Second annual symposium: Current status and future directions of SPECT/CT imaging by BIR Publishing

2nd annual symposium: Current status and future directions of SPECT/CT imaging 25 February 2013

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Welcome to the BIRâ&#x20AC;&#x2122;s 2nd Annual SPECT/CT imaging symposium: Current status and future directions of SPECT/CT imaging, organised by the Nuclear Medicine and Molecular Imaging Committee. This is a sell out event so please make use of all available seats. The exhibition will be open during break times in the catering areas. We value your feedback. Please complete the online survey so we can improve your experience at future events. To access the survey please enter https://www.surveymonkey.com/s/SPECT_CT_2013 into your internet browser. Your CPD certificate will be emailed to you after the meeting, please allow up to 3 weeks for it to be distributed. If you have any queries during the day please ask the event coordinator who will be happy to help. Please remember to return your badge at the end of the day. We hope you find the day both interesting and enjoyable.

Programme SESSION 1: BASIC SCIENCES, INFECTION AND CARDIOLOGY Chair: Dr L Livieratos, Guy’s & St Thomas’ NHS Foundation Trust, London Professor A Groves, University College Hospital, London 9.30 PHYSICS Dr L Livieratos, Guy’s & St Thomas’ NHS Foundation Trust, London 9.50 TRAINING IN HYBRID IMAGING Professor I Garai, Debrecen University, Hungary 10.10 INFECTION Dr M Umar Khan, Al-Jahra Hospital, Kuwait 10.30 NUCLEAR CARDIOLOGY Dr N Sabharwal, Oxford Heart Centre 11:00 Refreshments SESSION 2: SENTINEL NODE, NETS, BONE AND THYROID Chair: Dr T Barwick, Imperial NHS Trust, London Dr S Rizwan, Institute of Nuclear Medicine, London 11.30 SENTINEL NODE LOCALISATION Professor C Hoefnagel, Netherlands Cancer Institute 12.00 NEUROENDOCRINE TUMOURS Dr S Navalkissoor, Royal Free Hospital, London 12.20 SPECT/CT: HAND SURGEON’S PERSPECTIVE Professor B Povlsen, Guy’s & St Thomas’ NHS Foundation Trust, London 12.40 THYROID CANCER Dr H Mohan, Guy’s & St Thomas’ NHS Foundation Trust, London 13.00 DISCUSSION 13:15 Lunch SESSION 3: SPORTS INJURIES, ORTHOPAEDICS AND MALIGNANT BONE DISEASE Chair: Dr S Vijayanathan, Guy’s & St Thomas’ NHS Foundation Trust, London Professor G Cook, Guy’s & St Thomas’ NHS Foundation Trust, London 14.00 SPORTS INJURIES Dr R T Dhawan, Imperial College Healthcare Trust, London 14.30 KNEE AND HIP PROSTHESES Dr M Hirschmann & Dr H Rasch Kantonsspital Bruderholz, Switzerland 15.00 MALIGNANT BONE DISEASE Dr G Gnanasegaran, Guy’s & St Thomas’ NHS Foundation Trust, London 15.20 WRIST/HAND AND FOOT/ANKLE PAIN Dr S Vijayanathan, Guy’s & St Thomas’ NHS Foundation Trust, London 15:50 Refreshments

SESSION 4: ORTHOPAEDICS, PAEDIATRICS, LUNG AND PARATHYROID Chair: Dr M U Khan, Al-Jahra Hospital, Kuwait Dr S Lewitschnig 16:10 POST OPERATIVE SPINE Dr R T Dhawan, Imperial College Healthcare Trust, London 16.30 PAEDIATRICS Dr L Biassoni, Great Ormond Street Hospital, London 16:50 LUNG Dr K Wechalekar, Royal Brompton Hospital, London 17:10 PARATHYROID Dr A M Quigley, Royal Free Hospital, London 17:30 CT DOSE REDUCTION STRATEGIES Dr M Burniston, Royal Free Hospital, London 17:50 DISCUSSION 18:00 CLOSE

