2020 AUTUMN EDITION ISSUE 29
Special Feature
CELEBRATING WOMEN IN NUCLEAR MEDICINE
2020 AUTUMN EDITION ISSUE 29
Contents 3 6 7 13 14 18 Society Women at Work 28 • The History of the First State Branch of the ANZSNM in NSW • Unlocking the Secrets of Proton Beam Therapy • Geoff Currie - Admitted as Member of the Order of Australia • Discovery, A New Zealand Nuclear Medicine Department Voyage
38 • Incidental Vasculitis finding on PET/CT • I’m not crying, there’s something in my eye: a rare dacroscintigraphy case • 18F- FDG PET/CT for cardiac sarcoidosis - diet preparation for the vegan patient • Being Prepared for the Emotional Journey of Breast Cancer Patients • What's that? - Soft Tissue Uptake on Bone Scan: Artefact or Rare Finding?
55 Design & Production Ester Gomez, Creative Director Enovate Studio ester@enovatestudio.com www.enovatestudio.com
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The views expressed in any signed article in the journal do not necessarily represent those of the Society. The individual rights of all authors are acknowledged. © 2020 The Australian and New Zealand Society of Nuclear Medicine. 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).
From the President
I
am writing this report in the midst of one of the greatest challenges the world has faced. Certainly, in my memory, there has never been a more global event that is unfolding. I read news updates almost constantly, and I am horrified by the extent of the tragedy unfolding. At the same time, I am also amazed by acts of compassion and by hope driven by resourcefulness. The COVID-19 pandemic has changed everything in our lives in such a short time. Words such as ‘social distancing’ and ‘flatten the curve’ are in our daily vocabulary. In amongst this, we are caring for patients, supporting our colleagues and appreciating our loved ones.
In this report, I was planning to share my excitement and anticipation of the 50th Annual Scientific Meeting, to be held in Sydney from 24-26th April 2020. The ASM was planned to have an education program to cover all interests, social events for networking, highlight international attendees and speakers to celebrate with us, and a full exhibition hall with sponsors and exhibitors. We were planning to recognise our legends and embrace our emerging leaders. The word ‘unprecedented’ has been used more this month, than ever before, however, the cancellation of the ASM truly was unprecedented. I share the disappointment of all delegates who had planned to attend. I extend my thanks to the Conveners (Geoff Currie, Matt Ayers, Socrates Angelides and Hosen Kiat) for their efforts in creating a spectacular program, and I thank the sponsors, speakers, and all those that submitted abstracts for their contribution. ANZSNM will now work towards delivering the educational content as an ‘On-demand’ series over the remainder of the year, as we continue to ensure the educational needs of members are met. I have now almost completed my two years as President of ANZSNM. It is difficult to reflect on this time, without being influenced by the challenges. The ANSTO Molybdenum production issues were a major challenge, as this impacted so widely on our community. The cooperation of so many to try to minimise impact, and the focus on prioritising patient care, was however a demonstration of the strength of our NM community. The current COVID-19 pandemic is looming as an even greater challenge, and one that will require the entire community’s strength, courage and conviction to overcome. Amongst the challenges, there have also been achievements to be celebrated. The success of ARTnet in promoting and supporting high quality, collaborative clinical trials in Nuclear Medicine in Australia is highlighted by the recent publication of the ProPSMA trial in the Lancet in March, 2020.
“ANZSNM will now work towards delivering the educational content as an ‘On-demand’ series over the remainder of the year, as we continue to ensure the educational needs of members are met.”
This is a landmark paper demonstrating the clinical value of PSMA PET imaging in primary staging of men with high risk prostate cancer, showing benefit of PSMA PET over conventional imaging for accuracy and management change. This collaborative trial involved ten Nuclear Medicine sites across Australia, and achieved patient recruitment well ahead of target. This paper will have international impact in informing clinical care of prostate cancer patients. Congratulations to Professor Hofman and to all the Nuclear Medicine sites involved in this trial. The international profile of ANZSNM continues to grow, and I have really valued connecting with our international colleagues across the world in the last 2 years. Recognising the different challenges each health care system presents, and identifying common themes such as isotope supply, education and training needs, and research and development are all global issues. The last two years have given me a greater insight into this, and a more global view. Our connectedness across the world has never been greater.
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From the President (Continued) As I end my term as President, it is also a time for me to reflect on mentorship and on the professional relationships we build over our careers. I have been incredibly fortunate to have had wonderful mentors, and I work every day with capable and caring colleagues across all disciplines, who I value. Everyone plays a role in our NM work environments, to deliver excellence in care to patients, and also to create a workplace that is respectful and supportive. Many of our work colleagues also become our friends. This issue of Gamma Gazette has an article, Society Women at Work, which follows our 50th anniversary theme, and reflects on some of our pioneering women in Nuclear Medicine. I am grateful to Agatha van der Schaaf, who is my mentor and friend, for having compiled these stories and reflections on how Nuclear Medicine has changed over 50 years. “Everyone plays a role in our NM work environments, to deliver excellence in care to patients, and also to create a workplace that is respectful and
Lastly, as I complete my final President’s report, I would like to thank all those who have supported me over the last two years. ANZSNM General Manager, Raj Chandra and our secretariat are all incredibly hard working and dedicated, and I value their daily contribution to the Society. I am grateful for the enthusiasm and ideas of the Federal Council members, who all embrace their voluntary roles and combine this with busy workloads, in order to ensure the Society represents all members. The Executive of Federal Council provide constant support and guidance, including in difficult situations for which there is often no easy solution.
supportive.”
As I finish this report, I recognise we face uncertain times ahead. I have confidence however that we are a strong, supportive community and we will take care of each other in these difficult times. Please keep engaging with each other, keep connected through technology and please everyone, stay safe.
Ros
Roslyn Francis MANZSNM, President
Due to the recent and ongoing issues regarding COVID-19, some of the content in this edition may no longer be current, including references to the 50th ASM on April 24-26, 2020. Please visit our website www.anzsnm.org.au for all the latest updates on upcoming events, COVID-19 resources and more.
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Introduction to the Autumn Edition
W
elcome to the 2020 Autumn Issue of the Gamma Gazette. South Australia has seen a steady growth in Nuclear Medicine over this past year. The expansion of departments, increased participation in ANZSNM branch events and the transition to more PET/CT tracers has seen a buzz within our community. Thank you to all who contributed to the article submissions of this issue and the involvement of all committee members.
The 50th ANZSNM Annual Scientific Meeting is being held in Sydney this year, from the 24th to the 26th of April. Early bird registration remains open until the 11th of March and I encourage all those available to attend. The theme for the meeting this year is Local Innovation, Global Inspiration. Reflecting back on the past year it can be agreed that the Molybdenum and Technetium shortage was the defining event of 2019. Proving longer and more arduous than initially expected, the shortage greatly tested the capabilities of each department and stretched available resources further than ever before. The persistence and resilience of all those working within Nuclear Medicine during this time, through rescheduling patients, maximising cold kit usage, prioritising urgency of scans and adapting rapidly to changes, enabled the nation to continue providing Nuclear Medicine services where possible. Despite the downfalls, I believe the shortage not only came as an opportunity for individuals to strengthen their clinical skills, but also proved invaluable in the coming together of the Nuclear Medicine community as a whole during this difficult time. Thank you to all those involved, your continual dedication towards the benefit and assistance of patients during their time of need is truly appreciated. Another key event of importance last year was the proposed changes to the MRPBA professional capabilities. This national change was discussed between our South Australian branch committee members, with feedback submitted to the federal committee. Locally, proposed changes to the SA Radiation Protection and Control Act 1982 also took a lot of our focus at the start of 2019. In summary, I hope everyone has seen a pleasant start to the year and that 2020 brings success to each department. I encourage everyone to contribute and maintain involvement in the ANZSNM events throughout the year and look forward to seeing you all at the Annual Scientific Meeting. Madeline Buttfield MANZSNM- Branch Chair, South Australia
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Branch News New Zealand Branch News
H
ow quickly the summer holidays pass. As we return to work, we are relaxed, rested and have renewed energy to take on whatever 2020 will bring. Let’s ignore talk of cricket, the Boxing Day Test now permanently scratched from NZ sporting history – how exuberant were the Kiwi fans who set up residence in Bay 21!
The NZ Ministry of Health has proposed a new regulatory regime for therapeutic products and last year called for consultation on a new Therapeutics Products Bill designed to replace the Medicines Act. In its proposed state, the new Act would see radiopharmaceuticals classified as a therapeutic product and so they would fall under the new Act, regulations, and any codes of practice. This is a big change because previously radiopharmaceuticals were excluded from the Medicines Act and were only covered from radiation protection regulations and codes of safe practice. The new regulatory regime may have implications for hot labs dispensing radiopharmaceuticals for patients in-house, so a working party from the branch will get together to share our concerns with the current government. There are no radiopharmaceutical scientists or radiochemists currently working in NZ nuclear medicine facilities, with all duties performed by Nuclear Medicine Technologists in department hot laboratories, so changes to the laws around who can work in a “dispensary” may have an impact on us all. The University of Auckland continues to provide the only Post Graduate academic pathway for Nuclear Medicine Technologists in New Zealand. There are currently seven students at varying stages of their training, and the University is now running Nuclear Medicine specific papers every second year as demands for these papers has decreased. There are common papers to all the post grad modality programs, including Imaging Anatomy and Pathology and Professional Issues in Medical Imaging which run annually so students can start the program any time and work towards the post graduate qualification in
Nuclear Medicine. The NZ community are very grateful to Shelly Park, MI PG Clinical Coordinator, and Dr Beau Pontre, Acting Medical Imaging Programme Director, for all their efforts in keeping the program running and accessible for our NZ students interested in a career in Molecular Imaging. The GE 870 CZT scanner is now installed and commissioned at the Nuclear Medicine Department, Waikato Hospital. The scanner performance, image quality, and scanning acquisition times are overall improved compared with the previous, replacement scanner. The Nuclear Medicine Department at Christchurch Hospital is enjoying imaging with their new Siemens Intevo Bold SPECT/CT system. The new Siemens xSPECT Bone and iterative metal artefact reduction (iMAR) add a new dimension to bone imaging, and IQ.SPECT collimators have significantly decreased scan times for myocardial perfusion scans. They also managed to keep a Symbia T2 SPECT/CT system from dying after exposing it to the elements for the deep dark days of winter when the roof had to be ripped off their scanner room for a number of months so earthquake strengthening work could be completed. Congratulations also to Berry on his successful appointment to the ANZSNM Scientific Advisory Panel. Berry brings a wealth of knowledge and experience, and a NZ voice to the SAP. We looked forward to catching up with you all in Sydney later in the year! Pru Burns MANZSNM – Branch Chair, New Zealand
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Branch News South Australia Branch News
L
ast year South Australia held the 49th ANZSNM Annual Scientific Meeting with great success. The theme of this meeting was Precision Nuclear Medicine, and it saw a vast array of speakers sharing their ideas, research and discoveries with backgrounds extending from the manufacture of different PSMA isotopes, to the patterns and prevalence of immunerelated adverse effects in 18F-FDG PET/CT imaging. The pre-conference symposium was held in the beautiful wine region of the Adelaide Hills, and featured talks on the current use and upcoming opportunities of Artificial Intelligence and Theranostics within the wider Nuclear Medicine community. Adelaide experienced an exceptional attendance at this event - we hope all that were present not only found the meeting beneficial and enjoyable but were able to find time during your stay to appreciate our beautiful city. We would like to take this opportunity to extend a warm thank you to all our sponsors and volunteers whose hard work and contributions made the 49th Annual Scientific Meeting possible. Overall, four ANZSNM Branch meetings were held within South Australia throughout the year, as well as three specific technologist group meetings. A big congratulations is given to Madeleine Smith for winning the state Radpharm award and the opportunity to present ‘The Role of a Nuclear Arthrogram in Imaging for an Infected Prosthesis’ at the 50th Annual Scientific Meeting in Sydney this year. Congratulations also goes out to Alana Giacomelli for greatest academic performance in Nuclear Medicine at the University of South Australia for 2019 and to Wendy Phan for being awarded the best Nuclear Medicine presentation at the Student Conference. 2019 was concluded with the Annual AGM and quiz night, where the Nuclear Medicine staff were put to the test with questions covering all facets of Nuclear Medicine. This was a wonderful way to celebrate the conclusion of a challenging yet rewarding year within our Nuclear Medicine community. The South Australia branch welcomes the new decade with many exciting plans for 2020. We kick start our branch meetings in February, with the first being held at the Flinders Medical Centre on the 19th. A huge thank you is given to our outgoing chairperson, Elyse Connole, for her outstanding work over the last two years. Madeline Buttfield MANZSNM – Branch Chair, South Australia
Branch News New South Wales Branch News
T
he branch combined again with RAINS on Saturday 3rd November, 2019 for the whole day CPD Symposium at the Mercure Hotel, Sydney. The programme featured a wide variety of speakers including the ANZNSM President, Ros Francis, presentations on topics such as the latest in Theranostics, nuclear waste disposal in Australia and Peter Tually on some of the subtleties and hazards of equine nuclear medicine imaging.
