, R4, Table 1). When there is bi-lobar manifestation of the tumour, a same day bi-lobar approach to SIRT may be useful to provide more flexibility than single-injection whole liver SIRT (R5, Table 1). There is no rationale for a staged (separate days) bi-lobar approach. However, if this approach is chosen based upon individual factors such as treatment intent, a period of 3– 8 weeks should be left between the two treatments (R6, Table 1). Cone-beam CT angiography

Results A summary of all responses is provided in the Supplementary File 2. Centres at which the expert panel members practiced had a median of 14 years experience with 90Y-resin microspheres and more than 50% of centres conducted more than 40 SIRT procedures each year. The recommendations derived from the questionnaire responses are summarised below into those related to interventional strategy and pre-treatment considerations (Table 1), individual activity prescriptions (Table 2) and treatment evaluation (Table 3).

Interventional strategy and pre-treatment 99mTc-MAA simulation

There is evidence that cone-beam computed tomography (CBCT) may be useful for vessel targeting and may identify feeding branches to tumours that CT or magnetic resonance imaging (MRI) fail to detect [16] (R7, Table 1). Therefore, if available, CBCT is recommended to complement CT or MRI. Additionally, CBCT is useful for providing reliable information on extrahepatic arterial perfusion, and is helpful for differentiating areas of segmental perfusion and confirming full tumour coverage from the site of infusion [16, 17] (R7, R8, Table 1). However, CT and MRI remain valuable options for volumetric analysis before SIRT, and CT can be considered a minimum standard [18] (R9, Table 1). Hybrid CT/ angiography is preferred to CBCT where available. 99m

General pre-treatment considerations and the multidisciplinary tumour board

Tc-MAA scintigraphic imaging

Personalised SIRT needs a holistic view of the patient and the disease. The disease stage, long-term and immediate treatment aims, and morphological and biological characteristics of the tumour and the surrounding liver, should all be considered when establishing a SIRT treatment plan. As such, the continuous exchange of information and opinions between multiple specialties is required (R1, Table 1). The multidisciplinary tumour board (MDT) should, as a minimum, consist of the clinician overseeing the care of the patient (medical oncologist, radiation oncologist, hepatologist, surgeon, others), the team that will perform the treatment (e.g. interventional radiologist, nuclear medicine specialist, medical physicist,

Given the similar median size of macroaggregated albumin (MAA) particles and resin microspheres [19], MAA distribution pattern serves as a surrogate for how 90Y-resin microspheres will localise (R10, Table 1). While 99mTc-MAA acts as a reasonably accurate surrogate, it does have limitations and discrepancies between pre- and post-SIRT dose estimates can occur due to several factors including flow differences between MAA and resin microspheres, catheter position deviations and differences between imaging modalities used [20, 21]. During pre-treatment angiography, a calibrated amount of 99m Tc-MAA is administered at selected sites within the hepatic arterial tree. As MAA degrades rapidly in the liver [22] scintigraphy should start ≤ 1 h after administration.

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INDUSTRY NEWS Eur J Nucl Med Mol Imaging Table 1

Recommendations on the interventional strategy and pre-treatment 99mTc-MAA simulation when planning SIRT with 90Y-resin microspheres

Recommendation number

Recommendation

Strength of agreement

General pre-treatment considerations and the multidisciplinary tumour board R1 Treatment strategy and therapeutic intent should be defined by a multidisciplinary team R2 When available, whole body FDG PET/CT (for FDG-avid tumours) or Octreotate-PET/CT (for neuroendocrine tumours) should be performed in addition to the SIRT work-up procedure to assess presence of extrahepatic disease R3 The arterial liver anatomy should be assessed before simulation R4 Underlying liver function should be determined by clinical scoring (Child-Pugh, ALBI, etc.) R5 In cases of bi-lobar manifestation of the tumour, a single injection into the common hepatic artery is not recommended. A same day bi-lobar procedure (left and right hepatic artery separately in a single session) may be recommended depending on individual characteristics, such as liver function, treatment intent and practical considerations, such as the ease of patient visit R6 When staged (separate days) bi-lobar infusion is used, a period of 3–8 weeks should be left between the two treatments CT angiography R7 When available, cone-beam CT is useful for the identification of vessel targeting for SIRT R8 Cone-beam CT may also be useful for checking tumour perfusion, volumetric analysis for activity prescription and extrahepatic deposition assessment R9 Conventional cross-sectional imaging (CT or MRI) are options for volumetric analysis before SIRT 99m Tc-MAA scintigraphic imaging R10 Scintigraphic imaging of 99mTc-MAA is recommended before SIRT for identification of intra- and extrahepatic depositions, assessment of lung shunt, for calculation of the activity to be injected and volumetric analysis of the treatment field 99m Tc-MAA or cone-beam CT are both useful for extrahepatic R11 deposition verification R12 SPECT/CT is the recommended imaging method for evaluating 99mTc-MAA distribution within the liver R13 Tumours should be delineated on conventional cross-sectional images and correlated with 99mTc-MAA images R14 Conventional cross-sectional imaging (CT or MRI) and 99mTc-MAA SPECT/CT are all options for volumetric analysis before SIRT R15 The portion of a tumour with complete absence of vascularisation on perfusion CT/CBCT and/or metabolic activity on [18F]FDG PET/CT could be excluded from the target volume (and the healthy liver volume), consideration of the portion depends upon activity prescription calculation method R16 Generally, SIRT should be withheld for lesions with less 99mTc-MAA uptake than non-tumoural liver. In exceptional situations, SIRT may be appropriate, for example, when ablative SIRT is possible and in other clinical scenarios (i.e. if it is still possible to selectively deliver a significant amount of radiation to the lesion) R17 SIRT should be conducted as soon as possible after the simulation and no more than 4 weeks after simulation R18 If a staged (separate days) bi-lobar approach is planned, the need for a repeat of the simulation is greater with a greater interval between the two SIRT sessions. However, no clear agreement was reached on whether staged simulation should be recommended or not, and if staged simulation is performed, there was no agreement on whether or not to recommend performing the second simulation during the same session as the first SIRT R19 There is no consensus on whether the 99mTc-MAA simulation should be re-performed if the catheter position is modified or when additional embolisation is needed. Lung shunt estimation R20 Planar imaging should be used, as a minimum, for evaluating the lung shunt with 99mTc-MAA. SPECT/CT may be used to supplement this in selected cases

Strong Strong

Strong Strong Moderate

Strong Strong Moderate Moderate Strong

Strong Strong Moderate Moderate Moderate

Moderate

Strong None

None Moderate

ALBI, albumin-bilirubin; CT, computed tomography; FDG, fluorodeoxyglucose; MRI, magnetic resonance imaging; PET, positron emission tomography; SIRT, selective internal radiation therapy; SPECT, single-photon emission computed tomography; 99m Tc-MAA, technetium-99 m labelled macroaggregated albumin

Abdominal extrahepatic depositions identified on scintigraphy are caused by physiological accumulation of dissociated 99m Tc-pertechnetate (which can hinder accurate evaluation of

the gastric region) or 99mTc-MAA lodging in tissues. To limit dissociation, 99mTc-MAA should be prepared under strict quality control and sodium perchlorate may be given to reduce

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INDUSTRY NEWS Eur J Nucl Med Mol Imaging Table 2

Individual activity prescription recommendations for the use of SIRT with 90Y-resin microspheres

