Sept 2011

September2011 – Issue 3

The Official Publication of the Australian and New Zealand Society of Nuclear Medicine

National Registration ANZSNM ASM Darwin highlights

Contents

www.anzsnm.org.au

Welcome

4

President’s Report

5

Victoria/Tasmania Committee Profiles

6

Branch News ACT

8

New Zealand

8

Victoria/Tasmania

8

Western Australia

8

Nurses

8

Physics

8

SIG

Technologists

10

Accreditation Board

10

What’s That?

12

Original Article Influence of Gated Blood Pool Scans on Management of Oncological Patients

16

A Standardised Technique for Gastrointestinal Transit Evaluation in Paediatrics

21

Case Study Dry Mouth Syndrome

28

Renal Transplant Vascular Thrombosis Masked by Native Kidney Function

29

FET for the Characterisation of Brain Lesions

31

Multi-Modality Confirmation of Splenosis

32

Awards Honorary Life Membership: Dr John McKay

37

Kuhl-Lassen Award 2011: Prof Christopher C Rowe

38

International Awards

40

Society News ANZSNM Annual General Meeting Minutes

42

ANZSNM ASM Conference highlights and report

48

The Age Careers Expo

52

Diary Dates

53

National Registration Update: August 2011

54

Developing a new National Registration Board for MRS

57

ANZSNM Nuclear Medicine and PET Survey Results

61

Professional Indemnity Insurance Survey Summary

62

ANZSNM Research Grant 2012

64

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 see the back of the journal. March – February 1 June – May 1 September – August 1 December – November 1

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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 Victoria/Tasmania Branch Grace Kong Sze Ting Lee

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. 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

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Gamma Gazette September 2011

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. (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.

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

Accreditation Board Chairperson: Members:

All correspondence

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 Ms Sharon Mosley (ACT) email sharon.mosley@act.gov.au 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 Julie Crouch Mr Doug Mackey Mr David Lyall Mr David Thomas

Dr Nat Lenzo Dr Sze Ting Lee

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:

Dr Stefan Eberl, email: eberl@staff.usyd.edu.au

Research Grant Committee Chairperson:

Dr 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 Sarah Stephenson, email: Sarah_Stephenson@health.qld.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

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

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Welcome The Victoria/Tasmania Branch of the ANZSNM has compiled this issue of the Gamma Gazette. Welcome to the third issue of the Gamma Gazette. A sincere thanks to those who have submitted and contributed to this issue. We have a wide spectrum of interesting educational and scientific materials ranging from paediatrics, general nuclear medicine, SPECT/CT and PET cases, to the use of new PET tracers; a true reflection of what nuclear medicine and molecular imaging has to offer in our local setting. We would like to share with you the new ‘Awards’ section which highlights work done by some of our Victorian colleagues that have been recognised and given awards at an international level. This issue provides you an update of some recent Society-related events including National Registration, the recently conducted nuclear medicine and PET survey, and professional indemnity insurance survey. Summaries and photos of some recent exciting events including the Age Careers Expo, and the Darwin ANZSNM conference have also been included. We hope you enjoy this issue. Dr Grace Kong (Chair) Victoria/Tasmania Branch

PAYMENT OF FEES TO ANZSNM Please note that we no longer accept Diners or American Express credit cards. You can continue to use Visa or Mastercard to pay various fees. Alternatively you can still send a cheque or Australia Post Money Order (payable to ANZSNM) to the Secretariat. Membership fees You can join/rejoin/renew using Visa, Mastercard or cheque/money order as above, or pay your membership via the ANZSNM website using PayPal. Please read your membership renewal notice carefully when you receive it in December for the methods of payment available at that time. Further changes in payment options for all fees will occur when the new ANZSNM website is up and running. You will be advised of these changes and when they will be coming into operation. Any questions, please contact: Judi at the Secretariat 03 9756 0128 or anzsnm@21century.com.au

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Gamma Gazette September 2011

President’s Report Welcome to the 3rd edition of Gamma Gazette It is with great pleasure that I invite you all to read it, as it has been diligently put together by the Vic/Tas branch, under the expert guidance and organisation skills of the Branch Chair, Grace Kong. This edition would not have been possible if not for the contributions from all members. There are new sections, lots of Society news and many tantalising photos as well. There is an update on the National Registration Process, and I take this opportunity again to congratulate Mark Marcenko and Susan Baldwin for being appointed as the NM Technologist representatives on the Medical Radiations Practitioners Board of Australia (MRPBA). We now await the outcome of the Australian Medical Radiation Sciences Accreditation Council (AMRSAC), which has now been established and seeking 3 Directors with Nuclear Medicine experience. Applications for this closed on 26th August 2011. The biggest Society event which has happened since the last Gamma Gazette, has been the 41st Annual Scientific Meeting held in Darwin from July 16-18, with a sold out pre-conference in Kakadu on July 14-15. This is the first time that the annual conference was held in Darwin, and I remember when it was suggested that Darwin host the meeting, there was much enthusiasm from our Sydney colleagues, Paul Roach and Dale Bailey to convene this meeting. But perhaps it was the attraction of our pre-eminent invited speakers, or the hidden gems in this relatively uncharted territory in Australia, or perhaps it was the image of our convenors in their very attractive shorts on the website, which brought a huge crowd of >400 people to the conference, which exceeded our expectations. This was undoubtedly a huge success, from the Pre-conference in Kakadu to the Darwin Convention Centre and the invigorating Gala dinner at Pee Wee’s, which was more memorable for some than others. I would also like to take this opportunity to thank our sponsors for their ongoing commitment to our annual meeting, as without their generosity, this meeting would be unaffordable for our small community. For those of us who had the opportunity to go to the Northern Territory, it was an absolutely wonderful experience where the locals were warm and friendly, and it was not only an educational time but also extremely enjoyable. There is no doubt in my mind that the Organising Committee have made it an adventure for many of us who had the privilege of attending this meeting, and it has been quoted as being the “best ANZSNM Meeting ever”, which was echoed throughout the meeting, even from our harshest critics. So I’d like to congratulate the Organising Committee on this resounding success, particularly in organising it by remote control from Sydney, and working with our new Professional Conference Organisers as well. So, while it will be a very tough gig for us Melbournians to follow, we will do our best in 2012. On that note, I invite you all to save the dates for the next Annual Scientific Meeting in Melbourne, which will be held April 28-30 at the Melbourne Exhibition & Convention Centre in South Wharf. There will be a focus on continuing education sessions and a bumper poster session, with new initiatives. Please follow the link www.ansznm2012.com.au for more information. I hope to see many of you in Melbourne next year, but in the meantime ... Happy Reading the Gamma Gazette. Dr Sze Ting LEE President

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Meet the VIC/TAS Committee members

Photo from left to right: Marcia Wood, Grace Kong, Sze Ting Lee, Maria Triantafillou, Bridget Chappell, Gurinder Mudher Absent: Zlata Ivanov, Daniel Rossiter

Dr Grace Kong ANZSNM Vic/Tas Branch Chair Nuclear Medicine Physician Peter MacCallum Cancer Centre, East Melbourne, Victoria

Dr Sze Ting Lee ANZSNM President & Vic/Tas Branch Federal Council Representative Nuclear Medicine Physician Austin Health, Heidelberg, Victoria

Ms Bridget Chappell ANZSNM Vic/Tas Branch Secretary Senior Technologist - Clinical Trials and Research Austin Health, Heidelberg, Victoria

Ms Maria Triantafillou ANZSNM Vic/Tas Branch Treasurer Nuclear Medicine Technologist Southern Health Care Network, Clayton, Victoria

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Gamma Gazette September 2011

Meet the VIC/TAS Committee members Ms Marcia Wood ANZSNM Vic/Tas Branch Acting ANZSNMT Victorian Representative Senior Technologist - Clinical IT & Computing Austin Health, Heidelberg, Victoria

Mr Gurinder Mudher ANZSNM Vic/Tas Branch Committee Member Product Specialist (BSc Nuclear Medicine) Sirtex

Dr Zlata Ivanov ANZSNM Vic/Tas Branch Committee Member Australian Radiation Protection and Nuclear Safety Agency (ARPANSA), Yallambie Victoria

Mr Daniel Rossiter ANZSNM Vic/Tas Branch Tasmanian Representative Nuclear Medicine Technologist Northern Nuclear Medicine, NW Medical Centre, Brickport Road, Burnie, Tasmania

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Branch News AUSTRALIAN CAPTIAL TERRITORY WE are nearly at a year since the introduction of PET and it has been progressing well with the increasing availability of the PET/CT suite at The Canberra Hospital which has offered easier access to PET facilities for Canberra as well as the catchment area without the need to travel to Sydney. The ACT Branch was well represented at the 41st Annual Scientific Meeting in Darwin at the conference social events as well as in the crocodile tanks! Following the conference in Darwin we had Professor Leonard Freeman from the USA speak at our branch meeting and reiterate the positive aspects of V/Q scans versus CTA. Veteran Nuclear Medicine Technologist Chris McLaren has stepped down as the ACT representative on the TSIG and has been replaced by Ashlee Kimball. Thank you to Chris for all your hard work and dedication over the years and good luck to Ashlee in her new role. We would also like to thank Zachary King for his service as Branch Secretary. He has since moved to enjoy the sunshine in Brisbane. Craig Collins Secretary NEW ZEALAND WE are very grateful to Pru Burns from Pacific Radiology in Wellington for organising the post Darwin visit by Homer Macapinlac on July 19. Those of you who were in Darwin and heard Homer’s presentations will know what an interesting and enjoyable speaker he is. James Hayes from the Christchurch Polytechnic Institute of Technology organised an interactive videolink with groups in Auckland and Christchurch which enabled a much larger audience to benefit from Homer’s extensive experience. Our next gathering will be the 2011 ANZSNM NZ Branch Meeting in Wellington, November 5 & 6. This year the focus is on Oncology and Sports Medicine. We hope many of our colleagues from Australia will come over and join us. Details about the meeting can be found on the ANZSNM website. Dianne Wills Secretary VICTORIA/TASMANIA THE Victorian/Tasmanian branch participated at the Age Careers Expo for the first time, which was held on 6-8 May 2011 at the Caulfield Racecourse. The aim of this event was to promote Nuclear Medicine as a career option especially for technologists, and the target audience who attended the expo was senior secondary school students. We generated good interest and response. Sincere thanks to all the fifteen enthusiastic volunteers who helped to enable smooth and successful running of the event. A separate report (with photos) of this occasion is available within this current issue of the Gamma Gazette. We have initially planned for two scientific meetings in July 2011. Unfortunately Prof Brian McIver (Mayo Clinic, USA) was unable to come to Melbourne for a pre-conference talk due to personal reasons. However, we had the pleasure to invite Prof Dr Bernd Pichler (Head of the Laboratory for Preclinical Imaging and Imaging Technology at University of Tübingen Germany) for a post-conference talk on Tuesday July 19. This was held at the Peter MacCallum Cancer Centre and he shared with us his view on ‘The next generation of PET/CT’. Our next scientific meeting will be our Annual Day Seminar which is planned for Saturday 22nd October 2011 at the Royce Hotel in Melbourne. We have confirmed a series of expert speakers for this meeting who will cover a range of interesting topics including paediatrics, PET, sports medicine and the recent Japan Fukushima incident. More details on this meeting will follow, and we look forward to seeing many of you there. Dr Grace Kong Branch Chair WESTERN AUSTRALIA AS Teck mentioned in the last report, our Cardiac Imaging Workshop was held in May with a great line-up of speakers and plenty of interest among the Nuclear Medicine community. The visiting speakers, Dr Nathan Better from Melbourne and Anne McClenahan from Sydney, kept us entertained as well as informed. Thanks to the sponsors for the Workshop: Siemens, GMS, GE Medical and the ANZSNM. Thanks also to the Committee for their great organisation. Another inter-hospital meeting was held on July 5 with several interesting cases and updates from Dr Tony Hayes on his attendance at the SNM meeting in June, and from Dr Russell Troedson who had attended a couple of conferences in Europe. Angela Osley gave her paper, “Accelerated Protocol for 99mTc-MIBI Rest Myocardial

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Gamma Gazette September 2011

Imaging,” which she was to present in Darwin in the Mallinkrodt Award session. Refreshments for the meeting were kindly sponsored by GMS. We were very pleased and privileged to have a talk by Dr Philipp Kaufmann in Perth on the Monday after the end of the conference. Indeed there were quite a few of us on the plane to Perth that afternoon and I wondered if we were going to make it to the meeting venue in time. However it was well-timed by Geoff Roff and we arrived as planned. WA was well represented in Darwin with six oral papers and several posters. A post conference meeting will be held at Oceanic Imaging on 20 September so we should have plenty of information coming from the attendees of the wonderful Darwin meeting. A couple of changes on the Committee – Dr Teck Siew has resigned and Stephanie McMahon has been coopted by the Committee to take his place and to help Georgina with the secretarial duties. The very efficient Georgina goes on maternity leave this week but will stay active in the Committee. Diane Cheong WA Branch Chair

Special Interest Group News NURSES THE 41st Annual ANZSNM Meeting held in Darwin on July 17 was very productive. The attendance by both public and private sector nurses contributed a positive input and some interesting topics were introduced to be included in next meeting to be held in Melbourne in April 2012. Suggestions put forward for possible topics for the presentations were Radiation Safety, CT contrast, Thyroid treatment and scans, and sedation policy. Hopefully there will be available speakers to deliver these presentations from their expert area. There was also discussion about emergency trolley – whether the nurses are expected to be proficient in the use of items on the resuscitation trolley. The presentation by Mr Erwin Lupango on Lexiscan (Regadenoson) will be in next edition of Gamma Gazette. It was very interesting and I would like members to log on to the website to read it. The Darwin meeting minutes are on the website as well. I would like to invite members to contribute their input or any suggestions to myself or to the President, our contact details are on the website. We are just about seven months away from the next meeting in Melbourne so please start thinking and planning ideas to present at that meeting. Looking forward to seeing you all in Melbourne. Satinder Kaur Secretary/Treasurer

PHYSICS I thought I would open this report with a reminder of what the Physics SIG is and what we do. Although constitutionally a bit wordier, the objectives of the Physics SIG are simply (1) to seek and encourage best practice in the application of physics to nuclear medicine, and (2) to communicate with other professional groups in the Society by encouraging participation in SIG activities and through regular reports, such as this. Any member of the Society can be part of the Physics SIG via associate membership, although to vote on items you must be an ordinary member and this requires you to be a practicing nuclear medicine physicist. It might be worth knowing that most of the physicists of the Physics SIG are professionally represented by the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM). This representation by another body puts us in the nice position of being here for the science, clinical practice, and camaraderie, not to wave a political flag. The 2011 ANZSNM Physics SIG meeting was held in Darwin on Saturday July 16. It consisted of formal presentations followed by the Physics SIG AGM. Bernd Pichler of the University of Tübingen (Germany) presented on the very topical subject of “An overview of the site requirements and infrastructure issues in the establishment of PET/MRI in research and clinical settings”; Philipp Kaufmann from the University Hospital Zurich (Switzerland) presented on “Organ specific cardiac imaging”. Steve Meikle of the Brain Research Institute (Sydney) presented “Research and development on simultaneous imaging and behaviour measurements in animal models”, and Mark Reinhard from ANSTO (Sydney) discussed “The national standard for the Becquerel – exploring traceability options”. Thanks to Matthew Griffiths for chairing the meeting and AGM, and for his work over the past two years as Chair of the Physics SIG. The committee elections at the AGM mean I have the pleasure of working with Chithradevi Sathiakumar as Treasurer and Sylvia Gong as Secretary, with Graeme O’Keefe helping with the

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Special Interest Group News important task of Physics SIG representative to the Federal Council. In addition to the Physics SIG session at the ASM, we normally try to hold an annual Physics SIG Symposium. Last year it was combined with the annual meeting of the ACPSEM in Melbourne and Richard Smart presented a comprehensive review of this meeting in the March 2011 issue of the Gamma Gazette. The plans are not yet finalised for the symposium this year, but it looks set to be a hot topic in oncology imaging. Be on the lookout for further details. Most of the PowerPoint slides from past symposium talks are on the “Continuing Education Physics SIG Workshops” page of the ANZSNM Physics SIG section of the ANZSNM website. Finally, over the next couple of years the Physics SIG looks forward to working closely with the Technical Standards Committee on projects such as a review of the minimum QC standards for SPECT (including SPECT-CT), and standardisation on minimum QC requirements for PET. Darin O’Keeffe Chair, Physics SIG TECHNOLOGISTS THE ANZSNMT held its annual symposium this year in Adelaide at the conference centre at Adelaide Zoo on Saturday May 21. We had 65 attendees with a great range of topics covered including SPECT/CT, PET/ CT, V/Q SPECT, interesting case studies and an update on national registration, and enjoyed lunch with the pandas. All presentations generated lots of discussion, sometimes controversial. We would like to thank our sponsors, without their support these meetings would not be possible. Next year’s venue will be Hervey Bay in Queensland, including a one-day symposium and half-day whale watching trip to be held August 11, 2012. The membership of the committee has seen many changes over the last six months. On behalf of the committee I would like to thank Rick Hampson for his hard work over the last several years as both the WA representative and the Treasurer for the committee. Welcome to Diane Cheong as the new WA rep and Marcia Woods as the new Victoria rep. The current executive and membership for the TSIG is as follows: ÊÊÊUÊ > ÀÊEÊ -7ÊÀi«Ê âÊ > iÞÊ UÊ-iVÀiÌ>ÀÞÊEÊ <ÊÀi«Ê *ÀÕiÊ > iÀÌ ÊÊÊUÊ/Ài>ÃÕÀiÀÊEÊ+ `ÊÀi«Ê -ÕÃ> Ê > `Ü Ê UÊ6 VÌ À > ÊÀi«Ê >ÀV >Ê7 `à ÊÊÊUÊ- ÕÌ Ê ÕÃÌÀ> > ÊÀi«Ê V Ê >À > Ê UÊ7iÃÌiÀ Ê ÕÃÌÀ> > ÊÀi«Ê > iÊ i } ÊÊÊUÊ/>à > > ÊÀi«Ê V Ê >ÜÀi ViÊ UÊ /ÊÀi«Ê à iiÊ L i Following many years as the ACT representative on the TSIG, Chris McLaren has decided to step down from this post. Chris has worked tirelessly for both the TSIG and Society for many years and was directly involved in the development of the current CPD program. On behalf of the committee, I would like to acknowledge his hard work and thank him for his expansive contribution to the technologist profession. Thanks to all those who attended the Technologists Symposium at the Darwin conference. We had some fantastic presentations that were of a very high standard. Congratulations to Rebecca Wyborn who won the Radpharm Award for her case study presentation titled Cardiac 123I-MIBG Scintigraphy, and Culann Farrell the winner of the Mallinkrodt-Covidien Award for his presentation titled Modified In-Vivtro Red Blood Cell Labelling Using a Single Polyurethane Intravenous Cannula. Now is the time to start thinking about entering one of the awards for presentation in Melbourne 2012 . Liz Bailey Chair, ANZSNMT

Accreditation Board News The Accreditation Board met in Darwin on Wednesday July 13, just prior to the annual conference. THREE applications for assessment of overseas qualifications have been received since the April meeting. Two applicants were assessed as eligible to sit the OQA exam but the third needs to successfully complete the IELTS (English language) test before being eligible. There have been some changes to the exam to include scenario questions in addition to the MCQ. The AB recently participated in a teleconference with the Department of Education Employment and Workplace Relations to review the ANZSNM process for assessing overseas qualifications. The ANZSNM continues to meet the standards set by DEEWR. Accredited Technologists are advised to check CPD requirements in their state because some regulatory authorities work their CPD on an hours basis, so technologists may need to record that information as well as the points used by the ANZSNM for revalidation. If you are going on maternity leave, please apply

10 Gamma Gazette September 2011

for leave of absence from the ANZSNM CPD program. The CPD package will no longer be produced as the Gamma Gazette now offers opportunities for technologists to gain CPD points. There are currently four Nuclear Medicine Science programs at different stages of the accreditation assessment process. U The Accreditation Review Team (ART) has already commenced the approval process for the University of South Australia and a site visit was undertaken on 4th & 5th August. U Charles Sturt University commenced a four year undergraduate degree in 2011 and the ART will visit the university on 1st & 2nd September. U Royal Melbourne Institute of Technology full accreditation for its undergraduate 3-year program expires in 2011. The ART will visit the university in October to assess the 3-year program and the new postgraduate 2-year Masters program. U Dates for the assessment of The University of Newcastle undergraduate program are still to be confirmed. The Nuclear Medicine Technologist/Science Scope of Practice Review has received feedback on the Competency Based Standards and the survey to the profession has been complete. The next stage in the process is to form an expert panel to review the documentation. The review should be complete by early 2012. The Accreditation Board has written to the Australian Institute of Radiography to commence discussions regarding Nuclear Medicine Technologists having access to sit the MRI exam. It is expected that the ANZSNM will meet with the AIR in the near future. The Accreditation Board would like to give a special thanks to the mentors of the PDY Program. Unfortunately there was no time to arrange thank you drinks at the Darwin conference due to a packed program. The drinks will definitely be organised for the Melbourne conference. The new PDY Mentor feedback forms were introduced earlier this year and we have received positive feedback. The HURSOG course was part of the Darwin program and will also be included in the Melbourne conference in 2012. A separate report on National Registration is included in the Gamma Gazette. The Accreditation Board would like to give a special thanks to Jim Norman who has completed his term on the Board. Jim has contributed to the Board in a number of roles including Secretary, CPD co-ordinator and part of the Assessment Review Team for course accreditation. Applicants for a new board member have been received and have been circulated to the relevant groups for review. Julie Crouch Chair, Accreditation Board Congratulations to the following technologists who were granted Accreditation at the Board meeting in Darwin: McMAHON, Stephanie Leanne SMITH, Reuben William Congratulations also to the following technologists whose Accreditation has been revalidated following submission of CPD points: ARUNDELL, Kirsten BINIAKOS, Kathleen BRETTSCHNEIDER CHEN, Stephanie CHRISTY, Alison DAHER, Nicholas DAVEY, Sarah DUNCAN, David DUNLOP, Rachael FITZPATRICK, Renai

FRECKER, Sarah FREEBORN, Adam HANSEN, Lisa HASSALL, Sharn HEALEY, Seth HECTOR, Bradley HIMALAYA, Janet HOLLOW, Amy HUGHES, Jodie KIRTLEY, Amy LAVENDER, Christopher LE, Khang LIPINSKI, Andrew LOU, Antonio McCLENAHAN, Anne MITCHELL, Estelle Nola MEYER, Alexandra NEESON, Leah O’HALLORAN, Kylie PETTS, Tania STAFFORD, Angela TESTA, Christian

TRAVISS, Zoe-Beth URMERSBACH, Lauren VERDINI, Susan WATT, Katrina WHALAN, Kirrili WEINERT, Nikki WILSON, Sarah At the July meeting, the following departments were granted re-accreditation for the training of PDY technologists: Midland Nuclear Medicine – Cert. #87 Nuclear Medicine WA, Perth Radiological Clinic – Cert. #132 Guy’s & St Thomas’ (UK) – Cert. #133 Bendigo Radiology Nuclear Medicine – Cert. #137

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Answer on page 34

A: Whatâ&#x20AC;&#x2122;s that? Daniel Rossiter Dr Ruth Winterton Northern Nuclear Medicine, Burnie, Tasmania

An Unexpected Discovery in Paediatric Bone Scan

8-year-old boy, presents with pain in the left ankle for 2 months. An X-ray of the left ankle showed mild bony irregularity in the antero-medial metaphysis of the distal left tibia, which was reported as a probable normal variant. A bone scan was suggested to exclude an active bony lesion. The patient presented to the Nuclear Medicine Department, and appeared to be limping slightly, with most of his weight on the left leg â&#x20AC;&#x201C; causing subsequent left ankle pain.

