Gamma Gazette Autumn Edition 2019

2019 AUTUMN EDITION | ISSUE 26

CELEBRATING THE 50 ANNIVERSARY OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE

ANZSNM 2019

Looking back to the year ANZSNM was founded

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2019 AUTUMN EDITION | ISSUE 26

CONTENTS From the President

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Featured Article

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30 years on: The Cold War and Nuclear Medicine in Australia – a small example

Branch News

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Special Interest Group News

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Special 50th Anniversary Liftout

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Education and Continuing Professional Development (CPD) • Case Studies

• What’s that?

29 53

Articles

59

Calendar of Events

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Office Bearers

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Editorial

Design & Production

Events & Advertising Enquiries

Rajeev Chandra, General Manager ANZSNM Secretariat PO Box 6178, Vermont South, VIC 3133 1300 330 402 (03) 8677 2970 secretariat@anzsnm.org.au

Ester Gomez, Creative Director Enovate Studio ester@enovatestudio.com www.enovatestudio.com

marketing@anzsnm.org.au

Submissions secretariat@anzsnm.org.au

From the President The Australian and New Zealand Society of Nuclear Medicine was founded in 1969, and in 2019 we celebrate 50 years as a professional organisation. This is a time to reflect on the growth in Nuclear Medicine and the increasingly valuable role of our specialty in patient care and treatment decisionmaking. Technological advances have driven change in the world, and this impacts on every aspect of our daily lives, both at work and at home. Connectivity through the internet gives us access to information in seconds and also has allowed us to bridge vast distances seamlessly, to the great benefit of collaboration, knowledge and education. The challenge that is emerging however is how to use this connectivity responsibly and also how to manage the information overload that it brings.

Given the speed of change of the last 50 years, I wonder what the next 50 years will bring?

Roslyn Francis President

In Gamma Gazettes throughout 2019 we aim to give a snapshot of our history in Nuclear Medicine, and to acknowledge those who have contributed to our specialty and organisation. If you have photographs or stories that you would like to share then we welcome these contributions as we mark this time in our history. I hope you enjoy the Gamma Gazette throughout the year, and thank you to those who have taken the time to compile these reflective pieces.

The recent Federal Government announcement of a new Medicare rebate for FDG PET in breast cancer from 1st November 2019 is very welcome news. This follows on from a successful MSAC application by AANMS, originally submitted in 2013, and finally approved earlier this year following a resubmission. The wording of the rebate will be released in the next few months. This marks an important step forward in access to PET for patients with breast cancer, to guide appropriate treatment decisions. Congratulations to AANMS for their efforts and persistence for this important rebate.

The 49th ANZSNM Annual Scientific Meeting ‘Precision Nuclear Medicine’ is rapidly approaching. I am very much looking forward to a vibrant scientific program that holds wide interest and will stimulate discussion and future ideas. The theme of the Conference Awards dinner is 1969, to reflect the founding year of ANZSNM. I would like to extend my gratitude to the Conveners of Dr Gabby Cehic, Prab Takhar and Dominic Mensforth, and to their organising committee, for their energy, enthusiasm and hard work, which is enormously appreciated.

Thank you also to the Professional Conference Organisers, Phil Plevin, to our National and International invited speakers and to our sponsors, for ensuring the success of ANZSNM ASM 2019. A reminder that ANZSNM AGM for 2019 will be held on Sunday 28th April at 1230pm at Hall L of Adelaide Convention Centre and all members are encouraged to attend.

As I conclude this report and I think of my own journey and experiences in Nuclear Medicine, I reflect particularly on the people who have inspired me, with their dedication, commitment, vision and generosity. We all have such busy lives, we rarely allow ourselves the time to reflect and remember. I leave you with this quote from Dr Seuss (Suess-isms) as you reflect on your own memories and experiences in Nuclear Medicine.

“Sometimes you will never know the value of a moment until it becomes a memory” I look forward to seeing you in Adelaide.

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Featured Article

30 years on: The Cold War and Nuclear Medicine in Australia – a small example

Author: Dale Bailey PhD, Royal North Shore Hospital

This year marks the 30 year anniversary of the official end to the 20th century’s “Cold War” between the Eastern and Western hemispheres – predominantly the eastern European Soviet Union and the West’s US & NATO-aligned allies. For those born after this time, the Cold War was a period from the 1950s until the end of the 1980s where East & West were on a permanent status of high alert for a pre-emptive attack from one on the other, and the guaranteed retaliation to follow, most likely starting or at least certainly ending with all-out nuclear warfare referred to as “Mutually Assured Destruction”, or MAD. The military expenditure on the Mexican stand-off that was the Cold War was enormous and was probably what eventually contributed to the ultimate collapse of the Communist-led regime in the Soviet bloc, dominated by Russia. Essentially, the US and NATO outspent the Soviets on military preparedness. Much of the culture of this period is infused with the nihilism of this episode in human history (see Kubrick’s Dr Strangelove or read Neville Shute’s On the Beach, for example).

What has this global mega-event got to do with Australian Nuclear Medicine?

Not a lot. We did learn some years ago that, in spite of being a signatory to the Nuclear Non-Proliferation Treaty (NPT), we had a uranium enrichment programme at the AAEC (now ANSTO) based on centrifugation. The main reason for having such a programme is to be able to produce weaponisable uranium.

But my story is simpler and has a better outcome.

The first overseas meeting that I attended related to nuclear medicine and was a small (120 people) “retreat” style meeting in Zeist, on the outskirts of Utrecht, The Netherlands called IPMI (Information Processing in Medical Imaging) in 1987. It was held outside of the city in the woods in a Protestant church conference/retreat centre. The idea was for the senior researchers in the field to live for a week with the juniors just entering after completing their studies and have discussions over shared meals as well as lectures and presentations and other outside activities. The accommodation was fairly simple in keeping with a retreat for a religious order.

The Proceedings, hand-typed on actual typewriters or on new devices called “Word Processors”, which were actual hardware machines from IBM at the time, can be readily found online today with their hand-drawn graphs and figures.

I made many lasting friendships at that meeting – in particular, with David Townsend, then from Geneva, with whom I worked over the next 20 years or so on 3D PET imaging and reconstruction. David went on to develop the first combined PET/CT scanner. There was also a very quiet woman there who came from Prague in Czechoslovakia – I’ll simply call her Helena. She was an expert in a mathematical procedure applied to images known as Principal Component Analysis (PCA), or alternately, Factor Analysis. This process could take a dynamic sequence, such as a renal scan, and split the pixels into a number of parametric images representing the fractional components of intravascular vs extravascular or specifically-bound radiotracer based on decomposing the time-activity curves. Very impressive stuff. But still being in the Cold War period it was surprising and interesting to meet someone from the “Eastern Bloc” outside the barriers of the Soviet Union. This was around the time when David Bowie was singing about the Heroes “by the (Berlin) wall”. There was great fascination in the west with what went on behind the Iron Curtain, as it was known.

Helena and I spoke mostly about the science we were involved in and what our work involved and, at the end of the meeting, returned to our separate worlds.

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Featured Article

30 years on: The Cold War and Nuclear Medicine in Australia – a small example (Continued)

At this time, I was a junior member of the Physics group at Royal Prince Alfred Hospital in Sydney with colleagues such as Roger Fulton, Steve Meikle and Brian Hutton. There was no internet, email nor mobile phones or anything that could vaguely be described as social media, and the only way to communicate was by written note delivered by surface mail or by Fax, although this would likely not have been possible to eastern Europe.

After over a year back in Sydney after the Utrecht meeting I received a phone call at RPA one day from a male with a thick eastern European accent. He explained that he was a friend of Helena’s from Czechoslovakia who was in Australia visiting and asked if we could meet up. We arranged to meet at the local RPA watering hole in Newtown for lunch one day.

When we met, he told me that he was involved in the textile industry in Czechoslovakia and had been sent to Australia as a guest of the Australian Wool Board to learn how to grade the merino wool we produced. His English was very presentable and we discussed many issues over lunch, without touching on anything of any substance, though.

“We can be heroes...”. David Bowie and wife Angie at the Berlin Wall which separated East and West Berlin, and was symbolic of the Iron Curtain which separated the Eastern Bloc from the West.

Again, for those too young to recall, at this time citizens of the Soviet bloc were not able to freely choose where they would live and were effectively trapped in the Soviet Union, unable to escape. Many died trying to leave. Parents arranged to have their children smuggled out to the West knowing that it was highly unlikely that they would ever see them again. One ex-colleague as a teenager left his parents at the border, where they waved him goodbye, as he fled to the West over a high mountain pass. It was a very different world.

At the end of the lunch, my visitor leaned over close to me and said “Helena wants to defect to Australia”. He told me that she had sent him to meet with me to see if I could help arrange for her to come to Australia on the pretext of a scientific exchange or collaboration, with the intention that she would never return.

I was a little taken aback by this – it was all very clandestine and “spook” like. Could he actually be a spy testing me out? Was he checking up on her after her one visit to the West in 1987? I nevertheless agreed that I would look into the possibilities.

I wrote to Helena with a letter that said that we were very interested in her techniques and inviting her to come to spend a period of time with us at RPA in Sydney. It was all very slow progress corresponding by regular mail and, as it happened, events overtook us. Revolutions by the people started to happen in eastern Europe – the polish shipyard city of Gdansk where the Solidarity movement was born, the collapse of the Balkan multistate of Yugoslavia after the death of the dictator, Tito, or the relaxing of controls on open debate about society known as “glasnost” in Moscow.

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Featured Article 30 years on: The Cold War and Nuclear Medicine in Australia – a small example (Continued)

In early November 1989 the Berlin wall came down and the Cold War was effectively over. I had just moved to London on a short-term secondment to work at the world-renowned MRC Cyclotron Unit at Hammersmith Hospital in West London. I paid a visit to Sydney in the middle of 1990 and found Helena in the department at RPA. My colleagues at RPA had continued to correspond with her and invited her to join them in Sydney. In the end, she did not need to escape or defect from the Soviet Union as it splintered apart. Helena moved on to the USA and continued to work in the field of medical imaging.

My small encounter with the Cold War did not amount to much in the end as history overtook us, but looking back it was a fascinating time and a reminder of what our world was like only a short time ago.

Members of the physics team at RPA in 1990 (L to R): Roger Fulton, Dale Bailey, Brett Jackson (employed by Medical Applications at the time, part-based at RPA) Helena and Steve Meikle.

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WANT TO REDUCE INJECTED DOSE BY UP TO 25%?

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It’s now possible with the new 800 Series

Introducing the 800 Series. The new family of five nuclear medicine systems puts into practice everything we’ve learned over the course of 20 years by bringing the latest in SPECT/CT advancements to a wider range of clinical environments.

The 800 Series includes a collection of SPECT enhancements like SwiftScan Planar and SwiftScan SPECT that can increase sensitivity and enable reduction of scan times or injected dose by as much as 25 percent , without a loss in signal-to-noise ratio.1

gehealthcare.com.au 1 Compared to LEHR collimator, with Step & Shoot scan mode (for SPECT) / without Clarity 2D (for Planar).

As demonstrated in phantom testing using a bone scan protocol, Evolution processing (for SPECT), and a model observer. Because model observer results may not always match those from a human reader, the actual time/dose reduction depends on the clinical task, patient size, anatomical location and clinical practice. A radiologist should determine the appropriate scan time/dose for the particular clinical task.

Branch News Western Australia Branch News In November last year, the WA Branch held its AGM at Sir Charles Gairdner Hospital with some great speakers and a lovely casual dinner afterwards.

At the AGM Dr Liz Thomas and Simone Culleton announced their resignations from the WA Branch committee. We would like to sincerely thank them both for the time and dedication they have given to our committee over the years. We had previously called for any new committee nominations and were delighted to have three people keen to join us. Following a unanimous vote by those present at the AGM, all three are now our newest committee members. We welcome Rosemary Dallen, Jacqui Watts and Vivian Xiao on board. We have had a few other changes within the committee too, with Tiffany Langton now our Chairperson and Emma Brook our new Treasurer.

During our last few committee meetings, we have been discussing the difficulty often experienced by WA workplaces with attracting new technologists to move West and stay here. There is no degree offered over here for Nuclear Medicine so most of us are from SA, NSW or Victoria. We don’t usually have local graduates wanting to start work but did following the successful Health Workforce Australia Nuclear Medicine Scholarship Program offered to WA high school students a few years ago. This is an issue that has been taken to the ANZSNM Federal level

but we are working as a committee too to see how we can not only entice people to move but how to best support technologists who are new to WA once they’re here and how to encourage them to stay.

The WA Branch has started the New Year with a social event having dinner and watching the sun set over a working week. We held our first scientific meeting for the year at PRC Subiaco on Tuesday 5th March where we heard the second part of Dr Andrew Henderson’s presentation from last year’s AGM. There are also a few other presentations and interesting cases on the agenda for the night too.

This year WA has a number of meetings planned and will also be hosting the 2019 TSIG Symposium which will be held in late Spring. Further information will follow throughout the year and we are quite excited to have an opportunity for so many WA technologists to attend this year.

Finally, we would like to take this opportunity to officially thank all our industry partners who continue to generously support us financially, professionally and socially. We value our relationships with you and are glad that you like to be a part of the nuclear medicine community over here in WA. Georgina Santich - Secretary, WA Branch

South Australia Branch News This year we welcome our newest Branch Secretary/ Treasurer Tess Smith on board and farewell Dai Nguyen. Dai did an outstanding job organising society meetings, sponsorship and managing the accounts and she continues to serve the society as a committee member for the 2019 Annual Scientific Meeting.

Dom Mensforth will be retiring from his role as Federal Representative which he has served in since 2013. We thank Dom for his dedication in representing us and welcome Vicky Sigalas as his replacement this year.

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The 2018 AGM was once again held at the Belgium Beer Bar café with a delicious spread of shared mains and dessert followed by an entertaining quiz created and hosted by the Flinders Medical Centre NM staff.

We are looking forward to seeing everyone at the 49th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine in Adelaide.

Elyse Langeluddecke - Chairperson, SA Branch

Branch News New Zealand Branch News On 15 March 2019, during Friday Prayer, a devastating terrorist attack took place at the Al Noor Mosque and the Linwood Islamic Centre in Christchurch, New Zealand. Fifty men, women and children lost their lives, with many more injured. There are no words to express the profound sadness we are feeling after this horrific and tragic event.

On behalf of the New Zealand Branch we wish to extend our deepest sympathies to the victims and their families.

Many of us are experiencing immense fear, confusion and sorrow. We wish to offer support to all our members directly or indirectly affected by this incident.

Amidst this time of grief and mourning, it has been heartwarming to see how New Zealand, as a community, has banded together. It is imperative that we continue to support one another and celebrate our diversity. We must actively commit to the inclusion and acceptance of all people, both professionally and personally. We must strive to show each other kindness, respect, and compassion not just in our words but also in our actions.

As Martin Luther King Jr once said: Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.

They are us. Kia Kaha Christchurch and New Zealand.

This past September, Kirsten Worthington and the team from Invercargill hosted a successful branch meeting with approximately 50 delegates from around NZ and a few from Australia. The meeting was well supported by both delegates and trades.

The highlight was guest speaker, Mark Marcenko from Tasmania who spoke on 68Ga - PET PSMA imaging.

Berry Allan also gave a review of his use of 99mTc labelled PSMA to image prostate cancer.

Unfortunately, there were no NZ entrants for the Radpharm or Paul Orr Award this past year. However, there were two fabulous posters entered for the Poster Competition, with both parties sharing the award.

Congratulations to Trish Mead for her poster titled “75SeHCAT (bile acid malabsorption) Scans and to Alana Clark for her poster titled “Pilot Study Assessing for Diagnostic Benefit of Fusion of 68Ga-PSMA.” The Saturday evening gala dinner was held at Transport World - a local Invercargill museum, which displays the famous Texaco truck (only 2 remain in the world). The function was held in a display street within the museum amongst the old cars and paraphernalia.

The costumes were fantastic!

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Branch News New Zealand Branch News (Continued) Especially Chrissie Roodt, who took home the Kevin Award for her Speakeasy costume. Loads of laughs and dancing was had by all. Delegates had a rocky departure when the weather turned stormy, but all managed to make the return journey home safe and sound.

Guest speaker, Mark Marcenko

Kirsten Worthington - Convenor

The New Zealand Nuclear Medicine community has seen many changes over the past few months. Many sites around the country have seen upgrades to their imaging departments in the form of new cameras, we have welcomed new technologists and we continue to have students progressing through the distance education Nuclear Medicine program offered through the University of Auckland.

Excitingly, Lutetium-177 PSMA peptide receptor radionuclide therapy is now available to patients in New Zealand. This treatment is being offered to patients in Auckland under the direction of Dr. Remy Lim and his team at Mercy Radiology.

Finally, I have been asked to pass on a message from one of our local delegates, Jacqueline Metzler (nee Bague), former Charge Technologist with Ascot Radiology, as well as TSIG NZ Branch Representative (2014-2016). Jackie has recently departed NZ to take on a new role as Chief PET/CT Technologist in Victoria, Canada at a newly established PET department with BC Cancer. Jackie has asked me to pass on her sincere gratitude and thanks to the many colleagues she has had the opportunity to collaborate with throughout both New Zealand and Australia. She has great memories of her career, relationships, and experiences in New Zealand, and hopes to return to Australasia at some stage in the future.