Recommendation number

Activity prescription methods R21

Recommendation

Strength of agreement

A personalised approach to activity prescription is recommended when whole liver SIRT is planned and when selective non-ablative treatment is planned. The partition model (MIRD-based) or 3D dosimetry (voxel-based) are recommended, but the safety of these methods is still unproven R22 Likewise, when doing selective ablative treatment, an activity prescription method is needed and a personalised approach to activity prescription is recommended Personalised activity prescription methods (MIRD-based/voxel-based) R23 For selective ablative treatments, it is recommended to consider a higher specific activity, hence a lower number of microspheres. A high T/N ratio warrants the consideration of a higher specific activity R24 In the absence of a better surrogate, it is recommended to determine the T/N ratio from signal distribution evaluated from 99mTc-MAA SPECT/CT Lung shunt management R25 It is recommended that lung shunt limits are expressed as the calculated absorbed radiation dose (Gy) resulting from the administered activity (this does not exclude the use of percentages to express lung shunt limits) R26 On planar scans, recommended cut-off values for lung exposure are 30 Gy (single) and 50 Gy (cumulative) R27 This is preferred to expressing cut-offs as a percentage, if percentages are used, a cut-off of 20% is recommended R28 Measuring the patient-specific lung mass for assessing dose to lung tissue is recommended when LSF is close to the recommended cut-offs (when LSF is not close to cut-offs, the assumption of 1 kg lung mass is acceptable) Safety dose cut-off—whole liver/bi-lobar treatment R29 When patients have a ‘non-compromised’ liver, the recommended mean absorbed dose limit for safety to non-tumoural liver is 40 Gy, when doing whole liver treatment. When the liver is heavily pretreated or when there is suspicion of compromised liver function, this cut-off should be reduced to 30 Gy but should be estimated on an individualised basis Safety dose cut-off—lobar and segmental treatment R30 There was no clear agreement on whether to use the same absorbed dose safety limits for unilobar treatment as used for whole liver treatment, most experts would not R31 For unilobar or segmental treatment, when the volume and function of the contralateral liver lobe is sufficient (FLR cut-off of the contralateral liver lobe of 30–40%), a more aggressive treatment (than for whole liver treatment) may be useful (depending on several factors such as the intent of treatment, liver function and tumour type) R32 In unilobar or segmental treatment, if the function of the treated lobe is to be preserved, a mean absorbed dose cut-off of 40 Gy is proposed. In cases where some loss of function is acceptable, a higher cut-off could be used R33 There was no clear agreement on whether to perform a more aggressive unilobar treatment in cirrhotic patients Safety dose cut-off—lobectomy and segmentectomy R34 In lobectomy a mean absorbed dose to the non-tumoural liver of > 70 Gy for ablative therapy is proposed R35 A higher mean absorbed dose should be used for segmentectomy—possibly > 150 Gy Safety dose cut-off—SIRT before surgery R36 The minimal time window between SIRT and surgery should be defined by monitoring liver volumetry/function and tumour control, while considering the decay of 90Y which will reach safe levels after 1 month Efficacy dose cut-off R37 To target tumour ablation/complete response, a minimum mean absorbed dose cut-off of 100–120 Gy is proposed for mCRC R38 To yield a response, a minimum mean absorbed dose cut-off of 100–120 Gy is proposed for HCC R39 To yield a response, a minimum mean absorbed dose cut-off of 100–120 Gy is proposed for ICC R40 To yield a response, a minimum mean absorbed dose cut-off of 100–150 Gy is proposed for NET

Strong

Strong Strong Strong Strong Moderate None Moderate

Strong

None Strong

Moderate None Strong Strong Moderate

Strong Strong Moderate Moderate

CT, computed tomography; FLR, future liver remnant; HCC, hepatocellular carcinoma; ICC, intrahepatic cholangiocellular carcinoma; LSF, lung shunt fraction; mCRC, metastatic colorectal cancer; MIRD, Medical Internal Radiation Dose; NET, neuroendocrine tumour; SIRT, selective internal radiation therapy; SPECT, single-photon emission computed tomography; 99m Tc-MAA, technetium-99 m labelled macroaggregated albumin; T/N, tumour/normal liver

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INDUSTRY NEWS Eur J Nucl Med Mol Imaging Table 3

Treatment evaluation recommendations for the use of SIRT with 90Y-resin microspheres

Recommendation number

Recommendation

Strength of agreement

It is important to verify that the position/location of the catheter is the same during SIRT as it was during the 99mTc-MAA simulation by visually comparing the positions on angiography Post-SIRT residual activity of microspheres in the vial, tubing system and syringe should be measured Post-SIRT imaging for treatment verification is used for dosimetry and visual verification Post-SIRT imaging for treatment verification is used for future (re)-SIRT

Strong

Post-SIRT imaging should be performed using the best option available—it should be visual and quantitative and therefore 90Y-PET is preferred (when 90Y-PET is not available, BECT is an acceptable alternative—but is difficult to use to get quantitative verification) Post-SIRT dosimetry is recommended

Strong

When post-SIRT imaging and/or dosimetry shows areas of possible insufficient treatment of the tumour, it is recommended to wait for follow-up response imaging before deciding on the need to re-treat

Moderate

Treatment verification R41 R42 R43 R44 R45

R46

Strong Strong Moderate

Strong

Treatment response evaluation R47

BECT, 90 Y bremsstrahlung emission computed tomography; PET, positron emission tomography; SIRT, selective internal radiation therapy; MAA, technetium-99 m labelled macroaggregated albumin

gastric pertechnetate uptake. Focal gastrointestinal or pancreatic uptake is important as it may lead to severe radiation damage during 90Y-SIRT. Other sites include the gall bladder, the abdominal wall (through the falciform artery) and the hilar hepatic artery. Single-photon emission computed tomography/CT (SPECT/CT) has been shown to be more effective than planar imaging for identifying extrahepatic uptake sites [23]. It is recommended to identify and, if possible, remedy the vascular source of extrahepatic uptake, and to use angiographic imaging such as CBCT, before proceeding with treatment (R7, R8, R11, Table 1). Intrahepatic 99mTc-MAA distribution should be evaluated using SPECT/CT, instead of planar scintigraphy or SPECT alone (R12, Table 1), and ideally shows focal uptake at all tumour sites within the treatment field, with limited uptake in the non-tumoural liver parenchyma. Scatter and attenuation correction will improve both visual and quantitative SPECT evaluation. Compensation of attenuation can be done on planar images using geometric mean of antero-posterior views The degree of uptake in non-tumoural parenchyma is less relevant in the case of ablative segmentectomy, other low volume targets or in hypertrophy-inducing lobectomy. Conventional cross-sectional/metabolic images are used to identify tumour volume and should be correlated with 99m Tc-MAA images to improve delineations and report on areas of the tumour with limited or no uptake (R13, R14, Table 1). The portion of a tumour with complete absence of vascularisation on perfusion CT/CBCT and/or metabolic activity on [18F]fluorodeoxyglucose (FDG) PET/CT could be

99m

Tc-

excluded from the target volume (R15, Table 1). 99mTcMAA SPECT/CT is used to quantify uptake in tumour lesions and normal parenchyma for the purpose of activity calculation [24, 25]. Therefore, SIRT should generally be withheld for lesions with 99mTc-MAA uptake that is similar to, or less than, non-tumoural liver, and when there is a lack of enhancement on CBCT (R16, Table 1). In a limited number of cases, especially in mCRC, there is low concentration of 99mTc-MAA despite rim hypervascularisation on CBCT. These cases should not be excluded from treatment even if the 99mTcMAA cannot be used for predictive dosimetry. To limit anatomical/vascularisation modification caused by disease progression, treatment should be conducted as soon as possible after the simulation (R17, Table 1). When staged bilobar SIRT is used, performing staged (before each SIRT) simulation is not mandatory, the initially obtained lung shunt fraction can be carried over to the second treatment (R18, Table 1). The position/location of the catheter during the administration of 90Y-microspheres should be consistent with the position during the 99mTc-MAA simulation [26]. When a segmental treatment is planned, it is essential that the catheter position is in the same arterial branch. When segmental treatment is planned, lobar 99mTc-MAA simulation may be performed, for example, to avoid damage to the segmental artery. Clinical justification for adjustment or alteration of catheter position between sessions should be documented. The need to re-perform 99mTc-MAA simulation when the catheter position is modified may depend on the degree of position change; slight differences in catheter tip position, especially near

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vascular bifurcations, can induce major differences in hepatic distribution (R19, Table 1). Lung shunt fraction estimation The estimated lung shunt fraction (eLSF) represents the fraction of injected microspheres lodged within the pre-capillary bed of the lungs and can be estimated on images from the 99m Tc-MAA simulation, either planar or SPECT/CT (R20, Table 1), by dividing the counts of the lung by the sum of the counts in the lung and liver. This estimation is biased by two types of error: (1) some of the MAA particles are smaller than the resin microspheres and intrahepatic degradation of 99m Tc-MAA leads to lower liver and higher lung counts, increasing eLSF [22]; and (2) physical factors, such as volume averaging of the liver dome into the lung compartment during respiration, lower attenuation in lung versus liver tissue and scatter of liver activity into the lung, also increase eLSF. SPECT/CT with attenuation and scatter correction can reduce the latter error [27].