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Answer on page 35

B: What’s that? Dr Shakher Ramdave, Merrin Angwin, Maria Triantafillou Department of Nuclear Medicine, Southern Health Care Network. Victoria Australia Clinical Notes: 59-year-old male, smoker, 2 weeks of dysphagia, dysphonia. Ultrasound showed hepatomegaly, metastatic disease. Cervical lymphadenopathy. Blood tests showed low calcium level and high phosphate. Procedure: Bone scan was performed. Dose of 853MBq Tc–99m HDP was administered intraveously. Early whole body blood pool, delayed whole body images (figure 1) and SPECT/low dose CT from mid thorax to mid abdomen (figure 2, 3 and 4) were performed. WHOLE BODY BONE SCAN

Lt Posterior Rt

Rt Anterior Lt

WHOLE BODY BONE SCAN

Lt Posterior Rt

Rt Anterior Lt

Figure 1: Whole body blood pool and delayed scan.

Figure 2 SPECT/Low Dose CT

Figure 3 SPECT/Low Dose CT

Figure 4 SPECT/Low Dose CT

What is the pathology?

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Answer on page 36

C: What’s that? Marcia J Wood NMT, Dept of Nuclear Medicine & Centre for PET, Austin Health, Heidelberg, Victoria

Thyroid Lump for Investigation: A Case Study

Case Study: 79-year-old female with 3cm x 2cm thyroid lump for investigation. Query “hot” or “cold”. (A)Tc-99m Pertechnetate thyroid image shows a large “cold” nodule within the right lobe of the thyroid. (B) US transaxial slice through the Rt lobe of the thyroid shows a large cyst corresponding to the Tc-99m Pertechnetate images (yellow arrow), measuring 2.7 x 2.2 x 3.2 cm, with no associated calcifications. Multiple smaller nodules, both solid and cystic were seen through both the right and left lobes of the thyroid. (C) No abnormal vascularity was seen on Doppler imaging. (Images courtesy Dept. of Nuclear Medicine and Dept. of Radiology, Austin Health).

Q1: Based on the 3 images, what pathology does this patient present with? Q2: What is the likelihood of the cold nodule being malignant in this case? Q3: What factors influence whether a nodule is more likely to be benign or malignant? Q4: What are the most common causes of “cold” nodules? Q5: What techniques are available to further investigate “cold” nodules?

14 Gamma Gazette September 2011

Answer on page 35

D: What’s that? Marcia J Wood NMT, Dept of Nuclear Medicine & Centre for PET, Austin Health, Heidelberg, Victoria

Biliary Scintigraphy – To augment or not?

Case Study: (A) Initial 3 second dynamic images show prompt tracer uptake within the liver. Subsequent summed 2 minute show normal passage of tracer into hepatic ducts, common bile ducts and small intestine. After 60minutes of imaging, no activity is seen in the gallbladder. A “Rim Sign” is seen in liver adjacent to the gall bladder fossa (arrow). Q1: What is the normal appearance for a biliary study? Q2: What is the significance of the “Rim Sign” seen in the images? Q3: No gallbladder is seen after 60 minutes. What further imaging is required to reach an accurate diagnosis? Q4: What are the advantages and disadvantages of using Morphine Augmentation? (B) A second dynamic series over 1 hour was commenced, and 4 mg of morphine injected at the end of the 2nd minute.

Q5: Based on the second series of images, what is the diagnosis?

15

Original Article

,QÁXHQFH RI *DWHG %ORRG 3RRO 6FDQV RQ 0DQDJHPHQW RI 2QFRORJLFDO 3DWLHQWV Edward H. Wang1, Dishan H. Gunawardana2, Meir Lichtenstein2 Royal Melbourne Hospital ABSTRACT Purpose: The aim of this study was to evaluate the influence of gated blood pool scans (GBPS) on oncologists’ management of chemotherapy patients. Materials and Methods: A retrospective study was performed on a total of 176 breast cancer, leukaemia, lymphoma and myeloma patients treated with anthracyclines or trastuzumab who had sequential resting GBPS, within two years of each other. Results: In the study 3% of patients developed congestive cardiac failure (CCF). Change of management occurred in 7.4% of patients. Change of management was due to symptoms of CCF in 1.7% of patients and due to drop in left ventricular ejection fraction (LVEF) on GBPS in 5.7% of patients. Change in management resulted in a mean increase of 5% in LVEF. During monitoring, 35% of cancer patients had some reduction in LVEF. Conclusions: GBPS can predict the development of CCF. Management change based on a fall in LVEF can result in subsequent improvement in LVEF.

Key Words: Gated Blood Pool Scans, GBPS, LVEF, Cardiotoxicity, Anthracyclines, Trastuzumab

INTRODUCTION Gated blood pool scans can be used to evaluate cardiac function when administering potentially cardiotoxic chemotherapy, such as anthracyclines or trastuzumab.1 In order to pick up early cardiotoxicity before development of congestive cardiac failure (CCF), regular scans are used to detect decreases in left ventricular ejection fraction (LVEF).2 Anthracyclines and trastuzumab (Herceptin) are highly effective anti-cancer agents administered to many cancer patients. Gated blood pool scans (GBPS) are also known as multiple gated acquisition scans, or equilibrium radionuclide angiography (ERNA). Resting LVEF values derived from these scans are, despite their limitations, “the most widely used monitoring method for early anthracycline-induced cardiotoxicity”.1 Though many studies conclude that regular GBPS scans can prevent or predict CCF in cancer patients treated with anthracyclines3-6, there is still some disagreement about this7-8. In addition, most of the literature deals with the efficacy of GBPS in predicting anthracycline-induced cardiotoxicity, rather than trastuzumab-related CCF. This may be due to the relatively recent introduction of this agent, or because trastuzumab cardiotoxicity is thought to be reversible9-10. There is little literature that focuses on the influence of GBPS on patient management, other than a study by

Royal Melbourne Hospital, Grattan St, Parkville, Victoria 3050, Australia 1 School of Medicine, University of Melbourne, Parkville, Victoria, Australia 2 Nuclear Medicine Department, Royal Melbourne Hospital Address for Reprint Requests and corresponding author: Dishan Gunawardana, Department of Nuclear Medicine, Royal Melbourne Hospital, Grattan St, Parkville, Victoria 3050, Australia Telephone number: 61 3 9342 7480 Fax number: 61 3 9342 7342 Email: dishan.gunawardana@mh.org.au

16 Gamma Gazette September 2011

Peng et al.11 Furthermore, different studies show different incidences of cardiotoxicity in patients, and few studies state what proportion of patients experience any decline in LVEF on sequential GBPS. This study was conducted to analyse if GBPS can predict cardiac failure in anthracycline and trastuzumab treated patients and how often a fall in LVEF occurs in these patients. This study was also conducted to determine how GBPS influences patient management and the effectiveness of that management change.

METHODS Patients who had GBPS performed at the Royal Melbourne Hospital, Melbourne, Australia, between 25th January 1993 and 7th October 2008 were retrospectively reviewed. The inclusion criteria were that patients had at least two GBPS performed at our institution between 25th January 1993 and 7th October 2008 with the first scan performed before 6th July 2007 to allow for at least one year of followup and that less than two years had elapsed between at least two sequential scans to ensure that the scans would not monitor two different cancers. The patients had lymphoma, leukaemia, myeloma or breast cancer and had received treatment with anthracyclines, trastuzumab or both. For patients who had two courses or more of therapy monitored by GBPS scans which occurred more than 3 years apart from each other, only the first course was included for analysis. After reviewing their medical records, 176 patients were divided into three categories: “Anthracycline”, “Trastuzumab” and “Anthracycline and Trastuzumab”, depending on what therapy they were on when monitored by GBPS. Patients classified as “Anthracycline and Trastuzumab” patients had anthracyclines and trastuzumab within three years of one another. GBPS were performed after in vitro red blood cell labelling with technetium-99m (injected dose was proportional to body weight 800MBq [21.6mCi] for a 70kg patient). Left anterior oblique views

,QÁXHQFH RI *DWHG %ORRG 3RRO 6FDQV RQ 0DQDJHPHQW RI 2QFRORJLFDO 3DWLHQWV

were obtained and recorded in 24 intervals (gates) beTable 1: Patient Demographics tween the R waves of the cardiac cycle by an E-CAM or Breast Symbia (Siemens, Erlangen, cancer Germany) gamma camera. n=80 For this study, change in Age (years) management was defined as: (a) a reduction in dosMean 49.6 age of chemotherapy due to Range 30-73 cardiac symptoms or decline in LVEF; (b) cessation of treatment of chemotherapy Sex due to cardiac symptoms Male 0 or decline in LVEF or (c) Female 80 commencement of heart failure medication such as angiotensin-converting enTherapy zyme (ACE) inhibitors for Anthracycline only 47 chemotherapy-induced cardiomyopathy or drop in LVEF, Trastuzumab only 11 as noted in the medical reAnthracycline and cord. CCF was defined as a trastuzumab 22 note in the medical record of chemotherapy related cardiac failure. The GBPS results of patients were reviewed to see how many patients experienced a reduction in LVEF. An LVEF below 50% was considered to be below normal. For this study, a drop in LVEF was defined as any drop on sequential GBPS that fulfilled one of the following criteria: (a) a decline in LVEF of *5% to )50%; (b) a decline in LVEF of *10% to )60%; (c) a decline in LVEF of *15% to )65%. GBPS were said to predict CCF if patients developed CCF after a drop in LVEF. Patients with a drop in LVEF were said to have a “positive” GBPS, while patients without a drop in LVEF were said to have “negative” GBPS. The pre-chemotherapy LVEF and post-chemotherapy LVEF were also recorded. The pre-chemotherapy LVEF was defined as the LVEF found on GBPS within 3 years before the first cycle of anthracycline and/or trastuzumab chemotherapy, or the LVEF of the earliest scan found that was performed during chemotherapy. The post-chemotherapy LVEF was defined as the lowest LVEF after the last dose

Lymphoma n=41

Leukaemia n=49

Myeloma n=6

All patients n=176

45.4

42.7

48.5

46.7

18-77

18-72

26-66

18-77

23

26

5

54

18

23

1

122

41

49

6

143

0

0

0

11

0

0

0

22

of chemotherapy, or the most recent LVEF if chemotherapy had not been completed. RESULTS Demographics Patient demographics are shown in Table 1. The majority of patients in this study, 81% (143/176), were on anthracycline therapy, while 6% (11/176) were on trastuzumab therapy and 13% (22/176) were on anthracycline and trastuzumab therapy. Chemotherapy doses were available in 42 patients who had been administered anthracyclines. Of these 42 patients, the mean dose of doxorubicin in 19 patients was 222mg/m2 and the median dose was 236mg/m2, the mean dose of epirubicin in 22 patients was 599 mg/m2 and the median was 600mg/m2, and the dose of idarubicin in 1 patient was 54mg/m2.

Table 2: Characteristics of CCF Patients

Chemotherapy PN regimen

Date of last anthracycline or trastuzumab chemotherapy

CCF date

LVEF (%) on scans performed in last 6 months before CCF

Pre-chemotherapy LVEF (%)

Scan predictive?

Largest LVEF drop (%) before CCF

1

A

06/2000

12/2000

51

62

Yes

62 --> 51

2

A

11/1992

10/2005

None performed

58

Yes

58 --> 38

3

A

01/2007

06/2007

43

54

Yes

54 --> 43

4

A+T

07/2005

02/2006

38, 44

58

Yes

62 --> 38

5

A

11/2007

11/2007

54

51

No

No LVEF drop before CCF

CCF, congestive cardiac failure; LVEF, left ventricular ejection fraction; PN, patient number; A, anthracycline; A+T, anthracycline and trastuzumab.

X 17

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Table 3: Patients Who Had a Change in Management n = 13 Age (years) Mean

56

Range

36-72

Sex

11 female 2 male

Cancer type

9 breast cancer 3 lymphoma 1 leukaemia

Chemotherapy type

9 anthracycline 2 trastuzumab 2 anthracycline and trastuzumab

Change in management

4 had ACE inhibitors and/or frusemide commenced 6 had chemotherapy ceased or changed 3 had both

Cause of change in management

10 had a fall in LVEF on GBPS 3 had CCF symptoms

Pre-chemotherapy LVEF (%) Mean

54

Range

43-62

Post-chemotherapy LVEF (%) Mean

46

Range

36-54

No. of patients that developed CCF

5

Congestive Cardiac Failure Five patients in the study developed CCF (Table 2). Four patients were on anthracyclines and one was on anthracyclines and trastuzumab. The incidence of CCF in the sample was 3% (5/176). The incidence of CCF in the anthracycline patients was 3% (4/143), in trastuzumab patients 0% (0/11), and in anthracycline-and-trastuzumab patients 5% (1/22). Four out of 5 of the patients experienced a significant drop in LVEF before development of CCF. CCF occurred within a month of a cycle of chemotherapy in 1 patient, within a year of chemotherapy in 3 patients, and 13 years after chemotherapy in one patient. There were no recorded deaths from CCF. Change in Management Change in management occurred in 13 patients (7.4% of all patients), as shown in Table 3. In 10 of these patients (5.7% of all patients) the change in management occurred due to changes in LVEF on GBPS, while in 3 patients (1.7%) changes in management were triggered by the symptoms of CCF. In 4 patients ACE inhibitors and/ or frusemide were commenced, in 6 patients chemotherapy was ceased or changed and in 3 patients both occurred. In the patients where change of management occurred due to a fall in LVEF, the reduction was at least 5% to an LVEF of less than 55%. In the study, 35% (62/176) of cancer patients had a drop in LVEF

18 Gamma Gazette September 2011

during monitoring (Table 4). Using Fisherâ&#x20AC;&#x2122;s exact test, a statistically significant correlation between change in management and drop in LVEF was found (p < 0.001). However, of the 62 patients who had a drop in LVEF, only 14 had post-chemotherapy LVEF measurements below 50%. This may explain why the majority of patients with a drop in LVEF did not have their management altered. All of the CCF patients had their management changed. We also found that the average pre-chemotherapy LVEF was 64% and the average post-chemotherapy LVEF was 59%. However, the average pre-chemotherapy LVEF and post-chemotherapy LVEF for change-in-management patients and CCF patients were lower than the average pre-chemotherapy and post-chemotherapy LVEF for other patients (Table 5). The average LVEF of CCF patients on the GBPS scans closest to when they developed CCF was 48%. The average LVEF for change-in-management patients just before they had the change was 45%. Of the 13 patients who had their management changed, 7 had follow-up GBPS. Three of the 7 patients having follow-up GBPS were monitored for a period longer than 3 years, with the others monitored for less than 3 years. The average LVEF of these 7 patients just before their change in management was 42%, and the most recent GBPS of these 7 patients showed a mean improvement in LVEF of +5% to 47%. Only 1 patient had a final LVEF lower than

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were over-represented because their records were retained for longer periods of time. HowTable 4: Change in Management and Drop in LVEF ever, it should be noted that in this study, 4 of the 5 CCF patients experienced a significant No LVEF drop LVEF drop drop in LVEF before development of heart fail(GBPS negative) (GBPS positive) Total ure (Table 2), suggesting that GBPS were efn = 114 n = 62 n = 176 fective in predicting CCF in most patients. This finding is in agreement with those of many studChange in management 2 11 13 ies in the literature.3-6 Unfortunately, our study No change in management 112 51 163 may have an element of incorporation bias, as a diagnosis of CCF may be related more to drops that on the scan preceding the change in management, and this in LVEF on GBPS than symptoms of CCF, so the incidence of CCF patient’s change in management was cessation of trastuzumab may be overestimated. It was difficult to compare CCF incidence in trastuzumab patients to other studies due to the small sample size therapy for 2 weeks. In the 6 patients with improved LVEF on follow-up scans, their of trastuzumab patients. Some patients in this study were also treated with cyclophosphamanagement change was: 2 had chemotherapy changed, 2 received cardiac medication and 2 had both. No significant difference was mide, which is known to be cardiotoxic at high doses. However, as seen in terms of LVEF recovery between these patients. However, noted by Swain et al., at conventional doses the effects are small and will make little difference to the incidence of CCF.8 the patient numbers were too small for subanalysis. A proportion of patients in this study were treated with mediastinal radiotherapy, which has been associated with anthracycline cardiotoxicity.15 Unfortunately, radiotherapy details in the medical DISCUSSION records analysed for this study were unclear or incomplete, with GBPS are recommended to monitor cardiac function in guidelines dosages, dates and locations sometimes missing. Therefore, radiofrom the American College of Cardiology, the American Heart Asso- therapy had to be excluded from the analysis. There are few studies that focus on the influence of GBPS on ciation, and the American Society for Nuclear Cardiology. However, not all studies support their effectiveness in avoiding CCF.7 GBPS patient management. One retrospective study by Peng et al. dealing are relatively insensitive at picking up evidence of early myocardial with this involved 153 patients with LVEF <50%.11 They concluded damage secondary to anthracyclines, as there is little change in that falling LVEF seen on these scans is only one of many factors LVEF until a certain amount of damage has occurred, after which clinicians take into account. Our study found that 13/176 patients there is a rapid decline in function.1,12 Some studies have suggested had a change in management, and in 10/176 (5.7%) patients the this also means that LVEF usually drops significantly before the on- change in management was due to a drop in LVEF on GBPS (Table set of congestive cardiac failure, and that a low LVEF or a substantial 3). In those 10 patients who had their management changed due to drop in LVEF can still identify patients at elevated risk of cardiac drop in LVEF on GBPS, there was a drop in LVEF of at least 5% to less failure.3,4 In this study, the incidence of CCF in anthracycline patients than 55%. This suggests that clinicians are more likely to change was 3% (4/143), similar to the 2.6% incidence of CCF found by Mi- management when there is a significant drop in LVEF to a value tani et al.3 While Mitani et al. concluded that GBPS prevented CCF, near the lower limit of normal, which is usually taken to be 50%. as CCF incidence before routine GBPS monitoring was 7%, some This differs from the finding by Peng et al. that “oncologists use a studies conducted before GBPS were widely used found similar resting LVEF threshold of about 40% to consider withholding cardioincidences of CCF to this study.13,14 Lefrak et al.,13 in a study conduct- toxic chemotherapy”.11 However, it must be noted that their finding is ed without monitoring with GBPS scans, found that 2.8% (11/399) based on analysis of patients with LVEF values of <50%, unlike our of patients developed CCF, an incidence similar to the one found study, which did not select patients with certain LVEF values. In a study that focused on cardiac dysfunction in chemotherapy in our study. Von Hoff et al.,14 in a large study which also did not use GBPS to monitor cardiotoxicity, found that 2.2% (88/3941) of patients, Tan-Chiu et al. reported that 102/714 (14%) of patients patients developed CCF. On the other hand, Swain’s8 retrospective discontinued trastuzumab due to asymptomatic declines in LVEF on analysis of three trials where GBPS was used to monitor patients GBPS scans.16 They found that median LVEF decreased with chemofound that 5.1% (32/630) of patients were diagnosed with CCF and therapy treatment relative to baseline LVEF and that follow-up scans did not support the theory that GBPS can predict CCF. Table 5: Pre-chemotherapy LVEF and Post-chemotherapy LVEF in Patient Subgroups Making comparison even more difficult is the fact that Patients with Patients without the anthracycline dosages change in change in received by patients in this study may differ from those All patients CCF patients management management received by patients in past Mean pre-chemotherapy LVEF 64% 57% 54% 65% studies. In this study, chemMean post-chemotherapy LVEF 59% 43% 46% 60% otherapy doses could not be ascertained in the majority LVEF, left ventricular ejection fraction; CCF, congestive cardiac failure. of patients; patients on highdose chemotherapy trials

X 19

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after trastuzumab cessation due to asymptomatic drop in LVEF showed improvement in LVEF compared to nadir. These findings are similar to those of our study. In our study, we found that postchemotherapy LVEF was lower than pre-chemotherapy LVEF (Table 5). We also found that change-in-management patients had a mean increase in LVEF of 5% compared to the LVEF before management change.However, it must be noted that the study by Tan-Chiu et al. covered only breast cancer patients while we analysed a heterogeneous group of patients, including patients with lymphoma, leukaemia, myeloma, or breast cancer. In addition, their study analysed a trial where patients were managed with pre-determined criteria for discontinuation of trastuzumab based on LVEF drop. Our study, in contrast, looked at patients in a normal clinical setting to determine how patient management was influenced by drop in LVEF. We found that patients who experienced a drop in LVEF were significantly (p < 0.001) more likely to have their management changed than those who did not experience a drop in LVEF. In our study, 35% (62/176) of patients experienced a drop in LVEF during monitoring. However, the LVEF values of many of these patients (48/62) remained above the lower limit of normal value of 50% and thus no management change was required. Past studies have shown that stopping chemotherapy in response to falling LVEF is effective in reducing the incidence of CCF.2,3 This study found change in management could effectively increase LVEF. In this study, the 7 patients who were monitored with GBPS scans after their management was changed had a mean increase in their LVEF values of 5% after the change, indicating a potential benefit from the management change. In conclusion, GBPS can predict CCF in cancer patients. Our study supports previously published studies and shows that monitoring LVEF with GBPS results in management change that improves LVEF.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13. REFERENCES 1. 2.

3.

Shan K, Lincoff AM, Young JB: Anthracycline-induced cardiotoxicity. Ann Intern Med. 1996;125:47-58. Agarwala S, Kumar R, Bhatnagar V, et al: High incidence of adriamycin cardiotoxicity in children even at low cumulative doses: role of radionuclide cardiac angiography. J Pediatr Surg. 2000;35:1786-9. Mitani I, Jain D, Joska TM, et al: Doxorubicin cardiotoxicity: prevention of congestive heart failure with serial cardiac function monitoring with equilibrium radionuclide angiocardiography in the current era. J Nucl Cardiol. 2003;10:132-9.

20 Gamma Gazette September 2011

14.

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16.

