March 2013

ISSN : 2200-9876

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

March 2013

Contents

www.anzsnm.org.au

Welcome

4

President’s Report

5

Branch News

Queensland 6

South Australia

6

Western Australia

6

New South Wales

7

New Zealand

7

Vic/Tas

9

SIG

Technologists

10

Physics 10 What’s That?

11

International Relations Committee of the ANZSNM 12 ICRRT 2012

14

Report on European DOSE DATAMED projects 18

Case Studies

Role of nuclear medicine in diagnosis of transplant page kidney caused by a subcapsular urinoma 21

False positive iodine uptake in a renal cyst: Value of SPECT/CT

24

Submitted Papers

Comparison of bone scan quality with a 10-20% reduction in patient dose

26

Modified In-vivtro red blood cell labelling using a single polyurethane intravenous cannula

29

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

1

Journal Staff

Editorial copy & Advertising copy

Robyn Smith General Manager ANZSNM Secretariat PO Box 202, Parkville VIC 3052 Tel: 1300 330402 Fax: (03) 93879627 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: VIC/TAS Branch

Bridget Chappell,

Chair of the Vic/Tas Branch

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)

(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 July 1, 2012, the future role of the Accreditation Board was reviewed and Federal Council made a decision to disband the current Accreditation Board and re-allocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG).

The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam will now be managed by sub-committees of the TSIG, currently being formed.

(d)

In addition to TSIG, there are several other special interest groups that maintain standards of practice for their particular speciality and provide a forum for their development in Australia and New Zealand.

These include the Radiopharmacy, Physics and Nurses Groups.

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. Š 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

2 Gamma Gazette March 2013

The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation 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

General Manager & Secretariat

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

All correspondence ANZSNM Secretariat

PO Box 202, Parkville VIC 3052

Tel: 1300 330402

Fax: (03) 93879627 Email: secretariat@anzsnm.org.au Technical Standards Committee Chairperson:

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

Scientific Advisory Panel Chairperson:

Professor Dale Bailey

Branch Secretaries Australian Capital Territory New South Wales

Queensland South Australia Victoria/Tasmania Western Australia New Zealand

Ms Maree Wright, email: maree_wright@hotmail.com Position vacant, interim contact is Acting President Ms Liz Bailey, ebailey@nsccahs.health.nsw.gov.au Ms Nikki Weinert & Ms Kathy Roy, email: qldbranchsecretaryanzsnm@gmail.com Ms Nicole Ayars, email: nicole.ayars@health.sa.gov.au Dr Zlata Ivanov, email: zlata.ivanov@arpansa.gov.au Ms Georgina Santich, email: wabranchsecretary@hotmail.com Ms Dianne Wills, email: Dianne.Wills@cdhb.health.nz

Special Interest Groups Technologists

Radiopharmacy Physics/Computer Science Nurses

Ms Marcia Wood, email: marcia.wood@austin.org.au CPD Program Sub-committee: Dr Clayton Frater PDY 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

3

Welcome Welcome to the first issue of the Gamma Gazette for 2013. We have a wide spectrum of interesting educational and scientific materials ranging from general nuclear medicine – including renal transplants and red cell labelling techniques to articles focussing on radiation dose and diagnostic reference levels (DRLs).

This edition also includes a review of an international meeting which allows those of us not able to attend an update of advances and new trends on the world scene. I would like to thank those who have contributed their time and efforts in preparing articles and submissions for this issue.

I hope you enjoy the issue.

Bridget Chappell Vic/Tas Branch Chair

Accreditation Congratulations to the following departments which were granted Accreditation or Re-Accreditation for the training of PDY Technologists: St Vincent’s Hospital, Melbourne #62 Alfred Nuclear Medicine #18 Monash Medical Centre #21 Royal Perth Hospital #63 Wollongong Nuclear Medicine #84 Hastings Memorial Hospital #141 Western Health Sunshine Hospital #143 Mount Nuclear Medicine #24 Regional Imaging Riverina #1 Wollongong Nuclear Mediicne Shell Harbour #162 Concord Hospital Nuclear Medicine #14 Macquarie Medicial Imaging #163

4 Gamma Gazette March 2013

Congratulations to the following technologists who were granted Accreditation: James Green Jennan Haidar Andrew Castles Mitchell John Clack Dwayne Thomas Scott Kate Virginia Newton Tahlia Jade Spanhel Mathew John Stevens Joshua Poscoliero Rachel Anne Wilson Sally Louise McCartney Chloe Sikos Jarryd Gregory Whebell Renee Rulli

Thuy Thi Thanh Ta Hamish Ferguson Kungsonny Keo Divya Trichy Louis Gray Erin Jayne Sheldon Nadelle Hefer Kayla-Anne Pender Patrick George McCreanor Abby Hale Toby Irwin Nicole Elizabeth Higgins

President’s Report Welcome to the first issue of the Gamma Gazette for 2013. It’s hard to believe that another year has passed, time goes by so quickly. National registration for technologists has transitioned successfully. The ANSZNM have been contracted by the MRPB to run the supervised practice (PDY) program until December 2013. All graduates from approved courses are expected to enrol in the ANSZNM PDY program and complete either the 12 month or six month (for University of SA graduates only) supervised practice program.

The ANZSNM will provide a list of technologist who has successfully completed their PDY year to the MRPB so that full (unconditional) registration can be issued. Each candidate will also be issued with an Accreditation certificate from the ANZSNM in recognition of having completed the program.

The ANZSNM were approached by the SNMMI in 2012 to be involved in a Nuclear Medicine Global Initiative project, a joint undertaking of 10 organisations with an interest in promoting standards and quality in nuclear medicine. The first project to be undertaken by this group relates to ‘Dose optimisation in nuclear medicine and molecular imaging’, with Darin O’Keefe being nominated as the ANZSNM representative on this working group.

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 to advise the individual Annual Scientific Meeting local organising committee (LOC) in determining the scientific content and invited speaker selection for the ASM. This includes guiding the LOC in selection of named lectures (eg, 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 (eg, ANZSNMT, AANMS, ACPSEM, etc).

Membership compromises representation from each of the disciplines including a physician/radiologist, a scientist from physical sciences or engineering, a scientist from radiochemical or radiopharmaceutical sciences, a technologist, a representative from New Zealand (any discipline) and a representative from the Federal Council (any discipline). The newly elected chair is Professor Dale Bailey with the remaining membership yet to be finalised.

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 President-Elect of the WFNMB. This will create opportunities for sharing our knowledge and undertaking research with fellow colleagues in developing countries.

Just a reminder that the next ANZSNM ASM is fast approaching and is to be held in Perth at the Perth Convention Centre, April 11 – 15. Early bird registration has been extended to Friday March 15.

Liz Bailey President ANZSNM Federal Council Members at their last meeting for 2012.

Front row: Sze Ting Lee, Elizabeth Bailey, Lynda Jane Michel Back row: Sam Berlangieri, Jennifer Gault, Geoff Roff, Dale Bailey, Dylan Bartholomeusz, Susan O’Malley (Graeme O’Keefe was absent at this meeting and Sharon Mosley joined the Federal Council in February 2013.

5

Branch News QUEENSLAND Unfortunately the beginning of the new year has seen another natural disaster hit, with a large portion of Queensland being affected by the torrential downpour and winds caused by ex-tropical cyclone Oswald. We hope that all of our members are safe and that those that are affected are on the road to recovery.

We finished 2012 with our AGM and Radpharm presentations, which were held at The Prince Charles Hospital on November 8. We were very pleased with the fantastic turnout. There were four entrants for the Radpharm awards with Christian Testa, from the Princess Alexandra Hospital, being judged the winner and our representative for the ANZSNM Scientific Meeting to be held in Perth – best of luck Christian! The end of the year also saw Dr Andrew Southee (President) and Rowena Reichel and Penni Russell (Co-Secretaries) terms end. They have all contributed greatly to the branch, which is greatly appreciated by the newly elected committee members and all general members of the Qld branch.

This year brings fresh and exciting challenges with new committee members, Melinda Wilson (The Prince Charles Hospital) taking on the role as President, and Nikki Weinert and Kathy Roy (Princess Alexandra Hospital) taking over as Co-Secretaries.

The Queensland Branch held their first meeting for 2013 as a dinner meeting at the Pineapple Hotel in Brisbane on February 19.

We are currently in the process of organising our bi-annual branch symposium which is being held in September at the Carlton Brewery, half way between Brisbane and the Gold Coast. The planning and preparation is running smoothly, and we have been busy organising speakers. We would like to encourage all members to contact us if they have an interest in presenting at any future meetings or at the symposium.

Lastly, we would like to send out a big welcome to our new PDYs and any other members who have recently joined us in Queensland – we hope to meet you all very soon at upcoming events!

Nikki Weinert and Kathy Roy Qld Branch Co-Secretaries SOUTH AUSTRALIA 2012 for the SA ANZSNM Branch concluded with our AGM being held on December 5. I would like to thank all of those who attended the meetings throughout the year, the departments who hosted, our presenters, and also for the sponsorship the branch received.

Dylan Bartholomeusz (Federal Representative) and Adam Freeborn (Treasurer/Secretary) concluded their terms with the SA ANZSNM Branch. We are extremely grateful for their dedication and commitment over the years to the Nuclear Medicine Community. Dominic Mensforth and Nicole Ayars were elected as our new Federal Representative and Treasure/Secretary respectively, and we welcome them to the committee.

The prize for the SA Branch ‘ANZSNM selected best NM paper’, presented at the Medical Radiation student conference was awarded to Danielle Lutze. Her paper was titled ‘The effect of age on 18Fluorine (18F)-fluoro2-deoxy-D-glucose (FDG) uptake in brown adipose tissue (BAT) in the supraclavicular region of patients with lymphoma: a retrospective study”.

2013 looks to be another busy year and I encourage everyone to attend their local branch meetings.

Rachael Dunlop Chairperson SA Branch ANZSNM WESTERN AUSTRALIA Last October the WA Branch of the ANZSNM held their Radpharm meeting. There were some wonderful entries on the night, so thank you to all who got involved. Congratulations to Cedric Eustance who will be representing WA at the conference.

We finished up the year with the AGM at Royal Perth Hospital. After the formalities were taken care of, we finished the night with a barbeque and a quiz sponsored by Axiom Molecular, Genzyme and InSight Oceania.