Individual activity prescription Activity prescription methods Personalised therapeutic activity prescription in SIRT aims to maximise tumour response while sparing non-target tissues from undesired toxicity by tailoring the treatment according to patient-specific parameters (e.g. local activity and dose deposition, and tissue masses and functionality) (R21, R22, Table 2). The need for treatment personalisation is supported by several publications [4, 28–33], and is in compliance with the principle of optimisation expressed in the COUNCIL DIRECTIVE 2013/59/EURATOM Article 56 [34]. (Modified) body surface area method If personalised therapeutic activity prescription is feasible, it is preferred to the body surface area (BSA) method. Several studies demonstrated the lack of personalisation of the BSA method leading to under/overtreatment, and therefore, to poorer outcome when compared to more personalised approaches such as the partition model [4, 28, 35]. The safe use of modified BSA (mBSA), when a more selective treatment (e.g. lobar) is performed, has nevertheless been confirmed in a number of prospective trials. Personalised activity prescription methods (MIRD-based/voxel-based) (R23, R24, Table 2) Personalised activity prescription relies on dosimetry that considers the patient-specific anatomy and perfusion of microspheres [36]. According to the Medical Internal Radiation

Dose (MIRD) formalism, the absorbed dose under equilibrium to a compartment DC, knowing the administered 90Y-activity AC in that compartment and its mass MC is calculated by: 49:67 � Ac ½GBq� Dc ½Gy� ¼ ð1Þ M c ½kg� The partition model considers the distribution of microspheres into the lungs, the tumour and the non-tumoural liver, by 3D quantification on SPECT or SPECT/CT images [37–39]. The first estimation of the activity A to administer would then be calculated from the targeted dose to tumour DT by [40]: A½GBq� ¼

DT ½Gy� � ðM N ½kg� þ M T ½kg� � rÞ 49:67 � r � ð1−LÞ

ð2Þ

with L being the lung shunt fraction: L¼

total counts in lungs total counts in lungs þ total counts in liver

ð3Þ

and r the tumour to normal liver ratio (T/N ratio): r¼

average counts per ml in tumour average counts per ml in non−tumoural liver

ð4Þ

where MN and MT being the masses of non-tumoural liver and tumour, respectively. MIRD equations and partition model can be adapted to consider as many compartments as needed (i.e. for bi-lobar or segmental approaches) and by using 3D quantification. Using the activity obtained with Eq. 2, the absorbed dose to the considered compartments should be computed (Eq. 1), and if needed, the activity to administer should be adapted to respect the different safety/efficacy dose limits (with the primary consideration being the safety limits). A further degree of personalisation is voxel-based dosimetry, where each voxel is considered as a source and/or a target, allowing visualisation of 3D absorbed dose distributions [29, 41, 42] and the evaluation of degree of heterogeneity in both organs and targets through the dose volume histograms (DVHs) [43]. Individual activity prescription Lung shunt management During the 99mTc-MAA simulation, the eLSF allows (1) calculation of the absorbed dose to the lung parenchyma and (2) compensating prescribed treatment activity for shunted activity to prevent underdosing in target regions. The main safety purpose is prevention of radiopneumonitis, which can be fatal. The use of eLSF to define maximum radiation doses to the lungs has strongly reduced the incidence of radiopneumonitis; 2 cases out of 1022 treated patients in modern large randomised controlled trials that have used planar imaging

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[1–3, 44, 45]. Thresholds should be expressed as the calculated dose to the lungs (R25, R26, R27 and R28; Table 2). These historical thresholds suffer from methodological issues (described earlier) but are demonstrated to be safe.

4) SIRT before surgery SIRT before surgery is well tolerated [50, 51]. The time window between SIRT and surgery depends on tumour biology, 90Y decay and treatment aim (R36, Table 2).

Safety dose cut-off Efficacy dose cut-off 1) Whole liver/bi-lobar treatment A mean absorbed dose to non-tumoural liver of ≤ 40 Gy is considered safe (R29, Table 2). This dose level can be derived from external beam radiotherapy (EBRT), using biological effective doses [43]. Based on 90 Ybremsstrahlung emission CT (BECT) images, a liver dose of 52 Gy (95% CI 44–61 Gy) in a whole liver injection provided a 50% probability of ≥ G2 liver toxicity in patients with HCC [31]. Tolerability of SIRT depends on the initial liver function (Child-Pugh score or baseline bilirubin) [46]. Therefore, when the liver is heavily pretreated or when there is suspicion of compromised liver function, the cut-off should be reduced (R29, Table 2). 2) Lobar and segmental treatment In unilobar or segmental treatments, a more aggressive treatment (i.e. higher mean absorbed dose to non-tumoural parenchyma) can be considered when some loss of function due to treatment is acceptable (but not when function is to be preserved), but a cut-off was not agreed (R30, R31, R32, Table 2). In these treatment approaches, voxel-based modelling of the absorbed dose based on 99mTc-MAA distribution may help to predict the radiation-induced effects throughout the liver. Currently, DVHs allow estimation of the tissue volume fraction receiving a minimum dose threshold. 3) Lobectomy and segmentectomy Radiation lobectomy, with the intent to induce contralateral lobe hypertrophy while achieving tumour control and including a biologic test of time, may be considered in patients with unilobar disease and a small anticipated future liver remnant, in an attempt to facilitate curative surgical resection. While there is some evidence for a mean absorbed dose cut-off to achieve this, further validation is needed (R34, Table 2) [47–49]. Radiation segmentectomy may be considered for localised disease (≤ 2 segments) supplied by a segmental artery, and unamenable for other curative therapies because of the tumour localisation or patient comorbidities. The small volume of the liver treated allows administration of high mean absorbed doses to produce tumour ablation with low toxicity risk to the untreated parenchyma, but evidence is limited (R35, Table 2).

Heterogeneity exists among reported dose-outcome relationships because of the variability of the applied outcome measure (Table 4), which include (1) benefit to the patient increased (progression-free survival/overall survival (OS)/ quality of life); (2) local tumour response to the treatment anatomic response (RECIST) and metabolic response on [18F]FDG PET (partial or complete reduction of [18F]FDG uptake/metabolic volume/total lesion glycolysis [TLG]). Therefore, efficacy dose cut-offs should always be considered in the context of the applied outcome measurement. OS is currently the de facto clinical endpoint. Importantly, when metabolic response is the endpoint, cut-offs maximising probabilities of complete metabolic response should be prioritised for treatment planning. Another source of variability in the dose-outcome assessment stems from the different activity prescription methods used in different studies with many using BSA/mBSA models. Similarly, the reported tumour-absorbed doses may be based on 99mTc-MAA images collected in the treatment planning or may be based upon post-SIRT 90Y-PET/CT. 1) Liver dominant colorectal cancer metastases Several prospective and retrospective studies reported the existence of a lesion-based dose-response relationship (Table 4). Post-SIRT tumour-absorbed dose cut-offs of 60 Gy for predicting a metabolic response (defined as > 50% reduction of TLG) were reported (using partition model) [29], and doses > 50 Gy (using mBSA method) [30] and > 40– 60 Gy (using BSA method) [28] provided better responses in two studies using a similar endpoint. In these studies, lesions that received more than 100–120 Gy had a higher probability of complete metabolic response (R37, Table 2). 2) Hepatocellular carcinoma Several studies on pre- and post-therapy imaging indicate the recommended threshold tumour dose [31, 52, 53] (R38, Table 2). In the SARAH trial (using BSA method), a post hoc analysis of putative delivered dose based on 99mTc-MAA SPECT/CT showed that OS and disease control were significantly better with a tumour-absorbed dose ≥ 100 Gy [32]. The probability of disease control at 6 months was 72% (95% CI 46–89%) and 81% (95% CI 58–93%) with a tumour-absorbed dose of 100 Gy and 120 Gy, respectively. The probability for

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Chemorefractory mCRC (n = 30)

van den Hoven et al. 2016 [28]

BSA

Activity prescription method

Unresectable mNET (n = 15)

Partition model

Liver-only mCRC progressing after Partition model chemotherapy (n = 24) Unresectable mCRC progressing Modified BSA despite chemotherapy (n = 22) Unresectable HCC (n = 73) BSA

