March 2012

March 2012 – Issue 1

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

Contents

www.anzsnm.org.au

Welcome

4

President’s Report

5

New Zealand & South Australia Committee Profiles

6

Branch News

New Zealand

South Australia 8

8

Victoria/Tasmania

8

8

Western Australia

SIG

Radiopharmacy 12

Technical Standards Committee 13 Accreditation Board 14 What you need to know about the new National Registration Scheme

17

In Retirement 21 What’s That?

22

Having difficulty gaining IV access 26 Interesting Case: A fungating breast mass 28 Interesting Image: All, that is “Hot” is not infection 30 Submitted paper

Solitary Plasmacytoma: Incidental diagnosis by the contribution of nuclear imaging

32

Suspected Erythema Nodosum: Appearances on Gallium and PET scanning

36

Case Study

Fine Needle Aspiration Biopsy exacerbating and then curing Hyperthyroidism 39

Whole body bone scan plus SPECT/CT demonstrates a metastasis in an unusual bone site

40

Breast cancer with bony metastases confined to the left leg

42

Incidental

45

Bone marrow uptake or pus? 46

Potential false positive antigranulocyte antibody scan in a case of knee joint replacement

within 12 months of surgery

FDG PET appearances of arteritis associated with lymphoma 50

Tc Pertechnetate Uptake in Neonatal Breasts

99m

48

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 go to the website www.anzsnm.org.

March – February 1 September – August 1

June – May 1 December – November 1

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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 SA & NZ Branches

Barry Chatterton

Rachael Dunlop

Dianne Wills

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 organisations 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 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.

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.

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, which 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.

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. Š 2012 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).

ANZSNM website address: www.anzsnm.org.au

(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.

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

Dr Sze Ting Lee (Vic/Tas) email: szeting.lee@petnm.unimelb.edu.au Ms Julie Crouch (WA) email: jul.crouch@gmail.com Mr Geoff Roff (WA) email: geoffrey.roff@health.wa.gov.au Ms Lyndajane Michel (Qld) email: michell@qdi.com.au Mr Geoff Roff (WA) email: geoffrey.roff@health.wa.gov.au Dr Sue O’Malley (NZ) email: sue@omalley.co.nz Dr Dylan Bartholomeusz (SA) email: dylan.bartholomeusz@health.sa.gov.au Ms Liz Bailey (NSW) email: EBailey@nsccahs.health.nsw.gov.au Dr Graeme O’Keefe (Physics SIG) email: graeme.okeefe@petnm.unimelb.edu.au Ms Jennifer Guille (Radiopharmacy SIG) email: Jennifer.Guille@sesiahs.health.nsw.gov.au

Accreditation Board Chairperson: Members:

All correspondence

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:

Professor Richard Smart, email: r.smart@unsw.edu.au

Research Grant Committee Chairperson:

Professor Richard Smart

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

Mr Craig Collins, email: craig.collins@act.gov.au Mr Peter McConachie, email: Peter.McConachie@sesiahs.health.nsw.gov.au Ms Rowena Rose & Ms Penni Russell, email: qldbranchsecretaryanzsnm@gmail.com Mr Adam Freeborn, email: adam.freeborn@hotmail.com Miss Zlata Ivanov, email: zlata.ivanov@arpansa.gov.au Ms Stephanie McMahon, 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 Ms Jennifer Guille, email: Jennifer.Guille@sesiahs.health.nsw.gov.au Dr Darin O’Keeffe, email: darin.okeeffe@cdhb.health.nz Mr Erwin Lupango, email: Erwin.Lupango@sesiahs.health.nsw.gov.au

Ms Julie Crouch Mr Doug Mackey Mr David Lyall Mr David Thomas

Dr Nat Lenzo Dr Sze Ting Lee Ms Tale Liiv

Dr Clayton Frater

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

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Welcome Welcome to the March edition of the Gamma Gazette. The first edition for 2012! We hope everyone has had a relaxing, safe and happy holiday season.

This issue has been a collaboration between the South Australian and New Zealand branches. I would like to thank Associate Professor Barry Chatterton for volunteering to be our editor for the issue. His vast knowledge, experience and contributions within nuclear medicine are admired.

The South Australian ANZSNM branch holds four meetings per year including the AGM. Presentations are incorporated into each meeting. Topics have included therapy, scanning techniques and current research projects. An additional meeting is also held for the invited speaker from the ANZSNM Annual Scientific Meeting.

The Nuclear Medicine Degree can be obtained from the University of South Australia. As a four year degree, students complete many hours in clinical placement. Some students choose to gain experience at interstate departments as well. The university encourages research, and many students complete an honours degree in their final year.

South Australia has an excellent Nuclear Medicine community, which I am proud to be part of.

Rachel Dunlop South Australia New Zealand has fourteen Nuclear Medicine Departments, four in the South Island and ten in the North Island. There are also five dedicated PET/CT centres.

The branch holds one major annual meeting, over a weekend, and in a different centre each year. The weekend gathering includes lectures by invited speakers, presentations from members of the Australasian Nuclear Medicine community, a poster competition, trade displays and social events. This meeting is well attended and participants enjoy ‘catching up’ with other Nuclear Medicine professionals many of whom they have known for decades.

The branch also welcomes visits from guest speakers following the ANZSNM Scientific Meetings. In 2011 video linking enabled audiences in three major cities to participate in Dr Homer Macapinlac’s lecture. Hopefully we will make video linking a regular part of our continuing education.

Training Nuclear Medicine Technologists is an ongoing area of difficulty in NZ. The process for qualification requires an initial diagnostic radiography degree followed by a two year, distance learning Nuclear Medicine qualification. The low numbers of students in NZ has meant viability issues for providers of the appropriate distance learning courses.

The Christchurch department has been through a traumatic sixteen months of earthquakes and continuing aftershocks. Throughout this time, patients have been scanned during all but one of the departments normal working days. The staff have been grateful for all the messages of support from the Nuclear medicine community.

Thank you to all those who contributed to this edition of the Gamma Gazette. Your time and effort is much appreciated.

Diane Wills New Zealand Branch

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.

2012

April 27-30

ANZSNM 42nd Annual Scientific Meeting

Melbourne Exhibition & Convention Centre, South Wharf June 7-10

17th ISRRT World Congress &

CAMRT 70th Annual General Conference

Sheraton Centre, Toronto

Canada www.2012isrrt.org/ August 12

Annual TSIG symposium

Hervey Bay, Mantra Resort, Qld

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August 26-29

14th International Workshop on Targetry and Target Chemistry

Riviera Maya, Quintant Roo, Mexico info@wttc14.mx October 20

Vic/Tas Branch Annual Day Seminar

Hobart, Tasmania

2013

ANZSNM Annual Meeting to be held in Perth in 2013.

President’s Report This is my last President’s Report for the Gamma Gazette, as I will be stepping down at the Melbourne Conference in April. I can’t believe how quickly my two year term has passed, and it is time for me to reflect what I have done over the last few years on the Society front.

First and foremost, we have seen the successful implementation of the online journal, the Gamma Gazette, in the new concept colours of the Society, which has been a great success. But this would not have been possible if not for the extremely hard work of all members of the Society throughout Australia and New Zealand. It is wonderful to see all the branches come together and work to produce such amazing content over the last two years, and with this current edition put together by the South Australia and New Zealand branches, we have seen all the branches contribute to this journal during my two years here.

Special thanks is also to be given to Rachel Bullard, our Production Editor, who manages to compile each edition so beautifully; and also to Judi Anderson, our Secretariat, who collates and proof-reads the submissions.

As you will all be aware, National Registration for Nuclear Medicine Technologists/Scientists continues to move forward. The implementation of National Registration will occur in July 2012, and if those involved have not done so, I strongly recommend that you visit the APHRA website and register with them so that you will be kept abreast of all relevant information. Whilst the Accreditation Board of the Society will cease to exist in its current form when that occurs, the Society will continue to assist the newly formed national Accreditation Council with certain aspects until July 2013. There are numerous people within the Society who have been heavily involved in this process over the last few years. Whilst this is not an exhaustive list, I would specifically like to thank the following for their tireless work in this arena. They include David Lyall, Bridget Chappell, David Thomas, Elizabeth Bailey, Julie Crouch, and our SA representative – Adam Freeborn. More recently, Geoff Roff has also represented the Society in continued discussion with AMRSAC regarding our further involvement in the future. The paperwork which had to be ploughed through and the documents generated were phenomenal and could not have been done without the generous donation of their time and efforts to this matter.

The website committee has also been diligently been putting together the new website which will have dedicated member only sites for CPD and e-Learning. Thanks to the website committee members which include Geoff Roff, Peter Collins, Doug Mackey and Robert Barnett. I believe that we are on target for the official launch at the Melbourne conference in April.

There has been considerable efforts made in increasing our international profile, which has been very successful, with the involvement of representatives from the Society in various aspects to promote the high quality nuclear medicine which is practiced in our region. We have also been asked to assist with the curriculum for the Asian School of Nuclear Medicine, and other activities in nuclear medicine worldwide. I don’t think there is a single continent in the world where nuclear medicine is practiced which has been spared our presence!

There are many people to thank for this who have not only donated their time, but also funded themselves for many of these activities, including Andrew Scott, Peter Collins, Dale Bailey, Vijay Kumar, Heather Patterson and other members of the International Relations Committee, who will now concentrate their efforts this year to winning the bid to bring the World Federation of Nuclear Medicine and Biology Congress to Melbourne in 2018, with the voting to be held at the EANM in October 2012.

More recently, the Society has also been invited to consult on a project which is being led by Prof Andrew Scott from the Austin Hospital in Melbourne, to advise the Department of Health on the broader uses of PET in Australia and to investigate the use of radiopharmaceuticals in nuclear medicine services (including PET). This project will also be in consultation with the ANZAPNM and other relevant parties as well.

As mentioned at the last AGM in Darwin, the Society is moving towards restructuring its management structure and will be advertising for a General Manager with the intention to increase the professional profile of the Society nationally, liaising with government, and also on the international scene. More information on this will be available at the Melbourne conference.

Speaking of the Melbourne conference, we are now only less than 2 months away from the Annual Scientific Meeting in Melbourne, which will run from April 27-30. We have had a record number of abstracts submitted, a very robust scientific pre-conference and main conference program, with a great host of international speakers and local experts. In response to the increasing use of CTCA, Prof Barry Elison will return for a repeat performance of his very successful “CTCA 101” course he ran in Darwin for those who are interested, thanks to the sponsorship from Philips. Not to mention that the social program is going to be a spectacular one as well, with a pirate-themed Nuc’s Party at the Wharf Hotel, and the Masquerade Ball at the Marriner Ballroom at the Regent Theatre. Also, Fishing with John will also return with a boat leaving from the famous St Kilda pier, not forgetting the annual Golf with Gordon adventure too. So, don’t miss out on the early bird registration which is coming up quickly on the 8th of March 2012 and go to www.anzsnm2012.com.au for more information.

Finally, I would like to thank everyone on Council, Board and Committees, and members of the Society who have assisted me over the last two years, and made my job easier. Without them, and the support of my colleagues and employers at the Austin Hospital in Melbourne, I would not have been able to serve you in this capacity over the last two years.

I hope to see as many of you in Melbourne as possible at the Annual Scientific Meeting in April, and if not I wish you all a very productive year ahead.

Dr Sze Ting LEE President

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Meet the NZ & SA Committee members Dr Sue O’Malley Committee Position: Chairperson Current place of Employment: Christchurch (main), Wellington, Invercargill.

Current position in your workplace: CHCH – Clinical Lead Nuclear Medicine.

Wellington – Cardiologist and Physician in Nuclear Medicine. Invercargill – Physician in Nuclear Medicine.

Time served on the committee: 3 years as Chairperson What you hope to achieve from being on the NZ Branch Committee: To promote and advance NM services in NZ.

Jane Hassall Committee Position: Treasurer Current place of Employment: Christchurch Hospital, Christchurch Current position in your workplace: Second in charge Technologist Time served on the committee: 3 years What you hope to achieve from being on the NZ Branch Committee: To become more involved in our Nuclear Medicine Community.

Dianne Wills Committee Position: Secretary Current place of Employment: Christchurch Hospital, Christchurch Current position in your workplace: Technologist Time served on the committee: 2 years.

What you hope to achieve from being on the NZ Branch committee: I wish to give something back to the Nuclear Medicine community which has provided me with a stimulating and satisfying career for almost 25 years.

Prue Lamerton Committee Position: New Zealand Representative for the Technologists Special Interest Group (TSIG).

A member of the NZ Medical Radiation Technologists Board (NZMRTB).

Secretary of the ANZSNM TSIG. Current place of Employment: Hastings Memorial Soldiers Hospital.

Current position in your workplace: Team Leader Time served on the committee: On the TSIG committee for 3 years and took on the secretarial role after 6 months. The committee has seen quite a turnover of members in the past two years which is inevitable with the workload pressures put upon quite a lot of technologists. Liz Bailey (chair) NSW, Nick Lawrence (Tas) and I remain the three longest serving members and I am grateful that Liz and Nick have remained on the committee for continuity and stability.

What you hope to achieve from being on the NZ Branch Committee: I enjoy being involved in the committee and find the networking and friendship invaluable. I have particularly enjoyed seeing how far NZ has come in the last three years with a Wellington Cyclotron and 5 PET/CT centres. New Zealand has really progressed and in my role I want to ensure that all the NZ ANZSNM tech members are a working team alongside the rest of the members. I am always proud of the

6 Gamma Gazette March 2012

Meet the NZ & SA Committee members fact that at our NZ branch meetings we get an attendance rate of over 90% of our technologists which proves what a close knit community we are.

