June 2011

June 2011 – Issue 2

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

CPD – A Practical Guide: page 15 The use of radio-isotope imaging in cancer care: page 24

www.anzsnm.org.au

Contents

Society News Welcome

4

President’s Report

5

Queensland Committee Profiles

6

What’s That?

8

A Yank in Oz 10 Branch News

New South Wales

12

New Zealand

12

Queensland

12

Western Australia

14

South Australia

13

Victoria/Tasmania

13

Accreditation Board

14

CPD – A Practical Guide 15 Book Shelf 16 Obituary

Thea Lundberg

20

Kerry Watson

20

Hypothetical: A teaching case, answers 21 Diary Dates

22

Crossword

23

Article The use of radio-isotope imaging in cancer care

24

Case Atlas

25

Case Study Radionuclide imaging in ankle and foot pathology

28

Brain viability study

34

Abdominal aortic stent graft infection 36 38

Tumour of unknown origin

Deadlines The deadlines for each issue of Gamma Gazette for this year are set out below. These deadlines must be strictly adhered to in order to get the journal out on time. Do not leave the submission of copy until the last minute. For advice on how to submit material please see the back of the journal.

March – February 1 September – August 1

June – May 1 December – November 1

1

Journal Staff Editorial copy & Advertising copy

Design & Production

Ms Judi Anderson ANZSNM Secretariat PO Box 7108, Upper Ferntree Gully VIC 3156 Tel: (03) 9756 0128 Fax: (03) 9753 6372 email: anzsnm@21century.com.au

Rachel Bullard Deep Blue Design Studio email: deepbluedesign1@mac.com

This issue compiled by ANZSNM Queensland Branch

Lyndajane Michel

Andrew Southee

Aims and Objectives The Australian and New Zealand Society of Nuclear Medicine Limited The objectives of the Society are as follows: 1. Promote (a) the advancement of clinical practice

of nuclear medicine in Australia and

New Zealand; (b) research in nuclear medicine; (c) public education regarding the principles and applications of nuclear medicine techniques in medicine and biology at national and regional levels; (d) co-operation between rganisations and individuals interested in nuclear medicine; and (e) the training of persons in all facets of

nuclear medicine.

Submissions Scientific submissions of all aspects of nuclear medicine are encouraged and should be forwarded to the Editor through the Secretariat (see instructions for authors published on line at www. anzsnm.org.au). Letters to the Editor or points of view for discussion are also welcome.

2. Provide opportunities for collective discussion on all or any aspect of nuclear medicine. The Society has three standing sub-committees:

(a) The Accreditation Board, hich sets standards for the training and practice of nuclear medicine technology and recommends the issue of accreditation certificates to those technologists who attain the minimum standards of proficiency in nuclear medicine.

The Society is the only accrediting body for nuclear medicine technologists in Australia and New Zealand.

(b) The Technical Standards Committee, which sets minimum standards and develops quality control procedures for nuclear medicine instrumentation in Australia and New Zealand.

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

The view expressed in any signed article in the journal do not necessarily represent those of the Society. The individual rights of all authors are acknowledged.

The ANZSNM Gamma Gazette is published quarterly each year, March, June, September and December.

Deadlines for each issue of the journal are the first of each month prior to publishing. © 2011 The Australian and New Zealand Society of Nuclear Medicine Inc. Copyright is transferred to the Australian and New Zealand Society of Nuclear Medicine once an article/paper has been published in the Society’s ANZ Nuclear Medicine journal (except where it is reprinted from another publication).

ANZSNM website address: www.anzsnm.org.au

2 Gamma Gazette June 2011

(c) The Research Grant Committee, which

administers the annual ANZSNM

Research Grant.

In addition, there are a number of special interest groups which maintain standards of practice for their particular specialty and provide a forum for their development in Australia and New Zealand. These include the Radiopharmacy, Technologists, Physics and Nurses Groups.

Office Bearers Any changes or additions to the details listed should be forwarded in writing to the Secretariat as soon as possible President Past President Secretary & Vice President Treasurer Committee

Accreditation Board Chairperson: Secretary: Members:

All correspondence

Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.au Mr Geoff Roff (WA) email: geoffrey.roff@health.wa.gov.au Mrs Tracey Smith (NSW) email: tracenucmed@hotmail.com Miss Sharon Mosley (ACT) email: sharon.mosley@act.gov.au Ms Lyndajane Michel (Qld) email: michell@qdi.com.au Dr Sue O’Malley (NZ) email: sue@omalley.co.nz Dr Dylan Bartholomeusz (SA) email: dylan.bartholomeusz@health.sa.gov.au Ms Julie Crouch email: jul.crouch@gmail.com A/Prof Monica Rossleigh, email: m.rossleigh@unsw.edu.au Ms Liz Bailey, email: EBailey@nsccahs.health.nsw.gov.au Ms Julie Crouch Mr Jim Norman Mr Doug Mackey Mr David Lyall Mr David Thomas

Dr Nat Lenzo Dr Sze Ting Lee

ANZSNM Secretariat PO Box 7108, Upper Ferntree Gully VIC 3156 Tel: (03) 9756 0128; Fax: (03) 9753 6372 email: anzsnm@21century.com.au

Technical Standards Committee Chairperson:

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

Research Grant Committee Chairperson:

Dr Richard Smart

Branch Secretaries Australian Capital Territory New South Wales Queensland

South Australia Victoria/Tasmania Western Australia New Zealand

Mr Zachary King, email: Zachary.King@act.gov.au Mr Peter McConachie, email: Peter.McConachie@sesiahs.health.nsw.gov.au Ms Sarah Stephenson, email: Sarah_Stephenson@health.qld.gov.au Ms Rowena Rose. email: rowena_rose@health.qld.gov.au Mr Adam Freeborn, email: adam.freeborn@hotmail.com Miss Bridget Chappell, email: bridget.chappell@austin.org.au Mrs Georgina Santich, email: WABranchSecretary@hotmail.com Ms Dianne Wills, email: dianne.wills@cdhb.govt.nz

Special Interest Groups Technologists Radiopharmacy Physics/Computer Science Nurses

Ms Liz Bailey, email: ebailey@nsccahs.health.nsw.gov.au Mr John Bellen, email: john_bellen@health.qld.gov.au Dr Matthew Griffiths, email: matthewr_griffiths@health.qld.gov.au Mr Erwin Lupango, email: Erwin.Lupango@sesiahs.health.nsw.gov.au

Reporting of Abnormal Behaviour of Radiopharmaceuticals The Society maintains a register of reports of abnormal behaviour of radiopharmaceuticals.

Abnormal behaviour can be reported either by telephone fax or e-mail, or in writing to: Dr John Baldas, ARPANSA Mr J. Gordon Chan 619 Lower Plenty Road Department of Nuclear Medicine, Yallambie VIC 3085 Austin & Repatriation Medical Centre, Heidelberg VIC 3084 Tel: (03) 9433 2211 Tel: (03) 9496 3336 Fax: (03) 9432 1835 Fax: (03) 9457 6605 email: john.baldas@arpansa.gov.au email: gordon.chan@petnm.unimelb.edu.au

3

Welcome The Queensland Branch of the ANZSNM has compiled this, the second issue of the Gamma Gazette.

Our Branch meets regularly, usually four times each year. These dinner meetings are usually held at one of the teaching hospitals in Brisbane, the November/December meeting corresponding to the Radpharm Award. Usually every second year the branch holds a weekend symposium, the last was held at the Mooloolaba Surf Club and was very successful, attended by over 50 registrants.

Our Branch membership, like Queensland’s population, is spread throughout the State. Nuclear Medicine practices are now found right up the coastline to include Cairns, Townsville, Mackay, Rockhampton, Bundaberg, Hervey Bay , Maryborough, Gympie, the Sunshine Coast (seven practices now), Brisbane and the Gold Coast (four practices). The most western site is at Toowoomba, which has been established now for many years.

This geographic spread is different from other State Branches and does create challenges for continuing education for all categories of our membership, but particularly for technologists.

Another challenge facing Queensland Nuclear Medicine is the lack of a degree course available for students to undertake training to become technologists. The solution to technologist workforce issues is made even harder by the QMRTB which has different rules for the training for PDY graduate technologists than the ANZSNM’s program. One of the main differences relates to requirements for supervision of the PDYs in the workplace.

The beginning of 2011 has been difficult for most of Queensland’s Nuclear Medicine practices.

The floods and cyclones caused many down days. In Brisbane many units had to shut down for three days because of difficulty obtaining isotopes and also because staff were unable to get to work. To our knowledge no Nuclear Medicine department was actually flooded.

In this, the second edition of the Gamma Gazette we have continued on the successful format of the first edition with ‘eprofiles’ on our committee members, additions to the case atlas and more teaching cases. We have encouraged articles from our regional centres, and it is pleasing to be able to include an excellent article submitted from Bundaberg. Thankyou to all those who have contributed towards this addition.

We would encourage all ANZSNM members to make contributions to the Gamma Gazette and to give feedback on how it can be improved.

Andrew Southee and the Queensland Branch Committee

Accreditation Board Vacancy A position is available on the Accreditation Board for a technologist meeting the following criteria: • Accredited technologist for at least 3 years • Financial Member of the ANZSNM • Strong interest in continuing professional development and contributing to the profession via the Accreditation Board • Previous experience within the ANZSNM or other nuclear medicine committees Please address the above criteria and submit a CV to the ANZSNM Secretariat by email: anzsnm@21century.com.au by June 27, 2011.

4 Gamma Gazette June 2011

President’s Report It seems like only yesterday that I was writing the President’s Report for the inaugural Gamma Gazette newsletter, which was a special bumper edition, and I know many are still having the enjoyment of reading.

We are now at the second edition, which has been diligently put together by the Queensland Branch. I would like to thank Lyndajane (LJ) Michel, Andrew Southee and their team for their hard work. This edition would not be possible without your efforts.

