2019 AUTUMN EDITION | ISSUE 26
CELEBRATING THE 50 ANNIVERSARY OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE
ANZSNM 2019
Looking back to the year ANZSNM was founded
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2019 AUTUMN EDITION | ISSUE 26
CONTENTS From the President
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Featured Article
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30 years on: The Cold War and Nuclear Medicine in Australia – a small example
Branch News
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Special Interest Group News
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Special 50th Anniversary Liftout
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Education and Continuing Professional Development (CPD) • Case Studies
• What’s that?
29 53
Articles
59
Calendar of Events
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Office Bearers
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Editorial
Design & Production
Events & Advertising Enquiries
Rajeev Chandra, General Manager ANZSNM Secretariat PO Box 6178, Vermont South, VIC 3133 1300 330 402 (03) 8677 2970 secretariat@anzsnm.org.au
Ester Gomez, Creative Director Enovate Studio ester@enovatestudio.com www.enovatestudio.com
marketing@anzsnm.org.au
Submissions secretariat@anzsnm.org.au
From the President The Australian and New Zealand Society of Nuclear Medicine was founded in 1969, and in 2019 we celebrate 50 years as a professional organisation. This is a time to reflect on the growth in Nuclear Medicine and the increasingly valuable role of our specialty in patient care and treatment decisionmaking. Technological advances have driven change in the world, and this impacts on every aspect of our daily lives, both at work and at home. Connectivity through the internet gives us access to information in seconds and also has allowed us to bridge vast distances seamlessly, to the great benefit of collaboration, knowledge and education. The challenge that is emerging however is how to use this connectivity responsibly and also how to manage the information overload that it brings. Given the speed of change of the last 50 years, I wonder what the next 50 years will bring?
Roslyn Francis President
In Gamma Gazettes throughout 2019 we aim to give a snapshot of our history in Nuclear Medicine, and to acknowledge those who have contributed to our specialty and organisation. If you have photographs or stories that you would like to share then we welcome these contributions as we mark this time in our history. I hope you enjoy the Gamma Gazette throughout the year, and thank you to those who have taken the time to compile these reflective pieces. The recent Federal Government announcement of a new Medicare rebate for FDG PET in breast cancer from 1st November 2019 is very welcome news. This follows on from a successful MSAC application by AANMS, originally submitted in 2013, and finally approved earlier this year following a resubmission. The wording of the rebate will be released in the next few months. This marks an important step forward in access to PET for patients with breast cancer, to guide appropriate treatment decisions. Congratulations to AANMS for their efforts and persistence for this important rebate. The 49th ANZSNM Annual Scientific Meeting ‘Precision Nuclear Medicine’ is rapidly approaching. I am very much looking forward to a vibrant scientific program that holds wide interest and will stimulate discussion and future ideas. The theme of the Conference Awards dinner is 1969, to reflect the founding year of ANZSNM. I would like to extend my gratitude to the Conveners of Dr Gabby Cehic, Prab Takhar and Dominic Mensforth, and to their organising committee, for their energy, enthusiasm and hard work, which is enormously appreciated. Thank you also to the Professional Conference Organisers, Phil Plevin, to our National and International invited speakers and to our sponsors, for ensuring the success of ANZSNM ASM 2019. A reminder that ANZSNM AGM for 2019 will be held on Sunday 28th April at 1230pm at Hall L of Adelaide Convention Centre and all members are encouraged to attend. As I conclude this report and I think of my own journey and experiences in Nuclear Medicine, I reflect particularly on the people who have inspired me, with their dedication, commitment, vision and generosity. We all have such busy lives, we rarely allow ourselves the time to reflect and remember. I leave you with this quote from Dr Seuss (Suess-isms) as you reflect on your own memories and experiences in Nuclear Medicine. “Sometimes you will never know the value of a moment until it becomes a memory” I look forward to seeing you in Adelaide.
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Over the past 50 years, The Australian and New Zealand Society of Nuclear Medicine has been at the forefront of the Nuclear Medicine profession. To every single member and individual who has been part of this journey, thank you! We are committed to continue to be leaders in our industry and to work together to keep the society moving to the future.
