Gamma Gazette 2022/23 Spring/Summer Edition

Paediatric Theranostics - Current Considerations

The Bumpy Road of Establishing Nuclear Medicine in a Developing Country: Perspective from Iran 13th World Congress of Nuclear Medicine & Biology

The Future is Promising The Expanding Role of the Medical Physicist in the Age of Theranostics

The future is promising The expanding role of the medical physicist in the age of theranostics Paediatric Theranostics - Current Considerations

Living History: The ANZSNM Archives

The life of Gerhard Lowenthal: His Legacy Shimadzu Award Winner: Presentation at the EANM22

The Bumpy Road of Establishing Nuclear Medicine in a Developing Country: Perspective from Iran

Case Study: Equine bone scan for unexplained lameness Case Study: Feline hyperthyroidism with I-131 therapy Case Study: Lung ventilation for the detection of lung air leaks

Case Study: Stopping leaks: A case analysis of a Tc99m albumin study Case Study: The effectiveness of nuclear medicine lacrimal scintigraphy and dacrocystography in the detection of ephiphora

Dr Emlyn Owen Parry

Welcome to the Spring/Summer edition of the Gamma Gazette

London - MANZSNM President

Hello friends, Welcome to the last edition of the Gamma Gazette for 2022. Another year has flown by.

Our profession continues to flourish and this year it was nice to see an enthusiastic return to face-to-face interactions. The ANZSNM Council and the various sub-committees continue to work hard to pull together more educational and networking opportunities. It goes without saying that we are all looking forward to our flagship Annual Scientific Meeting in Adelaide next year. Hope to see you there.

Coming back to the latest Gamma Gazette issue, having celebrated 30 years of PET in Australia we now turn our attention to the future. Theranostics is an area set to have a substantial impact on the management of patients with cancer. Advances in this field have been led by researchers in our part of the world, many of whom are ANZSNM members. I find it amazing and inspirational to look around at our ANZSNM events and see the faces of the highly influential researchers who have published groundbreaking studies in high impact journals. This Gamma Gazette issue looks to the future and speaks of the prominent role theranostics will have in our profession, and the important role we all have in delivering this life saving treatment to patients who will benefit from it.

As the membership renewal period for 2023 will close on the 31st of December, I would urge you to consider renewing and continuing to support your Society and the profession.

Lastly, I would like to wish you a wonderful festive season and look forward to talking to you in the new year.

Kia kaha, Kevin

Kevin

Prof.

Director of the Department of Molecular Imaging and Therapy

Austin Health, Victoria

EDITORIAL COORDINATOR

Rajeev Chandra General Manager

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WWW.ANZSNM.ORG.AU

S.Rasoul Zakavi Professor of Medicine at MUMS, Nuclear Medicine Research Center

Emily Phipps University of South Australia, Allied Health and Human Performance Unit

ANZSNM Archivist

Prof. Dale Bailey Principal physicist Royal North Shore Hospital

Shiphrah Tagore Nuclear Medicine Technologist, Perth Radiological Clinic Western Australia

Prof. Karen Jones Senior Research Fellow The University of Adelaide, South Australia

Dr Ingrid Burvenich

Olivia Newton-John Cancer Research Institute, Victoria

Andrew Scott

INTRODUCTION TO THE SPRING/SUMMER EDITION

Welcome everyone to the Spring/Summer edition of the Gamma Gazette. We hope everyone has had a great 2022 thus far, this year has flown by and the WA Branch has continued to hold branch meetings via Zoom. These have been extremely successful with large numbers of participants from all across Australia and New Zealand. The most recent meeting was held in early September and there were some wonderful presentations by both technologists and doctors. With over 50 registrations, it was lovely to see many different topics. We invite you to continue the conversation from this and other presentations in Nucleus.

Although this has been a success, it has not been without its challenges to get people to present and we thank everyone who has volunteered in any capacity to help make these meetings run smoothly. We are looking forward to returning to face-to-face meetings, with the first one held at the AGM in November.

Our Radpharm Award for 2022 was held concurrently with the last meeting and we had three wonderful participants; Cassandra Koudela, Murray Wachtel and Caitlin Neville all from Sir Charles Gairdner Hospital. Congratulations to Caitlin Neville for her interesting and informative winning presentation. Good luck from all of WA's ANZSNM community for the upcoming ANZSNM Scientific Meeting to be held in Adelaide on 26th – 28th May 2023.

As some of you may be aware from our reports for 2021, WA like the other states have had staff shortages and trouble getting technologists to relocate from interstate. This year has seen an improvement on these numbers and we have had some of these positions filled, it has been lovely welcoming new people into our community. I am pleased to announce that Nuclear Medicine has recently been added to the Skilled Migration List as part of the WA Branch initiative to get more technologists into the industry. There are other activities been undertaken and hopefully can see the gap being filled further.

Thank you to all the contributors of this edition of the Gamma Gazette.

Tiffany Briggs — MANZSNM Branch Chair, Western Australia

WESTERN AUSTRALIA BRANCH NEWS

We are on a high having recently hosted our second Sunday session for the year and it was a great success. I would like to officially thank all our speakers, Xavia Jude, Hayley Smith, Dr. Jeremy Ong, Dr. Zeyad Al-Ogaili and Dr. Gaurav Ghosh. We had excellent topics ranging from 99mTc HMPAO WBC imaging, a comparison between 67Ga Citrate and 18F FDG for infection imaging, 18F FES PET, how PSMA has improved our knowledge of anatomy and a great presentation on managing diabetic patients having 18F FDG PET imaging. Many of these are available on EduTrace for members to log in and view as our speakers have kindly given their permission for this to occur.

We had three entries for our 2022 WA Branch RadPharm Award and I am pleased to announce Caitlin Neville from Sir Charles Gairdner Hospital is the 2022 winner. We certainly all wish Caitlin the best of luck when she presents at the 2023 ASM in Adelaide and we would like to thank both Cassandra Koudela and Murray Wachtel for their excellent entries too.

Following our broad call for Nuclear Medicine Technologists to move West and take one of the many positions vacant we had over here, as well as our WA Branch report about our shortage in 2021, we have had a lovely influx of new graduates and people who have done just that. It has been great to meet them and work with them too. There is still room over here for more of you of course, which is nothing new to hear for most of the Australian states and territories I know! Hopefully more new graduates will look West at the end of the year too. As a committee we will now look to assisting with resuming placements in WA for students.

The workforce issue has remained high on the list of topics we discuss and progress at our WA Branch Committee meetings and just recently we were alerted by Emma Brook to the fact our profession had not been included on the WA Skilled Migration List – we had no idea! Our Premier is in the process of removing unnecessary red tape for potential skilled migrants and making it easier for them to migrate to WA. With the ANZSNM’s help, a letter was created with assistance from our WA Branch Committee and was sent to our WA Premier and Health Minister requesting we please be added ASAP. I am delighted to report we are now on the list!

I am finding it quite a challenge recently to actively engage more people to present and contribute to the Society, either through presenting at a meeting, joining a committee or by contributing to the Gamma Gazette in some way and I appreciate this

is a very familiar experience across Australia and perhaps in New Zealand as well. “I’m already too busy” is a common theme but I feel that this is our Society, for us, so we should all look to contribute where we can. Please know that I am sincerely grateful for every single person who has said “yes” when I have asked them to please present or help in some way.

Previously we have had our WA departments take it in turns to host an in-person meeting throughout the year and they are then totally responsible for the content. Since moving to online that has definitely been more challenging so as a committee we will be looking to revert to in-person meetings and host them online and record them where possible too. I think that is one way to encourage more people to contribute – or at least it won’t be entirely the committee’s responsibility to source presentations to fill an hour or two!

In happy news, I am excited to say we finally had our first in-person WA Branch meeting in a very long time in early November. Pete Tually and his colleagues Chris Cowcher, Jack Meadows and Shiphrah Tagore had kindly offered to host our WA Branch AGM at their TeleMedVET rooms. GE were our sponsors for the evening and it was a really fabulous event! The evening was perfectly warm, the food and drinks were delicious and the socialisation in the fresh air amongst us all was well overdue. We had our biggest attendance in a very long time, with over 40 people coming along after work. There’s just never enough time to chat with everyone but we all agree it should become our regular end of year location!

Pete had arranged for some gorgeous four-legged friends to join us, one particular pony was pretty cheeky and it had no complaints when people wanted to feed it a sneaky piece of carrot. It was interesting to see how the animal side of nuclear medicine works in WA and everyone was able to

WESTERN AUSTRALIA BRANCH NEWS

(Continued)

enjoy a close up tour of the business. We are grateful to both Pete and Shiphrah for their presentations, as well as to Taylor Hope, Kate Romeo and Russell Troedson for volunteering to also present on the night. It was a really fun and informative event. Although it was a bit late for many of our interstate colleagues, most of the presentations have been uploaded to EduTrace for members to view.

Wishing everyone a very healthy and happy festive season, may you all enjoy your end of year celebrations safely and we look forward to contributing and learning with you in the new year.

Georgina Santich - MANZSNM Branch Secretary, Western Australia

Photos from our recent branch meeting at TeleMed

NEW ZEALAND BRANCH NEWS

As winter comes to an end and spring is in the air, we are all looking forward to some sunshine, longer days and more outdoor time. In June, we celebrated our PET/CT history with a webinar focused on the journey of PET/CT in NZ. This was a great event with an online attendance of 110! Even all the way from Spain. For ANZSNM members these presentations are available to watch on Edutrace.

We are all very proud of Prue Lamerton who was selected to be the worthy recipient of the Dr Elizabeth Bailey Lecture Award for 2022. She gave this presentation at the TSIG Symposium on the 20th of August.

Prue is an experienced and passionate technologist who has 43 continuous years in the nuclear medicine profession and has been instrumental in establishing the first PET/CT scanner in New Zealand. In addition, she has provided many years of service to the nuclear medicine community through a variety of roles in the TSIG, Branch Committees, Federal Council and the New Zealand Medical Radiation Technologists Board.

We had a very successful branch meeting in Ōtepoti/Dunedin on the weekend of the 3rd and 4th of November. Our theme for the meeting was: Around the world in 80 Decays and we heard a variety of presentations including, “PSMA PET//CT for Prostate Cancer Management: Health Inequalities in a New Zealand population ” and my absolute favourite, Professor Terence Doyle on “Humour in Medicine”. (Google Ig Nobel Prize!).

Our NZ Nuclear Medicine whanau (family) came together for the first time in almost three years and it was great to catch up. We were all inspired and motivated after some pretty robust discussions around Molecular Imaging in New Zealand. We also elected a new branch chair who I would like to introduce: Dr Rachelle Steyn RACP; AANMS; MMed (Nuclear Medicine); PGDip (HSE); MSc Advanced Oncology (DE)

Dr Rachelle Steyn is a Nuclear Medicine Specialist, working in the Department of Radiology, Fallen Soldiers War Memorial Hospital, Hawkes Bay, New Zealand. Rachelle obtained her Fellowship in Nuclear Medicine in South Africa in 2009 and worked as a Nuclear Medicine Specialist in the Department of

Dunedin NM Department who hosted the meeting

Karen Roeske, Jane Hassall, and Mike Ramyar from Alphatec

Jane Hassall and Anna Shaw from GE

Barry Bennington, Kelly Hamilton and Hannah Collinson-Smith

NEW ZEALAND BRANCH NEWS (Continued)

Nuclear Medicine affiliated with the University of Cape Town from 2010–2021 prior to immigrating to New Zealand. She completed her Masters in Nuclear Medicine (2013); Diploma in Health Science Education (2016) and her MSc in Advanced Oncology (2021) through the University of Ulm in Germany. After immigrating, she became a member of the Royal Australasian College of Physicians and Australian Association of Nuclear Medicine Specialists and an active participant of the National PRRT service in New Zealand.

Rachelle’s vision for Nuclear Medicine in New Zealand is to see it expand, grow and flourish so that all New Zealanders have access to high quality general Nuclear Medicine Services and in particular access to PET CT and Theranostics. With the year coming to an end, we had one last webinar on Tuesday 1st November: CT for Nuclear Medicine Technologists - An Imaging Refresher. If you missed it, head over to EduTrace to watch the presentations.

Trish Mead - MANZSNM Branch Chair, New Zealand

Professor Lyall Hanton Elemental: The Politics of Naming the Elements

Dr Sonya Cameron

What Harry Houdini and the Sentinel Lymph Node of Melanoma Have in Common?

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VICTORIA/TASMANIA BRANCH NEWS

The VIC/TAS Branch has been hard at work these last few months putting together our Annual Day Seminar, which was held on Saturday, 15th October. The event included a great collection of interesting speakers on varied topics.

With the 1-year anniversary of the Medicare Rebate for Alzheimer's Brain PET scans coming up, we thought it was a good opportunity to review the basics of these scans (for patients, techs and doctors) with a few experts from the Austin Hospital.

We also heard from a referrer about where these scans fit into overall patient management and how they can assist with the proper diagnosis. Further to this we will also have an update on the ISLAND Project in Tasmania and how Brain PET scans are assisting the population "overseas".

There was a presentation on the recent stock shortages and supply chain issues, which have affected us all, particularly in the health industry, and how companies and departments have coped.

We also had an update on the $71M Australian Precision Medicine Enterprise (APME) Project, a collaboration

between Telix Pharmaceuticals, GMS and Monash University.

Lastly, as the first graduates from the new 4-year RMIT Nuclear Medicine degree recently completed the course in June, we heard from a few of "The First Group" about their experiences so far; which created an interesting discussion for those sites with student placements.

Looking forward, we have our state Radpharm and SOP finals in November; keep an eye out for any interesting cases that would make a great presentation.

Finally, a big thank you to branch members Alanah and Christian who represented the ANZSNM at the RMIT Open Day. They were on hand to answer questions from future applicants and give some "real world" experience of Nuclear Medicine.

Kim Jasper - MANZSNM Branch Chair, Victoria/Tasmania

Alanah Incantalupo and Christian Testa at the recent RMIT Open Day

DO WHAT YOU COULDN'T ALONE

As a member of the leading Nuclear Medicine Community in Australia and New Zealand, you will have access to:

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www.anzsnm.org.au

Being a member of ANZSNM has provided me with the resources to connect with our wider nuclear medicine community.

It has given me the opportunity to lead the Technologist Special Interest Group where we provide tools to grow our knowledge and advance our careers, as well as advocacy, and to support each other through mentorship.

As Vice President, it is a privilege to represent all members of the ANZSNM. I encourage all working in nuclear medicine to join the Society.

Jones Senior Research Fellow, The University of Adelaide Vice President ANZSNM/TSIG Chair

Karen

QUEENSLAND BRANCH NEWS

On Thursday the 15th of September the Queensland Branch of the ANZSNM met online via Zoom for a fantastic evening of Education.

Our first speaker of the evening was A/Prof David Wong from The Wesley Hospital who spoke about “Emerging Technologies: challenges and rewards from a private perspective.” This presentation was due to be given at this year's ANZSNM Annual Scientific Meeting in Brisbane at the pre-conference symposium but due to COVID-19, A/Prof David Wong was unable to attend so it was fantastic to be able to see this presentation. As with all other presentations from our branch meetings you will also be able to catch up on EduTrace.

A/Prof David Wong's presentation started with a trip down memory lane, where he discussed the early days of the first PET scanner in Queensland right through to exciting innovative technologies that are being used at The Wesley Hospital (a part of the IMED Network) today.

Our final speaker of the evening was Maddison Carroll, our local ANZSNM federal representative and Nuclear Medicine Scientist at The Royal Brisbane and Women’s Hospital and Queensland Children’s Hospital (QCH). Maddison delivered a presentation on the one-year anniversary of PET/CT at QCH.

For those of us who do not routinely work in a dedicated paediatric facility this presentation was a fantastic insight into the day-to-day operations and the considerations of building a specialised PET/CT facility.

The second presenter of the evening was Dr Suek Chern Goh from the Princess Alexandra Hospital who spoke about a patient's journey through the hospital after the diagnosis of Diffuse Large B-cell lymphoma (DLBCL) with a particular emphasis on how PET/CT contributed to the patient outcome.

After the presentations attendees took part in a fun and interactive quiz via Kahoot! Our feedback so far using the Kahoot! platform is that it has been a fantastic addition to the evenings. Congratulations to our winners. Finally, we finished our branch meeting speaking about exciting events coming up for members. All in attendance were notified that positions for the Queensland Branch (Chairperson, Secretary and Treasurer) will be up for election at our AGM and Annual Radpharm award night in November this year. For those of you who are interested in a position on the branch please contact the branch at QLDbranchsecretary@anzsnm.org.au

Sarah Daniel - MANZSNM Branch Chair, Queensland

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TECHNOLOGIST SPECIAL INTEREST GROUP (TSIG)

As we approach the end of the year, we are proud of what we have achieved so far in 2022. We have provided four webinars, ran a successful Technologist Day Symposium, as well as initiating a studentdriven Student Representative Council (SRC) and a pilot Mentorship program. In addition to this, we have prioritised workforce shortage issues, engaged with our Branches by providing updates on TSIG activities at their local meetings, liaised with the MRPBA, strengthened collaborations with Women in Nuclear (WiN) and the SNMMI-Technologist Section (TS), and supported student initiatives, such as the paediatric colouring-in book created by 2nd year nuclear medicine students, Ruby and Rebecca, featured in this edition of the Gamma Gazette. We strive to advocate for nuclear medicine technologists and provide great value for ANZSNM membership.

