Gamma Gazzette Nov 2017

2017 NOVEMBER EDITION • ISSUE 22

THE OFFICIAL PUBLICATION OF THE AUSTRALIAN AND NEW ZEALAND SOCIETY OF NUCLEAR MEDICINE

CONTENTS 5

November 2017 | Issue 22

22

PRESIDENT’S MESSAGE

WHAT’S THAT The case of a ‘hot-headed’ patient FDG PET/CT scanning

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28

WELCOME

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MEET ATTENDO PLUS

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BRANCH NEWS New Zealand news Vic/Tas Annual Seminar

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SIG NEWS

14

eSCAN ACADEMY

17 CASE STUDIES TB or not TB The importance of a complete patient history

SPECIAL REPORT WFNMB 2018 update

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MEETING REPORTS RAINS Meeting ANZSNM & IAEA

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WORD SEARCH

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EVENTS CALENDAR

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OFFICE BEARERS

CONTENTS

November 2017 | Issue 22

Pages 8-9 Meet Attendo Plus

Page 10 New Zealand Branch News

Pages 28-29 RAINS Meeting

Pages 24-27 2018 WFNMB

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

Page 34 Calendar of Events

Design & Production Ester Gomez, Creative Director Enovate Marketing ester@enovatemarketing.com.au

Welcome to the new Gamma Gazette The welcome for this edition of the Gamma Gazette is a little different as it comes jointly from the Victorian/ Tasmanian Branch and the Secretariat.

As is customary, Branch members have worked over the last few months to bring together an edition which we hope is both interesting and informative.

The Branch have contributed several interesting case studies from Monash Health and St Vincent’s Hospital, a report on their recent Annual Seminar and the popular Word Search. In addition, there is extensive coverage of the forthcoming 2018 WFNMB meeting in Melbourne and a report from the recent EANM meeting in Vienna.

And all of the above comes in a refreshed format as an ongoing initiative of Council to ensure the Society is sensitive to the needs of the membership whilst conscious of cost. These changes are prompted by a recent survey of the membership which indicated that the Gamma Gazette remains popular with a majority of the membership but required some updating.

As well as the different look, the Gamma Gazette will also be available to you in a more friendly format where the pages can be easily ‘turned’ on your desktop or mobile device and to be made available in the new ANZSNM website.

The Council through the Secretariat would like to continue to work with the membership to make further changes which enhance its appeal, content and readability. Whilst the Branches will continue to take the lead to contribute content, the Secretariat is also keen to solicit suitable articles and information at all times from the wider membership. We will continue to promote Nuclear Medicine practice whilst at the same time widen the range of content, striking a balance between educational material and content of a more social nature such as articles about events. Accordingly readers are directed to the call for contributions on page 21 of this issue.

Finally from the Victorian/Tasmanian Branch, we look forward to a nice long summer break before gearing up for a busy 2018 when we will be the hosting Branch of the World Federation of Nuclear Medicine and Biology (WFNMB) Congress in Melbourne in April.

This quadrennial event will encompass our Annual Scientific Meeting as well as showcase the latest worldwide developments in Nuclear Medicine. We encourage all members to mark WFNMB in their calendars and make every effort to attend this unique event!

Wishing you all a joyous festive season and prosperous 2018.

On behalf of the Victorian and Tasmanian Branch of the ANZSNM

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President’s Message Disruptive Technologies

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t is tempting for each generation to think that the technological and social changes that they are experiencing are happening at a far greater rate and have more profound consequences than has ever occured previously. History tends to tell a different story, however, with periods such as the Industrial Revolution from 1760 in the UK having a far more profound effect on people’s lives than anything that Facebook, Google & Elon Musk are doing today.

Nevertheless, change is happening and we need to be able to adapt to these changes to take best advantage of what the developments in technology offer.

I would argue that the introduction of PET/CT at the turn of this century is probably the most profound case of a new, disruptive technology in nuclear medicine since the introduction of the gamma camera and technetium-99m around 1960. It is very clear to those who have PET that it is one of the major drivers in nuclear medicine today, because of the impact that the scans have on patient management. That is to say, the scans provide unique, valuable information about the individual patient usually regarding the staging of their disease, in the case of cancer.

We have a large number of new technologies currently being introduced or having been added in recent years that represent incremental improvements in nuclear medicine practice.

Examples include solid-state radiation detection (CZT detectors), advances in chelation chemistry in particular for radiometals, combined PET/MRI which itself required an enormous investment of time, money and resources for the development of new technology to enable this hybrid device to be constructed, the introduction of alpha-emitting radiopharmaceuticals for therapy, peptide receptor radionuclide therapies (PRRT), improved reconstruction algorithms, as well is the identification of new targets for diagnostic imaging and therapy from molecular profiling and biology.

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But none of these, I suggest, have or will have the impact in medicine that PET/CT alone has had. The reasons for this may be complicated and may include lack of funding or ability to recognise significant advances without having to “build a business case” and subject all new developments to a randomised controlled trial to demonstrate its potential benefit. But there are just some things, PET/CT being an example, that are hard to dismiss.

What are the next disruptive technologies heading our way? Certainly today there is a lot of interest in machine-based image analysis and interpretation - one area of which is known as Radiomics . These algorithms interrogate characteristics of medical images such as texture and heterogeneity in addition to size, shape and other more commonly used features of lesions and tissues. Much of the work to date has been with x-ray CT images but is now finding its way into MRI and PET as well. Another area could well be the use of PET for applications other than in oncology. What if functional imaging were to be taken up with such enthusiasm in the area of neurodegeneration, cardiovascular disease, chronic musculoskeletal conditions which have such a large impact on our workforce and society, or even the metabolic challenge of obesity and diabetes? Given a new therapy and a new radiopharmaceutical, any one of these may emerge as the “next big thing” for nuclear medicine.

Disruptive technologies for us extend further than diagnostic imaging and therapies and increasingly affect how we communicate and interact with each other. It is clear that, in our big cities, it is becoming more difficult in today’s busy world to hold conventional, mid-week scientific and clinical branch meetings. This may be unfortunate, however, it is the reality we see today. Do we need to meet together as a multidisciplinary group to exchange information and thoughts (as we did in the previous century) when we can so readily access similar content online or through rapid communication platforms today? Thinking further, do we really need to travel to the northern hemisphere to attend large scientific and clinical meetings, or would we do ourselves and the environment a favour by taking in the main lectures and teaching events online from the comfort of our home? The EANM, for example, is increasingly making this sort of content available for free as the rise and rise of nuclear medicine in Europe continues at great pace.

What this technology cannot replace, however, are the human interactions, discussions, debates, arguments and simply “catching up” that is such an important aspect of our meetings. Skype can only go so far.

On that note I want to take this opportunity to remind you that the Society is bringing the world’s best in nuclear medicine to your backyard in April next year for the12th Congress of the World Federation of Nuclear Medicine and Biology. It will be a long time, if ever, before such a stellar array of researchers, clinicians, speakers and lecturers in nuclear medicine from all points of the globe will assemble in Australia. At the recent Annual Congress of the EANM held in Vienna I was approached by numerous highly regarded colleagues in the field asking about the program for the Congress and offering their services to become involved. If you are sitting back and watching as the program takes shape, and still in two minds as to whether to attend or not, I would suggest that the time to decide to attend is now and I would get in while the early bird registration fees are still on offer. It will be a meeting not to be missed.

