July 2012

July 2012, Issue 6

The Official Publication of the Australian and New Zealand Society of Nuclear Medicine

Contents

www.anzsnm.org.au

Welcome

4

President’s Report – Outgoing

4

President’s report

5

Branch News

New Zealand

New South Wales 6

6

Western Australia

6

Victoria/Tasmania

7

SIG

Technologists 7

Physics

8

Nursing

8

Accreditation Board

10

The history of nuclear medicine 14 What’s That?

16

Life Member 17 Diary Dates

17

2012 ASM Report 18 2012 AGM Minutes 22 ANZSNM Financial Report 28 Starving in the land of plenty 30 Revolution or evolution 32 Case Study

99mTc-MAGIII diuretic renographic findings in sulfadiazine induced crystalluria 38

Diffuse Splenic Uptake on F-18 FDG PET: Assisting in rare Diagnosis of

PET/Diagnostic CT/MRI Fusion in the abdomen

42

Finding the Sentinal Node in patients with breast cancers

47

Visceral Leishmaniasis

40

Deadlines The deadlines for each issue of Gamma Gazette for this year are set out below. These deadlines must be strictly adhered to in order to get the journal out on time. Do not leave the submission of copy until the last minute. For advice on how to submit material please go to the website www.anzsnm.org March – February 1

July – June 1

November – October 1

1

Journal Staff Editorial copy & Advertising copy

Design & Production

Ms Judi Anderson ANZSNM Secretariat PO Box 7108, Upper Ferntree Gully VIC 3156 Tel: (03) 9756 0128 Fax: (03) 9753 6372 email: anzsnm@21century.com.au Rachel Bullard Deep Blue Design Studio email: deepbluedesign1@mac.com

This issue compiled by ANZSNM NSW Branch

Elizabeth Bailey

Tracey Smith

Peter McConachie

Dale Bailey

Marko Trifunovic

Daphne James

Matt Ayers

Submissions Scientific submissions of all aspects of nuclear medicine are encouraged and should be forwarded to the Secretariat (see instructions for authors published on line at www.anzsnm.org.au).

Letters to the Editor or points of view for discussion are also welcome.

Aims and Objectives The Australian and New Zealand Society of Nuclear Medicine Limited The objectives of the Society are as follows: 1. Promote (a) the advancement of clinical practice

of nuclear medicine in Australia and

New Zealand; (b) research in nuclear medicine; (c) public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; (d) co-operation between organisations and individuals interested in nuclear medicine; and (e) the training of persons in all facets of

nuclear medicine.

2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine. The Society has three standing sub-committees:

(a) The Accreditation Board, which sets standards for the training and practice of nuclear medicine technology and recommends the issue of accreditation certificates to those technologists who attain the minimum standards of proficiency in nuclear medicine.

The Society is the only accrediting body for nuclear medicine technologists in Australia and New Zealand.

(b) The Technical Standards Committee, which sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand.

If original or public domain articles are found and considered to be of general interest to the membership, then they should be recommended to the Editor who may seek permission to reprint. The view expressed in any signed article in the journal do not necessarily represent those of the Society. The individual rights of all authors are acknowledged.

The ANZSNM Gamma Gazette is published quarterly each year, March, June, September and December.

Deadlines for each issue of the journal are the first of each month prior to publishing. Š 2012 The Australian and New Zealand Society of Nuclear Medicine Inc. Copyright is transferred to the Australian and New Zealand Society of Nuclear Medicine once an article/paper has been published in the ANZSNM Gamma Gazette (except where it is reprinted from another publication).

ANZSNM website address: www.anzsnm.org.au

2 Gamma Gazette July 2012

(c) The Research Grant Committee, which

administers the annual ANZSNM

Research Grant.

In addition, there are a number of special interest groups which maintain standards of practice for their particular specialty and provide a forum for their development in Australia and New Zealand.

These include the Radiopharmacy, Technologists, Physics and Nurses Groups.

Office Bearers Any changes or additions to the details listed should be forwarded in writing to the Secretariat as soon as possible President Vice President Past President Secretary Treasurer Committee

Ms Liz Bailey (TSIG) email: ebailey@nsccahs.health.nsw.gov.au Dr Graeme O’Keefe (Physics SIG) email: graeme.okeefe@petnm.unimelb.edu.au Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.au Ms Lyndajane Michel (Qld) email: michell@qdi.com.au Mr Geoff Roff (WA) email: geoffrey.roff@health.wa.gov.au Dr Sue O’Malley (NZ) email: sue@omalley.co.nz Dr Dylan Bartholomeusz (SA) email: dylan.bartholomeusz@health.sa.gov.au Ms Jennifer Guille (Radiopharmacy SIG) email: jennifer.guille@sesiahs.health.nsw.gov.au Professor Dale Bailey (NSW) email: Dale.Bailey@sydney.edu.au

Accreditation Board Chairperson: Members:

All correspondence

ANZSNM Secretariat PO Box 7108, Upper Ferntree Gully VIC 3156 Tel: (03) 9756 0128; Fax: (03) 9753 6372 email: anzsnm@21century.com.au

Technical Standards Committee Chairperson:

Professor Richard Smart, email: r.smart@unsw.edu.au

Research Grant Committee Chairperson:

Professor Richard Smart, email: r.smart@unsw.edu.au

Branch Secretaries Australian Capital Territory New South Wales Queensland South Australia Victoria/Tasmania Western Australia (acting) New Zealand

Ms Maree Wright, email: maree.wright@act.gov.au Mr Peter McConachie, email: peter.mcconachie@sesiahs.health.nsw.gov.au Ms Rowena Rose & Ms Penni Russell, email: qldbranchsecretaryanzsnm@gmail.com Mr Adam Freeborn, email: adam.freeborn@hotmail.com Dr Zlata Ivanov, email: zlata.ivanov@arpansa.gov.au Ms Stephanie McMahon, email: WABranchSecretary@hotmail.com Ms Dianne Wills, email: dianne.wills@cdhb.govt.nz

Special Interest Groups Technologists Radiopharmacy Physics/Computer Science Nurses

Ms Marcia Wood, email: marcia.wood@austin.org.auu Ms Jennifer Guille, email: jennifer.guille@sesiahs.health.nsw.gov.au Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.health.nz Mr Erwin Lupango, email: erwin.lupango@sesiahs.health.nsw.gov.au

Mr Doug Mackey Dr Nat Lenzo Ms Tale Liiv

Dr Clayton Frater Mr David Lyall Ms Liz Bailey

Reporting of Abnormal Behaviour of Radiopharmaceuticals The Society maintains a register of reports of abnormal behaviour of radiopharmaceuticals.

Abnormal behaviour can be reported either by telephone fax or e-mail, or in writing to: Dr John Baldas, ARPANSA Mr J. Gordon Chan 619 Lower Plenty Road Department of Nuclear Medicine, Yallambie VIC 3085 Austin & Repatriation Medical Centre, Heidelberg VIC 3084 Tel: (03) 9433 2211 Tel: (03) 9496 3336 Fax: (03) 9432 1835 Fax: (03) 9457 6605 email: john.baldas@arpansa.gov.au email: gordon.chan@petnm.unimelb.edu.au

3

President’s Report – Outgoing I stepped down as President at the Melbourne Conference and I can’t believe how quickly my two year term has passed, and it is time for me to reflect what has happened over the last few years on the Society front.

First and foremost, we have seen the successful implementation of the online journal, the Gamma Gazette, in the new concept colours of the Society, which has been a great success.

But this would not have been possible if not for the extremely hard work of all members of the Society throughout Australia and New Zealand. It is wonderful to see all the branches come together and work to produce such amazing content over the last two years, and with this current edition put together by the NSW branch, we have seen all the branches contribute to this journal during my two years here. Special thanks should also be given to Rachel Bullard, our Production Editor, who manages to compile each edition so beautifully; and also to Judi Anderson, our Secretariat, who collates and proof-reads the submissions.

As you will all be aware, National Registration for Nuclear Medicine Technologists/Scientists continues to move forward.

Whilst the Accreditation Board of the Society will cease to exist in its current form when that occurs, the Society will continue to assist the newly formed national Accreditation Council with certain aspects until July 2013.

We have recently nominated two nuclear medicine technologists to AMRSAC sub-committees, who are Russell Booth for the Accreditation Committee and Karen Moyle for the Assessment and Professional Standards Committee. More information about our input and activities in this aspect can be found the in the Accreditation Board and ANZSNMT reports.

However, there are numerous people within the Society who have been heavily involved in this process over the last few years. Whilst this is not an exhaustive list, I would specifically like to thank the following for their tireless work in this arena.

They include David Lyall, Bridget Chappell, David Thomas, Elizabeth Bailey, Julie Crouch, and our SA representative – Adam Freeborn. More recently, Geoff Roff has also represented the Society in continued discussion with AMRSAC regarding our further involvement in the future. The paperwork which had to be ploughed through and the documents generated were phenomenal and could not have been done without the generous donation of their time and efforts to this matter.

The website committee has also been diligently putting together the new website which will have dedicated memberonly sites for CPD and e-Learning. Thanks to the website committee members which include Geoff Roff, Peter Collins, Doug Mackey and Robert Barnett. The new website was officially launched at the Melbourne conference.

There have been considerable efforts made in increasing our international profile, which has been very successful, with the involvement of representatives from the Society in various aspects to promote the high quality nuclear medicine which is practiced in our region. We have also been asked to assist with the curriculum for the Asian School of Nuclear Medicine, and other activities in nuclear medicine worldwide. I don’t think there is a single continent in the world where nuclear medicine is practiced which has been spared our presence! There are many people to thank for this who have not only donated their time, but also funded themselves for many of these activities, including Andrew Scott, Peter Collins, Dale Bailey, Vijay Kumar, Heather Patterson and other members of the International Relations Committee, who will now concentrate their efforts this year to winning the bid to bring the World Federation of Nuclear Medicine and Biology Congress to Melbourne in 2018, with the voting to be held at the EANM Annual Congress in October 2012.

More recently, the Society has also been invited to consult on a government project, which is being led by Andrew Scott from the Austin Hospital in Melbourne, to advise the Department of Health on the broader uses of PET in Australia and to investigate the use of radiopharmaceuticals in nuclear medicine services (including PET). This project will also be in consultation with the ANZAPNM and other relevant parties.

As mentioned at the AGM in Darwin, the Society is moving towards restructuring its management structure and has advertised for a General Manager with the intention to increase the professional profile of the Society nationally, liaising with government, and also on the international scene. There was great interest in the advertisement, which was released earlier this year, with the shortlisted applicants undergoing a final interview .

Finally, I would like to thank everyone on Council, Board and Committees, and members of the Society who have assisted me over the last two years, and made my job so much easier. Without them, and the support of my colleagues and employers at the Austin Hospital in Melbourne, I would not have been able to serve you in this capacity over the last two years.

I’d like to wish my successor, Ms Elizabeth Bailey, every success in leading the Society from strength to strength so that we will continue to be regarded as the premier nuclear medicine Society in Australia and New Zealand, which represents all professions in our multi-discipline speciality.

Dr Sze Ting Lee Outgoing President, ANZSNM

4 Gamma Gazette July 2012

President’s Report What’s next for the Society?

The ANZSNM has been the professional body representing the nuclear medicine fraternity since 1968 and is unique in the make-up of its membership, including physicians, technologists, physicists, radiopharmacists, nurses and students. With the formation of the Accreditation Board and PDY program, the requirement for university, department and individual accreditation was implemented. Since this time, the training programs offered within Australia for Nuclear Medicine Technologists have become recognised internationally for producing highly skilled professions. At present, the Society is primarily run by a group of dedicated nuclear medicine professionals who willingly assist with the daily needs of Society members and the profession.

However with increasing demands on individuals in the workforce and the need to improve the profile and professionalism of the Society both nationally and internationally, a change is needed.

A decision was undertaken to contract a general manager to take on the day to day running of the Society. They will be responsible for managing the commercial, human and financial resources of the ANZSNM and to play a major role in developing and promoting the ANZSNM to achieve its goals of: • membership growth; • greater public and government awareness of our organisation; • improved professional status for our members; • diversified income streams; • effective governance in the credentialing of professional qualifications.

The General Manager will be a key person involved in enhancing the ANZSNM’s professional management, role and profile within the Australian and New Zealand healthcare systems. They will be directly responsible to the Council of the ANZSNM via the ANZSNM President. With the restructure of the ANZSNM, the Society will move from being a collegiate organization to a professional body that is able to meet the needs of its members and respond to the needs of government and organisations with regards to Nuclear Medicine.

This will be an exciting transition period for the Society and we ask for your patience and support during this time. As part of this process, changes will be needed however all efforts will be made to reduce the impact on Society members. It is anticipated that the successful candidate will start in the position from 1st July 2012 with the transition from the existing Secretariat occurring over the next 3 to 6 months.

On behalf of the Council, I would like to thank-you for your support as we move forward into the next phase for the Society.

Liz Bailey President ANZSNM

5

Branch News NEW SOUTH WALES The NSW branch has been very active during the last three months. In March, St. George Hospital hosted a branch meeting with Susan Baldwin as the guest speaker. Sue discussed the upcoming implementation of the national registration scheme and was able to shed light on some of the queries and concerns raised by members.

Also at this meeting the branch honoured Karen Monney for all her hard work and dedication both on and off the committee over the years. Her infectious personality and friendly demeanour lifts each branch meeting she attends.

We were also lucky to have international speakers Prof Simon Cherry and Prof Harrison Barrett share their experience and expertise with us at the may branch meeting held at the Brain and Mind Institute prior to the national conference in Melbourne.

As for future plans, the Hunter Technologist group will be holding their annual Hunter tech meeting at the Hunter Valley on the weekend of 8th and 9th of September.

For more information please consult the advertising and registration form contained in this edition of the Gamma Gazette.

The next branch meeting will be held in September at a venue yet to be decided.

Peter McConachie Secretary NEW ZEALAND The NZ Branch is holding its Annual Meeting in Dunedin on Saturday 8 September and Sunday 9 September this year. Details and forms are available on the ANZSNM website or email chrissie.roodt@southerndhb.govt.nz or terry.doyle@southerndhb.govt.nz Lectures will be taking place at Dunedin Hospital’s Barnett Lecture Theatre. Dunedin Hospital is within easy walking distance from many motels and you will find the hospital’s main entrance off Great King Street.

You have the option on Friday evening to have drinks and a meal at the Otago University Staff Club, off Union Place, West Street which is left off Cumberland Street (close to Dunedin Hospital) or, if you wish, you can explore our wonderful city at your leisure.

The conference dinner will take place on Saturday evening at our wonderful, fully covered Forsyth Barr Stadium at 6.30pm. Because the dinner being held at the stadium, home of the Highlanders, our local rugby team, we encourage you to come along in the spirit of that and dress up in your best blue and yellow.

Dunedin is a lovely heritage and wildlife city in which you can spend time and explore. A great place to get information about the city, including maps, is at the Visitor Information Centre conveniently located in Princes Street, near The Octagon – city centre.

For more information about Dunedin please visit www.dunedinnz.com Pacific Radiology in Wellington had a new Nuclear Medicine Technologist, Chantel McCubbin from Australia, join their workforce in January. Welcome to the NZ Nuclear Medicine community, Chantel. We hope to meet you in Dunedin.

Dianne Wills Secretary

WESTERN AUSTRALIA As I write this update, it is 100 days until the opening ceremony of the London Olympics. I was lucky enough to glimpse the new Olympic stadium on a recent visit to London, and can confidently say that it looks just as spectacular as the setting for the AGM in Perth next year. For those of you who haven’t visited Perth for a while, I recommend that you return for the AGM 2013. The city is being transformed and the entertainment options on offer have come a long way in the last few years. The conference venue is in the city centre, within walking distance to a plethora of shops, restaurants, cafes, and small bars. The Swan River winds past the venue and King’s Park is just up the hill. The planning committee is also endeavouring to invite some high profile speakers who have yet to grace our shores.

The branch has held several meetings already this year and welcomes the invited speaker, Prof. Gregory Thomas, to speak to us immediately after the Melbourne meeting. His talk entitled ‘Does Cardiac CT play a role in ancient Egyptians and/or modern day humans?’ should attract plenty of attendees. Our committee is currently

6 Gamma Gazette July 2012

busy organising our annual CPD workshop. This year the topic will be musculo-skeletal imaging in deference to what most of us see day-in, day-out. The workshop will take place on Saturday July 7th at The University Club, The University of Western Australia. The speakers will cover a broad spectrum with MRI, Orthopaedic, Paediatric, and Sports Medicine specialists joining the fray.

Like the rest of you, WA members will be transferring to the National Registration Scheme from July. We are fortunate to already have state registration in place so that there is minimal effort required in these changes.

It is telling that the most often raised topic concerns liability insurance cover and the need to consider ‘run-off’ insurance so that workers are covered when they cease to practice Nuclear Medicine. If you are like me and have difficulty planning from one week until the next, pondering the future so far in advance can seem a bit daunting.

Rick Hampson Branch Treasurer

VICTORIA/TASMANIA The first half of the year has been a busy and rewarding one for the Victoria/Tasmania Branch, with the highlight being the ANZSNM Annual Scientific Meeting which was held in what turned out to be sunny Melbourne from April 27-30th. The meeting and the pre-conference symposium were extremely well attended and I would like to thank all members who supported this event.