The website tendering process is also well underway and the specifications for the tender include eLearning, CPD, as well as a membership database to name a few. During the formation of the tender document, it was recognised that a website could deliver an accounting system as well as other business or back office related systems. Rather than considering the Society’s business process, we have focused the requirements on member activities and addressed common scenarios. This tender was released to potential providers on April 30 and closed May 27. Now the final tenders have come back to the committee for further consideration. This tedious process has been overseen by the Web Committee, chaired by Doug Mackey and his team, including Robert Barnett (Secretary), Peter Collins and Geoff Roff. I’d also like to thank Tracey Smith and Diane Gentilcore who have provided some initial input into the website requirements. A further update will be provided in Darwin.

I’d like to take this opportunity to remind you that the Technologist’s CPD site has now been taken offline. If you require any more information on this, please don’t hesitate to contact the Secretariat.

The final processes for National Registration for Technologists/Scientists have been submitted. We are informed that the Minister will announce the structure and appointments to the Board in the second half of this year, and we will let you know in due course. In the meantime, I would sincerely like to thank David Lyall, Bridget Chappell, Elizabeth Bailey and Julie Crouch for their continued efforts in this very time-consuming matter over the last few years.

On the international front, there are further ties being established with the International Atomic Energy Agency (IAEA) in various training and educational activities held here in Australia, overseas and also online. Local experts have contributed in various IAEA initiatives, some of which are online, and can be found at http://humanhealth.iaea.org (Human Health Campus). I encourage all members to view this extremely valuable website.

For those who have applied to attend the iPET 2011 meeting at the Agency from November 8-11, you will hear from them in due course. If you have any queries in the meantime, please contact the Society Secretariat for further information. We also had the pleasure of welcoming the Chairman of the Asian Regional Cooperative in Nuclear Medicine (ARCCNM), Prof Hee-Seong Bom in Melbourne in March 2011. We will continue to strengthen our ties with our neighbours in the region to foster the development and growth of Nuclear Medicine and PET. The 41st ANZSNM Annual Scientific Meeting is steaming along under the supervision of the organising committee, headed by Paul Roach and Dale Bailey. The pre-conference with a Nuclear Cardiology theme is a sell-out (first time ever), and I am sure those who have the privilege of attending will be able to enjoy the charms of Kakadu together with gaining some knowledge in this ever-evolving field of nuclear medicine. The main program in Darwin is also extremely robust with a whole host of renowned international speakers and I strongly encourage as many of you to attend as possible. There are still flights available, and accommodation in Darwin, so if you have not registered…do reconsider & take advantage of the school holidays to bring the family along! More information is available at www.anzsnm2011.com.au Hope to see as many of you in Darwin as possible.

Dr Sze Ting LEE President

5

Meet the QLD Committee members Lyndajane Michel Committee Position: Federal Representative for Queensland, Past Chairperson Queensland Branch Current place of employment: Queensland Diagnostic Imaging, Holy Spirit Northside Current position in your workplace: Chief Nuclear Medicine Scientist Time served on the Committee: 7 years Reason for joining the branch: To help provide a forum for technologists’ input and to provide channels for communication for members.

What you hope to achieve from being on Qld Branch Committee: To maintain access for members, to provide a voice. To ensure a co-operative working relationship with regulating and governing bodies.

Andrew Southee Committee Position: Branch Chairperson Current place of employment: Northcoast Nuclear Medicine, a private company based in Buderim on the Sunshine Coast, also providing nuclear medicine services from Caloundra north up to Bundaberg.

Current position in your workplace: Nuclear Medicine Physician, CEO Time served on the committee: 3 years as Chairperson Reason for joining the branch: I joined the branch in 1994 when I moved to South-East Queensland from Newcastle. I saw the branch is a vital means of keeping in touch with issues affecting nuclear medicine.

What you hope to achieve from being on the Qld Branch Committee: ITo provide a means for all members to be able to raise issues which are affecting their delivery of nuclear medicine services. In this regard education, liaison with government bodies and support for our regional membership are all important.

Sarah Stephenson Committee Position: Joint Branch Secretary Current place of employment: Royal Brisbane and Women’s Hospital Current position in your workplace: Senior Nuclear Medicine Technologist Time served on the Committee: 3 years Reason for joining the branch: I joined the branch in 2001 when I moved to South-East Queensland from Adelaide. I think the branch is an important way to keep up to date with everything associated with Nuclear Medicine and I can’t deny it’s a great means to keep in touch with everyone socially at meetings etc!

What you hope to achieve from being on Qld Branch Committee: To provide the means for all members to have access to topics, speakers, etc. that are relevant to us and our profession.

6 Gamma Gazette June 2011

Meet the QLD Committee members Rowena Rose Committee Position: Joint Branch Secretary Current place of employment: Royal Brisbane and Women’s Hospital Current position in your workplace: ANuclear Medicine Technologist Time served on the committee: 6 months Reason for joining the branch: I joined the branch in 2004 when I moved to Brisbane to start my PDY and it is a great way to keep in touch with those that have moved on to other departments.

What you hope to achieve from being on Qld Branch Committee: To become more involved in the Nuclear Medicine community and to help keep others up to date with all Nuclear Medicine related topics and technologies.promote and develop education and training for nuclear medicine scientists,

Susan Baldwin Committee Position: QLD Technologist Special Interest Group Representative Current place of employment: QScan Radiology (from 9th May 2011); Queensland Diagnostic Imaging(for the past 9 happy years) Current position in your workplace: Senior Nuclear Medicine Technologist Time served on the committee: 1 year Reason for joining the branch: I wanted to help keep continuing education and attendance at our Qld branch meetings alive and well, and encourage our next generation of Nuclear Medicine Technologists to enjoy the ANZSNM activities.

What you hope to achieve from being on NSW Branch Committee: To have a voice and pay particular interest in seeing Nuclear Medicine Technologists are fairly represented in the National Registration process. And to support the ANZSNM continuing education and accreditation processes.

Tale Liiv Committee Position: Qld Branch Treasurer Current place of employment: Princess Alexandra Hospital Current position in your workplace: Advanced Nuclear Medicine Technologist Time served on the committee: 1st year Reason for joining the branch: To stay in touch with members in QLD, to keep informed about society ‘goings on’ and to learn new things!

What you hope to achieve from being on NSW Branch Committee: To give period of service to the Qld Branch after many years of being a member of the ANZSNM.

7

Answer on page 18

What’s that?

Marion Lewis and Terrie Adolphe Sutherland Nuclear Medicine and Bone Densitometry Sydney, NSW

A 37-year-old male with a history of decreased TSH presented for a Thyroid scan. Anterior pinhole and planar images were performed 10 minutes post 200 MBq Technetium-99m administration. The study showed a mild and uniform increase in tracer uptake throughout the thyroid suggesting Graves’ disease, and midline physiologic salivary activity. There was an incidental finding of abnormal tracer activity in the right upper hemi thorax seen on the pinhole and planar images. A whole body scan was performed for further evaluation.

Above: Anterior Pinhole

Right: Anterior Planar with marker

8 Gamma Gazette June 2011

Answer on page 19

What’s that?

Dr Joseph Wong and Peter Borham Northcoast Nuclear Medicine Buderim, Queensland

A 64-year-old man had a bone scan performed for staging of prostate carcinoma.

What is the cause of the intense activity at the right orbit?

Figure 1.

Anterior, posterior and lateral views 3 hours following injection of 800 MBq Tc-99m methylene diphosphonate.

9

A Yank in OZ Well, it has now been three and half years since I made the transition to Nuclear Medicine in Australia. It took 18 months to pass the exam, find a hospital that would take me on as a PDY, and gain my work visa. And all I can say is that it has been well worth the effort. Everyone has been wonderful and I am truly feeling at home here in Oz. The Royal Brisbane and Women’s Hospital was gracious enough to give me the opening into the Aussie way and after some growing pains, Thyroid uptake with Tc99m who knew??, I quickly came to really enjoy being here. I am now a fully qualified technologist and have become actively involved in the training of students and PDYs. I have given talks on cardiology and paediatrics, both passions of mine, to my departments and others in Queensland. I have even attempted to work on the other side and help begin to develop a continuing education program for Queensland Health. I am very eager to continue with the education and training side of nuclear medicine.

This year I have been lucky enough to be asked by the SNM to speak at the AGM in San Antonio, Texas, on my time here in Australia. It seems that they are interested in what I have been doing here. I will be giving a fifty minute presentation and question session on the first day of the AGM in the technologist section. I recently gave a modified version to the branch meeting of the Queensland ANZSNM and it was well received and seemingly entertaining.

I think there is such a great opportunity for both bodies to learn more about the other. I am truly excited. I will be talking to the University where I graduated from later in June and will be talking to them about the similarities and differences in the American and Australian system. Thanks to all the people that I have bugged with questions.

I look forward to being able to let everyone know how my talk was received and all that I have seen at the SNM. Kristen Hurst

10 Gamma Gazette June 2011

ONE DAY CT SAFETY COURSE

for

NUCLEAR MEDICINE TECHNOLOGISTS To be held

7:30am – 10:30am, Saturday July 16, in Darwin Course attendees will be expected to have successfully completed course reading and assignments prior to the event.

This course is offered by the ANZSNM Executive and Accreditation Board, in conjunction with the NSW Hospitals and Universities Radiation Safety Officers Group The course is intended to meet requirements for NSW EPA Licence Type IA16 The course is aimed at providing accredited nuclear medicine technologists with the additional knowledge required to safely use hybrid nuclear medicine scanners incorporating CT used for attenuation correction and anatomical localization thereby minimizing radiation exposures to the patient.

Entry requirements for applicants: Accredited Medical Radiation Scientists – Nuclear Medicine, currently holding a license issued by the NSW EPA Type S14 or S14Y, or equivalent.