I look forward to seeing you all in Melbourne in April.

Dale Bailey PhD President ANZSNM gamma GAZETTE -7-

Meet Attendo Plus Book, attend and track all your CPD activity anytime from anywhere!

The Australian and New Zealand Society of Nuclear Medicine in partnership with Attendo Plus is excited to announce the launch of the new Attendo Plus app, which has been especially designed to provide our members with a centralised platform to manage and track all their CPD activity, anytime from anywhere.

Empower yourself with the latest technology that Attendo Plus offers. Download the app today to register for upcoming CPD events, record attendance and your CPD points, manage your CPD certificates, access your logbook, network with your peers and more.

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DON’T MISS A THING! Keep up to date with all the upcoming ANZSNM CPD activities relevant to you. These include in person but also on line CPD programs.

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You can even see which exhibitors and event partners will be present at each CPD event in advance, allowing you to decide whether you wish to add a visit to your agenda.

KEEP IT ALL TOGETHER View your bookings, track your attendance, record the number of CPD credits, store and manage your certificates, set up your own CPD goals and use AttendO Plus as your CPD networking hub.

REMEMBER EVERYTHING Access your own CPD calendar with just one click. Keep everything that matters to you in one place. Set up alerts and use your journal to record all your learning progress and important notes from your events.

TAKE CONTROL Access your CPD certificates right after you have completed a CPD activity. Choose to print it directly from your mobile app or simply keep it in your certificates repository.

Use your phone to quickly and easily confirm your participation at any CPD activity by scanning the event’s QR code at the event’s venue. No need to bring with you printed bar codes or having to queue to sign-in.

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SEE YOUR PROGRESS AT A GLANCE Get an instant view of your overall progress and achievements at anytime from anywhere.

Track results against your goals and use AttendO Plus Log Book and Journal to help you move forward with your professional development.

ALWAYS ON SYNC, ALWAYS ON THE FLY AttendO Plus is always on the go with you. As you register, attend and complete your CPD events, AttendO Plus keeps working in the background by updating all the progress that you make.

attendoplus.com

Branch News New Zealand Hamilton hosted our annual branch meeting, Berry Allen and his able team at Waikato Hospital NM Department put on a fantastic scientific and social program. Berry organised some great local content.

PSMA was on point this meeting with presentations from Mr Michael Holmes Urologist on his perspective and Mercy Radiology’s registrar Dr Bonnie Leung on their experiences with Ga-68 PSMA imaging. Wellknown Australian Nuclear Medicine physician Dr Geoff Schembri presented to us on PSMA and Lutetium theranostics, and NET imaging.

Hawkes Bay NMT Prue Lamerton bought in the patient perspective of Lutetium treatment, by giving us a patient journey and then introducing the patient to us. It was fantastic to hear from a patient’s point of view about the process and his treatment. Not a dry eye in the house after he spoke! New motivation came from the audience about how we can provide Lutetium therapy here in NZ – so watch this space.

On Saturday night, a live band entertained us, and the theme of the evening was Rocky Horror Picture Show. Be warned, NZ NMT’s do not take dressing up lightly. Check out the brilliant photos.

Sunday speakers included Stuart Lillie from the Order of Radiation Safety talking to us on the recent introduction of the Radiation Act released in March 2017. Geoff Currie spoke on NM and the sympathetic nervous system. Geoff’s take home message was all about encouraging NMT’s to do more research, base it around what we see and take for granted each day.

As we head towards the end of 2017, the NZ branch would like to wish its Australian colleagues, a safe and happy Christmas, and all the best for 2018.

Pru Burns, NZ Branch Secretary

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Branch News VIC/TAS Annual Seminar Victorian and Tasmanian Branch members get together in Melbourne for their Annual Seminar.

On Saturday 16th September more than sixty Society members got together in the Crowne Plaza Melbourne for their Annual Day Seminar.

Representatives of the Society’s Secretariat were on hand at the start of the day to assist with members in further refining the AttendO app to sign in for the meeting to enable automatic generation of their attendance certificates. The Vic./Tas. Branch, after this event, were the most effective AttendO users with 98% use of the app to receive certificates via email. In addition, we had a photographer to give us the great pictures that accompany this article.

A wide range of topics were covered in the program led

by Sam Gledhill from the Movember Foundation who was formerly a Nuclear Medicine technologist. He described how the Movember organisation had grown from a fun bet between friends to an organisation that facilitated worldwide clinical trials for prostate and testicular cancer. He spoke at length about

the GAP2 “Imaging in Advanced Prostate Cancer” project in which he has been involved and which includes groups studying 4 different tracers - FACBC, F-Choline, FDHT and PSMA. David Krenus from Cyclotek spoke on recent developments in Theranostics in relation to neuroendocrine and prostate cancer. He discussed the

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fluorinated PSMA compound, developments for cold kit PSMA production as well as 177LuPSMA as a therapy option. The talk also included an update on the current state of Peptide Receptor Radionuclide therapy (PRPT), as well as a look at the future in terms of new tracers and clinical trials we can expect to see in 2018.

Vic/ T liste as bran ning ch to J memb ason e ’s ta rs lk

Jaso Bio n Brad m le PET edical y (Mo nas Ima /MR h g I in a re ing) dis sea rch cussing faci lity

Me l Sta anie C cey r Bak owthe er r,

Pro Ho f Ke n PE spita Mile T/M l) s s RI peak ( Prin ing ces on s A clin lex ica and l ra

VIC/TAS Annual Seminar (continued) Our Pioneer Speaker this year was Dr John Mackay who reminded the audience that Nuclear Medicine has been doing what we now call Theranostics, since 1940 in the form of radioiodine for thyroid cancer. His years of experience in treating many patients gave everyone a comprehensive review of diagnosis and treatment of thyroid disorders and thyroid cancer.

To whet the appetite for lunch, there was an informative presentation on Stomas from Stomal Therapy nurse Lisa Connolly of Monash Health. Given many of our patients attend our departments with stoma bags, it was interesting to learn about the different reasons as to when and why stomas are used, as well as the different types, and also the day to day challenges for these patients.

The afternoon session focused on PET/MRI, with a presentation from Jason Bradley from Monash Biomedical Imaging. He discussed the challenges with working in a research facility versus the clinical environment, and the various issues concerning PET/MRI scanning. Jason gave us an overview of some of the trials in which they are involved, including PSMA/MRI prostate imaging, brown fat activation studies as well as “functional” PET/MRI, where dynamic glucose utilization is studied.

The Branch was very fortunate to have Prof Ken Miles from the Princess Alexander Hospital in Brisbane to speak on the challenges and clinical impact of PET/MRI. There was an interesting discussion on when PET/CT or PET/MRI are better suited to the clinical question, and about when these studies can be used together for patients with prostate cancer, and for those with liver disease.

The program concluded with a short presentation on the World Nuclear Medicine Congress in Melbourne next year, which was a great chance to see how the program is shaping up. Following that we retired to the Wharf Hotel for postseminar drinks and the opportunity for members to catch up with other colleagues from around the state.

The day’s proceedings also included our AGM where we formally approved two new members coming onto the Committee – My Linh Diep and Christian Testa; David Thomas reported briefly on matters from Council; and there was an update on matters related to TSIG.

