Gamma Gazette Summer 2019 by ANZSNM

2019 SUMMER EDITION | ISSUE 25

CONTENTS Introduction

From the President

The 2018 ANSTO Molybdenum Crisis Special Report

Branch Updates

Special Interest Group News

ANZSNM Historical Archive

Education and Continuing Professional Development (CPD)

• Urine Matters - 3 Case Studies • What’s that?

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

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

Calendar of Events

Office Bearers

DISCLAIMER: The views expressed in articles and content within this Gazette are purely those of the authors and do not represent the views of the Society.

Introduction An Inevitable Crisis? “The time to repair the roof is when the sun is shining” – President John F Kennedy, State of the Union Address, Jan 11 1962

In the past five months we have experienced enormous difficulties arising from, initially, a breakdown on the production line in Building 23, the molybdenum generator facility, at ANSTO’s Lucas Hts facility. In this issue of the Gamma Gazette, we have focussed on this event and the impact that it has had on nuclear medicine practices in Australia. We have sought opinion from different groups at different levels as we have tried to accommodate the uncertainties in supply of molybdenum generators for technetium radiopharmaceutical production. Some of the commentary in the issue is raw. Some of our members have been hit hard by this crisis, and wanted to let us know. Other groups, particularly in metropolitan Australia, have been largely unaffected. The views expressed here, while not reflecting the views of the ANZSNM directly, certainly capture the views of individual members who wanted to share their experiences. Throughout this crisis, mistakes have been made. Communications have been deficient. We were unprepared for this crisis, in spite of having a plan in place that was last enacted in a similar global molybdenum shortage of 2009 – the roof should have been repaired earlier! Only over time will we come to understand what and why we have had this prolonged period of uncertainty in supply. We are fortunate to have a modern, reliable reactor for molybdenum production, unlike most of the rest of the world. A crisis like this, however, reminds us of how vulnerable we are being so isolated from the larger production centres of Europe and North America (although the US is less of a player than it ought to be). It emphasises why we need robust processes for local production. Vagaries of flight schedules, weather patterns & climate change, pilots’ whims to unload certain cargo, and general logistics has meant that we have been through a period of uncertain molybdenum supply common to many other parts of the world. For the most part, the Lucky Country has been mostly lucky with its supplies of technetium. But in June our luck ran out. This issue will, hopefully, stand as an historical snapshot of what has happened in this crisis, and in which we still find ourselves. It serves as a message to the community, industry, and government about the absolutely essential need for local domestic production capabilities. Dale Bailey PhD NSW Branch Representative, ANZSNM 2019 Summer Edition | gamma GAZETTE | 3

Over the past 50 years, The Australian and New Zealand Society of Nuclear Medicine has been at the forefront of the Nuclear Medicine profession. To every single member and individual who have been part of this journey, thank you! We are committed to continuing to be leaders in our industry and to work together to keep the society moving to the future.

From the President This edition of Gamma Gazette is focussed on the Tc-99m generator supply issues that Australian Nuclear Medicine practices have faced over the last five months. The contributions that have been written represent different aspects of how the crisis has impacted the Nuclear Medicine community, and they also provide insight into the background and events that have shaped the issues we are facing. World-wide it is recognised that Molybdenum/Tc-99m supply is fragile, however in Australia, we have been previously relatively protected and we felt ‘safe’ from supply issues. In June 2018 when we first received notification of the conveyer belt issues at ANSTO I don’t think any of us expected we would be in November 2018 and still battling supply issues.

Roslyn Francis President

A common theme of the articles in this issue of the Gamma Gazette is that of a 'willingness to help’, which is central to our Nuclear Medicine Community. We are a relatively small speciality, but one that embraces cooperation and an attitude of putting the needs of patients first. The Working Group that met weekly since the crisis began have all worked tirelessly to provide advice to ensure equitable supply, and also to provide us with information and updates that help us plan for what is ahead. As a Nuclear Medicine community we thank each member of the working group for their incredible efforts, and we really appreciate the cooperation of AANMS, ANZSNM and RAINS all working together so effectively with ANSTO and GMS during this time. We recognise also all of the contributions of our Departments and Practices to ensuring ongoing high quality care to patients despite the challenges of the last five months. As you read the contributions in this issue of Gamma Gazette, it is important to note that these articles represent the opinions of those who have written them. You may agree or disagree with these views. As a Society, it is important that we understand how the Tc-99m/Molybdenum crisis has impacted on you and your practice so please do keep us informed. All current ANZSNM members should have received membership renewal notification by email. Please do take advantage of the discounted early membership rates. We will be sending out a survey in the next few months to ascertain feedback on priority areas for the Society. We remain focussed on CPD, and in line with this, Sharon Tripodi has been recently appointed to the role of CPD Project Officer. 2019 Summer Edition | gamma GAZETTE | 5

From the President (Continued) Sharon will assist in identifying suitable CPD content and making this available through the ANZSNM website. As we approach our 50 year anniversary of the founding of ANZSNM, we look forward to celebrating the success of our speciality and the contributions that so many have made to Nuclear Medicine in Australia. In 2019, we look forward to acknowledging our history and also planning for the exciting opportunities in Nuclear Medicine for the next 50 years ahead. As I conclude my report, I would like to take this opportunity to remind everyone that abstract submissions and registrations are now open for the 2019 ANZSNM ASM in Adelaide. Please visit the conference website for further http://www.anzsnmconference. information. com/ANZSNM2019/

Special Report

Author: Dale L Bailey PhD

A chain on a conveyor belt jumps off its sprocket in the production line of ANSTO’s GenTech generators. Due to high levels of radiation in the facility the repair cannot be effected for a number of days until the levels reduce to those which are safe for the engineering team to enter the plant and repair it. ANSTO released a statement on Monday June 25 indicating “at this stage, ANSTO is advising there will be a minimum 10-day outage” and that they were working with international partners to minimise the impact on domestic supply for patients. Fast forward to the present, over four months later, and we are still experiencing the impact on daily activity in our hospitals and practices of this point failure on the production line. How did it get this bad? In this article I will try to pick this apart and see how this situation has evolved. BACKGROUND ANSTO was apparently performing well in recent years. In 2007 it replaced the ageing HIFAR reactor, which first achieved criticality in 1959, with a modern, low-enriched uranium (LEU) fuelled 20 MW research reactor from INVAP (Argentina) – OPAL (OPen Australian Light-water reactor). As other reactors around the world involved in molybdenum production were fast approaching their end of life (~50 yrs) we had a state-of-the-art device that was Australia’s single-largest investment in science in our history at the time (~$430m). OPAL has generally been a success story apart from initial teething problems related to leakage of primary cooling water into a secondary cooling system. But the uptime it has achieved & reliability are best-in-class. Around the same time, the US Congress passed a bill into law (but deferred

Fig. 1. The sprawling ANSTO facility on the southern tip of Sydney at Lucas Hts seen from the air. It is surrounded by a 1.6 km building exclusion zone, most of which is bushland. The reactors OPAL and HIFAR can be seen on the extreme left of the picture at the southern end of the facility. Building 23 sits just to the right of HIFAR in the picture.

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Special Report The 2018 ANSTO Molybdenum Crisis – What is Going On? (Continued) in implementation many times) that only reactor products from LEU reactors should be used in medical procedures, to minimise the risk of high-grade fission products and highly-enriched fuel falling into the wrong hands. OPAL was one of very few reactors at the time that could meet these criteria and hence looked set to play a major role in international molybdenum supply. The Canadians had a plan to build a number of smaller reactors, the Maple series, to replace their ageing Chalk River reactor which supplied almost half of the world’s molybdenum at the time. However, well into the construction phase it was found that the Maple reactor design had a fatal flaw that could, under certain circumstances, see it go into an uncontrolled nuclear chain reaction. The Maple plan was halted and eventually abandoned. In addition, ANSTO had spread out beyond its historical base in Sydney, predominantly at Lucas Hts, to take over the operation of the Monash campus-based Australian Synchrotron in Melbourne after the local management plan became unsustainable. Finally, its affable South African-born CEO, Dr Adi Paterson, had become a regular attendee at the ANZSNM Annual Scientific Meeting, something that had not been a regular activity of any of his predecessors. It seemed that medicine & health were getting more recognition than before and that closer alignment with the nuclear medicine community could result. DOMESTIC Mo-99/Tc-99m GENERATOR PRODUCTION ANSTO (formerly known as the AAEC – Australian Atomic Energy Commission) has been providing Mo-99/ Tc-99m radionuclide generators since the mid-1980s. This has been solely focused on the domestic (Aust & NZ) market. The facilities at Lucas Hts did not have the capacity to supply further afield. In September 2012 Senator Chris Evans announced that the Gillard Government had approved funding to ANSTO of $168m to build a large scale molybdenum production plant, to be known as the ANSTO Nuclear Medicine (ANM) facility, at Lucas Hts plus a small reprocessing facility using Synroc. In addition, at around this time ANSTO formed closer ties with the South African nuclear reactor operation, SAFARI, to work together on molybdenum supply and, importantly, to collaborate on backing each other up during periods of downtime, either planned or unplanned. Together, the two LEU reactors – SAFARI and OPAL – would provide up to 50% of the world’s molybdenum when the ANM plant came on line. Senator Evans promised that ANM would deliver an extra 250 jobs and earn $1b in export revenue. It was due to come on line in 2016.