SPEAKER PROFILES Dr L Livieratos, Guy’s & St Thomas’ NHS Foundation Trust Dr Livieratos is a Medical Physicist in Nuclear Medicine at Guy’s & St Thomas’ Hospitals and Imaging Sciences at King’s College, London. He has worked in PET methodology at Hammersmith Hospital collaborating with the MRC PET Oncology and PET Cardiology research groups on radiotracer image-based quantification and novel schemes for patient motion correction such as respiratory motion correction of PET projection data. He subsequently worked as a clinical scientist at Guy’s & St Thomas’ involved with diagnostic and therapeutic applications, including the clinical implementation of the first SPECT/CT in Europe with diagnostic 16-slice CT. He is involved with teaching of radionuclide imaging physics at King’s College and the supervision of students and trainee clinical scientists. His research interests include multi-modality imaging, image quantification and tracer kinetics methodology for translational applications and patient-specific dosimetry in targeted radionuclide therapy. Professor I Garai, Debrecen University, Hungary 1990 1994 1999 2004 2012

MD degree in the University Medical School of Debrecen, Hungary Board certification in Radiology, Debrecen, Hungary Board certification in Nuclear Medicine, Budapest, Hungary PhD degree in Theoretical Medicine Habilitation in medicine

She is associate professor in the University of Debrecen and medical director of ScanoMed Medical Diagnostic Research and Training Center Ltd. She coordinates the patient care and research activity and actively takes part in everyday patient care. She participates in evaluation of gamma camera and hybrid (PET/CT and SPECT/CT) nuclear medicinal examinations and in designing isotope therapies. She is widely experienced in imaging techniques of clinical pharmacological research, especially of human phase clinical trials. She is the qualified tutor of the Medical and Health Science Centre at the University of Debrecen. She is also a member of the Hungarian Nuclear Medicine Society and the Nuclear Medicine professional council. Research field of interest: Clinical pharmacological research, the possible applications of multimodal imaging, quantification in nuclear medicine.

Dr M Umar Khan, Al-Jahra Hospital, Kuwait Dr Muhammad Umar Khan graduated in 2001 from Allama Iqbal Medical College, Lahore, Pakistan. Subsequently, he completed his Residency and fellowship training (FCPS) in Nuclear Medicine in 2008 from Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan. Dr Khan trained in PET/CT Imaging at the Clinical PET Center St. Thomas’ Hospital, and the Hammersmith Hospital, Imperial Healthcare, NHS, London UK. Dr Khan is a recipient of the EANM Marie Curie training grant as well as the UICC ICRETT fellowship. He is a Union of International Cancer Control (UICC) Fellow and did his Radio-immunotherapy fellowship at the Royal Free Hospital. He has also received the ARCCNM and INCTR awards for his research papers. Presently he works in Ministry of Health Kuwait, Al-Jahra Hospital and the Kuwait Cancer Control Center as a Nuclear Medicine/ PET-CT Specialist. He is also the Site Co-coordinator for the Kuwaiti Board Nuclear Medicine residency training Programme. His areas of interest include molecular imaging in nuclear oncology and cross-sectional/hybrid imaging. Most recently Dr Khan has contributed a chapter titled “Radionuclide Infection Imaging: Conventional to Hybrid” in a book “12 Chapters in Nuclear Medicine” published by intech open access publishers. Dr N Sabharwal, Oxford Heart Centre, Oxford Trained in Cardiology in London and Oxford. Research focussed on MPS in the chest pain clinic. Currently Consultant Cardiologist in Oxford specialising in cardiac imaging (nuclear, CT & echocardiography). Treasurer and President-elect of British Nuclear Cardiology Society. Professor C Hoefnagel, Netherlands Cancer Institute, Holland Current position: Head of the Department of Nuclear Medicine The Netherlands Cancer Institute, Amsterdam Education/qualifications: 1967-1974 Medical training at the Free University in Amsterdam 1974 M.D. registration 1974-1979 Specialist training in internal medicine 1979 S.R.C. registration as internist 1979-1984 Specialist training in nuclear medicine 1984 S.R.C. registration as nuclear medicine physician 1989 Doctorate in medicine, University of Amsterdam Dissertation: The Clinical Use of 131I-meta-iodobenzylguanidine (MIBG) for the Diagnosis and Treatment of Neural Crest Tumors. Professional experience: 1974-1979 Resident in internal medicine and oncology (Andreas Hospital and The Netherlands Cancer Institute) 1979 Nuclear medicine (The Netherlands Cancer Institute) 1988 Head of department