Ch Br ristia a int nch n Tes rod Tre ta ( a uc ing sure Vic/T as Pr r) of Ke nM iles

I look forward to seeing you at our next event.

Kim Jasper Chair Victoria/Tasmania Branch

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SIG News Technologists brave the Ballarat weather The annual Technologist’s Special Interest Group (TSIG) Day Seminar was held on the 22nd July in freezing Ballarat. Despite the weather over 60 technologists took part with delegates coming from all over Australia and New Zealand, with regional Victoria being well represented.

To match the historic setting of Sovereign Hill, Paul Marks shared the history of ARPANSA - including its connection to Marie Curie! In another nod to history Kim Jasper shared how PYP scanning for Cardiac Amyloidosis is making a comeback, and Bridget Chappell retold the development of GFR calculations.

The focus then shifted to current breakthroughs with Liz Bailey speaking about the Royal North Shore’s experience with implementing a Lu-177 therapy program, and Payal Virdi sharing Lake Imagings’ incidental findings when using Ga68-PSMA. Peter Eu, in his inimitable way, shook things up with a rundown of the tracers that he is currently working on, with potentially some very exciting innovations in the pipeline.

In the last session for the day Suzanne McGavin discussed different learning and teaching styles using the latest in educational understanding. The take home point of this talk was that everyone has something of value to offer when it comes to educational needs within our departments, as there is a diversity of teaching styles and approaches that are effective for different learning styles. This was followed with a panel discussion in which we were able to get into the finer details of what this means and how it impacts our departments and universities.

Despite the interruptions of the poor heating, an 1850’s style shootout, snow falling, and more than a few tourists poking their heads in and being thoroughly confused, the day was a great success with many technologists gaining new insights into their craft.

Thank you to everyone who contributed to create this enjoyable event and a particular thanks to our major sponsors Siemens Healthineers and MIPS.

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E-LEARNING New partnership between eScan Academy and ANZSNM A new education tool for nuclear medicine professionals

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ACKGROUND: eLearning has become an important

part of education in the medical field and a valuable complement to reading textbooks and articles from journals and attending courses and educational sessions at scientific meetings. With more restrictions on who can travel to meetings eLearning is available whenever and wherever you want from your desktop or mobile device. Webinars, videos, webcasts and slides from educational sessions at scientific meetings are all examples of eLearning resources.

As part of its new strategy to provide more education resources for its membership, the Society has established a partnership with the eScan Academy, www.eScanAcademy.com to provide their novel eLearning tool to our members.

This tool that can provide interactive step-by-step training to learn how to read and interpret nuclear medicine images. A comprehensive database of educational cases covering all core disciplines of nuclear medicine will help all those involved in nuclear medicine training to enhance their diagnostic skills.

ANZSNM members can access eScan for $75 per year and this can be paid as part of renewing their 2018 ANZSNM membership.

The field of nuclear medicine is especially suited for eLearning. Even though fundamental and specialized knowledge is important, the skill of reading images is to a great extent based on experience from interpreting many cases. Therefore many curricula for specialist training now specify how many cases the resident or trainee must interpret.

The eScan Academy The Academy contains CME courses in all core disciplines of nuclear medicine. Within each core discipline, the courses explain how to read, manipulate, analyse and interpret all relevant nuclear medicine images using nothing but a standard internet browser. This includes planar images, gated cardiac images, MIP/raw images in cine mode, SPECT, SPECT/CT, and PET/CT. All patient cases are carefully selected and classified by our faculty of senior nuclear medicine professionals. Findings in the images are marked and described in teaching points, often with links to open access papers or guidelines. These teaching points simulate the situation when a senior nuclear medicine specialist sit beside and explain the findings in an image. With the eLearning tool, the expert is available whenever and wherever you want.

The eScan Academy was established by a group of experienced nuclear medicine professionals. The first goal was to develop an online teaching and eLearning platform that is easy, flexible and smart, with relevant content of high scientific quality. Now the focus is to enrich the value of the content by inviting experts in different fields to contribute with further cases. The eScan Academy provides more than 25 fully accredited courses for Continuing Professional Development which are accredited by the European Union of Medical Specialist and the American Medical Association.

MAKE THIS SPACE YOURS ADVERTISE IN GAMMA GAZETTE by emailing marketing@anzsnm.org.au

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Introducing

Biograph

See a whole new world of precision

Vision

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

Transcend digital with the Optiso UDR Detector

1 2 4 3

5

54 540 ps > 8 mm segment of response

Small crystals big impact

249 ps > 3.7 mm segment of response (Biograph aph Vision) Vision)

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

• 3.2 mm crystals • 249 ps time-of flight

siemens.com/mi

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

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

3. 100% coverage of the crystal area with SiPM sensors results in a timing resolution of 249 picoseconds and 3.4 times higher effective sensitivity for faster scans and lower dose.

4. A small block size delivers >1150 kilo counts per second effective peak NECR for improved clinical performance.

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

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1. Based on competitive literature available at time of publication. Data on file. * The availability of the Biograph Vision is subject to approval by the TGA (Australia) and Medsafe (NZ)

Case Study TB or not TB Nicole Smolcic, Monash health, Victoria

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LINICAL STUY: A 35-year-old female who is known to the infectious diseases clinic, presents with one month of flu like symptoms, palpable right cervical lymph node and right facial numbness.

The patient has a previous history of successfully treated tuberculosis. Sputum samples and QuantiFERON-TB Gold blood tests have returned a negative result for tuberculosis recurrence. An external diagnostic CT of the neck and chest reports enlarged cervical and axillary lymph nodes. The report concludes that the CT has the radiographic features of lymphoma and also notes scaring on the lungs likely due to previous tuberculosis infection. An external ultrasound guided biopsy of the cervical lymph node has also been completed. The histology report describes a metastatic carcinoma with “weak-mod patchy staining with GATA3” which is suggestive of a breast cancer primary. Due to these findings the patient is referred to the breast oncology team. The patient has no family history of cancer and has no strong risk factors.

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nvestigations: The patient is referred to our nuclear medicine department for a whole-body bone scan as part of a routine work up for staging of breast cancer. The patient had no other bone history. A whole body three phase bone scan is completed with a dose of 719 MBq of HDMP. A delayed SPECT/ CT of the lower limbs is also completed.

Figure 1: Whole body blood pool

Figure 2: Delayed whole body bone scan

The whole-body bone scan is unremarkable except for the 5cm left medial anterior tibial lesion which has no obvious cause. With no other areas of increased bony uptake this lesion is reported to have the appearance of a healing non-ossifying fibroma (NOF)[1]. It is not uncommon for NOFs to be asymptomatic. However, they are usually found in the adolescent population [1]. Known as a “do not touch lesion, NOFs will typically heal on their own without any intervention [1]. An ultrasound and mammogram of the breasts is also completed and reports no evidence of any significant abnormality.

With a diagnosis of a breast cancer primary becoming more unlikely an 18F FDG PET scan is ordered.

A weight based dose of 175 MBq is used with an uptake time of 90 minutes. A whole body PET/CT scan is performed from vertex to feet. The acquired scan reveals an intensely avid nasopharyngeal lesion (SUV of 19). In the provided clinic-pathological context of metastatic carcinoma on cervical lymph node biopsy, the PET findings are consistent with nasopharyngeal carcinoma, with bilateral cervical and right axillary nodal metastases and no evidence of avid distant metastatic disease.