Ritchie JL, Singer JW, Thorning D, et al: Anthracycline cardiotoxicity: clinical and pathologic outcomes assessed by radionuclide ejection fraction. Cancer. 1980;46:1109-16. Nousiainen T, Jantunen E, Vanninen E, et al: Early decline in left ventricular ejection fraction predicts doxorubicin cardiotoxicity in lymphoma patients. Br J Cancer. 2002;86:1697-1700. Schwartz RG, McKenzie WB, Alexander J, et al: Congestive heart failure and left ventricular dysfunction complicating doxorubicin therapy: seven-year experience using serial radionuclide angiocardiography. Am J Med. 1987;82:1109-18. Jensen BV, Skovsgaard T, Nielsen SL: Functional monitoring of anthracycline cardiotoxicity: a prospective, blinded, long-term observational study of outcome in 120 patients. Ann Oncol. 2002;13:699-709. Swain SM, Whaley FS, Ewer MS: Congestive heart failure in patients treated with doxorubicin: a retrospective analysis of three trials. Cancer. 2003;97:2869-79. Ewer MS, Vooletich MT, Durand JB, et al: Reversibility of trastuzumab-related cardiotoxicity: new insights based on clinical course and response to medical treatment. J Clin Oncol. 2005;23:7820-26. Guarneri V, Lenihan DJ, Valero V, et al: Long-term cardiac tolerability of trastuzumab in metastatic breast cancer: the M.D. Anderson Cancer Center experience. J Clin Oncol. 2006;24:410715. Peng NJ, Advani R, Kopiwoda S, et al: Clinical decision making based on radionuclide determined ejection fraction in oncology patients. J Nucl Med. 1997;38:702-5. Seidman A, Hudis C, Pierri MK, et al: Cardiac dysfunction in the trastuzumab clinical trials experience. J Clin Oncol. 2002;20:1215-21. Lefrak EA, Pitha J, Rosenheim S, et al: A clinicopathologic analysis of adriamycin cardiotoxicity. Cancer. 1973;32:302-14. Von Hoff DD, Layard MW, Basa P, et al: Risk factors for doxorubicin-induced congestive heart failure. Ann Intern Med. 1979;91:710-7. Pai VB, Nahata MC: Cardiotoxicity of chemotherapeutic agents: incidence, treatment and prevention. Drug Saf. 2000;22:263302. Tan-Chiu E, Yothers G, Romond E, et al: Assessment of cardiac dysfunction in a randomized trial comparing doxorubicin and cyclophosphamide followed by paclitaxel, with or without trastuzumab as adjuvant therapy in node-positive, human epidermal growth factor receptor 2-overexpressing breast cancer: NSABP B-31. J Clin Oncol. 2005;23:7811-9.

Original Article

$ 6WDQGDUGLVHG 7HFKQLTXH IRU *DVWURLQWHVWLQDO 7UDQVLW (YDOXDWLRQ LQ 3DHGLDWULFV 'XQFDQ 0 9H\VH\1 'DYLG - &RRN1 <HH ,DQ <LN2,5,6 6WHSKHQ - 5XWNRZVNL3 %URRNH 6 .LQJ1 7LPRWK\ 0 &DLQ1 &RUDO ) 7XGEDOO1 %ULGJHW 5 6RXWKZHOO4 -RKQ 0 +XWVRQ2,4,5 The Royal Childrenâ&#x20AC;&#x2122;s Hospital, Melbourne

BACKGROUND Constipation is a common problem in childhood, which usually responds to simple treatment regimes. Intractable chronic constipation (CC) occurs in a small subset of these children whose symptoms extend over at least 2 years, and who fail to respond to usual regimes. It is a distressing and disruptive problem for the affected patients and their families, who are often desperate for assistance.

OBJECTIVE To develop a standardised paediatric Gastrointestinal Transit (GIT) study, to identify different patterns of transit in children with CC, to facilitate objective treatment and monitor progress.

METHODOLOGY Since 1998 we have undertaken more than 800 individual paediatric GIT studies employing a standardised radio-labelled meal. This technique is the result of a joint cooperative process between Nuclear Medicine, Gastroenterology and Paediatric Surgery at The RCH, Melbourne. Gastric emptying, small bowel transit and colonic transit can be readily characterised. The data is quantifiable and reproducible. Radiation dose has been minimised, while retaining optimum imaging, with appropriate, weight related doses, and a post-study evacuation regime. The study is completed over 3 days and is readily accepted by patients and their families. The Royal Childrenâ&#x20AC;&#x2122;s Hospital (RCH), Melbourne Protocol â&#x20AC;&#x201C; The study is performed over 3 days (48 hour imaging) â&#x20AC;&#x201C; Patients cease all gastric/colonic motility medication for 5 days prior to, and for duration of the study

Department of Medical Imaging-Nuclear Medicine, The Royal Childrenâ&#x20AC;&#x2122;s Hospital, Melbourne 2 Department of Paediatrics, University of Melbourne 3 Australian Radiation Services Pty. Ltd. 4 Surgical Research Group, Murdoch Childrenâ&#x20AC;&#x2122;s Research Institute, Melbourne 5 Department of Urology, The Royal Childrenâ&#x20AC;&#x2122;s Hospital, Melbourne 6 Division of Paediatric Surgery, Department of General Surgery, Faculty of Medicine, University of Malaya, Malaysia 1

â&#x20AC;&#x201C; Fast (nil by mouth) for 4 hours prior to study (3 hours for infants) â&#x20AC;&#x201C; A single, Ga-67 citrate dose is administered in a liquid meal â&#x20AC;&#x201C; 10400mL full cream milk (or standard formula/lactose-free milk) â&#x20AC;&#x201C; Radiopharmaceutical dose administered is calculated according to patient weight (Table 1) with a dose range of 3 MBq â&#x20AC;&#x201C; 10 MBq (adult dose - 10MBq) Table 1: Example of radiopharmaceutical dose relative to patient weight Weight (kg)

Fraction of Adult dose

)15

0.30

20

0.50

30

0.58

40

0.70

50

0.81

60

0.89

70

0.97

80

1.00

Gastric Emptying Study procedure After ingestion [oral, Naso-Gastric Tube (NGT), Percutaneous Endoscopic Gastrostomy (PEG)] of liquid meal, gastric emptying study is commenced immediately â&#x20AC;&#x201C; Dual opposed head planar static imaging (Anterior and Posterior) â&#x20AC;&#x201C; MEGP Collimation â&#x20AC;&#x201C; Serial static images acquired at T0, T0+30 mins, T0+60 mins, and T0+120 mins â&#x20AC;&#x201C; Consistent radius measurements of camera heads and distance from patient for the remainder of the study (to be noted for future reference) After gastric empty phase (2 hours) patients can resume their normal diet Small Bowel Transit Study procedure Small bowel transit reference image is acquired at T0+6 hours with the same radius measurements of camera heads, and distance from patient, as the gastric empty study Colonic Transit Study procedure Colonic transit reference images are acquired at T0+24 hours, T0+30 hours, and T0+48 hours, with the same radius measure-

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ments of camera heads, and distance from patient, as the gastric empty and small bowel transit studies The patient is asked to document bowel motion(s) during the period of the study, to correlate with loss of activity Data Processing Gastric Emptying Study data Gastric half-emptying time is calculated using background and decaycorrected regions of interest (ROI) drawn around the stomach in T0, T0+30 mins, T0+60mins, T0+120 mins images. T0 and T0+120 mins are used to determine the two hour stomach retention.

Small Bowel and Colonic Transit Study data The geometric centre (GC) at each imaging time is determined by employing six ROI (Figure 1): 52, – pre-colonic - total image activity less colonic activity (after background/decay correction) 52, – caecum/ascending colon 52, – transverse colon 52, – descending colon 52, – recto-sigmoid colon 52, – excreted (total image activity less pre-colonic and colonic activity after background/decay correction)

Figure 1: Demonstration of ROI placement – –

Figure 2:

Counts for each ROI are corrected for decay and background Geometric mean counts are calculated from the background and decay corrected activity in each region, and is expressed as a fraction of total activity – Geometric Centre (GC) of activity.

Geometric Centre (GC) of activity = - (fraction of activity x region number)

PRESENTATION OF RESULTS

Figure 3: An example of the calculation steps - based on ROI at each time interval A: Background and decay corrected counts expressed as a % of total counts for each time point B: Geometric centre (GC) calculation for each time point [e.g. GC calculation at 24 hour = (0.00x1)+(0.19x2)+(0.22x3)+ (0.37x4)+(0.22x5)+(0.00x6) = 0.38+0.66+1.48+1.10 = 3.62] and the GC Index is the sum of all GC’s 22 Gamma Gazette September 2011

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Figure 3: C: Histograms displaying the percentage of the ingested meal present in the pre-colonic, each colonic segment, and excreted, at each time point of imaging D: Patient’s GC data plotted vs. time (with normal range referenced in blue)

Excretion:

0%

23%

32%

90%

Figure 4: Normal colonic transit pattern and corresponding ROI

NORMAL VALUES Gastric emptying: Small bowel transit: Colonic transit:

T½ < 50 mins, 2 hour retention < 15% 6 hour clearance from small bowel > 70% GC Index >13.75, Colonic excretion > 20% @ T0+24 hrs

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Bowel presentation can vary by either diagnosis or colon length (ROI demonstrated â&#x20AC;&#x201C; note: SB = Small Bowel and is pre-colonic, therefore not included in colonic ROI) â&#x20AC;&#x201C; Figures 4, 5 & 6.

Figure 5: Colonic Transit patterns in children with normal colonic length and corresponding ROI

Figure 6: Colonic Transit pattern in a child with elongated transverse colon and corresponding ROI

24 Gamma Gazette September 2011

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Figure 7: Multiple studies on a single patient. Using a template developed in house, all studies are easily displayed for comparison and to determine if there has been a response to various treatments or a relapse of pathology following withdrawal of treatment (Note: normal range referenced in black) Radiation Safety Table 2: Radiation effective dose is dependent on patient weight, and transit time (full excretion) Gallium-67 citrate effective dose (mSv) Age

Weight

Administration

(kg)

activity (MBq)

24

Transit time (full excretion) (hr) 36

48

72

96

120

3

14

3

1.5

2.2

2.8

3.9

4.7

5.4

5

19

5

1.9

2.8

3.6

5.0

6.0

6.9

10

32

6

1.4

2.1

2.7

3.8

4.6

5.2

15

55

8

1.3

1.9

2.5

3.4

4.2

4.7

Adult

>71

10

1.2

1.8

2.3

3.1

3.8

4.3

Following the completion of imaging, the laxative or other regime in place prior to the investigation is reinstituted. If, following the 48 hour images, there is significant colonic retention of activity, bowel disimpaction can be undertaken for radiation dose minimisation.

3. Patient > 12 yrs: 8 sachets per day for 3 days Note: if Movicol® is not tolerated, use Lactulose® and Senna® for disimpaction

KEY MESSAGES Protocol for bowel disimpaction at the end of NTS using Movicol® (macrogol with electrolytes): 1. 3 – 5 yrs: 2 sachets on day 1, then 4 sachets for 2 days, then 6 sachets for 2 days and 8 sachets daily thereafter; 2. 5 – 12 yrs: 4 sachets on day 1, then increase by 2 sachets daily until max of 12 sachets daily;

Meticulous and consistent attention to a standard protocol, patient preparation, positioning, camera acquisition settings, and raw/processed data presentation are required, to achieve accurate and reproducible results. This is necessary for understanding and monitoring transit patterns, and their

25

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responses to various interventions. As there is an increasing Australasian and worldwide interest in a shift to Nuclear Medicine techniques for assessment of Gastrointestinal Transit, the adoption of a simple, standardised format with universal diagnostic criteria would be of considerable benefit to our patients, and the Nuclear Medicine community.

REFERENCES Notghi, A.; R. Hutchinson; D. Kumar; N. Tulley & L. K. Harding (1994). Use of geometric center and parametric images in scintigraphic colonic transit studies. Gastroenterology, Vol. 107, No. 5, (Nov 1994), pp. (1270-7), pp.0016-5085 Chase, J.; V. J. Robertson; B. Southwell; J. Hutson & S. Gibb (2005). Pilot study using transcutaneous electrical stimulation (interferential current) to treat chronic treatment-resistant constipation and soiling in children. J Gastroenterol Hepatol, Vol. 20, No. 7, (Jul 2005), pp. (1054-61),0815-9319 Clarke, M. C.; J. W. Chase; S. Gibb; A. G. Catto-Smith; J. M. Hutson & B. R. Southwell (2009). Standard medical therapies do not alter colonic transit time in children with treatmentresistant slow-transit constipation. Pediatr Surg Int, Vol. 25, No. 6, (Jun 2009), pp. (473-8),1437-9813 Clarke, M. C.; J. W. Chase; S. Gibb; J. M. Hutson & B. R. Southwell (2009). Improvement of quality of life in children with slow transit constipation after treatment with transcutaneous electrical stimulation. J Pediatr Surg, Vol. 44, No. 6, (Jun 2009), pp. (1268-72; discussion 1272),1531-5037 Clarke, M. C.; J. W. Chase; S. Gibb; V. J. Robertson; A. CattoSmith; J. M. Hutson & B. R. Southwell (2009). Decreased colonic transit time after transcutaneous interferential electrical stimulation in children with slow transit constipation. J Pediatr Surg, Vol. 44, No. 2, (Feb 2009), pp. (408-12),15315037 Cook, B. J.; E. Lim; D. Cook; J. Hughes; C. W. Chow; M. P. Stanton; S. S. Bidarkar; B. R. Southwell & J. M. Hutson (2005). Radionuclear transit to assess sites of delay in large bowel transit in children with chronic idiopathic constipation. J Pediatr Surg, Vol. 40, No. 3, (Mar 2005), pp. (478-83),15315037 Hutson, J. M.; J. W. Chase; M. C. Clarke; S. K. King; J. Sutcliffe; S. Gibb; A. G. Catto-Smith; V. J. Robertson & B. R. Southwell (2009). Slow-transit constipation in children: our experience. Pediatr Surg Int, Vol. 25, No. 5, (May 2009), pp. (4036),1437-9813

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Gamma Gazette September 2011

King, S. K.; J. R. Sutcliffe & J. M. Hutson (2005). Laparoscopic seromuscular colonic biopsies: a surgeonâ&#x20AC;&#x2122;s experience. J Pediatr Surg, Vol. 40, No. 2, (Feb 2005), pp. (381-4),15315037 King, S. K.; J. R. Sutcliffe; B. R. Southwell; P. G. Chait & J. M. Hutson (2005). The antegrade continence enema successfully treats idiopathic slow-transit constipation. J Pediatr Surg, Vol. 40, No. 12, (Dec 2005), pp. (1935-40),1531-5037 Southwell, B. R. (2010). Colon lengthening slows transit: is this the mechanism underlying redundant colon or slow transit constipation? J Physiol, Vol. 588, No. Pt 18, (Sep 15 2010), pp. (3343),1469-7793 Southwell, B. R.; M. C. Clarke; J. Sutcliffe & J. M. Hutson (2009). Colonic transit studies: normal values for adults and children with comparison of radiological and scintigraphic methods. Pediatr Surg Int, Vol. 25, No. 7, (Jul 2009), pp. (559-72),1437-9813 Sutcliffe, J. R.; S. K. King; J. M. Hutson; D. J. Cook & B. R. Southwell (2009). Gastrointestinal transit in children with chronic idiopathic constipation. Pediatr Surg Int, Vol. 25, No. 6, (Jun 2009), pp. (465-72), pp.1437-9813 Yik, Y. I.; M. C. Clarke; A. G. Catto-Smith; V. J. Robertson; J. R. Sutcliffe; J. W. Chase; S. Gibb; T. M. Cain; D. J. Cook; C. F. Tudball; J. M. Hutson & B. R. Southwell (2011). Slowtransit constipation with concurrent upper gastrointestinal dysmotility and its response to transcutaneous electrical stimulation. Pediatr Surg Int, Vol. No. (Mar 4 2011), pp. 1437-9813 Yik, Y. I.; D. J. Cook; D.M. Veysey; S.J. Rutkowski; C. F. Tudball; B.S. King; T. M. Cain; B. R. Southwell & J. M. Hutson (in press). Targeting the causes of intractable chronic constipation in children: The nuclear transit study (NTS). Radioisotopes, Chapter No. In Press Yik, Y. I.; T. M. Cain; C. F. Tudball; D. J. Cook; B. R. Southwell & J. M. Hutson (in press). Nuclear transit studies of patients with intractable chronic constipation reveal a subgroup with rapid proximal colonic transit. J Pediatr Surg, Vol. No. in press), pp. 1531-5037

Case Study

'U\ 0RXWK 6\QGURPH Maria Triantafillou Department of Nuclear Medicine, Southern Health Care Network. Victoria, Australia Clinical Presentation: A 75-year-old female presented to our department with a history of ongoing dry mouth syndrome. The referring physician requested a salivary scan to assess salivary gland function. Clinical History The patient was diagnosed with papillary carcinoma of the thyroid gland in 2000. Since 2000, the patient had received a total of 436mCi (16.2GBq) of radioactive 131 Iodine in three separate doses. The most recent of these was 217mCi (8GBq), which was administered in October 2009 after fine needle aspiration of a cervical lymph node revealed a secondary thyroid carcinoma deposit. Salivary Scan Prior to commencement of the procedure, the patient was given a lemon sherbet lolly to suck on and stimulate the salivary glands. The patient was then positioned on the scanning bed in supine orientation with their neck extended. The gamma camera was positioned anteriorly over the patientâ&#x20AC;&#x2122;s face. An intravenous dose of 427MBq of Tc-99m Pertechnetate was administered and a dynamic series (2 minutes per frame, 128 x128 matrix) commenced thereafter. The patient was given 10mls of lemon juice 20 minutes after injection to further stimulate salivary secretion during image acquisition (Figure 1).

Figure 1: Dynamic Series Once the dynamic series was completed, three planar images were acquired; left lateral, right lateral and anterior (figure 2).

Figure 2: Planar Images There is activity noted in the nasal mucosa and to a lesser extent in the lips. There is virtually no activity noted in the major salivary glands.

28 Gamma Gazette September 2011

Case Study

5HQDO 7UDQVSODQW 9DVFXODU 7KURPERVLV 0DVNHG E\ 1DWLYH .LGQH\ )XQFWLRQ Dr Thomas W Barber MBBS BSc FRACP, Dr Martin H Cherk MBBS FRACP Department of Nuclear Medicine and PET Centre, The Alfred Hospital, Prahran, Victoria, Australia 3181 History A 52-year-old woman with end stage renal failure and residual urine output of 5-10 mL/hr underwent a living related renal allograft. Radionuclide renography with Tc99m mercatoacetyltriglycine (MAG3) day 1 post-transplantation revealed good renal allograft perfusion and parenchymal uptake with delayed parenchymal transit of radiotracer compatible with acute tubular necrosis (ATN). The patient’s urine output gradually increased posttransplant stabilising at 50-100 mLs/hr on day 5. Routine followup radionuclide renography day 5 post-transplantation showed no graft visualization compatible with Figure 1: acute cortical necrosis despite Radionuclide renography with Tc-99m MAG3 day 1 post-transplantation demonstrating good a sustained urine output. Duplex perfusion and parenchymal uptake with delayed parenchymal transit compatible with ATN. doppler ultrasound confirmed absent The patient’s urine output was 20-40mL/hr. flow within the grafted renal artery and vein and subsequent transplant cadaveric renal transplants with an incidence of 4.8% in one nephrectomy revealed an infarcted kidney with established series.2 This catastrophic complication is a major cause of graft cortical necrosis of 3-5 days duration. The patient’s urine output loss2,3 and typically occurs within the first 7 days following renal remained 50-100 mL/hr following the transplant nephrectomy. transplantation.4 This case is of particular interest as the patient’s sustained This was an unusual presentation for acute vascular thrombosis urine output was likely a result of the polyuric phase of post- as the patient’s sustained urine output from the native kidneys operative ATN in the residual functioning nephrons of the native masked clinical suspicion for acute graft failure. It is interesting kidneys rather than from the renal allograft. This hypothesis was to compare the residual native kidney function in this case to supported by tracer uptake visualised in the native kidneys on the reported higher incidence of graft thrombosis in paediatric radionuclide renography day 5 post-transplantation. patients with higher mean pre-transplant urine outputs.5 In this population it has been proposed that high native kidney urine Key Words: renal transplant; vascular thrombosis; native kidneys output may predispose to intravascular volume depletion resulting in reduced perfusion of the renal allograft which predisposes to vascular thrombosis.6 Discussion Radionuclide renography post-transplantation is valuable in Vascular thrombosis (arterial or venous) occurs in <1% of live measuring ischaemic damage,7 duration of graft non-function7 as donor renal transplants1 but has been reported to be higher in well as short and long term graft survival.7,8 A severe deterioration in renogram appearances can antedate clinical deterioration.7 This case provides a dramatic example of this situation since AUTHOR CORRESPONDENCE the radionuclide renogram gave the first indication of graft failure Dr Thomas Barber MBBS BSc FRACP, and, therefore, significantly influenced patient management. This Department of Nuclear Medicine and PET Centre, case also serves to illustrate the potential value of radionuclide The Alfred Hospital, Prahran, Victoria, Australia 3181 renography in the early post-allograft setting, particularly when Email: tomwbarber@yahoo.com.au clinical assessment may be difficult. Phone: +61390762432 Fax: +61390762599

29

5HQDO 7UDQVSODQW 9DVFXODU 7KURPERVLV 0DVNHG E\ 1DWLYH .LGQH\ )XQFWLRQ

Figure 2: Routine radionuclide renography with Tc-99m MAG3 day 5 post-transplantation demonstrating absent cortical transplant radiotracer uptake in the right iliac fossa renal allograft compatible with acute cortical necrosis. The patientâ&#x20AC;&#x2122;s urine output was 50-100 mL/hr and there was no pain in the right iliac fossa to clinically suggest acute allograft vascular thrombosis. Note the Tc-99m MAG3 uptake within the native kidneys (arrows) accounting for the patientâ&#x20AC;&#x2122;s sustained urine output which continued into the post-transplant nephrectomy period. References 1. Osman Y, Shokeir A, Ali-el-Dein B, et al.: Vascular complications after live donor renal transplantation: study of risk factors and effects on graft and patient survival. J Urol. 2003;169(3):859-862. 2. Hernandez D, Rufino M, Armas S, et al.: Retrospective analysis of surgical complications following cadaveric kidney transplantation in the modern transplant era. Nephrol Dial Transplant. 2006;21(10):2908-2915. 3. Tarzamni MK, Argani H, Nurifar M, et al.: Vascular complication and Doppler ultrasonographic finding after renal transplantation. Transplant Proc. 2007;39(4):10981102. 4. Penny MJ, Nankivell BJ, Disney AP, et al.: Renal graft thrombosis. A survey of 134 consecutive cases. Transplantation. 1994;58(5):565-569.

30 Gamma Gazette September 2011

5. van Lieburg AF, de Jong MC, Hoitsma AJ, et al.: Renal transplant thrombosis in children. J Pediatr Surg. 1995;30(4):615-619. 6. Harmon WE, Stablein D, Alexander SR, et al.: Graft thrombosis in pediatric renal transplant recipients. A report of the North American Pediatric Renal Transplant Cooperative Study. Transplantation. 1991;51(2):406-412. 7. Heaf JG, Iversen J: Uses and limitations of renal scintigraphy in renal transplantation monitoring. Eur J Nucl Med. 2000;27(7):871-879. 8. Stevens H, de Klerk JM, Mertens IJ, et al.: Quantitative baseline renography 48 hours after renal transplantation predicts long-term graft survival. Eur J Nucl Med. 2001;28(11):1677-1681.