As the ASM wound up, the ‘Age VCE and Careers Expo’ team of volunteers sprung into action under the management of new committee member, Melinda Rosenzweig. This year the expo ran over 4 days, from May 3-6, with the ANZSNM booth being manned by a band of new and returning enthusiastic volunteers including NMTs and Doctors. The volunteers educated and informed would-be students and passers-by on Nuclear Medicine and I would like to thank everyone who volunteered at the event and help with organising the promotional material for their assistance for again making this event a success. I would also like to thank the support of both ANSTO and Lantheus Medical Imaging for providing the Branch with “sweeteners” for the Expo, which were a huge hit with secondary school crowd. The branch is hoping to continue this involvement in 2013.

The Branch’s Annual Day Seminar and AGM will be held on the water at the Hobart Function and Conference Centre Hobart on October 20th 2012 with a varied range of topics to be covered with both Tasmanian and Victorian experts speaking. Confirmed Speakers include endocrinologist Prof John Burgess from Royal Hobart Hospital who will speak on Iodine Nutrition in Tasmania, and Dr Fraser Brown who will look at the ever evolving field of “Diagnostic Cardiology”. I hope to see our Tasmanian members there and some many of you from the Mainland who want to take opportunity to visit Hobart and sample all it has to offer.

With the introduction of National Registration for Nuclear Medicine Technologists and the requirement for Technologists to meet new mandatory CPD requirements, the Victoria/Tasmania branch will expand its CPD and educational opportunities for members. The branch is looking to offer a range of “Molecular Imaging Masterclasses” which will entail a 3-4hr CPD programme focussing on a specific topic, eg. Nuclear Cardiology, PET imaging and Musculoskeletal Imaging. These focussed events will have limited places eg. 20-30 participants with ANZSNM members having priority access for these events. We are looking to hold the first Masterclass in early 2013.

The Branch is also hoping to hold a combined CPD/end of year breakup event in early December so watch this space for further details. In January, we look forward to welcoming back Prof Kim Williams from USA for what will be another interesting update on Nuclear Cardiology.

Bridget Chappell Vic/Tas Branch Chair

Special Interest Group News TECHNOLOGISTS Firstly, a big thank you to all those who attended the Technologists Symposium at the Annual Scientific Meeting in Melbourne this year. Once again, the presentations were of a very high standard and very informative.

Congratulations to Jessica Welch, the winner of the Mallinkrodt-Covidien Award for her presentation titled “When is a high blood glucose level too high for FDG-PET Brain Imaging for Dementia?” and Andrew Dixon who won the Radpharm Award for his case study presentation titled “68Gallium-Dotate and Metastatic Phaechromocytoma”.

The ANZSNMT will hold held its annual symposium this year at Hervey Bay in Queensland on Saturday August u

7

SIG news 11, 2012, with a half-day whale watching trip to be held the following morning. The program will emphasise new technologies this year, such as PET/MR and Ultra fast, Low dose cardiac imaging. Please come and join us make this year’s symposium as successful as the previous years have been.

This year the committee welcomed Ashlee Harrison as the ACT representative. Additionally, Liz Bailey is now the President of the Society, and we congratulate her on taking on this new challenge. As a result, there has been a shuffling of roles within the ANZSNMT and the current executive and membership for the ANZSNMT is as follows: Chair & Vic Rep - Marcia Wood Secretary & NZ Rep - Prue Lamerton Treasurer & Qld Rep - Susan Baldwin NSW & Federal Council Rep - Liz Bailey WA Rep - Diane Cheong SA Rep - Nick Farnham Tas Rep - Nick Lawrence ACT Rep - Ashlee Harrison Finally, I would like to thank all those who have been involved in the transition to National Registration, which takes effect on July 1. This has included attending steering committee meetings, formulating/collating documents, investigating personal indemnity insurance options and advocating for NMT/NMSs. Your hard work, time and efforts are greatly appreciated.

Marcia Wood Chair, ANZSNMT PHYSICS The Physics SIG held a PET/MR mini symposium at the ANZSNM 2012 meeting in Melbourne. This symposium was used as a sampling exercise to gauge interest in the topic in preparation for a full-day PET/MR symposium planned for this coming December (date and venue to be confirmed). There was a good turn-out to the mini symposium.

Professor Simon Cherry (UC Davis, California) gave a presentation titled “The Birth and Rebirth of PET/MRI” in which he led us on a very interesting tour through the history PET/MR right up to the current technologies about to hit the market. I hope to place a copy of the presentation slides on the Society’s website in the next couple of months.

Professor Cherry’s presentation was followed by industry updates on PET/MR from Troy Havens (Philips) and Wellesley Were (Siemens). It was interesting to see what is coming to the market and great to talk with the company representatives, but there is some closely guarded commercial information and this was one of the reasons GE did not participate in the symposium. We hope there will be much more to discuss in December.

A number of members of the Physics SIG are working hard as members of the Technical Standards Committee working parties. Richard Smart has previously given details of the work parties and their briefs. If any Physics SIG member wishes to comment on the operation of these working parties, they can either contact myself, Graeme O’Keefe (as Physics SIG representative to the Technical Standards Committee), or the Technical Standards Committee Chair, Richard Smart, directly.

Darin O’Keeffe ANZSNM Physics SIG Chair NURSING The 42nd ANZSNM in Melbourne was an exciting time for the Nurses SIG. Not only did we gain professional knowledge about advancing in our field, but we are excited about using and implementing emerging technology.

Unfortunately we were unable to elect our new chair because there was no proper quorum. At present I’m still the Chairperson in the Special Interest Group.

During the Conference three interesting topics were presented: 1.

Nuclear Medicine Paediatric Sedation (presented by: Erwin Lupango) 2.

Infection Control (presented by: Satinder Kaur) 3.

Radiation Safety (presented by Lisa Mong) I would like to pay special thanks to the Conference Committee and ANZSNM President for their ongoing support of our SIG. Erwin Lupango Chair

8 Gamma Gazette July 2012

Accreditation Board News The Accreditation Board met on Thursday April 26, 2012 at the Melbourne Convention Centre • There were ten new PDY applicants which brings the current total of PDY technologists/scientists to 72 with 73 mentors in the program; • Several PDYs have overdue reports which are being sought; • Two applicants recently sat the OQA exam and failed to reach the pass mark whilst two applicants have been provided with Australian Skills Assessment letters; • There was one new accreditation for departmental PDY training and seven successful re-accreditations • Four leave of absence applications from the CPD program were approved. After discussion with the MRPB, maternity/paternity leave will still be considered as an acceptable ground for temporary leave of absence; • Sydney University has discontinued its CT course and the HURSOG course was not run in Melbourne due to lack of numbers; it is planned to possibly be run at the Perth meeting in April 2013; • In keeping with the Board’s plan to provide NM Scientists (other than Victoria) with a course that would allow them to eventually gain full licensing with regard to undertaking diagnostic CT accreditation, the Board has asked the VSNMT to submit their Diagnostic CT for Molecular Imaging course for accreditation • In relation to Competency Based Standards & Scope of Practice, a survey link has been circulated to the membership with a draft of the Scope of Practice in its final stages; • National Registration has caused a considerable review of a number of documents and current programs • In relation to CPD, the MRPB has published a Policy for the Approval of a CPD program and Draft Guidelines for Continuing Professional Development; • A working party was convened at the Melbourne meeting to discuss the CPD guidelines and what direction the Board could proceed in to meet requirements. To this end the working party is discussing changing the points system to one of hours with a conversion factor for existing points. A decision will be achieved by June for release to all NMSs and general implementation before 1st July 2012.

After many years’ guidance as the PDY Program co-ordinator, David Thomas left the Board at this meeting as did Dr Sze Ting Lee when her term as ANZSNM President ended. The Board thanks them both for their hard work and lengthy contribution to the Board and welcomes Elizabeth Bailey as the new ANZSNM President.

Following the Accreditation Board meeting held on Saturday June 30, 2012: PDY • five new PDY applicants which brings the current total of PDY technologists/scientists to 66 with 65 mentors; • Cluster models have been finalized for Victorian interns in 2013; • Currently the PDY model will continue until 2013 and is under review.

OQA • No applications received to undertake the Exam nor regarding Australian skills assessment.

CPD • Four leaves of absence from the CPD program were approved; • There were no requests for Approval of CPD activities or Programs; • The most recent revision of the ANZSNM CPD activities document/spreadsheet was restructured to add new categories and revised to reflect hours not points and submitted to AHPRA for approval – awaiting a response; • In the meantime the new activities document will be uploaded to the new website for use along with possible templates for departments and individuals to use for recording of hours and activities; • An update was sent to the membership on the 8th June 2012 advising them what the Board has undertaken and why. Further information will be sent to the membership as the Board gains feedback from AHPRA; • A template for converting points to hours will be released to the members in the next 2 months; • National Registration went live as of 1st July 2012. It is expected National Registration will cause a considerable review of a number of documents and current programs.

10 Gamma Gazette July 2012

Miscellaneous • Julie Crouch resigned from the Board as she is now a member of the Australian Medical Radiation Sciences Accreditation Council (AMRSAC). The Board thanked Julie for her years of hard work on the Board and her commitment to the profession; • Doug Mackey accepted the role of Chair; • The Board welcomed Elizabeth Bailey to the meeting as new ANZSNM President; • From 1 July 2012, by agreement between the Board and AMRSAC, AMRSAC will be responsible for exercising accreditation functions under the National Law. Clayton Frater Secretary

Congratulations to the following technologists who were granted Accreditation at the April meeting: Sally Elizabeth COOKE Aimee Lynne MOFFAT Rachel Joy WATTS Adrian Bruce WISEMAN Rebecca Natalie WYBORN And to the following technologists who were granted Accreditation at the June meeting: Claire Elise CHARTERS Lisa HUNT Eric O’YOUNG Belinda Karleen VAUGHAN The following technologists submitted the minimum requirement of 30 CPD points and have had their Accreditation revalidated for a further three years (from both meetings).

Bianca Abou-Haidar – Cert. #1297 Nicholas Alexopoulos – Cert. #263 Dale Anderson – Cert. #927 Lindsay Andrews – Cert. #667 Nethanet Assefa – Cert. #1140 Nicole Ayars – Cert. # 994 Maria Ayers – Cert. #557 Mathew Ayers – Cert. #488 Stacey Baker – Cert. #775 Andrew Ball – Cert. # 1334 Nicole Barnes – Cert. #748 Howard Barton – Cert. #280 Sarah Bass – Cert. #120 Naomi Basserabie – Cert. #293 Lauren Begg – Cert. # 1341 Peter Borham – Cert. #200 Silvana Brglevska – Cert. #1093 Michael Broun – Cert. #600 Kate Calnan – Cert. #1129 Bradley Camden – Cert. #380 Lauren Campbell – Cert. # 1353 Francis Chan – Cert. #522 Diane Cheong – Cert. #083

Annette Cotter – Cert. #514 Simon Cowell – Cert. #053 Tanya De Kort – Cert. # 974 Emma Fleming – Cert. # 1348 Peter Gentle – Cert. #164 Prue Gilby – Cert. #1314 Sherylene Gonzales – Cert. #1144 Richard Hampson – Cert. # 1179 Seva Hatzinikolas – Cert. #480 Emily Hong – Cert. #765 Kari Hughes – Cert. #758 James Hunter – Cert. #1128 Rebecca Hussey – Cert. # 891 Peter Kench – Cert. #330 Sue Ling Lee – Cert. #957 David Lyall – Cert. #700 Lisa Macfarlane – Cert. #749 Ruth Martin – Cert. #1102 Hannah McKee – Cert. # 1107 Luke McPherson – Cert. # 1332 Christopher Morris – Cert. #663 Michael Nanni – Cert. #541 Emily Nash – Cert. # 1352 Hadeel Nassar – Cert. #934 Paul Nguyen – Cert. #1112 Lyndell Oates – Cert. #434 Stephen O’Brien – Cert. #1097 Brenton O’Mara – Cert. #1316 Leanne O’Neill – Cert. #684 Matthew O’Rourke – Cert. # 1362 Kevin Pitstock – Cert. #437 Fiona Roberts – Cert. #662 Melinda Rosenzweig – Cert. # 976 Katherine Roy – Cert. # 1329 Tien Quach – Cert. #637 Jane Speirs – Cert. # 1324 Helen Stretch – Cert. #260 Rosemary Struck – Cert. #458 Meagan Suter – Cert. #431 Kirsten Sweetland – Cert. #704 Pete Tually – Cert. #649 James Turner – Cert. # 1330 Elspeth Vines – Cert. #165 Loral Wenceslao – Cert. #833 Riley Williams – Cert. # 1328 Zhijuan Kelly Zhong – Cert. #1071

Congratulations to the following departments which were granted Accreditation or Re-Accreditation for the training of PDY Technologists (both meetings): Western Hospital (Vic) – Cert. #5 Royal Children’s Hospital – Cert. #36 Westmead Hospital – Cert. #48 Hunter New England Health Imaging – Cert. #58 Royal Adelaide Hospital – Cert. #61 Canterbury-Bankstown Nuclear Imaging – Cert. #76 Townsville Nuclear Medicine – Cert. #77 Princess Alexandra Hospital – Cert. #80 Western Nuclear Medicine (NSW) – Cert. #85 Austin Health – Cert. #96 Townsville Hospital – Cert. #97 North Shore Radiology & Nuclear Medicine – Cert. #98 Diagnostic Nuclear Imaging – Cert. #99 Hornsby Hospital – Cert. #121 Subiaco Nuclear Medicine (Perth Radiological Clinic) – Cert. #139 PRP Diagnostic Imaging, North Gosford – Cert. #142 Ballarat Health Services – Cert. #151

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ATTENTION:

Daphne James School of Health Sciences

2012 Hunter Technologists Seminar Registration Form Dates:

Saturday 8th and Sunday 9th September, 2012

Venue:

Mercure Resort Hunter Valley Gardens, Pokolbin

Name:

Please Print

Address: Email: Telephone: Registration: (Please Tick)

Social Function Attendance:

Full Registration Saturday Wine Tasting

Saturday Only Welcome drinks - Saturday

Student Dinner - Saturday

Registration fees - Payable by 31st August, 2012: $130.00

Includes morning tea and lunch on both days, and wine tasting on Saturday afternoon.

$ 80.00

Saturday only

$ 55.00

Student – Saturday only

Payment of Registration Fees by Direct Deposit to:

Account Name: Hunter Technologists Group Bank: Commonwealth BSB: 062831 Account Number: 10328413 Please leave your name in the transaction description.

Once your payment is deposited, please fax or email this form to: Daphne James The University of Newcastle Fax: 02 49217053 Daphne.James@newcastle.edu.au

A receipt will be emailed to you. Thank you.

Note: Registration Desk: 8.30 – 9.00 Saturday.

Presentations start at 9:00 am sharp.

ANZSNM members - Please bring your member card for scanning

The history of nuclear medicine The Society is currently compiling a book on the history of nuclear medicine that will be available later this year. The following pages are a selection of photographs from this book.

Left: Class of 1976: back row from the left. Dr Roger Uren, Dr Robert HowmanGiles, Dr Barry Chatterton.

Also note Dr Norm Lyons back row 3rd from right.

Right: Celebrating 30 years in Nuclear Medicine this year.

Left to right: Daphne James, Sue Meikle, Sally Raymond, Marion Lewis, Lorraine Creswick.

Left: The Royal Prince Alfred Hospital (RPAH) physicists, circa 1990.

Left to right: Roger Fulton, Dale Bailey, Helena Sukova (physicist visiting from Czechoslovakia), Brett Jackson, Steve Meikle. Missing from group – Brian Hutton and Stefan Eberl.

14 Gamma Gazette July 2012

Back row: R. Cooper, J. Duggan, B. Shuter, D. Duncan, A. Aslani, K. Somerville.

Middle row: K. Duffey, M. James, G. Snowden, P. Hewitt, F. Diaz.

Front row: E. Steinert, A. Bernar, C. Komninos, Dr R. Hoschl, S. George, J. Jennings Sitting: A-M. Moreau, E. Bailey, J. Pather.

Above: St George Hospital staff.

Left: Sue Lefmann, Hornsby Hospital circa 1970s.

15

Answer on page 48

A: What’s that?

Jacqui Bevan PRP Diagnostic Imaging

78-year-old male presented for a bone scan to investigate the cause of right posterolateral knee pain and occasional stiffness in both hips. X-ray of the knees showed NAD. No history of cancer, other illness/injury.

16 Gamma Gazette July 2012

LIFE MEMBERSHIP

Chris McLaren

by Liz Bailey

C

hris is extremely passionate about his career as a Nuclear Medicine Technologist and has contributed in so many ways to the development of the profession. He has been a Nuclear Medicine Technologist for 32 years and has been an active member of the ANZSNMT for the past 25 years. He joined at a time prior to the CPD program to which Chris was a major contributor. He was instrumental in the instigation of CPD for Society members and helped create the original CPD database which the Society adopted as mandatory. Chris was also involved in the writing of the TSIG constitution 23 years ago as well as having input into the original (1996) and revised competency based standards (2006) for nuclear medicine technologists and the code of ethics. He is also an active member of the ACT Medical Radiation Scientists Board which regulates the registration of all Nuclear Medicine Technologists, Radiographers and Radiation Therapists in the ACT, while providing valuable expertise to the national registration steering committee over the past 3 years.

Chris worked closely with Bill Burch, contributing to the development of “Technegas” at the Royal Canberra Hospital and was co-author on the first research paper publishing the value of this ventilation agent. In the mid to late 1990s Chris pioneered imaging PET patients on a Co-PET system at the Canberra Hospital. This was done using a gamma camera with specially designed collimators and a thick crystal. He has written and contributed to a number of articles including a Colonic Transit investigation in infants titled “The Naked Truth – Wait not Weight” which was published in the first ANZSNM Gamma Gazette in March 2011. Chris has always believed in continuing professional development and was instrumental in promoting the current program of annual rural symposiums organised by the TSIG committee.