Final assessment is by MCQ on the day.

If you are interested in attending this course, please send expressions of interest to: Douglas Mackey: dougmacke@gmail.com Links Website: www.hursog.org

Crossword solution from March 2011 Gamma Gazette

11

Branch News New SOUTH WALES Firstly I would like to congratulate Husain Husain from Sydney University and Georgia Kent from Newcastle University for winning the NSW Branch Academic Book prize. Well done to both of you!

The May 18 meeting at Bankstown Hospital with Dr Vijay Kumar and Dr Jeremy Hoang talked about 68GaDOTATOC for PET imaging of neuroendocrine tumours (NETs). This was a combined meeting with the NSWNMS. Our next meeting will be at Concord Hospital on July 11. We are lucky to have international guest speaker, Dr Homer Macapinlac. He is one of the invited speakers for the Darwin Conference so if you can’t make it, here is your opportunity to come, listen and learn.

Don’t forget to bring your membership cards to meetings to be scanned for attendance.

Remember all future NSW branch meeting details are on the website and are regularly updated so don’t forget to check what’s coming up. Please contact me if your contact details change as we send lots of branch information via email. I can be contacted on tracenucmed@hotmail.com A big thank you to everyone for your support and feedback for the NSW/ACT first edition of the Gamma Gazette.

See you in Darwin.

Tracey Smith Branch Chair and Federal Representative

New Zealand New Zealand now has five PET/CT departments: two in Auckland, and one each in Hamilton, Wellington and Christchurch. The Ascot PET/CT in Auckland was opened most recently with its first patients in early April. In Wellington, Pacific Radiology have done 12 FET PET brain scans.

NZ’s only Cyclotron in Wellington had its first production run at the end of February. Now our PET/CT departments can scan patients during normal working hours.

On March 9 the Nuclear Medicine community in NZ lost Kerry Watson after a long battle with breast cancer.

Kerry had worked as a Technologist for 22 years at Auckland Radiology Group and worked previously at Taranaki Hospital and Auckland Hospital. She will be fondly remembered for her warm smile and sense of humour.

The Christchurch Hospital Nuclear Medicine Department staff have continued to function with professional resilience through the last eight months of earthquakes and continuing aftershocks. Despite the shocking devastation of nearby properties from the February 22 jolt, the hospital has remained open throughout and the department’s two Siemens cameras were largely unaffected. Like all Christchurch residents, the staff have been through a very stressful time and would like to thank all those who sent the many messages of support.

Dianne Wills Secretary

QUEENSLAND Well, the start to the year here in Queensland has been a turbulent one with wide-spread flooding throughout the state and Cyclone Yasi striking North Queensland, leading to 75% of the State being declared a natural disaster zone and Queensland turning from the Sunshine State into the Wet State. We hope that all our members are safe and that those affected are on the road to recovery. Our sympathies also go to those affected by floods in other regions of Australia and to earthquake-affected Christchurch and surrounds.

A big welcome to our new PDYs around Queensland who have started this year – we hope to meet you all at upcoming branch meetings.

We concluded 2010 with our AGM and Radpharm presentations which were held at The Princess Alexandra Hospital in late November. There were three entrants for the Radpharm awards with Penni Russell being judged the winner and our representative for the Darwin Conference. Good luck Penni. Thank you to Jenni Dolkens and Abraham Spear for your presentations. This year’s Radpharm presentations will be held towards the end of the year and we are inviting both PDYs and experienced staff to start looking for interesting cases to present.

2011 is set to be a busy year with many members attending the Technologist Symposium in Adelaide in May, the ANZSNM Conference in Darwin in July and a Qld Branch Symposium in September (TBC).

Our next meeting is on Tuesday July 12 and we will have international guest speaker Prof Bernd Pichler presenting at this meeting. It will be a great opportunity for those who are unable to attend the Darwin

12 Gamma Gazette June 2011

conference to hear an international speaker.

We are also looking forward to holding our next branch symposium in September (date and venue to be determined). The last one we held was very successful and enjoyed by all who attended. We will email details when we have more information. Please email the ANZSNM Secretariat to update your email address.

Could all Queensland members keep an ear out for meeting dates and remember to let us know of any ideas you have for venues, speakers or meetings. Our barcode reader has arrived now so please bring your new membership cards along to the next meeting.

Rowens Rose Branch Secretary

Western Australia We would like to thank Lisa Geyer for her many years of excellent service as the WA Branch Secretary. She has commenced her year-long travel overseas, and we wish her bon voyage and safe trip!

Congratulations to Julie Crouch and Amy Evans for being the recipients of the WA Branch Grants to the upcoming Society Annual Scientific Meeting in Darwin.

We had a very successful SPECT-CT workshop last year. This year’s workshop was on Nuclear Medicine Cardiac Imaging at the Mount Medical Centre on May 7. There will be many informative presentations and updates on Nuclear Cardiac Imaging. We are honoured to have Associate Professor of Medicine and Cardiologist, Dr Nathan Better from Melbourne as our Guest Speaker.

Teck Siew Branch Committee Member

SOUTH AUSTRALIA 2010 ended with a very enjoyable AGM, Dinner and Quiz Night held at the King’s Hotel in Adelaide. It was pleasing to see another big turnout for what is always a popular and enjoyable event. Thank you to Barry Chatterton for organising a very challenging quiz. Thank you also to Cyclomedica, GE and Siemens for their generous sponsorship of the evening.

The SA Branch Committee has remained the same for 2011, as I will continue for a second term as Secretary/Treasurer. I would like to thank Rachael Dunlop and Dylan Bartholomeusz for their hard work as Chairperson and Federal Committee Representative respectively.

Our first branch meeting for 2011 was held at Flinders Medical Centre in March, where Dr Neil Jones and Dr Anand Rose gave a very interesting presentation entitled “Evidence based evaluation of patients with suspected pulmonary embolism”. Our second meeting was held in May, hosted by Benson Radiology at Modbury Hospital, where Dr Sunil Gupta presented “Assessment of the limping child”. We look forward in July to hosting Dr John Valliant who will give a dinner presentation to the SA branch before presenting at the ASM in Darwin. I’m sure it will be a very informative and enjoyable event.

Adam Freeborn Branch Secretary/Treasurer

Victoria/Tasmania Branch The Victorian/Tasmanian branch has been busy preparing for the first participation at The Age Careers Expo held on May 6-8, 2011 at Caulfield Racecourse. The aim of this event is to promote Nuclear Medicine as a career option especially for technologists, and other related career streams such as radiopharmacists, radiochemists, nuclear medicine doctors and nurses were also included. We had sixteen enthusiastic technologists who volunteered to help with this event.

We again sponsored and presented two prizes to students from the School of Medical Sciences, Medical Radiations of RMIT University. Prizes were presented to Lavera Sovanny for ANZSNM Victoria Branch Award for Excellence in Clinical Practice, and to Adam Livori for the ANZSNM Victoria Branch 3rd Year Independent Project award on April 19, 2011.

We have planned for two scientific meetings in July 2011. Prof Brian McIver will present a talk on thyroid cancer at the Alfred Hospital on 12th July, and this meeting is sponsored by Genzyme. Following that, Prof Philip Kaufmann will give a post-conference talk which is planned for Tuesday 19th July at Peter MacCallum Cancer Centre.

Dr Grace Kong Branch Chair

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Accreditation Board News The Accreditation Board met on Saturday, April 30, 2011 in Melbourne.

Present: Jim Norman (Secretary), David Lyall, David Thomas, Doug Mackey, Julie Crouch (Chair) and Judi Anderson (ANZSNM Secretariat).

Apologies: Nat Lenzo (Physician) The Accreditation Board is the gazetted authority in overseeing the qualifications and entry into the Nuclear Medicine profession in Australia. The Board is in the process of including two long answer scenario questions to the exam that overseas Nuclear Medicine Technologists are required to sit before they can practice in Australia. These questions will be included in the next exam.

One person recently sat the OQA exam in Singapore and passed and one person also sat the exam in Brisbane and failed. The Accreditation Board has also received an application for assessment for eligibility to sit the exam later this year.

The Accreditation Board is in the process of setting up dialogue with the AIR to discuss the process required for Nuclear Medicine Technologists to operate MRI scanners.

Members of Board and the TSIG have been providing me with activities to include in the CPD package so that those technologists who have difficulty obtaining CPD points will have the chance acquire some of their points while learning from these activities. The Accreditation Board would really appreciate technologists in the profession to start to contribute to the CPD packages so that the package can continue to be provided. It’s important to remember that if you produce an activity, you will gain CPD points yourself.

The Board continues to have members involved in the National Registration process.

The Accreditation Board is seeking expressions of interest for a technologist to join the Board. It would be highly desirable that the candidate has an interest in continuing professional development.

Jim Norman Secretary

Congratulations to the following technologists who were granted Accreditation at the April 2011 meeting: DENMEADE, Kristie Anne MALONEY, Sean Michael NG PING MAN, Jean Ronny Wesley PARKER, Lauren Michelle RENSHAW, Laura Jane REYNDERS, Nicholas Gene STEVENSON, Samantha Jean VARIAWA, Sheruna YOONG, Simon Hao Seng

14 Gamma Gazette June 2011

The Board would like to congratulate the following technologists who have successfully gained and submitted the requried CPD points and thus have been revalidated: du JARDIN, Claire FEARNSIDE, Heidi KOSCH, Mark TARGET, Carol

The following departments were granted Approval/Re-approval for the training of PDY technologists at the same meeting: RadiologySA – Cert. #19 Castlereagh Imaging, Westmead – Cert. #40 Castlereagh Imaging, Penrith – Cert. #41 The Children’s Hospital at Westmead – Cert. #50 Barwon Medical Imaging – Cert. #56 Flinders Medical Centre – Cert. #59 Erina Diagnostic Imaging – Cert. #135

CPD – A Practical Guide This information is provided by the ANZSNM Secretariat based on the queries received in relation to how the CPD program works. Possibly not everything has been covered, but it is a start and additional information will be published as required. If at any time you have any queries about the program, please contact the Secretariat and don’t rely on what people in your department tell you – the information may not be correct and you could be disadvantaged!