Fig. 2. Then Prime Minister Robert Menzies “turning on” the HIFAR reactor at Lucas Hts in 1958. This is the same year that the current building housing the molybdenum production line was constructed.

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ANM was clearly to focus on the international market. Domestic generator production continued as it had since the 1980s in “Building 23” (B23) of the Lucas Hts facility (for an insight into what it is like inside this facility see the video jointly produced by ANSTO and the Society – “A Day in the Life of Australian Nuclear Medicine”). This building was amongst the earliest buildings to be constructed on the site along with the HIFAR reactor and was opened in 1958 as a research facility. I worked in this building as a cadet

Special Report The 2018 ANSTO Molybdenum Crisis – What is Going On? (Continued) under-graduate physicist for 6 months in 1981. Even at this time the building was showing its age and lacked infrastructure, particularly IT. I recall having to walk across the site past the soccer field to the computing facility housing the IBM mainframe to pick up printouts of programs I was working on, only to invariably find the program had crashed due to a software bug (my fault). Building 23 was a separate building to HIFAR where processing of reactor products was done. Eventually, it became the building to house the production line for the ANSTO generator, which has evolved to the GenTech generator we use today. While ANSTO replaced HIFAR with OPAL in 2007, B23 remained largely unchanged as the base for production of ANSTO Health products, including I-131 and Y-90. For further images see the ANSTO webpage at https://www.ansto.gov.au/news/independent-reportinto-safety-of-building-23-at-ansto for snapshots of the facility then and now – not much appears to have changed except for the introduction of flat-screen LCD monitors today. Prior to the production line problem of June this year, B23 was producing around 140 generators per week for domestic and New Zealand supply. Importantly, during the previous international molybdenum crisis of 2009 when Canada’s Chalk River reactor was closed due to a heavy water leak and the Netherland’s PETTEN reactor was shut down for routine maintenance for a month, we did not experience the impact that was felt in much of the rest of the world. At the time these two reactors accounted for almost two thirds of the world’s molybdenum supply (1) so the loss of both at the same time was profound. When this happened, ANSTO convened a crisis management group involving the nuclear medicine community and the commercial radiopharmacies to help manage the limited supplies that we had available at the time. While there were shortages, we were nowhere nearly as badly affected as most countries in the northern hemisphere. When many acute diagnostic imaging procedures such as myocardial perfusion scans and lung scans for pulmonary embolism (PE) are unavailable, referrers use alternate procedures. Some have never returned, so that the impact of these Tc-99m shortages is felt not just during the shortages but well beyond and, in some cases, may become a permanent drift away to other modalities. THE CURRENT SITUATION ANSTO experienced the mechanical failure on the GenTech production line around June 21-22 of this year. It released a statement on June 25 advising of this with the suggestion that the interruption would be a minimum of 10 days1. This occurred at the time of the Society of Nuclear Medicine & Molecular Imaging Annual Meeting in Philadelphia, USA and many members in leadership roles of ANZSNM and the AANMS were attending the meeting, as were a number of senior managers and staff from ANSTO. As many of us travelled back from the meeting to Australia we began to contact ANSTO about what was happening. The ANZSNM’s first notice to the membership was released on Thursday June 28. It concluded, based on verbal advice we had received, that “the expected shipments of generators from the US should mean that there is little impact on current workloads but it may be advisable to postpone non-urgent scans with 99mTc until normal service is returned”. 1

Most of the media releases and updates can be found on the “News & Events” page of the ANZSNM website.

Most of the media releases and updates can be found on the "News & Events" page of the ANZSNM website.

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Special Report The 2018 ANSTO Molybdenum Crisis – What is Going On? (Continued) From that point on, a “Working Group” was convened by ANZSNM, AANMS & RAINS which also included representatives from GMS and ANSTO. The NSW Ministry of Health joined soon after to be able to brief the Chief Medical Officer of any impending service interruptions. This group have advised ANSTO on how best to distribute the limited number of generators available. In the initial weeks of the current crisis many practices had no supplies of Tc-99m available at all and many patient scans were cancelled. Regional and rural areas were most severely affected. Interestingly, a year before the production failure, ANZSNM and AANMS had formed a small group with ANSTO comprising two representatives from each of the organisations, known as the Nuclear Medicine Liaison Group (NMLG). The NMLG was to meet twice per year to discuss various concerns related to radiopharmaceutical supply, availability and costs. This was formalised with an appropriate charter developed2. It had been felt that all sides needed a forum to voice concerns and understand the pressures each were experiencing, and to provide a mechanism to inform members about issues raised. What is still baffling is, in the immediate aftermath of the failure of the production line, that ANSTO senior management, who knew of the existence of this group, did not activate this mechanism for making contact with the nuclear medicine community, as ANSTO really only had access to its “customers” – those that they sold generators to directly. They had no mechanism for advising non-ANSTO supplied sites that they should anticipate shortages of Tc-99m radiopharmaceuticals. After the initial meetings of the working group, which have all been convened by teleconference, we have been trying to work with ANSTO staff to ensure efficient & equitable supply of Tc-99m. This has turned out to be a week-by-week proposition and the group has regularly met once or twice per week as required by the prevailing circumstances. Regular joint updates are provided after each teleconference for distribution to the members. After the initial weeks of severe limitation, we established a modus operandi for supply. If anticipated supply was deemed to be severe, we recommended that all metropolitan sites go onto unit doses supplied from the central radiopharmacy, GMS, in each capital city. Rural & regional areas would be asked to share generators between sites where possible. To try to maintain supply while ANSTO is unable to meet full domestic demand, Mo-99 produced in OPAL is being sent to Lantheus Medical Imaging (LMI) in Massachusetts, USA for incorporation into generators. These are then sent back to Australia for distribution by ANSTO. As the half-life of Mo-99 is 67 hrs, and the turn-around time for shipping, processing and return is around a week, it is clear that this is a very inefficient process. The reasons why we are not back to full domestic supply after 4 months remain unclear. The Working Group were initially told that the repair to the production line meant that the facility had to be revalidated by the TGA for GMP status. As it takes a number of weeks to culture bacteria to establish the sterility of the plant this was understandable. We were then informed that staff needed to be revalidated with new processes and that this would take some weeks while ramping back up to full domestic production. Most recently, we have been told that it was decided that while the system was down it was an opportune time to make other changes to the system to prevent a repeat of a similar failure. Unfortunately, this is being done while the SAFARI reactor is down for a prolonged maintenance break – the choice for the timing of our extended shortage is far from ideal. ANSTO, AANMS & ANZSNM Nuclear Medicine Liaison Group Charter 2017 22 ANSTO, AANMS & ANZSNM Nuclear Medicine Liaison Group Charter 2017

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Special Report The 2018 ANSTO Molybdenum Crisis – What is Going On? (Continued) From the nuclear medicine and general communities’ points of view it would seem to have been far better to return us to full domestic supply as quickly as possible (i.e., deal with the immediate, acute breakdown) and then to deal with system upgrades with planning and when we knew we would have adequate backup from SAFARI and the rest of the world. However, we can only speculate on the decision to prolong the limited production capability as we do not know the full details of the arrangements that are in place at present, as ANSTO will not discuss these citing that they are commercial-in-confidence, and we were not consulted about our preferred time-frame for return to a normal situation. Currently, as of early November, ANSTO is capable of producing about 70 generators locally per week and we continue to ship bulk Mo-99 to LMI in the US for processing and return to supplement the shortfall. There is no doubt that the deals done with LMI to keep a supply of Mo-99 coming into the Australian market have been necessary. We are not aware, though, of the price that we have had to pay for this. A number of organisations and people need special mention for maintaining the supply of Tc-99m over the past four months: GMS, who held the license to import LMI generators, agreed very early in the crisis to temporarily waive this and allow ANSTO to import the LMI generators directly, foregoing their commercial interests in doing so, and likewise, their staff in all capital cities have been extremely flexible in supplying radiopharmaceuticals as we have had to adapt to fluctuating import changes and shortages; members of the working group have been meeting frequently, including on weekends, and monitoring incoming flights and deliveries to try to keep our memberships abreast of the latest developments; and finally, the production-line staff at ANSTO have been operating for months now under enormous pressure with a very fluid, dynamic set of variables. They have been very amenable to the working group’s suggestions and tried to accommodate the group’s advice as much as possible whilst at the same time educating us on the vagaries of international transport and production schedules. We do not know when we will return to full domestic production and supply. At best guess this will be next year. We cannot fathom why it was decided by ANSTO that, in the middle of a crisis and global shortage of Mo-99, it would be a good time to upgrade their ageing system and delay the return to full local production. One message that does emerge from all of this is the vital necessity to have local production and supply channels so that we are not left at the behest of foreign suppliers with uncertainties due to local production issues and transportation uncertainties (weather, flight delays, logistics, etc). However, it will be for ANSTO to explain in time why the return to full domestic production did not occur in July or August of this year, and why we are still second-guessing when this will occur. Dale L Bailey PhD, Royal North Shore Hospital Immediate Past-President ANZSNM References: 1. Gould P. Medical isotope shortage reaches crisis level. Nature. 2009;460(7253):312-3.