Other functions: Dean of the European School of Nuclear Medicine (ESNM) Teacher European School of Nuclear Medicine (ESNM) Member EANM Advisory Council Member ESR/EANM Curriculum Committee Member EANM Scientific Committee Member EANM PET/CT Course Committee Member Dutch Nuclear Medicine Concilium Memberships: Dutch Society of Nuclear Medicine European Association of Nuclear Medicine Dr S Navalkissoor, Royal Free Hospital, London Dr Navalkissoor a consultant nuclear medicine physician, working at the Royal Free London NHS Foundation Trust, appointed in 2010. Dr Navalkissoor’s special interests include radionuclide therapy and oncological imaging (with a particular interest in neuroendocrine tumours). Professor B Povlsen, Guy’s & St Thomas’ NHS Foundation Trust, London Bo Povlsen is Consultant Orthopaedic Surgeon at Guy’s & St Thomas Hospitals NHS Trust since 1995. He completed his PhD and specialised in Hand Surgery at University of Linköping, Sweden where he was Consultant Hand Surgeon previously, but is now an external Associated Professor of Hand Surgery there. He has experience of using first wrist registration bone scan and now SPECT/CT scans for the diagnosis of hand pain for more than a decade. Dr H Mohan, Guy’s & St Thomas’ NHS Foundation Trust, London Consultant in Nuclear medicine (Since 2003) Guys & St Thomas’ Hospitals Special interest - Radionuclide therapy in Thyroid cancer and Multimodality imaging Dr R T Dhawan, Imperial College Healthcare Trust, London Dr Ranju T Dhawan is a dual specialty accredited Consultant Radiologist & Consultant Nuclear Medicine Physician; she was formerly a Nuclear Medicine Physician (UCL & Royal Brompton Hospitals) who subsequently re-trained in Diagnostic Radiology (King’s College & Royal Marsden Hospitals). She has since been based as a cross sectional Radiologist at St Mary’s Hospital, Imperial College Healthcare NHS Trust, London (2002 - current), practicing in both imaging specialties Dr Dhawan has sub-specialty interests in Chest Radiology and Hybrid Functional Imaging (SPECT CT & PET CT). Having worked with SPECT-CT for 5- 6 years, she has a niche interest in Spinal and Orthopaedic SPECT-CT (amongst other organ interests), collaborating closely with eminent clinical specialists in the area.

Dr M Hirschmann, Kantonsspital Bruderholz, Switzerland Dr Michael T. Hirschmann is a Consultant Orthopaedic Surgeon and head of academic research at the Kantonsspital Bruderholz in Basel, concentrating on knee and hip surgery including primary and revision reconstructive arthroplasty. The research group has been increasingly recognized worldwide for its contribution to orthopaedic imaging. In particular for having positively impacted the field of orthopaedic diagnostics in multimodality imaging for patients with pain following surgery including partial or total knee arthroplasty, high tibialosteotomies and ACL reconstruction. The purpose of their research is to provide and validate novel quantitative image analysis methodologies, to gain a better understanding of the cause of unexplained pain and suboptimal function following joint replacement and other orthopaedic surgical interventions. Dr G Gnanasegaran, Guy’s & St Thomas’ Hospital, London Gopinath Gnanasegaran MB, BS, MSc, MD, FRCP is a Consultant Physician in the Department of Nuclear Medicine at Guys and St Thomas’ NHS Foundation Trust, London, UK. He has written many journal articles and book chapters and has lectured and presented research at national and international meetings. He is currently; Chair-Nuclear Medicine and Molecular Imaging Committee for the British Institute of Radiology (BIR) and Member of EANM Bone Committee. Dr S Vijayanathan, Guy’s & St Thomas’ Hospital, London Sanjay Vijayanathan is a Musculoskeletal Radiologist at Guys and St Thomas’ NHS Foundation Trust, involved in cross modality MSK diagnostics and intervention. Dr L Biassoni, Great Ormond Street Hospital, London Consultant in Nuclear Medicine, Great Ormond Street Hospital for Children and Barts Health NHS Trust and Honorary Senior Lecturer, University College London. Lorenzo Biassoni was born in Genova, Italy, and did his medical degree and his post-graduate general medicine training at the University of Rome “La Sapienza”. He obtained his post-graduate specialist training certificate in Nuclear Medicine in Genova and in London, where he was awarded a Master degree in Nuclear Medicine. After working in Nuclear Medicine training posts at St Bartholomew’s Hospital and Guy’s and St Thomas’ Hospitals, he was appointed as a nuclear medicine consultant at Barking, Havering and Redbridge NHS Trust in 1999. In 2002 he moved as a Nuclear Medicine Consultant to Great Ormond Street Hospital for Children and Barts and the London NHS Trust. In 2006 he became the clinical lead of the Nuclear Medicine Unit, Department of Radiology, at Great Ormond Street Hospital. From 2002 to 2007 Lorenzo was a member of the Paediatric Committee of the European Association of Nuclear Medicine, and chaired the Committee from 2004 to 2007. In that capacity Lorenzo promoted paediatric nuclear medicine in Europe taking an active role in the scientific programme of many international Nuclear Medicine conferences and teaching events.