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Branch News New Zealand Branch News (Continued)

Yasmine Rennie & Karen Roeske

Mark Marcenko & Karen Roeske

Diana Huckett & Trish Mead

Behnam Farvardin, Isla Tree, Dr Josie Parker (back) Kirsten Worthington (front) & Alex Fox

Diana Huckett, Lynda Murray & Jane Hassall

Fraser Duncan, Alan Jones & Will Styles

Jane Hassall, Darin O’Keeffe & Barb Ovenden

As we begin 2019, there is much to look forward to. The New Zealand Nuclear Medicine community continues to push full steam ahead to bring the latest technologies and developments to our patients. I feel very honoured to be a part of such a diverse and passionate community.

On behalf of the NZ Branch, we look forward to catching up with our colleagues at the upcoming 2019 ANZSNM Annual Scientific Meeting in Adelaide as well as our local Branch Meeting in Rotorua in early September 2019.

Jessica Fagan - Secretary, New Zealand Brach

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Branch News Victoria and Tasmania Branch News We hope all of our members had a relaxing break over the Christmas and New Year period. January has meant one thing for the Vic-Tas branch over the last few years; a chance to catch up on the world of Cardiology from our regular speaker, Dr Kim Williams. This year’s talk, with thanks to our sponsor GMS, was on the link between cardiac conditions and plant-based diet and which imaging modality should be better utilised. It showcased the potential of Nuclear Medicine to provide not only physiological information but that the advancement of CT in Nuclear Medicine also opens wider doors for anatomical correlation.

Dr Kim Williams

non-invasive approach to cannulation, such as oral F-FDG administration, to yield diagnostic quality images and provide positive experience for needle phobic patient. After the judges’ deliberation, Lauren was chosen to represent our branch at the ANZSNM in South Australia and we wish her all the best.

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Dr Kim Williams' presentation

We also held the State finals of the Radpharm awards that evening and had three great presentations: Emma Harding (Austin Health) presented on the ‘Impact of the bone scan in a complicated meningococcal patient’, where the bone scan changed the patients management by revealing the severity of ischemia to the distal limbs and confirming necrosis prior to the right thumb and lateral below knee imitations; Nicholas Daw (Peter MacCallum Cancer Imaging) presented an ‘I-124 Case study’, showing the use of quantitative I-124 imaging and dosimetric analysis to enable personalized I-131 therapy doses to be prescribed; and Lauren Hudswell (Monash Health) presented ‘No needle to fear - An approach to needle phobic patients’ which discussed using alternative

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In continuing our goal of providing regular and quality CPD options for our members, the Vic-Tas branch is looking to host several “Master Classes” this year, rather than the traditional full day seminar. Our first class will be focussing on the non-medical side of Nuclear medicine, such as writing and updating a CV and interview techniques, as well as preparing a research article, poster, or case presentation. We will also be looking at incidental findings on Nuclear Medicine Imaging and the utility of the CTAC data.

We also hope to have either pre or post-conference speakers from the Annual Scientific meeting in South Australia come to Melbourne, but this will be confirmed once the Scientific Program has been finalised.

Keep an eye on Attendo Plus for further information on these upcoming events.

Kim Jasper - Secretary, VIC-TAS Branches

In loving memory of Rudolph Leopold Chmiel

b 24-7-1942 Poland d 30-12-2018 Baptcare, Doncaster.

Rudolph was a most talented doctor, much respected by his staff and colleagues.

He was a graduate of the Melbourne University and St. Vincent’s Hospital Medical Schools.

He completed post graduate training in Radiotherapy at the Peter MacCallum Clinic then pursued Nuclear Medicine, training at the Royal Melbourne Hospital with Dr. John Andrews. Whilst there he developed techniques using Technetium DTPA in the assessment of brain tumours, brain haemorrhage and CNS infections on the basis of diffusion across tissue concentration gradients.

He became Director of Nuclear Medicine at St Vincent’s Hospital,1973 where he was renowned for his innovation and medical insights. He continued his interest in the use of diffusion with Tc-99m DTPA to assess intra-abdominal abscess. He developed a technique using IV perchlorate and aliquots of Iodine to assess organification defects within the thyroid as observed in Hashimotos Thyroiditis.

He pioneered the use of Tc-99m labelled RBC in the assessment of leg DVT. He also refined the technique of assessing the site of GIT bleeding by using labelled RBC’s and taking sequences of one minute images that better depicted the site of gut bleeding. With the confidence of the neurosurgeons, particularly Mr. Keith Henderson, he pursued interests in CSF dynamics. Firstly, in elevating the CSF pressure once the intracranial cisterns had been outlined with a nuclear medicine tracer to detect CSF leakage. Using a similar approach, he studied rates of CSF absorption in patients suspected of Normal Pressure Hydrocephalus at graded elevation infusion pressures.

He was fluent in several European languages having been born into and coming from troubled times in Europe. Conversations were lively, at times unpredictable but always good fun.

“ His intelligence and curiosities spanned many fields. He was keenly interested in the function and design of the gamma camera and the evolution of digital imaging. His approach was an inspiration to his staff and registrars and overall a genuine breath of fresh air.

”

In his final years he was troubled by disabling Parkinson’s Disease and his demise was a blessed release.

He will be sadly missed by his friends and colleagues.

Colin Styles, Mack Jost.

Special Interest Group News TSIG Day Symposium, 24th August 2019 The ANZSNM Technologist Special Interest Group would like to invite you to our Annual Day Symposium, to be held on August 24th at The Esplanade Hotel in Fremantle, WA. We will have a great lineup of presenters showcasing some of the best that WA Nuclear Medicine has to offer, as well as exciting innovations and some quality career development.

As well as providing valuable CPD hours, this event provides the perfect excuse for a winter getaway.

Fremantle has everything you could want for any foodie, music lover, beachgoer, and great for families too.

Join us for dinner and drinks at Little Creatures Brewery after the day is over.

Registration and Call for Abstracts for this event is now open!

Register via website anzsnm.org.au/2019TSIG Send abstracts to secretariat@anzsnm.org.au EARLY BIRD PRICE STARTING AT ONLY $115 AND $70 (STUDENTS) Accommodation discounts are available at The Esplanade Hotel for registrants to this event.

Please visit bit.ly/TSIG2019 for more information.

Sponsorship opportunities still available, please contact the secretariat for more information.

Nicholas Daw Chair of the TSIG CPD and Education Committee

Annual Day Symposium

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REGISTER anzsnm.org.au/2019TSIG

Special Interest Group News International Relations Committee of ANZSNM In 2018, a Lancet Oncology Commission in Medical Imaging and Nuclear Medicine was established to review the global status of imaging in the management of cancer patients, and to provide guidance and recommendations for infrastructure, equipment, workforce and clinical guidelines for cancer imaging in developed and developing countries. ANZSNM is a formal participant in this project, which is being co-ordinated by all major Nuclear Medicine and Radiology societies, as well as IAEA and WHO. Prof Andrew Scott is on the Executive Committee of this project, and meetings at RSNA in December 2018 and ECR in February 2019 have been held to develop this project. Initial reports are planned for late 2019, with submission to IAEA and WHO and publication in Lancet Oncology to follow. Updates will be provided to ANZSNM members during the next 12 months.

to establish similar programs in these regions, with input from ARTnet. This reflects the impact of the ARTnet program in the international nuclear medicine community.

Following meetings with SNMMI and EANM during 2018 regarding the success of the ARTnet clinical trials program, further discussions are underway

Prof Andrew Scott Chair

ANZSNM was represented in a final IAEA Regional Cooperative Agreement project RAS/6/083 "Improving patient care and enhancing government participation in Nuclear Medicine programs" meeting in Singapore in December 2018. This program has resulted in enhanced teaching and training of nuclear medicine professionals, and increasing referrals for nuclear medicine studies, throughout the Asia-Oceania region. ANZSNM participation included hosting a teaching program during the WFNMB conference in April 2018, and provision of experts to training sessions run by IAEA in Thailand.

We thank the following corporate sponsors for their continuing support in 2019. By sponsoring, they demonstrate their commitment and instrumental role in the advancement of clinical practice and research in nuclear medicine.

Their sponsorship also helps strengthen the relationship between the members of the society and those from the sponsoring organisations, which enables their profession with the latest technology and developments in the field of Nuclear Medicine.

If you are a Company serving nuclear medicine professionals and interested in our Corporate Sponsorship package please contact secretariat@anzsnm.org.au 2019 Autumn Edition | gamma GAZETTE | 15

Over the past 50 years, The Australian and New Zealand Society of Nuclear Medicine has been at the forefront of the Nuclear Medicine profession.

To every single member and individual who has been part of this journey, thank you!

We are committed to continue to be leaders in our industry and to work together to keep the society moving to the future.

Special 50th Anniversary

A Nuclear Medicine Society The Beginnings

During the late 1960s, interest in nuclear medicine and a nationwide society of nuclear medicine had been growing strongly throughout the larger states of Australia. A Victorian group was established and a New South Wales group was just commencing.

In November 1968, a meeting of users of radioisotopes in medicine and biology was convened jointly

by Dr Provan Murray (physician, Prince of Wales Hospital), Mr Alan Downes (chemist, CSIRO) and Mr B. W. Scott (physicist, State Bureau of Physical Services) to discuss the desirability of the formation of a society embracing personnel involved in the use of radioisotopes. It was resolved, after considerable discussion, that a society be formed to bring together all those people interested in the use of radioisotopes in medicine and biology. Forty-eight people agreed to join such a society.

A steering committee, chaired by B. W. Scott, was appointed to investigate the name, objects and membership. Members of this committee included Drs J. N. Gregory, I. S. Jenkinson, J. G. Morris, C. Hambly, G. Lowenthal, Mr A. M. Downes and Associate Professor J. M. McRae. This committee produced a draft resolution, in due course, in which it was proposed that the society be called the Society of Nuclear Medicine (NSW). Great care was taken to define nuclear medicine in the widest possible terms and to ensure that the membership qualifications were free from discrimination between university graduates and non-graduates, or between medical and scientific or technical personnel, and that the society should remain a purely-scientific society.

The Royal Australian College of Radiologists was keen to promote nuclear medicine and the Royal Australian College of Physicians was interested in progressing plans to develop a course of training leading to a joint diploma. However, although in general agreement on this way forward, at a meeting in Sydney, both bodies decided to refer the matter to the forthcoming meeting in Adelaide so that the nuclear medicine specialists could take the matter over together. This decision was made through reservations expressed at that meeting by Dr John Morris and Dr Jim McRae. The meeting in Sydney was a very valuable one in the development and establishment of the impending society. It at least made it more obvious that workers in nuclear medicine were interested in their own affairs and that Adelaide would be a landmark meeting of specialists in the field from all over Australia.

In April 1969, Dr Harry Lander wrote to Professor W. S. C. Hare, expressing his desire to establish a college of nuclear medicine. He strongly felt that the interests of those working in the field of nuclear medicine could not be adequately represented by physicians, radiologists or pathologists, as the discipline was an entity in its own right. He realised that there would be difficulties in establishing such a college, but felt that they were surmountable. He sent copies of this correspondence to colleagues: Dr John Andrews and Dr Les Dugdale in Melbourne and Dr John Morris in Sydney.1

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Special 50th Anniversary

Australian Society of Nuclear Medicine was established in May 1969, Adelaide

First Asia and Oceania Congress of Nuclear Medicine and Biology held in Sept 1976, Sydney.

1969

1976 1970 The society changed its name to Australian and New Zealand Society of Nuclear Medicine (ANZSNM) as it is currently know at the 1st Annual Scientific meeting in 1970, Sydney. Membership started in New Zealand.

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Special 50th Anniversary

Australian Radiopharmaceutical Trial Network (ARTNET) launched in April 2014.

2014 2018

1994

12th Congress of the World Federation of Nuclear Medicine and Biology is held in Melbourne

6th Congress of the World Federation of Nuclear Medicine and Biology in 1994, Sydney.

Brian Hutton, Brenda Walker and Richard Smart promoting the Sixth World Congress

ARTNET Research

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Special 50th Anniversary

A Nuclear Medicine Society (Continued) Professor Hare’s response expressed his views on the subject of a national body of nuclear medicine: Such a society will prove an excellent forum for all those, both medical and non-medical, who are interested in the speciality. Secondly, as you have pointed out, there is a need for a course of training for medical graduates leading to a certificate. In addition I think there is a third need, which you imply, but which has not been discussed in detail yet, and that is for some sort of association of medical nuclear medicine specialists, through which they can promote their professional status etc. and which can act as a second forum for scientific discussion.

Ref 1

We have thought about the possibility of a college of nuclear medicine being set up from the outset. However, the number of medical graduates involved at this stage, and for a good number of years to come, is so small that it would be out of context with other established colleges. The College of Radiologists would be disappointed if such a move was made at this stage, as there is a strong feeling, along American lines, that the radiological sciences should stick together.

To this end, I am sure every effort would be made to promote and accommodate the speciality within the structure of the college. As time goes by, if my predictions are correct, we would look to nuclear medicine as playing a major part in college affairs. In a relatively short time, the number of nuclear medicine specialists should exceed the number of radiotherapists.2

Ref 3

Hare concludes his letter by emphasising the success of the impending Adelaide meeting, but adding: However, as Professor of Radiology, I hope the decisions which are made are such that those working in the radiological sciences will group together and not develop in isolation one from another. 2 There was very strong support from all recipients of Landers letter, but all had reservations with regard to the establishment of a college of nuclear medicine. Dugdale replied: I am in sympathy with the idea of formation of a college of nuclear medicine, but I am rather afraid that the practical difficulties involved may render it impossible at this stage.3 Dugdale elaborated on what he felt would be some of the difficulties associated with the proposal. He considered that foundation members Ref 6

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Special 50th Anniversary

A Nuclear Medicine Society (Continued) should be medically-qualified and involved in large-scale clinical applications of radioisotopes. He felt that with this vocation limitation, there would be probably only 15 to 20 people in Australasia suitable for full membership. He also felt that it would be difficult for non-medicallyqualified persons within such a college and that they, regardless of qualification or seniority, would never obtain full membership. This, he believed, would lead to bitterness within the departments of nuclear medicine. To satisfy all workers he said: I would think it desirable that an Australasian society of nuclear medicine be inaugurated, rather along the lines of the Society of Nuclear Medicine in the USA.3

Ref 2

Dugdale concluded in saying that he was looking forward with great interest to the meeting in Adelaide. However, John Andrews was a little more diplomatic in his reply:

Ref 4

As you know, there has been discussions going on for at least about two years regarding the future of nuclear medicine and its associations, and I have been in a somewhat unique position, being in both the Royal College of Physicians and the College of Radiologists. It is, however, the latter college that has asked me to help in the preparation of part 1 of a diploma. I felt, from the outset, it would be better if we were not irrevocably tied to any one college and, for this reason, it was my suggestion that the diploma should be a conjoint effort, involving both colleges; and this eventually became accepted by them.4 Previously, Andrews had thought of the possibility of an independent body of nuclear medicine, but rejected it because there were so few people actively working and interested in the field. Now, he felt that things may have changed. He concluded with what we would regard today as a very sound prediction:

Ref 5

Ref 7

I would be interested to hear other people’s opinions when we meet in Adelaide, which for nuclear medicine will be a very important meeting, I feel.4

2019 Autumn Edition | gamma GAZETTE | 21

Special 50th Anniversary A Nuclear Medicine Society (Continued) Foundation Meeting The Society was inaugurated in Adelaide, in May 1969, when the majority of specialists in nuclear medicine in Australia were gathered for the ‘Seminar in Nuclear Medicine’, conducted by the South Australian Branch of the (now Royal) College of Pathologists of Australia. At this historic meeting, at the Royal Adelaide Hospital on 21 May 1969, the following office Bearers were elected: President:

Dr H. Lander

Secretary:

Mr P. Simmons

Treasurer:

Dr P. M. Ronai

Committee:

Mr B. W. Scott (NSW)

Dr I. P. C. Murray (NSW)

Dr L. Dugdale (Vic)

Dr J. Andrews (Vic)

Dr M. Quinlan (WA)

Dr R. Stanford (WA)

Dr R. J. Connolly (Tas)

Dr R. Baker (SA)

Dr I. Buttfield (Qld)

Mr R. Boyd (ACT)

The meeting lasted two days; and with its initial 23 members, ‘The Australian Society of Nuclear Medicine’ was born.

By November that year, the ASNM membership, including both full Members and Associate (nongraduate) Members, totalled seventy-nine. State representation included:

22 | gamma GAZETTE | 2019 Autumn Edition

New South Wales – 24 Members & 6 Associates, Western Australia – 13 Members & 3 Associates, Victoria – 10 Members & 1 Associate, Tasmania – 7 Members & 1 Associate, South Australia – 6 Members, and Queensland – 4 Members.

In addition to the above, three medical or science graduates from New Zealand also joined the Society within its first six months. Foreseeing likely membership from New Zealand, the possibility of calling the Society ‘The Australian and New Zealand (or Australasian) Society of Nuclear Medicine’ had been raised at the inaugural meeting in Adelaide. But, unfortunately, as no New Zealanders were present at the foundation meeting, it was considered perhaps presumptuous to include any reference to New Zealand in the title of the Society at that time.