Disclaimer: The views and opinions expressed in the articles included in this special report (The 2018 ANSTO Molybdenum Crisis) are those of the authors and do not necessarily reflect those of the Australian and New Zealand Society of Nuclear Medicine.

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Special Report

A Rural Perspective on the Molybdenum Crisis Author: Pete Tually, RAINS

For want of a nail the shoe was lost. For want of a shoe the horse was lost. For want of a horse the rider was lost. For want of a rider the message was lost. For want of a message the battle was lost. For want of a battle the kingdom was lost. And all for the want of a horseshoe nail. Variation of a 13th century proverb, as quoted by Benjamin Franklin.

For the want of a nail….or from ANSTO’s perspective, a good sprocket! The proverb seemed apt considering the headwinds that our profession has faced over the last few months and whilst all is not lost there have been some episodes where one could be forgiven for thinking that strategic planning and risk mitigation had been misplaced! It is always regrettable when any patient is denied a nuclear medicine service that otherwise should be available however it is particularly significant in rural and remote areas. At our most distant practice in Kalgoorlie, the community scores highly in social disadvantage where mortality and morbidity rates, particularly amongst Aboriginal Australians, remain much greater compared to the metropolitan sector. Kalgoorlie is the stereotypical regional town with a lack of both primary and specialist medical care and diagnostic tests. In this region and other rural centers in WA, alternate services to help manage CAD, for example, are just not available. There is no cardiac CT, no dobutamine echocardiography, no MRI or coronary cath labs anywhere within a 700 km radius. Our radionuclide myocardial perfusion scans represent the only test for a remote indigenous community that sees a 2.5 greater rate of myocardial infarction in males below 45 years of age. On a weekly basis our GP’s (and the few specialists living in the western desert) often rely on the Fly-in-Fly-out services to help determine who needs to be transferred out to Perth or can be managed locally. Therefore, any reduction in nuclear medicine services in regions like ours is quite disruptive and, as it has been for many of our rural colleagues, the task of triaging cases for studies has been a difficult challenge.

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Special Report A Rural Perspective on the Molybdenum Crisis (Continued) Outside of the important clinical priorities, commercial considerations must also to be factored into the equation. Providing remote nuclear medicine is very expensive. There is an estimated 30% increase in operational expense due to the tyranny of distance (with costs for flights and transport of lead shield containers over vast distances). Moreover, the majority of our patients represent those of lower socio-economic status and as a private business offering a bulkbilling service it is necessary to meet a minimum patient caseload to ensure the sessions are economically viable. Restrictions to â€œurgent's onlyâ€? could not be sustained long term and our team has been grateful to GMS and the working party to ensure sufficient isotope has been made available for a regional centres during this testing time for the profession. Letâ€™s hope 2019 is a better year! Disclaimer: The views and opinions expressed in the articles included in this special report (The 2018 ANSTO Molybdenum Crisis) are those of the authors and do not necessarily reflect those of the Australian and New Zealand Society of Nuclear Medicine.

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Special Report

ANSTO: Journey to Sustainability Author: James Lee, ANSTO

We are the first to admit, it’s been a rocky few months at Australia’s Nuclear Science and Technology Organisation (ANSTO). Nuclear medicine production is one of the most complex manufacturing processes in the world and for many years we’ve been getting this right and building our supply to our local market. The output from these processes is potentially lifesaving medicines for patients around the country, and conservatively we know this benefits the lives of around 1 in 2 Australians. The $168.8 million ANM project will deliver a brand-new Mo-99 manufacturing facility for Australia in a matter of weeks. The new facility is finalising hot commissioning and will take over from building 54. This facility, alongside the world-class OPAL reactor, puts ANSTO, and Australia, in a strong position for significant home-grown research and development in the field of nuclear medicine technology. OPAL, one of the top research reactors in the world, continues to achieve over 300 operational days per year, in the top league of the world’s 240 research reactors. Nevertheless, on this journey to sustainability, we acknowledge that securing a local and reliable supply of nuclear medicine is a team sport. We could not do what we do without the fierce support of the wider nuclear medicine community and our Government stakeholders. ANSTO has a long history of reliably delivering our Tc-99m generators across Australia for many years, but not a particularly good short-term history. On June 22 this year, we had a mechanical failure involving the conveyor belt inside the ageing nuclear medicine production facility at our Lucas Heights campus, Building 23. As a result of the breakdown, generators that transport vital nuclear medicine (involved in the diagnoses of heart, lung, muscular-skeletal and cancer conditions each year) were interrupted, and so we have been supplementing domestic supplies with some from the USA. ANSTO is 100 per cent committed to fully restoring the local supply of nuclear medicine to hospitals and clinics around the country, and this is expected to occur early next year. Additionally, following a direction from ARPANSA, ANSTO is in the process of formulating an action plan to 85 recommendations after an independent review into Building 23. Safety is our number one priority as an organisation, and where the report has highlighted there is more work to do, we apologise. It is important for ANSTO to continue moving forward, and safely deliver reliable supplies of high-quality nuclear medicine products to both the domestic and international markets. What this recent period has brought into sharp focus for ANSTO, is the need for Australia to further strengthen stability around our local nuclear medicine manufacturing and production capabilities. This is achieved when the nuclear community works together to ensure stability is maintained.

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Special Report ANSTO: Journey to Sustainability (Continued)

Building 23 Hot cells in c1960s Credit; Max Dupain

Building 23 Hot cells as they look today

We will continue working with our Government stakeholders and the wider community to achieve the improvements needed, including the upgrade or replacement of Building 23, to continue to deliver nuclear medicine products to patients here in Australia, and around the world.

And there is also a new and exciting project with a large collaborative group from Sydney and Melbourne at the Australian Synchrotron on the 3D imaging of breast cancer, which will hopefully put us on a path to better diagnosis from as early as 2020.

ANSTO is looking to the future, continuing to work to make a large and growing contribution to the health of Australia, including projects like new radiopharmaceuticals to diagnose neuroendocrine tumours and monitor response to treatment.

So, while ANSTO has faced some recent challenges, we are an organisation that is willing to face these challenges head-on and make the changes necessary, so that we can continue to advance nuclear medicine in this country for the benefit of patients around the world.

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Special Report

ANSTO Generator Shortage Author: Matthew Ashton, GMS

“There is no education like adversity” - Benjamin Disraeli ANSTO’s 99Mo/99mTc generator shortage has undoubtedly tested the boundaries of the Australian Nuclear Medicine community’s strength and resourcefulness over the past few months, but also brought out the best in an industry with which GMS is extremely proud to be associated. As should always be the case, our first and foremost thoughts during this challenging period should remain with patients and the NM departments facilitating studies and treatment throughout the country. There have been incredibly difficult times endured by both patients and NM personnel since June and those involved at the coal face should be duly recognised for their fortitude and understanding. There’s many of us at GMS who have worked as technologists and experienced Moly shortages, camera breakdowns, logistical issues and so on… rescheduling the patient who has travelled 3 hours for a pivotal study is not an easy task. Rescheduling them for a 2nd or 3rd time – even more difficult. So once again, we empathise and thank the NM community for their ongoing dedication to patient care throughout this crisis. GMS would also like to thank our employees for their tireless work throughout the generator shortage. All have gone above and beyond expectations to ensure all available activity has been utilised efficiently to achieve maximum impact on patient throughput. From last minute dashes to the airport through to round the clock generator elution, extraordinary delivery schedules & beyond, our team should be extremely proud of their dedication and efforts. ANSTO has undeniably endured an extremely difficult period since manufacturing issues forced cessation of operations at their generator production facility. From our perspective, GMS would like to thank ANSTO for their ongoing cooperation with both commercial & industry groups to minimise disruption under great duress. ANSTO staff and personnel have worked incredibly hard behind the scenes to navigate their way through expected, unexpected and occasionally uncontrollable challenges. As always, GMS will continue to work with ANSTO wherever possible to maintain continuity of supply moving forward. Our sincerest thanks to the ANZSNM, RAINS & AANMS working group for overseeing and coordinating national distribution of available generators to ensure all regions received the best level of coverage possible despite variable logistical timeframes and limited resources. Leveraging expertise from all three organisations has been key to ensuring fair and equitable distribution throughout the country and we genuinely appreciate the accompanying joint communication released to the community on a regular basis since June. Finally, Lantheus Medical Imaging should also be commended for their responsive action during the initial fallout and ongoing manufacturing assistance throughout the process. LMI have been agile in scheduling additional manufacturing runs throughout the shortage and this has been crucial to maintaining generator supply to Australia.