One of the key roles for me has been to ensure the NZ students have a qualification that is accepted by the NZMRTB and in my role I have been able to gain the support and assistance of the TSIG. At this stage I would like to acknowledge the work put in by Dr Berry Allen and the NZ Nuclear Medicine Advisory Board and Professor Steven Meikle for his assistance in the NZ path towards the University of Sydney Masters in Molecular Imaging qualification that has recently gained the provisional acceptance from the NZMRTB for NZ students. Students will be able to begin study from the first semester next 2012.

National Registration is inevitably taking a huge chunk of committee work and, from a New Zealand perspective, it has been interesting seeing the national registration process evolve and to see how similar the process will be to NZMRTB registration and I hope my understanding of the processes will help the committee.

Rachael Dunlop Committee Position: Chairperson Current Place of Employment: Royal Adelaide Hospital Current Position in your work place: Technologist Time Served on the Committee: 2 years What you hope to achieve from being on the SA Branch committee: I would like to play an active role in the Nuclear Medicine community. I hope to facilitate in bringing everyone together through meetings and continuing education.

Adam Freeborn Committee Position: Secretary/Treasurer Current Place of Employment: Flinders Medical Centre Current Position in your work place: Technologist Time Served on the Committee: 3 years What you hope to achieve from being on the SA Branch committee: To be an active member of the Nuclear Medicine community.

Dr Dylan Bartholomeusz Committee Position: Federal Representative Current Place of Employment: Royal Adelaide Hospital, Jones and Partners Imaging Current Position in your work place: Nuclear Medicine Physician, Gastroenterologist Time Served on the Committee: 4 years What you hope to achieve from being on the SA Branch committee: On the committee I would like to work together with all other members to nurture and develop the role of Nuclear Medicine in the community. The Nuclear Medicine community has professionals of varied back grounds all working well together and this is to be encouraged and supported. National registration, training CPD issues are very important and as the SA representative I see myself as facilitating communication between the ANZSNM and individual members.

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Branch News NEW ZEALAND OVER the weekend of November 5-6, 2011 the Annual NZ Branch meeting was held at the Otago School of Medicine in Wellington. Pru Burns, a hard working organiser, has written a full report on this stimulating and fun occasion which can be found in this edition of the Gamma Gazette.

Dr Berry Allen reports that the Waikato Hospital Nuclear Medicine Department recently installed a solid state detector dedicated cardiac scanner to assist with improving waiting times, and to reduce patient imaging times so as to facilitate improved department efficiency. Waikato Hospital provides Nuclear Medicine services to a large geographical and population base, and has a regionally based Cardiology department providing a large referral for myocardial perfusion imaging.

Myocardial perfusion studies comprises a large proportion of the studies undertaken at Waikato Hospital.

The cardiac scanner was commissioned early August 2011 and since that time has allowed the department to improve the patient throughput significantly, reduce the administered radioactives and shorten the procedure protocol. The scanner has provided the opportunity to continue to improve and expand our cardiac imaging services. We continue to shrink our waiting times and now have the opportunity to continue to improve our cardiac imaging services.

Dianne Wills Secretary

SOUTH AUSTRALIA IN October, The Queen Elizabeth Hospital hosted our final branch meeting for 2011. Dr Gabrielle Cehic, Deanna Maglica and Davina Nicholls presented “LuTate Therapy for GEP-NET Patients: the early QEH experience”.

The SA branch were pleased to award the inaugural Student Conference Prize to Emma Brook, who presented “The effects of timing of a buffet meal presentation on energy intake following a nutrient preload in healthy lean men and women: relationships with antral area,” at the University of South Australia Student Conference.

The end of the year was marked with our AGM held at Ayers House. I would like to thank Lantheus, Insight, Siemens and GE Healthcare for their generous sponsorship.

Dr Dylan Bartholomeusz was re-elected as our Federal Representative as was I, Rachael Dunlop, as Chairperson. Adam Freeborn will continue on as Secretary/Treasurer. The AGM was a very well attended meeting and the night concluded with our annual quiz, which brought out much competitiveness between teams.

An Organising Committee has been formed to oversee preparations for the Adelaide ASM to be held in 2014.

Branch meetings will be starting up again in February. We hope to see high levels of attendance to meetings again this year and we wish everyone a happy, healthy and successful 2012.

Rachael Dunlop SA Branch Chairperson VICTORIA/TASMANIA This year has been a busy one so far for the Vic/Tas Branch with our first scientific meeting for the year being held at the Peter MacCallum Cancer Centre on January 18. At this meeting Prof. Kim Williams updated us on the trends and developments in Nuclear Cardiology over the last 12 months with his presentation “Nuclear Cardiology: 2011 in Review”. The meeting was well attended with over 50 doctors, technologists and nurses attending.

January also saw a reorganisation of the Vic/Tas Branch committee with the Branch Chair, Secretary and Treasurer position being vacated. The new bearers are:

Branch Chair Bridget Chappell

Secretary Zlata Ivanov Treasurer Daniel Rossiter I would like to thank both Zlata and Daniel for volunteering for these roles at a very busy time for the committee.

After the success of the Vic/Tas Branch’s involvement in last year’s VCE Age Careers Expo, the branch will again be participating this year. The Expo will be held in Melbourne at the Caulfied Racecourse from May 4-8, 2012. The committee will again be looking for volunteers to don their tri-foil t-shirts and introduce senior secondary school students to Nuclear Medicine and its different career paths.

With the ANZSNM ASM being held in Melbourne from April 27-30, the Vic/Tas Branch Annual Day Seminar

8 Gamma Gazette March 2012

will be heading south to Hobart. The meeting will take place on October 20, 2012 on the water at the Hobart Function and Conference Centre. The Committee hopes that many of our mainland members will travel down to join our Tasmanian members for the meeting.

As the countdown to the Melbourne 2012 ASM begins in earnest with the close of abstracts, the Branch and the ASM scientific committees are working hard to bring together an interesting, educational and memorable meeting. I hope that many of you will be able to join us for this meeting and look forward to seeing you in April.

Bridget Chappell

WESTERN AUSTRALIA Happy New Year to everyone, hopefully the year has started well and the wet weather hasn’t been too debilitating to everybody over in the east. In WA, 2011 finished with the AGM at Mount Hospital in November, with a meal and a quiz. Along with the other formalities, Dr Elizabeth Thomas and I were welcomed onto the committee at this meeting and look forward to working with the rest of the committee members in the coming year.

Preparations are well underway for the ANZSNM Annual Meeting to be held in Perth in 2013. The WA Branch is excited to host the rest of Australia next year, and to show off what our capital city has to offer.

The first meeting for 2012 is scheduled to be held in February at SKG. The presentations at our meetings and workshops have been excellent in past years, and hopefully this year will be no exception.

Stephanie McMahon WA Branch

NZ Branch Meeting Wellington November 5 & 6, 2011 The NZ branch meeting was held in Wellington at the Otago School of Medicine building November 5 & 6, 2011. It was well attended with just over 80 delegates, including our friendly trade vendors. This meeting is always a success, thanks to our wonderful sponsors – GMS, GE, Insight, Siemens, Alphatec, ANSTO Health, Cyclotek Pharmaceuticals, Covidien, Cyclomedicia and Pacific Radiology.

Highlights were: • Insight from Mr Chris Adams, a Wellington Plastic Surgeon, on his use of Sentinel node imaging and PET/CT in relation to melanoma staging • Chris’s talk went well with a presentation by Dr Anna Brooks on developing immune therapies for the treatment of cancer, in particular Anna’s work with Melanoma • An interesting talk from Celia Gordon, a RT at the Wellington Blood Dr Sue O’Malley, NZ Branch Chairperson, presenting a gift to and Cancer Centre, on the use of PET/CT in RT planning retiring Nuclear Medicine Physician, • Mr Robert Romero outlined the process Cyclotek Pharmaceuctials Dr John Turner. went through to build the first cyclotron facility in NZ • Dr Kevin Smidt gave an excellent tribute to Dr John Turner, Nuclear Medicine Physician, who is retiring from Christchurch Hospital • A very moving presentation from staff at Christchurch Hospital’s NM Department on their experiences during the September 2010 and the February 2011 earthquakes. We all learnt a lot from their presentation,

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NZ Branch Meeting in terms of identifying potential hazards within our departments, and on a more personal note – to always have a full tank of petrol and your mobile phone charged. Many thanks to Julie, Clare and Darin.

Awards went to: • The Paul Orr Award – Dr Berry Allen “Cardiac Imaging – 19 Highly Sensitive Points” Lynda Murray, Kirsten Worthington, Jane Hassall, Julie Archie and • The Covidien Poster Prize – Dr Darin O’Keeffe.

Dianne Wills “Whole Body Bone Scan plus SPECT/CT demonstrates a Metastasis in an Unusual Bone Site” No NZ branch meeting is complete without a branch dinner. This year we enjoyed the surroundings of the Wellington Waterfront, at Mac’s Brewery. Being Guy Fawkes night, we were entertained with a fantastic fireworks display, before enjoying a great local band.

Sunday morning saw a well attended AGM. • Discussed at length was the ongoing issue around training of Nuclear Medicine students in NZ. It looks hopeful that we may now have access to a course that suits our students. A huge thank you must go to Dr Berry Allen for his work and enthusiasm for getting this up and running.

• It was felt by the NZ branch that there is now a need for a committee to create a framework for PET/CT services who can then engage the relevant regulatory, accreditorial, and advisory bodies. The PET Advisory Committee is to include members from all aspects of the NZ PET community, physicians, radiologists, technologists and physicists.

• Dr Darin O’Keeffe highlighted the need for a “living” ANZSNM email list, NZ Branch Chairperson, Dr Sue O’Malley is to take Darin’s suggestion to the Federal Committee.

The branch meeting heads to Dunedin in 2012 ... imagine a branch meeting in a castle! Many thanks to Team Wellington for another great meeting, see you all in Dunedin.

Pru Burns NMT Pacific Radiology

Dr Berry Allen.

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Special Interest Group RADIOPHARMACY

Issues and news for our SIG include: Accreditation This is a slow process, but one which we hope will speed up once the formats are in place. The Federal Council of the ANZSNM has kindly given a budget of $4000 toward helping this process. The Subcommittee wants to use this money to assist a weekend workshop that allows a number of RPS from around Australia to have a face-to-face meeting to flesh out the bones we have constructed so far. We will let you know more on this over the next two months. We will additionally be making time at the Annual Scientific Meeting to further this process. Please advise us if you will be attending this meeting so you can be updated on any meetings.

Education There has been some interest shown from both within Australia and from overseas regarding the Master of Radiopharmaceutical Science at Macquarie University. Unfortunately no-one has actually enrolled as yet. I would like to encourage anyone mildly interested to look into this – even if you only want to do a few subjects. The course is well structured; it can be done over a period of time as each of the subjects is complete within itself. The subjects are highly relevant. The link is currently being updated – when available I will let you know. This course is available to anyone with an appropriate undergraduate degree, but is contingent on having the equivalent of a chemistry major, or being willing to undertake a bridging course in chemistry.

Registration Registration is a mechanism by which professionals are ‘Registered’ as accepted to gain employment in their profession. It should be contingent on some sort of established professional standards – such as accreditation. In some professions (like ours) it has not been established as yet. In many, it has been established but by the profession itself (like the Physicists). However, the Government (Federal) is moving toward the registration of all health professionals.

This move is to ensure competency standards are set, that an individual is assessed and has ongoing review, that those employed in the health system are appropriate (in education, skills and knowledge) to conduct the work they are employed for. Professions like physicians and nurses, pharmacists, have had ‘Registration’ for some time. The NM technologists/radiation scientists are going through the process now. It will affect us in the not so distant future. It was one of the reasons for initiating the move for accreditation – if we do not show willingness to regulate ourselves, others will do it for us. Although Accreditation will be by peer review, the Registration process will be controlled by government, with industry input. ACPSEM is currently working through the management of this process, and will be including the needs of the RPS with those of the physicists.

Quality Projects Both for reasons of collaboration, and to assist some quality issues to do with RCP measurements using ITLC, as prescribed by the USP or BP, it was proposed we collectively undertake a fact-finding project and, if necessary, some discussion around ‘best practice’. Whilst some consider we must use BP or USP, there was support for the gathering and collating of information relating to methods in use and any difficulties pertaining to those methods, and in producing a document which makes recommendations of method of choice, limitations, and conditions of use. It seems to be a not uncommon view that the methods prescribed by these authorities are not always the best in certain circumstances. As a group we would like to investigate this and compile a report which offers guidelines for implementation of methods. It is an opportunity for the group to collaborate, get involved in a quality project, hopefully with a useful outcome. We need to design a mechanism to execute the project. Anyone specifically interested in a role in this could contact me via email Jennifer.guille@sesiahs.health.nsw.gov.au.

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Annual Scientific Meeting We are hoping to provide an interesting program for the SIG meeting this year. If you have work – not yet ready for the wider public consumption, but that you would like to present to the specialist audience – please let Gordon Chan know on jgc@petnm.unimelb.edu.au. We will endeavour to include you in the SIG programme. We are fortunate that IDB are bringing Wouter A.P. Breeman to the meeting, whose interest and expertise is labeling of peptides (mainly chelated peptides, conjugated with chelators such as DTPA of DOTA), with radiometals as Ga-67/68, Y-90, In-111and lanthanides such as Lu-177. He will be a very relevant and interesting speaker.