Lorenzo is actively involved in teaching also at a national level, being the organiser and main teacher and examiner of the paediatric module of the MSc teaching programme in Nuclear Medicine run by Kingâ&#x20AC;&#x2122;s College University of London. He is regularly called to give review lectures on paediatric nuclear medicine at educational events run by the British Nuclear Medicine Society. Lorenzo is on the editorial board of two international nuclear medicine scientific journals and is a reviewer for paediatric nuclear medicine for several international peer-reviewed journals. He is also the UK representative on the Nuclear Medicine Subgroup of the European High Risk Neuroblastoma Study Group. Lorenzo is a member of ARSAC, a Department of Health Committee which advices the British Government on issues related with the use of radiations in healthcare. Lorenzoâ&#x20AC;&#x2122;s main clinical activity at present is aiming at expanding the range of paediatric nuclear medicine tests available at Great Ormond Street Hospital. His clinical interests include Nuclear Medicine in paediatric oncology, SPECT CT in benign bone diseases and Nuclear Medicine applied to the management of children with epilepsy. Dr K Wechalekar, Royal Brompton Hospital, London Dr Kshama Wechalekar is a nuclear physician at Royal Brompton Hospital, London. She currently is the head of department. She specialises in nuclear cardiology and interested in developing new methods of hybrid imaging. She has been working on developing hybrid imaging for VQ SPECT for lobar quantification. Dr A M Quigley, Royal Free Hospital, London Dr Quigley is a consultant in Nuclear Medicine at the Royal Free Hospital. Having gained her MRCP, she trained in radiology and radionuclide radiology in Manchester and London, gaining CCST in radiology in 2004 and CCT in Nuclear Medicine in 2005. Her special interests include radionuclide therapy and nuclear medicine imaging of amyloid patients at the National Amyloidosis Centre. She is the lead clinician for the Royal Free SPECT/CT service.

Abstracts 9.30 PHYSICS Dr L Livieratos, Guyâ&#x20AC;&#x2122;s & St Thomasâ&#x20AC;&#x2122; NHS Foundation Trust The most influential recent development in radionuclide imaging was by far the introduction of multi-modality systems combining functional (PET or SPECT) imaging with CT. Initially, the main marketing incentive for this was the acceleration of transmission scanning for attenuation correction in PET, leading to increased patient throughput and competitive cost effectiveness. However, the diagnostic enhancement of functional imaging by the addition of anatomical information was soon acknowledged, establishing dual-modality imaging in clinical practice. The impact of SPECT/CT became clearer with the introduction around the mid2000s of multi-detector CT components allowing structural imaging at improved versatility and image quality. This was a paradigm shift for SPECT/CT which until then operated CT components attached to the same gantry as the gamma camera and of limited image quality capabilities, especially in terms of axial slice thickness. With the growth of high-end SPECT/CT, differences in acquisition parameters of CT reflect diverse needs in terms of image quality such as voxel resolution and signalto-noise levels which may vary for different clinical applications. An assessment of this relationship between adequate image quality and radiation dose is critical in the context of defined disease pathways. An introduction to SPECT/CT and the current state of instrumentation and methodology will be presented focusing on aspects related to clinical implementation.