His wealth of knowledge, leadership and dedication has helped keep the TSIG in the great form it is today. Chris McLaren is a shining example of all the Society stands for. Congratulations Chris on being made a life member of the ANZSNM, it is well deserved.

Diary Dates

Email the Production Editor at the Secretariat on anzsnm@21century.com.au to list your upcoming conference and meeting dates on the diary page.

August 2-4

4th Modelling of Tumours

Hotel Grand Chancellor, Adelaide

Contact: Christine Robinson:

christine.robinson2@health.sa.gov.au August 11

Annual TSIG symposium

Hervey Bay, Mantra Resort, Qld

Details www.anzsnm.org.au August 26-29

14th International Workshop on Targetry and Target Chemistry.

Riviera Maya, Quintant Roo, Mexico. info@wttc14.mx September 8-9 Education Seminar

Hunter Technologist group (NSW)

Mercure Resort Hunter Valley Gardens, Pokolbin

Invited speakers include Professor Christopher Rowe,

Dr Eva Wegner and Dr Natalie Rutherford.

September 8-9

Annual Meeting, NZ Branch, Dunedin, New Zealand

Details and forms on the ANZSNM website or email

chrissie.roodt@southerndhb.govt.nz or

terry.doyle@southerndhb.govt.nz

Lectures at Dunedin Hospital’s Barnett Lecture Theatre October 20

Vic/Tas Branch Annual Day Seminar

Hobart, Tasmania October 20-31

EANM, Milan, Italy November 25-29

WARMTH IRCT 2012, Levi, Finland

2013

April 11-15

Exploring New Horizons ANZSNM Annual Scientific Meeting

Perth Convention & Exhibition Centre, Perth, WA

17

The 42nd Annual Scientific Meeting of the ANZSNM was held by the muddy waters of the Melbourne Yarra River. While it did not have crocodiles in the river or a wave pool outside the convention centre as there was in Darwin, there were the fireballs of Crown Entertainment Complex next door and exquisite fine food and wine, which are archetypical of the Melbourne culture.

With 600 attendees, a record number of abstracts, including 51 oral abstracts and more than 130 poster abstracts submitted, this bodes well for the conference.

We started the meeting off with the Pre-Meeting Symposium being held at the Royal Melbourne Zoo. This is the oldest zoo in the world, with over 300 animal species from Australia and around the world. The newly built Leopard Lodge was the perfect setting amongst the peacocks and the koalas, with some of our interstate and international visitors taking the opportunity to visit the zoo following the meeting. There were 130 attendees to the meeting which included a few international visitors.

The Pre-Meeting Symposium had an emphasis on therapy and cardiology, where our international experts teamed up with local experts on various novel and emerging topics in the nuclear

18 Gamma Gazette July 2012

medicine world. Richard Baum and Michael Hofman discussed international and local practices of peptide receptor imaging and therapy, while Ajit Padhy and Kate Moodie discussed liver imaging and therapies. Steve Larson stimulated our minds with his lecture on “Targeted therapy of solid tumours with radiolabelled antibodies”. Harvey Turner outlined the interesting practices of his outpatient nuclear medicine therapies in Western Australia. An outstanding lecture from Dinesh Sivaratnam on the status of nuclear cardiology in Australia in 2012 convinced us that we are still a thriving imaging modality. This was followed by a Geoffrey Robertson style hypothetical from Nathan Better which ended the day, with his panel of experts including: Greg Thomas (USA), Dinesh Sivaratnam, Dale Bailey, Paul Roach and Barry Elison. This was an outstanding performance, with exciting discussions.

On Saturday, the main meeting was officially opened by The Honourable David Davis, MP Minister for Health and Ageing.

There was also a congratulatory speech from the Secretary of the European Association of Nuclear Medicine (EANM), Savvas Frangos, who is the first official representative from the EANM to grace our

ASM. The multiculturalism of Melbourne was embraced by the opening performance by the Lion Dancers from the Chinese Youth Society of Melbourne, who brought good luck and weather to the meeting.

Our host of international speakers started the plenary sessions every day, with the first speaker being Simon Cherry from UC Davis in USA, who shared some interesting perspectives with his lecture entitled “New Advances and Instrumentation for Molecular Imaging”.

This included some very interesting perspectives on new PET technology, PET/ MRI, hybrid imaging beyond traditional PET/CT, SPECT without a collimator and new photomultiplier tubes, and memorably, the new Cerencov Luminescence imaging – of the blue light emitted by nuclear reactors. This was followed by Richard Baum from Germany introducing us to the concept of “Theranostics – the combination of diagnostics and therapy”, of which there was a recent supplement on this topic in the European Journal of Nuclear Medicine and Molecular Imaging.

Greg Thomas from UC Irvine, California shared with us his findings from his discoveries in ancient Egypt, with his lecture entitled “When did athrosclerosis begin – what we can learn from ancient

Egyptian mummies”.

He described the use of modern imaging technology to decipher the mysteries of atherosclerosis, even from ancient times, while Steve Larson from Memorial Sloan Kettering Cancer Centre, New York enlightened us with his experiences in Molecular Imaging in Drug Development. In particular, imaging therapy response in novel treatments and using molecular imaging to assess pharmacodynamics and pharmacokinetics of these treatments, including nanotherapy.

Our other international speakers included Ajit Padhy from Singapore sharing with us his experiences in Thyroid Cancer after decades of patient care, and Mike Sathekge from South Africa shared his experiences on Modern Imaging Techniques in Infection & Inflammation, particularly coming from a population with high endemic HIV and TB infections.

The ANZSNMT Symposium highlighted the fact that it has been 20 years since the first PET was performed in Australia, and invited three speakers on this topic to give us the Past, Present and Future of PET in Australia. We were entertained by the talks given by David Thomas, Jason Callahan and Mark Marcenko.

The Physics SIG invited Simon Cherry to present on the “Birth and Rebirth of PET/MR”, followed by industry presentations from Philips and Siemens on their respective PET/MR scanners. The Radiopharmaceutical Sciences SIG invited a IDB Holland sponsored speaker Wouter Breeman to discuss on “Quality control of Lu177 and radiolabelled peptides”. The Nurses SIG invited Lisa Mong to speak on “Radiation Safety for Health Professionals” to their audience.

The meeting was interspersed with Continuing

Education Sessions in Neurology, Pulmonary, Paediatrics, Cardiology and Oncology. I thank the speakers and moderators of these sessions for their hard work in putting these sessions together, which I hope was beneficial for the audience, especially with the use of the “audience response systems”.

We also had interesting moderators and presenters, both in the oral sessions and poster sessions, which was a huge success. Thank you to all of them as well for their efforts.

The dedicated Poster Walk for the larger than ever poster display was well received, with 129 posters presented, mainly in the fields of oncology/therapy, radiochemistry and physics. There was a similar split between those for PET and SPECT. Whilst the majority were in clinical imaging, there was an increasing number of posters on preclinical imaging.

The 15 top rated posters were given a mini-oral to decide on the GMS Best Poster Award, which was won by Ivan Ho Shon from Liverpool Hospital, Sydney on his poster entitled “Biodistribution of a novel HSP-90 ligand labelled with two different

u 19

isotopes (In-111 and Ga-67) for imaging of cell death. The other top rated posters included: • Ventilation subtraction in VQ SPECT: Are artefacts introduced? - Dale Bailey • Clinical application of 99mTc-Glucosamine pulmonary SPECT/CT – Robert Barnett • Detection of activated platelets in carotid artery thrombosis in mice with radiolabelled single chain antibodies for PET – U Ackermann • Management impact of FDG PET/CT in patients with differentiated thyroid carcinoma: a comparative study with I-131 whole body scan and serum thyroglobulin – Raef Boktor • Normal range for intra-patient variability in blood pool and liver SUV for FDG PET – Raef Boktor • Thermal control of brown adipose tissue (BAT) in 18F-FDG PET – Geoffrey Currie • 11C-Choline PET scanning is more accurate than biopsy in assessment of localised prostate cancer planned for radical prostatectomy – Sze Ting Lee • Glyoxia: Integrated analysis of glucose metabolism and hypoxia with 18F-FMISO and 18F-FDG PET in high grade glioma patients - A Leimgruber • Characterisation of I-124 radiolabelled anti-TAG72 pegylated diabody AVP0458 – Andrew Scott • In vivo Tau imaging with PET in Alzheimer’s disease – Victor Villemagne

• Microsphere therapy between pretreatment 99mTc-MAA and post-treatment 90 Y scans - S Kappadath • Technitium 99m DMSA scan as first investigation in identifying children at risk for vesicoureteral reflux and renal defects - K Michaela Dela Cruz • Analysis of the impact of time of flight reconstruction on [68Ga]-DOTATATE and [18F]-FDG scans – Elizabeth Bailey • Position dependent SPECT spatial resolution of a variable focal length conebeam collimator – Leighton Barnden The RADPHARM awards also highlighted some interesting case studies, and was won by Andrew Dixon from Royal Brisbane & Women’s Hospital, Queensland, with his presentation entitled “ 68Gallium-Dotatate and Metastatic Pheochromocytoma”. The highly coveted Mallinckrodt Covidien Award was won by Jessica Welch from Austin Hospital, Melbourne with her presentation entitled “When is a high blood glucose level too high for FDG-PET brain imaging for dementia?”. The ANZAPNM Registrar Award is also the last award to be given by the ANZAPNM (who have since changed

their name to Australasian Association of Nuclear Medicine Specialists – AANMS).

This award was presented to Manoj Bhatt from Royal Brisbane & Women’s Hospital, Queensland. And making its debut is the Gammasonics Award, which was for an abstract scoring the highest overall grading in the area of instrumentation, radiation protection, NM Physics and/or radionuclide therapy research. This award was won by Philip Calais from Fremantle Hospital, Western Australia for his abstract “Radiation dose to family members of non-Hodgkin’s lymphoma outpatients treated with iodine-131 labeled antiCD20 Mabthera”. Finally, the Victoria/ Tasmania Branch of the ANZSNM also sponsored an award for a NMT/NMS who has not previously submitted an abstract to the ANZSNM ASM, which was won by Wesley Ng from Austin Hospital for his abstract “18F-FDG uptake in bowel in diabetic patients treated with metformin”.

A HEARTY CONGRATULATIONS to all the award winners.

We were all touched by the introduction to our Pioneer Lecturer, Victor Kalff, who has been in the Nuclear Medicine field for over 30 years, and also a past President of the Society. The Lowenthal Lecture was

given by Ross Hanna, who was recently awarded ANZSNM life membership in 2010 and there could not have been a more deserving recipient.

Socially, there was a huge success at the Techs’ Party, sponsored by GMS,

and the theme Pirate’s Lair really brought out the best in everyone, especially those who dressed up for the occasion – as you can see from some of the pictures here. The annual Gala Dinner was also a resounding success, held in the ornate and medieval Plaza Ballroom at the Mariner Theatres, which was decorated to suit the theme of Masquerade Ball, where some outstanding costumes were on show. Golf with Gordon was again a success with the trophy won by none other than Gordon Chan himself, and I am told that there was no unfair advantage to his win!

So, by all accounts, the meeting was a huge success for the Society on the intellectual and social fronts, but for the meeting to be such a success, it takes a very effective team and a lot of support from individuals and institutions/ organisations to bring it to fruition.

In particular, I would like to sincerely thank my organising committee - Bridget Chappell & Maria Triantafillou, my Scientific Committee, especially Andrew Scott and Nathan Better, and the reviewers behind the scenes, for their tireless efforts in making this a successful meeting. Last but not least, I would also like to thank our sponsors for their ongoing commitment to our annual meeting, as without their generosity, this meeting would be unaffordable for our small community. In particular I’d like to thank our premium sponsors – Insight, GE, Siemens, ANSTO Health, GMS and Genzyme. I’d also like to thank our award sponsors – GMS, Covidien, ANZAPNM and Gammasonics for

their support of our profession.

I hope that all the attendees learnt a lot from the various sessions at the conference, and found it a successful meeting as well. Hope to see you all in Perth next year, and remember to save the dates for that, which is a bit earlier in April to coincide with school holidays – 11-15 April 2013.

Sze Ting LEE Convenor 42nd ANZSNM Annual Scientific Meeting Melbourne, Australia

ANZSNM Annual General Meeting 2012 DRAFT MINUTES Date: Time: Venue:

Saturday, 28th April 2012 Opened 5.10pm Plenary Hall 3, Melbourne Convention and Exhibition Centre, South Wharf, Melbourne

1. ATTENDANCE

1.1 Present: Jon Boekhoud, Victor Kalff, Jennifer Guille, Ebonie Jackson, Ashlee Harrison, Kera Pethybridge, Natalie Tavare, Antonio Lou, Clare Wright, Lynda Murray, Angela Stafford, Lauren Dorn, Hannah Saunders, Matt Patterson, Jeanelle Farmilo, Diana Gentilcore, Gabrielle Cehic, Peow Ong, Deanna Maglica, Russell Edwards, Julie Crouch, Adam Freeborn, Marko Trifunovic, Karen Wiki, Prue Lamerton, Justin Williamson, Jacky Maggs, Paul Marks, Noelene George, Erin Price, Lyndajane Michel, Erwin Lupango, Crystal Burgess, Melissa Koutsiofi, Sue Ling Lee, Phoebe Chung, Michelle Loneragan, Melanie Crowther, Clayton Frater, Justine Trpezanovski, Nicole Sorensen, Tracey Smith, Evan Read, Marcia Wood, Doug Mackey, Vivian Fernandes, Victoria Brooks, Manoj Bhat, David Binns, Suzanne Heath, Ailsa Cowie, Carol Charman, Elizabeth Thomas, Ros Francis, Barry Chatterton, Dylan Bartholomeusz, Peter Collins, Kevin Schmidt, Sue O’Malley, Sze Ting Lee, Geoff Roff, Aurora Poon, Cheryl Holland, Anthony Baricevic, Vijay Kumar, Allan Scott, Diane Cheong, Liz Bailey, Heather Patterson, Sam Berlangieri, Alla Turlakow, Dale Bailey, Damien Stimson, John Bellen, M Griffiths, Simon Cowell, John Baldas, Zlata Ivanov, Ilonka Bokor, Mary Potter, Elizabeth Williams, Daniel Armao, Alison Apostolou, James Turner, Robert Magill, Megan Horsfield (non member), Amit Maharaj, Rowena Rose, Scott Evans, David Vuong, Dilip Boddeti, William MacDonald, Ghee Chew, Richard Smart, Nick Alexopoulos, Robert Barnett, Darin O’Keeffe, Vanessa Lord, John McKay, Andrew Scott, Robin Low, Penny Maton, Peter Gentle, Leighton Barnden, Greg Wilton, Eugenie Ashby, Stuart Carter, Megan Grantham.

1.2 Apologies:

Elizabeth Croft, Thien Huynh, Fred Khafagi, Melissa Pack, Eddy Spee.

3.6 Physics SIG – attached

3.7 Radiopharmaceutical Science SIG – attached

3.8 Nursing SIG – attached

3.9 Technical Standards Committee (TSC) – attached

3.10 International Relations Committee (IRC) – attached

3.11 Conference Update

3.11.1 2013 Perth – attached 3.11.2 2014 Adelaide 4. SOCIETY RESTRUCURE

Sze Ting Lee reiterated this had already been touched on in her President’s Report and advised that interviews for General Manager position will be held in Sydney next week, and members will be informed of the outcome.

5. GENERAL BUSINESS WITHOUT NOTICE

5.1 Honorary Life Membership

Proposed Liz Bailey

Seconded by Prue Lamerton that Chris McLaren be granted

Honorary Life Membership.

Background to nomination: Chris is extremely passionate about his career as a Nuclear Medicine Technologist and has contributed in so many ways to the development of the profession. Chris has been a Nuclear Medicine Technologist for 32 years and has been an active member of the ANZSNMT for the past 25 years. He joined at a time prior to the CPD program, to which Chris was a major contributor.

He is also an active member of the ACT Medical Radiation Scientists board, providing valuable expertise to the national registration steering committee over the past 3 years.

His wealth of knowledge, leadership and dedication has helped keep the TSIG in the great form it is today. Chris McLaren is a shining example of all the Society stands for.

For these reasons and many more, we cannot recommend Chris more highly for this life membership.

Unanimously approved, with the plaque to be awarded at the Gala Dinner.

2. BUSINESS ARISING FROM PREVIOUS MINUTES

6. COUNCIL POSITIONS

Council positions for the coming year will be:

President Elizabeth Bailey

Vice President Graeme O’Keefe Treasurer Geoff Roff

Company Secretary Lyndajane Michel

3. REPORTS –attached as indicated

3.1 President’s Report – see page this issue Gamma Gazette

Accepted by Bill McDonald

Seconded Victor Kalff

3.2 Treasurer’s Report – attached

Accepted by Liz Bailey

Seconded Peter Collins

3.3 Accreditation Board Report – attached

3.4 ANZSNMT – attached

3.5 ANZAPNM – prepared by Janine Sargeant and presented by

Sze Ting Lee who advised that the new name had been

voted in at this afternoon’s ANZAPNM AGM, to Australasian

Association of Nuclear Medicine Specialist (AANMS).