Thanks to all who were involved with the efforts to make the night a success.

The committee has had a change of roles, with Geoff Roff stepping down as Federal Representative to be replaced by Dr Ros Francis at the ANZSNM conference this year. We thank Geoff for all his hard work and wish Ros

6 Gamma Gazette March 2013

Branch News good luck for the role.

Don’t forget the ANZSNM Annual Scientific Meeting is being held at the Perth Exhibition and Convention Centre between April 11-15 this year. Registration is now open, so get in and we look forward to seeing as many of you as we can in Perth this April!

Stephanie O’Donnell ANZSNM WA Branch Committee Member NEW SOUTH WALES Happy New Year to all. This is my last branch report as Chairperson of the NSW branch .I have enjoyed my time as Chair with the support of my very capable committee. What started as a two year deal has now been seven years ! I would like to especially thank Peter McConanchie who has been an outstanding treasurer and secretary who is also retiring from his current role. Peter has been a valuable member to our group and has been a pleasure to work with. Along with Peter and I, Bruce McBride our Physics rep is also resigning from the committee. Thank you Bruce for your efforts especially during the organisation of the 2009 Sydney conference.

We need some new faces and people who are willing to do their bit for the NSW branch to join our committee. If you are interested please contact Liz Bailey who is currently acting Chairperson.

Our last meeting of 2012 was held at Siemens and once again we would like to thank them for their support every year for our Christmas meeting. We were very privileged to have Richard Smart give us a presentation “ The humble dose calibrator: potential pitfalls, results of the Society’s dose calibrator surveys and the new DCPTP (Dose Calibrator Proficiency Testing Program) from ANSTO”.

Richard retired earlier in the year after 35 years service at St George Hospital. Richard has been an invaluable member of the ANZSM has served on multiple committees and has made a significant contribution to the Nuclear Medicine community. We were very grateful to him for coming to give us this presentation and we wish him luck in his future endeavours.

I would also like to thank the sponsors of our meetings throughout the year and I would like to send a special thank you to GMS for distributing our branch meeting flyers to members via the delivery boxes.

We have an exciting year planned for the NSW branch with some very interesting meetings planned so make sure you check the website and have your email addresses updated to receive flyers.

Tracey Smith Ex officio NSW branch NEW ZEALAND The New Zealand Nuclear Medicine community is presently experiencing a lack of availability of trained technologists. There are 2 locum positions coming up in 2013. One is for 8 days at Hawkes Bay Nuclear Medicine Department in April and the other is a month in Blenheim at the Wairau Hospital Nuclear Medicine Department.

Hawkes Bay is also looking for a permanent Technologist.

Prue Lamerton wrote: Is there anyone out there who may have thought of a change in lifestyle and would like to experience the fabulous Hawkes Bay. If you are a real foodie and wine lover this is the place to be with the very best of fresh NZ produce. Visit www.hawkesbaynz.com for more information.

Now for Nuclear Medicine, currently we have a GE Infinia 1 slice but are currently going through the tender process for a new SPECT/CT. We had an increase in scan numbers last year as we have a new Oncologist from America who is very keen on Nuclear Medicine and our myocardial scan referrals are on the increase as well.

In terms of staffing there is myself fulltime and Tom a student 0.6FTE and Anna currently on maternity leave who is only 1 day/week. We have a position for a dual scoped nuclear medicine and diagnostic 0.5 split technologist and if necessary we may be able to consider nuclear medicine only.

We have set a date for the 2013 ANZSNM NZ Branch Meeting. It will be held over the weekend of 19-20 October in Palmerston North. There will be more information on the ANZSNM website in the near future.

On a personal level, an 8.1 magnitude earthquake off the Solomon Islands this week reminded me that here in Christchurch we recently experienced our 11,000th aftershock and I thought a post earthquake progress report might be of interest. Nearly 2.5 years after the initial earthquake there are still thousands of Christchurch residents living in houses waiting for repairs or demolition. Our inner city is still partly blocked off. Places for live

7

Join us in Perth in April for the 43rd Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM 2013) • The Pre Meeting Symposium will be held on Friday 12th April at the University Club, located at the University of Western Australia. The Symposium will highlight advances in Molecular Imaging, and includes expert National and International speakers. This promises to be a day of education and ideas for the future. Program now available, please visit the website to download.

• The Annual Scientific Meeting will be held from Saturday 13th April to Monday 15th April, with a theme of ‘Exploring New Horizons’. The scientific program will hold interest for all, with an exciting panel of international and national speakers discussing a range of clinical and technology issues across all aspects of Nuclear Medicine and Molecular Imaging. In addition to invited speakers, there will be oral and poster presentations and award sessions. The large exhibition area at PCEC will provide an interactive space for our industry partners to display the latest in equipment and products.

Key DAteS: early Bird Registration Close 15 March 2013 (extended by 1 week) Committee Meetings 11 April 2013 Pre Meeting Symposium 12 April 2013 Annual Scientific Meeting 13 – 15 April 2013 For further information regarding the conference, please visit www.anzsnm2013.com.au We look forward to seeing you in ‘the West’ in April.

• Program highlights – Visit the website for up to date program highlights, including details for the invited presentations.

• 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.

Gala Dinner Sunday 14 April, 1900 – 2230 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 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

Branch News entertainment, movie theatres, restaurants and bars are still much reduced. Tourism and conference facilities are in very short supply and there is indecision about the fate of many of our communal properties, in particular our beloved cathedral.

The ‘rebuild’ is said to be starting but it is snail-like in progress. Zoning decisions have been delayed and insurance companies have not been issuing cover for new builds. It seems it may be a decade before we have a ‘whole’ city again.

However, despite all of these difficulties, there is great resilience amongst the people of Christchurch. There is a determination and hope that the ‘cleanish’ slate which the planners are now faced with gives opportunity for a new vision for our city, eg. exciting building designs and locations for more open, green areas. There has been and still continues to be much consultation with the public and experts on what form this vision will take. We look forward to inviting you all in the not too distant future to visit our city again in its exciting, rejuvenated state.

Dianne Wills Secretary NZ Branch ANZSNM VICTORIA/TASMANIA BRANCH REPORT 2013 will be another busy year for the ANZSNM in Victoria and Tasmania.

The branch has kicked off its annual Continuing Education activities early with Kim Williams annual January pilgrimage to Melbourne. Prof. Williams presented a review of Nuclear Cardiology in 2012 highlighting pertinent trends and emerging uses for Nuclear cardiology to over 50 attendees.

CPD and education events will be the main focus of the Branch in 2013 with several events being organised in the next few months. The first of the Branch’s Continuing Education (CE) master classes was held on February 23 at the Austin Hospital with 25 people attending. The half day seminar covered the use of PET/CT in radiation therapy planning and new advancements in PET instruments and radiotracers. I would like to thank all the speakers for their contribution to the event. The branch is hoping to hold another two CE Masterclasses later in the year focussing on Nuclear Cardiology and Muskuloskeletal Imaging and CT. In addition to these new CE sessions the Branch will also be again organising the Annual Day Seminar and the traditional post conference meeting which will be held on April 17. The speakers and venue will be confirmed in the near future.

The committee is also looking forward to once again supporting CE activities in Tasmania.

Other projects being undertaken by the branch in the next 12 months are focussed once again on the promotion of Nuclear Medicine and in particular Nuclear Medicine Technology and Medical Physics as vocations. The ANZSNM is working in conjunction with the VSNMT and the Victorian Department of Health on promoting these career options and raising the profile of Nuclear Medicine in Victoria in efforts to counteract projected future workforce shortages within the state. The ANZSNM in collaboration with the VSNMT has been successful in receiving funding from the Department of Health and will be initiating projects in the next few months to promote these fields. One of the events crucial to this is the annual Age Careers Expo which will be held again in May 2013. The branch will again be looking for volunteers to help spread the word and promote Nuclear Medicine as a career option. Anyone who may be interested can contact the branch committee via the society’s secretariat.

The branch has also been responsible for compiling this edition of the Gamma Gazette and I would like to thank those members who have contributed their time and talents in preparing articles.

Bridget Chappell Vic/Tas Branch Chair

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Special Interest Group News TECHNOLOGISTS Firstly, I hope 2013 finds all Technologists safe, well and refreshed after the holiday season. At a TSIG level, I am sure that there are plenty of challenges ahead for the committee and am thankful for their continued hard work representing the technologists of their states.

The Annual Scientific Meeting in Perth is rapidly approaching. Congratulations to all of the state winners for the Radpharm award and the best of luck with your presentations. We look forward to seeing lots of familiar faces at both the Technologist Symposium and the main meeting.

Over the past few months the TSIG has continued to build a working relationship with AHPRA and the MRPBA, and to advocate for technologists on issues arising as a result of their policies and guidelines. I would encourage all technologists to read the Communiqués circulated by the MRPBA as these often contain important information. The MRPBA website also lists current consultations and submissions of interest, and we would encourage Technologists to participate in these. The TSIG will ensure that adequate technologist representation is present at the various committees and working groups.

Lastly, just a reminder that the TSIG is a national body that represents YOU, the Technologists. We put together documents that define our role, our codes of practice and what standards we expect. We offer a CPD program that has been accepted by AHPRA to meet their specifications, and keep databases of this information to supply as required. We are the MRPBA contracted provider of supervised practice for 2013. If at any time, you have problems with registration, CPD requirements, auditing, etc, please contact the TSIG via the ANZSNM Secretariat. We may be able to help resolve any issues, provide guidance or advocate on your behalf if required.

Marcia Wood Chair, ANZSNMT PHYSICS The Physics SIG, in association with the ACPSEM Nuclear Medicine Speciality Group, recently held the symposium “PET/ MRI for Beginners”. This was the first of two symposia for 2013 and it was a bit of a catch-up because our ‘annual’ symposium had not been held since December 2010. The next symposium is planned for December with the topic options being discussed at the Physics SIG AGM in Perth next month. Current suggestions are topics on cardiac imaging, radionuclide therapy (including the role of PET imaging), parametric imaging and compartmental analysis, and a professional interaction symposium between radiation oncology and nuclear medicine. If anyone has some strong opinions on these or suggestions on other topics, please email me before the AGM. Plans are in place for the Physics SIG sessions on the Saturday of the Perth ANZSNM 2013 scientific meeting.

