December 2011 – Issue 4
The Official Publication of the Australian and New Zealand Society of Nuclear Medicine
Contents
www.anzsnm.org.au
Welcome
4
President’s Report
5
Western Australia Committee Profiles
6
Branch News
ACT
Queensland 8
Western Australia
8
Victoria/Tasmania
9
New Zealand
9
Technologists
10
Radiopharmacy 11
8
SIG
ANZAPNM Update 11 Accreditation Board 12 Adventure in Adelaide TSIG Day Seminar
13
Cryptic Crossword 14 Being a PDY in WA
15
What’s That?
16
AMRSAC
20
Original Article
A snapshot of research activities at the WA PET Service
24
Case Study NIS – Sodium Iodide Symporter: A case Study
26
Sickle Cell Disease diagnosed on Bone Scan
28
Articles
BioChroma – A new and patented technology for processing radioactive wastewater
from nuclear medicine therapy facilities in hospitals and clinics 31
The Opal Reactor 32
Deadlines The deadlines for each issue of Gamma Gazette for this year are set out below. These deadlines must be strictly adhered to in order to get the journal out on time. Do not leave the submission of copy until the last minute. For advice on how to submit material please go to the website www.anzsnm.org. March – February 1 September – August 1
June – May 1 December – November 1
1
Journal Staff Editorial copy & Advertising copy Design & Production
Ms Judi Anderson ANZSNM Secretariat PO Box 7108, Upper Ferntree Gully VIC 3156 Tel: (03) 9756 0128 Fax: (03) 9753 6372 email: anzsnm@21century.com.au Rachel Bullard Deep Blue Design Studio email: deepbluedesign1@mac.com
This issue compiled by ANZSNM Western Australia Branch Paul Brayshaw Stephanie McMahon Geoff Roff
Aims and Objectives The Australian and New Zealand Society of Nuclear Medicine Limited The objectives of the Society are as follows: 1. Promote (a) the advancement of clinical practice of nuclear medicine in Australia and New Zealand; (b) research in nuclear medicine; (c) public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; (d) co-operation between organisations and individuals interested in nuclear medicine; and (e) the training of persons in all facets of nuclear medicine.
Submissions Scientific submissions of all aspects of nuclear medicine are encouraged and should be forwarded to the Editor through the Secretariat (see instructions for authors published on line at www. anzsnm.org.au). Letters to the Editor or points of view for discussion are also welcome.
2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine. The Society has three standing sub-committees:
(a) The Accreditation Board, which sets standards for the training and practice of nuclear medicine technology and recommends the issue of accreditation certificates to those technologists who attain the minimum standards of proficiency in nuclear medicine. The Society is the only accrediting body for nuclear medicine technologists in Australia and New Zealand.
(b) The Technical Standards Committee, which sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand.
If original or public domain articles are found and considered to be of general interest to the membership, then they should be recommended to the Editor who may seek permission to reprint. The view expressed in any signed article in the journal do not necessarily represent those of the Society. The individual rights of all authors are acknowledged. The ANZSNM Gamma Gazette is published quarterly each year, March, June, September and December. Deadlines for each issue of the journal are the first of each month prior to publishing. Š 2011 The Australian and New Zealand Society of Nuclear Medicine Inc. 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). ANZSNM website address: www.anzsnm.org.au
(c) The Research Grant Committee, which administers the annual ANZSNM Research Grant. In addition, there are a number of special interest groups which maintain standards of practice for their particular specialty and provide a forum for their development in Australia and New Zealand. These include the Radiopharmacy, Technologists, Physics and Nurses Groups.
2 Gamma Gazette December 2011
Office Bearers Any changes or additions to the details listed should be forwarded in writing to the Secretariat as soon as possible President Vice President Past President Secretary Treasurer Committee
Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.au Ms Julie Crouch (WA) email: jul.crouch@gmail.com Mr Geoff Roff (WA) email: geoffrey.roff@health.wa.gov.au Ms Lyndajane Michel (Qld) email: michell@qdi.com.au Mr Geoff Roff (WA) email: geoffrey.roff@health.wa.gov.au Dr Sue O’Malley (NZ) email: sue@omalley.co.nz Dr Dylan Bartholomeusz (SA) email: dylan.bartholomeusz@health.sa.gov.au Ms Liz Bailey (NSW) email: EBailey@nsccahs.health.nsw.gov.au Dr Graeme O’Keefe (Physics SIG) email: graeme.okeefe@petnm.unimelb.edu.au Ms Jennifer Guille (Radiopharmacy SIG) email: Jennifer.Guille@sesiahs.health.nsw.gov.au
Accreditation Board Chairperson: Members: All correspondence
ANZSNM Secretariat PO Box 7108, Upper Ferntree Gully VIC 3156 Tel: (03) 9756 0128; Fax: (03) 9753 6372 email: anzsnm@21century.com.au
Technical Standards Committee Chairperson:
Professor Richard Smart, email: r.smart@unsw.edu.au
Research Grant Committee Chairperson:
Professor Richard Smart
Branch Secretaries Australian Capital Territory New South Wales Queensland South Australia Victoria/Tasmania Western Australia (acting) New Zealand
Mr Craig Collins, email: craig.collins@act.gov.au Mr Peter McConachie, email: Peter.McConachie@sesiahs.health.nsw.gov.au Ms Rowena Rose. email: rowena_rose@health.qld.gov.au Mr Adam Freeborn, email: adam.freeborn@hotmail.com Miss Bridget Chappell, email: bridget.chappell@austin.org.au Ms Stephanie McMahon, email: WABranchSecretary@hotmail.com Ms Dianne Wills, email: dianne.wills@cdhb.govt.nz
Special Interest Groups Technologists Radiopharmacy Physics/Computer Science Nurses
Ms Liz Bailey, email: ebailey@nsccahs.health.nsw.gov.au Ms Jennifer Guille, email: Jennifer.Guille@sesiahs.health.nsw.gov.au Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.health.nz Mr Erwin Lupango, email: Erwin.Lupango@sesiahs.health.nsw.gov.au
Ms Julie Crouch Mr Doug Mackey Mr David Lyall Mr David Thomas
Dr Nat Lenzo Dr Sze Ting Lee Ms Tale Liiv
Dr Clayton Frater
Reporting of Abnormal Behaviour of Radiopharmaceuticals The Society maintains a register of reports of abnormal behaviour of radiopharmaceuticals. Abnormal behaviour can be reported either by telephone fax or e-mail, or in writing to: Dr John Baldas, ARPANSA Mr J. Gordon Chan 619 Lower Plenty Road Department of Nuclear Medicine, Yallambie VIC 3085 Austin & Repatriation Medical Centre, Heidelberg VIC 3084 Tel: (03) 9433 2211 Tel: (03) 9496 3336 Fax: (03) 9432 1835 Fax: (03) 9457 6605 email: john.baldas@arpansa.gov.au email: gordon.chan@petnm.unimelb.edu.au
3
Welcome The Western Australia Branch of the ANZSNM has compiled this issue of the Gamma Gazette.
Welcome to the December 2011 edition of the Gamma Gazette, where the new format moves to WA for the first time! We are pleased to bring you an edition with the usual informative and educational articles along with a bit of local flavour. WA is geographically isolated from the rest of Australia, which is not a problem in this modern age of instant communication. However, the distance is always a consideration for interstate meetings and conferences as, on average, the travel is more costly and time-consuming for Western Australians. Like Queensland (and as mentioned by them in their June edition), there is no degree course for nuclear medicine technologists in WA and therefore any PDYs or new starters come from interstate (or overseas). In the case of PDYs, this often brings young easterners over to the west for a year of isolation from their friends and family, with returns for the weekend or holidays often impractical due to the distance and expense involved. The thoughts and experiences of such a PDY technologist appear in this issue. Despite the miles, WA holds its own in national nuclear medicine affairs and maintains a strong research presence. An example of PET research being undertaken by a department in WA appears later in this Gamma Gazette. The WA branch of the ANZSNM meets roughly once every two months on a Tuesday evening, a different nuclear medicine department hosting each meeting. There are also special talks and workshops organised at various times, and the AGM is held at the end of the year. We may be two or three hours behind the eastern seaboard, but we hope that this production reaches you all in time for Christmas as you head north, south, east or west (or stay put!) for the festive season, and that it provides some relaxing reading to refresh and stimulate the mind in preparation for an even bigger 2012! We will be partially ‘crossing the ditch’ for the next edition as we hand over the reins and say good luck to SA/NZ. Paul Brayshaw and Stephanie McMahon Western Australia Branch
Diary Dates
Email the Production Editor at the Secretariat on anzsnm@21century.com.au to list your upcoming conference and meeting dates on the diary page.
