2020 SPRING/2021 SUMMER EDITION ISSUE 31
2020 SPRING/2021 SUMMER EDITION | ISSUE 31
Contents
• Technologists Special Interest Group • International Relations Committee • Quality and Technical Standards Committee
• 50th Annual Scientific Meeting Recap • Award Abstracts
• Interesting Case: Lingual Thyroid • PET/CT for PETS Canines as a model for human disease: A case study of Prostate Adenocarcinoma in a Beagle • The Use of 11C-Methionine PET/CT and MRI in the Detection of Pituitary Adenomas • The Tale of Two Tracers – Investigation of the Use of Prostate Specific Tracers in the Imaging and Diagnosis of Metastatic Prostate Cancer • What's That? – Case 1 • What's that? – Case 2
• Gabby Cehic
• Nuclear Medicine Locum experience at Addenbrooke’s Hospital, Cambridge, United Kingdom • Understanding Medical Radiation Practitioner Regulation in NSW: an article brought to you by the Medical Radiation Practice Council of NSW (MRPC).
• Invitations to apply - 2021 ANSTO/ANZSNM Research Grant • 2019 update: PET dose extravasation frequency and impact in the Australian context
Design & Production
Editorial
Events & Advertising Enquiries
Ester Gomez, Creative Director Enovate Studio ester@enovatestudio.com www.enovatestudio.com
Rajeev Chandra, General Manager PO Box 6178, Vermont South, VIC 3133 1300 330 402 (03) 8677 2970 secretariat@anzsnm.org.au
marketing@anzsnm.org.au
Disclaimer
Submissions
secretariat@anzsnm.org.au
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
T
he year is rolling along so rapidly, it doesn't seem like it could be coming up to six months since I took on the role of President, but here we are! In that short time, a lot has happened with the Society. We have run and done the amazingly successful 2020 virtual Annual Scientific Meeting, and it was great to see that so many of you participated. Well done to all the award winners and finalists. Thank you to all of you who contributed your time and effort.
There has been a lot of discussion lately about the Cardiac Imaging MBS changes, and I am glad to be able to say that it looks like our efforts are starting to have an effect. We are also dealing with a number of other requests for advice and assistance on various nuclear medicine related matters, from both Australia and New Zealand and overseas.
P
lanning for the 2021 ASM is well under way, and I look forward to catching up with all my SA colleagues live in person, and with all the rest of you at all your various sites via the internet. Keep looking out for the call for abstracts and the opening of registration.
You will have seen in your email that renewals for your membership are open, and if you get in early you can renew at a reduced rate, giving you even more value! The Society is aware that some of our members have been affected financially by COVID-19, and we have put support mechanisms in place for anyone who will struggle with their membership fees for 2021 - if this is you, please contact me or the secretariat to access this support. What a strange new world we live in now! Things will never be the same again, and as a society we must adapt and keep working together. Keep up the good work and look after each other.
Daniel
Daniel Badger - MANZSNM, President
2020 Spring/2021 Summer Edition gamma GAZETTE 3
Introduction to the Spring/Summer Edition Welcome to the spring/summer edition of the Gamma Gazette the last edition for 2020, and what a year it has been. As we reflect on the last few months, it is hard to think about anything more than the ongoing COVID-19 pandemic.
However, amongst all of the difficulties we have faced this year, there have been some significant moments for our profession, in particular the release of several multi-centre publications further proving the impact of Nuclear Medicine as a diagnostic tool, and the full circle return of our profession to the use of radiopharmaceuticals for therapy. As I write this introduction, restrictions are starting to ease in some states, and we can now travel a little further from our home. Over the past 6 months, we have been forced to communicate with our friends, family and colleagues over the internet, the silver lining of this is that we have all become very well acquainted with the use of videoconferencing and more opportunities for CPD now available to staff who work outside our metropolitan areas. I hope you enjoy this edition of the Gamma Gazette bought to you by the Queensland Branch of the ANZSNM. Thank you to all of our contributors for their hard work. Stay Safe, Sarah Daniel - MANZSNM Branch Chair, Queensland
Call for Abstracts is NOW OPEN
4
gamma GAZETTE
2020 Spring/2021 Summer Edition
Branch News Victoria/Tasmania Branch News
T
he Vic/Tas Branch held their first online Day Seminar on Sat 14th November. Considering it was the first weekend in five months that Melbournians were able to leave the metropolitan area and escape the “Ring of Steel”, we were very happy to have over 30 technologists log on! As COVID-19 has had such a large impact on all of our lives in Victoria, we had lined up several speakers to discuss the impact that the virus and the subsequent restrictions has had on the day-to-day workings of the Nuclear Medicine community.
We heard from Danny Bucki-Smith (Tullamarine Radiophamacy) who has had to deal with the Melbourne curfew, as well as the border closure between Victoria and NSW, on top of world wide cold kit shortages. Graham Morl from ANSTO discussed the difficulties of importing “hot” products from overseas when there was an 80% drop in the number of passenger planes. Our Tasmania representative, Reuben Smith gave us the perspective of the Nuclear Medicine community in Tasmania, including the quarantine of Burnie hospital and the NW region of Tasmania, as well as how to maintain a reliable FDG delivery from Melbourne with little-tono passenger flights coming in. We then heard from Suzanne McGavin about the upheaval at RMIT when they had to pivot to an online course with about 8 hours warning! This was complimented by hearing from two of the current Nuclear Medicine students discussing the advantages and disadvantages of online learning, as well as how the experience has affected both first years with no prior university experience, and second and third years completing their clinical experience in an increasingly challenging environment. Thanks to Caitlin Jakubik (1st year) and Liz Doueal (3rd year) for their insight, and bravery in presenting to a group of qualified technologists and doctors.
Danny Bucki-Smith's presentation
To round out the day, we also heard from Dr Sidney Levi who presented some of the results of the ProPSMA trial looking at using PSMA PET scans in staging of newly diagnosed prostate cancer, as well as Mark Macenko (AHPRA Chair) who gave us an update on the new Professional Capabilities for Technologists. The afternoon session also included the state finals of the Radpahrm and SOPA (Student Oral Presentation) awards. We are pleased to announce that Ozanna Le (from Eastern Health) will represent Victoria with her case study on “The Role of myelolipoma scintigraphy in the differential diagnosis of fat containing lesions” and Katherine Nguyen’s presentation on “The overlooked benefits of thallium Chloride Tl201 for Myocardial Perfusion Imaging” will be our SOPA entrant. Congratulations to you both! A big thank you to GMS for sponsoring the event, and to the Vic/Tas branch committee members for their amazing effort at sourcing such a variety of interesting and informative speakers, as well as their hard work in organizing our first (and hopefully last!) online event. Kim Jasper – MANZSNM Branch Chair, Victoria/Tasmania
Suzanne McGavin
2020 Spring/2021 Summer Edition gamma GAZETTE
5
Branch News Victoria/Tasmania Branch News (Continued)
Mark Marcenko's presentation
Some of the meeting's participants Caitlin Jakubik's presentation
Committee Members Liz Doueal's presentation
Dr Sidney Levi's presentation
Dr Sidney Levi's presentation
6
gamma GAZETTE 2020 Spring/2021 Summer Edition
Suzanne McGavin
Branch News Queensland Branch News
O
n Tuesday the 28th of July the Queensland branch of the ANZSNM was fortunate enough to hold an inperson meeting at the Royal Brisbane and Women’s Hospital. We had a fantastic turnout both in-person and virtually, after the months that had preceded the event, our members were very happy to be able to socialise again. As it turns out, we were very lucky to do so, as restrictions here in Queensland came back into action just a few weeks after the event.
The evening began with a presentation from A/Prof David Pattison on “PSMA Targeted Imaging and Radionuclide Therapy Update” who gave us a fantastic overview of the ongoing work with PSMA and discussed the recent publication results of the TheraP and proPSMA trials. Our second speaker for the evening was Dr Andrew Redmond who is a Senior Staff Specialist at the Royal Brisbane and Women’s Hospital in the Infection Diseases Unit. Dr Redmond’s presentation was titled “An Overview of COVID-19 at Royal Brisbane and Women’s Hospital” and was a fascinating insight into the impact of COIVD-19 at a large metropolitan hospital, the changes to services that were required and the mammoth effort all of our healthcare workers have put in so far this year. I would also like to take this opportunity to congratulate two of our Queensland members on their achievements at the recent ANZSNM Virtual ASM.
and Brenda Tai from the Department of Nuclear Medicine and Queensland Specalised PET Services at the Royal Brisbane and Women's Hospital won The GMS Poster Award for her fantastic poster on “Validation of Automated Manufacture of [68Ga] Ga-DOTA-TATE for Clinical Use with High Activity Input”. Our next meeting which is inclusive of the Queensland state Radpharm award and the Queensland Branch AGM was held at Princess Alexandra Hospital on Tuesday the 3rd of November. All current committee positions were available for nomination at this meeting, and I urge any of our members who are interested in becoming a part of this organisation to put their name forward, it is a truly rewarding experience. Updates to follow. Stay Safe and Well, Sarah Daniel - MANZSNM Branch Chair, Queensland
Maddison Carroll from the Department of Nuclear Medicine at the Princess Alexandra Hospital won the National Radpharm Technologist Case Presentation Award Winner with her presentation on “Utilising Fluorine-18 Florbetaben ( 18 F-FBB) as a diagnostic tool for the assessment of cardiac amyloidosis”
2020 Spring/2021 Summer Edition gamma GAZETTE
7
Branch News New Zealand Branch News
I
nstead of waffling’s from me, I thought I would get some feedback from around the country which would be far more interesting! Here is what has been happening in NZ since the Gamma Gazette Winter Report.
NEWS FROM THE NORTH From Shelley Park, Medical Imaging Postgraduate Clinical Coordinator & Professional Teaching Fellow, University of Auckland. “The University of Auckland is pleased to report that Karen Roeske has returned to assist the Medical Imaging team in conjunction with Loren Katchel from Queensland, Australia. Karen is maintaining her clinical role at Pacific Radiology (Wellington) and will be involved in both undergraduate and postgraduate nuclear medicine teaching. The University is also delighted to announce the successful completion of the Postgraduate Diploma in Health Sciences in Nuclear Medicine programme for Behnam Farvardin from Southland Hospital, Invercargill. Another seven nuclear medicine trainees are expected to graduate within the year. The next delivery of the MEDIMAGE 720: Fundamentals of Clinical Nuclear Medicine course will be in semester 1 2021. This is the first nuclear medicine specific course of the PGDipHSc(Nuclear Medicine) and is the prerequisite for all subsequent nuclear medicine courses of the programme. Due to the small student numbers, this course will not then be offered again until 2023 (dependent on student enrolment numbers) therefore all departments are encouraged to consider their training requirements and ensure potential students are aware. Students do not need to have a clinical training position to enrol in MEDIMAGE 720 so if you know of someone who might be interested in training in nuclear medicine in the future, encourage them to enrol in the Postgraduate Certificate programme and complete four courses while waiting for a training position to become available. For more information about this option, please contact medicalimaging@auckland.ac.nz ”
8
From Lisa Hansen, Unit Charge at Ascot Radiology in Auckland. “We are looking forward to a hot lab upgrade. Woohoo. We have been hoping to start up with the FBB trial at Auckland University, however, COVID-19 has put the brakes on here. Several staff changes throughout the year, we now have three NMTs in our department.”
From David Newberry, Head of CT/SPECT SRG Radiology in Auckland. “SRG and Ascot Radiology have now joined forces under the umbrella of the parent company Integral Diagnostics (IDX). This means we now have a PET and SPECT combined service. We are also on the lookout for a CT Radiographer with or prepared to train in Nuclear Medicine. IDX through Ascot and SRG are hoping to push and expand Nuclear Medicine services here.”
From Jessica Fagan, Team Leader NM & PET at Mercy Radiology in Auckland. “Mercy Radiology is pleased to announce the opening of our new PETCT centre located in the suburb of Milford on Auckland’s North Shore. We have installed the uMI 550 (United Imaging) which is the first digital PETCT scanner in NZ! We are very impressed with the images so far, and we are very excited to bring this new technology to New Zealanders.”
gamma GAZETTE 2020 Spring/2021 Summer Edition
Branch News New Zealand Branch News (Continued) From Salomé Lingenfelder, MANZSNM Charge Technologist, Taranaki Base Hospital in New Plymouth. “I am really excited to say things are finally beginning to happen here in Taranaki, and I am so grateful for Victoria Brooks who kept on fighting for NM here! A new NM MIT, Juanita, has been appointed to fill Victoria’s post, their flight tickets from Doha are booked and if all goes well, will be here in October. We also have a business plan in progress for a new SPECT/CT, and the architects are busy with measurements for the old angio room in the department to see if it can be used for the SPECT/ CT, fingers crossed that it will be installed next year.”
From Charge Technologist Janice Hartshorne, Pacific Radiology in Wellington. “Over recent months we have reviewed our Nuclear Medicine service at Pacific Radiology Wellington, as part of planning for a SPECT CT machine upgrade and site change. The outcome of our careful review is sadly the decision to close our Nuclear Medicine service at the end of this year. However, we will continue to provide our regional PET-CT service at our Bowen branch.”
guidance- result very low failure/extravasation rate, Radiologists time not required. Commencing a PSMA study which may lead to increased PSMA PET utility (to validate against MRI/Bx). Full integration of tablet based consent forms for PET + sedation. Scanning dogs with NaF for dysplastic elbows osteotomy required-imaging proving valuable to guide treatment, may take over CT in future. New workflow for NaF to take all imaging off-line using new GE server configured protocols, very efficientless distractions and better patient focus.”
From Kirsten Worthington Unit Charge NMT from Kew Hospital, Invercargill. “Congratulations to Behnam Farvardin at Kew Hospital in Invercargill, on successfully completing his SOAP at the end of July. They have also taken on another trainee, Danae Bradley, who has commenced her studies at the beginning of Semester 2 (University of Auckland Postgrad Medical Imaging (NM pathway).” Jessica Fagan – MANZSNM Branch Secretary, New Zealand
NEWS FROM THE SOUTH From PET/CT Southern Cross, PRG in Christchurch, Denis Hely, UC PET. “Implementation of new GE software for PET FET/ FDG brain analysis with TACs, MRI fusion and auto-lesion contouring. Ability to save state and have Neuro Rad easily interact with dynamic data. Nuclear Medicine Technologists Ryan and Arminder have completed their US IV certification. We now have a low threshold to use US for cannulation
2020 Spring/2021 Summer Edition gamma GAZETTE
9
Branch News
NZ Branch Meeting, 31st October 2020, Wellington
T
rue to form, the day in Wellington was miserable. But as attendees watched virtually from the comfort of home in their “house clothes”, the weather was not an issue. Ten attendees joined in on site at “Branch Meeting HQ”, with a fantastic turnout on line with 47 attendees.