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Special Report

ANSTO Generator Shortage (Continued) As with all challenges, itâ€™s important we learn from this event, continuously strive for improvement and emerge from this period as a stronger, more robust industry. Engaging the right expertise, reviewing feedback, improving communication and greater transparency will be integral to developing contingencies as we move forward. Once again, a genuine thanks to the entire NM community for displaying unparalleled professionalism and ongoing patience during this time. Everyone involved should be incredibly proud of their efforts to ensure the best possible service and care has been provided to patients throughout the country.

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Special Report

Lessons Learned from the 99Mo Crisis Author: Geoff Currie, Charles Sturt University

They say “what doesn’t kill us makes us stronger” but that is only true if we learn from the crisis faced. There is much to learn from this crisis and if we (profession) or ANSTO do not, then Australian Nuclear Medicine really will be palliative. Objective reflection and evaluation is a powerful weapon to ensure post-crisis we don’t just survive but rather, we thrive. The breakdown and the impact of this ongoing crisis have been well documented by others in this edition and so I really wanted to try to focus on the positive outcomes we can expect if we learn from our suffering. I do want to recognise up front that we are still deeply entrenched in the crisis and it is completely understandable to be invested in simply surviving. But I hope that on the other side, we all have the chance to thrive in a stronger environment. A crisis is a period of time of intense difficulty or danger, or periods where an important decision must be made, or a turning point that is the crossroads between positive or dire outcomes. The period of late June 2018 until early 2019 is a crisis by all of those definitions. It started as the “99Mo Crisis” and morphed into the “ANSTO Crisis” which signalled for me the transition of the root of the problem being from 99Mo supply to ANSTO management of the issue. Both ANSTO and the nuclear medicine community (and our patients and referrers) faced intense difficulty. Indeed, commercial dangers lurked that put an enormous financial strain on the viability of some departments, enormous costs on ANSTO and the taxpayer, heavy weight on GMS and danger to patients who were not able to access crucial services (life-saving and life-changing) in a timely manner. ANSTO was thrown into a whirlwind of rapid-fire decision making that we can all agree was not ideal and, for a while there, looked like we were determined to provide proof positive of Murphy’s Law. There were numerous turning points, often taking us to the brink and then meandering back. So what did we learn? We have all seen those bushfire advertisements on television. Have a plan in advance. Know the plan. Communicate the plan. Have every stakeholder invested in the plan. There was no plan when this crisis started. ANSTO have had staff turnover that has seen corporate knowledge lost including crisis plans. A crucial lesson from this is that ANSTO needs to have regular meetings with ANZSNM, AANMS, RAINS and GMS to put contingency planning in place, provide updates on operations and to plan scheduled maintenance. Your representatives from the ANZSNM, AANMS and RAINS stepped in to form an ad-hoc working party that should already have been in place, ready to convene and informed ANSTO in the early decision making. Open and honest communication is essential through a readily identifiable spokesperson. ANSTO customers learned of the crisis from RAINS who learned of it from GMS customers and the ANZSNM, despite being in the USA at SNMMI with ANSTO leadership at the time, were not aware until I asked Dale Bailey for the ANZSNM position a whole week after the breakdown. He was at SNMMI and had heard nothing nor had the ANZSNM President. Subsequently, the communications came officially from unnamed “official spokesperson” within ANSTO and it was generally well sanitised leaving it as more political spin than usable information. Indeed, ANSTO statements often were at odds with the position departments were communicating to the media and various levels of Government. The communication from the working party worked well because there were consistent and identifiable spokespersons,

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Special Report Lessons Learned from the 99Mo Crisis (Continued) plus open, honest and regular updates. Often bad news but at least people were being empowered by knowledge. ANSTO communication breached all guidelines for managing a crisis; no consistent and identifiable spokesperson, not open and honest information because it was highly sanitised, employees were often in the dark, customers were definitely in the dark, and they did not update early or often. The other success RAINS had was the use of social media which for many was providing direct information well before other channels. We have learned the value of communication and the pathways to best overcome the communication barriers that we can apply to numerous aspects of professional practice. The lack of transparency of government organisation drives mistrust and we have seen that play out in the media. There is some really good PR advice used for companies confronting a crisis. Get ahead of the story, be proactive, be transparent and be accountable. I think ANSTO have failed on all counts. Getting ahead of the story was always going to be tough with concurrent media around the ARPANSA driven independent report. But that report provided an insight into management culture underpinning decision making that I think exacerbated the 99Mo crisis. So in some respects, conflating the two stories was appropriate but confounded ANSTOâ€™s capacity to get ahead of the story. Those management issues I think also shackled transparency, proactive management and gave the impression of lack of accountability; or misplaced accountability at least. We have learned that truth and perception are the same and can be your salvation or executioner. We have learned a punitive management culture is ineffective and unsustainable. Replacing blame attribution with examination and rectification of root causes is the pathway to reliable productivity. Personally, I learned how incredibly resilient our nuclear medicine community is. I have been in regular communication with many of you. Emails, phone calls, Facebook messages and I am aware how tough many of you have been doing it, and how frustrating some of the communication and transport delays have been. But at its worst, I saw health professionals committed to their patients, their departments (employers), their profession. This crisis has highlighted the nuclear medicine communityâ€™s collegiality, generosity and advocacy. The US Marines use the slogan; improvise, adapt, overcome. I think it is equally apt for the Australian Nuclear Medicine community. There are six domains of resilience and these are strengths of character that resides in the nuclear medicine collective: vision and congruence of purpose; composure in the face of adversity; reasoning and resourcefulness; collaboration and support networks; tenacity and persistence; and health, your health and wellbeing (physical and mental). After the global financial crisis, there was a lot of analysis. One observation was that the early signs of impending doom were not noticed because everyone who was around at the previous crash were now out of the industry. This might be also true for the 99Mo crash of 2018. There were three key learning outcomes of the GFC that I think we will come to learn in the investigation of the 99Mo crisis; creativity, reliability and sustainability. Indeed, these key lessons were quickly consumed in clinical practice. Creative patient scheduling, staff rostering and alternative approaches to answering referrer questions. Provision of reliability using low dose protocols1 and alternative radionuclides2. The emergence of greater sustainability using double daily elutions3 of generators to maximise activity profiles, minimise 99Mo and ultimately costs. What this crisis has taught us is that we can do more, with less, for lower costs without compromising patient care or outcomes. The nuclear medicine community has found creative ways to provide reliable services in a more sustainable way (environment and resource) and many of you have indicated that you will keep using those approaches post-crisis. That is learning how to survive a crisis that allows you to thrive post-crisis. 2019 Summer Edition | gamma GAZETTE | 19

Special Report Lessons Learned from the 99Mo Crisis (Continued) If ‘it’ is about to hit the fan you have a few options: 1. 2. 3. 4. 5.

Shut off the source of ‘it’, Put a barrier between ‘it’ and the fan, Evacuate the immediate vicinity of the fan to avoid ‘it’, Hold your ground and take your share of ‘it’, or Turn off the fan.

Only time will reveal what ANSTO has learned from the crisis. But I am confident that the strength and unity of ANZSNM, AANMS and RAINS, the broad support for all without any form of demarcation, and the preparedness of so many to willingly dive into the trenches will be one of those lessons ANSTO will bottle. Early in the crisis, I posted a message on the RAINS Facebook site. A beautiful picture looking deep into a lion’s eyes with the caption: the devil whispers “you can’t withstand the storm”, the warrior replied, “I am the storm”. I learned that the Aussie (Australian) Nuclear Medicine community are not just survivors, it is filled with warriors; a community I have always been proud to be part of but no more than I am at this moment. Geoff Currie Charles Sturt University RAINS member of the Crisis Working Party Footnotes: 1 Many departments were forced into low dose protocols and have been surprised at just how good image quality is. Despite advances in detector technology, our dose protocols have largely remained unchanged and this has reflected no pressure on 99mTc availability. In the northern hemisphere, patient doses have dropped substantially as availability and cost pressures of 99Mo/99mTc have remained tight for over a decade. This crisis has forced a realisation in Australia that high-quality studies can be performed with much lower doses and this provides an opportunity to embrace dose reduction strategies that offset, in part, the burden associated with the addition of CT. Sustainable, responsible and cost containing. 2 For some of you, what is old is new again. Like a good pair of jeans (501s), some radionuclides might lose favour but never go out of fashion. For some generations, the rediscovery of 67Ga citrate for infection imaging may have already been driven by the loss of Leukoscan availability. An ANSTO issue that has faded into obscurity in the 99Mo crisis. But 201Tl chloride use in myocardial perfusion studies and parathyroid imaging may have been a refreshing reminder of how good these agents are biologically (despite limitations in physical properties). For the newer generations amongst us, you may have been discovering these radionuclides clinically for the first time. There were also a few reports of utilisation of PET although widespread use would be limited by an absence of appropriate rebates. 3 We learn the value of the 99Mo/99mTc generator is that in transient equilibrium it offers a perfect daily use generator with equilibrium occurring at 4 half-lives of the daughter (24 hours in this case). That’s what I was taught and it drives the practice of 1 elution per day and the detriment of multiple elutions we sometimes need toward the end of the week. But that is not what I teach my students because it is not true and RAINS provided this advice widely at the beginning of the crisis. I won’t bore you with the maths but equilibrium actually occurs at 22.9 hours and equilibrium is NOT the point of maximum activity. Maximum activity occurs 18 hours after the previous elution. The most rapid growth of 99mTc on the column occurs early. So the 99Mo/99mTc generator is actually ideally suited to being eluted twice a day; at time zero and then 6 hours later which allows 18 hours before time zero the next day. This provides the greatest availability of 99mTc so departments can get by with more 99mTc from a much smaller (and cheaper) generator. This does need some adjustment to the daily scheduling to allow the large demands on 99mTc to be split over the 2 elutions. Those that have adopted this approach have been able to make limited 99Mo go much further and continuing this practice post-crisis will allow lower costs by reducing your generator size. Again, economically and environmentally sustainable.