I am pleased to report that my period of service as NSW Representative on the ANZSNM Federal Council and local chair of the NSW Branch are coming to a close at the Annual Scientific Meeting in April. If anyone is interested in getting involved in the activities of the NSW Branch and the Society at the national level please contact me or the ANZSNM Secretariat. The next few years promise to be an interesting one with the further emergence of more radionuclide therapy options, greater uptake in PET imaging, and potentially charting a new future for the ANZSNM in closer co-operation with the other organisations that represent nuclear medicine in Australia and New Zealand. Exciting times lie ahead. If NSW members have any comment or feedback on the current situation or ideas for future symposia or mid-week meetings likely to generate significant interest please let the members of the branch committee know (Andrew Cluff (RNS): andrew.cluff@health.nsw.gov.au; James Player (POWH): james.player@hotmail.com; Dale Bailey (RNS): dale. bailey@sydney.edu.au). Dale L Bailey MANZSNM - Branch Chair, New South Wales
Western Australia Branch News
W
A had an excellent year in 2019, with many interesting and diverse presentations and across the local branch meetings and a successful annual branch workshop. Thank you to everyone who participated in the society’s events. We also had the pleasure of hosting the TSIG seminar at the Esplanade Hotel in Fremantle which was well attended with a number of members visiting WA for the event from across the different states. As we settle into 2020, we are anticipating another wonderful year in WA. Over these past 12 months we have welcomed a few new technologists across the private and public nuclear medicine sites so we encourage all newcomers to join the ANZSNM and participate in branch meetings. We hope to host some social events throughout this year to help everyone network within the WA nuclear medicine community. Our first branch meeting for the year will take place on Tuesday 11 th February at the Harry Perkins Institute hosted by Sir Charles Gairdner Hospital. The WA branch has opted for a technologist focused workshop this year with the topic of interest being ECG Interpretation. This workshop is set to take place on March 7 th 2020 at Perth Radiological Clinic in Subiaco. The WA branch is also eagerly preparing to host the 2021 ANZSNM ASM and would appreciate any suggestions and expression of interest to volunteer in the planning process. Please don’t hesitate to contact the WA branch with any enquires or feedback regarding membership or branch events. Shiphrah Tagore MANZSNM - Committee Member, Western Australia
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Branch News Victorian/Tasmanian Branch News
T
he VIC/TAS Branch finished off 2019 with the Radpharm State Final. This was held on Fri 22nd November, where Nick Daw from Peter MacCallum Cancer Institute was named the State finalist. For the first time in the VIC/TAS branch, we also awarded a Student Oral Presentation Award, which was won by 2nd year RMIT student, Laetitia Mai. We have started 2020 with our first Branch Meeting, held on the 1st of February and titled “The Rainbow in the Storm – Surviving the 99mTc Shortage”. We are always grateful to have Dr Kim Williams speak at our branch meetings. His topic for this year is “Strategies for isotope Shortage”, which gave us the idea to have a meeting dedicated to how departments coped during the Molybdenum supply crisis of 2019. Over 50 technologists convened on Saturday 1st February at the Peter MacCallum Cancer for the first VIC/TAS branch meeting of 2020: “The Rainbow in The Storm – Surviving the 99mTc Shortage”. It gave our local community a chance to discuss and compare strategies for coping with the tracer shortages we were faced with in 2018 and 2019. Our first speaker was Dr Kim Williams, who gave an American perspective on the longer term supply issues they have faced in the United States, where they have had various technetium supply issues since 2008. This had led to an uptake in Rb-82 PET Cardiac scanning rather than an increase in Tl-201 scanning (due to its inferior imaging characteristics and increased radiation dose). We then heard from Kunthi Pathmaraj, the chief NMT at the Austin hospital, who detailed their department's experience through the two shortages (which occurred while they were renovating their department!). With a cyclotron on site, they were able to perform Na-F PET bone scans on a few of their patients, and also employed Saturday scanning for brain scans. After a morning tea break, it was great to hear from Daniel Bucki-Smith. As the Operations Manager of Tullamarine Radiopharmacy (which supplies the Melbourne Metro area with radiopharmaceuticals), he gave a different insight into the crisis, and also how they were able to still supply their 70+ sites with technetium every day, even if it was a very small amount! Our final speaker was Paul Bowen who is the Chief NMT of Monash imaging. As they are a multi-site department it was yet another way of looking at how departments dealt with limited tracer, including using Tetrofosmin when SestaMibi was unavailable. He was also able to provide a historical perspective for the younger audience members,
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who may not have realized that in the 1990s, pilots would sometimes refuse to transport the generators and tracers on their planes. We finished with a group discussion where attendees were able to share their experiences with reduced dose scanning, the use of the PET substitution codes and other ways to work around reduced tracer days. Hopefully this information will not need to be used again in the near future, but we hope this meeting has further empowered our members. Kim Jasper MANZSNM - Branch Chair, Victoria/Tasmania
Branch News Queensland Branch News
O
n the 7th of November 2019, the QLD Branch hosted our Annual General Meeting combined with the QLD Radpharm award presentations at The Pineapple Hotel in South Brisbane. Dr. Claire Cuscaden was the first speaker of the evening presenting on the “Prevalence of ATTR Amyloid in Australia and the Utility of Quantitative SPECT”. Following the opening presentation by Dr. Cuscaden, the QLD Branch enjoyed the following three presentations from Radpharm Award entrants: •
•
•
Jordan Zabolocki from the Department of Nuclear Medicine and Queensland Specialised PET Services, Royal Brisbane and Women’s Hospital presented on “18F-FDG PET/CT and Radio-guided Occult Lesion Localisation (ROLL) in BRAF Positive Metastatic Melanoma” Maddison Carroll from the Department of Nuclear Medicine at Princess Alexandra Hospital presented on “Utilizing 18F-Flurobetaben (FBB) as a diagnostic tool for the Assessment of Cardiac Amyloidosis” Chris Anderson from Queensland Diagnostic Imaging presented on “Contralateral Sentinel Node Drainage in Breast Cancer”
A panel of three judges determined the winner for the evening as Maddison Carrol from Princess Alexandra Hospital. Maddison will go onto represent Queensland at the Annual Scientific Meeting in Sydney this coming April. Congratulations and all the best for the ASM. Our first meeting for 2020 will be at The Prince Charles Hospital on the 18th of February starting at 6pm. We look forward to seeing you all there either in person or via videoconference. Sarah Daniel MANZSNM - Branch Chair, Queensland
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Special Interest Group News Scientific Advisory Panel (SAP) Update
T
he Scientific Advisory Panel exists to assist the Society by providing advice of a scientific nature on a range of matters
The original panel was asked to see the Society through the planning of the World Congress in Melbourne in 2018. Having done so, the panel members have now mostly resigned from their positions to reinvigorate the panel with some “new blood” from the ranks of the Society’s members. The latest membership of the SAP is: Discipline/Representing Physics ANZSNM Fed Council Technologists NM Specialist Radiopharm Sciences NZ Rep LOC Rep (2020, SYD) LOC Rep (2021, Perth)
Name
Institution
Role on SAP
Dale BAILEY RNSH, Sydney Chair Vacant - Kunthi Pathmaraj Austin Hospital ASM Awards SzeTing Lee Austin Hospital Medical perspective Giancarlo Pascali ANSTO RPS Rep Berry Allen Waikato Hospital NZ Rep Geoff Currie Charles Sturt Uni ASM 2020 liaison Liesl Celliers Sir Charles Gairdner Hospital ASM 2021 liaison
The new members were selected by the Federal Council after providing applications in response to a call for Expressions of Interest from all members in September. The SAP assists the LOCs of each year’s Annual Scientific Meeting (ASM) with selection of theme and speakers. We always welcome any comments or suggestions from all members – so if you have heard someone recently give a talk that impressed you and that you thought could be an addition to our clinical and scientific discussion, please let one of the SAP members know. Dale L Bailey MANZSNM - Chair
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From the Archives - Historical Photos
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From the Archives - Historical Photos
We have compiled a series of photos from the archives of the Society, which had not been included in the ANZSNM History book titled “Isotopes, Imaging and Identity” or published recently in any Gamma Gazette issues. These images and more can now be viewed on the website, and an overview of what is currently listed in the Society Archive has been outlined in the following pages. If you have anything you would like to contribute to the archive please email it to archives@anzsnm.org.au — Debra Huddleston. Visit the archive www.anzsnm.org.au/resources/archive/welcome
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From the Archives - Historical Photos
Section Branch Reports
Committee Reports
Conferences and Awards
Members and Honours
Page ACT
2
NSW
1
NZ
3
QLD
3
SA
3
VIC/TAS
3
WA
3
AANMS
1
Accreditation
2
ANZSNM Committee
6
ARTNET
1
Continuing Education
2
International Relations
1
Physics
2
Technical Standards
1
TSIG
4
AANMS Registrar Research Award
3
ANSTO/ANZSNM Research Grant Award
2
Curium Award
2
GMS Poster Award
3
Nuclear Medicine Undergraduate Abstract Award
1
Radpharm Award
3
Shimadzu Award
3
Australia Day Honours List
8
Honorary Life Members
11
Members
21 28
Obituaries Papers and Publications
ANZSNM Nuclear Medicine
(1970-1978)
1970 (x1), 1971 (x5), 1972 – 1978 (all) ANZ Nuclear Medicine
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Number of documents
2020 Autumn Edition
From the Archives - Historical Photos
(1979 – 2010)
1979 (x3), 1980 (all), 1981 (all), 1982 (x1), 1983 (x1), 1985 (x1), 1990 (x1), 1991 (x3), 1992 (x2), 1993 (x3), 1994 (x3), 1995 (x4), 2007-2010 (all) ANZSNM Historical Documents
3
Papers
21
WFNMB 6th World Congress Communication and Publication
7 1 + List
Presidents Past Rules and Guidelines
Photos
• • •
Accreditation
1
Award Rules
5
Constitution
1
CPD
1
Quality Control
4
Regulations
2
1930-1939
2
1940-1949
0
1950-1959
0
1960-1969
8
1970-1979
12
1980-1989
12
1990-1999*
119
2000-2009^
71
2010-2019”
84
* Includes photos from the WFNMB 6th World Congress in Sydney (NSW) in 1994. ^ Includes photos from the 2004 ANZSNM ASM in Wellington (NZ), 2007 ANZSNM ASM in Adelaide (SA), 2008 ANZSNM ASM in the Gold Coast (QLD) and 2009 ANZSNM ASM in Sydney (NSW). “ Includes photos from the 2010 ANZSNM ASM Auckland (NZ), 2017 ANZSNM ASM and the WFNMB 12th World Congress in Melbourne (VIC) in 2018.