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Case Study TB or not TB (continued)

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iagnosis and Management: A subsequent tibial biopsy is preformed which confirms a non-aggressive non-ossifying fibroma. A Naso-endoscopy and Biopsy is also performed which demonstrates a polypoid tumour. Histopathology reports an undifferentiated non-keratinising carcinoma.

An MRI is performed to complete the patients work up. The nasopharyngeal carcinoma is reported to measure up to 42mm, with infiltration of the right infratemporal space.

Perineural spread along the right V2 and V3 nerves to the middle cranial fossa and orbit is noted along with bilateral cervical level IIa and left intraparotid nodal involvement. MRI staging is reported to be T4N2Mx. As a result curative chemotherapy and possible adjuvant Radiation therapy is prescribed for this patient.

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iscussions: The infectious diseases clinic’s initial investigation for recurrence of tuberculosis after the patient’s first presentation is a result of antiquity.

Commonly known as “scrofula” extra pulmonary spread of tuberculosis affects the cervical lymph nodes in at least 20% of cases [2]. Lymphoma particularly follicular lymphoma is a common differential diagnosis upon biopsy of these lymph nodes [2]. However the result of the cervical lymph node biopsy is a suggestion of metastatic breast cancer.

According to the American Cancer Society up to 40% of cancers diagnosed in women under the age of 40 are forms of breast cancer [3]. The nasopharyngeal carcinoma is impressive on the PET scan however not a typical diagnosis in a young non-smoking female.

Nasopharyngeal carcinomas only represent a small amount of the global cancer burden - approximately 0.7% [4] – but it is three times more likely to occur in men than in women. According to the United Kingdom’s cancer research institute only approximately 240 cases are diagnosed in the United Kingdom each year [5]. This case is an excellent example of the sensitivity of 18F FDG PET scans in unknown primary cases.

References 1.

Hod N LY, Fire G et-al. Scintigraphic characteristics of non-ossifying fibroma in military recruits undergoing bone scintigraphy for suspected stress fractures and lower limb pains. Nucl Med Commun. 2007;28(1):2533.

2.

Thakkar K GS, Singh M. Lymphadenopathy: Differentiation between Tuberculosis and Other NonTuberculosis Causes like Follicular Lymphoma. Front Public Health 2016.

3.

Carey K. Anders aRJ, b Jennifer Litton,c Marianne Phillips,d and Archie Bleyere. Breast Cancer Before Age 40 Years. Semin Oncol. 2009;36(3):237-49.

4.

Ahmedin Jemal D, PhD, ; Freddie Bray P, ; Melissa M. Center M, ; Jacques Ferlay M, Elizabeth Ward P, ; David Forman P. Global cancer statistics. CA: A cancer journal for clincians 2001;61(2):69-90.

5. uk cr. About nasopharyngeal cancer. 2016 [cited 2017]; Available from: http://www.cancerresearchuk.

GAZETTE org/about-cancer/nasopharyngeal-cancer/about.

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Figure 3 SPECT/CT Lower Limbs

Figure 4 Whole body MIP

Figure 5 PET/CT Save screens demonstrating nasopharyngeal carcinoma

Case Study The importance of a complete patient history

By Lauren Hudswell

Abstract Small lymphocytic lymphoma (SLL), also known as chronic lymphocytic leukemia (CLL) depending on disease location, is one of the most prevalent types of chronic lymphomas in the western world [1].

Whilst this form of lymphoma is very common, presence of infiltration into cutaneous tissue of SLL cells is very rare. The spread to skin tissue significantly alters a patient’s prognosis. Hence, in patients who present with SLL for further diagnostic evaluation, obtaining a correct and full medical history is vital in determining whether progression of the diseases has occurred.

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ntroduction: Small lymphocytic lymphoma (SLL), also known as Chronic Lymphocytic Leukemia (CLL), was first reported in the early 1900’s by Turk et al [1]. It is considered a low grade Hodgkin’s lymphoma categorized by the occurrence of small B-lymphocytes that most commonly express the surface antigens CD5 and CD23 [1]. Cell transformations can occur in SLL/CLL, that although rare can cause the spread of cancerous cells to the cutaneous tissue. 18F-FDG PET/CT scanning is essential in determining whether systemic spread or large cell transformation has occurred.

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ase Report : A 60 year old women presented with an extended period of fatigue and overall body ache and a history of SLL, previously treated with chemotherapy. An 18F-FDG PET/CT scan was performed with an imaging range from the superior orbits to the upper thighs on a hybrid PET/ CT scanner following intravenous administration of 305MBq of 18F-FDG. A contemporaneous low dose, non-contrast CT scan was performed for purposes of attenuation correction and anatomical localisation. The uptake period was 81 minutes and the BSL was measured at 3.8mmol/L prior to injection. This imaging was compared with previous external CT imaging performed twelve months prior.

18F-FDG localisation highlighted mildly enlarged bilateral jugulodigastric lymph nodes, which demonstrated relatively low-grade avidity (SUV max 2.38), as seen in figure one. Further, mildly enlarged and numerous lymph nodes were evident bilaterally demonstrating similar low-grade avidity.

There was no evidence of avid lymphadenopathy demonstrated within the mediastinum.

There was uniform FDG avidity within the liver and spleen with no evidence of significant mediastinal, abdominal or pelvic lymphadenopathy.

No inguinal lymphadenopathy was evident. No abnormal F1: Whole body 18F-FDG PET scan FDG accumulation demonstrated within the axial or appendicular skeleton.

Mildly enlarged lymph nodes were demonstrated within the right and left neck as well as right and left axillae. Structurally these were stable when compared to previous imaging and the low-grade avidity would be in keeping with the current diagnosis of small lymphocytic lymphoma. There was no evidence of large cell transformation.

Incidental note was made of linear moderate to intense 18F-FDG avidity within the skin and subcutaneous tissues below the right eye and below the right and left angle and body of the mandible, as evident in figures two and three. There was no evidence of abnormal cutaneous FDG accumulation demonstrated elsewhere.

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Case Study The importance of a complete patient history (continued)

Figure 2: Fused PET/CT axial images similar morphological progressions.

Small lymphocytic lymphoma (SLL), also called chronic lymphocytic leukaemia (CLL), is a very common form of chronic lymphoma [1]. The two pathologies are very similar in their disease progression with the exception of the primary location of cancerous cells. SLL cells are predominantly found in the blood stream whilst CLL cells are found in the lymph nodes and bone marrow [3] Figure 3: Sagittal view of 18F-FDG PET/CT scan

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iscussion: PET/CT imaging plays a significant role in the confirmation of a clinical diagnosis by identifying characteristic features of this disease. Firstly, it is able to identify a variance in the energy usage of a cell, which is increased in cancerous cells due to their rapid proliferation [2]. Secondly, it is able to identify anatomical landmark correlation and as such determine the likely pathology. Finally, the pattern of uptake of a specific disease is able to differentiate between various diseases with

Whilst infiltration into dermal tissue can occur in up to 50% of patients with lymphoma, patients with CLL/SLL rarely experience this [4]. When skin lesions are reported, they occur most commonly in the head and neck region [5].

Dermal 18F-FDG localisation was identified under the right eye and both the left and right mandible, though the cause was initially unknown. Patients with CLL/SLL without dermal transformation commonly undergo chemotherapy with or without radiotherapy [6]. For those patients who do have a dermal transformation, the prognosis varies.

