July 2013

ISSN : 2200-9876

The official publication of the Australian and New Zealand Society of Nuclear Medicine

July 2013, Issue 9

Contents

www.anzsnm.org.au

Welcome ; From the Editor’s

4

President’s Report

5

Branch News

ACT

6

Queensland 6

New Zealand

7

Vic/Tas

7

Western Australia

7

SIG

Radiopharmaceuticals 8

Technologists

9

Technical Standards Sub-committee

11

Accreditation

11

What’s That?

13

Call for Life Membership Nominations 2014 15 ANZSNM Like Member Awards 2013

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ANZSNM Annual General Meeting 2013 Draft Minutes 18 ANZSNM Financial Statement Year End December 31, 2012 24 ANZSNM Annual Scientific Meeting 2013 Report 26 ANZSNM Annual Scientific Meeting Awards 29 Specific dose sources affecting nuclear medicine staff 32 Targeted approach to treating patients with locally advanced lung cancer reports exceptional survival rates 35 Health Workforce Australia Nuclear Medicine Scholarship Program 37 Case Studies

Myocardial uptake on a bone scan 38

Autonomous hyperfunctioning sublingual thyroid tissue in a patient with congenital hypothyroidism, resulting in hyperthyroidism suggestive of Graves’ disease

42

An interesting appearance of Ofuji’s disease on a F18 FDG PET/CT scan

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Interesting case

46

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.au March – February 1

July – June 1

November – October 1

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Journal Staff

Editorial copy & Advertising copy

Robyn Smith General Manager ANZSNM Secretariat PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 9387 9627 Email: secretariat@anzsnm.org.au

The Australian and New Zealand Society of Nuclear Medicine Limited

Design & Production

Rachel Bullard Deep Blue Design Studio Email: deepbluedesign1@mac.com

This issue compiled by WA and ACT branches:

Georgina Santich (WA)

Stephanie O’Donnell (WA)

Ashlee Harrison (ACT)

Maree Wright (ACT)

Sharon Mosley (ACT)

Submissions Scientific submissions on 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.

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.

Aims and Objectives

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 through standing committees and special interest groups: a) The Technical Standards Committee sets minimum

standards and develops quality control procedures

for nuclear medicine instrumentation in Australia

and New Zealand.

b) The Research Grant Committee administers the

annual ANZNM Research Grant.

c) The Technologists Special Interest Group. With the introduction of National Registration for Nuclear Medicine Technologists / Scientists as of 1st July 2012, the future role of the Accreditation Board was reviewed and federal council made a decision to disband the current Accreditation Board and reallocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG). The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam are now managed by sub-committees of the TSIG.

The ANZSNM Gamma Gazette is published three times a year: March, July and November.

Deadlines for each issue of the journal are the first of each month prior to publishing. © 2013 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

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d) The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality and provide a forum for development in Australia and New Zealand.

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 Treasurer Committee

Ms Liz Bailey (TSIG) email: ebailey@nsccahs.health.nsw.gov.au vacant Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.au Dr Sue O’Malley (NZ) email: sue@omalley.co.nz Prof Dale Bailey (NSW) email: Dale.Bailey@sydney.edu.au Ms Lyndajane Michel (Qld) email: michell@qdi.com.au Assoc Prof Roslyn Francis (WA) email: roslyn.francis@uwa.edu.au Mr Dominic Mensforth (SA) email: Dominic.Mensforth@i-med.com.au Dr Darin O’Keeffe (Phyics SIG) email: Darin.OKeeffe@cdhb.health.nz Ms Jennifer Guille (Radiopharmaceutical Science SIG) email: jennifer.guille@sesiahs.health.nsw.gov.au Dr Sam Berlangieri (Physician rep, ANZAPNM) email: berlangieri@petnm.unimelb.edu.au

General Manager & Secretariat

Ms Robyn Smith, Mrs Genevieve Butler

All correspondence ANZSNM Secretariat

PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 9387 9627 Email: secretariat@anzsnm.org.au Research Grant Committee

Chairperson: Dr Graeme O’Keefe, email: graeme.okeefe@petnm.unimelb.edu.au

Scientific Advisory Panel

Chairperson: Professor Dale Bailey, email: Dale.Bailey@sydney.edu.au

Branch Secretaries Australian Capital Territory Ms Maree Wright, email: maree_wright@hotmail.com New South Wales Position vacant, interim contact is Acting President Ms Liz Bailey, ebailey@nsccahs.health.nsw.gov.au Queensland Ms Nikki Weinert & Ms Kathy Roy, email: qldbranchsecretaryanzsnm@gmail.com South Australia Ms Nicole Ayars, email: nicole.ayars@health.sa.gov.au Victoria/Tasmania Dr Zlata Ivanov, email: zlata.ivanov@arpansa.gov.au Western Australia Ms Georgina Santich, email: wabranchsecretary@hotmail.com New Zealand Ms Dianne Wills, email: Dianne.Wills@cdhb.health.nz Special Interest Groups Technologists

Radiopharmacy Physics/Computer Science Nurse Member Liaison

Nicholas Farnham, email: Nicholas.Farnham@health.sa.gov.au CPD Program Sub-committee: Dr Clayton Frater PDY/Mentor Program Sub-committee: Ms Tale Liiv 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

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

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Welcome Welcome to the 9th online edition of the Gamma Gazette which follows the Annual Scientific Meeting in Perth in April. Many thanks to all who travelled the long distances to WA to participate in what turned out to be a successful, informative and fun few days. We appreciate that Perth seems to cost so much more than the other Australian cities, not only because of the kilometres. However, the program skilfully compiled by the Co-Convenors Ros Francis and Bill Macdonald, and their band of elves was sufficiently attractive to encourage you all to come.

A highlight of the ASM is always the presentation of Life Memberships of the ANZSNM. This year they were awarded to Perth’s Dr Agatha van der Schaaf and Sydney’s Professor Richard Smart. Congratulations to these two people who have made great contributions to the Society and to Nuclear Medicine in general over many years.

Many thanks to Jennifer Brand for the wonderful job she did of the photography at the ASM (with a little help from some of her friends at the Annual Dinner).

Thanks also to Stephanie O’Donnell and Georgina Santich as well as Ashlee Harrison, Maree Wright and Sharon Mosley for compiling this issue of the Gazette. I am sure everyone will find it an interesting and informative read.

Diane Cheong Chair WA Branch ANZSNM

From the Editors Welcome to the July edition of the Gamma Gazette. The WA and ACT Branches have collaborated to bring you this bumper edition! It’s a packed edition, full of all the 43rd Annual Scientific Meeting reports, including from the coconvenors Dr Ros Francis and Dr Bill Macdonald. Some of you might see yourselves in the photos we have included from the conference. You will also find the minutes and treasurers report from the AGM, a list of the award winners and the usual branch reports.

We have some excellent and very well researched case studies for you to read, as well as two interesting “What’s That?” cases to make you think. Cases range from unusual findings on bone and PET scans to a thyroid scan.

We have a poster about GI Bleeds from Sir Charles Gardiner Hospital Nuclear Medicine Department & WA PET Service; and a piece on Specific Dose Sources Affecting Nuclear Medicine Staff from the Canberra Hospital.

There is also a media release from Melbourne’s Peter MacCallum Cancer Centre about using PET/CT scanning to guide curative chemo-radiation therapy in patients with the most common form of lung cancer.

Information on the Health Workforce Australia Nuclear Medicine Scholarship program offered to WA high school students has been included. We have also interviewed the first student to be offered the scholarship, Eleni Shrestha, to hear how she has found the scholarship so far.

Finally, the WA Branch would like to wish Geoff Roff all the best in his new position in Victoria. Geoff has contributed to the Nuclear Medicine community throughout Australia over a number of years, including time as the ANZSNM President, assisting with the development of the current ANZSNM website and serving on two ASM organising committees. He served as the W.A representative on the ANZSNM Federal Committee from 2007 until 2013 as well as being a long serving and hard working committee member on the ANZSNM W.A. Branch. Good luck Geoff, we will miss having you around.

We hope you enjoy this issue of the Gamma Gazette, Georgina, Stephanie, Ashlee, Maree and Sharon

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President’s Report Welcome to the next issue of the Gamma Gazette following another successful Annual Scientific Meeting, this year in beautiful Perth.

Firstly, congratulations must go to the organisers of the 2013 Perth Annual Scientific Meeting for another outstanding meeting, with many members commenting on the high calibre of the scientific content and radiopharmacy expertise. Many thanks to co-convenors Dr Roslyn Francis and Dr Bill MacDonald, Dr Liz Thomas for co-ordinating the sponsor program, Cedric Eustance for the technologists’ symposium and the remaining committee members Karen Hindley, Diane Cheong and Geoff Roff for their hard work and dedication over the last 3 years. It was fantastic to welcome Dr Enrique Estrada who is the current President of the WFNMB and convenor for the 2014 World Federation meeting in Cancun Mexico and Brenda King the current President of the SNMMI-Technologist Section. The meeting included high level presentations from 7 international speakers covering a variety of topics with an emphasis on ‘New Horizons’. What an exciting time for the profession. Thanks must also go to our premium sponsors and exhibitors for their ongoing support of the meeting and we look forward to many more years of working together.

I am pleased to report that the history project is nearing completion with the first draft currently being reviewed. A title and table of contents has been completed with the preferred title being Isotopes, Imaging & Identity – The History of Nuclear Medicine in Australia and New Zealand. The society wishes to acknowledge the numerous members and colleagues for their varied contributions. The timeline for completion is end of August 2013 with a small print run being planned and the book being made available as an e-book for a small fee. Any members wishing to purchase a hardcopy of the history book, please contact the secretariat.

During the opening ceremony of the Perth ASM, the society in collaboration with the AANMS launched the formation of ARTnet (Australasian Isotopes, Imaging and Identity Radiopharmaceuticals Trials network), a clinical trials network to support and The History of Nuclear Medicine in Australia and New Zealand facilitate the development of research expertise and protocols within Australia and New Zealand. The network aims to provide assistance and skills to support research activities and to facilitate securing funds to support these activities.

It will be inclusive and open to any site that has the validated equipment and expertise to support the project. The network will also act as a linkage to national and international bodies such as TROG, AGITG, SNM CTN, WFNMB, ALLG and many others.

The council has finalised a strategic plan for the society that is available on the website, outlining our mission and vision statements and goals for the next 5 years. This is exciting times for the society and we look forward to working with members to achieve these aims.

Liz Bailey President ANZSNM As documented by Paul A. C. Richards On behalf of the ANZSNM Edited by Philip Bachelor

Published by the Australian and New Zealand Society of Nuclear Medicine

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Branch News AUSTRALIAN CAPITAL TERRITORY As a small branch, we are pretty quiet during the year here in Canberra, and the highlight for this year would have to be the wonderful presentation by Professor Koen Van Laere, covering research into current and future neuroimaging tracers, predominantly focusing on PET applications. We were all impressed with the depth of knowledge shared with us in April.

Our other focus this quarter has been on preparing articles for this issue of the Gamma Gazette, which WA Branch have kindly co-ordinated.

We also have a few changes to our Branch committee, with Ryan McKeown stepping down after a commendable 5 years as President, and Sharon Mosley agreeing to take on the responsibility. Due to other commitments, Nathan Jack has had to step down as Treasurer, and James Green has stepped up to fill this role (thankyou James). This does mean that all three of us are now from TCH, but in such a small community this shouldn’t be a problem.

We look forward to our next branch meeting hosted by CIG later in the year.

Maree Wright, ACT Branch Secretary QUEENSLAND We held our first meeting of the year on Monday the 11th of February and were fortunate enough to have Professor David Townsend from the Singapore Bioimaging Consortium give a presentation on PET/MRI (From PET/CT to PET/MRI: Advance or Distraction) at the Story Bridge Hotel. We were very pleased to have over 60 attendees and hope that we can continue to have strong numbers at the rest of the year’s meetings and events.

Our bi-annual branch symposium will be held on Saturday the 21st of September at Carlton Brewery, half way between Brisbane and the Gold Coast. We are currently in the process of planning the program and encourage any members who are interested in presenting on the day to contact us as soon as possible. It should be a wonderful day with plenty of good food, a bit of beer tasting, and a few friendly competitions.

Nikki Weinert and Kathy Roy Qld Branch Co-Secretaries NEW ZEALAND The NZ Branch members would like to congratulate Pru Burns for winning the 2013 Radpharm Award at the recent Annual Scientific Meeting of the ANZSNM in Perth. She is the first NZ winner of this award and we are very proud of her.

Pru has also taken the time to write the following review of the Perth Conference.

Dianne Wills Secretary NZ Branch Conference Review: 2013 ANZSNM Scientific Meeting, Perth, Australia With support from the Rouse Education Trust, I was fortunate to attend the 43rd Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine in Perth Australia on April 13-15, 2013. This year’s theme was “Explore New Horizons”, acknowledging the role of Nuclear Medicine being at the forefront of scientific developments in the understanding of the mechanisms of disease and its treatment.

The meeting is always well attended by Technologists, Nuclear Medicine Physicians, Radiologists, Physicists and Nurses. Perth was no exception, with over 400 delegates from New Zealand, Australia and South East Asia.

The quality of international speakers was very impressive. I particularly enjoyed the presentation by Professor Koenraad van Laere from Belgium, on New Horizons in Neuroimaging: are we out of targets? Mrs Bernadette Cronin, Radioisotope Services Manager from The Royal Marsden Hospital in London, gave a very NZ relevant presentation on New Horizons for the NMT, which looked at NM and PET/CT MRT role extension within the UK imaging environment.

As part of my attendance at the meeting, I was an entrant in the Radpharm Award category. The Radpharm Award requires an oral presentation based on a case study highlighting advancements in Nuclear Medicine practice. My presentation was on a PET/CT scan we performed using a new brain tumour imaging agent 18F-FET. I won the NZ branch category, which then required me to present the same case in Perth. There were 5 other Radpharm entrants from around Australia, very tough competition. I was very fortunate to win the overall

6 Gamma Gazette July 2013

Branch News Radpharm Award for 2013. I am extremely proud of this win, the first time a Kiwi has ever won in the 20-odd year history of the Award.

I would like to thank Cyclotek Australia for supplying the 18F-FET to us here in Wellington; Mr Kelvin Woon, Neurosurgeon at Capital and Coast Health, who is a huge supporter of this new tracer; and Dr Trevor Fitzjohn for constantly putting PET/CT into the limelight. Thank you also to my employer Pacific Radiology, for allowing me the time to work on my presentation and to attend the conference.

Most importantly I would like to thank the NZIMRT for supporting me through the Rouse Education Trust to attend this meeting. I would like to encourage all imaging technologists to think about presenting an interesting case from their departments. Patients are why we are here, and I always find case study presentations the most interesting!

Pru Burns Charge NMT, Pacific Radiology, Wellington VICTORIA/TASMANIA BRANCH REPORT The first half of 2013 has been busy for the ANZSNM in Victoria and Tasmania with many scientific meetings, promotional and CPD activities having taken place.

The branch welcomed 2 speakers to its Post Conference Scientific meeting that was held at the Peter MacCallum Cancer Centre on Wednesday April 17th. Professor Koenraad van Laere and Professor Stefano Fanti (after an epic journey across Melbourne that involved taxis, bicycles and a pre-meeting jog) spoke on Advancements in PET in the areas on Neurology and Oncology. The meeting was well attended with around 50 people attending.

The other focus of the branch in the first half of this year has been the promotion of Nuclear Medicine Technology and Medical Physics as careers options. The branch has been working in conjunction with the VSNMT and the Department of Health to create a “Careers and Curriculum Resource Website” for Nuclear Medicine and Medical Physics as well as other promotional activities. To this end the Branch is looking to formalise the status of the newly formed Promotions Working Party to tackle the increasing demands in this area. The group’s first task was to oversee the running of the AGE VCE and Careers Expo which took place at the beginning of May. I would like to thank everyone who selflessly volunteered their time to make this event possible.

In the 2nd half of 2013 the Branch focus will be on CPD activities. The Annual Day Seminar will be held on Saturday October 12th at the Crowne Plaza. The branch is hoping to hold another 2 CE Master Classes later in the year focussing on Nuclear Cardiology and Muskuloskeletal Imaging and CT with next one scheduled for late July/Early August. Details for all events will follow in next few months.