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Special Feature - Society Women at Work 1969 — 2019
ANZSNM recently celebrated 50 years as a professional organisation and is proud of being a society that embraces diversity, and encourages participation by all. This is reflected in our society statement ‘The one society for all nuclear medicine professionals.’ On reflecting on the achievement of 50 years as a professional society, I was curious to find out more about the women in nuclear medicine in Australia, and the early contributions to our profession and our society. I tasked my colleague, mentor and friend, Dr Agatha van der Schaaf, with compiling stories and achievements of these remarkable women. Dr Agatha van der Schaaf was the first female president of ANZSNM, and she approached this task with the professionalism, determination and thoroughness which marked her own incredible career. Thank you to all that have contributed to this special piece – it is a wonderful collection of anecdotes and reflections, which help us understand the challenges that were faced and overcome. In addition to the content below, several of our incredible women have provided more detailed stories, which can be accessed through the ANZSNM website. I would encourage you to read these stories, and enjoy reflecting on how much has changed over the decades in Nuclear Medicine, and how much promise our future continues to hold. A special thank you to Agatha for compiling these stories, and for your inspiration and leadership. A/Prof Ros Francis (ANZSNM President 2018-2020) 18
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Special Feature - Society Women at Work 1969 — 2019
Photo: Dr. Agatha van der Schaaf (left) and A/Prof Roslyn Francis (right)
Before the ANZSNM appointed a permanent secretariat in 1999 all the administrative work, including making hotel bookings for ASM attendees, fell to the national committee and as always the honorary secretary and treasurer carried a hefty workload, not aided by the fact that the committee members were geographically scattered, from Queensland to Western Australia. Of course, the internet had not been invented and word processing was unavailable. This magnificent contribution is the reason for honouring all women office bearers by listing them in this feature. Regrettably it was not possible to contact each one, but I have tried to collect a cross-section of their stories, as well as fascinating contributions by our pioneers. Agatha van der Schaaf (ANZSNM President 1991-1992)
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Special Feature - Society Women at Work 1969 — 2019
I
worked (in 1969) with Prof Jim McRae, who had just returned from the USA, working in nuclear
medicine. I was now in Room 326 in the Medical School where the positron camera was installed. It was used fundamentally for the diagnosis of cerebral tumours using As35.”
Photo: Millicent today
“Most of my highlights are episodes of fun and joy.”
Dr Millicent Hughes nee Marion
Read Millicent's story here ▷
Nuclear Medicine Consultant, Royal Adelaide Hospital 1969-1977, then Flinders Medical Centre and private practice Trained with David Kuhl at the University of Pennsylvania
L
ife was full of fun and excitement, then I received a letter from management at the
hospital that now I was a married woman I needed to resign my position. This set me back as I had
Photo: Helen operating a 2x5 inch Picker scanner in 1978 when the gamma camera was about to replace it.
never experienced or seen any problems before working in Sydney or Adelaide with married women having to resign their positions.” Read Helen's story here ▷
Mrs Helen Stretch nee Bavister NMT, trained at Royal Perth Hospital in the Department of Medical Physics in 1971, multiple positions in public hospitals and private practice in Western Australia, retired in 2012
M
y most recent years have been largely focused on the development of the professional
certification process and the Training, Education and Assessment Program (TEAP) for RPS, both
Photo: Jennie today
Ms Jennifer Guille
Trainee NMT 1971; Chief NMT, RNSH 1974 Chief NMT, Sydney Hospital 1978 Radiopharmaceutical Scientist, St Vincent’s Hospital 1982 Various positions in research and industry 1985-2002 Radiopharmaceutical Scientist, Prince of Wales Hospital 2002-present
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administered by ACPSEM, as well as the introduction of the Masters of Radiopharmaceutical Science at Macquarie University in 2016.” Read Jennie's story here ▷
Special Feature - Society Women at Work 1969 — 2019
I
n the US I learnt about cultural change and teamwork.”
Photo: Jill positioning an infant for imaging
Mrs Jill Wawn nee Freeman NMT especially Paediatric imaging at POW Hospital 19731980, subsequent career in management Trained at Stanford University 1969-1972 where she was part of a team performing bone scans in astronauts to detect avascular necrosis of the calcaneus
Jill campaigned to have the names of Nuclear Medicine Technologists included on publications and for the establishment of the Mallinckrodt Award. She took a major role in the development of NMT training courses.
M
y own impression when looking back was how much juggling and support was
required to manage work and family. I think it is better organised now - having two salaries is usually a necessity and there are more options for Photo: Jocelyn in 2019
childcare.” Read Jocelyn's story here ▷
Mrs Jocelyn Towson nee Cato Physicist in Nuclear Medicine 1979-2013 Royal Prince Alfred Hospital, special interest radiation safety and PET 1960s Trained at Cambridge University and St Bartholomew’s Hospital, London
I
n the early 1990s I got involved in the push for professional registration when I was
representing the ANZSNM (basically as a gatecrasher!) on an Australian Health Ministers Advisory Council (AHMAC) Working Party on Mutual Recognition for Health Occupations – aimed at standardising the regulation of health professions across the nation. . . I feel that area
Mrs Catherine McHenry NMT, then Chief NMT, at Royal North Shore Hospital 1973-1983, private practices in Brisbane, The Prince Charles Hospital 1998-2018 Secretary ANZSNM 1987-91, Vice President 1991-1992 Member of Ministerial Working Party on Mutual Recognition
was my best contribution to the profession although not all agreed at the time!” Read Catherine's story here ▷
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Special Feature - Society Women at Work 1969 — 2019
I
was unaware of the strong rugby culture which delegated women to the lower and forgotten ranks.
The idea was (that they) do most of the work, be on call and keep quiet”.
Photo: Josephine administering an injection to a surrogate patient under the first largefield-of-view gamma camera installed in Australia.
Dr Josephine Wiseman
Nuclear Medicine Consultant Royal North Shore Hospital 1973-1996, her own private practice 1997-2009 Trained at Johns Hopkins Medical Institutions with Henry Wagner during 1972-1973 ANZSNM Vice president 1977-1979 Society Archivist 1991-1997 Editor of RACP publication ”To Follow Knowledge”, 1988 which recorded the history of the Specialist Affiliations of the College
One of the professors said to me “They are Australian men and you cannot expect them to listen to you”. “I resigned from the VP position of the ANZSNM when a decision was made that the Mallinckrodt Prize of $1000 was too much for a technologist!” “I was treated with courtesy as a revered icon from the past.” Read Josephine's story here ▷
W
hen during the 70s I turned up for an AGM of what used to be the ANZAPNM, I was asked
to leave because “this meeting is only for doctors”. When I started in Nuclear Medicine, almost by accident, I had no idea what great opportunities would come my way and it has been a wonderfully fulfilling and varied career. I enjoyed the management and governance experiences, but nothing tops being part of a fabulous team delivering high quality services to patients. It has been very exciting to see Nuclear Medicine emerge from the doldrums of the latter part of the 20th century to the vibrant speciality of today, following the introduction and wide application of PET. It was most rewarding to be part of that renaissance.”
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Photo: Agatha today
Dr Agatha van der Schaaf Nuclear Medicine Consultant, Royal Perth Hospital then Sir Charles Gairdner Hospital from 1976 (Head of Department 1987-2007) till 2009 Member of the ANSTO Board 2002-2007 Associate member of the Australian Drug Evaluation Committee (now ACPM Advisory Committee on Prescription Medicines), during 1991-1999 17th President of the ANZSNM, First female President 1991-1992 Honorary Life Member ANZSNM 2013
Read Agatha's story here ▷
Special Feature - Society Women at Work 1969 — 2019
I
was always involved in the major decisions in the Department.
Something which has come to mind recently Photo: Brenda at 6th World Congress in Sydney, 1994
Mrs Brenda Walker Physicist Nuclear Medicine Prince of Wales Hospital 1971-2006 Secretary ANZSNM 1981-1984 Treasurer of the World Federation of Nuclear Medicine and Biology, 1990-1994, Treasurer of the 6th World Congress in Sydney in 1994
with the MeToo movement is that as a woman in Medical Physics I was always treated equally to the guys and with great respect within and outside the department.” Read Brenda's story here ▷
I
have been very fortunate to have a career in our exciting specialty. The need to
keep up with our evolving specialty has been stimulating and never boring. Attendances at conferences has always been interesting and apart from the knowledge gained there is also the development of friendship with colleagues in our specialty from around the world. However, I would like to emphasise the importance of continuing to take a thorough history and appropriate physical examination to enable optimal Nuclear Medicine practice - these are skills essential to optimise Nuclear Medicine reporting and management of our therapy patients.”
A/Prof Monica Rossleigh Trained at the Memorial Sloan Kettering Cancer Centre, New York 1984-1985 Nuclear Medicine Consultant, Royal Prince Alfred 1985-1988, Nuclear Medicine Consultant and Department Head, Prince of Wales Hospital 1988-Present Vice President ANZSNM 1997-1998 and 2007-2009 Treasurer AANMS 2012-2018 Pioneer Lecturer, ANZSNM ASM 2017 Invited Speaker, Philippine Society of Nuclear Medicine 2019
Read Monica's story here ▷
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Special Feature - Society Women at Work 1969 — 2019
From ‘unclear’ to ‘new clear’, from rectilinear scanning to PET-CT, science and technology has revolutionised our lives over 50 years. It has been an interesting and very rewarding career involving much travel and making many friends around the world. Photo: Heather today
I wish to thank all the ‘Nuclear Medicine team’
Heather Patterson Nuclear Medicine Technologist 1971–1974 Radiosotope Dept. NIRC, Belfast, NI 1974–1977 TBH, NM, New Plymouth, NZ 1977–1995 RPA, Sydney, NSW 1995–2007 Westmead Hosp. NSW 2007–2019 Sydney University / ANSTO 2018 Honorary Fellow of Asian Board of NM
who helped make the achievements possible. At the 2018 WFNMB in Melbourne I received an honorary Fellowship to the Asian Board of Nuclear Medicine.” Read Heather's story here ▷
Heather Hodges First Nuclear Medicine Technologist President Nuclear Medicine Technologist, Queensland 20th President of the ANZSNM 1997-1998 Honorary Life Member ANZSNM 2005
WOMEN OFFICE BEARERS ANZSNM
Presidents
Dr Agatha van der Schaaf 1991-1992 Ms Heather Hodges 1997-1998 Ms Vivienne Bush 2003-2004 Dr Sze Ting Lee 2010-2011 Ms Elizabeth Bailey 2012-2013 A/Prof Roslyn Francis 2018-2020
Secretaries
Mrs Brenda Walker 1981-83 Mrs Catherine McHenry 1987-1991 Ms Joanne Kidd 1997 Ms Vivienne Bush 2001-2002 Ms Maria Triantafilou 2003-2008 Mrs Tracey Smith 2009
Vice Presidents
Dr Josephine Wiseman 1977-1979 Ms Ruth McGennisken 1984-1985 Mrs Catherine McHenry 1991-1992 Ms Sarah Bass 1993-1994 A/Prof Monica Rossleigh 1997-1998 and 2007-2008 Mrs Penny Cameron 1999-2000 Mrs Tracy Smith 2010 Ms Julie Crouch 2011-2012
Treasurers
Ms Vivienne Bush 2005-2009 Ms Sharon Mosley 2010-2011 Dr Sue O’Malley 2013-2014 Ms Suzanne McGavin 2019- Present
To read all stories, visit www.bit.ly/anzsnm-women-at-work
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Gamma Gazette is the official publication of the Australian and New Zealand Society of Nuclear Medicine. Founded in 1969, the ANZSNM is the major professional Society for those practising Nuclear Medicine in Australia and New Zealand.