Case Study

)(7 IRU WKH FKDUDFWHULVDWLRQ RI EUDLQ OHVLRQV Mr Jason Callahan, Prof Rodney Hicks Peter MacCallum Cancer Centre, Centre for Molecular Imaging St Andrews Place, East Melbourne, Victoria, Australia

A 52-year-old male with a history of lung cancer treated with chemo and radiotherapy. Three new brain lesions with atypical appearance on CT scan were detected. MRI findings were suspicious for intra-axial metastases but could not rule out an infectious aetiology. A PET/ CT scan using fluoroethltyrosine (FET) was performed to differentiate between infection or disease recurrence. The patient had a dynamic scan for 30 minutes (not shown) that demonstrated low initial activity and slowly increasing uptake over time in the largest of the 3 lesions. A subsequent 10 minute static PET scan was acquired over the brain 45 minutes after administration of FET. The reconstructed PET was co-registered with the MRI using rigid registration on the Siemens TrueD workstation. The FET scan showed uptake in all three known lesions indicating viable tumour rather than an infective process. Discussion The most common PET tracer for the investigation of brain cancer is Fluorine-18 Flurodeoxyglucose (FDG). The high amount of normal FDG uptake in the brain however makes detection of brain tumours difficult. Additionally, low grade tumours may have relatively low FDG-avidity. FET is an analogue of the amino acid tyrosine that is actively transported into brain tumours due to up-regulation of amino acid transport whereas uptake in normal brain tissue is low, leading to excellent sensitivity since the target to background ratio is much higher in FET than FDG. FET also has low uptake in inflammatory lesions, leading to good specificity. Our own series directly comparing FET and FDG in patients with suspected brain tumours found that FET had a sensitivity of 93% and specificity of 100% compared to 27% and 90% for FDG.1 This supports data found in a number of international trials. 2,3 This case highlights the value of FET over FDG particularly in small brain lesions that could be either an infective or a malignant process. It is unlikely that an FDG scan of these lesions would be able to provide any definitive answer to the clinical question being asked. FET is now available as a GMP-product from Cyclotek Pty Ltd

as a result of research performed under the auspices of the CRC for Biomedical Imaging Development. Studies have now been performed for clinical indications in NSW and New Zealand in addition to those done at the Peter Mac using the Special Access Scheme. References 1. Lau, E.W., et al., Comparative PET study using F-18 FET and F-18 FDG for the evaluation of patients with suspected brain tumour. J Clin Neurosci, 2010. 17(1): p. 43-9. 2. Pichler, R., et al., Is there a place for FET PET in the initial evaluation of brain lesions with unknown significance? Eur J Nucl Med Mol Imaging, 2010. 37(8): p. 1521-8. 3. Pauleit, D., et al., Comparison of (18)F-FET and (18)F-FDG PET in brain tumors. Nucl Med Biol, 2009. 36(7): p. 779-87.

31

Case Study

0XLOWL 0RGDOLW\ &RQÀUPDWLRQ RI 6SOHQRVLV Katherine J Burton1, Bridget M Chappell1, Sze Ting Lee1,2, Salvatore U Berlangieri1, David L Thomas1, Andrew M Scott1,2, Christopher C Rowe1 1 Department of Nuclear Medicine & Centre for PET 2 Ludwig Institute for Cancer Research, Austin Health, Heidelberg, Victoria

Introduction Intrathoracic splenosis results from the deposition of splenic tissue in the thoracic cavity following simultaneous rupture of the spleen and diaphragm. These deposits may form mass lesions that can become symptomatic and mimic cancer, leading to an extensive, costly and invasive series of investigations usually resulting in unnecessary surgery. The key to diagnosing splenuculus lies in a high index of suspicion provoked by the history of abdominal trauma possibly in the distant past. This poster demonstrates the need for an accurate patient history in the investigation of thoracic lesions. And that because of its ability to demonstrate the functional nature of splenic tissue, a definitive diagnosis can be made using heat damaged RBC’s without the need for other diagnostic investigations or surgical interventions.

Case Study A 41-year-old woman with a strong family history of lung cancer was referred for a FDG PET/CT scan for investigation of possible malignancy, following the incidental discovery of multiple chest lesions on CT. The patient was generally asymptomatic except for recent lethargy. A non-contrast CT examination was performed due to the patient’s allergy to the contrast media. The scan demonstrated a large soft tissue mass in the left lung base. Under CT guidance two 18 gauge core biopsies were obtained but failed to provide a definitive diagnosis. The patient was then referred for a FDG PET/CT scan for diagnosis of the suspected lung carcinoma. FDG PET/CT Scan The patient was injected with 408MBq of FDG and emission images were acquired one hour later on a Philips Gemini PET/CT scanner. Images from the base of the skull to the upper thighs were acquired with a low dose, non contrast CT (ldCT) being performed for anatomical correlation with a 137Cs transmission scan being acquired for attenuation correction purposes. The pulmonary mass seen on diagnostic CT showed only mild metabolic activity on the FDG PET images suggesting a benign process (Figure 1). A smaller soft tissue nodule abutting the left atrium and a hepatic lesion seen on ldCT were not metabolically active, again suggestive of benign pathology. The spleen is absent and a 2cm non-FDG avid soft tissue lesion is in the splenic bed on ldCT. The patient did not mention any previous trauma at the time of the scan. In light of the lack of FDG avid disease in the presence of multiple lesions, the patient was subsequently contacted to obtain a more thorough history. She subsequently reported that she was shot in the abdomen at the age of 9, resulting in a laparotomy and splenectomy. The patient was then recommended for a liver/spleen scan the following day to confirm the diagnosis of splenosis. Tc-99m Liver Spleen Scan The patient was injected with 122MBq of Tc-99m Calcium Phytate with images acquired on a Phillips IRIX triple headed gamma camera. Initial dynamic imaging was performed with subsequent static imaging performed 20 minutes. Subsequent SPECT images were fused with IdCT images from the PET/CT study. Planar and 32 Gamma Gazette September 2011

SPECT images demonstrated a photopaenic lesion in the liver corresponding to the lesion seen on IdCT. Mild radiotracer uptake seen in the paravertebral region corresponding to the lesion on CT (Figure 2), however the remaining lesions were not visualised on planar or SPECT imaging. This may be due to insufficient colloid accumulation with the mass. The patient then was referred on for a 99mTc-heat damaged red cell (RBC) study to further investigate the likely splenunculus as it is more sensitive in the detection of splenic tissue. Tc-99m Heat Damaged RBC Scan Following IV administration of 853MBq of heat damaged Tc-99m RBCs, images were acquired on a Phillips IRIX gamma camera. Static planar images of the abdomen and SPECT were performed. The scan demonstrated multiple sites of ectopic foci corresponding

Figure 1: No markedly increased FDG avid lesions were identified on the coronal slices (A), particularly in the lung mass seen on axial CT (B), PET (C), or fused PET/CT (D) images.

0XLOWL 0RGDOLW\ &RQÀUPDWLRQ RI 6SOHQRVLV

Nuclear Medicine. 2006; 31(8):463-466. 2. Williams G, Rosen M, Parker J, et al. Splenic Implants detected by SPECT Images of Tc-99m labeled Damaged Red Blood Cells. Clinical Nuclear Medicine, 2006; 31(8):467-469. 3. Arden J, Kwan MD, David E, Intrathoracic Splenosis Mimicking Metastatic Lung cancer, Clinical Nuclear Medicine, 1994;19(2):93-95. Figure 2: Tc-99m sulphur colloid SPECT slices demonstrating mild radiotracer uptake in the paravertebral mass and a photopenic lesion in the right liver dome on fused coronal (A) and transaxial (B) SPECT/CT images. to the soft tissue lesions noted on IdCT. These included a large left paravertebral soft tissue mass which extends longitudinally, the splenic bed lesion and the para-cardiac lesion (Figure 3). Additional foci of radiotracer uptake in the left lateral abdominal wall, upper pole of the left kidney and in the left lower quadrant, adjacent to a loop of small bowel are also consistent with functioning splenuculi. A Tc-99m RBC Liver haemangioma study was organized to further investigate the cold hepatic lesion. Tc-99m RBC Haemangioma Study The final scan performed in this series was a Tc-99m RBC Haemangioma study. 890 MBq of TC-99m RBC were administered intravenously with dynamic blood flow and blood pool images of the liver being obtained. Planar and SPECT images were acquired 3 hours later. Initial imaging demonstrated a photopaenic area in the posterior aspect of the right hepatic lobe. This lesion appeared to have ‘filled in’ on the delayed views. These findings are consistent with that of a liver haemangioma. The delayed SPECT images confirmed this. Labeled RBC activity was also noted at the sites of splenosis in the left hemithorax and the left upper quadrant of the abdomen (Figure 4).

Figure 3: MIP image of Tc-99m Heat Damaged RBC Scan (A) and fused SPECT/CT images (B & C), demonstrating intense radiotracer uptake in the large paravertebral mass and multiple lesions in the lower thoracic and abdomen.

Discussion Nuclear medicine investigations were invaluable in confirming a final diagnosis of benign splenosis, and reassuring the patient that the lesions found on CT were not cancerous. The increased spleen:liver ratio obtained with the use of Tc-99m heat damaged red blood cell imaging when compared to the more readily available and easily performed colloid liver/spleen imaging demonstrates its superiority in diagnosis of splenosis. In this case, the smaller lesions and lesions close to the liver which may have been masked by high levels of hepatic colloid uptake are clearly visualised. In cases where there is a strong clinical suspicion of residual or heterotopic splenic tissue, a Tc-99m red cell scan should be considered as a first line option. This case also highlights the importance of obtaining an accurate patient history prior to the commencement of investigations as this may have resulted in the earlier diagnosis of splenosis, reduced patient anxiety, and negated the use of PET/CT. References 1. Hagan I, Hopkins R, Lybum I. Superior Demonstration of Splenosis by Heat-Denatured Tc-99m Red Blood Cell Scintigraphy compared with Tc-99m Sulfur Colloid Scintigraphy. Clinical

Figure 4: Early and delayed Tc-99m hemangioma study, demonstrating photopenia in the liver lesion on early images, followed by filling on the delayed images. The labeled RBC activity was also noted at the sites of splenosis in the left hemithorax and the left upper quadrant of the abdomen. 33

From page 12

A: What’s that? ... answer A bone scan with Tc-99m HDP was performed with whole-body blood pool images, whole-body delayed images, and SPECT tomography. It was considered that the uptake in the left foot and ankle was normal, with comparative disuse of the right foot and ankle, and with comparison of the left ankle epiphyseal plates with those in the left knee having the same level of activity. No evidence of increased osteoblastic activity was seen in the feet, ankles or lower legs. However, whole-body bone scanning revealed a site of increased Tc-99m HDP uptake on both the blood pool and delayed images in the right iliac crest. Further radiological imaging of the right iliac crest was suggested as essential, to determine the nature of the pathology. A CT scan of the pelvis was performed the following week. This was reported as “a large area of cortical destruction with lamellar/layering periosteal new bone” in the right ilium. Given the raised ESR, an aggressive bone neoplasm such as Ewing’s Sarcoma in a child of this age had to be excluded. No obvious adjacent abscess or fluid collection was present, so infection was thought to be less likely. A subsequent MRI with gadolinium contrast scan was reported as “in keeping with an aggressive, destructive lesion arising from/with an epicentre in the right iliac wing with marked enhancement, lamellar periosteal new bone formation and abnormal enhancing tissue present within the adjacent musculature” and a Ewing’s Sarcoma should be excluded, in view of the patients age and sex. Less likely differential diagnoses included infection, malignant transformation in fibrous dysplasia, metastasis from a neuroblastoma or osteogenic sarcoma. A Sestamibi bone marrow scan and a Gallium scan were requested by the Orthopaedic surgeons. The Tc-99m Sestamibi study was reported as normal distribution of the tracer in the pelvis and hips, while the Gallium-67 study demonstrated increased uptake of Gallium in the right iliac blade. The remainder of the pelvis and sacrum appeared normal. Given the normal Sestamibi study, and the increased uptake on the Gallium scan, infective changes on the basis of the Nuclear Medicine scans were considered the most likely cause of the patient’s pain. A biopsy of the right iliac blade was performed which was reported as chronic osteomyelitis, confirming the findings on the Bone, Sestamibi and Gallium scans. The patient was treated with 10 days of intravenous antibiotics and recovered completely. The patient rapidly became asymptomatic. No further sequelae in the 7 years to date have been reported. An MRI scan performed three months later showed regression of the pathological process in the right iliac bone and right sacral ala, with no involvement in the gluteus medius and iliacus muscles. Given the response to antibiotics, this further supports an infective process rather than neoplasia. This case demonstrates the usefulness of routine whole body scanning for all patients, especially paediatric patients, who find it difficult to localize the site of pain, and find it difficult, or are unable to communicate their symptoms. Three different Nuclear Medicine procedures are demonstrated in this case. All three scans were contributory to the final diagnosis in this patient.

34 Gamma Gazette September 2011

From page 13

B: What’s that? ... answer The images demonstrated diffusely increased tracer activity and uptake throughout the axial and proximal portion of proximal appendicular skeleton highly suspicious for diffuse marrow infiltration. A moderately intense focus of uptake in the right posterior ilium, extending from the inferior aspect of the right sacroiliac joint is likely a bony metastasis. There is bone tracer uptake within the left perihilar lung mass invading the left side of mediastinum, left lower pleural posteriorly and in the multiple, widespread hepatic metastases, periportal and retroperitoneal nodes. There is no bone tracer uptake within the area of post obstructive collapse/consolidation in the left lung and left pleural effusion. Note is made of atrophic right kidney. Diagnosis: Metastatic Small Cell Lung Cancer

From page 15

D: What’s that? ... answer A1: Following injection of tracer, liver should be seen within 5-15 seconds, with hepatic ducts, common bile duct (CBD) and gallbladder (GB) usually seen between 5-20 minutes but up to 60 minutes is normal. Cardiac activity should decrease over time and not be seen after 10 minutes. Small intestine should be seen within 60 minutes (Shackett, P., 2009). A2: “Rim Sign” is a mild-intense thin band of increased tracer uptake in parenchymal liver adjacent to the gallbladder fossa or lower part of the right lobe. It is seen in the first hour of imaging, persists over time and intensifies as liver activity clears. It is thought to result from inflammation from the gallbladder spreading to the adjacent liver and has a high PPV for complicated acute cholecystitis (Zeissman, H., 2003). A3: Non-visualization of GB at 60 minutes is abnormal. Delayed imaging at 3 to 4 hours is required for accurate diagnosis as many patients will have GB visualized on these images consistent with chronic cholecystitis. Non-visualization at 4 hours is indicative of acute cholecystitis (Zeissman, H. &Rehm, P., 2002). Intravenous morphine sulfate is an alternative to delayed imaging and causes contraction of the sphincter of Oddi. This increases bile duct pressure to a level that overcomes functional cystic duct obstruction and forces tracer back into GB if the cystic duct is patent (Shackett, P., 2009). Continued nonvisualization is consistent with acute cholecystitis (Zeissman, H., 2003). A4: Morphine augmentation has the same accuracy as using delayed imaging but reduces the imaging time required. It offers a better PPV than delayed imaging – 86% vs 59% (Zeissman, H., 2003). Contraindications include allergy to morphine, opiate addiction, elevated amylase or other pancreatic enzymes, or if it may obscure clinical symptoms (Shackett, P., 2009). A5: Continued non-visualization is consistent with acute cholecystitis (Zeissman, H., 2003).

References Shackett, P. (2009). Nuclear Medicine Technology: Procedures and Quick Reference. (2nd ed), Philadeplhia, Lippincott, Williams and Wilkins pp. 125-133. Zeissman, H. (2003). “Acute Cholecystitis, biliary obstruction, and bilary leakage.” Seminars in Nuclear Medicine, vol. 33, no. 4, pp. 279-296. Zeissman, H. and Rehm, P. (2002). Nuclear Medicine: Case Reviewed), St Loius, Mosby pp. 66,68,70, 206, 216, 338.

35

From page 14

C: What’s that? ... answer A1: Multinodular goiter (MNG) is demonstrated as multiple cold, warm and hot areas within an enlarged gland and represent a spectrum of hyperfunctioning to cystic thyroid adenomas (Mettler, F. & Guiberteau, M., 2006). A2: Dominant cold nodules require further investigation although the likelihood of malignancy is only 1-6% in a patient with MNG compared to 15-25% for a solitary cold lesion. The case study shows an example of a patient with a dominant cold nodule in her thyroid, which was subsequently demonstrated to be cystic on ultrasound. Multiple further small cysts were present, consistent with multinodular goitre. Although most “cold” nodules will be benign, the percentage of malignancies seen warrants further investigation depending on circumstances (Mettler, F. &Guiberteau, M., 2006). A3: Benign “cold” nodules are more likely to be seen in older patients, females, of sudden onset, that are soft or tender, multiple, or shrink with thyroid hormone treatment (Mettler, F. &Guiberteau, M., 2006). Malignant nodules are more likely in younger patients, males, those with history of radiation to head and neck, hard lesions, other neck masses, a family history of thyroid carcinoma or that do not shrink with thyroid hormone (Mettler, F. &Guiberteau, M., 2006; Hershman, 2008). In children, thyroid nodules are more likely to be malignant, representing 30 -50% of cases (Hababian, M., Debelke, D., Martin, W. et al., 1999). A4: Focal areas that do not concentrate radioisotope within the thyroid gland are considered “cold” or hypofunctioning nodules. Only 20% or less cold nodules will be malignant, with the other 80% resulting from degenerative nodules, nodular haemorrhage, cysts, inflammatory nodules (Hashimoto’s or de Quervains’s Thryoiditis), infiltrative disorders or non-thyroid neoplasms (Hababian, M., Debelke, D., Martin, W. et al., 1999) A5: Non-invasive techniques available include US, MRI and x-ray fluorescent scanning (Hababian, M., Debelke, D., Martin, W. et al., 1999). However, fine needle aspiration is a relatively simple technique that is frequently used and recommended for any suspicious or prominent non-functioning “cold” nodules to exclude malignancy (Hababian, M., Debelke, D., Martin, W. et al., 1999; Lacey, N., Jones, A. &Clarke, S., 2001).

References Hababian, M., Debelke, D., Martin, W. and Sandler, M. (1999). Nuclear Medicine Imaging A Teaching File), Philadelphia, Lippincott Williams & Wilkins pp. 2, 4,5,12-20, 24. Hershman, J. (2008a, June 2008). “Approach to the Patient with a Thyroid Nodule.” Merck Manual Professional Retrieved 11 October, 2009, from http://www.merck.com/mmpe/sec13/ch162/ ch156b.html. Lacey, N., Jones, A. and Clarke, S. (2001). “Role of radionuclide imaging in hyperthyroid patients with no clinical suspicion of nodules.” British Journal of Radiology, vol. 74, no. 882, pp. 486-489. Mettler, F. and Guiberteau, M. (2006). Essentials of Nuclear Medicine. (5th ed), Philadelphia, Saunders pp. 75-100.

36 Gamma Gazette September 2011

HONORARY LIFE MEMBERSHIP

Dr John McKay by Monica Rossleigh1 and Sze Ting Lee2 1 2

Dept. of Nuclear Medicine, Prince of Wales and Sydney Children’s Hospitals, Sydney, Australia Dept. of Nuclear Medicine & Centre for PET, Austin Health, Heidelberg, Australia

J

ohn was the first Nuclear Medicine Registrar trained under the supervision of IPC (Provan) Murray at the Prince of Wales Hospital in Sydney. In conjunction with ANSTO, they developed the first human bone scan agent. He worked in cooperation with John Morris at Royal Prince Alfred Hospital in Sydney to establish PET in Australia. This led to the establishment of PET facilities at the Austin Hospital in Melbourne and RPAH. John is rightly proud of having performed the first clinical PET study in Australia at the Austin Hospital in 1992. He has also played a major role in its establishment as a clinical imaging modality in our professional community. From an ANZSNM perspective, he is a past President of our Society and convened three Annual Scientific Meetings. He represented the ANZSNM internationally on many occasions in different forums. For example, he worked hard on behalf of the ANZSNM in its efforts to host the 2008 Asia Oceania Federation of Nuclear Medicine Biology meeting. While we were ultimately unsuccessful in this bid, the effort and multiple presentations he made on our behalf were significant. From the Accreditation Board (AB) perspective, John was a member from 1999 and became Chair in 2002 until 2008. John was a great support for technologists especially in the areas of education. John was instrumental with others on the AB in establishing the ANZSNM’s Accreditation Board as the National Office of Overseas Skills Recognition’s (NOOSR) Gazetted Authority for assessing overseas technologist qualifications including the development of the Overseas Qualification Assessment exam and allowing it to be available overseas. He also introduced the technologist Professional Development Year (PDY) program supported by mentorship, and also the introduction of resumption to professional practice. He was a dedicated supporter of the nuclear medicine course approval program and also supported the CPD program and linking this to validation John was always available to help with ANZSNM business and was also a friend and confidant to people on the AB offering support when things could get controversial. In particular, he often led difficult discussions between universities over course approval, and was instrumental in upholding the educational standards of the ANZSNM. With this long-standing history within the Society, he was not only invited as the Pioneer Lecturer for this year’s Annual Scientific Meeting in Darwin, but was also put forward by the Federal Council for Honorary Life Membership – proposed by Sze Ting Lee, and seconded by Julie Crouch. This was supported and voted in by the membership at the Annual General Meeting in Darwin without dissent.

37

KUHL-LASSEN AWARD 2011

Prof Christopher C Rowe by Victor Villemagne, MD Department of Nuclear Medicine and Centre for PET, Austin Health, Melbourne, Victoria

The Kuhl-Lassen award honours individuals who have made outstanding contributions to the field of brain imaging. The winner was selected by the Brain Imaging Council (SNM), Board of Directors.

P

rofessor Christopher Rowe recently received the 2011 Kuhl-Lassen Award at the Society of Nuclear Medicine Annual Meeting in San Antonio in June 2011. He had the privilege of delivering the lecture entitled “Redefining Alzheimer’s Disease: the role of molecular brain imaging”, and he is the first Australian to receive this award. Professor Rowe has made an outstanding and lasting contributions to the field of brain imaging not only in research and development of new methods and applications but also in promoting these advances to a wide audience to ensure their take-up into clinical practice. Professor Rowe trained in neurology and nuclear medicine at the Austin Hospital, Melbourne and Washington University, St Louis, USA. He is Director of Nuclear Medicine and PET at Austin Health, Melbourne and a Professorial Fellow of the University of Melbourne, the Mental Health Research Institute of Victoria and the Florey Neuroscience Institute. His department performs over 1000 brain SPECT and FDG PET clinical studies per year mainly for cognitive disorders and he leads a team of researchers focused on the development of PET for the better diagnosis and understanding of neurodegenerative diseases. Professor Rowe’s knowledge and international reputation has made him a regularly invited speaker at major international meetings and someone who is regularly sought to contribute to expert panels on early diagnosis of Alzheimer’s disease and to the organization of major neuroimaging meetings in the area of dementia. He is a cofounder and a current steering committee member and the Education Chair of the Neuroimaging Professional Interest Area for the US Alzheimer’s Association, former co-chair for organization of the Alzheimer’s Imaging Consortium preconference symposia for the 2009 International Conference on Alzheimer’s Disease (ICAD), and a current member of the National Institute on Aging and the Alzheimer Association Workgroup for defining the preclinical stages of Alzheimer’s disease. Professor Rowe has been a continuous member of the SNM for over 20 years, a reviewer of abstracts for the annual meeting since 1995, subchair for clinical neurology for the 2002 meeting, and a member of the Brain Imaging Council Board of Directors since 2005, serving as President

38 Gamma Gazette September 2011

in 2007/08. Following the retirement of Henry Wagner Jr as presenter of the highlights of the SNM annual scientific meeting in 2009, Christopher Rowe was invited to present the Neuroscience highlights of the 2010 and 2011 Society of Nuclear Medicine Annual Scientific Meeting. In Australia, his contribution to the development and practice of nuclear medicine has been recognized with the 2004 Australian Nuclear Science and Technology (ANSTO) Prize for Contributions to Nuclear Medicine and the 2010 Lowenthal Lecture/Award from the Australian and New Zealand Society of Nuclear Medicine (ANZSNM). We take this opportunity to congratulate Professor Rowe on this esteemed achievement.