The day began with a great live presentation from Dr Bernard Bendriem, Key Expert in Molecular Health for Siemens Healthcare, all the way from Knoxville, Tennessee. Dr Swee Tan, Surgeon/Research Scientist/Medical Humanitarian was an invited speaker. His presentation “A Paradigm Shift in the Understanding and Treatment of Cancer”, shared with us the Gillies McIndoe Research Institute’s successful experience with drug re-purposing in cancer treatment. Local heroes Nuclear Cardiologist Dr Sue O’Malley and Dr Tracy Melzer, MRI Research Manager, NZ Brain Research Institute, presented via Zoom from Christchurch. ANZSNM President Daniel Badger and Nuclear Cardiologist Dr Nathan Better took time out from their busy Saturday to present from Australia. Wellington Regional Hospital clinicians Dr Nichola Naidoo and Dr Mortiz Lua updated us on their experiences with Iodine131 in Oncology and Endocrinology respectively. I think we all missed the opportunity to connect with our colleagues from around New Zealand. Our branch meeting dinners are synonymous with late night dancing and fantastic costumes, so it was disappointing not to celebrate after a hard day of learning. Well ok … there was some celebrating, but minus the costumes this year. Thank you to our sponsors GE, GMS, Alphatech and Siemens for supporting our successful meeting. At the AGM it was agreed by all that we looked forward to whatever 2021 might bring, and a return to face to face meetings. Pru Burns - MANZSNM Co-convenor, New Zealand
10
gamma GAZETTE 2020 Spring/2021 Summer Edition
Branch News
NZ Branch Meeting, 31st October 2020, Wellington (Continued)
Dr Nathan Better – live from Melbourne.
Dr Darin O’Keeffe, receiving his Bronze Medal in the IAEA competition “Towards a Strong Radiation Safety Culture in Medicine” in Vienna, February 2020, just days before lockdown.
Dr Sue O’Malley presenting via zoom from her office at Christchurch Hospital.
Question time for Darin at “Branch Meeting HQ”
Special Interest Group/Committee Technologists Special Interest Group (TSIG)
I
was encouraged during the recent Annual Scientific Meeting, especially during the Radpharm and Student Awards where due to the fact that it was online meant that there were entrants from all over Australia and New Zealand, and that distance was not a factor in us joining together as a community. It is great to be able to come together as a community, and there are positives from more online opportunities. There have been many losses that must be recognized and grieved throughout this year, and I don't want to diminish them in any way. With the impact of the pandemic easing, it is now a time where we can begin to look to the future and start to focus on how we recover from this. There is a growing body of research that shows that one of the best ways to improve resiliency is to practice gratitude, and for that reason I have taken the opportunity to share a list of things I have been grateful for during the pandemic: 1. The ability to help, and the sense of purpose that has come from that. 2. The acceptance of Tele-health, a technology that has been available for many years is finally able to benefit the health of our communities. 3. The increased awareness of mental health and wellbeing. 4. The public respect and gratitude for healthcare workers. 5. The increased public awareness of health research. 6. The way that by moving CPD opportunities online means that the time and funding restrictions are limited. 7. Less unnecessary meetings! 8. Being more open to change as a result of having change forced on us. 9. Less Traffic! Add to this list with your own suggestions! Hopefully, the next opportunity for us to meet in person will be on February 6th when the TSIG Annual Symposium (postponed from 2020) will be held in Brisbane. We will have to wait and see as to how this event will run and will be guided by the relevant health recommendations, but we are excited that with online options this will be open to all technologists across Australia and New Zealand! Thank you Nicholas Daw - MANZSNM Chair, TSIG Committee
12
gamma GAZETTE 2020 Spring/2021 Summer Edition
International Relations Committee International Relations Committee (IRC)
O
ver the last three months, the ANZSNM IRC has continued its role in supporting interactions with international Nuclear Medicine bodies. The IRC has engaged with the World Federation of Nuclear Medicine and Biology (WFNMB) to contribute to a project with WHO on guidance for nuclear medicine services for practical implementation of COVID-19 protocols. A publication has been released by IAEA: COVID-19 Pandemic: Technical Guidance for Nuclear Medicine Departments, access is available: https://www-pub.iaea.org/MTCD/Publications/ PDF/COVID-19_web.pdf
The results of this project have led to two initial papers being published in Lancet Oncology, providing for the first time a modelling of the health impacts of improving access to imaging and nuclear medicine to global cancer care. The published papers are: Z.J. Ward, A.M. Scott, H. Hricak, M. Abdel-Wahab, D. Paez, M.M. Lette, H.A. Vargas, T.P. Kingham, R. Atun. Estimating the impact of treatment and imaging modalities on 5-year net survival of 11 cancers in 200 countries – a simulation-based analysis. Lancet Oncology 21:1077-1088, 2020. doi: 10.1016/S1470-2045(20)30317-X. Z.J. Ward, S. Grover, A.M. Scott, S. Woo, D.H. Salama, E.C. Jones, T. El-Diasty, B.R. Pieters, E.L. Trimble, H.A. Vargas, H. Hricak, R. Atun. The role and contribution of treatment and imaging modalities in global cervical cancer management survival estimates from a simulation-based analysis. Lancet Oncology 21:1089-1098, 2020. doi: 10.1016/ S1470-2045(20)30316-8.
The IRC has also been involved in a Lancet Oncology Commission project on the role of imaging and nuclear medicine in cancer care. This has involved extensive interactions with the International Atomic Energy Agency (IAEA), the World Health organisation (WHO), the Harvard T H Chan School of Public Health at Harvard University, Memorial Sloan-Kettering Cancer Center, and major international organisations (including SNMMI, EANM, AOFNMB, ALASBIMN, as well as RSNA, ACR, ESR, ASCO, ESMO) and leading nuclear medicine clinicians.
14
A major white paper is anticipated to be completed and published in Lancet Oncology in late 2020. ANZSNM has been a formal supporter of this project, which is anticipated to have major policy implications for support for nuclear medicine at a global level, and in particular in low and middleincome countries. In view of major international conferences being held “virtually”, the IRC will be involved in meetings with overseas nuclear medicine societies when these virtual meetings occur. Andrew Scott - MANZSNM Chair, International Relations Committee
gamma GAZETTE 2020 Spring/2021 Summer Edition
Scientific Advisory Panel Update News Scientific Advisory Panel (SAP) ANNUAL SCIENTIFIC MEETING The Scientific Advisory Panel has been working with the Federal Council and the Local Organising Committee of the 2021 Annual Scientific Meeting regarding the form that the meeting will take as, at the time of writing, restrictions on travel and physical distancing remain in place with no clear end in sight. A hub-and-spoke model with each state or regional area hosting the allowed number of members to attend at one location is, in particular, being examined closely.
ANSTO/ANZSNM ANNUAL RESEARCH AWARD The ANSTO/ANZSNM Annual Research Award of $20,000, which is overseen by the Scientific Advisory Panel, is being offered again next year. This issue of the Gamma Gazette will contain further information, and we encourage all to submit an application.
THE CASE FOR AN AUSTRALIAN CYCLOTRON The Society has taken the initiative that may arise after the COVID-19 restrictions are relaxed and the government looks for infrastructure projects to invest in to create jobs and economic activity. The Society has asked the Scientific Advisory Panel to have a look at the case for a medium energy cyclotron for Australia to ensure domestic supply of radionuclides such as iodine-123, gallium-67, thallium-201 and longer lived positron emitters such as iodine-124 and zirconium-89. The Minister for Industry and Science, the Hon Karen Andrews MP, has asked her policy division to work with the Society and develop the case. As part of this process, we have asked Heads of Departments and Chief Technologists to respond to a survey that attempts to gauge the level of interest in radionuclides that would be produced by a medium-energy cyclotron. The COVID-19 pandemic has demonstrated how fragile supply chains can be, both internationally and nationally, and hence the strategic location of a medium energy cyclotron to address future similar events is paramount. It should also have the capacity for export to our region and hence the potential for export revenues. The report should be available to the Federal Council by the end of October. We welcome any input that other members may have into this exercise. Dale L Bailey - MANZSNM Chair, Scientific Advisory Panel
2020 Spring/2021 Summer Edition gamma GAZETTE
15
By Suzanne McGavin, MANZSNM Co-Convenor
he year of 2020 will go down in the history books as one of chaos, uncertainty but above all, adaptability. The 50th ANZSNM conference was always going to be ‘One to Remember’ with the Sydney LOC putting in a tireless effort of gathering local and internationally renowned speakers to present to the ANZSNM community in an event not to be missed. The ANZSNM would like to acknowledge the work of the LOC volunteers for creating and promoting the event for 2020 and building a program which would be transferred easily in the future. Around March 2020, COVID-19 started to change the way the world worked. When the NSW government announced the restrictions that meant the ANZSNM couldn't hold the face-to-face annual scientific meeting, there was much worry about what would happen next. The federal council were in the hot seat, not just dealing with the financial implications for the society but also suddenly having to adapt the whole meeting and transforming it for the COVID-19 world. Emails, meeting and sleepless nights were standard, but the plan to record and move it online was soon becoming a reality. The 50th On-Demand Virtual ANZSNM Conference was launched on the 28th May 2020 and not to 16
gamma GAZETTE
2020 Spring/2021 Summer Edition
be without technical difficulties it was the start of a labour of love and commitment, as well as opportunity. Opportunity to show how Nuclear Medicine can adapt and move forward with the conditions of the times. Not only did the On Demand conference have all the bells and whistles of the face-to-face event, but members were also able to watch live and on-demand, from the comfort of their own space and on the timetable that suited them, all the conference sessions. Eight sessions were available, of live and prerecorded content, from experts around Australia and internationally with topics ranging from Cultural Proficiency and Diversity to Prostate and Radiochemistry and PET tracers. Many sessions were followed by Live Discussion Panels, another of the highlights of the conference. This provided a unique opportunity for members to ask questions and engage with the experts, something traditionally very limited at the face-to-face conferences. It was truly remarkable the added time, and commitment our speakers gave to create this opportunity during the busy clinical crisis of COVID-19. The conference was also able to host an inperson and broadcasted live, Pioneer Lecture by Professor Christopher Rowe and Lowenthal Lecture by Dr Kathy Willowson. Prof Rowe took us on a journey down memory lane regarding
his vibrant career and the important development in Nuclear Medicine to assist with neuroimaging of Dementia. It was a humbling display of the Pioneers we have within our community which have put Nuclear Medicine imaging in a prominent spot for neurology. Dr Willowson shared her research and passion about the convergence of SPECT and PET with the developing technology available in Nuclear Medicine to enhance our images and provide a higher diagnostic image and allow Nuclear Medicine to stray away from the ‘unclear medicine’ stereotype. These lectures allowed us all to appreciate the great work of people in our community to have a passion and drive to continue to allow Nuclear Medicine to excel. It was a pleasure to also hold all our awards in live events with the ability for viewers to ask questions and engage with each award entrant. An acknowledgement to all our entrants for providing high-level work in such a challenging space during COVID-19. The awards could not have been continued without the sponsorship from our industries, and we look forward to watching the progress of our winners. The conference also saw the ability to award our Life Membership to Professor Vijay Kumar for his outstanding contribution to the Nuclear Medicine profession. The conference is a special moment in our year to demonstrate appreciation for those who have dedicated their lives to the viability of the profession over the years. To be able to continue to present this award in person, was another conference marvel and another aspect which made the conference what it was. To close the conference, we were able to hold the Gala night. It was a little different but still produced the Gala night flare, fun and fortunes
A
Testimonials from attendees of the 50th Virtual ASM
s we close of 2020, the ANZSNM looks back on a journey through challenges, perseverance and strength. It is reminded of why we do what we do, of the people who are happy to voluntarily invest their time, and of all the amazing people we have in our profession. We would like to thank all our speakers, entrants and attendees for making the conference what it was. We look forward to the new challenges and applying all we learnt this year, to a mixture of delivery for the 2021 conference. of the conference that was. It was fantastic to be able to present the winners of our awards, reminisce on the last 50 years, look back on the 50th ANZSNM conference and end the night with a ‘Zoom dance off ’ streaming and coming live from across the country. Thank you to our dedicated members and attendees and our sponsors, for sticking by us when times were tough for everyone. We hope everyone was able to enjoy the conference and gain more knowledge, increase their passion and remind themselves that the Nuclear Medicine community can grow and adapt through any challenges.
2020 Spring/2021 Summer Edition gamma GAZETTE 17
Thank You F O R A T T E N D IN G T H E 50T H A S M T o LO C S yd ne y t e am, a l l p r e s e nt e rs , p an el l i s t s , me mb e rs , F e de r a l Cou n c il m e m be r s , t h e e x e c u t i ve t e a ms w ho t r av e l l e d a l ong t he r o a d a n d w o rk e d t o mak e t h is e v e nt h a pp e n, t he G e ne r al Ma na ge r , S e c r e t ar iat a nd M a rk e ti ng o f A N Z S NM Special thanks to our sponsors GO LD SPON SO R BR O NZE SP O NS O R
S ILVE R SPON S O R
GMS AWARD ABSTRACT GMS Poster Award Winner Validation of Automated Manufacture of [68Ga]GaDOTA-TATE for Clinical Use With High Activity Input Authors: Chun-Hui Tai1,2, Stephen Tapper1, Kristofer J. Thurecht2,3, Melissa J. Latter1 1 Nuclear Medicine and Specialized PET Services, Royal Brisbane and Women’s Hospital, Brisbane, Australia. | 2Centre for Advanced Imaging, The University of Queensland, Brisbane, Australia. | 3Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, Brisbane, Australia.
Introduction:
[68Ga]Ga-DOTA-TATE is a routinely manufactured radiopharmaceutical for diagnosis and staging of malignancies of neuroendocrine origin2. Currently, the clinical demand exceeds supply3,4. This is due to short half-life of 68 minutes and is particularly susceptible to radiolysis4,5, reflected as low radiochemical purity (RCP). As a result, restricted activity input ( ≤ 2.4 GBq) from a 68Ge/68Ga generator has been used at our site for production to prevent RCP falling below the monograph limit of 91%6.
Figure 1: A) Chemical structure of [68Ga] Ga-DOTA-TATE and B) PET scan showing uptake of [68Ga]GaDOTA-TATE in patient with Neuroendocrine tumours1
•
Figure 2: A) Schematic diagram of [68Ga]Ga-DOTA-TATE synthesis using B) ABX single-use cassette reagent kits and C) Scintomic GRP® Synthesizer, adopted from ABX instruction manual.
•
To increase laboratory efficiency, the processes for automated radiolabelling was optimised with higher activity using reaction additives, to improve RCP suitable for clinical use. A further challenge is to translate these findings into a clinical setting reproducible through validation.
Aim:
This study aims to validate the automated manufacture of [68Ga]Ga-DOTA-TATE suitable for routine clinical use, with ≥ 3 GBq [68Ga]GaCl3 activity input.
22
The synthesis method shown in Figure 2, was modified to combine the eluate of two 68Ge/68Ga generators (1GG100, E&Z) of highest activity. The optimum reaction additives for minimising radiolysis was found to be 3 mL of 2M HEPES with addition of 10 % ethanol.
gamma GAZETTE
On day 0, 7, 14, 22 and 28 of 2M HEPES preparation, syringes were tested for endotoxin, bioburden, appearance and pH evaluation. It was also utilised with addition of 10 % ethanol for manufacturing of [68Ga]Ga-DOTA-TATE. Quality control criteria listed in Table 1 were used to evaluate [68Ga]Ga-DOTA-TATE. RCP were re-tested at 1, 3 and 5 hours post end of synthesis (EOS).
Results and Discussion: •
Methods: •
In a grade C clean room laminar flow cabinet, 2 M of HEPES was prepared and dispensed 3 mL through 0.22 μM sterilising filter into syringes and stored in fridge (2 – 8 °C). Ethanol was filtered through 0.22 μM sterile filter into sterile vacuum vial and kept in clean room for ≤ 7 days.
•
As shown in Table 2, with activity input of 3 – 4.2 GBq, [68Ga]Ga-DOTA-TATE is reliably produced with the descripted method. 5 consecutives batches produced with day 0, 7, 14, 22 and 28 of syringes preparation meets all quality control specification. Total RCP from 5 consecutives batches has mean ± S.D of 94.5 ± 1.5. 2 M HEPES stored in syringes between 2 – 8 °C has meets pH, appearance and microbiological tests for up to 28 days.