The provisional plans for the sessions see a mix of submitted papers combined with invited speaker presentations on radionuclide therapy of the liver, and quantitative neuroimaging. Please remember that all are welcome to these sessions, not just Physics SIG members.

We recently had a request from ARPANSA to propose a Physics SIG member to be part of a liaison panel to look at diagnostic reference levels for radiopharmaceutical administrations. It was my pleasure to put forward Jocelyn Towson to join Richard Smart on this panel, continuing the excellent work they have both previously undertaken in this area.

In the transition to the new regulations in 2008, the Physics SIG specific objectives were lost. This will be addressed through a submission to the Federal Council, but it is a good opportunity to check the expectations placed upon the SIG and that the activities it undertakes are aligned with those of the ANZSNM. If you want more from the Physics SIG either as a member or non-member, please drop me an email.

Darin O’Keeffe, ANZSNM Physics SIG Chair

10 Gamma Gazette March 2013

Answer on page 20

What’s that?

Daniel Rossiter Ruth Winterton Northern Nuclear Medicine, Burnie, Tasmania

A 65-year-old gentleman was referred for a Nuclear Medicine bone scan for investigation of ongoing left hip pain of four weeks duration. A clinical history of tenderness over the left greater trochanteric region was provided.

X-ray of the left hip area did not reveal any trochanteric pathology.

A routine bone scan was performed using 25mCi 99mTc-HDP. Whole body blood pool imaging revealed a large, unexpected, photopenic area in the right side of the abdomen anterior to the right kidney.

In view of this unusual finding, an abdominal SPECT scan of the blood pool image was performed in order to delineate the photopenic area in question. SPECT tomography of blood pool images is not routinely performed in our department. It was noted that the right kidney was displaced posteriorly as compared to the left kidney, and the liver appeared to be displaced superiorly.

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International Relations Committee of the ANZSNM

Successful ANZSNM bid to hold the WFNMP Conference in Melbourne 2018 Report by Prof Andrew Scott, Austin Health

The International Relations Committee (IRC) of the ANZSNM was established in 2009 to assist the Federal Council on matters relating to a) ANZSNM relations with international Nuclear Medicine bodies, and b) co-ordination of training related activities in the Asia-Pacific region and elsewhere, particularly in developing countries.

The establishment of the IRC by the ANZSNM Federal Council was in response to a recognised need to improve interactions with major overseas Nuclear Medicine societies and Associations, particularly as local issues are inextricably linked and impacted by overseas trends in nuclear medicine practice. In addition, the need to take a greater role in the Asia-Oceania region, particularly in teaching and training, was identified as a key strategic goal for the ANZSNM. The current members of the IRC are Prof. Andrew Scott (Chairman), Mr Peter Collins (Deputy Chairman), Prof. Vijay Kumar (Secretary), as well as Prof. Dale Bailey, A/Prof. Barry Elison, Dr Sze Ting Lee, Ms Heather Patterson, and Mr Geoff Roff.

The IRC therefore assists with representations of ANZSNM at meetings with all major societies (ie SNMMI, EANM, AOFNMB), as well as the IAEA. This involves participation in regular meetings between ANZSNM and the Executive of these Societies / Associations, with discussions on

topics including global workforce and training issues, radiopharmaceutical supply, quality assurance programs, technical standards, and inter-society initiatives. This provides a high profile for the ANZSNM internationally, and ensures our local programs and initiatives are informed by best practice overseas.

As part of the engagement of ANZSNM with global Nuclear Medicine trends, the IRC assists in selecting a representative from a major Nuclear Medicine society to attend the ANZSNM Annual Scientific Meeting, and give lecture(s) on trends and clinical practice in their countries. This has been a highly successful initiative, and has strengthed links to many AsiaOceania Nuclear Medicine Societies.

The IRC is also the main group responsible for coordinating enquiries to the ANZSNM from Nuclear Medicine professionals interested in visting Australia for training.

Over the last five years there has been a surge in enquiries from overseas Nuclear Medicine specialists, technologists, chemists, radiopharmacists and physicists, to come to Australia for training in general nuclear medicine, therapy and particularly PET. This has been facilitated by the IAEA, which has established a range of funding programs for nuclear medicine professionals from developing countries to spend time (from 1 week up to 12 months) at major

Members of the International Relations Committee celebrating their successful bid for the 2018 WFNMB conference to be held in Melbourne.

Back row: Geoff Roff, Sam Berlangieri, Barry Elison, Dale Bailey.

Front row: Heather Patterson, Kunthi Pathmaraj, Sze Ting Lee, Peter Collins, Andrew Scott, Vijay Kumar, Sylvia Gong.

12 Gamma Gazette March 2013

Nuclear Medicine Departments to learn and train in new areas of practice. In addition, new educational programs (eg Foundations of PET-CT) established in Australia have been highly successful, attract up to 25 attendees from overseas, and often require placement of attendees in local Nuclear Medicine Departments for short periods of time. The IRC assists with identifying suitable sites for placements, is a principal contact for IAEA enquiries, and ensures that issues relating to teaching and training programs are addressed.

The profile of the ANZSNM internationally has been substantially improved over the last 5 years through these activities, and this is reflected in ANZSNM’s invitation to participate in a number of recent IAEA, SNMMI, EANM and AOFNMB strategic initiatives, and informs our local policy development.

The IRC has also had a major role in the recent successful bid by ANZSNM for the hosting of the World Federation of Nuclear Medicine and Biology (WFNMB) conference in 2018. The WFNMB is the peak group for Nuclear Medicine worldwide, and has close ties with all major Nuclear Medicine Societies / Associations, as well as the IAEA and WHO. Its charter is to co-ordinate policy, technical standards, teaching programs, and promote Nuclear Medicine worldwide. The WFNMB membership consists of all countries who have Nuclear Medicine practices and a professional Society. A major conference is held by the WFNMB every four years, with each country having an equal vote in the selection process.

Australia last hosted a major International Nuclear Medicine

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.

April 11-15

ANZSNM Annual Scientific Meeting

Exploring New Horizons

Perth Convention & Exhibition Centre, Perth, WA April 17

Vic/Tas Annual Day Seminar and traditional post

conference meeting

The speakers and venue will be confirmed in the

near future.

June 8-12

SNMMI meeting

Vancouver, BC Canada

meeting in 1994, which was a WFNMB conference in Sydney, attended by over 2,000 delegates.

In view of the major importance of this conference, and the hosting country provides leadership of the WFNMB for the four years leading up to the conference, the ANZSNM undertook to bid for the WFNMB 2014 conference at the AOFNMB meeting in 2008, however the vote was tied between Australia and Mexico, and Mexico was awarded the conference in a re-vote. Determined to rebid for the WFNMB 2018 conference, the IRC established a dedicated and talented team (www.anzsnm.org.au/cms/governance/ international-relations/2018-wfnmb-congress/) that attended major Nuclear Medicine meetings over a three year period, lobbied countries for support, developed a platform of global leadership for the WFNMB that was tirelessly promoted, and completed a major submission for the bid. At the EANM Scientific Meeting in Milan in October 2012, ANZSNM was voted unanimously as the successful bidder for the 2018 WFNMB conference, to be held in Melbourne. Prof. Andrew Scott was also elected as President-Elect of the WFNMB. This initiative will provide the ANZSNM with the opportunity to have global leadership in Nuclear Medicine for a four year period, as well as host the premier international Nuclear Medicine conference in Melbourne in 2018. Information on both the WFNMB and the Melbourne 2018 conference will be provided to ANZSNM members regularly over the next few years.

July 27

TSIG Symposium

Coffs Harbour, NSW Sept 30-Oct 4

IAEA Conference on Nuclear Cardiology

Vienna, Austria October 19-20

2013 ANZSNM NZ Branch Meeting

Palmerston North, NZ

13

World Association of Radiopharmaceutical and Molecular Therapy (WARMTH)

ICRRT 2012 7th International Conference on Radioparmaceutical Therapy Levi, Finland November 25-29, 2012 Report by Dr Mary-Anne Keady, Regional Imaging Tasmania, Calvary Hospital, Hobart, Tasmania The 7th International Conference on Radiopharmaceutical Therapy was held in Levi, Finland from November 25-29, 2012, in the ski resort Hotel Levi Panorama. Levi is in Lapland, located 150 km North of the Arctic circle and is closer to the North Pole than Rovaniemi, the home town of Santa Claus. The average temperature for this time of the year is normally ranges from -5 to -20 degrees celsius with three to six average daylight hours.1,2 An ironic location for a meeting of WARMTH (World Association of Radiopharmaceutical and Molecular Therapy), however the meeting was filled with many ‘warm’ experiences courtesy of overalls and snowboots provided to all delegates which allowed for warm gondola transport to and from the conference venue. The WARMTH theme continuing during opportunities for experiences including reindeer and husky sled rides, cross country skiing and snow mobile adventures requiring ‘Michelin Man ‘style layering and essential further shopping expeditions to downtown Levi for balaclavas, multiple scarves and double to triple thermal gloves. The Warm local hospitality included daily large buffets, highlighted by the finale Oenophilous Lappish farewell buffet in an farmyard in Kaukonen. A large Australian Continent was part of a diverse group of attendees many of whom hailed

14 Gamma Gazette March 2013

from third world countries, courtesy of the free registration to members of WARMTH and low accommodation and conference package costs, well below those of typical International meetings, reflecting the warm philosophy of WARMTH and ICRT objectives of information exchange of current advances between scientists from developed and developing countries.

The Pre Conference Symposium included an initial Symposium on Nuclear Cardiology included discussions on New Experimental Tracers for Myocardial Ischaemia presented by Professor Henry Bam from Korea and Assessment of Cardiac Dyssynchrony by Professor Patel from the All India Institute, New Delhi. A further Symposium on the Arctic Environment then followed with a range of presentations including topics as diverse as the ‘Human thermal responses during Reindeer Safaris in Cold’ presented

by Dr Susanna Paakkola of the Arctic Centre, University of Lapland, followed by a highly informative and talk Professor Thomas Ulric, Director of the Sodankyla Geophysical Observatory, University of Oulu entitled “Northern Lights Through the Eyes of a Space Scientist”. Both these talks triggered a call to adventure and desire to see first Use of RhTSH (Thryogen) in Thyroid Cancer Use of Rh-TSH (Thryogen)

in Thyroid Cancer Use of Rh-TSH (Thryogen) in Thyroid Cancer hand, the elusive Northern Lights for a couple of Australians for the remainder of the conference.