Wishing everyone a productive and interesting 2012.

Jennifer Guille Chair

Technical Standards Committee The Technical Standards Committee (TSC) has had a long history within the Society and has been intimately involved in establishing and maintaining technical standards on nuclear medicine equipment. It has been primarily a committee of physicists although attempts have been made in the past to include other nuclear medicine professionals.

In 2011 the ANZSNM Council adopted a revised Terms of Reference for the TSC intended to specifically broaden its membership. The committee for 2012 will include up to 10 members, with the members nominated by each Branch and SIG of the Society, together with an ANZSNM member nominated by the ANZAPNM. I have been nominated by Council to Chair the 2012 TSC. Most of the nominations have been received and a full list of the membership of the TSC will be published in the next Gamma Gazette.

The first meeting of the new committee will be held in February. We have a busy workload ahead of us and will be establishing working groups to tackle each task. Several TSC documents are due for revision, namely Minimum Quality Control Requirements for Nuclear Medicine Equipment, version 5.7 Nov 1999 and Requirements for PET Accreditation (Instrumentation & Radiation Safety), 4 May 2007. In addition, the work undertaken by the previous committee on software phantoms and clinical software validation needs to continue.

Many of you will be aware of the dose calibrator surveys which the TSC has co-ordinated every two years for more than two decades. The TSC is in discussions with the Activity Standards Lab at ANSTO on ways of improving this service to the nuclear medicine community. Once the proposals have been finalised we will be contacting all sites with the details of the new arrangements.

Richard Smart Chair ANZSNM TSC

13

Accreditation Board News The Accreditation Board met on February 11, 2012 in Melbourne Present were Julie Crouch (Chair), Judi Anderson (ANZSNM Secretariat), Clayton Frater (Secretary), David Lyall, Tale Liiv and Nat Lenzo (Physician). Apologies were received from Doug Mackey, David Thomas and Sze Ting Lee (ANZSNM President).

From the meeting: • Thirty-two new Nuclear Medicine Scientists were granted Accreditation There were 34 new PDY applicants which brings the current total of PDY technologists/scientists to 64 • Three NM scientists will soon be sitting the OQA exam and three applicants have been provided with Australian Skills Assessment letters • An amendment to the OQA application form was made in regards to IELTS levels • There was one new approval for departmental PDY training, congratulations to St Vincent’s Clinic Medical Imaging & Nuclear Medicine, Cert. #161 • From the PDY/Mentor Program Co-ordinator’s report it was noted that there may be some Victorian Intern positions available in 2013 for applicants from other States and a letter will be forthcoming from the coordinator • Several questions have been received recently concerning variances in the CPD points program and allocation of points for particular courses or programs. This will be discussed at the ANZSNM annual conference in Melbourne for possible revision or update • Four applications for leave of absence from the CPD program were approved • Course approval for South Australia and Charles Sturt universities four year courses were discussed • The HURSOG CT for Attenuation course will be conducted in Melbourne at the 2012 conference, a notice will soon be placed on the website when a presenter is located • The Board is reviewing options to provide NM Scientists (other than Victorian) with a course that would allow them to eventually gain full licensing with regard to undertaking diagnostic CT. At the previous meeting in November 2011, the Board thanked Jim Norman for his hard work and lengthy contribution to the Board and the ANZSNM over the years and wished him luck with his new challenge as a secondary school teacher.

Clayton Frater Secretary

Congratulations to the following technologists who were granted Accreditation at the February meeting: ACEVSKI, Brian ALCHEIKH, Abdul Rahman ALFARO-PIQUE, Andrea Francisca BROCKBANK, Renae Joan CINI, Sarah Marie DECKER, Thomas DIXON, Andrew John ELAMROUSY, Jean EVANS, Amy Elizabeth FINCHER, Luke GOPINATHAN NAIR, Divya GRAY, Kamber HARROLD, Mitchell Alexander KATCHEL, Loren Erika KELLY, Seamus Paul KENT, Georgia Beth KETE, Lauren Elizabeth

14 Gamma Gazette March 2012

LUCAS, Blake Collier MACKENZIE, Nathan James MARCHANT, Jenae Denise MOORE, Louise Ellen NGUYEN, Ruth Ngoc Yen PANDIT, Rigel PILGRIM, Beau Joseph REDDY, Shivan Deepam SOVANNY, Lavera Kaknika TAVARE, Natalie Catherine VAN ROSSUM, Stephanie Maree WEALE, James WILSON, Kate Gai WITTON, Isaac Nathanael YUAN, Zhi Cheng (Michael)

The following technologists submitted the minimum requirement of 30 CPD points and have had their Accreditation revalidated for a further three years. Those technologists who received the 30/9/11 notice to submit their points but who have not yet done so should submit their points summaries by 18th April for ratification at the next meeting of the Accreditation Board which will be held on Thursday, 26th April in conjunction with the Melbourne conference.

Donna Abbati – Cert. #345 Margaret Adams – Cert. #035A Sharon Alam-Fotias – Cert. #624 Berry Allen – Cert. #225 Sam Altamura – Cert. #265 James Anagnostou – Cert. #1114 Dojcin Anastovski – Cert. #763 Alison Apostolou – Cert. #686

Eugenie Ashby – Cert. #661 Mark Austin – Cert. #137 Kirsten Brown – Cert. #1104 Elizabeth Bailey – Cert. #521 Anthony Baricevic – Cert. #639 Kym Barry – Cert. #773 Trent Barter – Cert. #622 Barbara Bedford – Cert. #375 David Bell – Cert. #136 Max Bellon – Cert. #049 Elizabeth Bennett – Cert. #407 Sharon Berechree – Cert. #218 Scott Beveridge – Cert. #913 Heather Biggs – Cert. #1122 James Bilney – Cert. #472 David Binns – Cert. #242 Cristina Blefari – Cert. #819 George Bonovas – Cert. #427 Dean Booth – Cert. #1282 Julia Booth – Cert. #693 Russell Booth – Cert. #012 Lisa Bowker – Cert. #403 Lynne Bowlen – Cert. #382 Jodie Brackenreg – Cert. #625 Angela Brewer – Cert. #829 Daniel Bucki-Smith – Cert. #392 Prudence Burns – Cert. #922 Renee Buxton – Cert. #944 Jennifer Calcott – Cert. #411 Jane Cameron – Cert. #1106 Nicole Campbell-Rogers – Cert. #714 Zlatko Capari – Cert. #279 Claire Cardwell – Cert. #418 Nathan Cassidy – Cert. #716 Jeanette Chapman – Cert. #249 Todd Charge – Cert. #952 Phoebe Ka Wai Chung – Cert. #834 Julia Clifford – Cert. #156 Andrew Cluff – Cert. #1111 Tuesday Cole – Cert. #960 Leesa Collie – Cert. #698 Christopher Constable – Cert. #835 Trent Cook – Cert. #824 Ronald Cooper – Cert. #394 Elizabeth Croft – Cert. #189 Michelle Cunneen – Cert. #731 Geoff Currie – Cert. #373 Jenelle Dale – Cert. #415 Terri Davies – Cert. #495 Vanessa De Luca – Cert. #505 Mana Devadas – Cert. #1075 Nhan (Eric) Dieu – Cert. #961 Mark Dobson – Cert. #474 Suzanne Dodd – Cert. #659 Miranda Dooner – Cert. #1317 Christine Doukarellis – Cert. #1064 Kelly Dohnt – Cert. #1053 Joshua Duggan – Cert. #605 Gina Dunsdon – Cert. #712 Joanne Edgar – Cert. #429

Suzanne Edwards – Cert. #926 Julie Enger – Cert. #068 Scott Evans – Cert. #478 Roslyn Fagan – Cert. #275 Guy Fairbairn – Cert. #1063 Danielle Farhat – Cert. #1037 Katrina Felettigh – Cert. #1135 Sonia Ferraro – Cert. #861 Owen Ferry – Cert. #312 Kristine Field – Cert. #050 Cristina Franchi – Cert. #692 Dave Francia – Cert. #963 Stacey Frangos – Cert. #1108 Sarah Gales – Cert. #930 Patricia Garrido – Cert. #780 Diana Gentilcore – Cert. #486 Miriam Gibson – Cert. #778 Vickie Gillett – Cert. #815 Agnes Gleeson – Cert. #045 Carol Goodier – Cert. #187 Anne Gottliebsen – Cert. #089 Megan Grantham – Cert. #315 Judith Gray – Cert. #442 Kelly Green – Cert. #547 Lauree Gurr – Cert. #756 Heidi Hamilton – Cert. #572 Nicole Hardes – Cert. #691 Rhonda Harrup – Cert. #290 Jane Hassall – Cert. #413 Suzanne Heath – Cert. #306 Adam Hickey – Cert. #949 Maria Hodgson – Cert. #455 Ann Maree Holmes – Cert. #246 Mitchell Holmes – Cert. #1321 Rosie Hooper – Cert. #554 John Howard – Cert. #107 Debra Huddleston – Cert. #507 Michelle Hughes – Cert. #680 Joannah Ings – Cert. #592 Rita Jalota – Cert. #674 Kim Jasper – Cert. #721 Lysbeth Jenkins – Cert. #351 Philip Johnson – Cert. #449 Karen Jones – Cert. #423 Joanne Keane – Cert. #528 Judith Keane – Cert. #543 Anne-Maree Kerley – Cert. #630 Ly Khou – Cert. #1142 Brooke King – Cert. #933 Susan King – Cert. #302 Theo Kitsos – Cert. #827 Laurel Knott – Cert. #696 Julie Kohlenbecker – Cert. #253 Christos Koliris – Cert. #1136 Angelique Kounthapanya – Cert. # Melissa Koutsiofi – Cert. #790 Bronwyn Kovaceska – Cert. #1155 Susan Lamb – Cert. #942 Prue Lamerton – Cert. #130 Jo Landman – Cert. #325

Deanie Lee – Cert. #445 Fanny Lee – Cert. #383 Marion Lewis – Cert. #319 Kathryn Linn – Cert. #676 Robert Linsell – Cert. #299 Gary Little – Cert. #272 Andrew Lloyd – Cert. #515 Venessa Lord – Cert. #420 Melanie Magri – Cert. #734 Amit Maharaj – Cert. #920 Mark Marcenko – Cert. #38 Dawn Mathers – Cert. #1138 Penelope Maton – Cert. #587 Miroslav Matusica – Cert. #817 Linda McCarthy – Cert. #201 Ruth McGennisken – Cert. #025 Carrol McHarg – Cert. #309 Catherine McHenry – Cert. #658 Joanne Meaker – Cert. #682 Susan Meikle – Cert. #388 Jarrod Melican – Cert. #1079 Dominic Mensforth – Cert. #363 Lyndajane Michel – Cert. #278 Darko Mihalinac – Cert. #417 Marlena Milillo – Cert. #1101 Gary Minch – Cert. #379 Sabian Mison-Popow – Cert. #965 Anne Moase – Cert. #313 Dominic Morgan – Cert. #566 Jennifer Morris – Cert. #457 Belinda Mulholland – Cert. #577 Catherine Munn – Cert. #327 Lynda Murray – Cert. #441 Nerida Neumann – Cert. #1100 Jillian Nichols – Cert. #456 Gianoula Nikolovski – Cert. #483 Peter Nuttman – Cert. #395 Nancy O’Brien – Cert. #262 Keryn Octigan – Cert. #396 Ingrid Odgers – Cert. #567 Marisa Outerbridge – Cert. #792 Barbara Ovenden – Cert. #168 Melissa Pack – Cert. #679 George Pandos – Cert. #346 Elizabeth Parkinson – Cert. #316 Emma Parry – Cert. #683 Michelle Parsons – Cert. #670 Heather Patterson – Cert. #235 Helen Patterson – Cert. #020 George Pavlakos – Cert. #438 Russell Pearce – Cert. #559 Michael Pearson – Cert. #516 Jane Perry – Cert. #1222 Huong Pham – Cert. #940 Larry Pijaca – Cert. #1141 Jo-Anne Pinson – Cert. #374 David Pitrans – Cert. #1318 Sheila Porch – Cert. #540 Mary Potter – Cert. #171 Renee Praehofer – Cert. #1156

u 15

Accreditation Board News Erin Price – Cert. #504 Amy Pritchard – Cert. #873 Bruce Quick – Cert. #289 Deborah Rae – Cert. #318 David Raffles – Cert. #477 Amanda Raimondo – Cert. #544 David Rainey – Cert. #499 Susan Rattray – Cert. #460 Sally Raymond – Cert. #378 Helen Reece – Cert. #317 Ann Riitano – Cert. #190 Marianne Rivet – Cert. #613 Danielle Roach – Cert. #1145 Leighton Rogan – Cert. #675 Elizabeth Rose – Cert. #702 Rowena Rose – Cert. #1120 Anita Rossiter – Cert. #1143 Jennifer Rowe – Cert. #618 Joy Rowe – Cert. #492 Kim Ryan – Cert. #204 Peter Sandy – Cert. #303 Raj Sardana – Cert. #951 Mark Scalzo – Cert. #1157 Allan Scott – Cert. #114 Andrew Scouler – Cert. #1103 Justin Selkirk – Cert. #1127 Melissa Shields – Cert. #555 Gary Sienkiewicz – Cert. #542 Victoria Sigalas – Cert. #638