Special 50th Anniversary
A Nuclear Medicine Society The Beginnings
During the late 1960s, interest in nuclear medicine and a nationwide society of nuclear medicine had been growing strongly throughout the larger states of Australia. A Victorian group was established and a New South Wales group was just commencing. In November 1968, a meeting of users of radioisotopes in medicine and biology was convened jointly by Dr Provan Murray (physician, Prince of Wales Hospital), Mr Alan Downes (chemist, CSIRO) and Mr B. W. Scott (physicist, State Bureau of Physical Services) to discuss the desirability of the formation of a society embracing personnel involved in the use of radioisotopes. It was resolved, after considerable discussion, that a society be formed to bring together all those people interested in the use of radioisotopes in medicine and biology. Forty-eight people agreed to join such a society. A steering committee, chaired by B. W. Scott, was appointed to investigate the name, objects and membership. Members of this committee included Drs J. N. Gregory, I. S. Jenkinson, J. G. Morris, C. Hambly, G. Lowenthal, Mr A. M. Downes and Associate Professor J. M. McRae. This committee produced a draft resolution, in due course, in which it was proposed that the society be called the Society of Nuclear Medicine (NSW). Great care was taken to define nuclear medicine in the widest possible terms and to ensure that the membership qualifications were free from discrimination between university graduates and non-graduates, or between medical and scientific or technical personnel, and that the society should remain a purely-scientific society. The Royal Australian College of Radiologists was keen to promote nuclear medicine and the Royal Australian College of Physicians was interested in progressing plans to develop a course of training leading to a joint diploma. However, although in general agreement on this way forward, at a meeting in Sydney, both bodies decided to refer the matter to the forthcoming meeting in Adelaide so that the nuclear medicine specialists could take the matter over together. This decision was made through reservations expressed at that meeting by Dr John Morris and Dr Jim McRae. The meeting in Sydney was a very valuable one in the development and establishment of the impending society. It at least made it more obvious that workers in nuclear medicine were interested in their own affairs and that Adelaide would be a landmark meeting of specialists in the field from all over Australia. In April 1969, Dr Harry Lander wrote to Professor W. S. C. Hare, expressing his desire to establish a college of nuclear medicine. He strongly felt that the interests of those working in the field of nuclear medicine could not be adequately represented by physicians, radiologists or pathologists, as the discipline was an entity in its own right. He realised that there would be difficulties in establishing such a college, but felt that they were surmountable. He sent copies of this correspondence to colleagues: Dr John Andrews and Dr Les Dugdale in Melbourne and Dr John Morris in Sydney.1
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Education & CPD Case Study Impact of the bone scan in a complicated Meningococcal patient (Continued) CONCLUSION A 3–phase bone scan is a valuable procedure to determine perfusion and viability of bone and soft tissues. In this instance, both scans significantly changed the medical management of this patient, revealing the severity of ischaemic injury to the distal limbs and confirming necrosis prior to amputation. References 1. Kirsch E, Barton R, Kitchen L, Giroir B. Pathophysiology, Treatment and Outcome of Meningococcemia: A Review and Recent Experience. The Pediatric Infectious Disease Journal. 1996;15(11):967-979. 2. Milonovich L. Meningococcemia: Epidemiology, Pathophysiology, and Management. Journal of Pediatric Health Care. 2007;21(2):75-80. 3. Jafri R, Ali A, Messonnier N, Tevi-Benissan C, Durrheim D, Eskola J et al. Global epidemiology of invasive meningococcal disease. Population Health Metrics. 2013;11(1). 4. Department of Health | Meningococcal Disease (Invasive) [Internet]. Health.gov.au. 2019 [cited 4 January 2019]. Available from: http://www.health.gov.au/internet/main/ publishing.nsf/Content/ohp-meningococcal-W.htm
ANZSNM NZ Branch Meeting – For the first time, the NZ branch of the ANZSNM are joining with our MI and RT colleagues, in a combined meeting with the NZIMRT. This is a great opportunity to interact, learn and share what is happening in our Nuclear Medicine, PET/CT, Radiology and Radiation Therapy departments. Social functions include Welcome drinks on Friday 30th August, and Gala dinner Saturday 31st August. Call for abstracts have open now and registration will be available shortly. Attendance certificates will be issued via Attendo Plus. We would like to encourage all ANZSNM members, both in Australia and NZ, to consider coming to support this joint initiative. Come and present in a collaborative environment!
