March 2015

ISSN : 2200-9876

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

March 2015, Issue 14

Contents

www.anzsnm.org.au

Welcome

3

President’s Report

7

Branch News

Western Australia

8

New Zealand

9

Technologists

9

Scientific Advisory Panel

Column 8: Physics & Computer Science 12

SIG

10

International Relations Committee 16 Accreditation

17

Diary Dates

17

What’s That? 18 Biography 20 Crossword 22 Case Studies

Nuclear Medicines role in Imaging Paraganglioma 26

Cardiac metastases on PET-CT imaging 28

Scintigraphic diagnosis of segmental renal artery stenosis in a patient with a dual blood supply 30

Paper

A retrospective audit on the use of ensure plus for HIDA scans 32

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

2

July – June 1

November – October 1

Welcome Welcome to the first edition of the Gamma Gazette for 2015. In particular, we warmly welcome all new members of the ANZSNM. 2015 is shaping up to be another exciting year for the Society. Preparations are well under way for the Annual Scientific Meeting of the ANZSNM being held at the Brisbane Convention and Exhibition Centre from April 17-20.

Early bird registrations closed on March 6. The theme of the meeting is “Wheel of Change”. The scientific program looks excellent with a mix of both local and international speakers. For those of you who are unable to attend the meeting, we hope you get the opportunity to see one of the pre- or post-conference speakers in your state.

This edition contains interesting articles relating to the gastrointestinal system that were presented at our annual workshop held in August last year. As well we have two interesting scans under the “What’s That?” section for you to look at and we hope they will generate some discussion or further research at your workplace. There is also a case study with some surprising findings of cardiac metastases on PET-CT imaging.

In preparation for WA’s annual workshop in August this year we have a case study and a crossword related to the genitourinary system to start you thinking about it. We have also included a biography of a well known face in the W.A. nuclear medicine community.

Thank you to our generous sponsors and to all members who have contributed their time to the production of this edition. We encourage all members to get involved in supporting the society. We hope you enjoy this edition of the Gamma Gazette.

Dr Elizabeth Thomas WA Branch Chairperson

3

Journal Staff

Editorial copy & Advertising copy

Andrew St John General Manager ANZSNM Secretariat PO Box 6178, Vermont South, VIC 3133 Tel: 1300 330 402 Fax: (03) 8677 2970 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

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.

This issue compiled by the Western Australia 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.

2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine through standing committees and special interest groups: a) The Technical Standards Committee sets minimum

standards and develops quality control procedures

for nuclear medicine instrumentation in Australia

and New Zealand.

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 2015 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

4 Gamma Gazette March 2015

b) The Technologists Special Interest Group. With the introduction of National Registration for Nuclear Medicine Technologists / Scientists as of 1st July 2012, the future role of the Accreditation Board was reviewed and federal council made a decision to disband the current Accreditation Board and reallocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG). The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam are now managed by sub-committees of the TSIG. 2) The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality and provide a forum for development in Australia and New Zealand.

Office Bearers Any changes or additions to the details listed should be forwarded in writing to the Secretariat as soon as possible.

President Vice President Past President Treasurer Committee

Prof Vijay Kumar (IRC), email: vijay.kumar@health.nsw.gov.au Prof Dale Bailey (NSW), email: dale.bailey@sydney.edu.au Dr Elizabeth Bailey (TSIG), email: Elizabeth.Bailey2@health.nsw.gov.au Mr Dominic Mensforth (SA), email: dominic.mensforth@i-med.com.au Ms Lyndajane Michel (QLD), email: ljmichel@bigpond.com A/Prof Roslyn Francis (WA), email: roslyn.francis@uwa.edu.au Dr Doug Smyth (Radiopharmaceutical Science Rep), email: Douglas.Smyth@health.sa.gov.au Dr Susan O’Malley (NZ), email: sue@omalley.co.nz Dr Sam Berlangieri (Physicians Rep), email: berlangieri@mac.com Ms Sharon Mosley (ACT), email: Sharon.Mosley@act.gov.au Mr David Thomas (VIC/TAS), email: David.Thomas@austin.org.au Dr Darin O’Keeffe (Physics Rep), email: darin.okeeffe@cdhb.govt.nz

General Manager & Secretariat

Dr Andrew St John and Drajon Management Pty Ltd

All correspondence

ANZSNM Secretariat PO Box 6178, Vermont South VIC 3133 Tel: 1300 330 402 Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au

Branch Secretaries Australian Capital Territory New South Wales

Queensland South Australia Victoria/Tasmania Western Australia New Zealand

Ms Maree Wright, email: Maree.Wright@act.gov.au Position vacant, interim contact is Acting President Dr Liz Bailey, email: Elizabeth.Bailey2@health.nsw.gov.au James Turner and Louis Gray, email: qldbranchsecretaryanzsnm@gmail.com Kimberley Nguyen, email: kimberly.nguyen@bensonradiology.com.auu Dr Zlata Ivanov, email: zlata.ivanov@arpansa.gov.au Ms Georgina Santich, email: wabranchsecretary@hotmail.com Ms Pru Burns, email: pru.burns@prg.co.nz

Special Interest Groups Technologists

Radiopharmaceutical/Science Physics/Computer Science Technical Standards Committee Scientific Advisory Panel International Relations Committee Nurse Member Liaison

Dr Elizabeth Bailey, email: Elizabeth.Bailey2@health.nsw.gov.au CPD Program Sub-committee: Dr Clayton Frater, email: clayton.frater@sswahs.nsw.gov.au PDY Program Sub-committee: Ms Tale Liiv, email: Tale.Liiv@health.qld.gov.au Dr Doug Smyth, email: Douglas.Smyth@health.sa.gov.au Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.govt.nz Chairperson: Dr Darin O’Keeffe (Acting), email: darin.okeeffe@cdhb.govt.nz Chairperson: Prof Dale Bailey, email: dale.bailey@sydney.edu.a Chairperson: Professor Andrew Scott, email: Andrew.Scott@ludwig.edu.au Mr Erwin Lupango, email: Erwin.lupango@sessiahs.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

5

President’s Report The ANZSNM has been working tirelessly to provide our members the best support and service possible. I am delighted to inform you that the new website for the society and has been up and running since December 2014. It is a new and comprehensive platform for our members. As I mentioned before, the new website will assist in improving the professional status of our members, communication, membership benefits and promote greater awareness of the society within the public and government circles.

Our Secretariat, Dr Andrew St John, the new General Manager, and his team have been working hard with the website developers, Internet Vision Technologies (IVT) and the Federal Council to incorporate all essential information: to perform many tasks such as membership renewal, co-ordinate and publicise SIG activities, deliver CME and accreditation-related activities, and disseminating information through its on-line presence as well as in Gamma Gazette. Since the ANZSNM annual conference is less than a month away, the new website has provided an excellent platform for assisting in conference registration, housing and membership renewal and other essential tasks. The web conference page also carries the conference program including social activities, and an elaborate write-up on the visiting speakers from overseas and the local speakers. Thanks to the new website, which is user friendly, the financial membership is currently stable and growing. The conference registration is looking healthier than last year at this stage.

It is a proud moment for Australia, as it is now the official host of the WFNMB (World Federation of Nuclear Medicine & Biology). The World Federation Conference “Bell” was handed over to the new WFNMB leadership at the WFNMB-2014 meeting in Mexico in Aug 2014. The Executive Council members are: Prof. Andrew Scott, the President, Assoc. Prof. Sze Ting Lee, the Secretary General and Prof. Vijay Kumar, the Treasurer for the period of 2014-2018. Under the leadership of the ANZSNM, the WFNMB will be instrumental in expanding global nuclear medicine activities between 2014 and 2018, especially in education and training activities in many emergent new world regions, and in particular in the Asia and Oceania region, recently described as “the hottest spot in the development and expansion of nuclear medicine and molecular imaging”.

The Physics SIG ran another very successful symposium in February on “Looking Backwards to Tomorrow: Functional Imaging in Radiation Oncology”. The symposium had presenters and attendees from across the region.

See “Column 8” in this issue of Gamma Gazette for further details. Most of the presentations are now on the Physics SIG CPD page of the ANZSNM website.

The current annual conference of ANZSNM-2015 in Brisbane is shaping up very nicely with the participation by the Presidents of SNMMI, Dr Peter Herscovitch, President of SNMMI-TS, Dr David Gilmour and the President of ARCCNM (Asian Regional Co-operation Council in Nuclear Medicine), Dr Henry Bom. The prominent overseas speakers Prof. Marcus Schwaiger (Germany), Prof. Frank Roesch (Germany), Hojjat Ahmadzadehfar, (Germany), Dr Michael Knopp, (USA) and Dr John J. Mahmarian, have confirmed their participation, and be assured they will provide the latest developments in Nuclear Medicine. Their participation will continue to improve the bilateral relationships between ANZSNM and overseas associations. The Australian speakers complement the overseas speakers to provide a high quality education & conference in Brisbane.