Christopher Skilton – Cert. #1113 Kristin Slade – Cert. #475 Barbara Smiles – Cert. #386 Lailee Smith – Cert. #529 Teresa Smith – Cert. #511 Tracey Smith – Cert. #503 Timothy Smyth – Cert. #1153 Brian Sorensen – Cert. #687 Suzanne Sparshott – Cert. #648 Karolina Spirkoska – Cert. #435 Cathy Spratt – Cert. #408 Julia Squires – Cert. #840 Sarah Stammers – Cert. #931 Katherine Stanton – Cert. #798 Sarah Stephenson – Cert. #953 Danielle Stewart – Cert. #607 Amanda Stone – Cert. #527 Stephen Stone – Cert. #954 Katerina Swystun – Cert. #1133 Julie Tan – Cert. #496 Gary Taylor – Cert. #629 Lorraine Taylor – Cert. #634 Kimbra Teesdale – Cert. #160 Nancy Telfer – Cert. #595 Melanie Tempest – Cert. #536 David Thomas – Cert. #273 Nicole Tibbs – Cert. #531 Neville Tivendale – Cert. #671 Maria Triantafillou – Cert. #350

Justine Trpezanovski – Cert. #695 Michelle Turner – Cert. #745 Karen Tyrrell – Cert. #651 Francine Van Der Linde – Cert. #928 Maria Verlaan – Cert. #143 Duncan Veysey – Cert. #1105 Kerry Vickery – Cert. #578 Janis Von Takach – Cert. #502 Gregory Walker – Cert. #240 Lisa Warren – Cert. #744 Tahne Watson – Cert. #668 Brian Webb – Cert. #126 Neil Webb – Cert. #421 Jessica Welch – Cert. #771 Janelle Wheat – Cert. #950 David Wilkinson – Cert. #182 Dorethy Willems – Cert. #237 Joanne Williams – Cert. #610 Robert Williams – Cert. #397 Andrew Willmott – Cert. #1139 Joyce Wilson – Cert. #641 Melinda Wilson – Cert. #660 Greg Wilton – Cert. #736 Karen Winnett – Cert. #132 Carole Wood – Cert. #1270 Bianca Woolford – Cert. #782 Clare Wright – Cert. #167 Lili Yu – Cert. #1272 Kathy Zivchak – Cert. #1125

ONE DAY CT SAFETY COURSE

for

NUCLEAR MEDICINE TECHNOLOGISTS

To be held in conjunction with the Annual Scientific Meeting in Melbourne.

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

16 Gamma Gazette March 2012

15

In Retirement

A Fond Farewell to

Dr John G Turner The Nuclear Medicine community in New Zealand would like to wish Dr John G Turner a wonderful retirement.

John joined Dr Bevan Brownlie at the Nuclear Medicine Department of Christchurch Hospital as a registrar in 1974. He completed his MD in 1976 and then travelled with his family to Glasgow where he worked at The Glasgow Royal Infirmary. He did both Nuclear Medicine and thyroid work while there.

In 1979 John returned to Christchurch to rejoin Dr Brownlie as a Nuclear Medicine Physician. Christchurch Hospital at that time had a very dynamic team which also included Tom Rogers (Physicist) and Graeme Boniface (Radiopharmacist), and together they developed new radiopharmaceuticals, new techniques and acquired new equipment.

John succeeded Dr Brownlie as Clinical Director in 1981 and held that position until his retirement. Also that year he co-convened the ANZSNM Annual Meeting in Christchurch and he repeated it again in 1989. During much of that time he was Chairperson of the NZ Branch of the ANZSNM also.

He was on the Editorial Board of the European Journal of Nuclear Medicine for 14 years from 1991. John is a well respected teacher of both Nuclear Medicine and General Medicine to students of all levels, always very encouraging and a positive mentor to all at Christchurch Hospital and the whole Nuclear Medicine community in New Zealand.

During a visit to USA in 1978 he wrote to Dr Brownlie, excited by the potential of PET imaging and, when PET scanners became a possibility for our hospitals, he campaigned to get these services into the public hospital system but, to his great disappointment, was unsuccessful. Currently the five PET imaging facilities now in New Zealand are all in the private system.

John retired in December 2011 to spend time with his wife, enjoying his grandchildren, fishing and walking. They have recently sold their small farmlet where he successfully made small quantities of his own wine – which we got to sample on occasions, and has built a new home in Redcliffs, on the hill, overlooking the beach.

Luckily it only sustained minor damage in the earthquakes so he is looking forward to helping his wife develop the garden and complete his home over the coming years.

We wish John a well earned retirement and would like to thank him for his great and valuable contribution to Nuclear Medicine throughout his years of involvement.

All his staff agree that he has been a genial and approachable boss and we will miss his sense of humour. His wide knowledge and professional collegiality have been a hallmark of his leadership here. If only he had been as successful with his Rugby 15 picks, his Nuclear Medicine experience would have been complete!

Barbara Ovenden Nuclear Medicine Technologist Christchurch Hospital

21

Answer on page 18

A: What’s that?

Barry Chatterton Dept Nuclear Medicine, Bone Densitometry and PET, Royal Adelaide Hospital

Self-inflicted injury Three weeks after a suicide attempt, a 37-year-old male with a positive blood culture was referred for a bone scan to assess for potential sites of bony sepsis.

He also had new chest pain with T wave changes, but normal troponin and was referred for a Dipyridamole myocardial perfusion scan and CTPA. Selected images of the chest from the bone scan are shown (fig 1), and after infusion of Dipyridamole with no symptoms or ECG change, stress and rest myocardial images are shown (fig 2). Cardiac motility was normal and the LVEF was estimated at 48%.

How had the patient attempted to commit suicide?

Two “slices” of the CTPA are shown (figs 3 and 4).

What was the likely cause of the chest pain?

Right: Figure 1: Left anterior oblique and left posterior oblique images of the chest 2.5 hr after injection of 800 MBq 99mTc MDP.

Top: Figure 3: Coronal slice through LV apex of MIP image during CTPA showing enhancement.

Above: Figure 4: Coronal MIP image during CTPA showing defects in pulmonary arteries bilaterally indicating pulmonary embolism.

22 Gamma Gazette March 2012

Above: Figure 2: SPECT images of the chest after Dipyridamole stress and using 350MBq 99mTc tetrofosmin above, and 4 hours later at rest using 800MBq 99mTc tetrofosmin.

Answer on page 18

B: What’s that?

David Newbery Nuclear Medicine Technologist. New Zealand Medical Imaging. Auckland NZ

Unusual distribution of radiopharmaceutical 76-year-old male with pain in his right lower leg, suspicions of loosening of the tibial component of right total knee joint replacement (RTKJR) (1997).

Past history includes bilateral total hip joint replacement (THJR) in 2000 and extensive spinal surgery 10 and 2 years ago.

This patient was mobile and appeared to be in general good health.

Procedure: A bone scan was performed using 99mTc-DPD (Cis-Bio Teceos), 800MBq injected intravenously. Blood flow and pool images (figure 1) were acquired immediately after injection followed three hours later by planar static images of the legs and pelvis (figure 2).

Figure 1: Blood pool and flow images.

Questions: Why are these images of such poor quality, why so much soft tissue uptake?

Because of this unexpected result, images of the chest and thorax were also acquired. (figure 3).

What is the significance of the myocardial uptake?

The radiopharmaceutical used on this patient passed all QC tests and this patient had not had a recent myocardial infarct.

Figure 2: Delayed planar images of legs and pelvis.

Figure 3 23

From page 16

A: What’s that? ... answer The bone scan images performed show increased activity in the left 6th rib extending anteriorly from the posterior axillary line to the costo-chondral junction consistent with healing local trauma from a wound and subsequent thoracotomy. This was performed to repair the left ventricular laceration caused by the selfinflicted knife wound.

The Perfusion scan shows a fixed defect in the anterolateral wall of the left ventricle at the site of the wound and subsequent scar. There is some enhancement of this near the apex of the left ventricle seen on the frame from the CTPA (fig 3).

The CTPA shows bilateral pulmonary emboli which was the likely case of the new chest pain pain (Fig 4).

From page 17

B: What’s that? ... answer Consultation with the patient revealed that he had been diagnosed with Amyloidosis three years earlier.

Amyloidosis is the extracellular deposit of amyloid in different tissues and organs.

It can be organ specific or systemic.

Occurs mostly in men over 50 years old and amyloid is targeted by 99mTc-pyrophosphate and diphosphonates.

A protein is described as being Amyloid if due to an alteration in its secondary structure it takes on a particular aggregated insoluble form similar to a beta pleated sheet.

24 Gamma Gazette March 2012

Figure 3

From page 17

B: What’s that? ... answer Amyloidosis is a generic term used any time proteins are deposited in this fibril-sheet like form.

When there is amyloid present in the heart, a known symptom is arrhythmia.

Note the presence of a pacemaker (seen in planar views of the chest figure 3).

Amyloidosis is very uncommon; estimates have put it at around 10 cases per 1 million person years.

It is classified into different types, by the type of protein that make up the amyloid fibril.

• AL ( AmyloidLight chain) - Bone marrow produces too much of certain fragments of antibody proteins which build up in bloodstream and may deposit in body tissues.

About 10-15% of people with multiple myeloma will develop systemic AL Amyloidosis.

•

Senile Amyloidosis - Abnormal deposits of a blood protein.

•

Familial (hereditary) - Mutated Transthyretin protein (TTR), often affects the kidneys and nerves.

•

Inflammatory A - Develops along with chronic infectious or inflammatory disease, i.e.

Crohn’s disease, RA. Chronic TB.

•

Haemodialysis-associated A. -beta 2-microglobulin concentration in kidneys.

AL and Senile Amyloidosis are the more common types.

Diagnosis requires confirmation by biopsy. But as the symptoms are non specific and this disease is very rear it is not uncommon that the diagnosis is delayed more months if not years after the symptoms are first bought to medical attention.

Figure 4: Micrograph of a heart biopsy sample with the amyloid fibrils stained blue.

The amyloid deposits are seen everywhere and encircle each heart cell.

25

Having real difficulty gaining IV access?

Then perhaps consider one of these techniques Ken Southall, Pacific Radiology, Wellington, NZ INTRODUCTION I.V. access may prove to be difficult on paediatrics, the elderly, obese patients, or following chemo or radio-therapy etc. If you have unsuccessfully tried the usual techniques for achieving cannulation, such as ‘slapping’ the vein (releases histamine into the vein wall causing localised vaso-dilation), hot towel placement onto the area, or simply lowering the torniqued limb below the level of the heart, it is certainly worth considering one of these more advanced techniques before sending the patient away “sans-cannularis”.

1. ULTRASOUND GUIDANCE If you have access to U/S in your department, this is an excellent visual way to be 100% sure you have the cannula placed correctly into the vein. Using a linear array transducer on high frequency (i.e. 12-5mhz), locate the vein proximal to the intended puncture site (use doppler to ensure it’s not in an artery!) Insert cannula distal to the probe using your usual technique and advance it until the tip is visualised within the lumen on U/S as seen on the image here. (fig 1)

a new sterile adaptor for each cannulation. This device can also be used for spinal punctures, central venous access and PICC lines. Cost US$120 per unit. 20 cents per disposable adapter. Email: veid@vascular.co.il (fig. 2) 3. WARM AIR BAG This technique gently warms the entire limb, leading to vasodilation throughout, not just locally as in hot towel placement. Place tourniquet on desired extremity, then place limb into a large clear plastic bag. Insert the end of a hairdryer 5cm into the bag and turn on low. The bag should inflate, but allow air to escape from the bags opening to allow circulation of warm air over the extremity.

This technique would be good on a cold winters morning, is far quicker to set up than you might imagine, and is actually quite a pleasant experience. Cost approx. $30 for a hairdryer. (fig 3)

Figure 1

2. VEIN ENTRY INDICATOR DEVICE (VEID) The VEID device locks into place on the end of the cannula using a disposable adaptor. It measures the pressure within the cannula and gives an audible feedback of the needle tip location within 0.1 secs of it entering the vein. If the needle tip advances too far and exits the vein, the beep stops until the tip is withdrawn back into the veins lumen. The VEID is useful for approximately 2,000 patients, but requires Figure 2

26 Gamma Gazette March 2012

Figure 3

4. THE VEIN-VIEWER The vein-viewer locates subcutaneous vasculature and projects real-time images of the underlying vessels directly onto the skin! It uses a near infra-red light, which is reflected by the tissues but is absorbed by the blood cells within the vessels. This reflected light is then captured using a digital

camera sensitive to this particular frequency of light. A microprocessor then adds contrast to the image, which then projects a map of the vasculature onto the patients skin using a laser in real time. This is not a realistic option for most as the cost is US $25,000. Email: info@luminetx.com (fig 4).

OTHER ‘TIPS AND TRICKS’ FROM THE OLD-TIMERS • Use veins which you can ‘feel’ rather than the ones which look the best.

• Give the cannula a twist before use to free it from the sheath.

• Try a slight bend on the cannula to give you a better angle of entry.

• After advancement of cannula NEVER re-insert stillette as it may shear the plastic sheath.

• Antecubital fossa is often the best vein, the vein on the lateral aspect of the wrist near the thumb is also often prominent and straight.

• Hold onto vein distal to injection site to help immobilise the vein.

• Nitroglycerin ointment acts as a localised vaso-dilator which may help.

• When flushing an existing I.V. line to check for patency, use a 1ml flush as a higher pressure can be generated.