WORKFORCE ADVOCACY REPORT

In August this year we welcomed three new members to the Workforce Advocacy sub-committee – Sarah Daniel, Louise Campbell and Suzi McGavin. The three new members have provided biographies in this Spring/Summer Gamma Gazette. NMT workforce shortages are being felt across Australia and New Zealand. The WFA are always keen to hear individual site or state issues.

The Western Australian Branch have recently discovered that NMT was not on the Occupation Priority list for overseas applicants. Members of the WA Branch wrote a letter to their state Premier and Minister of Health highlighting the issue and asking for NMT to be included. All ANZSNM State Rep’s are now reviewing their individual documents, and already Queensland have found the same issue. This is the perfect scenario for the WFA subcommittee to get behind. We can help liaise between Branches and State/ Federal governments, with the support of the ANZSNM

Federal Council and President Dr Kevin London. I’d like to thank WA Branch members Georgina Santich, Stephanie O’Donnell and Branch Chair, Tiffany Briggs, for their work on this.

The TSIG Pilot Mentor Program is now live! We had 12 NMTs apply to be mentors, and six mentees. We had a 90-minute Mentoring Virtual workshop with Tina Cini, from Team leader Toolbox, in early September, mentors, mentees, TSIG OSC and WFA members attended. Tina is an amazing and motivating speaker, and provided us with insights into how to get the most out of this mentor-mentee relationship, and how to have those tough conversations. With the matching complete, we have set the ball rolling and look forward to checking in with the groups in about three months’ time. We are hopeful that this will be a successful pilot program, so keep an eye out next year to take part.

Karen Jones, Pru Burns and Emma Brook Chairs of TSIG Working Committees

Chair TSIG Chair WFA Committee Chair CPD&E Committee

Firstly, a warm welcome to our new committee members who joined the TSIG Continuing Professional Development and Education (CPD&E) Committee in July this year –Alicia Corlett, Alanah Incantalupo and Melissa Shields. We look forward to working with you and thank you for joining our committee. A huge thank you should also go out to our committee members Suzanne McGavin and Cristina Blefari who have stepped down after so much hard work and dedication. Your passion and experience on the CPD&E will be greatly missed.

The 2022 TSIG Annual Day Symposium was held on the 20th of August and was a great success with 134 attendees. We had a huge line up of local and international presenters which was well received on the day and now available on EduTrace for those who were unable to attend. Congratulations to Prue Lamerton who is the 2022 recipient of the Dr Elizabeth Bailey Lecture Award. As many of you can attest, Prue has had an illustrious career and her presentation outlined her experience and the contributions that she has made to Nuclear Medicine. The Symposium also included speakers on Theranostics as well as gender diversity and working with adult and paediatric patients with terminal illness, with discussions continuing on Nucleus. We would love to receive your feedback on the 2022 TSIG Day Symposium, particularly suggestions of or where the 2023 TSIG Annual Day Symposium should be held - please use this link

The Student Representative Council (SRC) met on the 3rd of August and again on the 3rd of November. They are actively discussing and reviewing their Terms of Reference. Jessica Watson has taken on the role of Chairperson and will lead the group in 2023. The enthusiastic group of students hope to run their own webinars in future, representating each of the universities, and to showcase what they are doing on behalf of their fellow students. Recently, the SRC represented at the RMIT University open day, and they look forward to promoting and showcasing our industry at future open days and career expos. We look forward to working with them.

We held a webinar to celebrate Nuclear Medicine and Molecular Imaging week (2-8 October), along with the Society of Nuclear Medicine and Molecular Imaging (SNMMI). This year’s theme was Lighting the Way to New Discoveries in Imaging and Therapy. On the 4th of October we showcased what we are doing in Nuclear Medicine with a great line up of speakers that exemplify what we are doing at the forefront of healthcare, which included presentations from Krystle Glasgow, Technologists Section President of the SNMMI, Dr Kate

Moody, Clare Mackenzie and Ashleigh Hull. On the 7th of November we held a Theranostics webinar with terrific presentations from Dr Lyzu Jasmin, Dr Aviral Singh and Dr James Buteau.

The CPD&E Committee are also busily working away on numerous other professional development activities, including revising the Annual Scientific Meeting Award rules. We will continue to provide excellent educational webinars in 2023 and are looking forward to a new initiative with the JMIRS to provide access to the journal and professional discussions on Nucleus. Please keep an eye out for this in the coming months and don’t forget to download the new Connected Communities App on your mobile device via your App Store to keep up to date with what’s happening on Nucleus.

Should you have any feedback or CPD Activities that you would like the CPD&E committee to organise please do not hesitate to reach out.

What’s coming up for the TSIG:

• ANZSNM Scope of practice document review on the Society website

Creating a liaison group with members from the University courses and the TSIG WFA

• Working on a brochure for college age students on the Nuclear Medicine Technologist career pathway

• Keeping up to date on NMT workforce issues across Australia and New Zealand

• Reviewing and revising ASM Award Rules

As always, please contact us via the TSIG email address tsigchair@anzsnm.org.au or interact with us on Nucleus.

Ngā mihi nui/Best wishes,

Karen Jones, MANZSNM, Vice President & Chair TSIG

Pru Burns MANZSNM, Chair TSIG Workforce Advocacy Committee

Emma Brook, MANZSNM, Chair CPD & Education Committee

Meet the new members of the TSIG Workforce Advocacy Committee

I'm Louise Campbell, Director PET Technology/Assistant Director Nuclear Medicine Technology at Royal Brisbane and Women’s Hospital (RBWH).

I have been fortunate to have had a long tenure in the Nuclear Medicine profession, during this time I have witnessed phenomenal leaps in technology and progression of the role of the Nuclear Medicine Scientist.

I am a graduate of RMIT and over my career I have worked as a Nuclear Medicine Scientist at Royal Melbourne Hospital, The Canberra Hospital, QDI in Brisbane (now Lumus) and at RBWH. I was seconded to Herston Imaging Research Facility (HIRF) as the Operations Manager for three years, where I had a wonderful opportunity to learn and apply MRI in a research setting, contribute as a Nuclear Medicine Scientist as a PET specialist in a purely research environment, and support early career researchers to initiate and commence imaging projects in MRI, CT and PET. I have furthered my education and hold a Graduate

Diploma in Business Administration (University of Canberra) and I hope to one day extend this to an MBA.

I have a husband, two daughters and two crazy labradoodles to make sure my homelife is equally as busy as my work life! I enjoy teaching Nuclear Medicine to undergraduate Radiotherapy students at Queensland University of Technology (sessional lecturer) and through this I also learn the practical applications of PET in radiotherapy planning. But despite a full plate, I remain highly committed and focused in contributing professionally. I was excited to join the TSIG WFA (Workforce Advocacy) working group recently, after 27 years in the profession, I am still highly motivated to contribute professionally to the development of the Nuclear Medicine Scientist workforce through the ANZSNM.

I’m Sarah Daniel, and have been involved in the ANZSNM as a member from 2013 and as the Queensland Branch Chairperson since 2018. January 2023 will mark my 10th year working in the field of Nuclear Medicine after graduating from the University of Newcastle.

I started my career as a PDY at IMED Radiology at The Wesley Hospital in Brisbane during which I was fortunate enough to be a part of the team who performed the first 68Ga-PSMA scan in Australia in 2014 and received training for the use of Diagnostic CT. This is where I found my passion for cutting edge technology and sharing what I had learnt with others so when the position to work as a Research Nuclear Medicine Scientist at UQ arose in 2017 I jumped at the opportunity. Since working at UQ I have gained valuable skills in comparative oncology imaging (canines), pre-clinical PET/ MRI imaging, teaching/tutoring, as well as 3T and 7T MRI operations. In 2019 I completed a Graduate Certificate in Magnetic Resonance Imaging and Positron Emission Tomography and aim to continue post-graduate studies in 2023. Most recently I was awarded the 2022 ANZSNM/ ANSTO Grant at the ANZSNM ASM in Brisbane which was certainly a career highlight, along with performing PET/

CT imaging on Australian animals such as Echidna and Green Sea Turtles.

In 2018 I secured the position of State-wide Clinical Educator at Queensland Health; I consider myself very lucky to be able to work both within the clinical profession of Nuclear Medicine and in Research. In my role as educator I work to liaise between the Universities and the placement sites to enhance the student experience, I also help staff members to further develop their skills and to continue their professional development. One of the best parts of my role is teaching students and new staff members what life is like in Nuclear Medicine after graduation, and all the pathways this career can offer. This is what prompted me to apply for a position within the TSIG Workforce Advocacy Group and I look forward to working with the team and taking our members' feedback onboard.

TSIG Workforce Advocacy Committee (Continued)

I am Suzi McGavin and have worked in Nuclear Medicine for a few decades now. Throughout my career I have worked in New South Wales, Queensland, Victoria, and now the Northern Territory.

I moved into academia to be a Lecturer and Stream Coordinator in Nuclear Medicine at RMIT University, Melbourne in 2018. I previously was the State-wide Educator of Queensland Health Nuclear Medicine facilities, and clinically worked across RBWH and LCCH as a Nuclear Medicine Scientist. Currently, I am working at the Royal Darwin Hospital, which also has NMTs involved in the Cyclotron.

I have completed tertiary qualifications including a Bachelor of Teaching and a Master’s in Health Management, which have helped me build programs and initiatives to advance the profession.

As an active participant in Nuclear Medicine professional bodies, I have held an executive position at ANZSNM’s Federal Council and previously at the TSIG CPD&E committee. Currently, I assist the Workforce Advocacy committee, providing a rounded engagement in the NM profession. I am passionate about supporting students in a learning environment, both in the tertiary and clinical settings.

I believe in building a strong workforce with the appropriate skills and support to ensure retention in the profession and building passion in those new to the profession.

TSIG Student Representative Council (SRC) Update

Jess Watson MANZSNM, Student Representative Committee Chair

The official launch of the ANZSNM TSIG Student Representative Council in May 2022 marks the beginning of the first TSIG group run by students, for the interest of students. Our representatives hail from Charles Sturt University, RMIT, the University of Newcastle and the University of South Australia, with each member bringing unique perspectives from their state and University. So far, our virtual meetings have provided a platform to explore the experiences, challenges and needs of current Nuclear Medicine students.

As a group, we have agreed upon the key responsibilities of the Council and laid the foundations of what we hope to achieve. This includes organising and developing CPD opportunities for ANZSNM student members, promoting the field of Nuclear Medicine to new and prospective students, and presenting at least one student run Webinar per year.

Keep an eye out for our first Webinar “Clinical Placement - The Student Perspective” to be presented in the first half of 2023.

As the year is coming to an end, the Committee has farewelled our graduating 4th year student, Jaya, as she embarks on her first job as a Nuclear Medicine Technologist. Congratulations Jaya! With the new year rolling around, we will be looking for new student representatives to join the Committee. If you’re someone who wants to fly the flag for students, this could be you! Expressions of interest will be sent out via your respective University TSIG representatives.

Acknowledgement and Recognition

We'd like to congratulate Ashleigh Hull, a nuclear medicine technologist currently undertaking her PhD at the University of South Australia, who has been recently awarded the Northern Communities Early Career Researcher Award.

The Northern Community Health (NCH) and Research Foundation is an active supporter of research and health initiatives to impact the lives of Northern Communities in South Australia. The Derek Frewin Early Career Researcher Award was established by the NCH Research Foundation in recognition of the outstanding contributions that Emeritus Professor Derek Frewin has provided to both the NCH Research Foundation and the University of Adelaide.

On the image (left), Ashleigh receiving the award from Professor Derek Frewin, Former Dean of the Adelaide Medical School, at the University of Adelaide.

We'd like to congratulate Prue Lamerton who was awarded the Dr Elizabeth Bailey Lecture Award for 2022 for her work in Nuclear Medicine.

Prue provided an inspiring presentation at the 2022 TSIG Annual Day Symposium, taking us on a journey across her career as a nuclear medicine technologist spanning 43 years. Prue later gave an encore presentation at the New Zealand Branch meeting held in September, where she was presented with her plaque.

REGIONAL NUC MED SCHOLARSHIP

PHYSICS SPECIAL INTEREST GROUP

George McGill MANZSNM, Chair, Physics Special Interest Group

A Postcard from the UK

There’s a reason physicists never buy lottery tickets: I had the good/mis-fortune of planning a family get together 9 months ago. It just so happened my flight landed right in the middle of a worldwide media event, which I’m relieved to report was NOT of my making. Thus, it was I found myself wandering around a very closed early autumnal central London. Unable to meet family as transport was restricted, with shutters down on stores and lights dimmed on West End shows, many had no choice but to take the opportunity to pursue the next favourite UK hobby, marathon queuing. I could say I queued for hours and saw the pageantry of HMTQ's final procession but I did not. Very few in London at this time did.

Like a few hundred thousand other visitors to the UK, I found the spectacle was a ‘For TV Special’ only. I only saw the 10 foot high army green barricades constructed around the ceremonial route, as the whole area was closed off at 3am - not because of excessive crowds - but because those are the unwritten rules. And so it is with processes being undertaken by a range of colleges and associations across Australia affecting NM physics practice. Many of these discussions will result in standards and rules which could affect our practice. Thankfully, the Society is being included thanks to the efforts of a range of nameless members who continually share their information for the benefit of us all in the Society. I am grateful for their contributions. This is not to say we should not remain diligent, as there is a difference between being engaged as an invited party to being a passive

observer with a view of a 10 foot barricade.

Since the last update, the representatives of the Physics SIG had a productive meeting with the ACPSEM NM Physics Leadership group to discuss the application of the Memorandum of Understanding. Progress was made on how the Society and College collaborate on matters of mutual interest. There are promising discussions developing a series of further education opportunities at both of the ASMs. As these happily occur 6 months apart, the ability to continue a theme and have a multidisciplinary approach to developments should be beneficial to all. Currently, the ACPSEM is conducting a scope of practice exercise with the aim of achieving AHPRA registration in future. A few glitches have been raised and I remain optimistic these will be resolved before long. Those members who retain concerns should email me directly so these can be raised on your behalf. As a clinically practicing clinical scientist/medical physicist, I welcome the development and hope it will ensure it supports the work of our NM colleagues in supporting the maintenance of standards and development of novel practices. As the safe and effective delivery of NM practices is of benefit to us all I’m looking forward to ensuring our voice is added to that of our NM colleagues in promoting practice. In other news, I can report the AANMS Theranostic committee has welcomed the contributions of the ANZSNM members supporting novel RNT practice and so it is especially heart warming to see the multidisciplinary nature of molecular therapy practice

being recognised. The potential for growth being discussed at their recent training event in Brisbane. It is hoped future events will continue to facilitate the exchange of ideas and good practice.

In related news, with the collaboration of ASRP, the Physics SIG has secured representation on the IRPA Tissue Reactions Topic Group. There has been growing interest on the impact of mal-administrations and extravasations. Such events are thankfully rare in Nuclear Medicine practice but it is no less useful to ensure we support and maintain adequate reporting mechanisms to review such events proactively. This is so we can learn as much as practical when they do occur and share information effectively for their avoidance in future. This is not to say tissue reactions are or have been a significant risk in diagnostic Nuclear Medicine, but it is prudent to share best practice and be prepared for supporting the growing number of molecular therapies where the risks are known to be greater.

Finally, I was hoping to share a useful update on Federal support for radiation practices but there was no further news on the national Federal Radiation Safety Strategy in which Nuclear Medicine Departments and Physicists have played a significant part elsewhere. All I have been told is…. soon. And so there it is in a nutshell, there will be more information to share… soon.

As always comments are welcome. Until then, I’m looking forward to getting home to blue skies and some warmer weather!

QUALITY AND TECHNICAL STANDARDS COMMITTEE (QATSC)

Darin O'Keeffe MANZSNM, Chair, Quality and Technical Standards Committee

Welcome to the new WA Branch representative

We welcome Emily Her (Medical Physicist, Royal Perth Bentley Group) to the Committee as representative for the Western Australia Branch. Emily's email address is available by logging into the QATSC committee details page on the ANZSNM website.

We still need a representative from the NSW/ACT Branch. In this role you would be representing the members of your Branch and helping shape nuclear medicine practice standards in Australia and New Zealand. If you are interested, please contact the QATSC Chairperson via QATSC@anzsnm.org.au, or talk with your Branch Chairperson about representation.

Resources Update

The ANZSNM does not necessarily endorse these resources. They are provided here simply for the purpose of notifying members of their existence. If you have come across a useful quality or technical standard, or other resource, please email the details to QATSC@anzsnm.org.au so it can be considered for inclusion in future QATSC updates.

The IAEA has a long history of supporting the development of nuclear medicine services, including the implementation of quality systems. For those centres preparing for an external audit of their quality system or even an internal audit for service improvement, you may want to have a look at the check lists and tools mentioned in "QUANUM 3.0: An Updated Tool for Nuclear Medicine Audits" (2021). It can be downloaded from https://www.iaea.org/publications/13619/quanum-30-an-updated-tool-for-nuclearmedicine-audits.

Although not strictly related to quality and technical standards, the 2021 IAEA "Atlas of Non-FDG PET-CT in Diagnostic Oncology" may be of interest to some members. It can be downloaded from https://www.iaea.org/publications/13581/atlas-of-non-fdg-petct-in-diagnostic-oncology.