2020 Spring/2021 Summer Edition
Validation of Automated Manufacture of [68Ga]Ga-DOTA-TATE for Clinical Use With High Activity Input (Continued) •
•
As shown in Figure 3, the validated method using optimised reaction additives has minimised radiolysis, as suggested in improved RCP, even with similar activity input from 68Ge/68Ga generators and product activity. [68Ga]Ga-DOTA-TATE manufactured with syringes stored after 14days can produce product of variable RCP. The syringe expiry has been assigned with 14 days and more investigation are required.
Conclusion:
We present a reliable validated method for automated production of [68Ga]Ga-DOTATATE suitable for up to 4.2 GBq [68Ga]GaCl3 activity input. This method manufactures sterile, high purity [68Ga]Ga-DOTA-TATE of up to 1872 MBq. After quality control, this can provide up to 5 patient doses per manufacture batch at our site with two operating PET/CT cameras.
Acknowledgement: • • •
Table 1 : Quality control acceptance criteria and test methods of [68Ga]Ga-DOTA-TATE at RBWH. Adopted from monograph6 and published literature7.
•
Postgraduate Scholarship, Royal Brisbane and Women`s Hospital Research Foundation. Travel grant, Faculty of Medicine, The University of Queensland. Q-TRaCE, Department of Nuclear Medicine and PET Services, Royal Brisbane and Women’s Hospital. The Thurecht Group, Australian Institute for Bioengineering and Nanotechnology, The University of Queensland.
References:
Table 2: Validation results of [68Ga]Ga-DOTA-TATE manufacture with 3 mL of 2 M HEPES stored in syringes of various days, and with addition of 10 % ethanol.
1. Schmidt, M. C. et al. 68Ga-DotaTATE PET-CT followed by Peptide Receptor Radiotherapy in combination with capecitabine in two patients with Merkel Cell Carcinoma. Int. J. Clin. Exp. Med. 5, 363–366 (2012). 2. Gofrit, O. N., Frank, S., Meirovitz, A., Nechushtan, H. & Orevi, M. PET/CT With 68Ga-DOTA-TATE for Diagnosis of Neuroendocrine: Differentiation in Patients With Castrate-Resistant Prostate Cancer. Clin. Nucl. Med. 42, 1–6 (2017). 3. Waldmann, C. M., Stuparu, A. D., van Dam, R. M. & Slavik, R. The Search for an Alternative to [68Ga]Ga-DOTATATE in Neuroendocrine Tumor Theranostics: Current State of 18F-labeled Somatostatin Analog Development. Theranostics 9, 1336–1347 (2019). 4. Dumulon-Perreault, V. et al. Validation of [68Ga]-Ga-DOTA-TATE using 68Ga produced by cyclotron. J. Nucl. Med. 60, 199–199 (2019). 5. Mu, L. et al. Identification, characterization and suppression of side-products formed during the synthesis of high dose 68Ga-DOTA-TATE. Appl. Radiat. Isot. Data Instrum. Methods Use Agric. Ind. Med. 76, 63–69 (2013). 6. British Pharmacopoeia. Gallium (68Ga) Edotreotide Injection - British Pharmacopoeia. https://www.pharmacopoeia.com/bp-2018/radiopharmaceutical/gallium--68ga-edotreotideinjection. html?date=2018-07-01&page=2. 7. Sasson, Revital, Vaknin, Dan, Bross, Avihai & Lavie, Efraim. Determination of HEPES in 68Ga‐labeled peptide solutions. J. Radioanal. Nucl. Chem. 283, 753–756 (2010).
Figure 3: Example of Radiochromatogram and manufacture details of [68Ga]Ga-DOTA-TATE produced with A ) current clinical method B ) validated optimised method using 3 mL 2M HEPES with addition of 10 % ethanol.days, and with addition of 10 % ethanol.
2020 Spring/2021 Summer Edition gamma GAZETTE 23
AANMS REGISTRAR AWARD ABSTRACT AANMS Registrar Award Winner Excellent suppression of physiological myocardial FDG activity in patients with cardiac sarcoidosis. Author: Dr Shyam Sankaran
Background:
Suppression of physiological myocardial FDG activity is vital in patients undergoing PET/CT for assessment of known or suspected cardiac sarcoidosis.
Aim:
This study aims to evaluate the efficacy of physiological myocardial FDG suppression following a protocol change to a 24-hour high fat very low carbohydrate (HFVLC) diet and prolonged fast.
Method:
A retrospective review of patients undergoing FDG PET/CT for the evaluation of cardiac sarcoidosis was performed. Prior to June-2018, patients were prepared with a single very high fat low carbohydrate meal followed by a 12-18 hour fast (group 1). After June2018, a protocol change was initiated with patients prepared with a HFVLC diet for 24-hours followed by a 12-18 hour fast (group 2). Focal myocardial activity was classified as positive, absent activity as negative and diffuse/focal on diffuse activity as indeterminate.
24
gamma GAZETTE
Results:
A total of 94 FDG PET/CT scans were included with 46 scans in group 1 and 48 scans in group 2. Studies were classified as positive, negative or indeterminate in 25 (54%), 7 (15%) and 14 (30%) scans in group 1 and in 13 (27%), 33 (69%) and 2 (4%) scans in group 2, respectively. In scans classified as negative, myocardial FDG activity was less than mediastinal blood pool activity in 5/7 (71%) scans in group 1 and 33/33 (100%) scans in group 2.
Conclusion:
Excellent myocardial FDG suppression can be achieved using a 24-hour HFVLC diet and prolonged fast, resulting in a very low indeterminate scan rate in patients with known or suspected cardiac sarcoidosis.
2020 Spring/2021 Summer Edition
RADPHARM AWARD ABSTRACT Radpharm Award Winner Utilising Fluorine-18 Florbetaben (18F-FBB) as a diagnostic tool for the assessment of cardiac amyloidosis Author: Maddison Carroll
Case Description:
A 60-year-old male patient with a new diagnosis of amyloidosis was investigated for possible cardiac involvement after having cardiac symptoms. Initial presentation included prostate and carpal tunnel involvement, determined through biopsy of the prostate.
Procedures Performed:
A 99mTechnetium diphosphono-propanodicarboxylic acid (99mTc-DPD) study was conducted to assist with classification between transthyretin (ATTR) and light chain (AL) amyloid subtypes. The patient also underwent a Fluorine-18 Florbetaben (18F-FBB) positron emission tomography (PET)/ computed tomography (CT) scan to assess the effectiveness of this tracer in the evaluation of cardiac involvement in patients with AL amyloidosis. Dynamic PET images of the myocardium were acquired for 40 minutes to assess uptake and retention of tracer. The SUVmax of the myocardium was used to create time-activity curves. This allowed for quantitative analysis of the uptake and retention of tracer over the 40 minutes.
Findings:
Combining both the 99mTc-DPD and the 18F-FBB study supported a diagnosis of AL amyloid. There was Grade 0 uptake of 99mTc-DPD within the myocardium as well as uptake and retention of 18F-FBB. Quantitative analysis determined an SUVmax of 10.23 was reached at 25 minutes post-injection and plateaued with minimal wash out. Subsequent bone marrow biopsy confirmed diagnosis of AL amyloid.
Outcome:
As the myocardium displays both a Grade 0 99mTcDPD uptake and retention of 18F-FBB, this supports that a combination of these studies can be a tool in diagnosis and characterisation of cardiac amyloidosis.
Discussion:
This case suggests inclusion of 18F-FBB PET/CT studies into the current diagnostic pathway for cardiac amyloidosis as it would provide a more efficient and less invasive method of subtype classification. A definitive diagnosis allows for identification of the appropriate treatment pathway, improving overall patient outcomes.
2020 Spring/2021 Summer Edition gamma GAZETTE 25
SHIMADZU AWARD ABSTRACT Shimadzu Award Winner [18F]Ethenesulfonyl Fluoride: Making Radiofluorination Reactions Accessible Author: A/Prof Giancarlo Pascali
Background:
F fluorinations currently rely on a time-consuming, multi-step process to prepare a suitable labelling solution. This is typically achieved by the removal of bulk water that precludes efficient nucleophilic fluorinations and through complexation with counter-ions. This aspect, as well as the significant inconvenience of transporting such labelling solutions, has negated the possibility for development of “shake & bake” 18F fluorination procedures. 18
Aims:
We aim to identifying a process that could make radiofluorination reactions accessible to a wider range of hospital settings including minimally equipped Nuclear Medicine departments.
tested [18F]ESF on more recently published precursor approaches (e.g. boronic acids, iodonium salts).
Conclusion:
We believe that [18F]ESF has significant potential to be a game changer in the radiochemistry field due to its straight-forward and reliable synthesis, ease of transport and user friendly radioabelling process. This innovative approach could represent the basis for operationally easy to use kits for the synthesis of 18F PET tracer, thus realizing an accessibility like the one of 99mTc radiopharmaceuticals.
Methods:
We have synthesized a new radiomolecule, [18F] ethenesulfonyl fluoride (ESF) and purified it by distillation and trapping into a standard silica cartridge as an absorbed gas. The cartridge can be shipped off-site and subsequently eluted with any solvent into a single-use vial containing the radiolabelling precursor, Et4NHCO3 and additional catalysts (where needed). The radiofluorination reaction is then performed using a standard heating block with magnetic stirring for 5-30 min depending upon the desired radiotracer.
Results:
We have tested this “radiofluoride relay” species in the radiolabelling of 7 widely utilized PET tracers (e.g. FDG, FLT, Fallypride) and 5 model substrates. In all cases, we obtained RadioChemical Yields comparable to or higher than those obtained using traditionally dried [18F]Et4NF complex. We have also
26
gamma GAZETTE
2020 Spring/2021 Summer Edition
CURIUM AWARD ABSTRACT Curium Award Winner Interobserver variability in interpretation of Ventilation-Perfusion lung scans (VQ scans) Author: Sarah Thomas
Background:
In Australia it is estimated that there are about 17,000 new cases of venous thromboembolism (VTE) being diagnosed each year with pulmonary embolism (PE) accounting for 40% of these cases. The clinical symptoms of PE can be mild and non-specific with death being the first symptom in approximately 25% of cases. Better technology and modern tests, including nuclear medicine Ventilation and Perfusion (VQ) scans, have added to the diagnosis and management of PE by improving rates of detection. Some variabilities between readers have been noticed in the interpretation of VQ scans, which has resulted from using advanced imaging techniques (SPECT CT).
Conclusion:
There is a significant amount of interobserver variability in analysing VQ scans. Hence, there is a need for a standardised approach with guidelines to interpret VQ scans to reduce interobserver variability and improve diagnosis and management of PE. This is an ongoing study with 800 planned subjects.
Aim:
This study aims to measure the interobserver variability in interpretation of VQ scans and the impact of interobserver variability on patient management and hence standardise an approach and guidelines to interpret VQ. This will increase the accuracy and precision in management of patients with suspected and diagnosed PE and minimise the use of unnecessary anticoagulation with its associated risks.
Method:
50 non-identified standard SPECT/CT VQ scans were blindly reviewed by 4 independent nuclear medicine physicians. Their assessments were graded as positive, negative or equivocal (Figure 1).
Results:
Of the 50 scans analysed, there was complete agreement of results in 50% of cases, with the remainder of cases demonstrating variability in interpretation between observers (Figure 2). Of this 50%, 3 readers agreed on 34% of cases and 2 readers agreed in 16% of cases.
2020 Spring/2021 Summer Edition gamma GAZETTE 27
NM UNDERGRADUATE STUDENT AWARD ABSTRACT
NM Undergraduate Student Award Winner What Comes First? The patient or education? Author: Laetitia Mai
Case Description:
This case explores the value of nuclear medicine in penile cancer staging as well as highlighting the importance of patient-centred care and radiation safety education in clinical practice.
Procedures Performed:
A 35-year-old male diagnosed with Penile Squamous Cell Carcinoma (SCC) was referred to the Nuclear Medicine Department for a Lymphoscintigraphy study prior to a Sentinel Lymph Node Biopsy (SLNB). 4 x 10MBq injections of 99mTc Antimony colloid were injected intradermally within the penectomy site. Eight professional staff were present during the procedure and there was little time to communicate appropriate radiation safety sharps disposal education.
Findings/Outcome:
Resultant images demonstrated focal accumulation within the bilateral inguinal sentinel nodes on the 30-minute acquisition. SPECT/CT was utilised to produce greater differentiation between the bilateral inguinal sentinel nodes and contamination.
Discussion:
This case demonstrates not only the value of lymphoscintigraphy imaging in penile cancer staging but also serves as a teaching case to remind the profession of the importance of adhering to our MRPBA professional capabilities, predominately patient centred care. It highlights the importance of maintaining patient centred care during sensitive procedures as well as the value of communication regarding correct disposal of radioactive material.
Welcome to a new generation of digital PET/CT As we continue to lead the way...
The world’s most trusted PET/CT solution 30 / 30 - As the next generation of the world’s first digital PET/CT, Discovery MI Gen 2* is the only PET/CT system that is engineered to reach an impressive 30 centimeters of coverage and has the potential to enable an exceptionally high sensitivity of 30 cps/kBq. Discovery MI Gen 2 Next generation. Even more in sight.
gehealthcare.com.au
*Technology in development. Not for sale. Not cleared or approved by the U.S. FDA or any other global regulator for commercial availability. © 2020 General Electric Company – All rights reserved. GE and the GE Monogram are trademarks of General Electric Company. GE Healthcare, a division of General Electric Company. GE Medical Systems, Inc., doing business as GE Healthcare. JB83260AU
Articles Nuclear Medicine Locum experience at Addenbrooke’s Hospital, Cambridge, United Kingdom Author: Chrystal Connie Douflias1 - 1Addenbrooke's Hospital, Cambridge, United Kingdom
In January 2020, I decided to take a unique opportunity to move to Cambridge in the United Kingdom (UK) to work as a locum nuclear medicine technologist at Addenbrooke’s Hospital. Whilst the culture shock was not overwhelming having arrived in the UK from Australia, I instantly noticed differences both in everyday customs and in nuclear medicine practice. Let’s just say I learnt the difficult way when asking a patient to slide their pants down to just above the knee for a PET/CT scan that, in the UK, pants means underwear! Although both a mortifying and humorous initial experience, it meant I quickly learnt from then on to ask patients to adjust their ‘trousers’, not pants. Aside from discrepancies in commonplace terms, there were also notable daily practice differences. The primary difference I had to be aware of was the UK’s heavy radiation protection laws. This meant that using the hand and foot monitor before going to lunch and leaving at the end of the day was mandatory. This assured there was no radiation contamination on your hands and/or feet. At the end of the day, we would also use a handheld radiation monitor to measure and record the areas used, assessing for potential contamination. Additional UK radiation protection laws meant that we had to have the tracer checked by two senior nuclear medicine technologists before injecting it into the patient, which is not standard practice in Australia. Along with the difference in daily practice, there were also clear technical differences compared to Australia. The key difference I noticed was the variation in tracers. For example, in Australia, VQ lung scans use 99mTc (technegas) however, in the UK, 81mKrypton (81mKr) is predominantly used. To scan the patient using 81mKr, a ventilator must be placed onto the patient throughout the scan as it has a short half-life of 13 seconds. Perfusion and ventilation can be achieved simultaneously, unlike 30
with the use of 99mTc in Australia, due to the different Kev peaks (140Kev for 99mTc and 190 +/- 3 KeV for 81mKr). During my time at Addenbrooke’s Hospital, I was also fortunate enough to see one of the two SeHCAT machines in the world, figure 1. This device was built from lead retrieved from a wreckage ship before the nuclear attacks at the end of WWII. The SeHCAT is used to determine how well a person’s gut can absorb bile acids and is used to help diagnose patients who suffer from chronic diarrhoea. A hard gelatin capsule containing 370 kBq [75Se] tauroselcholic acid is ingested by the patient three hours before the scan, after which the scan is conducted over approximately 20 minutes. The scan is then repeated 7 days later. Intriguingly, nuclear medicine staff are also scanned in the SeHCAT machine every quarter as a healthy control to assess for contamination. Aside from learning about this fascinating device, I learnt of several other exciting developments occurring at Addenbrooke’s Hospital such as the fact that it is one of the few places in the world that can offer both 11C-methonine investigation of pituitary adenomas and 11C-metomadate to investigation adrenal disease in PET/CT scanning. Following my time at Addenbrooke’s Hospital, I went on to work for the University of Cambridge with the simultaneous PET/MRI machine with attached hyperpolariser system. I conducted many research studies here involving the use of 11C-PiB, 68 Ga-Dotatate. 18F-AV1451 and 18F- Florbetaben. I am very honoured to have the opportunity and endorsement of being the lead radiographer for radiation therapy planning scans using MRI. I had the pleasure of working with incredible people such as the author of 'MRI from Picture to Proton', Dr Martin Graves, and I am so proud to be instrumental in ground-breaking research studies. Incredibly, we had the honour of being the first centre in Europe to conduct studies on COVID-19 patients.
gamma GAZETTE 2020 Spring/2021 Summer Edition
Articles Nuclear Medicine Locum experience at Addenbrooke’s Hospital, Cambridge, United Kingdom (Continued)
Figure 1: SeHCAT machine at Addenbrooke’s Hospital, Cambridge, United Kingdom
Figure 2: Dr Martin Graves, author of MRI from picture to proton and Chrystal Douflias, University of Cambridge.