9.50

TRAINING IN HYBRID IMAGING Professor I Garai, Debrecen University, Hungary

Tomographic imaging with radiolabelled compounds preceded computer tomographic technology. Hybrid technology has been used since 2000 in routine diagnostic work. Since then the clinical impact of integrated functional and morphological imaging has been proven by large number of studies. Even though several guidelines of hybrid technology have been written and are available in scientific literature, frequent and major deviations can be found in the adapting standards of different sites according to the international surveys of multimodality imaging. Therefore we have to emphasise the importance of continuous training focusing on the positive impact of standardisation on optimizing hybrid technology. High level SPECT/CT and PET/CT imaging can be supported only by experienced and well-trained staff. Conclusion: multidisciplinary (incl. MD, Physicist, Technician, etc.) and multilingual trainings are necessary to promote and sustain high quality hybrid imaging wordwide. Bibliography: 1. Variations in clinical PET/CT operations: results of an international survey of active PET/CT users.Beyer T, Czernin J, Freudenberg LS.J Nucl Med. 2011 Feb;52(2):303-10

2. Variations of clinical SPECT/CT operations: an international survey. Wieder H, Freudenberg LS, Czernin J, Navar BN, Israel O, Beyer T. Nuklearmedizin. 2012;51(4):154-60 3. Multimodality imaging in Europe: a survey by the European Association of Nuclear Medicine (EANM) and the European Society of Radiology (ESR).Cuocolo A, Breatnach E. Eur J Nucl Med Mol Imaging. 2010 Jan;37(1):163-7 4. EANM-ESR white paper on multimodality imaging.Stegger L, Schäfers M, Weckesser M, Schober O.Eur J Nucl Med Mol Imaging. 2008 Mar;35(3):677-80 5. Multimodality imaging training curriculum - general recommendations. European Association of Nuclear Medicine (EANM); European Society of Radiology (ESR).Eur J Nucl Med Mol Imaging. 2011 May;38(5):976-8

10.10 INFECTION Dr M Umar Khan, Al-Jahra Hospital, Kuwait Shaunak Navalkissoor1, Ewa Nowosinska1, Gopinath Gnanasegaran 2 John Buscombe3 1 Dept of Nuclear Medicine, Royal Free Hospital NHS Trust, London, UK 2 Dept of Nuclear Medicine, Guys & St Thomas’ Hospital NHS Trust, London, UK 3 Dept of Nuclear Medicine, Addenbrooke’s Hospital NHS Trust, Cambridge, UK This lecture focuses on the current evidence for the use of SPECT-CT in infection imaging. The single photon functional agents commonly used to image infection include leukocyte imaging (In-111 or Tc-99m labelled), Ga-67 citrate, Tc-99mbiphosphonates and radiolabelled antigranulocyte antibodies. Although many of these agents have been available for a long time, the development of hybrid SPECT-CT technology has brought these agents back to the forefront. This lecture demonstrates that the application of CT to single photon imaging techniques in imaging infection can result in significant improvements in the accuracy of the test (by increasing the specificity and better defining the location and extent of suspected disease). Hybrid fusion images also results in increased confidence of reporting and seems to be applicable to a wide range of clinical situations. For example in bone and joint disease one study showed fused SPECT-CT added additional value over side by side SPECT and CT in 65% for anatomical localization, increased diagnostic confidence in 71%, and altered interpretations in 47% of cases. In a paper looking at use of Ga-67 SPECT-CT in 13 patients with PUO. Ga-67 SPECT-CT was found to improve the diagnostic accuracy vs. planar and SPECT in 4/13 (31%) patients. We feel that overall SPECT-CT has a role in infection imaging, by providing a clearer assessment of whether or not infection is present and an accurate localisation of disease so that the optimum treatment can be administered.

10.30 NUCLEAR CARDIOLOGY Dr N Sabharwal, Oxford Heart Centre, Oxford This presentation will focus on the evidence for SPECT/CT in cardiac patients. The increasing world-wide evidence for such imaging systems will be reviewed. The added value of attenuation correction and anatomical abnormalities will be discussed. Coronary artery calcium scoring and CT coronary angiography are also technically possible in the same setting using this technology. The role of stand-alone systems with fusion software will also be explored. Comparison with alternative modalities will also be discussed. 11.30 SENTINEL NODE LOCALISATION Professor C Hoefnagel, Netherlands Cancer Institute, Holland Sentinel lymph node biopsy: In surgical oncology the sentinel lymph node biopsy (SLNB) is important procedure for the staging of operable tumours at the nodal level. If the first draining node(s) is/are found to be free of tumour cells, more extensive nodal surgery, which may be associated with additional morbidity and complications, e.g. lymphoedema, can be avoided. However, in order to base the entire treatment policy on the analysis of a single or few lymph node(s), it is imperative that the correct lymph node is identified as the sentinel node. Nuclear medicine plays an essential role in the preoperative mapping of sentinel lymph nodes, which subsequently can be selectively approached and resected, guided by an intraoperative gammaprobe. After this technique was introduced for melanoma and breast carcinoma in the early 1990â&#x20AC;&#x2122;s, the number of clinical indications has expanded significantly and the sentinel lymph node biopsy is used in a great variety of tumours. Imaging techniques: For some of the more traditional indications (e.g. melanoma, breast carcinoma, penile and vulvar carcinoma) planar lymphoscintigraphy, both in anterior/posterior and lateral projections and at several time intervals after administration of 99mTcnanocolloid, suffices to locate the sentinel node and mark its position on the skin in most cases. However, for tumours or lymphatics located in anatomically more challenging regions (e.g. the head and neck, abdominal and pelvic areas) more advanced technologies, such as SPECT/CT and intraoperative minigammacamera are needed. Clinical use: The complementary role of SPECT/CT in lymphoscintigraphy in a variety of tumour types (melanoma, breast cancer, head and neck tumours, penile and vulvar carcinoma, cervical and prostatic cancer and renal cell carcinoma) will be demonstrated, showing how the SPECT/CT fusion images and 3D volume rendering can highlight the exact location of the sentinel node in relation to essential anatomical structures, which are relevant to the surgeon. SPECT/CT may provide new insight into the lymphatic spread of tumours like cervical, prostatic and testicular cancer, bladder and renal cell carcinoma.