However, in view of the interest being shown in the Society by New Zealanders in the field of nuclear medicine, the name of the Society was to be reconsidered at the first Annual General Meeting to be held in Sydney on 11 February 1970. By that meeting, the membership had grown to over one hundred. This rapid growth was attributed to the encouragement of membership from as wide a group and variety of interests as possible. The only requirement being, that a member or potential member should have an interest in nuclear medicine in one or other of its many facets, which included graduates in medicine, physics, chemistry and pharmacy.

Membership was also open to technologists and representation from commercial interests, particularly in the fields of nuclear instrumentation and radiopharmaceuticals. Even at this early stage of development, many companies had taken out

Special 50th Anniversary A Nuclear Medicine Society (Continued) sustaining membership in the society. But, more importantly, their representatives had joined as individuals, many of whom took an extremely active role in affairs of the society.

The following year, in his presidential address at the Annual Scientific Meeting, in Melbourne in 1971, Dr Harry Lander was to say: Not only have many companies taken out sustaining membership in our society but more important, their representatives have joined our ranks as individuals and in many instances have been extremely active in the affairs of the society. This has undoubtedly been to our mutual benefit and certainly, in at least one respect, we must be rather unique and perhaps hold some sort of record. For I know of no other scientific society – at least in this dextrorotatory part of the world – in which successive secretaries have been drawn from the allegedly-tainted ranks of the world of commerce. I assure you that the society has gained much from this particularly close association and I would like to take this opportunity to thank our present Secretary, Mr R. J. L. Alsop of Consolidated Nucleonics Pty Ltd for the very valuable work he has performed on behalf of the society over the last twelve months.

The first Scientific Meeting of the Australian Society of Nuclear Medicine was held in conjunction with the Endocrine Society of Australia (joint sessions), over 11–13 February 1970, at the Prince of Wales Hospital, Randwick, NSW. The theme, over the three days, was focused on radioimmunoassy, thyroid disorders and invivo and invitro studies. Speakers included Professor Basil Hetzel, Drs Creswell Eastman, Proven Murray, Les Dugdale, Harry Lander, John Morris, David Cook, Fred Lomas and Ian Hales, and Mr Laurie W. Steven and B. W. Scott. Full registration was $5.00 and for Associates it was $2.00. Return air-travel to this meeting, from Melbourne through Ansett

Airlines of Australia, would have cost: first-class - $56.80, economy - $47.00 and group-travel $42.00.

The Society saw an unprecedented growth. The constitution was ratified at that first and very successful Annual Scientific Meeting in Sydney.

Following representation from New Zealand, the name was changed to the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) and by the second Annual Scientific Meeting, held in Melbourne, the membership numbered almost two-hundred. One of the major reasons for this rapid growth was the selflessness of the Victorian Radioisotope Study Group, which had been formed several years earlier. This group, with its already strong and active membership and regular, well-attended meetings, after negotiation with ANZSNM and of its own initiative, became the Victorian Branch of the ANZSNM. This meeting of minds and achievement of unity should be credited to Messrs R. J. de Groot, E. H. Clarke, R. J. L. Alsop and Drs B. Rush, J. T. Andrews and L. M. Dugdale.

The following letter was received from Mr R. de Groot, Honorary Secretary/Treasurer of the Radioisotope Study Group of Victoria.

A special general meeting of the Radioisotopes Study Group was held on 15 April 1970 at the Cancer Institute, Melbourne. The Chairman, Dr B. Rush, presided and approximately 20 members attended. Dr Rush outlined, briefly, the history of the group which came into being in 1966, following the successful completion of an eight week course on ‘Radioactive Isotopes in Diagnosis and Investigation’. Since then, a fairly vigorous programme of scientific meetings involving lectures, demonstrations and instructional evenings has been followed. Dr Rush paid tribute to Mr K. H. Clarke in the organization and running of this course and in the early work of the group.

2019 Autumn Edition | gamma GAZETTE | 23

Special 50th Anniversary A Nuclear Medicine Society (Continued) With a financial membership of 56 in 1969 and with regard to our previous years’ scientific programmes, the group may be regarded as a successful enterprise.

Dr Rush then referred to the Australian and New Zealand Society of Nuclear Medicine. This society was formed last year to cater for the interests of all people involved in the practice of nuclear medicine throughout Australia and New Zealand. A scientific meeting was held in Adelaide last year and another in Sydney in February this year.

In view of the formation of this society to cover interests similar to our own, but on a much wider regional scale, the committee of the Radioisotope Study Group has considered the future of the group and has held discussions with executive members of the society to explore the possibility of our group becoming the Victorian branch of the society.

The first two years of the Society were pivotal in the awakening of interest in nuclear medicine and its

It would appear that there is no good reason for the group to continue to exist as a separate entity and that we should all join the society instead.

However, as the society can hold only periodic or Annual Scientific Meetings on a wide regional scale, our local needs can be covered if we form a state branch and preserve our scientific programme and machinery for running it. This costs a small amount of money – mainly for postage etc. – and, as we do not want to pay two subscriptions, an agreement has been reached with the executive of the society to rebate a portion of each member’s subscription to the state branch for running expenses, so that we can continue to function as before.

new techniques

After brief discussion, it was resolved unanimously that the Radioisotope Group be disbanded and that all interested parties should apply for membership in the Australian and New Zealand Society of Nuclear Medicine and that the members of the society resident in Victoria form the Victorian branch of the society.

management but

24 | gamma GAZETTE | 2019 Autumn Edition

in Australia and New Zealand, not only for routine diagnosis and also for research.

Lander

Special 50th Anniversary A Nuclear Medicine Society (Continued) Members of that committee forming the Victorian Branch were: Chairman, Dr B. Rush; Honorary Secretary/ Treasurer, Mr R. de Groot; Mr R. Alsop; Miss J. Milne and Drs J. Andrews, J. Coghlan, L. Dugdale, E. Gilford and M. Pain.

Lander went on to say: Public interest has been aroused and become manifest by the considerable space and time which has been devoted to nuclear medicine and its various techniques by all forms of the mass media, both nationally and regionally, in the last year or two. There must be few branches of medicine, for example, which have gained as much attention as nuclear medicine did recently in the pages of that august publication: ‘The Australian Financial Review’. This publicity has been educational, not only to hospital administrators and to the holders of governmental purse strings, but has also been reflected in the generosity of certain public and private sectors of the community.

An example of this was evident in Adelaide, where a complete gamma camera was generously made available by Searle Nucleonics, solely for clinical research purposes. Outstanding contributions were provided by charitable foundations, community organisations and several altruistic individuals in support of the development and establishment of new departments of nuclear medicine in every state of Australia and both islands of New Zealand. Of note, in 1969, there were only two gamma cameras in Australia; two years later fifteen were in routine use with three in one laboratory and four departments having Dual 5” rectilinear scanners. Prior to this, the majority of expanding departments had a single head 3” or 5” rectilinear scanner for diagnostic imaging.

Lander also showed concern for inadequately trained physicians and the need for adequate standards of service in this expanding and new arena of medicine: It is possible that this expansion has occurred, and is occurring, too quickly. I’m sure that it will be obvious to all of you that too great a demand could lead all too easily to a rather large ‘credibility gap’ in the science. If poorly-trained physicians are placed in charge of departments in which the work is carried out by inadequately-trained technicians, only chaos can result and there will be a ‘backlash’ against the techniques we have to offer.

Historically, in the first two decades of the use of radioisotopes in Australia, the majority of laboratories in Australia and New Zealand were run either by trained therapy radiographers, physicists or technologists under somewhat minimal or even no supervision by medical officers. This had occurred as the radioisotope laboratories were regarded merely the ‘Cinderella’ offshoots of existing departments of radiology, radiotherapy, endocrinology or even pathology. Where then did this field of medicine belong and to whom should the discipline be entrusted?

Although there was interest from the above mentioned departments, it soon became obvious that nuclear medicine facilities must be autonomous and self contained.

2019 Autumn Edition | gamma GAZETTE | 25

Special 50th Anniversary

A Nuclear Medicine Society (Continued) Lander concluded on this note: Otherwise, they are forever likely to be understaffed or administered by persons who have little interest in, or cognisance of their full clinical potential. If a good service is provided, nuclear medicine ‘sells’ itself and there is generally little difficulty in obtaining adequate equipment and staff, for such is demanded by clinicians as a diagnostic service. If, however, inaccurate diagnoses are made, or misleading or erroneous results given at frequent intervals, then a service will inevitably fall into disrepute or, at best, not be used to its full advantage.

There was concern within the society that the greatest danger lay in persons without medical training, irrespective of their qualifications, pontificating upon medical matters about which they were inadequately informed; and clinicians ignorant of the art and science of nuclear medicine accepting these views without qualification. This very situation was largely responsible for the rather sorry plight of nuclear medicine in the United Kingdom and several European countries in the 1960s.

The society’s view was expressed by Harry Lander: … ultimate responsibility for, and control of the application of these techniques to clinical problems, must reside with the physician adequately trained in nuclear medicine techniques. The physician, physicist, chemist and technologist must all work together in harmony, each appreciating the value and limitations of him/herself as well as the other, if the best interests of the patient and the discipline are to be served.

It behoves us all – and I believe it is an important function of the society to ensure that adequate standards and safeguards with respect to both equipment and personnel are not only established but maintained in all units.

Every endeavour must be made to upgrade those units which do not provide a satisfactory service; and there are still several in this country.

Text references

1. Lander, H., pers. corresp. to Hare, W. S. C., 22 April 1969.

2. Hare, W. S. C., pers. corresp. to Lander, H., April 1969.

3. Dugdale, L. M., pers. corresp. to Lander, H., 29 April 1969.

4. Andrews, J. T., pers. corresp. to Lander, H., 1 May 1969.

Image references

All content has been extracted from the book 'Isotopes, Imaging and Identity. The history of the Australian and New Zealand Society of Nuclear Medicine.'

Download a digital copy of this book here

www.anzsnm.org.au/resources/publications 26 | gamma GAZETTE | 2019 Autumn Edition

1. Professor Provan Murray with jockey Shane Dye at the launch of National Nuclear Medicine Day 2 & 7. The first Large Field of View (LFOV) gamma cameras were single detector analog systems 3. The first mobile gamma camera, an Ohio Nuclear Mobile was purchased at Royal Prince Alfred Hospital, Sydney 4. Miss Sue Welch and Dr Basil Beirman at Geiger Cottage, Launceston General Hospital (mid 1950s) 5. A Thyroid probe installed at the Peter MacCallum Cancer Centre 6. First PET scanner installed in NSW at the Royal Prince Alfred Hospital (RPAH) Sydney in 1992. IN those days, an FDG brain scan being performed by Stefan Eberl would take about 20 to 25 minutes to acquire. On a modern PET/CT scanner, it can be done in 5 minutes.

PHD STUDENT VACANCIES Professor Karen Jones is a clinical researcher with a background in nuclear medicine. She leads a clinical research group, within the Centre of Research Excellence in Translating Nutritional Science to Good Health. Her research programme capitalises on her background in imaging and focuses on the role of the stomach in blood glucose and blood pressure responses to meals in health and diabetes.

In 2016, Radiology SA generously donated a gamma camera to her group which is now established adjacent a purpose-built radiation hot lab, within the new Clinical Research Facility in the Adelaide Health and Medical Sciences Building of the University of Adelaide – the only gamma camera that is 100% dedicated to clinical research in South Australia. Her group was also recently awarded research funds (Ian Potter Foundation; University of Adelaide; The Hospital Research Foundation) to purchase a second ‘research-dedicated’, but portable, gamma camera, to be located within the Royal Adelaide Hospital which will allow ‘high-risk’ research e.g. studies in the critically ill.

Future clinical research studies, utilsing imaging techniques, will evaluate potential effective management strategies based on recent insights into the mechanisms underlying glycaemia and blood pressure regulation after meals. Professor Jones seeks 1 – 2 PhD students to join her team (scholarships available). If you are interested please contact her: Professor Karen Jones (DipAppSc, PhD) William T Southcott Research Fellow in Nuclear Medicine Adelaide Medical School Faculty of Health and Medical Sciences The University of Adelaide E: Karen.jones@adelaide.edu.au P: 08 8313 7821

Professor Karen Jones (left) with some of the members of the Centre of Research Excellence in Translating Nutritional Science to Good Health in the Gamma Camera Suite of the Clinical Research Facility in the Adelaide Health and Medical Sciences Building of the University of Adelaide.

health.adelaide.edu.au

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Education & CPD Case Study PSMA PET/CT vs Multi Parametric MRI in Staging of Prostate Cancer Author: Rachel Watherston - Benson Radiology, South Australia

INTRODUCTION Prostate cancer is one of the most common cancer diagnosed in Australian men with one in seven diagnosed with prostate cancer by the age of 85. Detection of prostate cancer was originally achieved with a combination of blood tests (Prostate Specific Antigen-PSA), digital rectal examination and trans rectal biopsy. Now, with the addition of PSMA PET/CT and multi-parametric (MP) MRI there are more diagnostic tools to further aid in the detection of both new and recurrent disease.

I will examine four case studies of patients who underwent both 68Gallium-PSMA PET/CT and MP MR imaging in which lesions were not seen concurrently with both modalities.

All case studies were performed on a Siemens MRI scanner following standard protocol for prostate MP MRI including high resolution T2, post contrast, ADC/DWI (apparent diffusion coefficient/diffusion weighted imaging) images and upper abdominal T2 axial screen. All patients underwent specific preparation including treatment with Buscopan to inhibit motion artefact caused by nearby structures. The 68Ga-PSMA PET/CT scans were all performed on the GE Discovery IQ 5 ring PET/CT system with a total scan time of 13 – 15minutes; covering vertex to mid thigh. Reconstruction was performed using Q Clear reconstruction (Bayesian penalised likelihood reconstruction algorithm).

CASE STUDY ONE Patient A, a 67-year-old male presented for a prostate MRI for initial staging with a PSA level of 13.1ng/mL. Whilst the MRI demonstrated benign prostatic hyperplasia (BPH) there was no evidence of intermediate-high grade malignancy and it was scored 2 on the PI-RADS 2.0 scale. Five weeks later, patient A presented for a PSMA PET/CT scan with his PSA level now increased to 15ng/mL. He was injected with 116MBq 68Ga-PSMA with a 60 minute uptake time. The PET/CT demonstrated uptake in the base of the prostate gland, involving the right and left peripheral region (Image 1). Despite retrospective review of the previous MRI, the disease was still only evident on the PSMA imaging.

Image 1 - Patient A

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Education & CPD Case Study PSMA PET/CT vs Multi Parametric MRI in Staging of Prostate Cancer (Continued)

CASE STUDY TWO Patient B was a 60-year-old male who initially had a prostate MRI (on a 1.5T scanner) which showed a single lesion left mid-gland, giving PIRADS score of 4. Subsequent biopsy of this area came back with a negative result. Six months later he was referred for a PSMA PET/CT Scan with a PSA level of 17ng/ mL. He was injected with 137MBq 68Ga-PSMA with a 51 minute uptake time. The PSMA scan detected multifocal uptake within the prostate gland (Image 2 and 3) and equivocal uptake within an inguinal lymph node. One week later he attended for a follow up MP- MRI (on a 3T scanner) noting the multifocal disease demonstrated on the PET/CT Scan. Again, the MRI demonstrated an unchanged 7mm mid gland lesion in the Transitional Zone – Peripheral Zone (TZ-PZ) Interface (Image 4), but the bilateral basal and right apical gland abnormality show on PET was not evident.

CASE STUDY THREE

Image 2 - Patient B Prostate Base

Image 3 - Patient B Apex

Patient C, a 77-year-old male, initially presented for a staging prostate MRI which demonstrated a left side PZ lesion in the mid gland, with a PIRADS Score of 4-5, with a suspicious lymph node posterior to the left external iliac vein. The patient also went on to have a Nuclear Medicine Bone Scan (images unavailable) which demonstrated suspicious uptake in T11. Six months after the initial MRI, the patient presented for a 68Ga-PSMA PET/CT Scan with injection of 127MBq 68Gallium-PSMA and a 56minute uptake period. The PSMA PET/CT showed only mild PSMA avidity in the left mid gland lesion, corresponding with disease detected on MRI (Image 5). The T11 lesion and suspicious lymph node did not demonstrate any significant 68Ga-PSMA uptake (Image 6).

Image 4 - Patient B MRI

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Education & CPD Case Study PSMA PET/CT vs Multi Parametric MRI in Staging of Prostate Cancer (Continued)

Image 5 - Patient C Prostate

Image 6 - Patient C non-avid node

CASE STUDY FOUR Patient D, a 70-year-old male, presented for an initial staging MP-MRI with an increasing PSA and strong family history of prostate cancer. The MRI detected two PZ lesions, one in central mid gland (Image 7) and one in posteromedial left mid gland, the latter of which showed extra-prostatic extension and possible seminal vesicle involvement and equivocal bilateral pelvic wall lymph nodes.

Following the MRI, the patient was sent for a PSMA PET/CT Scan to evaluate the equivocal seminal vesicle and lymph nodes. The PSMA PET/CT demonstrated uptake within the left posteromedial mid gland lesion however there was no uptake noted within the central mid gland lesion, nor in any lymph nodes. This could possibly be attributed to the size of the lesion (6mm) being below the resolution of the PET/CT scanner.