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Education & CPD Case Study F-FDG PET/CT Hits the Bullseye for Assessing Off Target Inflammatory Response from Immunotherapy for Melanoma
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Authors: Sean Baker1 & Loren Katchel - 1Princess Alexandra Hospital, Brisbane, Australia
INTRODUCTION Melanoma is a highly aggressive form of cancer that develops in the skin’s melanocytes, however, it can occur in the eye or in the mucous membranes of the oral cavity, anus and genitalia.1 In most cases it arises in the skin due to overexposure to UV radiation, risk factors such as fair skin, family history and the BRAF gene mutation also increase the likelihood of development. Melanomas only account for 2% of all skin cancers, yet they attribute to 75% of all skin cancer related deaths in Australia.1 Treatment options for melanoma are dictated by the stage of the disease. The options can be a combination of surgical removal, chemotherapy, targeted therapies, radiation therapy and immunotherapy.2
A follow up brain MRI post treatment indicated disease recurrence in the surgical bed. A monitoring 18F-FDG PET/CT indicated disease progression as it showed an intensely FDG avid lesion in the patient’s left flank. The persisting parietal lobe lesion was re-excised and further treated with radiation therapy, the left flank lesion was excised, and the patient underwent an additional three cycles of chemotherapy.
A three-month follow-up PET/CT scan again showed disease progression with residual FDG-avidity being seen in the previously excised left flank region and an intensely avid left sided inguinal node was noted (figure 1). Due to the inefficiency of previous treatment, alternate options were discussed and it was decided that a four-cycle immunotherapy regiment would be the best option. The patient With recent developments there has been a underwent a combination of immune checkpoint greater use of immunomodulatory therapies blockade agents, Ipilimumab and Nivolumab, and whereby monoclonal antibodies are used to target continued to be monitored. b) T-lymphocyte activation regulators and thus inhibit 3 tumour cell related immune tolerance. For many INVESTIGATIONS years now 18F-FDG PET/CT has been a pillar for the staging, restaging and management of patients with After two cycles of immunotherapy, the patient had melanoma. The aim of this case study is to examine the a three-month follow-up 18F-FDG scan where he was utility of 18F-FDG PET/CT for the assessment of adverse intravenously injected with 359.22MBq of 18F-FDG inflammatory responses in melanoma patients on the and a skull vertex to toes PET/CT was acquired at 65 minutes post injection. Low dose non-diagnostic afore mentioned immunotherapy.4 CT was performed for attenuation correction and anatomical localisation purposes. The patient’s BSL CASE REPORT was 5.1 mmol/L prior to injection. A 25-year old male with malignant melanoma of unknown primary presented for staging. At the time of Imaging showed interval reduction in the size and diagnosis, he had a large parietal lobe metastasis that FDG-avidity of both the left flank region and the was treated with a craniotomy followed by stereotactic left inguinal lymph node, suggesting response to radiosurgery to the cavity. He then completed three treatment. However, diffusely intense 18F-FDG uptake cycles of the melanoma specific chemotherapy agents was noted in the thyroid (figure 2) and although indicative of thyroiditis, further investigations were Dabrafenib & Trametinib. recommended for correlation.
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Education & CPD Case Study Utilisation of Lymphoscintigraphy SPECT/CT imaging in the localisation of lymphatic leakage site following complicated femoral hernia repair. Author: Kimberly Nguyen - Benson Radiology, Ashford Specialist Centre, Adelaide, South Australia.
CASE STUDY A 44-year-old female presented with persistent intermittent right groin swelling following right femoral hernia repair. Initial CT imaging showed a 54mm enlarged right inguinal collection suggestive of infective post operative seroma/ lymphocele. The collection was also aspirated under ultrasound guidance and sent for microbiological testing, which showed no culture growth after 14 days incubation.
Figure 1: Transaxial CT scan image demonstrating 54mm inguinal collection on the right side.