On Day 1, the Local Organising Chairman, Professor Kalewi Kairemo welcomed the delegates at the Opening Scientific session, followed by opening remarks by Professor Ajit Kumar Padhy, The International Organising Chairman, ICRT 2012 and WARMTH President, and by a WARMTH Candle Lighting Ceremony by Professors Harvey Turner, Ajit Padhy, Richard Baum, Alan Perkins and Kalevi Kairemo and other members of the WARMTH Governing Body.

Day One of the Scientific Sessions started with a session on Thyroid Disease and included an excellent review on Use of Rh-TSH (Thryogen) in Thyroid Cancer by Dr Sze Ting Lee and interesting presentations from Professor Watanabe from Japan on Thyroid Cancer and the recent Fukushima Daiichi Nuclear Accident. 26 Poster presentations on Thyroid cancer followed thereafter with presentations from countries including six from Bangladesh, a presentation from Peru, Tunisia, Morocco and Sri Lanka and two presentations from Iran.

An interesting group of presentations on radiosynovectomy included a informative series from Germany including Dr Knut Liepe from Kassel, Dr Marika Vereb’s discussion of a Pilot Study to assess the effectiveness of Radiosynoviorthesis of Sacro- Iliac Joints with Re-186. Dr James Warrington of London, Canada presented a Review of a Multicentre Study on Safety and Efficacy of Y-90 Citrate Colloid and Re -186 Sulfide, and Dr Mohammad Sohaib from Pakistan discussed Hydroxyapatite Particles labelled with Beta- Emitting Lanthanoids for Radiosynovectomy.

Professor Mike Sathekge from Pretoria South Africa gave a most informative talk on assessing Tuberculosis response to Therapy during this session.

Bone Pain Palliation presentations on Day 2 included a presentation on the Experience of 177-Lu -EDTMP in bone pain palliation by Dr Jameel from Pakistan. Dr Sameneh Zalghari presented an interesting paper on the synthesis , radiolabeling and first biological evaluation of a new 166HoComplex for bone metastases radiotherapy.

During the final scientific sessions for the second day, Professor Andrew Scott presented an impressive data on Avibodies as a novel approach for targeting prostate and ovarian cancer. Professor Ralph McCready from Royal Sussex County Hospital, Brighton discussed Percutaneous Radionuclide Therapy (PERTH). Prof Vijay Kumar from the Westmead Hospital, finished the session with an impressive

paper on the development of New Radiopharmaceuticals for Diagnosis and Treatment of Arthritis.

WARMTH has a long strong history of international collaborations about which Professor Padhy enlightened the audience further at the beginning of day three. Further presentations on future Radionuclide therapy perspectives and international collaborations included a talk on IAEA perspectives on Radionuclide therapy by Professor Adriano Duatti, the WFNMB Perspectives from the WFNMB President Elect, Professor Andrew Scott and a final presentation on the rapid developments in Radionuclide therapy occurring in (South) Korea from Professor Dong Soo Lee of Seoul National University Hospital.

Two Scientific Sessions on Neuroendocrine tumours were held on the third day, highlighting the expansion of therapies to this group of tumours with multiple excellent presentations, too numerous to all include in this article. Of the highlights included a presentation by Professor Richard Baum from Bad Berka, Theranostics Centre for Molecular Radiotherapy/Imaging presented a wonderful paper entitled “ Personalised Radionuclide Therapy- Will it Remain a Dream or Become Reality.” Professor Irene Virgolini from Innsbruck presented data on long-term results in patients undergoing Peptide Receptor Radionuclide therapy from Innsbruck University Hospital. Professor Harvey Turner presented yet another wonderful paper discussing the issue of Clinical Trial Evaluation of Radiopeptide Therapy of Neuroendocrine Tumours after Dr Chiara Grana from the European Institute of Oncology, Milan’s presentation on Labelled Somatostatin analogues in the therapy of NETS. Professor Omar Alfonso from Uraguay discussed the role of Somatostatin analogues as possible theraganostic molecules for advanced prostate cancer.

Neuroendocrine tumour therapy shared a session with lymphoma therapy at which three presentations on lymphoma included an Australian perspective with Dr William Macdonald from Royal Perth Hospital presenting data on Initial Study - a Phase II Study of First-Line Iodine-131 -Rituximab Radioimmunotherapy of Follicular Non -Hodgkin’s Lymphoma.

The subsequent Poster presentations included a discussion on the production and quality control of 166

Dr William MacDonald

15

ICRRT 2012: 7th International Conference on Radioparmaceutical Therapy Ho-DOTA -Bevacizumab for Therapeutic Applications by Dr Alireza Khorrami from Iran and a series of posters from Dr Harshad Kulkarni on renal function after Peptide Receptor Radionuclide therapy as well as the and the safety and efficacy of such therapy after liver transplantation and presentations on Y90 SIRT therapy from Singapore and India.

The Dosimetry and Radio pharmacy sessions of the same day included three presentations on Personalised Medicine and dosimetry from Dr Suresh Srivastava of Brookhaven National Laboratory and Dr Matthias Blaickner of the Austrian Institute of Technology respectively and Professor Anna Celler from Vancouver presenting a paper on Personalized Image Based Dosimetry. A further 17 of18 poster presentations hailed from Iran included a variety of posters on a variety of new imaging agents including folate receptor, Indium 111 Quinolate, Ga-67 Maltolate Complex and Porphyrin imaging agents.

The final session on day 3 ,three of five presentations on the developments of therapeutic radiopharmaceuticals came from (South) Korea.

Day four commenced with a scientific session on Alpha therapy, with a wonderful presentation by Prof Oyvind Bruland from Oslo, Norway , on the exciting developments and outcomes of Radium -223 ( Alpharadin) in the Treatment of Skeletal Metastases in Prostate Cancer Patients. In particular the data from the ALSYMPCA, phase III, doubleblind, randomized, multinational study comparing Ra-223 plus best standard of care versus placebo plus BSC in patients with bone metastases in castration resistant prostate cancer (CRPC). Based on data from a planned interim analysis (n = 809), unblinded in June 2011 due to significant treatment benefit. The trial found that Ra-223 significantly improved overall survival in patients with CRPC with bone metastases versus placebo (median overall

The Presidential Sled.

survival 14.0 versus 11.2 months, respectively). Skeletal related events were lower in the Ra-223 versus placebo and time to 1st skeletal related events was significantly delayed (median time to Skeletal related event 13.6 month versus 8.4 months, respectively; P = .00046).3 The next session on breast cancer and miscellaneous topics included another exciting talk by Dr Chiara Grana from the European Institute of Oncology Milan about the developments and contributions by her group on Nuclear Medicine in Early Breast Cancer; from Sentinel Node to Intraoperative Avidination for Radionuclide Therapy. Dr Patricia Bernal from Colombia then spoke on Positron Emission Mammography.

The 17 poster presentation sessions after this included a heart rending presentation by Dr Masha Maharaj on her involvement in “Developing a Nuclear Medicine Outreach Program – The Polokwane Experience” in South Africa.

The difficulties faced by Dr Maharaj were a shock for even those working in Regional Australia. Although the support of radioiodine therapy as first line treatment for hyperthyroidism is plaudible, the lack of access to oral anti thyroid agents for initial therapy due to the bureaucratic controls ,was one example of the access to basic medical care we take for granted in developed countries.

The next scientific session on Liver and GI cancer included a range of excellent presentations including Professor Padhy ‘s discussion on Re188 Lipiodol Therapy for Hepatocellular cancer, Dr Kallur from Bangalore, India’s presentation on the Initial Experience with 1-131-Lipiodol Therapy in Local Disease Control and Survival in Patient with Advanced Hepatocellular Carcinoma and Metastatic Liver Disease from other Primary Tumours. Professor Andrew Scott, from the Ludwig Institute, Melbourne, discussed the Therapy of Australian and South African Contingents ready for husky and reindeer sled rides.

16 Gamma Gazette March 2013

Colorectal Cancer Tumours with an Agonist DR5 Antibody.

A subsequent session on new therapies and future trends included discussions by Dr Irene Virgoloni of Innsbruck, on Quality of Life Assessment in Neuroendocrine Tumour (NET) Patients followed by a presentation by a NET therapy patient Mr William Claxton, from the Carcinoid and Neuroendocrine Tumour Society, Singapore on the oncologic patient’s perspective of Quality of Life and Radionuclide Therapy.

The two final speakers in the final scientific session were members of the founding society of WARMTH. Professor Alan Perkin’s talk was entitled “ Radionuclide Therapy: From Radium to Radium”. Professor Harvey Turner spoke inspiringly yet again An Afternoon photo of downtown Levi with the lit ski fields of Levi Panorama on Outpatient Therapeutic Oncology based in the background. on and the current outpatient model he has developed in Perth.

REFERENCES Before the closing remarks and impressions were vocalised, it was clear that Therapeutic Nuclear 1. www.levi-lapland.com Medicine is alive and well, thriving in our country and in all 2. http://weather-and-climate.com continents of the globe.

3. J Clin Oncol 30, 2012 (suppl 5; abstr 9), ASCO 2012 The final day included a sight-seeing excursion to poster presentation. Radium-223 chloride impact on Rovaniemi to the Arctic Circle, Santa Claus Village and Arctic skeletal- related events in patients with castrationscience museum, followed by the traditional Oenophilous resistant prostate cancer (CRPC) with bone metastases: A Dinner with wines and beverages from around the globe Phase III randomised trial (ALSYMPCA) matching typical Lappish Buffet fare including reindeer 4. World Journal of Nuclear Medicine, Volume 11 / Issue in multiple forms!!! Many of the delegates were fortunate 3/September 2012. Abstracts of WARMTH’s 7th enough to experience a few a Lapland adventures – including International Conference on Radiopharmaceutical Therapy husky and reindeer sled rides or in some cases reindeer (ICRT 2012), Levi, Finland.( 117-200) bolting escapades, from which the author and Vijay Kumar were lucky enough to survive and both eventually fly out of Lapland alive!