The local organising committee led by Joseph Wong and Lyndajane Michel has been working hard to make it a grand success in Brisbane. The Professional Organising committee has been working very hard to offer the best service for the conference. I am sure it is going to be a grand occasion and I wish to see you all attend the premier annual event in Brisbane between 17-20 April.

The ANZSNM has joined forces with the AANMS in a number of recent developments, such as the clinical trials group, ARTnet, and a Radiopharmaceuticals Licensing and Registration working party to enhance dialogue with government, and we should see this continuing into the future. The options are also being explored to establish a Radionuclide Therapy multi-disciplinary group within the framework of the society.

I am delighted to again say that I am privileged to work with a team of dedicated members in the Federal Council, and with the Secretariat, and appreciate their support in all facets of running the activities of the Society.

I would greatly appreciate to hear from you as to how we can improve the services provided, as we expand further into the digital world.

Prof. Vijay Kumar President ANZSNM

7

Branch News WESTERN AUSTRALIA Welcome to the new year from Western Australia. I hope you all enjoyed a bit of rest and relaxation and 2015 has started well for you. The WA Branch finished last year with our AGM that we seemed to simply fly through and was followed by a delicious dinner. We had then organised for everybody to play lawn bowls for a bit of fun. The weather was perfect and the evening was full of laughs. We discovered we have some fairly competitive people amongst our branch and some of us who need to work on our technique a bit more! Thank you to Dr Liz Thomas for organising such a great night.

At the AGM Cedric Eustance stepped down from the committee after many years of dedicated service. I would like to officially thank Cedric for all his hard work and for sharing his knowledge and experience with us.

Diane Cheong stepped down from the WA Technologist Representative role and Amy Evans was voted in as the new representative. Thankfully Diane will stay on the committee with us a bit longer. The WA members officially voted Matt Patterson onto the committee and Simone Culleton was also voted on. Welcome to both of you and we all look forward to organising some great meetings with you.

Speaking of which, the WA Branch is busy organising our annual workshop for 2015. It will be held on Saturday August 1 at the University Club of WA. The topic for this year will be the Genitourinary System and we look forward to seeing many of you there. It is always a great day, full of excellent speakers and interesting presentations.

Our next branch meetings will be held by PRC in their new rooms at the Mount followed by international speaker Univ-Prof. Dr Frank Roesch at the Harry Perkins Institute of Medical Research. This year has also already seen the opening of WA’s newest nuclear medicine department at the brand new Fiona Stanley Hospital and we are looking forward to a tour later in the year at one of our branch meetings.

Finally, from everybody in the WA Nuclear Medicine community, we would like to wish Amy Evans the very best for her RadPharm presentation at the Annual Scientific Meeting in Brisbane in April.

Georgina Santich Secretary WA Branch Committee

u 8 Gamma Gazette March 2015

Branch News

continued

NEW ZEALAND Our New Zealand Branch will be holding the Annual Scientific Meeting in Auckland Hilton Hotel, 5-6 September 2015.

This is anticipated to be another great national meeting. Only the date and venue has been nominated, but we look forward to an exciting program.

The Local Organising Committee (LOC) for the ANZSNM Annual Scientific Meeting scheduled for 22-25 April 2016 with the Pre-Conference Symposium on Friday 21 April 2016 has been working with the members to engage with the meeting. A local photo competition to show case New Zealand’s cultural, geographical and lifestyle images has provided some inspiring photos that are to be part of our advertising for this exciting event in Rotorua. We wanted to get all members to participate and take ownership of the meeting. The Invited International speakers have been secured and the program now is taking shape with Invited Australasian speakers. We want to cater for the Molecular Imaging market and also provide leadership with advances in the SPECT CT sector. We recognise that there is a wide diversity of educational and academic interest, creating opportunities for the LCO and PCO to meet these challenges.

We are fortunate in working with “Outshine” the PCO who had previous experience in providing their skills in 2004 (Wellington) and 2010 (Auckland). We wish to provide exciting new boundaries but also some basic workshops for the SPECT CT community.

New Zealand has 5 PET centres . There is a transition now to SPECT CT from SPECT cameras only. This transition has been in last 5 years. A new post graduate course in Auckland is in its fledging state, but we have confidence this will grow and encourage more Medical Radiation Technologists to chose a career in molecular imaging.

New Zealand has had 3 Federal Committee (FC) members last year, which is the most at any one time. This has now dropped to 2. New Zealand has been well represented at FC level.

Dr Sue O’Malley

Special Interest Group News TECHNOLOGISTS The ANZSNM Technologist Special Interest Group has reached the end of another milestone with the cessation of the Professional Development Year (PDY) program as of March 31, 2015. The ANZSNM-TSIG along with the Accreditation Board developed the original scope of practice for nuclear medicine technologists and set the educational and professional standards that are still used today. The society would like to acknowledge all members that have been involved with this process over the past 20 or more years to ensure that we are internationally recognised for our high standard of work practice and skilled workforce for which other countries benchmark. We will continue to work with the MRPB to ensure that this continues.

The annual TSIG symposium for 2015 will be held in Hobart on Saturday 20th June at the Old Woolstore as part of the winter solstice. The program is currently being finalised and the registration form will be available shortly, so save the date in your diary.

The annual scientific meeting is fast approaching and will be held at the Brisbane Convention Centre April 18-20, with the Technologist Symposium scheduled for Saturday 18th April. The TSIG will also be holding a few workshop and discussion panels on Sunday April 19, with a CPD workshop firstly at 10:30am which will include an overview of the new ANZSNM website and options for CPD recording, an update from the MRPB on CPD requirements and a panel discussion to allow member to have input on the future direction of the website, how CPD is delivered and member engagement. The TSIG also recognises the time and effort given by all mentors involved with the PDY program and we will therefore be having a mentor’s workshop on Sunday 19th April after lunch to acknowledge the work of the mentors and to workshop ideas for the ongoing access to professional mentors for new graduates and trainee technologists. Please come along and join the conversation.

Look forward to seeing you in Brisbane.

Liz Bailey Chair TSIG 9

Special Interest Group News

continued

SCIENTIFIC ADVISORY PANEL The Scientific Advisory Panel has been active in the past few months with the following outcomes: • Successfully proposing 2 ANZSNM-hosted CME sessions to be presented at the 2015 SNMMI Scientific Meeting (Baltimore): – “Lung Imaging – From Planar to SPECT & PET with CT” (Moderators: Geoff Schembri and Dale Bailey) – “PET/CT & Molecular Imaging in the Management of Malignant Melanoma” (Moderator: Andrew Scott) • After peer-review, awarding the 2015 ANZSNM Research Grant to Dr Peter Kench (Discipline of Medical Radiation Sciences, University of Sydney) for the project entitled “Diagnostic Reference Levels for Patients Undergoing PET/CT Scans in Australia and New Zealand“.

In relation to continuing oversight of the Annual Scientific Meetings, the SAP advises the following regarding the next few years of meetings: ASM 2016 – Rotorua Theme: Hot Science – An Eruption of Isotopes Convenor(s): Sue O’Malley & Darin O’Keeffe Pre-conference Symposium: More than Numbers: the Role of Quantitative Imaging Confirmed international speakers include: Richard Wahl MD PhD, Mallinckrodt Institute of Radiology, St Louis, MO (NM Physician/Radiologist) John Humm PhD, Memorial Sloan Kettering Cancer Center, NY (Physics) Giuliano Mariani MD PhD, Pisa, ITALY (NM Physician/Physiologist) David Gilmore, Regis College, MA, USA (NMT) ASM 2017 – Hobart (TBC) Convenor: Barry Elison ASM 2018 – Melbourne Combined meeting with WFNMB Congress 2018 WFNMB President: Andrew Scott SAP Membership The current members of the Scientific Advisory panel are: Representing Name Physics SIG rep & Chair Dale Bailey Physician rep Andrew Scott Radiopharm SIG rep Vijay Kumar Technologist SIG rep Cedric Eustace NZ rep Sue O’Malley Fed Council rep Liz Bailey LOC rep – (QLD ASM 2015) Zachary King LOC rep – (NZ ASM 2016) Sue O’Malley ANZSNM Secretariat –

Role Chair Named lectures Research Grant ASM/Abstracts Awards at ASM Awards at ASM Committee member 2015 Committee member 2016 Secretariat

Term expires ASM 2015 ASM 2015 ASM 2015 ASM 2015 ASM 2015 ASM 2015 ASM 2015 ASM 2016 N/A

As you can see, the initial 2 year appointment to SAP is due to expire for all members (except for the ASM local organising committee representatives) at the 2015 ASM. If you are interested in applying to become a part of the SAP, please discuss with your relevant SIG or branch chairperson.