Contributions to the Clinical Development of Brain Imaging 1. Ictal/post-ictal SPECT for localization of a seizure focus Prof. Rowe played a pivotal role in the development of the methods for ictal SPECT with Tc-99m HMPAO, its validation and the subsequent world-wide take-up of this technique into routine clinical practice in the late 1980s and early 1990s. He conceived, designed and implemented a study of post-ictal and ictal SPECT in temporal lobe epilepsy for his higher research degree by thesis in 1987 shortly after the introduction of Tc-99m HMPAO (Ceretec). His subsequent ground breaking publications in Lancet, Annals of Neurology, Neurology, the Journal of Nuclear Medicine and other leading journals, backed up by frequent presentations at international neurology and nuclear medicine meetings, chapters in nuclear medicine and epilepsy surgery textbooks and a lecture tour of prominent nuclear medicine facilities in the USA, resulted in the worldwide acceptance of ictal SPECT as an important tool for pre-surgical localization of seizure foci. His publications in this field (9 manuscripts and 9 book chapters) have over 400 citations. 2. Beta-amyloid imaging with 11C-PiB for the detection of Alzheimer’s disease Professor Rowe leads a team of researchers using new PET tracers for diagnosis and investigation of neurodegenerative diseases, particularly Alzheimer’s disease and has performed over 700 brain amyloid PET

scans with 11C-PiB and 18F labelled tracers. Recognizing the enormous clinical potential of beta-amyloid imaging for Alzheimer’s disease, Prof. Rowe was one of the first nonGE sites to use 11C-PiB, scanning his first subjects in late 2004. He subsequently wrote the first paper on the use of amyloid imaging for the differential diagnosis of dementia. Published in Neurology in 2007, this paper has over 225 citations. He and his team have further defined the clinical significance of amyloid scan findings through longitudinal study of a large patient cohort of the Australian Imaging Biomarkers and Lifestyle study of ageing (AIBL) for which Prof. Rowe is the Neuroimaging Leader. He and his team have performed over 500 PiB scans and have over 40 publications in this field in major international journals. 3. Beta-amyloid imaging with 18F-Florbetaben (AV1) In 2008, Professor Rowe published the first report on the use of an F-18 labeled amyloid specific PET ligand in human subjects, in Lancet Neurology. This ligand, then known as AV1 or BAY94-9172, was subsequently acquired and taken into clinical development by Bayer Schering Pharma on the results of these findings and is now in the final stages of Phase III testing under the name Florbetaben. The study results combined with Professor Rowe’s enthusiastic and authorative presentations on the potential commercial market for new PET tracers in neuroscience were pivotal in the decision of Bayer Schering Pharma to make commercial development of radiopharmaceuticals for PET a major company focus. The results also validated the approach of Avid Radiopharmaceuticals Pty Ltd, the inventors of AV1, in the development of F-18 ligands for amyloid imaging encouraging further investment and development of additional F-18 amyloid ligands.

4. VMAT2 PET, muscarinic SPECT, nicotinic PET Professor Rowe is currently also contributing to the development of PET ligands for Parkinson’s disease and related disorders using VMAT2 imaging in collaboration with Avid Radiopharmaceuticals and the Australian Co-operative Research Centre for Mental Health. Having established the accuracy of F-18 VMAT2 imaging for assessing the integrity of the nigrostriatal pathway he is now addressing its management impact in suspected early PD and potential for presymptomatic detection of PD. He has previously investigated the clinical potential of imaging muscarinic receptors with SPECT and nicotinic receptors with PET.

Previous worthy recipients have included: Kirk Frey (2010) Chet Mathis (2009) Wolf-Dieter Heiss (2008) Richard Carson (2007) Satoshi Minoshima (2006) David Brooks (2005) Mike Devous (2004) Dean Wong (2003) Ron Tikovsky (2002) Yoshiharu Yonekura (2001) Peter Herscovitch (2000) Nora Volkow (1999) Albert Gjedde (1998) Marc Raichle (1997) Lou Sokoloff (1996)

39

International Awards Congratulations to our Victorian colleagues who have received international awards for their recent work and contributions. We would like to share with you their award winning abstracts.

Dr Sze Ting Lee Jan Esser Best Poster Award â&#x20AC;&#x201C; 10th Congress of the World Federation in Nuclear Medicine & Biology Cape Town, Sept 2010

Dr Jean-Mathieu Beauregard EANM Eckert & Ziegler Abstract Award â&#x20AC;&#x201C; Annual Congress of the European Association of Nuclear Medicine (EANM) Vienna, Austria, 2010

Dr Michael Hofman 1) Jan Esser Science Award for Best Oral Presentation â&#x20AC;&#x201C; 10th Congress of the World Federation of Nuclear Medicine and Biology Cape Town, September 2010 2) Eckert & Ziegler Abstract Award 2011 â&#x20AC;&#x201C; EANM, Birmingham, 2011 (upcoming)

Correlation of 11C-Choline Pet, Histopathology and PSA levels in Prostate Cancer Patients Undergoing Neoadjuvant Docetaxel Chemotherapy 6]H 7LQJ /HHD E ,DQ ' 'DYLVD 'DPLHQ 0 %ROWRQF 'DYLG &ORXVWRQF 'UDJDQ 'DPLDQRYLFKF &DUPHO 3H]DURF 'DYLG $QJXVF 7ULVK -HQNLQVF &KXQ <HZ )RQJF $QGUHZ 0 6FRWW D E a Ludwig Institute for Cancer Research, Melbourne, Australia b Centre for PET, Austin Health, Melbourne, Australia c Austin Health, Melbourne, Australia %DFNJURXQG Docetaxel is an effective treatment in castrateresistant prostate carcinoma (PC), but currently no factors that predict response are known. This study aimed to assess correlation between 11C-Choline PET and known prognostic factors of prostate specific antigen (PSA) and Gleason score in the setting of doxetaxel treatment before radical prostatectomy (RP). 0HWKRGV Patients with confirmed localized PC suitable for RP were recruited into this prospective pilot study. Chemotherapy response was assessed by change in PSA, CT, Gleason score or 11C-choline (CHOL) and 18 F-fluorodeoxyglucose (FDG) PET scans. PET scans were assessed visually and using SUVmax. FDG and CHOL PET scans were performed prior to two cycles of docetaxel given 3-weekly. Both PET scans and PSA were repeated prior to RP. Gleason score and histological findings on RP specimen were correlated with PET scans and pre-treatment TRUS biopsies. 40 Gamma Gazette September 2011

5HVXOWV Ten patients with median age 63 years (range 52-68 years) were enrolled and completed all study requirements. CHOL PET showed good to excellent correlation with RP pathology in all 10 patients, but FDG PET showed poor correlation with primary PC. Small non-significant decreases in PSA between baseline and week 6 were noted. Histology showed subtle changes with no confluent tumor necrosis or scarring related to therapy. &RQFOXVLRQ CHOL PET shows excellent tumour localization and correlates with a small median increase in PSA postchemotherapy, and may be useful as a marker to assess treatment response in PC. Neoadjuvant docetaxel treatment had no clear effect in the setting of this study design.

The tumoural â&#x20AC;&#x153;Sink Effectâ&#x20AC;? on the biodistribution of 68Ga-octreotate: implications for peptide receptor radionuclide therapy %HDXUHJDUG -0 +RIPDQ 06 .RQJ * +LFNV 5- Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia $LP Many 177Lu-octreotate therapy protocols use fixed injected activities (IA), based on reported renal dosimetry estimates. We assessed the impact of factors independent of IA on the biodistribution of 68Ga-octreotate. 0HWKRGV We selected 10 patients with highly varied somatostatin receptor-positive neuroendocrine tumour burden, who underwent PET/CT 30-60 minutes after 68Gaoctreotate injection. Volumes of interest were drawn and IA partition and average uptake values in %IA/cc were computed. Average uptake in tumour ([T]), renal cortex ([R]), spleen ([S]) and body background ([B]) were assessed for correlation with potential variables influencing biodistribution: fraction of IA sequestered in tumour (%T), fraction of IA excreted in urine (%E), patient weight (W) and a healthy tissue volume of distribution (Vd) which combines these factors defined by W/(1-%T-%E). Standardized uptake values (SUV) were calculated for significantly correlated factors. 5HVXOWV [T] was negatively correlated with W (r=-0.77; P=0.02). [T], [R], [S] and [B] were all negatively correlated with Vd (r= -0.75, -0.80, -0.76 and -0.75, respectively; P)0.02). Overall, [T] was predominantly decreasing with increasing W, whereas healthy tissue uptake was also substantially lowered by larger %T. %E had a slight additional negative effect on all biodistribution variables. Accordingly, the uptake in tumour and healthy tissues yielded significantly less inter-patient variability when normalised for W, %T and ÂŻ Ă&#x160;­¯ U6`Ă&#x2030;VV]Ă&#x160;-166`Ž°Ă&#x160; Ă&#x203A;iÂ&#x2DC;Ă&#x160;Ă&#x153;Â&#x2026;iÂ&#x2DC;Ă&#x160;Â&#x2C6;Â&#x2DC;VĂ&#x20AC;i>Ă&#x192;Â&#x2C6;Â&#x2DC;}Ă&#x160;>Ă&#x160;wĂ?i`Ă&#x160; Ă&#x160;LĂ&#x17E;Ă&#x160;

as much as 38% in the patient with the highest tumour burden (%T=42%), the predicted renal uptake in Bq/cc would not exceed the mean renal uptake of our patient cohort. &RQFOXVLRQ Our results suggest that tumoral sequestration is a major factor leading to a â&#x20AC;&#x153;sink effectâ&#x20AC;? that decreases activity concentration in healthy tissues, including the renal cortex. Body habitus and renal function are additional factors influencing tissue biodistribution, in a synergistic fashion. Compared with a fixed IA protocol, adjusting therapeutic IA may allow increasing tumoral radiation dose significantly without adding renal toxicity in patients with marked sink effect due to tumoral burden or large body habitus.

68Ga-Octreotate (GaTate) PET/CT is superior to 111In-Octreotide scintigraphy and conventional imaging with high management impact 0 +RIPDQ * .RQJ 2 1HHOV 3 (X 5 +LFNV Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia 2EMHFWLYH GaTate PET/CT has multiple potential advantages compared to conventional imaging of neuroendocrine (NET) and other somatostatin-avid tumours. This study reviews our clinical experience by evaluation of incremental diagnostic and management impact compared to conventional staging. 0HWKRGV 76 GaTate studies were performed in 59 patients (42 proven gastro-entero-pancreatic neuroendocrine tumours (GEP-NET), 10 suspected GEP-NET, 4 paranglioma/ phaechromocytoma, 2 suspected mesenchymal tumours & 1 esthesioneuroblastoma) with blinded scoring the number of abnormalities (1, 2-5 or >5) within organs and semiquantitative uptake analysis. Comparison with all available conventional imaging and clinical review was used to determine pre-PET stage and treatment intent, incremental diagnostic information and subsequent management impact (high, moderate or low) of GaTate PET/CT. 5HVXOWV 91% of GaTate were abnormal with high tumour-tobackground contrast (mean of SUVmax per patient of 32). Compared to conventional imaging, additional information was provided by GaTate in 69% of patients. In patients who underwent prior 111In-octreotide, additional information provided in 83%. Management impact was high in 47%, moderate in 10% and low in 41% (insufficient data to determine in 2%). &RQFOXVLRQ GaTate PET/CT provides additional information compared to 111In-octreotide and conventional imaging in a high proportion of patients. Consequent management impact was high including directing patients to curative surgery by identifying a primary site of disease, or directing patients with unsuspected metastatic disease to systemic therapy.

Gallium-68 PET/CT Ventilation Perfusion Imaging for Acute Pulmonary Embolism +RIPDQ 06 %HDXUHJDUG -0 %DUEHU 7 1HHOV 2& (X 3 +LFNV 5Centre for Molecular Imaging, Peter MacCallum Cancer Centre, Melbourne, Australia 3XUSRVH Ventilation and perfusion (V/Q) imaging has an established role in the regional assessment of lung function in a variety of diseases, including pulmonary embolism (PE). PET/CT offers an opportunity to further improve its accuracy and utility owing to superior resolution, speed and quantitative capability. This study aims to assess the feasibility of performing V/Q PET/CT imaging in a routine clinical setting, and compare image quality and diagnostic utility with V/Q SPECT/CT in patients referred with clinical suspicion of PE. 0HWKRGV 10 patients undergoing conventional V/Q SPECT/CT were prospectively recruited. PET/CT ventilation and perfusion imaging were performed following inhalation of Ga-68 labelled carbon nanoparticles (Galligas) and intravenous administration of Ga-68 labelled macroaggregated albumin (GaMAA). Blinded to the results of the other study, SPECT/CT and PET/CT image quality was measured according to a predefined standardised scored system assessing unevenness of radiotracer distribution and clumping of radiotracer. The number of matched or unmatched defects and diagnosis were also compared. A final diagnosis was obtained following patient follow-up. 5HVXOWV V/Q PET/CT was tolerated well in all patients without complication. 3 patients demonstrated normal ventilation and perfusion on both PET/CT and SPECT/CT. Qualitatively, PET / CT image quality was equivalent or superior to SPECT/CT in all patients with more homogeneous radiotracer distribution for both ventilation and perfusion studies. Based on SPECT/ CT, the diagnosis was acute PE in 2 patients, no PE in 7 patients and non-diagnostic in 1 patient. PET/CT diagnosis was concordant in 8 patients and these studies demonstrated a similar frequency and distribution of matched or unmatched segmental or subsegmental defects. In one discordant study, a non-diagnostic SPECT/CT was reported as normal with PET/ CT. In another, the diagnosis of PE established on SPECT/CT was not reported on PET/CT two days later, possibly due to clot lysis or migration between the two studies. &RQFOXVLRQ PET/CT V/Q scanning with Ga-68 labelled radiotracers is feasible, easily incorporated in clinical practice and attractive in the context of recent shortages in Tc-99m generators. Compared to conventional scintigraphy, advantages include superior image quality, faster acquisition, and potential for better regional quantitation of lung function. The short half-life of Ga-68 also enables more flexible acquisition protocols with the option of performing ventilation studies selectively in patients with abnormal perfusion. Further study is needed to assess whether V/Q PET/CT can improve diagnostic algorithms and outcomes for patients with suspected PE.

41

Society News ANZSNM Annual General Meeting Minutes 1. ATTENDANCE 1.1 Present: Lyndajane Michel, Lesley Bradford, Dale Bailey, Vijay Kumar, Peter Collins, Heather Patterson, Mary Potter, Cedric Eustance, Craig Collins, Zachary King, Kien Lee, Claire Domaingue, Culann Farrell, Jeanelle Farmilo, Chrissie Roodt, Teresa Smith, Sylvia Leung, Maria Triantafillou, Amanda Adams, Andrew Willmott, Erwin Lupango, Bruce McBride, Eva Wegner, Kate O’Donnell, David Lyall, Pete Tually, Merrin Angwin, John McKay, Victoria Brooks, Prue Lamerton, Justin Williamson, Coleen Lander, Stephen O’Brien, Amy Johnson, Angela Osley, Bob Cooper, Sue O’Malley, Dylan Bartholomeusz, Graeme O’Keefe, Bridget Chappell, Michelle Hughes, David Thomas, Julie Crouch, Amy Hollow, Diane Cheong, Susan Baldwin, Adrienne Little, Barbara Ovendon, Trish Mead, Jane Hassall, David Newbery, Ian Kirkwood, John Baldas, Paul Marks, Doug Mackey, Allan Scott, Clayton Frater, Dale Searcy, James Shephard, Ilonka Bokor, Erin McKay, Ghee Chew, Nick Lawrence, Will Marsham, Melissa Pack, Chris McLaren, Monica Rossleigh, Sharyn Pussell, Marko Trifunovic, Cheryl Holland, Alla Turlakow, Mark Dunstan, Vanessa Rischitelli, Dave Francia, Liz Bailey, Jennifer Guille, Ros Francis, Andrew Scott, Kristos Kyriacou, Chantelle Smith, Dawn Mathers, Geoff Roff, Tracey Smith, Sze Ting Lee, Carol Charman, Zlata Ivanov, Annette Cotter, Karen Winnett. 1.2 Apologies: Sue Lefmann, Karen Monney, Shane Morony, Darin O’Keefe, Salvatore Berlangieri, Nicholas Alexopoulos, Richard Smart, Adam Freeborn, Penelope Maton, Amy Hollow, Melinda Wilson, Catherine Henry, Darryl Shnier, Sharon Mosley, Agatha van der Schaaf, Walter Haindl 2. MINUTES OF THE PREVIOUS MEETING Held on Auckland 2010 Accepted: Proposer - Lynda Jane Michel Seconder - Susan Baldwin 3. BUSINESS ARISING FROM PREVIOUS MINUTES – Nil 4. REPORTS 4.1 President’s Report – Sze Ting Lee Refer to the President’s Report (Appendix 1) Accepted: Proposer – Peter Collins Seconder – David Thomas 4.2

Treasurer’s Report – Sharon Mosley (Audio report) The Audited Financial Report can be accessed on the ANZSNM Website. Accepted: Proposer – Zac King Seconded – Liz Bailey

4.3

Accreditation Board Report – Julie Crouch Refer to AB Report (page 10)

4.4

ANZSNMT Report – Liz Bailey

42 Gamma Gazette September 2011

The TSIG held its annual workshop this year in Adelaide at the conference centre at Adelaide Zoo on Saturday 21st May. We had 65 attendees with a great range of topics covered including SPECT/CT, PET/CT, V/Q SPECT, interesting case studies and an update on national registration. And lunch with the panda’s. Thank-you to the committee members, especially Nick Farnham who helped organise another great day. Next years venue will be Hervey Bay in Queensland, including a one-day symposium and half-day whale watching trip in early September, with the date yet to be confirmed. There has been significant progress made especially in the last 6 months in preparation for national registration. The call for submissions for the new national board closed 8th April with the society assisting several members to prepare submissions. Many documents have been prepared including overseas qualifications, English language skills, code of conduct & ethics, criminal history, CPD and recency of practice. The accreditation board have undertaken to update the scope of practice for NMT and have requested input from the TSIG. These documents will need to be approved by the national board once it is formed and be circulated to members for comment. The accreditation board will provide a more comprehensive update on the progress to date. Access to further education from higher education facilities such as the universities for both Australian and New Zealand technologists have been cancelled in the past 12 months. The Monash University course cancellation significantly disadvantaged access to further education for rural and remote technologists, with some students now not eligible for accreditation. At present, there are no approved nuclear medicine training courses available to NZ technologists except to enrol in the undergraduate program through the University of Newcastle at great cost to the employer and employee. The first issue of the on-line Gamma Gazette prepared by the NSW branch was very successful with plenty of education material. The Qld branch prepared the current issue which is available on-line through the ANZSNM website. A lot of positive feedback was received especially regarding the education value of the articles. In an attempt to better co-ordinate workshops and education weekends, the ANZSNM has posted a calendar of upcoming events on the ANZSNM website. Many of the workshops planned for 2011 and 2012 have already been added to this calendar. This will hopefully prevent any further clashing of events and will be updated with new events. The CPD database was deactivated as of 1st January 2011. This decision was made to allow for the web committee to proceed with updating the ANZSNM website. This will include a new CPD database with e-learning and access to on-line education tools. The use of membership cards at all future branch and ASM meetings will ensure that accurate attendance records

will be available, hopefully eliminating the need for hardcopy certificates. The membership of the committee has seen many changes over the last 12 months. On behalf of the committee I would like to thank Rick Hampson for his hard work over the last several years as both the WA rep and the treasurer for the committee. Welcome to Diane Cheong as the new WA rep and Marcia Woods as the new Victoria rep. The current executive and membership for the TSIG is as follows: Chair & NSW rep - Liz Bailey Vice Chair & ACT rep - Chris McLaren Secretary & NZ rep - Prue Lamerton Treasurer & Qld rep - Susan Baldwin Victorian rep - Marcia Wood Adelaide rep - Nick Farnham WA rep - Diane Cheong Tasmanian rep - Nick Lawrence I would like to thank all committee members for their hard work over the last 12 months and look forward to continuing with their great achievements in the upcoming year. 4.5

ANZAPNM – Monica Rossleigh Refer to ANZAPNM Report (Appendix 2)

4.6

Physics SIG – Graeme O’Keefe The principle activity of the Physics SIG for last year was the Physics SIG meeting which was a joint meeting with the EPSM-ABEC (Engineering and Physical Sciences in Medicine and the Australian Biomedical Engineering Conference.) This is the conference of the Australasian College of Physical Scientists and Engineers in Medicine (ACPSEM). The membership of the ACPSEM is heavily biased toward radiation oncology physicists. The Physics SIG meeting topic was Organ Specific Imaging with contributions from local speakers and significant contributions from international speakers with thanks to the sponsors Insight Oceania and Siemens. The joint meeting was a point of significant discussion at the last ANZSNM meeting as attendance at the combined meeting required payment of typical conference registration fees due to the location of the conference. This is at odds with the typically very low registration fees normally applied to Physics SIG meetings. These fees principally went to the ACPSEM rather than the ANZSNM. This joint meeting was considered an experiment at increasing the interaction between nuclear medicine and radiation oncology physicists. The meeting was well attended but perhaps not to the level that had been seen at other ANZSNM Physics SIG meetings. The interaction and feedback from the attendees was positive however the meeting was a financial burden on the Physics SIG and perhaps those who attended. Thus the experiment can be considered a partial success. It is recommend that such a joint meeting should be considered only every 3 years or so with the intervening years reverting to either local based meetings with a focus on practical education of junior physicists or a more general meeting that

may engages the remainder of the nuclear medicine community. Activity of the Physics SIG has been low due to the work commitments of the current Chair, (Matthew Griffiths), who has stepped down at this meeting. The new chair is Darin O’Keefe, and Federal Council Representative is Graeme O’Keefe. 4.7

Radiopharmacy/Radiochemistry SIG – Jennifer Guille The SIG meeting continued the trend of recent years, with good attendance, lively participation and a number of interesting reports. The main Business of the AGM was the election of a new Chair. Jennifer Guille was elected to the position, and took the opportunity, on behalf of the group, to acknowledge the contribution of John Bellen over recent years. He started the trend of creating interesting SIG meetings in Brisbane in 2007, and the trend has continued, with ever-increasing audience and participation. The last year has been busy for the SIG. The significant highlights are the establishment of a Masters in Radiopharmaceutical Science at Macquarie University (MU). The course is administered by the university, and has had to meet university requirements for inclusion as a post-graduate degree. It is open to chemistry graduates who meet the university standards for entry to a higher degree, OR to suitable graduates of other science-based degrees, although the applicant may be required to undertake the MU chemistry bridging course if the chemistry component of the undergraduate degree is inadequate for PG - level chemistry. MU has engaged in significant consultation with the profession via the SIG to make this course relevant to the profession. We have continued to work on the accreditation process, including a TEAP program, which will be administered by ACPSEM. Have gained representation to the TGA TWG for sterile drug manufacture where the release of FDG (and other PET radiopharmaceuticals) prior to sterility and pyrogen testing, is being debated. For the coming year our goals are to: appoint an Accreditation Panel; continue to work on the Accreditation modules which will establish competency standards for the profession; establish training and/or registrar positions.