The Gondola to Levi Panorama Hotel.

Dr Mary-Anne Keady and Professor Harvey Turner enjoying the Oenophilous Dinner.

17

Report on

European DOSE DATAMED projects Paul Marks, Anthony Wallace, Anna Hayton Diagnostic Imaging & Nuclear Medicine Section, ARPANSA In 2003 the European Union set up and funded a project called DOSE DATAMED 1 to develop methods for future surveys of population exposure from medical x-rays, including issuing guidance on suitable patient dose quantities and dosimetry methods. The work has been published on the European Commission website as Radiation Protection Report No 154 with two separate annexes. www.ddmed.eu/_media/background_of_ddm1:rp154.pdf www.ddmed.eu/_media/background_of_ddm1:dd_report_1. pdf www.ddmed.eu/_media/background_of_ddm1:dd_ report_1_a_.pdf In order to assess population exposures from medical radiology in terms of the collective or per caput effective dose, it is necessary to estimate representative mean effective doses for each type of x-ray examination that makes a significant contribution to the annual collective effective dose (S) in a country. As the effective dose cannot be measured directly, other dose quantities must be used.

Practical dose quantities are entrance surface dose (mGy) or the dose-area product (DAP, mGy.cm2) for simple radiography, the total dose-area product for fluoroscopy examinations, amount of administered activity (MBq) for nuclear medicine and the computed tomography dose index (CTDI, mGy) and the dose-length product (DLP, mGy. cm) for CT examinations. Factors for converting these dose quantities into effective doses are provided in the RP154 document. Guidance on assessing the frequencies of X ray examinations includes the definition of 225 specific X ray examinations and 70 broader categories of examinations.

A set of 20 examinations were identified as the ones contributing most significantly to S. The first aim of DOSE DATAMED 1 was to understand the uncertainties and differences in the current methodologies used for the surveys. National surveys in ten European countries around the millennium were reviewed in order to explain the differences seen in examination frequencies and patient doses, and their mutual influence on S in each country. The national regulatory frameworks, the health care systems, the methods for assessing frequencies and doses, as well as the national strategies for assessing population dose from medical x-rays, were reviewed. A set of 20 examinations were identified as those contributing most significantly to S, the so called “TOP 20” list. The “TOP 20” data and analysis results from ten European countries have been presented, compared and discussed in various international forums such as the International Radiation Protection Association 12 in Buenos Aires and

18 Gamma Gazette March 2013

European Society of Radiology 2009 in Vienna. Observed differences in the population dose from medical x-rays in Europe were thought to be real, i.e. much larger than the recognised uncertainties originating from survey design.

Furthermore, the differences were found to be primarily due to the different healthcare systems operating in each country. These differences included the level of funding for healthcare, the numbers of various types of medical practitioner in the country, the amount of medical imaging equipment available and details of which types of medical practitioner are allowed to refer patients for x-ray or to perform x-ray examinations In 2010 the European Commission launched the DOSE DATAMED 2 project with the objective of expanding the collection of available data on doses from radiodiagnostic procedures, both x-ray and nuclear medicine in the European Union. The data obtained will be used to facilitate and expand the further implementation of Radiation Protection 154. European Guidance on Estimating Population Doses from Medical X-ray Procedure, published by the European Commission in 2008.

To achieve the above objectives, the study aimed at: • providing advice and collecting feedback from the application of the guidance RP 154; • providing estimates of population doses in EU Member States and the population dose in European Union as a whole; • providing a database for population dose information which will enable continuous collection and follow-up of European population doses.

Article 12 of the European Directive 97/43/Euratom requires Member States to determine the population radiation dose from medical exposures.

The above European Directive is similar to section 3.1.8 of ARPANSA’s Code of Practice for Radiation Protection in the Medical Applications of Ionizing Radiation [RPS14] (2008) which states: 3.1.8 The Responsible Person must establish a program to ensure that radiation doses administered to a patient for diagnostic purposes are: (a) periodically compared with diagnostic reference levels (DRLs) for diagnostic procedures for which DRLs have been established in Australia; and (b) if DRLs are consistently exceeded, reviewed to determine whether radiation protection has been optimised.

Initially nuclear medicine practices in eight countries were assessed in the DOSE DATAMED 1 project. Data on frequency of the procedures, the amount of activity used,

and the kind of radiopharmaceuticals or radionuclides used were collected. For some countries detailed data for specific diagnostic examinations and therapeutic procedures are available, but for others, only categorised data was given. In the final report generated, the specific data is grouped into broader categories to enable a comparison. Based on the results of the different surveys, examinations of the following five organs were compared; bone, heart, thyroid, lung and kidney.

The figure above is an example of the contribution of the different groups of examinations to the total annual number of nuclear medicine examinations for the time period surveyed.

Results obtained in the survey provided information that allowed for the calculation of effective dose per caput for the five different nuclear medicine examinations and for a total summation of doses from all surveyed countries.

The Australian Perspective The development of a nationally coherent program for radiation protection of the patient in Australia is in its infancy. ARPANSA has been charged with the task of carrying out national diagnostic reference level NDRL

surveys for the Commonwealth Government. It is aware that the DRLs should be ‘owned’ by the respective professions and can only be constructed with appropriate consultation and ‘buy in’ from the relevant stakeholders. Consequently ARPANSA has been working with the Royal Australian & New Zealand College of Radiologists, Australasian Association of Nuclear Medicine Specialists, Australasian College of Physical Scientists & Engineers in Medicine, Australian Institute of Radiography, Australian & New Zealand Society of Nuclear Medicine, Department of Health & Ageing and the various State/Territory radiation regulators to achieve this goal.

ARPANSA has now established NDRLs for Multi Detector Computed Tomography (MDCT) doses, both for adult and paediatric patients. Information about the surveys and results can be found at: www.arpansa.gov.au/services/ndrl/ index.cfm DRLs for other medical radiation imaging modalities such as interventional radiology, mammography, nuclear medicine and general examinations are currently being constructed with future work scheduled to commence shortly. A liaison panel for nuclear medicine matters is being convened by ARPANSA with input from the AANMS and the SIGs of the ANZSNM. It is envisaged that the first meeting will take place early in 2013.

19

From page 11

What’s that? ... answer Routine delayed whole body scanning with SPECT tomography was performed 3 hours post injection. Normal uptake was observed in the kidneys.

Further findings on the delayed images were: 1. Focal uptake in the left 12th rib, probably an old rib fracture.

2. Increased uptake in the left greater trochanter, suggestive of a left trochanteric enthesopathy.

3. Increased uptake in the left ischial tuberosity, suggestive of a left hamstring enthesopathy.

Sonar correlation confirmed the presence of a large cyst in the right kidney. A CT Urogram demonstrated a very large anterior right renal cyst sized at 200 x 170 x 155 mm. It was noted that the liver was displaced superiorly with stretching of the right renal artery and vein.

The initially referred clinical problem of left trochanteric pain was reported as a left trochanteric enthesopathy, and has been treated with steroid injections under ultrasonic guidance.

A positive result was obtained.

If left untreated, a large renal cyst can potentially become infected, rupture or cause obstruction to the function of adjacent organs.

The incidental finding of a large photopenic area on this routine bone scan, led to the subsequent diagnosis of a large renal cyst, which was previously unknown, as the patient was asymptomatic. The cyst was recently drained via laproscope, and follow up is awaited.

20 Gamma Gazette March 2013

Case Study

Role of nuclear medicine in diagnosis of transplant page kidney caused by a subcapsular urinoma Merrin Angwin, Dr Naomi Shay, Dr Ian Jong Department of Nuclear medicine Southern Health, Victoria INTRODUCTION Page Kidney can be caused by haematoma, urinoma or a mass in the subcapsular or perinephric space. Compression of the kidney occurs activating the rennin-angiotensin-aldosterone system. This can lead to hypertension and renal ischemia; this may then cause a loss of renal function if not promptly diagnosed and treated.

We present a rare complication of a subcapsular urinoma, of a Page Cadaveric transplant kidney following a routine renal biopsy.

The biopsy was done for investigation of reduced perfusion to the lower pole associated with worsening transplant renal function.

The patient’s history and investigations, including serial renal ultrasounds, renal Tc-99m DTPA scans, CT scans, as well as follow-up will be presented.

previously demonstrated photopenic region, along the lateral surface of the transplant kidney (fig.3). This is consistent with a subcapsular urinoma surrounding the mid to lower pole. There was no evidence of a non-contained urinary leak.

Ultrasound showed a hypoechoic and septated collection surrounding the mid to lower pole of the transplant kidney (fig.4).

The collection had mass-effect, indenting the underlying renal cortex and elevated resistive indices at upper (0.83) and interpolar (0.87) regions. These findings were suspicious for subacute to chronic subcapsular collection, presumably due to the recent biopsy.

Under Ultrasound guidance, 207ml fluid (straw coloured) was aspirated and drain left in-situ. Pathology showed cloudy sterile fluid with Polymorphic Neutrophils and no growth.

CASE REPORT A 61-year-old male, 28 days post Cadaveric renal transplant, presented with worsening transplant renal function for investigation on background of reduced renal perfusion to the lower pole.

24 hours following routine transplant renal biopsy, the patient had new onset of right lower abdominal pain and was hypertensive (195/85).

Renal Ultrasound and Nuclear Medicine Renal Transplant DTPATc99m scans were performed on the same day. Initial blood flow and renal uptake images were obtained, in an anterior projection.

Clearance and drainage were assessed over 30 minutes, as per standard department protocol. Delayed statics were also acquired.

Reference was made with previous DTPA-Tc99m scans (fig.1) (day 1, and day 6 post transplant) and the renal Ultrasound.

Dynamic blood flow images demonstrated persistent reduced perfusion of the transplant kidney (not shown). Parenchymal clearance was mild to moderately delayed, as evident by the persistent elevated background count. There was persistent reduced perfusion to the transplant lower pole, as seen in days 1 and 6 DTPATc99m scans A new development of perinephric photopenia was noted along the lateral surface of the transplant kidney. Spontaneous drainage of the radiotracer was seen from the proximal collecting system into the bladder, with no evidence of any apparent urinary leak up to 30min post dose administration (fig.2). Subsequent post micturition static images demonstrated accumulation of radioactive urine within the

Above: Figure 1. DTPA scan, post renal transplant day 1.