Prof Dale Bailey PhD Chair ANZSNM Scientific Advisory Panel

u

10 Gamma Gazette March 2015

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11

Column 8 The Physics and Computing Special Interest Group newsletter Around the region REDCap: a web-based database for medical data As we become more involved in trials using imaging and radionuclide therapy in nuclear medicine at RNS we have recognised the need to develop a database to manage the data involved. We have piloted using REDCap (Vanderbilt University, USA). REDCap is a secure, web-based application for building and managing online surveys and databases. As it is web-based it does not need an application installed on any computer or smart device to use it. A bonus for us is that the Sydney University IT department are a REDCap consortium partner and as such manage the installation and maintenance of the software and the database. They even have a dedicated IT consultant to assist us.

We have developed a database for managing data for Neuro-Endocrine Tumours (NETs), their imaging, biochemistry, Quality of Life surveys, imaging, reports, MDT discussions, etc. An example of the interface for a single patient is shown in figure 1 below.

The interface allows the designer to use a variety of mechanisms to enter and store data including selecting dates from a calendar, giving “Y/N� responses, giving multiple options from a drop-down list, adding free text responses and uploading files. There is also some branching logic, which uses a drag-&-drop logic builder interface, so that questions can be hidden unless a certain response triggers their appearance.

12 Gamma Gazette July 2014

u

Column 8

continued

Figure 2: An “instrument” for collecting the data related to a DOTATATE PET scan in the database. The uploaded files containing the report (PDF) and MIP cine (avi) are displayed using the local computer’s default program for handling such a file (e.g., Adobe Acrobat and Windows Media Player in this instance).

Figure 2 shows an example of one collection “instrument”, for a Ga-68 DOTATATE PET scan event. The data that are captured and stored are shown, which includes the report (stored as PDF) and, in our case, the rotating MIP (as an avi format file). The data stored can be readily output in a variety of formats such as a printed page in PDF or a CSV-formatted Excel compatible file.

In summary, REDCap is not designed to be a comprehensive relational database for advanced database

13 u

Column 8

continued

applications, but is particularly well-suited to collecting clinical trial data where events are discretely defined.

It is not a substitute for a comprehensive electronic medical record (eMR), but has demonstrated itself to be useful for collecting & interrogating data for use in the setting of capturing minimum data for clinical events.

For more see project-redcap.org Dale Bailey PhD Nuclear Medicine, Royal North Shore Hospital, Sydney Faculty of Health Sciences, University of Sydney Physics SIG Symposium Sixty five people attended the Physics SIG symposium “Looking Backwards to Tomorrow: Functional Imaging in Radiation Oncology” held at the University of Sydney on Friday 13th February. The symposium consisted of presentations on the basics of radiation oncology and PET/CT imaging (finding common ground for the rest of the symposium), clinical presentations on the role of PET/CT in head and neck and in lung cancer management, scientific and technical presentations on 4D-PET/CT imaging, lesion contouring using PET, bringing SPECT data into treatment planning, radiation protection, and going beyond FDG imaging.

The symposium finished with a series of short presentations on how some centres use PET/ CT data in radiation oncology. We held another Dr Jeremy Booth, Royal North Shore Hospital, discussing successful green lecture (remote presentation) the basics of radiation oncology and explaining how they with A/Prof Stephen Bowen from the University use PET/CT data in treatment planning. of Washington discussing “Using PET/CT and SPECT/CT in radiation therapy planning”. PDF copies of most of the presentations will be on the ANZSNM website, but some will only be available to the symposium registrants. We thank the organising committee of Chithra Sathiakumar, Dale Bailey, and Darin O’Keeffe for planning and running the symposium, and all the 12 presenters for making it a very successful day.

How much are you giving?

The ARPANSA National Diagnostic Reference Level survey for Nuclear Medicine and PET administered activities is underway and closes at the end of May. If you have not yet participated, please see the ARPANSA website for for further information.

SIGnals IAEA PET QC and artefact document The IAEA has published an atlas on PET/CT quality control and artefacts. It can be found on the IAEA website.

IAEA training material The IAEA has recently published two handbooks on nuclear medicine physics and diagnostic radiology physics that are aimed at teachers and students.

Both are available for purchase or for free as PDF files, and both are serious texts with a lot of useful information. The links are Diagnostic Radiology Physics: A Handbook for Teachers and Students and Nuclear Medicine Physics: A Handbook for Teachers and Students

14 Gamma Gazette March 2015

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Column 8

continued

Radiation Protection – IAEA Draft Document The IAEA has recently put out a draft safety guide DS399 “Radiation Protection and Safety in Medical Uses of Ionizing Radiation” and are calling for comments from member states. The document contains 50 pages on “Specific recommendations for radiation protection and safety in nuclear medicine”. ARPANSA is developing a consolidated response o this draft document, although other organisations are also making submissions.

To submit via ARPANSA, contact Paul Marks. Alternatively, comments for consideration in the consolidated Australian response should be submitted to ARPANSA at international@arpansa.gov.au by close of business on Thursday 16 April 2015.

IT Corner Keeping current: the art of syndication If you want to keep up with the literature (or many other things for that matter) but are sick of your mail inbox crowded with table of contents from journals, there are alternatives. One of these is syndication. Really simple synication (RSS) is still alive and well in a growing plethora of consolidation tools. RSS uses the XML format, a format similar to the HTML format used with web browsers, but much more flexible (the X is for eXtensible). By using XML, RS ‘feeds’ can deliver a variety of content, but the most useful are little packets of information that can be read by an RSS reader or aggregator, and the results presented to you in a nice and friendly format.

RSS support is build into most modern web browsers and even Microsoft Outlook 2007+, but there are also a number of dedicated free and comercial software products available to perform this function. One example is Feedly which can be accessed through both a web browser and Android/iOS apps (feedly.com). Once you have such a tool or the web browser option, be on the look out for websites with terms such as ‘RSS’, ‘Feeds’, ‘Subscribe’, or RSS/feed icons such as . Try the RSS feed for the journal Radiology; depending on your browser it will show different results. The big bonus of many of these RSS readers is that once you have your feeds set up they will update automatically and the information comes to you, no more hunting around the net for the same old things. Another bonus is if you have access to a search engine such as Scopus.com you can set up a search to run automatically with the results feed to you using RSS. This can give you automatic notifications such as when your favourite research paper has been cited. It saves a lot of time if your searches are regularly run for you and you simply screen the results.

Editor’s note: The Society provides an industry service based on sone of these feeds under: anzsnm.org.au/industry-news

Feedly in action on the Android platform. You can quickly flick through paper titles and decide if you want to use them, store them, or share them. These are some results for an issue of the journal EJNMMI.

15

International Relations Committee

(IRC)

The IRC has been engaged in the development of a new project as part of the SNMMI Nuclear Medicine Global Initiative (NMGI). This project, on “Global Access and Availability of Radiopharmaceuticals�, will undertake a detailed analysis of the use of diagnostic and therapeutic radiopharmaceuticals world-wide, and identify key issues that impact on the availability and use of existing and new tests and therapies. this will involve all major regional societies and associations (eg SNMMI, EANM, AOFNMB, ALASBIMN, AANMS), and the ANZSNM is paying a key role in the program. Prof Andrew Scott is chairing the group, and Prof Vijay Kumar is also on the committee. We will provide updates to the ANZSNM membership on progress over the coming 12 months.

Plans are in place to have a number of major International society representatives at the upcoming ANZSNM annual scientific meeting, including Prof Henry Bom (President, AOFNMB), Prof Fred Verzijlbergen (PastPresident, EANM), Dr Peter Herscovitch (President of SNMMI) and Dr Uday Bhonsle (IAEA).

ANZSNM has been invited to participate in the International Conference on Clinical PET and Molecular Imaging (iPET 2015) in Vienna, Austria (5-9 October 2015), and we will be providing representatives for the Faculty at this meeting.

Members of the ANZSNM have also participated in a range of IAEA teaching / training and audit programs over the last 6 months in South-East Asia, including A/Prof Nathan Better (Cardiology), Ms Kunthi Pathmaraj (Audit) Prof Vijay Kumar, Prof Dale Bailey and Dr Elizabeth Bailey (Oncology/Teaching). There was also a 1 week intensive course on PET/CT Reporting in Oncology held at the Austin Hospital in Melbourne, organised by A/ Prof Sze Ting Lee and Prof Andrew Scott, which was attended by 16 Nuclear Medicine Specialists from Asia.

There were 35 lectures given by a faculty of 11 lecturers from Melbourne and Sydney. This demonstrates to active outreach programs ANZSNM members are contributing to in regional countries. The IRC is also engaged in enquiries from IAEA and regional governments for training placements in major Nuclear Medicine sites in Australasia.

Planning has commenced for the 12th WFNMB Congress to be held in Melbourne in April 20th to 24th, 2018, which is anticipated to involve over 2,000 attendees. Over the next 6-12 months it is intended to appoint a Professional Conference Organiser (PCO), and commence planning for the congress program.