Tc-MAA SPECT MIRD

99m

CR and PR according to mRECIST

Review of studies using treatment response and OS

Predictor of response and OS with a threshold of 100–120 Gy Median OS was 5.5 months when BSA used (mean radiation dose to tumour of 38 Gy) Median OS was 14.9 months when partition model was used (mean radiation dose to tumour of 86 Gy) Cut-off of ≥ 191.3 Gy for tumour-specific absorbed dose predicted tumour response with 93% specificity < 72.8 Gy predicted non-response with 100% specificity

BSA, body surface area; CR, complete response; CT, computed tomography; FDG, fluorodeoxyglucose; 99m Tc-MAA, technetium-99 m labelled macroaggregated albumin; HCC, hepatocellular carcinoma; ICC, intrahepatic cholangiocarcinoma; mCRC, metastatic colorectal cancer; mNET, metastatic neuroendocrine tumour; OS, overall survival; PET, positron emission tomography; BECT, 90 Y bremsstrahlung emission computed tomography; PR, partial response; TLG, total lesion glycolysis

Chansanti et al. 2017 [33]

Levillain et al. 2018 [29] Willowson et al. 2017 [30] Stigari et al. 2010 [31] Hermann et al. 2020 [32]

Retrospective assessment of OS in group receiving tumour Median OS 14.1 month in those receiving ≥ 100 Gy radiation-absorbed dose < 100 Gy or ≥ 100 Gy Median OS 6.1 months in those receiving < 100 Gy

Tumour-absorbed dose quantified on 90Y-PET versus TLG 50% reduction in TLG at 1 month associated with prolonged OS on 18F-FDG PET At least 40–60 Gy required to achieve 50% reduction in TLG TLG for each target lesion measured on FDG PET/CT Cut-offs of 39 Gy and 60 Gy predict non-metabolic response and high-metabolic response, respectively Peak standardised uptake value and TLG Approximately 50 Gy derived as the critical threshold for a significant response (> 50% reduction in TLG) CR and PR according to RECIST Median dose to achieve CR/PR was 99 Gy

Y-PET 3D voxel-based

Results

Response assessment

Lesion dosimetry assessment

Y-PET 3D voxel-based 90 Y-PET 3D voxel-based 90 Y-BECT 3D voxel-based 99m Tc-MAA Locally advanced unresectable BSA SPECT 3D HCC (n = 121) voxel-based Garin et al. 2019 HCC with PVT Multiple MIRD and 3D [52] voxel-based Levillain et al. Unresectable and chemorefractory BSA or partition 99mTc-MAA SPECT 3D 2019 [4] ICC (n = 58) model voxel-based

Population

Key studies on dose-response with 90Y-resin microspheres

Study

Table 4

Eur J Nucl Med Mol Imaging

INDUSTRY NEWS

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Patients with NETs have particular features that distinguish them from other patients eligible for SIRT: (1) absence of underlying liver disease, (2) relatively long OS and (3) pronounced hypervascular tumours with high T/N ratios on 99m Tc-MAA and post-therapy imaging [56]. There is a paucity of data regarding dose-response relationships in NET. Using partition model, a preliminary dose-response relationship was reported between 99mTc-MAA SPECT/CT and mRECIST-based response in 55 lesions in 15 patients—a higher mean tumour dose resulted in a better response rate (207 vs 114 Gy, in responders vs non-responders, respectively) [33]. Response rate was 96% when the tumour dose was > 191 Gy. No response was seen with a tumour dose < 73 Gy. Our recommendation is based on providing a sufficient dose to tumour while limiting the dose to healthy parenchyma to avoid long-term complications (R40, Table 2).

rate of the delivery system before and after treatment. Other options include quantitative imaging by 90Y-PET/CT or BECT, or measuring residual activity within each injection material using a dose calibrator. Post-SIRT imaging for qualitative and quantitative assessment is highly recommended to address two fundamental aspects (R43, R44, Table 3). Firstly, it allows the verification of the treatment to the intended territory. Identifying technical failure with lack of uptake in the target liver parenchyma and/or in selected lesions allows consideration of additional therapies in a timely manner [57]. Secondly, it serves to detect any possible extrahepatic activity, which can cause serious complications, such as ulceration and gastrointestinal bleeding [58]. Knowledge of microsphere deposition in non-target areas may guide appropriate actions to minimise possible radio-induced toxicity. Post-SIRT imaging of 90Y distribution may be performed using 90Y-PET/CT or BECT [59, 60]. Many studies have shown qualitatively superior resolution and contrast with 90Y-PET/CT compared to BECT, and 90YPET/CT can be easily used for quantification, supporting the use of 90Y-PET/CT as the preferred post-SIRT imaging technique [8, 10, 61] (R45, Table 3). However, when 90Y-PET is not available, BECT is an acceptable alternative to visually assess dose distribution [31]. Post-SIRT image-based dosimetry is recommended (R46, Table 3) to verify and evaluate agreement between planned and delivered dose. Post-SIRT dosimetry can help to assess the robustness of planned dose constraints, and to identify novel and more robust dose constraints guaranteeing the efficacy and safety of treatment [43, 62]. To correlate doses with patient outcomes, quantitative imaging with 99mTc-MAA SPECT/CT and/or 90YPET/CT is mandatory. As with all nuclear/radiology imaging, local acquisition, reconstruction and data analysis must be validated to provide quantitative accuracy and system recovery.

Treatment evaluation

Treatment response evaluation

Treatment verification

Clinical and biochemical assessment after SIRT for any significant side effects is typically performed at 1– 2 months post-SIRT. Imaging assessment of tumour response should be at 1–3 months post-SIRT, and every 2–3 months thereafter. The clinically relevant ‘treatment response’, and thus the most suitable imaging technique, is defined differently depending on the type of tumour (e.g. variable FDG avidity) and treatment goal. In a preoperative setting when bridging to surgery, complete metabolic response and/or tumour shrinkage (depending on tumour type) is the goal and high definition anatomometabolic imaging techniques are recommended (PET/ CT/MRI), often needing longer follow-up. In a noncurative setting, functional imaging techniques (PET/

tumour control increased when there was good concordance between pre-therapy 99mTc-MAA SPECT/CT and posttherapy BECT or PET/CT. 3) Cholangiocarcinoma There are few publications dealing with SIRT efficacy [54, 55], and only one [4] with tumour-absorbed dose, in patients with unresectable ICC. In particular, there are no reports of the absorbed dose threshold associated with tumour control. However, Levillain et al. showed that median OS (14.9 vs 5.5 months) and mean tumour-absorbed doses (86 vs 38 Gy) were significantly higher when therapeutic activity prescription was based on partition model compared to BSA method [4]. In the absence of robust evidence, our recommendation is based on the experience and data obtained from centres participating in the questionnaire (R39, Table 2). 4) Neuroendocrine tumours

With catheter-directed therapies, it is important to verify that the position/location of the catheter during the 99mTc-MAA simulation is consistent with the position during the administration of 90Y-microspheres [26] (R41, Table 3). However, factors such as flow, perfusion and nonlaminar hydrodynamics limit the ability to optimally reproduce position and flow dynamics. As a minimum, fluoroscopic reproduction of the catheter position should be performed during all administrations. Post-SIRT residual activity of microspheres should be measured to determine the actual administered activity (R42, Table 3). There was moderate agreement on how to achieve this; the most popular method was to determine the mean dose

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INDUSTRY NEWS Eur J Nucl Med Mol Imaging

MRI) indicating treatment resistance and early progression are recommended in order to rapidly identify the need for potential additional therapy. If there is possible insufficient treatment of the tumour, the need to re-treat should be assessed on follow-up (R47, Table 3), and the decision to re-treat earlier should consider the clinical status of the patient, the safety/suitability for re-treatment, and the overall clinical intent of treatment.