Below: Figure 2. DTPA scan, 28 days post renal transplant.

Merrin Angwin, Dr Naomi Shay, Dr Ian Jong Department of Nuclear Medicine, Southern Health, Victoria, Australia

u 21

Role of nuclear medicine in diagnosis of transplant page kidney caused by a subcapsular urinoma

Figure 3. DTPA scan, 28 days post renal transplant. Demonstrating accumulation of radioactive urine within the previously photopenic region, along the lateral surface of the transplant kidney.

Following the aspiration, the patient’s renal function and blood pressure improved and the pain resolved (fig.5 and 6).

A follow up DTPA-Tc99m scan and SPECT/CT, with 2x drains insitu, was done 41 days post transplant.

Normal cortical uptake and parenchymal transit of tracer was demonstrated with prompt drainage of the collecting system, with subtle area of previously documented lower pole infarct. No evidence of perinephric urinoma/collection on delayed imaging, 1 hour Fused SPECT/CT images demonstrated tracer to be confined to the renal cortex, collecting system, ureter and bladder (fig. 7).

Renal ultrasound showed decreased fluid collection, resistive indices at superior (0.68) and mid (0.71) kidney aspect within normal limits.

The kidney remains in situ, and the patient remains well, with ongoing follow up in an outpatient setting.

DISCUSSION In 1939, Page 2 induced a hypertensive response in canines by wrapping them in cellophane, causing compression of the kidneys.

The first clinical case of Page kidney involved an American football player with blunt trauma, leading to a renal heamatoma and hypertension, 1955, Engel and Page 12.

Page Kidney can be caused by a haematoma, urinoma or mass in the subcapsular or perinephric space. Compression of the kidney occurs, activating the rennin-angiotensin-aldosterone system. This is thought to be triggered by renal hypoperfusion, microvascular ischemia and the alteration of small-vessel haemodynamics from the external compression.1,3 This leads to hypertension and renal ischemia.

Page kidney has been well reported in the literature; McClune7 in 1991 reported 80 cases and Dopson1 in 2009 tabulated 28 cases, also reporting a shift in the etiology and frequency of page kidney attributed to the increased frequency of renal transplant biopsies 5.

Page kidney from biopsies of transplant kidneys accounted for 10 cases (36%). A clinical syndrome of Page kidneys, resulting from kidney transplant biopsies, is the occurrence of acute hypertension with a concomitant acute decrease in kidney function.2 This is not present in native Page kidneys.

22 Gamma Gazette March 2013

Figure 4. Ultrasound showing a hypoechoic and septated collection surrounding the mid to lower pole of the transplant kidney.

Peri-renal fluid collections identified in the early postoperative period can represent haematoma, urinoma or seroma.8 Abscess or lymphocle tend to develop weeks to months following the transplant.5 The etiology of the fluid will affect the management of Page kidney, utilising interventional radiology procedures of aspiration and drainage and catheter drainage. Urinomas require more complex management involving percutaneous drainage and/or operative measures.5,8 Perirenal fluid collections, post renal biopsy, are rare but more common than subcapsular collections.2,9 The case study presented here differs as a subcapsular urinoma.

Ultrasound guided biopsy can lead to complications in a small number of patients (3-8%).6,7 Urinomas can form secondary to urinary fistulas or leaks, occurring early post procedural (ie biopsy) period.5,8 Rarely subcapsular haematomas result.2,9 The lack of subcapsular urinoma literature points to them as being extremely rare.

Sonography and computer tomography (CT) show structures in the kidney, size and location of a fluid collection, but are nonspecific to the etiology.8 Nuclear medicine renal studies play an important part in detecting and distinguishing urinomas or urine leaks.5,10 Renal scans show extravasation of radioisotope into an area seen as initially ‘cold’. Delayed imaging is important in demonstrating increasing accumulation of radioisotope in an extrarenal location.8,11 SPECT/CT imaging can isolate the location of a leak posttransplant surgery.

This case demonstrates the potential for rapid loss of transplant renal function secondary to Page transplant kidney from any cause.

Early detection of Page kidney, follow by prompt decompression intervention is vital to the continuing viability of the transplant kidney, and ultimately leads to the recovery of transplant renal function.

References 1. Dopson SJ, Jayakumar S, Velez JC. Page kidney as a rare cause of hypertension: case report and review of literature. Am J Kidney Dis 2009; 54(2): 334-339.

2. Page IH. The production of persistent arterial hypertension by cellophane perinephritis. J Am Med Assoc 1939; 113(23): 2046-2048.

Role of nuclear medicine in diagnosis of transplant page kidney caused by a subcapsular urinoma

Above: Figure 5. Blood pressure (mm Hg).

Right: Figure 6. Creatinine (micro mol/L).

3. Posadas MA, Yang V, Ho B, Omer M, Batlle D. Acute renal failure and servere hypertension from a Page kidney post-transplant biopsy. The Sci World J 2010; 10: 1539-1542.

4. Bakri RS, Prime M, Haydar A, Glass J, Goldsmith D. Three ‘Pages’ in a chapter of accidents. Nephrol Dial Transplant 2003; 18: 1917-1919.

5. Richard HM. Perirenal transplant fluid collections. Sem Interv radiol; 21(4): 235-237.

6. Mathew A, Brahmbhatt B, Rajesh R, Kurian G, Unni VN. Page kidney. Indian J Nephrol 2009; 19(4): 170-171.

7. McCune TR, Stone WJ, Breyer JA. Page kidney: Case report and review of literature. Am J Kidney Dis 1991; 18(5): 593-599.

8. Akbar SA, Jafri SZH, Amendola MA, Maadrazo BL, Salem R, Bis KG. Complications of renal transplantation. Radiographics 2005; 25(5): 1335-1356.

9. Heffernan E, Zwirewich C, Harris A, Nguan C. Page kidney after renal allograft biopsy: Sonographic findings. J Clinical US 2009; 39(4): 226-229.

10. Moiarty KP, Lipkowitz GS, Germain MJ. Capsulectomy: Acure for the Page kidney. J Pediatric Surgery 1997; 32(6): 831-833.

11. Yu JQ, Zhuang H, Xiu Y, El-Haddad G, Kumar R, Alavi A. Small urine leak after renal transplantation: Detection by delayed 99m Tc-DTPA renography – A case report. J Nucl Med Technol 2005;33(1): 31-33.

Above: Figure 7. DTPA scan and SPECT/CT, with 2x drains insitu, 41 days post transplant compared with figure 8 (right) of CT scan of kidney, pre Ultrasound guided drainage.

23

Case Study

False positive iodine uptake in a renal cyst: Value of SPECT/CT Suranga Weerasooriya, Dylan Bartholomeusz Nuclear Medicine Department, Royal Adelaide Hospital Adelaide, South Australia

INTRODUCTION Whole body iodine scintigraphy has been used extensively in the follow up of patients with well differentiated thyroid cancer. While it is common to see iodine accumulation in the residual thyroid bed following surgery, any other abnormal uptake raises the possibility of functioning metastases. It is important to identify false positive uptake to avoid unnecessary ablative therapy.

False positive uptake has been reported in association with hiatus hernias, gastro-oesophageal reflux disease, cholecystitis, lactating and non lactating breast, inflammatory lung disease, lung malignancy, pericardial inflammation, pericardial effusion, thymic tissue, renal cysts and sebaceous cyst etc.1-3 We report subtle radioiodine uptake in an unsuspected renal cyst, which masqueraded as a possible metastatic deposit in the abdomen. The case emphasizes the value of SPECT/CT in resolving uncertainty.

CASE REPORT The patient is an 80-year-old man who had a right hemi thyroidectomy 5 years ago for a symptomatic multinodular goitre with a prominent nodule in the right lobe. The histopathology showed a papillary carcinoma. The TNM staging of the tumour was T3N1M0. Due to his significant cardiac co-morbidities at the time a completion thyroidectomy was not offered. Five years later he represented with right sided neck lymphadenopathy and a raised thyroglobulin. His pre surgical thyroglobulin level was 362 µg/L with no antibody detected.

The CT scan of the neck and chest showed several enlarged right neck nodes measuring up to 20 mm in maximum diameter.

A completion left thyroidectomy was performed. Histopathology confirms multi focal papillary cell carcinoma contained within the thyroid capsule.

Radioiodine therapy was ordered. This patient’s pre therapy thyroglobulin level was 7650 µg/L, with no interfering antibody being detected. Recombinant human 0.9 mg Thyrotophin (Thyrogen ®) was administered intramuscularly, daily on 2 consecutive days. This was followed by a 4 GBq dose of 131 Iodine that was administered without significant complications.

Whole body planar images were acquired on day 8 post therapy.

The planar images demonstrated uptake of iodine in the neck as well a faint but circumscribed uptake in the right sided abdomen.

The abdominal uptake was slightly unusual for excreted bowel activity. SPECT/CT images of the neck and the abdomen were then Suranga Weerasooriya MBBS, MSc, Dylan Bartholomeusz, MBBS, MD, FRACP Nuclear Medicine Department,Royal Adelaide Hospital, North terrace; Adelaide; South Australia Email Address for Correspondence Dylan.Bartholomeusz@health.sa.gov.au

24 Gamma Gazette March 2013

Above: Figure 1: Whole body planar images showing the residual thyroid bed uptake. Low grade uptake can be seen in the right mid abdomen Below: Figure 2: Fused SPECT/CT images of the neck localises the increased uptake in the neck to the thyroid bed.

performed. The images were obtained on a Seimens Symbia T6 gamma camera with 16 slice CT. The neck uptake was localised anterior to the right lamina of the

False positive iodine uptake in a renal cyst: Value of SPECT/CT

Figure 3: Transaxial images of the abdomen showing the uptake confined to a large right renal cyst. thyroid cartilage and corresponded to residual thyroid bed uptake.

The abdominal uptake in the right abdomen on SPECT/CT imaging was localised to a large renal cyst arising from the inferior pole of the right kidney.