2012
April 27-30 ANZSNM 42nd Annual Scientific Meeting Melbourne Exhibition & Convention Centre, South Wharf
August 12 Annual TSIG symposium Hervey Bay, Mantra Resort, Qld
June 7-10 17th ISRRT World Congress & CAMRT 70th Annual General Conference Sheraton Centre, Toronto Canada www.2012isrrt.org/
August 26-29 14th International Workshop on Targetry and Target Chemistry Riviera Maya, Quintant Roo, Mexico info@wttc14.mx
4 Gamma Gazette December 2011
President’s Report Welcome to the final edition of the Gamma Gazette for 2011, which has been diligently put together by Paul Brayshaw and Stephanie McMahon from Western Australia. They have had input from Society members from all over Australia, particularly from Western Australia. It was not so long ago that I remember the launch of the inaugural bumper edition for 2011, and I have received some feedback which we apply to every subsequent edition to move it from strength to strength. The efforts of all members of the Society, and the branches in particular who have put these versions together have to be commended for their enthusiasm and diligence throughout the year. Now that the aftermath of the Darwin conference has passed, I am pleased to announce that registration for the next ANZSNM Annual Scientific Meeting in Melbourne is now open, and I encourage all to submit an abstract or just participate in the proceedings to learn from experts from all over Australia and around the world. I also take this opportunity again to congratulate our dedicated members - Julie Crouch, Diana Gentilore and Sharon Mosley - for being appointed as Nuclear Medicine Directors in the newly formed Australian Medical Radiation Sciences Accreditation Council (AMRSAC). I am confident that they will fulfil their roles in ensuring that the high quality practice of nuclear medicine in Australia will be preserved. I am also very pleased to inform you that our New Zealand colleagues have put together a PET Advisory Committee to provide a reference source for guidance on issues concerning practice of PET in New Zealand and oversee relevant quality assurance programmes and initiatives. There will be representatives from experienced PET professionals from the ANZSNM involved in this committee. The Technical Standards Committee (TSC) have also recently elected Prof Richard Smart as the Chair of this committee to update the recommendations on quality control requirements for instrumentation used in nuclear medicine, which would be important source documents for government and regulatory bodies for nuclear medicine instruments. In particular, the TSC will collect and collate technical data and carry out surveys for the purpose of setting and determining compliance with good standards of practice, and facilitate and oversee surveys with and use of phantoms for assessing quality and consistency of clinical protocols. There will be representatives from all disciplines of our profession on this Committee. I’d like to also thank Dr Dylan Bartholomeusz for representing the Society at the Health Workforce Australia group in Adelaide on several occasions over the last 12 months. One of the main aims of this group is to gather demographic data on the health workforce, which will be used to fund training and plan for future workforce requirements. We will be sending out a survey in the next few months to gather some demographic data on our profession so that our needs will also be assessed by the government and given the appropriate funding and attention. We also continue to engage our colleagues from all around the world, and we were recently invited to a meeting of NM Society Leaders of the World, organised by IAEA, with participation from the SNM, EANM and WFNMB as well. We have discussed efforts to increase access to continuing education activities to the Nuclear Medicine community globally, and this will be an ongoing effort in the future. Finally, I would like to wish all members of the ANZSNM a very safe and Merry Christmas & Happy New Year for 2012. Dr Sze Ting LEE President
5
Meet the WA Committee members
WA branch committee members, from left to right: Ros Francis, Diane Cheong, Geoffrey Roff, Cedric Eustance, Rick Hampson, Adrienne Little. Absent: Georgina Santich Geoffrey
Roff Committee position: Branch Federal Council Representative Current place of employment: Royal Perth Hospital Current position in workplace: Senior Nuclear Medicine Technologist Time served on committee: 6 years Reason for joining the committee: I joined the branch as I believe it is a place where members of public and private meet together to share their knowledge and work together to make this profession we have chosen better. As we share our knowledge and experience we can make our profession grow. What you hope to achieve by being on the WA Branch committee: To help each member to work together, whether it is joining together for educational purposes, or uniting to be a voice on a certain issue.
Diane Cheong Committee position: Branch Chairperson Current place of employment: SKG Nuclear Medicine Murdoch Current position in workplace: Team Leader Time served on committee: On and off the committee for 30 years in various roles. Georgina
6 Gamma Gazette December 2011
Santich Committee position: Branch Secretary Current place of employment: Mount Nuclear Medicine Current position in workplace: Chief Nuclear Medicine Technologist Time served on committee: 4 years Reason for joining the committee: To get to know the WA Nuclear Medicine community and be actively involved. What you hope to achieve by being on the WA Branch committee: To help organise interesting and informative nuclear medicine events.
Meet the WA Committee members Rick Hampson Committee position: Branch Treasurer Current place of employment: Perth Radiological Clinic Current position in workplace: Chief Nuclear Medicine Technologist Time served on committee: 8 years Reason for joining the committee: To help drive education opportunities in the WA Nuclear Medicine community. What you hope to achieve by being on the WA Branch committee: To be part of a coherent dynamic group making a difference. Dr Ros Francis Committee position: Committee member Current place of employment: Department of Nuclear Medicine/WA PET Service, Sir Charles Gairdner Hospital; School of Medicine and Pharmacology, University of Western Australia Current position in workplace: Nuclear Medicine Physician Time served on committee: 2 years Reason for joining the committee: To support nuclear medicine in WA; research, education and training. What you hope to achieve by being on the WA Branch committee: To promote education through local meetings and workshops. Cedric Eustance Committee position: Committee member Current place of employment: Oceanic Medical Imaging/Armadale Kelmscott Nuclear Medicine Current position in workplace: Senior Nuclear Medicine Technologist Time served on the committee: 19 months Reason for joining the committee: For many years I have been involved with the British Nuclear Medicine Society and the European Association of Nuclear Medicine. It seemed natural to join the ANZSNM and continue with professional activities when I emigrated to Perth. The local branch is very active and members have been very welcoming. It feels good to be involved. What you hope to achieve by being on the WA Branch committee: I want to do anything I can to help with ANZSNM activities. I hope I can draw on my experience from BNMS and EANM committees and use it here. I don’t have a particular goal apart from supporting the other committee members and sharing the work. Adrienne
Little Committee Position: Committee Member Current place of employment: Mount Nuclear Medicine Current position in workplace: Senior Nuclear Medicine Technologist Time served on the committee: 11 months Reason for joining the committee: To keep myself and others informed about the current issues being faced within the Nuclear Medicine community and to help out behind the scenes. What you hope to achieve by being on the WA Branch committee: To encourage others to be actively involved so that we can have fun and exciting branch meetings and activities that will educate and unite all members in the WA Branch.
7
Branch News AUSTRALIAN CAPTIAL TERRITORY THIS quarter the ACT Branch of the ANZSNM held a meeting at The Canberra Hospital which included a tour of the PET/CT facility for Technologists within the Canberra and Wagga Wagga region. Thank you to Dr Paul Sullivan for his presentation on some unusual PET cases which have come through the department at The Canberra Hospital since the opening of PET/CT. Thank you also to Insight for their sponsorship of the meeting and Scott Beveridge’s presentation giving an in depth explanation of “time of flight” technology used in current generation PET scanners. Congratulations to Sharon Mosley on her appointment to the Australian Medical Radiation Sciences Accreditation Council (AMRSAC). The ACT Branch would like to wish everyone a Merry Christmas and a safe holiday season for all! Craig Collins Secretary QUEENSLAND WE’RE nearing the end of another busy year for the Queensland Branch. Our last meeting for the year will be our AGM and Radpharm presentation evening at the Princess Alexandra Hospital on 8th November kindly sponsored by GMS. We look forward to hearing some interesting presentations and wish the winner best of luck in representing Queensland in the Radpharm Award at the Melbourne conference next April. We recently held a Day Symposium on a Sunday at Sirromet Winery in Mount Cotton. It was a well attended day and I think everyone enjoyed the variety of talks, the delicious food and, of course, some wine tasting! The trivia segment at the end got very competitive and some unique answers were put forward! Thank you to all the speakers but an extra big thank you to Noelene George who travelled down from Rockhampton to talk about working in Nuclear Medicine in Central Queensland and how they were affected by the recent natural disasters. It was an interesting talk and we all had a lot of questions for Noelene. A big thank you to our Treasurer, Tale Liiv, for organising sponsorship from so many companies and, of course, to the companies (ANSTO, GE Healthcare Australia, and Healthcare Training Service) for their support of the Queensland Branch. A big thank you also must go to Rowena Rose who did a huge amount of organising to make this day run successfully. I will be resigning from my position at our AGM to go on maternity leave. Thank you to the Queensland Branch Committee members, it has been wonderful working with you all. You are a great bunch of people who are all so dedicated to what you do and it’s been an honour to be part of that. A particular thank you to my co-secretary Rowena Rose who has picked up everything involved with the job magnificently in the last year – it has been wonderful to work closely with you. We have proposed dates already set out for our meetings next year and look forward to seeing lots of Queensland Branch members attending. We hope everyone has a safe and happy festive season. Sarah Stephenson Secretary WESTERN AUSTRALIA THE Post Conference meeting was held at Oceanic Medical Imaging in September. We had several interesting cases, thankyou Cedric Eustance, Dominic Morgan, and Dr Geoff Bower. Amy Evans gave her presentation on “18FDG vs 68 Ga-Octeotate in Neuroendocrine Tumour Imaging” which she also presented at the conference in Darwin. Dr Ros Francis gave a very interesting summary about some of the sessions she attended at the Darwin Conference. The Radpharm Award Meeting is still to be held at Princess Margaret Hospital. It was scheduled for 18th October but was postponed. We look forward to hearing some excellent presentations for the Radpharm Award. This year’s AGM will be held at the Mount Hospital on 29th November. Congratulations to Georgina and her family on the birth of their son. Lewis Santich, welcome to the world. Congratulations to Dr Tatiana Segard, who attended the SNM 2011 Annual Meeting in San Antonio, Texas, June 4-8, as first author of a poster from the WA PET Centre. The poster received the third place award for “Best Poster” in the ‘Oncology: Clinical diagnosis’ track. Authors are Segard Tatiana, Robins Peter, Yusoff Ian, Ee Hooi, Morandeau Laurence, Campbell Elaine, Francis Ros. “Detection of hypoxia with 18F-fluoromisonidazole (FMISO) Positron Emission Tomography (PET) in suspected or proven pancreatic cancer.” SNM (Society of Nuclear Medicine) Annual Meeting 2011. This year saw the end of an era with the retirement of Dr Agatha van der Schaaf after almost 40 years of
8 Gamma Gazette December 2011
service to nuclear medicine in Western Australia. Dr van der Schaaf oversaw many changes to the department of nuclear medicine at Sir Charles Gairdner Hospital (SCGH), including the commissioning of the first PET service in WA, and she remained active in PET research until her retirement. SCGH gave Dr van der Schaaf an official send-off in August which was attended by many friends, both old and new. We wish her all the best for the future. Adrienne Little WA Branch Committee Member VICTORIAN/TASMANIAN BRANCH REPORT Since the last meeting, the Vic/Tas branch organised the September edition of the GG, under the supervision of Branch Chair, Grace Kong. Some good feedback regarding this, interesting articles and cases too. The Annual Day Seminar (PET, Paediatrics & Power Stations) was held in conjunction with the Branch AGM on 22nd October 2011. This was an extremely successful meeting, with ~100 attendees, and good sponsorship. Speakers and topics included: • Prof Andrew Scott 20 years of PET: Where do we go from here? • Mr Jason Callahan Emerging PET Technologies • Dr David Cook Paediatric Colonic Empyting Studies • Ms Brooke King Paediatric Positioning and Techniques • Dr HB Toh SPECT/CT in Bone Scanning • Prof Peter Johnston The Nuclear Accident in Fukushima The AGM saw the nomination of Melinda Rosenzweig onto the committee, and formal election of Ms Marcia Wood as the Victorian Branch ANZSNMT representative who has been in this position in a caretaker role for the last 9 months. Melinda is a Nuclear Medicine Technologist from Western Health in Victoria, and Marcia is a Senior Nuclear Medicine Technologist from Austin Healh. We welcome them onto the committee, and are sure that their contribution will see further developments in the field. Congratulations to the Vic/Tas branch Radpharm winner – Ms Natalie Tavare who is currently an Intern at Austin Health. Her topic was: Hepatobiliary Scintigraphy in the Assessment of Functional Future Remnant prior to Partial Hepatectomy. There is a branch meeting planned in January, for Prof Kim Williams, who is a nuclear cardiologist from the USA will give us an Update on Nuclear Cardiology. The branch is busily preparing for the ASM in Melbourne in 2012. Registration to open by the end of November. The plan is therefore to have the Vic/Tas Branch Annual Day Seminar in Tasmania next year in October. More information on this and other meetings to follow. Sze Ting LEE Vic/Tas Branch Representative
NEW ZEALAND The New Zealand Branch Meeting was held in Wellington, 5-6 November 2011. The meeting was convened by Pru Burns and Karen Wicki from Pacific Radiology group who did a great job. It was held in the University of Otago Medical School, Wellington Medical School campus. In total there were 85 registrants with 10 being industry registrations and the rest were members of the ANZSNM. The Invited speakers were: • Dr John Childs whose presentation title was: “Increasing access to PET scanning for cancer – an evidence based national approach” • Dr Neil Wilson whose presentation title was, “An oncologists Perspective on PET scans for Oncology • Mrs Celia Gordon whose presentation title was, “PET-CT for Radiation Therapy Planning” • Mr Robert Romero whose presentation title was’ “Breaking New Ground – How Cyclotek Pharmaceuticals • built the first radio pharmacy in NZ” • Dr Chris Adams, “The roles of NM in the diagnosis and management of Melanoma” There were 3 entrants for the Paul Orr Award and 3 entrants for the Radpharm award. The winner of the Paul Orr Award was Dr Berry Allen “Cardiac Imaging” – 19 Highly Sensitive Points of View. The Radpharm Award was not awarded this year. The social event happened to coincide with the public fireworks display held at the waters edge of Wellington city harbor on a stunning clear and relatively still Wellington night. The dinner and subsequent dance was held in the Mac Brewery in Wellington central.