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Case Study The importance of a complete patient history (continued) For patients with a specific type of CLL, B-CLL, dermal transformation is reflected by a fairly good prognosis, with dermal lesions resolving within 4-6 months with chemotherapy [6,7]. However in patients where the CLL has undergone Richter’s syndrome, with transformations to the skin after diagnosis, the prognosis is poor (6,7).

Upon further questioning of the patient at the end of the scan, it was identified that they had recently undergone cosmetic procedures including Botox and Dermafil injections. Therefore this uptake was subsequently attributed to be inflammatory changes related to the recent procedures. Had this information not been obtained, interpretation of the acquired images could have led to an incorrect treatment pathway.

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onclusion: Although 18F-FDG PET/CT scanning is highly sensitive in the detection of certain malignancies, it is sensitive for many indications including inflammatory and infective processes also [2]. The ability to differentiate between these conditions is complex and without a comprehensive history, reporting physicians can be misinformed leading to poorer patient management. As such, it is extremely important to obtain a full and truthful medical history from the patient prior to the commencement of the scan in order to determine variances in uptake of radiotracer.

References 1.

Dores GM, Anderson WF, Curtis RE, Landgren O, Ostroumova E, Bluhm EC, et al. Chronic lymphocytic leukaemia and small lymphocytic lymphoma: overview of the descriptive epidemiology.

British journal of haematology. 2007;139(5):809-19.

2.

Sazon DA, Santiago SM, Soo Hoo GW, Khonsary A, Brown C, Mandelkern M, et al. Fluorodeoxyglucose-positron emission tomography in the detection and staging of lung cancer. American journal of respiratory and critical care medicine. 1996;153(1):417-21.

3.

Santos FP, O’Brien S. Small lymphocytic lymphoma and chronic lymphocytic leukemia: are they the same disease? Cancer journal. 2012;18(5):396-403.

4.

Lu C, Li L, Qiao Q, Liu G, Fang L. Cutaneous manifestations in a patient with chronic lymphocytic leukemia involving the head, neck and distal extremities. Experimental and therapeutic medicine. 2015;9(3):877-9.

5. di Meo N, Stinco G, Trevisan G. Cutaneous B-cell chronic lymphocytic leukaemia resembling a granulomatous rosacea. Dermatology online journal. 2013;19(10):20033. Robak E, Robak T. Skin lesions in chronic lymphocytic leukemia. Leukemia & Lymphoma. 2007;48:855-65.

6.

Cerroni L, Zenahlik P, Hofler G, Kaddu S, Smolle J, Kerl H. Specific cutaneous infiltrates of B-cell chronic lymphocytic leukemia. America Journal of Surgical Pathology. 1996;20:1000-10.

You are invited!

We would like to invite all our members to submit relevant content to the Nuclear Medicine community, to be part of future editions of Gamma Gazette.

The material must relate to the scientific, technological and clinical aspects of nuclear medicine and can include, but is not limited to original research articles, case studies, educational papers, events reports, reviews or letters are welcomed.

Together with any material, we encourage contributors to include images that support the content being submitted.

To submit your content, simply send an email to secretariat@anzsnm.org.au with a brief introduction and your piece of content attached.

For more details on how to become a contributor, visit anzsnm.org.au/contribute

gamma GAZETTE 2018 GAMMA GAZETTE EDITIONS - 21 March 2018 - July 2018 - November 2018

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Your membership is almost up.

It’s time to renew it for 2018!

Keep up to date with the latest developments in nuclear medicine science.

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To renew or upgrade your membership, visit www.anzsnm.org.au

What’s that The case of a ‘hot-headed’ Patient My Linh Diep, Monash Health, Victoria

Introduction A middle-aged male, with past history of melanoma 11 years ago who now has back pain and elevated ALP, presented for a bone scan to exclude bony metastasis or Paget’s disease.

What is the explanation for the ‘hot’ appearance of the calvarium?

Figure 1: Delayed whole body bone scan

C

ase Report: The patient is a 65 year old male who had groin and abdominal melanoma 11 years ago and treated with surgical excision of the primary sites. The patient reports two to three years of back pain which increased with physical activity but with denial of pain elsewhere.

Perfusion imaging over the lumbosacral spine was acquired following injection of 789MBq of 99mTcHMDP. Whole body blood pool and delayed imaging ensued. No increased vascularity or hyperaemia were apparent in the lumbosacral spine and no osteoblastic lesions to explain the patient’s symptoms.

Patchy moderate to intense increased osteoblastic activity was present throughout the calvarium.

Contemporaneous low dose CT showed increased ground-glass attenuation in the diploic space with no bony expansion or cortical thickening. The posterior right parietal bone showed a moderately avid lesion with cortical thinning with no involvement of the soft tissue.

Comparison with an MRI of the pituitary gland from 2 years ago demonstrated patchy low T1 and high T2 with similar distribution to the bone scan. Presence of this intense increased patchy bone remodelling throughout the calvarium for two years was suggestive of an indolent or benign aetiology rather than malignancy. Appearance on low dose CT compatible with fibrous dysplasia.

D

iscussion: Fibrous dysplasia (FD) is a skeletal disorder caused by activating mutations of the GNAS gene and is generally slow growing1. FD is characterised by formation of fibro-osseous tissue and accounts for approximately 7% of benign bone tumours4. Less than 1% of fibrous dysplasia cases can undergo malignant transformation1. Phenotypic manifestations comprise monostotic FD, polyostotic FD or McCune-Albright Syndrome1. Clinical presentations include increasing pain, swelling, and pathology fracture4 but vary according to types of genotypic mutation.

For example, facial deformity, hearing impairment, and paresthesia can also manifest1.

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What’s that

The case of a ‘hot-headed’ Patient (continued)

Figure 2: Axial slices of fused SPECT/CT of calvarium

Figure 3: Coronal view of retrospectively fused SPECT/MRI of head

Radiologically, fibrous dysplasia depicts as a well-defined lucent lesion with a ground-glass appearance4. Commonly affected sites are the craniofacial bones, proximal femur and rib1. Imaging with CT would better characterise the sclerotic margin of fibrous dysplasia and assess the cortical bone.

Imaging with a bone radiotracer enables the assessment of periosteal reaction, metabolic changes, and multiplicity of lesions which is advantageous in optimising surgical strategy4. Interestingly, histological information offers little prognostic value to FD and hence a biopsy is only indicated when diagnostic confirmation is imperative prior to surgery1.

The diverse clinical presentation and progression of FD confers varied management strategies1. It is suggested that bisphosphonate therapy can help reduce pain and slow the growth of FD1,2. The location and extent of bony and/or soft tissue involvement greatly influences management. Often observation and monitoring of clinical changes are adequate1.

References 1.

JS Lee, EJ FitzGibbon, YR Chen, HJ Kim, LR Lustig, SO Akintoye, MT Collins, LB Kaban “Clinical guidelines for the management ofcraniofacial fibrous dysplasia” Orphanet Journal of Rare Diseases 2012, 7(Suppl 1):S2.

2.

Lustig LR, Holliday MJ, McCarthy EF, Nager GT. “Fibrous Dysplasia Involving the Skull Base and Temporal Bone.” Arch Otolaryngol Head Neck Surg. 2001;127(10):1239–1247.

3.