SPECT/CT also proved to be particularly helpful in the locating of non-axillary sentinel nodes in patients with breast cancer. In addition, in case of non-visualisation of the sentinel node by planar lymphoscintigraphy, SPECT/CT may still reveal and locate the sentinel node. In conjunction with the preoperative planar and SPECT/CT imaging in the Nuclear Medicine department, an intraoperative minigammacamera (Sentinella®) is used during surgery, which is particularly helpful in the head and neck region and in resection of intraabdominal or intrapelvic sentinel nodes guided by a laparoscopic gammaprobe. More recently this technique is also combined with fluorescence imaging during surgery after injecting a hybrid tracer (99mTc-nanocolloid + indocyan green). Conclusions: SPECT/CT is more sensitive and more accurate than planar lymphoscintigraphy in locating the sentinel node(s), in particular in tumours of the head and neck, the abdomen and the pelvis, as well as in the localisation of non-axillary sentinel nodes in breast carcinoma. SPECT/CT may influence the surgical approach of the sentinel node(s) and improve the staging procedure. 12.00 NEUROENDOCRINE TUMOURS Dr S Navalkissoor, Royal Free Hospital, London This talk describes the advantages of SPECT/CT in imaging and therapy of neuroendocrine tumours (NETs). The talk is categorised into the following sections: diagnosis of NETs; somatostatin receptor scintigraphy in NETs; MIBG imaging in NETs; Radionuclide therapy in NETs; miscellaneous uses of SPECT/CT in neuroendocrine tumours. For somatostatin receptor scintigraphy, the advantages of SPECT/CT over conventional scintigraphy are discussed. These advantages include discriminating physiological from pathological uptake, more accurately staging disease (both extent of disease and localisation of the primary), follow-up/restaging patients, and accurately determining somatostatin receptor status to plan ‘cold’ or radiolabelled somatostatin receptor treatment. The next section is on the value of SPECT/CT in mIBG imaging. The advantages of SPECT/CT compared to conventional planar/ SPECT scintigraphy, in more accurately staging patients, are discussed. The third section looks at the value of SPECT/CT in radionuclide therapy of NETs. The first radio-targeted therapy where SPECT/CT is used is peptide receptor radionuclide therapy treatment (PRRT). SPECT/CT adds value in Lu-177-DOTATATE post-therapy imaging by more precisely determining response to treatment and accurately determining patient/ tumour dosimetry. The second radionuclide therapy discussed is selective internal radiation therapy (SIRT) in NETs where the value of SPECT/CT in the Tc-99m MAA work up is described. The final short section looks at miscellaneous nuclear medicine tests in NETs, focussing on sulphur colloid studies and the value of SPECT/CT.