9
The NZ Branch Meeting for 2012 is scheduled to be held in Dunedin under the direction of Professor Doyle and his team in September 2012. We are all looking forward to this event. It is the first time one of these meetings will be held in Dunedin. Dr Homer Macapinlac very ably presented to our NZ NM community in Wellington as part of his post ANZSNM conference tour. This was extremely well attended. There was video link up with about 100 remote attendees to his presentation in Christchurch and Auckland. This went well and was very well attended. The Society hasn’t used this mode of presentation previously and it worked very well. The meeting itself was held at the University of Otago Medical School, Wellington Medical School campus site, with the able direction of the IT and communications support team. The cyclotron in Wellington has been producing FDG since February 2011. The location of the centre on the perimeter of the airport has strategic advantages for delivery of isotopes to Christchurch, Hamilton and Auckland. There have been surprising few interruptions due to weather. The number of NZ members of the ANZSNM has remained steady. We would like to attract PDY students to New Zealand. There are 2 nuclear medicine technologists training in New Zealand. There are ongoing issues about training in New Zealand. We recognise the need to continue education and interest in this field and provide pivotal imaging and management that continues to make Nuclear Medicine indispensible. We recognise the expansion of other radiological imaging techniques and need to work hard at keeping our referral base strong. PET had led a resurgence of interest in diagnostic and prognostic value of radio-isotopes. The national survey of NM in NZ (which will be submitted for release in the Gamma Gazette) had shown the trend of falling procedural numbers in some areas, steady state in others and growth, particularly in sentinel node imaging. There are now 5 PET centres in NZ: Wellington started service in 2008, with Christchurch Radiology Group following in 2010, and now 2 centres in Auckland at the Mercy Hospital site and the Ascot Hospital and a further centre in Hamilton. All these centres are privately funded. Currently the DHBs preferentially send their patients to local NZ sites and only a handful of very specialized PET scan patients are sent to Australia. There is ongoing investment in newer gamma cameras in many centres, with hybrid imaging preferred. Two new cameras are scheduled for installation in NZ, a cardiac dedicated camera in Hamilton (Dr Berry Allen was awarded with the Paul Orr award for this) and a SPECT/CT camera being installed in Invercargill. New Zealand has long suffered lack of fully trained Nuclear Medicine Physicians and adequate funding. We are also grappling with training issues which Dr Berry Allen has steered for a long time. This training issue was discussed at our last AGM with no final agreed training pathway. The possibility of a Masters course in Auckland holds promise. Dr Sue O’Malley Nuclear Medicine Physician and Cardiologist
Special Interest Group News TECHNOLOGISTS National registration is an ongoing issue for the profession with the primary concern of the TSIG being updating the Scope of Practice document. A working party has been formed with representatives from each State, the Accreditation Board and the TSIG to update the existing competency based standards to reflect the expanding role of an NMT. This document must be submitted to the National Board as soon as possible for approval before 1st July 2012. Professional indemnity insurance for NMTs as part of the National Registration process has been raised as a concern for the membership. The TSIG would like to acknowledge the hard work of Bridget Chappell in formulating a policy to cover NMTs. The committee reviewed the MIPS policy and this appears to offer all the requirements for PII, however quotes will also be obtained from Guild Insurance (AIR) and CGU (ASUM). The TSIG will work with Bridget to prepare an information leaflet for NMTs on the available options for PII which should be distributed to members by the end of the year. A letter from the TSIG has been forwarded to David Collier, Executive Director of the AIR, in regard to reviewing their existing criteria to allow an NMT to sit the final examination to obtain qualifications/certification to perform MRI. At this stage we are awaiting a response from the AIR. The annual TSIG symposium for 2012 will be held in Hervey Bay the weekend of 12th August. This will include a full day workshop and a half-day whale watching tour on the Sunday morning. The speakers and program are being finalised with sponsorship being sought. Liz Bailey Chair, ANZSNMT
10 Gamma Gazette December 2011
RADIOPHARMACY Just a quick update on events relating to the SIG. Accreditation guidelines are progressing, with the working party continuing to make progress. It is a long process – to look at all factors which need to be covered, measures of evidence of competency established, and how to make this work for a group which is very disparate in the individual activities we perform. I believe we are approaching a good model. I attended my first meeting as SIG rep on the Federal Council last week. It has emerged that although we voted to call ourselves Radiopharmaceutical Scientists at the AGM in Auckland (for reasons I will recap below), we are still the Radiopharmacy SIG as certain steps will need to be taken to change this legally within the ANZSNM. Our reasons for changing our name were: • Unless you are a registered pharmacist, you cannot use the term ‘radiopharmacist’ • The other commonly used term of ‘radiochemist’ is internationally seen to be more ‘target chemist’ than what we actually do As a result we opted for the mouthful ‘Radiopharmaceutical Scientist’, which is in keeping with international societies. We will explore the steps needed to change the name of the SIG officially. The ANZSNM Council has also approved a budget toward having a weekend working party, which will be able to include a number of people which represent all states, to complete the accreditation guidelines. This is much appreciated and we will be organising that for the New Year. Wishing you all a happy and safe festive season Jennifer Guille Chair
ANZAPNM Update Since November 1, 2011, the Health Insurance Regulations in relation to eligibility for Medicare benefits for PET services has removed three requirements, namely the need for PET training site accreditation, on-site neurology service and a “covered walkway”. The requirement for location of the PET service to be provided in a comprehensive facility remains, as do other requirements such as personal supervision by a credentialed specialist. ANZAPNM has been instrumental in the changes, and more updates to follow when available. Nationally, there are currently 33 cameras in 29 facilities, with a number of other cameras on order or planned. The Government’s Diagnostic Imaging Accreditation Scheme (DIAS) is in place and implementation is currently under review to see whether the workload on each facility in complying with the DIAS is excessive. One of the problems identified is the number of different accreditation schemes that are now in place. The DIAS Monitoring and Implementation Committee will consider the review results and advise Government on the review and other matters; the ANZAPNM is represented on this committee. The long-awaited report of the DI Funding Review has not yet been released. There was considerable debate about the validity of a number of statements in the document and the DHA has subsequently made substantial revisions. While the ANZAPNM focuses on strongly representing the interests of NM and NM patients, it also liaises closely with the RANZCR about the ongoing Government review, the broader diagnostic imaging sector and the consultation process as well as matters concerning the delivery of nuclear medicine services. As part of the review, there will be a strong focus on quality and patient safety. Arrangements to change the name of the Association to the Australasian Association of Nuclear Medicine Specialists is proceeding; the name change was proposed in acknowledgement that a greater number of dual trained radiologists are now members of the association. A new constitution has been drafted and is in review stage. I’d like to thank Janine Sargeant (CEO) from the ANZAPNM for her assistance in preparation of this report. Sze Ting Lee
11