AI - A number of organisations (and journals) are developing position statements on the adoption of artificial intelligence in medicine. The EANM has recently published a position paper on the application of artificial intelligence in nuclear medicine. It can be freely downloaded from https://link.springer.com/article/10.1007/s00259-022-05947-x.

Dose Calibrator QC

Routine quality control of dose calibrators is hopefully performed by all facilities that check patient doses or dispense radiopharmaceuticals. There are always lessons to be learnt and the RBWH physicists and Matthew Griffiths from the QATSC shares an observation from their routine checks.

They noticed a trend in downward readings for one of their Capintec dose calibrators, shown in the plot of the percentage difference from the expected reading across a number of years and sources (ignore the spikes – they are a known acquisition glitch).

SPECIAL INTEREST GROUP/COMMITTEE

This highlights the importance of plot ting percentage difference from the expected reading because the trend is not noticeable in the graph for the decaying source readings. Plotted on the same time scale.

The reason for the downward trend was the vial/syringe dipper. The QC is performed using a mock syringe source hung in the syringe holder of the dipper (a Ge-68/Ga-68 source for PET dose calibrator QC). The syringe holder had been bumping against the side of the dose calibrator and had broken free and was rising up the dip per stem. This caused the readings and apparent efficiency to decrease. The result is stable once the fault was found and fixed.

Other variability had been noted in the past, possibly due to using the mock syringe source in the vial source position and using non-Capintec dip per products.

But this is not just about dose calibrator QC. If left undetected, it also affects every patient dose drawn using the dose calibrator and could even propagate into PET SUV calibrations if it is used to prepare SUV phantoms.

Take home messages:

1. Careful dose calibrator checks are important, including checking for dipper and well-liner damage

2. Check the dipper’s syringe holder height with new Capintec products, the syringe holder can be loose

3. Only use the correct Capintec dipper product

4. Use the dipper’s syringe holder to hang the QC source - it’s a mock syringe not a mock vial source

5. Plot % difference not simply gross activity readings

6. Set pass/fail values (in this case +/- 5%) and investigate the reason for a trend

7. Consequences: avoid changes in dose measurements and potentially SUV changes in PET

Lu-177 DOTATE Yield

During an audit of 12 months production of Lu-177-DOTATATE, QATSC member Madhusudan Vyas observed a yield issue that he believes is related to the packaging of non-carrier-added Lu-177.

Quality and Technical Standards Committee (QATSC) (Continued)

Three suppliers were included in the audit: ANSTO, ITM, and Isotopia. From 47 batches it was noticed that the Isotopia's yield was 91 to 95%, while ANSTO/ITM's was 80 to 89.5%. Only one factor was variable in all three suppliers' vial packaging: ANSTO/ITM supplies in the 3 ml V-Vial Type I glass vial, closed with 20 mm bromobutyl stoppers, while Isotopia supplies in 10 mL V-Vial Type I glass vials, closed with 13 mm bromobutyl stoppers. It was observed that in comparison with the 10 ml vials, the 3 ml vials had a higher likelihood of retaining Lu-177 if drops of the vial contents splashed in the vial. This appeared to directly contribute to the product yield.  The mean and standard deviation (SD) of the percentage product yields were almost identical for the 3 ml ANSTO and ITM vials, being 88.9 (SD 3.17) and 88.7 (SD 3.23) respectively, and the t-test was 0.24 p(0.8). But the percentage product yields for the Isotopia vials were different, with a mean of 92.3 (SD 2.8) and t-test results were 2.8 p(0.0099) compared with the ANSTO vials, and 2.7 p(0.009) compared with the ITM vials.

Some of the key points highlighted from this audit were:

1. Packaging the Lu-177 in a 10 ml V-vial may prove to be a better option than the 3 ml V-vial as it minimizes the possibilities of splash-related loss of Lu-177, contributing to the overall yield.

2. It is unknown if metal impurities could be a contributing factor due to the limited data provided on the COA report from the ANSTO product. In consultation with stakeholders, ANSTO has identified this as a future requirement.

3. Gentle tapping of the vial and observing the glass vial for any product which may have escaped the bulk is an essential step before labelling as to minimise the possibility of low yield.

The Future is Promising

Professor Andrew M. Scott

Department of Molecular Imaging and Therapy, Austin Health; Faculty of Medicine, University of Melbourne; Olivia Newton-John Cancer Research Institute and La Trobe University, Melbourne, Australia

The field of theranostics combines nuclear imaging technologies PET and SPECT with radionuclide therapy through the use of small drugs, peptides or antibodies as carriers for therapeutic radionuclides (alpha-, beta- or augeremitters). The exponential, global expansion of oncologic theranostics stems from its promise to target and eliminate tumour cells with minimal side effects and its versatility across cancer types in both adults and children (1). Importantly, the theranostic approach addresses the challenges of target heterogeneity, common to cancers, in two important ways: firstly, the diagnostic aspect can evaluate the extent of intra-patient interlesion heterogeneity of target expression prior to therapy; secondly, the therapeutic aspect offers potential cross-fire radiation and bystander biological killing of adjacent, target-null tumour cells (1). Currently, an enormous opportunity exists to expand the efficacy of this technology, addressing the urgent needs of many thousands of patients across the world.

Theranostics in Australia: The Future is Promising (Continued)

The History of Theranostics in Australia

The long history of theranostics using a radionuclide for both diagnostic imaging and radionuclide therapy dates back to the 1930’s when Saul Hertz first presented the concept (2), followed by the actual use of radioactive iodine for treatment of hyperthyroidism and thyroid cancer in 1946 (3-5). 131I therapy currently has the greatest use and availability of any radionuclide based treatment globally (6). Radioiodine therapy was introduced into Australia in the 1940’s (7), and Medicare statistics for 2021 revealed 1802 doses given in Australia for hyperthyroidism and 600 doses for thyroid cancer (http://medicarestatistics.humanservices.gov. au/statistics/mbs_item.jsp), although inpatient 131I treatment may not attract a Medicare rebate and not all hyperthyroidism treatments with 131I will attract a Medicare rebate.

The true numbers for thyroid cancer (based on supply data) is likely to be more than 1,000 per year, and total treatments of 131I for hyperthyroidism and thyroid cancer close to 3,500 doses per year. The opportunity to expand the patient population eligible for 131I therapy may be enhanced through the use of redifferentiation therapy in radio-iodine refractory patients, and the I-FIRST study currently underway in Australia is exploring this approach.

In 2002, the FDA approved the first radioimmunotherapy for relapsed or refractory, low-grade or follicular B-cell non-Hodgkin's lymphoma, with the murine antibody ibritumomab (an IgG1 antibody) labelled with 90Y (8). A further anti-CD20 antibody (tositumomab) labelled with 131I received FDA approval in 2003 for the treatment of relapsed or chemotherapy/rituxanrefractory non-Hodgkin´s lymphoma (9). Clinical trials were also conducted with 131I-rituximab by Rod Hicks and Harvey Turner in Australia (10). Despite clinical efficacy both drugs were not commercially successful and were not marketed in Australia, and 131I-tositumomab was withdrawn from production in 2014. The reasons for the lack of clinical use of these effective therapies was complex, and in part related to frequent lack of co-operation between nuclear medicine and oncology clinics, in addition to medical reimbursement concerns in the US (11).

The use of radiopharmaceutical treatment for metastatic bone pain has also had mixed success, with initial trials demonstrating the efficacy of 89Sr-Cl3 and 153Sm-EDTMP (12-14) and important clinical efficacy data for 153Sm-EDTMP was generated in Australian trials led by Harvey Turner (15). Both 89Sr-Cl3 and 153Sm-EDTMP have been available in Australia and New Zealand, and achieved Medicare funding for use in patients, however

the cost and logistics of supply have however impacted on their use.

Despite the promise of 223Ra-dichloride (Xovigo®) in improvement of pain symptoms and overall survival in metastatic prostate cancer patients demonstrated in the ALSYMPCA trial (16) this radiopharmaceutical is not publically funded in Australia and New Zealand.

New Generation Theranostics

Initial studies explored auger electron therapy in NET patients with 111In-pentetreotide, which did not demonstrate substantial responses and were then followed by 90Y- and 177Lu-DOTATOC and DOTATATE therapies. The development of evidence for the safety and clinical utility for peptide receptor radionuclide therapy (PRRT) in NETs had major contributions from Australian researchers, with Rod Hicks creating one of the largest NET PRRT programs internationally and establishing the first European Neuroendocrine Society (ENETS) Centre for Excellence outside of Europe. A number of other Australian sites also participated in highly impactful PRRT multi-centre trials, including the CONTOL-NETs study.

THE NEXT MAJOR STEP IN THERANOSTICS BEGAN WITH THE DEVELOPMENT OF SOMATOSTATIN RECEPTOR TARGETING AGENTS FOR NEUROENDOCRINE TUMOURS (NETS).

In parallel with the worldwide expansion of radioiodine treatment, the completely new concept of theranostics was then explored in a number of oncology areas.

Theranostics in Australia: The Future is Promising (Continued)

The results of the international NETTER-1 study showing a significant progression-free survival benefit for somatostatin-receptor-positive midgut carcinoid tumours undergoing four cycles of 177Lu-DOTATATE treatment, as compared to the high-dose, octreotidereceiving control group, led to regulatory approval (17). Despite FDA and European approval of 177Lu-DOTATATE, and incorporation in clinical practice guidelines (18,19) there is still not Medicare funding for 177Lu-DOTATATE in Australia, although this treatment is provided in some major hospitals and private practices. The use of 68Ga-DOTATATE enables identification of suitable patients for treatment, and 68Ga-DOTATATE is now approved for Medicare funding in Australia in NET patients. Additional trials are currently underway exploring 177Lu-DOTATATE in other somatostatinreceptor positive cancers both in Australia and overseas. Prostate cancer imaging and therapy with 68Ga/18FPSMA and 177Lu-PSMA has over the last 10 years rapidly progressed from idea to safety, clinical efficacy and approvals. Through multi-centre trials of imaging (20-23) and therapy (VISION and TheraP studies) (24,25) in 2021 there was US-FDA approval of two PSMA PET agents, 18F-DCFPyL and 68Ga-PSMA-11, and in 2022 approval for 177Lu-PSMA-617. In Australia, 68Ga/18F-PSMA was approved for Medicare funding in July of this year. An application for 177Lu-PSMA funding is currently under consideration by MSAC. Multiple additional trials are currently underway in Australia and overseas, exploring the use of 177Lu-PSMA earlier in prostate cancer patient treatment, in conjunction with other treatments including radiosensitisers and immune-based therapies, as well as other therapeutic isotopes linked to PSMA (eg 67Cu, 225Ac, 212Pb).

Australian investigators have been pivotal in the generation of evidence for the use of theranostic diagnostics and treatments for NET and prostate cancer, and in novel cancer indications. In particular, the leadership of Rod Hicks, Michael Hofman, Louise Emmett, Ros Francis, Paul Roach, David Pattinson, Andrew Scott and many site investigators in conducting these pivotal trials has been key to the establishment of these imaging studies and treatments as safe, effective and globally accepted. In 2014, the Australasian Radiopharmaceutical Trials Network (ARTnet) (26) was established in Australia and New Zealand. In efforts led by Michael Hofman, Ros Francis, Louise Emmett, Paul Roach and Andrew Scott, a landmark management impact study (20) and also a randomised study of PSMA-11 PET/CT (proPSMA study) (23) were performed at multiple sites across Australia. The results of these trials led directly to MBS reimbursement in Australia and change to global clinical practice guidelines.

These studies also established an enthusiastic network of sites around Australia collaborating at a very high level. In 2015, Michael Hofman and team led the first prospective trial of PSMA-617 in a 50-patient study, which led to the conduct of the TheraP study which was a landmark practice-changing study and contributed to international approvals of 177Lu-PSMA. The ongoing leadership in prostate cancer trials by Michael Hofman, Louise Emmett and colleagues has set an international standard in multidisciplinary, evidence-based and highly impactful trial design and conduct.

Innovative new multi-centre trials involving ARTnet are currently underway aiming to establish safety and efficacy evidence for a range of new molecular imaging and theranostic areas, including patients with early stage and advanced prostate cancer (eg PRINCE, LuPARP, EVOLUTION, UpFrontPSMA, ENZA-P studies), iodinerefractory thyroid cancer (I-FIRST study), glioblastoma (FIG Study), cardiac amyloid (XSPECT study) and hospitalised patients with acute infections (SNAP study).

We have also provided national and international leadership in defining camera and workforce credentialling, led by Dale Bailey and Sze Ting Lee and members of ANZSNM and AANMS committees. The exploration of a range of novel targeting theranostic approaches has also been demonstrated in Australian trials well before international studies – for example, the first humanised anti-fibroblast activation protein (FAP) targeting and therapy trials were conducted in Australia in the early 2000’s (27), indicating the innovative approach to theranostics that has been implemented locally over many years.

The recent success of theranostics has led to the recent establishment of Australian biotechnology companies exploring nuclear medicine based imaging and therapeutic probes. These include Telix Pharmaceuticals, Clarity Pharmaceuticals, Radiopharm Theranostics, and AdvanCell. Australia has a rich history in development of novel radiopharmaceuticals, beginning with ANSTO with isotope supply and radiopharmaceuticals (eg 131I-MIBG), and Sirtex (established in Australia in 1997, now internationally based) with 90Y-Sir-Spheres, and additional companies involved in radiopharmaceuticals for imaging and therapy including Cyclotek and GenesisCare. A number of smaller start-up companies are also being established to develop novel therapeutics based on theranostic approaches.

Theranostics in Australia: The Future is Promising (Continued)

Projected Demand for Theranostics

The global market for radiopharma ceuticals has shown a steady 5.3% compound annual growth rate (CAGR), although the advances in Theranostic treatments has resulted in projected increase of ~11% based on recent approvals in NET and prostate cancer patients (Figure 1) (1). These projec tions could be dramatically changed if new theranostic treatments are validated and new indications and patient groups found to benefit from these treatment approaches.

Even with the current approved indications, a recent review found that in the US alone there would be at least 7,500 NET patients and 34,000 prostate cancer patients requiring 177Lu-DOTATATE or 177LuPSMA treatment totalling 150,000 individual infusions a year (28). This would extrapolate to over 11,600 infusions per year in Australia and 2,290 infusions per year in New Zealand based on population and similar incidence, which would require major changes to nuclear medicine department capacity and workforce to deliver such treatments. In view of the likely increase in numbers with new indications in the future, this highlights the importance of strategic planning for the unprecedented demand which will occur for theranostic treatments in the next 5-10 years, and addressing issues such as regional and remote access for patients living outside of major cities.

Figure 1. The Predicted Global Nuclear Medicine Market to 2026. This projected market growth reflects the availability of a greater number of agents, implementation at an increasing number of centres and projected increases in the numbers of patients with cancer globally. ©MEDraysintell Nuclear Medicine Report & Directory, Edition 2021. CRPC, castration-resistant prostate cancer; mCRPC, metastatic CRPC; NET, neuroendocrine tumour; PSMA, prostate-specific membrane antigen. (1)

Theranostics Guidelines and Training

Although this treatment approach is being rolled out in both developed and developing countries around the world, there are few consensus statements with regards to the overall safe practice of theranostics. There are a number of recently released statements and guidelines for the establishment of theranostics sites, and Australia and New Zealand has taken a leading role in outlining minimum requirements for Theranostics sites and for nuclear medicine specialist training (29-31), Globally, the IAEA has developed a "Training Curriculum for Nuclear Medicine Physicians" (32) which covers most nuclear medicine requirements but not specifically Theranostics, and does not address the training requirements for radiopharmaceutical scientists, physicists, technologists or nurses working in this field. A recently announced Lancet Oncology Commission will explore the global status of Theranostics, and the factors impacting on access and availability to established and new radionuclide-based treatments, and the minimum training standards for nuclear medicine staff working in Theranostics centres. The development of guidelines for sites, training and also treatments will be an essential component of the safe and effective implementation of Theranostics in the future.

Future Development of Theranostics in Australia and New Zealand

The rapid expansion of clinical indications of theranostics in NETs and prostate cancer has already demonstrated the need to upskill our nuclear medicine workforce, and engage in health technology assessment applications for funding for these indications in Australia. While US and European approvals have been announced for 177Lu-DOTATATE in NET patients, and 177LuPSMA-617 in castrate resistant metastatic prostate cancer patients, neither are commercially available in Australia. This highlights the challenges in international companies choosing to file and supply radiopharmaceuticals in many countries with small markets (including Australia and New Zealand), hence to achieve access and availability to the new generation theranostics it has become necessary to adopt a different approach to regulatory submissions and funding in our countries. The development of a sovereign capability for isotope production and radiopharmaceutical supply, as well as achieving funding for these imaging and therapy procedures, is a major

Theranostics in Australia: The Future is Promising (Continued)

focus of our nuclear medicine community and AANMS and ANZSNM are actively pursuing these applications at present. The development of harmonised protocols for radiopharmaceutical production and instrumentation for early phase trials, the importance of dosimetry and radiation safety for patients, staff and the community, and the engagement with regulatory agencies and patient groups will be important initiatives moving forward. With the increasing number of new clinical indications in theranostics, these strategies will ensure we have the optimal access to these treatments for our patients in the future.