12.20 SPECT/CT: HAND SURGEON’S PERSPECTIVE Prof B Povlsen, Guy’s and St Thomas’ Hospital, London This presentation will briefly describe the different types of conditions a hand surgeon treat. Diagnosis of pain will be discussed in detail. Examples of complex clinical cases where SPECT/CT scan have been used to alter the chosen treatment will be presented and discussed with the audience. 12.40 THYROID CANCER Dr H Mohan, Guy’s & St Thomas’ NHS Foundation Trust, London Post therapy imaging following radio iodine treatment provides vital information in appropriate staging and management of thyroid cancer. SPECT/CT is being increasingly used in this setting and provides additional information over conventional planar imaging in directing management of patients. This talk looks at the role of SPECT/CT imaging following radio iodine therapy, specific case studies and current literature evidence. 14.00 SPORTS INJURIES Dr R T Dhawan, Imperial College Healthcare Trust, London Competitive elite sport (and indeed amateur sports) places immense demands on athletes and the medical teams looking after them. Sports medicine is a far more exact and well-resourced science than it ever was and it demands more exact diagnostics. Whilst the combination of plain films, CT and MRI conventionally address majority of injuries, the emergence of Bone HDP SPECT CT offers sports medicine an exciting new modality to examine a somewhat different visual of the metabolic injury cascade. When embellished by CT, it has the potential to sometimes pick up otherwise occult findings and examine a different perspective of the patho-physiology with a potential bearing on pain generation. The role of Bone SPECT-CT in the clinical setting should however be seen in the context of other imaging and the technique used for trouble shooting and refining diagnoses rather than first-line imaging. Given we are dealing with a relatively young population, it should be utilized judiciously with due attention to protocols to optimize radiation. This lecture presents my experience in working closely with sports medicine specialists and orthopaedic surgeons who manage and treat elite and amateur athletes from several sports disciplines.

15.00 MALIGNANT BONE DISEASE Dr G Gnanasegaran, Guy’s & St Thomas’ Hospital, London Early detection or exclusion of bone metastases is important in management of patients with cancer. The skeletal system is the third most common site for metastases following lung and liver and radionuclide bone imaging with 99mTc-MDP is the standard imaging modality. Several reports emphasize the high sensitivity of 99mTc-MDP bone scan in the diagnosis of bone metastases. However, the specificity of radionuclide bone scan is quite variable or low. In general, the accuracy in characterising and localising benign and malignant lesions is limited and often will initiate the need for further radiological imaging such as CT or MRI for a definitive diagnosis. SPECT-CT may be useful in classifying equivocal or indeterminate lesions on a 99mTc-MDP bone scan [1-4]. Hoger et al have reported improved accuracy of bone scintigraphy by correctly classifying equivocal lesions [1,2]. Romer et al reported, SPECT-guided CT was able to clarify more than 90% of SPECT findings classified as indeterminate [3]. Further, Utsunomiya et al have reported increased diagnostic confidence with fused SPECT-CT images compared with separate sets of scintigraphic and CT images in differentiating malignant from benign bone lesions [9]. Recently Zhao and coworkers, assessed 141 lesions in 125 cancer patients with non-specific findings on planar imaging (5), and compared the efficacy of multislice SPECT/CT to SPECT alone and SPECT + CT. The sensitivity, specificity and accuracy of SPECT/CT were significantly higher than SPECT alone. When SPECT/CT compared to SPECT + CT the sensitivity was similar but notably, specificity and accuracy were significantly higher. Thus, available data suggests the addition of localised SPECT-CT in the assessment of indeterminate lesions on planar imaging improves diagnostic performance, diagnostic confidence and inter-observer agreement in most cases. In general, a definitive diagnosis is made in the majority of cases, which may reduce the use additional imaging, such as MRI. In general, there is convincing evidence to suggest a role for SPECT-CT in the assessment of equivocal lesions on planar imaging. SPECT-CT may provide a one-stop diagnostic service in cancer patients and may shorten the diagnostic process. SPECT-CT is spectacular. References: 1. Horger M, Bares R.The role of single-photon emission computed tomography/computed tomography in benign and malignant bone disease.Semin Nucl Med. 2006 ;36(4):286-94. 2. Horger M, Eschmann SM, Pfannenberg C, et al. Evaluation of combined transmission and emission tomography for classification of skeletal lesions. AJR. 2004;183:655–661. 3. Romer W, Nomayr A, Uder M, Bautz W, Kuwert T. SPECT-guided CT for evaluating foci of increased bone metabolism classified as indeterminate on SPECT in cancer patients. J Nucl Med. 2006;47:1102– 1106. 4. Utsunomiya D, Shiraishi S, Imuta M, Tomiguchi S, Kawanaka K, Morishita S, Awai K, Yamashita Y.Added value of SPECT/CT fusion in assessing suspected bone metastasis: comparison with scintigraphy alone and nonfused scintigraphy and CT.Radiology. 2006 ;238(1):264-71. 5. Zhao Z, Li L, Li F, Zhao L (2010) Single photon emission computed tomography/spiral computed tomography fusion imaging for the diagnosis of bone metastasis in patients with known cancer. Skeletal Radiol 39:147-53 6. T. Barwick, G. Gnanasegaran, and I. Fogelman. Potential applications and limitations of SPECT-CT in classifying bone lesions in patients with cancer. In I Fogelman et al; Radionuclide and Hybrid Bone Imaging DOI 10.1007/978-3-642-02400-9-29 ;735-749 7. G. Gnanasegaran, K Adamson and T. Barwick, , Multislice SPECT/CT gains wider clinical acceptance. Diagnostic Imaging Europe. Vol. 26 No. 1