Andrew Scott Chair of the IRC

16 Gamma Gazette March 2015

Accreditation Congratulations to the following technologists who were granted Accreditation: Daniel Hayes Scott Walker Sarah Bunting Kirsten Northey Megan Stirrat Preeth Karl Samra Shehzad Melissa Nocera Sarah Musgrave Grace Rainbird Kathryn Elphick Harry Power Matthew Fiddes Stephanie Bracci

Cheryl Pieres Sze-Yue Tso Nicolas Benson Ingrid Holmes Lauren Hurn Erica Bridson Robert Jamison Jennifer Neff Tess Bainbridge Christopher Lacey Elizabeth Thomas James Turnbull Abhishek Singh Elizabeth Marshall

Katerina Karvelis Andrew Simpson Ebony Perkins Rachael Bell Nichole Evans Simon Hannah Emily Rodgers Nicole Bosse Michelle Cooke Denise Rizea Aimee Love Aron Poole Leah Squire Jessie Johnson

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.

2015 17 – 20 April ANZSNM 45th Annual Scientific Meeting Brisbane, Queensland 6 – 10 June Society of Nuclear Medicine and Molecular Imaging Baltimore, Maryland USA

31 Oct – 4 Nov AOFNMB 2015 Asia Oceanic Congress of Nuclear Medicine and Biology Jeju, Korea 5 – 6 Septemberv New Zealand Annual Scientific Meeting Auckland Hilton Hotel Auckland, New Zealand

20 June TSIG 7th Annual Day Seminar Hobart, Tasmania

2016

1 August WA Annual Workshop: Genitourinary System University Club, WA

22 – 25 April 2016 ANZSNM Annual Scientific Meeting Rotorua, New Zealand

5 – 9 October International Conference of Clinical PET_CT and Molecular Imaging Vienna, Austria

2018

10 – 14 October EANM15 Hamburg, Germany

20 – 24 April 2018 WFNMB 2018 Congress Melbourne, Australia

17

Answer on page 24

What’s that?

Submitted by Gabrielle Morrissey Sir Charles Gairdner Hospital, Perth, Western Australia

A 51-year-old female with stage III papillary thyroid carcinoma received postthyroidectomy radioactive iodine therapy. Her post therapy Iodine 131 whole body scan is displayed above. Her dose was reduced (1000MBq) on the basis of significant remnant tissue on pre-therapy pertechnetate study. The volume of remnant was considered low volume on ultrasound and did not require re-operation.

18 Gamma Gazette March 2015

ANZSNM 2016

22-25 April Rotorua, New Zealand

Hot Science: An Eruption of Isotopes Energy Events Centre , Rotorua 2016

Key Dates Abstract Submissions Open - October 2015 Registration Open - October 2015

Invited Speakers A/Prof David Gilmore Associate Dean, Undergraduate Academic Affairs Program Director of Medical Imaging Programs Regis College, Boston, USA Dr John L. Humm, PhD Medical Physicist Memorial Sloan Kettering Cancer Center New York, USA Prof Giuliano Mariani Professor and Chief of Nuclear Medicine Director of Post Graduate Specialty of Nuclear Medicine, University of Pisa, Italy Prof Richard Wahl Elizabeth E. Mallinckrodt Professor Head: Department of Radiology Director: Mallinckrodt Institute of Radiology Washington University School of Medicine, St Louis, USA

www.anzsnm2016.com

Biography Career Biography of a Significant Member of the Western Australian Nuclear Medicine Community

Dr Geoffrey Donald Bower

MBBS (WA), FRACP, MSc (London)

Dr Geoff Bower has been a prominent figure in the Western Australian Nuclear Medicine Community and a member of the ANZSNM for over 34 years. He graduated from the University of Western Australia in 1970 and obtained Membership of the Royal Australian College of Physicians in 1974. He was a paediatric Renal Physician at Princess Margaret Hospital (PMH), W.A. before commencing his Nuclear Medicine registrar training at Sir Charles Gairdner Hospital, WA from 1980-1984. He moved to London in 1983 to complete a Master of Science at Guy’s Hospital. The dissertation for his Masters was on Thallium Myocardial Imaging using a seven pinhole gamma camera and involved angiographic correlation of MPS data from over 100 patients. Dr Bower was awarded his Masters in October 1985.

Upon his return to Perth in 1985, Dr Bower took up a locum position at Royal Perth Hospital for three months and was then asked to help set up the Nuclear Medicine department at PMH, along with Dr Paul Sprague and Nuclear Medicine technologist Helen Geijsel. PMH is the paediatric hospital in WA and during his time there, Dr Bower was involved in setting up a best practice protocol for direct cystograms. His association with the oncology wards at PMH was also highly satisfying, in particular his association with the Children’s Cancer Study Group (CCSG) and monitoring GFR. Dr Bower continued to work part time at PMH until 1989.

Also in 1985, Dr Bower started the first private Nuclear Medicine practice in WA Isotope Imaging was situated in West Perth, with assistance from Dr Paul Sprague. Isotope Imaging expanded with other Nuclear Medicine Physicians joining Dr Bower and practices were opened at the Surgicentre in South Perth, then at the Mount Hospital as well as at Glengarry Hospital, then at Hollywood Hospital. The first single head SPECT camera in Perth was in the West Perth practice and the first private SPECT/CT camera was installed at the Hollywood practice. Isotope Imaging was dissolved in 2006.

Dr Bower then continued a single private practice, Mount Nuclear Medicine, at the site of the Mount Hospital and worked with new enthusiasm using a solid state SFOV mobile camera.

He specialised in Sentinel Lymph Node (SLN) breast cancer work and SIR Sphere therapy for colorectal and primary liver cancers.

Dr Bower has been a member of the ANZAPNM (now AANMS) since 1984/5; he has been part of numerous committees including the ANZAPNM Council 1992-2002. He was Honorary Treasurer ANZAPNM 1996-1998, President ANZAPNM 1998-2000, Immediate Past President 2000-2002, a member of the Commonwealth Ministerial PET Advisory 20 Gamma Gazette March 2015

Committee 2000 and Chairperson of the ANZAPNM Quality and Practice Credentialing (QPAC) Committee for three years.

He has provided multiple choice exam questions for registrars in AANMS training. He has also lectured Medical Imaging students in renal nuclear medicine in the early years of the degree course at Curtin University, WA. He has been involved in FOLFOX and FOXFIRE SIR Sphere Studies 2005-current and was enrolling patients for an international multi-centre trial, ISCHEMIA, of medical or surgical treatments for moderately severe myocardial ischaemia. He also developed improved techniques for SLN studies for patients with breast cancer at the Mount Hospital in Perth.

Dr Bower has made many significant contributions to the ANZSNM and particularly the WA Branch. He has always been a willing contributor to the Branch and has officially been a member since the early 1980’s. Dr Bower was an organiser of the social program for the 26th ANZSNM Annual Scientific Meeting (ASM) in Perth, 1996 and a co-convenor of the 31st ASM in Perth in 2001. More recently he presented posters at the 37th ASM, “Optimal Sentinel Lymph Node Studies” in Adelaide in 2007 and at the 43rd ASM, “Effects of Altered Injection Technique on Breast Lymphoscintigraphy Results” in Perth in 2013. He also presented “Experience with Selective Internal Radiotherapy for Patients with Intrahepatic Cholangiocarcinoma” during the Oncology/Therapy session at the ASM in Perth, 2013.

Dr Bower rarely missed a branch meeting or presentation by one of the international conference speakers and frequently presented on a range of items at meetings and the annual workshops. These ranged from short case presentations, scientific presentations or research that he had been involved in. He was generous in sharing his extensive experience, and would frequently generate active discussion at meetings.

He encouraged technologists to be involved and contribute to branch meetings, and would include them in meetings by asking them to comment on scan appearances.

Dr Bower retired at the end of September 2014 and closed his private practice but he has since been spotted doing some locum work back at PMH. We are all grateful for his decades of dedication to the WA Nuclear Medicine community and the endless knowledge that he shared with us all. He is fondly remembered by so many patients for the caring nature he showed them.

We sincerely wish Dr Bower the very best for life after Nuclear Medicine and hope he enjoys his well earned retirement, whatever that may bring. Drinking a glass or two of a good red on the verandah in the evening? Maybe you’re cooking up a storm? Perhaps it’s fencing, mucking out stables, enjoying holidays with your wonderful family, playing with the dogs or working tirelessly in your paddocks? Sleeping in? I’m sure the list is endless now that you are retired! Well done on a wonderful and meaningful career!

Australian and New Zealand Society of Nuclear Medicine Limited ABN: 35 133 630 029

Isotopes, Imaging and Identity – The History of Nuclear Medicine in Australia Book

Order and Payment Form ANZSNM Members:

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crossword 22 Gamma Gazette March 2015

crossword clues Genitourinary Nuclear Medicine

Crossword by Amy Evans, Sir Charles Gairdner Hospital ACROSS 5. A diuretic is not expected to overcome this type of obstruction.