Acknowledgements

Andrew M. Scott is supported by NHMRC Investigator grant 1177837, and grants from NHMRC, Medical Research Future Fund, Victorian Cancer Agency, Cure Brain Cancer Foundation, National Breast Cancer Foundation, Victorian Government, and Australian Cancer Research Foundation. He receives Institutional funding for research/trials from Abbvie, Astra-Zeneca, Celgene, EMD Serono, ITM, Medimmune, Novartis, Telix, Curis, Adalta, Fusion, ImaginAb, Humanigen, and Antengene.

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24. Sartor O, de Bono J, Chi KN, Fizazi K, Herrmann K, Rahbar K, et al Lutetium-177–PSMA-617 for Metastatic Castration-Resistant Prostate Cancer. N Eng J Med 385:1091- 1103, 2021.

25. Hofman M, Emmett L, Sandhu S, Iravani A, Joshua AM, Goh JC, et al. [177Lu]Lu-PSMA-617 versus cabazitaxel in patients with metastatic castration-resistant prostate cancer (TheraP): a randomised, open-label, phase 2 trial. The Lancet 397(10276):797-804, 2021.

26. Francis RJ, Bailey DL, Hofman MS, Scott AM. The Australasian Radiopharmaceutical Trials Network (ARTnet) – Clinical Trials, Evidence and Opportunity. J Nucl Med 62(6): 755-756, 2021.

27. Scott AM, Wiseman G, Welt S, Lee F-T, Hopkins W, Mitchell P, et al. A Phase I Dose-Escalation Study of Sibrotuzumab in Patients with Advanced or Metastatic Fibroblast Activation Protein Positive Cancer. Clin Cancer Res 9: 1639-1647, 2003.

28. Czernin J, Calais J. How many theranostics centres will we need in the United States? J Nucl Med 63(6):805-806, 2022

29. Australasian Association of Nuclear Medicine Specialists Position Statement: Practice of Theranostics in Australia. August 2022. https://aanms.org.au/training/

30. Lee ST, Emmett LM, Pattison DA, Hofman MS, Bailey DL, Latter M, Francis RJ, Scott AM. The Importance of Training, Accreditation and Guidelines for the Practice of Theranostics: The Australian Perspective. J Nucl Med 63(6):819-822, 2022

31. Hermann K, Giovanella L, Santos A, Gear J, Kiratli, Kurth J, et al. Joint EANM, SNMMI and IAEA enabling guide: how to set up a theranostics centre. Eur J Nucl Med Mol Imag 49(7):2300-2309, 2022

32. https://www.iaea.org/publications/13579/training-curriculum-for-nuclear-medicinephysicians

The expanding role of the medical physicist in the age of theranostics

Dr Kathy Willowson Senior Medical Physicist in the Department of Nuclear Medicine at Royal North Shore Hospital

The exciting age of theranostics has resulted in much evolution in the field of Nuclear Medicine.

With this has come a changing role of many of the sub-specialties involved in the field, including that of medical physics. Historically, the medical physicist was largely involved in radiation safety matters, data analysis and camera quality control, a role which has expanded rapidly in the past 20 years to account for the changes in clinical practice. Recognising these changes and anticipating areas of future growth plays an important role in preparing our next generation of physicists.

The evolution of Theranostics

THE GROWTH OF MEDICAL PHYSICS HAS PERHAPS BEEN FUELED BY THERANOSTICS.

The growth of medical physics has perhaps been fueled by theranostics, and the introduction of such documents as the Australian perspective on training and guidelines for theranostics [1] has given guidance as to the expectations of physicists in the clinic. Below is a summary of what I see as the essential role of medical physicists in theranostics, including some of the key areas of growth and other areas which require an improvement in understanding.

Theranostics in Australia: The expanding role of the medical physicist in the age of theranostics (Continued)

Radiation Safety

Physicists should be involved in the delivery of therapeutic agents to ensure safety of both staff and patients and to ensure overall appropriate radiation protection practice is followed.

Given that the therapeutic radionuclide is chosen for its favourable properties, typically beta-minus emission accompanied by gamma emission, and a reasonably long half-life, radiation safety extends from the delivery process itself to release of the patient to the public thereafter. It has been shown that such therapeutics typically have a rapid clearance followed by a slower washout after ~24hours.

Imaging and Instrumentation

Imaging plays an important part in theranostics, from selection of suitable candidates for therapy, to assessment of delivered dose and measurements of response (see figure 1). Understanding the fundamentals of both hardware and software, and the constant improvements and additions to these, allows the theranostics process to be optimized.

The past 20 years has seen some remarkable changes in the hardware which contributes to daily clinical practice, including the introduction of PET/CT, PET/ MR and SPECT/CT, and more recently, the introduction of Total Body PET/CT. We have also seen the introduction of digital detector systems.

As such, large amounts of radioactivity can be expected to be excreted soon after delivery. Physicists should be involved with the general development of radiation safety SOPs, and specifically with the management of incontinent patients, waste storage and disposal, and evidencebased advice specific to the patient’s living conditions when they are discharged. They must also provide advice to staff managing the patient within the department and on the ward if required, based on dose rate readings, patient needs and patterns of contact.

For physicists involved in theranostics, a thorough understanding of the imaging process is needed, including appreciation of the differences between modalities, their strengths and weaknesses, and what data from each is required to contribute to the theranostics process. Diagnostic data are typically acquired with high resolution, quantitative whole-body PET/ CT, whilst post-therapy imaging is generally restricted to SPECT due to properties of the therapeutic radionuclides being used. The physicist should be involved in protocol design and optimization, advising on matters such as acquisition duration and frequency, and their role will vary depending on the extent to which the data is being used (i.e. quantitative analysis, predictive dosimetry, etc).

At the most basic level, the physicist should be responsible for design of reconstruction protocols which optimize the available data (whether it be single- or multi-field of view), balancing image noise against contrast for reader confidence. One of the major improvements to software which has had a great impact on theranostics is the introduction of quantitative SPECT. As mentioned above, SPECT is typically needed for post-treatment imaging, and as such, any dosimetry requires quantification of such data. Some sites will have vendor-based software, other sites will rely on their physicist to develop in-house software or apply purpose-built vendor neutral software. Either way, implementation, validation and quality control of quantitative SPECT for theranostics requires a solid understanding of the processes of attenuation correction, scatter correction, resolution recovery and dead time, as well as system sensitivity. The physicist should be involved in validation prior to implementation for each radionuclide, as

well as monitoring of stability over time. The physicist must also be aware of the limitations in the method and expected accuracy to aid in interpretation of results. The relationship between both hardware and software limitations with data assessment, whether it be derived from post-therapy images (e.g. dose measures) or diagnostic images (e.g. SUV, TLG), must also be well understood.

Ultimately, the physicist must ensure correct operation of all equipment, from dose calibrators through to imaging scanners and the software used to extract information from image data. This requires a sound understanding of the complete theranostics chain, from the radioactive compound used through to imaging and measurement, analysis and interpretation of results, as well as recognition of any deviation from normal operations. In addition, knowledge of computing in relation to correct processing, transfer, handling and display of data forms an essential part of the process.

Figure 1: PET images demonstrating appropriate selection (DOTA +; FDG -) and response measures of a 63yo pancreatic NETs patient treated with four cycles of Lutate. Images courtesy of Dr E Bernard, Royal North Shore Hospital.

Theranostics in Australia: The expanding role of the medical physicist in the age of theranostics (Continued)

Dosiometry

The publication of the 2013/59 Euratom EC Directive (article 56) was perhaps the first recognition of the importance of dosimetry in nuclear medicine. Interpretation of the document in the 2021 EANM position paper on article 56 [2] clearly suggests that the Europeans are striving towards dosimetry-guided patient specific prescription and verification wherever possible and relevant. Such thinking, combined with our increased ability due to developments in hardware and software, has seen a large focus on dosimetry in all aspects of nuclear medicine therapy. Dosimetry requires resources, namely an appropriately skilled physicist and access to quantification and dose software. It is reasonable to assume that not all theranostics procedures will benefit from dosimetry, particularly when weighed against the time needed to perform it – encompassing both imaging requirements which can be arduous for patients and facilities, as well as the data processing time itself. However, the full potential of dosimetry and what it may contribute to treatment optimization is not yet understood. Whilst post-treatment dosimetry is becoming more mainstream for monitoring dose to organs at risk, predictive dosimetry for treatment planning is not yet widely embraced. This is due to two main issues. Firstly, our ability to acquire images that allow for such predictions is hampered by the fact that many diagnostic studies are using short lived agents that do now allow for studies over a series of time points to appropriately capture the uptake and washout period, and thus allow for

calculation of dose. Secondly, we do not yet understand what our dose targets to disease and limits to organs at risk should be, which stems from a historically poor understanding of the radiobiology specific to low dose rate radiation. Physicists now understand there are vast differences in the radiobiology modelling of nuclear medicine therapeutics vs classic external beam radiotherapy, due to factors such as radiation type, cell kill mechanisms, dose heteroegeneity, dose rate, and interaction with the body’s immune response. However, we are seeing more and more evidence-based publications demonstrating appropriate radiobiology parameters for use in our dosimetry models, and the use of terms such as dose volume histograms, tumour control probabilities, and normal tissue complications probabilities are becoming more widely used and understood. The last 5 years has seen a lot of data presented in the literature on optimization of dosimetry protocols (hybrid methods, single time point methods, etc), and even ore recent additions demonstrating the use of posttreatment dosimetry monitoring of renal dose to inform the number of cycles tolerable for a given patient. It is clear that dosimetry is now a big part of the physicist’s role in theranostics, and one which we are still learning. It seems likely that in the future we will see dosimetry being performed for many studies, to both inform treatment (i.e. prescribe activity to the maximum tolerable dose) and assess dose to organs at risk to evaluate safety and inform further cycles.

Theranostics in Australia: The expanding role of the medical physicist in the age of theranostics (Continued)

Theranostics in Australia: The expanding role of the medical physicist in the age of theranostics (Continued)

The evolving state of nuclear medicine practice brings new challenges for the medical physicist today including:

• Better understanding of the role of genetic mutations in disease and implications for treatment, in conjunction with the role of inhibitors, immunotherapy and radiosensitisers

• Designing patient specific treatments protocols as opposed to a one size fits all approach

• Ability to process complex, multitimepoint data sets to provide estimations of absorbed dose

• Improved understanding of dose toxicity thresholds for organs at risk and tumour control probabilities

• Incorporation of radiobiology parameters specific to radionuclide therapy and extending standard dose metrics to BED, EUD

• Utilising AI for both anatomical and functional segmentation

• Incorporating radiomics

• Understanding alphas vs betas for treatment and the role of the immune system

Both the curriculum for higher degree students (e.g. Masters of Medical Physics) and the curriculum of the ACPSEM TEAP program have been modified in recent years to encapsulate this expanding role of medical physicists, and I think we may expect further growth in the future as our understanding of theranostics, and in particular dosimetry, continues to increase.

References

1. Lee ST, Emmett LM, Pattison DA, Hofman MS, Bailey DL, Latter M, et al. The Importance of Training, Accreditation and Guidelines for The Practice of Theranostics: The Australian Perspective. J Nucl Med. 2022.

2. M Konijnenberg, K Herrmann, et al. EANM position paper on article 56 of the Council Directive 2013/59/Euratom (basic safety standards) for nuclear medicine therapy. EJNMMI 48, 67-72 (2021).

The age of theranostics is certainly an exciting time to be a medical physicist, with adaptation of existing fundamentals as well as furthering of knowledge required to reach our full potential.

Paediatric TheranosticsCurrent Considerations

Nuclear

Thankfully, cancer in children is much rarer than in adults. Unfortunately, this fact also creates special challenges in conducting meaningful clinical trials in new treatment modalities such as theranostics. Because of their rarity, the recruitment of paediatric cancer patients to trialbased nuclear medicine therapies is considerably more difficult than in adult patients. Also, the very nature of dealing with children and issues around consent and the expectations of families make this a highly challenging space to work in. Despite these barriers, the potential for benefit with effective treatment of childhood cancer may be considerably greater than the treatment of cancer in adults. Children successfully cured of cancer have many years of life ahead of them and health economics infer that every dollar spent on delivering effective healthcare in childhood has the potential to return many more dollars to the economy over the subsequent healthy, productive lifetime.

Dr Kevin London

Medicine Physician; Ultrasonologist; Paediatrician; Advancing healthcare through clinical research initiatives

Theranostics in Australia: Paediatric Theranostics - Current Considerations

Current Considerations in Paediatric Theranostics

Theranostics has been used for decades in children and the most common indications are for the treatment of thyroid cancer and neuroblastoma, the latter being the most common extracranial solid tumour in childhood.

Children with thyroid cancer more often present with metastatic disease compared to adults, although the prognosis remains very good with current treatment programs including I-131 therapy. The main challenge currently is how to incorporate the use of targeted molecular therapies

Genetic alterations in thyroid cancer are common in children, often providing opportunities for the use of non-radioactive molecular targeted drug therapies. Medication such as lenvatinib and selpercatinib block specific tumour growth signaling pathways and are becoming more available in Australia for use in children with thyroid cancer. The question has shifted now towards which therapy offers the most benefit to children with thyroid cancer, radionuclide therapy with I-131 or molecular targeted drug therapy, or both. Figure 1 (below) illustrates this point in an 8-year-old boy with metastatic thyroid cancer. He underwent two cycles of

I-131 therapy to successfully treat the skull bone metastasis and kidney metastasis, with mild residual diffuse lung and neck nodal disease remaining on the I-123 scan.

The case for further I-131 treatment and molecular targeted drug therapy are both compelling, but only clinical trials will tell us which is more effective.

Neuroblastoma, on the other hand, generally has a poor prognosis. Traditionally 131I-MIBG therapy has been used with palliative intent in children with relapsed or recurrent disease. The more recent radionuclide agent 177 Lu-DOTATATE has emerged as a fantastic therapy in adults with neuroendocrine tumours and offers significant potential for use in children with neuroblastoma. Clinical trials are underway in children with high-risk neuroblastoma and it is emerging that getting the dose right is a key factor in producing a treatment response. Figure 2 (below) illustrates the use of dosimatry calculations in a 9-year-old boy undergoing 177Lu-DOTATATE. After treatment with 177Lu-DOTATATE whole body scanning was performed immediately after the infusion, and at 24 and 48 hours.

Theranostics in Australia: Paediatric Theranostics - Current Considerations

The kinetic profile of the recurrent abdominal neuroblastoma tumors can be mapped over time to calculate residence times in the tumours and critical organs, such as the kidneys, to allow dose planning for future treatment cycles. The aim being to maximise the tumour-absorbed dose and minimise the dose to critical organs.

In summary, theranostics in the paediatric population is a data-poor area. However, the potential for significant benefit is high and efforts are underway to recruit children with cancer to clinical trials that will be important in maximising clinical outcomes as has been shown in the relatively data-rich adult oncology space.

ANSTO/ANZSNM RESEARCH GRANT 2023

ANSTO/ANZSNM RESEARCH GRANT 2023

Applications are Now Open

Closing Date: 16 December 2022

ANSTO and the ANZSNM (“the Society”) are pleased to offer a competitive grant aimed at encouraging research in nuclear medicine in Australia and New Zealand. The grant is up to the value of $20,000 and is expected to run for approximately one year. ANSTO is Australia’s government-funded nuclear science organisation. Its vision is to deliver excellence in innovation, insight, and discovery through its people, partnerships, nuclear expertise and landmark infrastructure. In assessing applications for the grant, preference will be given to early career researchers in order to provide seed funding for pilot investigations that could lead on to further grant applications. The grant will be offered yearly but the evaluating committee reserves the right to not award the grant if there is no suitable application.

All aspects of nuclear medicine will be considered for this grant including, but not restricted to:

Novel developments in radiopharmaceuticals

Hardware and software innovation

Epidemiology and audit activities

Pilot clinical trials

Retrospective studies on outcomes in diagnostic and therapeutic procedures in nuclear medicine Education, training and professional development activities.

The ANSTO/ANZSNM Research Grant is intended to achieve one or more of the following:

1. Approach a meaningful conclusion in one year

2. Assist investigators striving to establish new programs or new directions 3. Fund initial exploratory research for which external funding will be sought subsequently 4. Address circumscribed clinical problems of a sort unlikely to attract industry funding

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

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

For further information on Research Grant Conditions & Applications visit https://www.anzsnm.org.au/members-centre/anstoanzsnm-research-grant/2023-research-grant/

Nucleus is ANZSNM's new Online members-only community to connect, communicate and collaborate with your peers.

Year-round networking with no geographic restrictions.

Participate in communities based on topics that are important to you.

Be a resource to others by responding to their questions to help strengthen the industry.

Share your own best practices, articles and resources.

Search for members to connect with new colleagues or reconnect with old friends from meetings.

Online discussions allow you to ask questions to your peers across the industry.

Papers, articles, and on-demand meeting presentations at your fingertips and searchable for easy access.

How to Access Nucleus?

THE ANZSNM ARCHIVES

Living History

Debra Huddleston ANZSNM Archivist

For those unfamiliar with the Archives, what can they expect to find in them?

The archives contain an extensive collection of photos, mainly taken from past magazines, with the exception of photos from the 1994 WFNMB 6th World Congress held in Sydney which were kindly donated by Richard Smart.