Bridget Chappell Vic/Tas Branch Chair WESTERN AUSTRALIA The 2013 Annual Scientific Meeting in April was held in Perth. It was well attended and there were lots of interesting talks. It is exciting to see where the future of Nuclear Medicine is heading with the use of hybrid technologies, the development of new tracers and the need for dual/multi modality training and greater cooperation with other medical imaging professionals. We hope those who came were able to enjoy what Perth had to offer even though the weather was not as sunny as we might have hoped.

We wish Geoff Roff all the best with his new endeavours as he relocates to Melbourne. The WA Branch Committee would like to thank Geoff for all his hard work and expertise over the years. We miss him already.

We are busy organising our annual Continuing Professional Education workshop that will be held on Saturday the 3rd of August at the University Club in Nedlands. The theme for this year is Endocrine Imaging. We encourage everybody to attend the workshop.

Adrienne Little WA Branch Committee Member

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Special Interest Group News RADIOPHARMACEUTICAL SCIENCE The last twelve months have been busy for members of the SIG. We are becoming a more cohesive group, with much better communication and interest and active involvement in the profession.

This is well illustrated by the number of members now representing our interests on a wide variety of working parties and panels.

Representation: • Federal Council J Guille Technical Standards Committee J Guille, G Snowden

– Dose Calibrator Survey

– PET Dose Calibrator Survey • Scientific Advisory Panel V Kumar • RACI Liason Committee A Katsifis Nuclear Medicine Liason Panel ARPANSA D Bodetti, J Baldas, Z Ivanov • Accreditation SubCommittee J Guille (Chair) , E Browne, A Katsifis, P Lam,

D Henderson, G Chan, T Boudier, J Poon,

V Kumar. D Bodetti, D Kumar • TGA Working Party G Chan In addition to involvement in these groups, we are undertaking a number of ‘Quality Projects’ each of which aim to improve some aspect of our profession.

Quality Projects • Accreditation Syllabus: There is a need for us, as a profession, to take control of developing competency standards and a method of assessment. If we do not do it, AHPRA may impose it on us and we may not have much say in how this is implemented, A working party comprising mostly NSW RPS, with teleconference in of those from other states who have maintained an interest, has now completed a working syllabus outline, and some of the guidelines, which have been circulated to everyone on the mailing list. The WP are now continuing to develop the guidelines for each of these sections, which include:

– Expected knowledge

– Expected skills

– Suggested method(s) of training for competency

– Suggested methods of demonstrationg competency

– Assessment criteria When these are complete a large working party will be convened, with representatives from each state and with varying areas of expertise to refine these documents for trial on a small group of RPS. The expected date of working party is Mid July, with initial examinations and trial of system to be complete by October 31, 2013. A grant of $4000 has been given by ANZSNM to assist with travel and accommodation for this WP. As many as can be afforded will be brought in for this exercise, and anyone who can obtain their own funding is also welcome.

• MQ Masters of Radiopharmaceutical Science, The first intake of students (6) in July, 2012, will graduate Dec 2013 or later. Two students are currently undertaking Major Research Project under supervision of A Katsifis and J Guille. Programme has been ‘rested’ for 2013. The new Dean of Science has indicated he would like us to attempt to obtain some funding to assist the running of this course, determine where within the University it will best be located (chemistry or Australian School of Advanced Medicine), and investigate the possibility of presenting some of the programme through on-line learning. Andrew and I are pursuing a number of these suggestions, including the fact that our profession has been listed as ‘endangered’ both by the NSW Ministry of Health, and on the Skilled Occupation List by the Federal Dept of Immigration. We hope the program will run in 2014, and that ‘online’ availability will follow shortly.

A number of people and institutions were very generous in assisting with this course, particularly the specialist unit CBMS 810. I would like to acknowledge their contribution and thank them for their involvement and generosity. They include: • RPA and Prof Michael Fulham, for their investment in the provision of lecture area, access to specialists (A Katsifis, S Eberl, P Lam, D Henderson, J Towson) • Richard Smart – who, as always, gave much of his time and knowledge to teach basic nuclear science and radiation safety.

• ANSTO - T Eastcott, Rod Manning (NMC) for excellent tours of the facilities and lectures • B Hutton – all the way from London, who gave excellent insight into the physics of imaging • Standardization of QC methods. British Pharmacopeia methods are often unsuitable for use in a normal NM department. In their place ‘other’ methods are often employed, usually distributed by word-of-mouth, and these

8 Gamma Gazette July 2013

Special Interest Group News are often not properly validated. We are attempting to gather information on those methods which are currently in use, and to validate those with merit so that they can be deemed an ‘acceptable alternative’ by the TGA. A survey has been sent to all RPS on the mailing list. It will also be sent to all members of ANZSNM, but we only require one answer per practice.

Dr Sheruna Naidoo (GMS) is leading the Working Party to analyse results and instigate validation of techniques.

We will keep you posted.

• Revision of the Guidelines for Good Radiopharmacy Practice. These were last reviewed in 2001. With the introduction of the new PIC/s code, these need to be reviewed to make sure they still comply. A Working Party is being established - to date Gordon Chan, John Baldas, Divesh Kumar. If you have an interest in this area, please advise us of this.

Proposed Quality Projects As our representative on the Federal Council I will be bringing a few requests that have come to my attention to be added to our ‘Quality Projects’ list.

• ANZSNM Website: This has recently been overhauled and it would be good for our group to use this as an education platform, and to enable the wider NM community access to information relevant to radiopharmaceiticals. To that end several proposed topics to potentially add were discussed positively in our AGM. – Specialist Practice Register – a request was made to place ‘methods’ on the ANZSNM website. For the newer practices, such as preparation of Ga-68 peptides, there may be a number of methods in use, with no one method is as yet established as the ‘Gold Standard’. A ‘Register of Practitioners of Special Practices’, which lists the names of practitioners willing to be contacted for advice on a topic, and their contact details, could be compiled for addition to the SIG section of the ANZSNM Website.

– Information about how to manage and report ‘abnormal behaviours of radiopharmaceuticals’ – was communicated to me in reponse to enquiries from several practices for information needed for DIAS submissions. John Baldas wrote an excellent communication, which could be modified for addition to the website.

Finally, to everyone who has contributed in even the smallest way to ensure the improved communication, education and development of our professional group … Thank you.

Jennifer Guille Chair TECHNOLOGISTS (TSIG) We move into our second year of the new executive structure of the TSIG that includes, Incoming Chairperson, Current Chairperson and Outgoing Chairperson to allow for fluid transfer of knowledge and administration of the TSIG. I would like to thank Marcia Wood the outgoing Chair for all the work that she has put in over the last 12 months to keep the TSIG running so smoothly. I look forward to working with her to continue the good work. The TSIG will continue in the provision of documentation to define Nuclear Medicine Technologists roles and practice, creating opportunity and guidance in education, CPD and National Registration of Technologists.

The Technologists’s Symposium at the Perth Annual Scientific Meeting was well attended and had very interesting content including a Plenary Session by Valerie Cronin from the UK, Radpharm Award case studies, free papers and a panel discussion on future directions of Nuclear Medicine Technologists. We were lucky to have assembled an experienced panel of Brenda King President of SNMMI-TS, Valerie Cronin Manager from Royal Marsden Hospital in London, Liz Bailey President of ANZSNM and Marcia Wood Chairperson of ANZSNMT. In the next twelve months will be looking to forge closer relationships with the SNMMI-TS, tapping into the knowledge base at an executive level and hopefully provide advice where we can, like in Graduate Education levels which Australia and New Zealand has some of the highest minimum requirements in the world.

Our next event is the TSIG Day Seminar at Coffs Harbour NSW on 27th July. The theme is Rural, Regional and Remote – Nuclear Medicine Outside of a Major City. As in previous years we invite all technologists to attend, the program will be available shortly.

If you have any queries about CPD, National Registration or any other concerns, you can contact your local State Representative or the ANZSNM Secretariat who will pass on the query to the appropriate person and you will receive a timely response.

Nicholas Farnham Chair, ANZSNMT

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Save the date. . .

AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE LIMITED ABN: 35133630029

TSIG Day Seminar Saturday 27th July 2013 Rural, Regional and Remote – Nuclear Medicine Outside of a Major City

Following the success of previous symposiums, the TSIG is holding it’s 5th Annual Day seminar this year at the Novotel Pacific Bay Resort Coffs Harbour NSW

Come join us for a day of Nuclear Medicine and sunshine in Coffs Harbour

Registration, accommodation and programme details will be available Registration, accommodation and programme details are now available on the website soon (www.anzsnm.org.au) so keep your diaries free on the website (www.anzsnm.org.au) make sure you are registered

Technical Standards Committee The PET Working Group has recently added the following sentences to the document “Requirements for PET Accreditation (Instrumentation & Radiation Safety) 2nd Edition (2012)” The performance specifications in this document are not intended to be applied retrospectively to PET scanners installed in any facility prior to January 1, 2013. For these systems the previous version of the standards will still apply. However, any scanner installed in a new geographical location after January 1, 2013 will be subject to the specifications in this document irrespective of the provenance of the scanner (e.g., second-hand, refurbished, moved to a different site address, etc).

This document [Version 2.3] is available from the Society website at: www.anzsnm.org.au/cms/assets/Uploads/Documents/Committees/Technical-Standards/Requirements-for-PETAccreditation-2nd-Ed-V2.3.pdf The Dose Calibrator Working Group, together with staff from ANSTO’s Activity Standards Lab (ASL) has recently conducted a trial of the proposed Dose Calibrator Intercomparison Programme. Four dose calibrators at three clinical sites in Sydney were assessed using standard sources of 99mTc and 131I. The measured data was directly entered into a tablet application developed at the ASL which was then automatically transmitted to the ASL for analysis. The results of this trial will enable the national programme to be finalised.

The Nuclear Medicine Equipment Working Group has drafted two documents: a minimum quality control schedule, and guidelines for performing quality control of gamma cameras. After review by the Working Group the documents will be forwarded to the Physics and Technologists SIGs for comments.

The Software Phantoms and Clinical Software Validation Working Group hopes to have a beta version of the audit tool available by 1 July 2013.

Accreditation Congratulations to the following departments which were granted Accreditation or Re-Accreditation for the training of PDY Technologists: Telemed Nuclear Imaging Mandurah and Bunbury #164 Southern X-Ray Clinics Wesley Nuclear Medicine #81 Medical Imaging Bankstown #165 Sutherland Nuclear Medicine #4 Prince Charles Hospital #106 Queen Elizabeth Hospital #34 Cabrini Health #39 PRP Diagnostic Imaging Tuggerah #144 Canberra Imaging Group John James Hospital #86 St George Private Hospital #89 Royal Prince Alfred Hospital #27 Liverpool Hospital #28

Congratulations to the following technologists who were granted Accreditation: Emma Louise Snow Kirrily Jane Hargreaves Kristen Trachsel Amanda Peter Eric Stoakes Payal Virdi Kimberly Nguyen Edward Michael Weniton Nicholas Robert Khan Stephanie Laura Tripodi Mark William Thornton George James Roy Eilidh Jean Wright Emma Jessica Brook Joshua Boyd

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Answer on page 34

What’s that?

Ryan McKeown and Chris Thomas National Capital Diagnostic Imaging, Canberra, ACT

A 51-year-old female presented to the Nuclear Medicine department to undertake a bone scan to investigate right sided upper cervical spine pain and headaches for 6 months following an MVA. The patient was injected with 911 MBq of 99mTc-HDP, with delayed images taken 2 hours later.

As part of departmental routine imaging, planar images were acquired from the top of the skull to the base of the pelvis (Figure 1). During the lumbar/pelvic image, an incidental finding of increased uptake was identified within the right proximal femoral shaft. An additional planar image of the femora and SPECT/CT were undertaken of this area.

What is it?

Figure 1: Delayed planar images using 99mTc-HDP

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Answer on page 36

What’s that?

Lauren Parker Nuclear Medicine Technologist, Numedica, NSW An 85-year-old male presented to the Nuclear Medicine department complaining of increasing pain in the throracic and lumbar spine. He had a history of chronic lower back pain. A CT performed three months prior showed disc bulging between L3 and L4. A small amount of degeneration was also noted within the spine. The patient had no history of cancer or any bony diseases.

A 3 phase bone scan was performed of the thoracic and lumbar spine. The following images were obtained in the delayed phase.

Figure 1

What is the possible cause for the intense uptake in the abdomen?

14 Gamma Gazette July 2013

Call for Life Membership Nominations 2014 Nominations required by 1 November 2013 Honorary Life Membership is a special member category that may be awarded to Society members who have made significant contributions to the objectives of ANZSNM and to Nuclear Medicine in Australia and/or New Zealand.

Ordinary Members and Associate Members of the Society are eligible for Honorary Life Membership and must be nominated and seconded by two current financial members of ANZSNM. Nomination submissions are judged on the fulfilment of specific criteria and there is no requirement within the Constitution for the Federal Council to award one or more Honorary Life Memberships each calendar year. The rules and submission process are outlined below:

ANZSNM Honorary Life Membership Nomination

Introduction Honorary life membership is a special category to which Ordinary Members and Associate Members may be elected.

Life Members will not be required to pay any future membership fees.

Qualification Criteria The following criteria must be fulfilled to be considered for life membership: 1. The candidate must have been active in the field of Nuclear Medicine for a minimum of 20 years; 2. The candidate must have made significant contributions to the Australian and New Zealand Society of Nuclear Medicine (ANZSNM).

Examples of significant contributions include: Serving on ANZSNM committees: Representing the ANZSNM on regulatory working parties or professional advisory panels, being a member of the Accreditation Board; 3. The candidate must have made significant contributions to Australian Nuclear Medicine;

Examples include research and development, commercial and professional support. educational advances; 4. Equal weight will be given to criteria 2 and 3 in the decision to elect the candidate to life membership.

How to propose an ANZSNM member for the category of Life Membership Nominations for life membership will be called for in the July issue of the Gamma Gazette. A financial member of the ANZSNM must prepare a submission outlining fulfilment of the above listed criteria. The proposal must be seconded by another financial member of the ANZSNM. The proposal must then be submitted to the secretariat by the 1st of November in any calendar year for consideration by the Federal Council at the upcoming meeting.

Documents to be submitted for to support the candidate’s proposal: The following documents must be submitted to the secretariat by the closing date: 1. A cover letter containing the proposed request and candidate’s details; 2. Evidence that the candidate fulfils all criteria (less than two pages total). The following items should be included:

a. Documentation showing that the candidate’s activity in the field of Nuclear Medicine began at least 20 years prior to the year in which life membership is to be awarded;

b. A list of the significant contributions made by the candidate to the ANZSNM;

c. A list of the significant contributions made by the candidate to the field of Nuclear Medicine.

Proposal Consideration Receipt of the proposal will be acknowledged by the ANZSNM secretariat. The secretariat may contact proposing members where clarification of the candidate details is required.

Approval for nomination will constitute a two-thirds majority supporting vote by members of the Federal Council. The principle proposing member will be notified of the committee’s decision by the secretariat prior to the Annual Scientific Meeting (ASM). The President of the ANZSNM will present the award to the successful candidate at the gala dinner of the ASM. The award will be acknowledged in the July issue of the Gamma Gazette.

Nominations Send nominations by mail, fax, or email to: ANZSNM Secretariat

PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 93879627 Email: secretariat@anzsnm.org.au

Honorary Life membership 2013

Congratulations to the two Members of ANZSNM awarded Honorary Life Membership at the Perth ASM in April 2013, Dr Agatha van der Schaaf and Professor Richard Smart.

15

ANZSNM Life Member awards Dr Agatha van der Schaaf

Dr Richard Smart

Nominated by Dr Elizabeth Thomas Seconded by A/Prof Roslyn Francis Awarded Life Membership at the Perth ASM, April 2013

Nominated by Mark Trifunovic Seconded by Tracey Smith Awarded Life Membership at the Perth ASM, April 2013

Dr Agatha van der Schaaf has been an outstanding member of the ANZSNM for over 30 years and has been instrumental in the development of Nuclear Medicine in Australia.