Image 7 - MRI

DISCUSSION Prostate Imaging and Reporting Data System (PIRADS) is the scoring method used in reporting prostate specific MRI. PIRADS score each lesion from 1 (clinically significant cancer is highly unlikely to be present) to 5 (clinically significant cancer is highly likely to be present). PIRADS examines the different image sequence (T2, DWI, Dynamic Contrast Enhancement) appearances which differs depending on where the lesion is located.

PIRADS v2 was published in 2012 and since then has been validated in numerous research scenarios, and in 2015 was published by European Urology and American College of Radiology.

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Education & CPD Case Study PSMA PET/CT vs Multi Parametric MRI in Staging of Prostate Cancer (Continued)

Whilst there has been significant improvement in the PIRADS Scoring System from v1 to v2, the system, like all imaging, is not flawless and there will be a proportion of cases that are false negative. There is varied figures amongst the literature in regards to negative predictive value for Prostate MP MRI. An article in European Urology [1] gives a median NPV of 82.4%, whereas Grey et. al. in BJU International [2] puts the NPV as high as 97.7% (with PIRADS Score of 1-2 being classed as negative). However, the evidence supporting the use of MP MRI in the initial staging of prostate cancer is overwhelming; supported further by the inclusion of Prostate MRI in the Medicare Benefits Schedule in July 2018 for both diagnosis and surveillance.

The sensitivity of PSMA PET/CT scanning varies throughout the literature, with most suggesting around 80-90%. The specificity of PSMA PET/CT is also high (up to 100%), particularly with extra-prostatic involvement. However, PET/CT does face its own limitations, in particular with sensitivity of the scanner with low grade/equivocal uptake and limitations

in spatial resolution. With rapid advances in PET imaging technology, these factors are becoming less of an issue; for example, the sensitivity of the PET/CT scanner in all 4 of these cases has a recorded sensitivity of 23.7cps/kBq and axial resolution of 4.5mm – 5.11mm (at 1 -20cm radius). Combined with the fact that some of the lesions in Case 3 and 4 were PSMA avid, this raises the possibility of false positives on MP MRI, hence not being identified on PSMA PET/CT. Unfortunately, there was no follow up on histopathology results from these cases to confirm either imaging results.

These cases confirm the value of both modalities in the diagnosis and staging of prostate cancer. Neither PET or MRI could be defined as more superior, rather both procedures should be viewed as an essential tool in the staging process. It also demonstrates the importance of communication across a multimodality team, with the ability to retrospectively review scans in conjunction with new results to examine false negatives/positives and ensure clinically important diagnoses are not being missed.

References 1. Moldovan, Paul C. et al. 2017, ‘What Is the Negative Predictive Value of Multiparametric Magnetic Resonance Imaging in Excluding Prostate Cancer at Biopsy?

A Systematic Review and Meta-analysis from the European Association of Urology Prostate Cancer Guidelines Panel’, European Urology, Volume 72 , Issue 2 , 250 – 266 2. Grey, A. D., Chana, M. S., Popert, R. , Wolfe, K. , Liyanage, S. H. and Acher, P. L. 2014, ‘Diagnostic accuracy of PI‐RADS scoring’, BJU International, Volume 115, pp.

728-735 3. American College of Radiology 2015, PIRADS Prostate Imaging – Reporting and Data System, viewed 2nd March 2019, < https://www.acr.org/-/media/ACR/ Files/RADS/Pi-RADS/PIRADS-V2.pdf> 4. Richenberg, J.L 2016, ‘PIRADS: Past Present and Future’, Clinical Radiology, Volume 71, pp 23 – 24 5. Applied Radiology 2019, ‘68Ga PSMA PET CT improves initial staging of high risk prostate cancer patients, viewed 1 March 2019, <https://appliedradiology. com/articles/68ga-psma-pet-ct-improves-initial-staging-of-high-risk-prostate-cancer-patients>

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Education & CPD Case Study Impact of the bone scan in a complicated Meningococcal patient Authors: Emma Harding, Jessica Welch, Christian Testa, Kunthi Pathmaraj, Sze Ting Lee, Andrew Scott - Austin Health, Heidelberg, Australia

BACKGROUND Neisseria meningitides is a Gram-negative bacterium1 that is naturally present in the nasopharynx in 5 – 15% of the general population without progressing to meningococcal disease3. There are 13 serogroups, however only organisms from A, B, C, X, Y, or W-135 are responsible for causing invasive meningococcal disease (IMD). Strains B, C, Y and W-135 are the most common strains in Australia for which there are vaccines available.

There are two forms of meningococcal disease: meningitis and meningococcemia. Meningitis is found primarily in the meninges while meningococcemia bacteria affect the systemic circulation1. Acute meningococcemia has a severe and sudden onset1. Symptoms typically begin with fever and headache, and progress to a purpuric rash, hemodynamic instability, shock, coma and often death1. The long term consequences of meningococcal disease include cognitive deficit, visual impairment, hearing loss, motor deficit, seizures, hydrocephalus, and loss of limbs due to tissue necrosis4. Worldwide, approximately 1.2 million cases of meningococcal disease are diagnosed annually, with around 135,000 fatalities. In Australia, 383 cases of invasive meningococcal disease were reported in 20174.

CASE HISTORY A 34 year old male collapsed at home and was transferred via ambulance to Austin Health. The patient had experienced mottled appearance on his skin and mild viral symptoms for three weeks prior, but suddenly deteriorated.

The provisional diagnosis was severe septic shock of unclear focus. Initial investigations performed included a CT of the brain, chest, abdomen and pelvis, and blood tests. These investigations failed to detect an intracranial abnormality or a septic focus within the chest, abdomen or pelvis. The patient was admitted to ICU. He remained in ICU for 19 days where coma was induced for the first 7 days, and the patient required resuscitation twice.

Meningococcaemia was diagnosed as serogroup MenW via blood cultures on the second day of admission.

The patient’s right thumb, right distal 2nd, 4th and 5th digits and both feet appeared black and leathery. His arms and legs were immobile due to pain and loss of sensation.

Photograph 1: Patient’s extremities appeared black, leathery and ulcerated.

A bone scan was initially requested to assess perfusion to the right thumb and to query the presence of osteomyelitis.

METHOD A three phase Bone Scan was performed using 99mTcMDP. A dynamic flow study of the hands was acquired following the intravenous administration of 686MBq of 99mTc-MDP. Additional blood pool acquisitions of the hands and whole body were acquired.

Delayed imaging was performed three hours post administration and included a whole body scan, delayed static of the hands and SPECT/CT of the feet.

2019 Autumn Edition | gamma GAZETTE | 33

Education & CPD Case Study Impact of the bone scan in a complicated Meningococcal patient (Continued) A low dose CT was performed and co–registered with the SPECT for the purpose of anatomical localisation.

Acquisition

Parameters

Matrix

Flow

3 sec/frame

64 x 64

Blood pool - Hands

120 seconds

128 x 128

Whole Body Blood Pool

25 cm/min

256 x 1024

Whole Body Bone Scan

12 cm/min

256 x 1024

240 seconds

256 x 256

20 sec/frame x 60 frames

128 x 128

Static – Hands SPECT/CT – Feet Table 1: Acquisition parameters

Image 1: Whole body blood pool

Image 2: Delayed whole body bone scan

RESULTS The bone scan demonstrated absent perfusion or tracer uptake in the right 1st metacarpal and entire right thumb, entire left foot, 1st and 5th proximal to distal phalanges of the right foot on the early and delayed imaging. Additionally, apparent mild reduction in tracer uptake was evident in the left femoral head, which was nonspecific and potentially artefactual.

The whole body bone scan identified little to no perfusion or bone uptake to the right thumb and, unexpectedly, to the bilateral distal lower limbs, consistent with peripheral ischemic injury resulting in bone and soft tissue necrosis.

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Education & CPD Case Study Impact of the bone scan in a complicated Meningococcal patient (Continued)

DISCUSSION The patient was treated with Ceftriaxone and Tazosin, specific antibiotics for severe bacterial infection.

Compartmental syndrome was diagnosed resulting in bilateral forearm fasciotomies to relieve the pressure and tension caused by the loss of circulation. Intensive physiotherapy was performed in an attempt to restore circulation to the lower limbs.

A second bone scan was requested 11 weeks following the initial bone scan, to assess viability of both feet, prior to a planned bilateral Below Knee Amputation (BKA).

This Bone Scan included dynamic flow of the feet following an injection of 669MBq of 99mTc-MDP, blood pool acquisitions of the feet and whole body, delayed imaging at three hours post administration of radiopharmaceutical, included a whole body scan, delay static of the hands and SPECT/CT of the feet.

Image 3: Blood Pool (left) and delay (right) static of handsbone scan

Image 4: Whole body bone scan September 2018

Image 5: Whole body bone scan November 2018

The bone scan findings were consistent with amputation at the carpometacarpal joint of the right thumb and diffuse mildly increased blood pool and osteoblastic activity present throughout the right wrist and small joints of the right hand. Blood flow, blood pool and osteoblastic activity in the distal right foot and mid to distal left foot was absent and unchanged since the previous bone scan.

The patient proceeded to surgery for bilateral BKA.

2019 Autumn Edition | gamma GAZETTE | 35

Education & CPD Case Study Impact of the bone scan in a complicated Meningococcal patient (Continued) CONCLUSION A 3â&#x20AC;&#x201C;phase bone scan is a valuable procedure to determine perfusion and viability of bone and soft tissues. In this instance, both scans significantly changed the medical management of this patient, revealing the severity of ischaemic injury to the distal limbs and confirming necrosis prior to amputation.

References 1. Kirsch E, Barton R, Kitchen L, Giroir B. Pathophysiology, Treatment and Outcome of Meningococcemia: A Review and Recent Experience. The Pediatric Infectious Disease Journal. 1996;15(11):967-979.

2. Milonovich L. Meningococcemia: Epidemiology, Pathophysiology, and Management. Journal of Pediatric Health Care. 2007;21(2):75-80.

3. Jafri R, Ali A, Messonnier N, Tevi-Benissan C, Durrheim D, Eskola J et al. Global epidemiology of invasive meningococcal disease. Population Health Metrics. 2013;11(1).

4. Department of Health | Meningococcal Disease (Invasive) [Internet]. Health.gov.au. 2019 [cited 4 January 2019]. Available from: http://www.health.gov.au/internet/main/ publishing.nsf/Content/ohp-meningococcal-W.htm

ANZSNM NZ Branch Meeting â&#x20AC;&#x201C;

For the first time, the NZ branch of the ANZSNM are joining with our MI and RT colleagues, in a combined meeting with the NZIMRT. This is a great opportunity to interact, learn and share what is happening in our Nuclear Medicine, PET/CT, Radiology and Radiation Therapy departments.

Social functions include Welcome drinks on Friday 30th August, and Gala dinner Saturday 31st August.

Call for abstracts have open now and registration will be available shortly.

Attendance certificates will be issued via Attendo Plus.

We would like to encourage all ANZSNM members, both in Australia and NZ, to consider coming to support this joint initiative.

Come and present in a collaborative environment!

Rotorua Energy Events Centre  � ��

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DATE

Education & CPD Case Study F-FDG PET/CT Hits the Bullseye for Assessing Off Target Inflammatory Response from Immunotherapy for Melanoma

18

Authors: Sean Baker1 & Loren Katchel - 1Princess Alexandra Hospital, Brisbane, Australia

INTRODUCTION Melanoma is a highly aggressive form of cancer that develops in the skin’s melanocytes, however, it can occur in the eye or in the mucous membranes of the oral cavity, anus and genitalia.1 In most cases it arises in the skin due to overexposure to UV radiation, risk factors such as fair skin, family history and the BRAF gene mutation also increase the likelihood of development. Melanomas only account for 2% of all skin cancers, yet they attribute to 75% of all skin cancer related deaths in Australia.1 Treatment options for melanoma are dictated by the stage of the disease.

The options can be a combination of surgical removal, chemotherapy, targeted therapies, radiation therapy and immunotherapy.2

A follow up brain MRI post treatment indicated disease recurrence in the surgical bed. A monitoring 18F-FDG PET/CT indicated disease progression as it showed an intensely FDG avid lesion in the patient’s left flank.

The persisting parietal lobe lesion was re-excised and further treated with radiation therapy, the left flank lesion was excised, and the patient underwent an additional three cycles of chemotherapy.

A three-month follow-up PET/CT scan again showed disease progression with residual FDG-avidity being seen in the previously excised left flank region and an intensely avid left sided inguinal node was noted (figure 1). Due to the inefficiency of previous treatment, alternate options were discussed and it was decided that a four-cycle immunotherapy regiment would be the best option. The patient With recent developments there has been a underwent a combination of immune checkpoint greater use of immunomodulatory therapies blockade agents, Ipilimumab and Nivolumab, and whereby monoclonal antibodies are used to target continued to be monitored. b) T-lymphocyte activation regulators and thus inhibit 3 tumour cell related immune tolerance. For many INVESTIGATIONS years now 18F-FDG PET/CT has been a pillar for the staging, restaging and management of patients with After two cycles of immunotherapy, the patient had melanoma. The aim of this case study is to examine the a three-month follow-up 18F-FDG scan where he was utility of 18F-FDG PET/CT for the assessment of adverse intravenously injected with 359.22MBq of 18F-FDG inflammatory responses in melanoma patients on the and a skull vertex to toes PET/CT was acquired at 65 minutes post injection. Low dose non-diagnostic afore mentioned immunotherapy.4 CT was performed for attenuation correction and anatomical localisation purposes. The patient’s BSL CASE REPORT was 5.1 mmol/L prior to injection.

A 25-year old male with malignant melanoma of unknown primary presented for staging. At the time of Imaging showed interval reduction in the size and diagnosis, he had a large parietal lobe metastasis that FDG-avidity of both the left flank region and the was treated with a craniotomy followed by stereotactic left inguinal lymph node, suggesting response to radiosurgery to the cavity. He then completed three treatment. However, diffusely intense 18F-FDG uptake cycles of the melanoma specific chemotherapy agents was noted in the thyroid (figure 2) and although indicative of thyroiditis, further investigations were Dabrafenib & Trametinib. recommended for correlation.

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Education & CPD Case Study F-FDG PET/CT Hits the Bullseye for Assessing Off Target Inflammatory Response from Immunotherapy for Melanoma (Continued)

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Figure 1: 18 F-FDG WB PET MIP a) March 2018 - FDG-avid left flank lesion b) June 2018 - Residual 18F-FDG uptake in left flank region and FDG-avid left inguinal node

Figure 2: Mid-immunotheraphy 18F-FDG PET/ CT September 2018 displaying diffusely FDG-avid thyroid, a)WB MIP, b) coronal fusion, c) axial fusion

The patient’s combination immunotherapy was temporarily stopped, his thyroiditis was brought under control with Dexamethasone and Propranolol, and then standalone Nivolumab immunotherapy was recommence after only a brief delay.

Thyroid function tests (TFT)s were performed showing a thyroid stimulating hormone reading of less than 0.05, coupled with a thyroxine reading of 77. A nuclear medicine thyroid uptake scan was also acquired which yielded an uptake ratio of 0 and along with the TFT results, thyroiditis was confirmed.

Another 18F-FDG scan was acquired following the completion of the patient’s remaining immunotherapy with similar acquisition parameters as previously noted. The imaging showed no significantly FDG-avid residual/ recurrent disease and no new FDG-avid disease was identified. 18F-FDG uptake was still present in the thyroid.

However, based on the patient’s TFTs, thyroiditis was completely resolved and the residual thyroid uptake could be a response to treatment. Overall, the scan appearance was reflective of a complete metabolic response to therapy, with no newly noted adverse responses to immunotherapy (figure 3).

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Education & CPD Case Study F-FDG PET/CT Hits the Bullseye for Assessing Off Target Inflammatory Response from Immunotherapy for Melanoma (Continued)

18

DISCUSSION Immune-related adverse events resulting from the combination Ipilimumab-Nivolumab immunotherapy, which is evident in the discussed patient, is proving very common, being reported as high as 70% in studies with melanoma patients. It has been widely reported that the risk of immunerelated adverse events such as colitis, hepatitis, hypophysitis, thyroiditis, nephritis, pneumonitis, dermatitis and arthritis is greater with Ipilimumab than what they are with Nivolumab.5,6,7 The onset of these adverse events typically occurs within 6 to 8 weeks of commencing these immunotherapy agents.

Some of these adverse events can be severe or life threatening and require immediate management, which can often include a combination of corticosteroids, immunosuppressants and treatment discontinuation.4 By managing these adverse events appropriately, you provide the best opportunity to continue the immunotherapy regiment without compromising the efficacy of the treatment.5 This is why the rapid detection of these adverse events is paramount as it allows for early and adequate intervention of the inflammatory processes. In this case 18F-FDG PET/CT demonstrated thyroiditis in a seemingly asymptomatic patient, which may have continued to go undetected without the scan.

As the patient’s thyroiditis was detected at a relatively early stage, the treating team were able to provide early intervention and resolve the process quickly.

As a result, the patient was able to recommence the Nivolumab immunotherapy promptly, with minimal compromise to the efficacy of the treatment.