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Articles
The History of the First State Branch of the ANZSNM in NSW Author: Andrew McLaughlin MBBS FRACP FAANMS MANZSNM
In early 1972 I travelled to the United States to take up an appointment of Visiting Fellow and Scientist at the Argonne Cancer Research Hospital (ACRH) at the University of Chicago (some years later it was renamed the Franklin McLean Memorial Research Institute). My supervisor was the late Paul V Harper MD, who was Director of the ACRH’s research medical cyclotron. Harper was also Professor of Surgery at Billings Hospital, the clinical medical centre of the University of Chicago, on 59th Street South, the beginning of the “combat zone”! He also was on the active roster for emergency surgical patient admissions after hours a remarkable man indeed. Chicago at the time was strong in US Nuclear Medicine personnel and research. Alex Gottschalk MD (deceased) was Director of Radiology, Paul B Hoffer MD (deceased) was Director of Nuclear Medicine and James Quinn MD (deceased) was Director of Nuclear Medicine at North Western University Medical Centre and editor of the Year Book in Nuclear Medicine. The Director of Nuclear Medicine at Chicago Children’s Hospital, at North Western, was James Conway MD (retired). Robert Henkin MD is still active at Lyola University Medical Centre. I worked in the basement of the ACRH, where the cyclotron and Harper’s office and laboratory were situated. Technetium-99m’s complex radiochemistry was solved there by the radiochemists, inventing Tc99m pertechnetate for brain scanning and Tc-99m sulphide colloid for liver scanning. Harper and team were also very interested in cyclotron produced 13N, 15O and 11C for labelling physiological molecules. These were difficult to use because of the very short half-lives. Performing well counting, of animal organ distribution studies for % of injected dose/g of tissue, of injected radiopharmaceuticals, was very tricky indeed because of the ultra-short half-lives. Nitrogen-13 ammonia was synthesized to test its feasibility for use for myocardial imaging. The basis of the theory was ammonia (13NH3) is the essential substrate for the synthesis of myocyte glutamate. Many
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mouse biodistribution studies were performed to demonstrate high uptake by the myocardium. These were repeated, following administration of a glutamate synthesase inhibitor (prior to repeating the bio studies) to prove it did block mouse myocyte synthesis of labelled glutamate. Imaging was the next problem to solve, as 13N was a positron emitter and there were no positron imaging devices then. With the help of the physicists in the Clinical Department, lead by Robert Beck, a conventional Nuclear Chicago Anger gamma camera was adapted. Firstly, they built a tungsten collimator by diamond tip drilling (many were sacrificed) sheets of tungsten which were glued together to create long parallel holes, for imaging. The camera was adapted from a stationary device to a mobile one by attaching four pneumatic wheels. It was towed by an adapted golf cart to travel in hospital corridors and elevators to reach the Cardiology Department exercise laboratory! This was where the first exercise and rest positron 13N ammonia myocardial perfusion images were produced, with the “honeycomb pattern” of the collimator overlying the image. Both images of rest and post exercise were produced in less than an hour. I was part of this team and a co-author of the report of this work, (laboratory workup and clinical) and was published in Radiology1. Now what’s all this to do with the subject of the NSW Branch history? Well, once a month the Clinical Department of Nuclear Medicine of the Billings Hospital hosted a lunchtime seminar with a visiting speaker, from Chicago or beyond. These were very informative and well conducted. I thought at the time we should be copying this in Sydney. I returned to Royal Prince Alfred Hospital, Nuclear Medicine as a full time Staff Specialist in mid-1973. After a few weeks settling back in again, I began to plan how to implement regular educational evenings. I enlisted Professor Provan Murray at Prince of Wales Hospital, who agreed it was a good idea. However, there was no formal structure in place, like a branch of
Articles
The History of the First State Branch of the ANZSNM in NSW (Continued)
the national ANZSNM, as it was itself only a few years Saturday morning. The afternoon was free for golf or old! I recruited a few others including Michael Yeates other activities. Saturday night included golf prizes and and Ern Crocker and along with Provan Murray, set dinner. about establishing a NSW state branch of the ANZSNM, A number of these weekends away were held. One at the first in the country. After a few informal meetings the Beachcomber Hotel, Toukley on the NSW Central working on its structure and a draft constitution, we Coast with guest speaker the orthopedic surgeon called a general meeting of members of the NSW Warwick Bruce, a friendly referrer of bone scans. The (Sydney) Nuclear Medicine community, physicians, format was the same as the Leura meeting. Another scientific officers and I can remember was at technologists, which, the California Hotel, from memory, was Katoomba (the site of held at Prince of Wales the origin of the initial Hospital. The meeting Christmas in July dinner was very successful tradition). The guest and the necessary speaker, was Roger Uren, structure, office bearers one of our own, on and Constitution were “Lymphoscintigraphy – agreed, elected and breast sentinel node and established. Hence, melanoma dermal studies”. the first State Branch It became apparent of a fledgling National that these weekends Society eventuated in were a luxury and too Speakers about mid to late 1973/ expensive for the average Picture from the first NSW Branch Weekend Symposium, Fairmont Hotel Leura 1997 early 1974. attendee and hence were L to R: Tony Freeman, Kevin Allman, Andrew McLaughlin, Ric Baker, Regular clinical abandoned. There may Vivian Bush and Geoff Story nights were organised have been other venues quarterly, with a that I have overlooked. (If nominated speaker/ anyone can think of one, subject followed by interesting case presentations, after please add to the list). a buffet dinner. Each hospital rotated as host. These Quarterly meetings were held for many years, with became very popular and well attended. the last of each year hosted by Siemens pre-Christmas. Due to their success, some years later, it was suggested Sadly, slowly, the attendances have fallen away, probably we have weekends out of town with an invited userdue to Sydney’s impossible 5pm traffic and most people’s friendly guest speaker. This was agreed upon and the busier lifestyles. The last NSW Branch Newsletter in the first meeting was held at the Fairmont Hotel, Leura, in Gamma Gazette I could find was in 2017! Many of the March 1997. Dr Anthony Freeman, a cardiologist at other state branches, including our friends across the Prince of Wales Hospital was the first guest speaker (see “ditch” are still active. photo of all the speakers). He was ideal as he was an active supervisor of Nuclear Cardiology stress studies Reference: 1 Harper P.V. et al. Clinical myocardial imaging with in adults and shunt studies in pediatrics at Prince of nitrogen-13 ammonia. Radiology. 1973, 108(3): p. 613-7 Wales Hospital. A delegate’s dinner was held on the Friday night and the educational component on the
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Articles
Unlocking the Secrets of Proton Beam Therapy Author: A Taqaddas1. 1Medical Physicist, Radiation Protection Supervisor Research Medical Physicist, Research Wormhole, Canada
INTENDED TARGET AUDIENCE This article is intended for those who have an interest in science and also professionals working in medicine and oncology fields who do not possess a deep understanding of technology advancements in Radiation oncology. INTRODUCTION The incidence of cancer worldwide has increased. According to International Agency for Research on Cancer the world wide burden for cancer is estimated to be 18.1 million new cases and 9.6 million deaths in 2018 [1]. About 50% of the new cases and more than 50% of cancer deaths globally in 2018 are expected to occur in Asia as Asia holds nearly 60% of the global population. Europe reports 23.4% of global cancer cases and 20.3% of cancer deaths while Americas account for 13.3% of worldwide population and reports 21.0% of cancer incidence and 14.4% of mortality worldwide. Asia and Africa reports higher percentages of cancer deaths than cancer incidences. Despite advances in cancer treatment, prognosis of various cancers remains poor. One of the challenges in cancer treatment is to spare normal tissues while treating malignant tissues. Various treatment modalities are used to manage cancer including surgery, chemotherapy, biological therapy and Radiation therapy (RT). Radiation therapy plays a significant role in management of various cancers e.g. Breast cancer, lung cancer, prostate cancer, brain cancer. It can be used as Primary treatment or salvage treatment in case of tumour recurrence or as part of combined modality treatment. 30
Most cancers are treated by high energy photons (X-Rays) and is called photon-based Radiation therapy. Photon based RT is also associated with significant treatment related acute and long-term toxicity or side effects such as skin problems (erythema), gastrointestinal toxicity, urological toxicity and risk of secondary cancers. Cancer is also treated with particle beams such as Proton beam (PB). Proton beam therapy (PBT) is getting popular as it exhibits many potential physical, dosimetric and biological advantages over photon-based Radiation therapy. The number of centres offering Proton beam therapy is increasing worldwide. USA already has lot of experience in PT and globally 70 facilities are providing PT to cancer patients [2]. Out of these clinically active PT centres, 33 centres are operational in USA. Thirteen proton therapy centres are either under construction or just finished construction this year. Four new PT facilities were planned to provide treatment in UK in 2019. Globally about 24 new PT facilities are under planning stages including three new PT centres in Australia [2]. Countries where New PT facilities that are either under construction or are in planning stages include EU (Belgium, Switzerland, Italy, France, Norway), China, India, Dubai (UAE), Saudi Arabia, Egypt, Singapore, Thailand, Taiwan,
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Argentina and USA. This article discusses briefly the physics of proton therapy to unlock the secrets and advantages of proton therapy in cancer treatment. BRAGG PEAK The advantages and secrets of Proton therapy are concealed in its Bragg peak curve. See figure 1 on the next page (please note this figure is hand drawn by author so it is not perfect). To view a perfect figure reader are referred to articles on Proton beam Radiotherapy. Unlike photon-based RT, protons display growing energy deposition with increasing depth in tissue resulting to a maximum energy deposition called Bragg peak close to end of range of the proton beam. This also means Protons have a welldefined range. The maximum dose deposition is followed by sharp dose fall off region. In other words, there is no energy deposition outside this range. The Bragg peak curve also shows low entrance dose. The Bragg peak can be positioned inside the tumour or target thereby giving maximum dose within the tumour while sharp dose fall-off ensures substantial sparing of normal tissues beyond the target [3]. As there is no exit dose and low entrance dose proton therapy results in less treatment induced toxicity. The integral dose in case of Proton therapy is lower than photon based IMRT (Intensity
Articles
Unlocking the Secrets of Proton Beam Therapy Modulated radiation therapy) and VMAT (Volumetric modulated Arc therapy) treatments. This in turn is likely to reduce incidences of secondary cancers in patients treated with proton therapy. On the contrary Photons produce both entrance and exit doses. As photon beam enters the tissue it produces a short build up region where the amount of energy deposited by photons in the tissue quickly increase with depth followed by an exponentially reducing energy deposition with increasing depth. See Figure 1 that compares photons and proton beam curves
Figure 1: Absorbed dose vs. Depth in tissue. The figure shows depth dose curves for photons, proton pristine beam and Proton Spread out Bragg peak (SOBP)
SPREAD OUT BRAGG PEAK (SOBP) As shown in figure 1 the width of pristine Bragg peak is very narrow. Normally tumour volumes are larger than width of a pristine Bragg
peak. This requires broadening of pristine Bragg peak to fully cover the entire tumour volume with uniform dose i.e. expanding the axial aspect of the peak region. This can be achieved by modifying the range and fluence of the beam. One way to produce a SOBP is by joining many pristine Bragg peaks and they ultimately give rise to a spread-out Bragg peak.
Interactions of Proton beam with Matter
Once proton beam enters the tissue it interacts with atoms of tissue in following three ways: • Inelastic • Elastic scattering • Non-Elastic Nuclear reactions Proton beams interact with orbiting electrons of atoms and maximum interaction takes place at the end of range leading to maximum energy absorption in tissues. This is because protons travelling through matter or tissue are decelerated as they lose their kinetic energy and decelerated protons are more likely to interact with orbiting electrons. This is one of the main methods through which protons continuously lose their kinetic energy. This process is termed inelastic coulombic interactions [4] Protons also interact with positively charged nucleus. In this case positively charged protons are deflected by positively charged nucleus of atoms in the tissue (repulsion). Thus, protons are scattered while losing negligible amount of energy. This type of interaction is classified as Elastic
(Continued)
scattering. In third type of interaction protons enter the nucleus of atoms in the tissue resulting in the production of various types of sub atomic particles such as neutrons, protons, deuterons, heavy ions etc. Non elastic Nuclear interactions are less [4].
LET and Relative Biological effectiveness (RBE): Proton
have high Linear energy transfer (LET) compared to photons. This means protons produce more ions per unit length resulting in more biological damage in tissues. Compared to Photons, protons are thus more likely to cause damage to DNA in cells. Generally, protons are considered to be 10% more effective than photons in causing biological damage or achieving same end point (e.g. cell mutation, aberration) and thus are given an RBE (Relative Biological Effective) value of 1.1 [5]. However, there are studies that show that RBE of Protons depends on dose per fraction, LET, biological end point and tissue type (i.e. α/β values) which means that RBE of protons can range from 1.3 to 1 [6-7]. BEAM DELIVERY METHODS Proton therapy has two beam delivery methods namely Passive scattering (PSPT) and Magnetic scanning (Active scattering). Passive scattering technique uses physical scatters to cover the treatment field with dose. In scanning method, magnets are used to deflect and maneuver the proton beam [8].
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Unlocking the Secrets of Proton Beam Therapy PSPT also involves compensators and apertures to conform the beam to the shape of the target and is less sensitive to organ motion. However, PSPT techniques results in production of neutrons due to interaction of protons with scatters, compensators and apertures and other beam modifying devices which in turn leads to increase in integral dose to patients and hence the risk of secondary cancer. In Scanning method no apertures and compensators are used and thus there is less neutron production. However scanning technique is more sensitive to organ motion than PSPT. Potential Advantages of PBT: • Low entrance dose • No exit doses • Low integral dose (dose outside the target) to normal tissues • Better sparing of normal tissue resulting in reduced treatment induced toxicity • More conformal dose • Potential for dose escalation to produce better tumour control • There is a potential for Less risk of developing secondary cancers According to ASTRO PBT Model policies, PBT is medically indicated for Ocular, base of skull, spinal cord (excluding spinal cord compression), liver and tumours requiring re-irradiation [9].