Branch reps NSW Dale Bailey

Vic/Tas Sze Ting Lee Qld Lyndajane Michel

SA Dylan Bartholomeusz WA Geoff Roff NZ Sue O’Malley

SIG Reps ANZSNMT Marcia Wood Physics Darin O’Keefe

Radiopharmaceutical Science Jennifer Guille Nurses Erwin Lupango

MINUTES OF THE PREVIOUS MEETING

Held on 17 July 2011 at Darwin Convention Centre

22 Gamma Gazette July 2012

7. BUSINESS WITHOUT NOTICE 7.1 President’s Appreciation Award Sze Ting Lee acknowledged that two people had assisted her enormously over the past two years on a daily basis, by telephone, email or in personal meetings – Geoff Roff & Andrew Scott. She presented each with a token of her appreciation for assisting her in her Presidency over the last two years.

7.2 Website

Robert Barnett who has built the new website showed the meeting the new website and its various sections, including the Technologist CPD area, log-in/password, how to activate your account. Sze Ting Lee asked if there is somewhere on the website where people can make suggestions or email him – he will wait to see if anything doesn’t work like it is expected to. It is Live now.

Website address is different at the moment but will revert to the original address shortly.

The University of Newcastle is complete and the final report is currently being considered by the Accreditation Board. The ART conducted the site visit at The University of Sydney on 6-7 February 2012. The ART is still finalizing the report for submission to the Accreditation Board.

I would like to thank the following members of the Professional Advisory Committee for their tremendous hard work and involvement in the process: Diana Gentilcore – UniSA Simon Cowell – RMIT Evan Read – RMIT Nancy Telfer – Former RMIT Peter Kench – UoS David Lyall – UoN Peter Borham – Former UoN (North Coast Nuclear Medicine) Allan Scott – Former AB (Liverpool) Margaret Carmody – John Hunter Hospital

8. DATE & VENUE OF 2013 AGM Perth Convention and Exhibition Centre, April 11 – 15th 2013

The ANZSNM is also considering the process for accreditation of the VSNMT Diagnostic CT for Molecular Imaging course which allows technologists to perform diagnostic CT in a hybrid environment.

There have been six applicants sit the OQA exam in the last 12 month in Australia and two overseas, unfortunately none of these applicants passed the exam. The ANZSNM will continue to be the gazetted authority for overseas assessment for the purpose of immigration after July 1st when national registration commences.

Currently there are 72 technologists enrolled in the PDY program and 73 mentors. We would like to thank all of the mentors for their continued support and we have organised a time for a mentor get together at the next conference in Perth.

A review of the CPD guidelines is being prepared to translate the current point system to time equivalents. This is to meet the MRPBA policy which requires participants complete a minimum of 60 hours of directed or self-directed CPD activities over a three-year cycle, with a minimum of 10 hours in any one-year period. Draft guidelines have been produced by the MTPBA and there is a focus on reflective practice, general and substantive activities.

Finally I would like to say a big thank you to David Thomas for his outstanding contribution to the Accreditation Board, particularly with running the PDY/Mentor program. This is David’s last Accreditation Board meeting.

I would also like to welcome Clayton Frater who has taken on the role of CPD and Tale Liiv who will be the new PDY/Mentor Program co-ordinator and all of the other Board members for their continued support.

Julie Crouch Chair

9. CLOSE

Geoff Roff thanked Sze Ting for all her work over the past two years as President.

Meeting closed at 6.05pm.

Agenda Item 3.2 Treasurer’s Report For 2011 the Society incurred a loss of $40,617. This was mainly due to the Conference loss of $55,000 but our administrative expenses have more than doubled as well. We made savings with regard to the Journal ($20,000) and our revenue increased by about $73,000 (this is mainly membership with some sponsorship) as compared to 2010.

As a company we had equity of $880,952 at the end of 2011 with most being represented by cash in the bank.

Our bank balance as of Thursday 26th April is as follows: • Cheque Account $62,818.43 • High Interest Account $889,333.58 • Debit Card $3,171.90 • IAEA $5.90 TOTAL $955,329.81 This time of year is when we receive most of our membership (therefore most of our income). With the hiring of a GM it is expected that revenue will increase without increasing membership.

Agenda Item 3.3 Accreditation Board Report The Accreditation Board has had a busy 12 months with the course accreditation process. There are currently 6 Nuclear Medicine Programs at different stages of the accreditation assessment process.

University of South Australia and Charles Sturt Universities have been granted full accreditation until January 2016 as long as conditions are met and recommendations are reported on. The process for RMIT and

Agenda Item 3.4 ANZSNMT Report National registration has been the primary focus of the TSIG over the last 12 months. A review of the Competency Based Standards (CBS) has been undertaken in conjunction with the Accreditation Board with the first draft hopefully being available for comment within the next month. This will include provision for extended scope of practice as well as advanced practice. Several documents have been approved by the national board including Continuing Professional Development, Recency of Practice, Professional Indemnity Insurance and Code of Conduct for registered health professionals. The AMRSAC council have u 23

formed to 2 working committees – Assessment and Professional Standards Committee and Accreditation Committee each with representation from the 3 professions as well as the professional associations to advise the council on course accreditation and accreditation and registration standards.

The society has attempted unsuccessfully to engage an insurance broker to develop a Professional Indemnity Insurance (PII) policy that would be available to society members. However, thanks to hardworking technologist members including Bridget Chappell, Nick Farnham and Susan Baldwin, there are several options for PII available to technologists including MIPS and CGU Insurance.

The TSIG and Accreditation Board are currently revising the CPD program to convert points to hours so as to comply with the requirements for national registration. A CPD evidentiary record template will be available over the next month via the new ANZSNM website that complies with the recommendations for record keeping released by the national board.

The annual TSIG symposium will be held on Saturday 11th August at the Mantra Resort Hervey Bay, with a half day whale watching tour on the Sunday morning. The registration brochure and program can be accessed via the new ANZSNM website. The RAINS annual workshop will again be held in November 2012, venue yet to be released. The Hunter group will also be holding a workshop in the Pokolbin Hunter wineries in September 2012. The annual NZ branch symposium will be in September at Dunedin with a great 2 day program covering a broad range of topics.

Registration brochures and programs will be available for all symposiums via the updated ANZSNM website.

The membership of the committee has once again changed over the last 12 months. On behalf of the committee I would like to thank Chris McLaren for his hard work over the last 20 years as both the ACT rep and the vice chair for the committee and welcome Ashlee Kimball as the new ACT rep. I have stepped down as chair of the TSIG and Marcia Wood will take up this role. The current executive and membership for the TSIG is as follows:

Chair & Victorian rep Marcia Wood

Secretary & NZ rep Prue Lamerton

Treasurer & Qld rep Susan Baldwin

NSW rep Liz Bailey

WA rep Diane Cheong SA rep Nick Farnham

Tasmanian rep Nick Lawrence ACT rep Ashlee Kimball I would like to thank all committee members for their hard work over the last 12 months and look forward to continuing as a member of the TSIG and supporting the new chair.

Liz Bailey President ANZSNMT Agenda Item 3.5 ANZAPNM Report 1. Change of Structure & Constitution As advised in the report to the ANZSNM’s 2011 AGM, the ANZAPNM will be changing its name to the Australasian Association of Nuclear Medicine Specialists.

Implementation of this name change is progressing, and will be accompanied by the offer of a fellowship and postnominals (FAANMS) for eligible members.

24 Gamma Gazette July 2012

The final part of the implementation process is being considered at the 2012 ANZAPNM AGM when the proposal to change from an incorporated association structure to that of a company limited by guarantee is being put to the membership. Members will also vote on a proposed new constitution. Both proposals are directed towards supporting the Association to operate with increased efficiency in the future.

2. PET The ANZAPNM has successfully urged removal of some requirements for MBS eligibility that were considered to restrict delivery of PET services unnecessarily, such as the requirement for PET training site accreditation.

The ANZAPNM has also continued to advocate strongly for the use of the data contained in the demographic data component of the PET Data Collection Project, which have not been fully utilized to assist in assessing the efficacy of PET. The Association has also urged that, where PET has been proven to be effective in a particular clinical indication, its effectiveness be accepted more broadly – i.e., if PET is demonstrated unequivocally to be effective in relation to one cancer indication, it should not be required to be demonstrated via a further full MSAC assessment, for each subsequent cancer indication. This concept is now being reviewed formally.

The ANZAPNM continues to urge the DHA to include a capital component in the PET MBS fees.

Notwithstanding, there are currently approximately 35 PET cameras operating in Australia, almost all in metropolitan areas.

3. Radiopharmaceuticals The ANZAPNM continues to urge government consideration of issues such as increased costs, supply issues (including registration/sponsorship) and radiopharmaceutical substitution. The Association has also promoted a role for ANSTO as a possible “sponsor of last resort” where radiopharmaceuticals may otherwise become unregistered with the sale of products to new pharmaceutical companies.

4. Advanced training in nuclear medicine The ANZAPNM has accredited 40 sites for advanced medical training in nuclear medicine for 2013; this includes 32 sites accredited for core NM training (general NM with or without PET), 5 sites accredited for PET training only, and 3 sites accredited for paediatric NM rotations. Several overseas sites in the UK and USA have also been approved for Australasian trainees to attend for core training for 12 months.

Of note is the fact that the majority of sites accredited for PET training only, under the previous PET MBS eligibility requirements, have chosen to remain in the training site accreditation program despite the removal of the requirement for this accreditation.

The Association continues to run the annual Basic Sciences Course (BSC) in Nuclear Medicine for physicians and radiologists training in nuclear medicine. Completion of this course is a requirement for completion of advanced training in NM. Training sites are also expected to underpin the formal BSC coursework by providing an ongoing learning environment for radiation physics, radiation safety and radiopharmacy training during each year of the two core years of training.

The intake of new trainees into the nuclear medicine advanced training program remains stable, although there has been a marked increase in the number of radiology trainees entering the program over the last few years. The ANZAPNM continues to liaise with the Royal Australian and New Zealand College of Radiologists (RANZCR)

in the consideration and development of proposals for convergence of training, to ensure that both physicians and radiologists in nuclear medicine are comprehensively trained to meet the requirements of hybrid imaging. This includes consideration of improved cross-sectional anatomy training for physicians and improved NM basic sciences training for radiologists.

Janine Sargeant Chief Executive Officer Agenda Item 3.6 Physics SIG Report Thank you to Matthew Griffiths for his role as Chair of the Physics SIG for the past two years, and for his hand-over of the Chair’s role.

The ANZSNM Physics SIG AGM was held on Saturday 28 April 2012 at 1 pm at the ANZSNM Conference and was attended by 14 members.

The minutes of the AGM will be available on the Society website in due course.

The Physics SIG did not hold the usual SIG symposium in 2011 because of a number of reasons, but we are currently planning a PET-MR symposium for mid December this year. The symposium will include a focus on the basics of MR technology, planning, and sequences, with the intention of getting the nuclear medicine physicists up to speed.

As always, all will be welcome and in the past there has been a good turnout from nuclear medicine specialists and technologists. I would also like to thank all those who attended the Physics SIG mini-symposium at the ANZSNM conference – there was a very pleasing turnout.

It was noted earlier in the year that the Physics SIG regulations don’t include specific objectives for the SIG. We will be putting a proposal to the Federal Council to address this.

The Physics SIG is planning a strong working relationship with the recently restructured Technical Standards Committee which Richard Smart will be talking about shortly. Additionally, I’m keen to foster relationships with international organisations such as the EANM to facilitate alignment of our practices with current and developing international standards.

The training and accreditation scheme for nuclear medicine physicists is managed by the ACPSEM. This process is no longer available for new trainees, having been replaced with the diagnostic imaging medical physicist training and accreditation scheme for optional dual accreditation in nuclear medicine and diagnostic radiology. In the future don’t be surprised if you hear of DIMPs in the Department.

There has been some email distribution issues within the Physics SIG (and my Branch) and I wish to make the proposal that we look at a means of automating the management of email addresses for both SIGs and Branches.

Darin O’Keeffe Chair, Physics SIG Agenda Item 3.7 Radiopharmaceutical Science SIG Report 1. Retirement of John Bellen It is with great sadness that we learnt John has actually retired from his position at RBH. John has been amongst the pioneers of radiopharmaceutical science in Australia, with a career that spans over 40 years, and started in Royal Adelaide Hospital, prior to moving to Royal Brisbane Hospital. In his normal self-effacing manner, John was very

quiet about this change in his role. Matthew Griffiths gave a tribute to John at our SIG meeting and more will be said in the Gamma Gazette.

John has been very influential in our SIG, and has agreed to remain on in his post as Immediate Past Chair for at least another 12 months.

We wish him well in his new lifestyle.

2. Accreditation Work continues to progress in developing an accreditation syllabus.

In the very near future a Working Party of ‘experts’ will be convened to fine tune the documents, prior to the formation of an examining committee.

3. Education The Masters of Radiopharmaceutical Science has its first students, commencing in second semester. This is exciting as it will hopefully be the beginning of an education pathway for the profession.

4. The SIG The SIG is attempting to build a stronger community.

• We have doubled our mailing list in the last 3 years, and attendance at SIG meetings now has a strong audience and good participation.

• We voted to form a 3-person executive (Chair, Secretary and Immediate Past Chair), and • Have agreed on a Quality Project – looking at the methods of determining RCP that are in use and the advantages and pitfalls of these. We are obliged to use those recommended by BP or USP unless good evidence can be made to support an alternative method. Many BP methods are quite ‘out of date’ or difficult to use in certain circumstances. We hope to be able to recommend a good solution, practical and yet also fulfilling the regulatory requirements.

The SIG meeting this year acknowledges a very interesting presentation by Wouter Breeman from Erasmus Medical Centre in the Netherlands (the home of the Erasmus project, a multicentre clinical trial on Lu-177 radiotherapy for neuroendocrine tumours). Wouter was sponsored by IDB Holland, and we were grateful to have had his expertise and informative talks in our SIG meeting.

Jennifer Guille Chair, Radiopharmaceutical Sciences Agenda Item 3.8 Nursing SIG Report The 42nd ANZSNM in Melbourne was an exciting time for the Nurses SIG. Not only did we gain professional knowledge about advancing in our field, but we are excited about using and implementing emerging technology. Unfortunately we were unable to elect our new chair because there was no proper quorum. At present I’m still the Chair person in the Special Interest Group.

During the Conference three interesting topics were presented: 1. Nuclear Medicine Paediatric Sedation (presented by: Erwin Lupango) 2. Infection Control (presented by: Satinder Kaur) 3. Radiation Safety (presented by Lisa Mong) I would like to pay special thanks to the Conference Committee and ANZSNM President for their ongoing support of our SIG. Erwin Lupango Chair, Nurses SIG u 25

Agenda Item 3.9 Technical Standards Committee Report The TSC has been reconstituted under Terms of Reference adopted by Council on 9th January 2012. The membership is currently: Richard Smart Andrew Campbell Peter Collins Dale Bailey Darin O’Keeffe David Binns Elizabeth Bailey Jennifer Guille Graeme O’Keefe Alex Pitman

Chair, nominated by ANZSNM Council nominated by WA Branch nominated by SA Branch nominated by NSW Branch nominated by NZ Branch nominated by VIC/TAS Branch nominated by NMT SIG nominated by Radiopharmaceutical Science SIG nominated by Physics SIG nominated by ANZAPNM

Note that neither the Qld nor ACT Branches had put forward a nomination for the Committee.

The first meeting was held by teleconference on 21 February 2012 with a face-to-face meeting to be held during ANZSNM12. The Committee agreed that the work of the TSC would be progressed through Working Groups. Each Working Group would typically contain 4 persons and each Working Group must be chaired by a TSC member but may contain non-TSC members.

Currently, the TSC has established four Working Groups: a. Dose calibrator Quality Assurance, including Ansto’s dose

calibrator proficiency testing program

Chair: Richard Smart

Members: Jennifer Guille, Elizabeth Bailey, Darin O’Keeffe,

Graeme Snowdon (external to TSC) b. Revision of Minimum Quality Control Requirements for Nuclear Medicine Equipment, version 5.7 Nov 1999

Chair: Andrew Campbell,

Members: Peter Collins, Elizabeth Bailey, Darin O’Keeffe

for CT component c. Revision of Requirements for PET Accreditation (Instrumentation & Radiation Safety), 4 May 2007

Chair: Dale Bailey

Members: Alex Pitman, David Binns, Graeme O’Keefe,

Darin O’Keeffe for CT component d. Software phantoms and clinical software validation

Chair: Peter Collins

Members: Elizabeth Bailey, Dale Bailey,

Robert Barnett (external to TSC) Darin O’Keeffe is a member of an ACPSEM CT QC Working Group. He is therefore a member of Working Groups b and c to ensure consistency in the recommendations between the TSC and the ACPSEM. Brief progress reports from the Working Groups a. Dose calibrator Quality Assurance This WG has met with Mark Reinhard and Lindsey Bignell from the Activity Standards Laboratory at ANSTO on two occasions to discuss the proposed Dose Calibrator Proficiency Testing Program (DCPTP). Dr Reinhard has had discussions with the Chief Metrologist at the National Measurement Institute and we are hopeful that it should be possible to extend the proficiency testing program to a calibration program with additional information provided by the 26 Gamma Gazette July 2012

nuclear medicine practices, such as the results of dose calibrator linearity checks.

It is envisaged that the DCPTP will be run annually. 99mTc will be included each year, 131I every 2nd year with other radionuclides on a less frequent basis. A 68Ge/68Ga standard source will be the most feasible way of assessing the response of PET radionuclides. b. Revision of Minimum Quality Control Requirements for Nuclear Medicine Equipment, version 5.7 Nov 1999 The EANM document Routine quality control recommendations for nuclear medicine instrumentation has been circulated to the working party. This document comprehensively covers the whole range of nuclear medicine instrumentation, from gamma cameras to non-imaging equipment. The TSC needs to consider whether its minimum quality control document should be extended in scope along similar lines as part of this review. This would entail covering a wider range of instrumentation - things such as QC for thyroid uptake probes, intra-operative probes, gamma counters, radiation monitors/dose rate meters. The adoption of an all encompassing approach might be of benefit in the New Zealand regulatory environment as the regulator may adopt the guidelines as part of their Code of Safe Practice.