DISCUSSION It has been previously reported that benign renal cysts can accumulate radio-iodine. The mechanism of this uptake still remains unclear. It is postulated that iodide enters the basolateral aspect of the cell through the electrically neutral Na/K/2Cl cotransporter and exits the cell through the apical CFTR (Cystic fibrosis transmembrane regulator) channel. These mechanisms probably mediate the active transcellular secretion of iodide into the cyst lumen.4,5 This case demonstrates the significant improvement in anatomical localization and diagnosis as a result of SPECT/ CT imaging, which would have otherwise been difficult.

Figure 4: Coronal images of the renal cyst showing iodine uptake within the right renal cyst.

REFERENCES 1. Anton Serafini, George Sfakianakis, Michalakis Georgiou and James Morris, Breast Cyst Simulating metastases on Iodine-131 Imaging in Thyroid Carcinoma, The Journal of Nuclear Medicine 1998; 39: 1910-1912 2. Bakheet SM, Hammami MM. Powe J. False-positive radioiodine uptake in the abdomen and the pelvis: radioiodine retention in the kidneys and review of the literature. Clin Nuc Medicine 1996;21:932-937 3. Brachman MB. Rothman BJ. Ramanna L, Tanasescu DE. Adelberg H, Waxman AD. False-positive iodine-131 body scan caused by a large renal cyst. Clin Nuc Med 1988:13:416-418.

4. Wen Christopher, Iuanow Elaine et al, Post-Therapy Iodine-131 Localization in Unsuspected Large Renal Cyst: Possible Mechanisms J Nucl Med 1998; 39: 2158-2161 5. Sullivan LP, Wallace DP et al, Chloride and fluid secretion in polycystic kidney disease. J Am Soc Nephrol 1998; 9: 903-916

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Comparison of Bone Scan quality with a 10-20% reduction in patient dose Kera Pethybridge, Bridget Chappell, Aurora Poon, Sze Ting Lee, Salvatore Berlangieri, Christopher Rowe Austin Hospital INTRODUCTION Planar bone scans are one of the most frequently performed Nuclear Medicine examinations that investigates a variety of conditions such as tumours, trauma and infection. Maintenance of high image quality is paramount for superior diagnostic efficacy.

Nuclear Medicine needs to balance the requirement for high quality diagnostic images whilst adhering to ALARA “As Low As Reasonably Achievable� principles.

With advancements in imaging technology delivering better sensitivity, our institution implemented a 10-20% reduction in administered dose for diagnostic imaging procedures to facilitate a reduction in effective dose to patients. This lead to Bone Scan doses being reduced from 800MBq to 700MBq. AIM

~800MBq). Two Target:Bgd ratios were calculated for optimal bone uptake. Regions of interest of equal size were positioned on three focus points on the posterior image of each WBBS; lumbar spine & femur (Target) and adductor muscle in thigh (background).

Statistical analysis including summary statistics, box-plots, paired comparison t-tests and 95% confidence intervals were performed for each dose group and comparison of the two groups undertaken.

RESULTS: QUALITATIVE REVIEW A total of 32 patients (64 WBBS) were analysed using with the comparison of the 2 dose groups with the 5 point Likert results summarised in table 1. The statistical modes derived from the Likert analysis demonstrate no difference between the image quality of the 2 dose levels, with identical modes for each criteria.

To determine if a 100MBq reduction in the administered dose of 99mTc-methylene diphoshonate (99mTc-MDP) impacts on image quality and diagnostic interpretation.

Table1: Image Quality Interpretation: Summary of Statistical Modes derived from Likert Analysis Scores.

METHODS A retrospective review was performed on patients having undergone two or more whole body bone scans (WBBS) on the GE Infinia Gamma Camera at the Austin Hospital in 2010 and 2011.

Patient inclusion criteria were as follows: Patients must have undergone two WBBS, WBBS have comparable uptake times and received doses of 800MBq (+/-10%) and 700MBq (+/-10%) with a calculated difference of 70-140MBq. Identical 99mTc-MDP preparation with resultant radiochemical purity > 90% and identical imaging parameters: scan speed, patient setup, collimator, energy window, matrix size.

Patient/Scan exclusion criteria were as follows: Evidence of patient movement, superimposition of bones, urinary contamination or subcutaneous injection sites.

Patient studies were anonymised and the paired WBBS randomized. A blind review of the bone scans was performed by 3 experienced Nuclear Medicine Physicians. Readers qualitatively assessed the scans using a five point Likert scale (1 = poor -> 5 = excellent) for the following: overall image quality, ability to detect lesions, perceived target:background (Target:Bgd).

Quantitative Target:Bgd analysis was performed on the grouped Bone scan data (Dose Group 1 = ~700MBq and Dose Group 2 =

Kera Pethybridge, Bridget Chappell, Auroa Poon, Sze Ting Lee, Salvatore Berlangieri, Christopher Rowe Department of Nuclear Medicine, Austin Health, Melbourne

26 Gamma Gazette March 2013

~800MBq ~700MBq

Sacroilliac Joint:Bgd

5

5

Impression of scan quality

4

4

Ability to detect lesions

5

5

Comparison of the paired image data contained only 1 ~800MBq WBBS determined to be superior in all categories by all reviewers.

Figure 1 demonstrates the comparative image quality of the 800MBq and 700MBq Dose levels in 2 analysed patients.

Table 2: Summary of Mean and standard deviation of Lumbar and Femur Target:Bgd ratios for 700MBq and 800MBq Dose Levels.

~700MBq ~800MBq

Lumbar mean

10.36

9.32

Standard deviation

5.35

4.05

Femur

mean

1.9

0.36

Standard deviation

2.01

0.6

Comparison of Bone Scan quality with a 10-20% reduction in patient dose

Figure 1: Image quality of the dose reduction on two patient’s WBBS. (A) Patient 132 ~800MBq, (B) Patient 132 ~700MBq, (C) Patient 128 ~800MBq, (D) Patient 128 ~800MBq.

QUANTITATIVE REVIEW Regions of interest of the femur and lumbar spine were place over normal bone activity excluding metastatic bone uptake as metastatic involvement in the bones may have altered between scans. Calculated Lumbar Spine and Femur Target:Bgd ratios for both dose groups are summarised in Table 2 and box plots displayed in Figure 2. The differences between 700MBq and 800MBq WBBS ratios in table 2 are minimal and further statistical analysis was used to differentiate if the differences are of any statistical significance.

Box Plot Analysis Box plots were generated for Target:Bgd for both Femoral and Lumbar regions at both dose levels illustrating the median values, interquartiles ranges and spread of data. (see Figure 2).

The box-plots illustrate the similarity between the 2 Dose Levels

(700MBq and 800MBq) comparable median values and interquartile ranges for both dose groups and locations (Femur and Lumbar).

Paired Comparison (T-Test) Analysis Paired comparison (T-test) and 95% confidence intervals anlaysis of the Target:Bgd ratios for Femur and Lumbar Spine was performed.

The mean difference and calculated 95% confident intervals between 700MBq and 800MBq Target:Bgd were Femur mean = 0.12 (95%CI = 0.07 ->0.31) and Lumbar mean = 1.02 (95%CI = -0.77-> 2.81). As both Confidence intervals include zero, the difference between the dose levels is not statistically significant.

The p-values for both Femur and Lumbar ratios were calculated at p = >0.2 also indicating no statistically significant difference in the image quality with a 10-20% reduction in activity of 99mTcMDP administered.

Figure 2: Statistical comparison of ~700MBq and ~800MBq WBBS target to background ratios. (A) Lumbar ratios (B) u Femur ratios.

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Comparison of Bone Scan quality with a 10-20% reduction in patient dose

DISCUSSION Each bone scan was assessed using a paired comparison of each patient’s two WBBS in an attempt to reduce confounding factors such as body mass index, metabolism, renal function and patient mobility. These factors may be minimised but cannot be excluded as these confounding factors can alter at any time with the patient’s condition and treatment plan. All patients included in the study were for restaging of various cancers so it is feasible that disease progression and treatment may have an affect on all confounding factors. ie. A patient with disease progression may have associated weight loss and decreased mobility; Chemotherapy may cause a decrease in renal function. All these factors could affect the 99mTcMDP uptake within bone.

With patients undergoing cancer re-staging and research studies, there is an increased frequency of sequential medical imaging such as CT, Bone and PET Scans. Patients are receiving an increased radiation burden and any effort to reduce dose whilst maintaining image quality is beneficial. In this scenario adherence to ALARA principles is of increased importance.

The effective whole body dose of 99mTc-MDP is 4.56mSv for 800MBq and 3.99mSv 700MBq dose. From the qualitative review there was no visual difference between the image qualities.

28 Gamma Gazette March 2013

From the quantitative review the Femur ratio differences is not significant (95% CI: -0.07 – 0.31, p-value is >0.2) and the Lumbar ratio difference is not significant (95% C!: -0.77 – 2.81, p-value is >0.2). Study results demonstrate no significant differences in image quality with a 100MBq decrease in 99mTc-MDP WBBS dose.

Therefore, according to ALARA there is no reason to give a Bone Scan dose greater than 700MBq for the average patient.

CONCLUSION A 100MBq reduction in the administered dose of 99mTc-MDP leads to a 12.5% reduction in the effective whole body dose from 4.56mSv (800MBq) to 3.99mSv (700MBq) without impacting on image quality or diagnostic interpretation.

REFERENCE 1. International Commision on Radiological Protection (1998).

Radiation Dose to patients from radiopharmaceuticals. Annual ICRP publication 80.

Modified In-Vivtro Red Blood Cell labelling using a single polyurethane intravenous cannula Culann Farrell Austin Health

INTRODUCTION

METHOD

Gated Cardiac Blood Pool (GCBP) studies are performed routinely in most Nuclear Medicine departments in order to assess the left ventricular ejection fraction (LVEF) and cardiac wall motion.

Commonly, serial LVEF measurements are used to assess cardiotoxicity in patients undergoing chemotherapy. In most departments the modified in-vivtro method of labelling Red Blood Cells (RBC) is preferentially used. This is due to it having a higher labelling efficiency than the in vivo method, while being faster and requiring less handling of the blood than the full in vitro method.

A set of ideal parameters for modified in-vivtro labelling were published in 1992.1 These suggested the administration of 1mg Stannous Ion (acceptable range 0.5-2.0mg) with a 10-30min delay before withdrawing 3-5mL of blood into a syringe containing ~800MBq 99mTc Pertechnetate.