16:10 POST OPERATIVE SPINE Dr R T Dhawan, Imperial College Healthcare Trust, London Decision making for spinal fusion is controversial. The intention is to remove a potential pain generator from failure of the normal joint structure that result in pathological movements that result in pain. Evidence for the pre-operative accuracy of disc levels for spinal fusion is limited. Following surgical intervention when patients have persistent pain, a combination of plain films, CT and MRI is conventionally used to assess the metalwork, fusion and potential nerve impingement. It is by and large a difficult clinical and imaging field due to inherent diagnostic limitations imposed by metalwork. Growing experience with Tc99m HDP Bone SPECT/CT in the post-operative suggests it can be a powerful tool and red flag issues not apparent on structural imaging alone. The strength of the modality though arises from the correlation of tracer signal with structural findings on CT. The lecture presents my collaborative experience (working with Specialist Spinal Units) in the understanding of the role and limitations of Bone SPECT-CT in the post-operative setting. 16:50 LUNG Dr K Wechalekar, Royal Brompton Hospital, London Ventilation perfusion imaging has been conventionally used as a planar technique for many decades. However it suffers from drawbacks of overlapping of anatomical segments and difficulties in visualising all lung segments making interpretation difficult and being inconclusive in some cases. Various studies in the last decade have shown advantage of performing SPECT over planar and prompted the EANM to issue guidelines for the diagnosis of pulmonary embolism in 2009. VQ SPECT identifies more and smaller mismatches with greater specificity & reduces inter-observer variability. It improves localisation of defects and their size and does not take longer than planar imaging time. It can generate images like planar and reduces indeterminate interpretation and delivers much lower radiation dose to patient. SPECT is not free from artefacts such as patient motion causing mis-registration or trapping of ventilation aerosols in emphysematous bullae but some of these can be better understood if reported in conjunction with CT. The SPECT can be co-registered with CT performed simultaneously or on a separate scanner with new hybrid software to combine structural and functional information. This is particularly useful in preoperative assessment of lung function for lobectomy, pneumonectomy and lung volume reduction surgery. This will allow the surgeons to accurately identify the dysfunctional segments for resection. We are working towards creating 3dimensional quantification software that can do individual lobar contribution It is time for reinventing VQ imaging for the benefits of reducing radiation dose to patients and by improving interpretation using new software and combining it with CT in selected cases.

17:10 PARATHYROID Dr A M Quigley, Royal Free Hospital, London Parathyroid adenomas account for 80-90% of cases of primary hyperparathyroidism, with the other 10-20% of cases secondary to either multiple adenomas, or gland hyperplasia. Imaging, and in particular SPECT/CT of parathyroid glands, has become increasingly important in the pre-operative work up patients undergoing parathyroid surgery, particularly with the move towards minimally invasive surgery using a unilateral surgical approach. Numerous methods of performing parathyroid scintigraphy are available, including dual isotope with subtraction and dual phase imaging using 99m Tc MIBI. Some studies have shown enhanced sensitivity of SPECT over conventional planar imaging. Increasingly SPECT/CT is becoming more widely available. As with planar and SPECT alone imaging, an abundance of protocols have been described. From the published literature, some studies have found SPECT/CT to offer an advantage over SPECT alone, particularly in the context of ectopic adenomas, both in terms of sensitivity and specificity. In the case of eutopic glands, consensus from the literature is less clear. Despite this, improved localization of tracer uptake afforded by the CT component of the study has been reported to reduce mean operating time and hence costs in the management of patients with hyperparathyroidism.

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