Dr van der Schaaf graduated from The University of Western Australia in 1967 and commenced training in Nuclear Medicine in 1972. She obtained Fellowship of the Royal Australian College of Physicians in 1975 and commenced work as a Consultant Nuclear Physician at Royal Perth Hospital in 1976. She worked there for ten years before taking up a consultant position at Sir Charles Gairdner Hospital, where she was Head of Department for almost 30 years. Agatha continued to remain extremely active in the Department until her retirement in 2011.

Dr van der Schaaf became a member of the ANZSNM in 1975 and has demonstrated outstanding commitment to the Society in the subsequent 38 years. She was a committee member of the Western Australia Branch of the ANZSNM for 6 years (1984-1990), during which she was the WA branch delegate on the Federal Committee (1987). She served on the ANZSNM accreditation board for 2 years (1989-1991) and was elected as the Vice President of the ANZSNM in 1989-1991, and President of the Society from 1991-1993. Agatha was the first female President of the Society. Dr van der Schaaf was the Scientific Program Organiser of the ANZSNM annual scientific conference in 1983 and 1991.

In addition to her involvement with the ANZSNM, Dr van der Schaaf has made significant contributions to the specialty of Nuclear Medicine in Australia. Her research interests have spanned over the life time of her career, and she has presented at numerous conferences and published many articles and abstracts. Her research interests have extended over the breadth of Nuclear Medicine, and in more recent years included PET research in mesothelioma.

Dr van der Schaaf has been a member of multiple other professional organisations and committees, including the Australian Nuclear Science and Technology Organisation Board (ANSTO), the Metropolitan Health Services Board (1997-2001) and the ANZAPNM Training Site Accreditation Committee. She is an outstanding clinician, educator and researcher and has served as a mentor for countless trainees.

The ANZSNM NSW Branch proposed that Dr Richard Smart be granted life-membership of the ANZSNM, as acknowledgement to his contribution in the fields of: nuclear medicine, radiobiology, medical radiation physics, and radiation safety.

Richard has dedicated his entire working career to the field of medical radiation physics.

Graduating in 1970 from Birmingham University with first class honours in Physics, Richard went on to subsequently obtain a Masters in Medical Science in 1971 and a PhD in Medical Physics in 1976. Fortunately for Australia, Richard accepted a position as medical physicist at St George District Hospital in NSW where he eventually held the position of Director of Medical Physics.

Richard is one of the most well known and respected medical physicists in Australia. He has diligently served the field of nuclear medicine in Australi a from his appointment until the present day. Richard has also served on several state and national committees including ANZSNM and ARPS, as secretary, vice-chairman and chairman.

Richard’s abilities have also been acknowledged internationally. As a result he has held several international positions with the World-Federation of Nuclear Medicine and Biology, and the International Atomic Energy Agency. In these roles Richard participated in missions to India, Pakistan, Bangladesh, Vietnam and Argentina. Richard has been invited as a guest speaker to many international conferences.

National and state governments seek Richard’s advice to this present day. Richard has served as a member of the National Radiation Health and Safety Advisory Council 1999-2008, and is currently a member of the NSW Radiation Advisory Council.

Richard also holds the following academic positions: Associate Professor in the Faculty of Medicine, University of NSW and Visiting Professional Fellow in the Faculty of Engineering, University of Wollongong.

16 Gamma Gazette July 2013

Diary Dates

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

July 27

ANZSNM TSIG Symposium

Coffs Harbour, NSW August 16 -18

1st Annual Conference of SISNM

South Indian Society of Nuclear Medicine

Coimbatore, Tamilnadu, India September 7

Hunter Technologist Group Meeting

Crowne Plaza Hunter Valley September 30-Oct 4

IAEA Conference on Nuclear Cardiology

Vienna, Austria October 13-16

ARPS Conference 2013

Cairns, QLD

(ARPS) Australasian Radiation Protection Society

October 15-17

ISCORN

Varese, Italy

(ISCORN) International Scientific Committee on Radionuclides in Nephrourology October 19-20

2013 ANZSNM NZ Branch Meeting

Palmerston North, NZ October 19-23 EANM’13

Lyon, France

(EANM) European Association of Nuclear Medicine November 17-21

WARMTH’s 8th International Conference on

Radiopharmaceutical Therapy, ICRT 2013

Manila, Philippines

(WARMTH) World Association of Radiopharmaceutical

& Molecular Therapy

ANZSNM Research Grant for 2014 Closing date 11 October 2013 for Research Grant to commence in 2014 The Australian and New Zealand Society of Nuclear Medicine (ANZSNM) offers an annual Research Grant to Society Members, consisting of one or more research grants up to a total value of $A20,000.

Based on a competitive process, the Research Grant is funded with the aim of supporting investigation, clinical projects or experimentation aimed at the discovery and interpretation of facts or the development or application of theories in the field of Nuclear Medicine/ Molecular Biology. Clinical Projects are defined as projects that centre on groups of patients or other human subjects. It is recognised that clinical and collaborative arrangements may dictate that some aspects of work funded may be carried out at other sites.

ANZSNM Research Grants are intended to achieve one or more of the following: 1. Approach a meaningful conclusion in one year.

2. Support investigator initiated clinical projects (as defined above).

3. Assist investigators striving to establish new programs or new directions.

4. Fund initial exploratory research for which external funding will be sought subsequently.

5. Address circumscribed clinical problems of a sort unlikely to attract industry funding.

6. Survey groups of patients to assess the success rate, sequelae, safety or any other aspect of diagnostic or radionuclide therapy protocols.

7. Bridge the gap of a year between completion of one external grant and the commencement of another.

Further information and the application form are available on the Society’s website.

Closing date for applications for the 2014 Research Grant is Friday 11 October 2013.

17

ANZSNM Annual General Meeting 2013 DRAFT MINUTES Date: Time: Venue:

Sunday, 14th April 2013 Opened at 10.15am Riverside Theatre, Perth Convention and Exhibition Centre, Perth WA

1. ATTENDANCE

1.1 Present: Elizabeth Bailey, Peter Collins, Andrew Scott, Alla Turlakow, Sam Berlangieri, Graeme O’Keefe, Cedric Eustance, Darin O’Keeffe, Richard Smart, Vijay Kumar, Heather Patterson, Allan Scott, Clayton Frater, Carol Target, Diane Cheong, Ros Francis, Liz Thomas, Amy Evans, Aurora Poon, Marcia Wood, John Baldas, Lisa Geyer, Grace Ha, Alan Ting, Jenny Calcott, Suzanne Fredericks, Elizabeth Clingan, Jennifer Brand, Gabriel Cehic, Geoff Schembri, Katherine Roy, Tale Liiv, Christian Testa, Kunthi Pathmaraj, Kera Pethybridge, Natalie Tavare, Theo Kitsos, Jack Meadows, Sammi Williams, Yasmin Tasker, Dominic Morgan, Angela Osley, Amy Johnson, Angela Duong, Grant Mitchell, Danielle Stewart, Vanessa Charles, James Westcott, Catriona Green, Justine Trpezanovski, Wesley NG, Sze Ting Lee, Sam Berlangieri, Hamish Ferguson, Steven Tsokas, Robert Cooper, Mark Marcenko, Susan Baldwin, Erwin Lupango, Jason Williamson, Victoria Brookes, Martin Blake, Melanie Dela Cruz, Stephanie O’Donnell, Adrienne Little, Culann Farrell, Karen Wiki, Pru Burns, Ghee Citon, Sally Sojan, Dylan Bartholomeusz, Douglas Smyth, Lynda Jane Michel, Geoff Roff, Zlata Ivanov, Grace Kong, Karen Winnett, Prue Lamerton, Jane Hassall, Pauline Collett, Marko Trifunovic, Chek Poh Beh, Georgina Santich, Jeanette Farmilo, Jennifer Guille, Emma Brook, Kathryn Adams, Joanne Landman, Kathryn Linn, Subanesan Nadesapillai, Jackie Bague, Victor Kalff, Thomas Barber, Ken Yap, Rachel Edison, Penny Wilkinson, John Richards, Monica Rossleigh, Penny Maton, Geoff Bower, Divesh Kumar, Brenda King, Erin McKay, Graeme Snowdon, Joe Cardaci, Allan Nickley, Uwe Ackermann, Elaine Campbell, Zlatko Capari, Ann Bernar, Emlyn Jones, Robyn Smith.

1.2 Apologies:

Dr Timothy Cain, Dr Andrew Tauro, F A Khafagi 2. MINUTES OF THE PREVIOUS MEETING Moved Lynda Jane Michel, Seconded Richard Smart That the Minutes from the ANZSNM AGM held on 28th of April 2012 at the Melbourne Convention and Exhibition Centre be confirmed and accepted as a true record.

CARRIED

18 Gamma Gazette July 2013

ANZSNMT – attached AANMS - attached Physics SIG - attached Radiopharmaceutical Science SIG – attached Nursing SIG – attached Technical Standards Committee (TSC) – attached International Relations Committee (IRC) – attached 2014 Adelaide – attached 2015 Queensland - attached

5. SPECIAL RESOLUTION MOTION: Proposed Geoff Roff, Seconded Elizabeth Bailey That the Constitution of the Society be amended: 1) To remove all references to the Accreditation Board.

2) To change clause references due to the removal of

clauses 65 & 66. (as circulated to Members and

attached to this agenda) CARRIED Geoff Roff, Treasurer, advised that he was seeking legal advice to determine whether it was adequate to ratify the change to the Constitution through a positive vote of 75% of the members in attendance or 75% of the total membership entitled to vote. He advised that the outcome will be communicated to members post ASM. However he asked for a vote on the motion from those present and the motion was carried.

6. LIFE MEMBERSHIP MOTION: Proposed Marko Trifunovic, Seconded Tracey Smith That Professor Richard Smart be granted Honorary Life Membership: CARRIED UNANIMOUSLY 7. BUSINESS WITHOUT NOTICE MOTION: Proposed Liz Thomas, Seconded Ros Francis That Agatha van der Schaaf be granted Honorary Life Membership: CARRIED UNANIMOUSLY 8. FEDERAL COUNCIL POSITIONS 2013 Council positions for the coming year were confirmed: President Elizabeth Bailey Vice President To be confirmed Treasurer Susan O’Malley Branch Representatives NSW Dale Bailey Vic/Tas Sze Ting Lee Qld Lyndajane Michel SA Dominic Mensforth WA Ros Francis ACT Sharon Mosley NZ Sue O’Malley

3. BUSINESS ARISING FROM PREVIOUS MINUTES No items were raised.

4. REPORTS –attached as indicated 4.1 President’s Report – attached.

Moved Dianne Cheong. Seconded Bill McDonald

That the President’s Report be received.

CARRIED 4.2 Treasurer’s Report – attached.

Moved Susan O’Malley, Seconded Peter Collins

That the Treasurer’s Report be received.

CARRIED

4.3 4.4 4.5 4.6 4.7 4.8 4.9 4.10 4.11

SIG Representatives Physics Darin O’Keefe Radiopharmacy Science Jennifer Guille ANZSNMT Elizabeth Bailey

President Elizabeth Bailey thanked Julie Crouch and Doug McKay for their excellent work in the Accreditation Board prior to it being disbanded due to implementation of the National Registration program. In addition, she conveyed appreciation to the Federal Council Members stepping down and welcomed the new council members. A presentation was made by the WA branch to Geoff Roff for his contribution to the WA Branch.

9. DATE & VENUE OF 2014 AGM Adelaide Convention and Exhibition Centre, April 25-28 2014 10. CLOSE President Elizabeth Bailey thanked all in attendance and closed the meeting at 11.15am Agenda Item 4.1 Presidents Report It has been an exciting time of change for the society over the last 12 months, starting with the successful recruitment of Robyn Smith in July last year into the role of General Manager for the ANZSNM. Robyn alongside Genevieve Butler have overseen the go-live of the new website, improved the financial record keeping for the society, liaised with the national registration boards regarding technologist registration and provided operational support to the council, branches and SIG’s. They are currently working with a small group of members to prepare an updated strategic plan for the society to reflect current objectives, collaborations and advancements for the profession.

With the successful implementation of national registration for technologists since 1st July 2012, the ANZSNM have been contracted by the MRPB (AHPRA) until December 2013 to provide the supervised practice or PDY program for graduates with no new enrolments to be accepted after 31st October 2013. After this time, the supervised practice program will be overseen by the Accreditation Council of the MRPB, chaired by Marilyn Baird with Allan Scott as the nuclear medicine representative.

Based on the model developed by other professional nuclear medicine bodies such as the SNMMI and EANM, the federal council have undertaken to form a Scientific Advisory Panel (SAP) to advise the individual Annual Scientific Meeting local organizing committee (LOC) in determining the scientific content and invited speaker selection for the ASM. This includes guiding the LOC in selection of named lectures (e.g., Lowenthal, Pioneer, etc.), overseeing the awards and Research Grant process, advising the Federal Council on matters of a scientific nature and to act as a liaison to Federal Council on scientific issues and content of the ASM to meet the needs of the participants and their disciplines. Membership compromises representation from each of the disciplines. The newly elected chair is Dale Bailey with the remaining members including Andrew Scott, Elizabeth Bailey, Sue O’Malley, Vijay Kumar and Cedric Eustance.

Over the last 7 months, the web committee lead by Robert Barnett and Geoff Roff has worked tirelessly to update the website and improve functionality. The continual improvements and ongoing maintenance required to meet the needs of members has demanded that the society engage a professional web administrator to continue with this good work. Future developments include updates to the CPD database, adding a few additional tabs for the ASM and SAP, a CE section to include on-line educational activities and a document search option. On behalf of the council and society

members, I would like to thank Robert Barnett for his hard work and dedication in creating and maintaining the current website for the past 12 months. His time and effort has ensured a very successful implementation for all members.

I am pleased to report that the history project is nearing completion with the first draft currently being reviewed. A title and table of contents has been completed with the preferred being Isotopes, Imaging & Identity – The History of Nuclear Medicine in Australia and New Zealand. The society wishes to acknowledge the numerous members and colleagues for their varied contributions.

The timeline for completion is end June 2013 with a small print run being planned and made available as an e-book.

As launched during the opening ceremony yesterday, the society in collaboration with the AANMS has formed and registered ARTnet (Australasian Radiopharmaceuticals Trials network), a clinical trials network to support and facilitate the development of research expertise and protocols within Australia and New Zealand. The network aims to provide assistance and skills to support research activities and to facilitate securing funds to support these activities.

It will be inclusive, involving more sites and act as a linkage to national and international bodies such as TROG, AGITG, SNM CTN, WFNMB, ALLG and many others.

Congratulations to Professor Andrew Scott and the members of the International Relations Committee on winning the bid to host the World Federation of Nuclear Medicine and Biology for 2018 in Melbourne. The leadership of the World Federation will be held by Australia from 2014 to 2018 with Professor Scott the PresidentElect of the WFNMB. This will create opportunities for sharing our knowledge and undertaking research with fellow colleagues in developing countries.

Finally, I would like to thank everyone on Council and the various Committees, and members of the Society who have assisted me over the last year, and made my job so much easier. With the exciting projects currently underway, the council aims to lead the Society on this path so that we will continue to be regarded as the premier nuclear medicine Society in Australia and New Zealand, representing all professions.

Liz Bailey President, ANZSNM Agenda Item 4.2 Treasurer’s Report The Melbourne ASM in 2012 returned a sizeable profit. However, the Society incurred a loss overall in 2012 mainly due to increased activity and projects undertaken by the Society and the transition to the new General Manager and Secretariat arrangement. The full details of income and expenditure are included in the audited accounts to be posted on the website for members to view following the ASM. As a company we had equity of $857,898 at the end of 2012 with most being represented by cash in the bank.

Our bank balance as of Friday 11th of April is as follows: • Cheque Account $219,55.69 • High Interest Account $807,708.45 • Debit Card $3,928.08 • WFNMB Aus $20.268.10 • WFNMB World Congress $50.00 $853,910.32 Geoff Roff Treasurer ANZSNM

u 19

Agenda Item 4.3 ANZSNMT Report The TSIG continues to be busy, with many activities underway. The bulk of our work continues to be related to the MRPBA and the transition to National registration. We have also continued our work in the areas of CPD and the PDY year. A working party has been formed to continue on the Scope of Practice project. And lastly, we are organising another symposium for late July this year.