Figure 4

27

interesting Case

A fungating breast mass Melissa Farnham Department of Nuclear Medicine, PET & Bone Densitometry, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia

After denying the presence of a mass for 18 months a 64-year-old female presented with a right fungating breast mass. A core biopsy was performed in which invasive ductal carcinoma was diagnosed. This patient had a strong family history of breast cancer. A Mammogram of the left breast was essentially normal. A whole body bone scan was performed to search for potential bony metastases.

A large photopenic defect with a surrounding rim of increased activity in the right chest wall was identified in keeping with the known 10cm right breast mass (Figure 1: A). A focus in the distal left fibula was consistent with the history of recent trauma to the area (Figure 1: B). Prominent activity in the sacro-iliac joints bilaterally was thought to represent degenerative change. There was no evidence of bony metastatic disease.

A staging contrast-enhanced CT scan of the chest, abdomen and pelvis showed the right breast mass containing gas superficially with disruption to the skin surface (Figure 2).

The breast mass appeared to be fixed to the chest wall.

There were multiple enlarged presumed metastatic lymph nodes seen in the right axilla. A 10mm nodule was identified in the left upper lobe laterally in the lung with a smaller node

Figure 1 (A & B): WBBS images taken 2 hours post 800MBq Tc-99m MDP injection.

28 Gamma Gazette March 2012

Figure 2: CT trans slice of breast mass. in the right lower lobe (Figure 3). There was no evidence of any pulmonary hilar, para-aortic or pelvic lymphadenopathy. Small sclerotic areas identified in both iliac bones were in keeping with the finding of the bone scan. There was a sub-centimeter low attenuating lesion in the mid portion of the liver (Figure 4).

A subsequent ultrasound of the liver confirmed this area as a liver cyst (Figure 5).

A gated blood pool scan was then performed prechemotherapy, with the calculated left ventricular ejection fraction of 70% (Figure 6).

A staging FDG PET scan was performed. Increased FDG uptake was seen within the large fungating right breast cancer with a focus superiorly within the axillary lymph nodes

Figure 3: CT cor slice of lung nodules.

Figure 4: CT transverse slice of the low attenuating lesion seen in the liver.

Figure 5: Ultrasound transverse image demonstrating the cystic nature of the liver lesion.

(Figure 7). Low grade abnormal focal tracer uptake was seen within the left upper lobe and right lower lobe in keeping with the presumed metastases seen on the recent CT scan.

Scan appearance of the iliac bones confirmed no metastatic involvement. Neoadjuvant chemotherapy and radiotherapy was given with good disease response and significant reduction of tumour size. A mastectomy and axillary clearance was performed to achieve local control of the breast cancer.

A follow up CT scan X months later showed multiple new pulmonary nodules. Due to this progression it was determined incurable and treatment was aimed to extend survival and maintain quality of life.

Figure 6: Processed GBPS with ejection fraction displayed.

Figure 7: FDG PET 1Hr afrer 300 MBq 18FDG coronal image with CT fused images demonstrating the fungating breast mass.

29

interesting Image

All, that is “Hot�, is not infection Wilson Vallat, Diana Lawrence, Allan Wycherley

Corresponding Author: Wilson Vallat.

Corresponding Author’s Institution: Lyell McEwin Hospital First Author: Wilson Vallat, M.B,B.S Abstract We report the case of a previously well 2yr old boy presenting with headache, neck pain and clinical features suggestive of sepsis. On arrival to emergency he was hypotensive. Intravenous access was difficult hence an Intraosseus cannula was inserted for resuscitation. Initial investigations including bloods, CXR, lumbar puncture failed to reveal an inflammatory or infective focus. A bone scan was performed to exclude osteomyelitis / septic arthritis.This case illustrates the importance of correlating imaging findings with clinical history to avoid erroneous conclusions Keywords: bonescan; intraosseous cannulation; osteomyelitis; resuscitation Discussion Intraosseous cannulation (IOC) was first described in 1922

by Drinker et al and Doan. Today it is a well described tool in resuscitation protocols. IO cannulation permits rapid access for obtaining marrow for initial laboratory assessment, fluid resuscitation, and drug administration until definitive vascular access is obtained. It takes advantage of the communication between the marrow cavity and abundant vasculature of long bones for absorbtion of fluids and drugs. IOC is reserved for acute, life threatening situations where other venous access (peripheral & central) methods have failed. It provides safe,

Figure 1: Blood pool images.

30 Gamma Gazette March 2012

effective, reliable access in critically ill patients.1,2 Common sites IO access are proximal or distal tibia, distal femur and proximal humerus. When restricted to use as a bridging procedure the reported complication rate is very low and include fractures, extravasation/compartment syndrome, osteomyelitis following prolonged use.3,4 Although not reported in the literature, fat embolism and growth plate injury are remote possibilities.5 Overall the benefits of this procedure when performed in the appropriate clinical setting outweighs the risks.

Figure 2: Delayed images.

There was hyperaemia and increased delayed tracer uptake at the LEFT proximal tibial metaphysis with flaring into the adjacent growth plate and less intense extension into the tibial shaft and distal metaphysic on both images.

While the appearance can be seen with infection, in this particular case the abnormality correlates with a history of intraosseous cannulation performed for resuscitation on admission.

References 1. Banerjee S, Singhi SC, Singh S, et al: The intraosseous route is a suitable alternative to intravenous route for fluid resuscitation in severely dehydrated children. Indian Pediatrics. 1994;31(12):1511-20.

2. Abe KK, Blum GT, Yamamoto LG: Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models. Am J Emerg Med 2000,18:126-129.

3. Nikolaus Haas: Clinical review: Vascular access for fluid infusion in children. Critical Care. 2004, 8:478-484.

4. Jane M Peutrell: Intraosseous cannulation. Anaesthesia and Intensive Care Medicine. 2006, 7: 28-30.

5. Joshua Nagler, Baruch Krauss, Intraosseous Cannulation in Children. New England Journal Medicine, 2011; 364:e14.

31

Submitted Paper

Solitary Plasmacytoma: Incidental diagnosis on a Sestamibi scan, and the contribution of nuclear imaging Mr Matthew Patterson, Dr Martin Tan, Mr Russell Edwards Lyell McEwin Hospital, Elizabeth Vale, South Australia

CASE REPORT A 62-year-old male presented for a Myocardial Perfusion Stress/ Rest scan with history of epigastric pain to rule out a cardiac cause. The images showed the patient to have no obvious signs of reduced perfusion to the myocardium; however, an incidental focus of increased 99mTc-Sestamibi uptake was noted on the cine display during the processing of the SPECT images. Separate SPECT processing of the incidental focus was also done with the cardiac image processing, but accurate anatomical localisation could not be confirmed (Figure 1). Subsequent SPECT/CT imaging of the thorax was also performed the same day, where the abnormal Sestamibi focus appeared to localise a large lytic lesion at the level T9 vertebrae (Figure 2).

The patient was then referred for a diagnostic CT which confirmed the lytic appearing lesion at T9 with no other abnormality seen within the chest, abdomen or pelvis. Serum protein electrophoresis showed a mildly raised paraprotein. There was no Bence-Jones

protein detected in the urine. With all these results combined, the possibility of a haemangioma, a monoclonal gammopathy of unknown significance (MGUS), or multiple myeloma was raised.

The patient then underwent an MRI of the thoracic spine to further clarify the matter. No fat signal was found within the T9 vertebral body, which ruled out the possibility of haemangioma, but the T1, T2 and fat suppressed signals were more typical for a malignant process. Given the absence of malignant deposits elsewhere in the body, the diagnosis of a plasmacytoma/myeloma was favoured.

Concern was then raised for the anterior aspect of the T9 vertebra, which appeared to be structurally compromised on both the CT and MRI images. After discussion it was then decided that a biopsy was to be performed of the T9 vertebrae, as well as installation of acrylic into the lytic areas as a prophylaxis against impending fracture.

The patient underwent the biopsy and vertebroplasty of the T9 vertebral body, and a 10mL aspirate of the marrow was obtained but unfortunately was not diagnostic. Reconstituted acrylic was however successfully injected into the vertebrae.

Figure 1. Initial raw un-gated SPECT images from the Rest phase imaging show the abnormal focus of Sestamibi uptake posterior to the myocardium.

32 Gamma Gazette March 2012

Solitary Plasmacytoma: Incidental diagnosis by the contribution of nuclear imaging

Figure 2: SPECT/CT images of the Rest phase of imaging give anatomical localisation of the abnormal Sestamibi uptake in the T9 vertebrae.

Further PET/CT scanning also showed increased 18-F DeoxyGlucose (FDG) uptake (SUV max 3.9) in the left-anterior aspect of the T9 vertebrae (Figure 3). Imaging was performed from the vertex of the skull to mid-thighs and no other abnormal focal increase of the FDG tracer was seen. The increase in uptake was again in keeping with a malignant process such as a plasmacytoma, although other tumours can also result in increased FDG uptake. It was also noted that benign tumours such as haemangiomas are unlikely to exhibit such uptake. Biopsies and the vertebroplasty performed 3 weeks earlier of the T9 vertebrae were also acknowledged, but was felt unlikely to cause the degree of uptake seen. Bone marrow biopsies showed no myeloma cells.

The patient has since agreed to commence Radiotherapy on the T9 vertebral lesion in the near future. Follow-up PET/CT and MRI scans have also been arranged for the future management of this patient.

DISCUSSION Solitary plasmacytoma is a large solitary focus of plasma cell proliferation.

This tumour has a median patient age of approximately 10 years younger than multiple myeloma.1,2 Pain is the most common symptom. However, if the myeloma occurs in the spine, it will usually present with fast developing paraplegia and gibbous deformity due to the vertebral collapse. 1,2 Plasmacytomas are extremely rare and are found in the

Figure 3: PET images also showing FDG avidity in the T9 vertebrae. proximal femur, vertebral bodies, and pelvis in order of descending frequency. 1,3 Solitary plasmacytoma occurs 70% of the time as an osseous lesion, while the remaining 30% are non-osseous lesions usually found in the upper respiratory tract.3,4 Plasmacytomas represent only 2–3% of all plasma cell dyscrasias.3,4 It is clinico-pathologically distinct from multiple myeloma, occurring on average a decade earlier, but shares the latter’s predilection for males and involvement of the axial skeleton.

u 33

Solitary Plasmacytoma: Incidental diagnosis by the contribution of nuclear imaging

4,5 The thoracic spine is the most common site of localisation. 5,6 Most cases manifest clinically with localised bone pain relating to tumour infiltration, compression fractures or symptoms of nerve root involvement or cord compression. 3,5 The following diagnostic criteria for solitary plasmacytoma have been proposed

by Dimopoulos et al7: A normal bone marrow without evidence of clonal plasma cell proliferation: • Normal findings on skeletal survey and MRI of the spine, pelvis, proximal femora and humeri; • Absence of anaemia, hypercalcaemia or renal impairment attributable to myeloma; • Low concentrations of serum or urine monoclonal protein and preserved levels of uninvolved immunoglobulins • Approximately 70% of the patients with solitary plasmacytoma develop multiple myeloma.

Most authors agree on strict diagnostic criteria for solitary plasmacytoma. There may be no other radiological identifiable lesions, and bone marrow at another site and must have no abnormal plasma cells. There may be no serum abnormalities and no Bence-Jones proteins in the urine. Some authors believe that the diagnosis can only be made if no other lesion is found for a period greater than 1 year. 8,9 Microscopically, solitary plasmacytoma appears as well to poorly differentiated sheets of plasma cells. These cells produce the same osteoclast stimulating factors found in multiple myeloma.

Microscopic analysis through the use of bone marrow biopsy is therefore the preferred histological technique for diagnosis. 8,10 IMAGING Myelomas generally produce a poor osteoblastic response therefore radiopharmaceutical agents such as 99mTc-labelled diphosphonate, are poorly taken up. However, reports have pointed to 99mTcSestamibi scintigraphy as a tracer for myeloma lesions.11,12 In the case described above, we used 99mTc-Sestamibi which, in common with any other radiopharmaceutical agent, is distributed throughout the body. Increased concentration is shown in the salivary and thyroid glands, in the heart, liver, hepatobiliary system, spleen, bowel, kidneys, and urinary tract. Other than Sestamibi’s most common use for the evaluation of myocardial perfusion, it has now expanded to include tumour imaging.11,12 The interpreting physician should also be aware that other abnormalities might be revealed in a 99mTc-Sestamibi scan.

Abnormalities with increased tracer uptake are: thyroid nodules (benign or malignant); parathyroid adenomas adjacent to the thyroid gland or anywhere in the mediastinum (for which sestamibi imaging is the procedure of choice); lung malignancies; breast malignancies (for which sestamibi has been approved by the Food and Drug Administration both for detection and for differentiation from benign processes); metastases of breast malignancies to the axillary lymph nodes; lymphomas; myelomas; brain tumors; sarcomas; and infectious processes and granulomas.11,12 Three patterns may be observed by whole body Sestamibi tumour scintigraphy in plasma cell proliferations: (i) normal, with physiologic uptake in salivary glands, thyroid, heart, liver, spleen, small intestine and bladder; (ii) diffuse bone uptake with a variable extension of intensity; (iii) focal uptake in bones or in soft tissues. A 34 Gamma Gazette March 2012

mixed diffuse-focal pattern can also be seen.12 The mechanism by which Sestamibi concentrates in malignant tissue is not clear. It is sequestered in the cytoplasm and mitochondria of cells in response to the electrical potentials generated across the membrane bilayers.12 It is lipophilic and readily crosses the cell and mitochondria membranes. The strongly electronegative mitochondria and plasma membrane potentials of the metabolically hyperactive malignant cells promote concentration of the cationic Sestamibi. 13 Since uptake is observed in many different types of malignancies, Sestamibi uptake is not tumour-specific. Sestamibi scintigraphy might nevertheless be useful as a whole-body screening procedure for patients with suspected multiple myeloma and provides an alternative to bone scintigraphy which rarely detects uncomplicated myeloma.14 As the primary aim of myocardial perfusion imaging is the evaluation of myocardial perfusion, processed tomographic slices typically include only the heart and small parts of adjacent organs.