Accreditation Board News The Accreditation Board met on Saturday, November 19th in Melbourne Present were Jim Norman (Secretary), David Lyall, Clayton Frater, Tale Liiv, David Thomas, Doug Mackey, Julie Crouch (Chair) and Judi Anderson (ANZSNM Secretariat). Apologies were received from Nat Lenzo (Physician) and Sze Ting Lee (ANZSNM President). The Board welcomed two new members, Clayton Frater (NSW) and Tale Liiv (Queensland). Both are very well qualified to involve themselves in Board issues and continue the good work that the Accreditation Board undertakes. As you are aware, the Accreditation Board is no longer providing CPD packages for members to obtain points for revalidation but we are in the process of organising alternative resources in place of the packages. Members who have not utilised the current packages may continue to do so. Two international technologists attempted the OQA exam but unfortunately both candidates were unsuccessful. They are able to resit the exam if they wish in the future. Information on National Registration and the newly formed Australian Medical Radiation Science Accreditation Council (AMRSAC) is included in a separate article within the Gamma Gazette. On a personal note I would like to thank everyone for their support while I was on the Board as I am stepping down to undertake a new career in Secondary Teaching. I have had great support from Julie Crouch, John McKay, Simon Cowell (RMIT), David Thomas and all the technologists who have assisted me along the way in approving university courses throughout Australia. I look forward to seeing many of you in the future. Clayton Frater will continue in my role as the Board member overseeing CPD and Secretary roles. Jim Norman Secretary Congratulations to the following technologists who were granted Accreditation at the November meeting: GHASEMZADEH, Mehrdad GREEN, Catriona Megan LEE, Terence Kean-Min MUNRO, Melissa Terese-Marie NOWICKI, Anna PATTERSON, Matthew William SAMANT, Rani SKALKOS, Stacey SPENCER, Claudy Marie Jean TRINH, Ai WILKINSON, Belinda Jennifer XU, Lisa Jane Congratulations also to the following technologists whose Accreditation has been revalidated following submission of CPD points: BALDWIN, Susan Jane BARGWANNA, Kerry BENGER, Tracy-Ann BERNAR, Ann BRADFORD, Lesley
12 Gamma Gazette December 2011
BRUNS, Mareeka BURTON, Katherine BUTTERWORTH, Mark CARMODY, Margaret CHRISTIAN, Caryl CONNAL, Katia COWIE, Ailsa DUNCAN, Angela FENECH, Renee FRATER, Clayton GALEA, Jo GAMBRILL, David GLEDHILL, Sam GRANEY, Karen GUTIERREZ, Jose HOSKING, Erika IOANNOU, Kim JAMES, Daphne JOHNSTON, Val KAILA, Amerjeet KEARNEY, Nicole MARTIN, Alana MATHEWS, Stephen McLAREN, Chris MITCHELL, Grant
ONG, Peow ROBERTS, Mirela RUNDELL, Maria SCARLETT, Luke SEARCY, Dale SMITH, Kellie SPEE, Eddy TRIFUNOVIC, Marko VARTZOKAS, Melissa WALTER, Tania WOODCOCK, Angela The following departments were granted accreditation re-accreditation for the training of PDY technologists: Eastern Health – Cert. #157 – cluster application PRP Diagnostic Imaging, Orange – Cert. #158 Bankstown Lidcombe Hospital – Cert. #74 Pacific Radiology – Cert. #75 Cairns Diagnostic Imaging – Cert. #116 Qld Diagnostic Imaging, Holy Spirit Northside – Cert. #117 Nepean Hospital – Cert. #118
Report on the “Adventure in Adelaide” TSIG Day Seminar The annual TSIG day seminar was held in May this year in the Adelaide Zoo’s function room. Technologists from all over Australia attended the day’s talks. At lunchtime we took our lunch boxes and water bottles into the Zoo especially to view their big attraction – the pandas. Wang Wang put on a great performance, cruising around his enclosure and offering lots of photo opportunities, while Funi had decided to just play it cool and hang around inside. The well-presented talks were varied and of topical interest: • Image Fusion - Dr Ghee Chew • Crossover of Radiology and Nuclear Medicine Procedures - Dr Michelle Nottage followed by a discussion panel • Working in Multidiscipline Department Medical Imaging - Nick Farnham • V/Q SPECT Protocol Development and Experiences - Liz Bailey followed by discussion panel. • Case studies including new Lutate therapy site experience – Committee members • Update on registration and Scope of Practice for ANZSNMT - Liz Bailey • How to build patient attendances - Nick Farnham and discussion panel • The Effects of the Earthquakes in New Zealand – Prue Lamerton The day was concluded with a very sociable dinner at the British Hotel. A great day all round. The meeting was sponsored by GE, InMed, GMS and Cyclomedica (speaker sponsor). Come and join us next year in Hervey Bay for another day of scintillating talks and whale-watching!
13
Crossword
This edition we have a cryptic crossword! The clues are most similar in style to those of the Times Crossword, which is also printed daily in The Australian. Good luck! Solutions next issue. 1
3
2
4
5
6
8
7
9
10
11
12
13
DOWN 1. State library holds back digestive fluid (4) 2. Jaw deception falls short of the stomach (7) 3. Anger ROM busted creating scintigraphic study (8) 5. Initially look after ocean inside shattered dune, a description of our radioisotopes (8) 8. Physician’s write-up of damaged pore during radiotherapy (6) 9. Uncle in Medicare confused with what we all do! (7,8)
14 Gamma Gazette December 2011
ACROSS 2. Note to everyone: Black climbing frame leads to storage place for 1 (4,7) 4. Preliminary view given by trustworthy lad? (5) 6. Randomly tick boxes showing reduced 10 (5) 7. One taken in by your old stick can oddly clear malignant disease (7,6) 10. Tracer concentration kept a union leader amused (6) 11. Lacking vessels of any kind, short vase held by current head of urology, taking lemon and rum for starters (9) 12. Trial able to be arranged on both sides (9) 13. Emits poorly in centre of fish, finds this study? (9)
Being a PDY in Western Australia – a personal experience Any university graduate who wishes to be Accredited with the ANZSNM must complete a Professional Development Year before they are allowed to work unsupervised. Some graduates obtain a career close to home and close to their families. However, most graduates don’t have the choice to stay at home, so travel hundreds of kilometres around the country to work. As there is no Nuclear Medicine degree available in WA currently, every PDY who works here has come from interstate. I came across to WA from NSW in January 2010 as a PDY. Knowing that no matter where I worked I was going to have to move, I applied for positions both in NSW and interstate. It was my first time living away from home and I didn’t really know anybody here. I had left my family, friends and partner to start a new life in Perth. In between looking for a place to live and finding my way around the city, I started my new job. I found the job relatively easy to jump into, it was like being on a long placement and I could take on as much or as little responsibility as I felt ready for. The best part about working in Perth was that I met a lot of other technologists very easily. As I was working in a small private practice, many of my PDY requirements had to be undertaken elsewhere. Over the year, I spent some time in three other nuclear medicine departments, as well as a radiopharmacy lab. Between that and the regular branch meetings I attended, I quickly became part of the WA nuclear medicine community and have since built relationships with both technologists and doctors. I was extremely homesick over the year, but my boss was very willing to let me take time off to fly back to NSW regularly. I would usually manage a trip back to see my family every couple of months, so by the time I felt really homesick it was usually only a couple of weeks before I would see everyone again. I was adamant throughout the whole year that I would be returning to NSW at the completion of my PDY, as I know many people are. I had accepted the position with the mindset that I would only have to stick it out for a year before I could return to what was comfortable. It wasn’t until late November during a conversation with a work colleague that I realised how disappointed I was going to be to leave the place I had begun to call home. By Christmas I had made the decision to stay in WA and soon after my partner joined me here. It has almost been another year and I still have no intention to leave WA anytime soon. I still get homesick, but Perth is definitely my home now too. To any future PDYs, try to keep an open mind while you are applying for positions. The thought of moving around the country may feel incredibly daunting, but you may find that the year goes a lot faster than you expected.
15
Answer on page 18
A: What’s that? Adrienne Little Department of Nuclear Medicine, Mount Hospital, Western Australia
Case Study: A 66-year-old woman was referred for a whole-body bone scan. She was recently diagnosed with cancer in the left breast with positive left axillary lymph nodes. She had no recent history of falls, trauma or previous fractures. She had a CT scan performed just prior to the bone scan. She was injected in the right antecubital fossa with 800 MBq of 99mTc-HDP, using the same cannula that was used for the CT scan. Images were acquired 2½ hours later. There was no evidence of dose extravasation at the time of the injection. What findings can be noted?
16 Gamma Gazette December 2011
Answer on page 18
B: What’s that? Peter Robins and Deanie Lee Nuclear Medicine, SKG Radiology, Subiaco, Western Australia
Clinical Notes: 27-year-old male with a history of osteosarcoma 9 years ago. He had previous proximal tibial resection with left total knee replacement. At routine follow-up bone scan, imaging was performed 3 hours after the injection of 1 GBq 99mTc HDP. Shown are the planar images of the thorax.
17
From page 16
A What’s that? ... answer Due to intense tracer uptake in the right elbow, further images were obtained. Orthogonal views were performed to prove there was no extravasation of radiopharmaceutical. What was found, however, was that the uptake in the right elbow aligned to the distal humerus. The physician reported the abnormality as fairly typical of Paget’s disease. Also low-grade diffuse changes in the right hip and lumbar spine were reported as benign. This case highlights that pathologies may possibly be missed if further imaging is not done to investigate the cause of hot-spot activity, particularly in the region of the elbow, where the majority of tracers are given, as this could have been mistaken as soft tissue activity at the injection site.