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Branch News

WA Branch News In August the WA Branch held our annual workshop at Trinity on Hampden Conference Centre. This year the focus was Cardiology. We had a wide variety of excellent speakers and a high attendance as always. Thank you to all those involved in organising and presenting at the workshop. In September we held our RadPharm Award night. Thank you to Cassandra Koudela and Rhonda Harrup for your fantastic presentations. We look forward to seeing Rhonda presenting as the WA representative at the conference in Adelaide next year. This meeting was held for the first time in WA’s brand new Perth Children’s Hospital. Those who attended the meeting were given a tour of the new nuclear medicine department – a big difference to Princess Margaret Hospital! Stephanie O’Donnell WA Branch Committee

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Branch News ACT Branch News Amid some wild and stormy weather, the first Capital Region Forum was a great success. With around 30 people attending to see a fantastic lineup of speakers, we will definitely be organising another one next year! A big thanks to our sponsors Siemens Healthineers, Imaxeon and GMS for their support, and for sending representatives on the day. We started with a yummy lunch, followed by the ACT branch AGM, where James Green presented a short update on the MRPB and Nick Ingold gave us an update on the goings on of the ANZSNM. The current committee will all be continuing in their roles, with some additional organising support kindly offered by two non-members, Ross Bevan from Canberra Health Services and Kate Anderson from GMS. We will be holding a Christmas gathering in late November, followed by a meeting early next year hosted by GMS at Belconnen. After some frantic rushing to resolve an unfortunate AV issue, we got into the education component of the day, and were treated to a very informative and entertaining talk from Siemenâ€™s Anne McClenahan, who gave us a great run-down on Siemens SPECT Quantitation, followed by an impromptu revision session on the mechanics of gating myocardial perfusion scans, and how to deal with those troublesome irregular heart rates without jeopardising the accuracy and integrity of the data. Continuing the humorous tone, Chris McLaren was dragged from retirement to deliver an insightful exploration of risks and consequences and reminded us that there are always new perspectives to be gained on the core components of our daily work. While the Tom Cruise link was a bit of a stretch (and the start of an unexpected recurring theme), we all learned something new. Professor Nick Brown from Canberra Health Services and the University of Canberra rounded out the first session with a wonderful presentation bringing structure to the process of getting started in clinical research practice and navigating the sometimes intimidating ethics approval process. 2019 Summer Edition | gamma GAZETTE | 23

Branch News ACT Branch News (Continued) Nick has recently moved from the research team at the AIS to the newly created Professor of Allied Health Research role and will bring a great amount of enthusiasm and impetus to research in the allied health professions. After a lovely break to catch up with colleagues and grab a coffee, I presented a summary of an upcoming research project we are developing at the Canberra Hospital, which will measure radiation exposure rates from patients, and bring together a multidisciplinary team to develop close-contact guidelines for our patients, hopefully solving the ‘but they’re hot’ problem for a wide range of health professions interacting with our patients after their scans. While we only had the one Radpharm entrant, Rachael Prior’s case exploring the role of NM in diagnosing and following a patient with T cell lymphoma was easily deemed to be of sufficient quality to represent the ACT next year at the Adelaide ASM. Congratulations Rachael, and good luck! Ross Bevan was kind enough to present a collaborative effort from the Canberra Hospital when our interventional radiologist was unavailable at the last minute. Combining a balloon occlusion test with concurrent cerebral perfusion imaging in complex brain aneurysms has been performed in three patients recently, and we are all learning a lot by working so intimately with the angio team. This novel application of a traditional imaging technique was the subject of much interest and a spirited Q & A session after the talk. Rounding out an excellent day, we had the esteemed Dr Iain Duncan give us a big-picture insight into the complexities of diagnosing and managing prostate cancer, using a wide range of diagnostic procedures including bone scans and Tc-99m PSMA. Iain also gave us some good pointers on the future of prostate imaging and some great tips for improving our accuracy in this area. Despite being on the tail end of a full day, Iain’s presentation was highly engaging, informative and funny, and one of the highlights of a great set of presentations. While we farewelled some of our interstate guests at the conclusion of the formal program, many of the locals then retired upstairs to enjoy the outstanding views of the sunset over the Brindabellas and drinks kindly provided courtesy of GMS. I think I will end the recap there, and leave the late night shenanigans in the dark where they belong. Overall, the day was a big success, and we will be working towards making the lineup even bigger and better next year. Thanks to all our sponsors, speakers, and everyone who attended and helped to make the day so great. See you all next month at the Christmas party! Maree Wright, ACT Branch Chairperson

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Branch News VIC/TAS Branch News ANZSNM VIC/TAS Branch – Cardiology Masterclass – 1st September 2018 A group of over 50 technologists and students escaped the cold Melbourne weather into the warmth of the European Bier Café for our Cardiology MastercLass. Although the VIC/TAS branch has held previous Masterclasses, this was the first to incorporate the social aspect (and be held in a pub!), as it included a dinner afterwards to allow members more time to catch up in a relaxed setting. We had three speakers on various aspects of Nuclear Cardiology. First up was Dr. Samuel Wright who gave us an update on the Role of Nuclear Cardiology in the current medical landscape. This included a review of how myocardial perfusion imaging compares to CTCA, stress echo, and the relatively new kid on the block; FFR. He then briefed us on Onco-cardiology, and how having cancer and its treatments can affect a patient’s heart. He also introduced the topic of FDG “hot spot” scanning in the heart which will be something for PET technologists to keep an eye out for. We then had Abu Sembera, a nurse from Monash Health giving us a review of patient care and drug interactions for Stress tests, which was a nice overview on all the ways that patient medications can interfere with our stress testing. Our final speaker was Rob Williams, who gave us his experience from the UK with Advanced Practice for NMTs, with regards to ECGs and drugs. He had trained technologists in the UK to perform stress tests, which had led to shorter waiting times with no change in incidence rate. He then gave an overview of the different stress agents and their interactions, followed by a few examples of different ECGs. We finished off the afternoon with the AGM, which gave members an update of what had been happening through the Society over the last 12 months or so. It was then time to do what we technologists do best, which is catch up with an old friend while making new ones. Kim Jasper VIC TAS Branch Chairperson

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Branch News

SA Branch News Dear Members, Since our last branch report, we have held two SA branch meetings and one technologistâ€™s meeting, all with good attendance. Our last meeting held in July was hosted by Dr Jones and Partners. Topics covered included The Value of P40 in Renal Lasix Scans presented by Dr Michael Kitchener and a review into Colonic Transit Imaging by Dr Barry Chatterton as well as a selection of interesting cases presented by Dr Felix Paterson. The ANZSNM Technologists AGM was held on Wednesday 14th November where nominations for the 2019 Radpharm award were presented as well as presentations from UniSA students. Sadly we are saying goodbye to our secretary/treasurer Dai Nguyen in mid-November. Dai has done a fantastic job behind the scenes organising meetings and events throughout the past two years. Nominations are open for anyone interested in the opportunity to fill the role. Please email nominations to myself or Dai. It is a fantastic way to contribute to the society and get to know the ins and outs of Nuclear Medicine in SA. Finally, we look forward to welcoming everyone to Adelaide for the 49th Annual Scientific Meeting in April 2019. Elyse Langeluddecke ANZSNM SA Branch Chairperson

