2020 SPRING/SUMMER EDITION ISSUE 28
A CONTINUING CELEBRATION OF 50 YEARS OF THE SOCIETY
2020 SPRING/SUMMER EDITION ISSUE 28
Contents
• • •
A glimpse of the Society's online archive A brief history of Nuclear Medicine and PET in Queensland Nuclear Medicine in a paediatric hospital over the years 1975-2017: a historical perspective with emphasis on administered patients' activities
• Role of 18F-FDG PET in the Management of Gestational Trophoblastic Neoplasia - A Case Study • Immunotherapy-Related Nephritis in a Melanoma Patient - A Case Study • Lymphangitis – A Suppurative Case Study • Rhenium-188 Cutaneous Brachytherapy for Non-Melanomatous Skin Cancer
Design & Production
Ester Gomez, Creative Director Enovate Studio ester@enovatestudio.com www.enovatestudio.com
Disclaimer
Editorial
Events & Advertising Enquiries
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
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. © 2019 The Australian and New Zealand Society of Nuclear Medicine. Copyright is transferred to the Australian and New Zealand Society of Nuclear Medicine once an article/paper has been published in the ANZSNM Gamma Gazette (except where it is reprinted from another publication).
From the President
I
t’s hard to believe that we are nearly at the end of another fast-paced year - I am sure we are all wondering where this year has gone! Since my last report in our Winter Edition, I have had the opportunity to attend a number of meetings both internationally and locally. I attended the EANM Congress in Barcelona in October, where we had a booth promoting the 2020 ASM Conference. Meetings in Barcelona included with EANM Executive, EANM Educational committee, SNMMI Executive and SNMMI Technologist group. Focus areas for ANZSNM continue to be educational initiatives/CPD opportunities and research activities, with ARTnet gaining a high international profile in clinical trials activities. There was also the opportunity for global discussions including on radioisotope supply, and also on future directions in Nuclear Medicine, in particular in therapy/theranostics. Preceding my trip to Barcelona I travelled to Rotorua, New Zealand where I had the chance to interact with the New Zealand Branch and to present at their conference which was, on this occasion, hosted jointly with the NZMIRT. I was able to attain insight into the challenges that our New Zealand members face, some of which are unique to New Zealand, and others which are common themes. Aside from the usual welcoming Kiwi hospitality, I was impressed by the energy of the NZ branch committee, and I look forward to their enthusiasm and ideas. Upon my return from Barcelona, I travelled to Canberra for the Capital Forum, where I provided an update on ANZSNM and ARTnet activities. Recently, I also attended and presented at the NSW Branch meeting in Sydney, which was co-hosted with the RAINS conference. Attending both the ACT branch and NSW branch meetings highlighted the educational strength of ANZSNM, and also provided a great opportunity for me to meet with branch members and industry/sponsors. Continuing the education theme, the TSIG symposium this year was held in Fremantle, and I was able to attend for part of this day. This was another excellent meeting with a varied program, and I enjoyed meeting and interacting with our technologist group. Education and networking are key activities for ANZSNM, and I would like to thank everyone who volunteers their time to ensure the success of these important activities for our profession. I cannot reflect on the last few months without discussing the issues of the Mo-99 production failure in ANSTO’s ANM facility, and its impact on our Nuclear Medicine community. The mechanical failure occurred in early September, and there has been a 2-month period of sourcing overseas Mo-99 in order to provide Tc-99m in Australia. As with the generator production issue last year, the focus has been on patient care and minimising patient impact, whilst trying to balance the complexity of supply needs/practice locations. The efforts of the members of ANZSNM, AANMS and RAINS who participated in the working group with representatives from ANSTO, GMS, NSW Health Ministry and TGA is greatly appreciated. ANZSNM particularly acknowledges Dale Bailey for his contribution to the working group, and for his leadership in ensuring communication to members. It is important that we continue active discussions regarding reliable radioisotope supply in Australia, and that we engage with Government on these critical issues. As I finish this last message for 2019, I encourage you to reflect again on our history over the last 50 years, which we have highlighted in each Gamma Gazette this year. In continuing the 50th anniversary celebrations, we celebrate our 50th ASM in Sydney from 24-26 April 2020. We look forward to this event with great anticipation. Abstracts and registrations are now open, so please visit the conference website and be amazed at the educational program! Lastly, I would like to wish you and your loved ones a wonderful festive season as we get ready to welcome the next decade! See you in the new year.