9. In renal transplants; _____ rejection occurs immediately (0-24 hours) after transplantation as a result of preformed antibodies in the recipients blood.

10. Diethylenetriamine Pentaacetic Acid can be abbreviated to _____.

11. The first primary method of renal excretion is _____ filtration through the glomerulus.

18. The second primary method of renal excretion is _____ secretion by the tubules.

19. 80% of renal plasma flow is cleared by _____ secretion.

21. Technetium 99m DMSA localises by binding to the _____ groups in the proximal renal tubules.

27. Transplanted kidneys can come from living or _____ donors.

28. Radionuclide cystography is more sensitive than is iodinated contrast cystography with reflux volumes as low as _____mL being detected.

29. A urinary _____ may be used in patients who cannot empty their bladder.

30. On blood flow images, normally perfused transplanted kidneys should have the sane intensity of activity as is seen in the adjacent _____ _____.

31. The clearance of para aminohippurate defines renal_____ _____.

34. Increases urine production.

35. DMSA stands for _____ acid.

36. The glomerulus acts as a semipermeable _____ allowing only compounds of relatively small molecular size to pass through.

37. On blood flow images, normally perfused native kidneys should have the same intensity of activity as is seen at the bifurcation of the _____.

38. A diuretic may overcome this type of obstruction.

39. Mercaptoacetyl triglycine can be abbreviated to _____.

40. Renin stimulates the production of angiotensin I, which is acted on by _____ to produce angiotensin II. DOWN 1. The clearance of _____ defines the GFR. 2. Technetium 99m MAG3 is protein bound and is cleared predominantly by the proximal _____.

3. In renal transplants; _____ rejection is an antibody mediated process that occurs 6 months to several years after transplantation.

4. Evaluation of the renal blood flow and function of native kidneys is performed from the _____ projection.

6. Transplanted kidneys are placed in the anterior _____ _____ with vascular anastomosis to the hypogastric artery and the external iliac vein.

7. Patients should be well _____ when renography is performed because dehydration may cause an abnormal renogram curve.

8. Technetium 99m DMSA binds sufficiently to the renal tubules to permit renal _____ imaging.

12. Angiotensin II induces vasoconstriction of the _____ arterioles, which restores glomerular filtration pressure and rate.

13. Significant renal artery stenosis decreases _____ arteriolar blood pressure which stimulates renin secretion by the juxtaglomerular apparatus.

14. The classic renogram curve is obtained by using agents that are eliminated by _____ _____.

15. Larger materials such as _____ do not pass through the glomerulus but may reach the urine by tubular secretion.

16. 20% of renal plasma flow is cleared by _____ filtration.

17. Evaluation of the renal blood flow and function of transplanted kidneys is performed from the _____ projection.

18. In renal transplants; _____ rejection is a cell mediated process characterised by lymphocytic infiltration, generally occurring within the first 2-3 months following transplantation.

20. Because a small amount of injected DTPA is bound to plasma proteins, it tends to _____ the GFR slightly.

22. ACE stands for _____ converting enzyme.

23. Acute tubular _____ commonly occurs in cadaveric transplants and results from ischaemia in the renal transplant after harvesting and before transplantation.

24. Radionuclide _____ is the technique of choice for the evaluation and follow up of children with suspected vesicoureteral reflux.

25. Generally, glomerular function declines earlier and more rapidly than does tubular function in response to ureteral _____.

26. A type of oral ACE inhibitor.

32. Overall, the renogram curves for each kidney should be reasonably _____.

33. A _____ is a time activity curve that provides a graphic representation of the uptake and excretion of a radiopharmaceutical by the kidneys.

Crossword solutions on page 35

23

From page 18

What’s that? ... answer

Planar imaging revealed a focus of iodine-avid tracer uptake in the right lower quadrant of the abdomen.

When correlated with SPECT/CT this localised to the mid appendix. The patient was asymptomatic.

The lack of other gastrointestinal tracer uptake reflects the paucity of clearance from the appendix

24 Gamma Gazette March 2015

in comparison.

An article also suggested that iodine accumulation in the appendix is simply an atypical variant of the normal intestinal activity secondary to iodine excretion into the bowel (Borkar, Grewal & Schoder, 2008, pp.551-552).

Does Ensure® ensure a reliable hepatobiliary result in the absence of Sincalide?

Ms B. Tomlin, Ms E. Brook, Dr M. Dunne Nuclear Medicine Department, Royal Perth Hospital, Western Australia, Australia.

Introduction Sincalide (Kinevac; Bracco Diagnostics Inc.), a cholecystokinin (CCK) analogue used in hepatobiliary imaging for assessment of chronic cholecystitis, is currently in short supply worldwide1. Due to impending non-availability of Sincalide in Australia, alternative methods for stimulating gallbladder contraction are necessary.

Ensure Plus® has been offered as a readily available and inexpensive alternative. However, Ensure Plus® is dependant on normal gastric emptying to accurately quantify gallbladder ejection fraction (GBEF). Lower limits of normal have been suggested in a well known but limited study2. This case investigates the degree of concordance between Sincalide and Ensure Plus® stimulated GBEF and highlights the need to interpret results of Ensure Plus® stimulated GBEF with caution.

Discussion In the absence of Sincalide, Ensure Plus® is a readily available, inexpensive, standardised fatty-meal substitute which has been shown to stimulate gallbladder emptying by stimulating endogenous release of cholecystokinin (CCK).

Statistical analysis of a small sample of healthy volunteers determined the lower limit of normal GBEF to be 33% following ingestion of the supplement2. Although “physiologic”, the effectiveness of this orally ingested “meal” depends on normal gastric emptying. Slow gastric emptying will result in a delay in the stimulated release of CCK in the proximal small bowel and thus delayed gallbladder emptying. This may lead to inaccurate quantitation of GBEF during a 60 minute investigation; particularly as the original study2 showed maximal gallbladder emptying occurred at the end of the imaging period between 55 and 60 minutes.

Case A 44 year old male presented with chronic epigastric colicky pain and upper abdominal tenderness. Previous abdominal ultrasound and CT studies were normal. A Nuclear Medicine hepatobiliary study was requested by the surgical team to assess for possible chronic cholecysitis.

An initial study was performed according to departmental protocol for hepatobiliary imaging (ensuring patient fasting and medication compliance). The gallbladder was visualised on a static image one hour post injection of 114MBq 99mTc HIDA (Hepatobiliary Iminodiacetic Acid). Emptying of the gallbladder was then stimulated by ingestion of 240 mL of Ensure Plus® within 5 minutes. Dynamic images were acquired at 15o LAO over the subsequent hour, where the contraction and slow secretion of activity into the small intestine was visualised. GBEF was calculated to be 30%, outside of the normal lower limit following stimulation with Ensure Plus® which has been reported to be 33%2. Clinical review of the patient by the supervising Nuclear Physician suggested the patient’s symptoms were not typical of gallbladder pain. Concern was raised that the study was false positive for chronic cholecystitis. It was decided that the study should be repeated with Sincalide.

The study was repeated the following day; the patient received no intervention between studies. An infusion of 1.7 µg Sincalide in 30 mL saline replaced Ensure Plus® as the gallbladder stimulant. The CCK analogue was infused over an hour whilst dynamic images at 15o LAO were acquired. Prompt gallbladder contraction and secretion of the activity into the small intestine was visualised. GBEF was calculated at 86% at 60 minutes; well within the normal range (normal >38%)3. The diagnosis of chronic cholecystitis was excluded.

Figure 1. GBEF calculated using Ensure Plus®

Figure 2. GBEF calculated using Sincalide

For both days the patient was suffering from reflux/heartburn pain and was unable to stay still for the entirety of the test, motion correction had to be applied to the dynamic images for GBEF calculation.

Clinical Outcome

Conclusion

The results of each study determine two very different clinical outcomes for the patient. Low GBEF (less than 35%) is a positive indicator for chronic cholecystitis. The treatment for this condition is a cholecystectomy4.

This case demonstrates the wide variability of GBEF in a single patient following stimulation with direct exogenous CCK (Sinclaide) and indirect endogenous CCK (Ensure Plus®). The results of GBEF following Ensure Plus® must therefore be interpreted with caution to avoid false positive diagnosis of chronic cholecystitis in patients with low GBEF. If the GBEF is normal (>33%) post Ensure Plus®, chronic cholecystitis is excluded. If the GBEF is abnormal (<33%), the diagnosis is not confirmed. If Sincalide is available the study should be repeated and accurate GBEF calculated. In the absence of Sincalide, an optimum further investigation is not yet clear. Additional imaging beyond 60 minutes may be valuable to capture maximum GBEF in patients with slow gastric emptying.

The patient did not require any surgical intervention based on normal hepatobiliary study results and is scheduled to have a gastroscopy in the future to investigate development of reflux symptoms.