4.8

Nursing SIG – Erwin Lupango The 41st ANZSNM in Darwin was an exciting time for the Nurses SIG. Not only did we gain professional knowledge about advancing in our field, but we are excited about using and implementing emerging technology. Total of 5 nurses attended the yearly Nursing SIG meeting. There are some issues raised and amended. 1.We are still in the process of increasing our members; we will try to ask help from MINA (Medical Imaging Nurses Association) for whatever support they can extend to our group. 2. New Interesting evidence based nursing-practice presentation for CPD points during the annual conference. 3. I will be retaining my position until next year’s

43

conference in Melbourne 4. Skill development in IV cannulation and ECG taking will be going to introduce in future group presentation. “Regadenoson (Lexiscan): General Nursing Consideration” was presented by Erwin Lupango. I would like to pay special thanks to the conference committee and ANZSNM President for their ongoing support of our SIG. 4.9

International Relations Committee – Andrew Scott The last 12 months has seen multiple international meeting attendances by committee members, engaging in teaching & training outreach programs throughout the world. The IRC is also working on the bid for the 2018 World Federation in Nuclear Medicine & Biology conference, which will be voted in 2012. Therefore, this is a very active time for the IRC.

4.10 Conference Update 4.10.1 2012 Melbourne – Sze Ting Lee (Convenor) provided the date and venue. Introductory presentation to be shown on Monday after meeting highlights. Save the dates for 27th to 30th April 2012. 4.10.2 2013 Perth - Ros Francis (Co-convenor) – mid April 2013 5. SPECIAL RESOLUTIONS “That the Constitution of the Society be amended by: (i) Under ‘Interpretation’ adding the definition in alphabetical order: “ANZSNMT” means the Australian and New Zealand Society of Nuclear Medicine Technologists. (ii) Under ‘Interpretation’ adding to the definition of Special Interest Groups the words: ‘(also referred to as “SIGs”) after ‘Special Interest Groups’ (iii) Under ‘Directors’ amending clause 38 by deleting: ‘(c) any additional members chosen by the Council (not exceeding 3) to represent the Professional Groups which the Council in its reasonable opinion believe are not adequately represented by the Branch appointments, and (d) the immediate Past-President (who will act ex officio unless appointed by reason of paragraphs (a) – (c) above) for a period of two years.’ And inserting in lieu thereof: (c) one representative from each of the following SIGs: ANZSNMT, Physics SIG & Radiopharmacy SIG, elected by its respective committee, (or by the Council should any SIG fail to elect a representative), (d) one representative chosen by the Council to represent the physician members of the Society, (e) the immediate Past-President (who will act ex officio unless appointed by reason of paragraphs (a) – (d) above) for a period of two years. (f) up to 3 further nominations by the Council should it deem it appropriate acting reasonably to retain persons of particular expertise; PROVIDED that the failure of the Council or any branch, group or interest to elect or nominate a representative to the Council will in no way cause a vacancy or inhibit the powers 44 Gamma Gazette September 2011

and functions of the Council.” Proposer: Geoff Roff Seconder: Tracey Smith This motion was passed with 92 in favour and 3 against (including proxies). 6. BUSINESS WITH NOTICE 6.1 Life Membership – Dr John Mckay Proposed by Sze Ting Lee Seconded by Julie Crouch This motion was passed unanimously – see article on John in this edition of the Gamma Gazette 6.2 Future directions of ANZSNM It has been more than 40 years since the Society was formed, and whilst there has been changes throughout the years, it is now time to review our function and how we, as a Society can be progressive and incorporate any changes necessary to be THE professional organization of Nuclear Medicine in Australia representing all disciplines of the profession. In particular, we are facing potential changes in our accreditation side of things, and increasing role in teaching and training in Australia and the region as well. So, we will be organizing a review of the Society’s function and roles, and recommendations as to the changes required to bring us to this more professional level. This is also to include recommendation for secretarial/legal/promotion purposes, which are crucial to the effective running of a professional Society. This review will include some interviews with members of the Society, so you may be contacted for input sometime in the next few months. And if you have any specific constructive input, please feel free to send these through to the Secretariat or myself in the next 3 months. These recommendations will be evaluated by Council at the next Federal Council meeting, and we will communicate any proposed changes to you at the time. 7. COUNCIL POSITIONS Resignations: Tracey Smith – from NSW representative, Federal Council Vice-President & Secretary Monica Rossleigh – from ANZAPNM & SIG representative Sharon Mosley – from Federal Treasurer, but remains as ACT representative Sze Ting thanked Tracey, Monica and Sharon for their tireless work for the Society over the years. New positions: Julie Crouch – Federal Vice-President Geoffrey Roff – Federal Treasurer Linda Jane Michel – Company Secretary Liz Bailey – NSW representative 8. DATE & VENUE OF 2012 AGM Saturday 28th April 2012 Meeting Closed 12.50

Appendix 1: Annual President’s Report They say change is good, and if that is the case, then the Society is bound for great things, as this has been a big year of change for us. We have changed to the Online Journal which took off with a bumper issue out together by the NSW/ACT branches, under the banner of Gamma Gazette, with attractive eye-catching colours which is now the new concept colours for the Society. Since then, the Queensland branch has produced Issue No. 2, which will be followed by the efforts of the Vic/Tas branch in September 2011, and then WA in December 2011. This online journal is now available to all members on the website. Speaking of the website, the website will also be revamped over the next 12 months to provide members with a more user-friendly, attractive one. The plan is to also have a more accessible portal for CPD documentation and relevant newslinks on this website. I’d like to thank the Website Committee for their efforts in this project, which is a rather tireless one. In the meantime, I am not sure if many of you have noticed, but there has been a few changes, which has been orchestrated by our very own immediate past president, Geoff Roff. We have now engaged Robert Barnett and his team of experts to see this process through. The aim is to launch this new website at the next Annual Scientific Melbourne in 2012. So, not long to go now…In the meantime, I plead to members for their patience and understanding whilst this process continues. The next 12 months will see some changes on the National Registration for NMT/NMS front. Whilst we are still not aware of the specifics of this, one thing is for sure…and that is IT IS going to happen, and will be implemented as of July 2012. As those of us who are now involved in a National Registration Program, you need to be aware that there will be some teething problems which will be ironed out in due course. Yes, this may change some of the functions of the Society, but the changes will need to be determined when we know the details. In the meantime, I would like to thank our Federal representatives on the Joint Steering Committee, who were David Lyall and Bridget Chappell, who had the great pleasure of wading through the mountain of paperwork this created, and provided the necessary advice and recommendations which the Society put to the Steering Committee on this issue. They also had the assistance of Elizabeth Bailey, Adam Freeborn and David Thomas and other members in this matter, whom I would also like to thank. In the meantime, we are going to attempt to improve the communications between the different disciplines in the Society. Hence the motion which will be put forward at the AGM to increase the number of Council Members so that all craft groups within the Society are represented. Teaching and training of Nuclear Medicine personnel is also another area, which is of significant importance, both on a national and international scene. Nationally, there is a shortage of adequate PDY placements of recently qualified technologists on a national scale, which is a double-edged sword. This impacts on the quality of students enrolling in our courses, and subsequent shortage of high quality graduates. To this cause, the Society has produced a Career’s brochure, which was organised by the Victorian/ Tasmanian branch committee and received great feedback and accolade from the intended audience at The Age Careers Expo held in Melbourne from May 6-8, under the supervision of Ms Bridget Chappell. This brochure is available for all members of the Society to request for further publicity. I strongly encourage all branches to

consider distributing this in their own jurisdictions too. On an international scale, we are doing our part in ensuring that we are assisting our international partners in the education in the nuclear medicine field. Ms. Heather Patterson has worked hard over the years to establish a Distance Assisted Teaching (DAT) course online, through the University of Sydney. Whilst this was originally for the benefit of our neighbouring countries who have less access to quality teaching, Heather has kindly agreed to link this with the Society website and share it with our Australian colleagues as well. The plan is to integrate this into the new website as well to allow accrual of CPD points. We are also strengthening our ties with the International Atomic Energy Agency, particularly in the field of PET/CT, where there is keen contribution to the establishment of a freely available PET/CT Teaching Library through the IAEA website and we have also been approached by the IAEA to provide our expertise to educate NM Professionals from our neighbouring countries in various initiatives around the world. Continued efforts are being made towards increasing our international profile and the International Relations Committee (IRC) are working hard towards our bid to host the World Federation in Nuclear Medicine and Biology conference in 2018. In particular, the efforts of our IRC under the guidance of Andrew Scott and his team have been instrumental in gaining the confidence and votes of various countries around the world, in particular we now have a huge presence in Asia, the Middle East and South America. We are particularly dedicated to the teaching and training within all nuclear medicine disciplines, and their continued contribution and promotion towards this process is much appreciated. Over the last 12 months, we have had a close link with the ANZAPNM, and I would like to particularly thank the Council of the ANZAPNM for keeping us informed of the proposed implementation of the Capital Sensitivity Measure for equipment more than 10 years old. Whilst we are not empowered to overturn this ruling, I am pleased to inform you that the transition period has been extended until 30th June 2012. The Association has also been instrumental in lobbying the government to increase the availability of PET funding, which is now available for 19 indications on the MBS. I can see that this will be a huge impetus to the expansion of PET in the country. However, it is important to emphasise the need for adequate training of PET professionals who are going to embark on this. So, I look forward to further interactions with the Association to ensure that the standards of PET personnel are maintained so that we maintain the great international reputation which we currently enjoy. Finally, I’d like to thank all members of the Council, Board, Branch and SIG committees who have been working tirelessly over many months and years to the Society’s benefit. Our key common goal is to promote the Nuclear Medicine profession and the Society’s profile on the national and international scene as being the peak body of Nuclear Medicine in Australia and New Zealand involving all disciplines of the profession. Their contribution and support of the Society over these years is much appreciated. The selfless volunteer of their time and efforts are immeasurable and all members are extremely appreciative of their efforts. And on a personal note, I’d like to acknowledge and thank my colleagues and employers at the Austin Hospital for their support and allowing me the time and flexibility to fulfil my position in the Society.

Thank you Sze Ting Lee, President ANZSNM 45

Appendix 2: ANZAPNM Report to ANZSNM 2011 AGM 1. Change of Name The ANZAPNM membership has voted for a change of Association name to: Australasian Association of Nuclear Medicine Specialists This Association has an increasing number of dual-trained radiologists in the membership (although the majority of members are physicians) and wished to have a name that was inclusive of both physician and radiologist members. The name change is currently being implemented. A fellowship and post-nominals (FAANMS) will be offered to eligible members as part of this implementation process.

walkway between buildings and co-location in a comprehensive cancer centre, as these requirements are considered to restrict delivery of PET services unnecessarily. The ANZAPNM continues to urge the DHA to include a capital component in the PET MBS fees. There are now 19 PET items in the MBS.

4. AHPRA The ANZAPNM made a submission to the Senate Inquiry into AHPRA, noting the myriad problems encountered by medical practitioners in attempting to obtain or renew their medical registration. The Senate’s report can be found at: http://www.aph.gov.au/Senate/committee/fapa_ctte/health_ practitioner_registration/index.htm

2. Capital Sensitivity The Department of Health and Ageing (DHA) foreshadowed a working group within the Diagnostic Imaging Services Table Committee (DIST Committee), to assist in developing advice about equipment upgrades etc. Dr Hugh Dixson (ANZAPNM Immediate Past President) has been nominated as a member of this working group, which also includes representatives from the manufacturers, the RANZCR and ADIA. At this stage the group has not met, and depending on how smoothly the implementation of the capital sensitivity measure proceeds, it may not be required. The ANZAPNM has advised the DHA that quality of service is more important than any arbitrary age limit, and has also urged that a transition period be granted so that planned replacement of older equipment can occur. This transition period is effectively in place to 30 June 2012.

3. PET The DHA is reviewing the eligibility requirements for PET items in the MBS. The ANZAPNM has urged removal of some requirements, including training site accreditation, covered

46 Gamma Gazette September 2011

We expect it will be some time before problems are rectified, due to the enormous scale of the implementation of the national registration scheme.

5. Telehealth and PCEHR Of the broader telehealth initiative of the federal government, the new “Personally-Controlled Electronic Health Record” (PCEHR) is likely to have a greater impact on imaging specialties. The PCEHR is due to be implemented from 1 July 2012 and a new set of e-consultation MBS items has been implemented from 1 July this year. Nuclear medicine practices should be well equipped to take advantage of the measures, given the high-level technology used in the specialty, but the ANZAPNM is keeping a close eye on any proposals for transmission and retention of images with the PCEHR, as this is likely to be the most complex aspect of these measures and potentially has significant cost implications.

Monica Rossleigh MD FRACP

INVITATION TO PARTICIPATE VERIFICATION OF THE PATIENTâ&#x20AC;&#x2122;S PREGNANCY STATUS PRIOR TO DIAGNOSTIC IMAGING PROCEDURES IN NUCLEAR MEDICINE

You are invited to participate in a research project investigating current practice and knowledge in determining the pregnancy status of a patient prior to diagnostic Nuclear Medicine procedures. The research is part of Daphne James Doctoral studies, within the School of Health Science at the University of Newcastle. Associate Professor Helen Warren-Forward (University of Newcastle) and Mr Paul Cardew from Hunter New England Health Service are supervisors. We are conducting a survey of personnel working in Nuclear Medicine departments to determine the awareness of international and departmental policy, currently used methods of questioning patients and to identify any potential difficulties that may arise. All members of the ANZSNM are invited to participate. Ethics approval has been gained by the University of Newcastle Human Research Ethics Committee (Approval Number H-2009-0270 and variations). The survey will be conducted online via SurveyMonkey and has been estimated to take no longer than 15 minutes to complete. The survey will be open from August to 30th November, 2011. When the survey is open, the link to the survey will be displayed on the ANZSNM web site. Your involvement in this project will assist in the first step of the development of practical guidelines for determining a patientâ&#x20AC;&#x2122;s pregnancy status prior to diagnostic Nuclear Medicine procedures, so please take the time to participate. Your response will be entirely anonymous. Thank you Daphne James (PhD candidate) Ass. Prof. Helen Warren-Forward Paul Cardew

47

New Technologies, Novel Tracers, New Therapies NORTHERN TERRITORY 2011 ANZSNM Annual Scientific Meeting Highlights Dale Bailey & Paul Roach The 41st Annual Scientific Meeting of the ANZSNM was held for the first time ever in Darwin. The location and the venue, combined with instructions from the organizing committee to leave the suits and ties at home, provided for a more relaxed and casual meeting than would be the norm in one of the big capital cities. In addition, the meeting was held in the school holidays for many states and thus allowed families to visit Darwin. In recognition of this the meeting had a half-day “family day” of cultural delights and an amphibious duck tour around Darwin, finishing at the Welcome Reception on the Saturday night. For those of us from the southern states, it was a welcome relief to be in Darwin in the middle of winter with an average daily temperature in the high twenties to thirty degrees. Prior to the main meeting commencing, a pre-conference symposium on nuclear cardiology was held in Kakadu National Park. This was combined with a busy touring programme which brought the delegates and their families into close contact with some large saltwater crocodiles of the region. The symposium discussed a number of innovations and new developments in the field of nuclear cardiology. We are all indebted to our international and national speakers for providing such a stimulating programme. Over 160 people made the journey to Kakadu. The pre-conference symposium was booked out weeks in advance. Many thanks to the sponsor, Imaging Connections, for their generous support of this event. The scientific meeting commenced at the Darwin Convention Centre on Saturday morning. How many convention centres in the world could boast of having an enormous wave pool in front of it and the sea as the backdrop? In total, the conference attracted over 420 people. There were approximately 150 abstracts submitted for presentation at the meeting – with eventually 57 papers being accepted for oral presentations and the remainder being presented as posters. In one way, the meeting was a victim of its own success in that the convention centre could only provide space for around 50 posters per day and therefore the posters had 90 80

81

By Submission category

No. of abstracts

70 60 50

43

40 30 20

15

10 0

11 3

Clinical

Technology

Physics

48 Gamma Gazette September 2011

RP Sciences

Student

to be split over two days with each poster only been on show for a day. This was unavoidable in the venue. The figure below shows the breakdown of the abstracts by submission category. The majority of abstracts (approximately half) were related to imaging with single photon emitting, non-PET, tracers. Studies with PET tracers accounted for about one third of the abstracts with the rest being related to therapy (¾20), education or other themes. Papers were submitted from the majority of states, New Zealand and 15 from further afield including Japan, Iran, Singapore, India, Malaysia and Thailand. One traditionally important function of the meeting is to encourage new investigators to present their work in the local environment before being placed on a large, overwhelming stage. This is particularly true for students and trainees and the meeting again sought to encourage submissions from the more junior members of our Society. Another important feature of the meeting is the striving for excellence seen in the different papers presented for awards. There are five awards covering different areas of nuclear medicine. The winners for this year’s awards were: UÊ -/"Ê Ü>À`\ Michael Hofman (Peter MacCallum Cancer Institute, Melbourne) – Ventilation and Perfusion PET/CT with Galligas and 68-Ga MAA: A Pilot Study with Comparison to Conventional SPECT/CT; UÊ < * Ê Ü>À`\ Samuel Wright (Royal Melbourne Hospital) – Comparison of Fractional Flow Reserve to Myocardial Perfusion Imaging in Predicting Cardiac Events; UÊ -Ê* ÃÌiÀÊ Ü>À`\ Isabelle Hung (Royal North Shore Hospital, Sydney) – Comparison of True & SPECT-Derived Planar Ventilation and Perfusion Image Analysis of Relative Lung Function; UÊ > À `ÌÉ Û ` i Ê Ü>À`\ Culann Farrell (Austin Health, Melbourne) – Modified In-Vitro Red Blood Cell Labelling Using a Single Polyurethane Intravenous Cannula; UÊ ,>`* >À Ê Ü>À`\ Rebecca Wyborn (Hunter Diagnostic Imaging, Newcastle) – Cardiac 123I-mIBG Scintigraphy. We congratulate all of the award winners on their excellence and success. There are also two plenary lectures given by individuals that the Society wishes to honour by their invitation to present – the

Lowenthal Lecture in keeping with the theme “The role of physical and biochemical measurements in nuclear medicine” and the Pioneer Lecture, where an individual who has made a significant contribution over the years to the local nuclear medicine community is honoured. This year’s lecturers did not disappoint. Dr Bill Burch was the Lowenthal Lecturer and Bill Burch presenting the Lowenthal received an extended, Lecture. standing ovation for his talk “Physics and Physic: Passing on a Baton”. Bill spoke about early developments in nuclear medicine at ANU and in Canberra in a number of areas, but the main theme was the pursuit of excellence and always asking the right question. Interspersed with wonderful photographs from his time in Antarctica in the 1960s, Bill led us down his personal path in the quest to develop a technetium-labelled ventilation imaging agent which, of course, became Technegas. He related stories of chasing sheep around paddocks, minor explosions and blind alleys, but eventually how he developed the carbon cage holding the 99mTc atom in an ultrafine aerosol that has become the gold standard for SPECT imaging of ventilation. For those in the auditorium during Bill’s mesmerizing presentation, I am sure it was one of the meeting highlights. The Pioneer Lecture was delivered by John McKay and showed what can be done in developing world-class facilities and professional organizations with dedication, zeal and the occasional inter-city rivalry. John challenged us also to recognize those individuals who had done so much to shape nuclear medicine and the Society into its present form. In particular he nominated Jim McRae, Frank Broderick and John Morris as important individuals in this development from the early days of nuclear medicine in Australia and, in particular, for the influence that they had on him.

John McKay being presented with the plaque by Sze Ting Lee for delivering the Pioneer Lecture

What was Different? Being Darwin, the Organsing Committee tried to do a few different things during the meeting. We think that most attendees agreed

that Darwin was a very good choice of location to hold this meeting. For a start, we were able to take advantage of the tropical climate and have the gala dinner under the stars. The Organising Committee also made a conscious decision to try and invite international speakers who we perceived as being “rising stars’ rather than well-established high-note speakers. Again, the concept was to try and do this a little differently to the usual approach. From the reaction that we observed, the delegates were stimulated by these speakers and found their presentations to be of very high calibre and relevant. We feel that we will be seeing these speakers on the international stage for many years to come, and hopefully they will fondly remember their time at this meeting. As part of the meeting we had a “Controversy Corner” debate on Saturday on the topic of whether PET should overtake conventional nuclear medicine in all areas of imaging. Michael Hoffman argued the case for the affirmative while Barry Elison and Dale Bailey mounted the response for the negative side. For this meeting we trialed the use of interactive voting pads that were used through the first two days of the meeting. Judging by the audience’s response, they were well received and added something extra to the sessions. From a presenter’s point-of-view, it is also good to get feedback during the talk about the audience’s composition, practice and opinions. We are grateful to PETNET Solutions Australia for the sponsorship of the voting pads. The International Relations Committee (IRC), chaired by Andrew Scott, invited the President of the Indonesian Society of Nuclear Medicine, Dr Hussein Kartamihardja, to be our guest at the meeting. It is perhaps ironic that his hospital is closer to Darwin than most of the rest of Australia and New Zealand. Hussein gave a short presentation about the recent developments in Nuclear Medicine in Indonesia. This is part of a programme of continuing outreach to neighbouring nuclear medicine societies by the IRC. Another session with a difference was entitled “Pearls and Pitfalls”. Our overseas invited speakers presented cases which initially stumped them and engaged the audience to reach a diagnosis.

Socially there were a few innovations at this year’s meeting. I have already mentioned the family day activities including the bush tucker tastings. John McKay hosted what is hoped to now become an annual event on par with “Golf with Gordon”, namely, “Fishing with John”. Many a fisherman’s tall story will be told for years to come from this day. As can be seen in the photo above, the participants seemed to enjoy themselves.

X 49

New Technology Of the three themes selected for this meeting, that of New Technology emerged as the one which was the subject of the greatest number of papers. We are starting to see the impact of a change from traditional scintillation/PMT-based detectors to solid-state devices. Phil Kaufmann talked about this in relation to dedicated SPECT cardiac cameras and Bernd Pichler explained to us the absolute necessity of this alternative technology in the development of combined PET and MRI scanners. Which nail will the PET/MRI hammer hit the hardest and most decisively? – noone seems to know at this stage, but it was clear to all that we are witnessing yet another major shift in diagnostic capabilities with the introduction of simultaneous PET/MRI. The impact of PET/MRI may not be as “game-shifting” as was the introduction PET/CT, but then again, it could be even greater. It is an exciting time to be witnessing this happen and we can only anticipate the paths that this technology might pursue. We were fortunate to have in Bernd Pichler a speaker who not only has been involved at the forefront of these developments, but who could also explain the technology and the challenges in an uncomplicated way. We should be mindful that when PET/CT was first introduced by David Townsend and colleagues, there was enormous debate/argument about the sense in “tying up” a CT scanner to be used every 45 minutes or so for 30 seconds and how it made no economic sense whatsoever. History has shown that this was indeed a sensible direction for PET technology to take. A number of other topics showed what might be considered incremental advances: quantitative SPECT/CT is emerging as an achievable clinical tool; time-of-flight PET scanners seem to consistently show improved image quality over previous generation machines; attenuation correction of cardiac studies, based on CTderived attenuation maps, seems to becoming the standard of care today; the added value of SPECT/CT over SPECT alone is being increasingly realized in more and more clinical applications; and new technology (both hardware and software) is helping to address the important issue of dose reduction to keep the radiation burden to the patient as low as achievable. The presentations in this area of new technology demonstrated that the field is moving forward and has exciting times ahead.