Singh, Amit Kumar et al. “Skull Base Bony Lesions: Management Nuances; a Retrospective Analysis from a Tertiary Care Centre.” Asian Journal of Neurosurgery 12.3 (2017): 506–513. PMC. Web. 26 Sept. 2017.

4.

Wei-Jun Wei, Zhen-Kui Sun, Chen-Tian Shen, Xin-Yun Zhang, Juan Tang, Hong-Jun Song, Zhong-LingQiu, Quan-Yong Luo“Value of 99mTc-MDP SPECT/CT and 18F-FDG PET/CTscanning in the evaluation of malignantlytransformed fibrous dysplasia.” Am J Nucl Med Mol Imaging 2017;7(3):92-104

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What’s that FDG PET/CT Scanning All the other things we can see

By Lauren Thomas

C

linical Notes: 58 year old male with nonkeratinizing nasopharyngeal carcinoma.

Staging examination prior to radiotherapy treatment.

T

echnique: PET/CT images acquired from neck to upper thighs along with a separate head and neck post injection of 260MBq of 18F-FDG. Uptake times were: 58min (Body) and 80min (H/N). BSL at time of injection was 5.2mmol/LThere was no evidence of avid lymphadenopathy demonstrated within the mediastinum. There was uniform FDG avidity within the liver and spleen with no evidence of significant mediastinal, abdominal or pelvic lymphadenopathy.

No inguinal lymphadenopathy was evident. No abnormal FDG accumulation demonstrated within the axial or appendicular skeleton.

Mildly enlarged lymph nodes were demonstrated within the right and left neck as well as right and left axillae. Structurally these were stable when compared to previous imaging and the low-grade avidity would be in keeping with the current diagnosis of small lymphocytic lymphoma. There was no evidence of large cell transformation.

Incidental note was made of linear moderate to intense 18F-FDG avidity within the skin and subcutaneous tissues below the right eye and below the right and left angle and body of the mandible, as evident in figures two and three. There was no evidence of abnormal cutaneous FDG accumulation demonstrated elsewhere.

FINDINGS: Primary Tumour: There is intense metabolic activity (SUVmax = 5.4), corresponding to the left side of the nasopharynx, consistent with the location of the primary carcinoma.

Nodal Metastases: No FDG avid nodal metastases.

Distant Metastases: No FDG avid distant metastases.

Further Findings: 1. Cross fused renal ectopia, with the left kidney fused to the lower pole of the right kidney.

2. Moderately increased metabolic activity (SUVmax = 4.7), corresponding to bilateral shoulder, sternoclavicular and hip joints. The patient has Ross River virus which could account for this appearance.

3. Uncomplicated diverticula in the large intestine.

Figure 5: PET/CT Save screens

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WFNMB 2018 “ The agony and ectasy of winning the meeting for Melbourne.�

The World Federation of Nuclear Medicine and Biology (WFNMB) organizes a quadrennial Congress which is the third largest nuclear medicine conference worldwide, behind the European (EANM) & American (SNMMI) nuclear medicine conferences. The first conference of the WFNMB was held in Tokyo and Kyoto, Japan in 1974 under the leadership of Professor Ueda. Australia had the privilege of hosting the 6th quadrennial event in Sydney in 1994 under the leadership of Professor Proven Murray. It left behind good memories and the pride of hosting the first of such an important forum by ANZSNM in Australia.

At the ANZSNM council meeting in 2006 it was decided that ANZSNM would bid to host the WFNMB - 2014 conference.

Peter Collins, the President of ANZSNM at that time, after consulting with senior members of the society, approached Andrew Scott from Austin Hospital in Melbourne, with the proposal to lead an ANZSNM bid. A committee was formed which consisted of: Andrew Scott (Chairman), Peter Collins (Vice-Chairman) and the following committee members: Dale Bailey, Vijay Kumar, Barry Elison, , Heather Patterson, Monica Rossleigh, Rod Hicks, Harvey Turner, Stefan Eberl, Roger Fulton, Michael Kassiou, David MacFarlane and Connie May as the Coordinator. Peter Collins approached the Melbourne Convention and Visitors Bureau (MCVB) for support and a firm financial base was established for the bid.

The bid committee was very focused and confident that it could win when the election was held in 2008 at the AOFNMB conference, New Delhi. But after the first round of voting Australia and Mexico (the other major contender) were drawn with 26 votes each.

The draw was totally unprecedented and Mexico won the recount with a narrow margin. This was unfortunate and spirits were dampened but the determination to win at the next bid was never compromised.

2018 World Federation of Nuclear Medicine and Biology Update

Andrew Scott reignited the idea of bidding again to host the WFNMB - 2018 in Melbourne and the existing bid committee was reformed with myself joining as Secretary with Andrew Scott (Chairman), Peter Collins (ViceChairman) on the executive, and with further new members Sze Ting Lee and Kunthi Pathmaraj (as coordinator).

Andrew Scott developed solid proposals, which were seen by the international community as legitimate targets and genuine efforts to consolidate WFNMB activities and for its long-term benefits.

The following key points were part of the re-energized bid proposals: • Commitment to promote and translate the policies and objectives of the WFNMB • Long-standing history of the ANZSNM community in promoting nuclear medicine in developing countries and active involvement in training-related activities in Asia-Pacific regions and beyond • Establishment of technical standards and promotion of scientific information • Commitment to extend the global reach of molecular imaging to all developed and developing countries through research, teaching and training.

• Ability to offer a first-class Congress featuring state-of-the-art lectures and continuing education sessions from distinguished international and local keynote speakers The bid was solidly backed up with support from the State of Victoria and Australian Government through the efforts of Andrew Scott. They came up with financial assistance to promote the WFNMB Congress and Melbourne for tourism and became good partners to consolidate our bid, which formed a solid foundation.

It was a historic moment when the voting took place at the EANM Conference in Milan in October 2012 to host the WFNMB-2018 congress. There were other contenders leading up to the voting stage but when the formal election was staged, Australia won the bid unanimously. The mandate was a clear indication of confidence by the rest of the world in Australia in delivering the best outcome for the World Federation. The bid committee celebrated the win with a lot of enthusiasm and commitments.

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2018 World Federation of Nuclear Medicine and Biology Update

The WFNMB-2014 in Cancun, Mexico was a big event for Australia as the batten was passed from Mexico to Australia. The President of WFNMB-2014, Enrique Estrada-Lobato struck the Bell elven times with a hammer, symbolically representing the conclusion of 11th WFNMB congress and handed it over to Andrew Scott – the incoming President of WFNMB-2018. This was a significant event where the leadership was bestowed upon the Australian team to conduct the next WFNMB activities.

The new WFNMB Executive committee was formed with Andrew Scott as the President, Sze Ting Lee as the Secretary General and Vijay Kumar as the Treasurer. The ANZSNM gave tremendous financial and other support to the meeting. The tasks facing the committee were enormous. The primary task was appointing the EANM secretariat for conducting the WFNMB activities. It had the added benefit of bringing the EANM and ANZSNM closer through WFNMB. The second task was selecting the appropriate event manager to conduct the WFNMB

Conference. MCI was selected as the professional conference organiser (PCO) due to their international experience and good track record for conducting large international conferences. The executive committee, assisted by Fiona Scott as the scientific administrator, has been working closely through monthly meetings, teleconferences etc.