References 1. Ziessman, H.A., & Petry, N.A. (2013). Sincalide is temporarily unavailable--again. Journal of Nuclear Medicine, 54(8), 17N. 2. Ziessman, H.A., Jones, D.A., Muenz, L.R., & Argarval, A.K. (2003). Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Supplement. The Journal of Nuclear Medicine, 44(8), 1263-1266.

Delivering a Healthy WA

3. Zeissman, H.A., Tulchinsky, M., Lavely, W.C., Gaughan, J.P., Allen, T.W., Maru, A., Parkman, H.P., & Maurer, A.H. (2009). Sincalide-Stimulated Cholescintigraphy: A Multicentre Investigation to Determine Optimal Infusion Methodology and Gallbladder Ejection Fraction Normal Values. The Journal of Nuclear Medicine, 51(2), 277-281.

4. Ziessman, H.A. (1999). Cholecystokinin Cholescintigraphy: Victim of Its Own Success? The Journal of Nuclear Medicine, 40(8), 2038-2042.

RPH M140409003

Case Study

Nuclear Medicines role in Imaging Paraganglioma Megan Stirrat, The Canberra Hospital

17-year-old male presents to Canberra Hospital ED with history of: • Intermittent but worsening haematuria of past 52/52 • Headaches lasting approximately two minutes after straining, dating back to 2009

GP had referred patient for a CT scan which shows bladder tumours and a retroperitoneal mass. The patient was then referred to Canberra Hospital for further investigation.

There was no previous family history of cancer, except for patient’s uncle who had previously been treated for paraganglioma.

Initial potential diagnosis was Transitional Cell Cancer of the bladder, and a bone scan was requested to rule out any bone metastasis.

The patient was given 900MBq of 99mTC-HDP and 3 hour delayed whole body imaging was performed as well as a double SPECT of the axial skeleton and static imaging No osseous metabolic uptake indicative of metastatic disease was noted. However the absence of the right kidney was noted and correlated with known high grade hydronephrosis .

However, further investigation and clinical correlation would be needed to rule out diagnosis of bladder TCC. Blood tests and further clinical correlation reduced the likelihood of bladder TCC. A new diagnosis of metastatic pheochromocytoma/ paraganglioma was discussed; as blood tests showed elevated catecholamines and patient has a family history of paraganglioma.

26 Gamma Gazette March 2015

Research has shown that up to a third of paragangliomas and pheochromocytomas may be familial in nature.1 18F-FDG PET imaging and 123I-MIBG imaging were both ordered to further investigate.

The patient was injected with 162MBq of 18F-FDG and PET imaging was commenced an hour after injection in conjunction with low dose CT for attenuation correction and anatomical localization.

The PET scan demonstrates FDG avid lesions which are visualised within the bladder (the likely primary) and extends to obstruct the right kidney (which is atrophic) and likely also the prostate. Disease is also noted bilaterally in iliac lymph nodes. A large aortocaval mass is also noted as being FDG avid. No other distant FDG avid disease is noted.

207MBq of 123I-MIBG was administered at 6 and 24 hour images were acquired.

On both the 6 and 24 hour images the same intense focus of activity in the centre of the abdomen is seen. This activity when compared to the PET scan is localised to the aortocaval soft tissue node.

SPECT/CT imaging at 24 hours illustrates the bladder base tumour and iliac lymphadenopathy demonstrates only very low level tracer activity.

Upon comparison of the PET and MIBG images two different diagnosis possibilities can be determined; 1. Paraganglioma at the aortocaval soft tissue mass and a non MIBG avid bladder base tumour (with regional nodal iliac disease) such as sarcoma.

2. Or less likely, there may be heterogenous molecular expression of the same pathology

u

Nuclear Medicines role in Imaging Paraganglioma

A month after the 123I-MIBG images were acquired the patient had his right kidney, right ureter, bladders masses, suspicious iliac nodes and aortocaval mass removed for histological assessment.

Upon histological assessment, it was established that all tumours were paragangliomas.

Paragangliomas (also known as extra-adrenal pheochromcytomas) are catecholamine-secreting tumours which arise from the chromaffin cells in sympathetic ganglia.1 Paragangliomas account for 15% of all pheochromcytomas and may arise anywhere chromaffin cells are found. Primary bladder paragangliomas only account for around 6% of all paragangliomas and around 0.06% all bladder tumours.

Paragangliomas secrete catecholamines, which include epinephrine, norepinephrine, and dopamine. It is the excess of these hormones in the body which cause the common symptoms of paragangliomas, these symptoms include; headaches, hypertension, tachycardia and diaphoresis.2 123 I-MIBG is actively taken up by neuroendocrine cells via the epipherine transporter and stored in the chromaffin storage granules, meaning that any catecholamine secreting tumour (i.e. paraganglioma) should theoretically also actively take up MIBG.3 18 F-FDG is a glucose analog, which demonstrates the glucose metabolism of cells. Therefore malignant cells are highly distinctive on a 18F-FDG scan as they exhibit high glucose metabolism.4 From imaging it is known that the bladder base tumour is not MIBG avid, but is FDG avid, demonstrating a high glucose turnover and highly indicative of a malignant neoplasm. However with being MIBG avid the tumour is not acting as paraganglioma cells are expected to. From this the conclusion could possibly be drawn that the bladder and retroperitoneal tumours are heterogeneous from the potential aortocarval paragangnlioma.

Pathology results would support this theory stating moderate nuclear pleomorphism is demonstrated in all tumour samples.

However without histological assessment of the aortocarval node,

this conclusion cannot be verified.

At the time of writing this study immunohistochemistry investigations were being carried out on several tissue samples in order to determine cell mutation and provide more answers as to why the some of the paragangliomas were not visualised on MIBG imaging as would be expected. Before any further treatment can be considered, further histological assessment of all of the neoplasms removed must be completed.

After initial surgical resection, curative treatment of metastatic paraganglioma can be difficult. Chemotherapy is often the next part of treatment especially in patients with fast growing tumours. Targeted radionuclide therapy using 131I-MIBG is often also considered, however would not be indicated for use with this particular patient due to the unusual appearance of the paragangliomas on 123I-MIBG imaging.5 Reference List 1. Joynt K, Moslehi J, Baughman K. Paragangliomas. Cardiology in Review. 2009;17(4):159-164.

2. Pastor-Guzmán J, López-García S, Giménez-Bachs J, RuízMondejar R, Cañamares-Pabolaza L, Atiénzar-Tobarra M et al.

Paraganglioma of the Bladder: Controversy regarding Treatment.

Urologia Internationalis. 2004;73(3):270-275.

3. Bombardieri E, Giammarile F, Aktolun C, Baum R, Bischof Delaloye A, Maffioli L et al. 131I/123I-Metaiodobenzylguanidine (mIBG) scintigraphy: procedure guidelines for tumour imaging.

European Journal of Nuclear Medicine and Molecular Imaging.

2010;37(12):2436-2446.

4. Taieb D, Neumann H, Rubello D, Al-Nahhas A, Guillet B, Hindie E. Modern Nuclear Imaging for Paragangliomas: Beyond SPECT. Journal of Nuclear Medicine. 2012;53(2):264-274.

5. Fliedner S, Lehnert H, Pacak K. Metastatic Paraganglioma.

Seminars in Oncology. 2010;37(6):627-637.

27

Case Study

Cardiac metastases on PET-CT imaging A/Prof Roslyn Francis1,2 and Cassie Mulcahy1 1. WA PET Service, Department of Nuclear Medicine, Sir Charles Gairdner Hospital, WA 2. School of Medicine and Pharmacology, University of Western Australia

The following cases all presented in the same week, and represent illustrative examples of cardiac metastases detected by PET imaging. All three patients were asymptomatic from their cardiac metastases.

Patient 1 presented clinically with a gastrointestinal bleed. Subsequent endoscopy with biopsy diagnosed lymphoma. The staging FDG PET scan shows extensive disease above and below the diaphragm. This included diffuse right atrial activity, which was associated with filling defects on contrast CT imaging. This appearance is in keeping with lymphomatous infiltration (figure 1).

Patient 2 had metastatic renal cell carcinoma with lung, mediastinal and retroperitoneal metastases. The restaging FDG PET scan following chemotherapy shows a new focal lesion in the left ventricle, in keeping with a myocardial metastasis (figure 2).

Patient 3 has a small bowel neuroendocrine tumour with mesenteric nodal involvement. The Ga68 octreotate PET-CT shows focal activity in the interventricular septum, which was confirmed as a metastasis on MRI (figure 3).

Discussion Autopsy findings suggest that cardiac metastases may occur in anywhere between 2.3% and 25% of patients with disseminated sites of metastatic cancer.1,2 They usually occur in the setting of multiple metastases, with solitary metastasis to the heart being a rare finding.

Bussani et al (2007) state that there are four main ways in which tumours can infiltrate the heart, these being: • By direct extension • Through the blood stream • Through the lymphatic system and • By intracavitary diffusion through either the inferior vena cava or the pulmonary veins2

Lymphatic spread tends to result in pericardial metastases, whereas haematogenous spread leads to myocardial metastases.