Clayton Frater continues to chair the CPD sub-committee. This subcommittee has been active in assessing activities for CPD suitability, developing guidelines, and answering queries. They are investigating methods for accurately quantifying hours for activities such as the conference, and scanning methods that could link to the online CPD database. Additionally, they are working to ensure that the requirements of our CPD program meet those of the MRPBA, as we are currently an accredited provider of CPD by the MRPBA. Tale Liiv continues to chair the PDY subcommittee, and this subcommittee have been continuing to administer our PDY program. Systems have been put in place to inform the MRPBA directly of PDY’s passing out of the program, so that the turnaround time with documentation is reduced. A shortened program was also developed to suit the MRBA ruling on the Uni of SA graduates, who require only a minimum 6 months of supervised practice. We also welcomed James Green to this committee as the general member.

The Scope of Practice working party has been reformed. Julie Crouch has agreed to chair the group, and we are in the process of selecting representatives from each state, and both public and private sectors, to work together towards creating a “Scope of Practice” document. We hope to have this document prepared and out for review in the next 6 months.

This years’ Annual TSIG Symposium will be held on July 27th in Coffs’ Harbour at the Novotel Pacific Bay Resort with the theme “Rural, Regional and Remote – Nuclear Medicine Outside of a Major City”. We will be seeking speakers and sponsorship over the next few weeks, and hope to have a preliminary program available shortly.

The move to National Registration is still not complete, and a large amount of the TSIG’s time has been spent discussing and preparing submission papers to MRPBA consultations and draft guidelines. We have held a face to face meeting with the chair of the MRPBA and 2 of his colleagues. This has opened dialogue with the group and they have since sought to make these meetings a regular occurrence.

The Accreditation Committee of the MRPBA has been announced and initially there was no person on the committee with any expertise in either Nuclear Medicine or Radiation Therapy selected. We formally replied to this with a letter expressing our dissatisfaction. We were assured that they were looking to source people to assist the committee in these areas. We have been informally notified of the Nuclear Medicine selection, and we are satisfied that the person is appropriate. The importance of this committee cannot be underestimated as it will be responsible for setting the criteria for the academic institutions to produce practitioners in each of the fields of medical radiations practice.

In the last month we have written two submissions to the MRPBA in response to their draft guidelines for supervised practice and provisional registration requirements. We await the findings of these, as these will determine the requirements for NMT’s to undergo supervised practice or provisional registration.

20 Gamma Gazette July 2013

The ANZSNM is contracted to provide supervised practice/PDY programs for 2013, but cannot enter any new participants after the end of October. It remains to be seen what the requirements will be for graduates from university programs at the end of this year.

Membership of the TSIG committee has remained stable. Prue Lamerton is attending her last meeting as the NZ representative.

We thank Prue greatly for all of her hard work over the years, especially during her tenure as the TSIG secretary. Her input, experience and enthusiasm will be missed by all of us. Stuart Carter (Auckland Ascot PET centre) will be the incoming NZ representative.

Marcia Wood TSIG Chair Agenda Item 4.4 AANMS Report AANMS name change Over the past year the Association’s change of name and corporate structure has been completed. As an organisation with a membership comprising both nuclear medicine physicians and radiologists who have also completed formal training in nuclear medicine, the Association’s new name: “Australasian Association of Nuclear Medicine Specialists” better recognises the “mixed” membership.

Fellowships With the new name, AANMS Council has also established Fellowships of the new Association. AANMS Fellowships recognise the distinct nuclear medicine training and experience, adherence to a philosophy of quality nuclear medicine and ongoing professional development in the specialty. The first such Fellowships have been awarded this year and to mark the occasion, the AANMS is holding a Fellows’ Dinner during the Perth conference so Fellowship certificates can be personally awarded.

Training and CPD The AANMS continues its involvement with the training of new nuclear medicine specialists through the Joint Specialist Advisory Committee, the Basic Sciences Course and the Continuing Assessment Program. The AANMS Basic Sciences Course is an important part of the training program for new specialists and the AANMS appreciates the ongoing involvement of a number of physicists and radiopharmacists who provide excellent lectures and practical session supervision for this course, both at the course venue, and also in the Nuclear Medicine Departments where the practical sessions are provided.

The newer Cross-Sectional Anatomy Course, which is now in its seventh year, and the planned Nuclear Medicine Masterclass, will provide expanded CPD options for Nuclear Medicine Specialists, particularly with the expanding role of other imaging in association with nuclear medicine services.

Government Liaison The AANMS has continued its involvement in discussions on diagnostic imaging, access to radiopharmaceuticals and expanded public funding of PET services. These are ongoing activities.

In relation to PET, the AANMS is preparing a number of MSAC applications seeking new Medicare items for PET services.

ARPANSA recently announced its intention to look at nuclear medicine diagnostic reference levels (DRLs); the AANMS has representation on the committee working on this project.

Ongoing liaison with ANZSNM Unusually, the two current Presidents of the AANMS and ANZSNM are located in the same nuclear medicine department, so liaison has stepped up several notches over the past year! This has been a good development and we hope to continue this closer level of communication in coming years. The announcement of a joint venture between the AANMS and ANZSNM to establish a cooperative research entity in nuclear medicine is an exciting development for the two organisations and both organisations are looking forward to the implementation of this proposal.

A close working relationship between our two organisations will be particularly important in the lead up to the WFNMB meeting in Melbourne in 2018, which was secured by the Society last year.

Sam Berlangieri AANMS representative Agenda Item 4.5 Physics SIG Report The ANZSNM Physics SIG AGM was held on Saturday 13 April 2013 at 12:00 pm at the ANZSNM Conference and was attended by 11 members. The minutes of the AGM will be available on the Society website in due course, but of more immediate note is that the SIG committee was re-elected for another term.

The Physics SIG held a symposium on “PET/MRI for Beginners” at the University of Sydney on 15 February 2013. We had around 120 registrants and a mixture of physicists, physicians, and technologists. I would like to thank Dale Bailey, Chithra Sathiakumar, and Graeme O’Keefe for their help as the organising committee, and to Kathy Willowson, Matthew Griffiths, Marissa Bartlett, and Leighton Barnden for their further assistance. I would also like to thank all of the sponsors who helped make the symposium financially possible, especially the gold sponsors Siemens and Insight Oceania. From the positive feedback I received, the symposium was considered a success and I was especially pleased with the response to the remote presentation on clinical PET/MRI imaging given by Professor Pamela Woodard from MIR/University of Washington in St Louis. PDF copies of the presentations will be on the Physics SIG web page when I receive the last of the talks, with the exception of some embargoed material pending publication.

The Physics SIG received support from the Federal Council to hold two symposia this year so we could get back to our regular cycle of holding them in December. However, the timing of the February symposium was liked and we have decided to drop the December symposium and go with February again next year. The topic being looked at is radionuclide therapies, especially I-131, Lu177 and Y-90, and their corresponding imaging and safe use.

We had a request from ARPANSA to put forward a representative from the Physics SIG to join a liaison panel looking at diagnostic reference levels in nuclear medicine. Jocelyn Towson was put forward and she is joining Richard Smart who is also providing physicist input to the panel.

The Physics SIG is still looking at the objectives it wants to put forward for the SIG and this was briefly discussed at the AGM yesterday. I hope to have something to the Federal Council in the next few months once is has been endorsed by the SIG members.

Finally, the Physics SIG was looking at a two-page newsletter to go out to SIG members quarterly with news from members, updates on local practice, changes to standards, useful websites, etc., with the target audience being the Physics SIG members. It was decided

yesterday that we should look at putting this into the Gamma Gazette because there may be items of interest to other members.

So with the permission of the membership, we would like to look at doing this, as a kind of ‘physics corner’ in the Gazette.

Darin O’Keeffe Physics SIG Chairperson Agenda Item 4.6 Radiopharmaceutical Science SIG Report presented by Jennifer Guille Representation: The SIG is becoming well represented on a variety of panels and committees.

Federal Council J Guille Technical Standards Committee J Guille, G Snowden Dose Calibrator Survey PET Dose Calibrator Survey Scientific Advisory Panel V Kumar RACI Liaison Committee A Katsifis Nuclear Medicine Liaison Panel ARPANSA

D Bodetti, J Baldas, Z Ivanov Accreditation Sub Committee J Guille (Chair) , E Browne,

A Katsifis, P Lam, D Henderson,

G Chan, T Boudier, J Poon,

V Kumar,D Bodetti, D Kumar TGA Working Party G Chan Quality Projects Accreditation Syllabus – expected date of working party is Mid July, with initial examinations and trial of system to be complete by October 31, 2013 MQ Masters of Radiopharmaceutical Science – first intake of students (6) in July, 2012, graduate Dec 2013 or later. Two students currently undertaking Major Research Project under supervision of A Katsifis and J Guille. Programme ‘rested’ for 2013, expect to run 2014.

Standardization of QC methods – BP methods are often unsuitable for use in a normal NM department. In their place ‘other’ methods are often employed, usually distributed by word-of-mouth, and these usually have not been validated. We are attempting to gather information on those methods currently in use, to validate those with merit so that they can be deemed an ‘acceptable alternative’ by the TGA. ANZSNM Website Specialist Practice Register – a request was made to place ‘methods’ on the ANZSNM website. For the newer practices, such as preparation of Ga-68 peptides, there may be a number of methods in use, with no one method yet established as the ‘Gold Standard’. A ‘Register of Practitioners of Special Practices’, which lists the names of practitioners willing to be contacted for advice on a topic, and their contact details, is to be compiled for addition to the SIG section of the ANZSNM Website.

Information about how to manage and report ‘abnormal behaviours of radiopharmaceuticals’ – will be written and added to the website.

Jennifer Guille u Radiopharmaceutical Science SIG Chair 21

Agenda Item 4.7 Nursing SIG Report During the last two years it has become difficult to maintain a SIG committee for nursing and I have held several discussions with the Federal Council and General Manager raising my concerns about the sustainability of the SIG. However, a successful Nurse Symposium has been held in Perth in conjunction with the ASM and the future of the SIG was discussed. It was agreed to recommend for Federal Council to disband the Nursing SIG and to suggest that a Nurse Symposium be held during the annual scientific meeting. This proposal was put to the Federal Council and fully supported. It was agreed that members would be able to attend this annual Nurse Symposium free of charge and other delegates would pay a nominal fee.

The Council also agreed for Erwin Lupango to act as the Nurse Member Liaison Officer.

Erwin Lupango Nursing SIG Chair Agenda Item 4.8 Technical Standards Committee Report The TSC has not met together however the individual Working Groups have progressed their allocated tasks working independently.

Dose calibrator Quality Assurance This WG has met with Mark Reinhard from the Activity Standards Laboratory at ANSTO to further discuss the proposed Dose Calibrator Proficiency Testing Program (DCPTP). He reported that the National Measurement Institute has now recognised that a minor change to the Regulation is required to enable ANSTO to issue calibration sources referenced to the Secondary Standard maintained by the Activity Standards Lab (ASL). This legal issue has effectively delayed the program for 12 months. It is expected that this change should not delay the program further.

A trial of the program will be undertaken at three clinical sites in Sydney in May 2013.

Revision of Minimum Quality Control Requirements for Nuclear Medicine Equipment, version 5.7 Nov 1999 The working party has made reasonable progress recently over the past several months.

• The group has discussed all major issues identified from comments made by the members and has come to a consensus view to resolve all of these issues.

• The working party has also formed the view that guidance on minimum QC requirements for a wider range of nuclear medicine instrumentation would be valuable, but that this should be in a separate document. The scope of that document would cover the range of equipment detailed in the EANM document Routine quality control recommendations for nuclear medicine instrumentation.

It is hoped that a draft document, incorporating decisions made at the March teleconference, will be ready for the TSC meeting being held at the ANZSNM meeting on April 13.

Revision of Requirements for PET Accreditation (Instrumentation & Radiation Safety), 4 May 2007 This WG completed its task in 2012 with the publication of version 2.2 of the Requirements document. The Chair of this WG continues 22 Gamma Gazette July 2013

to answer any queries about the current document, with referral to other members if necessary.

Software phantoms and clinical software validation • Work continues on the online software audit tool but further work is needed before it can be made available as a beta test version for selected testers.

Page 2 • The Online audit tool will assist ANZSNM in it’s training role as incoming WFNMB leaders.

Paediatric administered activity schedules This new WG was established following a request to the ANZSNM Federal Council for a policy on paediatric administered activity schedules. The WG will review best-practice in paediatric administered activity schedules, with a view to a recommended policy.

Professor Richard Smart TSC Chair Agenda Item 4.9 International Relations Committee Report A verbal report was provided by Andrew Scott, Chair of the IRC: It has been a very exciting and successful year for the IRC having successfully bid to hold the WFNMB Congress in Melbourne in 2018 and to compose the Executive Committee of the WFNMB for the years 2015-2018. As President-Elect of the WFNM until 2014, I am joined by the IRC executive committee consisting of Mr Peter Collins, A/Prof Vijay Kumar and Dr Sze Ting Lee as well as the members of the IRC. I acknowledge the efforts of the committee in winning the bid to hold the world congress in 2018. We will now be focusing on the promotion of Nuclear Medicine around the world, in collaboration with the IAEA, EANM, SNMMI, AORNMB and ASNM, especially with education and training, clinical procedures and research in Nuclear Medicine. ANZSNM is well regarded in the international nuclear medicine community and has a strong profile with the key international societies. Recently Dr Sze Ting Lee was appointed to the newly formed Asia & Oceanic Society of Nuclear Medicine.

Agenda Item 4.10.1 Conference Update – Adelaide 2014 The 44th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine, which will be held in Adelaide, South Australia from the 25th – 28th April 2014. The Meeting will be held at the Adelaide Convention Centre located centrally in the city of Adelaide, overlooking the River Torrens and the new Adelaide Oval.

The theme of the meeting is “A Fusion of Ideas, Modalities, and Disciplines”, with an emphasizing the place of Nuclear Medicine in the multi-disciplinary practice of medicine. Renowned international speakers from Europe and USA, including Professor Sam Gambhir, Professor Wim Oyen, Associate Professor Clemens Decristoforo and Professor Jamshid Maddahi, have agreed to speak at the conference, in addition to local and interstate experts both in Nuclear Medicine and associated fields such as Oncology and Surgery.

The Pre-conference Symposium, focusing on the integral value of molecular imaging in modern medicine, will be held at

The Farm, a brand new conference venue in the heart of the beautiful Barossa Valley, only one hour from the centre of Adelaide.

The scientific conveners are Dr Michael Kitchener and Dr Steve Unger aided by a very active committee with excellent guidance and planning by the PCO Plevins and associates. At the time of the council meeting the venues and main speakers had been confirmed, the website was active, advertising brochures produced, block bookings for accommodation made and sponsorship prospectus produced so that we could approach potential sponsors a the Perth meeting. A separate budget summary to date was forwarded to the secretariat.

Dylan Bartholomeusz Local Organising Committee – ASM 2014 Agenda Item 4.10.1 Conference Update – Queensland 2015 Following an assessment of the ACT as a destination for the 2015 ASM, a decision was made not to hold the 2015 ASM in Canberra.

It was therefore recently decided to hold the 2015 conference in Queensland. The last ASM in QLD was the very successful conference held at Jupiter’s Casino in 2007. The Local Organising Committee for 2015 is still being established but I am pleased to confirm the following participants will join me: Dr Bruce Goodwin, Melinda Wilson (branch Chair and TPCH), Zach King (Tech TPCH) and the joint QLD Branch Secretaries Katherine Roy and Nikki Weinert.

We are in the preliminary stages of selecting a destination and venue and a professional conference organiser to assist us.

The Secretariat and General Manager team have experience in organising conferences and we intend to utilise this resource in addition to a local conference organiser in order to rationalise the conference management expenditure.