Proton therapy in Pediatric cancers RT treatment can leave children suffering from cancer with long term radiation induced 32
side effects including neurocognitive dysfunction, hormonal disturbances, hearing loss, short stature and secondary cancers [1011]. The frequency and intensity of long-term complications in pediatrics treated with RT is therefore a major concern for radiation oncologists. This is because children have radio sensitive developing tissues and thus low threshold for developing late side effects. Above all children are expected to live long lives and therefore more likely to end up having radiation induced secondary cancers. The rationales for using PBT lies in the facts i) it can give more conformal dose while sparing normal tissues in children and ii) also low integral dose ensures less risk of developing secondary cancers in later years in these patients, iii) dose escalation is possible if needed to cure the disease or to achieve better local control. Each case must be assessed individually to see its suitability for PBT. PBT, is considered particularly effective for pediatric cancers such as CNS tumours by ASTRO PBT Model policies [9]. The Stockholm group also deemed PBT as an ideal indication for most of the pediatric CNS, skull base tumours and retinoblastomas [12]. The Stockholm group also observed significant dose reduction to cochlea, temporal lobes and hypothalamic-pituitary axis in proton therapy plans for posterior fossa Ependymoma cases compared to photon-based RT plans. For craniopharyngioma cases proton beam plan delivered reduced dose to supratentorial brain. For
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(Continued)
Medulloblastoma (MB) PBT plans resulted in lower doses to lung, heart, face, abdomen, pelvis but higher doses to scalp and para spinal soft tissue [12]. The most significant difference observed for posterior fossa ependymoma was educed dose to cochlea, temporal lobes and hypothalamic-pituitary axis [12]. Pediatrics suffering from Medulloblastoma are very likely to achieve potential benefit of low secondary cancer risks associated with PBT. In Medulloblastoma a large volume of tissue is irradiated (i.e. Brain and spinal cord) and therefore there is a high risk of late morbidity and secondary cancers. These patients are likely to get decreased morbidity because with PBT, anterior midline structures of the thorax (lungs, heart, esophagus), abdomen (stomach, liver, pancreas) pelvis (kidneys) are spared. A study comparing Cranio-spinal irradiation (CSI) using 3D CRT (conformal Radiation therapy), Tomotherapy and PBT found PBT to be superior than Tomotherapy and 3D CRT with reduced doses to esophagus, stomach, liver, lung, pancreas, and kidney and lower risk of secondary cancers [13]. Another study comparing LAR (Lifetime attributable risk) of radiation induced secondary cancer between PBT and Intensity modulated photon therapy (IMXT) also found that PBT was associated with significantly reduced LAR than IMXT [14]. Another study concluded that proton beams are associated with decreased expected incidence of radiation induced secondary
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Unlocking the Secrets of Proton Beam Therapy
(Continued)
cancers for Rhabdomyosarcoma (by a factor of >=2) and Medulloblastoma (a factor of 8-15) compared to Intensity modulated or conventional x-rays (Photon-based RT) in pediatrics [15]. There are barriers to wide spread adoption of PBT [11]. See figure 2. CONCLUSION: The use of Proton Beam Therapy in cancer treatment is increasing worldwide due to its unique physical, biological and dosimetric properties. There is considerable evidence that compared to other radiation treatment techniques (e.g. IMRT, VMAT, Tomotherapy) Proton beam radiation plans result in better sparing of critical structures and in low integral dose. This in turn leads to reduced short and long-term treatment induced morbidity in cancer patients and allows for dose escalation as well. Most Figure 2:PBT characteristics. PSPT= Passive Scattering Proton therapy pediatric cancers seem to benefit from PBT and therefore PBT is recommended for pediatric cancers by various groups. The physics of Proton therapy unlocks the secrets of this therapy and its potential advantages over other RT modalities. It is important to remember that proton treatments are not always better for all types of tumours. PBT requires on going research to better understand its short comings to use them effectively. References [1] International Agency for Research on Cancer. Latest global cancer data: Cancer burden rises to 18.1 million new cases and 9.6 million cancer deaths in 2018. Press Release, World Health Organization, 2018. Available online: https://www.iarc.fr/wp-content/uploads/2018/09/pr263_E.pdf Accessed: 13/10/2018 [2] Particle therapy Co-operative Group, 2019. Available at: https://www. ptcog.ch/index.php/facilities-in-planning-stage (Accessed 13/10/2019) [3] Paganetti H., and Bortfield T., “Proton Beam radiotherapy- The state of the Art,” New Technologies in Radiation Oncology (Medical Radiology Series), 2005. [4] Newhauser D., and Zhang R., ‘The physics of Proton therapy,’ Physics in Medicine and Biology, 2015, 60, R155 [5] Fossum C., Beltran C., Whitaker T., Ma D., et al., ‘Biological Model for Predicting Toxicity in Head and Neck Cancer Patients Receiving Proton Therapy,’ International Journal of Particle Therapy, 2017 [6] Paganetti H., “Relative biological effectiveness (RBE) values for proton beam therapy. Variations as a function of biological endpoint, dose, and linear energy transfer,” Institute of Physics and Engineering in Medicine, 2014, 59, R419-R472 [7] Paganetti H., Niemierko A., Ancukiewicz M., Gerweck L., et al., ‘Relative biological effectiveness (RBE) values for proton beam therapy,’ International Journal of Radiation Oncology Biology Physics, 2002, 53, 407–21. [8] Varian Medical Systems. Proton beam therapy. Scattering versus scanning treatment techniques.
[9] American Society for Radiation Oncology. Model Policies. Proton Beam therapy. 2014, Available at: https://www.astro.org/uploadedFiles/ Main_Site/Practice_Management/Reimbursement/ASTRO%20PBT%20 Model%20Policy%20FINAL.pdf (Accessed 13/10/2019). [10] Jimenez R., Sethi R., Depauw N., Pulsifier M., et al., ‘Proton radiation therapy for pediatric medulloblastoma and supratentorial primitive neuroectodermal tumors: outcomes for very young children treated with upfront chemotherapy,’ International Journal of Radiation oncology, Biology, physics, 2013, 87, 120-6 [11] Grill J., sainte-rose C., Jouvet a., et al.; French society of Paediatric oncology: treatment of medulloblas-toma with postoperative chemotherapy alone: an sFoP prospective trial in young children. Lancet Oncol, 2005, 6, 573–580 [12] Indelicato D., DO T., and La Perriere N., ‘Consensus Report from Stockholm Pediatric Proton therapy Conference,’ International Journal of Radiation Oncology, Biology, Physics, 2016, 96, 387-392.
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Congratulations to Geoff Currie AM Admitted as Member of the Order of Australia, Australia Day 2020 for "significant service to nuclear medicine and medical radiation science" Statement from Geoff Currie "It is an honour and a privilege to be able to represent and advocate for the nuclear medicine community in Australia, as well as internationally. To be nominated by my nuclear medicine peers and recognised for the leadership and innovation I have provided is humbling but gratifying. I have been very fortunate to have been gifted with amazing opportunities for clinical practice, research and education associated with frontier technologies that, with a lot of hard work, have changed the lives of many Australians. While achievements leading to this award have also translated into high-quality outcomes at Charles Sturt University, the award recognises activities over several decades outside of my employment amongst political, professional and general population communities. I have enjoyed leadership status in my profession in Australia and across the globe for more than a decade and been proactively committed to the responsibility that comes with that status. Obviously these accomplishments and representing the nuclear medicine industry in the general community, amongst key stakeholders, across the health care sector, and at all levels of Government can only be achieved with support from some amazing collaborators, colleagues and friends with whom I thank and share this award. It comes as no surprise that the foundations of this award are crafted in collaboration with organisations like RAINS, ANZSNM, ANSTO, CSU, SNMMI-TS, CAMRT, JNMT, JMIRS and others with a rich history of impact, insight, inclusiveness and inspiration. It is a very exciting time in nuclear medicine with the convergence of multiple frontier technologies, each having enhanced capability and improved patient outcomes. Like the nuclear medicine community (as highlighted during the 99Mo crises), amongst these frontier technologies the whole is much greater than just the sum of the parts. To have been afforded the opportunity to contribute to crafting the developments that shape the nuclear medicine landscape and to drive frontier technologies evolving the nuclear medicine ecosystem is reward in itself. ANZSNM 2020 in Sydney is not just a celebration of 50 years, recognition of the hard work contributed by so many to position our profession so strongly, and celebrating the emerging leaders that are the future of our profession. ANZSNM 2020 is also a career capstone that will be a showcase of the convergence of these synergistic frontier technologies; theranostics, molecular pharmacology, AI & machine/deep learning, radionuclide developments in PET & therapy, and hybrid instrumentation. As a profession, there is so much on the horizon to be excited about and I am proud to have contributed in some way to positioning us favourably for that.� Geoff Currie MANZSNM, AM
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Articles Technologists e-Poster
Discovery, A New Zealand Nuclear Medicine Department voyage that has made a real difference Author: Prue E. Lamerton MANZSNM, Hawkes Bay District Health Board, Nuclear Medicine, Hastings, New Zealand
AIM
Hybrid SPECT/diagnostic CT scanners are now commonplace within most Nuclear Medicine (NM) departments in New Zealand. This poster aims to show how the acquisition of the GE Discovery 670 SPECT/ CT (16 slice) provided the mechanism to fulfil the requirements of a business case designed to reduce CT waiting lists for cancer patients in line with New Zealand government targets and provide a disruption free service for Hawkes Bay public health CT patients.
MATERIALS & METHODS
Hawkes Bay on the East Coast of the North Island of New Zealand currently has a population of 166,000 and ranks 9th in size out of the 16 regions. There is currently no PET/CT service in Hawkes Bay. Following the purchase of the GE 670 tandem SPECT/ CT there was a period of 4 weeks where the CT was to be the only CT service for the hospital when the main CT was upgraded. Once the installation was complete it became clear that both services could work alongside each other necessitating a change for both scopes of practice. This included: • • • • •
a need for clear communication with referrers and CT technologists CT staff training and maintaining their skills on the operating system of the hybrid scanner education of booking staff to accommodate CT into the Nuclear Medicine schedule Nuclear Medicine Technologists training in Diagnostic CT allocation of a weekly CT session
Figure 1 - GE Healthcare Discovery NM/CT
Figure 2 - Map of New Zealand
The Nuclear Medicine Undergraduate staff trained in diagnostic CT through the Australian Charles Sturt University and RAINS which along with clinical supervision enabled an extension to their scope of practice to perform diagnostic CT on a hybrid SPECT/ CT scanner. 2020 Autumn Edition gamma GAZETTE 35
Articles Discovery, A New Zealand Nuclear Medicine Department voyage that has made a real difference
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During the installation of the main CT scanner our SPECT/CT scanner took on the full workload of the hospital and outpatient service including trauma, biopsies and VCs. During this period, we managed to maintain our Nuclear medicine service on top of the CT scans. This required co-operation from both NM and CT medical imaging staff. As the operating platform for both CTs varied it was necessary to maintain CT staff skills on the NM scanner should it be needed for emergency work. One morning a week was dedicated to CT scans only .
RESULTS The graph above shows the Nuclear Medicine scan numbers over a 2 year period with numbers only dipping in the last few months due to a staffing issue. It is predicted to continue to increase even though we are providing some CT service as well.
The graph above demonstrates the ability to accommodate diagnostic CT scans within the Nuclear Medicine department without reducing the Nuclear Medicine service. The initial peak of CT in 2014 was due to the installation of the main CT scanner when the SPECT/CT was used for all the in and outpatient CT scans for a period of 3 weeks.
The graph above shows peaks and troughs of CT numbers over a period of 2 years. The most CT scans performed/month have occurred in the months of November and December 2018 when the main CT experienced a couple of faults. This highlights the fact that there was no disruption to the CT service.
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Articles Discovery, A New Zealand Nuclear Medicine Department voyage that has made a real difference
(Continued)
The scan on the left (page 36), shows the ability of the CT to localise to the calcaneo-cuboid and talo-navicular joints with a fracture of the distal calcaneal fragment. Our referrers are now sending in requests for staging cancer scans as well as CT scans on the same referral. The patients are expecting now to only have one visit to the hospital meaning only one IV line is required. The scan above is an example of fusion SPECT 123 I MIBG scan with the diagnostic CT improving differential diagnosis.