Time: 6:30PM
Event Sponsored by
Live Zoom event
2020 Spring/2021 Summer Edition gamma GAZETTE 31
Articles/Member Information Understanding Medical Radiation Practitioner Regulation in NSW: an article brought to you by the Medical Radiation Practice Council of NSW (MRPC) LAW AND MRPC ROLE The Health Practitioners Regulation National Law (NSW) (NSW Health Law) is the law which governs Health Practitioner regulation in NSW. The Medical Radiation Practice Council (MRPC) of NSW is a statutory body that functions independently of any employer and has clear procedures for managing complaints and mandatory notifications about registered Medical Radiation Practitioners and Medical Radiation Practice Students in NSW. MRPC focusses on ensuring safe, professional practice by minimising risk to the public and maintaining public safety. MRPC has legal powers which enable it to act to prevent unsafe practice. MRPC is funded by a proportion of the annual AHPRA registration fee paid by Medical Radiation Practitioners practising in NSW. MRPC is a council within the Health Professional Councils Authority (HPCA) which is an administrative agency of the NSW Ministry of Health. The HPCA works closely with the Health Care Complaints Commission (HCCC), and all complaints are co-managed. The HCCC investigates complaints of a serious nature which can be prosecuted before the NSW Civil and Administrative Tribunal. MRPC is made up of six members, including four practitioner members, a community member and legal member. Each member is appointed by the NSW Governor on the recommendation of the NSW Minister for Health. Appointment terms last for three years with an opportunity for three terms to be served by one member. About one-third of all Medical Radiation Practitioners in Australia practise in NSW. MRPC was first established in July 2012, which aligns to the national registration of Medical Radiation Practitioners with the Australian Health Practitioner Regulation Agency (AHPRA).
32
COMPLAINTS & PROCESS To date, 123 complaints have been received by the MRPC/HCCC, 58 have been referred to MRPC for further management. Types of complaints and notifications received can be:• performance-based; • relate to the health of an individual practitioner and their ability to practise; or • may be due to a breach of professional or local code of conduct. Complaints. Notifications can come from a variety of sources such as employers, patients, treating or non-treating practitioners or be a self-notification. In NSW, regardless of the source of the complaint or whom it is directed to, information is shared between MRPC, HCCC and AHPRA, ensuring appropriate management. For example: if a complaint is received by AHPRA about a NSW based practitioner then the complaint will be transferred to MRPC for management after consultation with the HCCC. Any conditions placed on a practitioner or student by the MRPC are notified to AHPRA and conditions are made public on the national register as they apply nationally. Complaints that are being managed by MRPC adhere to a clear process and follow one of the following pathways: health, performance, or conduct. The practitioner will receive details of the complaint and will be asked to respond to the complaint. MRPC then considers all the information available to it at the time of review. If more information is needed, then it will be sought. All decisions and assessments are made in a fair process to ensure the
gamma GAZETTE 2020 Spring/2021 Summer Edition
Understanding Medical Radiation Practitioner Regulation in NSW: an article brought to you by the Medical Radiation Practice Council of NSW (MRPC) (Continued)
all outcomes result in public protection and safety. Where necessary immediate review and response process is used. Otherwise, matters are reviewed at a monthly meeting (apart from January). NOTIFIABLE CONDUCT Mandatory notifications relating to professional practice, conduct and the health of a practitioner have high importance. Education providers, employers and practitioners must make a mandatory notification if they have
formed a reasonable belief that a practitioner is placing the public at risk or is unsafe to practice. Section 140 of the NSW Health Law defines notifiable conduct which includes: sexual misconduct, significant departure from professional standards, intoxication and or practising with an impairment which does or has the potential to put the public at risk of substantial harm.
Types of risks and reporting thresholds for different groups Impairment
Intoxication
Departure from standards
Sexual misconduct
Treating practitioners must report practitioners who: are practising with an impairment, and place the public at substantial risk of harm.
are practising while intoxicated by alcohol or drugs, and place the public at substantial risk of harm.
are significantly departing from professional standards, and place the public at substantial risk of harm.
have engaged in, are engaging in or might engage in sexual misconduct connected to their practice.
Non-treating practitioners must report practitioners who: are practising with an impairment, and place the public at risk of substantial harm.
are practising while intoxicated by alcohol or drugs.
by significantly departing engage in sexual from professional misconduct connected standards, and place the to their practice. public at risk of harm.
Employers of practitioners must report practitioners who: are practising with an impairment, and place the public at risk of substantial harm.
are practising while intoxicated by alcohol or drugs.
by significantly departing engage in sexual from professional misconduct connected standards, and place the to their practice. public at risk of harm.
Available from: https://www. medicalradiationpracticeboard.gov.au/CodesGuidelines/Codes-and-Guidelines/Guidelines-formandatory-notifications.aspx
detrimentally affect the person’s capacity to practise their profession or undertake clinical training (for a student). Management of health complaints is constructive and non-disciplinary.
Impairment is defined in the National Law as: a physical or mental impairment, disability, condition or disorder (including substance abuse or dependence) that detrimentally affects or is likely to
PROCESS After review of available information, if MRPC finds a need, it is likely that a practitioner or student would be directed to attend an independent
2020 Spring/2021 Summer Edition gamma GAZETTE 33
Articles/Member Information Understanding Medical Radiation Practitioner Regulation in NSW: an article brought to you by the Medical Radiation Practice Council of NSW (MRPC). (Continued)
assessment with a council appointed practitioner to help us determine the current health status of the practitioner and whether if the practitioner has an impairment, as defined by National Law (NSW), any further action is required to ensure public safety. A review with an Impaired Registrants Panel may also be required. Support is facilitated to ensure that practitioners are able to practise safely wherever possible. Sometimes, practice must be restricted to ensure public safety. Conduct issues can arise from practitioner behaviour which leads to the character being questioned. The Conduct Pathway allows MPRC to manage complaints that may constitute unsatisfactory professional conduct or professional misconduct. After review of available information, it is likely that, if further action is required, the practitioner or student would be directed to attend a counselling interview. However, for more serious matters, a council inquiry may be arranged. In consultation with the HCCC, the most serious of matters may need to be referred for investigations to the Director of Proceedings to determine whether the matter should be prosecuted before the NSW Civil and Administrative Tribunal (NCAT) or elsewhere. Notifications or complaints where disciplinary action is not warranted may result in the identification of performance issues. Through the performance program, MRPC is able, constructively and with a non-discipline approach, to manage a practitioner’s performance and focus education and retraining to address knowledge or skill gaps to ensure public safety.
34
PROFESSIONAL STANDARDS All Medical Radiation Practitioners are required to meet the standards set for their profession. Professional performance is considered unsatisfactory if it is below the standard reasonably expected of a practitioner at an equivalent level of experience or training. When a performance issue is raised with MPRC, and it is determined that further action is required, then MPRC will often arrange for a Performance interview and Performance Review Panel. If deficiencies are found, conditions may be placed on the practitioner’s registration, if this is considered an appropriate method to assist the practitioner to reach the standards necessary to ensure public safety. REHABILITATION AIM Conditions are notified to AHPRA for inclusion on the national register and apply nationally. The aim of performance assessments, interviews, reviews, and conditions is always to ensure that the practitioner can be rehabilitated, if possible, to practise safely and minimise risk to the public. MRPC performs a core function of regulation within NSW, contributing and supporting education and research, working collaboratively with the HCCC. The HPCA’s support enables the MRPC to perform our regulatory and legislative functions to ensure that protecting the public is achieved.
gamma GAZETTE 2020 Spring/2021 Summer Edition
visit www.anzsnm.org.au for all details
Inviting applications for ANSTO/ANZSNM Research Grant 2021 Closing date: 31st December 2020 For further information on Research Grant Conditions & Applications visit www.anzsnm.org.au/membership/awards-grants/anstoanzsnm-research-grant/ ANSTO and the ANZSNM (“the Society”) are pleased to offer a competitive grant aimed at encouraging research in nuclear medicine in Australia and New Zealand. The grant is up to the value of $20,000 and is expected to run for approximately one year. ANSTO is Australia’s government-funded nuclear science organisation. Its vision is to deliver excellence in innovation, insight, and discovery through its people, partnerships, nuclear expertise and landmark infrastructure. In assessing applications for the grant, preference will be given to early career researchers in order to provide seed funding for pilot investigations that could lead on to further grant applications. The grant will be offered yearly but the evaluating committee reserves the right to not award the grant if there is no suitable application. All aspects of nuclear medicine will be considered for this grant including, but not restricted to: • novel developments in radiopharmaceuticals; • hardware and software innovation; • epidemiology and audit activities; • pilot clinical trials; • retrospective studies on outcomes in diagnostic and therapeutic procedures in nuclear medicine; • education, training and professional development activities. The ANSTO/ANZSNM Research Grant is intended to achieve one or more of the following: 1. 2. 3. 4. 5.
Approach a meaningful conclusion in one year; Assist investigators striving to establish new programs or new directions; Fund initial exploratory research for which external funding will be sought subsequently; Address circumscribed clinical problems of a sort unlikely to attract industry funding; Survey groups of patients to assess the success rate, sequelae, safety or any other aspect of diagnostic or radionuclide therapy protocols; 6. Bridge the gap of a year between completion of one external grant and the commencement of another. The evaluating committee will consist of one representative from ANSTO, one member of the Society's Scientific Advisory Panel and the ANZSNM President or their delegate. The successful applicant/team is expected to acknowledge ANSTO’s and the Society’s support in any publications and provide a report to be published in the Gamma Gazette upon completion. The applicant will ideally present the outcome(s) of the research at the next ANZSNM ASM. Conj A/Prof Giancarlo Pascali Scientific Advisory Panel ANZSNM
2020 Spring/2021 Summer Edition gamma GAZETTE 35
PET dose extravasation frequency and impact in the Australian context Authors: Geoff Currie and Stephanie Sanchez
RESEARCH The aims of this project were to provide an Australian context to extravasation rates in PET using the quality assurance device (LARA produced by Lucerno Dynamics and distributed in Australia by Bayer). As previously outlined, PET and SUV depend on reliable pharmacokinetic modelling, part of which is predictable dose delivery. Partial extravasation of the intravenous (IV) dose administration undermines predictability of dose delivery and potentially the accuracy of SUV calculation. The device (LARA) is a simple, non-invasive way to not only determine partial dose extravasation but to potentially characterise the pharmacokinetic behaviour of the extravasated volume. Given the value of SUV inpatient management, determining treatment options and monitoring progress or response to treatment, this form of quality assurance represents an essential and powerful tool in the clinical PET department. The extravasated portion of doses may go undetected if the injection site is outside the field of view and standard imaging protocols with the arms extended above the head ensure this is the case. Data from the USA using this device suggests as many as 33% of doses are partially extravasated and go undetected. The work resulted in 4 peer-reviewed journal publications: Sanchez, S & Currie, G 2020, Topical sensor for the assessment of injection quality for 18F-FDG, 68Ga-PSMA and 68Ga-DOTATATE positron emission tomography, Journal of Medical Imaging and Radiation Sciences, vol. 51; no. 2: pp. 247-255. https://doi.org/10.1016/j.jmir.2020.01.003 This first publication provided an evaluation of the extravasation rates at the first site of data collection for 18F FDG, 68Ga PSMA and 68Ga DOTATATE. This extended previous understanding because the LARA device had only previously been validated with 18F FDG. In total, 296 patients were evaluated using the proprietary metrics. The extravasation rate was only 1.1% which was substantially lower 36
than previously reported rates. The analysis also identified 9.1% of patients with abnormal time activity curves or metrics (score) in the absence of extravasations. That is, slow venous clearance of the injection. The study concluded that topical monitoring and characterisation of PET dose administration is possible and practical with the LARA device which could provide the insights into variables that could eliminate extravasation as a cause of image quality or SUV accuracy issues. Sanchez, S & Currie, G 2020, Topical Sensor for the Assessment of Positron Emission Tomography dose extravasation; Metric Performance with an Autoinjector, Journal of Nuclear Medicine Technology, in press, doi:10.2967/jnmt.120.245043 The data was further evaluated from a metric performance perspective. The “score� used to guide decision making is based on weighted product of a number of simple metrics. This paper outlines the calculation of these metrics and the potential limitations. Of note was that the majority of the metrics depended on the actual dose administered and presumed via original validation a 18F FDG dose of approximately 600MBq. Consequently, the metrics contained errors when used for PET scans with doses more typically 220 MBq. A number of specific metrics were demonstrated to be independently more predictive of injection quality, including TC50 and ndAvgN. We introduced our own metric (CEnd ratio), which normalised the total count dependence of data at the end of the monitoring period, and this was also shown to be robust. The paper concluded that partial extravasation of PET doses can be readily detected and differentiated using time activity curve metrics. The paper also recommended validation of key metrics in a larger and more diverse cohort. Sanchez, S & Currie, G 2020, Topical device detection of 18F FDG dose leakage, Journal of Nuclear Medicine Technology, vol. 48; no. 3: pp. 283284, doi:10.2967/jnmt.119.240283 This paper is a case study from the primary data collection that provided a unique insight into data
gamma GAZETTE 2020 Spring/2021 Summer Edition
PET dose extravasation frequency and impact in the Australian context (Continued)
interpretation. Indeed, it highlighted the critical importance of manual evaluation of time activity curves rather than reliance on proprietary metrics alone. In this case, the LARA data indicated a severe extravasation of the injection and the PET scan image quality supported that position. Closer investigation, however, revealed that the dose had not been extravasated but rather that the connector was leaky and the dose leaked into the pillow on which the injection arm was being supported. The teaching case concluded that auto-injector set-up with a large bore cannula and high volume flush minimise partially extravasated doses compared to hand injection and reduce staff radiation dose but leave the patient and injection unsupervised. The LARA device provided a useful tool for more timely critical evaluation and problem-solving; extending advantage to the patient and practice. Currie, G & Sanchez, S 2020, Topical Sensor metrics for 18F-FDG positron emission tomography dose extravasation, Radiography, in press, https://doi. org/10.1016/j.radi.2020.07.013 Following the results from the primary site, a second site was recruited to collect patient data. Unfortunately, COVID-19 interrupted data collection at the 100 patient mark. A multi-site,
multi-national pooling of 18F FDG PET/CT data was undertaken with 863 patients from 6 sites in the USA and 2 sites in Australia. A number of metrics from LARA were analysed using conventional statistical analysis and using an artificial neural network. The results indicated that extravasation was independently predicted by the time taken for the injection sensor counts to reach double the counts of the reference sensor (tc50), the normalised difference between injection and reference sensors counts at 4 minutes post-injection (ndAvgN), or the ratio of injection sensor counts to reference sensor counts at the end of data collection (CEnd ratio). The algorithm developed using the artificial neural network produced 100% sensitivity and 100% specificity against grounded truth for detecting extravasation by weighting and scaling these 3 key metrics; CEnd ratio, ndAvgN and tc50. The data also revealed a number of significant differences between the Australian data and the USA data that could explain the lower extravasation data reported in some departments (table 1). Table 1: A summary of the combined demographic data and sub-divided by country. The bold data reflects statistically significant difference between the USA and Australian cohorts for key variables.