A preliminary look has been taken at the current version of the document Minimum Quality Control Requirements for Nuclear Medicine Equipment (version 5.7, 1999) document and initial comments on areas that require updating made for consideration by the working party. c. Revision of Requirements for PET Accreditation (Instrumentation & Radiation Safety), 4 May 2007 The PET Accreditation Review Working Group has reviewed the 2007 document, defined the areas that the group believe need to be revised, and sourced supplementary information for cross-referencing and consistency. The working party plans to meet at the Annual Scientific Meeting in Melbourne in April 2012 and anticipates having the revised document ready for submission to Federal Council by the end of 2012. d. Software phantoms and clinical software validation The online software audit software developed by Robert Barnett and Peter Collins will be beta tested (by a few nominated user groups) in the next 1-2 months with the GBPS dataset from the UK. The software can be used for either audits or as a training tool (where users test their processing skills against known results from a previous audit). The software will be tested initially in the training mode – using the results from a recent Australian audit conducted

by Elizabeth Bailey and Dale Bailey.

Peter Collins met with members of the UK Nuclear Medicine Software Audit group last October in Birmingham. They are keen to collaborate with ANZSNM in the use of our online audit software with their recently developed datasets (e.g. gated MBI).

Richard Smart Chair, TSC Agenda Item 3.10 International Relations Committee Report Members of IRC (International Relationship Committee) attended four different international and regional conferences to seek support for WFNMB bid in 2011: SNM (Tx Jun), EANM (Birmingham, Sept), ALASBIMN (Brazil, Oct) and WARMTH (Vietnam, Nov).

The traditional flagship conference for Nuclear Medicine in USA

at San Antonio Tx (attended by Vijay Kumar, Sze Ting Lee & Andrew Scott) and European NM meeting in Birmingham (attended by Peter Collins & Sze Ting Lee) were good focal points to canvas the support of many participating countries. These conferences well attended with over 5000 delegates. Obviously all the key people from all over the world attended these meeting. ANZSNM had a booth and we have displayed our banner and pamphlets for WFNMB bid for 2018. We had wine and cheese session which attracted many members but more importantly the banner carrying the colourful picture of Melbourne and Australian attractions was instrumental for attracting a lot of interest throughout the conference.

Andrew Scott and Vijay Kumar attended ALASBIMN (Latin American conference of Nuclear Medicine & Biology) in Recife, Brazil as invited speakers. It was a great opportunity to meet many key members of the Latin American congress and Presidents of Nuclear Medicine societies and explain to them personally the advantages of the World Congress in Melbourne. Andrew Scott and Sze Ting Lee attended WARMTH (World Therapy Radiopharmaceutical conference) in Vietnam. It was good opportunity to meet the Presidents of Asian Nuclear Medicine counterparts and seek their support.

Many key members of the congress and Presidents of several Nuclear Medicine societies were approached and it was possible to explain to them personally the advantages of the World Congress in Melbourne. Our bid was underpinned with our commitment in teaching and our strength in the involvement of regional and global programs in Nuclear Medicine. The members were delighted at our passion and commitment and indicated strong support for our bid. Some members introduced their President of Nuclear Medicine Society and we are building up our database for key contacts.

It has been prudent so far and we are going from strength to strength by net-working with key players in the field. Furthermore, it appears that there are no strong contenders for the bid. IRC members have been attending a number of International meetings to build up our International standing in Nuclear Medicine and a successful bid for 2018.

Prof. Vijay Kumar Secretary for IRC & WFNMB bid committee Agenda Item 3.11.1 Conference Update – Perth 2012 Meeting dates: 11-15 April 2013 Meeting Venue: Perth Convention Centre Organising Committee: Co-Conveners: Roslyn Francis (Secretary) and

William Macdonald (Scientific Committee) Technologist Rep: Cedric Eustace Treasurer: Diane Cheong Social Rep: Karen Hindley Sponsorship: Liz Thomas Federal Rep: Geoff Roff Key Dates: Call for Abstracts Open July 2011 Registration Opens November 2011 Call for Abstracts closes 24 January 2013 Notification of Acceptances 22 February 2013 Author Acceptances 8 March 2013 Early Bird Close 8 March 2013 The organising committee has met regularly over the last 12 months,

and is making good progress with preparation for ANZSNM 2013. The meeting dates have been confirmed as 11-15 April 2013 at the Perth Convention Centre. The theme of the meeting is ‘Exploring New Horizons’. A logo has been designed and the website is in preparation, for launching at ANZSNM2012.

Five international speakers have agreed to speak at the conference: • Professor Valerie Lewington , Professor of Clinical Therapeutic Nuclear Medicine, King’s College, London • Professor Stefano Fanti, Director of Nuclear Medicine, University of Bologna, Italy • Mrs Bernadette Cronin, Radioisotope Services Manager, Department of Nuclear Medicine and PET/CT, The Royal Marsden NHS Foundation Trust., Sutton UK • Professor Koenraad van Laere, Clinical Head of Nuclear Medicine, Leuven University Hospital, Belgium • Dr Robert Hendel, Director of Cardiovascular Intensive Care Unit and Outpatient Cardiac Imaging, Miller School of Medicine, University of Miami Hospital, USA All are excellent speakers, and are experts in their field. This is the first ANZSNM conference for all five speakers, in keeping with the theme of Exploring New Horizons.

Mirvac Bunker Bay Resort in the South West of WA is the proposed venue for the Pre-Conference Symposium. The resort has excellent conference facilities and is in a picturesque location, surrounded by pristine beaches and attractive wineries. As the proposed venue is a 3 hour drive from Perth, there will be a short survey at ANZSNM 2012 in order to confirm delegate interest in a Pre-Conference symposium in the South West of WA, prior to confirming this location.

The social program is also progressing well. The Opening Reception will be at the Perth Convention Centre Trade Exhibition Hall. The Gala Dinner will be at the new Fraser’s State Function Centre, in an elevated location in Kings’ Park, with stunning views of Perth.

ANZSNM 2013 will be launched in Melbourne on April 30th. The organising committee is looking forward to welcoming delegates to Perth in 2013.

Roslyn Francis Agenda Item 3.11.2 Conference Update – Adelaide 2013 An organising committeee has been formed with representation from all the professional groups and have held initial meetings. Dr Steve Unger and Dr Michael Kitchener are co conveners of the scientific committee, Ms Rachael Dunlop is secretary and Mr Adam Freeborn, treasurer.

After initial negotiations, Plevin & Associates Pty Ltd have been chosen as the local meeting planner and we have made preliminary bookings to hold the meeting at the Adelaide Convention Centre from Saturday 26th to Monday 28th April 2014 with the pre-conference symposium to be held at the Barossa Valley, Novotel resort, on Friday 25th April (Anzac day). As the Barossa is only about one hour’s drive away, we can set off mid morning, giving people time to attend the dawn service.

Our next aim is to plan out the scientific content and approach potential international speakers.

Dylan Bartholomeusz

27

Australian and New Zealand Society of Nucelar Medicine Limited

28 Gamma Gazette July 2012

A full financial report is available on the ANZSNM website anzsnm.org.au 29

Starving in the land of plenty Dale Bailey Professor in Medical Radiation Sciences in the Faculty of Health Sciences, University of Sydney and Principal Physicist, Department of Nuclear Medicine, Royal North Shore Hospital, Sydney Health reform has been on the agenda since the former PM, Kevin Rudd, promised to end the ‘blame game’ of ultimate responsibility for the health system. Everyone acknowledges that the health system could be improved, and how funding is delivered is one aspect of that. However, reform should not just be limited to governance models and funding arrangements but also ideally allow us to be smarter and more responsive in how we deliver health services.

Take the example of our field, Nuclear Medicine, a form of diagnostic imaging using radioactive contrast agents.

This field is a well established part of medical practice here in Australia. We have highly trained medical specialists, scientists and medical technologists working together to perform high quality scans on a daily basis for thousands of individuals. Our training in these areas is second to none, and even well ahead of countries such as the US and UK. We even export many of our training programmes to the rest of the world and train many individuals from developing countries here who return to help establish this field back in their home countries. And, by and large, the medical imaging scanners that we use are state-of-the-art and match anything used elsewhere. In research, we have made many important contributions internationally to the field. In short, we should be offering the best possible service available to Australians.

Sadly, we are not.

On average, at least once in the lifetime of every Australian they will have a Nuclear Medicine imaging procedure where a small amount of a radioactive compound attached to a targeted molecule (or tracer) is introduced into the body to study its fate. The amounts given are minute and the principle of the approach is that the agents have no pharmacological effect on the body. If they did the test would not be valid. The tracer is imaged with a special highly sensitive scanner and displays how the body is handling the tracer. Nuclear Medicine imaging is important because it shows the function of the body which, in most disease states, exhibits change before any macroscopic anatomical abnormalities are visible.

There was a discussion session held in Parliament House, Canberra, in early 2010 which addressed the issue of why we were lagging behind the rest of the world in this field. We have the staff, we have the equipment, and our referrers know how to select the most appropriate patients to have a scan - so what are we missing?

The answer, in part, is that we are starved of many of the wide array of tracer agents used to do these scans, mostly due to excessive regulation and the need to constantly prove the study’s clinical and cost effectiveness in the local

30 Gamma Gazette July 2012

Australian context.

A couple of examples: there is a particular SPECT brain imaging tracer available in North America, Europe and much of the rest of the world that is used to determine whether a patient has early manifestations of Parkinson’s Disease or not. Without this scan, the alternative is to wait for a year or so and see if the symptoms progress and gets worse. If they do, then it is likely that the individual is suffering Parkinson’s Disease. So the poor patient has to sit and wait, and worry, about whether they are going to be afflicted with this degenerative disorder and progress, or not. This will often be resolved with the imaging test.

Why don’t we offer the imaging test in Australia? The company that provides it has determined that the cost of applying for a license to our regulators is too high to recover their outlay from any profits in selling the tracer in such a small, niche market. The diagnostic tracer goes through the same licensing process as a therapeutic drug that will be used by a large number of patients; the tracer we would like to use, conversely, would only be clinically indicated in a few hundred patients in a year. There is just not enough profit in it commercially. We are starved for these agents in this land of plenty.

Secondly, to have the diagnostic tracer available as a Medicare reimbursed item, the company is likely to be asked to carry out expensive clinical trials, reproducing what has been demonstrated in identical studies overseas since the 1990s. These studies are always performed prior to use in man as they are necessary to demonstrate the safety of the agent and its value in helping manage the patient’s condition. However, in Australia, with our small population, the numbers required to prove the value of the agent, and the time it would take us to carry out the study to accumulate these numbers, is difficult and may well be impossible to achieve. As one senior executive from a company that provides our imaging agents and equipment put it, when I asked why some developments never make it to Australia, “Australia is just like Texas”. What he meant was that the population of Australia is similar to the state of Texas (we are less, in fact) and if his company didn’t market their product in one state of the USA, well, it didn’t make too much difference to their business’ bottom line. It does, of course, matter to the patient who may or may not have Parkinson’s Disease and is left to wait for months or years to see if the condition develops. We are starved for the diagnostic agents that we are equipped to use due, in part, to the requirements of our regulators and licensing authorities.

We are not alone in this regard. The European Union is currently talking to the medical profession about reforming the system of regulation for these imaging agents. They, too, currently force these “tracers” to go through the same

evaluation as a therapeutic drug, i.e., one that is intended to have a pharmacological effect on the body. But the Europeans are reforming their system. And they have a potential population of over 400 million from which to draw patients for a clinical trial. We will always struggle. If we were smarter we would scrutinize their clinical trials of these agents, look at their findings and recommendations, and expedite their availability in Australia if appropriate. No-one is suggesting that we deregulate the system and allow poor practice, but the reality of these studies, and the risk profile of the tracers, needs to be seen in context. They are not given in therapeutic amounts, but rather homeopathic “trace” levels.

A couple of years ago an early-stage Phase 1 clinical trial for TeGenero Immuno Therapeutics in the UK made headlines by causing a “biochemical storm” (a cascade of pro-inflammatory cytokine release) in the first volunteers in the trial which left them in intensive care units for weeks to months after having life threatening reactions to the drug.

This caused a major rethink of how these trials should be conducted. One option that has been promoted by the EU is a so-called “Phase 0” study whereby the new drug is attached to a radioactive tracer and injected into the volunteers to see if its behaviour is similar to that seen in previous studies in mice, rats and primates. It is even allowed to be performed prior to any of the conventional blood profiling and toxicology studies have been performed. This has been dubbed a “micro-dosing” approach. This is the same as the nuclear medicine imaging study in terms of the amount of tracer administered. So now, the EU has realised this enormous contradiction: on one hand they advocate using “tracer” studies as the first-in-man part of testing a new drug because, at the levels administered, they have no effect on the body, and on the other hand, when applying to introduce an agent for diagnostic imaging purposes, they make it comply with all of the testing and evaluation for a therapeutic drug that is given in amounts one million to one thousand million times greater. It is just inappropriate and denies access to these agents in a sensible time frame.

Another reason that we lag behind the rest of the world is this incessant need to prove “in the Australian context” what the rest of the world has usually already proven and is happily using.

At our hospital in Sydney we have installed the latest state-of-the-art high-end scanner, called a Positron Emission Tomography, or “PET”, scanner with money provided by the Federal Government. Former Prime Minister Kevin Rudd even stopped by to inspect it and declare it open for business. It is the most sensitive device available today and produces images of extraordinary quality depicting, mostly, where cancer has spread in the patient’s body. However, we are only able to scan a limited number of types of cancer. This is like having a brand new Ferrari and only being allowed to use the first two gears. For one particular clinical indication for a scan, in non-Hodgkin’s lymphoma, we needed to await the outcome of an evaluation by a committee of the Federal Health department as to whether this imaging test was useful or not. We were waiting for this indication to be funded

in 2002, but the department decided to conduct its own evaluation in a prospective study which took over 7 years.

Seven years! The technology moves so fast that the scanners used in the evaluation are now certainly older generation systems and so the results are no longer necessarily relevant. Furthermore, the evaluation has overly complicated the situation by asking the question as to whether the imaging test has any impact on how long the patient lives, rather than simply “did it help manage the patient better and more appropriately?”, which is equally valid. To continue with the car analogy, what we have done in Australia is like running a 7 year test to see whether the choice of tyres fitted to a 2003 model Commodore has had any impact on how long the car remained in circulation. Obviously, the better the tyres, the less chance there may be of the car being involved in an accident, but there are clearly other factors that come into play! And yet, this is what the health department’s evaluation has been like: does having the scan in the initial definition of the extent of disease have an impact on how long the patient survives? Of course, it must to some extent but there are many other factors as well such as the patient’s general health status, how well they tolerated and responded to the treatment, whether they have had to modify their lifestyle and their compliance to the changes, etc. By forcing the technology to be evaluated against survival and outcome measures, and not simply “did the test change the way the patient was managed at the time?”, we have suffered a long delay in introducing this technology that the UK, Europe, the US and much of the rest of the world have been using since 2003. How long must Australia cancer patients wait?

And what is worse, if we want to evaluate whether this type of imaging is useful in another type of cancer, say breast cancer for example, the model established is that we will need to start to prospectively collect a set of data in the Australian context which will be highly likely to prove (again) what the rest of the world has already demonstrated. If the local study didn’t echo the overseas findings you would be worried, all other factors being equal. And that will take another 5-6 years, by which time the technology and agents have moved on again.

By all means, let’s have health reform and debate about funding models and the like, but we should also look at other ways to work smarter and be more flexible to modernise our current health system and unlock the latent potential that we have, but which is restricted by excessive and inappropriate regulation and need for local evaluation.

Dale Bailey is Professor in Medical Radiation Science in the Faculty of Health Sciences, University of Sydney and Principal Physicist in the Department of Nuclear Medicine, Royal North Shore Hospital, Sydney. The opinions expressed are his own and do not necessarily reflect the views of the university or the hospital.

Adapted from a speech at Parliament House, Canberra on March 19 2010 at the ‘Science Meets Parliament’ event.

31

Invited Contribution

Revolution or evolution?

Dale Bailey Professor in Medical Radiation Sciences, University of Sydney* and Principal Physicist, Department of Nuclear Medicine, Royal North Shore Hospital, Sydney One of the major advances in imaging in the last decade has been the combination of existing functional imaging techniques such as SPECT or PET with X-ray CT, giving an anatomical framework to the functional image. PET/CT and SPECT/CT have changed the practice of Nuclear Medicine considerably since their introduction. This article examines how this hybrid technology evolved, its revolutionary impact, and that it is now seen as the first of potentially many multimodality hybrid imaging devices.

Early Days: Nuclear Medicine prior to X-ray CT Imaging Nuclear Medicine imaging was born in the 1950s and 1960s out of the need to image the soft tissues of the body in an era when X-rays could only image bone and contrast, prior to the development of cross-sectional imaging techniques such as X-ray CT, MRI or ultrasound. Prior to the mid-1970s, the only way to image organs such as brain, liver, spleen, kidney, lungs and the like with X-rays was to introduce a contrast agent (barium, iodine, air, etc) into a space or vascular compartment.

This was frequently invasive, cumbersome and often extremely unpleasant for the patient. The functional aspect of nuclear medicine imaging was generally not employed to provide kinetic information such as metabolic rate or organ perfusion, as we do today, but rather as a means to transport the ‘signal’ to the targeted organ of interest. For example, to image the brain the radiotracer would be injected into a peripheral vein and then, after a period of time, would localise sufficiently in the brain and emit gamma photons which could be detected externally.