Four weeks later the patient underwent a nuclear medicine lymphoscintigraphy study for the localisation of the lymphatic leakage site. The patient was injected in the first web space of each foot with 20MBq of 99mTc Nanocis. Serial planar imaging demonstrated normal lymphatic drainage on the left, into inguinal, pelvic and para-aortic nodes. On the right, uptake was visualised within right inguinal node with gradual accumulation of low grade, extranodal activity in the right anterolateral inguinal region, corresponding with the collection seen on CT
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imaging. SPECT/CT imaging was then performed to confirm uptake within a right external iliac/common femoral node close to the anteromedial acetabular margin, demonstrating activity extending to the medial aspect of the inguinal collection. This node was marked on the skin surface anteriorly and laterally and the patient was sent to theatre for operative ligation of the leak site.
Education & CPD Case Study Utilisation of Lymphoscintigraphy SPECT/CT imaging in the localisation of lymphatic leakage site following complicated femoral hernia repair. (Continued)
DISCUSSION Lymphatic leakage is a rare postoperative complication which can lead to further health problems. Early ligation or suture of the leakage site is helpful to avoid metabolic complications and shorten hospitalisation stay. Nuclear medicine lymphoscintigraphy with SPECT/CT imaging can play a pivotal role in locating the site of lymphatic leak, resulting in an improved patient outcome. References: Lv S et al. A review of the postoperative lymphatic leakage.
Figure 2 Planar lymphoscintgraphy images acquired 15 minutes post injection to 100 minutes post injection.
Oncotarget. 2017 Sep 15; 8(40): 69062–69075. Tyndall, S et al. Groin lymphatic complications after arterial reconstruction. Journal of Vascular Surgery. 1994 vol.19 (5): 858 – 864.
Figure 3 Transaxial SPECT/CT image demonstrating lymphatic nodal uptake adjacent to the medial aspect of the right sided inguinal collection.
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o f exc e l l e n c e i n Nuclear Medicine
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of The Australian and New Zealand Society of Nuclear Medicine
• Free subscription to Gamma Gazette, the society's official magazine, which provides news, educational articles and a means of publication for individual members’ research work. • Exclusive access to EduTrace, the society's platform of educational resources to support your CPD • Access and discounted prices to Local Branch Meetings, which keep members up to date with the latest developments in nuclear medicine. • Exclusive invitations to education seminars which highlight developing aspects of nuclear medicine run by special interest groups. • Exclusive invitation and a discounted rate to attend the society's Annual Scientific Meeting which is the major education event for nuclear medicine in Australia and New Zealand and includes international and national experts. • Advocacy and representation with suppliers and government bodies • Specialised interest groups (SIGs) for Technologists, Radiopharmaceutical Scientists and Physicists • Access to industry Awards for the recognition of members who present new research and development activities at local or national meetings. • Access to The ANSTO/AZNSNM Research Grant Award of $20,000 every year. • Exclusive access to members-only resources, including historical publications and records of the Society’s activities since its establishment in 1969. • Subscription to the society's monthly news update, delivering the latest news, events, job vacancies and other matters relevant to the profession. • Access to a network of professionals through local and national events and conferences • Free Attendo Plus CPD & Compliance mobile app.
anzsnm.org.au/membership
Articles Relevance of the blood glucose concentration, and current management with GLP-1 receptor agonists, to clinical gastric emptying measurement in diabetes (Continued) MEASUREMENT OF GASTRIC EMPTYING While there are a number of techniques that can be used to measure gastric emptying, including SPECT, MRI, non-radioisotopic breath tests, absorption kinetics of oral drugs e.g. paracetamol, radiopaque markers, the Smart Pill and ultrasonography, scintigraphy, developed in the 1970s-80s, remains the ‘gold standard’8. The US and Europe have developed guidelines for standardisation of the technique9, 10, however, the suggested test meal, ‘powdered Eggbeaters®’ with bread, jam and water, has significant limitations and is not available in Australia. A recent audit in South Australia demonstrated marked variations in the technique used – test meals, radiopharmaceuticals (dual or single isotope) and imaging times, between nuclear medicine departments (unpublished), which is clearly suboptimal. Two important issues overlooked in this audit were the relevance of measurement of blood glucose concentrations and the increasing use of glucagon-like peptide-1 (GLP-1) receptor agonists in patients with diabetes, which represents the focus of this article.