From page 17
B: What’s that? ... answer There is prominent symmetrical soft tissue uptake in the musculature lateral to the scapulae. This uptake is within the teres major muscle belly bilaterally due to dystrophic uptake that occurs in muscle groups after overuse. The patient confirmed recent excessive weight-lifting. Teres major is a thick muscle that arises from the inferior angle of the scapula and from the fibrous septa interposed between the teres minor and infraspinatus muscles. The fibres are directed upward and laterally inserting into the medial lip of the intertubecular sulcus of the humerus. Teres major draws the humerus medially and backwards and rotates it medially. Activity in strength sports such as weight-lifting can cause rhabdomyolysis secondary to over-exertion. The proposed mechanism of radiotracer uptake is absorption to denatured proteins and binding to mitochondrial calcium. References Hod N, Ashkenazi I, Cohen I, Drori M, Horne T. Scintigraphic Evidence of Specific Muscle Groups : Rhabdomyolysis Secondary to Over- exertion on Bone Scan. Isr Med Assoc J 2005; Sep 7(9): 614-5
18 Gamma Gazette December 2011
15
AMRSAC The Australian Medical Radiation Sciences Accreditation Council (AMRSAC) was formed jointly by the State Registration Boards, Universities, the Australian Institute of Radiography (AIR) and the Australian and New Zealand Society of Nuclear Medicine (ANZSNM). Some founding directors were appointed so that the whole formal process could proceed. An independent panel was formed which included representation from Radiography, Radiation Therapy and Nuclear Medicine nominated by their respective Societies. Recommendations were made to the Founding members who then appointed the directors. AMRSAC has been appointed by the Medical Radiation Practice Board of Australia (MRPBA) to exercise accreditation functions for the medical radiation practice profession under the national scheme. National registration for Medical Radiation Practitioners comes into effect from July 2012. The objectives of AMRSAC are to: a) Develop accreditation standards for approval by the National Board or respective State or Territory Registration Boards; b) assess programs of study, and the education institution that provides the programs of study, to determine whether the programs meet accreditation standards approved by the National Board or respective State or Territory Boards; c) assess authorities in other countries who conduct examinations for registration in medical radiation practice, or accredit programs of study relevant to registration in medical radiation practice, to decide whether persons who successfully complete the examinations or programs of study conducted or accredited by the authorities have the knowledge, clinical skills and professional attributes necessary to undertake medical radiation practice in Australia; d) oversee the assessment of the knowledge, clinical skills and professional attributes of overseas qualified medical radiation practitioners who are seeking registration to undertake medical radiation practice in Australia and whose qualifications are not approved qualifications for this health profession; and e) make recommendations and give advice to the National Board or respective State or Territory Registration Boards about any matter referred to in the above. The following members have been appointed to AMRSAC Experience Community Director Health Sciences Accreditation Council director Academic practitioner director Diagnostic Radiography Academic practitioner director Nuclear Medicine Academic practitioner director Radiation Therapy Accreditation/registration practitioner director Diagnostic Radiography Accreditation/registration practitioner director Nuclear Medicine Accreditation/registration practitioner director Radiation Therapy Clinical practitioner director Diagnostic Radiography Clinical practitioner director Nuclear Medicine Clinical practitioner director Radiation Therapy
Director Tim Benson Karen Murphy Jan McKay Diana Gentilcore Eileen Giles Francesca Holloway Julie Crouch Kate Wilkinson Ingrid Egan Sharon Mosley Robert Lin
The Directors representing the nuclear medicine profession are: Diana Gentilcore Academic Practitioner Director Nuclear Medicine Julie Crouch Accreditation/Registration Director Nuclear Medicine Sharon Mosley Clinical Practitioner Director Nuclear Medicine
20 Gamma Gazette December 2011
AMRSAC Bio – Tim Benson Tim Benson is an experienced health consumer and has been a member of the boards of (the national peak) Consumers Health Forum of Australia and (the WA peak) Health Consumers Council of WA. Tim’s experience as a community or consumer representative has been developed over 15 years of activities including membership of the Physiotherapy Board of Australia and previously the WA Physiotherapists’ Registration Board. Tim has also been part of a Quality Use of Pathology Technical Advisory Group to the Department of Health & Ageing and a member of a NHMRC Guidelines Development Executive for Diabetes Complications for Foot & CVD. Although Tim is not a clinician, he brings to all his committees a wealth of experience in governance (having worked in senior management positions in financial organisations for over eighteen years), a great understanding of community health issues due to his years of practical involvement, and the ability to inform process, based on his management qualifications and rich life experiences. Tim has recently been appointed to the National Lead Clinicians’ Group - a body providing advice to the Minister of Health (Nicola Roxon) on future directions for health policy. He is the only community representative on this 15-person group and his wealth of experience will certainly enhance its effectiveness. Prior to being appointed as a Director of AMRSAC, Tim was a member of a number of Accreditation Review Teams for ANZSNM. Tim is passionate about community involvement in all aspects of health where he sees that, to be a safe and high quality process for patients upon which they can rely, there needs to be a voice advising what is really important to the recipients of any tests or treatment. Due to his involvement with National Registration & Accreditation since its inception, Tim is ideally placed to add value to the new accreditation council for the MRS.
AMRSAC Bio – Sharon Mosley Sharon Mosley currently works as a Senior Nuclear Medicine Scientist at The Canberra Hospital. She was selected to fill the role of Director with current clinical experience. Sharon has until recently been the ACT representative and Federal Treasurer for the ANZSNM. Sharon’s biography will be included in a future issue of the Gamma Gazette.
21
AMRSAC Bio – Diana Gentilcore Diana Gentilcore is a Senior Lecturer in Nuclear Medicine in the School of Health Sciences at the University of South Australia. After graduating with a Diploma of Applied Science (Nuclear Medicine) in 1992, Diana worked as a nuclear medicine technologist in both private and public departments until the end of 1995 when she was then appointed as a tenured Lecturer in Nuclear Medicine in the School of Medical Radiation at the University of South Australia. After seven years in this position, Diana embarked on a research career in 2003 and commenced a PhD with the Discipline of Medicine, The University of Adelaide. Diana’s use of nuclear medicine techniques in her PhD studies was acknowledged early and she became the inaugural recipient of the William T Southcott Scholarship in Nuclear Medicine. Her internationally published research includes the first study to validate the use of 3D ultrasound as a measure of gastric emptying against the ‘gold standard’, scintigraphy. In 2008, Diana was awarded a prestigious Heart Foundation of Australia Postdoctoral Research Clinical Fellowship, having previously held an esteemed National Health and Medical Research Council of Australia Australian Clinical Research Postdoctoral Training Fellowship. Diana returned to the University of South Australia in 2010 in a continuing academic appointment as a nuclear medicine educator and stream coordinator. In her current role, she is also the Medical Radiation (i.e. nuclear medicine, medical imaging and radiation therapy) Honours Program Director of the Bachelor of Medical Radiation Science undergraduate course. In her position, Diana liaises with Medical Radiation practitioners to ensure that Honours research projects are completed in collaboration with supportive clinical sites and supervisors. Diana has made continuous contributions to the nuclear medicine profession since the commencement of her ANZSNM membership in 1993, serving on the Education Advisory Panel, the Accreditation Board Professional Advisory Committee and the Web Site Committee. Diana is the current Chairperson of the ANZSNM Technologist group (South Australian Branch), a position she also held previously between 1996 and 1998, and an invited member of the nuclear medicine peer-review panel of The Radiographer. As an accredited nuclear medicine technologist and educator, Diana is committed to the continual development of the profession in its quest to provide nuclear medicine services of the highest standard. With a comprehensive range of complementary skills and experience, Diana’s appointment as a Director (Academic Practitioner) of the Australian Medical Radiation Sciences Accreditation Council (AMRSAC) will allow her to present an objective, informed perspective of education and accreditation-related issues in the nuclear medicine and medical radiation professions.
22 Gamma Gazette December 2011
AMRSAC Bio – Julie Crouch Julie Crouch is a Nuclear Medicine Technologist who is registered with the Medical Radiation Technologist Board WA and has been an active member of the ANZSNM since 1995. Julie began her career in Nuclear Medicine with Northern Regional Health Authority in the UK before moving to Perth in 1995. She has spent the last 15 years working in Perth in senior roles as a Nuclear Medicine Technologist. Julie was instrumental in the establishment of The WA PET Service at Sir Charles Gardiner Hospital, where she held the position of Chief Nuclear Medicine Technologist. Julie is currently a partner of Oceanic Medical Imaging, an independent medical imaging practice; a role which includes clinical nuclear medicine. Julie has been actively involved with the ANZSNM over the last 14 years, serving as Vice President of the ANZSNM, Chair of the Accreditation Board and WA Branch of the ANZSNM. The ANZSNM is the group vested with executive authority from DIMIA to assess international applications for nuclear medicine in Australia. Overseas qualification assessment has been one of Julie’s main functions since she joined the Accreditation Board, including representing the organisation at Assessing Authority Conferences. More recently, Julie has been a member of the ANZSNM Accreditation Review Team for the course assessment at The University of Newcastle and The University of South Australia. Julie is the nuclear medicine member of the Medical Radiation Technologist Board WA and was appointed when it first commenced in 2006. The establishment of the State Board required the development of a number of policies and she was the nuclear medicine representative for: • Resumption of Professional Practice which reviewed the professional practice requirements for Medical Radiation Technologists (MRTs) re-entering the workplace following a leave of absence • Registration Committee, a sub-committee of the WA Registration Board, with the mandate to assess registration applicants to determine the adequacy or qualifications and recommend professional development activities to achieve registration standards. • Code of Practice/Ethics Working Party with the charter to interpret and advise on relevant legislation and establish all policies and procedures for the Registration Board. • Continuing Professional Development Party Julie has a varied experience with accreditation and registration. She will continue to add value in her role as a Director (Accreditation/Registration practitioner) of the Australian Medical Radiation Sciences Accreditation Council (AMRSAC).