USA only (n=569)
Australia only (n=294)
Proportion of studies (%)
65.9
34.1
Extravasation rate (%)
8.8
1.0
<0.001
Severe extravasation rate (%)
1.9
0.3
<0.001
Venous stasis (%)
6.3
0.7
<0.001
Mean dose (MBq)
568.9 (95% CI 562.9-574.9)
219.8 (95% CI 211.5-228.1)
<0.001
Over 70 years (%)
41.8
48.3
0.151
9.5 (95% CI 8.9-10.2)
62.3 (95% CI 60.5-64.1)
<0.001
Autoinjector (%)
2.8
99.0
<0.001
20 gauge (or larger) cannula (%)
2.0
77.9
<0.001
Antecubital injection (%)
56.9
83.3
<0.001
Left side injection (%)
30.6
70.4
<0.001
Butterfly injection (%)
46.2
0
<0.001
333.9 (95% CI 283.6-384.3)
116.2 (95% CI 46.0-186.4)
<0.001
18.0 (95% CI 9.4-26.5)
0.6 (95% CI -11.2 to 12.4)
0.020
2.1 (95% CI 1.2-2.9)
1.0 (95%CI -0.2 to 2.2)
0.169
Flush (mL)
Mean tc50 Mean ndAvgN Mean CEnd ratio
P
PET dose extravasation frequency and impact in the Australian context (Continued)
Table 2: Summary of metrics against outcome of injection (combined data only).
Mean dose (MBq)
Normal
Abnormal but insignificant
Vascular Retention
Total Extravasated
Severe Extravasated
P
423.9
487.3
561.2
568.6
484.4
<0.001
Over 70 years (%)
43.2
43.4
44.4
65.7
50.0
0.182
Injection in hand (%)
19.0
35.1
7.9
43.9
16.7
<0.001
Left side injection (%)
50.2
30.4
29.0
29.3
33.3
<0.001
Butterfly injection (%)
27.7
29.8
52.6
48.8
50.0
<0.001
Mean flush volume (mL)
31.0
23.2
12.0
13.1
12.7
<0.001
Autoinjector used (%)
42.6
26.8
5.3
4.9
8.3
<0.001
20 gauge or larger needle (%)
33.1
21.0
5.2
4.9
18.2
<0.001
tc50
52.8
377.8
412.6
2082.8
2302.6
<0.001
ndAvgN
-0.5
9.2
11.3
47.7
564.3
<0.001
CEnd ratio
0.97
1.23
1.03
2.74
43.14
<0.001
DISCUSSION Extravasation rates and the severity of extravasation can be minimised by: • • • • •
More careful management of injections in older patients. Where possible, injecting in the antecubital fossa. Use of a cannula and avoid butterfly administrations. Use of a 20 gauge (or larger) bore for the injections. Use of an auto-injector instead of manual injection (avoiding rapid bolus and ensuring higher flush volume).
The recognition of extravasated doses as misadministration with associated investigation and reporting requirements of ARPANSA in Australia may also be a factor in reducing rates through training and education. In contrast, the NRC in the USA, with respect to radiopharmaceutical administration, have determined that “extravasation frequently occurs ……… it is virtually impossible to avoid …….. does not consider extravasation to be misadministration…” and thus exempts reporting and accountability requirements in cases of extravasation misadministration. Extravasation was independently predicted by a tc50 and ndAvgN. Clearly, these metrics lack the ability to discriminate between normal, vascular retention and extravasated injections for some patients. There is potential to improve the robustness of metrics by including the CEnd ratio and limiting aUCR10 to the window 4-10 minutes post-injections (aUCR4-10) instead of 1-10 minutes. Mathematical calculation of
38
gamma GAZETTE 2020 Spring/2021 Summer Edition
the 3-minute peak-to-tail ratio (PT3 ratio) and the extravasation fraction is a potentially important metric in determining impact and recourse associated with SUV calculation. This can be automated to allow the user to select the start points of both region A and region B, windowed for 3 minutes (180 seconds), subtraction from each value the corresponding reference count, summation of all points in each 3-minute window and dividing the value for A by B to produce a ratio. The inverse of that expressed as a percentage could be expressed as the extravasation fraction. These are outlined in detail in the 4th publication (Currie & Sanchez 2020). CONCLUSION Partial extravasation of PET doses can be readily detected using topical sensors or imaging the injection site during scanning. Partial extravasation of the PET dose is inadequate and threatens both the integrity of the study quantitation and the procedural reputation. Extravasation should require reporting and should demand training/education to ensure reliability of SUV, optimal image quality, improved patient outcomes and limitation of unnecessary tissue doses to patients. The techniques and metrics developed in this research provide a cheap and simple mechanism to detect extravasation and characterise extravasation severity; potentially providing a mechanism to adjust dose delivered and SUV accuracy.
Download it from the iTunes Store
Attendo Plus is the mobile digital app that helps you manage your events, track CPD points, avoid filling out forms, allows you to quickly check-in to any live webinar or face to face event and much more. Save time, keep digital records of your attended events, get digital certificates of attendance and keep informed of what events yours and other organisations are running with Attendo Plus.
Download it from Google Play
Education & CPD Case Study Interesting Case: Lingual Thyroid Author: Eleanor Kelliher, The Townsville University Hospital
INTRODUCTION First described by Hickman in 1869, the lingual thyroid is an uncommon clinical finding, resulting from failure of the thyroid gland to descend into its normal pre-tracheal position during embryogenesis. The presence of the thyroid gland at the tongue base may result in various symptoms; However, most patients are asymptomatic.4 Treatment of symptomatic lingual thyroid includes hormone-suppressing therapy and/or surgical intervention.2
PATIENT HISTORY AND PRESENTATION A 4-year-old female presented to the emergency department at a regional hospital after a family member noticed a lump at the back of her throat. Prior to presentation, her parents stated she had reduced oral intake and some dysphagia. On examination, a pink cystic lesion measuring 2.5 x 2.5cm was found at the base of the tongue. Routine thyroid function tests performed revealed increased levels of Thyroid Stimulating Hormone (TSH) with normal levels of T4 and T3 indicative of subclinical hypothyroidism. Initial investigations consisted of a computed tomography (CT) neck with contrast (Figure 1). This revealed two avidly enhanced soft-tissue masses suggestive of ectopic lingual thyroid. An absence of thyroid tissue was also noted within the thyroid bed. Ultrasound findings (Figure 2) supported the CT diagnosis, comparably identifying two heterogenous avascular masses in the sublingual region with no evidence of thyroid tissue in the thyroid bed. To confirm findings, a nuclear medicine thyroid scan was requested; this was subsequently delayed due to contrast administration, the patient returned to Mount Isa and commenced 25 mcg of Thyroxine, taken daily.
Figure 1: CT Neck SAG
40
gamma GAZETTE 2020 Spring/2021 Summer Edition
Figure 2: Ultrasound Sublingual Region
Education & CPD Case Study Interesting Case: Lingual Thyroid (Continued) IMAGING A 99mTc- Sodium Pertechnetate (99mTc04-) nuclear medicine thyroid scan was performed. Following the EANM dose guidelines for paediatrics, an intravenous injection of 43MBq of 99mTc04- was administered. Images in the anterior and lateral planes were acquired using a pinhole collimator (Figure 3). The pinhole images demonstrated two foci of radiotracer uptake superior to the chin marker, with an absence of functioning thyroid tissue in the thyroid bed. This corresponded to the enhanced soft-tissue masses noted within the tongue base on the diagnostic CT scan. Overall, findings demonstrated lingular thyroid tissue.
Figure 3: NM Thyroid Scan
DISCUSSION Thyroid gland development occurs on approximately the 24th day of gestation. As the thyroid gland develops and descends from the foramen cecum to its pre-tracheal position, ectopic tissue may become lodged along its route.1 The exact molecular mechanisms for abnormal thyroid embryogenesis are unclear. Studies have indicated that mutations in gene transcription factors NKX2-1, FOXE-1 and PAX8, which are responsible for thyroid maturation and differentiation may play a key role in the abnormal migration.3 Lingual thyroid is a mass of ectopic thyroid tissue seen at the base of the tongue. It is the most common location for functioning ectopic thyroid tissue; however, its presentation is relatively rare.6 The prevalence of lingual thyroid is between 1:100,000-1:300,00, with a female to male ratio of approximately 3:1-8:1. This figure increases to 1:4000-1:8000 if the patient has a history of thyroid disease. Among 70% of all cases, lingual thyroid is the only functioning thyroid tissue, resulting in mild hypothyroidism, which typically presents during periods of increased thyroid hormone demand. Symptoms can present at any age; however, most lingual thyroid are detected during puberty or pregnancy. The severity of these symptoms are mostly related to the size of the lingual mass, and may include; dysphagia, dysphonia, dyspnoea, airway blockages and bleeding.5 Treatment options for lingual thyroid are varied. In general, for asymptomatic patients with normal thyroid function, therapy is not required; however, patients are kept under observation. For symptomatic patients’ treatment will depend upon the size of the mass, nature of the symptoms and thyroid function tests. In the case of hypothyroidism, suppressive therapy is administered using exogenous thyroid hormone. Therapy will suppress the level of TSH and ultimately reduce the size of the mass. Surgical excision is rarely necessary, indications may include; severe obstruction, ulceration, haemorrhage, cystic degeneration and malignancy.1 2020 Spring/2021 Summer Edition gamma GAZETTE 41
Education & CPD Case Study Interesting Case: Lingual Thyroid (Continued)
CONCLUSION Lingual thyroid remains a rare disease. Although the pathogenesis is unknown, genetic factors have been associated with abnormal embryogenesis. The majority of cases are asymptomatic; however, following gland enlargement, symptoms may arise. Nuclear medicine thyroid imaging, computed tomography, ultrasound and thyroid function tests are the primary diagnostic tools. Surgical excision is uncommon.1
References 1.
Nasiru Akamnu I, Idowu Olusegun F. Ectopic thyroid: etiology, pathology and management. HORMONES [Internet]. 2011 [cited 10 September 2020];10(4):261-269. Available from: http://www.hormones.gr/739/article/ectopic-thyroid:-etiology-pathology-andmanagement‌.html
2.
Allegra E, Bianco M, La Boria A, Franco T, Ferrise P. Ectopic lingual thyroid with vascular anomalies. International Medical Case Reports Journal [Internet]. 2013 [cited 10 September 2020];:55. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3772693/
3.
Alanazi S, Limaiem F. Ectopic Thyroid [Internet]. Ncbi.nlm.nih.gov. 2020 [cited 10 September 2020]. Available from: https://www.ncbi.nlm. nih.gov/books/NBK539892/
4.
Amr B, Monib S. Lingual thyroid: A case report. International Journal of Surgery Case Reports [Internet]. 2011 [cited 10 September 2020];2(8):313-315. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215257/
5.
Sturniolo G, Violi M, Galletti B, Baldari S, CampennĂŹ A, Vermiglio F et al. Differentiated thyroid carcinoma in lingual thyroid. Endocrine [Internet]. 2015 [cited 10 September 2020];51(1):189-198. Available from: https://eds.a.ebscohost.com/eds/pdfviewer/ pdfviewer?vid=1&sid=0173bee4-a546-4d5c-8a41-9d25f8d1d0c4%40sessionmgr4007
6.
Castro P, Volpato L, Tramujas J, Borges A. Ectopic Thyroid at the Base of the Tongue of a Young Patient. Case Reports in Dentistry [Internet]. 2016 [cited 10 September 2020];2016:1-4. Available from: https://www.hindawi.com/journals/crid/2016/9174970/
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/gamma-gazette-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. 42
The ANZSNM Gamma Gazette is published times a year. Deadlines for each issue of the journal gamma GAZETTE 2020 Spring/2021 Summerthree Edition can be found on our website anzsnm.org.au
Education & CPD Case Study PET/CT for PETS Canines as a model for human disease: A case study of Prostate Adenocarcinoma in a Beagle Authors: Sarah Daniel1,2, Zachary Houston1,3,4, Nicholas L. Fletcher1,3,4, Craig Bell1,3,4, Nicole Atcheson1, Aiman AlNajjar1, Christopher Howard1,3,4,5, Stephen M. Mahler1,3,5, Rod Straw6,5, Kristofer J. Thurecht1,3,4,5 1 Centre for Advanced Imaging, The University of Queensland, St Lucia, Australia, 2Department of Nuclear Medicine and Queensland Specialised PET Services, Royal Brisbane and Women’s Hospital, Herston, Australia, 3Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, Australia, 4ARC Centre for Bio-Nano Science and Technology, The University of Queensland, St Lucia, Australia, 5ARC Training Centre for Biopharmaceutical Innovation, The University of Queensland, St Lucia, Australia, 6Brisbane Veterinary Specialist Centre and The Australian Animal Cancer Foundation, Albany Creek, Australia.
In 2017 the Centre for Advanced Imaging [CAI] at The University of Queensland received a 2.5-million dollar grant from the Australian Cancer Research Foundation [ACRF] to fund the Facility for Molecular Imaging Agents in Cancer. This facility allows researchers to use molecular imaging to improve cancer detection, characterisation and treatments through the use of comparative oncology. Comparative oncology is the study of spontaneously occurring cancers in companion animals; in particular, canines, as a model to further understand the mechanisms of human disease. A 10-year old male beagle was admitted to the veterinary clinic after being observed to have a reduced appetite, lethargy, intermittent vomiting, upon physical examination, the patient had painful cranial abdominal palpitation, and bloodwork showed a mild ALP elevation and mild neutrophilic leucocytosis. The patient was then referred onto have an abdominal x-ray that demonstrated a 13cm abdominal mass followed by an abdominal ultrasound, which showed a cavitated mass, that was most likely, associated with the spleen. The abdominal ultrasound also showed that the prostate gland was enlarged with mineralisation, which was highly suspicious for prostatic neoplasia. Exploratory laparotomy is the treatment of choice for splenic masses in canines; with the incidental finding in the prostate gland, a surgical biopsy was able to be performed simultaneously. The surgery involved the removal of the spleen inclusive of the mass, a punch biopsy of the liver and five wedge biopsies of the prostate gland which were all sent for histopathological analysis.