Fig. 3: 123 I MIBG Fig 3.123 I MIBG SPECT/diagnostic CT
CONCLUSION
The installation of the GE Discovery 650 SPECT/CT has brought about many changes to the Nuclear Medicine Department in the Hawkes Bay Hospital. We now have open communication with the CT department. There is no disruption to the CT service. We have seen a considerable reduction to the Ministry of Health waiting times for CT cancer patients even if it has meant doing one extra CT a day when required. Our patients have loved having only the one-day visit with one IV line only and the same staff doing both scans. The staff have enjoyed the flexibility by being able to expand their scopes of practice. The radiologists/Nuclear Medicine specialists, referrers and patients have benefited from the improved diagnostic confidence and reduced wait times. Finally, the Nuclear medicine Department were awarded second place in the Hawkes Bay health awards in 2017 for excellence in service improvement. 2020 Autumn Edition gamma GAZETTE 37
Education & CPD Case Study Incidental Vasculitis finding on PET/CT Author: Madeline Buttfield MANZSNM, Benson Radiology, South Australia
CASE DESCRIPTION: A 72-year-old female was referred to our Nuclear Medicine department for an 18F-FDG PET/CT scan for investigation of solitary pulmonary nodule previously identified on a chest CT. PROCEDURES INVOLVED The patient was intravenously injected with 188.1 MBq of 18F-FDG following a six hour fast with a blood sugar level of 4.6 mmol/L. After an uptake period of 63 minutes, scanning was performed craniocaudally from vertex to thighs, with the patient positioned supine with arms above the head. Five bed positions were acquired (3 at 2.5 mins and 2 for 5 mins over the lung fields). Respiratory gating was used to reduce the effect of breathing artefact within the reconstructed images. FINDINGS Markedly intense abnormal activity was noted within the bilateral internal carotid arteries and bilateral vertebral arteries, extending into the intradural segments. Intense subclavian and axillary vascular activity was similarly identified. This marked uptake was seen to continue throughout the thoracic, ascending, arch and descending segments of the patient’s aorta (Figure 1). Extensive abnormal vascular activity was further noted in the abdominal aorta, iliac arteries and the extent of the femoral vessels covered within the scan field of view. These findings of the 18F-FDG PET scan suggested marked evidence of large vessel vasculitis. The pulmonary nodule of interest was identified within the right epicardium, however displayed only low-grade non-specific activity (Figure 2) with the aetiology unable to be determined from the PET scan. No avid adenopathy was noted. DISCUSSION Large vessel vasculitis is an autoimmune disease typically caused by the inflammation of blood vessels that can result in tissue ischemia and irreversible organ damage (Kermani et al. 2011). Increased risk of malignancy, as well as vasculitis as a manifestation of malignancy, has been reported within the literature (Kermani et al. 2011). Symptoms of vasculitis are typically non-specific, with the organs affected dependant on the pattern of vasculitis (Cimmino 2016).
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Figure 1 Axial slice of PET/CT scan demonstrating the low-grade pulmonary nodule of interest as well as marked descending aorta activity.
Figure 2 Maximum Intensity Projection Image of PET scan demonstrating extent of large vessel vasculitis.
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Education & CPD Case Study Incidental Vasculitis finding on PET/CT (Continued) In reference to this case study, the patient had complained of increasing deafness - a symptom potentially associated with the marked vasculitis evident within the carotid and vertebral arteries. Additional symptoms of this disease include fever, weight loss, malaise and fatigue – similar to those of oncology (Cimmino 2016). Currently, diagnosis of large vessel vasculitis is dependent on imaging techniques such as that of CT, MRI or PET/CT, with further biopsy to confirm (Cimmino 2016). Late diagnosis of large vessel vasculitis can be accompanied by aortic complications and fatality, therefore prompt action regarding the disease is paramount (Balink et al. 2014). OUTCOME In light of the 18F-FDG PET/CT findings, expedited rheumatological assessment was recommended to the referring doctor. It was additionally recommended that further CT observation was undertaken on the suspicious pulmonary nodule. References M.A. Cimmino 2016, ‘Clinical diagnosis of large vessel vasculitis’, Rheumatic Diseases, vol. 75, no. 2. T.A. Kermani, K.J. Warrington, S. Amin 2011, ‘Malignancy risk in vasculitis’, Therapeutic Advances in Musculoskeletal Disease, vol. 3, no. 1. J. Balink, R.J. Bennink, H.J. Verberne, ‘The role of 18F-FDG PET/CT in large-vessel vasculitis: appropriateness of current classification criteria?’, BioMed Research International, vol. 2, no. 20
GAMMA GAZETTE CONTENT SUBMISSIONS
Scientific submissions on all aspects of nuclear medicine are encouraged and should be forwarded to the Secretariat (instructions for authors published at https://www.anzsnm.org.au/activities/gammagazette-content-submission-and-guidelines/). 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 ANZSNM Gamma Gazette is published three times a year. Deadlines for each issue of the journal can be found on our website anzsnm.org.au
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Education & CPD Case Study I’m not crying, there’s something in my eye: a rare dacroscintigraphy case
Authors: Remi Hillery MANZSNM & Maddison Carroll MANZSNM, Princess Alexandra Hospital, Brisbane
BACKGROUND
Dacrocystocele is an anomalous dilation of the lacrimal sac resulting from narrowing or obstruction of the Hasner valve distally or the Rosenmuller valve proximally in the nasolacrimal system (Fig. 1 below). This causes an accumulation of fluid in the drainage system that appears as a blue-grey swollen mass1. It frequently occurs during prenatal development and is typically a congenital abnormality2. Its incidence is very rare in adults and is usually secondary to an external cause such as trauma, surgery or inflammation. The most common symptoms are swelling of the medial canthal region and chronic excessive tearing3. It is regularly mistaken as a haemangioma, encephalocele, glioma, dermoid cysts or malignant process and must be differentiated from these for appropriate treatment1. It is often diagnosed through clinical examination and imaging such as dacryocystography, ultrasound, magnetic resonance imaging (MRI) and computed tomography (CT). These tests can effectively assess obstruction but are less accurate for evaluation of nasolacrimal canal stenosis. They also predominantly require cannulation of the canalicular system, which is an invasive procedure.2,5. Nuclear Medicine dacroscintigraphy is a non-invasive test used to assess the patency of the nasolacrimal system that involves low radiation exposure6. It is useful in evaluating epiphora, partial obstructions and functional nasolacrimal duct obstructions, as it assesses flow dynamics and other physiological aspects of the lacrimal system. The use of SPECT/ CT in dacroscintigraphy offers anatomical localisation and overcomes issues of poor resolution and anatomical details, thus offering an effective tool in evaluating abnormalities of the nasolacrimal system7.
CASE REPORT
The patient presented with a 10-year history of chronic epiphora of the left eye and one instance of dacrocystitis the year prior. There was no history of trauma, paediatric epiphora or medical procedure to the left eye. The left lacrimal gland was painful on palpitation and had 100% reflux on lacrimal irrigation. These symptoms are indicative of nasolacrimal obstruction. A nuclear medicine lacrimal study was ordered to diagnose and assess the cause of epiphora. At presentation, the patient had no prior imaging of the orbits and nasolacrimal system.
Figure 1 Diagram of the nasolacrimal system8
INVESTIGATION Using a 1ml syringe, 5MBq of 99mTcPertechnetate was dispensed to the lateral superior aspect of each eye as a topical solution. A dynamic acquisition begun immediately at 10sec/frame for 12 frames. Interval 1-minute
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Education & CPD Case Study I’m not crying, there’s something in my eye: a rare dacroscintigraphy case (Continued)
statics were then acquired 3, 5, 10, 15, 20, 25, 30 and 60minutes post-administration. A SPECT/CT including the orbits and nasal passage was acquired at T+60minutes to localize and define the obstruction. Initial dynamic imaging shows normal tracking of radiotracer within the right nasolacrimal duct. The interval statics continue to indicate normal drainage within the right system and no movement of tracer in the left orbit (Fig. 2) As seen in Figure 3, the SPECT/CT identified tracer tracking normally along the right nasolacrimal duct and into the right nasal cavity and right base of tongue region. Instilled topical radiotracer is seen over the surface of the left eye, with no radiotracer entering the left nasolacrimal duct. The low-dose CT identified a 14x10mm ovoid hypodensity in the anteromedial aspect of the left orbit, in keeping with a dacrocystocele, depicting the cause of nasolacrimal blockage in the left eye (Fig. 4).
Figure 2 Dacroscintigraphy planar imaging up to 60 minutes depicting abnormal drainage of left nasolacrimal duct
Figure 3 CT, SPECT/CT Fusion, planar and SPECT data (clockwise from top left) displaying 99mTc- pertechnetate accumulation within the right nasolacrimal duct and absent from the left Figure 4 CT, SPECT/CT Fusion, planar and SPECT data (clockwise from top left) distinguishing dacrocystocele
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Education & CPD Case Study I’m not crying, there’s something in my eye: a rare dacroscintigraphy case (Continued)
PATIENT MANAGAMENT
Dacryocystocele in adults is typically managed with surgery due to it being a chronic and permanent obstruction. This procedure, known as dacryocystorhinostomy, involves endoscopic removal of the dacryocystocele and creation of a new tear drain between the eye and nose. Patients presenting with only epiphora often respond effectively to this treatment3,4. In this case, the dacroscintigraphy findings identify the patient as eligible for this surgical procedure as the most effective treatment option.
CONCLUSION
Dacroscintigraphy is a non-invasive imaging method to diagnose and assess obstruction of the nasolacrimal system. The utility of SPECT/CT hybrid imaging provides specific localisation of abnormalities in conjunction with functional information to guide appropriate treatment options. References 1
Cavazza, S., Laffi, GL., Lodi, L., Tassinari, G. and Dall’Olio, D. (2008). Congenital dacryocystocele: diagnosis and treatment. [online] Acta Otorhinolaryngol
Ital. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689544/ [Accessed 29 Jan. 2020]. 2
Kanasakar, P. and Sundar, G. (2018). Dacryocele in an adult presenting as facial cellulitis. [online] Available at: https://www.nepjol.info/index.php/gmj/
article/view/22412/19071 [Accessed 29 Jan. 2020]. 3
Anwar, MJ., Choudhry, SA., Aadil, M., Asif, A. and Ameer, A. (2017). Idiopathic acquired dacryocystocele presenting only with epiphora: a very rare case
study. [online] Cureas. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5669535/ [Accessed 29 Jan. 2020]. 4
Lee, JH., Moon, SW., Shin, YW. And Lee, YJ. (2010). Dacryocystocele in adult: A report of five cases. [online] J Korean Opthalmol Soc. Available at: https://
synapse.koreamed.org/search.php?where=aview&id=10.3341/jkos.2010.51.5.751&code=0035JKOS&vmode=FULL [Accessed 29 Jan. 2020]. 5
Barna, S., Garai, I., Kukuts, K., Gesztelyi, R., Toth, L. and Kemeny-Beke, A. (2019). Clinical utility of SPECT/CT and CT-dacyocystography-enhanced
dacryoscintigraphy in the imaging of lacrimal drainage system obstruction. [online] Ann Nucl Med. Available at: https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC6768911/ [Accessed 29 Jan. 2020]. 6
Gokhale, SM. (2018). Dacryoscintigraphy: A pictoral essay. [online] Indian J Nucl Med. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC6011558/ [Accessed 29 Jan. 2020]. 7
Mahesh, L. (2017) Imaging modalities for lacrimal disorders. [online] Principles and Practice of Lacrimal Surgery. Available at: https://link.springer.com/
chapter/10.1007/978-981-10-5442-6_11#citeas [Accessed 29 Jan. 2020]. 8
Wright, K. (n.d.). Nasolacrimal Duct Obstruction - Wright Center. [online] Wright Center. Available at: / [Accessed 29 Jan. 2020]. (image)
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Education & CPD Case Study F- FDG PET/CT for cardiac sarcoidosis - Diet preparation for the vegan patient
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Author: Rachel Watherston MANZSNM, Benson Radiology, Adelaide
INTRODUCTION
Sarcoidosis is a condition in which sarcoid granulomas form in different tissue throughout the body.1 Sarcoidosis can appear in any organ, but is typically seen in lungs or hilar lymph nodes; the cause for the condition remains unknown. Cardiac Sarcoidosis is rarer, although it is thought that the prevalence of cardiac involvement may be greater, but remains undiagnosed as it can present as clinically silent.2 In those patients that present with cardiac symptoms these may include: atrioventricular block, ventricular tachycardia or other arrhythmias.2 Diagnosis of cardiac sarcoidosis is ideally performed with Cardiac MRI or 18F-FDG PET Scan. Echocardiography, electrocardiogram (ECG) and holter monitoring may also be used to evaluate any cardiac abnormalities and arrhythmias; however, these tests do not confirm the presence of sarcoidosis and thus MRI or PET imaging +/- endomyocardial biopsy would need to be performed.3 The American College of Cardiology4 denies a “gold standard” in cardiac sarcoidosis imaging, and instead refers to benefits of both. Whilst MRI evaluates fibrosis, PET imaging evaluates inflammation and has the added benefit of being able to image the whole body looking for further sites of sarcoidosis including lungs and lymph nodes and also allow for follow up imaging for further progression of disease, or response to treatment. FDG PET for cardiac sarcoidosis requires suppression of physiological myocardial glucose metabolism with a very low carbohydrate, high fat diet; therefore, there is a risk of a non-diagnostic scan if correct patient preparation is not adhered to.