23
Original Article
A snapshot of research activities at the WA PET Service Dr Roslyn Francis, Dr Tatiana Segard, Penny Maton, Elaine Campbell WA PET Service/Department of Nuclear Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia
INTRODUCTION Sir Charles Gairdner Hospital is a large tertiary referral and teaching hospital with over 570 beds located in Perth, Western Australia. The West Australian PET Service was established in late 2002 within the Department of Nuclear Medicine at Sir Charles Gairdner Hospital. Initially, radiopharmaceuticals were sourced from the eastern states until the onsite cyclotron became operational in late 2003. The department has 5 cameras in total, 3 SPECT/CT gamma cameras and 2 PET/CT cameras. The department is also preparing to install a small animal imaging suite on an interim basis with the West Australian Institute of Medical Research (WAIMR) including a nano SPECT/CT camera, Bio PET/CT and a 3T small animal MRI. The department has an ongoing commitment to conducting research of a high quality and relevance to nuclear medicine and PET imaging whilst fostering successful research collaborations with internal and external stakeholders. The onsite cyclotron allows the WA PET Service a unique opportunity to work closely with staff at the Radiopharmaceutical Production and Development (RAPID) centre to develop and evaluate the clinical utility of a number of novel PET tracers. The following is a brief overview of some of the most recent clinical trials using novel tracers that the department has undertaken and a look at some future projects within the department. Hypoxia imaging with 18F-fluoromisonidazole (18F-FMISO) Figure 1. Transverse views of an FMISO PET-CT study (above) and an FDG PET-CT PET/CT. study (below) for a patient with mesothelioma. Only a small volume of the metaboliCurrent evidence suggests that cellular resistance to cally active tumour appears hypoxic. chemotherapy and radiotherapy is linked to the presence 1,3 of hypoxia within solid tumour cells. The WA PET service poster prize in the Oncology section. has recently completed two pilot studies assessing the Western Australia has a high incidence of mesothelioma, due in part activity of the hypoxia imaging agent 18F-labelled fluoromisonidazole (18F-FMISO) using positron emission tomography/computed tomography to previous asbestos mining operations at Wittenoom in the state’s (PET/CT) compared with metabolic activity corresponding to uptake north, so a number of research studies focus on the development values on 18F-fluorodeoxyglucose (18F-FDG) PET/CT. A pilot study of a suitable imaging modality for patients with malignant pleural assessed 10 patients with suspected or proven pancreatic carcinoma. mesothelioma (MPM). This disease often has a poor prognosis and is Each patient undertook one 18F-FMISO and one 18F-FDG PET/CT scan. known to be resistant to chemotherapy and radiotherapy treatments. Quantitative measurements of hypoxia were taken using 18F-FMISO A pilot study at the WA PET Service aimed to investigate global and maximum standardised uptake value (SUVmax) and tumour to regional hypoxia in MPM. A study group of 20 patients with confirmed background muscle (T/B) ratio, with metabolic activity assessed using MPM, not receiving active treatment at the time of imaging, was 18 F-FDG SUVmax. Metabolic activity at the tumour site was demonstrated identified and a comparison of 18F-FMISO PET/CT to 18F-FDG PET/CT was in all 10 participating patients however, although pancreatic cancers undertaken. Sites of maximal tumour activity were identified and regions are known to demonstrate molecular markers of hypoxia, only two of interest were drawn on both PET/CT scans. 18F-FDG activity was patients in this group exhibited significant 18F-FMISO activity. Due to the determined using maximum standardized uptake value (SUVmax), and minimal 18F-FMISO activity detected in the pilot study, 18F-FMISO PET/ on 18F-FMISO PET/CT both SUVmax and tumour to background (muscle) CT contributed limited information on the assessment of hypoxia in this measurements were assessed. Preliminary findings on 11 patients were patient group. Dr Tatiana Segard presented a poster of this research at presented by Dr Tatiana Segard at the 2011 World Conference on Lung the 2011 SNM annual meeting in San Antonio, Texas and received a Cancer in Amsterdam, with results showing that 10 of the 11 patients
24 Gamma Gazette December 2011
A snapshot of research activities at the WA PET Service
had 18F-FMISO activity on visual analysis, an example of which is shown in Fig. 1. One patient, who had previously received treatment and was now in remission, had no 18F-FMISO or 18F-FDG tumour activity detected. There was a positive correlation between intensity of metabolic activity on 18 F-FDG PET/CT and hypoxia on 18 F-FMISO PET/CT as assessed by SUVmax (r=0.89, p<0.001) and between 18F-FDG SUVmax and 18 F-FMISO tumour to background activity (r=0.78, p=0.008). This preliminary finding demonstrated that 18F-FMISO was able to identify Figure 2. These images demonstrate enhanced 18F-FLT (left) and 11C-MET (right) uptake at the site of a areas of hypoxia in patients previous glioma resection at the right lateral temporal lobe post chemo-radiotherapy. with MPM and tumours that Future directions demonstrated 18F-FMISO activity also had higher 18F-FDG SUVmax. The department also collaborates on a variety of multi-centre research projects including a phase-III multi-centre study of Alpharadin (226Ra) in Amino acid transport and cellular proliferation with 11C-methionine 11 18 18 patients with prostate cancer and numerous other drug trials. There ( C-MET) and F-fluorothymidine ( F-FLT) PET/CT is further collaboration with the McCusker Alzheimers Research Increased uptake of 11C-methionine (11C-MET) in brain tumour tissue Foundation and Professor Ralph Martins, with amyloid (11C-PIB) and reflects increased amino acid transport that is associated with tumour 3 metabolic (18F-FDG) PET imaging for investigation of Alzheimers disease. tissue and not seen in unaffected brain tissue. This is particularly The WA PET Service took possession of a new Siemens mCT useful on PET/CT imaging allowing a demonstrated high contrast 64-slice, time-of-flight PET/CT scanner in October 2011 which will have between tumour and normal brain tissue. This prospective pilot study a significant positive impact on service delivery for clinical and research of 30 patients with histologically or cytologically confirmed glioblastoma activities. Also, collaboration with the University of Western Australia and multiforme (WHO grade 4) is still in its early stages. It is hoped the the West Australian Institute of Medical Research (WAIMR) has resulted study will obtain preliminary information on the clinical utility of 11C-MET in an Australian Cancer Research Fund (ACRF) grant for small animal and 18F-FLT imaging in distinguishing pseudo-progression from true imaging, with PET/CT, SPECT/CT and MRI to be installed in 2012. progression in patients receiving adjuvant chemotherapy at the time of their routine MRI scan. All imaging is completed after 2-3 cycles of treatment. PET images are fused with the MRI and semi-quantitative CONCLUSION analysis using regions of interest is performed. Currently, 20 patients have been recruited to this study which is supported by an ANZSNM The department has a strong commitment to collaboration with internal research grant (2010) and a Pfizer Australia cancer research grant and external stakeholders to produce high-quality research that will (2010). eventually lead to better outcomes for all patients. The definitive goal is the development of imaging modalities, using novel tracers that will Apoptosis imaging with 99mTc-labelled Annexin V and SPECT/CT ultimately contribute to better patient management by producing better Tumour size in mesothelioma is usually assessed with diagnostic CT diagnostic and therapeutic monitoring models. but this disease is difficult to image and measure due to its growth pattern. The condition does not develop as a single solid tumour but rather as a rind around the pleura in the chest that resembles an REFERENCES onion skin. Often significant changes in size are not detectable on CT for 2-3 months after chemotherapy has commenced. Annexin 1. Imam SK: Review of positron emission tomography tracers for V is an apoptosis marker and may detect cell death within hours of imaging of tumor hypoxia. Cancer Biother Radiopharm, June chemotherapy administration. Annexin V imaging may be able to 2010;25(3):365-74 determine chemotherapy effectiveness at an early stage in treatment. 2. Danny Rischin, Rodney J. Hicks, Richard Fisher, David Binns, June The pilot study will recruit 15 patients with cytologically or histologically Corry, Sandro Porceddu, and Lester J. Peters: Prognostic Significance proven MPM who are due to commence chemotherapy. Participants of [18F]-Misonidazole Positron Emission Tomography–Detected will have imaging with 99mTc-labelled Annexin V at baseline and then Tumor Hypoxia in Patients With Advanced Head and Neck Cancer at 48 hours after commencement of chemotherapy. It is hoped the Randomly Assigned to Chemoradiation With or Without Tirapazamine: study will permit earlier prediction of the efficacy of chemotherapy, A Substudy of Trans-Tasman Radiation Oncology Group Study 98.02. resulting in fewer patients continuing ineffective treatment, J Clin Oncol, May 2006;24(13):2098-104. individualization of chemotherapy treatments and more rapid and 3. Pieter L. Jager, Willem Vaalburg, Jan Pruim, Elisabeth G.E. de Vries, reliable identification of new drugs which may be effective in this disease. Karl-Josef Langen, and D. Albertus Piers: Radiolabeled Amino Acids: This study is supported by a Sir Charles Gairdner Hospital research grant Basic Aspects and Clinical Applications in Oncology. J Nucl Med, (2010/11). March 2001;42(3):432-445. 25
Case Study
NIS – Sodium Iodide Symporter: A case Study Nicole Kearney, Suresh Viswanathan, Leonard Allen Nuclear Medicine and PET, Hunter New England Imaging, Newcastle NSW INTRODUCTION The patient was an 80-year-old female who first presented in December 2008 for ablative 131I therapy for papillary thyroid carcinoma. Six weeks prior she had had a total thyroidectomy. She received 3.8GBq of 131I in capsule form on a Friday and remained isolated in a hospital ward until the following Monday (day 3), when whole-body and static imaging was acquired. Images demonstrated central neck 131I uptake, thought to be residual thyroid tissue. No other abnormal uptake was identified (Fig. 1). In May 2009 a new midline neck mass was discovered on CT and excised, confirming papillary thyroid cancer metastases. She was admitted to hospital for 5.1GBq 131I ablative therapy. Images at day three post therapy demonstrate no abnormal uptake in the thyroid bed or elsewhere on the whole body scan (Fig. 1). In October 2010 the patient developed new neck node metastasis, which was confirmed on excision biopsy. There were enlarged deeper lymph nodes in the neck that were suspicious for metastasis. She returned for further 5.1GBq 131I therapy. Instead of T3/T4 withdrawal, the TSH was stimulated by Thyrogen. Images were acquired at day 3 following isolation in the hospital over the weekend. Images again demonstrated no abnormal 131I uptake (Figure 1). Thyroglobulin levels were within the normal range prior to each presentation.
The patient presented in early January 2011 with enlarged palpable and deep neck nodes. Her endocrinologist was concerned these were papillary carcinoma metastasis and that the previous scans failed to show 131I uptake by the metastasis. A PET scan was performed later that month to determine if these lesions were malignant and for staging. The patient was injected with 283MBq 18F-FDG and scanned from the skull vertex to sub inguinal region. Low-dose CT was performed for anatomical localisation and attenuation correction. Images demonstrated multiple enlarged and hypermetabolic neck lymph nodes. The two largest lesions in the left subclavicular fossa caused trachea deviation to the right. Tracer uptake was also noted in the left thyroid cartilage region and the right subclavicular region, highly suspicious for metastasis. Small areas of tracer uptake in the right lung mid-zone were also highly suspicious for metastasis. On first presentation the patient had limited disease and she was staged into a low-risk category. Subsequent development of lymph node metastasis put her into a high-risk group and therefore 5.1GBq of 131I was administered. The thyroglobulin levels were within normal limits at each presentation. The patient is currently undergoing palliative radiotherapy to the metastasis in her neck region to alleviate pressure on the trachea and has surgery planned. A follow-up PET scan is to be performed after radiotherapy to assess treatment response. It was felt that the lack of 131I uptake by the metastases meant loss of the sodium/iodide symporter (NIS) and as a result further treatment with 131I would not be successful. Figure 2.
Figure 1. Corresponding author: Nicole Kearney Ph. 02 49213390 F. 02 49213392 nicole.kearney@hnehealth.nsw.gov.au
26 Gamma Gazette December 2011
Figure 3.