Macroscopic analysis determined; 1. The mass within the spleen was a nonneoplastic lesion. With the possible causes being; haemorrhagic infarct, blunt trauma or rupture of a hyperplastic splenic nodule. 2. Liver biopsy was benign nodular hepatocellular hyperplasia. 3. Malignant neoplasia of the prostate with significant potential for local invasion and distant metastasis. Diagnosis of Prostate Adenocarcinoma. Treatment options for the prostate adenocarcinoma such as a prostatectomy, conventional radiation therapy or medical management with diversion and stenting options were discussed. The histopathological findings of the prostate gland enabled the patient to be referred to an ongoing research study at CAI which has shown promising results using polyethylene glycol [PEG] based hyperbranched polymers [HBP] for targeted drug delivery in transgenic mice models.[1] All PET/CT imaging was performed on a SIEMENS Biograph Horizon PET/CT scanner. General anaesthesia was used for all imaging procedures, and the patient’s heart rate, blood pressure, and SpO2 were carefully observed and recorded.
2020 Spring/2021 Summer Edition gamma GAZETTE 43
Education & CPD Case Study PET/CT for PETS Canines as a model for human disease: A case study of Prostate Adenocarcinoma in a Beagle (Continued)
Figure 1: Canine patient being positioned for [68Ga]-PSMA whole-body PET/CT imaging.
The patient underwent an initial [68Ga]-PSMA whole-body PET/CT examination. [68Ga]-PSMA was manufactured offsite at Q-TRaCE (Royal Brisbane and Women’s Hospital) and delivered to CAI where 91MBq was administered intravenously. Imaging commenced at 60-minutes post-injection at 3 minutes per bed position, increasing to 4 minutes per bed over the pelvic region.
Figure 3:[68Ga]-PSMA-11 PET/CT coronal whole-body canine, 60 minutes postinjection.
All PET/CT images were sent to a veterinary radiologist at Colorado State University for image analysis. Both [68Ga]-PSMA and [67Ga]HBP-PSMA whole-body PET images were unable to detect the presence of the prostate adenocarcinoma, despite the heterogeneous appearance within both the left and right lobes of the prostate gland on the low dose CT scan. Figure 2: [68Ga]-PSMA-11 PET/CT Trans-axial cross section of the canine prostate, 60 minutes post-injection. Demonstrating bloom from urine within the urethra and absence of uptake within the prostate gland.
24-hours after the [68Ga]-PSMA imaging was performed a secondary PET/CT scan commenced. Imaging began immediately after an intravenous injection of 132MBq of [64Cu]HBP-PSMA. Dynamic images were obtained for 60-minutes post-injection over the region of the liver, followed by a wholebody PET/CT at 1-hour post-injection. Whole-body imaging was also performed at 24 and 48 hours post-injection of [64Cu]HBP-PSMA. PET acquisition times were adapted to allow for decay and excretion of the radiotracer. 44
The results of the initial PET/CT imaging determined that the patient’s prostate adenocarcinoma was not PSMA avid. A subsequent prostate biopsy was performed and sent to a laboratory for further testing where it revealed, as suspected, no PSMA expression. However, a high expression of epidermal growth factor receptors [EGFR] were identified.
Figure 4: : [64Cu]HBP-PSMA PET/CT Trans axial cross section of the canine prostate, 24 hours post-injection. Demonstrating uptake within the urethra and absence of uptake within the prostate glandand absence of uptake within the prostate gland.
gamma GAZETTE 2020 Spring/2021 Summer Edition
Education & CPD Case Study PET/CT for PETS Canines as a model for human disease: A case study of Prostate Adenocarcinoma in a Beagle (Continued)
Figure 6:[64Cu]HBP-EGFR PET/CT Trans axial cross section of the canine prostate, 24 hours post-injection.
Figure 5:[64Cu]HBP-PSMA PET/CT whole-body coronal imaging, 24 hours post-injection. Demonstrating biodisribution of the tracer.
Figure 7: [64Cu] HBP-EGFR PET/CT whole-body coronal imaging, 24 hours post-injection. Demonstrating biodisribution of the tracer and accumulation within the prostate gland.
EGFR is frequently overexpressed in prostate cancers and has been associated with more aggressive forms of the disease.[2] Following the biopsy results, the patient then underwent a series of whole-body PET/CT scans using the radiotracer [64Cu]HBP-EGFR. Imaging commenced at 24 and 48 hours post 128MBq intravenous injection. PET/CT imaging using the patient specific target [64Cu]HBP-EGFR was able to positively identify 2 lesions within the prostate gland that were identified on the low-dose CT scan and contrast-enhanced MRI images. At 24 hours post-injection regions of interest confirmed the SUVmax of 4.11 in the rightsided prostate lesion and 3.76 in the left-sided prostate lesion. The SUVmax observed in the liver was 2.6 at 24 hours post-injection. No nodal or distant metastases were identified using [64Cu]HBP-EGFR, CT or MRI.
By using a personalised target for this patient, HBP as a transport mechanism for targeted drug delivery can be observed using PET/CT imaging. Pharmacokinetics/ tracer distribution patterns were also similar to those observed in pre-clinical mice models. This lead to administration of a HBP loaded with doxorubicin, delivering a payload of chemotherapy directly to the prostate cancer cells. References for this case study can be found on page 66.
2020 Spring/2021 Summer Edition gamma GAZETTE 45
Education & CPD Case Study The Use of 11C-Methionine PET/CT and MRI in the Detection of Pituitary Adenomas Author: Chrystal Connie Douflias1 - 1Addenbrooke's Hospital, Cambridge, United Kingdom
ABSTRACT The pituitary gland is anatomically located between the hypothalamus and the pineal gland. This pea-sized oval structure lies in the sella turcica, which is a small depression in the sphenoid bone.1 The pituitary gland is divided into an anterior and posterior part.1 The anterior pituitary is the largest section, and its function is to produce and release six hormones.1 These include Somatotropin, thyroid-stimulating hormone, adrenocorticotropic hormone, follicular stimulating hormone, Luteinizing hormone and prolactin.1 The posterior pituitary is a direction extension from the hypothalamus and does not directly synthesise hormones but is where oxytocin and antidiuretic hormone are released.1 Pituitary tumours which are measured <4mm are seen in about 10% of patients with intra-cranial tumours.2 Pituitary adenomas however are the third most common intra-cranial neoplasms in adults.2 Pituitary adenomas can be classified as micro-adenomas (<1cm diameter) or macroadenomas (≼1cm diameter)2. Macroadenomas are also twice as common as microadenomas4. Patients who Pituitary adenomas typically present with hormone hypersecretion, visual and neurological defects.2 Once diagnosed a pituitary adenoma can be treated either with medication, surgery and/or radiation therapy.3 This case report provides an overview of the use of Magnetic Resonance Imaging (MRI) and the use of Nuclear Medicine PET/CT 11C-Methionine and its role in the diagnosis of pituitary adenomas. A general overview of the protocols undertaken in both imaging modalities will also be detailed. Key Words: Pituitary, 11C-Methonine, PET/CT, MRI, Adenoma, Nuclear Medicine, Imaging
INTRODUCTION A 43-year-old female patient was referred for an MRI pituitary and nuclear medicine (NM) 11C-methonine PET/CT scan query pituitary adenoma. MRI pituitary scan highlighted a mass in the pituitary; however, was unclear characterising the abnormal tissue. She presented with clinical symptoms of raised IGF-1 and growth of the size of feet. The patient was diagnosed with pituitary adenoma from her 11C-methonine PET/CT scan and underwent resection of the pituitary tumour. The patient then returned one month for a follow-up MRI and 11C-methonine scan, which showed low-grade pituitary adenoma remaining with no symptoms. The PET/CT protocol used the tracer 11C-methonine, which can distinguish abnormal pituitary versus normal pituitary gland. MRI also aided in the detection of the patient’s pituitary adenoma. This case study will explore the diagnosis of the pituitary adenoma for this patient using PET/CT and MRI and the treatment planning used.
46
gamma GAZETTE 2020 Spring/2021 Summer Edition
Education & CPD Case Study The Use of 11C-Methionine PET/CT and MRI in the Detection of Pituitary Adenomas (Continued) MRI PROCEDURE The patient presented to Addenbrooke’s Hospital to the MRI department for an MRI of the pituitary with contrast. The magnet utilised was a 1.5T GE system. The protocol consisted of sagittal T1 fast spinecho (FSE), Coronal T1 FSE, Coronal T2 FSE. Following an intravenous injection of 5mls of gadobutrol (gadovist) a Sagittal T1 FSE, Coronal T1 FSE and Sagittal Three-dimensional fast spoiled gradient-echo dual-echo (3D FSPGR) asset was performed. The MRI images, figure 1, shows 10 x 10 x 7 mm mildly enhancing soft tissue focus at the right inferior lateral aspect of the pituitary fossa, involving the fossa floor with dehiscence of the bone with the sphenoid sinus. There is slightly different signal characteristics compared to sinus mucosa and may represent a pituitary adenoma. MRI images could not conclude a pituitary adenoma at the right inferior lateral aspect of the pituitary fossa. The patient was then referred for further imaging using 11C-methonine PET/CT scan.
Figure 1: MRI Sagittal and Coronal shows 10 x 10 x 7 mm mildly enhancing soft tissue focus at the right inferior lateral aspect of the pituitary fossa
NUCLEAR MEDICINE PET/CT PROCEDURE The patient presented to Addenbrooke’s Nuclear Medicine department with a suspected lesion in the right side with inferior extension into the sphenoid sinus. The pituitary MRI, figure 1, was not conclusive and hence was referred for a 11C-methonine pituitary scan, figure 2. The 11C was produced on site as it has a half-life of 20 minutes. This process involves labelling methonine with 11-Carbon in the cyclotron. The patient was injected intravenously with 376MBq of 11C-methonine. Following injection of the tracer, an uptake period of 20 minutes was conducted. The scan was carried out for 20 minutes in a GE PET/CT scanner. A low-dose CT was performed for attenuation correction and localisation purposes. Findings showed intense radiopharmaceutical uptake in the right side of the pituitary fossa (SUV max 9.0). The lesion appears to extend across underlying bone into the sphenoid sinus. The described lesion appears consistent with a pituitary adenoma.
2020 Spring/2021 Summer Edition gamma GAZETTE 47
Education & CPD Case Study The Use of 11C-Methionine PET/CT and MRI in the Detection of Pituitary Adenomas (Continued)
Figure 2: PET/CT 11C-methonine Axial and sagittal scans show intense focal uptake in the pituitary adenoma
RESULTS The patient then underwent resection of the pituitary adenoma, which was carefully planned using the PET/CT and MRI images. One month post-resection she returned for a follow-up MRI and PET/CT 11C-Methonine scan, figure 3 and 4.
in size. As before, there is depression of the floor of the right side of the sella and there is a small bony defect which contains normal pituitary tissue. Soft tissue thickening and enhancement on the right of the sphenoid sinus is in keeping with post-operative change, although a small volume of residual adenoma is not excluded. The suprasellar cistern and cavernous sinuses are normal.
Figure 4: PET/CT 11C-methonine Axial shows low-grade activity in the resected pituitary adenoma. Figure 3: T1-weighted imaging after IV gadolinium in Sagittal and Coronal planes.
Since the previous MRI and PET/CT scan a triangular soft tissue lesion inferior to the gland on the right side of the sella (adenoma) has been removed, but the pituitary gland has not changed
48
Low-grade tracer activity is seen at the site of previous resected pituitary adenoma which is anteroinferior aspect of the pituitary fossa. Lowgrade activity is also seen in the left lateroposterior aspect of the pituitary fossa.
gamma GAZETTE 2020 Spring/2021 Summer Edition
Access to awards for the recognition of members who present at local or national meetings, including the ANSTO/ANZSNM Research Grant Award valued at $20,000.
To view all awards and application criteria visit anzsnm.org.au or click HERE
Education & CPD Case Study The Use of 11C-Methionine PET/CT and MRI in the Detection of Pituitary Adenomas (Continued) The images obtained by MRI and 11C-Methonine PET/CT images were assistive in the successful diagnosis of the pituitary adenoma. No variations were made to the protocol for this patient.
DISCUSSION The patient underwent investigation for a pituitary adenoma after she clinically displayed raised IGF-1 and change in size of feet. This can sometimes be common with a pituitary adenoma due to the growth hormone it stimulates. The gold standard for pituitary adenoma diagnosis is an MRI scan.4 This is because of the high-quality signal characterisation between tissues. In this particular case the MRI was inconclusive and the 11C-methonine confirmed the pituitary adenoma for this patient. Although the 11C-methonine study has many diagnostic benefits it can only be performed at a few hospitals around the world. This is because of how hard the tracer is to make. It needs to be done on-site with a cyclotron and needs to be injected into the patient very quickly as it only has a half-life of 20 minutes. This also needs to be done by specialised team of radiopharamacists and radiographers working together. For this patient she was diagnosed with a macroadenoma as it was 10x10x7mm. The definition of macroadenoma is a mass ≥1cm in diameter.2 If positive, macroadenomas will display isointense to grey matter in T1 sequences and moderate to bright enhancement post T1 gadolinium in the MRI scan.4 In a 11C-methonine PET/CT scan the macroadenoma will demonstrate increased radiopharmaceutical uptake within the lesion as it is highly hypermetabolic. In a normal pituitary gland it would not take up the tracer.
CONCLUSION The patient showed persistent symptoms associated with pituitary adenoma and was diagnosed with a macroadenoma from an MRI with contrast and 11C-methonine scan. The patient then underwent resection of the adenoma and after a month post operation, had follow up imaging. The MRI was able to detect an abnormal tissue, however could not confirm that it was an adenoma of the pituitary. The PET/CT scan was able to provide functional information and was confirmatory for a pituitary adenoma. The patient is now able to manage their symptoms from this diagnosis by surgical removal of the gland.
References 1.
Radiopaedia , 2019 ‘Pituitary gland’ Viewed 4 October https://radiopaedia.org/articles/pituitary-gland?lang=gb#nav_gross-anatomy
2.
BMJ Publishing Group, 2019, ‘pituitary adenoma’ Viewed 18 October https://bestpractice.bmj.com/topics/en-gb/1030
3.
Davis, D, Laws, E, Ilstrup, D, Speed, J, Caruso, M, Shaw, E, Abboud, C, Scheithauer, B, Root, L and Schleck, C, 1993, ‘ Results of surgical treatment for growth hormone-secreting pituitary adenomas’ , Journal of Neurosurgery, pp. 70-75
4.
Radiopaedia , 2019 ‘Pituitary macroadenoma’ Viewed 15 November 2019 https://radiopaedia.org/articles/pituitary-macroadenoma1?lang=us
50
gamma GAZETTE 2020 Spring/2021 Summer Edition
Education & CPD Case Study The Tale of Two Tracers – Investigation of the Use of Prostate Specific Tracers in the Imaging and Diagnosis of Metastatic Prostate Cancer Authors: Shenelle Nash1 & Loren Katchel2 - 1University of Newcastle, NSW, Australia; 2Princess Alexandra
Hospital, QLD, Australia
INTRODUCTION Prostate cancer is defined by the uncontrolled division of prostatic cells. It is the most common malignancy in males within western society and is the second leading cause of malignancy-induced deaths for men in Australia. With improvements in screening, and early diagnosis, 85% of prostate cancers are diagnosed in the early stages; wherein treatment is often curative.1 The cause of prostate cancer is still unknown; however, disease onset appears to be influenced by age, genetics, hormones, diet, and lifestyle.1 Prostate cancer is expected to account for 22% of new malignancy diagnoses for males in 2020.2 Treatment for prostate cancer includes surgery, radiotherapy, chemotherapy and hormone therapy.1 Since its development, Prostate Specific Membrane Antigen (PSMA) labelled with Gallium-68 (68Ga) has been a keystone in the imaging, staging and monitoring of metastatic prostate cancer. More recently, however, there has been a shift towards Fluorine-18 (18F)-labelled prostate compounds, such as 18 F-PSMA-1007 and 18F-DCFPyL, which have shown to be beneficial in many ways.3,4 This study aims to examine the use of these two tracers in a single patient in order to gain a better understanding of their individual applications.