Figure 3: Post immunotherapy 18F-FDG WB MIP showing no new or residual FDG-avid disease and persistent thyroid uptake in line with response to treatment

CONCLUSION With immunotherapy reportedly having higher progression-free survival and objective response rates, it is apparent that there will be increased future application of immunotherapy for the treatment of melanoma.6 In this case along with many other reported cases 18F-FDG PET/CT has proved to be a very valuable tool for the detection and diagnosis of immune-related adverse events in patients on immunotherapy for melanoma.5 Therefore, early imaging with 18F-FDG PET/CT as an immune-related adverse event detection tool should be considered as a routine procedure in the melanoma immunotherapy treatment pathway. Imaging at 6-8 weeks after commencing immunotherapy could be vital for diagnosing and treating immune-related adverse events as well as ensuring the overall treatment continuity.7

References: 1. Melanoma Institute Australia 2018, Understanding Melanoma - What is melanoma?, viewed 5 Nov, 2018 https://www.melanoma.org.au/understandingmelanoma/what-is-melanoma 2. SkinCancer.net 2017, Excision of Skin Cancer viewed 5 Nov, 2018 <https://skincancer.net/treatment/excision-surgery/> 3. Perng P, Marcus C, Subramaniam R. 2015, ‘18F-FDG PET/CT and Melanoma: Staging, Immune Modulation and Mutation-Targeted Therapy Assessment, and Prognosis’, American Journal of Roentgenology. vol. 205(2), pp. 259-270.

4. Postow M. 2015, ‘Managing Immune Checkpoint-Blocking Antibody Side Effects’, American Society of Clinical Oncology Educational Book, vol. 35 pp. 76-83.

5. Wong A, McArthur G, Hofman M, Hicks R. 2017, ‘The Advantages and Challenges of Using FDG PET/CT for Response Assessment in Melanoma in the Era of Targeted Agents and Immunotherapy’, European Journal of Nuclear Medicine and Molecular Imaging, vol. 44, pp. 67-77.

6. Larkin J, Chiarion-Sileni V, Gonzalez R, Grob J, Cowey C, Lao C et al. 2015, ‘Combined Nivolumab and Ipilimumab or Monotherapy in Untreated Melanoma’, New England Journal of Medicine, vol. 373(13), pp. 1270-1271.

7. Perng P, Marcus C, Subramaniam R. 2015, ‘18F-FDG PET/CT and Melanoma: Staging, Immune Modulation and Mutation-Targeted Therapy Assessment, and Prognosis’, American Journal of Roentgenology. vol. 205(2), pp. 259-270.ion of immunotherapy for the treatment of melanoma

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Education & CPD Case Study Return of Heat Denatured 99mTc RBC Spleen Studies

Author: Jessica Keen - NMT Monash Health, VIC

INTRODUCTION Heat Denatured 99mTc Red Blood Cell Spleen studies are infrequently performed in most nuclear medicine departments, despite their accuracy in determining the presence of functional splenic tissue. A new study being conducted at Monash Health by medical student Sarah Luu and Deputy Director of Infectious Diseases A/Prof Ian Woolley in association with Spleen Australia and Alfred Health has seen the demand for these studies grow.

Their research is still underway but required recruiting patients who had undergone a splenectomy following trauma and was designed to assess the long-term outcomes of these patients, with a facet of the study focusing on identifying those with residual functional splenic tissue. Following blood test screening for HowellJolly bodies and immunoglobulin Memory B cells which are indicators for functional splenic tissue, patients were referred to Nuclear Medicine to locate any functional splenic tissue (1).

Patients without functional splenic tissue have an increased risk of contracting infections and often require life-long treatment with antibiotics and up-todate immunizations particularly against pneumococcal, meningococcal, Hemophilus influenzae and annual influenza vaccinations (4). These patients also maintain caution around others that may be unwell and around animals to avoid bites and scratches which could introduce infections (3).

Depending on the type and severity of the splenic trauma, splenic tissue has been known to lodge anywhere in the peritoneal cavity and can regenerate in a process known as autotransplantation (4). Due to this phenomenon, patients whom have undergone splenectomies as a result of trauma have a reduced risk of contracting infections due to having residual or ectopic functioning splenic tissue (3). The volume of functional splenic tissue is also hypothesized to correlate with improved immunity (3).

BACKGROUND

CASE STUDY HISTORY

The spleen itself is a blood-rich organ which serves the purpose of proliferating lymphocytes which support the immune system (2). The spleen also filters out defective and aged blood cells and platelets from the circulation whilst its macrophages remove foreign matter from the blood. The spleen is also involved in storing platelets, monocytes and breakdown products in the blood such as iron that can be returned to the blood when needed (2).

A 34-year-old male presented to the Nuclear Medicine department after being recruited for this study, having undergone a splenectomy following a motor cycle accident 9 years ago. The patient had reported taking daily antibiotics since the surgery up until the past 6 months when he was recommended to withdraw from them by his medical specialist. The patient would instead only take antibiotics when he began feeling unwell.

Splenectomies are most commonly performed following trauma to the abdomen to prevent lifethreatening hemorrhaging occurring into the peritoneum. Splenic ruptures can occur from motor vehicle accidents, assaults, sporting injuries, complications during abdominal surgery, infections, malignancy or from hematological conditions (3).

LABORATORY PROCEDURE

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Invitro labelling of RBCâ&#x20AC;&#x2122;s with Tc-99m was performed using a Eu-TagÂŽ kit. For this process, 3ml of whole blood was taken from the patient in a syringe with ACD which is then combined with the reaction syringe (containing stannous chloride, sodium citrate and dextrose) and

Education & CPD Case Study Return of Heat Denatured 99mTc RBC Spleen Studies (Continued) incubated for 10 minutes at room temperature, this allows the stannous ion to diffuse across the RBC membrane (5).

The contents of syringe I (containing sodium hypochlorite) is then added to the reaction syringe and mixed to oxidize any extracellular stannous ion. This is then followed by the addition of syringe II (containing citric acid, sodium citrate and dextrose) which is also mixed and further sequesters any extracellular stannous ions (5).

An evacuated vial is then placed into a lead pot with the RBC’s added, followed by the addition of 1GBq of 99mTcO4-, where the 99mTcO4- diffuses across the RBC membrane and is reduced by the stannous ion.

The whole vial is then placed into a shielded hot water bath at 49.5 degrees Celsius +/-0.5˚C for 15 minutes to denature the red blood cells (5). Care is taken not to overheat or underheat the red blood cells as this can lead to increased liver uptake or conversely increased blood pool activity, both which reduce splenic uptake (6).

Figure 1. Planar Images demonstrating splenic tissue in the left posterior abdomen.

Approximately 800MBq of Tc-99m Denatured RBC’s is then drawn up and reinjected into the patient within 30 minutes after blood withdrawal.

IMAGE ACQUISITION Imaging commences 30 minutes post injection with anterior/posterior planar statics performed including all the thorax down to liver, and another over the abdomen including from the liver to the bottom of pelvis (figure 1). A SPECT/CT (figure 2) is then performed to include any splenic tissue identified as per the reporting Nuclear Medicine Physician’s instructions.

Figure 2. Coronal Fused SPECT/CT demonstrating posterior perinephric splenic tissue.

FINDINGS In this case, the reporting physician noted on the SPECT/ CT, 2 foci of denatured red blood cell accumulation in the left upper quadrant, one posterior to the

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Education & CPD Case Study Return of Heat Denatured 99mTc RBC Spleen Studies (Continued) gastric fundus measuring 1.8cm in diameter (figure 3) and another measuring 2.2cm in diameter in the left perinephric space (figures 2 & 4) which is in keeping with residual splenic tissue.

CONCLUSION Heat denatured 99mTc labelled red blood cell scintigraphy is highly sensitive and accurate in determining the presence and volume of functional splenic tissue. As this study is still in progress, it will be interesting to follow up their findings as more patients are referred to the department for imaging. More importantly for the patients who have undergone a splenectomy, it is exciting to determine if these patients do in fact have residual functional splenic tissue, as this could greatly impact on their treatment regiments including reduced dependence on antibiotics and how they live their everyday lives.

References:

Figure 3 Top: Axial CT and SPECT/CT, Bottom: MIP Images localizing splenic tissue posterior to gastric fundus.

Figure 4. Top: CT and SPECT/CT, Bottom: MIP Images localizing perinephric splenic tissue.

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1. Spleen Australia Annual Newsletter [Internet]. Spleen.org.au. 2018 [cited 27 February 2019]. Available from: https://spleen.org.au/vsr/files/2018_Spleen_ Australia_annual_newsletter.pdf 2. Marieb E, Hoehn K. Human anatomy & physiology. 9th ed. Essex: Pearson; 2014. 817-818 p.

3. Splenic rupture â&#x20AC;&#x201C; Knowledge for medical students and physicians [Internet].

Amboss.com. 2019 [cited 28 February 2019]. Available from: https://www. amboss.com/us/knowledge/Splenic_rupture 4. Return of normal functioning spleen after traumatic splenectomy. Journal of the Royal Society of Medicine [Internet]. 2004 [cited 27 February 2019];97(8):391. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC1079560/ 5. Kowalsky R, Falen S. Radiopharmaceuticals in Nuclear Pharmacy and Nuclear Medicine. 3rd ed. Washington: American Pharmacists Association; 2011.196197 p.

6. Infrequently Performed Studies in Nuclear Medicine: Part 1. Journal of Nuclear Medicine Technology [Internet]. 2008 [cited 27 February 2019];36(3):141,142. Available from: http://tech.snmjournals.org/content/36/3/132.full

Education & CPD Case Study Congenital Hypothyroidism (CH) and Lingual Thyroid in Neonate on Thyroid Uptake Scan Author: My Linh Diep - Monash Health, Victoria

CLINICAL HISTORY • Female neonate born at term gestation.

• Routine Neonatal Screening Test (NST) at two days old found elevated TSH of 121.

• Mum denied health problems during pregnancy.

Referred for nuclear medicine thyroid uptake scan by paediatric endocrinologist.

IMAGING Patient presented to nuclear medicine department at eight days old for thyroid uptake scan with peripheral intravenous cannula inserted by paediatric endocrinologist. Patient intravenously administered 28MBq of 99m TcO4-. Imaging commenced after uptake of 15 minutes. Simultaneous static acquisition of the neck in the anterior and left lateral view for five minutes. No uptake found in the native thyroid bed. Small focal area of pertechnetate uptake in the floor of the mouth yielding 1.3% uptake. Thyroid uptake scan concluded ectopic thyroid tissue in lingual or thyroglossal duct tract region.

MANAGEMENT Patient seen in Outpatient Clinic at Monash Children’s Hospital for congenital hypothyroidism (CH). Patient commenced 50 µg thyroxine three days per week and 25 µg four days per week, equating to total of 250 µg per week. Clinical follow-up two weeks later showed body weight and length tracking on the 90th centile and head circumference on the 50th centile. Patient was breastfeeding on demand and gaining weight. Thyroid function tests showed significantly improved TSH and T4. Mum reported patient being sleepier compared to siblings but patient otherwise showed continued growth in length and weight.

Figure 1. Anterior and left lateral static acquisition of neck on Philips CardioMD gamma camera.

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Education & CPD Case Study Congenital Hypothyroidism (CH) and Lingual Thyroid in Neonate on Thyroid Uptake Scan (Continued)

Figure 2. Anterior view of neck with ROI over focal area of uptake in lingual region. Background ROI over supraclavicular area.

Repeat TFTs and clinic follow up at 14 weeks of age revealed slightly suppressed TSH and slightly elevated T4.

Hence, thyroxine dose was reduced to f 225 µg/week. Follow-up is planned for two months’ time.

UNITS

REFERENCE RANGE

Table 1. Serial TFTs in first 20 weeks of life. Reference range is age-specific.

DISCUSSION The patient in this case study demonstrates pertechnetate uptake in an ectopic thyroid gland, a form of thyroid dysgenesis3. Approximately 80% of primary CH is associated with thyroid dsygenesis3. Almost 90% of thyroid ectopy occurs in the lingual region, owing to halted descent of the thyroid gland which usually moves from the

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Education & CPD Case Study Congenital Hypothyroidism (CH) and Lingual Thyroid in Neonate on Thyroid Uptake Scan (Continued) foramen caecum (base of tongue) to its expected position in the central midline neck during embryologic development.2 It is typical for the lingual thyroid to be singular and the only source of thyroid hormone production2. An ectopic thyroid can develop a goitre which can produce obstructive tongue base symptoms if not appropriately treated2. Approximately 33% of children with thyroid ectopy also have hypothyroidism.

Thyroid ectopy and hypothyroidism in adults is rare, as the condition usually manifests at an early age1,2. Ultrasonography, useful to confirm structural absence of the thyroid gland in its expected position, and thyroid uptake scan are key diagnostic tools to investigate thyroid dysfunction3. The pertechnetate thyroid uptake scan may also identify alternate causes for the presenting hypothyroidism such as thyroid agenesis, which is characterized by absent pertechnetate uptake in the neck, or dyshormonogenesis which is characterized by pertechnetate uptake within a normally sited thyroid gland.

visual and psychomotor development in the first three years of life and appropriate intervention are imperative3. Physiologic hormone demands change through major stages of growth2. Hence, ongoing monitoring through school years, puberty and adulthood is also recommended3.

This case report highlights the vital role a thyroid uptake scan plays in early detection of childhood primary CH and lingual thyroid. Prompt progression to hormone therapy is correlated with higher chances of normal cognitive and physical development into adulthood1,3.

References: 1. David S. Saleh, Sarah Lawrence, Michael T. Geraghty, Patricia H. Gallego, Karen McAssey, Diane K. Wherrett and Pranesh Chakraborty.

“Prediction of congenital hypothyroidism based on initial screening thyroidstimulating-hormone” BMC Pediatrics (2016) 16:24 2. Germano Guerra, Mariapia Cinelli, Massimo Mesolella, Domenico Tafuri, Aldo Rocca, Bruno Amato, Sandro Rengo, Domenico Testa.

“Morphological, diagnostic and surgical features of ectopic thyroid gland: A review of literature” International Journal of Surgery 12

CH is the most common preventable cause of intellectual disability1 and can be graded biologically based on serum free T4 levels.

According to the European Society of Paediatric Endocrinology guidelines serum free T4 level <5 pmol/L is classified as mild CH, 5 < 10 pmol/L is moderate CH, and 10 – 15 pmol/L is severe CH3. Untreated CH in young children result in neurological, psychiatric and somatic deficits1.

(2014) S3eS11 3. Juliane Léger, Antonella Olivieri, Malcolm Donaldson, Toni Torresani, Heiko Krude, Guy van Vliet, Michel Polak, Gary Butler on behalf of ESPE-PES-SLEP-JSPE-APEG-APPES-ISPAE, and the Congenital Hypothyroidism Consensus Conference Group. “European Society for Paediatric Endocrinology consensus guidelines on screening, diagnosis, and management of congenital hypothyroidism” Hormone Research in Paediatrics 2014;81:80–103

Over the last 30 years the TSH screen, a component of the neonatal screening program, plays a major role in early detection of CH in neonates1. Early treatment with thyroxine within the two weeks of birth optimises developmental outcomes3. Fortnightly follow up of TSH values is recommended until normalisation, then 2 – 4 month follow ups thereafter. Monitoring of speech,

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Education & CPD Case Study Utilisation of Lymphoscintigraphy SPECT/CT imaging in the localisation of lymphatic leakage site following complicated femoral hernia repair.

Author: Kimberly Nguyen - Benson Radiology, Ashford Specialist Centre, Adelaide, South Australia.

CASE STUDY A 44-year-old female presented with persistent intermittent right groin swelling following right femoral hernia repair.

Initial CT imaging showed a 54mm enlarged right inguinal collection suggestive of infective post operative seroma/ lymphocele. The collection was also aspirated under ultrasound guidance and sent for microbiological testing, which showed no culture growth after 14 days incubation.

Figure 1: Transaxial CT scan image demonstrating 54mm inguinal collection on the right side.

Four weeks later the patient underwent a nuclear medicine lymphoscintigraphy study for the localisation of the lymphatic leakage site. The patient was injected in the first web space of each foot with 20MBq of 99mTc Nanocis.

Serial planar imaging demonstrated normal lymphatic drainage on the left, into inguinal, pelvic and para-aortic nodes. On the right, uptake was visualised within right inguinal node with gradual accumulation of low grade, extranodal activity in the right anterolateral inguinal region, corresponding with the collection seen on CT

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imaging.

SPECT/CT imaging was then performed to confirm uptake within a right external iliac/common femoral node close to the anteromedial acetabular margin, demonstrating activity extending to the medial aspect of the inguinal collection.

This node was marked on the skin surface anteriorly and laterally and the patient was sent to theatre for operative ligation of the leak site.

Education & CPD Case Study Utilisation of Lymphoscintigraphy SPECT/CT imaging in the localisation of lymphatic leakage site following complicated femoral hernia repair. (Continued)

DISCUSSION Lymphatic leakage is a rare postoperative complication which can lead to further health problems.

Early ligation or suture of the leakage site is helpful to avoid metabolic complications and shorten hospitalisation stay.

Nuclear medicine lymphoscintigraphy with SPECT/CT imaging can play a pivotal role in locating the site of lymphatic leak, resulting in an improved patient outcome.

References: Lv S et al. A review of the postoperative lymphatic leakage.

Figure 2 Planar lymphoscintgraphy images acquired 15 minutes post injection to 100 minutes post injection.

Oncotarget. 2017 Sep 15; 8(40): 69062â&#x20AC;&#x201C;69075.

Tyndall, S et al. Groin lymphatic complications after arterial reconstruction. Journal of Vascular Surgery. 1994 vol.19 (5): 858 â&#x20AC;&#x201C; 864.