Endocardial metastases are rare.

Studies have shown that melanoma has a high incidence of cardiac metastases, with up to 28% of patients with disseminated disease developing cardiac metastases, thought to be due to haematogenous spread which is commonly seen in this tumour type).1,2 Cardiac metastases also occur with a relatively high incidence in metastatic lung cancer (adenocarcinoma 21%, squamous cell lung ca 18%), breast cancer (15%) and renal cell cancer (7%).2 In lymphoma, most cases with cardiac involvement are B cell lymphoma, with the presentation usually occurring late in the disease course.3

Figure 1: a) PET–CT scan demonstrating intense FDG activity in the right atrium. B) Contrast CT scan demonstrates a filling defect in the right atrium.

28 Gamma Gazette March 2015

Cardiac metastases on PET-CT imaging

Figure 2 (left): FDG PET-CT demonstrating a myocardial metastasis in the left ventricle in patient with metastatic renal cell carcinoma.

Figure 3 (left and above): a) Ga68 octreotate PET-CT demonstrating focal activity in the interventricular septum b) MRI confirms a lesion at this site Most cardiac metastases are small and are asymptomatic.

Only one tenth of patients with cardiac metastases at autopsy had clinical symptoms from the lesions. The clinical presentation of cardiac metastases may include pericardial effusion, heart failure, valvular dysfunction or arrhythmias.1 Cardiac metastases may also occur with neuroendocrine tumours. A recent published study has demonstrated that up to 4% of patients with small bowel neuroendocrine tumour may develop myocardial metastases detected on Ga68 Octreotate PET.4 The myocardial metastases did not appear to be symptomatic and most were treated with somatostatin analogues.

References 1. K. Reynen*, U. Köckeritz & R. H. Strasser. Metastases to the heart. (2004) Annals of Oncology 15: 375–381 2. Bussani, R., De-Giorgio, F., Abbate, A., & Silvestri, F. (2007).

Cardiac Metastases. Journal of Clinical Pathology, 60(1), 27-34.

3. Agrawal, K., Rai Mittal, B., Manohar, K., Kashyap, R., Bhattacharya, A., & Varma, S. (2012). FDG PET/CT in Detection of Metastatic Involvement of Heart and Treatment Monitoring in Non-Hodgkin’s Lymphoma. World Journal of Nuclear Medicine, 11(1), 33-34.

4. Calissendorff J, Sundin A, Falhammar H. (2014) 68Ga-DOTA-TOCPET/CT detects heart metastases from ileal neuroendocrine tumors Endocrine. Sep;47(1):169-76.

29

Case Study

Scintigraphic diagnosis of segmental renal artery stenosis in a patient with a dual blood supply Richard Gauci and Peter Robins Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Nedlands, WA Learning Objectives 1. Appreciate the scintigraphic appearance of segmental renal artery stenosis in a kidney with dual arterial supply.

2. Take note of customized processing of renal perfusion scan to accurately assess functional anatomy.

Clinical History A 94-year-old female was referred for a renal perfusion scan. Her background included a history of right pelviureteric junction (PUJ) obstruction causing acute renal failure some months prior. Following removal of her JJ stent the surgical team requested clarification on the cause of her mild persisting renal impairment and whether her right PUJ obstruction persisted.

Findings Her right PUJ was dilated but draining satisfactorily. Her left kidney was small, poorly functioning and contributing only 27%. There was delayed concentration and excretion from upper pole, while the lower pole remained normal (see figure 1).

Figure 2. Heavily calcified renal artery

Figure 1. Two selected images from the dynamic (1 minute frames) series demonstrating prompt concentration in the lower pole of the left kidney but delayed concentration in the upper pole.

This was only evident on separate analysis of the left upper and lower poles (see figure 4 & 5). Non-contrast CT imaging shows a heavily calcified renal artery to the left upper pole and a noncalcified accessory renal artery to the left lower pole (see figure 2 & 3).

Report summary and findings are: 1. Patulous right collecting system but no significant persisting PUJ obstruction.

2. Poorly functioning left upper pole with features of renal artery stenosis. Heavy calcification seen on CT is supportive of the diagnosis.

30 Gamma Gazette March 2015

Figure 3. Non-calcified accessory renal artery

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Case Study: Scintigraphic diagnosis of segmental renal artery stenosis in a patient with a dual blood supply

Figure 4: The renogram curves comparing left to right kidney without differentiating the left upper and lower poles.

Figure 5: Note that the label of right kidney = left upper, and the label of left kidney = left lower.

The two renograms from the one kidney demonstrating delayed uptake and excretion in the left upper pole.

3. Normal functioning left lower pole with accessory renal artery supplying this part of the left kidney.

Discussion The presence of an accessory renal artery is common, in only 70% of cases there is a single renal artery supplying each kidney.1 Renal artery stenosis is less common but the prevalence increases with age.2 We describe a case of renal artery stenosis with an aberrant renal artery supplying a functioning left lower pole. The case highlights the importance of the selected fields when processing renograms and is a reminder of the diagnostic capacity of functional imaging.

References 1 Standring S (Ed). Grayâ&#x20AC;&#x2122;s Anatomy â&#x20AC;&#x201C; The Anatomical Basis of Clinical Practice. London, Elsevier Churchill Livingstone Publishers 2005, 1274-1275.

2 Safian R, Textor S. Renal-Artery Stenosis. N Engl J Med, Vol. 344, page 431-442, No. 6, February 8, 2001.

31

Paper

A retrospective audit on the use of ensure plus for HIDA scans Diane Cheong Aim of the Audit When Cholecystokinin (CCK), supplied as Sincalide and manufactured by Bracco Diagnostics, became unavailable in January 2013, a literature review was undertaken in our department to determine the most suitable substitute. The fatty meal that was decided upon was Ensure Plus which was convenient, of consistent quality and has a suitable fat content. We were concerned however, that there appeared to be a greater proportion of patients with a low or just normal gallbladder (GB) ejection fraction (GBEF) since using Ensure Plus. The question to be answered was “Is Ensure Plus reliable?”

This paper reports the preliminary results obtained from the audit.

Aim of the Audit • A literature review of studies using fatty meals was undertaken.

• A retrospective review of all 99mTc HIDA (HIDA) studies performed in the department since January 2013 was undertaken, • Attempts were made to obtain clinical follow-up from some of the referring doctors, however this was unsuccessful.

• The medical records of patients who had been admitted to the hospital were reviewed and the histopathology of resected gallbladders obtained.

Literature Review The most useful paper was by Ziessman et al, from Georgetown University Hospital, Washington, DC who in 2003 published “Cholecystokinin Cholescintigraphy: Methodology and Normal Values Using a Lactose-Free Fatty-Meal Food Supplement” in the Journal of Nuclear Medicine. They derived a range of normals from 17 asymptomatic subjects, using 240 ml of Ensure Plus containing 11.4g of fat, 1485 kJ, and 50g of carbohydrate. The derived normal value was greater than 33% GB emptying by 60 minutes after the meal. The paper also referred to Stone et al, who in 1992 reported that 10g of fat was needed for good GB emptying, while 4g of fat did not produce GB contraction Another paper published in the Annals of Nuclear Medicine in 2009

by Al-Muqbel, et al from Jordan reported on the use of a “standard fatty meal” of “a chocolate bar” and 200ml of full fat yoghurt, providing an average of 20g of fat and 320 calories. They examined 198 patients over 4 years and used an arbitrary normal GBEF greater than 50% at 30 minutes after the meal. Cholecystectomy was performed on 61 of the 103 patients with a low GBEF and histopathology confirmed 58 with GB disease.

No other reliable reports were found of the use of a fatty meal.

CCK CCK is a peptide hormone secreted by discrete endocrine cells lining the mucosa of the small intestine. Some cells in the central nervous system and peripheral nerves innervating the intestine also secrete CCK. Its action is to stimulate contraction of the GB and relaxation of the Sphincter of Oddi, so that bile enters the duodenum to continue digestion of food.

In 1928 CCK was found to cause GB contraction in dogs and in 1943 a similar compound was found to stimulate pancreatic enzyme secretion. Twenty-three years later it was realised that these two hormones were the same.

A substitute for Bracco CCK can be compounded in regional

32 Gamma Gazette March 2015

pharmacies but it is of inconsistent quality and sterility (Society of Nuclear Medicine, 2013). Other substitutes that have been seen to cause GB contraction are magnesium sulphate (Epsom salts); erythrmycin i.v. which increases muscular contraction of the GB but with inconsistent effect and adverse reactions; subcutaneous Bethanechol which acts on muscarinic receptors; and more bizarrely, rectal distension (Ziessman et al, 2003).