Standard accepted protocols for modified in-vivtro RBC labelling for GCBP studies require injection of stannous pyrophosphate (PYP) by direct injection or through a separate line to that which the blood is taken from.2 Published literature recommends this method for optimal RBC labelling, however it appears that previous studies used Teflon and heparin infused cannulas, which have been for the most part superseded by polyurethane in many hospitals.3,4 Our department has seen an increase in patients presenting for GCBP studies who have challenging venous access due to chemotherapy treatments and axillary clearances resulting in limited options for cannulation. In particular, a number of clinical trial patients found the experience of finding multiple IV sites quite traumatic, leading to complaints from the CCT nursing staff. This prompted us to investigate the effect on labelling efficiency of using a single polyurethane cannula for the entire labelling procedure, and whether it was possible to do away with the need to give PYP into a separate vein.

93 patients who presented to the department for GCBP were divided into two groups. Exclusion criteria for the initial intake were current participation in a clinical trial that depended on the result of the study and patients arriving with cannulae in situ that could not be identified as polyurethane or failure to meet study time points for blood withdrawal and QC. In total 18 patients were excluded.

Pyrophosphate was reconstituted with 3.5mls of 0.9% normal saline. 1ml of the reconstituted Pyp was drawn up and administered to the patient in one of two ways:

AIM To test whether performing RBC labelling using a single polyurethane cannula has a significant impact on labelling efficiency, as well as the relationship between labelling efficiency and image quality.

Corresponding Author Culann Farrell Department of Nuclear Medicine and Centre for PET, Austin Health, Heidelberg, Victoria

Group 1: 43 patients (21 on chemotherapy, 22 not on chemotherapy) given PYP through the same polyurethane cannula their blood was taken from. The 1ml patient dose was further diluted to 3ml to minimise residual stannous ion in the cannula, then immediately flushed with 20mls of 0.9% normal saline.

Group 2: 32 patients (11 on chemotherapy, 21 not on chemotherapy) given PYP as a separate injection through a metal needle into the contralateral arm to where blood was taken.

The remainder of the labelling for both groups was as per our standard clinical in-vivtro method. Blood was taken 20 minutes after PYP administration and incubated with 99mTc Pertechnetate for a further twenty minutes before being reinjected. A window of five minutes either side of each time point was allowed to ensure the methods reflected the flexibility that is required in our day to day practice.

Prior to re-injection a 0.25ml sample of blood was removed from the patient syringe in order to determine labelling efficiency. This was placed in a counting tube with 2ml of 0.9% normal saline and spun in a centrifuge at 3000rpm for ten minutes. The supernatant was then removed and placed in a dose calibrator, as were the whole blood cells. Labelling efficiency was calculated by the formula: Labelling Efficiency %= Activity in RBCs Total Activity in RBCs & Supernatant x 100 Three patients with severely low (<10%) labelling efficiencies were excluded from Group 1. One patient had shown a continuing decrease in image quality over two years of serial imaging, another was receiving treatment for anaemia and the third had abnormal tracer distribution on both their GCBP and a bone scan within the u

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Modified In-Vivtro Red Blood Cell Labelling Using A Single Polyurethane Intravenous Cannula

same week that we have so far been unable to explain.

Imaging was commenced immediately following readministration of the patient’s blood. Images were acquired in anterior, left lateral and left anterior oblique (LAO) planes for seven minutes per view on a 128x128 matrix with 24 bins. The LAO angle was chosen to optimise separation of the left ventricle in each patient. A copy of the ECG was recorded to ensure that there were no significant variances in R to R interval that could impact on the image interpretation portion of the study.

The quality of the images was assessed using two methods.

Analysis of signal to noise ratios (S:N) was performed by drawing regions over the left ventricle and the septum on the raw LAO images as shown in Fig. 1. The complete filtered series for each patient was then anonymised and reviewed by three Nuclear Medicine Physicians and one Nuclear Medicine Registrar with image quality rated excellent, good, poor or non-diagnostic according to Table 1.

Table 2: Mean labelling efficiency.

Total

Group 1 84.09%

Chemotherapy Non-Chemotherapy 80.24%

(SD 12.04) (SD 16.20)

87.93% (SD 4.04)

Group 2 87.74

83.26%

88.06%

(SD 6.75)

(SD 5.90)

(SD 6.11)

Table 3 gives the results of the doctor’s visual assessment of the studies. Group 2 has a higher percentage of studies rated good or better, but also a higher number of studies rated non-diagnostic.

Table 3: Results of visual assessment.

Percentage of Scans rated Good or Excellent

Total Chemotherapy Non- Non Chemotherapy Diagnostic

Figure 1. ROI positioning for calculation of S:N.

Group 1

73.9%

72.6%

75.0%

0.0%

Group 2

85.2%

90.9%

82.1%

2.3%

Although the overall numbers of scans of each classification were similar between all the doctors, there were a number of scans where individual doctor’s interpretations varied significantly. Fig. 2 displays the image quality results of two of the doctors graphed against each other.

Table 1: Image quality assessment criteria by doctors.

Non-Diagnostic Poor Good Excellent 0

1

2

3

Individual patient results were graphed alongside their signal to noise ratio and the qualitative assessment of image quality.

RESULTS Mean labelling efficiencies are shown in table 2. The 3% difference between the two groups was found to be not statistically significant (Z score -1.72, p=0.0854). Labelling efficiency was slightly higher for each of the chemotherapy and non-chemotherapy subsets in group 2 compared to group 1. Once again the difference for each patient sub group was not statistically significant (p=0.4542 and p=0.9345 respectively).

30 Gamma Gazette March 2013

Figure 2: Image quality results for the same patient set by different doctors.

Assessment of signal to noise ratio showed a slightly higher average rating for Group 2 compared to Group 1 overall, with a statistically significant difference (p=0.0006) between patients on chemotherapy. Non-chemotherapy patients in Group 1 performed better than their counterparts in Group 2. Neither the differences in chemotherapy patients or total groups were statistically significant.

Results are given in table 4.

When graphing labelling efficiency no direct relationship could

Modified In-Vivtro Red Blood Cell Labelling Using A Single Polyurethane Intravenous Cannula

Table 4: Signal to Noise Ratio.

Total

Chemotherapy Non-Chemotherapy

Group 1 2.89

2.50

3.24

(SD 0.69)

(SD 1.23)

Group 2 3.09

3.64

2.82

(SD 0.98)

(SD 0.76)

(SD 1.09) (SD 0.91)

Figure 3: Relationship between S:N and labelling efficiency.

Figure 4: Relationship between labelling efficiency and doctor’s assessment.

(a) Figure 6: Single study with quality assessment varying from 1 to 3.

Figure 5: Relationship between S:N and doctor’s assessment.

(b)

Figure 7: (a) S:N 2.04, LE 88.41% (b) S:N 3.12, LE 88.28%.

be found to either signal to noise ratio (Fig. 3) or the qualitative assessment of the images (Fig. 4). This was true also for graphing signal to noise ratio vs the qualitative assessment (Fig. 5).

DISCUSSION Labelling efficiency for the modified in vivtro method has been quoted at around 85-90% at the time of injection.4,5 This was

consistent with the results of both Group 1 and Group 2. Crucially, it was significantly higher than the 18.7% average label published for Teflon cannulas.4 The effect of chemotherapy in decreasing labelling efficiency is well documented, so our lower results with chemo patients were not surprising.6 Although a smaller number of the Group 1 studies were assessed as being good image quality or better, the amount of variance between individual doctor’s interpretations complicates direct comparison based on raw numbers. Fig. 6 demonstrates a study

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Modified In-Vivtro Red Blood Cell Labelling Using A Single Polyurethane Intravenous Cannula

(a)

(b)

Figure 8: (a) S:N 3.72, LE 79.9% (b) S:N 3.55, LE 92.6%.

that was interpreted as excellent quality by one senior consultant, and poor by another.

Similarly, Fig. 7 shows two studies with comparable labelling efficiency, but very different signal to noise ratios. This is complimented by Fig. 8, which has two studies with similar S:N but vastly different labelling efficiency.

As there was no demonstrated relationship between labelling efficiency and the either the doctor’s rankings or signal to noise ratio, it can be said that percentage label did not have a major impact on image quality in this study.

CONCLUSION Modified In-Vivtro RBC labelling using a single polyurethane intravenous cannula did not demonstrate an impact on clinical interpretation of patient scans in this study. As a result we have implemented this method as part of our clinical protocol.

ACKNOWLEDGEMENTS Bridget Chappell Dr Peter Santos Dr Aurora Poon Dr Sam Berlangieri Dr Sze Ting Lee

32 Gamma Gazette March 2013

REFERENCES 1 Kelly, MJ, Cowie, AR, Antonino, A, Barton, H, Kalff, V, 1992, ‘An assessment of factors which influence the effectiveness of the modified in vivo technetium-99m-erythrocyte labelling technique in clinical use’, J Nucl Med, vol. 33, no. 12, pp.2222-2225 2 Ell, PJ, Gambhir, SS, 2004, Nuclear Medicine in Clinical Diagnosis and Treatment, 3rd edn, Churchill Livingstone, Sydney 3 Hambye, AS, Vandermeiren, R, Vervaet, A, Vandevivere, J, 1995, ‘Failure to label red blood cells adequately in daily practice using an in vivo method: methodological and clinical considerations’, Eur J Nucl Med, vol. 22, no. 1, pp.61-67 4 Millar, AM, Wathen, CG, Muir, AL, 1983, ‘Failure in labelling of red blood cells with 99mTc: interaction between intravenous cannulae and stannous pyrophosphate’, Eur J Nucl Med, vol 8, pp.502-504 5 Callahan, RJ, Froelich, JW, McKusick, KA, Leppo, J, Strauss, HW, 1982, ‘A modified method for the in vivo labelling of red blood cells with Tc-99m: concise communication’, J Nucl Med, vol. 23, no. 4, pp315-318 6 Gomes, ML, Nunes de Oliveira, MB, Bernardo-Filho, M, 2002, ‘Drug interaction with radiopharmaceuticals: effect on the labelling of red blood cells with Technetium-99m and on the bioavailability of radiopharmaceuticals’, Bra Arch Biol Tech, vol.

45, pp.143-149

Australian and New Zealand Society of Nuclear Medicine