This was all acquired, however, in a non-dynamic mode as the imaging equipment in the 1960s in nuclear medicine, prior to the introduction of the gamma camera, involved long acquisition times. The image was slowly built up using a point-by-point raster scanning motion which caused a light to shine in proportion to the detected gamma event rate and thereby expose a piece Figure 1. An image from a rectilinear scanner of radiolabelled bloodpool superimposed on a chest X-ray from the mid-1960s. The hybrid image demonstrates a pericardial effusion seen in the large, expanded avascular space between the left ventricular contents on the nuclear medicine scan and the outer edge of the heart silhouette on the planar chest X-ray.

*

Address for Correspondence: Department of Nuclear Medicine, RNS Hospital, St Leonards NSW 2065; E:Dale.

Bailey@sydney.edu.au ** Personal communication, Professor Terry Jones, London c.1998

32 Gamma Gazette July 2012

of film. It did, however, result in life-size images of the organ being studied which could be conveniently superimposed on a planar X-ray, providing one of the earliest forms of medical image fusion (figure 1). It is interesting to note that some of the original inventors of the PET (positron emission tomography) camera, upon hearing Sir Godfrey Hounsfield present results obtained with his original EMI (CT) scanner at the Radiological Society of North America (RSNA) annual meeting in 1974 considered abandoning their attempts to develop PET as “Hounsfield has already demonstrated that it is possible to image the brain in cross-section”**, again underpinning the early notion that the functional aspect of nuclear medicine was simply a means to transport the tracer to the organ of interest to provide an “anatomical” image of a soft tissue structure.

Evolution of Nuclear Medicine Tomography Nuclear Medicine has often been at the forefront of technological innovation in medical imaging. For example, the first attempts at tomography by image reconstruction from projections was attempted by nuclear medicine pioneers in the early 1960s,1 the first use of digital computers to acquire, analyse and review medical image data came in the mid1960s,2 the first gating of physiological signals to “freeze” organ motion (in this case, the heart) came in the 1970s,3 and the first imaging discipline to develop a standard file format for inter-computer communication, Interfile.4 In fact, Australians can be pleased with their contributions to the field of nuclear medicine in a number of areas – image reconstruction by filtered back-projection was pioneered in radioastronomy at the Australian National University in the 1950s,5 block-iterative image reconstruction using OSEM (ordered subset estimationmaximisation)6 came from a collaboration between statisticians at Macquarie University and physicists at Royal Prince Alfred (RPA) Hospital in Sydney, and some of the first examples of simultaneous multi-modality “hybrid” medical imaging, in SPECT (single photon emission computed tomography), was developed by scientists at RPA/Sydney University and University of Technology Sydney (UTS) in collaboration with the Australian Nuclear Science & Technology Organisation (ANSTO)7 (figure 2).

Multimodality Imaging in Clinical Practice Today, multi-modal ‘hybrid’ imaging is increasingly being

Figure 2. A SPECT scan (“RADIONUCLIDE DISTRIBUTION”) with simultaneously acquired radionuclide transmission CT scan (“ATTENUATION SCAN”), both using the gamma camera, showing the deposition pattern throughout the lungs of an inhaled radio-aerosol along with the ‘fused’ image (“DISTRIBUTION + ATTENUATION”). Both scans were acquired in around 10 minutes total (from circa 1986).

developed and utilised. From simple 2D planar imaging examples such as the bone scan in figure 3, to the highly sophisticated PET/CT and, now, PET/MRI scanners, that are commercially available and in routine clinical use. Professor David Townsend, who now heads a large molecular imaging programme in Singapore, and colleagues first showed combined modality PET/CT images in 1999.8 It should be remembered that, little over ten years ago when PET/CT was introduced commercially, the field was fiercely divided over whether this was a sensible direction to be heading in. The faction opposed to the development of multi-modality scanners such as PET/CT argued that it made no sense to have a CT scanner sitting idle for most of the time and being used for less than 60 seconds every hour or so. While they recognised the inherent value of fused image displays of anatomy and function, they argued that this could be readily achieved with software co-registration algorithms from data acquired on separate devices at different points in time. History has shown that the view of the supporters of combined PET/CT scanners prevailed in this debate as it is virtually impossible now to purchase a stand-alone PET scanner – they are either the wellestablished PET/CT combination or, now, PET/MRI. History has also demonstrated that the high price tag for a combined scanner has not proven to be a barrier to its adoption by the imaging community and commercial success.

SPECT/CT also appeared commercially around the time that PET/CT did. However, the design of these machines was

Figure 3. A 99mTc (technetium-99m) bone scan (top right) view of the left hand along with a planar X-ray (top left) and a fused image of the two (bottom row) helps to accurately pinpoint the focal uptake seen on the bone scan to an anatomical location. This is an example of a scaphoid fracture.

To accurately co-register the data the hand is fixed in a heatsensitive mesh (as used in radiotherapy, moulded to the limb, and then the images taken on a mobile X-ray unit and the gamma camera. While sufficient for many applications, 2D multimodal imaging such as this is being replaced by tomographic (SPECT/CT) approaches (from circa 1994). quite different. SPECT cameras at the time carried a price tag of around $A400k-$A500k (in 2003 dollars). Stand-alone PET scanners, in contrast, cost over $A2.5M. Thus, to add a low-end (single or dual slice) diagnostic CT scanner to a PET scanner would be expected to increase the price of the PET by approximately 33%. With the SPECT scanner, however, it would be more like a 200-300% increase which would be hard to sell commercially; therefore, SPECT/CT development commenced with a low-cost solution – the GE Infinia Hawkeye, an X-ray tube used for dental imaging, mounted to a slowly rotating gamma camera gantry.9 The CT scan would take 7-8 minutes to acquire over the 40cm axial field of view of the gamma camera and beam current was restricted to 2.5 mA. Slice thickness likewise was fixed at 10mm in the first versions. This device proved to be immensely popular because the added value provided by the X-ray CT information to the low spatial resolution SPECT scans, even on a device with such restricted CT performance, was overwhelming. “Unclear Medicine” became “New Clear Medicine”.

Having witnessed this, but seeing the need for better quality and faster CT to combine with the SPECT, we embarked on an ambitious project at Royal North Shore (RNS) Hospital in Sydney to build a SPECT scanner combined with a diagnostic CT. Fortunately, for us, in Australia the government reimbursement for CT scanning decreases dramatically for scanners more than 10 years old and consequently these can be bought second hand relatively inexpensively. In partnership u

33

Invited Contribution

Revolution or evolution?

Figure 4. Left – the in-house SPECT-CT system developed at RNS Hospital, Sydney in 2004. The normal CT bed was mounted on a new base with wheels to easily remove it from the system when not required. The gamma camera detectors are supported from the carriage above the system and are moved out of the way when acquiring the CT. Right – a 99mTc bone SPECT/CT scan (coronal and transaxial sections shown) from the system showing focal uptake in the region of the superior articular facet of the lumbar vertebra confirming osteomyelitis after a laminectomy. with Philips and Insight Oceania in Australia, we devised a way to combine a SKYLight gamma camera and a ‘pre-loved’ Picker PQ5000 single slice spiral CT scanner to provide high quality images from both devices without compromising the performance of either.10 The system, introduced in 2004, was one of the first in Australia to offer SPECT combined with a diagnostic quality CT scan, and remains in use to this day.

Figure 4 shows the system configuration and an example of the data that it produces. At around the same time, other camera manufacturers such as Siemens and Philips started to introduce prototype SPECT cameras combined with single and multi-slice diagnostic CT scanners which were affordable, at roughly twice the price of a conventional SPECT system.

Today, SPECT/CT scanners are common and widely used when performing studies such as myocardial perfusion imaging (purely for the attenuation correction maps derived from the

CT), bone scans, gallium scans for infection, neuro-endocrine and tumour imaging, lung scanning, 131I scans in thyroid cancer and more.11 In discussions with the major equipment vendors it seems that, in the past few years, combined SPECT/CT scanners have accounted for up to 50% of their total SPECT camera sales. In fact, it is now highly likely that there may be more CT scanners in your hospital’s Nuclear Medicine department than in Radiology. Figure 5 shows an example from a contemporary SPECT/CT scanner.

How has the fusion of these technologies impacted on practice, and is it worth the expense? The answer would appear to be yes. Whether it is PET/CT or SPECT/CT the results of combining the modalities is surprisingly consistent: reports using integrated, fused CT with SPECT or PET are generally altered from the SPECT or PET alone in 30-40% of cases and the overall diagnosis or location of the abnormality is altered in 10-15% of cases.12-19 Steven Vogel and Stephen Wainwright, zoologists interested in comparative biomechanics and the form and function of organisms, wrote in 1969 that “structure without function is a corpse, function without structure is a ghost”20 which seems an appropriate way of describing the synergy we see in PET/CT and SPECT/CT images. Vogel describes his combined studies of animal form and function (anatomy and physiology) as “functional morphology”.21 This term could equally well apply to the data produced by combined multi-modality scanners such as SPECT/CT, PET/CT and the newer developments such as PET/MRI and “fusion ultrasound” – displaying ultrasound images in real time on top of a cross-sectional anatomical study such as MRI or CT.

Figure 5. An infected screw after knee replacement on a 99mTc bone SPECT/CT scan.(Images courtesy of Dr Robert Cooper, Mater Hospital, Sydney. Used with permission)

34 Gamma Gazette July 2012

PET/MRI - Technological Revolution?

Recently, the major PET camera manufacturers have started to install and test scanners with PET and

vacuum tube to give a gain of ~10-6. Electrons, being charged particles, however, are affected by strong magnetic fields such as found in the MRI scanner and thus cannot be used in the vicinity of a high B field. In fact, if the gamma camera’s μ-metal shielded covers are removed the performance of the PMTs is even affected by changing the detector’s orientation with respect to the earth’s magnetic field (~10-5T).

The PET camera manufacturers that have developed PET/MR imaging capabilities have pursued different paths up until now. Siemens Healthcare has pursued a fully integrated approach permitting simultaneous acquisition of the PET and MRI scans for whole body imaging Figure 6. Artist’s impression of a possible site configuration for the applications. They have replaced the PMTs on Siemens BioGraph mMR combined PET/MRI system. The MRI and PET their PET scintillation detectors with avalanche systems are co-located in the same gantry permitting simultaneous photodiodes (APDs), which do the same job acquisition of the PET and MRI scans in a compact footprint. (Image as the PMT in converting light to an electrical courtesy of Siemens Healthcare and used with permission). signal with sufficient gain for pulse height spectroscopy and positioning but are unaffected by the magnetic field. The APD-based ring of scintillators is placed inside the bore of an MRI scanner, thus permitting simultaneous PET and MR imaging capability. As the APDs in use presently do not have sufficiently high timing resolution, the time-of-flight mode of operation introduced into PET in recent years is not currently supported on this system. Time-of-flight acquisition and reconstruction in PET uses the arrival time of the two coincidence photons by the opposed detector to ascribe an approximate origin to the radiation, thus permitting higher quality images to be reconstructed compared with non time-of-flight systems. The system has a small footprint, is compact and can fit inside a standard MRI scanning room (figure 6).

Philips Medical, in contrast, have kept their PET and MRI machines in separate gantries in the same room with a Figure 7. The Philips Ingenuity TF PET/MRI system is shown. scanning bed that rotates on a turntable able to move the The system consists of two separate scanners. The PET patient from one scanner into the other without changing beds system in the foreground retains time-of-flight capability by (figure 7). The PET system’s detectors have been shielded using conventional detector components. There is no CT scanner, though, in this case unlike the vast majority of PET Manufacturer Simultaneous Same room Utility Time-of-Flight systems. The subject is scanned on one of the scanners and

PET/MRI? design? factor* PET? then the bed rotates on a turntable to provide access to the GE 7 7 1 3 other scanner. The dimensions for this system are width of 2.6m and overall length of 8.4m. (Image courtesy of Philips Philips 7 3 0.5 3 Healthcare and used with permission).

Siemens 3 3 2 7 MRI capability. The challenges in developing a truly integrated PET/MRI device are formidable and certainly not something we could undertake as we did with our in-house SPECT/CT system. The major consideration is that the technology that the gamma camera has been based on since its inception in 1958 is the scintillation crystal and photo-multiplier tube (PMT).

The PMT captures the light released by the scintillation crystal after a photon is absorbed and turns the emitted visible light flash into an electrical signal for processing. The output from the PMTs in a gamma camera provides both energy information (spectroscopy) and localisation of the event for x-y positioning.

The PMT accelerates and liberates electrons in a multi-stage

Table 1: Comparison of some pros and cons of the three PET/ MRI system designs available at present. The Utility Factor can be defined as the number of scans possible at any point in time divided by the number of scanners (i.e. 2). The GE system can have a subject in each scanner at the same time (utility factor of 1), the Siemens system can acquire 2 scans simultaneously in one scanner footprint (utility factor of 2)and the Philips system has one subject in two systems sequentially (utility factor of 0.5). Scanning time for the full examination, using identical protocols would be half for the Siemens system compared to the other two. u

35

Revolution or Evolution?

Invited Contribution

from the MRI scanner’s B-field and so have retained the tried and tested PMTs. Clearly, such an approach uses sequential imaging to gather both sets of data.

GE at this stage has developed a prototype system with the scanners in separate rooms and a scanning bed transfer system between the two rooms. In this design, both systems can be used simultaneously but any one subject still has to have two sequential scans.

Figure 8. Simultaneous whole body FDG PET/MRI scan (Image courtesy of Siemens Healthcare and used with permission).

36 Gamma Gazette July 2012

Multimodal Imaging: Clinical Evolution At this stage there is not enough clinical experience to suggest which of these three approaches will prove to be the best option for future development. Certainly the Siemens system has the advantages of a smaller footprint and faster scanning times, but there has been a compromise on not being able to acquire time-of-flight data on the PET component at this stage.

An example whole body FDG PET/MRI scan is shown in figure 8. With the technology for photon detection moving so rapidly it is perhaps too early to predict what future system designs will be like. The clinical application areas for PET/MRI are still being investigated. PET/CT is clearly a device that has had a major impact in cancer management. PET/CT had a dramatic impact on patient throughput in PET as the CT scan could be used to derive the tissue absorption factors for photon attenuation correction. This had significant advantages over previous systems which employed radionuclide sources for transmission measurements. PET/MRI, however, is not able to directly provide attenuation factors, particularly for bone, and therefore new short RF pulse sequences along with image processing and classification routines are being investigated to determine a suitable approach.22 At this stage it is not clear if PET/MRI will replace PET/CT in any clinical applications or open up new areas. In oncology there would seem to be clinical potential for PET/MRI in brain, breast, prostate, liver and possibly pancreas imaging, amongst others, being areas where CT is recognised as not the optimal soft tissue imaging device. Beyond that we can only speculate, however, degenerative conditions of the brain and CNS, cardiovascular disease and metabolic disorders may well be where combined PET/MRI provides unique information. Indeed, with some of our largest causes of mortality and morbidity being obesity, diabetes, arthritis & other joint disorders, plus cardio- and cerebro-vascular disease.23 PET/MRI may open new windows into some of the most troubling and challenging health problems facing our society.

There is no serious talk yet of a combined SPECT/MRI machine, as SPECT generally still uses moving detectors which would be incompatible with an MRI scanner. However, stationary detectors based on solid state systems are starting to appear.24 A potential advantage to a combined SPECT/ MRI system is that the cost of the SPECT system would add a virtually insignificant amount to the cost of the MRI system, unlike the case for PET/MRI. Returning to the earlier comments about the debate as to the merit of developing combined PET/CT scanners, is it absurd to suggest that in 10 years’ time PET/MRI may have

replaced, or have an equal installed base, as PET/CT does today? Only time will tell. It is clear, however, that today we are at a significant moment in time in the development of multimodality imaging with the introduction of PET/MRI. In conclusion, I would suggest that the advances in multi-modality imaging represent a continuous evolution in technology and multimodal imaging. However, for the patients we image on these devices in the clinic each day the impact is real and revolutionary.

REFERENCES 1. Kuhl DE, Edwards RQ. Image separation radioisotope scanning. Radiology. 1963;80:653-62.

2. Kuhl DE, Edwards RQ. Perforated tape recorder for digital scan data store with grey shade and numeric readout. J Nucl Med. 1966 Apr;7(4):269-80.

3. Parker JA, Secker-Walker RH, Hill R, Siegel BA, Potchen EJ. A New Technique for the Calculation of Left Ventricular Ejection Fraction. J Nucl Med. 1972;13:649-51.

4. Cradduck TD, Bailey DL, Hutton BF, Deconinck F, Busemann-Sokole E, Bergmann H, et al. A Standard Protocol for the Exchange of Nuclear Medicine Image Files.

Nucl Med Comm. 1989;10(10):703-13.

5. Bracewell RN. Strip integration in radio astronomy. Aust J Phys. 1956;9:198-217.

6. Hudson HM, Larkin RS. Accelerated image reconstruction using ordered subsets of projection data. IEEE Trans Med Imag. 1994;MI-13(4):601-9.

7. Bailey DL, Hutton BF, Walker PJ. Improved SPECT using simultaneous emission and transmission tomography. J Nucl Med. 1987;28(5):844-51.

8. Beyer T, Townsend DW, Brun T, Kinahan PE, Charron M, Roddy R, et al. A Combined PET/CT Scanner for Clinical Oncology. J Nucl Med. 2000;41(8):1369-79.