There is a near complete collection of ANZSNM publications which includes ANZSNM Nuclear Medicine News (1970 – 1978), ANZSNM Newsletter (1979 – 1994), ANZ Nuclear Medicine (1995 – 2010) thanks to contributions from Life Member Dr John Andrews, Ruth McGennisken and Giovanni Bibbo. There is a link to the ANZSNM History Book titled Isotopes, Imaging and Identity: The History of Nuclear Medicine in Australia and New Zealand which was documented by Paul Richards on behalf of the ANZSNM and has contributions from many ANZSNM members.

Other sections under development include Past Branch and Committee Reports, Past Conferences and Awards List, Member Information including Achievements, Honours, Obituaries, Retired members, Current and Past Presidents of the ANZSNM, Past Rules and Guidelines, and a What’s New/ Information Required section. Society Women at Work (1969 – 2019) has been completed by Dr Agatha van der Schaaf, first female President of the ANZSNM, an initiative from Past President A/Professor Roslyn Francis.

Why are archives important in a Society like the ANZSNM?

The archives provide a record of significant events that have happened in the ANZSNM over the last 50 years. They enable us to learn more about the Society, how it started, who was involved and what changes have taken place over that time. We can see what the ANZSNM’s purpose is, its culture and the members who helped shape the society into what it is today. We have all played a part in the ANZSNM, some big, some small. The archives are a snapshot of what has happened in the past. If there is a way to make them more representative of all ANZSNM members please get in touch with me.

What has been the most rewarding aspect of your job as the ANZSNM archivist?

I responded to a request for an Archivist over 4 years ago from then President Professor Dale Bailey. I have enjoyed watching the archives collection grow over that time. I feel extremely satisfied to have just completed scanning all available issues of the ANZSNM Nuclear Medicine News, ANZSNM Newsletter and ANZ Nuclear Medicine to provide members with a comprehensive listing that can be easily accessed on the website. The other aspect I have particularly enjoyed is being able to upload information to the archives section of the website myself and organise it how I choose.

What content in the archives have you found most interesting?

I am very interested in how the ANZSNM started and has developed over the years.

I enjoy looking at photos of members taken at conferences and meetings, remembering some of the people who have worked in Nuclear Medicine since I first started in this field over 30 years ago. I also like to see recognition of people’s achievements such as Conference Awards, Australian and New Zealand Honours, and Honorary Members of our Society

What would you suggest members read in the archives?

Whilst I would love everyone to have a look through the entire section of the archives I would suggest that the area you review will likely be dependent on what stage of your Nuclear Medicine journey you are in. For anyone who has stepped in as President of the ANZSNM it may be this section. If you have been a member of the ANZSNM for a long period of time you may like to look at the photos of past and present members or the section which highlights information about them or their achievements. Or look for information about yourself?

If you are new to a committee you might like to see some past reports. As someone new to Nuclear Medicine and the ANZSNM you might like to spend more time looking through the archives to better understand the background of the field you are working in.

SUBMITTED ARTICLES & CASE STUDIES

Living History: The ANZSNM Archives (Continued)

What periods are still missing? Which items would you encourage members to send your for publication in the archives?

• ANZSNM Newsletter:

• 1970 – Issues 2 to 6

• 1971 – issue 1

• 1979 – issue 1 (March/April)

• ANZ Nuclear Medicine:

• 1988 – March issue as the current version I have is incomplete

• Australian and New Zealand Honour’s List

• Yvonne Ho – photo

• Rick McLean – photo

• Paul Richards - photo

How can people contribute to the archives?

•

Honorary Members

• Vivienne Bush – photo and information

• Peter Collins – photo and information Ray DeGroot – photo and information

• Ivor Surveyor – photo and information

• Ian Hales – photo only

• Rob Howman-Giles – information

Any contributions to the archives can be emailed to archives@anzsnm.org.au. Everyone is welcome to submit content to the archives.

His Legacy THE LIFE OF GERHARD LOWENTHAL

Rina Harber

Gerhard Lowenthal's niece

Gerhard Claus Lowenthal, born in Berlin 26 August 1916, died Sydney 31 October 2015. He was married and had one son who pre-deceased him.

There are various spellings of his first name: Gerhart, Gerhard and Gerhardt

He came to Australia just before WW2. He completed a BSc in Physics and a BA in History at the University of Melbourne. He then worked as a physicist at the Commonwealth Department of Supply on Standards of Temperature.

In the mid to late 1950s he was offered an Australian Atomic Energy Commission scholarship for PhD studies on the properties of hard metals. He and his family then moved to Sydney so he could pursue his studies.

He received an MSc in Physics from the University of NSW. His thesis was: The extension of the international temperature scale down to about 20°K. His PhD was: Measurement of the specific heats of metals at high temperatures

He went to work at the Australian Atomic Energy Commission after he completed his PhD. He was appointed to set up Australian Standards of Radioactivity. By the 1970s the work was internationally recognised and led to Australia being given a place (with about 12 other countries) at the Consultative Committee for Standards of Ionising Radiations of the International Committee for Weights and Measures (CIPM) in Paris. He represented Australia on the Consultative Committee for Weights and Measures until the mid 1980s.

He authored/edited several books, supervised PhD students and taught at adult education for many years into his retirement. Between 1980 and 1988 he also was the Australasian editor for two international scientific journals concerned with nuclear radiation applications. He published, alone and jointly, some 50 refereed papers.

He was awarded the French Legion of Honour (Chevalier de l’Ordre National du Merite) in 1994 for his work with the CIPM and other work relating to Australasian-French scientific cooperation and was made a Member of the Order of Australia in January 1999. This was awarded “For service to Science particularly in the field of radioisotope metrology and to adult education”. He was also elected a member of the Royal Society of NSW in 1989 and received the Society’s medal in 1995. He received life membership of the ANZ Society of Nuclear Medicine in 1983. He was also a Fellow of the Australian Institute of Physics. He was a foundation member of the International Committee for Radionuclide Metrology.

There is an article in the ANZ Nuclear Medicine, March 1995 which gives some details of his career. Click here to read it.

SHIMADZU AWARD WINNER

Presentation

at

the

EANM22

Dr ingrid Burvenich Senior Research Scientist (NIF Fellow)

Dr Ingrid Burvenich has received the Shimadzu Award for her work in radiopharmaceutical science at the Annual Scientific Meeting (ASM) of the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) in 2021 which was held as a virtual meeting.

She won the award for her work on the in vitro and in vivo characterization of 89Zr-Df-radiolabeled bispecific anti-PD-L1/TGF-βRII fusion protein bintrafusp alfa, a collaboration project between the Tumour Targeting Laboratory of the Olivia Newton-John Cancer Research Institute (ONJCRI) and EMD Serono/Merck.

“Winning the Shimadzu Award felt very rewarding. It was my first award ever, so it gave me a great boost to keep up the motivation and hard work that is needed in a science career. This recognition will also help with securing future funding for my research projects” Dr Burvenich said.

“I used the travel award to join the 35th annual meeting of the European Association of Nuclear Medicine (EANM). Joining the EANM annually facilitates my ongoing research activities and translational role within the Tumour Targeting Laboratory at ONJCRI (Tumour Targeting Laboratory – Olivia Newton

John Cancer Research Institute (onjcri.org.au)), but also as a National Imaging Facility Fellow. I enjoyed the plenary talks and the M2M (from molecule to man) track. This track covers translational developments in molecular imaging and therapy and brings together radiochemists, physicists, and clinicians to actively stimulate multidisciplinary interplay between the various scientific disciplines concerned with molecular/nuclear imaging and therapy.”

“

Today, nuclear medicine is changing clinical practice, exemplified by the current 68Ga-PSMA PET developments and 177Lu-PSMA therapy. This creates exciting possibilities for every research scientist working in this field today, knowing that their molecule too one day might change clinical practice and improve outcomes for patients.”]

“

The conference was also an ideal place to network and have meetings with different exhibitors. I joined the editorial board meeting of the EJNMMI, caught up with Mediso to discuss progress with the installation of our recent preclinical PET/3T MRI at the Olivia Newton-John Cancer Research Institute and met up with former colleagues from different countries.”

The Bumpy Road of Establishing Nuclear Medicine in a Developing Country: Perspective from Iran

S.Rasoul Zakavi MD IBNM FANMB

When I was asked to write about nuclear medicine in Iran, I was wondering how to introduce Iran to the readers of Gamma Gazette in the first place.

One of the most ancient civilizations, now geographically is limited by Caspian Sea in the north and Persian Gulf in the south, and bordered on land with 7 countries that are mainly Turkey and Iraq on the west and Turkmenistan, Afghanistan

and Pakistan on the east (Figure 1). Though older people might remember Iran as a peaceful Middle East country famous for its Persian carpet, caviar, pistachio and poetry, younger generations are more likely to see it as a rouge country frequently hitting the headline with news about nuclear activities. These contradicting views are a reflection of major political events that have happened in Iran and their impact can also be traced in the story of establishing nuclear medicine in the country.

Figure 1- (a) Map depicting Iran and its neighboring countries; (b) Major cities within Iran. The author’s city is in the top north-east corner near the border with Afghanistan and Turkmenistan

Nuclear Medicine Research Center, Mashhad University of Medical Sciences, Mashhad, Iran

SUBMITTED ARTICLES & CASE STUDIES

Establishing Nuclear Medicine in Iran (Continued)

How did nuclear medicine begin in Iran? Nuclear Medicine Training Programs

You may be surprised to know how early it began; the first nuclear medicine activities started in 1960 in Tehran. Although, initially it was limited to radio-immunoassay tests and measurement of thyroid iodine uptake, installing the first gamma camera in 1964 further expanded its role in diagnostic disciplines1. A few years later, in 1972, when the American Board of Nuclear Medicine (ABNM) certification was issued for the first time, a few Iranians were among the first board licensees2. Although some of them have continued their brilliant job in top universities in the USA and won many prestigious awards, others decided to return home and foster nuclear medicine in Iran2. Those who opted to work at home had focused on introducing nuclear medicine to local medical communities and setting up nuclear medicine departments, before establishing Iranian Society of Nuclear Medicine (IRSNM) on June 18th 1978. Prof. Sadegh Nezam Mafi from Tehran University who founded the very first nuclear medicine department back in 1960 was elected as the president of IRSNM3(Figure 2). However, after the Iranian revolution in 1979 and consequent turmoil that was aggravated by Iran-Iraq war, the IRSNM entered a period of dormancy before resuming its usual activities in 1993. The same year the first issue of Iranian Journal of Nuclear Medicine (https://irjnm.tums. ac.ir) was published. It is now a semi-annual publication indexed in Emerging Sourcing Citation Index and some other major indexing centers3

In 1983, a group of ABNM-certified nuclear physicians including Prof. Mohsen Saghari, launched a nuclear medicine residency program in Tehran University of Medical Sciences (TUMS). The initial curriculum, which required three year of training, was updated subsequently and extended to four years. To ensure a high quality of training, the Ministry of Health and Education has been holding a yearly examination to award Iranian Board of Nuclear Medicine (IBNM) certification to the successful applicants who have finished their residency program in nuclear medicine. Although IBNM certification is not mandatory for nuclear medicine practice in Iran it recognises the high quality of graduates atop of their initial certification by the host universities. Furthermore, IBNM certification is mandatory for employment in an academic center in the country. Later on, Iran and Shahid Beheshti Universities joined the training league followed by Mashhad University of Medical Sciences in 2007 and Shiraz University in 2014. Currently, the five Universities combined, train about 15-20 nuclear medicine specialists each year.

Radiopharmacy

Along with development of nuclear medicine centers, the School of Pharmacy in TUMS has begun to offer a PhD program in radiopharmacy since 1995 in joint collaboration with Atomic Energy Organization of Iran

(AEOI)4. The graduates have played an important role not only in educational programs in nuclear medicine, but also in research centers throughout the country. Later on, Babol University joined the program and now they train 4-6 radiopharmacists each year. Consequently, a local company hired trained radiopharmacists and launched production of a number of radiopharmaceuticals to meet the ever-growing demand of newly founded nuclear medicine centers. This boded quite well in a time that the national currency was plunging and the importing of radiopharmaceuticals were becoming hardly cost effective5. The company, Pars Isotope, expanded its activities later to produce not only radiopharmaceuticals but also a variety of radioactive generators. Now it supplies nearly all kinds of cold kits ranging from MDP to PSMA, plus FAPI, Octreotate, CXCR4 and a few other proteins for labeling, and sells a range of generators such as Mo-99/Tc-99m, Rb-81/Kr-81m, Ge-68/ Ga-68 and W-188/Re-188. Additionally, it provides a number of beta-emitters such as I-131, Re-188, Y-90, Sm-153 and Lu-177 with affordable prices6. Now the company not only supplies radiopharmaceuticals locally, but also exports to other countries around the world.

Figure 2- Prof.Sadegh Nezam Mafi (in white coat standing third from the right) with his students who were the founders of nuclear medicine in Iran.

SUBMITTED ARTICLES & CASE STUDIES

Establishing Nuclear Medicine in Iran (Continued)

But the way was not always smooth for them, as the beginning of the paralyzing sanctions against Iran on July 1, 2010 curbed its activities transiently and ceased production of Mo-99/Tc-99m generators completely. Consequently, all nuclear medicine centers in Iran stopped working for a month. Although, they finally managed to weather the storm and resume production of generators and radiopharmaceuticals, it showed the nuclear medicine community that carrying a “nuclear” in the name could make them more vulnerable to political disputes! 7. Again, on May 8, 2018, when the USA pulled out of the Iran JCPOA deal and imposed secondary sanctions, the import of raw material for production of radiopharmaceuticals became a strenuous labour and raised a lot of concerns about the deleterious effect of politics on nuclear medicine8.

Training of Technology staff

Expansion of nuclear medicine departments greatly increased the demand for nuclear medicine technologists. Initially technologists certified in radiology were working in nuclear medicine departments after a short onsite training. However, Babol and Kermanshah Universities felt the need for trained technologist in nuclear medicine and began to offer a dedicated bachelor program in 2003. Now they train around 30-40 technologist each year. The curriculum for the program is not significantly different from similar programs in the USA and England9

Engineering

In line with nuclear medicine growth, seven universities rushed into offering PhD programs in medical physics, medical engineering and related disciplines like image processing and radiobiology10. Expectedly, a medical engineering company used this opportunity to produce a variety of nuclear medicine devices such as Heliprobe, Gamma Probe, Animal SPECT, Animal PET, Interaoperative gamma camera, Cardiac SPECT and General SPECT. Now they commercialized these products to meet the local demand11

Research activities

A number of research centers, pre-clinical laboratories, and technology startups were born along with expansion of nuclear medicine activities, which played an important role in production of scientific data necessary for clinicians and for companies interested in nuclear medicine. Moreover, Iran’s share of publications in nuclear medicine has increased dramatically in the last few decades12, and it hosted 10th Asia Oceania Congress of Nuclear Medicine in Tehran in May 16-20, 2012 (Figure 3). Furthermore, apart from publishing of Iranian Journal of Nuclear Medicine, Iran has been the host and sponsor of Asia Oceania Journal of Nuclear Medicine and Biology (http://aojnmb.mums.ac.ir ) since the beginning.

Figure 3- Asia Oceania Congress of Nuclear Medicine and Biology in Tehran in 2012.

Establishing Nuclear Medicine in Iran

Current status and new challenges

Currently, about 300 nuclear physicians are working in nearly 200 nuclear medicine centers and 16 PET/CT centers in the country. Moreover, four cyclotrons are active in the production of PET tracers. Apart from all conventional nuclear medicine activities, new molecular imaging such as FAPI, PSMA and CXCR4 are also available and practiced in many centers. Furthermore, Tc-99-PMSA scanning is offered for patients who cannot afford Ga-68-PSMA. Radionuclide therapy is also very active and a number of beta-emitters (Lu-177-PSMA, Lu-177-Octreotate, Sm-153EDTMP, P-32-Colloid, Re-188-colloid, and I-131-MIBG, I-131NaI) are commonly used for treatment of patients. Additionally, a few patients were treated with Lu-177-FAPI and Lu-177-CXCR4, but it is not approved yet.

Home to more than 86 million people, it is clear that Iran has fewer nuclear medicine facilities per million population than many developed and developing countries by a factor of 2-7 13. Yet, the investment in nuclear medicine is severely limited and the outlook is not promising, as the governmental spending in healthcare, which was 6.7% of GDP in the last two decades, has been dwindling in the last few years14. Furthermore, despite subsidization of radiopharmaceuticals by the government, nuclear medicine centers should pay much higher prices for any imported instrument, as a direct result of sanctions and problems with money transfer. Adding to the problem has

References

SUBMITTED ARTICLES & CASE STUDIES

(Continued)

been the soaring inflation in Iran and plunging of national currency in recent years as well as the compulsory tariffs for nuclear medicine procedures, defined by the Ministry of Health, usually without consultation with stakeholders. While the tariff for an average nuclear medicine procedure has increased roughly twofold since 2018, the Iranian Rial has plummeted to one ninth of its value in the same period. Moreover, only about one third of the tariffs are covered by the insurance companies and the rest should be paid out of pocket. Not surprisingly, these incoherent policies made nuclear medicine unprofitable in Iran and breeds the ground for emmigration of many scientists and physicians to other countries.

In summary, nuclear medicine activities began in 1960 in Iran and flourished in the following decades so much that it now produces many radiopharmaceuticals and a number of nuclear medicine devices. Yet, despite the great strides made in the last few decades, inappropriate health policies associated with hurdles brought about by the sanctions against Iran are ruining its remarkable achievements. The case example of Iran not only shows the great potential of nuclear medicine in a developing country, but also reveals its vulnerability to political decisions that may vanish the results of decades of hard work by a dedicated scientific community.