Figure 3 Transaxial SPECT/CT image demonstrating lymphatic nodal uptake adjacent to the medial aspect of the right sided inguinal collection.

2019 Autumn Edition | gamma GAZETTE | 47

Biograph Vision

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At Siemens Healthineers, we were inspired to make breakthrough improvements in PET/CT. Biograph VisionTM, featuring Optiso Ultra Dynamic Range (UDR) detector introduces the first1 silicon photomultiplier (SiPM)based detector with 3.2 mm LSO crystals and 100% detector coverage, resulting in a cascade of clinical and workflow benefits.

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1 2 4 3

5

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54 540 ps > 8 cm segment of response

• 3.2 mm crystals • 214 ps time-of flight

1. LSO, a fast and efficient scintillator, is grown and cut in-house through a vertically-integrated manufacturing process to ensure the highest quality.

2. 3.2 mm crystal elements are individually selected and deliver high isotropic spatial resolution; higher spatial resolution may result in improved lesion detectability.

3. 100% coverage of the crystal area with SiPM sensors results in a timing resolution of 214 picoseconds and 3.9 times higher effective sensitivity for faster scans and lower dose.

4. A small block size delivers >1870 kilo counts per second effective peak NECR for improved clinical performance.

5. High-flow direct-cooling of the detector plate allows the detector to operate at room temperature for outstanding performance, serviceability and improved patient comfort.

214 ps > 3.2 cm segment of response (Biograph Vision)

aph Vision)

Fast time-of-flight enables smaller segments of response. This improves the signal-to-noise ratio.

healthcare.siemens.com.au/molecular-imaging 1. Based on competitive literature available at time of publication. Data on file.

Printed in Australia | © Siemens Healthcare Pty Ltd, 2019

Education & CPD Case Study The Advantage of PET/MRI over MRI Alone: Multiple Meningioma a Case Study Authors: Remi Hillery1, James Turner1 1 Department of Nuclear Medicine and Molecular Imaging, Princess Alexandra Hospital, Brisbane, Australia

INTRODUCTION A meningioma is a slow growing intracranial tumour that originates from the meninges, accounting for approximately 35% of all primary brain tumours in adults. Ninety percent of these tumours are benign.

There is no known cause of meningiomas, but there is a 2:3 male to female prevalence, with approximately 2.3% going undiagnosed1.

The use of hybrid imaging in the form of PET/MRI plays an important role in investigating meningiomas and therapy planning for lesions in complex locations and in disease recurrence3. PET/MRI may provide additional critical information for treatment planning that MRI alone is not capable of, leading to better patient outcomes.

The occurrence of multiple meningiomas in a single person accounts for up to 10% of all meningiomas, and while they may be more difficult to manage, surgery is still the preferred option for treatment of symptomatic lesions2. Meningiomas may appear sporadically, through familial means (including Neurofibromatosis Type 2 or familial meningiomatosis), from previous head trauma or be radiation induced. There are various symptoms of meningioma, which depend on the location of the lesion1.

CASE REPORT

Meningiomas have a high level of expression of Somatostatin Receptor subtype 2 (SSTR2), in which there is excellent tumour-to-background ratio. Thus imaging with somatostatin receptor ligands has been established2.

DOTATATE is a somatostatin analog that has shown a high affinity for SSTR2, and once labelled to 68Gallium, can be used for Positron Emission Tomography (PET) imaging for improved spatial resolution and quantification2.

While Magnetic Resonance Imaging (MRI) alone is the gold standard for imaging meningiomas, it may have inadequate sensitivity and specificity in cases of scar formation within patientsâ&#x20AC;&#x2122; post-surgery or postradiation therapy2.

A 52-year-old female presented to the PET department for a 68Gallium-DOTATATE PET/MRI scan querying meningioma recurrence. The patient had a history of childhood leukaemia that was treated with radiation therapy to the brain.

In 2014, the patient underwent stand-alone brain MRI imaging that reported at least four old meningiomas and one new lesion in the left frontal lobe, with a WHO Grade I. She was diagnosed with multiple intracranial meningiomas and required a right parietal craniotomy to resect a large parasagittal meningioma that was causing leg weakness. The patient also underwent retinal detachment surgery to her left eye. Otherwise, the patient was functioning well.

In 2015, further MRI imaging showed the meningiomas were increasing in size, growing to WHO Grade II. The patientâ&#x20AC;&#x2122;s treating team were planning Gamma Knife radiotherapy treatment, and requested her to have a 68Gallium-DOTATATE PET/MRI scan for accurate localisation of the recurring lesions. These images would accurately localise the sites of disease and be used extensively in her treatment planning.

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Education & CPD Case Study The Advantage of PET/MRI over MRI Alone: Multiple Meningioma a Case Study (Continued) IMAGING The patient was intravenously injected with 142 MBq 68Gallium-DOTATATE and had an uptake time of 45 minutes. Following this, a single station PET/MRI of the brain was performed using the Siemens Biograph mMR 3T. The procedure involved simultaneous high resolution axial T2 weighted images and intravenous

Fig. 1 – Example of head coil and positioning used during PET/MRI brain acquisitions

Fig. 2 - MIP of patient’s brain PET/MRI showing multiple DOTATATE-avid lesions

Gadolinium enhanced T1 weighted sequences.

An ultrashort TE MRI sequence was also used for attenuation correction. The entire image acquisition took approximately 30 minutes.

Imaging showed multiple DOTATATE-avid small durally based lesions, both supratentorial and infratentorial, which appeared consistent with meningiomas, with a total of 15 to 20 likely sites (many more than originally suspected from MRI alone) (Fig. 2 & 3).

Fig. 3 - Fused axial slice demonstrating multiple Gallium-68-DOTATATE avid lesions

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There was a small area of cerebral gliosis underlying the right parietal craniotomy that is consistent with the patient’s prior surgical resection (Fig. 4). There also appeared to be an altered signal in the left ocular globe, likely related to the patient’s recent retinal detachment surgery.

Education & CPD Case Study The Advantage of PET/MRI over MRI Alone: Multiple Meningioma a Case Study (Continued) DISCUSSION Despite management of single meningiomas being extensively studied, there is only limited information on the histology and suitable treatment pathways for multiple meningiomas. Often multiple meningiomas are difficult to manage, as each lesion may have different aetiologyâ&#x20AC;&#x2122;s and cause various symptoms depending on location. It is difficult to determine which lesion may be responsible for particular symptoms, whether it requires treatment and what the best treatment option is4.

The use of hybrid PET/MRI provides a more comprehensive investigation as it combines the anatomical information of the MRI with the quantitative molecular biology of PET imaging4. 68Gallium-DOTATATE used in conjunction with PET/MRI has been proven useful in the diagnosis, grading and monitoring of meningiomas, particularly in treatment planning, as well as delineating tumour extent and determining therapy induced changes versus recurrence5. It has a very high tumour-to-background ratio and is a reliable predictor of tumour growth in WHO Grade I & II tumours, with higher sensitivity than stand alone MRI5. As 68Gallium- DOTATATE is taken up areas of increased SSTR2 expression, it may also be used in the application of determining patient suitability for DOTATATE-based therapy as an option of treatment4.

Fig. 4 - MRI, PET and Fused Slice of brain PET/MRI displaying area of cerebral gliosis following craniotomy

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Education & CPD Case Study The Advantage of PET/MRI over MRI Alone: Multiple Meningioma a Case Study (Continued) PET/MRI utilises a single radiopharmaceutical dose and acquires images simultaneously, taking the same amount of time as stand-alone MRI, and has been found superior in the setting of differential diagnosis between therapy-induced changes and recurrence5.

PET/MRI provides accurate multi-parametric imaging that is highly sensitive and has improved lesion detection with the high-contrast anatomical MRI information and quantitative PET information, and can incorporate DWI, perfusion MRI and MR spectroscopy.

This overall diagnostic advantage results in a better treatment outcome for the patient6.

CONCLUSION Multiple meningiomas are challenging to accurately diagnose and even more difficult to determine best treatment pathway1. PET/MRI imaging with 68Gallium-DOTATATE plays an important role in management and therapy planning, as it provides more substantial information on recurrent meningiomas or meningiomas in complex locations. In addition PET/MRI also provides necessary information for radiotherapy planning, including delineating resection margins and target volumes of these lesions 5.

In this particular case the patientâ&#x20AC;&#x2122;s disease could have been significantly underestimated if only standalone MRI imaging was performed. Given the 68Gallium-Dotatate PET/MRI scan identified many more lesions (15-20) compared to the number of lesions (5) identified on the standard MRI scans. For Gamma Knife treatment the PET/MRI provided an accurate reflection of disease extent, leading to more accurate treatment planning and ultimately improved patient outcomes.

References: 1 Wong, R.H., Wong, A.K., Vick, N., & Farhat, H.I. (2013). Natural history of multiple meningiomas. Surgical Neorology International, 71(4). doi: 10.4103/21527806.112617. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3683641/ on 13/03/2019 2 Rachinger, W., et al. (2015). Increased 68Ga-DOTATATE uptake in PET imaging discriminates meningioma and tumor-free tissue. Journal of Nuclear Medicine, 56(3), 347-353. doi: 10.2967/jnumed.114.149120. Retrieved from http://jnm.snmjournals.org/content/56/3/347.full.pdf+html on 13/03/2019 3 Sommerauer, M., et al. (2016). 68Gallium-DOTATATE PET in meningioma: A reliable predictor of tumor growth rate? Neuro-Oncology, 18(7). doi: 10.1093/ neuonc/now001. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/26865086 on 13/03/2019 4 Miles, K.A., Voo, S.A., & Groves, A.M. (2018). Additional clinical value for PET/MRI in oncology: moving beyond simple diagnosis. Journal of Nuclear Medicine, 59(7), 1028-1032. doi: 10.2967/jnumed.117.203612. Retrieved from http://jnm.snmjournals.org/content/59/7/1028.full.pdf+html on 13/03/2019 5 Iagaru, A., Hope, T., & Veit-Haibach, P. (2018) PET/MRI in oncology. Springer International Publishing (eBook). doi: 10.1007/978-3-319-68517-5. Retrieved from https://books.google.com.au/ lr=&id=g7ZIDwAAQBAJ&oi=fnd&pg=PA185&dq=advantages+of+pet.=saX34aHwt5&sig=la9AJbXo87Cmo8QX2X9Iikvpqws#v=onepage&q&f=false on 12/03/2019 6 Rosenkrantz, A.B., et al., (2016). Current status of hybrid PET/MRI in oncologic imaging. American Journal of Roentgeneology, 206(1), 162-172. doi: 10.2214/ AJR.15.14968. Retrieved from https://www.ajronline.org/doi/full/10.2214/AJR.15.14968 on 13/03/2019

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Education & CPD Whatâ&#x20AC;&#x2122;s that Whatâ&#x20AC;&#x2122;s that? Case 1 - There is often more than meets the eye Author: Lauren Hudswell - Monash Health. Victoria

CLINICAL NOTES The patient is a 68-year-old male with elevated parathyroid hormone and calcium levels who presented for investigation of a suspected parathyroid adenoma. Whilst a medical history was obtained for this patient, they did not provide a complete history. A dual isotope parathyroid scan was performed with 39.9MBq of 99m Tc-Pertechnetate for the thyroid image acquired at 15 minutes post administration and 819MBq of 99mTcSestamibi for the parathyroid image acquired 30 minutes post administration. Delayed statics and SPECT/CT were performed three hours post 99mTc-Sestamibi administration. What is the eye catching feature of this scan?

Image 1: Top Row: 99mTc04- images. Middle Row: Early 99mTc-Sestamibi images . Bottom Row: Delayed 99mTc-Sestamibi images

DISCUSSION Localisation of 99mTc-Sestamibi occurs via passive diffusion in the mitochondrial membranes where increased number and activity of mitochondria results in increased localisation of tracer(1). As such, both parathyroid and cardiac tissue are evident on a 99mTc-Sestamibi scan. Though this scan is positive for a parathyroid adenoma contiguous and behind

the right lobe of the thyroid in the lower pole, there is also another feature that makes this an interesting image. Seen slightly in the thyroid images but much clearer in the early and delayed parathyroid images, the heart is located on the right hand side of the chest and the liver on the left as evident in images 1-3 (above and following page). After further questioning of the patient it was identified that the patient had situs inversus totalis (SIT).

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Education & CPD Whatâ&#x20AC;&#x2122;s that Whatâ&#x20AC;&#x2122;s that? Case 1 - There is often more than meets the eye (Continued)

Image 2: Fused coronal SPECT/CT Slice

SIT is a congenital condition with an incidence of 1:10,000 (2), where there is complete mirror image reversal of major thoracic and abdominal organs. It is also referred to as situs inversus with dextrocardia, whereby the heart angles towards the right side of the chest instead of the left (2,3). This transposition of anatomy includes the lymphatic system, blood vessels, intestines and nerves. The lungs are also transposed with the right lung being bilobed and the left being trilobed (2). SIT is also closely linked with Kartageners syndrome (KS), a syndrome of dysfunctional cilia, which this patient was also diagnosed with. KS occurs in 20-25% of all SIT cases (3).

CONCLUSION

Image 3: Fused transaxial SPECT/CT Slice

This is an interesting educational case for students, interns and technologists who may not have previously come across SIT in a clinical setting. It is a helpful reminder that it is important to consider all components of an acquired image, and not just the anatomy or physiology being investigated, for the detection of incidental findings. In many patients with SIT there can be a delay in diagnosis and treatment with symptoms often presenting on the contralateral side to traditional diagnosis.

Surgical procedures in patients with SIT are complex, requiring surgeons to recognise the mirror image of anatomy prior to the operation. Further imaging would be required for this patient prior to the parathyroidectomy to identify the location of surrounding vasculature.

References 1. Ponto J. Mechanisms of Radiopharmaceutical Localisation. The University of New Mexico Health Sciences Center, College of Pharmacy. 16. 2012:16(4) 2. Mujo T, Finnegan T, Joshi J, Wilcoxen K, Reed J. Situs ambiguous, levocardia, right sided stomach, obstructing duodenal web, and intestinal nonrotation: A case report. J Radiol Case Rep 2015;9(2):16-23 3. Roongruanchai J, Narongsak W, Plakornkul V. Situs inversus totalis and ultrastructure of respiratory cilia: report of cadaveric case. J Med Assoc Thai 2012;95(1):132-13

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Education & CPD What’s that What’s that? Case 2 Author: Barry Chatterton

BACKGROUND A 23-year-old keen athlete (football, basketball) presents with four year history of right groin pain.

Radiopharmaceutical : 99m TC HDP 700MBq

FIG 1 - The blood pool images show increased vascularity in the region of the pubic symphysis. The delayed scan shows increased uptake, particularly to the right of the midline in the right pubic bone adjacent to the symphysis.

Figure 1: Blood pool (1min after injection) and

delayed images (3 hr after injection) anterior planar images of pelvis.

FIG 2 - The delayed SPECT/CT shows increased activity in the right pubic bone adjacent to the symphysis. This is associated with a small calcified adjacent focus and secondary ossification centre.

This junction of the pubis, apophysis and soft tissue might be expected to represent an area of biomechanical weakness that endures considerable forces during athletic single stance manoeuvres.1 ANSWER The findings are those of “Pubic apophysitis”2. A secondary ossification centre located along the anteromedial corner of pubis beneath the insertions of symphysial joint capsule and adductor longus tendon. Chronic stress may cause distraction of this ossification centre with chronic inflammation.

Figure 2: Delayed (3hr) SPECT/CT images

(radionuclide, low dose CT, fused) with transverse, coronal and sagittal images centred on the pubic rami.

The condition usually presents in the mid teen years and with rest is usually self-limiting. This patient had continued to exercise despite symptoms.

The abnormality may be seen on SPECT/CT, CT or MRI scans.

References: 1 Robinson P, Salehi F, Grainger A, et al. Cadaveric and MRI study of the musculotendinous contributions to the capsule of the symphysis pubis. AJR Am J Roentgenol 2007;188: 2: Pubic apophysitis: a previously undescribed clinical entity of groin pain in athletes. Sailly M, Whiteley R, Read JW, et al.Br J Sports Med2015;49:828–834.

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Articles Production of metallic radionuclides on a medical cyclotron Author: Courtney Hollis - SAHMRI

Metallic radionuclides are widely used in nuclear medicine as components of diagnostic and theranostic radiopharmaceuticals. Generator production of 99mTc and 68Ga has led to these being two of the most commonly used metallic radionuclides, for SPECT and PET imaging respectively. However, recent supply chain issues and shortages have highlighted the vulnerability and reliance on 99mTc and 68Ga generators.

Moreover, not all metallic radionuclides with desirable physical properties for the development of new radiopharmaceuticals are amenable to generator production.

The Research and Development (R&D) team at the Molecular Imaging and Therapy Research Unit (MITRU), a part of the South Australian Health and Medical Research Institute (SAHMRI), are focussed on developing Good Manufacturing Practices (GMP) production for metallic radionuclides using cyclotron radiation. The radionuclides routinely produced are 64 Cu, 89Zr and 68Ga. MITRU has a dedicated external beam line on a GE PETtrace 880 cyclotron for solid target irradiation. This is combined with a Comecer electrochemical/dissolution/storage (EDS) unit with pneumatic transfer system (PTS) which allows production of a solid target via electroplating, transfer of the target to the irradiation unit on the external beam line, and dissolution of the irradiated target.