Future directions Published data on personalised SIRT from blinded or prospective randomised controlled trials are limited. Recently, a randomised trial showed that personalised activity prescription based on 99mTc-MAA SPECT/CT with glass microspheres significantly improved median OS in patients with HCC [63]. Therefore, personalised SIRT with 90Y-resin microspheres must be included in future prospective randomised controlled trial designs. In the meantime, these recommendations provide guidance for personalising SIRT with 90Y-resin microspheres in primary and metastatic liver cancers, but we acknowledge that the absence of prospective data limit the strength of these recommendations. Furthermore, efforts are needed to provide CE- and/or FDA-approved treatment planning software, dedicated personnel and dosimetry reimbursement, so that personalised SIRT becomes part of clinical routine. Several developments in SIRT are ongoing, and therefore, were not endorsed in these recommendations. Visual and quantitative assessment of the hepatic function using hepatobiliary scintigraphy and/or MRI-primovist, and posttreatment quantitative dosimetry using BECT images are promising, but more data are needed. As stated in the ‘Introduction’ section, this living document will continue to be updated as new data emerge.

Acknowledgments We thank the additional members of the expert panel who kindly completed the electronic questionnaires that formed the basis of these recommendations: Hojjat Ahmadzadehfar (University Hospital Bonn, Germany), Nuri Arslan (Near East University Hospital, Nicosia, Cyprus), Jon Bell (The Christie NHS Foundation Trust, Manchester, UK), Guiseppe Boni (Pisa University Hospital, Pisa, Italy), Daniel B. Brown (Vanderbilt University Medical Center, Nashville, USA), William A. Dezarn (Wake Forest School of Medicine, Winston-Salem, USA), Harun Ilhan (Ludwig Maximilians University of Munich, Germany), Alexander Kim (Georgetown University, Washington DC, USA), Walter Noordzij (University of Groningen, The Netherlands), Javier Orcajo Rincón (Hospital General Universitario Gregorio Marañón, Madrid, Spain), Lorraine Portelance (Sylvester Comprehensive Cancer Center, Miami, USA), Daphne Rietbergen (Leiden University Medical Centre, Leiden, The Netherlands), William S. Rilling (Medical College of Wisconsin, Milwaukee, USA), Amanda Rotger (Hospital General Universitario Gregorio Marañón, Madrid, Spain), Shyam M. Srinivas (UPMC, Pittsburgh, USA), Lars Stegger (University of Münster, Germany), Andrei Todica (Ludwig Maximilians University of Munich, Germany), Kathy Willowson (University of Sydney, Australia). Martin Gilmour of Empowering Strategic Performance (ESP) Ltd., Crowthorne, UK provided medical writing and editorial support, which was sponsored by Sirtex Medical in accordance with Good Publication Practice guidelines. Authors’ contributions Hugo Levillain and Patrick Flamen developed the initial concept of this project and manuscript. All authors participated in the SC meetings to develop the questionnaire or contributed to this via email. All authors completed the electronic questionnaire. All authors contributed to the interpretation of the questionnaire responses and the development of these into a list of recommendations (presented in the tables in this manuscript). All authors provided input into the writing, reviewing and revision of the manuscript. All authors approved the submitted version of the manuscript. All authors accept responsibility for the entire content of this submitted manuscript. Funding Funding of honoraria to attend meetings, and logistical and editorial support for this investigator-initiated venture was provided by an independent study grant from Sirtex Medical. Data availability Data from the survey used in the current study are available from the corresponding author on reasonable request.

Compliance with ethical standards

Conclusion Personalised activity prescription, based on dosimetry and multidisciplinary management for optimisation of safety and efficacy, is recommended when conducting SIRT with 90Yresin microspheres. Practitioners are encouraged to use these recommendations to perform personalised SIRT with 90Y-resin microspheres. This publication is not endorsed by any government entity or professional organisation. Decisions to modify or disregard these recommendations are the responsibility of managing clinicians. Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s00259-020-05163-5.

Conflict of interest HL has acted in an advisory role and received honoraria from Sirtex Medical. OB has received consultancy and proctor fees from Sirtex Medical. CMD has been a consultant for Sirtex Medical, Novartis, Terumo, AAA, Ipsen, and Bayer. AD has received lecture and honoraria fees from Sirtex Medical. SG has received lecture fees from Sirtex Medical. OSG has received lecture and consulting fees from Sirtex Medical. SCK has received research grants from Boston Scientific and GE Healthcare, and has served as a consultant for Boston Scientific, Sirtex Medical, ABK Biomedical, Varian Medical, and Terumo Medical. AK has not received any compensation from Sirtex Medical or other microsphere vendor. Sarah Cannon has been the recipient of a past grant for a phase II clinical study and fees to compensate it for AK involvement in an advisory role 2018–2020. NK has served as a consultant and has received research support from Sirtex Medical. DML receives consulting fees from Sirtex Medical and Eisai Pharmaceuticals. DCM has received consultancy fees from Sirtex Medical. AM has received research grants from Sirtex Medical and BTG/Boston Scientific

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INDUSTRY NEWS Corp and is a consultant for Sirtex Medical, Boston Scientific Corp and ABK Medical. AMdlC has received proctor, consultancy and speaker fees from Sirtex Medical. DCEN has received grants from Sirtex Medical, Bayer, MSD and Norvatis, and lecture honoraria from Sirtex Medical and Bayer. PMP has received consultancy and speaker fees from Sirtex Medical. CP has received lecture fees from Sirtex Medical. MRF has received lecture fees from Sirtex Medical. RS is a consultant for Boston Scientific, Eisai, Exelixis, Genentech, Cook and Sirtex Medical. BS received lecture and/or consulting fees from Adaptimmune, Bayer, BMS, BTG, Eisai, Ipsen, Lilly, Roche and Sirtex Medical, research fees from BMS and Sirtex Medical. LS has received lecture fees from Sirtex Medical. DYS served as a consultant to Sirtex Medical. BJdWvdV has received consulting/lecture fees from Sirtex Medical. PF has acted in an advisory role and received honoraria from Sirtex Medical. Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors.

Eur J Nucl Med Mol Imaging 6.

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Consent to participate Not applicable Consent for publication Not applicable Code availability Not applicable Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

11.

12.

13.

14.

15.

References 1.

Vilgrain V, Pereira H, Assenat E, Guiu B, Ilonca AD, Pageaux GP, et al. Efficacy and safety of selective internal radiotherapy with yttrium-90 resin microspheres compared with sorafenib in locally advanced and inoperable hepatocellular carcinoma (SARAH): an open-label randomised controlled phase 3 trial. Lancet Oncol. 2017;18(12):1624–36. Chow PKH, Gandhi M, Tan SB, Khin MW, Khasbazar A, Ong J, et al. SIRveNIB: selective internal radiation therapy versus sorafenib in Asia-Pacific patients with hepatocellular carcinoma. J Clin Oncol. 2018;36(19):1913–21. Ricke J, Klumpen HJ, Amthauer H, Bargellini I, Bartenstein P, de Toni EN, et al. Impact of combined selective internal radiation therapy and sorafenib on survival in advanced hepatocellular carcinoma. J Hepatol. 2019;71(6):1164–74. Levillain H, Duran Derijckere I, Ameye L, Guiot T, Braat A, Meyer C, et al. Personalised radioembolization improves outcomes in refractory intra-hepatic cholangiocarcinoma: a multicenter study. Eur J Nucl Med Mol Imaging. 2019;46(11):2270–9. Zhen Y, Liu B, Chang Z, Ren H, Liu Z, Zheng J. A pooled analysis of transarterial radioembolization with yttrium-90 microspheres for the treatment of unresectable intrahepatic cholangiocarcinoma. Onco Targets Ther. 2019;12:4489–98.

16.

17.

18.

19. 20.

21.