1- Gholamrezanezhad A, Mirpour S, Akhavan Behbahani A, Nuclear Medicine in Developing Countries: Perspective from Iran; JNM (51)5; 14N-22N, 2010, 2- Poul F Høilund-Carlsen, Abass Alavi: A giant in Nuclear Medicine turns 80 and is still going strong! Hell J Nucl Med. 2018 Jan-Apr;21(1):85-87.

3-Keyhan Newspaper, June 18th, 1978

4- https://gsia.tums.ac.ir/en/page/15552/Department-of-Radiopharmacy

5- Amir Reza Jalilian, Davood Beiki, Arman Hassanzadeh-Rad, Arash Eftekhari, Parham Geramifar, Mohammad Eftekhari , Production and Clinical Applications of Radiopharmaceuticals and Medical Radioisotopes in Iran., Seminars in Nuclear Medicine, 2016 (46);4; 340-358

6- https://parsisotope.com/

7- Zakavi SR. Economic Sanctions on Iran and Nuclear Medicine. Asia Ocean J Nucl Med Biol. 2019; 7 (1): 1-3

8-Farsad, M.,Rahmim, A.,Dadparvar, S.,Farahati, J.,Mirzaei, S. Alavi, A. Economic sanctions are against basic human rights on health. European Journal of Nuclear Medicine and Molecular Imaging, 2019;May;46(5):1046-1047

9- M Gholami - Evaluating the curriculum for BS of radiologic technology in Iran: an international comparative study, Entomology and Applied Science Letters, 2018 - pajouhesh. lums.ac.ir

10- http://medicine.tums.ac.ir/medical-physics

11- http://pnpmed.com

12 - https://www.scimagojr.com/countryrank.php?area=3600&category=3614

13- Diana Paez,Tarik Becic, Uday Bhonsle, Amir R.Jalilian, Rodolfo Nuñez-Miller, Joao Alberto Osso Jr.; Current Status of Nuclear Medicine Practice in the Middle East; Seminars in Nuclear Medicine, 46(4); 2016; 265-272

14- https://www.theglobaleconomy.com/Iran/Health_spending_as_percent_of_GDP/

SUBMITTED ARTICLES & CASE STUDIES

13th World Congress of Nuclear Medicine & Biology. 7-11 September 2022 Kyoto, Japan

Dale Bailey, MANZSNM Royal North Shore Hospital, Sydney

The four-yearly meeting of the World Federation of Nuclear Medicine and Biology was recently held in Japan. The previous congress was held in Melbourne in 2018 but that seemed a very distant memory with all that has taken place in the last four years. It was appropriate to hold this congress in Japan as it occurred almost 50 years after the first world congress which was held in Tokyo. Consequently, the theme for the meeting was “Summarize the past half century and discuss the next half century of WFNMB”.

In spite of the travel restrictions still in place, which made the trip to Japan more challenging than usual, over 2000 attendees were present. The official opening of the meeting came with a prerecorded personal message from the Emperor of Japan, Naruhito. This was followed by a lecture from Prof Koichi Tanaka, an electrical engineer who has spent almost his entire professional career working for the Shimadzu Corporation and who, at the relatively young age of 43, was awarded the Nobel Prize in Chemistry for “ for the development of soft desorption ionisation methods for mass spectrometric analyses of biological macromolecules ”. He discussed his work on the early detection of Alzheimer’s Disease using analytical and medical technologies.

The world congress meeting is not just a single event and has for the last few congresses included

The Kinkakuji Zen Buddhist temple in Kyoto built for the shogun prior to his death in 1408 which is covered in gold leaf. It is also known as the Golden Temple. The temple is set in magnificent grounds filled with tall trees and numerous waterfalls (picture by the author).

13th Congress of Nuclear Medicine & Biology (Continued)

a number of other meetings running concurrently or on either side of the main congress. One such meeting was the annual congress of the AsiaOceania Federation of Nuclear Medicine & Biology, the publisher of the journal Asia Oceania Journal of Nuclear Medicine & Biology, of which I am an Assistant Editor. I strongly urge you to consider publishing in this journal as it continues to rise in the journal rankings and does not charge publications fees but is Open Access for all articles. Another parallel meeting at the Kyoto congress was the International Conference on Radiopharmaceutical Therapy (ICRT) which held its meeting known as “WARMTH” (World Association of Radiopharmaceutical & Molecular Therapies) on the day prior to the opening of the World Congress meeting. In this meeting, as well as the main congress, there was much discussion around theranostic approaches in oncology. A number of Japanese speakers conceded that Japan was a number of years behind in the takeup of theranostics. As you might imagine, Australia was well represented in these sessions by ANZSNM members such as Michael Hofman, Sze Ting Lee, Kunthi Pathmaraj and Andrew Scott. Neurosciences also featured prominently throughout the congress as this is an area in which Japanese nuclear medicine has had a long-standing leadership role with novel radiopharmaceuticals, unique imaging instrumentation and new clinical applications. I was fortunate to be involved in a session discussing Total Body PET and was surprised to learn that quite a number of systems are currently being installed, especially in Europe. In SPECT, the continuing emergence of multi-detector stationery CZT imaging systems was of note. These systems are claimed to be able to perform “whole-body” SPECT/CT examinations in a time comparable to a routine PET examination, which will certainly move whole-body imaging applications in SPECT along by introducing new protocols for routine scans.

Some of the highlights for me included a number of presentations using the alpha-emitter 212Pb for therapy which can be extracted from the leftover waste of mining activities and, hence, where Australia is well placed to become a major producer. Andrei Iguara from

Stanford presented some interesting work using a new potential theranostic agent known as [68Ga]RMZ which targets the gastrin releasing peptide receptor (GRPR). He showed his group’s use of this agent in prostate cancer as a complement to PSMA and FDG imaging. A group from Chiba, Japan, (LinqMed) presented their work using 64Cu in pancreatic cancer as both an imaging and therapeutic radionuclide; in Australia we generally consider this only as a PET imaging radionuclide although our group has speculated in the past about the potential role for positrons in therapy.

Visiting Japan for any reason is special to experience a totally different culture. Whether or not you believe we are moving into a post-pandemic world, in Japan it is still very much a dominating factor in the society. While not mandated virtually everyone wears a mask when in public and on public transport. There is very high implementation of clear acrylic screens between diners sitting at the same table when eating, between panellists during discussion in the congress, and even between the news anchors sitting at the same table on the TV news. The news came through of the death of Queen Elizabeth while we were in Kyoto and so that event and location will always be inseparable for me. Kyoto was previously the capital city of Japan prior to Tokyo and is a wonderful place to visit with a large number of publicly-accessible temples, castles and shrines. The food is also a great treat with many new flavours (such as chrysanthemum with seaweed) and always magnificently presented.

The next World Congress of Nuclear Medicine & Biology will be held in Trujillo, Colombia in 2026 and next ICRT meeting of WARMTH will be in Accra, Ghana from May 1-5 in 2023. The 2023 Asia-Oceania Congress will be held in Jordan and the 2024 congress will be held in Bali, Indonesia. For those members who often attend international conferences in Europe and North America these meetings certainly give you some very different options.

1 Hioki T, Gholami YH, McKelvey KJ, Aslani A, Marquis H, Eslick ME, et al. Overlooked potential of positrons in cancer therapy. Sci Rep. 2021;11(1):2475.

CASE STUDY: EQUINE BONE SCAN FOR UNEXPLAINED LAMENESS

Shiphrah Tagore

INTRODUCTION: Over the last three years horses have raced their way into the WA nuclear medicine world and generated many notable findings within the horse industry. Prior to the use of Nuclear Medicine, the horse racing and eventing industry relied heavily on general radiography to diagnosis the various orthopaedic injuries. We, in nuclear medicine, are well aware that general radiography has several limitations and can often miss subtle abnormalities which can have detrimental impacts on the horse’s health.

This equine case involves a four yr old gelding referred to TeleMed Vet services for hind limb pain and lameness.

METHODS: MDP injected through a cannula and horse is scanned 3 hours post injection. Horse is held in a monitored stable with all necessary amenities. Approximately 30 minutes prior to scanning, the vet team administers frusemide to void the horse’s bladder in order to prevent artefact. The horse’s hooves are also bandaged to avoid contamination whilst in the holding stable. The horse is then scanned in our custom-built facility with the assistance of the vet team using a GE single head camera. Static images of the hind of horse were performed, in addition to SPECT imaging of the pelvis. These images are motion corrected and then analysed.

RESULTS: The acquired images demonstrated uptake within the left carpus however, this horse also had an incidental finding of MDP uptake in the left humerus. Injuries concerning the humerus are seldom diagnosed on imaging within equine medicine and this finding could make a critical impact on the rehabilitation process utilised for this horse.

Nuclear medicine technologist - Perth Radiological Clinic, Western Australia

EDUCATION & CPD | Case study

CASE STUDY: FELINE HYPERTHYROIDISM WITH I-131 THERAPY

Shiphrah Tagore Nuclear medicine technologist - Perth Radiological Clinic, Western Australia

INTRODUCTION: In July of this year, cats have pounced their way into the Nuclear Medicine field with WA’s first feline patient being scanned at TeleMed Vet. Hyperthyroidism affects over 10% of senior cats and their disease management can have a significant toll on both the animal and owners. The use of 131-I for treatment of hyperthyroidism has significant success across both human and animal medicine and we were delighted with the outcomes so far in WA. Our first feline patient was a female 12yr old presenting with thyrotoxicosis.

METHODS: The cat is cannulated by the vet team and pertechnetate is administered for thyroid uptake imaging. Imaging is performed at 20 minutes post injection with anterior, lateral and SPECT imaging acquired using a GE single headed camera. Dosimetry values are then calculated using well-renowned, Australian cat therapy

pioneer vet’s research. These calculations are based on morphology and pertechnetate uptake of the thyroid. I-131 is then administered subcutaneously behind the neck. Patient is then admitted to a custom-built therapy room with 24/7 monitoring until background radiation levels return to the required reading.

RESULTS: Large focal area of increased activity involving the right lobe of the thyroid associated with a smaller focal area of increased activity lying dorsally, left of the mid line. Thyroid uptake of pertechnetate was measured at 3.7%. Six-week follow-up biochemistry then indicated successful management of patient’s symptoms and cessation of thyroid medication.

EDUCATION & CPD | Case study

CASE STUDY: LUNG VENTILATION FOR THE DETECTION OF LUNG AIR LEAKS

Cassandra Koudela Nuclear Medicine Technologist - Sir Charles Gardiner Hospital

INTRODUCTION: 79 year old male had a moderately large right pleural effusion found on CT. He presented to Sir Charles Gardiner Hospital (SCGH) 1 month later a chest x-ray taken to assess his condition. The patient had a chest drain inserted and 1200ml of fluid drained. Over the course of several chest x-rays he had right sided pneumothorax with collapse of the right lower lobe and a right hydropneumothorax. The hydropneumothorax continued in increase in size over a series of x-rays, suggestive of an ongoing air leak. The patient underwent a pleuroscopy to locate the source of the air leak, however, this was unsuccessful. A CT chest 3 days post pleuroscopy illustrated the large right pneumothorax, with atelectasis of the partially inflated right upper and middle lobes. However, no direct bronchopleural fistula or leak site was detected.

THE CHALLENGE: The treating respiratory physician approached the nuclear medicine department to see if we could do anything to find the source of the air leak. After many discussions with the nuclear medicine physicians and reading several case studies of ventilation only scans being used to find an air leak, we agreed to investigate the patient’s air leak.

SCANNING: The patient was brought down from the ward, accompanied by the treating respiratory physician who remained for the scan. 516MBq of 99mTc pertechnetate was loaded into a TechnegasPlus machine and delivered via patient administration set. The patient laid supine on the scanning bed of a Symbia Intevo Bold™ SPECT/CT, the suction of the chest drain was clamped off. The patient inhaled Technegas until a 5kcount per second dose was achieved via the PPM. An initial dynamic imaging was performed. The imaging was ceased at 3 min as focal uptake of tracer at the superolateral aspect of the right lung was observed. A SPECT/CT was then acquired which demonstrated the focal accumulation of tracer at the right upper lobe anterior segment anterior aspect with underlying defect. This was suggestive that this was the site of the bronchopleural fistula. The findings were discussed with the treating respiratory physician who noted that this focal defect was distant from the site of the recent biopsy. The patient’s chest drain suction was restarted and a further 5 minute dynamic was acquired this was followed up with a repeat SPECT/CT. The images did not change in appearance despite the suction.

EDUCATION & CPD | Case study

Case Study: Lung ventilation for the detection of lung air leaks

(Continued)

PROTOCOL: Dynamic images

Matrix size : 128 x 128 Zoom: 1.00 Detectors: Both Collimators : LEAP Orientation: Head Out Patient Position: Supine 15 second per view 20 frames

SPECT/CT

Matrix size : 128 x 128 Zoom: 1.00 Detectors: Both Collimators : LEAP Orientation: Head Out Patient Position: Supine Rotation Direction: CW Start Angle: 0º Degree of Rotation: 180º Number of Views: 48 Time per View: 15 sec Orbit: Non-circular Mode: Step and Shoot

TREATMENT: The air leak was treated by the insertion of an endobronchial one-way valve. During expiration this one-way valve allows air and mucus to exit however during inspiration air is prevented from moving past the valve. Endobronchial valves have also been shown to be beneficial in treatment of persistent air leaks in the lungs. The device was inserted via bronchoscopy.

DIAGNOSIS: The patient’s biopsy results confirmed pleural mesothelioma. Pleural effusions are seen in the vast majority of patients at some stage during their disease.

THE PATIENT’S JOURNEY: A new air leak was detected 24 hours after the endobronchial valve was inserted. The patient was treated with pleurodesis, a procedure performed to obliterate the pleural space to prevent recurrent pleural effusion or pneumothorax. Pleurodesis is commonly accomplished by draining the pleural fluid or intrapleural air followed by either a mechanical procedure or instilling a chemical irritant into the pleural space, which causes intense inflammation and fibrosis subsequently leading to adhesions between the two pleural membranes. Pleurodesis is most commonly used

for recurrent malignant pleural effusions, to reduce patient discomfort and hospitalization during palliative care. The patient underwent several clamp tests, but the rocket drain was unable to be removed. A second endobronchial valve was inserted. The patient was diagnosed with staph lugdunensis. Staphylococcus lugdunens most commonly occurs as abscesses. It appears to colonize various skin and more frequently than staphylococcus aureus. The patient was discharged from the hospital and the next x-ray of the patient demonstrated a collapsed right lung with a large volume right-sided hydropneumothorax. The patient died 14 days later.

CONCLUSION: Despite the tragic end to this case study, the role nuclear medicine played in diagnosis of this patient was beneficial. The lung ventilation scan was the only imaging this patient had that found the source of an air leak and it led directly to therapy and resolved the presenting air leak. The technique used on this patient can be applied to others with similar difficulties to locate leaks and can lower the radiation burden of these patients. In the 2 and half month period this patient was in hospital they underwent:

44 Chest x-rays

6 Chest CTs

1 Lung ventilation scan

3 Head CTs

This represents a high radiation burden for any patient.

EDUCATION & CPD | Case study

STOPPING LEAKS: A CASE ANALYSIS OF A TC99M ALBUMIN STUDY

Murray Wachtel Nuclear Medicine Technologist - North Metropolitan Health Service

Introduction: Tc99m labelled albumin studies are nuclear medicine imaging procedures designed to detect protein-losing enteropathy (PLE). PLE is a condition resulting in proteins leaking into the gastrointestinal (GI) tract, which can result in hypoproteinemia. Following the same principles as GI red blood cell studies, albumin is radiolabelled and then imaged to detect activity leaking in the GI tract.

BACKGROUND: The patient is a female in her early 20s with a prior clinical history of systemic lupus erythematosus. She presented to the emergency department, with complaints of shortness of breath, fever, and malaise. Blood tests revealed reduced albumin and lymphocyte levels. Diagnostic imaging revealed a right pleural effusion, mild pericardial effusion, and free fluid surrounding the left iliac fossa. A staph infection was also detected. Further, diagnostic tests ruled out heart, kidney, liver failure, and diet as causes of low albumin levels.

PROCEDURE: Donor human serum albumin was labelled with 1.5GBq of in a gentisic acid, stannous chloride, and phosphate buffer solution. The radiolabelled albumin was incubated for 30 minutes, quality control tests were then performed for radiochemical purity and pH. Anterior Posterior static imaging was done using low energy high resolution collimators at 10 minutes for the abdomen. Following this, a chest static is taken, to ensure there is no uptake in the thyroid activity and therefore minimal unbound in the injection. Further abdominal imaging is performed at 30mins, 1 hr, 2 hr, 4hrs.

IMAGES: On the 4-hr abdominal static, faint activity was seen posterior and slightly medial to the right kidney. A SPECT/CT was performed, localising the albumin leak in the central and right small bowel.

Planar Statics

Case Study: Stopping leaks: A case analysis of a Tc 99m albumin study (Continued)

DIAGNOSIS: This led to a diagnosis of protein-losing enteropathy. The cause of her PLE was believed to be the result of a flare-up of systemic lupus erythematosus (SLE). SLE is an autoimmune condition, resulting in PLE in 3.2 to 7.5% of SLE patients (Chen et al, 2014).