The dissolved irradiated target is then transferred to the Comecer Taddeo-PRF purification module which performs the remote and automated purification of the product to give the metallic radionuclide in a form suitable for use as an active pharmaceutical ingredient (API).

Cu is a low energy positron and beta emitter with a half life of 12.7 h, which makes it a promising candidate for both diagnostic (PET imaging) and theranostic applications. The extended half-life makes it practical to ship the radionuclide or 64Cu labelled radiopharmaceuticals across Australia. The R&D team at MITRU routinely produce 64Cu in the form of

Image 1: Comecer EDS unit with PTS connected to irradiation unit

Image 2: Irradiation unit on external beamline of GE PETtrace 880 cyclotron

64

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Image 3: Comecer Taddeo-PRF purification module.

Articles Production of metallic radionuclides on a medical cyclotron (Continued) CuCl2 in 0.05 M HCl for use as an API at activities of up to 18 GBq. Due to its versatility there has been an abundance of novel research using 64Cu, as evidenced by the recent ANZSNM conference.

64

This has culminated with on-going clinical trials of 64 Cu radiopharmaceuticals such as neuro endocrine tumour imaging agent, 64Cu-SARTATE, and the hypoxia imaging agent, 64Cu-ATSM.1-2

Research continues at MITRU to further refine the cyclotron production of 64Cu, 89Zr and 68Ga to allow for the supply of these metallic radionuclides to research groups and companies located in Adelaide (68Ga) and Australia wide (64Cu and 89Zr).

Further reading: 1. First-in-human trial of

Cu-SARTATE PET imaging of patients with

64

neuroendocrine tumours demonstrates high tumour uptake and

Zr is a longer-lived positron emitter with a halflife of 78.4 h, which matches the biological half-life of an intact monoclonal antibody, making it ideal for immuno-PET imaging. At MITRU the R&D team produce 89Zr in the form of 89Zr-oxalate in 1 M oxalic acid for use as an API at activities of up to 4 GBq. In a recent study MITRU produced 89Zr was used to label antibodies directed to innate immune markers CD11-B and IL-1β, which are indicators of colonic inflammation.3 Further development of this immunoPET technology could provide a less invasive approach than endoscopy for the diagnosis and monitoring of inflammatory bowel disease. 89Zr has also been used to label anti-EphA2 antibody for the immuno-PET imaging of epithelial cancers.4 89

retention, potentially allowing prospective dosimetry for peptide receptor radionuclide therapy. Hicks RJ, Jackson P, Kong G, Ware RE, Hofman MS, Pattison DA, Akhurst T, Drummond E, Roselt P, Callahan J, Price R, Jeffery C, Hong E, Noonan W, Herschtal A, Hicks LJ, Harris M, Hedt A, Paterson BM, Donnelly P. Journal of Nuclear Medicine, 2018, ahead of print. doi: 10.2967/ jnumed.118.217745.

2. Evaluation of Hypoxia with Cu-ATSM. Lapi SE, Lewis JS, and Dehdashti F. Seminars in Nuclear Medicine, 2015, 45(2), 177–185.

3. Immuno-PET of Innate Immune Markers CD11b and IL-1β Detect Inflammation in Murine Colitis, Dmochowska N, Tieu W, Keller MD, Wardill HR, Mavrangelos C, Campaniello MA, Takhar P, and Hughes PA. Journal of Nuclear Medicine, 2018, ahead of print, doi: 10.2967/jnumed.118.219287 4. Molecular Imaging and Quantitation of EphA2 Expression in Xenograft Models with 89Zr-DS-8895a. Burvenich IJG, Parakh S, Gan, HK, Lee F-T, Guo N, Rigopoulos A, Lee S-T, Gong S, O’Keefe GJ, Tochon-Danguy H, Kotsuma M, Hasegawa J, Senaldi G, and Scott AM. Journal of Nuclear Medicine, 2016,

Ga is a shorter-lived positron emitter, with a half-life of 68 minutes, which is routinely used in clinical PET facilities worldwide; generally in the form of [68Ga]GaDOTA-TATE for imaging neuroendocrine tumours and [68Ga]Ga-PSMA for prostate cancer.5-6 68

57(6), 974-980.

5. 68Ga-DOTATATE Compared with 111In-DTPA-Octreotide and Conventional Imaging for Pulmonary and Gastroenteropancreatic Neuroendocrine Tumors: A Systematic Review and Meta-Analysis. Deppen SA, Blume J, Bobbey AJ, Shah C, Graham MM, Lee P, et al. Journal of Nuclear Medicine, 2016, 57, 872-878.

As previously mentioned, 68Ga is obtained from the decayed parent radionuclide 68Ge using commercial 68 Ge/68Ga generators. However, these generators are not without drawbacks; only a limited and finite quantity of 68Ga is able to be accessed (< 1.85 GBq per elution) and the high demand for 68Ga radiopharmaceuticals means that supply chain issues, leading to availability shortages, are keenly felt.

The MITRU R&D team have developed a method of producing 68Ga at activities of up to 6 GBq.7

6. Sensitivity, Specificity, and Predictors of Positive

Ga-Prostate-specific

68

Membrane Antigen Positron Emission Tomography in Advanced Prostate Cancer: A Systematic Review and Meta-analysis. Perera M, Papa N, Christidis D, Wetherell D, Hofman MS, Murphy DG, et al. European Urology, 2016, 70, 926-937.

7. Rapid and automated production of Ga-68 chloride and Ga-68-DOTATATE on a medical cyclotron. Tieu W, Hollis CA, Kuan K, Takhar P, Stuckings M, Spooner N, and Malinconico M. Nuclear Medicine and Biology, 2019, manuscript accepted.

2019 Autumn Edition | gamma GAZETTE | 57

Now Available in Print & Digital KEY CONTENT • Case studies • Papers & Abstracts • Industry Specific Reports • Industry News • Events and Awards • Community Members Profiles

Gamma Gazette is the official publication of the Australian and New Zealand Society of Nuclear Medicine.

Founded in 1969, the ANZSNM is the major professional society for those practising Nuclear Medicine in Australia and New Zealand.

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Articles Innovative cancer research An ANSTO radiochemist has been awarded a scholarship to carry out research at the world-renowned Sloan Kettering Cancer Center in New York.

To coincide with World Cancer Day, ANSTO is pleased to announce that radiochemist Leena Hogan (pictured below) has been awarded the prestigious ‘Dr Joan R. Clark Research Scholarship’ from the University of Sydney.

Leena Hogan, Radiochemist

As the recipient of the scholarship Hogan will be travelling in March 2019 to the world-renowned Memorial Sloan Kettering Cancer Centre (MSKCC) in New York. The seven week trip is supported by the University of Sydney and ANSTO, and Hogan will be working in the laboratories of eminent cancer researcher Prof Jason S. Lewis, the Emily Tow Jackson Chair in Oncology at MSKCC. Prof Lewis develops radiopharmaceuticals for targeted diagnosis and treatment of cancer.

His laboratories specialise in using cutting-edge, non-standard radionuclides including zirconium-89, lutetium-177 and gallium-68. These radionuclides are attached to biological vectors (often small molecules, peptides or antibodies) and then evaluated in preclinical animal models to determine suitability for advancement to human clinical trials.

Using the best methods available to attach radionuclides to radiopharmaceuticals is critical to their work.

As part of her PhD studies at ANSTO and The University of Sydney, Hogan has been working on new ways to attach radionuclides, like gallium-68, to biological vectors to produce new radiopharmaceuticals.

“My work is aimed at improving the way we attach the radionuclide to the radiopharmaceutical. Our new method can potentially improve currently available radiopharmaceuticals by increasing their sensitivity for detecting tumours, increasing their brain uptake and decreasing radiation burden to patients”.

During her time at MSCKK Hogan will have access to world-class radiochemistry and pre-clinical PET imaging facilities.

These facilities will allow her to determine if the new ligand system – developed during her PhD – called ‘NOTET’ works better than ‘NOTA’ or ’DOTA’ which are the current gold standards for gallium-68 radiolabelling.

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Articles Innovative cancer research (Continued) The highly efficient radiopharmaceutical development pipeline at MSKCC will allow Hogan to evaluate her ligands in 7 weeks, a task that could take 6-12 months at ANSTO. “If NOTET proves better than NOTA or DOTA in a number of ways, including how well it holds onto the gallium-68, it could become the new gold standard for radiolabelling with gallium-68,” said Hogan.

Hogan explains that not only is NOTET designed to hold onto gallium-68 more strongly than NOTA or DOTA but it is predicted to be less ‘polar’ or form more lipophilic complexes with gallium-68.

This has tremendous potential applications as increased lipophilicity may allow the development “first in class” gallium-68 radiopharmaceuticals for diagnosing brain diseases.

“Currently almost all PET radiotracers for diagnosing brain diseases are based upon the radionuclide fluorine-18, but our ligand NOTET may open up this entire field to gallium-68.

Gallium-68 has the advantage over fluorine-18 that it can transported to hospitals in generators. This alleviates the need for local cyclotron production of the radioisotope and can save hospitals millions of dollars,” said Hogan.

Hogan went on to explain that another challenge in the design of ligands for gallium-68 radiopharmaceuticals is finding a temperature that efficiently allows radiolabelling but does not decompose the sensitive biological vector (small molecule, peptide or antibody).

“The potential great advantage of NOTET is that it can be radiolabelled under mild, room temperature conditions, and that these conditions are favourable for many sensitive biological vectors. We will be performing a side-by-side comparison of NOTET with NOTA / DOTA in neuroendocrine tumour animal

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models using gallium-68 DOTATATE. Hopefully we will demonstrate NOTET allows greater sensitivity for detecting tumours, radiolabelling at lower temperatures, and a decreased radiation burden to patients,” said Hogan.

Head of radiochemistry at ANSTO Dr Ivan Greguric has developed an ongoing, strong relationship with Prof Lewis and MSKCC. Previous collaborative projects include the evaluation of a prototype ANSTO developed gallium-68 generator.

Prof. Lewis has also participated in an ANSTO breakfast symposium on multi-modal imaging at the recent WFNMB2018 conference in Melbourne.

“This is great opportunity for Leena to work at a worldleading cancer research facility and experience, firsthand, clinical translation of basic research into first in human radiopharmaceutical trials,” said Greguric.

The results of the work undertaken at MSCKK will be included in Hogan’s PhD thesis and forthcoming scientific publications. Her PhD Is supervised by Emeritus Professor Trevor Hambly at the University of Sydney and ANSTO’s Dr Nigel Lengkeek.

The award is named in honour of the American chemist and former University of Sydney Fulbright scholar who pioneered early work in the field of x-ray crystallography. The award allows outstanding inorganic chemistry PhD students to study abroad at world class research institutes.

This article has been reproduced with the permission of ANSTO. For more details, visit ansto.gov.au/news

Articles Relevance of the blood glucose concentration, and current management with GLP-1 receptor agonists, to clinical gastric emptying measurement in diabetes Authors: Karen L. Jones1,2,3, Kate Romeo3, Cristina Blefari3 Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, The University of Adelaide, Adelaide, Australia Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia 3 School of Health Sciences, University of South Australia, Adelaide Australia 1 2

ABSTRACT Despite being developed in the late 1970’s - 1980’s, scintigraphy still represents the ‘gold standard’ measurement of gastric emptying and, in the past decade, referral rates have increased substantially, consequent to the recognition that disordered, particularly delayed, emptying occurs frequently.

Guidelines for standardisation have been developed, however, there is marked variation in the technique between users. Gastroparesis occurs in ~40% of people with longstanding type 1 (insulindependent), or type 2, diabetes and gastric emptying measurements are, accordingly, performed frequently in this group. Diabetes is associated with both elevated (hyperglycaemia) and abnormally low (hypoglycaemia) blood glucose concentrations – hyperglycaemia slows, while hypoglycaemia accelerates, gastric emptying.

Glucagon-like peptide-1 (GLP-1) receptor agonists are increasingly used to treat hyperglycaemia in type 2 diabetes and, particularly when “short-acting”, have profound effects to slow gastric emptying.

INTRODUCTION Clinical research is particularly rewarding when the outcomes can be translated into significant changes in clinical practice – this is the case for information relating to the effects of acute changes in blood glucose and so-called GLP-1 receptor agonists on the rate of gastric emptying. Gastric emptying is a complex process, dependent on the integration of contractions in different regions of the stomach and proximal small intestine, to deliver nutrients into the small intestine, to maximise digestion and absorption. Solid food is

ground in a highly regulated manner into particles <1mm in size (the lag phase) before it is emptied in an overall linear pattern, while high-nutrient liquids empty after no, or little, lag phase in a linear, and low-nutrient liquids in a monoexponential, fashion.

Inhibitory feedback arising from the interaction of nutrients with the small intestine plays a major role in the regulation of gastric emptying. In health, gastric emptying exhibits a low intra-, but, substantial interindividual, variation of 1-4kcal/min1. The latter is even greater in patients with diabetes given that disordered gastric emptying, particularly, abnormally slow (gastroparesis), occurs frequently i.e. in ~3050% of patients with longstanding diabetes, and some patients have more rapid emptying2, 3. Patients with diabetic gastroparesis frequently experience bothersome upper gastrointestinal symptoms, such as nausea, fullness and vomiting4, 5 which affect quality of life adversely6. The incidence of diabetic gastroparesis is increasing, in part because both type 1 and type 2 diabetes are more common, and it represents a major cause of health care costs7. In people with diabetes who are taking insulin, gastroparesis may lead to increased fluctuations in glycaemia and a propensity to hypoglycaemia so that overall blood glucose control, usually assessed by measurement of glycated haemoglobin, is poor, which increases the risk of diabetic complications such as eye, kidney and nerve damage8. Hence, measurement of gastric emptying in diabetes is important. In Australia, there has been an approximate doubling in the number of scintigraphic gastric emptying referrals/annum in the last decade (~5400 in 2018; Medicare Australia).

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Articles Relevance of the blood glucose concentration, and current management with GLP-1 receptor agonists, to clinical gastric emptying measurement in diabetes (Continued) MEASUREMENT OF GASTRIC EMPTYING While there are a number of techniques that can be used to measure gastric emptying, including SPECT, MRI, non-radioisotopic breath tests, absorption kinetics of oral drugs e.g. paracetamol, radiopaque markers, the Smart Pill and ultrasonography, scintigraphy, developed in the 1970s-80s, remains the ‘gold standard’8. The US and Europe have developed guidelines for standardisation of the technique9, 10, however, the suggested test meal, ‘powdered Eggbeaters®’ with bread, jam and water, has significant limitations and is not available in Australia. A recent audit in South Australia demonstrated marked variations in the technique used – test meals, radiopharmaceuticals (dual or single isotope) and imaging times, between nuclear medicine departments (unpublished), which is clearly suboptimal. Two important issues overlooked in this audit were the relevance of measurement of blood glucose concentrations and the increasing use of glucagon-like peptide-1 (GLP-1) receptor agonists in patients with diabetes, which represents the focus of this article.

EFFECTS OF BLOOD GLUCOSE ON GASTRIC EMPTYING It is now well established that acute changes in the blood glucose concentration have major reversible effects on the rate of gastric emptying in both healthy subjects and patients with diabetes8.

Hyperglycaemia

Studies by our group11, 12 and others13, 14 have established that acute hyperglycaemia (~15 mmol/L) has a profound effect to slow gastric emptying in both health and diabetes. In a study by Fraser and colleagues, the number of patients with type 1 diabetes with abnormally delayed gastric emptying of

solid and liquid meal components was greater during hyperglycaemia when compared to euglycaemia (~45 mmol/L)15. Furthermore, Schvarcz et al have shown in health and type 1 diabetes that even changes in blood glucose within the normal physiological postprandial range (~4-8 mmol/L) have a significant impact on gastric emptying of solids and liquids.

Hypoglycaemia

While a number of studies have evaluated the effect of hyperglycaemia (~15 mmol/L) on gastric emptying, information relating to the effects of hypoglycaemia (~2-3 mmol/L) on gastric emptying is much more limited16. In a series of studies by Schvarcz and colleagues, using a so-called glucose-insulin clamp, hypoglycaemia (~2.0 mmol/L) was shown to accelerate gastric emptying of solids and liquids in healthy subjects and patients with uncomplicated type 1 diabetes substantially17, 18. In a subsequent study by our group, using scintigraphy, the marked acceleration of gastric emptying by hypoglycaemia (~2.6 mmol/L) was shown to occur in people with longstanding type 1 diabetes19. This study also demonstrated that the magnitude of the acceleration was greater when baseline gastric emptying was relatively slower. Further studies by our group have also shown in healthy subjects that hypoglycaemia (~2.6mmol/L), induced via a glucose-insulin clamp, accelerates glucose absorption markedly, as assessed by the glucose analogue, 3-O-methylglucose (3OMG)20.

Accordingly, at a minimum, fasting blood glucose concentrations should be assessed in all patients with diabetes, and ideally measured at 30-minute intervals during the gastric emptying study. In the event that fasting levels are high, any delay in gastric emptying should be viewed circumspectly due to the potential effects of hyperglycaemia.