Novel tracers We turn now to the second of our NT themes, “Novel Tracers”. There was an excellent review from Andrew Scott on the use of PET tracers other than FDG throughout Australia. In the same session, Homer Macapinlac provided details of his experience with PET radiopharmaceuticals used for the imaging of hypoxia,

angiogenesis and proliferation and then Ros Francis outlined her experience using some of these radiopharmaceuticals in both clinical and research settings in Perth. Perhaps the novel radiopharmaceutical that was most topical at this meeting was Gallium-68. Several abstracts were presented, including one from Graeme Snowdon from RNSH and another from Damian Stimson from RBWH, which described the use of automated synthesis modules for gallium 68 DOTATATE. An interesting overview of the clinical use of Gallium 68 DOTATATE was provided by Nazar et al from New Delhi. They reviewed 70 patients with neuroendocrine tumours and assessed the prognostic significance of Gallium-68 DOTATATE and F18-FDG uptake in which is was found that patients who were DOTATATE avid had a better prognosis than those who were FDG avid. Michael Hofman from Peter MacCallum Cancer Institute in Melbourne also presented a paper on the use of “Galligas” which won the ANSTO award. In their series, 10 patients with suspected PE underwent both V/Q SPECT/ CT and V/Q PET/CT (using Gallium-68 Technegas, or “Galligas”, and Gallium-68 MAA). They concluded that the PET study was faster, had high resolution and had superior image quality which resulted in more homogeneous images thus identifying smaller defects. The same group presented a poster on the use of Gallium-68 MAA addressing the effect of pH on labelling yield. As we know, not all departments have access to PET and Gallium/Germanium generators and there was an interesting abstract from Kristen Worthington from Invercargill using Tc-99m Tektrotyd for somatostatin receptor imaging. This is a technetium based kit (originally, I believe, from Poland) that allows practices in remote locations, such as Invercargill, to overcome the inherent supply problems that can affect imported radiopharmaceuticals, such as In-111 Octreotide. Other new tracers presented at the meeting included I-124 cG250, an antibody that binds to G-250 antigen (which is expected in over 90% of renal cell cancers). Davis et al, from the Ludwig Institute of Cancer Research in Melbourne, presented results of a pilot study of five patients with renal cell carcinoma. In the area of neurology, the group from the Austin Hospital presented a poster on F-18 florbetaben, a fluorinated beta-amyloid labelling radiopharmaceutical. Their assessment of 45 patients, with follow-up of up to one year, found that the degree of Florbetaben uptake was a strong predictor of progression from mild cognitive impairment to Alzheimer’s disease. In endocrinology, there was an abstract from Campbell and Garcia from Royal Brisbane Hospital using F18 –DOPA to assess congenital hyperinsulinism and pancreatic oversecretion. Several abstracts of animal studies were presented at the meeting using novel radiopharmaceuticals. The Ludwig group presented results from a microPET study of mice which assessed the halftime, biodistribution and tumour uptake of Zr-89hu3S193,

an antibody to Lewis-Y antigen. There were two SPECT animal studies, both involving pharmacokinetic studies on mice. Berghofer, from ANSTO, assessed various urokinase plasminogen activator inhibitors in prostate adenocarcinomas xenografts and Andrew Scott, from the Ludwig Institute, assessed the use of In111 CS-1008, an antibody to the human death receptor-5 (DR-5). So in summary, the novel tracers presented at this meeting were predominantly PET based. At Royal North Shore Hospital, we commenced our PET service approximately 15 months ago. In addition to FDG, we are now performing F-18 FET, Gallium-68 DOTATATE as well as Y-90 SIRT PET studies and intend to commence Gallium-68 citrate and Galligas imaging within the next 12 months. All of these are available from commercial suppliers so there is certainly the option in Australia of moving beyond FDG at any site where PET is undertaken.

New Therapies The last of our NT themes was “New Therapies”. Osman Ratib gave an excellent review of the use of PET/MRI in therapy. In particular, PET/MRI appears to have a promising clinical role in areas such as brain tumours, prostate cancer and paediatric malignancies. Homer Macapinlac also gave an excellent overview of the role of SPECT/CT in therapy. There was, however, relatively little in the way of new developments in radionuclide therapy presented at the meeting. There were no oral abstracts specifically on the therapy although there were several posters, from Kao et al in Singapore, assessing the role of Y-90 PET/CT in patients undergoing SIR spheres therapy. He showed examples of the superiority of PET and internal pair imaging to show the hepatic distribution of SIRspheres, compared with the conventional bremsstrahlung SPECT imaging. Thus, it appears that in Australia and New Zealand, there are challenges in facilitating the development of new radionuclide therapies. Therapy appears to be restricted to limited institutions and there are clearly funding limitations. In Australia, the MBS does not satisfactorily address true costs of therapeutic radiopharmaceuticals (with agents such as MIBG, now increasingly expensive and without a rebate). ANSTO have been increasingly expected to operate using cost recovery, and State health departments, in general, appear to be of the view that funding radionuclide therapy is not their role. For commercial companies with new products, there are regulatory and commercial barriers that also need to be overcome. In view of these obvious challenges, we made a deliberate decision to focus on therapy at this meeting. While John Valliant’s late withdrawal from the meeting

was disappointing, it is important to remember that the annual scientific meeting is a forum where radionuclide therapy can be promoted. This is the one meeting each year which allows the direct interaction to occur between clinicians, industry, scientists and relevant craft groups.

Conclusion Finally, we would like to thank the various people that made this meeting a great success. In particular, our international speakers Homer Macapinlac, Philip Kaufmann, Kristen Waterstram-Rich, Bernd Pichler, Bryan McIver and Lenny Freeman, as well as our national speakers Ros Francis, Bill Burch and John McKay. Thanks to the organising committee, including Vijay Kumar, Heather Patterson and, in particular, Liz Bailey and Monica Rossleigh, whose experience from organising the 2009 Sydney meeting was invaluable to us as we convened this meeting. A big thank you to all of our sponsors, to our professional conference organisers arinex, the Darwin Convention Centre and all of our venues (including Crocosaurus Cove, Pee Wee’s at the Point and the Holiday Inn at Kakadu). A sincere thanks to the ANZSNM for choosing to hold this conference in Darwin, and particularly the President, Sze Ting Lee, for her support. Lastly, a big thank you to our families who have put up with us, as we have spent much time organising this meeting over the last couple of years. We hope that you enjoyed your time in Darwin, learned a lot at the conference and had a chance to explore this unique and magnificent part of Australia.

Careers Expo 2011 ANZSNM attends the Age Careers Expo 2011 Natalie Tavaré and Blake Lucas Department of Nuclear Medicine & Centre for PET, Austin Health, Heidelberg, Victoria For the very first time the ANZSNM participated in a booth exhibition at the 2011 Age Careers Expo held at the Caulfield racecourse. The main aim is to make students aware of nuclear medicine as an available career option and promote nuclear medicine technologist as a career option for senior secondary school students. The Expo was held over three days commencing on Friday May 4 and continuing through to Sunday May 6 with over 190 exhibitors from Universities to the Navy, to Medicine and Beauty Therapy. The booth contained professionally printed pamphlets provided by the ANZSNM, explaining what Nuclear Medicine is, what other types of careers that Nuclear Medicine could offer (such as Physicists, Radiopharmacists, Nurses, Physicians), and an array of handouts with information on Australia-wide Nuclear Medicine Science courses and upcoming hospital open days, as well as course brochures from RMIT and the University of Newcastle. These shared the table with some commonly used Nuclear Medicine appliances such as lead pots and syringe shields. Bridget Chappell pulled out her creative skills and displayed a wide range of images of the different types of scans that Nuclear Medicine can acquire. She also designed the trefoil T-Shirts worn by the volunteers, organised the black and green ‘Nuclear Medicine’ boiled lollies and bagged the 10kg of candy into tasty portions. On the first day Bridget, Evan Read (RMIT) and ourselves (Blake Lucas and Natalie Tavaré) saw 9526 students from metropolitan and rural high schools attend the event. (Whether they wanted to or not, they attended!!) They arrived in flocks at 9am and the first floor was a sea of students trying to find as many freebies as they could! The amount of interest that the Nuclear Medicine booth had was astonishing. We had a lot of genuine interest from students who seemed very excited and the main questions were: ‘What pre requisites do I need? What score do I need? And where can I study Nuclear Medicine?’ We were very lucky to have Evan Read from RMIT to help answer all the technical questions that we didn’t have much knowledge about, however, by the time Sunday came around we were all experts! On Saturday, Christian Testa, Anna Nowicki, Sarah Cini and Evan Read helped out in the morning with a slow start developing into another busy day. The lunchtime relief was Kera Pethybridge and Natalie Tavaré who teamed up with Christian to see out the afternoon. The afternoon had a lot of inquisitive students as well as their parents visit the booth, which seems very promising for the future of the profession. This made us feel it was well worth our time and efforts. As enjoyable as the day was, it was definitely a relief to have some food and beverages that were provided at the end of the day and as the organisers mentioned over the loud speaker ‘thank goodness they have left’! For the final day Grace Kong, Mariela Nowosad, Kylie O’Halloran and Michelle Hammond offered their time and knowledge to the students and parents during the first half of the day while Gurinder Mudher, Tian Mi and Wesley Ng saw the Expo to its close. We would like to thank everyone who helped with the event and its planning including Julia Booth, and to acknowledge the assistance of the various universities currently offering Nuclear Medicine Science Programmes in providing us with information and particularly the assistance of Evan Read, David Lyall, Kerry Thoirs and Diana Gentilcore, Janelle Wheat and Peter Kench. The Age Careers Expo was attended by over 32,000 students, parents and teachers over the three days. We feel that the ANZSNM’s participation at the Expo was very successful and we are looking forward to attending in 2012.

52 Gamma Gazette September 2011

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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.

September 4-8, Moscow 7th International Conference on Isotopes Forum that brings isotopes scholars, producers and users together. Plenary meetings, parallel scientific sections, poster reports, and a specialty exhibition. September 20 WA post conference meeting at Oceanic Imaging, WA October 15-19 EANM Annual Congress of the European Association of Nuclear Medicine Birmingham, United Kingdom. http://eanm11.eanm.org/ October 22 Vic/Tas Annual Day Seminar, the Royce Hotel in Melbourne. Topics to include paediatrics, PET, sports medicine and the recent Japan Fukushima incident November 5 & 6 New Zealand Branch Meeting At The Otago School of Medicine, Wellington Campus Contacts: pburns@pacificradiology.co.nz christophersalt@ccdhb.org.nz

November 8-11 IPET 2011 (IAEA) Vienna, Austria November 12 & 13 Integrative Imaging Symposium RAINS symposium, Stamford Grand North Ryde, NSW Contact: Geoff Currie email-gcurrie@csu.edu.au November 28 – December 2 4th ICRT-2011 & 10th AGM of ARCCNM Ho Chi Minh City, Vietnam. www.icrt-2011.warmolth.org

2012 April 27-30 ANZSNM 42nd Annual Scientific Meeting Melbourne Exhibition & Convention Centre, South Wharf June 7-10 17th ISRRT World Congress & CAMRT 70th Annual General Conference Sheraton Centre, Toronto Canada www.2012isrrt.org/ 53

National Registration Update: August 2011 Bridget Chappell ANZSNM Representative, Medical Radiation Practitioners National Steering Committee The countdown to the implementation of a National Registration Scheme for all Medical Radiation Practitioners continues with the time to July 1st 2012 now measurable in days and months rather than years. The last six months have seen many developments on the National Registration front and include the formation of the National Board and the completion of the Medical Radiation Practitioners National Steering Committee (MRPNSC) work. In March and April 2011 the Australian Health Ministers’ Advisory Council, AHMAC, placed advertisements in the national press seeking nominations and expressions of interest for appointments to the National Boards of the four professions for whom registration will be introduced on July 1st 2012. In addition to seeking interested individuals from the professions and community for board positions, AHMAC also invited submissions on the National Boards’ size and composition and preferred accreditation arrangements, including the ANZSNM. AHMAC’s call for nominations for National Board members was well supported with over 200 applications received across the four professions. They also received 45 submissions from interested groups and individuals on the size and composition of the National Boards and 25 submissions on Accreditation arrangements. Following consideration of all nominations and submissions, by the Health Ministers, the Australian Health Workforce Ministerial Council released a communiqué announcing the National Board appointments, the size and composition of the Board and preferred accreditation arrangements on July 18th 2011. The Health Ministers determined that the Medical Radiation Practice Board of Australia (MRPBA) will be comprised of 12 members, eight practitioner members (four diagnostic radiographers, two radiation therapists and two nuclear medicine technologists) and four community members. The resultant Board has members from the three professions encompassed under the MRP umbrella and also has representation from every Australian State and Territory. The list of MRPBA appointees is as follows: Practitioner Members: Neil Hicks – Chair and member from Western Australia (Diagnostic Radiographer) Christopher Hicks – Member from the Australian Capital Territory (Diagnostic Radiographer) Christopher Pilkington – Member from South Australia (Diagnostic Radiographer) Tracy Vitucci – Member from New South Wales (Diagnostic Radiographer) Marcia Fleet – Member from Victoria (Radiation Therapist) Kar Giam – Member from the Northern Territory (Radiation Therapist) Susan Baldwin – Member from Queensland (Nuclear Medicine Technologist) Mark Marcenko – Member from Tasmania (Nuclear Medicine Technologist) Community Members: Liz Benson, Myrtle Green, Robyn Hopcroft and Rosie Yeo. The Health Ministers also determined that the newly formed Boards should decide on the preferred accreditation arrangements. The MRPBA will decide on whether accreditation functions will be performed by an external accrediting body or a committee established by the Board. In addition to determining the responsible accreditation authority, the MRPBA will be responsible for the preparation and eventual adoption of the five registration standards mandated under the National Law. These mandatory standards relate to professional indemnity insurance, criminal history, continuing professional development, English language skills and practice. The MRPBA held its first meeting in Melbourne on 26 July 2011 and will meet regularly in the lead up to July 1st 2012 and beyond. During this time the MRPBA will formulate and ratify the mandatory standards, determine an accreditation authority, and set the grand-parenting requirements for individuals working in NSW and South Australia who do not currently require registration. At their first meeting, the MRPBA agreed to a 1 December – 30 November annual registration period bringing it into line with the other 10 already registered professions.

54 Gamma Gazette September 2011

MARK MARCENKO Mark Marcenko is a registered nuclear medicine technologist with Medical Radiation Science Professionals Registration Board of Tasmania and has been a member of the ANZSNM since 1995. Mark began his career in Canada before immigrating to Australia in the 1990s. Since his arrival, Mark has worked in both Nuclear Medicine and PET practices though out Queensland, Victoria and Tasmania. For the past 16 years Mark has worked in both Nuclear Medicine and PET for I-Med imaging in Tasmania. In April this year he moved to the Royal Hobart Hospital to oversee the implementation and running of their new PET service. Mark’s job as the supervisor specialist Technologist in the PET/CT department allows him to work collaboratively and interact with CT radiographers and radiation therapists on a daily basis. Throughout the last six years Mark has been involved with the Medical Radiation Science Professionals Registration Board of Tasmania of which he has been Chair since 2005. His work with the Registration Board has also seen him represent Tasmania on the National Coalition of Regulatory Authorities. For the last two years Mark has been a member of the Medical Radiation Practitioners National Steering Committee representing Tasmania but also bringing his Nuclear Medicine knowledge and understanding of issues unique to the profession to his role on this committee. Through his work as a regulator and his experience as a technologist who has been registered in three states (Tasmania, Victoria and Queensland), Mark feels he has a strong understanding of why there is a need for a National Registration Scheme, but has not lost sight that his first and foremost responsibility on the newly created national board is to protect the public.

SUSAN BALDWIN Susan Baldwin is a registered nuclear medicine technologist with MRTB QLD and an Accredited member of the ANZSNM. Susan began her career as a radiation therapist graduating from Queensland Institute of Technology in 1981 with a Diploma of Applied Science – Radiation Therapy. In 1991, after 13 years in radiation therapy during which time Susan also spent time in the new Nuclear Medicine department at the RBH, she took up a full time position in the nuclear medicine department. In 1999 Susan was awarded the Queensland Cancer Fund DB Duncan Scholarship to study PET in USA. On returning to Australia, she was invited to take up a position at National Institutes of Health, Bethesda NIH, as an international Fogarty Fellow. Whilst at the NIH Bethesda, Susan worked with several pioneers in molecular imaging, on novel and diverse PET research projects. After a further two years in the USA, Susan returned to Brisbane in 2002 and joined Queensland Diagnostic Imaging as a Nuclear Medicine Technologist. More recently she has worked as the Manager of Medical Imaging Services, St Andrews War Memorial Hospital, Brisbane and in May this year, was delighted to accept a nuclear medicine position with Qscan Radiology Clinics, Queensland. Susan holds qualifications with ANZSNM, Nuclear Medicine Technologist Certification Board – USA, Canadian Association of Medical Radiation Technologists, is a faculty member of the International Society for Clinical Densitometry and is an assessor in nuclear medicine technology with NATA . Susan is currently the Queensland representative and Treasurer of the ANZSNM Technologist Special Interest Group, and is a keen advocate of continuing education for technologists. She feels that it is a great privilege and responsibility to be appointed to the National Medical Practitioners Board and will work diligently to ensure a fair and smooth transition in registration of our medical imaging technologists, radiation therapists, and nuclear medicine scientists and technologists.

As the MRPBA work in preparing for the National Registration of Medical Radiation Practitioners winds up, the work of the MRPNSC is completed. The MRPNSC, which comprised representatives from the regulatory authorities, professional associations and the university sector, held its last meeting on Friday July 29 in Melbourne. Over the last two years the members of this committee have worked collaboratively to produce draft standards for the MRPBA’s consideration and worked to establish an independent accrediting authority. All standards drafted and reviewed by MRPNSC have been submitted to the National Board and may form the basis of the registration standards released for public comment over the next few months. In the lead up to July 2012 the MRPBA are required to release all mandated registration standards

X 55

National Registration Update: August 2011 for public consultation and they encourage all interested parties to review all proposals during this time. Information on how to access and comment on these proposals will be provided in the next few months. Information on the MRPBA’s work and copies of their communiqués can be obtained from the National Registration and Accreditation Scheme 2012 project website www.nras2012.ahpra.gov.au until the MRPBA’s website is established and accessible through the AHPRA website www.ahpra.gov.au We would like to congratulate both Susan Baldwin and Mark Marcenko on their appointment to the MRPBA and wish them well in bringing their knowledge and expertise of Nuclear Medicine to the Board. The Society would also like to take this opportunity to thank all those Nuclear Medicine Technologists/Scientists who have been involved in the National Steering Committee and its working parties, in particular David Lyall and Bridget Chappell who represented the ANZSNM throughout the process, and Simon Cowell for his early involvement; Elizabeth Bailey and Adam Freeborn who represented the unregistered states – NSW and South Australia – as well as the individuals who participated on the Regulatory Standards Working Parties, including David Thomas, Adam Freeborn, Elizabeth Bailey, David Lyall and Bridget Chappell. References HAMES, The Hon Dr Kim: Chair, Australian Health Workforce Ministerial Council, Communiqué 18 July 2011: Health Ministers Announce National Board Appointments for the four Health Professions joining the National Registration and Accreditation Scheme in 2012; Australian Health Workforce Ministerial Council, 18 July 2011 Hicks, Neil: Communiqué: First meeting of the Medical Radiation Practice Board – 26 July 2011; Australian Health Practitioner Regulation Agency, 4 August 2011 MRPBA Profiles: Nuclear Medicine The MRPBA will have two Nuclear Medicine practitioner members on the Board – Susan Baldwin from Queensland and Mark Marcenko from Tasmania. As Board members, Susan and Mark’s main responsibility will be to utilise their specialised knowledge of Nuclear Medicine Practice to help protect the public. The ANZSNM would like to congratulate them on their appointments and wish them well in their new roles.

56 Gamma Gazette September 2011

Developing a new National Registration Board for MRS â&#x20AC;&#x201C; Behind the Scenes Ingrid Egan, Marilyn Baird, Neil Hicks, Francesca Holloway, Wayne Nuss Reprint from recent AIR journal SPECTRUM (permission granted by authors and AIR)

1. Introduction National registration for Medical Radiation Practitioners (MRPs) has been anticipated in Australia since 2008. It will finally become a reality in July 2012. This landmark event means that Medical Radiation Science will go from a partially registered profession to a fully registered profession after some 30 years of lobbying by the states/territories. In October 2008, the National Steering Committee for Medical Radiation Practitioners, a group comprising representatives from the existing State and Territory MRP Registration Boards collectively referred to in the first instance as the Council of Regulating Authorities (CORA), the Australian Institute of Radiography and the Australian and New Zealand Society of Nuclear Medicine created a submission titled â&#x20AC;&#x153;Towards a Safe National Radiation Practice Workforceâ&#x20AC;? that argued for the inclusion of the medical radiation science professions in round two of the implementation of the national registration and accreditation scheme. The absence of State Registration Boards in New South Wales and South Australia had prevented our professions being included in the initial implementation of the scheme in 2010. Ultrasound has not been considered as a separate discipline for registration. From July 1 2012 all MRPs will be registered by a single national board. Moreover, all MRPs will be bound by the policies developed by the national board e.g. Code of Conduct and other more generic national policies the board will be required by law to implement e.g. Professional Indemnity Insurance. Shortly after the submission was approved work commenced on developing a submission regarding the size and format for the new national board which will be known as the Medical Radiation Practice Board of Australia or MRPB, for radiographers, nuclear medicine technologists and radiation therapists.