The scientific program for WFNMB-2018 was another huge task for Andrew Scott and Dale Bailey who are the Chair and Co-chair for the Scientific program committee. The preliminary program was designed by the committee and subsequently discussed at the SNMMI-2017 conference in Denver. The international contingency of track-chairs had the opportunity to get a birds’ eye-view of the whole program and streamlined the program professionally.

One of the major tasks for Andrew Scott as the Chair of the Governing Council, was to totally revamp the existing constitution of the WFNMB - through teleconference and face to face meetings with the executive committee which consisted of the presidents of major regional societies eg. SNMMI, EANM, ALASBIMN, ARCCNM etc. The governing council also included representation from IAEA and WHO to make it truly international and world-wide. Industry interaction and engagement were managed by Sze Ting and Fiona Scott to make a financially successful World congress in Melbourne. They have succeeded in obtaining substantial industry support particularly from Asian companies.

It is very interesting to note that WFNMB-2022 will be held in Kyoto, Japan under the leadership of Dr Seigo Kinuya. This is an ideal scenario as Australia will benefit enormously with a big attendance from Japan, as they are the hosts of the WFNMB-2022.

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2018 World Federation of Nuclear Medicine and Biology Update

It is now getting very close to staging this significant event - the WFNMB Congress in Melbourne from April 20-24, 2018, in conjunction with the 48th Annual Scientific Meeting of the Australian New Zealand Society of Nuclear Medicine (ANZSNM). The venue for the Congress is the state-of-the-art Melbourne Convention and Exhibition Centre. See other details of the meeting in this issue of the Gamma Gazette or visit the website: https://wfnmb2018. com/ The post-congress symposium is organised at Cairns Convention Centre, Cairns on 26th and 27th April 2018. The theme for the conference is “Prostate cancer: a multidisciplinary approach” with Paul Roach and Louise Emmett as the convenors for this event. Keynote Speakers are Prof Ian D Davis, Prof Richard Baum and A/ Prof Declan Murphy who are all internationally renowned in this field. The conference will include post-conference tours in and around Cairns and you have a chance to visit the green island reef, crocodile and Australian wild life adventures.

Don’t forget, the gastronomic gourmet treats in Cairns are waiting for you as well. Further details are on the Congress website as above.

The focus of WFNMB conference is to promote the State of the Art and Future of Nuclear Medicine globally. The committee members have worked for more than a decade and your solid support is of paramount importance to make it successful and memorable. The congress is organised with you in mind and your participation is the best way to complement all our efforts. Submit your abstracts, take advantage of the early bird registration and make full use of the conference to see the galaxy of international experts, including two Nobel Laureates (Professor Brian Schmidt, Nobel Laureate in Physics 2011 and Professor Peter Doherty Nobel Laureate in Medicine 1996).

Be assured of many entertainments during the course of the conference to satisfy your aesthetic aspects as well.

Come in a big way and support the event, you won’t be disappointed!

Prof Vijay Kumar Treasurer, WFNMB-2018

RAINS meeting 2017 Annual Integrative Imaging Conference Report: 4th-5th November, Port Macquarie, NSW

More than 150 delegates joined 20 speakers and our sponsors (ANSTO Health, InMed, Carestream, GMS, MIPS, Telemed) at Rydges Hotel in Port Macquarie for our 14th annual meeting. Those arriving early on Friday had the opportunity to enjoy a relaxing sunset river cruise on the Hastings with plenty of dolphins joining us for the journey. Delegates joined us from New Zealand, as far north as Central QLD, west to Perth and south to Hobart.

The weekend program included two streams. The first was the IA16D Diagnostic CT training program that RAINS has offered for a few years now. Including the 69 in attendance in Port Macquarie, more than 500 nuclear medicine technologists from Australia, New Zealand and the UK have completed the course. It will continue to be offered where we can get 25-30 participants.

The main program had a theme of “Art and Science�. Delegates explored advances in science (technology, protocol, procedures) and celebrated the evolution of art (professionalism, patient education/ communication, advanced practice). A great array of speakers including Prof Hosen Kiat, A/Prof Barry Elison, Prof Dale Bailey, Dr Daphne James, Dr Peter Kench and many more provided engaging and interesting presentations around cardiac imaging, occupational exposure, cyclotron production, 68Gadotatate and PSMA, waste management, imaging developments, image guided therapy, anxiety and MRI, advanced practice and more.

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RAINS meeting 2017 (continued) Port Macquarie, NSW

Many delegates joined colleagues at the Saturday night dinner which was a great chance to catch up with colleagues we may not see as often as we like. Despite the late night, 140 delegates (plus speakers) managed to make session 1 Sunday morning which is a reflection of both the calibre of the program and the professionalism of our delegates.

The President of ANZSNM also provided an update to delegates on activities and plans which were well received by delegates, promoted discussion and debate, and left everyone eager to see how these positive initiatives develop leading into the next presidential term.

RAINS also had its AGM on Saturday and detailed succession planning to move from our first decade under the direction of our founding trio (Pete Tually, Matt Ayers and Geoff Currie) through the next decade and beyond led by the next generation. The next 2 years (new term of elected) will see mentoring and succession management from President (Matt Ayers), Immediate Past President (Pete Tually), Vice President and Treasurer (Geoff Currie) to Secretary (Chris Skilton), Ordinary member representatives (Amy Hollow, Renee Cartmell, Elizabeth Brettschneider) and Associate member representatives (Laura Skelly and Sarah Pascoe). It is a great time for RAINS. An interesting discussion around advanced practice revealed that delegates were enthusiastic about exploring opportunities to develop new skills in ECG interpretation and stress testing, and in image interpretation / reporting. In 2018 we will be celebrating our 15th year of the conference and will bring it back to Sydney (3/4 November). It is important to take our conference to our rural communities but cycling through Sydney every few years allows greater equity and reduced costs associated with travel and accessibility. Most come through Sydney to get to Wagga Wagga or Port Macquarie for example.

We are excited to announce a multi-track program focussed on enhancing “Scope of Practice” on Saturday and opportunities for “advanced practice” on Sunday. Join the RAINS Facebook page (https:// protect-au.mimecast.com/s/78eDB7UDYlbbtk?domain=facebook.com) for more information and to get updates on the 2018 program.

Dr Geoff Currie Convenor gcurrie@csu.edu.au

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ANZSNM & IAEA ANZSNM showcases the ANZ approach to Radiopharmaceutical Production & Regulation at IAEA meeting

Above: IAEA Headquarters, Vienna.

The IAEA recently hosted a 5 day Technical Meeting (TM) on “Regulatory Aspects of Radiopharmaceuticals Production� in its Vienna Headquarters, with the scope to capture the diverse approaches of developed and developing countries in the production, delivery and administration of this class of diagnostic and therapeutic agents. The meeting was attended by 14 Member States, most of them involving local regulatory experts, but also involving representatives from EMA and EANM (European case), and the FDA and SNMMI (USA case). Australia and ANZSNM was represented by Dr. Giancarlo Pascali (ANSTO). This initiative was a follow-up from a previous TM held in 2015. The 2017 meeting enlarged the geographic spread of participants considerably by involving also professional representatives from developed countries.

The TM allowed the representatives to share the situation regarding radiopharmaceutical production and regulation in their country, and allowed highlighting of the strong points existent and pitfalls encountered.

