Nuclear Medicine in Greece
Chariklia Giannopoulou, MD Assistant Director
Dimitris Kalkanis, MD Registrar Nuclear Medicine Dept
“Evangelismos� Hospital, Athens, Greece
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Lu xe m bo ur g N et he rl a nd s
Ita ly
re ec e
er m
G
G
Fr an ce
Fi nl an d
D en m ar k
system/100.000 inhabitants
Ionizing radiation imaging systems/population in EU 2004
5
4,5
4
3,5
3 Mammograph
2,5 CT
Îł-Camera
2
1,5
1
0,5
0
Nuclear Medicine in Greece • Founded in 1973 (1958) • 270 NM specialists – Education • • • •
5 years Internal Medicine Nuclear Medicine Radiology+Cardiology/Endocrinology/Oncology
– National exams by Ministry of Health – Accreditation – License to • Practice NM • Order and/or to inject radiopharmaceuticals
– PET: EANM /SNM courses + practice abroad – EANM/SNM fellowship
Nuclear medicine imaging systems in Greece 250
200
150 Îł-camera PET/CT 100
50
0 1999
2002
2005
Distribution of NM facilities in Greece - 2006
Distribution of Îł-cameras in Greece 2003 60
50
40
NHS
30
Private
20
10
0 Athens
Thessaloniki
Heraklion Îł-cam eras 2003
Rest
NM procedures per year in Greece 250000
200000
150000
NHS
procedures
PRIVATE TOTAL
100000
50000
0 2001
2002
2003
Diagnostic NM procedures in Greece, 2003 100000
90000
80000
in vivo procedures 2003
70000
60000 NHS
50000
Private
40000
30000
20000
10000
0 Athens
Thessaloniki
Heraklion
Rest
NM procedures in Greece oco card
2004 Onco
Cardiac
Bone
“Evangelismos” Hospital 2005 Tertiary NHS Hospital, founded 1884 970 beds, 36 clinical deps,13 laboratory depts, 49.937 pts/year (2004), 2.882 employees
905 2135 1176
ONCOLOGY CARDIOLOGY OTHERS
“Evangelismos” Hospital • Oncology SPECT – MDP-Tc99m – Ga-67 – MIBG-I 123/131 – NorChol – Octreoscan – Neospect – V-DMSA – Sestamibi
• Cardiology SPECT – Tl-201 – Sestamibi – Tetrofosmin – Ventriculography
• Others SPECT/Planar – – – – –
Renal Gastric emptying Lung Brain DATscan
PET •
Whole body, cross-sectional tomographic scan, with the use of positron emitting radiopharmaceuticals – Functional imaging • Metabolic changes precede anatomic changes • Molecular imaging
– Better image quality – Quantification of results – Non interventional imaging
PET radiopharmaceuticals • • • • • • • • • •
11C: 20.4 min 11CO 11C-Raclopride 11C-N-
ethylspiroperidol 11C-hydroxyephedrine 11C-acetate 11C-L-deprenyl 11C-L-methionine 11C-thymidine 11C-Flumazenil
• •
13N:
10 min 13N-ammonia
• • •
15O:
120 sec 15O-water 15O-butanol
• • • • • • • • • • • • • • • •
18F: 110 min 18F-fluoride 18F-FDG 18F-6-fluoroDOPA 18F-fluoromethane 18F-N-methylspiroperidol 18F-6-fluoronorepinephrine 18F-14-fluoro-6-
thiaheptadecanoate 18F-16-fluoro-17b-estradiol 18F-fluoroethyl-oubain 18F-Fluoromisonidazole 82Rb+
ion 68Ga-EDTA 62Cu-PTSM 76Br-bromolisuride 124I-monoclonal antibody
18FDG
• Glucose analogue • Metabolically trapped in cells with glycolytic phenotype (cancer cells) • Reflects metabolism, viability, proliferation • Mostly utilized radiopharmaceutical in PET Oncology – 18F T1/2 =110 min
18FDG Abstracts SNM 2005
500 450 400
FDG 490
350 FDG 300
11-C 15-O
250 200 150 100
11-C 102 15-O 30
50 0 1
PET procedures in USA
Oncology 5% Neurology 75%
Oncology 85%
Cardiology 5%
Cardiology 15%
Mid-1980s
Neurology 10% 2002-2004
Major indications for PET/CT in Oncology • • • • • •
Initial diagnosis Initial staging Restaging after therapy Treatment monitoring Relapse monitoring Radiotherapy planning
The contribution of PET/CT to improved patient management • Change in stage (30% of patients) – Avoidance of unnecessary diagnostic or therapeutic procedures • Cost, toxicities, morbidity, mortality