2019 Autumn Edition | gamma GAZETTE | 63

Articles Relevance of the blood glucose concentration, and current management with GLP-1 receptor agonists, to clinical gastric emptying measurement in diabetes (Continued) EFFECTS OF GASTRIC EMPTYING ON BLOOD GLUCOSE While the blood glucose concentration markedly influences the rate of gastric emptying, the relationship is bi-directional such that, in both healthy subjects21 and patients with type 2 diabetes22, approximately 35% of the variance in the postprandial blood glucose response is dependent on the rate of gastric emptying i.e. more rapid gastric emptying leads to a greater rise in blood glucose.

GLUCAGON-LIKE PEPTIDE-1 RECEPTOR AGONISTS GLP-1 receptor agonists are now used widely, and increasingly, in the management of type 2 diabetes, to lower elevated fasting and postprandial blood glucose concentrations. The hormone, GLP-1, released from the intestine stimulates insulin, suppresses glucagon and slows gastric emptying – all contributing to a reduction in blood glucose. GLP-1 receptor agonists were developed because GLP-1 is broken down rapidly (2-4 min) in the circulation and can be “shortacting” (e.g. lixisenatide, exenatide BD) or “longacting” (e.g. dulaglutide, liraglutide, exenatide QW) based on their plasma half-life8. The first available GLP1 receptor agonist, exenatide BD, available since 2005, is a synthetic version of Exendin-4, first identified in the venom of the Gila Monster lizard – but that is another story! Short-acting GLP-1 receptor agonists lower postprandial blood glucose concentrations substantially, predominantly via their marked effect

64 | gamma GAZETTE | 2019 Autumn Edition

on slowing of gastric emptying (Figure)23 and are frequently associated with gastrointestinal symptoms such as nausea and vomiting, particularly soon after commencement of treatment24. In contrast, longacting GLP-1 receptor agonists are thought to have more profound effects on lowering fasting, as opposed to postprandial, blood glucose concentrations via their insulinotropic actions25. We have recently shown, however, that long-acting GLP-1 agonists have an effect to slow gastric emptying (unpublished). During clinical measurement it is, therefore, important to recognise the potential effects of GLP-1 receptor agonists on gastric emptying. If ceasing medication prior to measurement, the drug should be withdrawn for at least 4 half-lives.

SUMMARY In patients with diabetes, technologists are recommended to: • measure fasting blood glucose concentrations.

• ask all type 2 patients whether they are taking a GLP-1 receptor agonist as part of their management and, if so, which one.

• allow adequate time for the drug to be ‘washed out’ effectively, if ceasing medication prior to the gastric emptying study.

• provide all relevant information to the reporting physician.

Articles Relevance of the blood glucose concentration, and current management with GLP-1 receptor agonists, to clinical gastric emptying measurement in diabetes (Continued) References 1. Brener W, Hendrix TR, McHugh PR. Regulation of the gastric emptying of glucose. Gastroenterology 1983;85:76-82.

2. Jones KL, Horowitz M, Wishart JM, Maddox AF, Harding PE, Chatterton BE. Relationships between gastric emptying, intragastric meal distribution and blood glucose concentrations in diabetes mellitus. J Nucl Med 1995;36:2220-8.

3. Horowitz M, Harding PE, Maddox AF, Wishart JM, Akkermans LM, Chatterton BE, et al. Gastric and oesophageal emptying in patients with type 2 (noninsulin-dependent) diabetes mellitus. Diabetologia 1989;32:151-9.

4. Schvarcz E, Palmer M, Ingberg CM, Aman J, Berne C. Increased prevalence of upper gastrointestinal symptoms in long-term type 1 diabetes mellitus.

Diabetic Medicine 1996;13:478-81.

5. Du YT, Rayner CK, Jones KL, Talley NJ, Horowitz M. Gastrointestinal Symptoms in Diabetes: Prevalence, Assessment, Pathogenesis, and Management.

Diabetes Care 2018;41:627-37.

6. Talley NJ, Holtmann G, Agreus L, Jones M. Gastrointestinal symptoms and subjects cluster into distinct upper and lower groupings in the community: a four nations study. Am J Gastroenterol 2000;95:1439-47.

7. Wang YR, Fisher RS, Parkman HP. Gastroparesis-related hospitalizations in the United States: trends, characteristics, and outcomes, 1995-2004. Am J Gastroenterol 2008;103:313-22.

8. Phillips LK, Deane AM, Jones KL, Rayner CK, Horowitz M. Gastric emptying and

13. Samsom M, Akkermans LMA, Jebbink RJA, Van Isselt H, VanBergeHenegouwen GP, Smout AJPM. Gastrointestinal motor mechanisms in hyperglycaemia induced delayed gastric emptying in type I diabetes mellitus.

Gut 1997;40:641-6.

14. MacGregor IL, Gueller R, Watts HD, Meyer JH. The effect of acute hyperglycemia on gastric emptying in man. Gastroenterol 1976;70:190-6.

15. Fraser RJ, Horowitz M, Maddox AF, Harding PE, Chatterton BE, Dent J. Hyperglycaemia slows gastric emptying in type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1990;33:675-80.

16. Marathe CS, Marathe JA, Rayner CK, Kar P, Jones KL, Horowitz M. Hypoglycaemia and gastric emptying. Diabetes Obes Metab 2019;21:491-8.

17. Schvarcz E, Palmer M, Aman J, Berne C. Hypoglycemia increases the gastric emptying rate in healthy subjects. Diabetes Care 1995;18:674-6.

18. Schvarcz E, Palmer M, Aman J, Lindkvist B, Beckman KW. Hypoglycaemia increases the gastric emptying rate in patients with type 1 diabetes mellitus.

Diabetic Medicine 1993;10:660-3.

19. Russo A, Stevens JE, Chen R, Gentilcore D, Burnet R, Horowitz M, et al. Insulininduced hypoglycemia accelerates gastric emptying of solids and liquids in long-standing type 1 diabetes. J Clin Endocrinol Metab 2005;90:4489-95.

20. Plummer MP, Jones KL, Annink CE, Cousins CE, Meier JJ, Chapman MJ, et al. Glucagon-like peptide 1 attenuates the acceleration of gastric emptying

glycaemia in health and diabetes mellitus. Nat Rev Endocrinol 2015;11:112-28.

induced by hypoglycemia in healthy subjects. Diabetes Care 2014;37:1509-15.

9. Abell TL, Camilleri M, Donohoe K, Hasler WL, Lin HC, Maurer AH, et al.

21. Horowitz M, Edelbroek MA, Wishart JM, Straathof JW. Relationship between

Consensus recommendations for gastric emptying scintigraphy: a joint report

oral glucose tolerance and gastric emptying in normal healthy subjects.

of the American Neurogastroenterology and Motility Society and the Society of Nuclear Medicine. J Nucl Med Technol 2008;36:44-54.

10. Rao SS, Camilleri M, Hasler WL, Maurer AH, Parkman HP, Saad R, et al.

Evaluation of gastrointestinal transit in clinical practice: position paper of the American and European Neurogastroenterology and Motility Societies.

Neurogastroenterol Motil 2011;23:8-23.

11. Jones KL, Berry M, Kong MF, Kwiatek MA, Samsom M, Horowitz M. Hyperglycemia attenuates the gastrokinetic effect of erythromycin and affects the perception of postprandial hunger in normal subjects. Diabetes Care 1999;22:339-44.

Diabetologia 1993;36:857-62.

22. Jones KL, Horowitz M, Carney BI, Wishart JM, Guha S, Green L. Gastric emptying in â&#x20AC;&#x153;earlyâ&#x20AC;? noninsulin-dependent diabetes mellitus relationship to oral glucose tolerance and appetite. J Nucl Med 1996;37:1643-8.

23. Jones KL, Rigda RS, Buttfield MDM, Hatzinikolas S, Pham HT, Marathe CS, et al. Effects of lixisenatide on postprandial blood pressure, gastric emptying and glycaemia in healthy people and people with type 2 diabetes. Diabetes Obes Metab 2019 [ePub ahead of print].

24. Marathe CS, Rayner CK, Jones KL, Horowitz M. Glucagon-like peptides 1 and 2 in health and disease: a review. Peptides 2013;44:75-86.

12. Plummer MP, Jones KL, Cousins CE, Trahair LG, Meier JJ, Chapman MJ, et

25. Drucker DJ, Buse JB, Taylor K, Kendall DM, Trautmann M, Zhuang D, et al.

al. Hyperglycemia potentiates the slowing of gastric emptying induced by

Exenatide once weekly versus twice daily for the treatment of type 2 diabetes:

exogenous GLP-1. Diabetes Care 2015;38:1123-9.

a andomised, open-label, non-inferiority study. Lancet 2008;372:1240-50.

Corresponding author: Professor Karen Jones, William T Southcott Research Fellow in Nuclear Medicine, Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Level 5 Adelaide Health and Medical Sciences Building, Cnr North Tce and George St, Adelaide, SA 5005, Australia.

Email: karen.jones@adelaide.edu.au | Telephone: +61 8 8313 7821

2019 Autumn Edition | gamma GAZETTE | 65

EVENTS CALENDAR

6

26 - 28 April 2019

1 May 2019

49th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine

QLD Branch Meeting

Adelaide Convention Centre, Sth Australia CPD Points

1

9 - 12 May 2019

11 June 2019

13th Asia Oceania Congress of Nuclear Medicine and Biology

WA Branch Meeting (Post Conference)

QUBE/Qbox hotel Shanghai, Pudong New Area, Shanghai, China

SKG Radiology, St John of God Hospital, 12 Salvado Road, Subiaco, WA, 6008 CPD Points

1

22 - 25 June 2019

3 July 2019

SNMMI Annual Meeting

SA Branch Meeting

Anaheim, California, USA

Women's and Children's Hospital

1

CPD Points

6 July 2019

24 July 2019

VIC/TAS Branch Scientific Meeting (The A to Z of Thoracic Imaging)

SA Branch ANZSNMT Meeting (Biliary Imaging)

Austin Health, 145 Studley Road, Heidelberg VIC 3084

1

Visit website for venue details CPD Points

RSA Calvary, North Adelaide

1

CPD Points

CPD Points

anzsnm.org.au Attendo Plus mobile App

50th Annual Scientific Meeting of the Australian and New Zealand Society of Nuclear Medicine 24th â&#x20AC;&#x201C; 26th April 2020 Sydney, Australia

www.anzsnmconference.com/ANZSNM2020

@anzsnm2020 ANZSNM 2020 on Facebook: http://bit.ly/anzsnm2020 On behalf of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) and New Zealand Society of Nuclear Medicine, which will be held in Sydney, from the 24th â&#x20AC;&#x201C; 26th April 2020. The theme of the

past (2020 hindsight) and a strategic look forward (2020 vision).

The main program will be supported by pre-conference learning, big data and their role in precision medicine (Intelligent Imaging Summit 2020) on 24 April.

Mark ANZSNM 2020 in your diary.

Please refer to the Conference website for more

See you in Sydney in April 2020!

ANZSNM 2020 Conference Manager Plevin and Associates Pty Ltd Tel +61 8 8379 8222 | anzsnm2020@plevin.com.au

Back to Basics

CROSSWORD CLUES Down

Across 3. …. tumour, the second most common benign parotid tumour, representing up to 10 – 15% of all parotid epithelial tumours.

9. A type of upper urinary tract infection.

11. … cells are specialized stellate macrophages located in the liver sinusoids.

12. ... disease is characterized by structural and functional neurodegeneration.

13. … cancer, is the third most common thyroid cancer.

14. A condition comprising cholesterol stones, black pigment stones or brown pigment stones.

15. Method in which phosphate groups bind to the hydroxyapatite crystal in bone.

17. A breakdown product of creatinine phosphate in muscle.

FIND THE ANSWERS ON PAGE 71

1. Telmisartan (Micardis) is a type of … II receptor blocker.

2. A syndrome with symptoms including nausea, vomiting, early satiety, postprandial fullness, bloating and upper abdominal pain.

4. … shunt, also known as LeVeen Shunt.

5. A process of blood formation occurring primarily in the bone marrow.

6. A condition of excess circulating bilirubin.

7. Hormone with molecular formula C15H10I4NNaO4. Also known as levothyroxine.

8. Avascular … commonly affects the ends of long bones.

10. A peptide hormone that regulates the endocrine system, also known as growth hormone-inhibiting hormone.

16. … effects occur by chance and is thought to follow the linear-quadratic no threshold hypothesis.

18. The amount of blood pumped out of the ventricle divided by the total amount of blood in the ventricle equal the … fraction.

19. Abnormally reduced cardiac muscle mobility.

22. Syndrome is characterized by hypercortisolism.

24. Pharmaceutical labelled with Carbon-11. Metabolized into acetyl-CoA. 27. A common indication for CSF leak investigation.

20. Method of radiopharmaceutical localization in the RES following intravenous colloid injection.

21. ... acid is utilized in assessing renal cortical defect.

23. German for ‘braking radiation’.

25. … cell is the most abundant cell in the adrenal medulla.

Columnar in shape.

26. An outpouching of the small intestine.

28. Secreted by the alpha cells of the pancreatic islets to increase blood sugar.

29. …. -90 is a pure beta emitter with half-life of 2.6days & average tissue penetration of 2.5mm in liver.

30. ... famously said ‘Fish are friends not food’. Also name of exercise test protocol with four 3-minute stages.

2019 Autumn Edition | gamma GAZETTE | 68

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OFFICE BEARERS President Vice President Past President Treasurer Committee

A/Prof Roslyn Francis (WA) Dr Daniel Badger (SA) Prof Dale Bailey (NSW) Mr Dominic Mensforth (SA) Ms Marcia Wood (TSIG) Dr Rajiv Bhalla (RPS) Mr Nicholas Ingold (ACT) Ms Judy Duong (QLD) Ms Victoria Brooks (NZ) Mr Christian Testa (VIC/TAS) Dr Geoff Schembri (AANMS Representative)

General Manager & Secretariat All Correspondence

Rajeev Chandra and Drajon Management Pty Ltd ANZSNM Secretariat, PO Box 6178, Vermont South, Victoria 3133 Tel: 1300 330 402 | Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au

Branch Secretaries Australian Capital Territory New South Wales Queensland South Australia Victoria/Tasmania Western Australia New Zealand

Mrs Rachel Prior Vacant Miss Remi Hillery and Ms Loren Katchel Mrs Tess Smith Ms My Linh Diep Ms Georgina Santich Ms Jessica Fagan

Special Interest Groups/ Committees Technologists Radiopharmaceutical Science Physics Technical Standards Committee Scientific Advisory Panel International Relations Committee

Chairperson: Dr Elizabeth Bailey Chairperson: Dr Rajiv Bhalla Chairperson: Dr Daniel Badger Chairperson: Dr Darin Oâ&#x20AC;&#x2122;Keeffe Chairperson: Prof Dale Bailey Chairperson: Prof Andrew Scott

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: ARPANSA 619 Lower Plenty Road Yallambie VIC 3085 Tel: (03) 9433 2211 Fax: (03) 9432 1835 Mr J. Gordon Chan Department of Nuclear Medicine, Austin & Repatriation Medical Centre,

Heidelberg VIC 3084 Tel: (03) 9496 3336 Fax: (03) 9457 6605 email: gordon.chan@petnm.unimelb.edu.au

AIMS AND OBJECTIVES OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE 1. Promote: • The advancement of clinical practice of nuclear medicine in Australia and New Zealand; • Research in nuclear medicine; • Public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; • Co-operation between organisations and individuals interested in nuclear medicine; and • The training of persons in all facets of nuclear medicine.

2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine through standing committees and special groups: • The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand.

• The TSIG Committee is the group overseeing the Technologist Special Interest Group (TSIG) and ensures that all projects, committees and activities of the TSIG align with the values and strategic plan of the ANZSNM. It reports directly to the ANZSNM Federal Council and oversees the two TSIG working groups: CPD & Education Working Group and Technologist Workforce Advocacy Working Group. The committee is able to form working groups to perform specific tasks as required to provide opportunities for the benefit of Technologist members of the ANZSNM after consultation with the ANZSNM Federal Council.

• The Radiopharmaceutical Science SIG and a Physics SIG that maintain standards of practice for their particular speciality and provide a forum for development in Australia and New Zealand.

CONTENT SUBMISSIONS Scientific submissions on all aspects of nuclear medicine are encouraged and should be forwarded to the Secretariat (instructions for authors published 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 ANZSNM Gamma Gazette is published three times a year. Deadlines for each issue of the journal can be found on our website anzsnm.org.au

DISCLAIMER ANSWERS CROSSWORDS 1. Angiotensin 2. Gastroparesis 3. Warthin’s 4. Peritoneovenous 5. Haematopoiesis 6. Hyperbilirubinemia 7. Thyroxine 8. Necrosis 9. Pyelonephritis 10. Somatostatin 11. Kupffer 12. Alzheimer’s 13. Medullary 14. Cholelithiasis 15. Chemisorption

16. Stochastic 17. Creatinine 18. Ejection 19. Hypokinesis 20. Phagocytosis 21. Dimercaptosuccini 22. Cushing’s 23. Bremsstrahlung 24. Acetate 25. Chromatin 26. Meckel’s 27. Otorrhea 28. Glucagon 29. Yttrium 30. Bruce

The views expressed in any signed article in the journal do not necessarily represent those of the Society.

The individual rights of all authors are acknowledged. © 2019 The Australian and New Zealand Society of Nuclear Medicine.

Copyright is transferred to the Australian and New Zealand Society of Nuclear Medicine once an article/paper has been published in the ANZSNM Gamma Gazette (except where it is reprinted from another publication).