CASE REPORT The patient, a 78-year-old male, was diagnosed with prostate cancer back in 2015. Soon after the initial diagnosis, the patient underwent a radical prostatectomy. The patient was further treated with radiation therapy and androgen deprivation therapy post-surgery. Over the next 3 years, the patient’s disease was monitored with annual 68Ga-PSMA PET/CT scans, which demonstrated no evidence of recurrence or metastatic disease, until his most recent 68Ga-PSMA scan in 2018 (figure 1a). A new right hilar lymph node demonstrating intense PSMA expression consistent with metastatic disease was noted (figure 1b). There were also two non-PSMA expressing right upper lobe pulmonary lesions that had increased in size compared to previous imaging, which were also suspicious for metastases.
2020 Spring/2021 Summer Edition gamma GAZETTE 51
Education & CPD Case Study The Tale of Two Tracers – Investigation of the Use of Prostate Specific Tracers in the Imaging and Diagnosis of Metastatic Prostate Cancer (Continued)
Based on these results, the patient went on to have a round of enzalutamide therapy, however, his PSA continued to rise, and the patient returned twice more to the Molecular Imaging department for restaging scans. Both sets of imaging utilised 18F-labelled prostate imaging tracers, his first using 18 F-DCFPyL and the most recent using 18F-PSMA-1007, for the investigation of disease progression and to assess the presence of bony lesion involvement.
INVESTIGATION F-DCFPyL Imaging - The patient was injected with 205MBq of
18
F-DCFPyL intravenously through the right cubital fossa. A vertex-to-thighs PET/CT was acquired at 125 minutes post-injection with a low-dose non-diagnostic CT performed for attenuation correction and anatomical localisation. In addition, a late arterial diagnostic CT of the pelvis with IV contrast was performed. 18
Figure 1: a) 68Ga-PSMA PET image acquired in 2017 with no evidence of disease recurrence or metastases visualised. b) 68Ga-PSMA PET image acquired in 2018, arrow indicates PSMA expression in right hilar lymph node.
The scan showed multiple prominent, sub-centimetre lymph nodes in the perivascular space, aortal pulmonary window and left paratracheal space (figure 2). There was evidence of intense 18F-DCFPyL uptake in the subcarinal space and right hilar nodes, showing a moderate increase in size compared to previous 68Ga-PSMA imaging. There was also evidence of increasing involvement of pulmonary nodules in the right upper lobe and in the right middle lobe, showcasing moderate 18F-DCFPyL uptake. No evidence of bony involvement was seen. Overall, the scan showed evidence of disease progression when compared to previous 68Ga-PSMA imaging. F-PSMA-1007 Imaging - Another PET/CT scan was indicated 12 months later.
18
The patient was injected with 216MBq of 18F-PSMA-1007 intravenously through the right cubital fossa. A vertex-to-thighs PET/CT scan was acquired at 128 minutes post-injection. Scan region and time/bed was consistent with 18F-DCFPyL imaging. This was also followed by a late arterial diagnostic CT of the pelvis with IV contrast.
Imaging showed multiple nodal metastases with mild 18F-PSMA-1007 uptake in the right and left medial supraclavicular lymph nodes, which remained unchanged in size, but showed intense 18F-PSMA-1007 uptake which was not seen on the 18F-DCFPyL imaging (figure 3).
52
gamma GAZETTE 2020 Spring/2021 Summer Edition
Figure 2: 18F-DCFPyL PET image acquired in 2019
Education & CPD Case Study The Tale of Two Tracers – Investigation of the Use of Prostate Specific Tracers in the Imaging and Diagnosis of Metastatic Prostate Cancer (Continued) There was evidence of growth of the node in the paratracheal space and evidence of 18F-PSMA-1007 uptake in the pre- and paratracheal spaces. There was also evidence of mild 18F-PSMA-1007 uptake in the right hilar lymph node, which was enlarged. There was evidence of osseous bony metastases with moderate 18F-PSMA-1007 uptake, in the distal left clavicle, manubrium, lateral right 4th rib and the right scapula (figure 4). This scan showed progression of the disease from soft tissue metastases to the inclusion of bony metastasis.
DISCUSSION Both 18F-DCFPyL and 18F-PSMA-1007 were seen to accumulate in previously known metastases. All lesions visualised with the earlier 18F-DCFPyL scan were also localised on the 18F-PSMA-1007 scan (figure 5). The 18F-PSMA-1007 scan also showed an increase in appearance of localisable metastases; however, this is most likely due to disease progression rather than a higher sensitivity of PSMA. Both tracers are seen to have similar normal biodistribution, with tracer accumulating in liver, spleen, kidneys, small intestine, lacrimal, salivary and parotid glands. 18F-PSMA-1007 has a slightly higher uptake in visceral organs, however, this difference is insignificant in terms of radiation dosimetry and image quality.4
Figure 3: Comparison fused PET/CT images of supraclavicular lymph nodes a) 18F-DCFPyL and b) 18F-PSMA-1007; arrows indicate disease progression.
Figure 4: 18F-PSMA-1007 fused PET/CT images, a) bone metastasis can be seen in the manubrium, b) bone metastasis in the right scapula.
The slight difference in biodistribution is explained by the tracers’ methods of excretion. 18F-DCFPyL is excreted renally, whilst 18F-PSMA-1007 is metabolised via hepatobiliary excretion. This explains the higher renal and urinary uptake in 18F-DCFPyL (figure 5a) and the higher rates of localisation in the liver, gallbladder, spleen, and pancreas in 18F-PSMA-1007 (figure 5b).4 2020 Spring/2021 Summer Edition gamma GAZETTE 53
Education & CPD Case Study The Tale of Two Tracers – Investigation of the Use of Prostate Specific Tracers in the Imaging and Diagnosis of Metastatic Prostate Cancer (Continued)
wherein hepatic metastases have been known to occur. This is due to the lower hepatic background seen in 18F-DCFPyL compared with 18F-PSMA-1007.4,8,9
Figures 5a & 5b: Comparison of (a) 18F-DCFPyL PET and (b) 18F-PSMA-1007 PET
As the scans acquired for this patient were not taken at directly comparable time points, it is not possible to draw conclusions regarding higher efficacy of one tracer over another. However, it can be stated that both tracers are able to effectively localise to metastatic prostate cancers and produce comparable images for the staging and restaging of metastatic prostate cancer.
CONCLUSION
F-PSMA-1007 holds one clear advantage over 18 F-DCFPyL, in that it is temporarily retained in the kidney parenchyma, which is a definite advantage in terms of staging of local recurrence5. The urinary clearance for 18F-PSMA-1007 is only about 1.2% of injected activity during the first 2 hours, with the addition of only a further 0.7% 2 to 4 hours postinjection4. Comparably, 18F-DCFPyL has a urinary clearance of 11% in the first 2 hours, and a further 5% up to 3 hours post-injection6. This also means that 18F-PSMA-1007 provides a lower dose to the urinary bladder and tract, whilst the dose to the kidneys remains comparable. 18F-PSMA-1007 also presents an advantage in that it is an ideal tracer for therapy applications with Lutetium-177 as it contains a chelator which is suitable for binding with therapeutic nuclides. 4,7
This case study supports current evidence that 18 F-DCFPyL and 18F-PSMA-1007 are largely comparable in terms of the localisation of metastatic prostate cancer. 18F-PSMA-1007 offers one marked benefit in that it contains chelates able to bind to therapeutic agents such as Lutetium-177, hallmarking potential in theranostics. Due to delayed renal excretion, 18F-PSMA-1007 may also be advantageous in imaging of local metastatic remnant or recurrent disease. Excellent image quality is observed with both tracers, each providing high tumour-to-background ratios, good sensitivity and specificity for metastasis. Further research is needed into the applications of these tracers before a clear demarcation in their uses and efficacy can be determined.
F-DCFPyL may hold similar advantages in terms of hepatic localisation in regards to late stage disease
References for this case study can be found on page 66.
18
18
54
gamma GAZETTE 2020 Spring/2021 Summer Edition
EduTrace is proudly sponsored by GMS, Global Medical Solutions
EDUTRACE
YOUR CPD E-LEARNING PORTAL * Exclusive to ANZSNM members
EDUTRACE PROVIDES ACCESS TO A WIDE RANGE OF COURSES ON-DEMAND TO ADD TO YOUR CPD CONTINUING EDUCATION The content includes proprietary programs as well as others shared by international imaging and therapy organisations with which the ANZSNM has developed excellent relationships over the past 50 years
Resources including webinars, case studies and online seminars Contributions from local and world experts National and overseas industry conference presentations and webinars Access from any device, anywhere at any time. Integration of CPD points with Attendo Plus mobile app
VISIT
anzsnm.org.au/edutrace to get started
Education & CPD What’s that What's That? Case 1 Authors: Remi Hillery & Catriona Stevenson, Sunshine Coast University Hospital, QLD
INTRODUCTION A 69-year-old female presented to the emergency department with syncopal episodes. On arrival, she had sinus tachycardia and a D-Dimer of 12.51. She had a background of Stage IV metastatic NSCLC, with intracranial metastases, and was currently on pemetrexed. She had previously undergone immunotherapy and radiation therapy to the left bronchus. A contrast-enhanced HCAP had been performed 3 months prior; however, due to an eGFR of 26, a V/Q scan was requested to exclude PE. A CXR was also ordered, but not performed until after the V/Q study. The patient had no prior history of PE or DVT and was not experiencing any shortness of breath or chest pain. She had not undergone any long periods of travel or immobilisation and was not on blood thinners. The patient was known to have COPD.
METHOD 400MBq of Technetium pertechnetate was loaded in the Technegas generator, and Technegas was administered to the patient until a count rate of 1.6kcps was reached posteriorly. A SPECT was then acquired with the patient’s arms raised. Following this, 256MBq of 99m Tc-MAA was administered intravenously, providing a count rate of 10.1kcps posteriorly. Another SPECT was then performed, followed by a low-dose CT for attenuation and localisation correction.
FINDINGS The ventilation and perfusion imaging demonstrated homogenous radiotracer distribution in the right lung, with no unmatched segmental or subsegmental perfusion defects. The left lung demonstrated no perfusion, with faint radiotracer uptake, reflecting residual ventilation activity. This is consistent with an occlusion at the level of the left main pulmonary artery. The imaging also showed chronic scarring/atelectasis in the left lower lobe, which was consistent with the patient’s history of diffuse centrilobular emphysema.
BACKGROUND Pulmonary Embolism (PE) is a potentially fatal pathology if left untreated and is associated with a higher mortality rate in people with underlying diseases such as cancer and renal impairment.1
FIG 1. SPECT/CT axial fusion slice
V/Q scans are utilised to diagnose the likelihood of PE by assessing the airflow in the lungs (ventilation) and blood supply to the lungs (perfusion) using appropriate radiopharmaceuticals orally (as a gas that is breathed in by the patient) and intravenously.2 Mismatched segmental defects where there is adequate ventilation but poor perfusion may indicate a thrombus, in which they are reported in probability; high, intermediate or low clinical suspicion, using the PIOPED criteria.1
56
gamma GAZETTE 2020 Spring/2021 Summer Edition
Education & CPD What’s that What's That? Case 1 (Continued)
A saddle PE is a rare form of large clot occurring at the level of bifurcation of the main pulmonary arterial trunk. Its incidence is between approximately 2-5% of PE cases.3 It may cause right ventricular disfunction and is associated with a higher one-year mortality rate and major adverse event when compared to a non-saddle PE. The diagnosis of saddle PE often causes clinical concern due to it being suggestive of a large, unstable clot burden and an increased risk of sudden haemodynamic collapse.4
DISCUSSION Nuclear Medicine V/Q scans are a suitable and non-invasive imaging modality for establishing the diagnosis of pulmonary embolism (PE).1 CTPA (Computed Tomography Pulmonary Angiography) is currently the gold standard for diagnosing FIG 2. Static Extractions of Ventilation compared to Perfusion, acute PE, however, V/Q scans offer a sufficient demonstrating no perfusion to the left lung alternative and may be preferred for patients that are contraindicated for CT due to renal failure or contrast allergies, or for young female patients (particularly if pregnant) or those who are unable to fit in
FIG 3. Splash pages displaying slices A) transverse, B) coronal & C) sagittal
2020 Spring/2021 Summer Edition gamma GAZETTE 57
Education & CPD What’s that What's That? Case 1 (Continued) a CT scanner.5 V/Q scanning was the modality of choice for this patient due to her renal impairment, which was a reason for contraindication of CTPA, as her eGFR was 26. Diagnosing a PE is challenging due to the often non-specific symptoms, as well as up to two/ thirds of cases presenting as asymptomatic.5 The most common signs and symptoms of PE include dyspnoea, tachypnoea, pleuritic pain, leg pain or swelling, cough, orthopnoea, tachycardia, wheezing and crackles.2 This patient had symptoms including sinus tachycardia and a cough but also had a history of COPD. She was not on any blood thinning medication; thus, investigation was vital to ensure accurate diagnosis and an appropriate treatment pathway could be developed. A D-dimer blood test is often performed to aid in this diagnosis. This test measures the plasminderived degradation product, a small protein fragment present in the blood after a blood clot is broken down, to rule out PE with high sensitivity and negative predictive value.5 An increased D-dimer level is not specific for PE and may occur in any condition where fibrin has been formed and degraded by plasmin. Normal levels are considered to be between 0.02 and 0.49 mg/L, however this patient’s results were 12.51 mg/L.1 This was a good indication that further investigation would be required to exclude PE as the cause of the positive D-dimer results.
CONCLUSION Saddle PE is a rare and alarming disorder that is potentially fatal, although treatment is highly effective and can vastly improve survival rates. The accurate and prompt diagnosis of saddle PE is vital but may be challenging if patients are unable to undergo CTPA imaging. In this instance, Nuclear Medicine offered a suitable alternative imaging option of a V/Q for this patient due to their renal impairment, contraindicating the use of contrast agents.1 The scan results justified the use of anticoagulation therapy in which their treating team was able to begin in a timely fashion, and follow-up imaging demonstrated complete resolution of the saddle PE.
References 1.
Carson, J. L., Kelley, M. A., Duff, a., Weg, J. G., Fulkerson, W. J., Palevsky, H. I., Schwartz, S., Thompson, T., Popovich, J., Hobbins, T. E., Spera, M. A., Alavi, A., & Terrin, M. L. (1992). The clinical course of pulmonary embolism. The New England Journal of Medicine, 326, 1420-1245. https://doi.org/10.1056/ nejm199205073261902
2.
2. Bobbie, M. (2014). Diagnosis and management of acute pulmonary embolism. Journal of the American Academy of PAs, 27(4), 18-22. https://doi.org/10.1097/01. JAA.0000444729.09046.09
3.
3. Satya, R., Bagherpour, A., Christofferson, M., & Satya, R. J. (2011). Large saddle pulmonary embolism in patient with previously placed IVC filter: A case report of successful Angiojet thrombectomy. Respiratory Medicine CMA, 4(3), 133-135.