Hendlisz A, Van den Eynde M, Peeters M, Maleux G, Lambert B, Vannoote J, et al. Phase III trial comparing protracted intravenous fluorouracil infusion alone or with yttrium-90 resin microspheres radioembolization for liver-limited metastatic colorectal cancer refractory to standard chemotherapy. J Clin Oncol. 2010;28(23): 3687–94. Gates VL, Esmail AA, Marshall K, Spies S, Salem R. Internal pair production of 90Y permits hepatic localization of microspheres using routine PET: proof of concept. J Nucl Med. 2011;52(1):72–6. Kao YH, Tan EH, Ng CE, Goh SW. Yttrium-90 time-of-flight PET/ CT is superior to Bremsstrahlung SPECT/CT for postradioembolization imaging of microsphere biodistribution. Clin Nucl Med. 2011;36(12):e186–7. Kao YH, Steinberg JD, Tay YS, Lim GK, Yan J, Townsend DW, et al. Post-radioembolization yttrium-90 PET/CT - part 1: diagnostic reporting. EJNMMI Res. 2013;3(1):56. Padia SA, Alessio A, Kwan SW, Lewis DH, Vaidya S, Minoshima S. Comparison of positron emission tomography and bremsstrahlung imaging to detect particle distribution in patients undergoing yttrium-90 radioembolization for large hepatocellular carcinomas or associated portal vein thrombosis. J Vasc Interv Radiol. 2013;24(8):1147–53. Bagni O, D'Arienzo M, Chiaramida P, Chiacchiararelli L, Cannas P, D'Agostini A, et al. 90Y-PET for the assessment of microsphere biodistribution after selective internal radiotherapy. Nucl Med Commun. 2012;33(2):198–204. Salem R, Padia SA, Lam M, Bell J, Chiesa C, Fowers K, et al. Clinical and dosimetric considerations for Y90: recommendations from an international multidisciplinary working group. Eur J Nucl Med Mol Imaging. 2019;46(8):1695–704. Diamond IR, Grant RC, Feldman BM, Pencharz PB, Ling SC, Moore AM, et al. Defining consensus: a systematic review recommends methodologic criteria for reporting of Delphi studies. J Clin Epidemiol. 2014;67(4):401–9. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, AlonsoCoello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650): 924–6. Schmidt GP, Paprottka P, Jakobs TF, Hoffmann RT, Baur-Melnyk A, Haug A, et al. FDG-PET-CT and whole-body MRI for triage in patients planned for radioembolisation therapy. Eur J Radiol. 2012;81(3):e269–76. Louie JD, Kothary N, Kuo WT, Hwang GL, Hofmann LV, Goris ML, et al. Incorporating cone-beam CT into the treatment planning for yttrium-90 radioembolization. J Vasc Interv Radiol. 2009;20(5): 606–13. van den Hoven AF, Prince JF, de Keizer B, Vonken EJ, Bruijnen RC, Verkooijen HM, et al. Use of C-arm cone beam CT during hepatic radioembolization: protocol optimization for extrahepatic shunting and parenchymal enhancement. Cardiovasc Intervent Radiol. 2016;39(1):64–73. Ertreo M, Choi H, Field D, Lischalk JW, Cohen E, Lynskey GE, et al. Comparison of cone-beam tomography and cross-sectional imaging for volumetric and dosimetric calculations in resin yttrium-90 radioembolization. Cardiovasc Intervent Radiol. 2018;41(12):1857–66. Zolle I, Bremer PO, Janoki G. Monographs of 99mTc pharmaceuticals. In: Zolle I, editor. Technetium-99m pharmaceuticals. Berlin, Heidelberg: Springer; 2007. Gnesin S, Canetti L, Adib S, Cherbuin N, Silva Monteiro M, Bize P, et al. Partition model-based 99mTc-MAA SPECT/CT predictive dosimetry compared with 90Y TOF PET/CT posttreatment dosimetry in radioembolization of hepatocellular carcinoma: a quantitative agreement comparison. J Nucl Med. 2016;57(11):1672–8. Song YS, Paeng JC, Kim HC, Chung JW, Cheon GJ, Chung JK, et al. PET/CT-based dosimetry in 90Y-microsphere selective

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

INDUSTRY NEWS Eur J Nucl Med Mol Imaging

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34. 35.

36.

internal radiation therapy: single cohort comparison with pretreatment planning on (99m)Tc-MAA imaging and correlation with treatment efficacy. Medicine (Baltimore). 2015;94(23):e945. Grosser OS, Ruf J, Kupitz D, Pethe A, Ulrich G, Genseke P, et al. Pharmacokinetics of 99mTc-MAA- and 99mTc-HSAmicrospheres used in preradioembolization dosimetry: influence on the liver-lung shunt. J Nucl Med. 2016;57(6):925–7. Lenoir L, Edeline J, Rolland Y, Pracht M, Raoul JL, Ardisson V, et al. Usefulness and pitfalls of MAA SPECT/CT in identifying digestive extrahepatic uptake when planning liver radioembolization. Eur J Nucl Med Mol Imaging. 2012;39(5): 872–80. Sancho L, Rodriguez-Fraile M, Bilbao JI, Beorlegui Arteta C, Inarrairaegui M, Moran V, et al. Is a technetium-99m macroaggregated albumin scan essential in the workup for selective internal radiation therapy with yttrium-90? An analysis of 532 patients. J Vasc Interv Radiol. 2017;28(11):1536–42. Ilhan H, Goritschan A, Paprottka P, Jakobs TF, Fendler WP, Todica A, et al. Predictive value of 99mTc-MAA SPECT for 90Y-labeled resin microsphere distribution in radioembolization of primary and secondary hepatic tumors. J Nucl Med. 2015;56(11):1654–60. Giammarile F, Bodei L, Chiesa C, Flux G, Forrer F, KraeberBodere F, et al. EANM procedure guideline for the treatment of liver cancer and liver metastases with intra-arterial radioactive compounds. Eur J Nucl Med Mol Imaging. 2011;38(7):1393–406. Dittmann H, Kopp D, Kupferschlaeger J, Feil D, Groezinger G, Syha R, et al. A prospective study of quantitative SPECT/CT for evaluation of lung shunt fraction before SIRT of liver tumors. J Nucl Med. 2018;59(9):1366–72. van den Hoven AF, Rosenbaum CE, Elias SG, de Jong HW, Koopman M, Verkooijen HM, et al. Insights into the doseresponse relationship of radioembolization with resin 90Y-microspheres: a prospective cohort study in patients with colorectal cancer liver metastases. J Nucl Med. 2016;57(7):1014–9. Levillain H, Duran Derijckere I, Marin G, Guiot T, Vouche M, Reynaert N, et al. (90)Y-PET/CT-based dosimetry after selective internal radiation therapy predicts outcome in patients with liver metastases from colorectal cancer. EJNMMI Res. 2018;8(1):60. Willowson KP, Hayes AR, Chan DLH, Tapner M, Bernard EJ, Maher R, et al. Clinical and imaging-based prognostic factors in radioembolisation of liver metastases from colorectal cancer: a retrospective exploratory analysis. EJNMMI Res. 2017;7(1):46. Strigari L, Sciuto R, Rea S, Carpanese L, Pizzi G, Soriani A, et al. Efficacy and toxicity related to treatment of hepatocellular carcinoma with 90Y-SIR spheres: radiobiologic considerations. J Nucl Med. 2010;51(9):1377–85. Hermann A-L, Dieudonne A, Ronot M, Sanchez M, Pereira H, Chatellier G, et al. Relationship of tumor radiation-absorbed dose to survival and response in hepatocellular carcinoma treated with transarterial radioembolization with yttrium-90 in the SARAH study. Radiology. 2020;296(3):673–84. Chansanti O, Jahangiri Y, Matsui Y, Adachi A, Geeratikun Y, Kaufman JA, et al. Tumor dose response in yttrium-90 resin microsphere embolization for neuroendocrine liver metastases: a tumorspecific analysis with dose estimation using SPECT-CT. J Vasc Interv Radiol. 2017;28(11):1528–35. Council Directive 2013/59/Euratom. Off J Eur Union 2014;57. Grosser OS, Ulrich G, Furth C, Pech M, Ricke J, Amthauer H, et al. Intrahepatic activity distribution in radioembolization with yttrium-90labeled resin microspheres using the body surface area method - a less than perfect model. J Vasc Interv Radiol. 2015;26(11):1615–21. Garin E, Lenoir L, Edeline J, Laffont S, Mesbah H, Poree P, et al. Boosted selective internal radiation therapy with 90Y-loaded glass microspheres (B-SIRT) for hepatocellular carcinoma patients: a new personalized promising concept. Eur J Nucl Med Mol Imaging. 2013;40(7):1057–68.

37.

38.

39.

40. 41.

42.

43. 44.

45.

46.

47.

48. 49.

50.

51.

52.