EFFECTS OF BLOOD GLUCOSE ON GASTRIC EMPTYING It is now well established that acute changes in the blood glucose concentration have major reversible effects on the rate of gastric emptying in both healthy subjects and patients with diabetes8. Hyperglycaemia
Studies by our group11, 12 and others13, 14 have established that acute hyperglycaemia (~15 mmol/L) has a profound effect to slow gastric emptying in both health and diabetes. In a study by Fraser and colleagues, the number of patients with type 1 diabetes with abnormally delayed gastric emptying of
solid and liquid meal components was greater during hyperglycaemia when compared to euglycaemia (~45 mmol/L)15. Furthermore, Schvarcz et al have shown in health and type 1 diabetes that even changes in blood glucose within the normal physiological postprandial range (~4-8 mmol/L) have a significant impact on gastric emptying of solids and liquids. Hypoglycaemia
While a number of studies have evaluated the effect of hyperglycaemia (~15 mmol/L) on gastric emptying, information relating to the effects of hypoglycaemia (~2-3 mmol/L) on gastric emptying is much more limited16. In a series of studies by Schvarcz and colleagues, using a so-called glucose-insulin clamp, hypoglycaemia (~2.0 mmol/L) was shown to accelerate gastric emptying of solids and liquids in healthy subjects and patients with uncomplicated type 1 diabetes substantially17, 18. In a subsequent study by our group, using scintigraphy, the marked acceleration of gastric emptying by hypoglycaemia (~2.6 mmol/L) was shown to occur in people with longstanding type 1 diabetes19. This study also demonstrated that the magnitude of the acceleration was greater when baseline gastric emptying was relatively slower. Further studies by our group have also shown in healthy subjects that hypoglycaemia (~2.6mmol/L), induced via a glucose-insulin clamp, accelerates glucose absorption markedly, as assessed by the glucose analogue, 3-O-methylglucose (3OMG)20. Accordingly, at a minimum, fasting blood glucose concentrations should be assessed in all patients with diabetes, and ideally measured at 30-minute intervals during the gastric emptying study. In the event that fasting levels are high, any delay in gastric emptying should be viewed circumspectly due to the potential effects of hyperglycaemia.
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EVENTS CALENDAR
6
26 - 28 April 2019
1 May 2019
49th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine
QLD Branch Meeting
Adelaide Convention Centre, Sth Australia CPD Points
1
9 - 12 May 2019
11 June 2019
13th Asia Oceania Congress of Nuclear Medicine and Biology
WA Branch Meeting (Post Conference)
QUBE/Qbox hotel Shanghai, Pudong New Area, Shanghai, China
SKG Radiology, St John of God Hospital, 12 Salvado Road, Subiaco, WA, 6008 CPD Points
1
22 - 25 June 2019
3 July 2019
SNMMI Annual Meeting
SA Branch Meeting
Anaheim, California, USA
Women's and Children's Hospital
1
CPD Points
6 July 2019
24 July 2019
VIC/TAS Branch Scientific Meeting (The A to Z of Thoracic Imaging)
SA Branch ANZSNMT Meeting (Biliary Imaging)
Austin Health, 145 Studley Road, Heidelberg VIC 3084
1
Visit website for venue details CPD Points
RSA Calvary, North Adelaide
1
CPD Points
CPD Points
anzsnm.org.au Attendo Plus mobile App
50th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine 24th – 26th April 2020 Sydney, Australia
www.anzsnmconference.com/ANZSNM2020
@anzsnm2020 ANZSNM 2020 on Facebook: http://bit.ly/anzsnm2020 On behalf of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) and New Zealand Society of Nuclear Medicine, which will be held in Sydney, from the 24th – 26th April 2020. The theme of the
past (2020 hindsight) and a strategic look forward (2020 vision). The main program will be supported by pre-conference learning, big data and their role in precision medicine (Intelligent Imaging Summit 2020) on 24 April. Mark ANZSNM 2020 in your diary. Please refer to the Conference website for more
See you in Sydney in April 2020!
ANZSNM 2020 Conference Manager Plevin and Associates Pty Ltd Tel +61 8 8379 8222 | anzsnm2020@plevin.com.au