However, because the unprocessed data includes target and nontarget organs with radiopharmaceutical uptake, it is important that the interpreting physician evaluate all the information available; incidental findings in the other organs may lead to an earlier diagnosis of pathologic conditions that require treatment.

The occurrence of incidental findings may in most cases be the responsibility of the nuclear medicine technologist. Mainly because they usually have the jurisdiction of what information is to be displayed for the reporting physician.

In the case discussed above, Sestamibi myocardial perfusion imaging led to the diagnosis of a lytic lesion in the T9 vertebral body and subsequent early treatment for this disease.

A particular advantage of the use of Sestamibi in tumour diagnosis is its capability for very accurate localisation and biopsy of the lesion with the use of SPECT/CT imaging.

The preferred initial imaging for the diagnosis and staging of plasmacytoma (according to the 2009 International Myeloma Working Group consensus statement15) remains the skeletal survey. Patients suspected of having multiple myeloma based on bone marrow aspiration results should undergo a radiographic skeletal survey. Whole body imaging, especially in conjunction with new MR techniques, is advocated when possible. Other whole body techniques, including low dose CT, PET/CT with FDG, and scintigraphy with Sestamibi are still being evaluated. 16,17,18,19 Shortt et al20 compared FDG PET/CT, whole body MRI, and bone marrow aspiration with biopsy in 24 patients (13 women, 11 men; mean age, 67.1 years; range, 44-83 years) with myeloma proven by bone marrow biopsy. When MRI and PET/CT were used in combination, specificity and positive predictive values of 100% were found.

CONCLUSION The major diagnostic benefit of Sestamibi tumour scintigraphy is its high negative predictive value; however the overlap between benign and malignant tumours detected by Sestamibi scanning decreases the usefulness as a single diagnostic tool for plasmacytoma13.

Sestamibi tumour scintigraphy compared to standard X-ray, is more specific in identifying active bony myeloma lesions, may show additional soft tissue tumour localisations and offers the advantage of confirming inactive bone lesions. 13 As discussed in this case,

Solitary Plasmacytoma: Incidental diagnosis by the contribution of nuclear imaging

Sestamibi may be taken up by tumour cells other than myeloma.

This does reduce specificity but allows for the possible detection of additional neoplastic disorders.

It is for this reason that routine keen observation (within reason) of nuclear medicine procedures is essential, particularly given the sensitive, but not necessarily specific, attributes of radiopharmaceuticals used in nuclear medicine.

In conclusion, the interpretation of myocardial perfusion imaging should not be limited to the heart, because it can reveal other pathologic conditions. Because the ultimate goal is the wellbeing of the patient, any available information should be examined, interpreted, and followed up if required.

REFERENCES 1.

Meletios A. Dimopoulos, Lia A. Moulopoulos, Alice Maniatis, and Raymond Alexanian; Solitary plasmacytoma of bone and asymptomatic multiple myeloma; J of Haem.; 2000;96:20372044 2. Donna M. Weber; Solitary Bone and Extramedullary Plasmacytoma; J of Haem.; 2005; 3. Dimopoulos MA, Moulopoulos LA, Maniatis A, et al. Solitary plasmacytoma of bone and asymptomatic multiple myeloma.

Blood. 2000;96:2037-2044.

4. Brinch L, Hannisdal E, Foss A, et al. Extramedullary plasmacytomas and solitary plasma cell tumours of bone. Eur J Haematol. 1990;44:131-134.

5. Liebross RH, Ita CS, Cox JD, et al. Clinical Course of extramedullary plasmacytoma. Radiother Oncol.

1999;52:245-249.

6. Bolek TW, Marcus RB, Mendenhall NP. Solitary plasmacytoma of bone and soft tissue. Int J Radiat Oncol Biol Phys.

1996;36:329-333.

7. Dimopoulos MA, Kiamouris C, Moulopoulos LA. Solitary plasmacytoma of bone and asymptomatic multiple myeloma.

Hematol Oncol Clin North Am 1999;13:1249–57.

8. Delauche-Cavallier MC, Laredo JD, Wybier M, et al. Solitary plasmacytoma of the spine. Long-term clinical course. Cancer.

1988;61:1707-1714.

9. Ellis PA, Colls BM. Solitary plasmacytoma of bone:

clinical features, treatment and survival. Hematol Oncol.

1992;10:207-211.

10. Rajkumar SV, Dispenzieri A, Kyle RA. Monoclonal gammopathy of undetermined significance, Waldenström macroglobulinemia, AL amyloidosis, and related plasma cell disorders: diagnosis and treatment. Mayo Clin Proc 2006; 81:693-703.

11. Maffioli L, Steens J, Pauwels E, Bombardieri E. Applications of 99mTc-sestamibi in oncology. Tumori 1996; 82:12-29.

12. Adams BK, Fataar A, Nizami MA. Technetium 99 m-sestamibi uptake in myeloma. J Nucl Med 1996; 37:1001-2.

13. Wakasugi S, Teshima H, Hashizume T, et al. Tc-99m MIBI localization in bone marrow: a marker of bone marrow malignancy. Clin Nucl Med 1988; 23:664-71.

14. Ericoballeari, Guiseppevilla et al.; Technetium-99m-sestaMIBI scintigraphy in multiple myeloma and related gammopathies: a useful tool for the identification and follow-up of myeloma bone disease; Haematologica 2001; 86:78-84 15. M Dimopoulos1, E Terpos et al.; International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple Myeloma; Leukemia (2009), 1–12.

16. Scutellari PN, Spanedda R, Feggi LM, Cervi PM. The value and limitations of total body scan in the diagnosis of multiple myeloma: a comparison with conventional skeletal radiography. Haematologica 1985; 70:136-42.

17. Ghanem N, Lohrmann C, Engelhardt M, Pache G, Uhl M, Saueressig U et al. Whole-body MRI in the detection of bone marrow infiltration in patients with plasma cell neoplasms in comparison to the radiological skeletal survey. Eur Radiol 2006;16: 1005–1014.

18. Libshitz HI, Malthouse SR, Cunningham D, MacVicar AD, Husband JE. Multiple myeloma: appearance at MR imaging.

Radiology 1992; 182: 833–837.

19. Rosa Fonti et al.; 18F-FDG PET/CT, 99mTc-MIBI, and MRI in Evaluation of Patients with Multiple Myeloma; J Nucl Med 2008; 49:195–200 20. Shortt et al.; Whole-Body MRI Versus PET in Assessment of Multiple Myeloma Disease Activity; Am J Roentgenol.:192, April 2009

35

Submitted Paper

Suspected Erythema Nodosum: Appearances on Gallium and PET scanning Mr Dominic Mensforth Dip App Sci (Nuclear Medicine), Dr Dylan Bartholomeusz MBBS, MD, FRACP Dr Jones & Partners Medical Imaging, St Andrews Hospital, 350 South Tce, Adelaide, SA 5000

CLINICAL PRESENTATION A 62-year-old man presented with a three week history of left elbow swelling that was now red, hot and tender. He also had tender skin nodules on his abdomen, left thigh and left lower leg (Figure 1). The

Figure 1: Skin lesions on left lower leg.

initial clinical diagnosis was erythema nodosum. An ultrasound of these areas to assess the lesions as well as a chest x-ray.

The ultrasound scans suggested the presence of a vasculitic panniculitis. The chest x-ray showed multiple 1cm focal densities in each lung. It was suggested that CT be used to further investigate the lungs and that the panniculitis may be granulomatous in nature.

A chest CT scan was undertaken a fortnight later and showed multiple non-calcified masses throughout both lung fields together with some small non-calcified lymph nodes (Figure 2). One small calcified nodule was seen in the left upper lobe. It was suggested that the lesions were metastases and that the calcified nodule could be a small granuloma and further investigation was indicated.

Sarcoidosis was regarded as a possibility.

Blood tests showed an increase in Angiotensin Converting Enzyme (ACE).

Gallium Scan A week after the Chest CT scan 215 MBq of Gallium-67 Citrate was administered intravenously and imaging was undertaken 24 and 48 hours later. Whole body scans were acquired at both time points, with SPECT imaging of the chest and abdomen and planar images of the lower limbs (Figures 3-6).

These images show multiple superficial foci of increased uptake in both lower limbs, right forearm, left elbow, anterior abdomen and right axilla. Visual and palpable nodules on the skin surface were identified at all these sites. This was considered to be a lymphocytic or granulomatous associated response.

In the mediastinum increased uptake was seen in right paratracheal nodes. Further uptake was seen posteriorly in the mediastinum and the left lung.

The differential diagnosis at the conclusion of the scan was sarcoidosis, diffuse soft tissue malignancy or lymphoma.

Subsequent Investigations A CT guided core biopsy of a lung nodule contained necrotic tissue and patchy lymphocytic infiltration, considered non-specific, subsequent biopsy of skin nodules lead to the diagnosis of T-cell non-Hodgkin’s lymphoma.

Once the diagnosis was confirmed, the patient was treated over several months with chemotherapy, stem cell transplant and radiotherapy and is currently well and in remission.

PET scans were performed after the completion of three cycles of chemotherapy (figures 7 & 8) and seven months after the completion of therapy (figure 9). The last PET scan showed only post-therapy inflammation and no residual uptake in any of the previous lesions.

Figure 2: CT slice showing bilateral multiple lung nodules.

36 Gamma Gazette March 2012

Suspected Erythema Nodosum: Appearances on Gallium and PET scanning

Above: Figure 3: 48 hour whole body Gallium scan.

Right top: Figure 4: Posterior tibiae image acquired at 24 hours.

Right middle: Figure 5: Transverse abdominal SPECT slice showing the superficial nature of the lesion.

Right bottom: Figure 6: Sagittal SPECT slice showing uptake in a mediastinal lesion.

DISCUSSION The differential diagnosis for gallium uptake in skin lesions includes infection, uptake in surgical wounds, acne vulgaris, cutaneous sarcoidosis and exfoliative erythroderma.1 Rarer causes include. leprosy, lymphocytic lymphoma, mycosis fungoides, erythema nodosum and polyarteritis nodosa.1,2,3,4

As Gallium uptake is not specific for lymphoma and given the uncertain aetiology of the soft tissue lesions and the intense uptake seen in these lesion at the time of the scan, the differential diagnosis remained broad. Prior to the advent of 18FDG PET scanning, gallium scans were useful in the staging and follow-up of lymphoma. A follow-up gallium scan was not performed as the lesions were also 18FDG avid and PET scans were used to assess treatment response.

u 37

Suspected Erythema Nodosum: Appearances on Gallium and PET scanning

REFERENCES FL Datz (1995), Gamuts in Nuclear Medicine (3rd Edition), St Louis, USA, Mosby Winzelberg G, Rabinowitz J. (1984) Whole Body Gallium-67 Scintigraphy in a Patient with Sarcoidosis and Biopsy-Proven Erythema Nodosum. Clinical Nuclear Medicine 9(7):418

Peng NJ, Wang JH, Hsieh SP, Jao GH, Tsay DG, Liu RS. (1998) Ga67 and Tc-99m HMPAO Labeled WBC Imaging in Erythema Nodosum Leprosum Reaction of Leprosy. Clinical Nuclear Medicine 23(4):248-50 Hussain R Christie DR Gebski V Barton MB. (1998) The Role of the Gallium Scan in Primary Extranodal Lymphoma. Journal Nuclear Medicine 39(1):95-8

Left: Figure 7: PET MIP image after completing 3 cycles of chemotherapy.

Above: Figure 8: Fused PET/CT transverse slice through the distal femora, showing bilateral soft tissue uptake.

Right: Figure 9: PET MIP image performed after the completion of all therapy.

Minor inflammatory uptake seen in distal right thigh. All other lesions resolved.

38 Gamma Gazette March 2012

Case Study

Fine Needle Aspiration Biopsy exacerbating and then curing Hyperthyroidism Dr M.I. Kitchener Dr Jones & Partners Medical Imaging, St Andrew’s Hospital Adelaide, South Australia

CLINICAL INFORMATION 68-year-old lady noted to have an MNG with a suppressed TSH in early 2010. The thyroid scan from March 2010 showed a hyper-functioning nodule in the left upper pole, a “cold” nodule in the left mid to lower pole laterally and patchy reduced activity elsewhere in the gland. (Figure 1) The uptake was 1.63%. On biochemical monitoring, her TSH remained suppressed but there was a subsequent mild rise in the FT3 levels, becoming just above the Figure 1. March 2010. Anterior normal range by April-June pin-hole image showing evidence of 2011. Neomercazole and PTU a multi-nodular goitre, with a hyper- were briefly tried but could not functioning nodule in the left upper be tolerated. pole and relatively reduced activity In September 2011, in the left mid to lower pole laterally. the patient became overtly thyrotoxic, with tremor, palpitations and increased anxiety, with a significant elevation in both her FT4 and T3 levels (table 1). Her symptoms were quickly controlled on beta blocker therapy. The repeat thyroid scan performed on 12.10.11 showed reduced uptake in the previously noted left upper pole “hot” nodule. There was also persistent reduced activity in the right upper and left lower poles, with relatively improved activity elsewhere. The thyroid uptake had fallen to 1.05%.