Roslyn Francis, President
Roslyn Francis 2020 Spring/Summer Edition gamma GAZETTE 3
Branch News
New Zealand Branch News
M
erry Christmas from New Zealand to all our ANZSNM colleagues! It’s the time of the year when our department workloads start to increase, as the push to get scans performed and reported before Christmas goes a bit nuts. At the same time, daylight savings means we all want to be outside, making the work-life balance tip in the favour of life away from work. We would like to share our sympathy with those living in areas of Australia who have suffered through the recent bush fires. These fires are on such an enormous scale, such devastation to the landscape, wild life and the people living in these areas. Victoria Brooks is very well known to many ANZSNM members. Victoria has been the Charge NMT at Taranaki Base Hospital in New Plymouth for 34 years, and has contributed hugely to the NZ branch and Federal Council, most recently as our branch Chairperson. In January 2020, Victoria will leave Taranaki for a new adventure, detonating (sorry renovating!) a house on the Whangaparaoa Peninsula, north of Auckland. Always extremely passionate and supportive of the Nuclear Medicine community in NZ, Victoria has fought hard for her patients to have access to quality Nuclear Medicine examinations. Her drive to see a public PET department and better access to PET scans for public patients is inspiring and our branch and its members will miss Victoria’s enthusiasm. FOMO means Victoria will attend the social functions in Sydney next year, much to the enjoyment of her NZ peers - who are hoping she will design our costume for the Gala dinner! Congratulations to Prue Lamerton, Unit Charge Nuclear Medicine at Hastings Hospital, on winning the EANM’19 Best Regional e-Poster at the meeting recently in Barcelona. Prue’s poster, titled “Discovery, A New Zealand Nuclear Medicine Department voyage that has made a real difference” discussed the utilisation of hybrid SPECT/diagnostic CT scanners and the expanding role within Nuclear Medicine and Radiology departments in New Zealand. In public Radiology departments, rolling NMT/MIT 24-hour strikes have meant NM department waiting lists are ballooning out. Negotiations broke down in early November, and this week (25th November 2019) facilitation is taking place between the NMT/MIT union, APEX, and the MoH and DHB’s. From early 2020 the New Zealand MRTB (equivalent to AHPRA and the MRPBA) will offer an online examination as a pathway for registration for NMT’s wanting to work in New Zealand. The online exam will be offered to those overseas applicants with academic qualifications and clinical experience that have been assessed as not being equivalent to that of an entry-level practitioner in the scope of practice of NM. This will not apply to our Australian colleagues, who under the Trans-Tasman Mutual Recognition Act 1997 (TTMRA) are automatically eligible to register and work here as NMT’s. Finally, congratulations to the Department of Medical Imaging at the University of Auckland for having their application for a named nuclear medicine specialisation approved. All students now undertaking the Nuclear Medicine pathway of the Postgraduate Diploma in Health Sciences (Medical Imaging) will gain the qualification of PGDipHSc (Nuclear Medicine). From the NZ branch, Meri Kirihimete me te Hape Nū Ia” (e kī ana te Pākehā) ki ngā iwi me ngā hapū katoa. Pru Burns - Branch Chair, New Zealand 12
gamma GAZETTE 2020 Spring/Summer Edition
Education & CPD Case Study Role of 18F-FDG PET in the Management of Gestational Trophoblastic Neoplasia (Continued)
“In patients with chemotherapy resistance, PET/CT performed after treatment was more useful than conventional examinations in identifying sites of resistance and in guiding patient management.”