NIS – Sodium Iodide Symporter: A Case Study
DISCUSSION This case demonstrates papillary thyroid cancer metastases that are not detected with 131I scintigraphy, despite showing avid 18F-FDG uptake on PET images. It has been postulated that this is due to the loss of the sodium/iodide symporter by the thyroid cancer cells. Sodium/iodide symporter (NIS) is an intrinsic transmembrane glycoprotein which mediates active transport of iodide and sodium across the cytoplasmic membrane. In the thyroid gland, where it is naturally expressed, it facilitates accumulation of iodide by follicular cells to concentrations 20- to 40-fold over plasma levels, essential for production of thyroid hormones.1,2,3 NIS is the molecule that mediates radioiodine uptake. A decrease in NIS gene expression in lymph node metastases compared with both normal thyroid and primary tumour tissues suggests that a reduction of NIS gene expression may be a consequence of cancer progression.4 A lower expression of the NIS gene is associated with more advanced tumour stages and an absence of NIS expression has been shown to correlate with a negative total body 131I scan.5,6,7 If the NIS gene expression is low or non-existent, 131I therapy and scanning may not be suitable in patients with papillary thyroid carcinoma when disease progression is suspected. NIS has been cloned since the mid 1990s and this has allowed further research into the gene.8 A study published in 2002 by Cho et al. demonstrated that rats bearing intracerebral gliomas that had been retrovirally transduced with human NIS retained significant amounts of radioiodine at 24 hours post-injection.9 A paper published in 2007 by Goel et al. described a similar study using mice implanted with NISinfected multiple myeloma cells. Again, this study demonstrated radioiodine accumulation in the tumour cells.10 There are numerous other studies that demonstrate the use of the NIS gene to ablate various tumour cells with radioiodine and to assess molecular therapy.11,12,13 REFERENCES 1. Carrasco N. (1993) Iodine transport in the thyroid gland. Biophys; 1154:65-82 2. Preedy V, Burrow G, Watson R. (2009) Comprehensive handbook of iodine: nutritional, biochemical, pathological and therapeutic aspects. Elsevier, Oxford UK
3. Shen D, Kloos R, Mazzaferri E, Jhiang S. (2001) Sodium iodide symporter in health and disease. Thyroid; 11(5)415-425 4. Arturi F, Russo D, Schlumberger M, Du Villard J, Caillo B, Vigneri P, et al. (1998) Iodide symporter gene expression in human thyroid tumours. Journal of Clinical Endocrinology and metabolism; 83; 2493-2496 5. Arturi F, Russo D, Giuffrida D, Schlumberger M, Filetti S. (2000) Sodium-iodide symporter (NIS) gene expression in lymph node metastases of papillary thyroid carcinomas. European journal of endocrinology, 143; 623-627 6. Lee S, Choi K, Han J, Park Y, Choi M. (2007) Relationship of sodium/iodide symporter expression with I-131 whole body scan uptake between primary and metastatic lymph node papillary thyroid carcinomas. Journal Endocrinology Investment; 30(1):28-34 7. Mandell R, Mandell L, Link C. (1999) Radioisotope concentrator gene therapy using the sodium/iodide symporter gene. Cancer Res; 59:661-668 8. Dai G, Levy O, Carrasco N (1996) Cloning and characterisation of the thyroid iodide transporter. Nature; 379:458-460 9. Cho J, et al. (2002) In vivo imaging and radioiodine therapy following sodium iodide symporter gene transfer in animal of intracerebral gliomas. Gene therapy; 9:1139-1145 10. Goel A, et al. (2007) Radioiodide imaging and radiovirotherapy of multiple myeloma using VSV (Δ51)-NIS, an attenuated vesicular stomatitis virus encoding the sodium iodide symporter gene. Blood; 110:2342-2350 11. Siddiqui F, Barton K, Stricker H, Steyn P, Larue S, Karvelis K, et al. (2007) Design considerations for incorporating sodium iodide symporter reporter gene imaging into prostate cancer gene therapy trials. Human Gene Therapy; 18(4):312-322 12. Miyagawa M, Beyer M, Wagner B, Anton M, Spitzweg C, Gansbacher B, Schwaiger M, Bengel F. (2004) Cardiac reporter gene imaging using the human sodium/iodide symporter gene. Cardiovascular Research; 65(1):195-202 13. Marsee D, Shen H, MacDonald L, Vadysirisack D, Lin X, Hinkle G, Kloos R, Jhiang S. (2004) Imaging of metastatic pulmonary tumors following NIS gene transfer using single photon emission computed tomography Cancer Gene Therapy;11:121–127
27
Case Study
Sickle Cell Disease diagnosed on Bone Scan Joanne Landman Department of Nuclear Medicine, Royal Perth Hospital, Perth, Western Australia KEY WORDS: Sickle Cell Disease, splenic infarct, bone infarct
CLINICAL/PATIENT HISTORY A 19-year-old African woman presented to the Emergency Department with three days of increasing sternal pain, which she rated as 8 out of 10 in intensity. There was no history of recent trauma. She reported that one week prior she had two days of fever, sweating, shortness of breath and sore throat/neck. On examination, she was tender over the manubrium and upper left ribs. The pain was worse on inspiration and with chest wall compression. The area was neither erythematous nor hot, and she was afebrile. She had no abdominal pain and no organomegaly. Her chest was clear, with no cough or sputum. Chest and sternal x-rays were performed with no pathology identified (Fig. 1, Fig. 2). The differential diagnosis was septic arthritis or osteomyelitis, and a Bone Scan and full blood examination were ordered. Bone scan A three-phase bone scan was performed using 900MBq of 99mTc-MDP. Dynamic and tissue phase images of the thorax appear normal, although it is difficult to clearly see the sternal area due to tracer activity in the cardiac blood pool (Fig. 3). Delayed whole-body images were acquired (Fig. 4) showing several areas of abnormality: irregular tracer uptake in the spleen; a small area of increased uptake in the mid-right femur; and photopaenia in the manubrium. There is also generalised increased uptake in the calvarium and increased uptake in the knees, humeral and femoral heads. Planar oblique views (Fig. 5) and SPECT-CT of the thorax (Fig. 6, Fig. 7) showed complete absence of tracer in the photopaenic area of the manubrium, consistent with bone infarct and avascular necrosis. SPECT-CT showed that the irregular splenic uptake correlated with areas of splenic calcification and necrosis, consistent with splenic infarct. The increased uptake in the calvarium, knees, hips and shoulders was reported as likely due to marrow expansion, and the femoral lesion to be a small marrow infarct. Given the patient’s symptoms and African heritage, the bone
Figure 1.
Figure 2.
28 Gamma Gazette December 2011
Figure 4. scan appearances were thought to be highly suggestive of Sickle Cell Disease (SCD). The acute onset and nature of the patient’s symptoms are consistent with an episode of Sickle Cell Crisis.
Figure 3.
Pathology The patient’s blood film results were reviewed (Table 1). They revealed elevated calcium, parathyroid hormone (PTH), Creactive protein, serum ferritin and white cell count. Red cell count, haemoglobin, iron, folate and vitamin D levels were all low (Fig. 8). The pathologist also noted moderate anisocytosis and moderate numbers of spherocytes, Howell-Jolly bodies, target and sickle cells. These results are consistent with SCD, thus confirming the bone scan findings. Folate deficiency is common due to
Sickle Cell Disease diagnosed on Bone Scan
rapid consumption by proliferating erythroid precursors. Low iron with high serum ferritin and low haemoglobin are consistent with anaemia. The patient’s low vitamin D levels are likely due to her dark skin pigmentation causing inadequate exposure to ultraviolet radiation from sunlight. The presence of anisocytosis, spherocytes, Howell-Jolly bodies, target and sickle cells, is consistent with hyposplenism due to splenic infarct. Typically, white cell count and C-reactive protein levels are mildly elevated in SCD, and many studies report patients having elevated calcium and PTH. OUTCOME The patient was treated for Sickle Cell Crisis with intravenous hydration, oxygen and analgesia. Supplements were commenced to treat the folate and vitamin D deficiencies. Serial blood tests were stable and her pain resolved. She was discharged with a haematology clinic appointment for follow-up and management of the disease. DISCUSSION SCD is an inherited blood disorder where mutation of the beta globin gene results in abnormal haemoglobin. The disease is more common in people and their descendants from regions such as Asia and Africa, where malaria is prevalent. Beta globin genes are inherited from both parents. Where one inherited gene is mutated the person is a carrier of the Sickle Cell Trait and is usually asymptomatic. Carrying a single mutated gene has a survival benefit as the malaria parasite dies when the cell it inhabits is destroyed by sickling. SCD occurs when both inherited genes are mutated. The elasticity of normal red blood cells enables them to deform to pass through capillaries. In SCD, low oxygen tension causes the cell to distort. Repeated sickling reduces elasticity, stopping the cells returning to their normal shape (Fig. 9). Abnormally-shaped cells are haemolysed in the spleen or become trapped in capillaries causing ischaemia or infarct, severe pain and organ damage. Increased red cell production by bone marrow cannot keep up with the loss of red cells, resulting in anaemia. Splenic infarct is a common complication and makes patients more prone to infections, most commonly osteomyelitis and
Figure 5.
Figure 6.
Table 1: Full Blood Examination Results normal range Serum Calcium 2.87 2.15-2.6 mmol/L PTH 8.5 0.7-7.0 pmol/L C Reactive Protein 34 <5.0 mmol/L White Cell Count 16.93 4.0-11.0 x109/L Ferritin – Plasma 430 30-220 μgl/L Vitamin D 23 >50 nmol/L Haemoglobin 93 115-160 mmol/L Red Cell Count 3.6 3.8-4.8 x1012/L Haematocrit 0.28 0.37-0.47 Iron – Plasma 5 9-30 μmol/L Folate 243 260-1450 nmol/L Urea – Plasma 2.7 3.0-8.0 mmol/L Creatinine 44 45-90 mmol/L Figure 7.
u 29
Sickle Cell Disease diagnosed on Bone Scan
Figure 8: Example of abnormal cells in Sickle Cell Disease
Figure 9: Left to right: increasing cell deformation with decreasing oxygenation. pneumonia. Bone and bone marrow infarct are also common, particularly in the metaphyses of long bones, and femoral and humeral heads. Other complications include stroke, renal necrosis, jaundice and gallstones. Dehydration or anything that reduces oxygen levels in the blood can trigger Sickle Cell Crisis. Symptoms can include worsening anaemia, severe pain, fever and shortness of breath. In more than 25% of cases patients are unaware they have the disease before an episode of acute pain. There is no cure for the disease. Sickle Crisis is treated with administration of intravenous fluids, analgesics, oxygen therapy, and blood transfusion if the anaemia is severe. Newly-diagnosed patients are counselled about the implications of the disease, particularly the increased risk of infection and of their children inheriting the disease. They are advised to avoid precipitating factors and activities that reduce oxygen saturation to minimise the risk of Sickle Crisis. Increased numbers of immigrants from malaria-prone countries has resulted in the percentage of the population with SCD growing. According to the Chief Pathologist at Perth’s Princess Margaret Hospital for Children, twenty years ago there were no reported cases of SCD; ten years ago, approximately one case per year was reported; the rate is currently approximately 25 cases annually. New cases are mostly children of refugees. Adult refugees and immigrants are screened for the disease before entry to Australia, but there is currently no national screening program for children and babies. Perth’s King Edward Memorial Hospital have recently introduced Sickle Cell screening for at-risk newborns in response to the increase in SCD and Sickle Cell Trait in the population of Western Australia. This case demonstrates that patients can be unaware that they have the disease until they experience Sickle Cell Crisis. With the increase in SCD, Nuclear Medicine practitioners need to be more aware of the scan appearances and of the population groups at risk. REFERENCES Wintrobe’s Clinical Haematology 12th Edition 2009. J Greer, J Foerster, G Rodgers, F Paraskevas, B Glader, D Arber, R Means.