Problems with a Fatty Meal The fact that GB emptying relies upon gastric emptying following a meal is the foremost problem as delayed gastric emptying will cause a delay in production of endogenous CCK. A patient presenting in the emergency department with acute symptoms suggestive of GB disease or any other acute abdominal disorder is very likely to have delayed gastric emptying. Therefore those HIDA studies that are performed at this stage will possibly indicate a prolonged GBEF purely due to delayed gastric emptying. In these cases a normal GBEF might be observed if imaging is continued for longer than 60 minutes, particularly if a longer lag time can be seen on initial post-meal dynamic imaging.

In this acute phase vomiting can also be a problem, in which case a meal is quite intolerable.

Milk has also been used in other practices, but the lack of an established normal range and the possibility of lactose intolerance renders it unsuitable.

Some of our patients had previous gastric surgery such as a lap band or sleeve gastrectomy, both of which reduce the stomach volume such that the patient cannot ingest the required volume of the meal to provide the necessary 10g of fat.

Gastro-oesophageal reflux can make the examination very uncomfortable during 60 minutes of scanning in the supine position.

Using Ensure Plus – Our Protocol Most commonly in Australia Ensure Plus is available in a 200 ml tetrapak in flavours of vanilla, chocolate and strawberry. It contains

u

A retrospective audit on the use of ensure plus for HIDA scans 9.84g of fat, 0.4 g carbohydrate (all sugars), no lactose, 12.5g of protein, and 1263 kJ (300 calories). In our department it is used at room temperature rather than chilled.

Patients with a GB must fast for 4 hours, having eaten in in the previous 24 hours, and no narcotic analgesics in the 12 hours before the study. Females of reproductive age must complete a pregnancy form 200 MBq of 99mTc Hepatolite is injected i.v, the patient remains sedentary for 60 minutes, then lies supine under the gamma camera which is at 20 degrees LAO. If the GB has filled the patient drinks the Ensure Plus, and imaging begins at 2 min/frame for 60min (30 frames). The pain score is noted at the beginning and during the acquisition.

Table 1: Surgery and Histopathology

GBEF<33% GBEF>33% Total (Abnormals) (Normals) 42

94

136

18 (+4 n/a)

11

33

16

10

26

CC*

12 (75%)

7 (70%)

19 (73%)

Mild CC*

3 (19%)

2 (20%)

5 (19%)

No of Patients Surgery Histopathology

No CC* 1 (6%) 1 (10%) 2 (8%) Patient Demographics *CC â&#x20AC;&#x201C; Chronic cholecystitis From January 2013 to August 2014 there were 149 patients referred for HIDA studies. Thirty came directly from Table 2: Histopathology Results for the Abnormals with Surgery the Emergency Department, 113 from hospital clinics or wards, and 7 from GPs or specialists outside the hospital.

Pt EF Pt EF No GB filling was seen at 60 minutes 1 2 need histopathology 12 20 mild CC/cholesterolosis in 8 patients and these went on to have a morphine study instead. Five other 2 2 Other hospital 13 21 CC patients were referred for Sphincter 3 7 moderate CC 14 21 need histopathology of Oddi dysfunction following previous cholecystectomy and this group had a 60 4 8 CC 15 22 moderate CC / cholesterolosis minute acquisition starting at the time of 5 11 Other hospital 16 23 CCs / cholesterolosis injection of 99mTc HIDA. Ensure Plus was consumed when the hepatic ducts appeared 6 13 Other hospital 17 25 moderate non-specific CC and all had a normal Hopkins score 7 13 CC / cholesterolosis 18 26 no significant inflammation calculated from the time/activity curves obtained from the images.

but small calculi++ 8 14 mild CC 19 26 CC b) Results 9 16 mild CC/cholelithiasis 20 27 CC Our radiological records were examined and indicated that 42 of the patients had a 10 17 mild CC 21 28 CC, no stones cholecystectomy within our hospital system, 11 17 Other hospital 22 30 CC so these were followed up using their hospital records. without a record of GB surgery (to date).

Of the 136 patients who had a GB and were studied with Ensure Plus, 42 (31%) had a GBEF less than 33%. Of these, 18 (43%) had a cholecystectomy at our hospital. Another four patients had a Sensitivity and Specificity cholecystectomy at another hospital, and the remaining 20 patients From Table 1, there were 15 true positives, 2 true negatives, 8 false still have to be contacted directly for follow-up. The remaining 11 negatives and 1 false positive. This gives a Sensitivity of 65% and patients who had a cholecystectomy had a GBEF greater than 33%, Specificity of 66%. and these were included in the follow-up of hospital records.

All of the patients who had surgery should be contacted and asked Histopathology was available on all the cholecystectomies apart whether it relieved their symptoms. This would provide an even better from two of the abnormals and one of the normals. Seventeen of the18 analysis of sensitivity and specificity. This will be done in due course. patients with a low GBEF had confirmed chronic cholecystitis and 9 of the 11 normals also had chronic cholecystitis (See Table 1). Among Correct Diagnosis with Ensure Plus? the normals here there were five with gallstones and five had other Has Ensure Plus been a reliable substitute for exogenous CCK? gastrointestinal problems: prior sleeve gastrectomy (2), pancreatitis Without comparative results of sensitivity and specificity for studies (2), hepatic resection (1). using CCK this question cannot be answered conclusively. However it A more detailed analysis of the histopathology results for each is reassuring that of the 18 positive studies which were followed with patient is displayed in Table 2 for those with abnormal HIDA scans and surgery, all the GBs appeared abnormal at surgery and histopathology in Table 4 for those with normal scans. In all the following tables the available in 15 of these confirmed it. There was just one patient with patients are sorted by their GBEF in ascending order. no significant GB inflammation but she was 86 years old and had Table 3 gives an analysis of the patients with abnormal scans

33 u

A retrospective audit on the use of ensure plus for HIDA scans GB sludge on ultrasound and CT showed 3 small stones.

One could argue that the normal range should be increased to reduce the number of false negatives, but only one of these patients had a GBEF below 50%. These patients in particular need to be questioned about the effectiveness of their surgery as it is very possible that there was some other cause for their symptoms.

Table 3: Follow-Up of the Abnormal Results with no Surgery (at SJoGH)y Pt

EF Pt

23

7

33 25

24

10

34 26

25

12

prob no surgery (religion)

35 26

26 13 Further Development 27 15 Although there was a perception of false positives before undertaking this audit 28 16 this appears to be not so. However it was 29 16 considered that delayed gastric emptying particularly in the acute cases might have 30 21 some influence on the results.

Consequently, in April 2014 the protocol

was changed to having the patients semirecumbent during imaging, with the belief 31 24 that this would promote gastric emptying.

The patients tolerated this position much 32 24 better and the Ensure Plus could be given without moving the patient. A note of caution however was that the GB tended to lie more medially in this position, necessitating a camera angle of more than the usual 20 degrees LAO.

EF

Ca colon.

No mention of GB removal

36 26

Other specialist, stones ++

37 27

Referred for surgery

38 29

Referred for surgery

39 29

No private cover

40 29

No real fat problem – likes to drink olive oil.

Renal stones, Lyme disease

41 31

GP states “probable Crohn’s disease”

42 32

Table 4: Histopathology for Patients with Normal GBEF who had Surgery EF Surgeon’s notes and/or histopathology 35 Chronically inflamed GB + adhesions. Sleeve gastrectomy.

Histopathology - CC, cholesterolosis

55 GB thickened, oedematous + adhesions, wide cystic duct (CD).

Histopathology - mild changes, mild cholesterolosis

60 CC/cholelithiasis (multiple stones <4mm) 64 Omental adhesions, no significant pathology, no stones 67 No active inflammation, mild CC + 10 yellow stones <1mm 74 CC, no stones 82 CC/cholelithiasis (multiple <1mm) 88 CC/cholelithiasis (multiple <1mm) 88 CC/cholelithiasis (multiple <1mm) References 90 CC, no stones Al-Muqbel K et al, Usefulness of fatty meal- stimulated 94 Many abdominal surgeries, no pathology available cholescintigraphy in the diagnosis and treatment of chronic acalculous cholecystitis, Ann Nucl Med, 2009 23:137-142 pharmacy/services/di/kinevac.htm, Accessed 3 March 2015 Society of Nuclear Medicine, Sincalide is Temporarily UnavailableZiessman HA , Hepatobiliary Scintigraphy in 2014, J Nucl Med 2014; Again, interactive.snm.org, Accessed 3 March 2015.

55:967-975 Stone G, et al, Gallbladder emptying stimuli in obese and normalZiessman HA et al, Cholecystokinin Cholescintigraphy: Methodology weight subjects, Hepatology, 1992; 15:L795-L798 (Online) and Normal Values Using a Lactose-Free Fatty-Meal Food UIC College of Pharmacy, Drug Information Centre, Alternatives to Supplement, J Nucl Med August 1,2003; 44:1263-1266 Sincalide (Kinevac) for Scintigraphic Studies, https://www.uic.edu/

34 Gamma Gazette March 2015

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crossword solutions

Australian and New Zealand Society of Nuclear Medicine