When a technologist completes their Professional Development Year (PDY) or Intern year (in Victoria) and applies for Accreditation, this Accreditation will become effective from the date of the next Accreditation Board meeting. Board meetings are held four times a year – usually in February, April (in conjunction with annual conference though this may change depending on date of conference), August and November. Technologists accredited at meetings in first half of year will have a revalidation date of 30 June, and those accredited in the second half of the year will have a revalidation date of 31 December. Accreditation is granted for three years and you need to accrue a minimum of 30 CPD points over three years to revalidate for a further 3-year period.

CPD activities attended prior to your Accreditation date (the actual date of the Board meeting) do not count toward CPD points as it is your Accreditation that is revalidated from accrual of points.

Revalidation of Accreditation Approximately two months before your revalidation date you should receive a letter from the Secretariat reminding you that you need to submit your points summary, telling you how to go about this and the deadline by which the points should be received at the Secretariat. For this reason, it is important that you make sure that the Secretariat has a current mailing address for you. If you have provided a home address for your Accreditation certificate to be mailed to, then that is the address to which revalidation and/or CPD mailings will be sent – even if you have given a work address as the mailing address for membership matters.

Recording & submitting your points Now that the CPD Database has been dismantled, pending the rebuilding of the ANZSNM website, an Excel spreadsheet template has been placed on the Society website which can be used to record your points. You should save a copy of the template to your computer and enter your points so that you can print this off and send to the Secretariat when requested to do so for revalidation.

For the purposes of revalidation, we only need to see that you have accrued a minimum of 30 points from more than one category and the template will make it easy for the Secretariat to see this at a glance. You can use your own Excel document or a Word document, but it is recommended that you use the headings as shown in the template because they correspond with the Activities Schedule and are grouped into the different categories as had originally been set out on the CPD Database.

A revised CPD Activities & Points Schedule has recently been posted to the Society website which gives an indication of the type of activities for which points can be earned and the number of points per activity.

CPD Audit It is suggested you should try to accrue more than the minimum of 30 points because if you are audited and any of your points are not accepted, if you have more than 30 points, you won’t need to complete additional activities to reach the 30 point minimum.

If you are audited (5% of technologists revalidating each year are randomly selected for audit), you will receive a letter requesting that you submit documentary proof of the points you have claimed, and given a date by which that documentation should be received at the Secretariat. Following the audit, you will be advised that it has been successful, or additional information may be sought by the auditor.

CPD Package The Society provides a CPD package each year which is usually worth 5 or 6 CPD points, which is at least half your annual requirement if you average the 30 points out over three years. However you don’t have to actually accrue 10 points per year, just as long as you have at least 30 points at the end of the 3-year period. The package is provided online and technologist members are advised when it is available via email. It is located in the Members Only area of the Society website and you need a password/log-in to access it – the same password/log-in that you have used to access the Gamma Gazette. (The previous CPD Database had a separate log-in/password which doesn’t gain you access to the Society website.)

The above covers the main queries received at the Secretariat, but if there is anything you are not sure about, please contact Judi, preferably by email (anzsnm@21century.com.au) in case it is something she can’t answer herself and needs to refer.

15

Book Shelf The following information is supplied by the publisher and no responsibility is taken for accuracy.

Case-Based Approach to Nuclear Medicine Case-Based Nuclear Medicine, Second Edition presents the latest information on the field of nuclear medicine in a highly visual, case-driven format. The book has been updated to include the latest technology used for nuclear imaging, including the latest cardiac and PET/CT imaging systems.

“This book focuses on the common presentations of diseases, and describes the findings in a manner that will allow the reader to understand how images are affected by normal physiology and by disease,” says author Dr Kevin Donohoe, Harvard Medical School, Boston, Massachusetts. “The reader should then be able to apply that knowledge when encountering the innumerable variations in scan findings seen in the daily practice of medical imaging.”

The authors launch each case in this completely expanded edition with a clinical presentation and follow with concise patient histories, as well as imaging findings and differential diagnoses. Bullet-pointed pearls and pitfalls emphasize key points. To facilitate self-assessment, Case-Based Nuclear Medicine cases are presented as “unknown” cases requiring readers to develop their own differential diagnosis.

Case-Based Nuclear Medicine, an image-based approach to nuclear medicine, offers residents, fellows and clinicians a user-friendly atlas that’s perfect for cramming for exams, preparing for rounds or using as a quick reference.

In addition, readers receive a scratch-off code that provides access to a full year of RadCases’ online database of 250 nuclear medicine cases.

Donohoe/Van den Abbeele Case-Based Nuclear Medicine, Second Edition 2011/2nd Edition/600 pp/444 illustrations/softcover ISBN (EUR, Asia, Africa, AUS): 9781588906526 $99.95/€89.95 About the Authors Kevin J. Donohoe, MD, Staff Physician, Division of Nuclear Medicine, Beth Israel Deaconess Medical Center; Associate Director, Beth Israel Deaconess Radiology residency program, Boston; and Assistant Professor of Radiology, Harvard Medical School, Boston, Massachusetts.

Annick D. Van den Abbeele, MD, Chief of Department of Imaging, Founding Director of the Center of Biomedical Imaging in Oncology, and Director of Nuclear Medicine at the Dana-Farber Cancer Institute; Associate Professor, Department of Radiology, Harvard Medical School, Boston, Massachusetts.

Critical Care Radiology With more than 550 high-resolution images, Critical Care Radiology includes the must-know information for performing and interpreting radiographs in an intensive care situation. Focusing on the chest and abdomen, this succinctly-organized text also offers special sections on pediatric patients in intensive care settings.

“This book places special emphasis…on the differential diagnosis of morphologic findings and their interpretation within the clinical context, and on accurately discriminating between normal and abnormal findings,” says author Dr Cornelia Schaefer-Prokop, MD, AMC Amsterdam, Amsterdam, The Netherlands.

This comprehensive guide also includes pertinent information on the ICU patient following abdominal and thoracic surgery, lung transplantation and Infantile Respiratory Distress Syndrome. Each chapter in this concise

16 Gamma Gazette June 2011

reference contains information on classification, imaging and differential diagnosis of the different diseases.

Additionally, helpful tables highlight important points and practical recommendations, and summaries of key points appear at the end of each chapter.

“I hope that this book will help radiologists, residents in radiology, and even clinicians to interpret the often difficult and nonspecific findings in children and adults,” says Dr. Schaefer-Prokop.

Because of the special circumstances for this kind of imaging, this concise, yet thorough manual is a musthave for any resident or practicing radiologist who encounters intensive care patients.

Schaefer-Prokop Critical Care Radiology 2011/248 pp/561 illus/hardcover ISBN (EUR, Asia, Africa, AUS): 9783131500519 $149.95/€119.95 About the Author Cornelia Schaefer-Prokop, MD, Associate Professor of Radiology, AMC Amsterdam, Amsterdam, The Netherlands.

Essentials of Clinical MR Edited by Val M Runge/John N Morelli

Essentials of Clinical MR provides readers with the must-have background they need to interpret magnetic resonance images and make successful clinical diagnoses.

Intuitively arranged by body region, this user-friendly manual explores the most commonly encountered diseases through concise case examples supplemented by clearly labeled MR images. Using case descriptions as starting points, each section thoroughly surveys a different anatomic area, providing tips on imaging techniques followed by an in-depth discussion of the image interpretation.

Features: • Complete coverage of the diseases most frequently seen in clinical practice • Over 650 images clearly illustrate the MR appearance of each disease • Relevant, up-to-date information on contrast media and contrast enhanced MRA. This easily accessible guide is both the ideal introductory text for radiology residents, MR technologists, and medical students, as well as a practical daily reference for anyone involved in the interpretation of clinical MR. Val M Runge/John N Morelli (editors) Essentials of Clinical MR 260 pages, 280 illustrations, paperback € [D] 49.95 ISBN 978- 1-60406-406-3

Books can be purchased online from www.thieme.com

17

From page 8

What’s that? ... answer Technetium-99m is an agent commonly used for thyroid imaging, but also accumulates in the salivary glands & gastric mucosa. It was concluded that the area of activity seen in the right hemithorax was the stomach and on questioning, the patient had a history of oesophagectomy due to Barrett’s oesophagus.

Barrett’s oesophagus refers to the abnormal change in the cells of the inferior portion of the oesophagus.1 It is considered to be a premalignant condition because it is associated with an increased risk of oesophageal cancer, more specifically, adenocarcinoma.2,3 The cells of Barrett’s oesophagus, after biopsy, are classified into nondysplastic, low-grade dysplasia, highgrade dysplasia, and carcinoma.2 Treatment options for high-grade dysplasia and carcinoma generally include oesophagectomy.

Oesophagectomy involves removing the patient’s oesophagus and the top part of the stomach. The stomach is then pulled up into the chest and connected to the remaining normal portion of the oesophagus.4

References 1. http://en.wikipedia.org/wiki/Barrett’s_esophagus 2. Shaheen NJ, Richter JE (March 2009). “Barrett’s oesophagus”. Lancet 373 (9666):850-61. (http://ncbi.nlm.nih.gov/pubmed/19269522) 3. Koppert L, Wijnhoven B, van Dekken H, Tilanus H, Dinjens W (2005). “The molecular biology of esophageal adenocarcinoma”. J Surg Oncol 92 (3): 169-90.