30 Gamma Gazette December 2011
Dacie & Lewis Practical Haematology 9th Edition 2001. SM Lewis, BJ Bain, I Bates Williams Hematology 7th Edition 2006. MA Lichtman, TJ Kipps, K Kaushansky, E Beutler, U Seligsohn, JT Prchal Hematology: Basic Principles and Practice 5th Edition. R Hoffman, EJ Benz, SJ Shattil, B Furie, LE Silberstein, P McGlave, HE Heslop, J Anasti Serum Calcium, Parathyroid Hormone and Vitamin D status in Children & Young Adults with Sickle Cell Disease. Ann Clin Biochem 1993 Jan; 30(Pt 1):45-51. S Mohammed, S Addae, S Sulieman, F Adzadu, S Annobil, O Kaddouni, J Richards Splenic Accumulation of 99mTc Diphosphonate in a patient with Sickle Cell Disease: Case Report. Journal Nuclear Medicine Vol 17 No 2 1975; 108-109. W Goy, J Crowe Sickle Cell Anaemia: Teaching Case. Jan 1995. S Mondro, JS Nagel Sickle Cell Anaemia with splenic infarct: MIR Teaching Case. Oct 1996. B Gordon, H Roya Full Blood Count & Reticulocyte count in painful sickle crisis. Emerg Med J 2006 April; 23(4): 302-303 A Bernard, A Ventkat Differentiation between Bone Infarction and Acute Osteomyelitis is Children with Sickle Cell Disease with use of sequential bone marrow and bone scans. Journal Bone & Joint Surgery – American Volume 83-A912) Dec 2001 pp1810-1813 D Skags, S Kim, N Green, D Harris, J Miller A Comprehensive Guide to Sickle Cell Disease. Sickle Cell Disease Association of America Different Findings in Tc-99m MDP bone scintigraphy with Sickle Cell Disease: report of three cases. Annals of Nuclear Medicine 2007; 21(5): 311-14 S Cerci, H Suslu, C Ceci, M Yildz, F Ozbek, T Baki, A Yesildag, D Canatan Radionuclide Bone Imaging Findings in Recurrent Calvarial Infarction in Sickle Cell Disease. J Nucl Med 1998; 29:411-413 T Burke, J Tatum, M Fratkin, K Baker Natural History of Bone & Bone Marrow Infarction in Sickle Hemoglobinopathies. J Nucl Med 2002; 43 (7):896-900 S Kim, J Miller Severe Hypoxemia Secondary to Acute Sternal Infarction in Sickle Cell Anemia. J Nucl Med 1991; 32: 1617-1618
BioChroma – A new and patented technology for processing radioactive wastewater from nuclear medicine therapy facilities in hospitals and clinics José Canga Rodríguez
While undergoing nuclear medicine therapy using 131I radioisotope at a hospital, patients generate wastewater with a considerable amount of radioactivity. Thus, contamination can reach levels of as much as 90% of the radioactive dose administered to the patient, depending on the type of therapy the patient underwent. Given its radioactive half life of 8.02070 days, there is a significant risk of 131 I radioisotope accumulation after its discharge into the sewer network (through sanitary wastewater) and into the environment. Therefore, it is advisable to collect this effluent in a separate system for its treatment prior to final discharge to the municipal sewer. In spite of the clear scientific evidence of the severe contamination of this specific type of wastewater, a harmonised legal framework has still not been devised for all member states of the European Union. A survey conducted by the Radiological Protection Institute of Ireland clearly spotlights the discrepancies existing among concepts for managing radioactively contaminated effluents. The survey examined thirteen countries, six of which stipulate the installation of wastewater treatment systems, three of which permit the wastewater to be discharged directly following dilution and four of which permit both options, depending on the specific conditions of the respective sanitary system. Delay and decay (natural decomposition of the isotope) is the most commonly used technical method of abating 131I, but it is frequently criticised as being complex and very expensive. While searching for alternatives to this old-fashioned technology, EnviroDTS (a subsidiary of the EnviroChemie group of companies) developed an alternative method called BioChroma, which is patent protected. This paper describes the technology and presents, as an example, a system that was installed and successfully commissioned in the middle of 2008 in a nuclear medicine ward with 12 beds in Stuttgart (Germany). Based on existing legislation, the responsible authorities and the company that operated the hospital agreed on a maximum activity level of 5 Bq/l of the radionuclide 131I in the final wastewater. If a typical delay and decay system would have been installed, the 180 m3 treatment plant
that was already available in the hospital cellar would have to be extended by additional 150 m3. By implementing the patented BioChroma process, the space equirements were reduced by 75%. For instance, since the new system was integrated into the existing installation, tanks accounting for 120 m3 could be used as buffering volume in the new wastewater treatment plant. The operation of the plant is currently producing very good results with values below the pecified limit of 5 Bq/l for the isotope 131 I. In addition, 90Y has been reported to be eliminated at the same time. Over the past two years of operation, the wastewater treatment plant has been able to achieve a maximum processing capacity of more than 2,000 l/day, which equates to a nuclear medicine ward with 20 beds. The highest level recorded during the test period (of 180 days after start-up) was a peak of nearly 2,800 l/day. It is needless to say that these results have exceeded all expectations and underline the incredible potential offered by this new technology. Summarising, it is fair to state that a BioChroma installation provides a nuclear medicine therapy facility with a higher level of operation flexibility. For example, a ward could be able to cope in the future with an extension of its capacity (number of patients) or to comply with stricter radiation regulatory limits without undertaking any expansion of the wastewater treatment plant.
Corresponding author: José Canga Rodríguez MSc Chemical Engineering / MSc Environmentally Sustainable Process Technology Key Account Manager - Pharmaceutical and Life Sciences Industry EnviroChemie GmbH Address: In den Leppsteinswiesen 9 64380 Rossdorf GERMANY Tel. +49 61546998-13
31
The OPAL Reactor Shaun Jenkinson General Manager, ANSTO The OPAL reactor is one of a small number of mixed-use research reactors globally that are responsible for the world supply of reactorbased isotopes, in particular Mo-99/Tc-99m, the workhorse of nuclear medicine. During the recent Mo-99 global crisis the Australian market was cushioned because of local irradiation and processing capability. ANSTO is one of only two organisations in the world that has the capability of completing all three critical steps that ensure Tc-99m generators (Gentech) are manufactured ready for distribution. The Mo-99/Tc-99m supply chain is described below.
Mo-99/Tc-99m Supply Chain Irradiation: The OPAL reactor will operate at high power for 300 days in the 2012 financial year which compares favourably with the highest performing mixed-use reactors. This reliability ensures that Mo-99 target plates are irradiated routinely to meet local and overseas demand. Australian product is made using Low Enriched Uranium (LEU) target plates and the OPAL reactor uses LEU fuel. This makes ANSTO unique as the only 100% producer of LEU/LEU Mo-99 and therefore meeting non-proliferation requirements. Processing: After irradiation, the target plates are transported in shielded containers to the on-site processing facility. The purification and separation of Mo-99 from other fission products takes around 24 hours. In July 2010, ANSTO received approval from ARPANSA to increase processing capacity from two to four production runs per week. At the same time an improvement process was undertaken to improve the process yield and the reliability. Since April 2011, ANSTO has routinely been running four production runs per week with a consistent and reproducible yield. This remains a complex process and one that needs constant vigilance. The dedication and commitment of the staff continues to play a significant role in this improved capability and reliability. Finished Goods/Bulk export: The bulk Mo-99 is transported to
32 Gamma Gazette December 2011
the finished goods facility where it is either dispensed for export customers or sent into the local facility. For local product Mo-99 is dispensed in a “clean room” environment on to generator columns which are then placed in the shielded Gentech casings ready for dispatch. There is 100% testing of all Gentechs before they are released for shipping to customers. The reliable production of isotopes from ANSTO Health’s facilities has been critical in allowing Australia to avoid recent major shortages of molybdenum-99. While international production has returned to normal, the world’s major radioisotopeproducing reactors are expected to cease operation by 2020 – so the world is turning to Australia to play a crucial role in maintaining international supply. This was demonstrated during May and June this year when the NRU (Canada) was shut down for an extended period as part of its operating conditions, a situation that will occur annually. During this period ANSTO increased production to support the North American demand without impacting its commitment to deliver critical product to the Australian market. The Nuclear
The OPAL Reactor
Energy Agency has noted that international shortages of isotopes experienced around the world in 2009 were least felt in Australia and the Pacific, thanks to reliable production from ANSTO and the efforts of ANSTO Health. ANSTO provides a variety products and services through its commercial divisions such as ANSTO Health. ANSTO Health is a manufacturing organisation that produces radiopharmaceuticals through irradiation of targets in the iconic OPAL reactor and also from bulk isotopes imported from overseas. ANSTO is located in a southern Sydney campus within easy access of the airport. ANSTO Health plays an important role in the nuclear medicine and health industries within Australia, supplying around 550,000 patient doses of radiopharmaceuticals each year that benefit the health of Australians. Products and Indications of key products of ANSTO Health Product
Indication
Mo-99
Bulk export
Gentech/Tc-99m
Organ imaging of the liver, ling, bone, kidney & heart
Sodium Iodide I-131
Hyperthroidism & Thyroid cancer
Quadramet Sm-153
The relief of bone pain in patients with painful osteoblastic skeletal metastases
Chromium Cr-51
The determination of GFR rate
Gallium Ga-67
Hodgkin’s Disease, lymphomas and bronchogenic carcinoma. Acute infections.
mIBG I-123
Dectection, staging and follow-up of neuroblastomas
Thallium TI-201
Myocardial perfusion imaging
Sir Spheres
Un-resectable metastic liver tumours
Reactor Products
Cyclotron Products
3rd Party Manufacture
33
Australian and New Zealand Society of Nuclear Medicine