The other history of note has been the recurrent fine needle aspiration of a left-sided cystic thyroid nodule (x4), which is in the left mid to lower pole region on ultrasound, measuring up to 27 x 16 x 17mm in size. The onset of the hyperthyroid symptoms occurred within a week of the last FNA. The patient was referred for radio-iodine therapy for her hyperthyroidism. However, in view of her clinical history and scan findings, repeat TFT’s were performed just over 4 weeks after the previous Table 1

results and showed normal biochemistry. Radio-iodine was therefore not administered.

DISCUSSION The overall picture indicates that the hyper-functioning thyroid nodule in the left upper pole was initially causing a low-grade T3 toxicosis.

Subsequent imaging (Figure 2) shows loss of function of the nodule, which in the absence of any specific treatment such Figure 2. October 2011. Anterior as radio-iodine or alcohol pin-hole image showing that the injection is consistent with hyper-functioning nodule in the infarction of this nodule. left upper pole is now “cold”, with The blood tests 2 weeks relatively improved uptake in the beforehand demonstrated lower poles bilaterally. an acute exacerbation of the hyperthyroidism. Given the scan appearances, this is presumably secondary to release of pre-formed thyroid hormone associated with infarction of the thyroid nodule (1). While spontaneous infarction of autonomous functioning nodules is well recognised, this is more common with larger nodules. The temporal relationship to the fine needle aspiration and the prior reports of FNA causing thyroid nodular infarction (2) suggests that this is the most likely explanation even though the nodule being investigation with FNA was reported to be in the left mid to lower pole on thyroid ultrasound.

CONCLUSION This case demonstrates that thyroid nodular infarction is a rare cause of temporary worsening or new onset hyperthyroidism, which only requires symptomatic relief and not definitive treatment such as radio-iodine therapy. It also illustrates the importance of proper clinical assessment by the nuclear medicine specialist prior to the requested administration of radio-iodine therapy to avoid unnecessary therapy.

1/4/11 14/6/11 1/8/11 29/9/11 1/11/11 TSH (0.5-4.0) 0.3 0.04 0.05 0.01 1.4 FT4 (10-25) 12 14 13 30 12 FT3 (3.1-5.4) 5.6 6.0 5.1 10.7 3.8

REFERENCES 1. Hamburger et al, Ann Intern Med 1979;91(3):406-9 2. Das et al, Acta Cytol 2009; 53: 571-5 39

Case Study

Whole body bone scan plus SPECT/CT demonstrates a metastasis in an unusual bone site Dianne Wills Nuclear Medicine Department, Christchurch Hospital, Christchurch, NZ

CLINICAL HISTORY In December 2008 a 43-year-old Maori woman presented with an 18 month history of vaginal pain and bleeding. An ultrasound showed a cervical mass. Examination revealed a 6-7cm necrotic cervical tumour. Biopsy confirmed squamous cell carcinoma of the cervix.

Cisplatin chemotherapy and radiotherapy were commenced January 2009. Brachytherapy followed in March 2009.

However by June 2009 there was a recurrence of the cervical cancer and the patient was treated palliatively until April 2010 when a CT showed numerous cavitating lung metastases.

In October 2010 the patient complained of several months’ history of increasing left foot pain and swelling. Differential diagnoses included gout and trauma. A nuclear medicine bone scan was performed.

Whole body bone scan and SPECT/CT: • A Siemens Symbia T2 camera was used for the planar bone scan and SPECT/CT. • Dynamic blood flow and blood pool images were taken upon injection of a 700 MBq dose of 99mTc HDP. • Three hours later a whole body scan was performed.

• Anterior/posterior and lateral/medial planar views of the feet followed.

• SPECT/CT of the feet completed the examination.

• The dynamic, and blood pool images showed markedly increased activity over the left mid foot. (Figure 1)

• On the delayed planar views and SPECT/CT reconstructions there was markedly destructive lytic changes throughout the cuneiforms and navicular. (Figure 2) • The CT showed a destructive lytic lesion surrounded by increased HDP uptake (Figure 3) and was well displayed on the 3D fused display (Figure 4).

• No other significant abnormality was demonstrated in the skeleton to suggest metastatic disease. (Figure 5). The interpretation was that the mid foot changes could reflect tumour involvement or possibly infection OUTCOME A biopsy a week later confirmed metastatic squamous cell carcinoma.

Palliative radiotherapy was given to the left ankle and proximal foot in November 2010 and again in March 2011 with resulting effective pain relief during the last months of the patients life.

DISCUSSION Cervical cancer causes the death of about 65 New Zealand women each year and is diagnosed in 180 women, 80% of whom are under 65. Maori women are twice as likely to get cervical cancer than nonMaori and the disease is four times as likely to cause their death.¹ Changes to the cervix caused by the human papilloma virus (HPV) over long periods of time are considered to be the main cause of cervical cancer.² Metastatic spread in cervical cancer is most commonly to the lungs then the liver. Bone spread is the next most likely site but is uncommon, arising in only 1.1% of patients in a recent study.³ Distal appendicular skeletal metastases are an even more infrequent finding.

CONCLUSION This investigation of lytic changes in the foot using SPECT/CT was particularly helpful in making a more specific diagnosis. The Whole Body bone scan was also valuable and initially showed the unusual bone abnormality in the foot while eliminating any other areas of metastatic bone disease.

Figure 1. Dynamic and blood pool views of feet showing increased activity over the midfoot.

40 Gamma Gazette March 2012

Whole body bone scan plus SPECT/CT demonstrates a metastasis in an unusual bone site

REFERENCES 1. NZ Gynaecological Cancer Foundation. (2004). NZ Cancer Control Audit: Gynaecological Cancer Statistics. Retrieved from http:// www.silverribbon.co.nz/index.cfm/pageid/118/ViewPage/ Gynaecological+Cancer+Statistics.

2. Southern Cross Medical Library. (2007). Cervical Cancer.

Retrieved from http://wwwsoutherncross.co.nz/AboutTheGroup/ HealthResources/MedicalLibrary/tabid/178/vw/1/ItemID/ 199/Cervical-Cancer.aspx.

3. Thanapprapasr, Duangmani MD; Nartthanarung, Adisak MD; Likittanasombut, Puchong MD; Na Ayudhya, Nathong Israngura MD; Charakorn, Chuenkamon MD; Udomeubpayakul, Umaporn MSc (Biostst); Subhadarbandhu, Thanya MD; Wilailak, Sarikapan MD. Bone Metastasis in Cervical Cancer Patients Over a 10-Year Period. International Journal of Gynaecological Cancer (April 2010) ;Vol. 20:373-378.

Left: Figure 2. Delayed planar views of feet showing detail of the lytic changes in the cuneiforms and navicular.

Above: Figure 3. CT only and fused with bone scan showing lytic lesion with peripheral uptake.

Figure 4. 3D reconstruction of the SPECT/CT.

Figure 5. Whole Body bone scan showing no other significant abnormalities suggesting metastatic disease

41

Case Study

Breast cancer with bony metastases confined to the left leg William Pham, Steven Unger

Dept of Nuclear Medicine, The Queen Elizabeth Hospital

INTRODUCTION Breast cancer is the most commonly diagnosed cancer in Australian females,1 with the most common site of metastasis being bone.2 Despite this, metastases isolated to one limb and to distal limb sites are rarely encountered.3, 4 We report on a vague presentation of left ankle pain with unremarkable plain X-rays, with a final diagnosis of skeletal metastases confined predominantly to the left leg discovered on bone scintigraphy.

CASE HISTORY A 77-year-old woman presented with a self-detected lump in her left breast, accompanied by systemic symptoms of fatigue and weight loss. A wide local excision and sentinel node biopsy were performed, with the sentinel node positive for tumour involvement. A further axillary clearance was performed, with 0 of 16 lymph nodes involved.

The carcinoma status was both oestrogen and progesterone positive but her2/neu negative. A metastatic work-up revealed no bony or visceral involvement. The patient was commenced on Arimidex and adjuvant radiotherapy treated to a total of 50 Gy in 25 fractions, with 6 MeV x-rays, over 5 weeks.

The patient remained asymptomatic for fours years, before presenting to her general practitioner with gradually increasing left ankle pain of a stiff and aching nature over several months. Under the initial impression of osteoarthritic pain, an X-ray of the left ankle was ordered. The X-ray images revealed a bony spur on the calcaneal attachment of the plantar fascia, Achilles tendon enthesopathy and mild osteoarthritic changes in the ankle joint, mid foot and hind foot (Figure 1).

Given the history of breast cancer and lack of response to simple analgesia and NSAID therapy, a whole body bone scan was arranged.

The images of the study revealed metastatic bone infiltration mostly confined to the left leg, with abnormalities noted in the left femur, left tibia and left calcaneum. There were also mild foci of irregular uptake in the lumbar spine at L1 and L2 (Figure 2, Figure 3, Figure 4). The lesions were confirmed to be metastatic bone disease on CT, in addition to metastatic involvement of the liver and para-aortic lymph nodes. The patient was treated with radiotherapy to her left leg as well as adjuvant hormonal therapy with exemestane, but rapidly deteriorated and died one month later.

DISCUSSION AND CONCLUSIONS This patient developed radiologically occult metastases generally confined to her left leg, an unusual area for presentation of bone metastasis secondary to breast cancer.

42 Gamma Gazette March 2012

Figure 1. Lateral view of the left ankle showing a calcaneal bony spur, calcified Achilles tendon and mild osteoarthritic changes.

5 year disease free survival in patients undergoing conservative breast surgery with adjuvant radiotherapy is 85%, with an 8.5% chance of distant metastasis.2 Touboul et al describes three independent factors affecting likelihood of distant metastasis, number of axillary lymph nodes involved, high histological grade and isolated local recurrence.2 Of the patients developing metastatic disease, clinical studies indicate that 10% - 63 % develop bony metastasis,3 autopsy studies indicate 45%-84% have bony metastasis.3 Patients with breast cancer uncommonly experience metastasis to the lower limbs, and rarely experience metastasis to the distal portions. Long bone metastases occur in 3.5% of patients with breast cancer, Figure with 3. 90% of these involving the femur.4 75% of patients with metastatic femoral lesions also had other associated bony

Breast cancer with bony metastases confined to the left leg

metastasis.4 Necropsy of 650 patients revealed only 1 tibial metastasis (0.15%) and no lesions in the feet.5 In 50%-74% of patients with metastatic bone disease, pain is the presenting symptom.6,7 However, 95% of distal bony metastases are associated with classic bone pain (i.e. progressive, constant, aching, worse on rest).8 The mechanisms of such include periosteal stretching and endosteal irritation.9 Radioisotope bone scans are more sensitive than X-rays in detecting secondary osteoblastic bony tumours secondary to breast cancer. Use of X-ray evaluation of bone metastases may be challenging, as associated changes can only be seen with trabecular losses over 30%.10 However, radioisotope bone scans are able to detect trabecular loss of 5%-15%.11 Our patient experienced pain isolated to the left ankle, mimicking osteoarthritis. An x-ray was performed with relatively unremarkable results; however a rather surprising bone scan revealed a rare pattern of metastatic uptake mainly isolated to one limb. This case demonstrates the importance to having a high index of suspicion of pain in a person at risk of bony metastases, and the need for early bone scintigraphy if the plain X-rays are inconclusive.

Figure 2. Early blood pool images showing intense bony hyperaemia of the left distal femur and through the left tibia.

REFERENCES 1. AIHW & AACR (Australian Institute of Health and Welfare & Australasian Association of Cancer Registries) 2004, Cancer in Australia, 2001, AIHW Cat. No. CAN 23, AIHW, Canberra.

2. Touboul E, Buffat L, BĂŠlkacemi Y, et al. Local recurrences and distant metastases after breastconversing surgery and radiation therapy for early breast cancer.

International Journal of Radiation Oncology, Biology and Physics.

1999. 43(1):25-38 3. Kamby C. The pattern of Figure 3. Delayed whole body bone scan focused on the lateral aspects of the feet, showing metastases in human breast uptake at the inferior surface of the left calcaneum. cancer: Methodological aspects and influence of prognostic factors.

5. Secondary growths in cancer of breast. The Lancet. 1989.

Cancer Treatment Reviews. 1990.

8:98-101.

17, 37-61 6. Janjan NA, Payne R, Gillis T, et al. Presenting symptoms 4. Knutson CO, Spratt JS. The natural history and management in patients referred to a multidisciplinary clinic for of mammary cancer metastatic to the femur. Cancer. 1970, bone metastases. Journal of Pain Management. 1998.