CASE HISTORY
The patient, a 61-year old female, presented for an 18 F-FDG PET Scan for “evaluation of lung nodules, ? lung cancer, ? sarcoid. On review of the patient’s recent imaging there was evidence of multiple nodules with both lungs which had been monitored with regular CT scans over 6+ years. Most recently, a cardiac MRI had been performed which demonstrated multiple regions of fibrosis within the myocardium. This distribution
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of fibrosis, combined with the peribronchovascular interstitial distribution of pulmonary nodules was highly suggestive of cardiac and pulmonary sarcoid. With this additional information, it was decided that a specific cardiac preparation prior to the FDG PET Scan should be followed to better assess the myocardial fibrosis.
METHODS
Our practice’s standard protocol for FDG PET imaging in regards to fasting, is for a 6 hour fast (minimum 4hour for diabetic patients); with specific guidelines in place for diabetic patients’ dependent upon their medication. For evaluation of the myocardium, specifically cardiac sarcoidosis, in FDG PET Scans, we ask patients to follow a high fat/protein diet for 24-48 hours, followed by an 18 hour fast prior to their appointment. This is usually achieved by following the specific diet preparation for 1-2 days; ensuring to eat evening meal by 6 pm, with an overnight fast and 18 F-FDG injection approximately midday the next day. Upon discussion with our patient, we discovered that she was a Type II Diabetic who takes metformin twice daily. In addition, the patient also followed a strict vegan diet. After consultation with the reporting Radiologist and Senior PET Technologist; the patient was instructed to follow a specifically designed high fat/protein, low carb diet for 48 hours. She was advised to finish her evening meal on the second day by 7 pm (at which time she could take her evening metformin dose); she was then to fast overnight and the following morning, and not take her usual metformin dose; and was scheduled for a 12 midday 18F-FDG injection. Due to FDG supply complications, the patient’s PET scan was further delayed resulting in a 20-hour fast. The vegan diet proved to be an additional complication in the preparation of the patient’s PET scan. The patient advised us that her diet consisted mostly of cereal, fruit and dairy free yoghurts for breakfast and snacks, with her midday and evening meals consisting mostly of beans, legumes, meat substitutes and vegetables. This was clearly not suited for a low carbohydrate diet as required for her PET
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Education & CPD Case Study F- FDG PET/CT for cardiac sarcoidosis - Diet preparation for the vegan patient
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(Continued)
scan. The following suggested diet was given to the patient, along with the instruction to keep net carbohydrates < 10grams per day. When creating the diet plan, thought was given not only to the carbohydrate component but also to the flexibility allowed to the patient to ensure that this diet was able to be tolerated and the patient not left feeling hungry, or limited in choice. Breakfast
• • •
Tofu scramble with capsicum and mushrooms- can use nuttelex Unsweetened coconut milk smoothie with spinach/berries/almond butter Homemade chia seeding with unsweetened coconut milk
Lunch / Dinner
• • • • •
Cauliflower (or other non-starchy vegetable) soup- can add small amounts of coconut milk/cream Cauliflower rice with tofu “Zoodles” (zucchini noodles) with homemade pesto Salad with lettuce, cucumber, spinach, kale, vegan cheese olive oil Tofu with low carb vegetables, mushrooms cooked in nuttelex
Snacks / Beverages
• • • • •
Vegan cream cheese and seed crackers Berries (in moderation) Small amounts of low carb nuts- macadamias, walnuts, pecans Unsweetened tea/coffee Water and mineral water
Foods to avoid
• • • • • •
Meat substitute Beans/Legumes Rice Starchy Vegetables Fruit Sugars/sweeteners (Stevia allowed)
RESULTS
Upon presentation to the department, the patient confirmed she had followed the specified diet as requested for 48 hours, and had not eaten or taken her diabetic metformin since the previous evening. All other PET/CT preparation was also adhered to. Her baseline BSL was recorded as 5.3mmol/L. As previously mentioned; the FDG injection was delayed due to supply issues resulting in a total 20 hour fast. The patient was injected with 298.6MBq of 18F-FDG, and scanned after a 55 minute uptake time. Imaging was performed from skull base to mid-thigh at 3 minutes/bed with an additional 10 min bed position over the heart. A diagnostic CT chest with intravenous contrast was also performed post PET/CT as requested. Imaging was performed on a Discovery IQ 5 ring PET/CT scanner. The PET/CT demonstrated adequate cardiac suppression of physiological glucose metabolism. There were multiple areas of increased FDG avidity including the apical left ventricle (Image 1) and patchy uptake within
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Image 1
Education & CPD Case Study F- FDG PET/CT for cardiac sarcoidosis - Diet preparation for the vegan patient
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(Continued)
the basal inferior and inferolateral wall and basal intraventricular septum. (Image 2) These regions corresponded to the sclerosis seen on the recent cardiac MRI and were supportive of a diagnosis of Sarcoidosis. In addition to the cardiac sarcoidosis noted; there was also low grade uptake seen within multiple lung nodules and moderate uptake within hilar nodes, consistent with Sarcoidosis. (Image 3) Due to the adequate cardiac suppression of physiological FDG uptake; and the concordance with MRI imaging, it was determined that further cardiac imaging with 99mTc-Sestamibi was unnecessary. It was noted that if biopsy was to be performed for histological confirmation; there were hilar nodes that could be targeted as an endomyocardial biopsy of the apical region may be more difficult to obtain.
Image 2
DISCUSSION
This case demonstrates the importance of adequate diet preparation prior to a cardiac 18 F-FDG PET scan. With careful preparation and explanation to the patient, the correct preparation should be followed to allow optimal FDG imaging. Furthermore, correlation with previous imaging, such as MRI, can be utilised to confirm the diagnosis and negate the need for further nuclear imaging or difficult endomyocardial biopsy. The FDG PET/CT scan also allowed for further evaluation of areas of Sarcoidosis, which could also allow for an easier biopsy site. Furthermore, this case shows that adequate cardiac suppression is possible with a variety of diet factors including veganism. With careful research and planning, a suitable diet plan was prepared that not only allowed cardiac suppression on the PET/CT scan, but was also tolerated well by the patient and allowed her flexibility and choice in her 48 hour preparatory diet.
Image 3
References: 1.
Lung Foundation Australia. 2018. Sarcoidosis Fact Sheet. retrieved from: <https:// lungfoundation.com.au/wp-content/uploads/2018/09/Factsheet-Sarcoidosis-Jul2016.pdf>
2.
Birnie, D. Nery, P. Ha, A. Beanlands, R. 2016. Cardiac Sarcoidosis. Journal of the American College of Cardiology, Volume 68, 4. pp 411-421. DOI: 10.1016/j.jacc.2016.03.605
3.
Foundation for Sarcoidosis Research. 2018. Understanding Cardiac Sarcoidosis. Retrieved from: <https://www.stopsarcoidosis.org/understanding-cardiac-sarcoidosis/>
4.
Bravo, P. Taqueti, V. 2017. Cardiac MRI vs. PET for the Evaluation of Cardiac Sarcoidosis: Consider MRI first. American College of Cardiology. Retrieved from: <https://www.acc.org/ latest-in-cardiology/articles/2017/04/10/08/43/cardiac-mri-vs-pet>
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Education & CPD Case Study Being Prepared for the Emotional Journey of Breast Cancer Patients Author: Chrissie Roodt, Charge Nuclear Medicine, Southern DHB, New Zealand
INTRODUCTION
Sentinel Lymph Node Scintigraphy provides important information for the surgical approach (Turkmen, 2019). In addition breast scintigraphty is non-invasive (Bombardieri et al., 2003) and SPECT/CT is more sensitive and accurate than planar lymphoscintigraphy in locating non-axillary sentinel nodes (Hoefnagel, 2018). Knowledge of lymph node status also influences breast and skeletal regional treatment strategies (Borrelli et al., 2017). Sentinel lymph node biopsy is based on the fact that tumors drain in a certain way through the lymphatic system and the sentinel lymph node is the first to be affected by metastasis if the tumor has spread. A clean sentinel lymph node suggests a low likelihood that other nodes will be affected. Sentinel lymph node biopsy is a safe procedure for the patient and staff. From the perspective of the Medical Radiation Technologist (MRT) this procedure is simple and part of a daily routine. However, the prevalence of breast cancer in females in society (24% of new cancer cases reported in 2018 – 2.1 million women (Bray et al., 2018)) makes for an emotionally charged and traumatic experience for patients. In this article I’ll discuss the development of a four phase workflow that puts empathy with the patient and an understanding of the emotional journey at the center of the procedure.
The Emotional Journey: Developing a Credible Persona A persona describes important characteristics of a group of people within the context of a process or situation. It reflects believable traits of a rounded real-world person/ character. Using a simple story for the persona that reflects a typical journey or lived experience, the readers can immerse themselves and see the world from the perspective of the persona (Nielsen, 2019). A persona can be used to clarify process, develop new approaches and to understand how to interact with people in a certain manner. The aim was to create an empathetic description of the breast cancer patient. The description generates a level of involvement for the target audience, in this case the readers of this article, and specifically the MRT that works with the cancer patients daily. The goal is to ensure that patients are treated with empathy and respect in a consistent manner, resulting in patients benefiting in the department from an experience that is rich with understanding and with a positive view on being supported towards recovery.
Meet Sarah Sarah is a client advisor, aged 45. She dresses professionally, and we discover that she loves to dress up. Her mother is 70 years of age and in excellent health. Sarah is proud of her 20-year-old daughter who studies accounting. When Sarah was a teenager her favourite movie was ‘Shirley Valentine’ and that inspired her to save for a trip to Greece. She loves nature, goes hiking regularly, grows her own veggies and lives a healthy life. Although she is not tech savvy, she is in total control of her life, and her home and work environment.