EFFECT ON TREATMENT: To manage her low protein level, the patient was placed on a high protein diet. This was done to increase the synthesis of albumin to counteract her protein loss. The recommended protein intake for someone suffering PLE is 2-3g of protein per kilogram per day (Nagra and Dang, 2022). However, this was insufficient, resulting in her developing a left pleural effusion whilst in the hospital. After diagnosing PLE, prednisolone was used to manage the SLE flare, enabling the GI tract to heal, and stopping the PLE. She was discharged within the month. Follow-up X-rays revealed no pleural or pericardial effusions.

Alternatively, treatment can involve use of immunosuppressive agents like cyclophosphamide used concurrently with corticosteroids like prednisolone

References

for SLE-PLE patients. Combined, these agents show a response rate of 88.9% within 6 months for patients with SLE-PLE (Chen et al, 2014).

ALTERNATE DIAGNOSTIC TEST: The most common test to diagnose PLE is the Alpha 1 antitrypsin (A1AT) faecal test. A1AT is a high molecular weight molecule similar to albumin. It is given to the patient, then measured 24hrs later in the patient's faeces and blood, with clearance mimicking that of albumin. It is cheaper and doesn’t require technical radiochemistry experience. However, the results can be inaccurate in patients with diarrhoea or high stomach pH which can degrade A1AT (Nagra and Dang, 2022).

Additionally, the sensitivity of A1AT faecal clearance tests are lower than tc99m labelled albumin studies at 46% (95% CI 20-74%) and 100% (95% CI 72-100%) sensitivity, respectively (Chau et al, 2011).

CONCLUSION: Tc99m labelled albumin study successfully diagnosed the patient’s PLE, enabling effective treatment of her condition leading to a full recovery.

Chau, TN, Mok, MY, Chan, EYT, Luk, WH, Lai, KB, Li, FTW, Leung, VKS and Wong, R. 2011,’ Evaluation of Performance of Measurement of Faecal 1-Antitrypsin Clearance and Technetium-99m Human Serum Albumin Scintigraphy in Protein-Losing Enteropathy’, Digestion, vol. 84, no.3, pp.199–206

Chen, Z, Li, MT, Xu, D, Yang, H, Li, J, Zhao, JL, Zhang, HH., Han, SM, Xu, T and Zeng, XF 2014,’ Protein-losing enteropathy in systemic lupus erythematosus: 12 years experience from a Chinese academic center’, PloS one, vol. 9, no.12, p.e114684.

EDUCATION & CPD | Case study

THE EFFECTIVENESS OF NUCLEAR MEDICINE LACRIMAL SCINTIGRAPHY AND DACROCYSTOGRAPHY IN THE DETECTION OF EPIPHORA: A CASE STUDY REVIEW

Emily Phipps University of South Australia - Allied Health and Human Performance Unit

Abstract: Epiphora is characterised as the execisive tearing from one or both eyes due to an obstruction or stenosis in the lacrimal pathway (Avdagiv & Phelps 2020). The most common treatment of epiphora is dacryocystorhinostomy (DCR) surgery, however, reobstruction may proceed the surgery (Patella et al. 2018). Obstructions in the lacrimal system can be distinguished via nuclear medicine lacrimal scintigraphy followed by a dacrosystogram (DCG) (Seungheon et al. 2020). An 80-year-old male presented to the department to evaluate for bilateral nasolacrimal stenosis with delayed clearance. Nuclear medicine lacrimal scintigraphy and DCG images were acquired to evaluate for bilateral epiphora.

INTRODUCTION: An 80-year-old male patient presented into the department with ‘watery eyes’ after receiving left DCR surgery for epiphora 12 months ago. The referral requested a nuclear medicine lacrimal scintigraphy study to evaluate for possible bilateral nasolacrimal stenosis with delayed clearance. A DCG to anatomically locate the obstruction proceeded the nuclear medicine examination.

Epiphora refers to excessive tearing from one or both eyes (Avdagic & Phelps 2020). It occurs due to the complete or partial obstruction of the lacrimal pathway, leading to the overproduction of tears (Avdagic & Phelps 2020). The lacrimal pathway is a continuous anatomical structure consisting of the punctum, canaliculus, lacrimal sac and nasolacrimal duct (Bae et al. 2020). Nasolacrimal stenosis is the narrowing or blocking of the nasolacrimal pathway causing delayed clearance thus epiphora (Bae et al. 2020). The traditional treatment for epiphora is DCR surgery (Patella et al. 2018). However, DCR often leads to reobstruction of the anastomotic tract by fibrotic scars and osteogenic activity (Patella et al. 2018). Pre-operative imaging characterization of the occlusion is required to detect the specific cause and location of the obstruction

(Patella et al. 2018; Ramesh 2022). Nuclear medicine lacrimal scintigraphy, also known as dacryoscintigraphy (DSG), is utilized to assess lacrimal drainage, providing a physiological assessment of tear flow (Park et al. 2019). DCG may proceed the DSG scan to help locate the site of obstruction in the lacrimal system (Bickle 2022). Thus, nuclear medicine scintigraphy and DCG are useful in the diagnosis and localization of epiphora, assisting in treatment planning.

NUCLEAR MEDICINE PROCEDURE PROTOCOL

The departmental nuclear medicine lacrimal scintigraphy protocol was utilized. To begin, the procedure was explained to the patient and the clinical history was obtained. It was established that the patient did not have itchy eyes and that both eyes were over producing tears. Verbal and written consent were then attained.

185 mega Becquerels (MBq) of Tc-99m pertechnetate in 0.5mL was dispensed into a micropipette. The patient was positioned supine on the bed with their head propped up using three pillows. The patient was directed not to blink. 2-3 drops of the radiolabeled solution were placed into the lateral canthus of each eye using the micropipette, ensuring the pipette did not touch or make contact with the corneal surface of the eyelashes. Any spillage was dabbed with a tissue and discarded. The patient was encouraged to blink normally.

Image acquisition commenced immediately after radiopharmaceutical administration with the patient remaining in their supine, propped position. A 20-minute anterior dynamic image was acquired, 60 seconds per frame. 20% window was centered over 140keV photopeak with a 128 X 128 matrix using a low energy collimator on a Simens SYMBIA dual-headed hybrid imaging system. Any tears formed during acquisition were gently whipped after the dynamic image. The patient was then instructed to

EDUCATION & CPD | Case study

Case Study: The effectiveness of nuclear medicine lacrimal scintigraphy and dacrocystography in the detection of ephiphora (Continued)

blow their nose. A 3-minute static ‘post nose blow’ image was then acquired on a 256 X 256 matrix. The resultant images were then processed and reported by the doctor

FINDINGS

As seen in figure 1, the patients right eye showed tracer passage to the lacrimal sac but no further distal propagation. These findings support proximal functional impediment to drainage. The left eye shows tracer extension to the lacrimal sac but no further propagation as well. Likewise, Features support functional impediment to nasolacrimal drainage proximally. The nose blow image did not show any further tracer propagation. Therefore, from the nuclear medicine lacrimal scintigraphy study, the patient was diagnosed with bilateral proximal nasolacrimal impediment with delayed clearance.

A contrast questionnaire was completed to ensure the patient would have no allergic reactions. The patient was positioned supine on the x-ray table with a cushion under their head and arms by their side. The radiologist placed a small cannula into the opening of the tear canal in the medial portion of the lower eye lids. The patient was instructed to close their eyes. Tape was placed on the cannula and the patient was instructed not to move so the cannula would remain in place. Non-ionic iodinated contrast was injected into the tear canals via the catheter. X-ray images were acquired immediately, allowing the visualization of tears flowing from the eyes to the nose.

FINDINGS

As seen in figure 2, the right eye was cannulated in the inferior punctum. The acquired image showed antegrade passage to the lacrimal sac and proximal nasolacrimal duct. Retrograde passage of contrast via the superior canaliculus spilled onto the conjunctiva. A small volume of antegrade passage via the nasolacrimal duct to the nasal cavity was visualized. It was reported that the features were presumed a manifestation of back pressure relating to subtotal nasolacrimal duct stenosis. As seen in figure 3, left eye was cannulated in the inferior punctum. Free antegrade passage was seen via the lacrimal sac the left eye showed clearance from the nasolacrimal duct to the nasal cavity. A small volume of retrograde passage was seen via the superior canaliculus to the conjunctiva.

DCG PROCEDURE PROTOCOL

DCG was specifically used to locate the obstruction in the nasolacrimal duct (Bickle 2022). To begin, the procedure was explained to the patient and consent was obtained.

Figure 2: The resultant DCG image of the right eye showing right eye stenosis with delayed clearance.

Figure 3: The resultant DCG image of the left eye showing partial left eye stenosis with delayed clearance.

Figure 1: The resultant sequential dynamic and static images acquired for the lacrimal scintigraphy study, showing bilateral obstruction.

EDUCATION & CPD | Case study

The DCG following the DSG study proved clinically relevant for the patient’s treatment management. The DSG images proved there was bilateral obstruction and nasolacrimal stenosis, however, the location was unclear. The DCG study was able to conclude there was right eye nasolacrimal stenosis however, the pressure of the contrast revealed the left eye had partial nasolacrimal stenosis and delayed clearance. Thus, it is apparent that the DCG images following the DSG improved the clinical journey of the patient, aiding treatment management, therefore validating radiation exposure.

DISCUSSION

Epiphora is caused by obstruction or stenosis in the lacrimal pathway (Detorakis et al. 2014). Treatment of epiphora due to nasolacrimal obstruction is usually performed by DCR surgery (Seungheon et al. 2020). To prepare for DCR surgery, the anatomical and functional success must be defined (Aksoy et al. 2018). The anatomical success refers to a patent ostium from lacrimal duct to nasal cavity and the functional success refers to the draining of the tear into the nasal cavity without any obvious complaint (Aksoy et al. 2018). Anatomical success can be defined via scintigraphy imaging in preparation for DCR surgery (Aksoy et al. 2018). In some cases, persistent epiphora is reported despite an anatomically patent drainage route post DCR (Seungheon et al. 2020). In such cases, imaging of the lacrimal outflow by various modalities including DSG and DCR may be required for an accurate decision making concerning the causes of epiphora, for the potential

associated pathophysiological mechanisms, as well as for the selection of an appropriate surgical treatment (Seungheon et al. 2020). Thus, imaging is needed for workup management prior to DCR surgery.

Patients are referred for a DCG to delineate the site of stenosis or obstruction (Singh et al. 2019). However, the forced injection may overcome partial obstruction or stenosis, therefore, should be performed following a nuclear medicine lacrimal scintigraphy study (Detorakis et al. 2014).

Nuclear medicine lacrimal scintigraphy has been extensively used to assess lacrimal drainage, facilitating the definite diagnosis of obstructions and stenosis of the lacrimal system (Ines et al. 2021). The study is not performed under manual injection pressure such as DCG, therefore the images reflect physiological drainage conditions (Detorakis et al. 2014).

Treatment management for patients with epiphora is therefore influenced by nuclear medicine lacrimal scintigraphy and DCG imaging (Ines et al. 2021; Seungheon et al. 2020). The anatomical success, stenosis or obstruction and the location of the stenosis or obstruction can be established via DSG and DSC (Aksoy et al. 2018). Following the lacrimal patency establishment, DCR surgery is planned by means of the acquired images (Aksoy et al. 2018). Thus, both imaging modalities are vital in patient management.

Current literature explores both DSG and DCG individually, however, there

are limited case studies investigating their clinical relevance when performed simultaneously. DSG has been found to be a highly sensitive, non-invasive modality used to evaluate functional nasolacrimal obstruction (Ali et al. 2022). However, in the case of abnormality, confirmatory procedures such as DCG are required for anatomical localization (Ali et al. 2022). It is known that DCG studies should follow DSG to evaluate the physiological drainage conditions of the lacrimal system (Detorakis et al. 2014). Therefore, patients with epiphora will benefit from both DSG and DCG imaging modalities.

The patient’s disease management pathway coincided with the current literature as the DSG images shows the physiological obstructions and the DCG images helped locate the obstructions. Although optimal in evaluating obstructions in the lacrimal pathway, nuclear medicine scintigraphy is limited in anatomical location information. Nuclear medicine assisted in patient treatment planning as it was able to provide a physiological diagnosis of bilateral obstruction with delayed clearance. As the patient previously had DCR surgery to their left eye the DSG images demonstrated persistent epiphora on the left eye and more recent stenosis in the right eye. Nuclear medicine lacrimal scintigraphy preceding DCG imaging is therefore widely used as a monitoring tool pre and post treatment for patients with epiphora.

CONCLUSION

It is evident through literature that nuclear medicine lacrimal

Case Study: The effectiveness of nuclear medicine lacrimal scintigraphy and dacrocystography in the detection of ephiphora (Continued)

Case Study:

scintigraphy is used to evaluate the physiological drainage of the lacrimal system. Several of the patient’s clinical indications coincided with epiphora. DSG imaging in conjunction with DCG imaging allowed a definite diagnosis for the patient which in turn contributed to improving the patient’s quality of life via treatment planning. The two modalities together allowed the physiological and anatomical assessment of the patient’s lacrimal system, therefore validating DSG and DCG imaging for patients with epiphora.

References

Aksoy, IJ, Yildirim, Y, Topal, T, Cesmeci, E & Cakir, Y 2018, ‘Functional success evaluation of lacrimal drainage system by dacroscintigraphy after transcanalicular diode laser dacryocystorhinostomy’, Indian Journal of Ophthalmology, vol. 66, no. 8, pp. 1161-1164.

Ali, MS, Mohammadreza, C, Mohsen, BK, Babak, F, Alireza, EA & Reyhaneh, M 2022, ‘Diagnostic value of lacrimal scintigraphy in the evaluation of lacrimal drainage system obstruction: a systematic review and meta-analysis’, Nuclear Medicine Communications, vol. 43, no. 8, pp. 850-868.

Avdagic, E & Phelps, PO 2020, ‘Nasolacrimal duct obstruction as an important cause of epiphora’, Disease-a-Month, vol. 66, no. 10, pp. 1-7.

Bae, SH, Park, J & Lee, JK 2020, ‘Comparison of digital subtraction dacrocystography and dacryoendoscopy in patients with

epiphora’, Eye, vol. 35, no. 1, pp. 877-882.

Ramesh, S 2022, ‘Treatment of Epiphora’, Foundational Papers in Oculoplastics, Springer, Cham, pp. 315-328.

Bickle, I 2022, ‘Dacrocystography’, Radiopaedia, viewed 7 October 2022, <https://radiopaedia.org/articles/dacryocystography>.

Detorakis, ET, Zissimopoulos, A, Loannakis, K & Kozobolis, VP 2014, ‘Lacrimal Outflow Mechanisms and the Role of Scintigraphy’, World Journal of Nuclear Medicine, vol. 13, no. 1, pp. 16-21.

Ines, C, Luisa, P, Maryam, J, Mohamed, S, Jackie, MJ & Dizdarevic, S 2021, ‘Lacrimal scintigraphy MNMS Guidelines’, British Nuclear Medicine Society Professional Standards Committee’, vol. 42, no. 4, pp. 459-467.

2019, ‘Development of Predictive Models in Patients with Epiphora Using Lacrimal Scintigraphy and Machine Learning’, Nuclear Medicine and Molecular Imaging, vol. 53

Patella, F, Panella, S, Zannoni, S, Jannone, ML, Pesapane, F, Angileri, SA, Sbaraini, S, Leradi, AM, Soldi, S, Franceschelli, G & Carrafiello, G 2018, ‘The role of interventional radiology in the treatment of epiphora’, Gland Surgery, vol. 7, no. 2, pp. 103-110.

Seungheon, K, Sungwon, Y, Jinhwan, P, Hwa, L & Sehyun, B 2020, ‘Correlation Between Lacrimal Syringing Test and Dacryoscintigraphy in Patients with Epiphora’, The Journal of Craniofacial Surgery, vol. 31, no. 5, pp. 442-445.

Singh, S, Ali, MJ & Paulsen, F 2019, ‘Dacryocystography: From theory to current practice’, Annals of Anatomy, Institute of Clinical and Functional Anatomy, Germany, pp. 33-40.

The effectiveness of nuclear medicine lacrimal scintigraphy and dacrocystography in the detection of ephiphora (Continued)

NUCLEAR MEDICINE STUDENTS

RMIT MEDICAL RADIATIONS NUCLEAR MEDICINE SUBMISSION

As part of the Spring/ Summer Gamma Gazette we thought it might interest our fellow ANZSNM members to learn about some of the things being taught to our Nuclear Medicine undergraduates, in the Medical Radiations Program at RMIT University.

Over the past couple of years, we have sought to transform our laboratory sessions into more informative and specialised opportunities for teaching, whilst utilising our knowledge in chemistry, biochemistry, physics, and clinical applications of nuclear medicine to better engage our students. Our aim is to provide an environment where our students can build on their current learning and know more about the ‘why’ things are occurring. This then helps our students to better understand difficult concepts, and engage with us in a less-formal setting.

Particularly, after 2020 and the lockdowns we experienced in Melbourne due to the pandemic, we wanted to better engage with our students and get them active in their learning, whilst helping them to ease back into Uni life with their peers. We had used tools like ‘Kahoot’ an app we introduced during online teaching, which is a gameshow where students join and compete to answer questions (see Image 1). We now use this as a regular feature in our labs as a pre-learning check, as questions are written by us and it helps us to identify gaps in knowledge, which we can revisit during the lab session.