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Branch News QLD Branch News The Queensland Branch has had a great year filled with new ideas and content packed meetings. Allowing our regional partners to dial and participate in the CPD activities through video conferencing has been one of our major successes to reach more members. With the majority of meetings being metropolitan based in Brisbane, sites as far as Townsville were able to participate in events which previously were unattainable. I would strongly encourage all states to investigate the possibility of recording/video linking meetings which will further open up the options for states around Australia to dial into a variety of ANZSNM branch CPD activities. Over the course of the year we have been fortunate to have a wide variety of speakers to promote interdisciplinary collaboration within the Nuclear Medicine community. Our major event, the Qld Symposium was held on a gorgeous weekend on the sunny Gold Coast starting with a free yoga session to relax the mind for a day of learning. We had a great turnout of members which reflected the high quality program on offer. Speakers such as Physicians, Surgeons, ECG technologists, Nuclear Medicine Scientist and even a Wellbeing expert enlightened members on the current progress and involvement of Nuclear Medicine in a variety of aspects regarding patient management outside of what happens in our own departments. Our Wellbeing speaker challenged members to set future goals and motivated them to produce action plans to continue to develop in various aspects of their lives. This day was definitely a highlight of our committee term. All our meetings could not have been possible without the generous sponsorship of a large group of companies which have enabled high quality venues and inclusions producing fantastic ANZSNM events. As our AGM rolls around in November, our committee says goodbye. I have moved on to Melbourne and others hand the baton to a new group of keen members with new ideas and enthusiasm to provide the best for our members. Suzanne McGavin ANZSNM QLD Branch Chair Person

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Special Interest Group News TSIG Day Symposium, 4th August 2018 This year the TSIG Day Symposium was held in the beautiful Adelaide Hills, with the speakers having to compete with the breathtaking views on display. The morningâ€™s sessions showed how accessible innovation can be. With examples of embracing multi-disciplinary teams, dose optimisation using ARPANSAâ€™s dose reference levels, and embracing new technologies as a means of remaining profitable in private practice. It was evident that many ways in which we can make useful changes are already at our fingertips. We then heard about the extensive process that has occurred in developing Copper based radiotracers, the difficulties of ensuring radiation safety in theranostics especially to non-compliant patients, and the possibility that Whole Body SPECT could one day replace WB planar imaging. We then heard some of the exciting research that is occurring within the academic side of our industry, and the opportunities that this presents. We then moved on to some career development, where we were encouraged with some tips and tricks to develop in our public speaking. This was a very motivating talk, and I look forward to the outcomes of this at future events. The day was very well attended, and those there walked away encouraged and motivated in pursuing innovation and change within their Nuclear Medicine careers. Special thanks to Karen Jones and Adam Freeborn and others on the TSIG CPD and Education Committee for organising this event, and also to Siemens Healthineers, and Imaxeon, as well as ANSTO, GMS, Gamma Gurus, Curium, and MIPS for sponsoring this event. Nicholas Daw Chair of the TSIG CPD and Education Committee

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Debra Huddleston

Launching in 2019: ANZSNM Historical Archive

I have recently taken on a newly created position of Historian with the ANZSNM. I have been working with Dale Bailey, Immediate Past President of the ANZSNM, and the ANZSNM Secretariat, to determine what the role of Historian might entail and the best approach to making some long stored historical documents (e.g. old Gamma Gazettes going back to 1980, many photos that would no doubt be of interest) available to members of the ANZSNM. A few months ago, I started scanning some of these documents and uploading them to the digital cloud. The specific role of the Historian is still a work in progress but includes creating a database of items such as award winners at ANZSNM Conferences and recording of other important information that ensure the Societyâ€™s history and legacy is readily available.

visit anzsnm.org.au to learn more

Education & CPD Case Study

Urine Matters - 3 Case Studies

Authors: Dr Felix Paterson and Dr Michael Kitchener, Dr Jones & Partners Medical Imaging, St Andrew's Hospital, Adelaide

CASE 1 Prostate cancer for staging. Whole body scan performed for bony staging (Figure 1). What are the relevant findings?

This was confirmed on review of a previously performed delayed phase CT demonstrated below (Figure 3).

Figure 1 Figure 1: Whole body bone scan imaging shows focal abnormal activity inferior to the bladder in the right superior pubic ramus on the anterior projection. No other bony metastases were visualised.

Figure 2

However, as this activity was also clearly demonstrated on the posterior projection, SPECT/low-dose CT imaging was then performed. What does the SPECT/CT screen capture (Figure 2) show?

Figure 2: SPECT/CT â€“shows activity localising to the posterior peripheral zone of the right prostate in a region with increased density on the low-dose CT images. The patient had undergone a contrast enhanced CT earlier in the day, with contrast seen filling the bladder. On review of the low dose CT, there is the filling of an ectopic ureter that can be demonstrated to insert into the prostatic urethra with radioactive urine spilling into the prostatic parenchyma.

Figure 3 2019 Summer Edition | gamma GAZETTE | 31

Education & CPD Case Study Urine Matters (Continued) - Case Study 1 Discussion: In this case imaging with SPECT/ low dose CT provided clarity and accuracy that significantly changed the report and therefore the course of management. It was also helpful to have additional past imaging with contrast to accurately delineate the anatomy. Ectopic ureters occur in both males and females and are associated with a duplex renal collecting system on the ipsilateral side in 80% of cases as was the case with this patient. An ectopic ureter by definition does not insert into the normal location of the bladder trigone, the most common site of ectopic ureter insertion in males is the prostatic urethra which occurs in approximately 54% of cases. Ectopic ureters are much more common in females and also more often symptomatic. An ectopic ureter becomes symptomatic when it inserts into the ureter beyond the external urethral sphincter. This is very common in females but almost never occurs in males.

Venue to be advised RSVP: 7th January 2019 at www.anzsnm.org.au Enquiries/Radpharm submission: My Linh Diep President, American College of Cardiology James B. Herrick Professor Chief, Division of Cardiology Rush University Medical Centre

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Education & CPD Case Study

Urine Matters (Continued) - Case Study 2 CASE 2 75 year old male with known prostate cancer and a rising PSA from 0.4 to 5.0 in 6 months. Recent fall, with ongoing left hip and thigh pain. A whole body bone scan was performed (Figure 1). What are the salient features? Figure 1: The scan shows a recent post-traumatic right 5th rib fracture, with degenerative skeletal changes and no evidence of bony metastatic disease or recent pelvic/hip fractures. However, there is an unusual appearance to the left kidney, with retention of activity. As the left renal pelvis and proximal ureter are clearly defined separately, the possibility of obstruction of the lower pole moiety of a previously undiagnosed duplex kidney was raised. The patient then went on to have a CT urogram (Figures 2, 3 & 4).

Figure 1

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Education & CPD Case Study Urine Matters (Continued) - Case Study 2

Figure 2

Figure 3 Figures 2-4: The CT images show a multi-located cystic structure in the left psoas muscle extending down to the acetabulum. A rim of contrast is seen anteriorly confirming communication with the renal collecting system. However, no leak was seen on the subsequent retrograde pyelogram. Figure 4

The presumed urinoma was treated conservatively and slowly resolved.

Discussion: Urine leaks most commonly result from trauma and may be occult initially leading to complications such as hydronephrosis, paralytic ileus, abscess formation and electrolyte imbalance. In the nuclear medicine setting, urine leaks are most commonly seen after renal transplantation following failed ureteric implantation. They may be confined encapsulated fluid collections or manifest as free fluid. While renal urine leaks are most common after renal trauma, ureteric leaks are more commonly iatrogenic in nature after abdomino-pelvic surgery or endo-urological procedures. Treatment varies but includes conservative management, stent insertion or nephrostomy drainage. Reference: Titton RL et al, Urine Leaks and Urinomas: Diagnosis and Imaging-guided intervention, Radiographics 2003: 23: 1133-47

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Education & CPD Case Study Urine Matters (Continued) - Case Study 3 CASE 3 A 67 year old man with Gleason 9 metastatic prostate cancer at diagnosis, with pelvic lymph node and bony metastases on MRI (normal bone scan). PSA fell from 27 to 0.07 over 12 months with Lucrin therapy but then started to rise, with a doubling time of approximately 7 months. It was 6.17 just before the PSMA PET scan (see Figure 1).

Figure 1

Figure 2

The PSMA scan showed widespread bone and lymph node metastases, as well as prominent activity in the left ureter (Figure 2). The corresponding diagnostic CT images from 2016 and 2018 are shown below (Figure 3). What is the most likely explanation for the PSMA activity in the left ureter?