We look forward to bringing you an exciting and vibrant ASM in beautiful Queensland! Please pass on any ideas you have for the event to the Secretariat.

Lynda Jane Michel Local Organising Committee 2015 ASM QLD

KEY DATES FOR ASM 2014 ADELAIDE

2013

Call for abstracts open - September Registration opens - November

2014

Call for abstracts close - 31 January Notification of acceptance - 3 March Author registration close - 10 March Earlybird registration close - 15 March

23

Financial statements presented to the 2013 AGM of – Australian and New Zealand Society of Nuclear Medicine Limited

24 Gamma Gazette July 2013

A full financial report is available on the ANZSNM website anzsnm.org.au 25

The 43rd Annual Scientific Meeting Join us in Perth in April for the 43rd Annual Scientific was held at the Perth Convention and betweenSociety April 11-15. of Meeting of the Australian andExhibition NewCentre Zealand Nuclear Medicine (ANZSNM 2013) There were 422 attendees to ANZSNM 2013 traveling locally, interstate and

• The Pre Meeting Symposium will beoverseas. held onTheFriday 12th April at the largest contingent was from University Club, located at the University of Western The NSW with 169 registrants,Australia. followed by WA Symposium will highlight advances inwith Molecular Imaging, and with includes 89 registrants and Victoria 68 expert National and International speakers.

This promises to be a day of registrants.

The Pre-Meeting Symposium “The visit education and ideas for the future. Program now available, please Molecular Imaging Revolution: From Bench the website to download. to Bedside” was held on Friday 12th April

• The Annual Scientific Meeting will be held from Club, Saturday 13th April at the University University of Western Crawley.New There Horizons’. was a wide The to Monday 15th April, with a theme Australia, of ‘Exploring of expertise among the speakers scientific program will hold interest range for all, with an exciting panel of who came from both Australia and international and national speakers discussing a range of clinical and overseas, with presentations from several technology issues across all aspects of Nuclear Medicine and Molecular international speakers; including Professor Imaging. In addition to invited speakers, will beof oral and poster Jason there Lewis Director the Radiochemistry presentations and award sessions. The large exhibition area atatPCEC and Molecular Imaging Probe Core will provide an interactive space for our industry partners Cancer to display the Memorial Sloan-Kettering Centre, latest in equipment and products. New York, Professor Stefano Fanti Head of Nuclear Medicine and PET, University of

• Program highlights – Visit the website for upItaly to date Bologna, and Drprogram Richard Zimmermann highlights, including details for the invited presentations.

Chrysalium Consulting, Lalaye, France.

• Social Program.

Welcome Reception Friday 12 April, 1800 – 1930 Perth Convention Exhibition Centre Nuc’s Party Saturday 13 April, 1900 – 2330 Fremantle Prison & The Monk Brewery Dress: Jail Break (Themed)Nuc’s Party with a difference! Experience the darker side of the Fremantle Prison history with an eerie tour by torchlight….once you have survived this hair raising experience, enjoy canapés, beverages and dance the night away at the funky Monk Brewery, located a short walk from the Fremantle Prison and in the heart of Fremantle’s night life.

All of the speakers were engaging and informative and this was a lively day of discussion and interaction. There is Gala Dinner certainly widespread interest throughout Sunday 14 April, 1900 – 2230

Key DAteS:

Fraser’s State Reception Centre, Kings Park Dress: Black and White Ball

The Frasers State Reception Centre, Kings Park is the venue for the Gala Dinner and will be one of the memorable highlights of the Meeting. Guests will be treated to a sumptuous three course meal and fine Australian wines with stunning views of Perth by night.

The Gala Dinner is included for all registration categories (excluding student and day registrations).

Tickets are limited.

Perth Convention & Exhibition Centre 26 Gamma Gazette July 2013

Australia and New Zealand for expanding research capability within our nuclear medicine practices. early Bird Registration Close The Welcome Reception was held 15Perth March 2013 (extended by 1 week) at the Convention and Exhibition Centre on Friday evening, which provided Committee Meetings an opportunity for delegates to register April 2013the official opening of and 11 mingle before the ASM the following morning from the Pre Meeting ANZSNM President, Symposium Liz Bailey.

12 April The quality 2013 of scientific presentations throughout the conference was very Annual Scientific Meeting impressive. Abstract submissions resulted 13 – 15 April 2013 in 58 oral and 52 poster presentations being presented at the conference, with further information regarding the For categories of Oncology/Therapy and Radiopharmacy having the largest number the conference, please visit of abstracts submitted. www.anzsnm2013.com.au Plenary presentations in the conference, with a theme of ‘New Horizons’ were We forward to seeing given by look Professor Koenraad van Laereyou in ‘the in April.

Clinical HeadWest’ of Nuclear Medicine, Leuven University Hospital, Belgium, Ms Bernadette Cronin Radioisotope Services Manager, The Royal Marsden NHS Foundation Trust, UK, Professor Stefano Fanti Head of Nuclear Medicine and PET, University of Bologna, Italy and Professor Robert Hendel Director of Cardiovascular Intensive Care Unit and Outpatient Cardiac

www.anzsnm2013.com.au

Meeting Managed by arinex pty ltd Level 10, 51 Druitt Street Sydney NSW 2000 Australia P: + 61 2 9265 0700 F: + 61 2 9267 5443 E: nm2013@arinex.com.au

Images supplied by Tourism WA

www.anzsnm2013.com.au

Imaging, Miller School of Medicine, University of Miami Hospital, USA. All these presentations were thought provoking and provided valuable insights into nuclear medicine as it is developing overseas and into the future.

We were privileged in 2013 to have a large contingent of international speakers. In addition to those listed above we also heard excellent talks from Professor Enrique Estrada Lobato, Head of Nuclear Medicine and PET, National Cancer Institute, Mexico City, Mexico, Professor Markus Luster, Professor of Nuclear Medicine, University Hospital, Ulm, Germany, Professor Kalevi Kairemo, Chief Physician, Molecular Radiotherapy and Nuclear Medicine, International Comprehensive Cancer Centre Docrates, Helsinki, Finland, Professor Jason Lewis Director of the Radiochemistry and Molecular Imaging Probe Core at Memorial Sloan-Kettering Cancer Centre, New York, and Dr Adrienne Brouwers University Medical Center Groningen, The Netherlands.

The Technologists symposium on

Saturday was a great success. An impromptu panel discussion “Current, changing and extended roles for Nuclear Medicine Technologists”, co-chaired by ANZSNM President Liz Bailey and Ms Bernadette Cronin proved to be a valuable addition to the program.

The Lowenthal Lecture was presented on Sunday by Professor Richard Fox, Department of Physics, University of Western Australia and was entitled “Ionising Radiation: Boon or Burden?”.

Prof Fox reminded us of the potential dangers from ionising radiation and the u

27

need to consider risk vs benefit on a daily basis in our practices.

The Exhibition Hall of the conference was a great place to mingle with our sponsors, to relax a little and to view the poster display area. The trade displays were of a high standard and the support of our sponsors is greatly appreciated.

On the social side, Golf with Gordon was held on Thursday 11 April at Araluen Golf Resort in the scenic Perth hills. Saturday night saw the annual “Nuc’s Party” take place at Fremantle Prison with the theme “Jail-break”. A tour of the heritage-listed prison was followed by drinks, nibbles and live music at The Monk Brewery. The Gala Dinner on Sunday evening was held at Fraser’s Restaurant in King’s Park, with spectacular views over Perth CBD. This was a sell-out event and The Lost Boys and the Wendys kept the dance floor jumping all night.

As Co-Convenors, we would like to thank all those who travelled from both near and far to attend ANZSNM 2013. A special thank you must go to all the invited speakers, our sponsors, and to the team at Arinex for their on-site support during the event in Perth.

Finally, thank you to all those on the Organising Committee and the Scientific Program Committee of ANZSNM 2013, who gave generously of their time in helping to organise the meeting, and without whom the conference would not have been such a success.

Hope to see you all in Adelaide in 2014!

A/Prof Roslyn Francis and Dr Bill Macdonald ANZSNM 2013 Organising Committee: Dr Bill Macdonald, A/Prof Roslyn Francis, Diane Cheong, Dr Elizabeth Thomas, Geoff Roff, Karen Hindley, Cedric Eustance ANZSNM 2013 Scientific Committee: Dr Bill Macdonald, A/Prof Roslyn Francis, Dr Roger Price, Dr Andrew Campbell, Cedric Eustance, Penny Maton, Dr Elizabeth Thomas, Dr Peter Robins

28 Gamma Gazette July 2013

ANZSNM Awards presented at the ASM 2013 in Perth Information for 2014 Awards www.anzsnm.org.au/cms/governance/awards/ RADPHARM Case Presentation Award 2013

The winner of the RADPHARM Award 2013 is Pru Burns from Pacific Radiology in Wellington New Zealand. The RADPHARM Technologist Case Presentation Award is held in conjunction with the Annual Scientific Meeting (ASM) relating to an oral case presentation of a single patient’s study (s) performed within the Nuclear Medicine workplace. Proudly sponsored by GMS, the RADPHARM Branch award winners will receive complimentary registration to the following years ANZSNM ASM. In addition GMS provides the overall winner will receive $1,000 toward a CPD activity.

For information on entering the RADPHARM Award for 2014 please contact your local branch or the ANZSNM website.

F-FET PET/CT: Needle in a Neurological Minefield Pru Burns, Pacific Radiology, Wellington New Zealand 18

Background: In late October 2010, a 67 year old female with worsening seizures underwent an EEG, CT brain scan and then an MRI. She had a known history of partial seizures for 2 years and chronic bipolar disorder. The MRI showed a mesial temporal lobe lesion, suggestive of a low grade tumour, but there was no enhancement. The Neurologist requested a biopsy, but the Neurosurgeon involved declined as he felt a blind biopsy would result in a poor yield procedure. A 18F-FET PET/CT scan was suggested to identify an area of increased activity that could then guide sterotatic biopsy to enable a correct histological diagnosis.

Method and Results: An 18F-FET PET/CT was performed on this patient. Imaging began 30 minutes post injection of 244MBq 18 F-FET. A CT scan was performed for attenuation correction, with the PET scan range being one 15cm bed over the brain. The scan showed a clear focus of markedly increased uptake of 18F-FET in the left temporal tip just behind the sphenoid wing. There was no uptake in the mesial temporal aspect. Correlation with MRI showed a much larger area of oedema but no contrast enhancement.

Discussion and Conclusion: The 18F-FET scan confidently predicted the optimal site for sterotatic brain biopsy. By locating where the active tumour was, a successful biopsy was performed and pathological confirmation of the diagnosis enabled more confident surgical planning for this patient. The use of 18F-FET brain imaging is in it’s infancy in New Zealand, this case study clearly demonstrates it’s value in Neurological Imaging.

Above left: Axial T1 SPGR MRI image showing large area of odema.

Above right: Fused PET/CT 18F-FET image showing specific area of uptake to guide best biopsy site.

Mallinckrodt Award 2013

The winner of the Mallinckrodt Award 2013 is Suzanne Fredericks from Wollongong Hospital in New South Wales. The Mallinckrodt Award is held in conjunction with the Annual Scientific Meeting (ASM) with the aim of fostering the spirit of innovation and progress in Nuclear Medicine. The Award is provided for the presentation of an oral scientific or technical paper that best demonstrates value in improving knowledge in any aspect of Nuclear Medicine.

The Mallinckrodt Award is sponsored by Mallinckrodt and consists of a A$1500 prize towards the winner’s attendance of a CPD activity of their choice. This could be attendance at a scientific meeting either local or international, or any other approved CPD activity. For information on entering the Mallinckrodt Award in 2014 visit the ANZSNM website.

It’s Time to Revise – Dose Reduction in Nuclear Medicine Suzanne Fredericks, Wollongong Hospital NSW Background: As technology improves and the use of CT in Nuclear Medicine increases, it is important to assess the administered doses and resultant effective doses to patients undergoing a Nuclear Medicine study. The addition of low dose CT in Nuclear Medicine has led to an increase in the effective dose for patients undergoing routine Nuclear Medicine scans. A study was conducted to decrease the administered radiopharmaceutical dose and CT exposure to decrease the resultant effective dose of routine scans.

Method: A randomized trial of average weight patients (approximately 70kg) were injected with a reduced dose of radiopharmaceutical for either a whole body bone scan or one day myocardial perfusion scan. The CT for localization was also reduced for the whole body bone scan patients. All other parameters remained unchanged as per normal protocol. The effective dose was calculated for the reduced dose patients and compared to the standard protocol effective dose.

Results: The implementation of the dose reduction strategies resulted in more than a 25% decrease in effective dose for a standard bone scan with CT localization and 18% reduction for one day myocardial perfusion scan with CT for attenuation correction.

There was no comment from the physician regarding the imaging from the reduced dose patients as opposed to the standard dose patients.

Conclusion: There was a significant reduction in effective dose for the patients who received a reduced radiopharmaceutical and CT exposure which did not affect acquisition time of the scan or hinder diagnostic quality. Further research will be conducted into reducing other studies within the Wollongong Nuclear Medicine Department. The importance of the revision of administered effective doses is paramount to maintain the ALARA principle and keep current with the improvements in technology and imaging equipment.

Gammasonic Award 2013

There were two winning abstracts of the Gammasonic Award in 2013, Dr Erin McKay and Casper Marciniak and Dr Erin McKay, both from St George Hospital, New South Wales. The objective of the Gammasonic Award is to encourage scientific communications u

29

ANZSNM Awards presented at the ASM 2013 in Perth in the general field of radiation measurement and dosimetry. The Award is made for the abstract submitted for presentation at the Annual Scientific Meeting (ASM) scoring the highest overall grading in the area of instrumentation, radiation protection, NM physics and/or radionuclide therapy research.

The Award of A$1000 is provided by Gammasonics Pty Ltd and is to be used towards a continuing education related activity. For information on entering the Gammasonic Award 2014 please visit the ANZSNM website.

Individual Variation in Renal Dosimetry of Lu-177 Octreotate Erin McKay, St George Hospital, New South Wales Background: It is recognised that the dose limiting organs for Lu-177 Dotatate radionuclide therapy are the kidneys and the red bone marrow. The radiation dose to kidneys is of particular interest as it may not achieve full expression for many months post-adminstration. Kidney dose depends on renal update and clearance rates and on the mass of tissue in which the activity is retained.

Aim: To establish a method for routine measurement of Lu-177 activity concentration in the kidneys and to investigate inter – and – intra – subject variation in renal dosimetry.

Method: Whole-body and SPECT/CT imaging was acquired at 5 hours post-administration of 8GBq of Lu-177 dotate, for 296 cycles of therapy representing 92 individual subjects, of which 53 had completed a full 4 cycles of therapy. Follow-up SPECT imaging was performed at 24 hours for 27 subjects and at 7 days for 10 subjects. SPECT projections were corrected for dead-time and scatter then reconstructed with an OSEM algorithm incorporating distance-dependent resolution and attenuation correction using CT-based mu-maps. Kidney counts were measured using VOI defined on co-registered CT images, then converted to units of activity using camera-specific sensitivity calibration.

Results: The mean renal activity at 5.5 hours was 205 MBq (ranges 35 – 450 MBq). Intra-patient variability was low (median 16% SEE) except in cases where renal pathology was demonstrated. Average renal clearance half-time was 55+/- 12 hours.

Conclusion: In the absence of renal pathology, the initial cycle of therapy provides a good predictor of uptake (and hence dosimetry) in subsequent cycles. Analysis should be based on quantitative SPECT as planar analysis proved sensitive to the presence of background activity around the kidney.

Implementation and Validation of a Chanellised Hotelling Observer Casper Marciniak, Erin McKay, St George Hospital Sydney Background: It is known that mathematical model observers can predict the performance of human observers in various image assessment tasks, in particular “signal known exactly” lesion detection tasks. Consequently, they promise to be useful in optimising medical image reconstruction and post-processing algorithms.

Our aim was to implement one such model observer, the Chanellised Hotelling Observer (CHO), and validate its skill in detecting hot and cold lesions in simulated image data.