4. http://www.barrettsinfo.com/content/8a_what_is_esophagectomy.cfm

18 Gamma Gazette June 2011

From page 9

What’s that? ... answer The activity is located within a right ocular prosthesis. The ocular prosthesis was implanted 4 years ago and is made of coralline hydroxyapatite. The coralline hydroxyapatite has a mineral content and porous microarchitecture identical to human bone. The implanted prosthesis develops ingrowth of fibrovascular tissue, thereby becoming integrated with synchronous eye movements possible. The bone tracer uptake is due to chemical adsorption into the crystalline structure of the hydroxyapatite and can be present from 2 to 6 months after surgery. This is well demonstrated in the SPECT/CT image (Figure 2).

References 1. Leitha T, Staudenherz A, Scholz U. Three-phase bone scintigraphy of hydroxyapatite ocular implants.

Eur J Nucl Med, 1995; 22: 308-314.

2. Kanishi D. 99mTc-MDP accumulation mechanisms in bone. Oral Surg Oral Med Oral Pathol, 1993; 75: 239-246.

Figure 2: SPECT/CT showing intense activity confined to the right intraocular prosthesis due to chemical adsorption of Tc-99m methylene diphosphonate onto the prosthesis.

19

Obituary Thea Lundberg 22/01/1950 – 2/1/2011 The ANZSNM and Nuclear Medicine community in Queensland mourn the significant loss of our dear friend and colleague, Thea Lundberg, who passed away on 2nd January this year.

Thea was a Nuclear Medicine pioneer in Brisbane, where she was one of the founding technologists of the Royal Brisbane Hospital’s Nuclear Medicine Department. She was always a tremendous mentor to all staff, and kind, caring and generous of her time and knowledge.

Thea began work as Cadet Radiographer (Therapeutic Radiography) on January 15, 1968, and during her 2-year Cadetship she completed training within Nuclear Medicine. She was then rotated between Radiation Therapy at the Queensland Radium Institute, and Nuclear Medicine at the Royal Brisbane Hospital campus.

Thea was appointed as a Senior Radiographer for Nuclear Medicine on December 1, 1986, where she continued her employment and extremely valuable input, until her retirement on August 21, 2007.

In her private life, Thea was a dedicated and tireless supporter of her local parish school and church, St Williams at Keperra, and was always available to help her family and friends.

Thea was, above all else, totally dedicated to her children, Theresa and Damien, and her grandchildren who gave her so much love and joy, in her very full lifetime.

She is so greatly missed by all who knew and loved her, privately and professionally. Her enormous strength and incredibly positive outlook during her life, is an inspiration for us all.

The beautiful saying below was written by Thea, and these are touching thoughts for all of us to reflect on, and carry with us:

It took a long time to learn, but life is what you make of it yourself.

You can try to be as good as other people at things, but you are yourself and not them.

So, it is best to find what you like to do and what you are good at and then find people with similar interests.

Trust the people who love you most.

Spend time with people who make you happy.

Help those people who you can, to be better people.

Sue Baldwin and Travis Pearson

Kerry Watson On March 9, 2011 the Nuclear Medicine community in New Zealand lost Kerry Watson after a long battle with breast cancer.

Kerry had worked as a Technologist for 22 years at Auckland Radiology Group and worked previously at Taranaki Hospital and Auckland Hospital.

She will be fondly remembered for her warm smile and sense of humour.

Dianne Wills

20 Gamma Gazette June 2011

ANSWERS (from March 2011 Gamma Gazette)

Hypothetical A Teaching Case

CPD ACTIVITY

Submitted by Tracey Smith Â

Answer 1 This is totally dependant on how /where you source your dose ie in house radiopharmacy or central radiopharmacy. Please use the steps below as a possible guideline on how to proceed.

1.

2.

3.

4.

5.

Stay Calm- contact your supervisor, physician and/or radiopharmacist Either yourself or physician inform the patient there appears to be a problem with the study. Ask the patient to wait outside until you investigated.

Check the camera is functioning correctly- is the peak correct. Has the quality control been performed correctly for this days scanning?

Try to work out what has been injected into the patient by: i) looking at the information provided on the syringe that has been dispensed- -what labels are present? ii) working out who dispensed this dose- did you or did someone do it for you? If possible contact this person iii) Going to the hotlab and check all radiopharmacy records. Check vials already reconstituted for present activity or activity that is missing or been removed. If central radiopharmacy account for all delivered and administered doses. iv) checking any residual activity – use the dose calibrator on different isotope settings and record these.

Image the residual syringe under the camera and peak for different isotopes.

Perform a whole body image or static images to help indicate biodistribution and give you an idea what the isotope may be

Answer 2 The most likely isotope is Thallium. You can determine this by looking at the biodistribution present on the images.

Answer 3 This incident should be reported to your supervisor and the physician in charge, or RSO, depending on the staffing and policy in your department/state. A report should also be written and filed. It would also be appropriate to contact the referring physician.

Keep in mind this is a radiation incident and it should be fully investigated so steps can be put in place to ensure this does not happen again.

Answer 4 The patient should be informed by the physician or supervisor in charge after an investigation of how the incident occurred. The patient should be given information on the isotope that has been injected and the approx radiation dose. You should give an explanation of how this has occurred. You should also inform the patient on how/when the correct procedure can occur-if the patient wishes to do so.

Answer 5 Report the incident to the relevant authorities in your state if warranted or required by your states legislation.

The webiste www.arpansa.gov.au will give information for local authorities in your state

References Radiation Protection Radiation Protection And Radiation Protection Radiation Protection

Series No. 14 Code of Practice in the Medical Applications of Ionizing Radiation Series No. 14.2 Safety Guide in Nuclear Medicine

These are very useful documents to have on hand in your department.

They can be found at www.arpansa.gov.au

21

Attention

All

Nuclear Medicine/ Radiology Nurses Would you like to

Do you have an interest in professional and self development?

win $500?*

Would you like to travel Australia and New Zealand to increase your knowledge?

2011 brings the 41st Annual ANZSNM Meeting to be held in Darwin, Australia. For your chance to win $500 just prepare a Nursing-based creative 30 minute presentation to present to your peers at the conference in July 2011. *Conditions apply

Please contact: Erwin Lupango CNS, President, Nursing SIG (T) +61 2 9382 2203 (F) +61 2 9382 2235 (E) Erwin.lupango@sesiahs.health.nsw.gov.au

Diary Dates

Email the Production Editor at the Secretariat on anzsnm@21century.com.au to list your upcoming conference and meeting dates on the diary page.

June 19

Certification Course in Clinical Bone Densitometry for Technologits

Randwick Labor Club, Randwick, Sydney info@bonedensity.net.au July

11 NSW Branch Meeting Darwin Conference Speakers Homer Macapinlac and Bernd Pichler Concord Hospital, 6pm

July

12 VIC/TAS Scientific Meeting Prof. Brian McIver will present a talk on thyroid cancer at the Alfred Hospital, Melbourne.

Sponsored by Genzyme

July 14-18

ASM, Darwin

Great pre-conference program and invited speakers www.anzsnm2011.com.au/ July 16

One Day CT Safety Course for Nuclar Medicine Technologists

ASM, Dar win

22 Gamma Gazette June 2011

July

19 VIC/TAS Scientific Meeting Prof Philip Kaufmann will give a post-conference (ASM) talk at Peter MacCallum Cancer Centre

September 4-8, Moscow

7th International Conference on Isotopes

This is one of the largest forums that brings isotopes scholars, producers and users together and includes plenary meetings, parallel scientific sections, poster reports, and a specialty exhibition.

The 7th International Conference on Isotopes offers a

unique opportunity to present your products and services to a wide audience.

November 12 & 13

Integrative Imaging Symposium

RAINS are holding this symposium at the Stamford Grand North Ryde, NSW.

Contact Geoff Currie email-gcurrie@csu.edu.au

2012 April 27-30 ASM

Melbourne Convention Centre

Crossword 10

2 4

1

6

13

3

5

7

8

15

12

14

17

16

9 18

11

19

Answers in the September issue of Gamma Gazette.

ACROSS 1. Adrenal Medulla secretions 3. Bone Mineral _______.

5. Furosemide, AKA. 7. Type of agent ideal for measuring ERPF. 9. What element does Tl 201 mimic in the body?

11. Alternative leukocyte labelling radioisotope to Tc-99M. 13. MAA is denatured human serum _______.

15. Ga 67 binds to transferrin which is a type of _______.

17. As Low As Reasonably Achievable.

18. Ventilation agent with 5.3 day half life.

19. An analogue of norepinephrine used to localise pheochromocytomas.

Down 2. Dipyridamole causes ____________.

4. Type of primary malignant bone tumor.

6. Malignancy of melanocytic cells.

8. Classic appearance of pulmonary emboli defects.

10. First radionuclide widely used for bone imaging.

12. Location of the Circle of Willis.

14. Any abnormal change involving tissue or an organ.

15. Osteoporosis is present when the bone tissue becomes more ______.

16. Increased PTH is generally caused by a solitary _______.

23

The use of radio-isotope imaging in cancer care Professor Ken Miles Specialist in Radiology and Nuclear Medicine

Radio-isotope imaging has several important roles in the care of patients with cancer from staging and treatment planning through to assessment of treatment response and complications, and detection of relapse.

S

election of the most appropriate cancer treatment is usually based on the tumour stage and for many cancers radio-isotope imaging can contribute to staging.

Staging is based on the size of the tumour, spread to loco-regional lymph nodes and the presence of distant metastases. Although these features are often well demonstrated by CT, radio-isotope bone scanning is also valuable for the detection of skeletal metastases for example in breast and prostate cancer. Although CT provides detailed images of the morphology of body structures, it is increasingly recognized that radio-isotope imaging techniques depicting the functional status of tumours can provide supplementary information which improves the accuracy of staging. Imaging tumour glucose metabolism with Positron Emission Tomography (PET) for example, can enhance the staging of lung and oesophageal cancers and lymphoma.