26(6):1199-1203

u 43

Breast cancer with bony metastases confined to the left leg

16(8):171-178 7. Mercandate S. Malignant bone pain: pathophysiology and treatment. Pain. 1997. 69(1/2):1-18 8. Leeson MC, Makley J, Carter JR. Metastatic Skeletal Disease Distal to the Elbow and Knee. Clinical Orthopaedics & Related Research. 1986: 206:94-99 9. Berruti A, Dogliotti L, Gorzengo G, et al. Differential patterns of bone turnover in relation to bone pain and disease extent in bone in cancer patients with skeletal metastases. Clinical chemistiry. 1999. 45:1240-1247 10. Nicolini A, Ferrari P, Sagripanti A, Carpi A. The role of tumour markers in predicting skeletal metastases in breast cancer patients with equivocal bone scintigraphy. British Journal of Cancer. 1999. 79(9/10):1443-1447 11. Robinson LA. The gamma probe shows promise as an effective technique to locate bone metastases. Journal of the Moffitt Cancer Centre. 1997. 4:6

Figure 4. Delayed whole body bone scan showing intense osteoblastic activity in the distal left femur, throughout the left tibia and in the left foot. Mild uptake visualised in the proximal and diaphysis of the femur, and in the lumber spine (L1, L2).

44 Gamma Gazette March 2012

Case Study

Incidental 99mTc Pertechnetate Uptake in Neonatal Breasts Chew, C.G. MBBS FRACP Department of Nuclear Medicine, Royal Darwin Hospital

A 12-day-old boy was noted to have an elevated TSH on routine screening test and sent for a thyroid nuclear scan to evaluate for neonatal hypothyroidism.

The scan showed a lingual thyroid. Low grade radioactivity noted in the chest was localised to the breasts on SPECT. Physiological neonatal breast uptake of 99m Tc Pertechnetate is a recognised phenomenon attributed to transplacental passage of maternal oestrogen. This can manifest clinically as gynaecomastia with nipple discharge that is referred to as “witch’s milk”.

REFERENCES 1. Hurst W., Williamson B., McGregor R. Tecnetium-99m Uptake in Neonatal Breast Clinical Nuclear Medicine 1989 14(1): 61 1989 2. Othman S, El-Desouki M. Neonatal Gynaecomastia Visualized During Tc99m Pertechnetate Thyroid Scintigraphy Clinical Nuclear Medicine 2003; 28: 988 – 989

Figure 1. 99mTc pertechnetate uptake by a lingual thyroid and physiological gastric mucosal activity. Note low grade radioactivity in the chest.

Figure 2. A SPECT scan localises the chest radiotracer activity to the breasts - a. right, b. left breast

45

Case Study

Bone marrow uptake or pus?

Julie Tan

Department Nuclear Medicine, PET and Bone Densitometry Royal Adelaide Hospital, Adelaide, South Australia

CLINICAL HISTORY The patient was a 34-year-old female with history of intracranial aneurysm and cranioplasty. She developed headaches with fever but no changes seen on CT head.

The question of infection of the right frontoparietal surgical site was raised.

Exametazime (HMPAO) labelled white cell (LWC) scan Following the administration of autologous labelled white blood cells, whole body images were obtained at 30 minutes and 3 hours.

SPECT/CT of the head was also performed.

The whole body images demonstrated physiological distribution of labelled white cells in the liver, spleen and bone marrow. There was early uptake in the lungs which cleared on the delayed images.

In the skull, there was relative deficiency of bone marrow uptake in the right frontoparietal region. The SPECT/CT images showed a small low grade focus of labelled white cell accumulation within the cranioplasty near the skull vertex. This corresponded to an area of lucency on the low dose CT. The intensity of uptake was less than usually seen in the normal bone marrow in the skull. No other

white cell accumulation was seen in relation to the cranioplasty or adjacent soft tissues.

Bone Marrow Scan Planar and whole body imaging with SPECT/CT of the skull were performed 3 hours after the administration of 99m-Technetium antimonysulphide colloid.

There was no significant colloid accumulation at the above site of white cell activity adjacent to the cranioplasty in the skull vertex.

This was regarded as suspicious of a focus of infection rather than physiological white cell activity in the marrow.

There was diffusely reduced tracer activity in the right frontoparietal bone in keeping with relative deficiency of the bone marrow secondary to the cranioplasty. Tracer distribution elsewhere was physiological.

COMMENTS The LWC scan findings raised the possibility of a small focus of infection within the bone of the right cranioplasty. An island of

Figure 1. Tc 99m Exametaxime (HMPAO) LWC Scan, Sagittal View, Fusion and SPECT Images.

Increased uptake (shown circled) suggestive of infection in the right frontoparietal region.

46 Gamma Gazette March 2012

Bone marrow uptake or pus?

Figure 2. Tc 99m Antimony Colloid Bone Marrow Scan, Sagittal View, Fusion and SPECT Images. Corresponding area of increased uptake on HMPAO LWC Scan shows no focal uptake (Shown circled) in the right frontoparietal region. residual bone marrow is a possible alternative explanation as the intensity of uptake is very low. The absence of normal marrow elsewhere in the cranioplasty suggested s a significant degree of devascularisation in the flap. No other focus of labelled white cell accumulation was seen to suggest a pyogenic source of infection.

Correlation with the Bone Marrow Scan and the discrepant uptake suggested that the focus of prominent white cell activity adjacent to the craniotomy on the recent white cell scan was not active bone marrow and therefore likely active infection.

REFERENCES Martindale, A., Papadimitriou, J.M., Turner, J.H. Technetium-99m Antimony Colloid for Bone Marrow Imaging Journal Nuclear Medicine 1980 Kniseley, R. Marrow Studies with Radiocolloids Seminars in Nuclear Medicine 1972

47

Case Study

Potential false positive antigranulocyte antibody scan in a case of knee joint replacement within 12 months of surgery Muralidaran Yogananda* Dr Lorna Que, Dr Ibrahim Hassan and Dr Michael Rutland Auckland City Hospital, New Zealand

INTRODUCTION False positive findings were reported on patients who underwent antigranulocyte scan (sulesomab-Leukoscan) within 12 months of prosthetic joint surgery. We report a similar case with a Besilesomab – monoclonal antibody scan which showed increased uptake on the periprosthetic region.

PATIENT A 60-year-old patient was admitted after recent right total knee joint replacement (TKJR) with shortness of breath, cellulitis, worsening knee pain and swelling. The cause for her symptoms was not revealed by CTPA, adrenal MRI and echocardiogram. An antigranulocyte antibody scan was recommended to check for infection or other bone pathology. We performed a two phase bone scan of the TKJR and an antigranulocyte antibody (Besilesomab) study to specifically check for periprosthetic infection. In addition a whole body and SPECT/CT of the abdomen during the antigranulocyte antibody scan was performed to rule out infection elsewhere.

Two phase Bone Scan The patient was injected with 400 mBq of 99mTc MDP and an initial blood pool image at 10 minutes followed by 3 hours delayed planar images were acquired on GE Hawkeye Infinia SPECT/CT scanner.

The two phase bone scan (99m Tc-MDP) of the TKJR showed increased blood pool activity suggestive of synovial inflammation (Figure 1:A). In the delayed planar images, increased uptake can be seen in the femoral and tibial compartments of the right TKJR with associated soft tissue swelling in the distal femoral region laterally and a few centimetres above the lateral femoral condyle

Figure 2. Scintimun scan slightly increased uptake of tracer around the Right TKR at 4hrs and 24 hours.

(Figure1:B).The recent surgery could have been the cause for the increased uptake in the right TKJR. Infection cannot be ruled out because of the abnormal blood pool activity and increased soft tissue uptake. As the prosthesis had been recently placed, an antigranulocyte antibody study was suggested to specifically check for periprosthetic infection.

Figure 1. Increased blood pool activity – synovial inflammation (A) and increased uptake in the femoral and tibial compartment at 3 hours (B).

48 Gamma Gazette March 2012

Antigranulocyte antibody (Besilesomab) study The patient was injected with Scintimun ((Besilesomab) 715MBq intravenously. Wholebody and SPECT/CT (low dose CT scan – approximately 3 mSv) images of the abdomen and pelvis were obtained at 4 and 24 hours with a GE Hawkeye Infinia SPECT/CT scanner (Figure: 2 & Figure 3:A&B). Planar images showed a slightly increased uptake of tracer around the TKJR and no abnormal areas of uptake in the abdomen

Potential false positive antigranulocyte antibody scan in a case of knee joint replacement within 12 months of surgery

Figure 3. Scintimun SPECT/CT of abdomen at 3 (A) and 4 (B) hours – no focal uptake.

and pelvis region in SPECT/CT scan.

Increased uptake of tracer around the right TKJR may be due to infection or bone marrow stimulation by recent surgery.

To distinguish between these two possibilities, further imaging with 99mTc-sulphur colloid bone marrow scintigraphy was undertaken.

99mTc-sulphur colloid bone marrow scan Following intravenous administration of 300 mBq of 99m Tc Sulphur colloid, further images were acquired on a GE infinia Hawkeye hybrid gamma camera. The static planar images of the knees showed increased bone marrow activity around the right TKJR (Figure 4). The bone marrow scan appearances resembled to those of the earlier Besilesomab study, suggesting that the changes seen on bone scintigraphy with MDP are due to physical and surgical effect of the prosthesis.

CONCLUSION We believe that bone marrow stimulation following surgery is the reason for increased uptake of antigranulocyte antibody in the TKJR region. A bone marrow scan may help reduce false positives, if antigranulocyte antibody scintigraphy is performed on prosthetic joints within 12 months of surgery.

REFERENCES 1. C S Low and A Notghi : Sulesomab (Leukoscan) imaging in joint prostheses. Rad Magazine, 37,431,29-31

Figure 4. 99m Tc Sulphur Colloid scan – Bone marrow activation by recent surgery.

2. Adriana Blazeski,Kenneth M Kozloff, Peter JH Scott : Besilesomab for imaging inflammation and infection in peripheral bone in adults with suspected osteomyelitis. Dove press journal. Reports in Medical Imaging 2010:3 3. Stefan Gratz et.al : Nuclear Medicine Imaging in the detection of complications after total knee arthroplasty (TKA). The open medical imaging journal, 2008.2,24-31.

49

Case Study

FDG PET appearances of arteritis associated with lymphoma Rachael Dunlop Department of Nuclear Medicine and PET Royal Adelaide Hospital

CASE REPORT A 78-year-old female patient with known thyroid diffuse large B-cell lymphoma was referred for a 18F-FDG PET/CT scan for staging in 2008.

Images were obtained from the base of skull to upper thighs. FDG avid foci were visible within the thyroid bed and the pancreatic tail, corresponding with known areas of disease. Increased FDG uptake within the right colon was reported as physiological. Faint uptake throughout the large vessels was noted, with normal physiological uptake elsewhere (Figure 1A).

A post chemotherapy study was performed nine months later (Figure 1B). The uptake within the thyroid bed and pancreatic tail had resolved. There was marked change showing increased uptake of FDG throughout the large vessels. Arteries involved included the entire aorta, and arteries of the upper limbs, iliac and femoral vessels suggesting extensive large vessel arteritis.

Arteritis (or vasculitis) is “inflammation and necrosis with leukocytic infiltration of the vessel wall. Reactive pathological damage to the wall and surrounding tissues is also seen”.1 The inflammatory tissues produce glucose transporters and glycolytic enzymes resulting in increased FDG uptake of the vessels (1). The administration of corticosteroids is a common form of treatment.1 A follow up scan in over 3 years later was performed (Figure 1C) to determine current activity of the lymphoma or arteritis. The images demonstrate no scan evidence of activity of either disease.

Arteritis and other inflammatory diseases are often treated with immunosuppressant drugs which may have induction of lymphoma as a side effect.3,4 This was not the scenario in this case as the lymphoma was diagnosed first.

Arteritis presenting as part of a malignancy is rarer.5,6

This case study has shown the occurrence of a possibly paraneoplastic arteritis and the utility of 18F-FDG PET/CT scans to diagnose and monitor this condition. PET/CT has also been shown to be useful in diagnosing large vessel arteritis in patients presenting with fever of unknown origin.7 REFERENCES 1. Case Report – FDG PET/CT for diagnosis and follow-up of vasculitis; Otsuka, H, Morita, N, Yamashita, K & Nishitani, H, The Journal of Medical Investigation vol 54, August 2007, pp345349.

2. Treatment of Vasculitis, Taylor, HG & Samanta A, British Journal of Clinical Pharmacy, vol 35, 1993, pp93-104.

3. Grulich AE, Vajdic CM, Cozen W Altered Immunity as a Risk Factor for Non-Hodgkin Lymphoma Cancer Epidemiol Biomarkers Prev 2007;16(3):405–8 4. Ji J, Liu X, Sundquist K, Sundquist J, Hemminki K. Cancer risk in patients hospitalized with polymyalgia rheumatica and giant cell arteritis: a follow-up study in Sweden.Rheumatology (Oxford).

2010 Jun;49(6):1158-63 5. Hutson TE, Hoffman GS.Temporal concurrence of vasculitis and cancer: a report of 12 cases. Arthritis Care Res. 2000 Dec;13(6):417-23.

6. Fain O, Hamidou M, Cacoub P, et al. Vasculitides associated with malignancies: analysis of sixty patients Arthritis Rheum. 2007 Dec 15;57(8):1473-80 7. Case Report – PET/CT findings in large vessel vasculitis presenting as FUO, a case report; Akin, E, Coen, A & Momeni, M, Clinical Rheumatology, vol 28, 2009, pp 737-738

Maximum intensity projections of 18FDG scans performed at presentation (A), 9 months (B) and 3.5 years (C) after patient presented with thyroid and pancreatic lymphoma (A). large vessel arteritis occurred during treatment (B) and had resolved along with the original lymphoma in (C).

50 Gamma Gazette March 2012

Australian and New Zealand Society of Nuclear Medicine