Ho S, Lau WY, Leung TW, Chan M, Johnson PJ, Li AK. Clinical evaluation of the partition model for estimating radiation doses from yttrium-90 microspheres in the treatment of hepatic cancer. Eur J Nucl Med. 1997;24(3):293–8. Ho S, Lau WY, Leung TW, Chan M, Ngar YK, Johnson PJ, et al. Partition model for estimating radiation doses from yttrium-90 microspheres in treating hepatic tumours. Eur J Nucl Med. 1996;23(8):947–52. Ho S, Lau WY, Leung TW, Chan M, Chan KW, Lee WY, et al. Tumour-to-normal uptake ratio of 90Y microspheres in hepatic cancer assessed with 99Tcm macroaggregated albumin. Br J Radiol. 1997;70(836):823–8. Gulec SA, Mesoloras G, Stabin M. Dosimetric techniques in 90Ymicrosphere therapy of liver cancer: the MIRD equations for dose calculations. J Nucl Med. 2006;47(7):1209–11. Dieudonne A, Garin E, Laffont S, Rolland Y, Lebtahi R, Leguludec D, et al. Clinical feasibility of fast 3-dimensional dosimetry of the liver for treatment planning of hepatocellular carcinoma with 90Ymicrospheres. J Nucl Med. 2011;52(12):1930–7. Dewaraja YK, Devasia T, Kaza RK, Mikell JK, Owen D, Roberson PL, et al. Prediction of tumor control in (90)Y radioembolization by logit models with PET/CT-based dose metrics. J Nucl Med. 2020;61(1):104–11. Cremonesi M, Chiesa C, Strigari L, Ferrari M, Botta F, Guerriero F, et al. Radioembolization of hepatic lesions from a radiobiology and dosimetric perspective. Front Oncol. 2014;4:210. van Hazel GA, Heinemann V, Sharma NK, Findlay MP, Ricke J, Peeters M, et al. SIRFLOX: randomized phase III trial comparing first-line mFOLFOX6 (plus or minus bevacizumab) versus mFOLFOX6 (plus or minus bevacizumab) plus selective internal radiation therapy in patients with metastatic colorectal cancer. J Clin Oncol. 2016;34:1723–31. Wasan HS, Gibbs P, Sharma NK, Taieb J, Heinemann V, Ricke J, et al. First-line selective internal radiotherapy plus chemotherapy versus chemotherapy alone in patients with liver metastases from colorectal cancer (FOXFIRE, SIRFLOX, and FOXFIRE-Global): a combined analysis of three multicentre, randomised, phase 3 trials. Lancet Oncol. 2017;18(9):1159–71. Chiesa C, Maccauro M, Romito R, Spreafico C, Pellizzari S, Negri A, et al. Need, feasibility and convenience of dosimetric treatment planning in liver selective internal radiation therapy with (90)Y microspheres: the experience of the National Tumor Institute of Milan. Q J Nucl Med Mol Imaging. 2011;55(2):168–97. Lau W, Kennedy A, Kim Y, Lai H, Lee R, Leung T, et al. Patient selection and activity planning guide for selective internal radiotherapy with yttrium-90 resin microspheres. Int J Radiat Oncol Biol Phys. 2012;82(1):401–7. Malhotra A, Liu DM, Talenfeld AD. Radiation segmentectomy and radiation lobectomy: a practical review of techniques. Tech Vasc Interv Radiol. 2019;22(2):49–57. Cardarelli-Leite L, Chung J, Klass D, Marquez V, Chou F, Ho S, et al. Ablative transarterial radioembolization improves survival in patients with HCC and portal vein tumor thrombus. Cardiovasc Intervent Radiol. 2020;43(3):411–22. Inarrairaegui M, Pardo F, Bilbao JI, Rotellar F, Benito A, D'Avola D, et al. Response to radioembolization with yttrium-90 resin microspheres may allow surgical treatment with curative intent and prolonged survival in previously unresectable hepatocellular carcinoma. Eur J Surg Oncol. 2012;38(7):594–601. Lemaire M, Lucidi V, Bouazza F, Katsanos G, Vanderlinden B, Levillain H, et al. Selective internal radiation therapy (SIRT) before partial hepatectomy or radiofrequency destruction for treatment of hepatocellular carcinoma in cirrhotic patients: a feasibility and safety pilot study. HPB (Oxford). 2018;20(7):641–8. Garin E, Rolland Y, Edeline J. (90)Y-loaded microsphere SIRT of HCC patients with portal vein thrombosis: high clinical impact of

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

INDUSTRY NEWS

53.

54.

55.

56.

57. 58.

99mTc-MAA SPECT/CT-based dosimetry. Semin Nucl Med. 2019;49(3):218–26. Garin E, Rolland Y, Laffont S, Edeline J. Clinical impact of (99m)Tc-MAA SPECT/CT-based dosimetry in the radioembolization of liver malignancies with (90)Y-loaded microspheres. Eur J Nucl Med Mol Imaging. 2016;43(3):559–75. Saxena A, Bester L, Chua TC, Chu FC, Morris DL. Yttrium-90 radiotherapy for unresectable intrahepatic cholangiocarcinoma: a preliminary assessment of this novel treatment option. Ann Surg Oncol. 2010;17(2):484–91. Rafi S, Piduru SM, El-Rayes B, Kauh JS, Kooby DA, Sarmiento JM, et al. Yttrium-90 radioembolization for unresectable standardchemorefractory intrahepatic cholangiocarcinoma: survival, efficacy, and safety study. Cardiovasc Intervent Radiol. 2013;36(2):440–8. Braat A, Kappadath SC, Ahmadzadehfar H, Stothers CL, Frilling A, Deroose CM, et al. Radioembolization with (90)Y resin microspheres of neuroendocrine liver metastases: international multicenter study on efficacy and toxicity. Cardiovasc Intervent Radiol. 2019;42(3):413–25. Pasciak AS, Bourgeois AC, McKinney JM, Chang TT, Osborne DR, Acuff SN, et al. Radioembolization and the dynamic role of (90)Y PET/CT. Front Oncol. 2014;4:38. Rodriguez-Lago I, Carretero C, Herraiz M, Subtil JC, Betes M, Rodriguez-Fraile M, et al. Long-term follow-up study of gastroduodenal lesions after radioembolization of hepatic tumors. World J Gastroenterol. 2013;19(19):2935–40. Eur J Nucl Med Mol Imaging

Eur J Nucl Med Mol Imaging 59. 60.

61.

62.

63.

Tafti BA, Padia SA. Dosimetry of Y-90 microspheres utilizing Tc99m SPECT and Y-90 PET. Semin Nucl Med. 2019;49(3):211–7. Yue J, Mauxion T, Reyes DK, Lodge MA, Hobbs RF, Rong X, et al. Comparison of quantitative Y-90 SPECT and non-time-offlight PET imaging in post-therapy radioembolization of liver cancer. Med Phys. 2016;43(10):5779. Kao YH, Tan AE, Lo RH, Tay KH, Tan BS, Chow PK, et al. Nontarget activity detection by post-radioembolization yttrium-90 PET/ CT: image assessment technique and case examples. Front Oncol. 2014;4:11. Strigari L, Konijnenberg M, Chiesa C, Bardies M, Du Y, Gleisner KS, et al. The evidence base for the use of internal dosimetry in the clinical practice of molecular radiotherapy. Eur J Nucl Med Mol Imaging. 2014;41(10):1976–88. Garin E, Tselikas L, Guiu B, Chalaye J, Edeline J, de Baere T, et al. Personalised versus standard dosimetry approach of selective internal radiation therapy in patients with locally advanced hepatocellular carcinoma (DOSISPHERE-01): a randomised, multicentre, open-label phase 2 trial. Lancet Gastroenterol Hepatol. 2021;6(1): 17–29. https://doi.org/10.1016/S2468-1253(20)30290-9.