The best example of the use of imaging in treatment planning is provided by radiotherapy which often uses imaging to guide the delivery of treatment so that the tumour is maximally irradiated whilst minimizing the dose to adjacent normal tissues. Radio-isotope imaging techniques are beginning to make an impact in this area by more clearly defining the tumour position and possibly enabling a higher dose of radiation to be delivered to the most active tumour area. Radio-isotope imaging can also be used to confirm that a tumour is expressing a specific molecular target for a particular anti-cancer drug, for example the use of octreotide scanning prior to somatostatin receptor blockers. Furthermore, tumour imaging with sestamibi can identify patients likely to exhibit resistance to treatment as this agent is ejected from cancer cells by the same mechanism as that used by some tumours to eject chemotherapy agents.

Furthermore, radio-isotope imaging can guide surgical treatment, for example the use of lymphoscintigraphy to

identify the axillary lymph node most likely to demonstrate breast cancer metastasis. Demonstrating the location of this ‘sentinel’ node, can enable the surgeon to minimise the extent of surgery and so reduce the likelihood of complications such as lymphoedema.

Follow-up imaging during or on completion of cancer treatment is often used to assess how effective therapy has been. This assessment is frequently made on the basis of serial measurements of tumour size, for example RECIST (Response Evaluation Criteria In Solid Tumours).

However, a number of recently introduced cancer drugs may produce little change in tumour size despite being effective. Therefore new imaging techniques for tumour response evaluation are emerging. FDG-PET is one such example which has become an established method for assessing treatment response in lymphoma.

Once a tumour has been successfully treated, imaging may have a role in detecting relapse when suspected on the basis of new symptoms or a rise in serum tumour markers. Although the initial investigation in such cases is CT, FDG-PET is may be used when CT is normal, for example in detecting recurrent colorectal cancer.

Medical imaging is a rapidly changing specialty with new techniques emerging all the time, including advances in radio-isotope imaging. Health care professionals with an interest in cancer imaging not only have to keep up with these technological advances but also keep pace with advances in cancer treatment to ensure that imaging techniques are applied most appropriately.

With an increasing incidence of cancer in an ageing population and the continued development of novel and effective treatments, cancer imaging is set to increase in importance in the near future.

Professor Ken Miles

Prof Miles is a fellow of the International Cancer Imaging Society and editor of the journal Cancer Imaging. He works with Queensland Diagnostic Imaging at Holy Spirit Northside and St Andrew’s Hospital and conducts cancer imaging research at the Brighton & Sussex Medical School, UK.

24 Gamma Gazette June 2011

case atlas

We are encouraging you to contribute to a new resource we are trying to build for the ANZSNM. It is called Case Atlas. We are hoping to make this available as a teaching/resource on the new website but in the meantime have a look what has been presented here.

If you have any interesting cases or contributions please forward to Tracey Smith: tracenucmed@hotmail.com

Submitted by Clare Radley, The Prince Charles Hospital, Chermside, QLD

Bone Scan Clinical History 73-year-old man came to department for a bone scan. His previous history was that of known staph. aureus L1-2 discitis and R sacroilitis. He was now complaining of L hip pain. He was known to have a LTHJR. The bone scan demonstrated increased activity around the hip prosthesis on both the blood pool and delayed phases, making it suspicious for infection. The increased activity in the R sacroiliac region was also thought to be due to ongoing infection.

We then performed a gallium scan which demonstrated infection chiefly involving the L iliopsoas muscle, and also probably the acetabular component of the hip prosthesis.

Findings Subsequent ultrasound guided aspiration, CT and fluroscopic examinations confirmed infection in the iliopsoas bursa extending through the greater sciatic notch into the retroperitoneal pelvis.

Case Atlas is continued on the next page 25

case atlas

continued

Submitted by Clare Radley, The Prince Charles Hospital, Chermside, QLD

PR Bleeding Clinical History An 82-year-old man presented with the history of fresh PR bleeding overnight, associated with a drop in his Hb from 115 to 85. He had nil haemorrhoids on examination and was on aspirin for AF. It was presumed that he had a likely lower GI bleed and we were asked to localise the site of the bleeding.

Interpreting the scan was made difficult by the large renal cysts that the patient had compressing the abdominal contents, leading to them be ectopically located.

He was administered 900MBq of Ultratag and imaged for about 35min in the anterior plane. On first interpretation of the scans, the was what appeared to be either a small aneurysm or very tortuous R iliac vessel.

Findings After SPECT/CT imaging, it was proven that it was neither an aneurysm or tortuous vessel, but a small bleed, originating in what appeared to be the hepatic flexure, lying directly anterior to the R iliac vessel.

26 Gamma Gazette June 2011

Submitted by Clare Radley, The Prince Charles Hospital, Chermside, QLD

Osteopetrosis Clinical History A 54-year-old woman presented for a bone scan. Her history was given as having a previous ORIF of her R proximal femur shaft, and left hip arthroplasty with ORIF of a communited fracture of her proximal L femoral shaft. She now had an infection in her L and a bone scan was ordered to determine whether the infection was in the bone or restricted to the soft tissues.

Her hip x-rays were checked to see what sort of prostheses/ORIFs were inserted, and it was noted that the patient had a disorder called osteopetrosis.

Osteopetrosis is an extremely rare inherited disorder and is also known as ‘stone-bone’ disease, ‘marble-bone’ disease and Albers-Schonberg disease. In Osteopetrosis, the bones harden and become denser. It is dysfunction of the osteoclasts that mediate the pathogenesis of this disease. This process leads to the bones becoming more brittle and easier to fracture. Cases can range from mild to severe with serious forms of the disease leading to stunted growth and limb deformities. Increased pressure on cranial nerves from excess bone in the skull can also lead to blindness, deafness and facial paralysis.

In bone scans, a patient will typically demonstrate increased uptake in their metaphyses of their long bones, which also take on a typical ‘splayed’ shape. This uptake pattern is generally more obvious in the knee joints.

Findings In this case, the bone scan demonstrated no positive evidence of infection associated with the left hip prostheses or femoral internal fixation device.

27

Case Study

Radionuclide imaging in the ankle and foot pathology Dr Iulia Heinle and Dr Frank Heinle Wide Bay Nuclear Medicine, Bundaberg, Australia Background The ankle and foot are complicated anatomical structures whose disorders present sometimes a significant clinical challenge.

Patients are often referred to the Nuclear Medicine Department for unexplained prolonged symptoms or acute pain where X-rays fail to reveal an abnormality or are inconclusive.

Methods

Discussion

Three-phase bone scans were acquired 2-3 hours after iv injection of ca 740MBq Tc99m-MDP using a dual head SPECT CT gammacamera equipped with a LEHR collimator. The planar images of the feet were acquired over 5 min in anterior, posterior, lateral and plantar foot positions. In selected cases (hind and mid foot pathology), additional SPECT CT images were obtained. The study population consisted of 44 consecutive patients over a period of 8 months, including 13 males (aged 7 to 75 years; mean age 47 years) and 31 females (aged 18 to 79 years; mean age 54 years). Cases of inflammatory arthritis or osteoarthritis were excluded from the study.

Bone scintigraphy has an incontestable value in the diagnosis of stress fractures, as it is positive before the changes on X-rays are apparent and up to 50% of the stress fractures are never observed on X-rays.

A bone scan can confirm the diagnosis of reflex sympathetic dystrophy. Bone scans can facilitate the diagnosis of painful accessory bone syndromes.

Fractured sesamoids and sesamoiditis will show increased activity and hence can be easily identified on a bone scan, while normal bi-partite sesamoids will show normal activity.

Bone scintigraphy is particularly useful in early stages of osteomyelitis, since it is positive before the occurrence of radiographic changes.

Bone scan is useful in the diagnosis of plantar fasciitis and its differential diagnosis from other causes of painful heel syndrome as well as in detecting a bone reaction at the site of a tendon’s insertion (tibialis posterior, peroneus longus, etc).

In some circumstances, whole body bone scans reveal unexpected pathology in the foot (such as Paget’s disease).

Results The conditions identified on bone scintigraphy were: – inflammatory arthritis, post-traumatic arthritis, osteoarthritis (21) – plantar fasciitis (14) – stress fractures (9) – occult traumatic fractures (4) – non-union of fractures (2) – Lisfranc fracture-dislocations (1) – ankle and malleolar injuries (6) – anterior and posterior impingement syndromes (1) – osteomyelitis (5) – reflex sympathetic dystrophy (RSD) (5) – avascular necrosis (AVN) (1) – Achilles enthesopathy/tendonitis, retrocalcaneal bursitis (5) – enthesopathy and tendinitis other than calcaneal (4) – accessory bones: accessory navicular, accessory cuboid (osperoneum), os vesalianum (base of the 5th metatarsal) (2) – sesamoiditis, fracture of the sesamoids (6) – Paget’s disease (1)

Case 1 60-year-old female with comminuted fracture of the 5th right MT 2 months ago. Now pain in the right big toe and swelling.

X-rays: old healed fracture at the base of the 5th MT. OA in the 1st right MTP joint.

Bone scintigraphy: increased diffuse vascularity and bony

28 Gamma Gazette June 2011

Conclusion Bone scintigraphy is a sensitive method that may rule out the necessity for further investigation, may document focal pathology, detect the origin of a bone abnormality when there is an ill-defined pain and guide further clinical management.

SPECT and SPECT CT have proven to be useful tools in the investigation of hind and mid foot abnormalities, increasing the diagnostic accuracy and specificity, while their use in the imaging of the fore foot is still limited by their relatively poor spatial resolution.

SPECT CT does not obviate the need for X-rays.