9. Bocher M, Balan A, Krausz Y, Shrem Y, Lonn A, Wilk M, et al. Gamma camera-mounted anatomical X-ray tomography: technology, system characteristics and first images. Eur J Nucl Med. 2000;27(6):619-27.

10. Bailey DL, Roach PJ, Bailey EA, Hewlett J, Keijzers R. Development of a cost-effective modular SPECT/ CT scanner. Eur J Nucl Med Mol Imaging. 2007 Sep;34(9):1415-26.

11. Mariani G, Bruselli L, Kuwert T, Kim EE, Flotats A, Israel O, et al. A review on the clinical uses of SPECT/CT. Eur J Nucl Med Mol Imaging. 2010 Oct;37(10):1959-85.

12. Schillaci O, Danieli R, Manni C, Simonetti G. Is SPECT/ CT with a hybrid camera useful to improve scintigraphic imaging interpretation? Nucl Med Commun. 2004 Jul;25(7):705-10.

13. Roach PJ, Bailey DL. Combining Anatomy and Function: The Future of Medical Imaging (Editorial). Internal Med J. 2005;35(10):577-9.

14. Roach PJ, Schembri GP, Ho Shon IA, Bailey EA, Bailey DL. SPECT/CT imaging using a spiral CT scanner for anatomical localization: Impact on diagnostic accuracy and reporter confidence in clinical practice. Nucl Med Commun. 2006 Dec;27(12):977-87.

15. Schillaci O, Simonetti G. Fusion imaging in nuclear medicine--applications of dual-modality systems in oncology. Cancer Biother Radiopharm. 2004 Feb;19(1):110.

16. Schillaci O. Hybrid SPECT/CT: a new era for SPECT imaging? Eur J Nucl Med Mol Imaging. 2005 May;32(5):521-4.

17. Bar-Shalom R, Yefremov N, Guralnik L, Gaitini D, Frenkel A, Kuten A, et al. Clinical performance of PET/CT in evaluation of cancer: additional value for diagnostic imaging and patient management. J Nucl Med. 2003 Aug;44(8):12009.

18. Israel O, Mor M, Gaitini D, Keidar Z, Guralnik L, Engel A, et al. Combined functional and structural evaluation of cancer patients with a hybrid camera-based PET/ CT system using (18)F-FDG. J Nucl Med. 2002 Sep;43(9):1129-36.

19. Pfannenberg AC, Eschmann SM, Horger M, Lamberts R, Vonthein R, Claussen CD, et al. Benefit of anatomicalfunctional image fusion in the diagnostic work-up of neuroendocrine neoplasms. Eur J Nucl Med Mol Imaging.

2003 Jun;30(6):835-43.

20. Vogel S, Wainwright SA. A Functional Bestiary: Laboratory Studies about Living Systems. Reading. MA: AddisonWesley Publishing Co; 1969.

21. Vogel SA. Form and Function in Organisms. Integrative and Comparative Biology. 1988;28(2):671-80.

22. Hofmann M, Steinke F, Scheel V, Charpiat G, Farquhar J, Aschoff P, et al. MRI-based attenuation correction for PET/ MRI: a novel approach combining pattern recognition and atlas registration. J Nucl Med. 2008 Nov;49(11):1875-83.

23. Begg S, Vos T, Goss J, Mann N. An alternative approach to projecting health expenditure in Australia. Aust Health Rev. 2008 Feb;32(1):148-55.

24. Iwata K, Kwon S-I, Hasegawa BH, Bennett PR, Cirignano L, Shah KS, editors. Description of a prototype combined CTSPECT system with a singleCdZnTe detector. IEEE Nuclear Science Symposium; 2000: IEEE.

37

Case Study

99mTc-MAGIII diuretic renographic findings in sulfadiazine induced crystalluria Chris Kon Fessa1,2, Heather Zimmerman1,2, Andrew James Willmott1,2, Monica Anne Rossleigh1,2,3

ABSTRACT Sulfadiazine-induced crystalluria is an uncommon cause of ureteric obstruction. Most cases occur in adults with acquired immunodeficiency syndrome, who are being treated for toxoplasmosis. Paediatric presentations are rare. We present a ten-year-old boy on combined sulfadiazine and pyrimethazmine for the treatment of recurrent toxoplasmosis retinitis. Basic imaging findings consistent with sufadiazineinduced crystalluria induced a normal abdominal plain X-ray and extremely small echogenic foci in the bladder on ultrasound assessment.

Further imaging evidence for this condition in our case was parenchymal retention of tracer on F+O99mTcMAGIII diuretic renogram, most likely due to intraparenchymal acetylsulfadiazine crystal precipitation.

Keywords: sulfadiazine, sulfadiazine induced cystalluria, 99mTc-MAG III diuretic renogram, nuclear imaging, toxoplasmosis

REFERENCES 1. Albala DM, Prien EL, Galal HA. Urolithasis as a hazard of sulfonamide therapy. J Endourol 1994;8:401-403.

2. Crespo M, Quereda C, Pascual J, et al. Patterns of sulfadiazine acute nephrotoxicity. Clin Nephrol 2000;54:68-72 3. Catalano-Pons C , Bargy S, Schlect D, et al. Sulfadiazine-induced nephrolithiasis in children. Pediatric Nephrol 2004;19:928-931.

4. Kane D, Murphy JM, Keating S, et al. Renal ultrasonic findings in sulfadiazine induced renal failure. Br J Radiology 1996;69:925928.

5. Sasson JP, Dratch PL, Shortsleeve MJ. Renal US findings in sulfadiazine-induced crystalluria. Radiology 1992;185:739-740.

6. Dusseault B, Croce K, Pais V. Radiological characteristics of sulfadiazine urolithiasis. Urology 2009;73:928.e5-6.

7. Lee SA, James CW, Szabo, et al. Sulfadiazine-induced nephrolithiasis detected by spiral CT. Del Med J. 2004;76:59-63.

8. Perazella M. Drug-induced renal failure: update on new medications and unique mechanisms of nephrotoxicity. Am L Med Sci 2003;325:349-362.

1. Department of Nuclear Medicine, The Prince of Wales Hospital Randwick NSW Australia 2. Department of Nuclear Medicine, Sydney Children’s Hospital Randwick NSW Australia 3. The University of New South Wales Medical School Institution: Department of Nuclear Medicine, The Prince of Wales Hospital Barker Street Randwick NSW Australia 2031 Reprint Requests: Department of Nuclear Medicine, The Prince of Wales Hospital Barker Street Randwick NSW Australia 2031 Email of corresponding author: cfessa@yahoo.com.au No funding received for the publication of the interesting image case.

38 Gamma Gazette July 2012

9. De Sequera P, Albalate M, Hernandez J et al. Acute renal failure due to sulphadiazine crystalluria in AIDS patients. Postgrad Med J 1996;72:557-558.

Figure 1.

A ten-year-old boy presented with central abdominal pain and vomiting three weeks after commencing 100mg/kg sulfadiazine and 1mg/kg pyrimethazmine daily for the treatment of recurrent toxoplasmosis retinitis. Routine bloods tests revealed normal renal function and a mild leuckocytosis. Urinalysis demonstrated microscopic blood and no evidence of urinary infection on culture.

An initial abdominal ultrasound revealed mild dilation of the right renal pelvis measuring 13mm in the transverse dimension.

99mTc-MAGIII diuretic renographic findings in sulfadiazine induced crystalluria

Figure 2.

Five days later, a repeat abdominal ultrasound was performed due to the development of macroscopic haematuria. A, The right pelvicalyceal dilatation had resolved. B, There was now a left 5mm pelvicalyceal dilation in the transverse dimension. C, Echogenic debris was present in the bladder.

Figure 3.

A diuretic renogram was performed two days later with the simultaneous administration of 132MBq Tc Mercaptoacetyltriglycine (MAGIII) and 32.5mg Frusemide (1mg/1ml).

The scan demonstrated a mild reduction in relative function of the left kidney.

There was normal drainage of radiourine from the right pelvic-ureteric system but there was retention of tracer in the left renal parenchyma throughout the study with no urinary excretion into the left pelvis identified. This was most likely explained by intraparenchymal precipitation of acetylsulfadiazine crystals impeding secretion of tracer into the urine. Following these findings, sulfadiazine and pyrimethazmine were ceased and replaced with clindamycin and the patient was also hydrated.

The abdominal pain, vomiting and haematuria resolved within 48 hours. Sulfadiazine is an antimicrobial used in combination with pyrimethazmine for the treatment of toxoplasmosis. Sulfadiazineinduced urolithiasis or cystalluria is an uncommon cause of ureteric obstruction and symptoms typically develop between one to four weeks from the commencement of the medication.1 It is difficult to diagnose with any single imaging modality. Plain x-ray imaging is unremarkable as sulfadiazine crystals and lithiasis are radiolucent.2,3 Ultrasound findings include echogenic foci in the renal parenchyma and urinary bladder and/or hydronephrosis.3-5 However, these findings do not occur in every case.4 Computed Tomography can detect sulfadiazine included lithiasis and is characterised by very low attenuation.6,7 In our case, no renal

calculus was seen on abdominal ultrasound or x-ray and no renal calculus was passed in the patientâ&#x20AC;&#x2122;s urine. The echogenic debris in the urinary bladder is suggestive of crystalluria. Sulfadiazine is excreted largely in the urine in two forms; sulfadiazine and acetylsulfadiazine. Acetylsulfadiazine is a weak acid that can precipitates to form crystals in the lumens of the distal nephrons with urine pH<7 resulting in crystalluria, urolithasis, obstruction and acute renal injury.8 Contributing factors leading to crystal formation include high oral doses, dehydration and underlying renal disease. In line with these factors, hydration and urine alkalization as well as cessation of medication form the mainstay of treatment.9

39

Case Study

Diffuse Splenic Uptake on F-18 FDG PET: Assisting in rare Diagnosis of Visceral Leishmaniasis Laura Renshaw, Sandeep K Gupta, Len Allen

Department of Nuclear Medicine & PET, Hunter New England Imaging, Newcastle, Australia

INTRODUCTION PET/CT is an underutilised imaging tool in challenging cases of aetiology of fever of unknown origin.

We present a case of fever of unknown origin where three weeks of extensive in-hospital work-up failed to reach a diagnosis. The PET/ CT scan eventually became the critical turning point of diagnosis and assisted in the final diagnosis of Visceral Leishmaniasis, a deadly parasitic disease, extremely rare in Australia.

CASE REPORT A 69-year-old Australian woman presented with history of high fevers with night sweats and lethargy. The patient was on methotrexate

and adalimunab (Humira) medications for rheumatoid arthritis and rheumatoid pulmonary nodules, which were ceased on admission.

She had an extensive travel history, with the most recent trips in the preceding five years to China, Tibet, France, Spain and Portugal.

Places of travel in the prior years included Asia (Vietnam, Cambodia, Indonesia & India), North America (USA, Canada & Mexico), Europe (Italy, France,) and Zimbabwe.

On examination, the only positive finding was mild splenomegaly.On blood examination, there was severe pancytopaenia with the lowest Haemoglobin 78 (normal 115-165) g/L, WBC counts 1.6 (normal 4.0-11.0)Ă&#x2014;109/L and Platelets 32 (normal 150-400) x109/L. The inflammatory markers were raised with peak ESR 114 (normal 1-20) mm/hr and CRP 170 (normal <3.1) mg/L. During the course of admission, the cultures were negative, as were serologies for multiple infectious diseases. The

Figure1: 18F-FDG PET â&#x20AC;&#x201C;CT Left: MIP AC image, Middle: Fused coronal image & Right: Fused MIP Image.

The images show intense FDG accumulation in the enlarged spleen and no other focal hypermetabolic lesions.

The physiological pattern of neck musculature and bowel uptake is noted.

40 Gamma Gazette July 2012

Diffuse Splenic Uptake on F-18 FDG PET: Assisting in rare Diagnosis of Visceral Leishmaniasis

immunology screen and tumour markers were also negative. The bone marrow biopsy showed mildly reduced haemopoiesis with normal trilineage maturation; no abnormal lymphoid cell populations were identified. Transthoracic echocardiogram revealed no vegetations. The CTs showed multiple pulmonary nodules with evidence of cavitations in two foci, many small mediastinal lymph nodes and mild splenomegaly. A Fine-needle biopsy on a pulmonary lesion was non-diagnostic.

The patient continued to have fevers, night sweats and remained extremely ill. PET/CT was performed, which demonstrated the only positive finding of intense FDG accumulation in the enlarged spleen (Figure 1). A differential diagnosis of splenic lymphoma or acute malaria was raised. In the absence of other localising abnormality, laparoscopic splenectomy was performed. The histopathology and PCR were consistent with visceral leishmaniasis caused by L. infantum. The patient was placed on liposomal Amphotericin treatment and her symptoms resolved. Blood cell counts returned to normal. Approximately 10 months of follow-up showed no further similar events.

DISCUSSION In this patient, the critical turning point of diagnosis was the PET/ CT scan, which allowed a more targeted management plan while avoiding unnecessary invasive tests and imaging.

FDG-PET is an invaluable but under utilised tool in infection imaging. Leishmaniasis is not included in the differential diagnosis of isolated spleen uptake of FDG1 and only one similar case was found in literature.2 Malaria may also be considered in the differential diagnosis of such avid isolated spleen hypermetabolic activity.3 With increased international tourism and migration from endemic regions, this case reinforces the importance of raising awareness of this neglected disease in non- endemic countries, such as Australia.

While there are a few case reports of cutaneous leishmaniasis, only six patients with visceral leishmaniasis have been reported in literature in Australia.4-10 Of these, three patients were immunocompetent, five had HIV and one patient had the disease on background of renal transplant.

This case not only demonstrates the utility of PET/CT in cases of infections of unknown origin but also highlights the need of vigilance for rare infections especially in travellers and the migrant population.

REFERENCES 1. Liu Y. Clinical significance of diffusely increased splenic uptake on FDG-PET. Nucl Med Commun. 2009; 30: 763-9.

2. Lupi A, Todeschini G, Zanco P. Diffuse metabolic activation of reticuloendothelium on F-18 FDG PET imaging in a case of visceral leishmania. Clin Nucl Med. 2006; 31: 34-6.

3. Kawai S, Ikeda E, Sugiyama M, Matsumoto J, Higuchi T, Zhang H, et al. Enhancement of splenic glucose metabolism during acute malarial infection: correlation of findings of FDG-PET imaging with pathological changes in a primate model of severe human malaria. Am J Trop Med Hyg. 2006; 74: 353-60.

4. Stark D, van Hal S, Lee R, Marriott D, Harkness J. Leishmaniasis, an emerging imported infection: report of 20 cases from Australia. J Travel Med. 2008; 15: 351-4.

5. Ju O, Grove DI, Jaksic WJ, Dart GW. Visceral leishmaniasis: a trip to the Greek Islands is not always idyllic. Med J Aust. 2004; 181: 446-7.

6. Auyeung P, French MA, Hollingsworth PN. Immune restoration disease associated with Leishmania donovani infection following antiretroviral therapy for HIV infection. J Microbiol Immunol Infect. 2010; 43: 74-6.

7. Hamilton A, Kelleher A, Marriott D. A case of severe visceral leishmaniasis resulting from travel to Greece. BMJ Case Rep. 2009; 2009.

8. Hume SC, Aboltins CA, Thursky KA, Daffy JR, Stanley PA. Visceral leishmaniasis due to Leishmania donovani in a patient with advanced HIV infection. Med J Aust. 2010; 192: 474-5.

9. Matthew G MD, Cooper D. Visceral leishmaniasis in HIV infected patients. A report of first two Australian cases. Annu Conf Australas Soc HIV Med. 1996; 45: 14-17.

10. Ma DD, Concannon AJ, Hayes J. Fatal leishmaniasis in renaltransplant patient. Lancet. 1979; 2: 311-2.

41

Case Study

PET/Diagnostic CT/MRI Fusion in the abdomen Marko Trifunovic, Prof J.Magnussen, Dr C.Saunders, Dr D.Chung, Dr K. Witte

Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University NSW 2109

Diagnostic CT and MRI are proven modalities offering high anatomic definition and the ability to separate many types of soft tissue that are in close proximity to one another. The diagnostic abilities of CT and MRI are further enhanced through the use of contrast agents in various imaging protocols comparing; pre and post contrast; venous and arterial phases; the use of gadolinium in MRI. MRI has the added ability to suppress selected radiofrequencies while enhancing others to highlight certain types of tissue and to increase contrast. CT and MRI are proven modalities in diagnosing a large variety of cancer; however when they are combined with PET the overall sensitivity and specificity of all three modalities is increased (J.Czernin, M.Allen-Auerbach& H.R.Schelbert 2006). PET facilitates the evaluation of metabolic and molecular characteristics of a large range of neoplastic activity (J.Gaa, E.J Rummeny, M.D.Seeman 2004), but as we know its ability to localise these sites in specific anatomy has only improved since the introduction of PET/CT hybrid cameras and more recently PET/MRI hybrids or manual fusion.

Each of these modalities struggles to identify primary and metastatic disease in the abdomen when not used in conjunction with the others. Radioisotopes used in PET (predominately FGD) have variable physiological distribution and a large range of normal limits making diagnosis challenging. FDG uptake in the digestive tract, genitourinary tract, fat, bone marrow may vary greatly from patient to patient but still be within normal limits (J.Gaa, E.J Rummeny, M.D.Seeman 2004). PET does have the ability to detect malignancy in its early stage before structural change occurs (J.Gaa,

E.J Rummeny, M.D.Seeman 2004), as compared to MRI and CT that depend on structural changes to detect lesions.