As PE is a potentially life-threatening disorder, prompt treatment is required, often in the form of anticoagulation therapy.1 Low-Molecular-WeightHeparins (LMWH) are a suitable therapy option to prevent and treat unwanted blood clots in patients who are hemodynamically stable. They do this by deactivating one of the proteins in blood that is used to form a clot.2 This patient was put on a subcutaneous LMWH, Clexane, for treatment. She had a follow up CT Chest, Abdomen, Pelvis with contrast once her eGFR had increased, with results stating no proximal pulmonary arterial filling demonstrated (allowing for a non-dedicated CTPA), and she was able to cease her Clexane medication. 58
https://doi.org/10.1016/j.rmedc.2010.11.005 4.
4. Kwak, M.K., Kim, W. Y., Lee, C. W., Seo, D. W., Sohn, C. H., Ahn, S., Lim, K. S., & Donnino, M. W. (2013). The impact of saddle embolism on the major adverse event rate of patients with non-high-risk pulmonary embolism. The British Journal of Radiology, 86(1032). https://doi.org/10.1259/bjr.20130273
5.
gamma GAZETTE 2020 Spring/2021 Summer Edition
5. Moore, A. J. E., Wachsmann, J., Chamarthy, M. R., Panjikaran, L., Tanabe, Y., & Rajiah, P. (2018). Imaging of acute pulmonary embolism: an update. Cardiovascular Diagnosis and Therapy, 8(3), 225-243. https://doi.org/10.21037/cdt.2017.12.01
Education & CPD What’s that What’s That? - Case 2 Author: Judy Duong
CLINICAL HISTORY A 70-year old male with known renal cell carcinoma was referred to have a nuclear medicine bone scan for staging assessment prior to trial recruitment.
METHOD The patient was intravenously injected with 825MBq of 99mTc-HDP in a right cubital fossa cannula. Initial whole-body blood pool images were acquired and delayed whole-body images were obtained at 2-hours postinjection.
Figure 1: Initial whole-body blood pool images
Figure 2: 2-hour delayed whole-body images
2020 Spring/2021 Summer Edition gamma GAZETTE 59
Education & CPD What’s that What’s That? Case 2 (Continued) After reviewing the planar images, the nuclear medicine physician requested a double-bed SPECT/CT over the torso. The first SPECT bed position was acquired over the pelvis to reduce the visualisation of the bladder during the acquisition. Hang on…what’s that?
Figure 3: First SPECT frame (anterior projection)
RESULT The patient’s bone questionnaire reported no pain other than occasional minor lower back pain and a previous right arm fracture 30 years ago. The SPECT/CT and additional planar imaging demonstrated intense radiotracer uptake throughout the right ulna. Due to the patient’s habitus, the right ulna was within the extended field-of-view (eFOV) of the low-dose CT on the SPECT/CT images. The edge of the eFOV often produces a blurring artefact which can be seen in figure 4. With the Nuclear Medicine department located in radiology, the patient was sent for further x-ray imaging of the right forearm.
Figure 4: SPECT/CT fusion angled to the right forearm
60
gamma GAZETTE 2020 Spring/2021 Summer Edition
Education & CPD What’s that What’s That? Case 2 (Continued)
Figure 5: Planar scintigraphy of the hands and forearms Figure 6: Plain radiographs of the right forearm
The intense radiotracer uptake seen throughout the right ulna, correlating with the bony expansion, cortical thickening and coarse trabeculation seen on the plain radiograph and low-dose CT, is consistent with Paget’s disease.1
DISCUSSION Paget’s disease of the bone, also known as osteitis deformans, is a bone remodelling disorder that can involve one (monostotic) or multiple (polyostotic) skeletal sites anywhere in the body.2,3 Patients are often asymptomatic with it frequently discovered as an incidental finding of unrelated investigations or imaging procedures.3 The most commonly involved site is the pelvis followed by the spine, skull, femur, tibia, humerus and scapula.1,2,3 Other sites such as the ulna are far less common and involvement in the hands and feet are rare.3
CONCLUSION This case serves as a reminder that Paget’s disease can occur in any bone of the body and highlights the importance of ensuring that all bones are included in the imaging process particularly in an otherwise normal looking bone scan.
References 1.
Ziessman, H, O’Malley, J & Thrall, J 2014, ‘Skeletal scintigraphy’, in H Ziessman, J O’Malley & J Thrall (eds), Nuclear medicine: the requisites, 4th edn, Elsevier Saunders, Philadelphia, pp. 98-130.
2.
Ralston, SH, Corral-Gudino, L, Cooper, C, Francis, RM, Fraser, WD, Gennari, L, Guanabens, N, Javaid, MK, Layfield, R, O’Neill, TW, Russell, RGG, Stone, MD, Simpson, K, Wilkinson, D, Wills, R, Zillikens, MC & Tuck, SP 2019, ‘Diagnosis and management of Paget’s disease of bone in adults: a clinical guideline’, Journal of Bone and Mineral Research, vol. 34, no. 4, pp. 579-604.
3.
Shaker, JL 2009, ‘Paget’s disease of bone: a review of epidemiology, pathophysiology and management’, Therapeutic Advances in musculoskeletal Disease, vol. 1, no. 2, pp. 107-125.
2020 Spring/2021 Summer Edition gamma GAZETTE 61
People in Nuclear Medicine
Queens
Birthday
Honours Member of the Order of Australia Dr Gabrielle Cehic The Society would like to congratulate Dr Gabby Cehic for her award of the Member of the Order of Australia (AM). Dr Cehic's award citation is “for significant service to medicine, to nuclear oncology and to professional medical groups”. Gabby would be known to many of you and was one of the coconvenors of the 2019 Annual Scientific Meeting in Adelaide. The President Daniel Badger had this comment “I work closely with Gabby and I can state with no exaggeration that she has an exceptional drive to provide and continually improve care for all our patients, to improve outcomes and their journey in Nuclear Medicine, not just in Nuclear Oncology/Radionuclide Therapy, but also in all aspects of Nuclear Medicine. Gabby is the driving force behind the introduction and continued success of the “Lutate” peptide receptor radionuclide therapy (PRRT) program treating people with Neuroendocrine Tumours (NETs) in South Australia. She puts in many extra hours above and beyond the call of duty and is the person most likely to be still in the department working when I leave my office late in the evening. Gabby is a selfless and humble team player. Her response to my personal congratulations was typical: “Thanks Daniel – a great boost for our team”. The Official Award Extract and Gabby's many achievements can be found HERE
62
gamma GAZETTE 2020 Spring/2021 Summer Edition
Dr Gabby Cehic – MANZSNM Adelaide
In 1969, the Australian and New Zealand Society of Nuclear Medicine was founded by a group of visionaries. In 2020, we've grown into a diverse, inclusive community of members including Technologists, Physicists, Radiopharmacists, Physicians, Nurses, Chemists and others practising Nuclear Medicine. Today, we continue to face new challenges with passion and purpose. Working together, we're building an enduring future.
Explore our heritage at anzsnm.org.au/archive
Ta k e a B r e a k RBWH NUCLEAR MEDICINE CROSSWORD 1
3
2
4
5
6 7
8 9
10
13
11
14
12
15 16
17
18 19
20
DOWN
ACROSS
2.
1.
Where will you find NaI crystals? (2-words 5,4) 3. Old cranky detector (2-words 5,6) 6. Another species that commonly undergoes131I therapy 8. Diamox is a type of ______ commonly used to treat glaucoma 10. Afternoon train trip in London (2-words, 2,4) 12. Beta + Lead 14. For an eGFR below _____ careful weighing of the risk versus the benefit of iodinated contrast media administration needs to be undertaken 15. Most commonly spotted on a Friday after 3pm 16. Emitted electron after electron capture 20. Type of bone measured by pQCT
Whilst in Queensland we have "super"NMS,what radiopharmaceutical can we not vent our patients with? 4. 14 C Urea breath test is used to identify______ pylori 5. Phosphorylation prevents me from escaping the cell 7. 68Ga-DOTATATE is a form of ________receptor 9. Bright Spark 12. Beta + Lead 11. As Low As _______ Achievable 13. Less common type of lung scan 17. Lead of the periodic table 18. The most commonly used target material in an x-ray tube anode 19. Decayed Thallium
Responses can be found on page number 66
2020/2021 EVENTS CALENDAR International Conference on Clinical PET–CT and Molecular Imaging in the Era of Theranostics (IPET-2020) 24-26 November 2020
TSIG Wellness Webinar
SA Branch Meeting AGM
25 November 2020
2 December 2020
Online via Zoom Time: 7:30pm
Virtual Zoom Meeting Time: 6:30 pm
TSIG Annual Day Symposium 6 February 2021
British PET/CT Course 27-29 April 2021
Virtual and Face-to-face Customs House, Brisbane
London and Virtual
IAEA Headquarters, Vienna, Austria
HSNM&MI Seminar | CNS SPECT/CT IMAGING EDUCATIONAL COURSE 18-19 December 2020 Athens, Greece
51st ANZSNM Annual Scientific Meeting Key Collaborations, Key Impacts Unlocking the potential of Nuclear Medicine 21-23 May 2021
For more details and registration details visit
anzsnm.org.au
Attendo Plus mobile App
RBWH NUCLEAR MEDICINE CROSSWORD
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
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
•
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 Quality and 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
of the TSIG align with the values and strategic plan of the ANZSNM. It reports directly to the
1. 2.
3. 4.
ANZSNM Federal Council and oversees the two TSIG working groups: CPD & Education Working Group and Technologist Workforce Advocacy
5.
Working Group. The committee is able to form working groups to perform specific tasks as
6.
required to provide opportunities for the benefit of Technologist members of the ANZSNM after consultation with the ANZSNM Federal Council. •
7.
The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for
8.
their particular speciality and provide a forum for development in Australia and New Zealand.
66
gamma GAZETTE
2020 Spring/2021 Summer Edition
REASONABLY BREMSSTRAHLUNG QUANTIATIVE THIRTY VO AUGER PB TUNTEN MERCURY CORTICAL
Pearce, A., Fuchs, K., Fletcher, A., & Thurecht, V. (2016). Targeting Nanomedicines to Prostate Cancer: Evaluation of Specificity of Ligands to Two Different Receptors In Vivo. Pharmaceutical Research, 33(10), 2388–2399. [2] Kharmate, G., Hosseini-Beheshti, E., Caradec, J., Chin, M. Y., & Tomlinson Guns, E. S. (2016). Epidermal Growth Factor Receptor in Prostate Cancer Derived Exosomes. PloS one, 11(5), e0154967. https://doi.org/10.1371/journal.pone.0154967 [3] Pearce, A. K., Simpson, J. D., Fletcher, N. L. et al. (2017). Localised delivery of doxorubicin to prostate cancer cells through a PSMAtargeted hyperbranched polymer theranostic. Biomaterials, 141, 330–339 [1]
References Case Study: The Tale of Two Tracers – Investigation of the Use of Prostate Specific Tracers in the Imaging and Diagnosis of Metastatic Prostate Cancer.
Technologist Special Interest Group (TSIG) and ensures that all projects, committees and activities
11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
References Case Study PET/CT for PETS Canines as a model for human disease: A case study of Prostate Adenocarcinoma in a Beagle
medicine and biology at national and regional levels;
KRYPTON TABLESALT ANGERCAMERA HELICOBACTER FDG FELINE SOMATOSTATIN DIURETIC SCINTILLATION PMTUBE
9.
Oderda M, Mondino P, Zitella A, Gontero P, Tizzani A. Update on epidemiology and risk factors of prostate cancer. Urologia Journal. 2008;75(3):143-148. Prostate cancer in Australia statistics | Cancer Australia [Internet]. Canceraustralia.gov.au. 2020 [cited 22 September 2020]. Available from: https://www.canceraustralia.gov.au/affectedcancer/cancer-types/prostate-cancer/statistics Ferreira G, Iravani A, Hofman M, Hicks R. Intra-individual comparison of 68Ga-PSMA-11 and 18F-DCFPyL normal-organ biodistribution. Cancer Imaging. 2019;19(1). 4. Giesel F, Will L, Lawal I, Lengana T, Kratochwil C, Vorster M et al. Intraindividual Comparison of18F-PSMA-1007 and18F-DCFPyL PET/CT in the Prospective Evaluation of Patients with Newly Diagnosed Prostate Carcinoma: A Pilot Study. Journal of Nuclear Medicine. 2017;59(7):1076-1080. 5. Giesel F, Cardinale J, Schäfer M, Neels O, Benešová M, Mier W et al. 18F-Labelled PSMA-1007 shows similarity in structure, biodistribution and tumour uptake to the theragnostic compound PSMA-617. European Journal of Nuclear Medicine and Molecular Imaging. 2016;43(10):1929-1930. 6. Giesel F, Hadaschik B, Cardinale J, Radtke J, Vinsensia M, Lehnert W et al. F-18 labelled PSMA-1007: biodistribution, radiation dosimetry and histopathological validation of tumor lesions in prostate cancer patients. European Journal of Nuclear Medicine and Molecular Imaging. 2016;44(4):678-688. 7. Werner R, Derlin T, Lapa C, Sheikbahaei S, Higuchi T, Giesel F et al. 18F-Labeled, PSMA-Targeted Radiotracers: Leveraging the Advantages of Radiofluorination for Prostate Cancer Molecular Imaging. Theranostics. 2020;10(1):1-16. 8. Szabo Z, Mena E, Rowe S, Plyku D, Nidal R, Eisenberger M et al. Initial Evaluation of [18F]DCFPyL for Prostate-Specific Membrane Antigen (PSMA)-Targeted PET Imaging of Prostate Cancer. Molecular Imaging and Biology. 2015;17(4):565-574. 9. Giesel F, Knorr K, Spohn F, Will L, Maurer T, Flechsig P et al. Detection Efficacy of 18F-PSMA-1007 PET/CT in 251 Patients with Biochemical Recurrence of Prostate Cancer After Radical Prostatectomy. Journal of Nuclear Medicine. 2018;60(3):362-368.
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.
AVA I L A B L E I N P R I N T & D I G I TA L
Don't miss all the latest
Fre e for m emb ers
Cas e St u d i es Pa p e rs & A b st ra c t s I n d u st r y Sp e c if i c Re p o r t s I n d u st r y N ews Eve nt s a n d Awa rd s M e m b e r P ro f i l es R E A D I T T O DAY
anzsnm.org.au
OFFICE BEARERS President Vice President Past President Treasurer Committee
Dr Daniel Badger (SA) Vacant A/Prof Roslyn Francis (WA) Ms Suzanne McGavin (VIC) Dr Kevin London (NSW) Mr Nicholas Ingold (ACT) Ms Judy Duong (QLD) Ms Prudence Burns (NZ) Mr Christian Testa (VIC/TAS) Mrs Victoria Sigalas (SA) Prof Karen Jones (TSIG) A/Prof Giancarlo Pascali (RPS) Dr Samuel McArthur (AANMS Representative) Prof Andrew Scott (IRC)
General Manager & Secretariat All Correspondence
Mr Rajeev Chandra ANZSNM Secretariat, PO Box 6178, Vermont South, Victoria 3133 Tel: 1300 330 402 | Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au
Archivist
Ms Debra Huddleston
Branch Secretaries Australian Capital Territory New South Wales Queensland South Australia Victoria/Tasmania Western Australia New Zealand
Mrs Rachael Prior Currently Vacant Miss Remi Hillery & Ms Loren Katchel Mrs Tess Smith Ms My Linh Diep Ms Georgina Santich Mrs Jessica Fagan
Special Interest Groups/Committees Technologists Radiopharmaceutical Science Physics Quality and Technical Standards Committee Scientific Advisory Panel International Relations Committee
Chairperson: Mr Nicholas Daw Chairperson: A/Prof Giancarlo Pascali Chairperson: Mr Andrew Chicco (Acting) Chairperson: Dr Darin O’Keeffe Chairperson: Prof Dale Bailey Chairperson: Prof Andrew Scott