As bone scintigraphy is usually not highly specific, the interpretation of a positive bone scan of the ankles and feet should be undertaken only in correlation with the clinical data and X-rays.

uptake in the whole of the right foot and ankle in keeping with reflex sympathetic dystrophy changes. Increased vascularity and bony uptake at the base of the 5th right MT suggesting slow healing/delayed union of the fracture. OA in the 1st right MTP joint and the 2nd right and 1st left MTP joints.

Radionuclide Imaging in the ankle and foot pathology

Case 2 72-year-old female with pain on the outer border of the left foot for 2 months. No injury. Tender 5th left MTP area, no swelling. ?Fracture.

Past history of stress fractures of the 2nd and 3rd right MT in 2006.

X-rays: mild degenerative changes in a few IP joints and the 1st left

MTP joint. Small bone fragment close to the edge of the left cuboid.

Bone scintigraphy: increased vascularity and bony uptake close to the tuberosity of the left cuboid in keeping with a fracture of the os peroneum. Mild right plantar enthesopathy. Mild OA in both forefeet.

Case 3 73-year-old female with tenderness at the left MTP joints, the foot locks up.

X-rays: degenerative changes at the 1st left MTP joint with early degenerative changes at the intertarsal joints and a moderate calcaneal spur.

Bone scintigraphy: increased vascularity along the sole of the left mid foot with moderately avid focal uptake at the left cuboid tuberosity suggesting a peroneus longus tendinitis with a secondary bony reaction at the cuboid tuberosity. Mild osteoarthritic changes in the 4th right TMT joint and both 1st MTP joints.

51

Radionuclide Imaging in the ankle and foot pathology

Case 4 59-year-old male with pain and tenderness on the lateral aspect of the right ankle.

CT: prominent peroneal tubercle which could be a normal variant or could indicate a peroneal tendinopathy.

Bone scintigraphy: increased vascularity along the peroneal

tendon at the lateral aspect of the right hind foot and increased delayed uptake in the peroneal tubercle of the right calcaneus consistent with active peroneal tendinitis and periosteal reaction at the underlying peroneal trochlea. Mild arthritis in the right ankle. Medial left sesamoiditis.

Case 5 65-year-old male with persistent pain in the left heel in the last 4 months. Past history of repeated traumas/sprains to the left ankle.

X-rays: small calcaneal spur Bone scintigraphy: increased vascularity along the sole of the left foot and focal hyperemia and increased bony uptake in the

inferior aspect of the left calcaneus consistent with left plantar fasciitis. Increased vascularity in the left lower leg, ankle and foot and increased uptake in the left tibiotalar and subtalar joints and at the left medial malleolus in keeping with a ligament and malleolar injury associated with post-traumatic synovitis/arthritis. OA in the right ankle and the 1st left MTP joint.

Case 6 56-year-old female with left heel pain and fever. Erythema and tenderness on calcaneus.

X-rays: normal.

Bone scintigraphy: increased vascularity in the posterior aspect

of the left calcaneus as well as along the soles of both feet and increased bone uptake in the posterior and superior aspect of the left calcaneus consistent with Achilles tendinitis. Mild bilateral plantar enthesopathy. OA in the 1st and 3rd right MTP joints.

30 Gamma Gazette June 2011

Radionuclide Imaging in the ankle and foot pathology

Case 7 60-year-old male with prostate cancer. Asymptomatic feet.

Bone scintigraphy: increased uptake in the left calcaneus suggests Paget’s disease. Osteoarthritic changes in the 1st right TMT and the 2nd left TMT joints.

Case 8 34-year-old female with pain in the distal right 2nd toe.

X-rays: fairly large partially fused accessory ossicle along the medial margin of the right navicular and minor degeneration at the TMT joints.

Bone scintigraphy: increased focal vascularity in the medial aspect of the right foot with increased focal delayed uptake medially to the partially fused accessory navicular bone. Normal uptake in the 2nd right toe.

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Radionuclide Imaging in the ankle and foot pathology

Case 9 7-year-old boy with pain and swelling of the right foot after fall off trampoline 4 weeks ago. Tender over lateral malleolus and the 3rd and 4th MT heads. The foot has been in a partial cast for 3 weeks.

CT: sclerosed and thin navicular (suggesting avascular necrosis), osteopenia in the right foot and diffuse soft tissue swelling in the mid foot. ?Osteomyelitis.

Bone scintigraphy: increased vascularity and bony uptake in the

right mid foot as well as the right distal tibial growth plate and to a lesser degree the proximal tibial growth plate. Photopenic area in the right navicular. The findings are suspicious of infection in the mid foot and AVN or osteomyelitis of the navicular; RSD changes are present. Cold defects have been reported in osteomyelitis and appear to be related to a more aggressive type of infection. The patient was transferred to the hospital where osteomyelitis of the navicular with Staphylococcus aureus was confirmed.

Case 10 46-year-old female with injury to the left foot 5 months ago (slipped in bath). Complaining of pain on the lateral side of the foot.

X-rays: normal.

Bone scintigraphy: very mildly increased vascularity in the left mid foot. Delayed images show increased uptake in the 2nd-5th left tarsometatarsal joints consistent with a Lisfranc ligament injury.

Mild left plantar enthesopathy.

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Radionuclide Imaging in the ankle and foot pathology

Case 11 65-year-old female with pain in the area of the 2nd left MT. X-rays: minor periosteal reaction at the base of the 2nd MT. Bone scintigraphy: severely increased focal vascularity and bony

uptake in the 2nd left MT with activity flaring along the MT shaft consistent with a stress fracture. Mildly increased uptake in the posterior aspect of the left talus indicates a posterior impingement syndrome.

Case 12 30-year-old male with severe pain in the right foot, especially involving the 1st MT. Swelling of the right great toe and tenderness overlying the proximal phalanx. No history of trauma.

X-rays: fragmented right medial sesamoid. Lateral sesamoid appears intact.

Bone scintigraphy: increased vascularity and bony uptake

medially beneath the head of the 1st right MT consistent with a fracture of the medial sesamoid or inflammation of a bi-partite sesamoid. Arthritic changes in the 1st right MTP joint, the right tibiotalar joint, 1st right TMT joint and the PIP joint of the 3rd left toe. Mild bilateral plantar enthesopathy and mild left Achilles enthesopathy.

Case 13 54-year-old female with painful swollen right foot over the last 3 weeks. Dropped a heavy object on the right foot recently.

X-rays: degenerative changes at multiple joints in the right foot and a prominent calcaneal spur.

Bone scintigraphy: severely increased vascularity in the 2nd right

MTP joint with mild hyperemia along the metatarsal shaft as well as in the 1st and 2nd left MTP joints. Avid delayed uptake in the head of the 2nd right MT with activity flaring along the MT shaft consistent with a stress fracture. Mild OA changes in both 1st MTP joints, the 2nd left MTP joint, the 3rd left and the 2nd and 3rd right TMT joints and prominent left sesamoiditis.

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Case Study

Brain viability study Loren Katchel The Townsville Hospital, Queensland, Australia History On 28/09/10 the 19-year-old male patient visited his general practitioner with complaints of headaches, nausea, chills, and a cough, Antibiotics and bed rest were prescribed. The following day the patient was admitted to his local hospital as symptoms had worsened with constant vomiting and increased confusion. The patient then later fell unconscious while undergoing a CT scan, the patient was then air lifted to the Townsville Hospital on the 30/09/10 for further investigation.

The patient has no history of overseas travel, no history of intravenous drug use, and has not been in contact with any animals recently.

Pathology Meningitis is the inflammation of the meninges, spinal cord and the lining of the brain.

It’s most commonly caused by a bacterial or viral infection, it can however develop from a fungal infection or can be a result of other conditions, like neurosurgery, cerebrospinal fluid leak, or piercing head trauma (Matthews, Miller & Mott, 2007).

Viral meningitis: Accounts for more cases then bacterial meningitis, although usually less severe. Symptoms have the potential to resolve on there own without treatment. Viral meningitis may arise from influenza, varicella zoster, HIV, mumps (Govan, Macfarlane, & Callander, 1991).

Bacterial meningitis: Although relatively rare, bacterial meningitis has the potential to be rapidly fatal. Development usually occurs when a bacterium invades the meninges either directly or through bacterial contamination of the bloodstream from site of infection and travels to the brain (Govan, Macfarlane, & Callander, 1991).

Signs and symptoms: Of meningitis are relatively similar across all subtypes of the disease, however symptoms of viral meningitis generally tend to be milder (Adams, Graham & Harriman, 1988).

Inflammation of the meninges can cause stiffness in the neck, headache, which are probably the two most common symptoms associated with meningitis. Other signs and symptoms include nausea, fever, vomiting, phonophobia, photophobia, confusion, irritability, sleepiness, and in severe cases, seizures, and in some cases a non-pruritic rash (Adams, Graham & Harriman, 1988).

These signs and symptoms may only take a few hours or up to two days to develop, and are often mistaken for a severe cold or influenza. As a result, patients may not seek medical attention immediately and even may be wrongly diagnosed by medical professionals (Adams, Graham & Harriman, 1988).

tion, that had worsened in the second scan. There was also noted fluid and mucosal thickening seen in the sphenoid, ethmoid, frontal and maxillary sinuses. In both CT’s the tentorium cerebelli appeared hyperdense. The overall conclusion gained from the two brain CT’s is that there is diffuse cerebral oedema with central herniation, which is indicative of menegitis.

Previous Imaging The patient had two brain CT’s (no contrast) in the four day period prior to his brain viability study.

The first on 29/09/10 at the Gladestone Mater Hospital and then another the following day after he had been air lifted to the Townsville Hospital.

The CT scans showed a loss of grey-white matter differentia-

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Radiopharmaceuticals Dose And Administration The patient received a 700 MBq bolus injection of 99mTc Hexamethylpropylene Amine Oxide (HMPAO) or commercially known as ceretec, via administration into the patients central line.