30 Gamma Gazette July 2013

Method: A software implementation of the CHO was developed in C using the FFTW Fourier transform library. CHO analysis templates were generated for 3 phantoms (lesion free, hot lesion and cold lesion) at 3 noise levels (low, medium and high), using 9 training sets of 10 images, each with different noise realisations. Signal-tonoise ratio (SNR) was calculated for each template. The templates were then applied to 6 sets of 10 test images, each containing 5 lesion present and 5 lesion free images in order to establish lesion detection ability.

Results: The SNR trended as expected, decreasing as image noise increased. For hot lesion templates the SNR at low, medium and high levels was 13.6, 6.55 & 5.21 respectively whilst for the cold lesion data each produced 2 false positives and 1 false negative result.

Conclusion: These initial results, although based on a limited dataset, demonstrate that this implementation of the CHO is capable of differentiating between lesion free and lesion present image data over a range of noise levels.

The AANMS Registrar Award 2013

The AANMS Registrar Award recognises work that provides new data of clinical and scientific merit involving the use of Nuclear Medicine technology. The winner of the ANZAPNM Registrar Award 2013 is David Pattison. The Award winner receives A$3,000 for the purpose of attending an approved Nuclear Medicine activity.

For information on entering the Award in 2014 please visit the ANZSNM website.

Quantitative assessment of thyroid-to-background ratio improves the inter-observer reliability of 99mTc-Sestamibi Thyroid Scintigraphy for investigation of Amiodarone-Induced Thyrotoxicosis.

David Pattison (MBBS, FRACP)1,2, James Westcott (BAppSc[MedRad])1, Meir Lichtenstein (MBBS, FRACP)1, H.B. Toh (MBBS, FRANZCR)1, Dishan Gunawardana (MBBS, FRACP)1, Nathan Better (MBBS, FRACP)1,3, Simon Forehan (MBBS, FRACP)1,2, Dinesh Sivaratnam (MBBS, FRACP)1,3.

Affiliations: 1 Department of Nuclear Medicine, Royal Melbourne Hospital, Parkville, Australia 2 Department of Endocrinology, Royal Melbourne Hospital, Parkville, Australia 3 Department of Cardiology, Royal Melbourne Hospital, Parkville, Australia Background: Amiodarone-induced thyrotoxicosis (AIT) is caused by excessive hormone synthesis and release (AIT I), a destructive thyroiditis (AIT II), or a combination of both (AIT Ind). No gold standard diagnostic test is available, however use of 99m-Tc Sestamibi Thyroid Scintigraphy (99mTc-STS) was recently described as an accurate tool for differentiating subtypes. This has important therapeutic implications as AIT I, AIT II and AIT Ind are managed with carbimazole, prednisolone, or combination therapy, respectively. However, the information available to guide reporting of 99mTc-STS is qualitative and highly subjective. This study aims to compare the inter-observer reliability of 99mTc-STS before and after use of quantitative thyroid-to-background ratios (TBR) displayed on a time-activity curve for differentiation of AIT subtypes.

Methods: An audit of nuclear medicine departments at Royal Melbourne Hospital (Parkville, Vic) and Cabrini Hospital (Malvern,

ANZSNM Awards presented at the ASM 2013 in Perth Table 1: Fleiss Kappa statistics assessing inter-observer reliability for each series of reporting and diagnostic comparison (Kappa < 0 poor agreement, 0.01–0.20 slight agreement, 0.21–0.40 fair agreement, 0.41–0.60 moderate agreement, 0.61–0.80 substantial agreement, 0.81–1.00 almost perfect agreement).

Diagnostic comparison

Series 1 Percentage Agreement Kappa (Median, [Range]) (Κ)

Series 2 Percentage Agreement Kappa (Median, [Range]) (Κ)

AIT I vs AIT Ind vs AIT II

47% [47-63]

0.30

80% [73-80]

0.67

AIT I vs (AIT II & Ind)

80% [67-87]

0.48

94% [87-100]

0.84

AIT II vs (AIT I & Ind)

77% [60-87]

0.44

80% [73-93]

0.64

AIT Ind vs (AIT I & II)

47% [47-73]

-0.05

82% [73-93]

0.51

Vic) identified 15 consecutive 99mTc-STS studies performed for AIT. These studies were de-identified and re-processed with standardised background intensity. Four nuclear medicine physicians reported the studies according to previously established criteria (Series 1). Quantitative thyroid-to-background ratios (TBR) and estimated ‘normal’ range TBR were subsequently provided before the studies were re-ordered and reported again (Series 2).

Inter-observer reliability was calculated using Fleiss’ kappa statistic (STATATM statistical software, Texas) for each assessment.

Results: See table 1 above.

Conclusion: 1. Use of quantitative thyroid-to-background ratio improves the inter-observer reliability of reporting 99mTc-STS for investigation of different types of AIT. 2. There is ‘almost perfect’ agreement upon differentiation of AIT I from AIT II and AIT Ind, with important implications for rationalizing use of corticosteroid therapy.

3. Prospective identification of AIT Ind is improved from ‘poor’ to a ‘moderate’ level of agreement to facilitate rational use of combination therapy at diagnosis.

GMS POSTER AWARD 2013 The winner of the GMS Poster Award 2013 is Amy Evans from Sir Charles Gairdner Hospital, WA. The GMS Poster Award is held in conjunction with the Annual Scientific Meeting (ASM) with the aim of encouraging innovative and progressive work in the field of Nuclear Medicine. The Award is provided for a poster presentation on investigational, case study or other work demonstrating value in improving knowledge in any aspect of Nuclear Medicine.

The award, sponsored by GMS consists of a cash prize of A$500. For information on entering the GMS Poster Award in 2014 please visit the ANZSNM website.

The importance and benefit of performing a 99mTC-MAA breakthrough scan prior to SIRT: A case study Amy Evans. Sir Charles Gairdner Hospital, Western Australia Introduction: Selective internal radiation therapy, or SIR-Spheres, is an effective treatment for primary and secondary tumours localized to the liver. A hepatic artery perfusion scan, or 99mTcMAA-breakthrough study, is performed prior to administration of the spheres and is an effective way to manage therapy dose and predict tracer distribution. The primary aim of this poster is to highlight both the importance and benefits of performing the breakthrough study. The secondary aim of this poster is to increase knowledge of scan appearance and causes for unexpected tracer distribution.

Method: 24 99mTc-MAA hepatic artery perfusion scans were performed at our site in 2012. The scans are classed by whether or not SPECT/CT was performed, shunt size, tracer distribution and the reason for altered biodistribution.

Results: 50% of the studies required SPECT/CT, which was predominantly used to assist with abnormal scan findings. 19 of the 24 studies demonstrated a normal liver/lung shunt. The biodistribution was either normal, involving extra hepatic uptake or containing no liver. It was found that altered biodistribution in the hepatic artery perfusion scan was caused by liver/lung shunting, inadvertent delivery of 99mTc-MAA to other organs, free pertechnetate in the 99mTc-MAA dose, reflux of hepatic arterial blood to abdominal organs as well as delay in imaging (greater than 1 hour) following administration of 99mTc-MAA. Discussion: There are multiple methods to improve scan quality and increase reporter confidence: • Perform SPECT/CT in equivocal cases • Minimise free pertechnetate by ensuring radionuclidic purity of the MAA or utilising sodium perchlorate.

• Inject tracer slowly to avoid reflux.

• Image within an hour.

Conclusion: The study is essential for the SIRT patient as it allows: • Quantification of liver/lung shunting • Identification of administration problems • Identification of patients at risk of developing side effects

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Specific dose sources affecting nuclear medicine staff Report by Ashlee Harrison Department of Nuclear Medicine, Canberra Hospital, Canberra, ACT INTRODUCTION The emphasis of received radiation dose in the field of Nuclear Medicine is primarily focused on patient dose. This article aims to address specific dose sources encountered by Staff in Nuclear Medicine and subsequently enable staff to reduce occupational dose.

This study was conducted over 12 months to investigate the occupational doses received

by Nuclear Medicine Scientists and Nurses in The Canberra Hospital Nuclear Medicine Department. There were three areas that were investigated regarding average dose received; per week day, per camera and from individual scans including PET. The dose received by staff was measured in micro Sieverts (ÎźSv). The Sievert (Sv) is a unit used to derive a quantity called equivalent dose. This equivalent dose relates the absorbed dose in human tissue to the effective biological damage of the radiation.

The staff involved in the study wore an electronic personal dosimeter and recorded the scans performed and the dose received each day. There were six Nuclear Medicine Scientists and three Nurses participating in the study and data was collected over a 12 month period. The data was background corrected allowing for 2ÎźSv per working shift as background.

RESULTS Unsurprisingly the highest staff doses were received on the Generator delivery day and decreased in proportion to the activity of the generator over the week.

The data on the average dose received per camera roster is largely only for the benefit of the staff at the Canberra Hospital.

The SPECT-CT camera is used for 2 cardiac clinics, 2 bone clinics and one parathyroid clinic per week. The dual head (non SPECTCT) camera is used for 5 bone clinics per week. The MPS is a single head camera that is used mainly for GHPS, Thyroid and adult DTPA studies but also performs HIDA and Gastric empty

Daily Radiation Dose to Staff Per Camera

studies weekly. The ECam is used primarily for paediatric renal studies using Mag3 and DMSA and colonic transit scans.

The data collected on dose received per individual scan definitely provided the most interesting results. The scans included in the study were only those that are performed weekly.

The data used for this results series was taken from shifts that only performed one specific scan type per shift. For example if during one shift a staff member performed six bone scans only, the data was included. However for any shifts that included multiple scan types during a single shift, the data was not included in the averages. This lead to a some scan types that are routinely scheduled on the same day as other scan types to have very few numbers included in the data, indicated by an asterisk.

The results indicate that the dose received to staff from a bone scan is in fact higher than received from a cardiac study using a single day protocol. Also Thyroid Iodine 131 Therapy administrations present a very low dose. Participating in administering either the outpatient or inpatient therapy capsule exposes the staff member to little more than participating in a paediatric scan.

The average dose received from performing a Bone scan was compared to the dose received from performing an F18-FDG PET scan. At the Canberra Hospital an automated F18-FDG injector is used to administer the dose to the patients whereby avoiding the main source of radiation PET staff.

A comparison between the departments in respect to the nursing staff was made. The results surprisingly indicate that nurses in PET actually receive on average one quarter radiation dose than that of the cardiac nurses.

DISCUSSION It was expected that the daily staff doses would be directly in proportion with the generator activity. The generator is delivered on Wednesdays with Tuesday consequently being the lowest in activity. The doses received by staff throughout the week correlate directly to the

32 Gamma Gazette July 2013

Daily Radiation Dose to Staff Per Scan

generator activity as expected.

As was demonstrated, scanning using that the ECam was expected to allow for the lowest dose received as it is mainly utilised in Paediatric studies. It was also expected that the second lowest dose would be received when working on the MPS. The actual dose received from scanning with this camera was however much closer to the dual head cameras than expected. It was expected by staff that the most dose received from a camera roster would be from working on the SPECT-CT. It was therefore surprising to the staff that running the dual head camera produced a marginally higher dose. This has been attributed to the scan types on this camera providing a lower dose than expected.

In regards to the data on individual scan types it was the expectation of staff that the cardiac scans, being the largest dose to patients, would also be the largest dose to staff. The results however indicate that performing a bone scan in fact exposes the staff member to a higher dose. It is thought that this is due to the length of time spent with the patient as well as the cardiac stress dose administration being performed by the medical staff. The highest dose source from a specific scan is received from the GHPS. This is attributed to the dose size administered to the patient as well as the length of time spent post dose administration next to the patient. Setting up ECG dots, ensuring the ECG feed is accurate and positioning for the left anterior oblique are time consuming activities that are performed standing within one metre of the patient post injection. Interestingly the doses received from performing the Iodine 131 Therapies were among the lowest. This has been attributed to patient preparation prior to the dose administration.

In the comparison between the dose received from performing a PET scan and a Bone Scan it is expected by the wider Nuclear Medicine community that PET scanning exposes the staff member to a much higher dose. In many departments the staff are rotated through PET in order to minimise their doses. In PET the dose administration is the primary dose source for staff. At The Canberra Hospital we have an automated injection infuser that prepares and assays the dose as well as administering it to the patient once the cannula has been inserted and a line connected from the patient to the machine.

Using this injector has enabled staff to reduce their occupational dose to that of just 1.6ÎźSv per scan, marginally below performing a bone scan.

The main aspect of nursing in Nuclear Medicine at The Canberra Hospital is performing the Cardiac stress tests. The comparison between this and working in the PET department has surprisingly indicated that Cardiac Nurses receive four times the dose than that of the PET nurse. This has been attributed to the fact that the time spent nursing with cardiac patients is majority during and post the stress dose administration whereas the PET nursing role is largely performed prior to the dose administration.

CONCLUSION This data can be used as a foundation for dose minimisation strategies. Once the specific dose sources have been pinpointed, investigations can now be made into how to reduce the dose in target areas. Some changes we are incorporating as a result of this data include ensuring all cardiac patients have their ECG dots on prior to dose administration and GHPS patients being positioned under the camera prior to the dose administration. The acquisition terminal which also contains the ECG machine has been placed further from the patient and the Technologists performing the scan have also been instructed to stand at a greater distance when performing tasks at the terminal. It has also been made clear that there is no need to rotate staff through the Iodine 131 therapy administrations but it is necessary for staff to rotate through PET, so Nuclear Medicine staff can lower their doses.

Special Thanks to Nuclear Medicine Technologists and Nurses at The Canberra Hospital for your contributions.

33

From page 13

What’s that? ... answer SPECT/CT findings confirmed the diagnosis of Fibrous Dysplasia in association with a small medullary infarct.

Fibrous Dysplasia is a common benign intramedullary fibro-osseus lesion that may involve one bone (monostotic), or multiple bones (polyostotic). They are reported to represent 5-7% of all benign bone tumours.

Common sites include long bones, ribs, craniofacial bones and pelvis.

Scintigraphic appearance is greatly increased uptake of radiopharmaceutical at actively forming lesions, particularly in adolescents. Uptake of radiopharmaceutical remains increased throughout the patient’s life but becomes less intense as the lesions mature. The appearance on CT is described as being similar to ground glass.

Most lesions are monostotic, asymptomatic, and are identified incidentally, treated with clinical observation (follow up X-rays taken every six months to verify that there has been no progression) and patient education. Other treatments include the use of bisphosphonates to improve function, decrease pain and lower fracture risk, and surgery for correction of deformity, prevention of pathologic fracture and eradication of symptomatic lesions.

References • DiCaprio, M and Enneking, W. (2005) “Current Concept Review: Fibrous Dysplasia” The Journal of Bone and Joint Surgery.

• Early, P and Sodee, D (1995) Principals and Practices of Nuclear Medicine 2nd ed.

• en.wikipedia.org/wiki/Fibrous_dysplasia_of_bone

Figure 2: SPECT/CT images of right proximal femur.

34 Gamma Gazette July 2013

Targeted approach to treating patients with locally advanced lung cancer reports exceptional survival rates Clinical researchers from Melbourne’s Peter MacCallum Cancer Centre have used PET/CT scanning to guide curative chemo-radiation therapy in patients with the most common form of lung cancer, reporting survival rates higher than have ever been published for patients with locally advanced disease.

In a study of 76 patients with non-small cell lung cancer unsuitable for surgery, the research team, led by Peter Mac Radiation Oncologist Associate Professor Michael MacManus, used combined PET/CT imaging to select 50 patients who could benefit from radical radiation therapy and chemotherapy in combination (radical chemo-radiation therapy) over a six-week course with curative intent, leading to a four-year survival rate of 32 per cent for patients with locally advanced disease (stage IIIA), when historically they would have a long term survival rate of between 10 and 20 per cent.

The unique study also indicated the remaining 26 patients could receive no benefit from radical chemoradiation therapy due to the detection of advanced disease and they received more appropriate palliative and supportive therapies, sparing them from the unnecessary toxicity of aggressive treatment toward the end of life.

Associate Professor MacManus says the quality of the images provided by PET/CT has greatly increased the potential of radical chemo-radiation therapy as an effective curative approach for patients with locally advanced lung cancer, for whom surgery is not an option.