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Education & CPD Case Study Being Prepared for the Emotional Journey of Breast Cancer Patients (Continued) The Journey One Saturday morning Sarah was getting ready to go shopping with her daughter. While looking in the mirror, she noticed something different and felt a lump in her right breast. Emotions swept over her as she stood in front of the mirror: “What is this? Is this cancer, am I going to die, like so many other women I have heard about, I feel sick!” Sarah felt as if she was looking at herself from a position outside of her body. She tried to reassure herself that she does not have a family history of breast cancer. Almost angry, she reminded herself of her plans for the future! Then she started to worry again about losing her job. What would happen to her mom and daughter? Haines (2016) says that trauma can cause feelings of losing connection with our bodies and waves of fight and flight emotions. Sarah’s experience is typical of the range of feelings that our cancer patients go through. Some will put off seeing a general practitioner (GP) and others will take action and hope to overcome the situation by taking back control. Sarah decides to regain control and makes an appointment with her GP. Two weeks later and in a whirlwind of events Sarah had a mammogram, MRI scan, ultrasound, blood tests, X-rays, a pre-admission session with her surgeon, anaesthetist and breast care nurse. She had to face the difficult task to break the news to her daughter and mother: she was diagnosed with breast cancer and needed surgery and a lymph node biopsy. She was overloaded with information from so many people and she felt tired. On the day of the visit to the nuclear medicine department, she is at an all time low. She is facing a radio-active tracer injection for imaging and mapping, with breast surgery the next day. She is worried about finding parking close to the horrible hospital, will she be in time for the appointment? And there is the injection. Sarah is afraid of needles and was told she would be injected with a radio-active material – very concerning! Will she even find the Nuclear Medicine Department?! When I started my studies, my wise dad told me that when a patient enters a hospital they turn deaf and blind. They listen and nod, but do not hear. They look but don’t see. This is what happens to Sarah. Overwhelmed by all the stress triggers people lose the ability to pinpoint events and places (Haines, 2016). By the time that Sarah reaches the Nuclear Medicine Department, she is deeply stressed and in a very negative emotional state. I have identified four distinct phases of interacting with our patients: Arrival, Preparation, Consent and Hand-Over. 4 Phase Workflow French philosopher Michel Foucault stated that there is a form of power and knowledge in every relationship, whether it is between a child and a parent, an employee and an employer and even a patient and a medical staff member. Sarah lost control over so many aspects of her life when she Arrival Preparation Consent Hand-Over discovered that lump in her breast and as I walk up to meet her, she is in a very vulnerable position. She has no control over the relationship between herself and me – the MRT. According to a psychologist at the DHB, I Build Be Inform & Positive Progress have between 2 – 3 seconds to build trust. I have to be friendly, positive, Trust Clear Assure confident, professional and calm. My message to Sarah is that I can help her. Of course, you cannot win the trust of all patients, but one has to remain professional and confident.
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Education & CPD Case Study Being Prepared for the Emotional Journey of Breast Cancer Patients (Continued) Sarah is relieved to see a friendly face. She feels that she will be looked after. But she is in for another, rather unexpected event: she has to undress and put on a stupid looking formless gown! By asking Sarah to undress and wear a gown takes away personal power, leaving her vulnerable. My instructions during the preparation phase must be very clear - exactly what to take off, what to keep on, which side the opening of the gown is, where to store her clothes and personal belongings, and what to bring with her next. It is crucial not to have her wait in the changing cubicle before taking her through for the procedure. Before she knows it, the friendly MRT is back and Sarah is relieved to hear things explained in the simplest of terms (I use ‘baby language’) and she feels that she can ask questions about the procedure. “That needle… but it sounds like they’ll be using the thinnest of needles and I may only feel a little sting. Sounds reasonable and I know what to expect. It does not sound at all like a dangerous or even painful exercise. I can do this!”
Hand-Over
Sarah's Emotions
+
By answering questions carefully, by listening to the patient and by using simple language to explain the procedure, power and confidence is transferred back to the patient. Informing and assuring the patient must take as long as it takes! The procedure is over and Sarah feels like she has one less hurdle to overcome. She hears that she is in good hands the next day. There is hope after all! It is always good to hear that your surgeon is a perfectionist and leaving Sarah with the assurance that she is in good hands will ease her journey to emotional recovery.
CONCLUSION
The value of human warmth and gestures of well-being can never be underestimated. How rewarding is it to send a patient on her journey filled with hope? She still has to face the unknown, but she knows there are competent people who will look after her. We only see a small part of a patient’s life. A whole universe lies behind her. Empathy – that is why we do this job!
"We all have within us the ability to endure, recover and learn from overwhelming events." Trauma is really strange - Steve Haines (2016)
-
Positive Progress
References •
Bombardieri, E., Aktolun, C., Baum, R. P., Bishof-Delaloye, A., Buscombe, J., Chatal, J. F., . . . Reske, S. N. (2003). Breast scintigraphy: procedure guidelines for tumour imaging. European journal of nuclear medicine and molecular imaging, 30(12), B107-B114.
•
Borrelli, P., Donswijk, M. L., Stokkel, M. P., Teixeira, S. C., van Tinteren, H., Emiel, J. T., & Olmos, R. A. V. (2017). Contribution of SPECT/CT for sentinel node localization in patients with ipsilateral breast cancer relapse. European journal of nuclear medicine and molecular imaging, 44(4), 630-637.
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Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: a cancer journal for clinicians, 68(6), 394-424.
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Haines, S. (2016). Trauma is really strange. London: Singing Dragon.
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Hoefnagel, C. A. (2018). Lymphoscintigraphy and Sentinel Node Localization in Breast Cancer Lobar Approach to Breast Ultrasound (pp. 215-226): Springer.
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Nielsen, L. (2019). Making Your Personas Live Personas-User Focused Design (pp. 57 - 67): Springer.
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Turkmen, C. (2019). Nuclear Medicine Imaging in Breast Cancer. In A. Aydiner, A. Igci, & A. Soran (Eds.), Breast Cancer (pp. 223-237). Cham, Switzerland: Springer.
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Education & CPD What’s that Soft Tissue Uptake on Bone Scan: Artefact or Rare Finding? Authors: Jessica Fagan MANZSNM and Dr Jenny Davidson MANZSNM, Mercy Radiology, Auckland, NZ
INTRODUCTION
A 70 year old woman with metastatic breast cancer, new metastatic disease at T5 and previous knee pains, presented to the department for a staging bone scan, to exclude further bony metastatic disease.
CASE REPORT
Mrs X was originally diagnosed with breast cancer in 2010. Shortly after this, she underwent a right mastectomy and subsequent chest wall radiotherapy. She presents with a recent history of back and knee pain for 6 months. She has known metastatic breast cancer to the liver and is currently on Letrozole and Ibrance. Delayed phase (3hr) whole body planar imaging and SPECT/CT of the whole spine was performed following injection of 738MBq 99mTc-HDP.
Figure 1: Delayed whole body bone scan. Arrows pointing to soft tissue uptake seen on the right posterior images.
The planar whole body bone scan showed multiple areas of degenerative changes in the wrists, feet, ankle and knees. Soft tissue uptake was seen posteriorly on the right, most likely correlating with known liver metastases. On subsequent SPECT/CT images, soft tissue uptake within the posterior liver was found to be associated with a large metastatic deposit on CT, and correlated with the soft tissue uptake seen on initial planar imaging. Osseous metastatic disease was also found in the T3 and T5 vertebrae, as well as right xiphisternum. Comparison with previous CT images of the Chest, Abdomen and Pelvis from 5 months prior, confirmed the presence and location of liver metastases, which at the time of functional imaging had shown progression from previous cross sectional imaging.
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Education & CPD What’s that Soft Tissue Uptake on Bone Scan: Artefact or Rare Finding? (Continued)
DISCUSSION
After injection and initial distribution throughout the body by perfusion, 99mTc labelled diphosphates, such as HDP, diffuse out of the blood stream and into the extracellular space. Initial accumulation of the tracer is primarily related to blood supply, however other possible mechanisms of increased activity include increased osteoid formation, increased mineralization of osteoid, or interrupted sympathetic nerve supply.¹ Initial deposition of the tracer is thought to be due to chemisorption on the bone surface.¹ Diphosphonates concentrate in the mineral phase of bone, which is two thirds crystalline hydroxyapatite and one third amorphous, noncrystalline calcium phosphate.¹ That is, due to its affinity for calcium, HDP binds to the calcium located in the bony structures of the body.² Soft-tissue tumours or their metastases (especially in the liver) may calcify.¹ This can result in soft-tissue activity due to the binding of HDP to the calcifying metastasis, following a Figure 2: Coronal Fused SPECT CT images of posterior spine. Arrow pointing to soft tissue uptake found similar physicochemical process as described above. in right posterior liver. The asymmetric uptake in the Causes of extraosseous activity on bone scans can be attributed T5 vertebra can also be seen on this image. to many factors. Most commonly incorrect radiopharmaceutical preparation and administration, as well as artefacts such as, urine contamination on the skin surface, must be considered. Additionally, compiling a comprehensive medical history will aid physicians in diagnosis of abnormalities, utilizing the knowledge of pre-existing conditions. Correlation with previous imaging and the aid of SPECT/CT, both contribute to more accurate diagnosis, especially in rarer cases of soft tissue uptake on a bone scan, like the case presented above. References: 1.
F.A., Mettler Jr., M. J., Guiberteau, Essentials of Nuclear Medicine Imaging (Saunders Elsevier, United States of America, ed. 5, 2006).
2.
G. M. Weiner, et. al, “Artifacts and non-osseous uptake in bone scintigraphy.” Radiol Oncol 2001; 35(3):185-91. www.onko-i.si/fileadmin/onko/datoteke/ dokumenti/013503-weiner.pdf.
2020 Autumn Edition gamma GAZETTE 53
T i me t o Re l a x WORD SEARCH
WORDS TO FIND Chemotherapy Head and Neck Hodgkin Metastatic Cervix Radiotherapy Epilepsy Dementia Sarcoma Colorectal Ovarian Adjuvent Staging Non small cell Breast Uterine Recurrent Non Hodgkin Oesophageal Lymphoma Restaging
JUMBLE WORDS 1. CALNRUE 2. MMGAA RAY 3. DAIEILNCDOUR 4. LEMOAMAN 5. LOMMAPHY 6. NHIS IPLSTN 7. DESO OCRBIAARTL 8. CCODIIENNEC NIGUTONC 9. ROONISPT 10. AISORYTL NUOMYALPR LUOEND 11. YADEC
Responses can be found on page 56 Content submitted by Madeleine Buttfield, Benson Radiology
2020 EVENTS CALENDAR SA Branch Meeting
WA Branch Meeting
1 April 2020
7 April 2020
Radiology SA Time: 5:30 pm
Perth Children's Hospital Time: 5:30 pm
CPD Points
CPD Points
50th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine 24 — 26 April 2020 International Convention Centre Sydney CPD Points
SNMMI 2020 Annual Meeting 13 - 17 June 2020 New Orleans Ernest N. Morial Convention Center, New Orleans, Louisiana, USA
SA Branch Meeting 5 August 2020 Topic: Cardiac Imaging Venue: To be confirmed Time: 6:00 pm
WA Branch Meeting
SA Branch Meeting
17 June 2020
1 July 2020*
Royal Perth Hospital Time: 6:00 pm
Dr Jones & Partners Time: 6:00 pm
CPD Points
CPD Points
TSIG Annual Day Symposium
SA Branch Meeting
22 August 2020
9 September 2020
Customs House, 399 Queen St, Brisbane City, QLD
Royal Adelaide Hospital Time: 6:00 pm
CPD Points
CPD Points
CPD Points
WA Branch Meeting Radpharm Presentation 16 September 2020 Topic: Radpharm Presentation Night SKG Radiology Time: 5:30 pm
33rd Annual Congress of the European Association of Nuclear Medicine 17 — 21 October 2020 ACV – Austria Center Vienna, Bruno-Kreisky-Platz 1, 1220 Vienna, Austria
WA Branch Meeting AGM 17 November 2020 QScan Time: 6:00 pm CPD Points
CPD Points
SA ANZSNMT AGM Dinner, Radpharm Awards & University Student Presentations 18 November 2020 Venue to be confirmed Time: 5:30 pm CPD Points
International Conference on Clinical PET–CT & Molecular Imaging in the Era of Theranostic (IPET-2020) 23 — 27 November 2020 IAEA Headquarters, Vienna, Austria
SA Branch Meeting AGM & Quiz Night 2 December 2020* Venue to be confirmed Time: 6:00 pm CPD Points * Final dates are pending to be confirmed
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AIMS AND OBJECTIVES OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE 1. Promote: • The advancement of clinical practice of nuclear medicine in Australia and New Zealand; • Research in nuclear medicine; • Public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; • Co-operation between organisations and individuals interested in nuclear medicine; and • The training of persons in all facets of nuclear medicine. 2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine through standing committees and special groups: • The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand. • The TSIG Committee is the group overseeing the Technologist Special Interest Group (TSIG) and ensures that all projects, committees and activities of the TSIG align with the values and strategic plan of the ANZSNM. It reports directly to the ANZSNM Federal Council and oversees the two TSIG working groups: CPD & Education Working Group and Technologist Workforce Advocacy Working Group. The committee is able to form working groups to perform specific tasks as required to provide opportunities for the benefit of Technologist members of the ANZSNM after consultation with the ANZSNM Federal Council. • The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality 58 gamma GAZETTE 2020 Autumn Edition and provide a forum for development in Australia and New Zealand.
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