Brain viability study

Mechanism Of Uptake HMPAO is a lipophillic substance that with the combination of 99mTcO4 and following reduction with Sn2+ forms a neutral complex. Due to its lipophillic nature ceretec is able to cross the blood brain barrier with rapid first pass accumulation (Mettler, & Guiberteau, 2006). With time however, 99m Tc-HMPAO becomes less lipophillic due to its breakdown to a secondary complex that demonstrates minimal brain retention, and is therefore the reason why 99mTc-HMPAO should be used within thirty minutes of prepartion. After brain uptake has occurred tracer diffusion out of the brain isn’t possible due to the fact that HMPAO gets metabolised to a hydrophilic form. Main clearance processes are through the intestinal tract which accounts for around 50% of tracer excretion, and roughly about 40% through kidney filtration (Mettler, & Guiberteau, 2006).

Normal Biodistribution Normal distribution of 99mTc-HMPAO involves the tracer crossing the blood brain barrier and around 5% of the injected activity remaining localised in the brain, with barely any late redistribution seen (Saha, 1998). In a normal brain the ratio of tracer uptake is higher in grey matter than white as 99mTcHMPAO distribution is proportional to regional cerebral blood flow (Saha, 1998).

SCAN APPEARANCE Following bolus injection, there was no evidence of intracranial perfusion seen in the dynamic images, nor any delayed active uptake in intracranial structures in the static images. These imaging finding are representative of brain death, most probably caused by meningitis.

Scanning Techniques Images were acquired according to the Townsville Hospital protocol. All images where acquired with the patient supine and in the head in position, while the patient remained on his bed, this was achieved because of detector configuration being in trolly position. A Low Energy High Resolution Collimator was employed and detector two was the acquiring camera for all collected data.

Dynamic Imaging • An anterior flow of the skull was imaged initially following injection of the radiopharmaceutical.

• A 128 x 128 matrix was used to collect the 180 x 1 second frames.

• The detector orientation was at 0°.

Planar Imaging • 5 minutes post injection a 3 minutes anterior static of the patients skull was acquired.

• This imaging was done using a 256 x 256 matrix.

• The detector orientation was at 0°.

• Following the Anterior image a right lateral of the patients skull was acquired.

• The 256 x 256 matrix remained the same.

• The detector orientation of 0° was unchanged, but instead the patient head was reposition in order to obtain the lateral view.

MANAGEMENT On October 1 the patient was taken of all forms of life support and was announced clinically dead. Doctors went on to discuss the potential of organ donation with the patients family, however they decided against it (Matthews, Miller & Mott, 2007).

REFERENCES Adams, H., Graham, D. & Harriman, D. (1988). An Introduction to Neuropathy. New York:Churchill Livingstone.

Govan, A., Macfarlane, P. & Callander, R. (1991). Pathology I llustrated 3rd Edition. New York: Churchill Livingstone.

Matthews, C., Miller, L. & Mott, M. (2007). Getting Ahead of Meningitis and Encephalitis. Nursing Journals: Nov, 2; (36-42) Mettler, F. & Guiberteau, M. (2006). Essentials of Nuclear Medicine Imaging 5th Ed. Philadelphia: Saunder Elsevier.

Saha, G. (1998). Fundamentals of Nuclear Pharmacy 4th Edition.

New York: Saunder Elsevier.

Schneider, A. & Szanto, P. (2009). Pathology 4th Edition.

Philadelphia: Wolters Kluwer.

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Case Study

Abdominal aortic stent graft infection Procedure performed: Nuclear Medicine 99mTc- HMPAO Labeled White Cell Scan Luke Cahill Nuclear Medicine Student, University of Newcastle CLINICAL History • In 2010 a 71-year-old male presented after experiencing chronic lower back and abdominal pain for a duration of 2 weeks, recently becoming sever over the last 24 hour period.

• Patient had a history of long standing hypertension, hypercholesterolemia, coronary heart disease, as well as COPD. • Physical examinations revealed no obvious lower back or abdominal pathology.

• CT with IV contrast revealed a ruptured Suprarenal Abdominal Aortic Aneurysm with a transverse dilation of 6cm in diameter.

• Subsequently an Endvovascular Aneurysm Repair was carried out using a 26 x 80cm tube stent graft which was implanted just above the Renal Artery.

• 6 days post surgery the patient represented with a high fever (39.8), severe chills, malaise and a decreased appetite.

• Physical examination revealed patient discomfort of the abdomen within the region of the stent graft surgery.

• Blood analysis revealed an increased WBC count of 20.4 x 109/L. • Supporting blood cultures identified growth of Salmonella Choleraesuis.

• A diagnoses of an infection of the patients previous abdominal aortic stent graft was proposed.

Pathology • Aortic Stent Graft Infections are a rare but life threatening medical complication with an incident rate of less the 0.5%.

• Most common indications of an Aortic Stent Graft Infection are either pre-existing aneurysm’s that have become exposed to bacteremia, or from the result of a direct trauma such as the surgical intervention to peripheral arteries.

• 80% of all Abdominal Aortic Stent Graft Infections are caused by gram-positive micro organisms. Most common being Staphylococcus and Salmonella.

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• Specific to this patient’s case, their risk of infection to the aortic stent graft was heightened as a result of the damage sustained to the Mucosal barrier of the intestines due to the severity of the initial aneurysm rupture.

Abdominal aortic stent graft infection

Whole Body Scan • Delayed Whole Body Images demostraight quite normal biodistributional uptake within the Liver, Spleen, Lungs and Bone Marrow.

• There is a small focus of increased uptake centrally within the mid abdomen just anterior to the L3 vertebra

SPECT CT • SPECT CT images revealed a focal intensity of white cell activity within the anterior aspect of the abdominal aorta.

• This corresponds with the region of this patients previous stent graft implantation.

Expected Continued Management • The classical treatment and management approach for this type of aortic graft infection typically involves the complete excision of the infected graft with reconstruction of the distal circulation via clean and unaffected tissue.

• However due to this patients underlying medical complications this option would be poorly tolerated and inherit an increased mortality risk. Therefore a more conservative treatment approach was implemented.

• Surgical debridement, drainage, systemic antimicrobial therapy and local antibiotic irrigation was therefore subsequently carried out.

• While this is a slower acting and conservative treatment approach, it allowed for the complete preservation of the patients original abdominal aortic stent graft.

References 1. Doherty, G., & Way, L. (2010). Current surgical diagnosis & treatment. Ohio: McGraw-Hill Professional.

2. Frogge, H., & Goodman, M. (2009). Cancer nursing: Principles and practice. Boston: Jones & Bartlett Publishers.

3. Jasmin, C. (2010). Textbook of Bone Metastases. Chichester: John Wiley & Sons Publications.

4. Mettler, F. A. Jr., & Guiberteau, M. J. (2006).

Essentials of nuclear medicine imaging.

Philadelphia, Pennsylvania: Saunders Elsevier.

5. Shields, T. (2008). General Thoracic Surgery.

Lippincott: Williams & Wilkins.

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Case Study

Tumour of unknown origin Nicholas Khan Nuclear Medicine Student, University of Newcastle

Patient History A 44-year-old male underwent CT scan to investigate sore lower back, caused by a coughing spell three weeks previously. The CT identified minor L3 fracture, incidentally found part of a large, lytic lesion in the right sacroiliac joint, suspected to be a secondary malignancy. Patient was referred for a bone scan later that day to assess sacroiliac lesion and to identify further osseous involvement.

Lytic Metastases Radiographically lytic bone lesions are caused by the destruction of bony matrix and can be caused by a number of both benign and malignant factors.1 Malignant causes of lytic lesions are usually the metastases of one of several cancers, including renal, breast and thyroid carcinomas and multiple myeloma; they are often indicative of relatively aggressive tumours, with the exception of thyroid metastases which are often slower growing.2 Once these metastases become lodged in bone marrow, they stimulate the localised release of osteoclasts, increasing the rate of bone resorption, causing a photopaenic defect on scintigraphic images.3 A reactive osteoblastic response may also occur in the affected bone, causing a rim of increased radiopharmaceutical activity surrounding the metastasis.4 Bone Scan • Anterior blood flow appears normal • Blood pools demonstrate photopaenic sacroiliac lesion identified on earlier CT. New photopaenic defect also seen in the right lobe of the liver.

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Tumour of unknown origin

• Delayed imaging identifies the original lumbar fracture; also the photopaenic sacroiliac lesion, with a reactive rim of increased osteoblastic activity. The liver mass now appears as very slightly increased activity above the right kidney.

Outcome This patient went on to have a chest/abdomen/pelvis CT the following day, seen below, which visualised both the lytic sacroiliac lesion and a large liver lesion, but not the suspected primary tumour. The following week, the patient had a biopsy of the sacroiliac lesion which identified the cells as an adenocarcinoma. The prognosis of patients with cancers of an unknown primary site is generally poor, with a 5-year relative survival rate of just 9.1%.5

References 1. Kowalczyk, N., & Mace, J. D. (2009). Radiographic pathology for technologists (5th ed.). St. Louis, MO: Mosby Elsevier.

2. Murray, I. P. C., & Ell, P. J., (Eds.). (1998). Nuclear medicine in clinical diagnosis and treatment (2nd ed., Vol. 2.).

Edinburgh: Churchill Livingstone.

3. Mundy, G. R. (1997). Mechanisms of bone metastasis.

Cancer, 80, 1546-1556.

4. Collier, B. D., Fogelman, I., & Rosenthall, L. (1996). Skeletal nuclear medicine. St. Louis, MO: Mosby.

5. Australian Institute of Health and Welfare, & Australasian Association of Cancer Registries. (2008). Cancer in Australia: an overview 2008. Canberra: Australian Institute of Health and Welfare.

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Australian and New Zealand Society of Nuclear Medicine