Nuclear medicine in Greece (Chariklia Giannopoulou)

Nuclear Medicine in Greece

Chariklia Giannopoulou, MD Assistant Director

Dimitris Kalkanis, MD Registrar Nuclear Medicine Dept

“Evangelismos� Hospital, Athens, Greece

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Ita ly

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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