2. The Medical Radiation Practitioners National Steering Committee for Registration and Accreditation (MRP NSC) In 2008 CORA established a committee to act as a steering group for the transition to national registration. This National Steering Committee brought together to the â&#x20AC;&#x153;round tableâ&#x20AC;? the professional associations (AIR, ANZSNM), the University Heads of MRS disciplines, State Registration Boards and the New Zealand Medical Radiation Technologist Registration Board. The Medical Radiation Practitioners National Steering Committee (MRP NSC) is comprised of 4 groups: 1. Conference of Regulating Authorities (CORA) a group representing the existing State and Territory Medical Radiation Practitioner Registration Boards: UĂ&#x160; i`Â&#x2C6;V>Â?Ă&#x160;,>`Â&#x2C6;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;/iVÂ&#x2026;Â&#x2DC;Â&#x153;Â?Â&#x153;}Â&#x2C6;Ă&#x192;Ă&#x152;Ă&#x192;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;Â&#x153;vĂ&#x160;+Ă&#x2022;iiÂ&#x2DC;Ă&#x192;Â?>Â&#x2DC;`Ă&#x2020;Ă&#x160;­7>Ă&#x17E;Â&#x2DC;iĂ&#x160; Ă&#x2022;Ă&#x192;Ă&#x192;Ă&#x160;qĂ&#x160; Â&#x2026;>Â&#x2C6;Ă&#x20AC;Ă&#x160; - Ă&#x160;>Â&#x2DC;`Ă&#x160; Ă&#x20AC;>Â&#x2DC;ViĂ&#x192;V>Ă&#x160; Â&#x153;Â?Â?Â&#x153;Ă&#x153;>Ă&#x17E;Ă&#x160; (CORA Secretary) UĂ&#x160; i`Â&#x2C6;V>Â?Ă&#x160;,>`Â&#x2C6;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;/iVÂ&#x2026;Â&#x2DC;Â&#x153;Â?Â&#x153;}Â&#x2C6;Ă&#x192;Ă&#x152;Ă&#x192;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;Â&#x153;vĂ&#x160;7iĂ&#x192;Ă&#x152;iĂ&#x20AC;Â&#x2DC;Ă&#x160; Ă&#x2022;Ă&#x192;Ă&#x152;Ă&#x20AC;>Â?Â&#x2C6;>Â&#x2DC;Ă&#x2020;Ă&#x160;­ iÂ&#x2C6;Â?Ă&#x160; Â&#x2C6;VÂ&#x17D;Ă&#x192;Ă&#x160;qĂ&#x160; iÂŤĂ&#x2022;Ă&#x152;Ă&#x17E;Ă&#x160; Â&#x2026;>Â&#x2C6;Ă&#x20AC;Ă&#x160; - ÂŽĂ&#x160; UĂ&#x160; i`Â&#x2C6;V>Â?Ă&#x160;,>`Â&#x2C6;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;*Ă&#x20AC;>VĂ&#x152;Â&#x2C6;Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;iĂ&#x20AC;Ă&#x192;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;Â&#x153;vĂ&#x160;6Â&#x2C6;VĂ&#x152;Â&#x153;Ă&#x20AC;Â&#x2C6;>Ă&#x2020;Ă&#x160;­ >Ă&#x20AC;Â&#x2C6;Â?Ă&#x17E;Â&#x2DC;Ă&#x160; >Â&#x2C6;Ă&#x20AC;`Ă&#x160;>Â&#x2DC;`Ă&#x160;-Ă&#x152;>Â&#x2DC;Ă&#x160; >Ă&#x17E;Â?Â&#x153;Ă&#x20AC;]Ă&#x160;,i}Â&#x2C6;Ă&#x192;Ă&#x152;Ă&#x20AC;>Ă&#x20AC;ÂŽĂ&#x160; UĂ&#x160; ,>`Â&#x2C6;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;-VÂ&#x2C6;iÂ&#x2DC;ViĂ&#x160;*Ă&#x20AC;Â&#x153;viĂ&#x192;Ă&#x192;Â&#x2C6;Â&#x153;Â&#x2DC;>Â?Ă&#x192;Ă&#x160;,i}Â&#x2C6;Ă&#x192;Ă&#x152;Ă&#x20AC;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;Â&#x153;vĂ&#x160;/>Ă&#x192;Â&#x201C;>Â&#x2DC;Â&#x2C6;>Ă&#x2020;Ă&#x160;­ >Ă&#x20AC;Â&#x17D;Ă&#x160; >Ă&#x20AC;ViÂ&#x2DC;Â&#x17D;Â&#x153;]Ă&#x160; Â&#x2C6;VÂ&#x2026;iÂ?Â?iĂ&#x160; V >Ă&#x20AC;Ă&#x20AC;Â&#x153;Â&#x2DC;]Ă&#x160; Registrar) UĂ&#x160; ,>`Â&#x2C6;Â&#x153;}Ă&#x20AC;>ÂŤÂ&#x2026;iĂ&#x20AC;Ă&#x192;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;Â&#x153;vĂ&#x160;Ă&#x152;Â&#x2026;iĂ&#x160; Â&#x153;Ă&#x20AC;Ă&#x152;Â&#x2026;iĂ&#x20AC;Â&#x2DC;Ă&#x160;/iĂ&#x20AC;Ă&#x20AC;Â&#x2C6;Ă&#x152;Â&#x153;Ă&#x20AC;Ă&#x17E;Ă&#x2020;Ă&#x160;­ >Ă&#x20AC;Â&#x17D;Ă&#x160;*>Â?Â&#x201C;iĂ&#x20AC;Ă&#x160;>Â&#x2DC;`Ă&#x160;,Â&#x153;}iĂ&#x20AC;Ă&#x160;7iVÂ&#x17D;iĂ&#x20AC;Ă&#x152;ÂŽĂ&#x160; UĂ&#x160; i`Â&#x2C6;V>Â?Ă&#x160;,>`Â&#x2C6;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;-VÂ&#x2C6;iÂ&#x2DC;Ă&#x152;Â&#x2C6;Ă&#x192;Ă&#x152;Ă&#x192;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;Â&#x153;vĂ&#x160;Ă&#x152;Â&#x2026;iĂ&#x160; Ă&#x2022;Ă&#x192;Ă&#x152;Ă&#x20AC;>Â?Â&#x2C6;>Â&#x2DC;Ă&#x160; >ÂŤÂ&#x2C6;Ă&#x152;>Â?Ă&#x160;/iĂ&#x20AC;Ă&#x20AC;Â&#x2C6;Ă&#x152;Â&#x153;Ă&#x20AC;Ă&#x17E;Ă&#x2020;Ă&#x160;­ Â&#x2026;Ă&#x20AC;Â&#x2C6;Ă&#x192;Ă&#x152;Â&#x153;ÂŤÂ&#x2026;iĂ&#x20AC;Ă&#x160; Â&#x2C6;VÂ&#x17D;Ă&#x192;ÂŽ UĂ&#x160; i`Â&#x2C6;V>Â?Ă&#x160;,>`Â&#x2C6;>Ă&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;Ă&#x160;/iVÂ&#x2026;Â&#x2DC;Â&#x153;Â?Â&#x153;}Â&#x2C6;Ă&#x192;Ă&#x152;Ă&#x192;Ă&#x160; Â&#x153;>Ă&#x20AC;`Ă&#x160;­ iĂ&#x153;Ă&#x160;<i>Â?>Â&#x2DC;`ÂŽĂ&#x2020;Ă&#x160;­,>iĂ&#x153;Ă&#x17E;Â&#x2DC;Ă&#x160; Ă&#x2022;Ă&#x20AC;Â&#x2C6;Â&#x2DC;Ă&#x160;>Â&#x2DC;`Ă&#x160; iÂ&#x2DC;Â&#x2DC;Â&#x2C6;viĂ&#x20AC;Ă&#x160;`iĂ&#x160;,Â&#x2C6;``iĂ&#x20AC;ÂŽ UĂ&#x160; 1Â&#x2DC;Ă&#x20AC;i}Ă&#x2022;Â?>Ă&#x152;i`Ă&#x160;-Ă&#x152;>Ă&#x152;iĂ&#x192;\Ă&#x160; -7Ă&#x160;>Â&#x2DC;`Ă&#x160;- Ă&#x160;qĂ&#x20AC;iÂŤĂ&#x20AC;iĂ&#x192;iÂ&#x2DC;Ă&#x152;>Ă&#x152;Â&#x2C6;Ă&#x203A;iĂ&#x192;Ă&#x160;Ă&#x192;ÂŤÂ&#x153;Â&#x2DC;Ă&#x192;Â&#x153;Ă&#x20AC;i`Ă&#x160;LĂ&#x17E;Ă&#x160; ,Ă&#x2030; <- Ă&#x160; (NSW: Ingrid Egan â&#x20AC;&#x201C; MRP- NSC Secretary, SA: Adam Freeborn (also Katrina Rech) 2. Australian Institute of Radiography (AIR) the professional association representing Radiographers, Radiation Therapists and Sonographers; (David Collier, Tim Way and Bruce Harvey)

X 57

Developing a new National Registration Board for MRS – Behind the Scenes

3. Australian and New Zealand Society of Nuclear Medicine (ANZSNM) a professional association representing Nuclear Medicine Scientists and Technologists; (David Lyall, Bridget Chappell.) 4. Medical Radiations Australia, Council of Medical Radiations Discipline Heads (MRA) a group representing Australian Universities offering Medical Radiation Sciences programs of study (Kerry Thoirs). The MRP NSC determined create a series of working parties which allowed many others within the profession to contribute to the creation of a raft of policies for submission to the new national board. Draft documents have been produced for the national registration standards and guidelines (as per National Law Act 2009 s38 and guidelines and codes of conduct s39) with Francesca Holloway as Registration Standards Project Manager. These working parties have been developing policies related to: – Continuing Professional Development (Lead: Neil Hicks. MRPNSC: Christopher Hicks, David Collier, Marilyn Baird, MRA: Kerry Thoirs, AIR: Min Ku, ANZSNM: Bridget Chappell, Adam Free born, and John Ryan – Recency of Practice (Lead: Marilyn Baird. MRPNSC: Christopher Hicks, Ingrid Egan, – Wayne Nuss, Adam Freeborn, Mark Marcenko, MRA: Kerry Thoirs, AIR: Bruce Harvey, Sharon Brackenridge, ANZSNM: Bridget Chappell, and John Ryan – Supervised Practice (Lead: Wayne Nuss. MRPNSC: Roger Weckert, Mark Marcenko, Ingrid Egan, David Lyall )MRA: Shane Dempsey AIR :Bruce Harvey, Tim Way, David Collier, ANZSNM: David Thomas, Adam Freeborn, Elizabeth Bailey – Code of Conduct and Ethics (Lead: Ingrid Egan. MRA: Kerry Thoirs, AIR: Jo Page, ANZSNM: Elizabeth Bailey – Scope of Practice (Lead: Ingrid Egan. All members of MRPNSC ) Other Mandatory Standards such as Criminal History (CH), Professional Indemnity Insurance (PII) and English language proficiency (ELP) had no working party because the Board has no discretion but to implement the nationally agreed upon policies. Nevertheless other professions’ standards were reviewed by the Steering Committee with Francesca Holloway as lead. These draft standards and guidelines will be submitted to the new MRP Board. The MRP Board will consider the submissions and develop standards which will be made available for public comment over the next 12 months via websites. The MRP NSC also consulted with all university heads of discipline in September of 2010 regarding course status and outlined the areas of National Registration that may impact upon Australian education.

3. A new Accreditation Council for Medical Radiation Science After much intense negotiation the MRP NSC also created a proposal for an Australian Medical Radiation Sciences Accreditation Council (AMRSAC). It is expected that such a body will in the future accredit university courses, and ensure that MRS practice will be maintained at the highest levels of competence. The development of a new MRP Accreditation Council began with the Steering Committee and was driven by the Accreditation Working Party. The Accreditation working party had tripartite representation of all current stakeholders: i.e. MRS Professional Associations, State Regulators and University Heads. The working party was lead by Neil Hicks and Stan Naylor (Registrar) and included from the AIR : David Collier, Tim Way and Bruce Harvey; from ANZSNM: David Lyall and Bridget Chappell; and University Head of Disciplines: – Kerry Thoirs and Shane Dempsey. During the development of the Constitution for the proposed “MRS Accreditation Council” extensive consultation occurred with Pharmacy, Physiotherapy, Optometry, Psychology , Podiatry, Dental and Chiropractic Accreditation Councils, all of which had recently undergone review. The Accreditation Council working party together with the National Steering Committee have agreed upon a budget and constitution and begun the process to have the new Australian Medical Radiation Sciences Accreditation Council, AMRSAC incorporated, should the submission be successful.

58 Gamma Gazette September 2011

4. Government Groups Overseeing National Registration The Australian Health Practitioner Regulation Agency, AHPRA (www.ahpra.gov.au/), is overseeing the National Regulation scheme and state/professional body representatives have been meeting with the NSC on several occasions during this process. AHPRA have also established the National Registration and Accreditation Scheme, National Reference Group (NRG) comprised of representatives from the State Boards to assist in the transition from the current state based registration to the new National Scheme in July 2012.

5. What registration will mean to you and the profession? The aim of national registration is to protect the public by providing for the registration of health practitioners and a common system of investigations into the professional conduct, performance and ability to practice, of registered health practitioners. Another purpose of registration is to protect the title of radiographer, radiation therapist and nuclear medicine technologist. Practitioners should be proud of being registered and understand that their actions outside of the health care setting can have a direct effect on the perceptions patients or colleagues have about the capacity of practitioners to deliver their service in a professional manner. Registration articulates the expectations of a health professional. These are stated in relation to the capacity of a registrant to exercise professional autonomy and accountability; confidentiality; gain informed consent; a duty of care; independent professional judgement; work in partnership with other professionals and health care providers and demonstrate effective and appropriate communication skills. One immediate change to the current approach to dealing with instances of inappropriate conduct is that “medical radiation practitioners and employers will be legally obliged to report a registrant who they believe has engaged in notifiable conduct.

notifiable conduct, in relation to a registered health practitioner, means the practitioner has: (a) practised the practitioner’s profession while intoxicated by alcohol or drugs; or (b) engaged in sexual misconduct in connection with the practice of the practitioner’s profession; or (c) placed the public at risk of substantial harm in the practitioner’s practice of the profession because the practitioner has an impairment; or (d) placed the public at risk of harm because the practitioner has practiced the profession in a way that constitutes a significant departure from accepted professional standards. (ref: Health Practitioner Regulation National Law Act 2009.) In summary, the benefit of registration is improved patient safety. The implementation of compulsory national registration for medical radiations’ practitioners in Australia next year is no doubt a very positive development. On an industry level, it will ensure that all practitioners are governed by a uniform code of professional conduct to which they must adhere and by which they will be held accountable for any breaches of practice. Importantly, compulsory national registration will also deliver additional comfort to members of the general public who, when using the services of a radiographer, radiation therapist or nuclear medicine technologist, want to know that the person they are dealing with is operating under strict standards and guidelines and that they have full recourse should they feel that any breaches of practice may have occurred. Furthermore, the new MRP Registration board will facilitate workforce mobility by allowing practitioners to move between states and know they retain their registration whilst ensuring that the standards of practice as outlined in this paper are applied consistently across Australia. For too long medical radiations practitioners have struggled to be recognised. The commitment by the Federal Government to implement national registration for medical radiations practitioners testifies to the important service we deliver within health. The achievement of national registration is something to be applauded and celebrated. Slowly and inexorably medical radiation practitioners will achieve the recognition they deserve and be able to ensure that our “best-practice “standards are met consistently across Australia. The process has truly begun. We urge all practitioners to embrace the new order and support the new National Board.

X 59

Developing a new National Registration Board for MRS â&#x20AC;&#x201C; Behind the Scenes

References Baird M A (2010). Expectations and responsibilities: What it means to be a registrant with the MRPB. Newsletter, (September). Victoria: MRPB Health Practitioner Regulation National Law Act 2009.

Medical Radiation Practice National Steering Committee (2008) Towards a Safe National Radiation Practice Workforce.

Top: MRP National Registration Steering Committee April 2011. L to R : N. Hicks, K. Rech, B. Chappell, M. Palmer, M. Baird, J. Ryan, D. Collier, B. Harvey, T. Way, D. Lyall, A. Freeborne, S. Naylor, F. Holloway, C. Hicks, M. Marchencko, K. Thoirs and W. Nuss. Above: David Collier and David Lyall (AIR CEO and ANZSNM Accreditation rep).

60 Gamma Gazette September 2011

Above: SA (Adam Freeborn), NSW (Ingrid Egan).

Survey Results ANZSNM Nuclear Medicine and PET Survey Results by Tracey Smith

Thank you to the 238 people who entered information for the ANZSNM survey. It was great to see so many people from different nuclear medicine fields and areas of Australia and New Zealand participate to give us a good snap shot of current Nuclear Medicine Practice. We would like to express our sincere gratitude to PETNET solutions, who provided a prize of two full registrations to the ANZSNM conference in Darwin, with Andrew Lloyd and Alicia Mansfield being the winners. A summary of the results are below.

Some interesting points from the survey results. UÊ 8.7% of those who responded had over 10 years’ experience in Nuclear Medicine U 79.3% of respondents incorporate multimodality services U 69.6% of respondents attend branch meetings – Well done U 69.5 % of respondents have 1-3 SPECT/CT cameras in their departments U 49.1% of people reconstitute their own kits U Bone and Cardiac are still the number one studies NMTs do everyday U 80.5 % of respondents do therapy studies U 173 respondents went on to give details about the therapies they perform U 96% of respondents used I-131 for both thyrotoxicosis and/or ablation, 11% Sr89, 18% Y90 microspheres or for joints, 0.5% Y90-Zevalin, 4% P32, 9% MIBG, 6% Sm-153, 7% Lu-177, 3% In111, 0.5% Re-188 U Some of these therapies were used rarely and some, like Y90 microspheres, were used weekly in some centres U Only 33% of those surveyed had access to PET U Of the 100 people who answered the PET question about tracers, 51% used FDG everyday, indications for oncology with Lung and Lymphoma being dominant. PET tracers were used minimally 4.7%, for dementia and epilepsy U 13 respondents have access to other PET tracers including F18- FLT, FET, F-DOPA, C11-choline, FAZA, NaF, FCH, Ga-68, Zr89, C11-PIB, Rb-82 U 29 respondents said they wished they had access to F18-FLT, F18-FET, F-DOPA, Ga-68, F18Choline, Zr89, F18-FAZA, F18- FMISO, C11- PIB, F18-NaF, F18-FCH, Rb-82, C11-methionine, Cu64, F18-Amyloid, I-124. A full report is available on the ANZSNM website.

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Professional Indemnity Insurance Survey Summary Bridget Chappell, Tracey Smith, Elizabeth Bailey

In July 2012 the Federal Government’s National Registration scheme for Medical Radiation Practitioners, MRP, including Nuclear Medicine Technologists/Nuclear Medicine Scientists, will be introduced. As part of this National Scheme, all MRP individuals seeking registration will be required to meet all mandatory registration standards set in place by the newly formed Medical Radiation Practice Board of Australia (MRPBA). One of the mandatory standards NMT/NMS will need to meet in order to gain registration covers Professional Indemnity Insurance (PII). Although the exact PII requirements have yet to be set by the MRPBA, individuals will need to ensure that they have appropriate PII cover either through their employer’s insurance policy, union membership or their own individual PII policy. To assist individuals who may require cover following the introduction of National Registration, the ANZSNM is collaborating with a PI insurance provider to formulate cover specifically for NMT/NMS. To assist the insurer in providing the most appropriate cover for individuals, the Society needs to gain an accurate and up-to-date picture of NMT/NMS across Australia. To obtain the most up-to-date and accurate information, the ANZSNM undertook an on-line survey; 233 individuals completed the survey with the results summarised as follows: General Demographics Results Questions 1 – 7 in the survey were general questions regarding the work performed by NMT/NMS throughout Australasia. From these questions it was found the vast majority of respondents, 94.4%, work in a clinical Nuclear Medicine setting and are full time employees with 74.4% working 31 hours or more per week. New South Wales had the most NMT/NMS, followed by Victoria and Queensland (See table1) The majority of respondents hold senior or Chief Technologist/Scientist positions in their workplace, 42.1% and 24.0% respectively, while only 2% of respondents hold trainee positions. The routine activities performed by NMT/NMS and information on the annual gross income are summarised in Figures 1 and 2.

Table 1 Percentage

Number of Responses

New South Wales

37.3

87

Victoria

24.5

57

Queensland

15.9

37

Western Australia

9.4

22

South Australia

7.7

18

ACT

2.6

6

Tasmania

1.3

3

New Zealand

1.3

3

PII Results Of the 233 individuals who completed the survey, 58.8% (n=137) currently have PII. Of those who currently have PII cover , employees were the common provider followed by unions and the public hospital insurance policy. Only 5.3% (n=8) of those with PII cover had their own PII policy. When asked whether they would be interested in obtaining personal PII cover, 42% (n-98) of respondents answered yes. Several questions and comments were raised regarding Professional Indemnity Insurance (PII) with the major issued addressed below: U Availability of PII – Some comments noted that PII was already available through other providers and

62 Gamma Gazette September 2011

Figure 1: What activities do you routinely undertake as part of your job? (multiple answers are allowed) Response Percent

Response Count

General Nuc Med Scanning

93.1%

217

PET Scanning

28.3%

66

BMO

32.2%

75

Ultrasound

2.6%

6

Radiopharmaceutical Administration

91.4%

213

Radionuclide Therapy Administration

54.1%

126

Stress testing

42.5%

99

Students/Trainee Supervision

71.7%

167

Diagnostic CT on Hybrid cameras

40.3%

94

Pharmaceutical Administrations eg. Lastix

63.9%

149

Management

49.4%

115

answered question

233

skipped question

0

outlets such as the coverage under public hospital insurance policy or private employers’ policy, union membership and other professional associations which include cover as part of membership fees e.g. AIR and ASUM/ASA. Individuals should check the level of PII cover available with their employer and unions/professional associations to ensure the Registration standard is met.

Figure 2: What is your approximate gross annual salary? Response Percent

Response Count

2.2%

6

20 – 40,000

6.0%

14

40 – 60,000

17.7%

41

60 – 80,000

23.7%

55

80 – 100,000

27.2%

63

100 – 120,000

10.8%

25

<20,000

U Concerns about the added cost of 3.4% 8 120,000+ getting PII cover – Most individuals 9.1% 21 Prefer not to answer this question may already receive appropriate 232 answered question PII cover through their employer or union so may not need to take 1 skipped question out additional cover therefore not incurring any further cost. However this should be checked against the PII Registration standard once it has been ratified by the MRPBA. U Is there a need for PII cover given little or no malpractice suits targeting NMT/NMS? – Malpractice suits or disciplinary actions against NMT/NMS for malpractice or negligence are extremely rare. However the need for PII is mandatory under legislation hence individuals will need to ensure coverage to be able to practice in Australia. The need for NMT/NMS to hold PII cover is linked into their ability to practice and is not for the benefit, financial or otherwise, of any other affiliated profession. All 14 registered professions are required to hold PII. Prior to any Registration Standard being ratified and adopted by the MRPBA it will be released for public comment. This should occur in the next three months. Should any individual feel strongly opposed to the introduction of mandatory PII cover or any other Registration Standards, they can address their concerns via a submission directly to the MRPBA for consideration.

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ANZSNM Research Grant for 2012 The Australian and New Zealand Society of Nuclear Medicine (ANZSNM) is offering one Research Grant per year under a competitive process. The Grant is funded with the aim of supporting investigation, clinical projects or experimentation aimed at the discovery and interpretation of facts or the development or application of theories in the field of Nuclear Medicine/ Molecular Biology. Clinical Projects are defined as projects that centre on groups of patients or other human subjects. It is recognised that clinical and collaborative arrangements may dictate that some aspects of work funded may be carried out at other sites. ANZSNM Research Grants are intended to achieve one or more of the following: 1.

Approach a meaningful conclusion in one year.

2.

Support young investigators initiated clinical projects (as defined above).

3.

Assist young investigators striving to establish new programs or new directions.

4.

Fund initial exploratory research for which external funding will be sought subsequently.

5.

Address circumscribed clinical problems of a sort unlikely to attract industry funding.

6.

Survey groups of patients to assess the success rate, sequelae, safety or any other aspect of diagnostic or radionuclide therapy protocols.

7.

Bridge the gap of a year between completion of one external grant and the commencement of another.

Further information and the application form are available on the Societyâ&#x20AC;&#x2122;s website. Closing date for applications is Friday 14 October 2011.

64 Gamma Gazette September 2011

Australian and New Zealand Society of Nuclear Medicine