Figure 3 2019 Summer Edition | gamma GAZETTE | 35

Education & CPD Case Study Urine Matters (Continued) - Case Study 3 Discussion: The left kidney is very hydronephrotic with no significant remaining parenchyma and no obvious PSMA activity (Figure 4). Therefore the ureteric activity is not due to physiological â€œhold-upâ€? of urine. The CT shows solid soft tissue in the ureter, not a tubular/cystic structure (Figure 5). The findings have also slowly progressed since diagnosis. The two main diagnostic options to consider are a PSMAavid separate ureteric TCC or a prostate cancer metastasis. Ureteric prostate cancer metastases are very rare, with only 40-50 reported in the literature. They often present with flank pain. Ureteric metastases are more common with primary breast, colon, lung and lymphomatous malignancies. 90% of ureteric malignancies are TCC, which shows variable PSMA expression/uptake. PSMA-expressing TCC has been associated with a higher stage and decreased patient survival. A decision was made not to investigate the left ureteric lesion further. Given the high-grade level of PSMA avidity in the left ureter is similar to all the other metastatic lesions, it is considered more likely to be an unusual prostate cancer ureteric metastasis. Figure 4 Reference: Liu P et al, A hidden ureteral metastasis that originated from prostate cancer: a case report and literature. Transl Cancer Res 2017;6(3):650-655 Schallier D et al, Ureteral Metastasis: Uncommon manifestation in Prostate Cancer. AntiCancer Research 2015; 35: 6317-6320

Figure 5

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Call for Abstracts The Organising Committee invites abstract submissions for presentations at the Australian and New Zealand Society of Nuclear Medicine (ANZSNM) 49th Annual Scientific Meeting 2019. Submissions from all disciplines of Nuclear Medicine are invited for poster and oral presentations. The Committee will integrate sets of individual oral papers into thematic sessions. Length of presentations will be determined once all submissions have been reviewed.

Key Dates

Themes

Friday 25 January 2019 Abstract submission close Deadline for abstract submission at 5:00pm ACST (Australian Central Standard Time).

Abstracts may be submitted under the following themes:

To meet publication timelines for the Internal Medicine Journal there will be no extensions. From Monday 25 February 2019 Authors will be notified by email of the result of their abstract submission. Monday 11 March 2019 Presenter registration deadline.

• • • • • • • • • • • • • • •

Cardiology Oncology Neurology Therapy Renal/Urology Gastroentrology Muscoloskeletal Paediatric Infection/Inflammation Technology Physics Radiation Safety Radiopharmacy/Radiochemistry Education/Student General/Other.

How to submit an Abstract To be selected to present you are required to be a member of the Australian and New Zealand Society of Nuclear Medicine and to submit an abstract via the website. All abstracts must be submitted electronically.

Awards Five awards are on offer for the 2019 meeting - GMS Poster Award, The Curium (formerly Mallinckrodt) Award, Shimadzu Award, Radpharm Award* and AANMS Registrar Research Award.

Not a member? Why not join? ANZSNM members receive generous registration fee discounts and the opportunity to submit abstracts for a number of awards. Associate Membership is available for students and medical trainees for free upon approval. Join today here anzsnm.org.au/membership

Education & CPD What’s that

What’s that? Authors: George Pandos and Elyse Langeluddecke , South Australian Medical Imaging, The Queen Elizabeth Hospital

Case study: A 67 year old male was admitted to ICU after a recent drainage of a left elbow abscess, which was positive for gram positive cocci. The patient also had a history of dilated cardiomyopathy. He was now presenting with septic shock and worsening ischaemic cardiomyopathy due to sepsis. Abdominal ultrasound, CT chest and abdomen, and a Nuclear Medicine bone scan were all requested to exclude other overt sources of sepsis. The patient was injected with 890 MBq of 99mTc-hydroxymethylene diphosphonate (HDP) on the ICU ward and later transferred to the nuclear medicine department for 3hr-delayed whole body bone imaging (Figure 1).

Figure 1: Dual intensity whole body bone scan

The bone scan shows reduced renal activity bilaterally and diffusely soft tissue uptake throughout the body, findings reported as consistent with severe acute tubular necrosis (ATN). There was no evidence of osteomyelitis; however diffuse uptake indicating inflammation of both wrists (seen separately on static imaging) could not rule out septic arthritis at these joints. There was also intense diffuse activity throughout the liver. What’s that liver uptake? Follow-up: Abdominal ultrasound showed moderate hepatic steatosis with no focal liver lesions; pancreas, kidneys and spleen are unremarkable. The CT demonstrated diffuse bilateral pneumonia and the liver heterogeneity consistent with hepatitis. 38 | gamma GAZETTE | 2019 Summer Edition

Education & CPD What’s that What’s that? (Continued) Given the patient’s history, the intense liver uptake on bone scan is suggestive of diffuse hepatic necrosis secondary to severe hypoxia and/or cardiogenic shock. Discussion: Hepatic uptake on bone scans is a non-specific finding with various causes documented. Faint liver uptake on 99mTc-HDP/MDP bone scans is more commonly seen as a result of underlying metastatic cancer in particular from breast and colon cancer1,2. However, diffuse and intense uptake as seen in this case is a much rarer finding and is typical of acute hepatic necrosis. Acute hepatic necrosis has a very high mortality rate and recovery is unlikely; the patient died several weeks later. The clinical course of acute hepatic necrosis resembles an acute, toxic injury to the liver with dysfunction or failure despite minimal or no jaundice. Other organ failure, such as lung, kidney or bone marrow, may also be present and may overshadow the hepatic injury.4 Alternative causes of diffuse hepatic uptake on a bone scan imaging to consider include the administration of another hepatic radiopharmaceutical (such as 99mTc-sulfa colloid or a 99mTc- labeled white blood cell scan) within the previous day(s) 1,2. Excessive aluminium in the technetium pertechnetate eluate or ‘aluminium breakthrough’ can result in colloid formation. This can lead to hepatic uptake once injected, however lower bone uptake is also seen in these cases1. Routine quality control testing of technetium-production, renders this, as(is) unlikely to be the cause. Intravenous gadolinium injections used in MRI scanning has also been documented to cause hepatic uptake on bone scans and as such ‘at least 2 days of interval between MRI and bone scintigraphy might be needed to avoid hepatic uptake’2,3. Hepatic uptake has also been rarely described in patients with hepatitis, amyloidosis, recent iron therapy and other malignancies including myeloma and lymphoma 2,5. References: 1. Al-katib, S, Al-faham, Z & Balon, H, 2015, ‘Liver uptake on one Scanning: A diagnostic Algorithm’, Journal of Nuclear Medicine Technology, Vol. 43, No. 2, pp. 135-136. 2. Chen, P, Marentis, T & Brown, R 2014, ‘Diffuse Liver Uptake on 99mTc-MDP Bone Scan Secondary to Severe Hepatic Failure’, Clinical Nuclear Medicine, Vol. 39, No. 7, pp. 658-659. 3. Kyoungjune, P, Kim, S, Kim, I; Suh & Tak, K, 2012, ‘Hepatic Uptake of Tc-99m DPD on Bone Scintigraphy: The Influence of the Interval With Gadolinium-Containing Contrast of MRI, Clinical Nuclear Medicine’, Clinical Nuclear Medicine, Vol. 37, No. 2, pp. 134-136. 4. National Institutes of Health (NIH), 2017, Acute Hepatic Necrosis, viewed on 5th October 2018, <https://livertox.nih.gov/Phenotypes_ahn.html>. 5. Qui, Z, Xue, Y, Song, H & Luo, Q 2013, Diffuse hepatic uptake of 99mTc methylene diphosphonate on bone scintigraphy in a case of hypercalcemia and diffuse large B cell lymphoma, Hellenic Journal of Nuclear Medicine, viewed 10th October 2018, <http://www.nuclmed.gr/wp/wp-content/uploads/2017/03/70-2.pdf>.

2019 Summer Edition | gamma GAZETTE | 39

Education & CPD What’s that

What’s that? Author: Clair Coat, The Queen Elizabeth Hospital

Case Report: A 64 year old female inpatient was referred to the department complaining of ongoing right back and rib pain. She was febrile on admission with high CRP and being treated for cholecystitis. After further investigation, it became evident that this patient also had a history of NASH (non-alcoholic steatohepatitis)induced cirrhosis. The patient presented for a bone scan in order to investigate the possibility of osteomyelitis in the setting of infection. She was administered 810MBq of 99mTc HDP and dual phase imaging was acquired.