Numerous research studies have identified the need for the use of all three modalities in conjunction with each other and especially in the field of image fusion to increase sensitivity (early detection) and specificity (exact type of neoplasm) and its anatomical location.

Identifying a pancreatic mass is problematic for CT and MRI. Often they can identify pancreatic cancer through indirect evidence (dilation or stenosis of the pancreatic duct) however are unable to identify the mass itself. J.Ruf et al 2006 states PET/MRI image fusion improves the anatomical assignment and interpretation of FDG foci in pancreatic cancer.

J.Gaa et al 2006 states that MRI has superior sensitivity when imaging the liver for lesions while PET has superior sensitivity detecting diseased lymph-nodes in the abdomen. They also state that the combination of PET/MRI fusion increases the accuracy in identifying gastrointestinal carcinoids.

With this in mind we offer the following three cases as an example of the usefulness of PET/MRI fusion imaging in the abdomen. PET scans were acquired with a diagnostic quality contrast enhanced CT using a GE Discovery Time of Flight PET/64 slice CT. The MRI was acquired on a Siemens 3 Tesla Magnetom Verio. Images where then fused together using the GE AW Volume Share 4 manual registration tools. Bone landmarks were used to register the MRI to the CT images. CT images are then replaced by the correct order of PET images.

Case 1 images: Fused PET/CT images characterise lesion invasion into acetabulum. Due to beam hardening soft tissue involvement is difficult to see.

42 Gamma Gazette July 2012

PET/Diagnostic CT/MRI Fusion in the abdomen

Case 1 images: PET/MRI fusion images characterises; soft tissue evolvement (obturator internus), extent of muscle and bone involvement.

Case 1

Case 2

History A 64-year-old male presented with known recurrent urothelial carcinoma (originating from the lining of the bladder). A PET/ diagnostic CT and a MRI were ordered to assess the pelvic sidewall and the extent of the disease in the pelvis. Patient has had a previous right total hip replacement.

History A 55-year-old female with history of breast cancer, initially diagnosed with DCIS in 2001, status post lumpectomy, with recurrence in 2006, status post-mastectomy with axillary lymph node dissection, and 5 years Tamoxifen therapy. CT imaging revealed pulmonary nodule and multiple liver lesions, however multiple biopsies of the liver lesions have been inconclusive. The purpose of this exam is disease re-staging.

Procedure The patient arrived after fasting for 6 hours, with a blood glucose concentration of 6.1 mmol/l. An intravenous injection of FDG was given followed by a 60min uptake period. Whole body imaging was performed from base of brain to proximal femora using a GE Discovery Time of Flight PET / 64 Slice CT. Axial T2, coronal T1, axial T2 fat sat, coronal T2 STIR, as well as axial and coronal T1 fat saturated images postcontrast were obtained.

Findings PET: The large left pelvic sidewall mass (65 x 84 x 82mm craniocaudal) demonstrates a rim of intense metabolic activity with central photopenia in keeping with central necrosis. The lesion abuts the left ilium laterally with cortical erosion at the level of the acetabulum. The most metabolically active site is the rim of the mass posteriorly (SUV max 17.8) and anterolaterally (SUV max 14.6). There is mild FDG uptake extending into left obturator internus on co-registered PET/MRI images which is suspicious of muscle involvement. Images in the pelvis are significantly degraded by beam hardening artefact from the patientâ&#x20AC;&#x2122;s total hip arthroplasty.

No obvious free fluid is seen.

MRI: There is evidence of denervation of the obturator internus muscles and the posterior adductor muscles for the left hip. The sciatic nerve bundle appears preserved with a fat plane present.

No extension into the peri-rectal fat is seen. There is large recurrent tumour involving the left pelvic sidewall with evidence of extension into the left acetabulum through to the subarticular bone. This has increased since January. The tumour extends from the posterior aspect of the pubic bone through to the presacral region, but spares the sciatic nerve bundle. There is involvement of the obturator nerves with denervation to the obturator internus muscle and posterior left adductors. No separate lymphadenopathy is seen. No free fluid.

Procedure PET:The patient arrived after fasting for 6 hours and a blood glucose level was checked to be in the normal range. An intravenous injection of FDG was given followed by a 60min uptake period.

Whole body imaging was performed from skull vertex to mid thighs using a GE Discovery Time of Flight PET / 64 Slice CT. A diagnostic quality, contrast enhanced CT was performed through the chest, abdomen and pelvis, with low-dose CT imaging elsewhere for attenuation correction and lesion localisation purposes. There was good alignment between the PET and CT. Water was used as an oral contrast agent to assist in bowel distention.

MRI: In-and-out of phase scans were acquired through the liver followed by an axial T2 fat saturated sequence. 5-phase postcontrast imaging was also performed and followed by image fusion with the PET CT study.

Findings PET: 1. Multiple liver lesions demonstrating intense peripheral hypermetabolism and central hypometabolism, most consistent with metastatic disease. These findings correspond with centrally hypodense and peripherally enhancing lesions demonstrated on CT. Of note, not all of the lesions identified on CT demonstrate abnormal metabolic activity, for example lesions within the right hepatic dome and mid posterior right hepatic lobe.

2. Area of intense hypermetabolism in the region of the pancreatic body, with evidence of pancreatic ductal dilatation proximal to this.

3. A 6mm pulmonary nodule in the lingular segment of the left upper lobe, SUV max 1.8; nodules of this size are at the lower limits of PET sensitivity, therefore the degree of metabolic activity is worrisome.

In addition, 2-3mm pulmonary nodules are also seen within the left u upper lobe and right upper lobe.

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PET/Diagnostic CT/MRI Fusion in the abdomen

Case 2 images: PET/CT images indicate multiple lesions in the liver. Some are FDG avid some are not.

4. An 8mm right thyroid nodule with abnormal metabolic activity.

Further evaluation with thyroid ultrasound and possibly FNA is suggested. The remainder of the thyroid is heterogeneous.

Given the history of Hodgkinâ&#x20AC;&#x2122;s disease and subsequent breast cancer as well as a pattern of disease suggestive of pancreatic cancer, a mismatch repair gene abnormality could be considered.

a pancreatic primary neoplasm as given the pattern of metastases seen on the PET study and the pancreatic tumour itself would be unusual to be secondary disease from previous breast carcinoma.

MRI: Numerous liver lesions are again noted with relative sparing of segments 5 and 6 but involvement of the remainder of the liver in both the left and the right lobes with lesions ranging in size from <10mm up to the largest area which is in segment 4A measuring approximately 55 x 60mm. These demonstrate irregular T1 and T2 signal as well as areas of post-contrast enhancement as well as presumed central necrosis or liquefaction.

A separate enhancing mass is seen within the mid body of the pancreas measuring 21 x 16mm. There is upstream dilatation of the pancreatic duct, reaching nearly 6mm in diameter.

The features are consistent with multiple liver metastases with areas of irregular central necrosis. The uniformly enhancing pancreatic mass with upstream dilatation is likely to represent

History A 58-year-old male with previous (2 years ago) sigmoid colorectal cancer. Initial surgery and treatment considered successful.

Patient has a 10cm rectal stump. Now presents for staging assessment due to suspected local recurrence. Patient underwent a PET/attenuation correction CT scan 8 weeks prior at another PET centre.

CASE 3

Procedure PET:322MBq 18F-Fluorodeoxyglucose (scaled to weight). The patient arrived after fasting for 6 hours and a blood glucose level was checked to be 7mmol/L. An intravenous injection of FDG was given followed by a 60min uptake period. Whole body imaging was performed from base of brain to proximal femora using a GE Discovery Time of Flight PET / 64 Slice CT. A diagnostic quality, contrast enhanced CT was performed through the abdomen and pelvis, with lowdose CT imaging elsewhere for attenuation correction and lesion localisation purposes.

There was good alignment between the

Case 2 images: PET/MRI fused images indicate FDG avid mass and a MR enhancing mass in the pancreas with dilated duct. A 2nd primary pancreatic tumour with multiple metastatic disease to liver is suspected.

44 Gamma Gazette July 2012

PET/Diagnostic CT/MRI Fusion in the abdomen

Case 3 images: Local recurrence at site of previous surgery. Invasion into S2 seems likely however diagnostic CT has minimal changes.

PET and CT. Water was used as an oral contrast agent to assist in bowel distention.

MRI: Sagittal T1, T2, axial T1, T2, DWI, coronal T2, post-contrast axial and coronal FST1 and axial FS T2 sequences through the pelvis.

Findings PET: No dilatation is seen to suggest obstruction. Previous sigmoid colectomy is noted. There is a lobulated intensely FDG avid (SUV max. 21.6) presacral mass superior to the surgical clips extending from the inferior aspect of S1 to the inferior aspect of S2. The mass measures 32 x 37 x 45mm and abnormal uptake extends into the left superior aspect of S2 with minor sclerosis. Laterally, there is focal sclerosis which is not significantly metabolically active. A further subcentimetre nodule which is intensely FDG avid is seen to the right of the mass in keeping with adjacent small nodes. Mild uptake is seen in the anterior abdominal wall associated with the stoma.

MRI: 54 x 29 x 38mm, glucose avid mass in the presacral space in keeping with local recurrence, with invasion through the presacral fascia into the S2 vertebral body, the mass has invaded through the presacral fascia into the S2 segment with subtle cortical breach and marrow involvement of a 29 x 22 x 19mm area which comes into close proximity with the S2 nerve root as it passes through the sacral foramina.There is involvement of a small bowel loops within the peritoneal cavity and left common iliac vein and left ureter.

The right internal iliac artery abuts the tumour mass, although it is difficult to ascertain if this is adherent to the mass.

Intensely metabolically active presacral soft tissue mass which is highly suspicious of recurrent tumour with definite extension into the adjacent sacrum, well demonstrated on the co-registered MRI. There is also involvement of an adjacent small bowel loop with tethering, retraction and invasion (as shown on the MRI).

Comparison was made to the previous PET/ attenuation corrected CT performed 8 weeks prior. The lesion has increased marginally in size and now involves the sacrum which was not detected on the previous study.

DISCUSSION 1.

Multiple imaging modalities incorporating fusion gave a far more detailed diagnosis.

2. In Case 1 beam hardening due to hip prosthesis obscured the localisation of FDG uptake in the muscles. PET fused with MRI gave the exact location and extent of

Case 3 images: invasion of S2 by recurrent bowel cancer well demonstrated

by PET/MRI fused images. MRI demonstrates bone marrow involvement.

45

u

PET/Diagnostic CT/MRI Fusion in the abdomen

tumour invasion into the muscle, bone and obturator nerve.

3. In Case 2 pathology results of liver biopsies were inconclusive.

Intense FDG uptake in some of these liver lesions indicates that they are metastatic in nature, not a primary. This was further clarified by using contrast in the CT scan highlighting enhancing lesions. Intense FDG uptake in the body of the pancreas with dilation of duct on CT is detected and gives the first indication of where the primary might be. MRI images indicate an enhancing lesion in the pancreas with dilation of the pancreatic duct. MRI images fused with PET clearly indicate that this pancreatic mass is FDG avid and the primary source of the liver metastatic disease.

4. In Case 3 PET/Diagnostic CT indicates local recurrence in the area of previous surgery and metastatic disease in sacral spine 2. MRI images indicate the mass has invaded through the presacral fascia into sacral 2 spine and marrow involvement can be seen. MRI images fused with PET clearly indicate that the mass and secondary extension is FDG avid. Further MRI images reveal that there is small bowel retraction and involvement.

From this small sample of patients we can conclude that fusing PET/Diagnostic CT and MRI adequately deals with the following problems: localising to specific anatomy FDG avid lesions when CT artefacts obscure soft tissue, correlating and verifying primary pancreatic lesions found on PET/CT to MRI images, detailing the extent of invasive tumours into the surrounding tissue (both soft tissue and bone), delineating between metastatic deposits and invasive tumours, and detailed mapping of liver lesions. When all three modalities are fused together they create a detailed and comprehensive scanning procedure for the patient’s benefit.

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REFERENCES J. Ruf, E. Lopez Hänninen, M. Böhmig, I. Koch, T. Denecke, M. Plotkin, J. Langrehr, B. Wiedenmann, R. Felix, H. Amthauer (2006) “Impact of FDG-PET/MRI Image Fusion on the Detection of Pancreatic Cancer” Pancreatology 2006;6:512-519 (DOI: 10.1159/000096993) A. Malesci, L.Balzarini, A.Chiti, G.Lucignani (2004) “Pancreatic Cancer or chronic pancreatitis? An answer from PET/MRI image fusion” European Journal of Nuclear Medicine and Molecular Imaging, Volume 31, Number 9, 1352, DOI:10.1007/s00259004-1583-0 J. Gaa, E.J.Rummeny, M.D. Seemann (2004) “Whole body imaging with PET/MRI” European Journal Medical Research 2004, 9:309-312 M.D. Seemann, J.Gaa , G.Meisetschlaeger, E.J.Rummeny (2006) “Assessment of the extent of metastases of gastrointestinal carcinoid tumours using whole-body PET,CT, MRI, PET/CT and PET/MRI” European Journal of Medical Research 2006 11:5865 J.Czernin, M.Allen-Auerbach &H.R.Schelbert (2006) “Improvements in Cancer Staging with PET/CT: Literature-Based Evidence as of September 2006”. The Journal of Nuclear Medicine Vol.48 No.1 78S-88S

Case Study

Finding the Sentinal Node in patients with breast cancer Patrick Butler

Department of Nuclear Medicine, St George Hospital, NSW Australia

CLINICAL HISTORY A 65-year-old woman discovers a 1cm mass in her right breast. Biopsy reveals invasive carcinoma. The patient undergoes lymphoscintigraphy to locate the sentinel node (Figure One).

SCAN FINDINGS Lymphoscintigraphy is a teachnique where microscopic radiolabelled particles are injected around a tumour and then travel to the closest lymph node remaining there for several hours. The node is marked on the skin in the anterior and lateral projections (Figure Two) and localised intraoperatively by the surgeon using a specially designed probe (Figure Three) to detect the node at operation and resect it (Figure Four). Often a second technique is used simultaneously in that a blue dye is injected in the operating room and some of this dye travels to the sentinel node. Both techniques ensure a greater than 98% localisation rate.

DISCUSSION In patients with breast cancer, one of the major prognostic indicators is the presence or absence of spread into the axillary lymph nodes. For this reason, the standard of care in the past was to clear all the axillary lymph nodes at the time of surgical resection of the primary tumour. The problem with this approach is the increased chance of lymphedema with up to 13% patients having this problem after axillary lymph node clearance. It has also been recognised that with greater patient awareness of breast cancer and improved screening programs, the incidence of axillary node involvement is dropping in patients undergoing surgery. It is now clear that only the closest or sentinel node needs to be taken to accurately stage the patent. If the sentinel node is free of metastasis, axillary clearance is not needed and local recurrence is rare. Conversely, a positive sentinel node indicates that the axillary nodes should be taken out.

Top left, figure 1: Radionuclide scintigraphy with outline overlay showing site of injection of tracer around tumour with subsequent localisation in sentinel lymph node.

Top right, figure 2: Intra-operative photograph at time of sentinel node biopsy showing the skin markers (X).

Above left, figure 3: Intra-operative photograph showing the probe localising the sentinel node.

Above right, figure 4: Intra-operative photograph showing resection of the sentinel node.

CONCLUSION Breast cancer is the most common class of cancer in women worldwide. Staging with sentinel node biopsy leads to a substantial reduction in surgical morbidity with a high level of accuracy in selecting patients who require axillary lymph node clearance.

REFERENCES The Sentinel Node Procedure in Breast Cancer. J Nucl Med 2011: 52;405-414

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From page 16

A: Whatâ&#x20AC;&#x2122;s that? ... answer RESULT Planar imaging demonstrates bilateral degenerative change in the medial compartment of the knees, confirmed by SPECT/CT imaging. Incidentally noted, is a focus of intense tracer uptake in the right inguinal region which corresponds to an inguinal hernia containing bladder. Also noted on low dose CT is a left inguinal hernia containing loops of small bowel.

OVERVIEW A hernia is defined as any structure that passes through or protrudes from an abnormal hole or defect in a membrane. The most commonly occurring hernias are in the peritoneum (abdominal cavity) and the diaphragm (hiatus hernia) with inguinal hernias being the more common form(<75%), affecting about 2% of the whole adult population and are approximately 10 times more common in males than females. Umbilical, incisional and femoral hernias are other variants.

Inguinal hernias are generally classified as either direct or indirect; Direct hernias arise from a weak point in the abdominal fascia and are generally an acquired condition, occurring during adulthood. Indirect hernias are more often a congenital condition where the inguinal ring fails to close in utero, after the testicle has passed through. Further classification of hernias describe Reducible (contents can be manually pushed back into the peritoneal cavity) or Irreducible (contents cannot be manually pushed into the cavity).

Irreducible hernias are those that are at risk of complications and may require intervention. An Incarcerated hernia occurs when the tissue (usually small bowel) becomes trapped in the opening and blood flow becomes compromised. The incarcerated tissue can then become a Strangulated hernia â&#x20AC;&#x201C; where the blood flow has been jeopardised and the tissue begins to die. This is usually associated with extreme pain, fever and tachycardia.

Hernias involving the urinary bladder are thought to represent 1-3% of all inguinal hernias, with predominance for occurrence on the right side and can evolve from the inguinal or femoral canal. Itâ&#x20AC;&#x2122;s widely documented that most bladder hernias are asymptomatic and are discovered incidentally during surgical or imaging investigation for an unrelated issue. Confirmation of the presence of urinary bladder within the hernia can be done simply by cystography, ultrasound or a contrast-enhanced CT scan.

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Australian and New Zealand Society of Nuclear Medicine