• Change in management (20% of patients) • Treatment monitoring – Individualization of treatment • Flexibility • Cost , toxicities, morbidity, mortality
– Assessment of efficacy of novel therapies • Research tool • Liaison with industry
“Diagnosing Early Always Pays” or
(
with Popper’s Approach
)
Diagnosing Late never Pays
PET use evidence level in various neoplasias Neoplasm Lung - SPN
Diagnosis Staging Restaging
X
X
X
A
X X X
X
A
X
X X
Thyroid
X
Testicle
X X X
Breast Melanoma Head and Neck CUP
X X X
X
Musculoskeletal
X
Evidence
X
Brain & Spinal Cord
Esophagus
Treatment
X
Colon & Rectum Lymphoma
Recurrence
A
X
B B
X X X
B B B
X
B C
X
X
C C
Single Dose Carboplatin at 72 hrs
Scientific contributions on PET/SPECT at SNM Congress U.S.A. 1200 1000 800 600 400 200
19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05
0
PET SPECT
SPECT and PET scientific contributions in Oncology (2003 EANM Congress) 25
20
15 SPECT FDG PET/PET others
10
5
0 Brain
Head and
Thyroid
Lung
NET
Breast
Neck
SPECT 45%; FDG PET / PET others 55%
Lymphoma
Number PET Scanners/Million in Europe, end 2002
USA - PET sites projection
USA
Estimated demand for cancer-related PET scans in England, 2005
Lung cancer
Suitability for radical therapy Solitary pulmonary nodule Monitoring recurrence
10.000
Lymphoma
Staging, monitoring treatment response
15.000
Colorectal ca
Recurrence assessment, resection of liver mets
5.000
Oesophageal ca
Suitability for radical therapy
2.000
Others with level “B” evidence
Brain,spinal cord, Thyroid, Testicular, Sarcoma,Melanoma
5.000
Others with level “C” evidence
Head and neck, Breast ca, Unknown primary
3.000
TOTAL 40.000
Projected need of PET/CT facilities - Greece
UK model
12
USA model
26
PET/CT facilities in Greece
4
PET/CT facilities in Greece • • • •
“Hygeia” Hospital “Iatrikon” Hospital “Foundation for Biomedical Research” “Evangelismos” Hospital
Hygeia Hospital • • • • • • • •
Started on 26-06-2004 Siemens Biograph LSO 80pts/month, approx.1000pts/year Variety of cancer types Waiting of one week 70% pts from Athens 20% pts from Thessaloniki 10% pts rest of Greece
PET/CT to be installed
• • • • •
Thessaloniki Heraklion Alexandroupolis Larissa Patra
FDG Production Unit • In 2004, BIOKOSMOS SA launched the operation of the first Production Facility for Radiopharmaceuticals in Greece • Particle accelerator (cyclotron) for the production of radioisotopes (dual particle, dual energy) • Radiopharmaceutical – Synthesis unit – Dispension unit – QC Laboratory
• The Facility is licensed by the Ministry of Development, the Greek Atomic Energy Commission and certified by the National Organization for Medicines (E.O.F.) according to the Good Manufacturing Practice for Radiopharmaceuticals, the guidelines of the European Union and the World Health Organization.
Reimbursement • Proposal by the National Advisory Committee: – – – – – –
Lung Lymphoma Colorectal Oesophagus Head and Neck Breast
• Not yet approved by the NHS or private insurance companies • € 1500 (FDG-PET/CT)
The power of positrons Jun 8th 2006 From The Economist print edition
Scanning the future
Conclusions • There is a growing market for PET in Greece • Greece is acquiring a major role in PET in the Balkans • Greek doctors acknowledge the benefits of PET in patient management • Nuclear Medicine in Greece is standing up to a similar level to the rest of the EU • Education of physicians, technologists and staff is adequate to dealing with clinical PET • Issues to be solved: – Installation of new PET equipment – Reimbursement – Availability of deliverable radiopharmaceuticals
Thank you