‘Before we had PET/CT to guide planning we risked irradiating too large an area, causing greater toxicity and discomfort, and in 25 per cent of cases we would have missed some of the tumour altogether, rendering this and any future treatments sub-optimal,’ says Associate Professor MacManus.

‘A PET/CT scan combines structural information on the shape of a tumour from a CT scan with functional information about the tumour’s level of metabolic activity from a PET scan, an upgrade in definition of the tumour that enables us to target the entire cancer with radiation therapy.

While patients were recruited and treated between March 2004 and February 2007, researchers monitored progress for five years to ensure the method was validated with a longer term picture of survival results; the findings were published in Radiotherapy and Oncology.

Associate Professor McManus presented previously at an ANZSNM ASM on ‘How PET is changing the management of Lung Cancer’

Top: CT scan of a patient on the study, the green outline showing the area to be targeted if radiation therapists had planned from CT information alone; rendering treatment suboptimal.

Bottom: PET/CT scan of the same patient, taken at the same time, showing their locally advanced lung cancer as red, yellow and green fields, with the final target for radiation therapy shown by red outline; enabling clinicians to plan treatment targeting all tumours.

35

From page 14

Whatâ&#x20AC;&#x2122;s that? ... answer Further images, including a SPECT CT of the abdomen were obtained to determine the cause of the uptake.

From this, it was determined that the extreme uptake in the abdomen was actually a distended bladder as well as reflux back into one of the kidneys and hydronephrosis.

Upon discussion with the patient it was discovered that he had not passed more than a dribble of urine in several weeks and was unable to empty anything at all upon being asked. The patientâ&#x20AC;&#x2122;s doctor was immediately called and he was admitted into hospital the following morning for further tests to determine the cause of the bladder and kidney issues.

Figure 2

36 Gamma Gazette July 2013

Health Workforce Australia Nuclear Medicine Scholarship Program WA Education Update Kathryn Linn Chief Technologist, Royal Perth Hospital The Health Workforce Australia Nuclear Medicine Scholarship program currently has three WA students completing their studies at the University of Newcastle: one in second year and the other two in first year. The scholarship program provides financial assistance to Year 12 WA graduating students who want to study Nuclear Medicine at the University of Newcastle.

The scholarship will overcome some of the Nuclear Medicine Technologist workforce shortages that currently exist in WA. All three students currently enrolled in the program are doing exceptionally well in their studies and are adjusting to life away from their families. A recruitment process for a clinical tutor is underway. This role will assist students with their studies throughout the three year degree as well as promoting the course at secondary schools throughout WA. 2014 will be the final year of new students with the program officially ending late 2016.

A student’s perspective Eleni Shrestha Second year student, University of Newcastle How did you hear about the scholarship?

I received an email from both my high school careers advisor and chemistry teacher, which I believe was sent to most of my class. I did a little bit of research into it and contacted Kathryn Linn.

What made you interested in nuclear medicine?

It was nearly the end of the year and I was coming up for exams. I didn’t really have any idea what I wanted to study at university but I enjoyed science at school and knew that I wanted to study something in health science. Nuclear medicine seemed really interesting and the scholarship seemed able to support my move out of home.

How do you find the course?

I really enjoy the course and love studying anatomy, although there is quite a bit more physics involved than I originally thought.

What are your hopes career-wise?

At this stage I am not sure where my career choice will take me but I can say that I am hoping to find employment at Fiona Stanley, which is very close to where I live.

What does the scholarship give you?

The scholarship pays me a living allowance which mostly covers my rent. It also gives me $1000 per semester for flights to and from Perth, which is lovely.

Do you have a mentor in WA? Well no, I don’t have a mentor although I believe the position is currently being advertised. So far I haven’t had any issues, although I am in contact with Kathryn Linn if anything was to come up.

Do you have to complete all of your placements in WA? No, I don’t have to and I won’t do all of my placements here but really it makes sense for me to come to Perth for placement. It saves me paying two lots of rent and gives me a chance to spend some time at home with my family and friends over here. It also saves other students from having to fork out the extra cash to fly over here if I take one of the places.

Do you have any obligations to complete in relation to your scholarship?

Really the only thing that I need to do is pass all of my subjects which really aren’t all that difficult…

What changes would you like to see as part of scholarships to WA students?

I am very privileged to have a scholarship which gives me such great opportunities. The only things I would like to see changes to is its availability to students. I find that in WA many people don’t have a slightest clue what nuclear medicine is and by making the explanation clearer and promoting the scholarship earlier on in the year this would make a lot of difference.

How do you find living away from home?

I don’t actually mind living away from home and now I am really glad that I do. I have matured a lot over the last year and a half and am way more capable and independent than most people my age. The hardest part about moving away was that I had only just turned 17 which made the social transition harder. I was unable to go to many of the social events, and as I was living on campus this made life a little difficult. My scholarship allowed me to go home often and regular phone calls helped my transition. Now I wouldn’t change my decision to move to “Newie” for the world. I have made loads of friends in Newcastle and I am really enjoying the course!

37

Case Study

Myocardial uptake on a bone scan Amy Evans Sir Charles Gairdner Hospital, WA Patient Presentation A 76-year-old male presented to the Nuclear Medicine department at Sir Charles Gairdner Hospital for a bone scan in April 2013. He was currently an in-patient at Sir Charles Gairdner Hospital and had been in hospital for 4our days. He had a history of locally advanced adenocarcinoma of the prostate and required an assessment of the disease extent prior to therapy which he had previously refused.

Imaging 950MBq of 99mTechnetium-HDP was administered intravenously to the patient. The patient was scanned on a Siemens Symbia T6 dual headed gamma camera at threehours post injection of the radiopharmaceutical. The patient had a whole body bone scan followed by a SPECT/CT of the lumbar spine and thorax.

Scan Appearance The patient had two catheter bags during the image acquisition which can be seen on either side of the patientâ&#x20AC;&#x2122;s femora. The images demonstrated intense focal uptake of the tracer at the 9th rib posteriorly. This correlated to the sclerotic changes demonstrated on the CT images and was reported as a metastasis. There was also focal uptake of the tracer at the right zygoma however this was thought to be benign. Degenerative changes were noted throughout the skeleton. An interesting finding was the diffuse, increased uptake of the tracer throughout the myocardium. There was no definite reason given by the reporting physician for this uptake which lead to further investigation.

Myocardial Uptake on a Bone Scan Bone scanning using 99mTc-labelled diphosphonates is one of the most commonly performed imaging procedures in nuclear medicine.1 A normal bone scan demonstrates relatively diffuse, symmetrical uptake of the tracer throughout the skeleton with urinary bladder activity, faint renal activity and minimal soft tissue uptake.1 Most of the time extra-osseous uptake of 99mTc-diphosphonates is an unexpected, incidental finding.2 Myocardial uptake is considered a normal scan appearance during blood pool imaging in a bone scan,

Above: Whole body bone scan demonstrating rib metastasis (blue arrow) and diffuse cardiac uptake (red circle). however, this is not true for delayed imaging.3 The delay between injection and imaging time, which is typically 1-3 hours, should allow ample time for the tracer to clear from the soft tissue.1,3 On some occasions, extra-skeletal uptake is remnant activity from other, recently performed, radionuclide imaging procedures.1

Below: SPECT/CT images of the thorax demonstrate tracer uptake throughout the left ventricle of the same intensity as the bone.

38 Gamma Gazette July 2013

u

Myocardial uptake on a bone scan

Bone Scan 2006

Bone Scan 2013

Above: Wholebody bone scan images from 2006 (pictured left) and 2013 (pictured right) demonstrating cardiac uptake of 99mTc-HDP (red circles).

Cardiac uptake has been reported on a bone scan in cases of cardiac amyloidosis, arrhythmogenic myocardial calcification, hypercalcaemia, hyperparathyroidism, hypervitaminosis D, long standing congestive heart failure, chronic renal failure, myocardial infarction, pericarditis, pericardial effusion, unstable angina, metastatic neoplasms, milk alkali syndrome, Albright hereditary osteodystrophy, inflammation, infection, oedema, phlebitis, radiation therapy, adriamycin, ischemic cardiomyopathy, myocardial contusion, breast metastases and post direct current cardioversion or resuscita tion.1,2,3,4,5,6,7,8,9,10,11 Indeed, there are a wide variety of conditions that cause soft tissue uptake on a bone scan and the reasons behind this uptake are usually multifactorial.1 Calcification of the soft tissue is the key process that enables 99mTc-labelled diphosphonates to be taken up by these non-osseous structures.1,5,6 The two main types of calcification that affect the myocardium; dystrophic calcification and metastatic calcification.5,7,11 Dystrophic calcification may take place when tissues are damaged or necrotic.2,5,11 This damaged tissue allows excess circulating calcium to enter the cytoplasm where it is readily taken up into the mitochondria.7 Myocardial infarction is an example of when dystrophic calcification may occur.11 Metastatic calcification is essentially the deposition of calcium salts on non-osseous structures due to local or systemic metabolic disruption.5 Disorders such as hyperparathyroidism can lead to metastatic calcification due to the increase in calcium in the systemic circulation.12 There are circumstances in which calcification is not the cause for myocardial uptake for 99mTc-diphosphonates.11 For example, amyloidosis, which is defined as the result of amyloid proteins depositing within soft tissue can be responsible for cardiac uptake.3 99m Tc-diphosphonate uptake in the heart due to cardiac amyloidosis is well reported in the literature.1,2,35,9,10,11 While it is known that the

fibrils that occur in amyloidosis have a physiologic affinity for calcium, the exact mechanism of the bone tracer’s uptake remains unknown.11 Further Patient History In view of the fact that myocardial uptake on a bone scan appears non-specific it seemed appropriate to learn more about the patient history in order to determine a true cause.

The patient’s most recent discharge summaries were reviewed for information regarding his current medical condition. On his most recent visit, the patient had originally presented to hospital with 2 days of worsening back pain radiating to the abdomen. He had associated unsteadiness on his feet with reported trauma to his head from hitting a door. On top of this he was confused. He also had a history of chronic kidney disease. He was transferred to urology with an initial diagnosis of acute on chronic renal failure. It was determined that his back pain was caused by obstructive uropathy due to his locally advanced prostate cancer.

The patient’s blood work was consistent with chronic renal failure. He had elevated creatinine (496μmol/L) and blood urea nitrogen (17mmol/L). His fasting glucose level was slightly increased (6.8mmol/L). His calcium plasma was within normal range (2.39mmol/L).

Previous Imaging The patient had a previous bone scan in 1999 and 2006 at the age of 62 and 69 respectively. The scan from 1999 was not available for viewing, however the report did not indicate myocardial uptake of the bone tracer. The images from 2006 demonstrated diffuse cardiac uptake of the tracer however this was less intense to the scan u 39

Myocardial uptake on a bone scan

Table 1. Reasons for the Increasing Prevalence of Extra Osseous Calcification in Chronic Kidney Disease16 The average age of chronic dialysis patients is on the rise.

Improvement in survival combined with prolonged exposure to risk factors for calcification.

Uncontrolled calcium-phosphate product in end stage renal patients.

Below: Supine x-ray demonstrating calcified vas deferens/ seminal vesicles. (blue arrow) performed most recently.

More recently, the patient had x-rays and CT scans to assess his conditions. X-rays performed of the chest, abdomen and lumbar spine reported no significant findings; however, heavy calcification of the vas deferens, aorta and iliac arteries was documented as an incidental finding. The CT scans of the head, abdomen and pelvis documented bilateral hydronephrosis and hydroureter which was attributed to the locally advanced prostate carcinoma. Interestingly, the CT report also noted incidental findings of bilateral seminal vesicle calcification.

Metastatic Calcification The patientâ&#x20AC;&#x2122;s current medical condition which includes chronic kidney disease, increased blood urea nitrogen and the calcification demonstrated in the vas deferens, aorta and iliac arteries as well as the lack of known cardiac illness leads the author to believe that the cause of myocardial uptake in the bone scan, in this case, is due to metastatic calcification secondary to chronic renal failure.

Metastatic calcification in patients with chronic renal failure is well described in the literature.4,5,6,7,9,11,12,13,14,15,16,17,18,19 In fact, 70% of patients with chronic kidney disease have significant coronary artery and aortic calcification.17 In chronic kidney disease patients, soft tissue calcification takes place long before end stage renal disease.19 Metastatic calcifications most commonly occur in the kidneys, lungs and gastric mucosa whereas the heart, vasculature, thyroid, liver and skeletal muscles are less common.5,11 The reason that they are more common in the kidneys, lungs and gastric mucosa is due to the high intracellular pH in these structures and the fact that calcium salts are most likely to occur in an alkaline environment.5 Caucasian males with a history of dialysis are at greatest risk of developing metastatic calcification.19 The prevalence of extra skeletal calcifications in chronic kidney disease patients is on the rise.16 (see table 1) It is generally accepted that the probability of metastatic calcifications occurring is positively linked to increases in the solubility product of serum calcium and phosphorus: Ca x PO4.5,11,12,14 The calcifications seem to manifest when the solubility of the product exceeds 5mmol/L (60mg2/dl2).5,12 However, more recently, the predictive value of the solubility product in metastatic calcification has been brought into question.14 It has been suggested that not only are there systemic and local factors in the body that promote calcification (including calcium, phosphorus and the parathyroid hormone), there are several inhibitors that are detrimentally affected by chronic 40 Gamma Gazette July 2013

Improved objective quantification methods of calcium deposits.

kidney disease which effects the normal balance that would normally prevent metastatic calcification.14,17,19 This means that metastatic calcifications may still transpire in patients with both a calciumphosphorus product and parathyroid hormone within normal limits.7 In addition to this, there is growing support that smooth muscle cells can transform into osteoblast-like cells which further contributes to the calcification of the heart and blood vessels.14,19 Soft tissue calcification is both a passive and an active process.19 (see Figure 1) It is believed that the passive process takes place when calcium enters the cell of soft tissue structures through passive diffusion across the cell membrane, which is enabled by the concentration gradient, and then deposited in the mitochondria.5,7 Accumulation of the calcium within the cell takes place when the capacity of the cell to actively expel calcium is exceeded.5 It is also suggested that, when first deposited, the calcium phosphate deposits form an amorphous structure with a large adsorption surface and increased blood supply.5,11 Over time, the deposit essentially changes into a hydroxyapatite structure.5,11 In visceral structures, the deposits are generally amorphous compounds containing calcium, phosphate and magnesium known as whitlockite.5 The active process of calcification involves the vascular smooth muscle cells undergoing de-differentiation to transform into osteoblastlike cells.14,15,17 Elevated uraemia as well as hyperphosphatemia and hyperglycaemia can induce this process.14 The transformation enables these newly formed cells to produce bone matrix proteins which then regulate mineralisation.15,17 The presence of elevated calcium, phosphorous and abnormal bone remodelling further accelerate the mineralisation.14,15 Although there are currently several imaging techniques that have documented the detection of metastatic calcification there is yet to be a universally accepted, gold standard method.18 Plain film radiographic imaging can only detect calcifications once they have reached a certain degree of intensity.19 In some cases, metastatic calcification deposits can be tiny in size, evading detection from anatomical imaging such as x-ray and CT.5,12 Furthermore, the motion artefact caused by the beating heart can affect the quantitation of visible calcification Figure 1. Factors Responsible for Calcification18

u

Myocardial uptake on a bone scan

deposits although this will soon be overcome with the introduction of ultra-fast CT scanners that utilize echocardiographic gating.18 It is well documented that active metastatic calcifications in soft tissue structures will accumulate 99mTc-diphosphonate and demonstrate uptake on a bone scan.4,5,7,12,13 The uptake may not necessarily correlate with the anatomical presence of calcifications if any or all of these calcifications are inactive.12 It has been suggested that radionuclide imaging may detect metastatic calcifications more readily than the alternative radiographic procedures.5,7 It is believed that 99mTc-diphosphonates bind to metastatic calcifications in the same fashion that they bind to bone.5,7,11 That is; the diphosphonates are adsorbed onto the surface of the hydroxyapatite crystal.5,7,11 Areas of newly calcified deposits would demonstrate the same increased uptake as with new bone due to the increased blood flow and expanded surface area of the amorphous deposit.5,7,11 However, the amorphous compounds that make up the whitlockite found in the visceral deposits demonstrates significantly decreased uptake of the bone tracer due to the presence of magnesium.5 (see figure 2) Indeed, radionuclide imaging has the potential to serve as a strong imaging tool in the detection and early diagnosis of calcification in high risk chronic kidney disease patients.7 Figure 2. Uptake of 99mTc-Diphosphonates in Metastatic Calcifications5

Calcification is more frequently seen in chronic kidney disease patients than the healthy population and is more severe and occurs more rapidly as well.17 It has been demonstrated that the arteries of patients with chronic kidney disease have higher levels of calcification that those of age matched individuals.14 Metastatic and vascular calcifications are associated with a significantly increased morbidity and mortality rate.17,18,19 50% of all cardiovascular deaths associated with abnormal tissue calcification occur in renal dialysis patients.17 The mortality rate of dialysis patients, including the younger population, with associated cardiovascular disease is 20 times more than that of an age matched member of the general population.17,18 Conclusion Myocardial uptake on a bone scan is a non-specific incidental finding.