Figure 1: Whole body blood pool (left) and whole body delay (right) images The Blood Pool images showed scattered photopenic areas, consistent with ascites. Delayed whole body imaging showed subtle activity in the upper/mid lumbar spine, likely due to degenerative activity. The report stated that there was no evidence of osteomyelitis. Both the initial whole body blood pool (above, left) and the delayed whole body (above, right) images demonstrated markedly increased activity throughout both kidneys which was homogenous in distribution. What’s that? At the time of the study, the reporting doctor noted that ‘hot’ kidneys have been shown to be associated with cirrhosis, however drug (such as gentamicin) reaction remains a differential. Clinical correlation of renal function was recommended. Blood tests after this scan showed a GFR of 45mL/min, and significantly raised CRP and serum creatinine. Discussion: 99mTc-HDP is a tracer used for imaging active osseous abnormalities in nuclear medicine. It is taken up by the bones as a phosphate analogue (Elgazzar 2006), with higher tracer accumulation in areas of increased blood flow and bone formation such as in malignant disease (Wyngaert et al. 2016). 40 | gamma GAZETTE | 2019 Summer Edition

Education & CPD What’s that What’s that? (Continued) This tracer is excreted through the renal system, and so activity will be noted in the kidneys and urinary tract, though after a sufficient interval this activity should be low-grade (Wyngaert et al. 2016). In cases where there is significant retention of activity in the renal system, there are a number of possible explanations. Poor hydration, renal failure, dilatation of urinary system, incorrect tracer labelling and certain medications can be to blame for the accumulation of 99mTc-HDP in the kidneys (Koizumi et al.) (Bernard et al.). Hepatorenal syndrome is a secondary condition found in some people with advanced liver dysfunction, and is a manifestation of systemic circulatory dysfunction. This syndrome leads to the development of renal failure (Ng et al. 2007) in patients with cirrhosis with ascites and acute liver failure (Yeung et al.). This is caused by the local production of intrarenal vasoconstrictors (Gines, P, Arroyo, V 1999) as a result of the increased activity of the renin-angiotensin system (Bernardi). Clinically, this condition is characterised by a low GFR (<40mL/min) and very concentrated urine (<500mL urine/day)( Gines, P, Arroyo, V 1999). Rapid diagnosis and management are important as this condition comes with a very poor prognosis (Ng et al. 2007) unless a liver transplant can be performed. Hepatorenal syndrome has been linked to decreased bone uptake and increased renal accumulation of tracer in a number of cases (Erhamamci et al. 2013). Erhamamci et al. (2013) further suggested that diffusely increased renal retention of osseous tracer may be an early predictor of renal dysfunction or hepatorenal syndrome. The increased accumulation and retention of osseous tracers in the kidneys in cases of hepatorenal syndrome can be explained by the slow emptying and low output of the kidneys in renal failure. In this case, hepatorenal syndrome may have been to blame for the markedly increased accumulation of tracer in the kidneys. The patient passed away several months after the bone scan was acquired and this syndrome was not confirmed; however, these scintigraphic findings in conjunction with blood test results support renal failure, likely as a result of her advanced cirrhosis. This case brings to light the importance of collecting a comprehensive history from a patient and investigating further when abnormal images are acquired. In cases of tracer accumulation in the kidneys, this may serve as an early warning sign for kidney dysfunction and could potentially lead to earlier intervention and improved prognosis for the patient. References: Bernard, M, Hayward, M, Hayward, C, Mundy, L 1990, ‘Evaluation of Intense Renal Parenchymal Activity (“Hot Kidneys”) on Bone Scintigraphy, Clinical Nuclear Medicine, vol. 15, no. 4, pp. 254-256. Bernardi, M, Trevisani, F, Gasbarrini, A, Gasbarrini, G 1994, ‘Hepatorenal disorders: role of the renin-angiotensin-aldosterone system’, Seminars in Liver Disease, vol. 14, pp. 23-34. Byucsics, T, Krones, E 2017, ‘Renal dysfunction in cirrhosis: acute kidney injury and the hepatorenal syndrome’, Gastroenterology Report, vol. 5, no. 2, pp127-137. Elgazzar, A 2006, The Pathophysiologic Basis of Nuclear Medicine, Springer-Verlag, Berlin. Erhamamci, S, Aktas, A, Bahçeci, T, Kavak, K 2013 ‘Osseous and Nonosseous Bone Scan Findings in Liver Transplant Candidates with end-stage Chronic Liver Disease’, Molecular Imaging and Radionuclide Therapy, vol. 22, no. 2, pp. 23-31. Ginès, p, Arroyo, V 1999, ‘Hepatorenal syndrome’, Journal of the American Society of Nephrology, vol 10, no. 8, pp. 1833-1839. Koizumi, K, Tonami, N, Hisada, K 1981, ‘Diffusely Increased Tc-99m-MDP Uptake in Both Kidneys’, Clinical Nuclear Medicine, vol. 6, no. 8, pp. 362-365. Ng, C, Chan, M, Tai, M, Lam, C 2007, ‘Hepatorenal syndrome’, The Clinical Biochemist Reviews, vol. 28, no. 1, pp. 11-17. Wyngaert, T, Strobel, K, Kampen, W, Kuwert, T, van der Bruggen, W, Mohan, H, Gnanasegaran, G, Delgado-Bolton, R, Weber, W, Beheshti, M, Langsteger, W, Giammarile, F, Mottaghy, F, Paycha, F 2016, ‘The EANM practice guidelines for bone scintigraphy’, European Journal of Nuclear Medicine and Molecular Imaging, vol. 43, pp. 1723-1738. Yeung, E, Yong, E, Wong, F 2004. ‘Renal Dysfunction in Cirrhosis: Diagnosis, Treatment, and Prevention’, Medscape General Medicine, vol. 6, no. 4, p 9.

2019 Summer Edition | gamma GAZETTE | 41

EVENTS CALENDAR

16 January 2019

1-3 April 2019

VIC/TAS Branch Scientific Meeting 'ASNC2018 Highlights'

British Nuclear Medicine Society Spring Meeting

TBA

The King’s Centre, Oxford

CPD Points

www.bnms.org.uk

1-5 April 2019

26-28 April 2019

CNL and TRIUMF 11th Symposium on Targeted Alpha Therapy (TAT11)

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

Ottawa, Canada

Adelaide Convention Centre, South Australia

www.tat11.com

CPD Points

anzsnm.org.au Attendo Plus mobile App

23-24 FEB 2019

CANCER IMAGING SYMPOSIUM Oncology Onwards

Preliminary Program

Keynote Speaker

Professor Rod Hicks

The right test at the right time Co-Convenors Key Topics Tony Mulcahy & Aarthi Raman PET/MRI Event Contact Hybrid Imaging PET/CT cisymposium2019@gmail.com Multimodality Breast Imaging Registration Details Role of Imaging in Response Assessment https://www.trybooking.com/XOFB Cancer Care Patient Experience

Saturday

Sunday

8.30-9.00 9.00-9.30 9.30-10.00

23rd Feb Registrations Intro + Patient Journey Dr. Rod Hicks – The Right Test at The Right Time 10.00-10.30 NM/MI Techs – PET/CT

9.00-9.30 9.30-10.00

Morning Tea

10.30-11.00

11.00-11.30 Cancer Imaging – Adult General Hospital

11.00-11.30 RECISTing Change – role of CT & MRI in

11.30-12.00 Cancer Imaging – Specialist Hospital

11.30-12.00 RECISTing Change – emerging role of PET in

12.00-12.30 NM Techs – general vs specialist cancer

12.00-12.30 Oncologist – optimising imaging for response

response assessment response assessment care

assessment Lunch

13.30-14.00 PET/MRI – RCH experience 14.00-14.30 PET/MRI – Future prospects for cancer

care 14.30-15.00 PSMA Therapy 15.00-15.30 Sponsor – Guest Speaker

PLATINUM SPONSOR

10.00-10.30 Dr. Kate Moodie – Multi-Modality Breast

Imaging Morning Tea

10.30-11.00

12.30-13.30

PETER MACCALLUM CANCER CENTRE LEVEL 7 LECTURE THEATRE 305 GRATTAN STREET MELBOURNE VIC 3000

24th Feb Registrations Sponsor – Guest Speaker

17.00

Social Function

12.30-13.00

Conclusion

OFFICE BEARERS President Vice President Past President Treasurer Committee

General Manager & Secretariat All Correspondence

A/Prof Roslyn Francis (WA) Dr Daniel Badger (SA) Prof Dale Bailey (NSW) Mr Dominic Mensforth (SA) Ms Marcia Wood (TSIG) Dr Rajiv Bhalla (RPS) Mr Nicholas Ingold (ACT) Ms Judy Duong (QLD) Ms Victoria Brooks (NZ) Mr David Thomas (VIC/TAS) Dr Geoff Schembri (AANMS Representative) Dr Andrew St John and Drajon Management Pty Ltd ANZSNM Secretariat, PO Box 6178, Vermont South, Victoria 3133 Tel: 1300 330 402 | Fax: (03) 8677 2970 Email: secretariat@anzsnm.org.au

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

Mrs Rachel Prior Vacant Ms Leica Baker and Ms Karen Lindsay Ms Dai Nguyen Ms My Linh Diep Ms Georgina Santich Ms Jessica Fagan

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

Chairperson: Dr Elizabeth Bailey Chairperson: Dr Rajiv Bhalla Chairperson: Dr Daniel Badger Chairperson: Dr Darin Oâ€™Keeffe Chairperson: Prof Dale Bailey Chairperson: Prof Andrew Scott Mr Erwin Lupango

Reporting of Abnormal Behaviour of Radiopharmaceuticals The Society maintains a register of reports of abnormal behaviour of radiopharmaceuticals. Abnormal behaviour can be reported either by telephone fax or e-mail, or in writing to: ARPANSA 619 Lower Plenty Road Yallambie VIC 3085 Tel: (03) 9433 2211 Fax: (03) 9432 1835

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ANZSNM

Published on Dec 6, 2018

Gamma Gazette Summer 2019

Published December 2018

Gamma Gazette Summer 2019

Published on Dec 6, 2018

Published December 2018

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