The presentations provided a wide set of experiences: from the tightly regulated USA situation, to the European challenges of different country implementation, up to the limited availability and lack of proper regulation of most the developing countries. Particularly for the latter countries, this initiative represented an important forum where better understanding of the peculiarities, challenges and opportunities related to the production, use and distribution of radiopharmaceuticals could be gained.

The Australian experience represented a refreshing point of view in which a favourable regulatory environment, practical approach and a stable track record of successes and skills have joined together to provide some of the best access to novel radiopharmaceuticals currently found in any of the developed countries. It was evidenced by the audience that this unique approach, which makes Australia one of the countries of choice to perform new clinical trials, is linked to the high mutual respect between the Therapeutic Goods Administration (TGA) and the public hospitals, justified by decades of harmonised

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ANZSNM & IAEA (continued) application of high standards of quality and patient care, even without Good Manufacturing Process (GMP) licensing. This is in part due to the availability of highly skilled professionals, updated instrumentation and up-to-date departments, which are products of Australia’s financial situation and educationally efficient reality.

One of the aims of the TM was to collect a set of recommendations that would potentially drive the implementation of global IAEA guidelines on the regulatory aspects of radiopharmaceutical production. A preliminary draft classified the improvements into 4 topics: Regulations, Guidelines, Education & Training, and Communication. It is important to note that, under the “Regulations” heading, a recommendation was included to limit the GMP licensing to commercial entities, therefore taking inspiration from the approach employed in Australia. A particular focus will be given to the requirements to conduct Clinical Trials that are safe and accessible, and also in this case, the example of ANZSNM and its contribution to ArtNET has been identified as an example of success.

ANZSNM has made significant input into this important initiative which has been well accepted. Our example has pointed out a practical, but indeed safe and efficient, way to conduct research that effectively improves the patient access to nuclear medicine products or to better designed treatment pathways. The Australian & New Zealand Nuclear Medicine approach is already successful: if we can contribute to help developing countries to achieve a better health system, we will have performed our mission, and we definitely want to aim at this important global target.

Above: Participants at the 2017 IAEA Technical Meeting on Radiopharmaceutical Production.

The immediate past-President of the SNMMI, Sally Schwartz, is seen in the 2nd row, left-hand side and immediately behind her is the current

Giancarlo Pascali PhD Senior Research Scientist, ANSTO

President of the Canadian Association of Nuclear Medicine, Dr Andrew Ross. GCP is in the back row in the middle.

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WORD SEARCH WHERE ARE THE DRUGS?

ADENOSINE AMLODIPINE ASPIRIN ATROPINE CAPTOPRIL CARBIMAZOLE CLEXANE COLOXYL DIPYRIDAMOLE DOMPERIDONE

DOPUTAMINE ENALAPRIL ENDONE FRUSEMIDE IRBESARTAN LACTULOSE LUGOL MAXOLON METOCLOPRAMIDE MORPHINE

NEOMERCAZOLE NEXIUM OLMESARTAN ONDANSETRON PERINDOPRIL RANITIDINE THYROXINE TRIIODOTHYRONINE VERAPAMIL WARFARIN

Submitted by: My Linh Diep, Monash Health VICTORIA

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CALENDAR OF EVENTS NOVEMBER

21 WA Branch AGM Perth Radiological Clinic, Western Australia

26 Nov - 1 Dec Radiological Society of North America (RSNA) Annual Meeting Chicago, USA

29 SA Branch AGM & Quiz Night Belgian Beer Cafe, Forbidden Function Room 27-29 Ebenezer Place, Adelaide, SA

DECEMBER

13 SA Branch Radpharm & UniSA Presentations Venue to be advised Register at anzsnm.org.au or from your Attendo Plus mobile app

OFFICE BEARERS President Vice President Past President Treasurer Committee

Prof Dale Bailey (NSW) | dale.bailey@sydney.edu.au A/Prof Roslyn Francis (WA) | roslyn.francis@uwa.edu.au Prof Vijay Kumar (IRC) | vijay.kumar@health.nsw.gov.au Mr Dominic Mensforth (SA) | dominic.mensforth@drjones.com.au Ms Marcia Wood (TSIG) | marcia.wood@austin.org.au Dr Divesh Kumar (RRS) | divesh.kumar@health.wa.gov.au Ms Victoria Brooks (NZ) | victoria.brooks@fulford.co.nz Dr Paul Roach (AANMS) | paul.roach@sydney.edu.au Mr David Thomas (VIC/TAS) | david.thomas@austin.org.au Dr Daniel Badger (SA) | daniel.badger@health.sa.gov.au Ms Clare Radley (NZ) | c.e.radley@gmail.com Mr Nicholas Ingold (ACT) | nick@garranmedicalimaging.com.au

General Manager & Secretariat

Dr Andrew St John and Drajon Management Pty Ltd

All Correspondence

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 | rachael1285@gmail.com Vacant Ms Leica Baker and Ms Karen Lindsay | qldbranchsecretaryanzsnm@gmail.com Ms Dai Nguyen | dai.nguyen@sa.gov.au Ms Jessica Welch | jessica.welch@austin.org.au Ms Georgina Santich | wabranchsecretary@hotmail.com Ms Pru Burns | pru.burns@prg.co.nz

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

Chairperson: Dr Elizabeth Bailey | elizabeth.bailey2@health.nsw.gov.au Chairperson: Dr Divesh Kumar | divesh.kumar@health.wa.gov.au Chairperson: Dr Daniel Badger | daniel.badger@health.sa.gov.au Chairperson: Dr Darin O’Keeffe | darin.okeeffe@cdhb.govt.nz Chairperson: Prof Dale Bailey | dale.bailey@sydney.edu.au Chairperson: Professor Andrew Scott | andrew.scott@ludwig.edu.au Mr Erwin Lupango | erwin.lupango@sessiahs.health.nsw.gov.au

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

Mr J. Gordon Chan Department of Nuclear Medicine, Austin & Repatriation Medical Centre, Heidelberg VIC 3084 Tel: (03) 9496 3336 Fax: (03) 9457 6605 email: gordon.chan@petnm.unimelb.edu.au

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

2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine through standing committees and special groups:

• The Technical Standards Committee sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand.

• The Technologists Special Interest Group. With the introduction of National Registration for Nuclear Medicine Technologists / Scientists as of 1st July 2012, the future role of the Accreditation Board was reviewed and federal council made a decision to disband the current Accreditation Board and re-allocate ongoing responsibilities to the ANZSNM – Technology Special Interest Group (TSIG). The PDY and mentor program, CPD program, department accreditation and the overseas qualification exam are now managed by sub-committees of the TSIG. •

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

CONTENT SUBMISSIONS Scientific submissions on all aspects of nuclear medicine are encouraged and should be forwarded to the Secretariat (instructions for authors published at www.anzsnm.org.au).

Letters to the Editor or points of view for discussion are also welcome.

If original or public domain articles are found and considered to be of general interest to the membership, then they should be recommended to the Editor who may seek permission to reprint.

The ANZSNM Gamma Gazette is published three times a year: March, July and November. Deadlines for each issue of the journal are the first of each month prior to publishing.

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

The individual rights of all authors are acknowledged. © 2017 The Australian and New Zealand Society of Nuclear Medicine Inc. Copyright is transferred to the Australian and New Zealand Society of Nuclear Medicine once an article/paper has been published in the ANZSNM Gamma Gazette (except where it is reprinted from another publication).