METHODS This was a Retrospective study of 41 patients between 2002-2010 at San Raffaele Hospital, Heidelberg. The mean age was 35 (17-56 years). 38 patients were from point of primary staging, and three included post first line chemotherapy due to resistance. All 38 referred for primary staging received conventional evaluations, including gynaecological examination, βHCG serum measurement, chest x-ray, TV-US, abdominal and chest CT scan, before treatment. If lung metastases were present, CT brain also performed. An FDG PET scan was performed for staging (PET in 6 patient, PET/CT in 35 patients). Low risk patients were treated with methotrexate and folic acid. High risk patients were treated with multiagent chemotherapy (EMA-CO regimen). Monitoring during treatment consisted of weekly βHCG measurements. Monitoring post treatment included one year of monthly βHCG measurements in low-risk patients and two years in high-risk patients. An FDG PET scan was repeated at end of chemotherapy if staging scan was positive for extra-uterine disease. Patients with persistent disease were treated again with chemotherapy or with surgical removal of tissue showing persistent disease. RESULTS For staging, PET was concordant with TV-US in 91% patients, (3 false negatives), and CT in 81% patients (7 false negatives). PET did not provide any additional information during staging. For treatment response: 12 patients received a PET/CT on completion of chemotherapy. Eight high-risk patients also received PET/CT after the first line chemotherapy when βHCG became undetectable. Of these eight, PET/ CT showed a complete metabolic response in all; however CT demonstrated remaining lung and liver metastases in two of these patients (false positives). Of seven chemotherapy-resistant patients, conventional imaging plus a second PET/CT scan were performed to identify site of resistance. In one of these patients, PET/CT detected an FDG-avid lung nodule not found on CT. In two patients, the CT scan showed disease in multiple organs including the lung and liver, while PET/CT revealed the persistence of GTN at a single disease site in the lung of one patient, and uterus of the other. In one chemotherapy resistant patient, PET/CT identified uptake in an axillary lymph node, not identified by CT. CONCLUSION FDG PET is not useful for staging, but is useful for treatment monitoring, or in patients with chemo-resistant disease. For Stage 1, TV-US is still the best for diagnosis. However, FDG PET can benefit high-risk patients due to precise mapping of active metastases, and also assists in reducing false-positive found on CT post-treatment. 42
gamma GAZETTE 2020 Spring/Summer Edition
References for this article can be found on page 58
Education & CPD Case Study Immunotherapy-Related Nephritis in a Melanoma Patient: A Case Study Author: Rosemary Dallen, WA PET Service, Sir Charles Gairdner Hospital
CASE DESCRIPTION
A 52-year-old female with BRAF mutant metastatic melanoma was referred to our department for staging, and then surveillance PET scans. After the staging scan demonstrated multiple sites of disease, the patient began treatment with Novartis PDR001 (spartalizumab) immunotherapy combined with dabrafenib and trametinib. During her treatment, the patient developed drug-induced nephritis, which was diagnosed on FDG PET. TECHNIQUE Whole body planar imaging and SPECT/CT of the spine and pelvis (low dose CT for attenuation-correction and localisation) were performed three hours post injection of 800MBq 99mTc-HDP.
PROCEDURES PERFORMED
Four wholebody 18F-FDG PET/CT scans were performed, each approximately 10 weeks apart. Uptake time ranged from 63-79 minutes, and imaging was performed on a Siemens Biograph TruePoint16 and a Siemens Biograph64 mCT.
FINDINGS
The first PET scan demonstrated multiple FDG-avid metastases in the liver, skeleton, lung, right hilum, left deltoid, and subcutaneously in the lateral left hip. Immunotherapy was then commenced. On the second PET scan, 10 weeks later, there was a complete metabolic response of hepatic and pulmonary metastases, and partial metabolic response at all other sites. Twelve weeks later, a third PET scan demonstrated a complete metabolic response however, there was new diffuse renal parenchymal uptake and minimal urinary excretion, in keeping with immunotherapy-related nephritis. This finding was highlighted in the report to alert the patient’s clinician. Six days after this scan, the patient presented to the emergency department, reporting fevers, shortness of breath, and tachycardia. The final PET scan, nine weeks from the 4th, demonstrated no metabolic evidence of recurrent melanoma, in addition to resolution of the nephritis.
OUTCOME
Due to the PET scan findings, immunotherapy was ceased and the patient continued with dabrafenib and trametinib only. The patient was treated with prednisolone which led to resolution of her nephritis, confirmed on the final PET scan. The four PET scan MIPs are displayed consecutively in figure 1.
Figure 1 2020 Spring/Summer Edition gamma GAZETTE 43