Image 2: Clare demonstrating the retention of the blue dye on the Sep-Pak and the elution of the red dye using the more polar mobile phase.

As our labs cover many topics including: radiation safety, radiopharmaceutical preparation, different radiation detection systems, and QC techniques, we thought it be of interest to highlight some sessions we run.

The iTLC & Sep-Pak laboratory: This lab is run in for our first-year students and solidifies their learnings about how we can separate different chemicals from a mixture and why this is important in the QC of radiopharmaceuticals. To help our students understand the separation of a radiopharmaceutical and its impurities we begin by separating a dye mixture (using both iTLC and Sep-Paks) into its

individual colours, which highlights the importance and role of the solid and mobile-phases (see Image 2 above).

Next we then apply this by performing the QC of more common NM radiopharmaceuticals (such as 99mTc-HDP and 99mTc-MAG3), and look at ‘where’ and ‘why’ the product and impurities are separating, and how we can use this to determine our radiopharmaceuticals purity.

The 14C- Urea laboratory: This lab is part of our second-year sessions and is great for consolidating learning around non-imaging nuclear medicine procedures, and patient focus. Thanks to the pharmaceutical company Tri-Med, who kindly donated kits for our students (C14-Urea PYTest), all our students can experience the process of instructing a ‘patient’ to complete the test or being the ‘patient’ undergoing this procedure (substituting the 14C-Urea tablet with a tic-tac®).

Image 1: Students competing in a pre-lab Kahoot session- the winners (Parsa, Emily and Ivana) and their great choice of names are shown

Teaching Nuclear Medicine to our Undergraduates in the Laboratory- our aim, how we engage, and what is working!

RMIT Medical Radiations Nuclear Medicine Submission (Continued)

Students receive a referal and a ‘patient’ and must apply their knowledge to determine the suitability for the test to proceed and any potential issues, as well as what is important to ensure a meaningful test outcome. During this lab our students learn the ‘why’ about the chemistry and physiological processes occurring from ingestion of the 14C-Urea tablet- the sample collection- and the reading of the sample (see Image 3).

The Monte Carlo laboratory:

This session is also run for our second-year students, and here we utilise Monte Carlo simulation software to further our student’s knowledge of radiation dose, safety, radiosensitivity and tissue weighting factors by examining different clinical scenarios. We look at a scenario and then alter parameters such as: time, dose, radioisotope (99mTc, 18F etc), the source location and area of the body exposed.

These scenarios generate a simulation, which our students can view, and highlights to them the changes and their effect on a person and various organs of the body. This software also provides our students with a hands-on experience in using the software, and an appreciation of its role within Nuclear Medicine. Our goal is to reinforce their current understanding of radiation safety, and extend this further into how they think and behaviour towards radiation safety for their patients, colleagues, and themselves. In keeping with the theme of ‘Monte Carlo’ and the casino that the technique was named after our students receive a ‘chip’ to play during the lab session, and after each clinical scenario is presented must decide if they are for (red) or against (black) the question raised by placing their chip. The last remaining student with a chip is the winner, and this easily our loudest lab sessions to-date, see Image 4 for the non-winners but still grinners showing the NM chips.

Finally, we are always looking to enhance our laboratory sessions and provide relevant experiences for our students. We are very grateful to the companies and hospitals who have kindly shown their facilities to our students (GMS AustraliaTullamarine Radiopharmacy, The Royal Melbourne Hospital and Cyclotek, as well as to all who have donated kits and equipment in recent years, notably The Royal Melbourne Hospital, the Austin Hospital and Tri-Med (pharmaceuticals), which has helped us to develop new and engaging lab sessions. We hope this article has been informative and highlighted some of what we do with our students during their time with us as Nuclear Medicine undergraduates, and if you wish to know more or discuss further, please reach out to the NM team.

Image 3 a & b: Students using the C14-Urea PYTest in lab sessions (Rae and Nicky complete a test, whilst Connor has a tic-tac®).

Image 4: Academic staff Karim and Alicia are all smiles as they show the ‘Monte Carlo’ chips used in our radiation safety lab, which helps to highlight the role of Monte Carlo simulation in NM.

Raju's Nuclear Medicine C O L O U R I N G B O O K

Second-year nuclear medicine students at the University of South Australia, Ruby Holman and Rebecca Mangelsen have been working on a special project, which they are both excited and proud to present! A project to make a kid's experience with scans a bit more fun and colourful!

Could you tell us about ‘Raju’s Colouring-in Book’?

Raju’s colouring-in book was designed to provide children, aged 4-10, with an educational distraction whilst visiting the nuclear medicine department. Through games and interactive questions, our book provides a tour of a typical nuclear medicine department and describes a general nuclear medicine procedure. Our goal is to provide children with information about their visit to alleviate patient anxiety, ultimately improving their clinical experience. The book introduces children to terms such as “gamma camera” and “technologist” in a fun and engaging way.

What led to the creation of the booklet?

We both have a passion for paediatric care combined with a love for children and nuclear medicine! Ruby has had extensive experience in paediatrics from a patient point of view and, at an early age, previously completed a similar project: a colouring-in book for asthmatic children. Ruby's previous experience and our clinical knowledge allowed us to notice a gap in the information available

for paediatric patients undergoing nuclear medicine procedures. Hence, we developed Raju’s Colouring-in Book to fill the education gap. Our book aims to provide children with information about their procedure in a fun, engaging, and age-appropriate way to positively influence their hospital journey.

What went into the process?

In May 2022, we started with a conceptual design for a colouring-in book with interactive elements to capture the interest of children. Over the course of 3 months, we began writing the storyline and designed our main character, Raju, with a strong focus on gender and cultural inclusivity. Soon after, we reached out to our university lecturer, Vicky Sigalas, who connected us with the chief technologist at the Women’s and Children’s Hospital in Adelaide. We undertook a department tour which provided us with important insights into the workflow of a paediatric department. We sought inspiration for our illustrations from the bright colours and wall décor in the department to ensure that children would relate to what they see and read on the pages of our book to the environment around them.

We applied for many grants across Australia, however, we were unsuccessful. In September we approached Karen Jones, another of our university lecturers, who also happens to be the Vice-President of the ANZSNM and

A project made by Ruby Holman and Rebecca Mangelsen

Ruby Holman (left) and Rebecca Mangelsen (right)

Raju's Nuclear Medicine Colouring Book (Continued)

Chair of the Technologist Special Interest Group (TSIG). We were welcomed with immense support for our project and have since been collaborating with the ANZSNM to refine our design and work with their graphic designer, Ester, to turn our ideas into reality. We are now in the final stages of printing and are really excited about what is to come!

When will it be available and where will it be distributed?

The book will be donated to nuclear medicine departments throughout Australia and New Zealand by late November. The departments included in the initial distribution of books include the Women’s and Children’s Hospital in South Australia, Royal Children's Hospital in Melbourne, Perth’s Children’s Hospital, Prince of Wales Hospital in NSW, Queensland Children’s Hospital, The Children’s Hospital at Westmead in NSW, Royal Darwin Hospital, Royal Hobart Hospital, Christchurch Hospital, Wellington Hospital, and Auckland City Hospital.

How can people request copies?

We have included a wide range of departments in our initial distribution, and we hope to present the findings of a survey about our book at the ANZSNM 2023 Annual Scientific Meeting in Adelaide. At the conference, we will have spare copies of the book for interested individuals to look over and take back to their respective departments.

After the conference, other interested departments can contact the ANZSNM to request a free pdf copy of the book and we will explore the notion of secondary distribution. Based on our anticipated success we would love to explore the idea of creating an online interactive version/app and expanding our series to include more specific scans.

What has been the most rewarding experience whilst creating the book?

So far, the most rewarding experience whilst creating our book was transforming our design vision into feasible goals to allow us to progress to the printing stage. Our individual growth within the nuclear medicine profession has been outstanding as we have both developed our professional skillset in communication, organisation, time management and project planning.

However, we both agree that the most rewarding experience is yet to come! We are beyond excited for our books to be received within their respective departments and the opportunity to hand deliver our books to the Women’s

NUCLEAR MEDICINE STUDENTS

Raju's Nuclear Medicine Colouring Book (Continued)

and Children’s Hospital in Adelaide and the Queensland Children’s Hospital while on placement in Brisbane! We are ecstatic to see our vision come to life and hopeful to receive reaffirming feedback on its positive influence on patient care!

How has the ANZSNM and being a student member helped you with your initiative? Did you have any mentors within the Society?

Being a student helped us look at the project from both a clinical and an educational perspective. The ANZSNM was extremely helpful through the entire process; they have a strong focus on student initiatives and, hence, were very eager to support us in our endeavours.

Our mentors within the Society include Karen Jones, the Vice-President of the ANZSNM and Chair of the TSIG, Vicky Sigalas, the State Federal Representative of the South Australia and Northern Territory Branch, and our lecturer Kathy Guerrero, who is also the Secretary of the South Australia and Northern Territory Branch. The unique, yet complementary, expertise of our mentors provided a well-rounded outcome to our book, which incorporates the multidisciplinary team of nuclear medicine, education, and paediatric deliverance.

What would you say to other students keen to develop similar initiatives?

Go for it! The nuclear medicine community is such an encouraging and supportive team of multidisciplinary individuals. Every technologist, nurse, physician, radiochemist, physicist, and student have their unique perspective to contribute. Developing a student project initiative is not only a great way to positively make a difference in the health care experience of patients but also to develop your professional skill-set by collaborating with other dynamic, like-minded individuals. The networking opportunities are invaluable, and you can develop your skills in communication, project management, time management, and organisation which are highly transferable into the nuclear medicine industry!

lecture and clinical experience enjoyable. However, as I progress in my clinical placements, seeing the diversity and breadth of nuclear medicine is what excites me the most about my future. I am not only referring to the diversity of procedures, but also that no two days, and no two patients are the same. I enjoy that nuclear medicine is a continual brain game, both academically and interpersonally.

Rebecca: The field of nuclear medicine is continually evolving, which excites me the most! There are so many amazing innovations and prospective applications in treatment strategies and technology which all aim to improve patient care. I enjoy the scope and breadth that nuclear medicine has to offer which accommodates my passions for both science and patient care. I am beyond excited to start my career in nuclear medicine and be at the forefront of innovation to deliver a high standard of patient care!

What would you say to those wondering if Nuclear Medicine is for them?

The greatest thing about nuclear medicine is the diversity. Everyone within the industry has their own reason for joining, unique to their interests. The field has a great balance of science and healthcare, hence, the nuclear medicine community consists of a diverse team of professionals. Being a part of the nuclear medicine community means that you are part of a multidisciplinary team comprising physicians, nurses, physicists, radiochemists and technologists. Hence, there are positions suitable for everyone.

What do you enjoy the most/excites you about the field of Nuclear Medicine?

Ruby: My love for physics was the primary reason I decided to study nuclear medicine. Physics, coupled with my enthusiasm for patient care, continues to make every

Karen Jones with Ruby and Rebecca.

Dr Emlyn Owen Parry Jones

MBBS, FRACP, FAANMS

7th January 1946- 18th August 2022

The ANZSNM is saddened to learn of the recent passing of Dr Emlyn Jones, a dedicated Nuclear Medicine physician and longstanding member/fellow of the ANZAPNM/AANMS. We extend our sympathies to Emlyn's family and friends and his colleagues at Queensland X-Ray.

On Thursday, August 18, Dr Emlyn Owen Parry Jones, passed away after a short battle with illness. Beloved husband of Deborah, loved father and father-in-law of Bryn and Clare, Stephen and Elizabeth, Rebekah and Glen, Samuel and Kelli, Huw and Cindy, Louise and Alec and loving grandfather to Millie, Oliver, Henry, William, Noah, Arlo, Nicholas, Sophie and Oscar. He was seventy-six.

Dr Jones trained in nephrology at the Princess Alexandra Hospital, University of Newcastle (UK) and University of Western Ontario (Canada). He was the director of the Renal Unit, Toowoomba Base Hospital between 1978-2001.

He commenced his training in Nuclear Medicine in 1974 at the Royal Brisbane Hospital and then Royal Prince Alfred and Sir Charles Gairdner Hospitals. He initiated a private Nuclear Medicine practice at St Andrew’s Hospital in Toowoomba in 1984.

In 1997, he joined Queensland X-Ray where he remained head of the nuclear medicine departments at St Andrew’s and St Vincent’s Hospitals until the onset of his illness in 2021.

Emlyn was a regular fixture at conferences, regularly attending the annual event and giving the Pioneer Lecture at the Brisbane ANZSNM in 2015. He was a strong advocate for rural and regional nuclear medicine, and oversaw the growth of nuclear medicine in the Darling Downs. He grew the facility from a single camera department to multi-department, multi-camera, multi-modality with the introduction of PET/CT in 2015.

He was much loved and considered family by those he worked alongside, with over 30 technologists passing through his departments and learning the art of Nuclear Medicine under his caring and generous tutelage.

Emlyn had many interests outside of medicine, including a passion for music, nature and travel, and considered the beautiful Bunya Mountains a home away from home. Above all else, however, he loved spending time with his family. Emlyn’s life was celebrated at a remembrance ceremony in Toowoomba last week attended by family, friends and many past and current members of the Toowoomba Medical and Nuclear Medicine community.

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Upcoming Annual Scientific Meetings CONFERENCE CONVENING COMMITTEE

The locations for the next few years’ Annual Scientific Meetings are shown in the following table. We have also contracted the All Occasions Group as the Professional Conference Organiser (PCO), based in Adelaide, to run the meeting for the next few years.

Location Dates Confirmed(C) / Proposed(P) Status

May 26-28 (C)

Year 2024 2026 2027

Christchurch, NZ

2023 Adelaide Convention Centre Gold Coast or Sydney

Apr 26-28 (C) Te Pae Christchurch Convention Centre 2025

Adelaide Convention Centre. Pre-congress symposium at Adelaide Zoo. May 9-11 (P) Proposal to co-ordinate with International Society of Radiopharmaceutical Scientists Congress 2025 (May 4-8, Gold Coast)

To Be Confirmed

To Be Confirmed

The CCC is also reviewing the current conduct of the various awards at the ASM and welcomes comments and feedback on this. If you think that your local branch would be interested in hosting a meeting in the years to come please let any one of the committee know.

Conference Convening Committee members 2022-23

Prof Dale Bailey (Sydney) – Chair

Dr Berry Allen (Waikato, NZ)

Ms Pru Burns (& Next+1 LOC Rep) (Wellington, NZ)

Prof Andrew Scott (Melbourne) Clin Prof Paul Roach (Sydney) Prof Rathan Subramanian (Otago, NZ)

Ms Shikha Sharma (Sydney) Next LOC Rep - Dr Daniel Badger (Adelaide)

Prof Dale Bailey PhD Chair - Conference Convening Committee

SA/NT Branch Annual Dinner, AGM & Quiz Night

The Lion Hotel, North Adelaide 5:30pm-6:00pm

For more details and registrations visit

DEC 13

International Conference on Integrated Medical Imaging in Cardiovascular Diseases (IMIC-2022) IAEA Headquarters, Vienna, Austria 13-16 December

Attendo Plus mobile App anzsnm.org.au

“Being a member of the ANZSNM provides me with a valuable opportunity to share ideas and stay informed of changing practices within Nuclear Medicine.

The member events have allowed me to expand my professional network as well as being a chance to stay connected to friends within the profession. ANZSNM membership has been instrumental in keeping me connected, motivated and excited about my profession and future opportunities in Nuclear Medicine.”

Katherine Guerrero

www.anzsnm.org.au

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ANZSNM member

PRESIDENT

Dr Kevin London (NSW)

Vice President

Prof Karen Jones (SA)

Immediate Past President

Dr Daniel Badger (SA)

Treasurer

Ms Suzanne McGavin (VIC)

COMMITTEE

Ms Maddison Carroll (QLD)

Ms Prudence Burns (NZ)

Mr Christian Testa (VIC/TAS)

Mrs Victoria Sigalas (SA)

Ms Rosemary Dallen (WA)

Prof Karen Jones (TSIG)

A/Prof Giancarlo Pascali (RPS)

Dr Samuel McArthur (AANMS)

Prof Andrew Scott (IRC)

SPECIAL INTEREST GROUPS/COMMITTEES

Technologists

Chair: Prof Karen Jones Radiopharmaceutical Science

Chair: Dr Nigel Lengkeek Physics

Chair: Mr George McGill Quality and Technical Standards Committee

Chair: Dr Darin O’Keeffe Scientific Advisory Panel

Chair: Prof Dale Bailey International Relations Committee

Chair: Prof Andrew Scott

BRANCH SECRETARIES

New South Wales/Australian Capital Territory

Dr Kevin London (Chair) Queensland

Ms Anisa Kumari and Ms Rebecca Wyborn

South Australia/Northern Territory

Ms Katherine Guerrero

Victoria/Tasmania

Ms My Linh Diep

Western Australia

Ms Georgina Santich New Zealand

Ms Trish Mead

Archivist

Ms Debra Huddleston

GENERAL MANAGER & SECRETARIAT

All Correspondence

Mr Rajeev Chandra, General Manager

ANZSNM Secretariat, PO Box 6178, Vermont South, Victoria 3133

Tel: 1300 330 402 | Fax: (03) 8677 2970

Email: secretariat@anzsnm.org.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 individ uals 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 activi ties 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.