It can be difficult to determine the cause of such uptake and is often left unexplained. In this case, the author feels there is a high likelihood that active calcification processes within the myocardium have caused the patients myocardial uptake on the bone scan. There is potential, especially with myocardial uptake in patients with chronic kidney disease, for early detection of often asymptomatic and potentially fatal myocardial calcifications. Indeed, attributing a cause for incidental non-osseous findings on the nuclear medicine bone scan would significantly increase the diagnostic value of the study.

Reference List 1. Love, C., Din, A., Tomas, M., Kalapparambath, T., & Palestro, C. (2003). Radionuclide bone imaging: an illustrative review.

Radiographics, 23(2), 341-358.

2. Gentili, A., Miron, S., & Bellon, E. (1990). Nonosseous accumulation of bone-seeking radiopharmaceuticals.

Radiographics, 10(5) 871-881.

3. Kulhanek, J., & Movahed, A. (2003). Uptake of technetium 99m HDP in cardiac amyloidosis. The International Journal of Cardiovascular Imaging, 19(3), 225-227.

4. Taylor, R. (2003, November). Multifactorial uptake of Tc-99m methylene diphosphonate in chronic renal failure. Clinical Nuclear Medicine, 28(11), 939-940.

5. Castaigne, C., Martin, P., & Blocklet, D. (2003, June). Lung, gastric, and soft tissue uptake of Tc-99m MDP and Ga-67 citrate associated with hypercalcemia. Clinical Nuclear Medicine, 28(6), 467-471.

6. Ergun, E., & Ceylan, E. (2001, November). Soft tissue uptake observed on Tc-99m MDP bone scans – Rare imaging patterns in two cases. Clinical Nuclear Medicine, 26(11), 958-959.

7. Ejaz, A., Nisar, N., Gandhi, V., Eilers, D., Shirazi, P., & Ing, T. (1995, June). Metastatic soft tissue calcification in chronic renal failure detected by radionuclide imaging. Clinical Nuclear Medicine, 20(6), 505-507.

8. Karanauskas, S., Starshak, R., & Sty, J. (1991, May). Heterotopic Tc-99m MDP uptake secondary to phlebitis. Clinical Nuclear Medicine, 16(1), 329-331.

9. Braga, F., Miranda, J., Lucca, L., Garcia, T., & Ferraz, A. (2000, May). Heart and lung accumulation of Tc-99m MDP with normal radiographs in patients undergoing hemodialysis. Clinical Nuclear Medicine, 25(5), 377-378.

10. Chadrawar, S., George, M., Al-Akraa, M., Harber, M., & Buscombe, J. (2009). Myocardial uptake of Tc-99m HDP in a patient with prostate carcinoma. Nuclear Medicine Review, 12(2), 78-80.

11. Zuckier, L., & Freeman, L. (2010, July). Nonosseous, nonurologic uptake on bone scintigraphy: atlas and analysis. Seminars in Nuclear Medicine, 40(4), 242-256.

12. Nizami, M., Gerntholtz, T., & Swanepoel, C. (2000, June). The role of bone scanning in the detection of metastatic calcification – A case report. Clinical Nuclear Medicine, 25(6), 407-409.

13. Sahin, A., Seven, B., Yildirim, M., & Varoglu, E. (2004, December).

Heart and soft-tissue uptake of Tc-99m MDP in a hemodialysis patient. Clinical Nuclear Medicine, 29(12), 854-855.

14. Moe, S., & Chen, N. (2008). Mechanism of vascular calcification in chronic kidney disease. Journal of the American Society of Nephrology, 19, 213-216.

15. Moe, S., & Chen, N. (2004). Pathophysiology of vascular calcification in chronic kidney disease. Journal of the American Heart Association, 95, 560-567.

16. Drueke, T. (2002). Foreword: Extraskeletal calcifications in patients with chronic renal failure. Nephrology Dialysis Transplantation, 17, 330-331.

17.

National Kidney Foundation. (2011). Chronic kidney disease – mineral and bone disorder (CKD-MBD): A focus on vascular calcification. [Brochure]. Retrieved from: http:// www.kidney.org/professionals/tools/pdf/CKD_MBD_A_ FocusOnVascularCalcification.pdf 18. Srija, M., Brahmbhatt, B., Lakshminarayana, G., Mathew, A., Rajesh, R., Kurian, G., & Unni, V. (2012). Extensive vascular calcification in end stage renal disease. Amrita Journal of Medicine, 8(1), 42-44.

19. Drueke, T. (2005). Pathophysiological aspects of vascular calcification in chronic renal failure. Nefrologia, 25(Suppl. 2).

96-99.

41

Case Study

Autonomous hyperfunctioning sublingual thyroid tissue in a patient with congenital hypothyroidism, resulting in hyperthyroidism suggestive of Graves’ disease Colin Mercer Canberra Imaging Group

Background Congenital hypothyroidism presents in approximately 1 in 3500 new births, or 70 babies annually in Australia (Coakley & Connelly, 2006). The most common cause is thyroid dysgenesis where the thyroid gland fails to develop properly. In these cases the thyroid gland may be absent or ectopic. Routine screening of newborns with congenital hypothyroidism present with low recorded thyroxine (T4) and triiodothyronine (T3) hormones. Treatment of congenital hypothyroidism consists of thyroxine replacement shortly after birth for life.

Ectopic thyroid tissue is a rare presentation, resulting from anomalies in the embryological development of the thyroid gland. It occurs in 1 per 100 000 - 300 000 people, however it rises to 1 per 4000-8000 patients where thyroid disease is present (Noussios, G. et al, 2011). The location in these cases can be anywhere along the embryologic development pathway, including the tongue, lateral neck, mediastinum, and the sub-diaphragmatic organs (Noussios, G. et al, 2011).

Unlike congenital hypothyroidism where there is low levels of T3 and T4, Graves’ disease causes the thyroid gland to overfunction. It is an autoimmune disease that is characterised by antibodies that behave similarly to thyroid stimulating hormone (TSH). These antibodies stimulate the TSH receptors, and result in the thyroid gland producing high levels of thyroxine, often producing symptoms of hyperthyroidsim.

LT Lateral Anterior Figure 1: Focal uptake seen in the area just below the base of the tongue.

Introduction The following case report presents a patient with congenital hypothroidism, who developed thyrotoxicosis, and following 99mTc thyroid imaging demonstrated functional sublingual thyroid tissue, with uptake and blood tests consistent with Graves’ disease.

Case report A 31-year-old female with a history of congenital hypothyroidism, developed symptoms consistent with hyperthyroidism over a number of months. Symptoms included tremors, tachycardia, palpitations, sleeping difficulty, and fatigue. Her blood test results revealed high levels of T3 and T4, with very low readings 42 Gamma Gazette July 2013

Figure 2: Normal physiological uptake throughout the remainder of the body.

u

Autonomous hyperfunctioning sublingual thyroid tissue in a patient with congenital hypothyroidism, resulting in hyperthyroidism suggestive of Graves’ disease Figure 3: SPECT/CT demonstrates focal uptake at the base of the tongue.

Tranverse

Coronal

Sagittal of TSH. The patient had been taking thyroxine since birth, which had been very stable and well controlled during her life, up until her onset of recent symptoms.

It was deemed necessary to conduct a 99mTc thyroid scan to evaluate possible causes for the sudden change in hormone levels.

The patient was not required to cease thyroxine for the normal 4-6 weeks, as any functioning thyroid tissue identified, would be deemed to be functioning outside the normal negative feedback control mechanisms.

Twenty minutes following the injection of 99mTc, planar neck, whole body, and SPECT/CT images were acquired. Anterior and left lateral planar images in Figure 1, demonstrates a focal area of abnormal tracer accumulation in the area just below the base of the tongue, with normal salivary gland uptake. There is absent uptake in the thyroid bed consistent with congenital hypothyroidism.

Whole body imaging in Figure 2 demonstrated normal physiological uptake throughout the remainder of the body. SPECT/CT in Figure 3 demonstrates a focal area of abnormal tracer accumulation, and localises the uptake to the base of the tonuge.

Discussion Following the 99mTc thyroid scan, the hyperfunctioning ectopic thyroid tissue was localised to the base of the tongue. As the patient was on thyroxine, and the lesion did not demonstrate any suppresion

from the current thyroxine treatment, it was suggestive of functional thyroid tissue operating outside the normal negative feedback system. With consultation with the referring endocrinologist, the clinical diagnosis of Graves’ disease was made.

Follow up antibody testing was arranged to confirm the diagnosis, and the patient ceased thyroxine from the date of the scan. The treatment of Graves’ disease was withheld until accurate T3 and T4 levels could be established following the cessation of thyroxine. It was hoped that the small amount of functional thyroid tissue at the base of the tongue, coupled with the addition of Graves’ disease, would be sufficient to supply enough thyroid hormones for the patient. Depending on follow up T3 and T4 blood test results, either thyroxine replacement or treatment for Graves’ disease may need to be administered.

REFERENCES Coakely, J., & Connelly, J. (2006).

Congenital Hypothyroidism. Retrieved from www.apeg.org.au/ portals/0/resources/congenitalhypothyroidism.pdf Noussios, G., Anagnostics, P., Goulis, D. G., Lappas, D, & Natsis, K. (2011). Ectopic thyroid tissue: anatomical, clinical, and surgical implications of a rare entity. European Journal of Endocrinology, 165, 375-382. doi:10.1530/EJE-11-0461

43

Case Study

An interesting appearance of Ofuji’s disease on a F18 FDG PET/CT scan Laura Renshaw, Dr Sandeep K. Gupta Hunter New England Imaging Nuclear Medicine and PET Department

Abstract FDG PET/CT imaging is well known and established imaging tool in the fields of oncology, neurology, cardiology and infection. Its other uses and applications are still being discovered in research and findings around the world. A patient was referred for a routine staging PET scan for left upper lobe malignancy. The patient underwent the PET scan as per protocol and the images confirmed the known malignancy and also displayed low to moderate uptake throughout the skin of the trunk as well as the lower limbs, an unusual cutaneous appearance. On further questioning of the patient and investigation of past histology, these lesions were in fact eosinophillic pustular folliculitis, also known as Ofuji’s disease. To date, no other reported or published images could be found of a PET scan showing this chronic skin condition.

Case Report A 75-year-old female was referred to the Hunter New England Imaging PET department for a FDG PET/CT scan. The request asked for a routine staging of a left upper lung malignancy.

The PET/CT scan was performed with 252 MBq of F18 Flurydeoxyglucose injected IV and imaging performed 1 hour post injection. Imaging was performed from vertex to thighs with the arms raised above the head. A low dose CT was performed for anatomical localisation and attenuation correction purposes. The scan demonstrates the CT confirmed large left hilar mass lesion with intense FDG accumulation. A separate lesion in the left lung apex also shows similar FDG accumulation. An avidly hypermetabolic lesion in the left pelvis is strongly suspicious for malignancy/ metastasis. As seen in the figure, there are numerous small foci of low to moderate FDG accumulation throughout the skin of the trunk as well as upper and lower limbs. These are in keeping with history of steroid responsive cutaneous lesions demonstrating a very unusual appearance.

Following patient interview and examination, photographs were taken of the skin for educational purposes, the patients full consent was gained. The patient stated she had the skin lesions since approximately 2007. In 2010 she had an exacerbation of symptoms and has since felt the condition is mostly unresolved. Histology performed in 2007 confirmed the skin lesions to be oesinophilic pustular folliculitis, also known as Ofuji’s disease, a rare chronic skin condition. The etilolgy of Ofuji’s in unknown, there is 3 variants which have been described, the classic eosinophillic pustular folliculitis, HIV-associated folliculitis and an infantile variety. “Ofuji’s” refers to the HIV negative type. The disease is characterised by itchy pruritic pustules which infiltrate the hair follicles and eosinophils. The most common treatment for Ofuji’s is oral glucocorticoids.

Discussion While the patients PET/CT scan would have undoubtedly helped with her staging and disease management it is also helpful for technologists and reporting Nuclear Medicine Physicians to be aware of unusual and uncommon appearances on scans and the

44 Gamma Gazette July 2013

Figure 1: The FDG PET/CT scan, showing the widespread uptake of the lesions on the patient.

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An interesting appearance of Ofuji’s disease on a F18 FDG PET/CT scan

excellent ability of FDG PET to demonstrate other rare pathologies.

When unusual scan appearances occur it is also helpful to further interview the patient to gain a more concise medical history. To date, no other published images of Ofuji’s on a PET scan could be found.

References 1. Ellis, E; Scheinfeld, N (2004). “Eosinophilic pustular folliculitis: a comprehensive review of treatment options”. American journal of clinical dermatology 5 (3): 189–97.

2. Ota T, Hata, Y, Tanikawa A, Amagai M, Tanaka M, Nishikawa T (2001) Eosinophilic pustular folliculitis (Ofuji’s disease): indomethacin as a first choice of treatment. Clinical and experimental Dermatology 26 (2): 179-81.

3. Rajendran P, High W, Maurer T. HIV-associated eosinophilic folliculitis. Up-to-date. www.uptodate.com/contents/hiv-associated-eosinophilicfolliculitis?source=search_result&search=ofuji%27s&selectedTi tle=3%7E3 Last updated: Dec 13 2012.

Figure 2: Images of the patients skin lesions, taken with consent for educational use.

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Case Study

Interesting case Lauren Campbell Canberra PET/CT Service

Date: 27/04.2013 BSL: 5.5 mmol Dose: 330 MBq (F18-FDG) Clinical Indication: Left facial tumor with bone and left orbital infiltrate ? SCC. Awaiting biopsy. Multiple bilateral pulmonary metastases.

Results & Findings PET CT imaging was undertaken from the skull vertex to lower femora with low dose CT performed for attenuation correction and anatomical localisation. Recent diagnostic CT from April 2012 was available for comparison. The large soft tissue mass described on

Figure 1: Anterior & Lateral Views 46 Gamma Gazette July 2013

diagnostic CT is metabolically active in a heterogenous pattern with the appearances suggesting solid tumor and necrosis. There is evidence of bony infiltration and destruction with abnormal metabolic activity extending into the skull and through the facial and skull bones and also into the left orbit.

Low level to moderate tracer activity is noted within ipsilateral cervical nodes extending to the supraclavicular region. Multiple abnormal metabolic foci are present within the lung fields.

Low level activity is seen within the mediastinal nodal stations with the most prominent being in the aortopulmonary window however tracer uptake at this site is similar to background. Tracer distribution otherwise appears normal. There is no evidence of abnormal uptake within the liver or abdomen. Uptake within the skeleton is diffusely increased which may be secondary to reactive changes. No focal bony abnormality is identified to suggest metastatic disease

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Interesting Case

Figure 2 a b c: Impression The study is in keeping with a large metabolically active soft tissue mass causing widespread destruction of the left facial and skull bones and infiltrating through the skull and orbit. Metabolically active ipsilateral; supraclavicular nodes; Pulmonary metastases; Low level mediastinal nodal activity present ? significance.

Figure 3 47

Australian and New Zealand Society of Nuclear Medicine