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Affiliations Hugo Levillain 1 & Oreste Bagni 2 & Christophe M. Deroose 3 & Arnaud Dieudonné 4 & Silvano Gnesin 5 & Oliver S. Grosser 6 & S. Cheenu Kappadath 7 & Andrew Kennedy 8 & Nima Kokabi 9 & David M. Liu 10 & David C. Madoff 11 & Armeen Mahvash 12 & Antonio Martinez de la Cuesta 13 & David C. E. Ng 14 & Philipp M. Paprottka 15 & Cinzia Pettinato 16 & Macarena Rodríguez-Fraile 13 & Riad Salem 17 & Bruno Sangro 13 Lidia Strigari 18 & Daniel Y. Sze 19 & Berlinda J. de Wit van der veen 20 & Patrick Flamen 1

Department of Nuclear Medicine, Jules Bordet Institute, Université Libre de Bruxelles, Rue Héger-Bordet 1, B-1000 Brussels, Belgium

Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA

Nuclear Medicine Unit, Santa Maria Goretti Hospital, Latina, Italy

Nuclear Medicine, University Hospitals Leuven and Nuclear Medicine & Molecular Imaging, Department of Imaging and Pathology, KU Leuven, Leuven, Belgium

Department of Interventional Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, USA

Clinica Universidad de Navarra-IDISNA and CIBEREHD, Pamplona, Spain

Department of Nuclear Medicine, Hôpital Beaujon, AP-HP.Nord, DMU DREAM and Inserm U1149, Clichy, France

Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore, Singapore

Institute of Radiation Physics, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland

Department of Interventional Radiology, Technical University Munich, Munich, Germany

Department of Radiology and Nuclear Medicine, University Hospital Magdeburg, Germany and Research Campus STIMULATE, Otto-von-Guericke University, Magdeburg, Germany

Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

Department of Radiology, Northwestern University, Chicago, IL, USA

Department of Medical Physics, IRCCS Azienda OspedalieroUniversitaria di Bologna, Bologna, Italy

Department of Imaging Physics, University of Texas MD Anderson Cancer Center, Houston, TX, USA

Sarah Cannon Research Institute, Nashville, TN, USA

Division of Interventional Radiology and Image Guided Medicine, Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA

Department of Interventional Radiology, Stanford University School of Medicine, Palo Alto, CA, USA

Department of Nuclear Medicine, The Netherlands Cancer Institute, Amsterdam, The Netherlands

Department of Radiology, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada

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TIME TO RELAX By Paul Brayshaw

I’m back! Just when you thought it was safe to open your magazine at the puzzle page, another mind-frying cryptic crossword slaps you in the face and demands to be solved. Currently in lockdown? The perfect excuse to pretend to be working at home whilst instead slotting in a few clues. If you need to end the torture, I can be reached at Paul.Brayshaw@health.wa.gov.au, however there may be a solution grid lying around somewhere between the boastful case studies and the picture of an attractive young couple holding up an impossibly beautiful child advertising some sort of medical equipment you can’t live without. I am happy to provide hints, provided you remember that I’m three hours behind most of you and may not have had my coffee yet. The style is most similar to the Times or Guardian cryptics. Good luck!, Paul There are three missing clues, for three mystery words that are closely related. ACROSS 1. Gland wrapped around tip of rectum possibly prone (9) 9. ? 10. Rolled oats served with song when returning to old hotel (7) 11. Ideal romance assumes quiet, intimate beginnings for foreigner (5) 12. Nuclei too decayed to effect manner of delivery (9) 13. Giant heard to turn the screw (7) 15. More stupid going topless to get dye (5) 17. Taboo act by American causing hole in head (5) 18. Illustration, an instance of our raison d'etre (6) 19. Position to pass back to other modality in brief (5) 20. Old scientist with lie thrown into horrific gaol (7) 23. Ash initially grew tall around barrier in China (5,4) 25. Audibly pursued expanse of land (5) 27. Mournful member I found in each club (7) 28. Highlights symbols written above notes (7) 29. Be less flustered with men in musical groups (9)

DOWN 1. See 2d. 2 & 1d. Nasty pathogens on a roll - a description of our mystery words! (10,6) 3. Inflicting great suffering, losing right to be twisted and devious (8) 4. Old gaming console I read about today, aiming initially to go back (5) 5. Odd person to insert coin in cold rice pudding? (9) 6. Snooping, placing lines in clink (6) 7. Bligh or Meares, say, going either way (4) 8. Waste of time losing first to form strategic friendship (8)

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14. ? 16. Lobes gone off on top of spaghetti? (9) 17. ? 18. Feature of weather map the girl's dropped in moist ground (8) 21. Obvious to change leader that's lying hidden (6) 22. Pests found inside secret police - how our mystery words may manifest (6) 24. Odds? Quite the reverse! (5) 26. Major structural support (4)

FILL IN THE GAPS

Solutions can be found on page 68

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2021 ANZSNM UPCOMING EVENTS MARCH

QLD Branch Meeting 6:45 pm Face to Face and Virtual Event via Zoom

MAY

SA & NT Branch Meeting and Scientific Presentation 5:30 pm Refreshments 6:00 pm Presentation Women's and Children's Hospital

JULY

WA Branch Post-Conference Meeting 5:30 pm Refreshments 6:00 pm Meeting & Presentation Sir Charles Gairdner Hospital

20 SEP

21 NOV

WA Branch Meeting Radpharm Presentation Night 5:30 pm Refreshments 6:00 pm Meeting & Presentation QScan

WA Branch Meeting - AGM 5:30 pm Refreshments 6:00 pm Meeting & Presentation Perth Radiological Clinic

APRIL

WA Branch Pre-Conference Meeting 5:30 pm Refreshments 6:00 pm Meeting & Presentation Perth Children's Hospital

MAY

51 st ANZSNM Annual Scientific Meeting Live and Local Meeting 21 - 23 May

JULY

SA & NT Branch Meeting and Scientific Presentation 5:30 pm Refreshments 6:00 pm Presentation Benson Radiology

SEP

SA & NT Branch Meeting and Scientific Presentation 5:30 pm Refreshments 6:00 pm Presentation Flinders Medical Centre

21 21 22 NOV

SA & NT Branch AGM & Quiz Night 5:30 pm Refreshments 6:00 pm Presentation Venue to be confirmed

2 0 2 1 I N T E R N AT I O N A L U P C O M I N G E V E N T S APRIL

27 OCT

27 - 29 April British PET/CT Course London and Virtual

MAY

BNMS Virtual Spring Meeting 2021 Virtual Meeting

20-23 October 34 th Annual Congress of the European Association of Nuclear Medicine Virtual Event

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

For more details and registeration details visit

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JOB VACANCIES Chief Executive Officer NIF is looking for an innovative, collaborative, inclusive and inspiring leader to lead the next stage of the organisation’s development. CLICK TO LEARN MORE

Head of Radiochemistry We are currently searching for an experienced Radiochemist to join our team based in Brisbane, Australia. Your primary responsibility will be the research and development of new radiochemistry syntheses and novel radioligands. You will lead the development of Radiochemistry and Molecular Imaging at CAI through engaging in collaborative research, teaching, course development and postgraduate supervision. CLICK TO LEARN MORE

SOLUTIONS CROSSWORS

GAMMA GAZETTE AUTUMN EDITION 2021 | ANZSNM.ORG.AU

SOLUTIONS FILL THE GAPS

PRESIDENT Dr Daniel Badger (SA) Vice President Dr Kevin London (NSW) Immediate Past President A/Prof Roslyn Francis (WA) Treasurer Ms Suzanne McGavin (VIC) COMMITTEE Mr Nicholas Ingold (ACT) Ms Maddison Carroll (QLD) Ms Prudence Burns (NZ) Mr Christian Testa (VIC/TAS) Mrs Victoria Sigalas (SA) Prof Karen Jones (TSIG) A/Prof Giancarlo Pascali (RPS) Dr Samuel McArthur (AANMS Representative) Prof Andrew Scott (IRC) 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 Australian Capital Territory Ms Sally McCartney New South Wales Mr 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 Archivist Ms Debra Huddleston

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

AIMS AND OBJECTIVES OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE 1. Promote: • The advancement of clinical practice of nuclear medicine in Australia and New Zealand; • Research in nuclear medicine; • Public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; • Co-operation between organisations and individuals interested in nuclear medicine; and • The training of persons in all facets of nuclear medicine. 2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine through standing committees and special groups: • The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand. • The TSIG Committee is the group overseeing the Technologist Special Interest Group (TSIG) and ensures that all projects, committees and activities of the TSIG align with the values and strategic plan of the ANZSNM. It reports directly to the ANZSNM Federal Council and oversees the two TSIG working groups: CPD & Education Working Group and Technologist Workforce Advocacy Working Group. The committee is able to form working groups to perform specific tasks as required to provide opportunities for the benefit of Technologist members of the ANZSNM after consultation with the ANZSNM Federal Council. • The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality and provide a forum for development in Australia and New Zealand.